The ongoing pandemic coronavirus disease 19 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a matter of global concern. Environmental factors such as air ...pollution and smoking and comorbid conditions (hypertension, diabetes mellitus and underlying cardio-respiratory illness) likely increase the severity of COVID-19. Rheumatic manifestations such as arthralgias and arthritis may be prevalent in about a seventh of individuals. COVID-19 can result in acute interstitial pneumonia, myocarditis, leucopenia (with lymphopenia) and thrombocytopenia, also seen in rheumatic diseases like lupus and Sjogren’s syndrome. Severe disease in a subset of patients may be driven by cytokine storm, possibly due to secondary hemophagocytic lymphohistiocytosis (HLH), akin to that in systemic onset juvenile idiopathic arthritis or adult-onset Still’s disease. In the absence of high-quality evidence in this emerging disease, understanding of pathogenesis may help postulate potential therapies. Angiotensin converting enzyme 2 (ACE2) appears important for viral entry into pneumocytes; dysbalance in ACE2 as caused by ACE inhibitors or ibuprofen may predispose to severe disease. Preliminary evidence suggests potential benefit with chloroquine or hydroxychloroquine. Antiviral drugs like lopinavir/ritonavir, favipiravir and remdesivir are also being explored. Cytokine storm and secondary HLH might require heightened immunosuppressive regimens. Current international society recommendations suggest that patients with rheumatic diseases on immunosuppressive therapy should not stop glucocorticoids during COVID-19 infection, although minimum possible doses may be used. Disease-modifying drugs should be continued; cessation may be considered during infection episodes as per standard practices. Development of a vaccine may be the only effective long-term protection against this disease.
Key Points
• Patients with coronavirus disease 19 (COVID-19) may have features mimicking rheumatic diseases, such as arthralgias, acute interstitial pneumonia, myocarditis, leucopenia, lymphopenia, thrombocytopenia and cytokine storm with features akin to secondary hemophagocytic lymphohistiocytosis.
• Although preliminary results may be encouraging, high-quality clinical trials are needed to better understand the role of drugs commonly used in rheumatology like hydroxychloroquine and tocilizumab in COVID-19.
• Until further evidence emerges, it may be cautiously recommended to continue glucocorticoids and other disease-modifying antirheumatic drugs (DMARDs) in patients receiving these therapies, with discontinuation of DMARDs during infections as per standard practice.
The number of rheumatology journals, and papers related to this specialty, is expanding every day. Careful consideration for ethical aspects of such published work is mandatory for authors, readers, ...reviewers, editors, and all stakeholders. Recent instances of lack of appropriate research ethics committee overview, or participant consent for inclusion in the research study, or a case report, resulting in retractions, emphasize the need for greater awareness regarding these ethical aspects. Authors should strive to avoid redundancy, especially for review articles, both systematic and narrative. Clinical trial registration before commencing enrolment is mandatory as per contemporary norms. Transparent declaration of authorship contributions as well as appropriate attribution of authorship are recommended, since these may help avoid subsequent authorship conflicts. Authors, reviewers, and editors should disclose conflicts of interest, both financial and non-financial. Unbiased peer review is a critical part of editorial decision making; recent instances of peer review fraud have resulted in numerous retractions of scientific papers. Any reproduction of text, figures, or tables should be with due attribution to source, and after seeking permission of the copyright holder. Citations to published work should be relevant and diverse. Research assessment should rely on the assessment of quality of published work, rather than mere citation analyses. Authors should beware predatory, low-quality journals, and utilize social media channels to ethically promote their research with due consideration to privacy and copyright. Rheumatology societies should collaborate to develop guidelines for ethical research reporting, and educate young scientists regarding these principles.
The pharmacotherapy of Takayasu arteritis (TAK) with disease-modifying anti-rheumatic drugs (DMARDs) is an evolving area. A systematic review of Scopus, Web of Science, Pubmed Central, clinical trial ...databases and recent international rheumatology conferences for interventional and observational studies reporting the effectiveness of DMARDs in TAK identified four randomized controlled trials (RCTs, with another longer-term follow-up of one RCT) and 63 observational studies. The identified trials had some concern or high risk of bias. Most observational studies were downgraded on the Newcastle-Ottawa scale due to lack of appropriate comparator groups. Studies used heterogenous outcomes of clinical responses, angiographic stabilization, normalization of inflammatory markers, reduction in vascular uptake on positron emission tomography, reduction in prednisolone doses and relapses. Tocilizumab showed benefit in a RCT compared to placebo in a secondary per-protocol analysis but not the primary intention-to-treat analysis. Abatacept failed to demonstrate benefit compared to placebo for preventing relapses in another RCT. Pooled data from uncontrolled observational studies demonstrated beneficial clinical responses and angiographic stabilization in nearly 80% patients treated with tumour necrosis factor alpha inhibitors, tocilizumab or leflunomide. Certainty of evidence for outcomes from RCTs ranged from moderate to very low and was low to very low for all observational studies. There is a paucity of high-quality evidence to guide the pharmacotherapy of TAK. Future observational studies should attempt to include appropriate comparator arms. Multicentric, adequately powered RCTs assessing both clinical and angiographic responses are necessary in TAK.
The coronavirus disease 2019 (COVID-19) pandemic has led to a massive rise in survey-based research. The paucity of perspicuous guidelines for conducting surveys may pose a challenge to the conduct ...of ethical, valid and meticulous research. The aim of this paper is to guide authors aiming to publish in scholarly journals regarding the methods and means to carry out surveys for valid outcomes. The paper outlines the various aspects, from planning, execution and dissemination of surveys followed by the data analysis and choosing target journals. While providing a comprehensive understanding of the scenarios most conducive to carrying out a survey, the role of ethical approval, survey validation and pilot testing, this brief delves deeper into the survey designs, methods of dissemination, the ways to secure and maintain data anonymity, the various analytical approaches, the reporting techniques and the process of choosing the appropriate journal. Further, the authors analyze retracted survey-based studies and the reasons for the same. This review article intends to guide authors to improve the quality of survey-based research by describing the essential tools and means to do the same with the hope to improve the utility of such studies.
The global impact of COVID-19 pandemic has led to a rapid development and utilization of mobile health applications. These are addressing the unmet needs of healthcare and public health system ...including contact tracing, health information dissemination, symptom checking and providing tools for training healthcare providers. Here we provide an overview of mobile applications being currently utilized for COVID-19 and their assessment using the Mobile Application Rating Scale. We performed a systematic review of the literature and mobile platforms to assess mobile applications currently utilized for COVID-19, and a quality assessment of these applications using the Mobile Application Rating Scale (MARS) for overall quality, Engagement, Functionality, Aesthetics, and Information. Finally, we provide an overview of the key salient features that should be included in mobile applications being developed for future use. Our search identified 63 apps that are currently being used for COVID-19. Of these, 25 were selected from the Google play store and Apple App store in India, and 19 each from the UK and US. 18 apps were developed for sharing up to date information on COVID-19, and 8 were used for contact tracing while 9 apps showed features of both. On MARS Scale, overall scores ranged from 2.4 to 4.8 with apps scoring high in areas of functionality and lower in Engagement. Future steps should involve developing and testing of mobile applications using assessment tools like the MARS scale and the study of their impact on health behaviours and outcomes.
We evaluated clinical response, normalization of inflammatory markers, angiographic stabilization (primary outcomes), relapses and adverse events (secondary outcomes) in Takayasu arteritis (TAK) ...patients following corticosteroid monotherapy. MEDLINE, EMBASE, Web of Science, Scopus, Pubmed Central, Cochrane library, clinical trial databases and major international Rheumatology conferences were searched for studies reporting outcomes in TAK following corticosteroid monotherapy (without language/date restrictions). Risk ratios were calculated for controlled studies. Proportions were pooled for uncontrolled studies. Heterogeneity was assessed using
I
2
statistic. Quality assessment of individual studies utilized the Newcastle–Ottawa scale. GRADE methodology ascertained certainty of individual outcomes across studies. Twenty-eight observational studies (1098 TAK) were identified. Twenty-three uncontrolled studies (580 TAK) were synthesized in meta-analysis. Clinical response was observed in 60% (95% CI 45–74%, 19 studies), normalization of inflammatory markers in 84% (95% CI 54–100%, 4 studies) and angiographic stabilization in 28% (95% CI 6–57%, 4 studies). Relapses occurred in 66% (95% CI 18–99%, 4 studies). Adverse events were reported in 51% (95% CI 2–99%, 4 studies). All pooled estimates had considerable heterogeneity, unexplained by subgroup analyses (time period, geographic location or number of patients). Two studies reported lesser restenosis following vascular surgery and fewer relapses when corticosteroids were combined with immunosuppressants compared with corticosteroid monotherapy. All outcomes had very low certainty. While corticosteroid monotherapy induces clinical response in most TAK patients, angiographic stabilization is observed in fewer than one-third. Most patients relapse following corticosteroid withdrawal. Preliminary evidence supports up-front addition of immunosuppressants to retard angiographic progression and reduce relapses (PROSPERO identifier CRD42021242910).
Teleconsultation has assumed a central role in the management of chronic and disabling rheumatic diseases, such as the idiopathic inflammatory myopathies (IIM), during COVID-19. However, the ...feasibility, challenges encountered, and outcomes remain largely unexplored. Here, we describe our teleconsultation experience in a prospectively followed cohort of adult and juvenile IIM. 250 IIM enrolled into the MyoCite cohort (2017-ongoing) were offered the option of audio/visual teleconsultation using WhatsApp during the nationwide lockdown. Clinical outcomes (major/minor relapse) and prescription changes were compared between IIM subsets. Socio-demographic and clinico-serological characteristics of those who sought teleconsultation were compared with those who did not. 151 teleconsultations were sought over a 93 day period by 71 (52.2%) of 136 IIM (median age 38 years, F:M 4.5:1). Nearly one-third (38%) consulted on an emergency basis, with voice consultations being the primary medium of communication. Over a quarter (26.8%) reported relapse (15.5% minor, 11.3% major), these being more common in JDM 71.4%, OR 8.9 (1.5–51) as compared with adult IIM, but similar across various antibody-based IIM subtypes. Patients who relapsed required more consultations 2(2–3) vs 1(1–2),
p
0.009. The demographic and socioeconomic profile of the patients seeking consultation (
n
= 71) was not different from those who did not (
n
= 65). Voice-based teleconsultations may be useful to diagnose and manage relapses in IIM during the pandemic. Patient education for meticulous and timely reporting may be improve care, and larger multicentre studies may identify subsets of IIM that require greater care and early tele-triage for effective management of the condition.
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