Integrating spiritual disposition intervention into behavioral medicine: A case report on systemic lupus erythematosus from India

Background: Systemic Lupus Erythematosus (SLE) is a chronic inflammatory systemic autoimmune disease. The disease manifests as the body's immune cells start attacking healthy connective tissue, which affects the skin, kidneys, blood vessels, brain, and other vital organs. As with any other chronic illness, the disease has psychological implications.Purpose: Literature suggests patients with SLE experience anxiety, depression, anger, and stress along with physiological symptoms. There is a strong association between the occurrence of stress and the onset of the disease. These psychological symptoms can be ameliorated through spiritual activities such as meditation, mindfulness, journaling, and reading.Mehtod: This case report is based on the importance of spirituality in the healthcare system. The study focuses on the concept of a whole-person-centered approach to the medical care industry. Spirituality has been proven to have a positive effect on health and illness. Hence, a 10-week intervention with 30 sessions focusing on spiritual dispositions was provided to the patient for this study, along with regular pharmacological treatment. The present case report is of a 56-year-old woman from New Delhi, India, who was diagnosed with SLE 2 years ago.Results: The results reveal the positive effect of the intervention, as it led to a significant decrease in stress levels and depressive symptoms; it also resulted in improved quality of life, an enhanced coping style, and bolstered health hardiness. There was an increase in the score of a spiritual personality.Conlcusion: Spiritual Disposition as an intervention was sucessfull in reducing psychological implications of the disease thus leading to overall positve growth in the patient.

COVID‐19 Vaccination In Autoimmune Diseases (COVAD) Study: Vaccine Safety In Idiopathic Inflammatory Myopathies

Introduction/Aims

In this study we investigated COVID‐19 vaccination–related adverse events (ADEs) 7 days postvaccination in patients with idiopathic inflammatory myopathies (IIMs) and other systemic autoimmune and inflammatory disorders (SAIDs).

Methods

Seven‐day vaccine ADEs were collected in an international patient self‐reported e‐survey. Descriptive statistics were obtained and multivariable regression was performed.

Results

Ten thousand nine hundred respondents were analyzed (1227 IIM cases, 4640 SAID cases, and 5033 healthy controls [HCs]; median age, 42 [interquartile range, 30‐455] years; 74% female; 45% Caucasian; 69% completely vaccinated). Major ADEs were reported by 76.3% of the IIM patients and 4.6% reported major ADEs. Patients with active IIMs reported more frequent major (odds ratio [OR], 2.7; interquartile range [IQR], 1.04‐7.3) and minor (OR, 1.5; IQR, 1.1‐2.2) ADEs than patients with inactive IIMs. Rashes were more frequent in IIMs (OR, 2.3; IQR, 1.2‐4.2) than HCs. ADEs were not impacted by steroid dose, although hydroxychloroquine and intravenous/subcutaneous immunoglobulins were associated with a higher risk of minor ADEs (OR, 1.9; IQR, 1.1‐3.3; and OR, 2.2; IQR, 1.1‐4.3, respectively). Overall, ADEs were less frequent in inclusion‐body myositis (IBM) and BNT162b2 (Pfizer) vaccine recipients.

Discussion

Seven‐day postvaccination ADEs were comparable in patients with IIMs, SAIDs, and HCs, except for a higher risk of rash in IIMs. Patients with dermatomyositis with active disease may be at higher risk, and IBM patients may be at lower risk of specific ADEs. Overall, the benefit of preventing severe COVID‐19 through vaccination likely outweighs the risk of vaccine‐related ADEs. Our results may inform future guidelines regarding COVID‐19 vaccination in patients with SAIDs, specifically in those with IIMs. Studies to evaluate long‐term outcomes and disease flares are needed to shed more light on developing future COVID‐19 vaccination guidelines.

Services provided for axial spondyloarthritis patients by rheumatologists in India: a survey

Objective

We sought to evaluate the current knowledge and attitudes of Indian rheumatologists concerning axial spondyloarthritis (axSpA) with respect to recent terminology for diagnosis, management strategies and additional services.

Methods

The survey was designed for spondyloarthritis care given by rheumatologists in the Indian health-care context. The structured survey consisted of a combination of multiple-choice and open-ended questions. An anonymous Web-based questionnaire was sent to 710 members of the Indian Rheumatology Association, and descriptive analysis of responses was done.

Results

The survey respondents were from government and private health-care facilities and gave a response rate of 19% (133 of 710). About 49% of respondents were using the terminology axSpA for a new diagnosis of spondyloarthritis (SpA). BASDAI was used routinely as the main disease monitoring tool by most respondents (76.2%). Same-day MRI was available to 42.9% (51 of 119) respondents. Selective cyclooxygenase-2 inhibitors were the preferred first NSAID for 50% of respondents, and SSZ was the most preferred DMARD for peripheral arthritis. Financial constraints were the most common factor that affected the initiation of biologics and also the most common reason for stopping biological therapies. Nearly 65% (80 of 122) of respondents did not have a multidisciplinary team available in clinical practice, and only 15% of respondents had access to patient support groups.

Conclusion

For a new diagnosis, the terminology of axSpA is not fully accepted by Indian rheumatologists. The axSpA management given by Indian rheumatologists is in agreement with recent guidelines, however, there is a significant lack of accessibility to multidisciplinary care and patient support groups in India.

Tuberculosis in Children with Rheumatic Diseases Treated with Biologic Disease-Modifying Anti-Rheumatic Drugs

Chronic rheumatic diseases entail the use of biologics in children. Immunosuppressive effects of drug therapy put children at risk of various infections including tuberculosis (TB). Even though TB is a major concern among individuals on biological DMARDs, the incidence and distribution among children on these drugs is not known. Hence, we performed a literature search to ascertain the prevalence of tuberculosis amongst children with rheumatic disorders treated with biological agents. Articles available on MEDLINE and SCOPUS published on or after January 1, 2010 to 1 October 2019 were reviewed and collated. We found that published data on TB infections in children with rheumatic disorders on biologics is scant even from regions with highest TB burden. Tuberculosis was reported on occasion (0–5 cases per country) in the developed world with most reports being from Turkey. While most of the retrospective studies suggest that TB risk is minimal in the paediatric rheumatology patients, prospective studies suffer from a short observation period. Most registries focus on response to therapy rather than complications. In this review we have then discussed about the variation in screening strategies for latent TB and the role of bacille Calmette-Guerin (BCG) vaccination. Based on the dearth of data and inconsistency in data collection, we propose a way forward in the form of establishing well-designed long-term prospective national registries from countries with high background prevalence of TB with focus not only on treatment efficacy but also on adverse events and infections.

Distinct T-cell immunophenotypic signature in a subset of sarcoidosis patients with arthritis

BACKGROUND

The objective of the study was to assess T-cell subsets in sarcoidosis patients with or without articular involvement.

METHODS

Treatment-naïve patients were divided into Group A (articular) and Group B (non-articular) based on joint involvement. Flow cytometric analysis of T-cell subsets and pro-in˜flammatory cytokines were carried out in the peripheral blood.

RESULTS

Patients in group A (n = 29, mean age 40 ± 10.1 years) were compared with group B (n = 18, 43 ± 12.2 years). T-cell subsets: the CD4/CD8 ratio was abnormal in two groups but had no significant difference (p = 0.63). Ratios of Th1/Treg, Th2/Treg and Th17/Treg were significantly increased in group A as compared to group B [p < 0.001] indicating polarisation of T-cell subsets. CD8 T-cells in group A had higher granzyme B expression (p = 0.03). B cells were increased in group A [p = 0.04]. Ratio of IFN-γ /IL10, IL-4/IL10, IL-17/IL10 in sera as well as culture supernatant were significantly higher in group A as compared to group B.

CONCLUSION

AB0989 TUBERCULOSIS RISK IN CHILDREN WITH RHEUMATIC DISEASES TREATED WITH BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS

Background:

Chronic rheumatic diseases entail the use of biologics in children. Immunosuppressive effects of drug therapy put children at risk of various infections. Tuberculosis (TB) is a leading chronic infection in certain parts of the world. Recent estimates suggest the prevalence of TB in India to be 3.2 cases per thousand population1.

Objectives:

Thus we reviewed the prevalence of Tuberculosis amongst children with various rheumatic disorders treated with different biologics.

Methods:

The search strategy for writing review articles proposed by Gasparyan et al2. was followed. Articles available on MEDLINE and Scopus, published on or after January 1, 2010 to 1 October 2019, were reviewed. (Figure 1) Details on Tuberculoisis and disease variables were collected (Table 1).

Table 1.

Data extraction form

Data extraction formDrugStudy characteristics Country of study Type of study Year Author DOIOutcomes reported Number of participants Total number of Tuberculosis reportedDisease variable Disease or type of JIA (PA-RF+, PA-RF-, OA, OA extended, ERA, jspA, SJIA, PsA, Undifferentiated, only uveitis) Duration of JIA before biologics (Median, IQR) Duration of follow-up (Median) Exposure in patient yearsInfectious events Total no of infection events Major/ serious Infections- Number of events Opportunistic infections Minor Infections- Number of eventsTreatment received Biologic Doses received Duration of biologic treatment Concomitant drugs Steroids OtherFigure 1.

Number of articles obtained after searching through MEDLIEN and Scopus.

Results:

Data on infections in children with rheumatic disorders on biologics is scant (Table 2, Figure 2A). Tuberculosis was reported on occasion (0-5 cases per country) in the developed world with the highest Tuberculosis reports being from Turkey (Figure 2B). There is particular paucity of data from regions with highest number of incident cases or prevalence of tuberculosis more than 100 per 10 000 population (figure 2C, D).

Table 2.

Summary of data on tuberculosis in paediatric rheumatology with various biologics

JIALupusMyositisAutoinflammatory syndromesVasculitisInfliximab783(A)547(B)00010(C)9(B)Adalimumab2925 (A)489(B)0001(B)11(C)Etanercept6974 (A)2019(B)0001(C)Certolizumab37 (A)0(B)0000Golimumab224 (A) 3(B)0000Rituximab107 (A) 51(B)75(B)48(E) 185(C)03(C)Belimumab0(A) 0(B)39(B)000Anakinra471 (A) 63(B)0029(A) 27(B)1(D)0Canakinumab196 (A)004(A)109(E)0Tocilizumab998 (A)0002 (B) 9(C)Abatacept521 (A)0000Combination of anti TNFs3(A)0000

A: Registry data, B: Cohort, C: Case series, D: Anecdotal reports E. Trials

Figure 2

A. Data available on children with pediatric rheumatic disorders on biologics B. Number of Tuberculosis cases reported from studies summarized in figure 2A C. Number of cases worldwide*D. Global incidence of Tuberculosis per 10000 people#

Retrospective studies of duration 10 m- 10years suggest that TB risk is minimal in pediatric rheumatology patients on biologics in low TB incident areas. However, most prospective studies suffer from short observation period (Table 2). Most registries focus on response to therapy rather than complications.

Conclusion:

TB risk is minimal with biologics use in peadiatric rheumatology in areas with low TB incidence (<99 cases per 10 000 population). However, most prospective studies are hampered by short observation period. There is insufficient data to establish safety in countries with high background prevalence of TB. Long term prospective national registries are needed from in TB countries with focus on risk factors for infections.

References:

[1]TB Statistics India | National, treatment outcome & state statistics [Internet]. TB Facts | TB, tests, drugs, statistics. [cited 2019 Jun 13]. Available from:https://www.tbfacts.org/tb-statistics-india/

[2]Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD (2011) Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int 31:1409– 1417. doi:10.1007/s00296-011-1999-3

Disclosure of Interests:

Chengappa Kavadichanda: None declared, Adarsh M B: None declared, Sajal Ajmani Consultant of: Elly lily, Speakers bureau: J and J, Ilaria Maccora: None declared, Suma Balan: None declared, Athimalaipet Ramanan Consultant of: Abbvie, Eli Lilly, UCB, Novartis and SOBI, Speakers bureau: Abbvie, Eli Lilly, UCB, Novartis and SOBI, Vikas Agarwal: None declared, Latika Gupta: None declared

Utility of neutrophil CD64 and serum TREM-1 in distinguishing bacterial infection from disease flare in SLE and ANCA-associated vasculitis

Bacterial and opportunistic infections are a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis owing to treatment with immunosuppressants. Commonly used laboratory tests are unreliable in differentiating infection from active disease patients. Fc receptor (FcγR1 or CD64) expression on neutrophils and soluble TREM-1 (triggering receptor expressed on monocytes) are potential biomarkers of bacterial infections. Our aim was to measure the clinical usefulness of quantitative CD64 measurement on neutrophils and soluble TREM-1 measurements in differentiating bacterial infection from active disease in patients with SLE and ANCA vasculitis. Patients with bacterial infection (n = 25), active disease (n = 51), and healthy controls (n = 20) were included. Neutrophil CD64 expression using flow cytometry and sTREM-1 and procalcitonin levels by ELISA were studied. The percentage of neutrophils with CD64 expression and their mean fluorescence intensity in patients with infection (68.8 (56.9-86.5)%, 1037 (229-1828)) were significantly (p < 0.05) higher as compared to those without infection (7.7 (2.6-13.1)%, 456 (20-968)) and controls (7.05 (1.4-9.5)%, 99.5 (54.7-140.7)). The sensitivity and specificity of CD64 expression on neutrophils to diagnose bacterial infection (using a cutoff value of 30%) was 85% and 84%, respectively, whereas the sensitivity and specificity of procalcitonin was 75% and 85%, respectively. There was no significant difference in soluble TREM-1 levels between the two groups. Quantitative measurement of CD64 on neutrophils can distinguish between systemic infection and the flare of autoimmune diseases.

SLE presenting as migratory arthritis, chorea and nephritis

We present a case of a 12-year-old girl who presented with migratory arthritis, chorea and ascites. She was diagnosed to have systemic lupus erythematosus (SLE) and subsequently responded to immunosuppressive therapy. She had been misdiagnosed earlier as having rheumatic fever. Our case highlights the fact that SLE should be considered in the differential diagnosis of a patient with migratory arthritis & chorea. Generally, chorea in SLE is immune-mediated rather than due to ischemia and has good prognosis.

Aetiology, outcomes & predictors of mortality in acute respiratory distress syndrome from a tertiary care centre in north India

Background & objectives:

Acute respiratory distress syndrome (ARDS) is a common disorder in critically ill patients and is associated with high mortality. There is a paucity of literature on this condition from developing countries. This prospective observational study was designed to find out the aetiology, outcomes and predictors of mortality in ARDS.

Methods:

Sixty four consecutive patients who satisfied American-European Consensus Conference (AECC) definition of ARDS from medical Intensive Care Unit (ICU) of a tertiary care centre in New Delhi, India, were enrolled in the study. Demographic, biochemical and ventilatory variables were recorded for each patient. Baseline measurements of serum interleukin (IL)-1β, IL-6, tumour necrosis factor-alpha (TNF-α), procalcitonin (PCT) and high sensitivity C-reactive protein (hsCRP) were performed.

Results:

Common causes of ARDS included pneumonia [44/64 (68.7%)], malaria [9/64 (14.1%)] and sepsis [8/64 (12.5%]. Eight of the 64 (12.5%) patients had ARDS due to viral pneumonia. The 28-day mortality was 36/64 (56.2%). Independent predictors of mortality included non-pulmonary organ failure, [Hazard ratio (HR) 7.65; 95% CI 0.98-59.7, P=0.05], Simplified Acute Physiology Score (SAPS-II) [HR 2.36; 95% CI 1.14-4.85, P=0.02] and peak pressure (P_peak) [HR 1.13; 95% CI 1.00-1.30, P = 0.04] at admission.

Interpretation & conclusions:

Bacterial and viral pneumonia, malaria and tuberculosis resulted in ARDS in a considerable number of patients. Independent predictors of mortality included non-pulmonary organ failure, SAPS II score and P_peak at baseline. Elevated levels of biomarkers such as TNF-α, PCT and hsCRP at admission might help in identifying patients at a higher risk of mortality.

Methotrexate-induced pancytopenia: a case series of 46 patients

AIM

Methotrexate (MTX) has the potential to cause serious adverse reactions and even mortality. We analyzed the predisposing factors and outcome in patients with MTX-induced pancytopenia admitted into our unit from 1996 to 2015.

METHODS

Patients were identified by departmental database search. Pancytopenia was defined as white blood cell count (WBC) < 3500 cells/mm³ , hemoglobin (Hb) < 11 g/dL and platelet count < 150 000 cells/mm³ . Severe pancytopenia was defined as WBC < 2000 cells/mm³ , Hb < 10 g/dL and platelet count < 50 000 cells/mm³ .

RESULTS

Forty-six patients were included in the study (female = 35). Twenty-four had been under the care of either primary care physicians or orthopedic surgeons and presented to us with pancytopenia. Sixteen patients had severe pancytopenia. Disease distribution was as follows: rheumatoid arthritis 33, psoriasis eight, systemic sclerosis two and others three. The median dose of MTX was 10 mg/week and median duration of treatment was 11 months. The median cumulative dose was 750 mg. Symptoms at presentation included: oral mucositis (n = 37); fever (n = 24); diarrhea (n = 12), bleeding gums (n = 5) and purpura (n = 3). The potential risk factors were: hypoalbuminemia (n = 23), renal insufficiency (n = 14), dosing errors (n = 13) and non-supplementation of folates (n = 7). Thirteen patients died. WBC at admission was found to determine survival (P < 0.05).

CONCLUSION

In patients on MTX, oral mucositis and fever can herald pancytopenia. MTX-induced pancytopenia is associated with high mortality. WBC at admission is the most important prognostic factor. There is need for increased awareness among physicians to minimize prescribing errors. A national guideline on monitoring of patients on MTX is desirable.

Behcet's disease without oral ulcers presenting with erythema nodosum and deep venous thrombosis

We present a young male with recurrent erythema nodosum and recent deep vein thrombosis with scrotal ulcers but no oral ulcers. He was diagnosed as having Behcet's disease (BD) and subsequently responded to immunosuppressants and anticoagulation. This case highlights that up to 2% patients with BD may not have oral ulcers. Timely institution of therapy in our patient resulted in a favorable outcome.