Coronavirus disease 2019 outcomes among patients with rheumatic diseases 6 months into the pandemic.

OBJECTIVE: In earlier studies, patients with rheumatic and musculoskeletal disease (RMD) who got infected with COVID-19 had a higher risk of mechanical ventilation than comparators. We sought to determine COVID-19 outcomes among patients with RMD 6 months into the pandemic. METHODS: We conducted a cohort study at Mass General Brigham in Boston, Massachusetts, of patients with RMD matched to up to five comparators by age, sex and COVID-19 diagnosis date (between 30 January 2020 and 16 July 2020) and followed until last encounter or 18 August 2020. COVID-19 outcomes were compared using Cox regression. Risk of mechanical ventilation was compared in an early versus a recent cohort of patients with RMD. RESULTS: We identified 143 patients with RMD and with COVID-19 (mean age 60 years; 76% female individuals) and 688 comparators (mean age 59 years; 76% female individuals). There were no significantly higher adjusted risks of hospitalisation (HR: 0.87, 95% CI: 0.68-1.11), intensive care unit admission (HR: 1.27, 95% CI: 0.86-1.86), or mortality (HR: 1.02, 95% CI: 0.53-1.95) in patients with RMD versus comparators. There was a trend towards a higher risk of mechanical ventilation in the RMD cohort versus comparators, although not statistically significant (adjusted HR: 1.51, 95% CI: 0.93-2.44). There was a trend towards improvement in mechanical ventilation risk in the recent versus early RMD cohort (10% vs 19%, adjusted HR: 0.44, 95% CI: 0.17-1.12). CONCLUSIONS: Patients with RMD and comparators had similar risks of poor COVID-19 outcomes after adjusting for race, smoking and comorbidities. The higher risk of mechanical ventilation in the early RMD cohort was no longer detected in a recent cohort, suggesting improved management over time.

Association of Race and Ethnicity With COVID-19 Outcomes in Rheumatic Disease: Data From the COVID-19 Global Rheumatology Alliance Physician Registry.

OBJECTIVE: Racial/ethnic minorities experience more severe outcomes of coronavirus disease 2019 (COVID-19) in the general US population. This study was undertaken to examine the association between race/ethnicity and COVID-19 hospitalization, ventilation status, and mortality in people with rheumatic disease. METHODS: US patients with rheumatic disease and COVID-19 were entered into the COVID-19 Global Rheumatology Alliance physician registry between March 24, 2020 and August 26, 2020 were included. Race/ethnicity was defined as White, African American, Latinx, Asian, or other/mixed race. Outcome measures included hospitalization, requirement for ventilatory support, and death. Multivariable regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) adjusted for age, sex, smoking status, rheumatic disease diagnosis, comorbidities, medication use prior to infection, and rheumatic disease activity. RESULTS: A total of 1,324 patients were included, of whom 36% were hospitalized and 6% died; 26% of hospitalized patients required mechanical ventilation. In multivariable models, African American patients (OR 2.74 [95% CI 1.90-3.95]), Latinx patients (OR 1.71 [95% CI 1.18-2.49]), and Asian patients (OR 2.69 [95% CI 1.16-6.24]) had higher odds of hospitalization compared to White patients. Latinx patients also had 3-fold increased odds of requiring ventilatory support (OR 3.25 [95% CI 1.75-6.05]). No differences in mortality based on race/ethnicity were found, though power to detect associations may have been limited. CONCLUSION: Similar to findings in the general US population, racial/ethnic minorities with rheumatic disease and COVID-19 had increased odds of hospitalization and ventilatory support. These results illustrate significant health disparities related to COVID-19 in people with rheumatic diseases. The rheumatology community should proactively address the needs of patients currently experiencing inequitable health outcomes during the pandemic.

Management of primary vasculitides with biologic and novel small molecule medications.

PURPOSE OF REVIEW: Vasculitides can affect small, medium and/or large vessels, leading to end-organ damage, decreased quality of life and death. Glucocorticoids remain the backbone of treatment for systemic vasculitis but are associated with numerous toxicities. In recent years, the efficacy of glucocorticoid-sparing biologic and novel small molecule therapies has been demonstrated. RECENT FINDINGS: In giant cell arteritis, tocilizumab was superior to glucocorticoid monotherapy in maintenance remission and cumulative glucocorticoid exposure and is now approved for the treatment of giant cell arteritis. In addition to the previously demonstrated efficacy of rituximab for remission induction in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, recent trials have also demonstrated its superiority for remission maintenance compared to alternative approaches. Mepolizumab is superior to standard of care alone with regard to remission rates and glucocorticoid-sparing effect in refractory eosinophilic granulomatosis with polyangiitis. Avacopan has shown significant promise in ANCA-associated vasculitis as part of a glucocorticoid-free induction regimen in a recently completed phase 3 trial. Use of biologics in rarer vasculitides remains guided by reports from small case series. SUMMARY: Biologics and other novel therapies have an increasingly important role in the management of systemic vasculitis. Additional studies are needed to define their optimal use and to guide their use in more rare forms of vasculitis.

Efficacy of Tocilizumab in Patients Hospitalized with Covid-19.

BACKGROUND: The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear. METHODS: We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses. RESULTS: We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo. CONCLUSIONS: Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).

Gastric antral vascular ectasia in systemic sclerosis: Association with anti-RNA polymerase III and negative anti-nuclear antibodies.

OBJECTIVE: Gastric antral vascular ectasia (GAVE) is a vascular manifestation of systemic sclerosis (SSc) that can lead to iron deficiency anemia or acute gastrointestinal (GI) bleeding. We aimed to identify clinical features associated with GAVE. METHODS: We performed a cohort study of SSc patients who were seen at Stanford between 2004 and 2018 and had undergone esophagogastroduodenoscopy (EGD). We compared the clinical features of those with and without GAVE, and multivariable logistic regression was performed to identify clinical correlates with GAVE. RESULTS: A total of 225 patients with SSc who underwent EGD were included in this study and 19 (8.4%) had GAVE. Those with GAVE were more likely to have scleroderma renal crisis (SRC) (21% vs 3%; p < 0.01), positive anti-RNA polymerase III antibody (71% vs 19%; p < 0.01), nucleolar pattern of anti-nuclear antibody (ANA) (33% vs 11%; p=0.04), and negative ANA (<1:80 by immunofluorescence) (33% vs 11%; p=0.02). On multivariate analysis with multiple imputation, anti-RNA polymerase III positivity (OR 4.57; 95% CI (1.57 - 13.23), p < 0.01) and ANA negativity (OR 3.75; 95% CI (1.21 - 11.62), p=0.02) remained significantly associated with GAVE. CONCLUSION: Positive anti-RNA polymerase III antibody and ANA negativity were significantly associated with GAVE. Further studies are necessary to determine whether patients with these autoantibody profiles should undergo screening endoscopies for GAVE.

Using electronic visits (E-visits) to achieve goal serum urate levels in patients with gout in a rheumatology practice: A pilot study.

OBJECTIVE: Achieving goal serum urate levels in patients with gout remains difficult in primary care and rheumatology practices. This study measured the ability of an asynchronous electronic visit (E-visit) program to facilitate achieving a goal serum urate (SU) of less than 6.0 mg/dL. METHODS: We performed a retrospective cohort study in a large academic medical center rheumatology practice between April 1, 2017 and May 31, 2018. Patients with gout and SU levels over 6.0 mg/dL were enrolled in an E-visit program and were compared with historical controls who received usual care, matched 1:1 for age and sex. The primary outcome of interest was the proportion of patients achieving SU target of less than 6.0 mg/dL at six months. RESULTS: Sixty-two patients were enrolled by their rheumatologist in the gout asynchronous E-visit program and were compared to 62 historical controls who were seen within one year prior to E-visit program initiation. Baseline characteristics including age, sex, body mass index, renal function, and initial SU were similar among patients enrolled in the E-visit program and controls. At six months, a significantly higher proportion of patients in the E-visit program achieved goal SU of less than 6.0 mg/dL compared to controls (63.8% vs 33.9%, respectively, p < 0.01), and the E-visit patients had a lower mean SU level than historical controls (5.5 mg/dL versus 6.7 mg/dL, respectively, p < 0.01). CONCLUSION: A physician-initiated E-visit program led to a substantial improvement in the rate of achieving goal SU among patients with gout within an academic rheumatology practice.

Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: a comparative cohort study from a US 'hot spot'.

OBJECTIVE: To investigate differences in manifestations and outcomes of coronavirus disease 2019 (COVID-19) infection between those with and without rheumatic disease. METHODS: We conducted a comparative cohort study of patients with rheumatic disease and COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR), compared in a 1:2 ratio with matched comparators on age, sex and date of COVID-19 diagnosis, between 1 March and 8 April 2020, at Partners HealthCare System in the greater Boston, Massachusetts area. We examined differences in demographics, clinical features and outcomes of COVID-19 infection. The main outcomes were hospitalisation, intensive care admission, mechanical ventilation and mortality. RESULTS: We identified 52 rheumatic disease patients with COVID-19 (mean age, 63 years; 69% female) and matched these to 104 non-rheumatic disease comparators. The majority (39, 75%) of patients with rheumatic disease were on immunosuppressive medications. Patients with and without rheumatic disease had similar symptoms and laboratory findings. A similar proportion of patients with and without rheumatic disease were hospitalised (23 (44%) vs 42 (40%)), p=0.50) but those with rheumatic disease required intensive care admission and mechanical ventilation more often (11 (48%) vs 7 (18%), multivariable OR 3.11 (95% CI 1.07 to 9.05)). Mortality was similar between the two groups (3 (6%) vs 4 (4%), p=0.69). CONCLUSIONS: Patients with rheumatic disease and COVID-19 infection were more likely to require mechanical ventilation but had similar clinical features and hospitalisation rates as those without rheumatic disease. These findings have important implications for patients with rheumatic disease but require further validation.

Recent advances in the diagnosis and management of giant cell arteritis.

PURPOSE OF REVIEW: Giant cell arteritis (GCA) has classically been diagnosed by temporal artery biopsy and treated with high-dose, long-term glucocorticoid therapy. Noninvasive imaging increasingly is employed for diagnostic purposes, but further studies are needed to determine the role of imaging in monitoring longitudinal disease activity. Glucocorticoid-sparing therapy mitigates the numerous adverse effects of glucocorticoids. This review addresses new developments in these areas. RECENT FINDINGS: For diagnosis, when performed at a center with expertise in its use, temporal artery ultrasound has an estimated sensitivity and specificity of 78 and 79%, respectively. State-of-the-art time-of-flight positron emission tomography/computed tomography (PET/CT) has an estimated sensitivity and specificity of 71 and 91%, respectively. The sensitivities of both imaging modalities decrease following glucocorticoid administration. Tocilizumab is an effective glucocorticoid-sparing therapy, demonstrating sustained glucocorticoid-free remission in 56% of patients receiving weekly tocilizumab compared with 18% of patients receiving a 52-week prednisone taper. The traditional acute phase reactants are of no value in patients treated with interleukin-6 receptor (IL6-R) blockade, and thus, the development of new biomarkers is an important priority in the field. SUMMARY: Noninvasive imaging techniques are increasingly used in the absence of temporal artery biopsy to confirm diagnostic suspicions of GCA. Tocilizumab reduces the cumulative glucocorticoid exposure and increases the rate of sustained remission. Ongoing efforts are directed towards new methods to identify disease flares.

Enhancing the Inpatient Consultation Learning Environment to Optimize Teaching and Learning.

Subspecialty consultation is an increasingly used resource in inpatient medicine. Teaching the primary team is an important element of effective consultation and has many potential benefits. However, within academic medical centers many barriers to effective consultation and the consult learning environment exist. High workload, burnout, inexperience, lack of familiarity between teams, quality of the consult requests, and pushback may impede teaching and learning. Herein, the authors review the role of teaching and learning during consultation, challenges to effective consultation facing fellows, and interventions that can enhance primary team-fellow interactions and learning.

Spontaneous tumor lysis syndrome in a patient with metastatic prostate cancer.

Tumor lysis syndrome (TLS) is a life-threatening oncological emergency, with most cases occurring in hematological malignancies following the initiation of treatment. However, on rare occasions, TLS may occur in solid tumors as well. In the present case study, the case is reported of a 56-year-old African-American man who presented with a recent diagnosis of prostate cancer, abdominal pain, elevated transaminases, renal insufficiency, hyperkalemia, and hyperuricemia, consistent with spontaneous TLS in the setting of metastatic prostate cancer. A computed tomography scan of the patient's abdomen demonstrated diffuse metastatic tumor burden. Following treatment with allopurinol, rasburicase, and initiation of anti-androgen therapy for the prostate cancer, the patient's TLS laboratory results normalized, however, his renal functions continued to decline. TLS is rare in solid tumors, and particularly rare in prostate cancer, with only six other case reports of the syndrome occurring to the best of our knowledge. This case report highlights the need for early recognition of TLS, even in cases that are not typically associated with the syndrome, as prompt diagnosis will affect early management and may be able to prevent or minimize complications.