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   Table of Contents - Current issue
December 2020
Volume 15 | Issue 6
Page Nos. 73-226

Online since Monday, January 18, 2021

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Inflammatory myositis - Foray into the future p. 73
Neil McHugh, Latika Gupta
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Bye-bye muscle biopsy, we have autoantibodies with us now Highly accessed article p. 74
Victoria Riddell, Sarah L Tansley
Muscle biopsy is generally considered the gold standard diagnostic tool for patients with presenting with features suggestive of idiopathic inflammatory myopathy. Muscle biopsy is however an invasive test, the histopathological findings can be influenced by previous treatment and not all patients with myositis spectrum disease have muscle involvement. Myositis specific and associated autoantibodies can now be identified in the majority of patients with myositis. When present they identify homogeneous patient subgroups and have the potential to be key tools in developing a personalised approach to disease management. Here we review the utility of myositis specific and associated autoantibodies as diagnostic and prognostic tools.
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The clinicoserological spectrum of inflammatory myopathy in the context of systemic sclerosis and systemic lupus erythematosus p. 81
John D Pauling, Sarah Skeoch, Julie J Paik
Autoimmune rheumatic diseases (ARDs) are characterized by a pathological triad composed of autoimmunity/inflammation, microangiopathy, and aberrant tissue remodeling. Disease terms such as idiopathic inflammatory myopathy (IIM), scleroderma/systemic sclerosis (SSc), and systemic lupus erythematosus (SLE) are helpful clinically but disguise the considerable overlap that exists within these “distinct” disorders. This is perhaps best demonstrated by inflammatory myopathy, which can be present in SSc or SLE, but can itself be absent in clinically amyopathic IIM. Archetypal clinical manifestations of ARD (such as Raynaud's phenomenon) are frequently present, albeit with varying prominence, within each of these diseases. This is certainly the case for inflammatory myositis, which has long been recognized as an important clinical feature of both SSc and SLE. Progress in elucidating the clinicoserological spectrum of ARDs has identified autoantibody specificities that are strongly associated with “overlap” disease and the presence of inflammatory myositis in SSc and SLE. In this review, we shall describe the prevalence, burden, prognostic value, and management considerations of IIM in the context of both SSc and SLE. A major emphasis on the value of autoantibodies shall highlight the value of these tools in predicting the future occurrence of inflammatory myositis in both SSc and SLE. Where applicable, unmet research needs shall be highlighted. The review emphasizes the importance of myopathy as a common feature across all the ARDs and highlights specific antibody specificities that are strongly associated with myopathy in the context of SLE and SSc.
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Picking interstitial lung disease out of the myositis haystack p. 91
Jennifer Hannah, Harsha Gunawardena
Interstitial lung disease (ILD) is a common manifestation of the connective tissue disease (CTD) associated idiopathic inflammatory myopathies (IIM). Although patients may be diagnosed as having polymyositis (PM) or dermatomyositis (DM) under the IIM spectrum, it is quite clear that risk, pattern of ILD and disease course between subgroups of patients is different. The natural history may be asymptomatic and slowly progressive or stable, chronically progressive or fulminant rapidly progressive depending on ILD subtype. ILD can be the initial presenting feature and this can make recognition of an underlying CTD-IIM overlap more difficult with some patients initially misdiagnosed with idiopathic pulmonary fibrosis. Therefore, early recognition and characterization of patients can influence management and prognosis. It is clear than certain clinical and serological features phenotype patients into more specific CTD-IIM ILD subgroups. A number of myositis-CTD overlap associated antibodies and their clinical patterns have been described over the last few years. The hallmark CTD-IIM ILD subgroup is antisynthetase syndrome, characterized by autoantibodies to tRNA synthetases. Muscle weakness is not universally present and parenchymal lung disease can predominate. Anti-MDA5 DM has a distinct cutaneous pulmonary phenotype and is significantly associated with the development of ILD with different patterns seen in different ethnic groups. Other autoantibodies associated with ILD include those targeting nucleolar autoantigens such as anti-PM-SCL, again with characteristic syndromes. Picking ILD out of the “myositis haystack” can be complex. This heterogeneous disease group requires robust multidisciplinary collaboration between rheumatologists, pulmonologists, thoracic radiologists, and histopathologists to bring together clinical assessment to reach a diagnostic conclusion so optimal outcomes can be achieved.
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Pathogenesis of muscle weakness in inflammatory myositis p. 99
Sai Kumar Dunga, TG Sundaram, Chengappa G Kavadichanda
Idiopathic inflammatory myositis (IIM) is a heterogeneous group of autoimmune diseases. These are characterized by muscle weakness and fatigue along with other systemic manifestations, ranging from pulmonary alveolitis to vasculopathic ulcers. Muscle weakness is encountered in a majority of individuals with IIM. Several hypotheses for muscle weakness have been proposed, but none have been convincingly proven. Understanding of the pathophysiology of muscle weakness is necessary to better delineate therapeutic options and tailor exercise regimens in patients with IIM. In this review, we have attempted to delineate the immune and nonimmune pathways implicated in muscle weakness and integrated them with the clinical, histopathological, and imaging findings in IIM.
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Juvenile dermatomyositis: Controversies and recent developments in management p. 112
Himanshi Chaudhary, Satish Kumar Loganathan, Surjit Singh
Juvenile dermatomyositis (JDM) is an autoimmune disorder of childhood that mainly affects the skin and muscles. As compared to adults, children are more likely to suffer from disease relapses and long-term complications such as lipodystrophy, insulin resistance, calcinosis, and systemic vasculopathy. There have been significant advancements in our understanding of the pathophysiology, disease course and complications of JDM in the last two decades. Due to scarcity of clinical trials in JDM, therapeutic decisions in every patient with JDM remain a challenge. This review aims to provide a comprehensive overview of the controversies, challenges in clinical management and latest advances in treatment regimens of JDM.
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Idiopathic inflammatory myopathy: From muscle biopsy to serology p. 123
Ritu Verma, Vimal Kumar Paliwal
Idiopathic inflammatory myopathies (IIMs) are heterogeneous group of muscle disorders characterized by variable degree of muscle weakness and muscle inflammation. Various classification systems have been proposed for myositis. However, there remains a diagnostic uncertainty due to the presence of overlapping clinical and pathological features. Similar treatment outcomes to immunosuppressant drugs further add to diagnostic confusion. Introduction of myositis-specific and myositis-associated autoantibodies has widened the disease spectrum of IIMs. Despite being very crucial for the diagnosis and classification of myositis, these autoantibodies are not always present. Therefore, histopathological features and immunohistochemical markers are considered gold standard for the diagnosis of myositis. A correct diagnosis has important clinical and therapeutic implications. In this review, we have focused on salient clinicopathological features and newly developed serological markers in major subtypes of IIMs.
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Cancer in myositis p. 131
Albert Selva-OCallaghan, Maria Terrones-Peinador, Joana Rita Marques-Soares, Albert Gil-Vila
There is an intriguing relationship between cancer and myositis. The immunosuppressive agents commonly used to treat myositis patients are known to favor the development of cancer, but this factor does not seem to be the main cause of the association. Most myositis patients who develop cancer are considered to have cancer-associated myositis, which suggests that there are some types of etiopathogenic relationship between these two conditions. The malignancy usually appears within 3 years of the myositis diagnosis, and the risk of cancer depends on the myositis phenotype, with classic or amyopathic dermatomyositis (DM) and immune-mediated necrotizing myopathy being the main associated phenotypes. Several considerations regarding the pathogenesis of this association and strategies to detect occult malignancy in these patients are discussed here, with special emphasis on the role of autoantibodies as markers of this condition. Anti- TIF1g (Transcription Intermediary Factor 1 gamma) antibodies have been extensively studied in patients with cancer-associated DM. In addition, we discuss the peculiarities of treating patients with cancer-associated myositis and suggest some good treatment options, and finally, we examine the cancer–myositis relationship with regard to the recently described concept of myositis as an immune-related adverse event derived from the use of checkpoint immune inhibitors to treat cancer.
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Statin-associated muscle disorders p. 137
Alan Xu, Vidya Limaye
Statins are one of the most widely used and reputable medications worldwide, with strong evidence of mitigating cardiovascular complications and with a generally favorable safety profile. Nevertheless, statins have commonly come under scrutiny, owing to their associations with muscle disorders. Statins are known to cause a range of effects on muscles, varying from mild self-limiting symptoms to detrimental muscular necrosis. In particular, there has been emerging evidence of statin-associated necrotizing autoimmune myositis related to the presence of anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) autoantibodies. Patients often demonstrate proximal muscle weakness and hyperCKemia, and treatment guidelines are not robust owing to the rarity of the disease. Nevertheless, literature provides evidence for use of corticosteroids, and there are emerging data supporting the incorporation of immunomodulatory agents such as methotrexate, intravenous immunoglobulin, and rituximab. In performing this review, we searched databases in PubMed and EMBASE written in English and limited to the last two decades. Keywords used included “statin,” “myositis,” “autoimmune myopathy,” “anti-HMGCR,” and “necrotising.” Articles were selected by relevance to the topic, and articles pertaining to antisignal recognition particle myopathy and other forms of myositis were excluded.
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Sporadic inclusion body myositis in the rheumatology clinic p. 145
Fernando Henrique Carlos de Souza, Gustavo Luiz Behrens Pinto, Jean Marcos de Souza, Pablo Arturo Olivo Pallo, Leonardo Santos Hoff, Samuel Katsuyuki Shinjo
Sporadic inclusion body myositis (sIBM) is a progressive and insidious skeletal muscle disorder characterized classically by the quadriceps, wrist, and finger flexor weakness. The main irreversible complications of sIBM are dysphagia and walking difficulties. The disease affects more men than women, and the symptom onset mainly occurs between 50 and 70 years of age. Due to its slow progression, sIBM diagnosis is frequently delayed and therefore misdiagnosed as other muscle diseases. sIBM remains refractory to treatment (e.g., glucocorticoid, and immunosuppressive/immunomodulatory/immunobiological drugs). Although there have been no robust clinical trials, training exercise/physiotherapy should be prescribed regularly in sIBM patients.
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Emerging therapeutics in idiopathic inflammatory myopathy p. 153
Shinji Sato
Idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of systemic autoimmune diseases characterized mainly by inflammation of muscle tissue. Although IIM traditionally encompasses polymyositis, dermatomyositis (DM), and inclusion body myositis, the disease concept has been changing in association with progress in diagnostic techniques. Thus, the new disease entities of amyopathic DM (ADM) or clinically ADM and immune-mediated necrotizing myopathy have been recognized recently. Because of the variety of symptoms or low prevalence or difficulty in correct evaluation of muscle strength and function in IIM patients, no standard treatment strategies have been established yet. Currently, glucocorticoids remain the first line of treatment of IIMs, but in addition to these, several other immunosuppressive agents or intravenous immunoglobulin have been used in a variety of different combinations. However, due to clinical heterogeneity of these conditions as well as the number of therapeutic target organs, IIM therapy remains challenging, and refractory cases are especially difficult to treat. In recent years, new therapeutic approaches using biologics or Janus kinase inhibitors, plasma exchange therapy, and other agents have been evaluated for IIMs. However, validation of the efficacy of these new treatment options remains an issue to be resolved. In this article, the author reviews current treatment strategies and new emerging therapies for IIM patients.
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The evolving spectrum of interstitial lung disease in myositis—Management pearls p. 163
Takahisa Gono
Idiopathic inflammatory myopathies (IIMs) are characterized by muscle inflammation caused by exacerbated autoimmunity reactions. Patients with IIMs also have extramuscular lesions, such as skin rash, arthritis, interstitial lung disease (ILD), and cardiomyopathy. ILD is one of the leading causes of mortality in patients with IIMs. Thus, physicians need to manage patients with IIM-associated ILD (myositis-ILD) appropriately to prevent the development and progression of ILD. Predictive factors for morality should be considered at the time of making decisions on therapeutic strategies for myositis-ILD. There have been numerous prognostic factors associated with mortality or pulmonary dysfunction. According to the latest research, which contains the large database analysis enrolling 499 incident cases of myositis-ILD with the comprehensive measurement of myositis-specific autoantibodies (MSAs), the presence of anti-melanoma differentiation-associated gene 5 antibody, age ≥60 years, C-reactive protein ≥1 mg/dL, and pulse saturation oxygen <95% have been identified as independent risk factors for mortality. We should also consider the severity of ILD, such as lower values of vital capacity and extensive ILD, and disease behavior to. The clinical characteristics of myositis-ILD are highly diverse. Thus, the categorization of homogenous groups by MSAs and prognostic factors is required to offer appropriate therapeutic regimens to individual patients with myositis-ILD. This effort will contribute to improve the daily quality of life as well as the survival rate in patients with myositis-ILD.
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Assistive devices: Regaining mobility in myositis p. 175
Samira Davalbhakta, Akshay Oswal, Sanat Phatak
Assistive devices (ADs) refer to external devices adapted to improve tasks and function. The common types of ADs include those improving mobility such as wheelchairs and walkers, positioning devices such as standing frames, custom-made devices (orthotics) such as fitted shoes and braces, and daily living devices. In inflammatory myositis, ADs are of utility in combating weakness, improving mobility, preventing and treating contractures, preventing falls, and assisting in daily chores. This narrative review looks at the evidence for the use of ADs in myositis and disorders with a similar pattern of muscle weakness (e.g., muscular dystrophy) subsequent to a literature search. A range of devices, from ankle orthoses to robotic exoskeletons, has been used in children with these diseases, and is part of the rehabilitation process. Evidence for their use in inflammatory myositis comes mainly from inclusion body myositis where progression is usual, and distal movement loss additionally affects functionality. In these patients, gait ADs and lower limb orthoses have been shown to be useful. Patient acceptability of these interventions is paramount in choosing the correct device and fit. An interaction of the treating rheumatologist with the physiatrist, the physical therapist, the occupational therapist, and the patient is paramount in ensuring compliance and benefit.
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Is polymyositis a rare or over-diagnosed entity? A descriptive follow-up study of patients initially admitted in a tertiary center with the diagnosis of polymyositis p. 180
Pablo Arturo Olivo Pallo, Matheus Santos Rodrigues Silva, Fernando Henrique Carlos de Souza, Samuel Katsuyuki Shinjo
Objective: This study aimed to describe a significant sample of patients with an initial diagnosis early-stage polymyositis (PM) in who were reclassified to different diagnoses after new evaluations during follow-ups. Subjects and Methods: In a single-center descriptive study conducted from 2000 to 2019, 108 patients with an initial presumptive diagnosis of PM were admitted to our tertiary center and were reevaluated during follow-up. Patients with promptly suspected or definite initial diagnoses of other autoimmune or hereditary myopathies were excluded. Results: The mean age of the 108 patients when admitted initially into our center was 45.3 ± 15.4 years; they were predominantly female (70.4%) and Caucasian (81.5%). During a median follow-up period of 4.0 years and constant diagnostic reinvestigation, only 30 (27.7%) out of the 108 participants maintained the PM diagnosis, whereas the other patients were re-diagnosed with immune-mediated necrotizing myopathy (20.4%), inclusion body myositis (18.5%), muscular dystrophy 13.0% as (13.0%), antisynthetase syndrome (8.3%), metabolic myopathies (5.6%), and other muscle diseases (7.3%). The initial clinical and laboratory parameters were not distinguishable between the PM and reclassified patients. Twenty-two of 30 patients with PM continued follow-up in our service, all with clinical remission or complete clinical response, full recovery of muscle strength, and normalization of the serum levels for muscle enzymes. Conclusions: Patients with PM should be reevaluated constantly, as PM can mimic other muscle diseases. Notably, only one-third of our large patient samples maintained diagnoses of PM until the end of the present study's data collection.
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Serum fatty acid-binding protein 3 levels differentiate active from inactive myositis and correlate with response to therapy p. 187
Latika Gupta, Sanjukta Majumder, Amita Aggarwal, Ramnath Misra, Able Lawrence
Background: Delay in the diagnosis of idiopathic inflammatory myopathies (IIMs) and resultant muscle wasting leads to a setting, wherein conventional biomarkers fail to identify inflammation amid damage. Fatty acid-binding protein 3 (FABP3) has a selective location and function lending unique potential as a specific biomarker in IIM. Methods: Patients with IIM (ACR/EULAR criteria) prospectively evaluated for clinical features and laboratory data were screened to identify cases without ongoing infection, pregnancy, and renal disease. Clinical data and sera of patients and healthy controls were retrieved, and case details supplanted with standard outcome measures. For the inception cohort, 6-month follow-up sera were used for comparison of FABP3 using ELISA. Nonparametric tests were used for analysis and results expressed as median and interquartile range. Results: One hundred and thirty two IIM patients (M:F 1:3.1) of age 38 (24.5–46.0) years and 0.9 (2.3–5.1) year long disease were compared with ten healthy controls. FABP3 levels were higher in active (5.73 vs. 2.91 ng/ml, P = 0.0351) disease, more so in early IIM (n = 16, 21, 3.84 vs. 0.00 ng/ml, P = 0.002). Levels fell with treatment in responders (n = 7, 14.5–7.5 ng/dl, P = 0.03) but not in nonresponders. A serum FABP3 ≥ 4.066 had a high specificity (80.6%) to distinguish active from inactive myositis, albeit lower than conventional biomarkers. Conclusion: Serum FABP3 is elevated in active IIM, especially early disease, and decreases with treatment among responders. FABP3 has a favorable specificity but insufficient sensitivity, limiting role as a stand-alone biomarker. It might be useful in early IIM, without renal or cardiac involvement, pending further validation.
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Combined case record forms for collating obstetric outcomes in rare rheumatic diseases p. 191
Rajat Kharbanda, R Naveen, Durga Prasanna Misra, Vikas Agarwal, Latika Gupta
Background: Evaluating the fertility and obstetric outcomes in women with rare rheumatic diseases is challenging as it needs to take into account various influencing factors. Aims and Objectives: The aim is to draft a structured case record form (CRF) for collating obstetric outcomes in rheumatic diseases Materials and Methods: Clinical CRFs were designed for inflammatory myositis, ANCA associated vasculitis, Takayasu arteritis and systemic sclerosis with the objectives in mind, taking into account disease characteristics, drugs administered, and the changes related to the pregnant state. The forms underwent four rounds of revision by two rheumatologists with trial runs on three patients each. The form was scrutinized for face validity, ambiguity and were designed to ease filling them in a busy outpatient setup. Results: The CRF forms for obstetric outcomes in patients were labelled as version 10.0, 11.0, 12.0, and 13.0 for myositis, AAV, TA, and SSc. Conclusion: Beginning with a well-designed CRF is the first step in collating proper data for research. This paper details the steps involved in the same for collating obstetric outcomes in tfour rare rheumatic illnesses.
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Development of the myocite biobank: Cost-efficient model of public sector investigator-driven biobank for idiopathic inflammatory myositis p. 194
R Naveen, Anamika Kumari Anuja, Mohit Kumar Rai, Vikas Agarwal, Latika Gupta
Background: Biobanking refers to the cryopreservation of the various biologic samples for future research. In the era of omics, biobanking has emerged as a vital process to aid research, more so for rare diseases. Aims and Methods: We describe herein the development of a biobank for idiopathic inflammatory myopathies (IIMs), a rheumatic illness with low prevalence. This study addresses the sample collection, transport, storage, maintenance, retrieval, and disposal of samples with a focus on cost-effectiveness, limitations, ethics, and legal aspects involved. Discussion: Financial constraints are juxtaposed next to a wealth of clinical data in the developing countries with a large population size and consequently high burden of rare diseases. Fine-tuning efforts toward the development of bio-archival facilities can maximize outcomes from research units in these countries. A time and cost-efficient model can be the first step toward such initiatives in the appropriate setting. Unique ethical, executive, and scientific challenges were encountered by the authors while establishing the MyoCite biobank in a resource-poor setting. The various efforts to foreclose these obstacles are discussed. Conclusion: This brief summarizes the unmet need, unique challenges, and potential solutions based on the authors' experiences gathered while setting up the MyoCite biobank for research in IIM. It also outlines the means and directions for national and global collaborations in the times ahead.
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Intravenous immunoglobulin in the management of idiopathic inflammatory myositis: A single centre retrospective review p. 200
Jeet Hemantkumar Patel, Lalit Duggal, Ved Chaturvedi, Neeraj Jain, Gurbir Bhandari, Mayank Gupta
Objective: Intravenous immunoglobulin (IVIG) has been used in the treatment of severe idiopathic inflammatory myositis (IIM) in the past. We conducted a retrospective analysis of IIM cases and compared patients who received IVIG with those who did not. Methods: Electronic records from the year 2015–2019 were searched for myositis cases using the terms “myositis, inflammatory myositis, autoimmune myositis.” Cases with dermatomyositis, polymyositis, necrotizing autoimmune myositis, and connective tissue disease myositis/overlap myositis were included (n = 28) and those with infectious or granulomatous myositis were excluded (n = 7). Relevant data were noted. Participants were classified into cases and controls based on IVIG use for treatment. Results were expressed as median and interquartile range. Nonparametric testes were used for comparisons. Results: Word search revealed 35 cases of myositis. Of them, 28 patients were included in the study. From these patients, ten patients had treatment with IVIG and 18 had not. The median age was 49.5 (39.5, 57) years, and disease duration 5.5 (2.5, 12) months. IVIG-treated patients had a more extended hospital stay and less arthritis (P < 0.05). A common indication of IVIG use was esophageal ± respiratory muscle weakness (n = 5/10). In the IVIG group, there was a higher rate of pulse glucocorticoids use (P = −0.02); however, the use of other drugs was similar. Sepsis, gastrointestinal complications, and pneumonia were higher in IVIG-treated patients (P < 0.05). IVIG-treated patients had a higher mortality rate and lower response compared to controls (P < 0.05). Conclusion: IVIG is often the drug of choice for patients with infections in IIM in the Indian setting. Although the IVIG group suffered high mortality, confounding factors, and small sample size, limit conclusions on the usefulness of IVIG in IIM. However, this study showed that IVIG might not alleviate infections complicating IIM cases. Further studies are required.
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Tacrolimus in refractory juvenile dermatomyositis: Case report and review of literature p. 205
Anand Prahalad Rao, Vinyasa Kolli, Indhuja Rajarathinam, Jyothi Raghuram
Juvenile dermatomyositis (JDM) is the most common type of inflammatory myositis in childhood, characterized by proximal muscle weakness and rash. The standard treatment of JDM involves steroids and methotrexate (MTX). A small proportion of patients do not respond to steroids and MTX. We present a couple of patients with refractory JDM who had failed to respond to steroids and MTX. Introduction of tacrolimus led to complete remission of the disease in a patient and partial control in the other. Literature review was done which revealed ten patients with JDM who were treated with tacrolimus with encouraging results in the form of significant reduction in the cutaneous and muscle disease activity. Tacrolimus is an useful drug in the management of refractory JDM.
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Idiopathic inflammatory myopathies: Contributions from India p. 209
Anand Narayan Malaviya
A careful literature search would reveal significant contributions by Indian clinicians and basic researchers in the field of Idiopathic inflammatory myopathies (IIMs). The main drug used for its treatment, methotrexate (MTX), was synthesized for the first time by an Indian biochemist Yella Pragada Subbarow, working in New York (1948). Its first use for treating IIM patients was also by an Indian physician working in Boston (1968), Anand Narayan Malaviya. Similarly, there are several publications on the different aspects of the disease from India. Although the publications in the 1980s and 1990s were only a few and far between, starting early in this millennium, the pace of publications rapidly picked up. From the early purely clinical-observation-based papers, the area of research that has been covered in more recent papers has become much wider. Epidemiology, different age groups, unusual presentations, mimics of IIM, treatments being used and response to treatments, histoimmunopathological studies, studies of myositis-specific antibodies, basic immunological research in IIM, genetic studies, are now being published frequently. In this 'Introductory' paper, a time-line summary of the Indian contribution in the IIM research from India has been provided.
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Conquering myositis, beyond remission p. 217
Amber OConnor, TG Sundaram
Akin to a stowed sailboat, limiting management of chronic illnesses such as idiopathic inflammatory myopathies (IIM) to diagnosis, investigations, and drug prescriptions, is like leaving the seas unchartered. The importance of holistic care, including psychological and social support, cannot be overemphasized. In the face of adversity, patients seek refuge in friends and kin for emotional support. In such times, mutual support from others with common experiences has great potential in improving management. In this era of borderless e-communication, online patient communities are paving the road for wholesome and holistic care to bring about a positive change in patients' lives. Through this interview with Amber O'Connor, who not only survived, but conquered IIM over 16 long years, we take you through the oft-ignored realms of patient awareness, education, support communities, the power of being understood, and the transformative effect these little things can have in enriching patients' lives.
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An atypical presentation of antisynthetase syndrome p. 220
Mayank Kapoor, Minakshi Dhar, Sukdev Manna
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Sociocultural challenges in patients with myositis and the unmet need for patient support groups: Perspectives from North India p. 222
Rudrarpan Chatterjee
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The muscle rap p. 225
Benzeeta Pinto, Sakir Ahmed
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We are in charge of treating myositis! p. 226
Ilke Coskun Benlidayi
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