The impact of the COVID-19 pandemic on patients with juvenile idiopathic inflammatory myopathies

The impact of the COVID-19 pandemic on patients with juvenile idiopathic inflammatory myopathies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of the COVID-19 pandemic on patients with juvenile idiopathic inflammatory myopathies Dawn M Wahezi, Yi BY This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3070382/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Sep, 2023 Read the published version in Pediatric Rheumatology → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Throughout the COVID-19 pandemic, there have been concerns regarding the risks of infection in patients with autoimmune disease. In this study, we investigated the impact of the pandemic on patients with juvenile idiopathic inflammatory myopathies (JIIM). Methods: Data were collected using a patient/caregiver survey via Research Electronic Data Capture (REDCap) database. Eligibility included JIIM diagnosis and current age less than 21 years old. Surveys were distributed via the CureJM organization, social media, Childhood Arthritis and Rheumatology Research Alliance (CARRA) network and Dr. Peter Dent Pediatric Rheumatology Bulletin Board. Results: Eighty-four respondents accessed the survey, 70 (83%) consented to participate, and 54 out of 70 completed the full survey (77%). Twenty-seven out of 57 patients (47%) tested positive for COVID-19, with 7 (12%) testing positive more than once. Despite broad usage of immunosuppressive medications, 24 out of 27 (89%) reported mild symptoms with none requiring hospitalization. Four patients reported a flare of JIIM symptoms after COVID-19; three of whom held immunomodulatory medications during their infection. Thirty-seven out of 54 respondents (69%) reported vaccination against COVID-19, with 9 out of 37 (24%) reporting minor vaccine side effects and one reporting JIIM flare post vaccination. Twenty-one out of 54 (39%) respondents reported psychosocial concerns related to the COVID-19 pandemic. Conclusions: Patients with JIIM, including those on multiple immunosuppressive medications, had mild symptoms related to COVID-19. Most patients tolerated COVID-19 vaccination well. Few patients had disease flare post-COVID-19 or vaccination. Mental health concerns were demonstrated in JIIM patients during the COVID-19 pandemic. pediatric rheumatology juvenile idiopathic inflammatory myopathies Figures Figure 1 Introduction Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, there have been concerns regarding the risks of infection with severe acute respiratory syndrome coronarvirus 2 (SARS-CoV-2) in patients with autoimmune conditions and particularly in those on immunosuppressive therapy. Numerous questions arose surrounding safe access to medical care, community risk reduction to prevent exposure to SARS-CoV-2, and modification of immunosuppressive therapy to decrease the risk of severe complications from COVID-19. Although data are mixed, reports in the literature of patients with adult-onset rheumatic disease suggest that patients with conditions such as systemic lupus erythematosus (1) as well as those on immunosuppressive therapies, such as rituximab, cyclophosphamide and mycophenolate mofetil, may be at higher risk of poor outcomes (2, 3). To date, there is little evidence to suggest that children with rheumatic disease are at increased risk of more severe outcomes due to COVID-19. In addition to concerns directly related to COVID-19, investigations in patients with idiopathic inflammatory myopathies (IIM) and juvenile idiopathic inflammatory myopathies (JIIM), have also explored the relationship of SARS-CoV-2 as a viral trigger implicated in the underlying pathogenesis of these conditions. Given the overlapping clinical manifestations, including cutaneous features, myositis, interstitial lung disease, and myocarditis, as well as activation of the interferon (IFN) pathway, SARS-CoV-2 has been speculated to be responsible for an increased incidence (4) and disease flare in patients with IIM/JIIM (5, 6) throughout the COVID- 19 pandemic. Additional considerations for these observations include reports of patients expressing apprehension about safe access to the hospital system, medication access difficulties (7) and delays to clinical care, simultaneously contributing to the risk of exacerbating the underlying disease during the COVID-19 pandemic (8). To date, there are few studies examining the overall impact of the COVID-19 pandemic in children and adolescents with JIIM with limited data on health outcomes related to COVID-19, the potential for disease flares, and the association with psychosocial morbidity in this population. Furthermore, there are fewer studies examining the COVID-19 pandemic from the perspective of patients with JIIM and their caregivers. In this study, we investigated the impact of the COVID-19 pandemic on children and adolescents with JIIM, specifically examining outcomes related to SARS-CoV-2 exposure, COVID-19, COVID-19 vaccination, as well as the impact on overall psychosocial well-being. Patients and Methods Population Participants were eligible if they were diagnosed with JIIM, under the age of 21 years old at the time of the survey and had history of SARS-CoV-2 exposure, COVID-19 and/or COVID-19 vaccination. Caregivers were required to complete surveys for participants under 18 years old. After obtaining institutional review board (IRB) approval, participants were recruited via patient distribution lists within the CureJM organization and via social media. Pediatric rheumatology providers were also recruited via the Childhood Arthritis and Rheumatology Research Alliance (CARRA) network and the Dr. Peter Dent Pediatric Rheumatology Bulletin Board to assist with survey distribution. All participants provided written consent to participate in the study. Patient/Caregiver Survey Data were collected using a patient/caregiver survey in English and Spanish via Research Electronic Data Capture (REDCap) database. Survey components included six topic domains: (1) Demographics: age, sex, race, ethnicity, and additional comorbidities that pose increased risk of severe outcomes related to COVID-19; (2) JIIM disease features: subtype, primary JIIM manifestations, myositis specific autoantibodies (MSA), medications prior to COVID-19 and patient global assessment scale (GAS) prior to COVID-19; (3) SARS-CoV-2 exposure: close contacts, medications modifications, and patient GAS after exposure; (4) COVID-19: testing, number of infections, symptoms, hospitalization data, medication modifications, and patient GAS after COVID-19, as well as data on disease flare after COVID-19; (5) COVID-19 vaccination: type of vaccine, side effects, disease flare after vaccine, medication modification, and patient GAS after vaccination; (6) Overall impact of the COVID-19 pandemic: access to medical care, as well as psychological and/or emotional impacts due to the COVID-19 pandemic. In the final question of the survey, participants were provided a free text option to include any “additional comments or concerns regarding COVID-19” to be used in thematic analysis. Statistical analysis Statistical analysis was performed with STATA software, version 15.1. Descriptive statistics were performed, including median and interquartile range (IQR) for non-normally distributed continuous variables, and frequencies and percentages for categorical variables. Non-parametric testing was performed using the Wilcoxon signed-rank test examine for changes in patient GAS. Chi-square and Fischer’s exact were used to assess comparisons using categorical variables. Thematic analysis (9) was used to examine themes across the qualitative data collected in the final question of the survey. Three researchers (DW, ER, TR) independently coded qualitative data to identify, analyze and interpret pattern responses and themes, followed by a discussion to resolve any discrepancies. Results Survey respondents Eighty-four respondents accessed the survey, with 70 (83%) consenting to participate. Among those who consented, 54 completed the full survey (77%). Surveys were primarily completed in English (98%), by parents/caregivers (93%) and with the majority of patients reported as female sex (70%), white (74%) and non-Hispanic (64%) (Table 1). JIIM history The majority of patients (n=70) were reported as having juvenile dermatomyositis (JDM) (95%). Median disease duration of JIIM was 3.97 years [IQR: 2.03, 7.96], with a range from 0.25 to 16.09 years. Primary JIIM manifestations, myositis specific autoantibodies and medications taken within 6 months prior to COVID-19 are listed in Table 1. Median number of baseline medications was 2 [IQR: 2, 3] with a maximum baseline of 5 medications, reported in 4 patients. A total of 81% of respondents reported being on two or more immunosuppressive medications prior to COVID-19. COVID-19 exposure Among respondents, 44 out of 58 (76%) reported a known exposure to SARS-CoV-2 during the COVID-19 pandemic. The most common exposure (n=44) was a household contact (52%), followed by a relative/friend (39%) and a school contact (32%). Among those who had a known SARS-CoV-2 exposure (n=44), 24 (55%) report testing positive for COVID-19 themselves after the exposure. COVID-19 Among respondents, 27 out of 57 (47%) reported testing positive for COVID-19, with 7 out of 27 (26%) testing positive on more than one occasion. The majority (89%) reported typical symptoms of fever, cough, headache and fatigue (Figure 1a). No patients were hospitalized or received medications specifically to treat COVID-19. Four respondents (15%), all of whom were female, white, and non-Hispanic, reported a flare of JIIM symptoms after COVID-19 including rash, weakness, myalgias/arthralgias and abdominal pain; three of these respondents reported holding immunomodulatory medications for 7-14 days in the context of active COVID-19 (Table 2). Among patients who tested positive for COVID-19, there was minimal change in patient global assessment scale (GAS) prior to and post-COVID-19 (median GAS [IQR]: 2 [0,3] and 3 [1,5] respectively; p=0.32) (Figure 1b). COVID-19 vaccination Thirty-seven out of 54 respondents (69%) reported vaccination against COVID-19, with 9 out of 37 (24%) reporting minor vaccine side effects including arm pain, headaches, fever and chills. One respondent (3%) reported JIIM flare post vaccination including rash, weakness and myalgia; this respondent did not report delaying JIIM medications in the context of COVID-19 vaccination. Medication modifications Medication modifications made in response to SARS-CoV-2 exposure (n=44), COVID-19 (n=27) or COVID-19 vaccination (n=37) included medications being held or delayed for 7-14 days in 16%, 26%, 22% respectively. Overall impact of the COVID-19 pandemic Sixteen out of 54 respondents (30%) reported concerns related to either delayed appointments (n=10), difficulty obtaining medication (n=4) or avoidance of hospital care due to risk of exposure (n=4). In addition, 21 out of 54 (39%) respondents reported psychosocial concerns related to the COVID-19 pandemic including anxiety (n=18), depression (n=13), stress (n=12), social withdrawal (n=8), irritability (n=4), anger (n=2) and two respondents endorsed suicidal ideation. Themes expressed in final free text comments of the survey most commonly included stressors related to protective measures (such as masking and excessive cleaning) (n=4), medications (n=2), social isolation (n=3) and school closures (n=2). Themes also included concerns related to JIIM flare (n=3) and COVID-19 vaccination (n=2), as well as overall reassurance that COVID-19 resulted in mild illness in the JIIM patient (n=6). Two patients expressed frustration regarding a lack of empathy from others. Representative excerpt quotes include: “It was a stressful time to be on immunosuppressants”; “The isolation was the worst part”; “although she did eventually contract covid-19….it did not have any negative impacts on her health and the situation ultimately relieved a lot of stress for her and our family to know that she came through it fine”. Discussion To our knowledge, this is the first study to examine the overall impact of the COVID-19 pandemic on children and adolescents with JIIM and one of few studies to examine the pandemic from the perspectives of patients with JIIM and their caregivers. Based on our findings, patients with JIIM, including those on multiple immunosuppressive medications, had mild symptoms related to COVID-19 with none requiring hospitalization. Furthermore, only four patients out of 27 (15%) who tested positive for COVID-19 reported flare of their underlying disease after the infection. Three of the four patients who flared had withheld immunomodulatory medications in the context of active COVID-19, which could have contributed to the disease flare. Despite initial concerns that children with rheumatic disease and/or those receiving immunomodulatory medications would be at increased risk of severe outcomes related to COVID-19, there has been limited data to suggest increased risk of hospitalization or severe illness (10–12). Literature from the COVID-19 Global Rheumatology Alliance (GRA) indicates that adult patients with certain diseases (e.g. systemic lupus erythematosus), additional comorbidities (e.g. lung disease) or those receiving certain immunomodulatory medications (e.g. rituximab, cyclophosphamide, mycophenolate mofetil) may be at higher risk for worse outcomes (1, 2), however these findings are not consistent across studies and have not been replicated in children. Our survey results help to provide additional reassurance to patients with JIIM and their families, demonstrating that no JIIM patients in this cohort reported severe outcomes from COVID-19 and none required hospitalization, including those on numerous immunosuppressive medications. A few reports suggest an increased incidence of JIIM within the era of the COVID-19 pandemic (4, 13). Additional studies suggest increased risk of JIIM flare after COVID-19 infection (5, 6). In our study, 4 respondents (15%) reported flare of underlying JIIM, with one respondent reporting initial onset of JIIM, in the context of active COVID-19. Symptoms of JIIM flare included worsening rash, weakness, muscle/joint pain and one respondent reporting gastrointestinal involvement. Disease flares were more likely to be after first episode of COVID- 19 and more likely in those who were instructed to hold their immunomodulatory medications in the context of an active infection. Despite reassuring data suggesting that children and adolescents with rheumatic disease are not at increased risk of severe outcomes from COVID-19, conventional clinical practice has been for providers to withhold immunosuppressive medications in the context of active infection. Given that symptoms from active COVID-19 can vary widely and there is limited data regarding the impact of immunosuppressive medications on those symptoms, clinical guidance provided by the American College of Rheumatology (ACR) recommends that disease-modifying antirheumatic drugs be held in cases of confirmed symptomatic COVID-19 (14). It is suggested that medications may be restarted 7–14 days after resolution of fever and respiratory symptoms. In our survey, 7 out of 27 (26%) of patients held their immunosuppressive medications in the context of active, symptomatic COVID-19, with three patients developing JIIM flare. Given our limited sample size, it is difficult to determine which factors may have led to JIIM flare, including immune activation from COVID-19 infection, delaying of immunosuppressive medications or other factors not identified in this study. There have been few case reports that describe new onset JIIM or disease flare after COVID-19 vaccination (15). No larger studies have been published to verify that people with autoimmune disease are at higher risk of adverse reactions from COVID-19 vaccination, and the ACR clinical guidance recommends that children with rheumatic disease receive COVID-19 vaccination in accordance with current US Food and Drug Administration (FDA), Center for Disease Control (CDC) and local recommendations (14, 16). In our survey, 69% of respondents report receiving the COVID-19 vaccination, with reports of minor side effects. One respondent (3%) reported JIIM flare after the 2nd dose of the Pfizer-BioNTech COVID-19 vaccine, requiring intensification of immunomodulatory medications to treat disease flare. Accumulating evidence suggests an increased emotional burden experienced by patients with chronic disease throughout the pandemic (7, 17, 18). This burden has been compounded by limited access to medical care, fears related to underlying illness and risks related to COVID-19, as well as stressors related to quarantine and social distancing. In a prior study, Wilkinson et al. surveyed household members of families with JDM and found disruption of medical treatment in 40% of patients. Parents and caregivers expressed themes of stress, fear and anxiety throughout the course of the pandemic (17). Similarly, in our survey, disruption in medical care was reported in 30% of respondents and mental health concerns were reported by almost 40%, with caregivers most commonly discussing themes of stress related to protective measures and social isolation, as well as fears related to JIIM flare. Finally, the respondents for this survey were made up of predominantly white and non-Hispanic patients, with 10% of respondents reporting black race and 31% reporting Hispanic ethnicity. Given that patients in black and Hispanic populations may have more complications related to JDM (19, 20) and were disproportionately impacted by the COVID-19 pandemic with higher risk for poor physical and mental health outcomes (7, 21), our study may be inadvertently biased to those with less severe outcomes. Larger investigation into a more diverse patient population would be beneficial in further evaluating these results. There are several limitations to our study. First, given the rarity of JIIM, we had a relatively small sample size with only 70 respondents consenting to participate and only 54 completing the full survey. Second, due to regulatory concerns, parents/caregivers were required to complete the survey for any children under 18 years of age, resulting in only 7% completion by individual patients. It has been demonstrated that discordance exists between patient and parental responses on patient experience surveys (22), and parental input may have impacted responses to measures, including the patient GAS and psychosocial impact questions. It is uncertain how these responses might vary with patient self-reporting. Conclusions Our findings suggest that children and adolescents with JIIM, including those on numerous immunosuppressive medications, are not at increased risk of severe outcomes from COVID-19. Furthermore, very few patients experienced disease flare after COVID-19 or COVID-19 vaccination. Additional investigations are needed to examine the impact of COVID- 19 on a more diverse population of children and adolescents with JIIM and to further investigate strategies to reduce the mental health burden on these children and their families. Declarations Ethics approval and consent – Institutional Review Board approval was obtained from the Albert Einstein College of Medicine/Montefiore Medical Center IRB. Written consent was obtained prior to survey completion. Consent for publications – N/A Data Availability – The data generated in this study is not publicly available due to individual privacy, but portions of the data may be made available from the corresponding author upon reasonable request. Competing interests – N/A Funding – N/A Authors’ contributions – Study design and initial data collection (DW, DJ, ER, BY, TR); Analysis and interpretation of data (DW, DJ, ER, BY, JD, ST, SK, TR); Drafting and revising article (all authors); Acceptance of final article (all authors) Acknowledgements The authors wish to acknowledge the Cure JM Foundation, Childhood Arthritis and Rheumatology Research Alliance (CARRA) and the ongoing Arthritis Foundation financial support of CARRA. 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Tables Table 1: Demographics and JIIM baseline features (n=70)* N (%) Sex Female 49 (70) Male 20 (29) Prefer not to answer 1 (1) Current age of JIIM patient Under 5 5 (7) 6-10 years 22 (31) 11-14 years 20 (30) 15-17 years 11 (16) 18-21 years 12 (17) Race (n=68) White 50 (74) Black/African American 7 (10) American Indian 1 (1) Asian 2 (3) Other Race 4 (6) Prefer not to answer 4 (6) Ethnicity Hispanic 22 (31) Non-Hispanic 45 (64) Prefer not to answer 3 (5) JIIM Subtype (n=62) JDM 59 (95) JPM 3 (5) JIIM clinical manifestations at diagnosis (n=62) Skin Disease 52 (84) Muscle Disease 54 (87) Gastrointestinal Involvement 7 (11) Lung Involvement 9 (15) Heart Involvement 6 (10) Joint Disease 16 (26) JIIM autoantibodies (n=63) P155/140 (TIF-1) 8 (13) MJ (NXP-2) 5 (8) Jo-1 (anti-synthetase) 2 (3) Mi-2 1 (2) MDA-5 (CADM-140) 4 (6) Other 3 (5) Negative Antibodies 3 (5) Unknown or not done 37 (59) Medications during 6 months prior to COVID-19 exposure/infection (n=62) Steroids 25 (40) Methotrexate 34 (55) Hydroxychloroquine 26 (42) Intravenous immunoglobulin (IVIG) 25 (40) Mycophenolate mofetil 17 (27) Rituximab 11 (18) Anti-TNF agent 1 (2) Calcineurin Inhibitors 2 (3) Other** 6 (10) None of the above 8 (13) Total number of immunosuppressive medications prior to exposure/infection with COVID-19 (n=62) None 9 (15) One 3 (5) Two 24 (39) Three or more 26 (42) *N= 70 participants, except where otherwise indicated. **Other medications include abatacept (n=1), leflunomide (n=1) and tofacitinib (n=2). Table 2: Features of JDM patients who reported flare of underlying disease post COVID-19 (n=4; all were female, white, and non-Hispanic) Age group (years) Disease duration (years) MSA Baseline medication COVID vaccine Patient GAS prior to COVID-19 Patient GAS post COVID-19 COVID-19 positive more than once Meds held for COVID-19 (days) 6-10 7.96 MJ MTX, HCQ, IVIG no 2 8 Yes, Milder 2 nd time Yes (7 days) 11-14 2.05 Unknown Steroids, MTX, HCQ, IVIG, MMF no 3 6 Yes, Milder 2 nd time Yes (14 days) 18-21 9.9 p155/140 HCQ, IVIG, Orencia yes 3 5 No Yes (14 days) 19-21 1.51 MDA-5 None yes 1 9 Yes, diagnosed after first episode No Cite Share Download PDF Status: Published Journal Publication published 12 Sep, 2023 Read the published version in Pediatric Rheumatology → Version 1 posted Editorial decision: Minor revision 23 Jul, 2023 Reviewers agreed at journal 03 Jul, 2023 Reviewers invited by journal 03 Jul, 2023 Editor assigned by journal 20 Jun, 2023 First submitted to journal 15 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3070382","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":215219851,"identity":"8f3e1b45-aad1-4e8a-a2da-5be166476168","order_by":0,"name":"Dawn M Wahezi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYDCCAwxsQFJCDsKzkSBeizGQYGxgSCNeC0NiA0QLETr4biQ/e/Dhj0X62vbe4w8+JFjImbc3MD6u+IVbi+SNNHPDGTwSudvOnEtsnJEgYSxz5gCz4dk+3FoMbieYSfNIALXcyDFs5v0hkThDIoFNsrEHn5b0b9J/DCTSzUBa/iQAtcg/IKQlx0yaIUEiAayFAaRFgoFNsuEHHr/cf1Mm2XNAwnDbmTOGM3uAfpHgSWw2bGzArYXvzPFtEj/+1MmbHe8x+PAjoU5Ogv3wwYcNf3BrwQaA8cPYRpoWECDRllEwCkbBKBjWAACelFSg/JXMWQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-0543-7805","institution":"Children's Hospital at Montefiore","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Dawn","middleName":"M","lastName":"Wahezi","suffix":""},{"id":215219852,"identity":"3307c4d1-6481-4d40-9740-286d094e0644","order_by":1,"name":"Yi BY","email":"","orcid":"","institution":"Children's Hospital Los Angeles","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"BY","suffix":""}],"badges":[],"createdAt":"2023-06-16 04:14:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3070382/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3070382/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12969-023-00873-0","type":"published","date":"2023-09-12T15:01:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":39586418,"identity":"ca755666-b409-4d5b-ae33-199db3197c20","added_by":"auto","created_at":"2023-07-05 15:19:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55179,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a)\u003c/strong\u003e Twenty-four patients out of 27 who tested positive for COVID-19 reported acute COVID-19 symptoms. Total 108 symptoms were reported \u003cstrong\u003e(b)\u003c/strong\u003eGlobal assessment scale (GAS) for JIIM disease activity reported by participants pre- and post-COVID-19 (n=25).\u003c/p\u003e","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-3070382/v1/3e4d2a53fd52aa2e902561ee.png"},{"id":43301095,"identity":"4e6e7c9d-0626-4d15-bab4-d7a5b8d8b1ab","added_by":"auto","created_at":"2023-09-18 15:08:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":367488,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3070382/v1/037763c2-e1f7-454a-ab0e-afc91649d9c6.pdf"}],"financialInterests":"","formattedTitle":"The impact of the COVID-19 pandemic on patients with juvenile idiopathic inflammatory myopathies","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince the onset of the coronavirus disease 2019 (COVID-19) pandemic, there have been\u0026nbsp;concerns regarding the risks of infection with severe acute respiratory syndrome coronarvirus 2\u0026nbsp;(SARS-CoV-2) in patients with autoimmune conditions and particularly in those on\u0026nbsp;immunosuppressive therapy. Numerous questions arose surrounding safe access to medical care,\u0026nbsp;community risk reduction to prevent exposure to SARS-CoV-2, and modification of\u0026nbsp;immunosuppressive\u0026nbsp;therapy\u0026nbsp;to\u0026nbsp;decrease\u0026nbsp;the\u0026nbsp;risk\u0026nbsp;of\u0026nbsp;severe\u0026nbsp;complications\u0026nbsp;from\u0026nbsp;COVID-19.\u003c/p\u003e\n\u003cp\u003eAlthough data are mixed, reports in the literature of patients with adult-onset rheumatic disease\u0026nbsp;suggest that patients with conditions such as systemic lupus erythematosus (1) as well as those\u0026nbsp;on immunosuppressive therapies, such as rituximab, cyclophosphamide and mycophenolate\u0026nbsp;mofetil, may be at higher risk of poor outcomes (2, 3). To date, there is little evidence to suggest\u0026nbsp;that children with rheumatic disease are at increased risk of more severe outcomes due to\u0026nbsp;COVID-19.\u003c/p\u003e\n\u003cp\u003eIn addition to concerns directly related to COVID-19, investigations in patients with idiopathic\u0026nbsp;inflammatory myopathies (IIM) and juvenile idiopathic inflammatory myopathies (JIIM), have\u0026nbsp;also explored the relationship of SARS-CoV-2 as a viral trigger implicated in the underlying\u0026nbsp;pathogenesis of these conditions. Given the overlapping clinical manifestations, including\u0026nbsp;cutaneous\u0026nbsp;features,\u0026nbsp;myositis,\u0026nbsp;interstitial\u0026nbsp;lung\u0026nbsp;disease,\u0026nbsp;and\u0026nbsp;myocarditis,\u0026nbsp;as\u0026nbsp;well\u0026nbsp;as\u0026nbsp;activation\u0026nbsp;of\u0026nbsp;the interferon (IFN) pathway, SARS-CoV-2 has been speculated to be responsible for an\u0026nbsp;increased incidence (4) and disease flare in patients with IIM/JIIM (5, 6) throughout the COVID-\u0026nbsp;19 pandemic. Additional considerations for these observations include reports of patients\u0026nbsp;expressing\u0026nbsp;apprehension\u0026nbsp;about\u0026nbsp;safe\u0026nbsp;access\u0026nbsp;to\u0026nbsp;the\u0026nbsp;hospital\u0026nbsp;system,\u0026nbsp;medication\u0026nbsp;access\u0026nbsp;difficulties\u003c/p\u003e\n\u003cp\u003e(7) and delays to clinical care, simultaneously contributing to the risk of exacerbating the\u0026nbsp;underlying\u0026nbsp;disease during the\u0026nbsp;COVID-19 pandemic (8).\u003c/p\u003e\n\u003cp\u003eTo date, there are few studies examining the overall impact of the COVID-19 pandemic in\u0026nbsp;children and adolescents with JIIM with limited data on health outcomes related to COVID-19,\u0026nbsp;the potential for disease flares, and the association with psychosocial morbidity in this\u0026nbsp;population. Furthermore, there are fewer studies examining the COVID-19 pandemic from the\u0026nbsp;perspective of patients with JIIM and their caregivers.\u0026nbsp;In this study, we investigated the impact\u0026nbsp;of the COVID-19 pandemic on children and adolescents with JIIM, specifically examining\u0026nbsp;outcomes related to SARS-CoV-2 exposure, COVID-19, COVID-19 vaccination, as well as the\u0026nbsp;impact\u0026nbsp;on overall psychosocial well-being.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were eligible if they were diagnosed with JIIM, under the age of 21 years old at the\u0026nbsp;time of the survey and had history of SARS-CoV-2 exposure, COVID-19 and/or COVID-19\u0026nbsp;vaccination. Caregivers were required to complete surveys for participants under 18 years old.\u0026nbsp;After obtaining institutional review board (IRB) approval, participants were recruited via patient\u0026nbsp;distribution lists within the CureJM organization and via social media. Pediatric rheumatology\u0026nbsp;providers were also recruited via the Childhood Arthritis and Rheumatology Research Alliance\u0026nbsp;(CARRA) network and the Dr. Peter Dent Pediatric Rheumatology Bulletin Board to assist with\u0026nbsp;survey\u0026nbsp;distribution.\u0026nbsp;All\u0026nbsp;participants provided\u0026nbsp;written\u0026nbsp;consent\u0026nbsp;to participate\u0026nbsp;in\u0026nbsp;the\u0026nbsp;study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient/Caregiver\u0026nbsp;Survey\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a patient/caregiver survey in English and Spanish via Research\u0026nbsp;Electronic Data Capture (REDCap) database. Survey components included six topic domains: (1)\u0026nbsp;Demographics: age, sex, race, ethnicity, and additional comorbidities that pose increased risk of\u0026nbsp;severe outcomes related to COVID-19; (2) JIIM disease features: subtype, primary JIIM\u0026nbsp;manifestations, myositis specific autoantibodies (MSA), medications prior to COVID-19 and\u0026nbsp;patient global assessment scale (GAS) prior to COVID-19; (3) SARS-CoV-2 exposure: close\u0026nbsp;contacts, medications modifications, and patient GAS after exposure; (4) COVID-19: testing,\u0026nbsp;number\u0026nbsp;of\u0026nbsp;infections,\u0026nbsp;symptoms,\u0026nbsp;hospitalization\u0026nbsp;data,\u0026nbsp;medication\u0026nbsp;modifications,\u0026nbsp;and\u0026nbsp;patient\u0026nbsp;GAS after COVID-19, as well as data on disease flare after COVID-19; (5) COVID-19\u0026nbsp;vaccination: type of vaccine, side effects, disease flare after vaccine, medication modification,\u0026nbsp;and patient GAS after vaccination; (6) Overall impact of the COVID-19 pandemic: access to\u0026nbsp;medical\u0026nbsp;care,\u0026nbsp;as\u0026nbsp;well\u0026nbsp;as\u0026nbsp;psychological\u0026nbsp;and/or\u0026nbsp;emotional\u0026nbsp;impacts\u0026nbsp;due\u0026nbsp;to\u0026nbsp;the\u0026nbsp;COVID-19\u0026nbsp;pandemic. In the final question of the survey, participants were provided a free text option to\u0026nbsp;include any \u0026ldquo;additional comments or concerns regarding COVID-19\u0026rdquo; to be used in thematic\u0026nbsp;analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical\u0026nbsp;analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed with STATA software, version 15.1. Descriptive statistics\u0026nbsp;were performed, including median and interquartile range (IQR) for non-normally distributed\u0026nbsp;continuous variables, and frequencies and percentages for categorical variables. Non-parametric\u0026nbsp;testing was performed using the Wilcoxon signed-rank test examine for changes in patient GAS.\u0026nbsp;Chi-square\u0026nbsp;and\u0026nbsp;Fischer\u0026rsquo;s\u0026nbsp;exact\u0026nbsp;were\u0026nbsp;used\u0026nbsp;to\u0026nbsp;assess\u0026nbsp;comparisons\u0026nbsp;using\u0026nbsp;categorical\u0026nbsp;variables.\u003c/p\u003e\n\u003cp\u003eThematic analysis (9) was used to examine themes across the qualitative data collected in the final question of the survey. Three researchers (DW, ER, TR) independently coded qualitative data to identify, analyze and interpret pattern responses and themes, followed by a discussion to resolve any discrepancies.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eSurvey\u0026nbsp;respondents\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEighty-four respondents accessed the survey, with 70 (83%) consenting to participate. Among\u0026nbsp;those who consented, 54 completed the full survey (77%). Surveys were primarily completed in\u0026nbsp;English (98%), by parents/caregivers (93%) and with the majority of patients reported as female\u0026nbsp;sex\u0026nbsp;(70%), white\u0026nbsp;(74%) and non-Hispanic\u0026nbsp;(64%) (Table\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eJIIM\u0026nbsp;history\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of patients (n=70) were reported as having juvenile dermatomyositis (JDM) (95%).\u0026nbsp;Median\u0026nbsp;disease\u0026nbsp;duration\u0026nbsp;of JIIM\u0026nbsp;was 3.97\u0026nbsp;years [IQR:\u0026nbsp;2.03,\u0026nbsp;7.96], with\u0026nbsp;a\u0026nbsp;range\u0026nbsp;from\u0026nbsp;0.25 to\u003c/p\u003e\n\u003cp\u003e16.09 years. Primary JIIM manifestations, myositis specific autoantibodies and medications\u0026nbsp;taken within 6 months prior to COVID-19 are listed in Table 1. Median number of baseline\u0026nbsp;medications was 2 [IQR: 2, 3] with a maximum baseline of 5 medications, reported in 4 patients.\u0026nbsp;A total of 81% of respondents reported being on two or more immunosuppressive medications\u0026nbsp;prior to\u0026nbsp;COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCOVID-19\u0026nbsp;exposure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong respondents, 44 out of 58 (76%) reported a known exposure to SARS-CoV-2 during the\u0026nbsp;COVID-19 pandemic. The most common exposure (n=44) was a household contact (52%),\u0026nbsp;followed by a relative/friend (39%) and a school contact (32%). Among those who had a known\u0026nbsp;SARS-CoV-2 exposure (n=44), 24 (55%) report testing positive for COVID-19 themselves after\u0026nbsp;the\u0026nbsp;exposure.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCOVID-19\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong\u0026nbsp;respondents,\u0026nbsp;27\u0026nbsp;out\u0026nbsp;of\u0026nbsp;57\u0026nbsp;(47%)\u0026nbsp;reported\u0026nbsp;testing\u0026nbsp;positive\u0026nbsp;for\u0026nbsp;COVID-19,\u0026nbsp;with\u0026nbsp;7\u0026nbsp;out of\u0026nbsp;27 (26%) testing positive on more than one occasion. The majority (89%) reported typical\u0026nbsp;symptoms of fever, cough, headache and fatigue (Figure 1a). No patients were hospitalized or\u0026nbsp;received medications specifically to treat COVID-19. Four respondents (15%), all of whom were\u0026nbsp;female, white, and non-Hispanic, reported a flare of JIIM symptoms after COVID-19 including\u0026nbsp;rash, weakness, myalgias/arthralgias and abdominal pain; three of these respondents reported\u0026nbsp;holding immunomodulatory medications for 7-14 days in the context of active COVID-19 (Table\u0026nbsp;2). Among patients who tested positive for COVID-19, there was minimal change in patient\u0026nbsp;global assessment scale (GAS) prior to and post-COVID-19 (median GAS [IQR]: 2 [0,3] and 3\u0026nbsp;[1,5]\u0026nbsp;respectively; p=0.32) (Figure\u0026nbsp;1b).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCOVID-19\u0026nbsp;vaccination\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThirty-seven out of 54 respondents (69%) reported vaccination against COVID-19, with 9 out of\u0026nbsp;37\u0026nbsp;(24%)\u0026nbsp;reporting\u0026nbsp;minor\u0026nbsp;vaccine\u0026nbsp;side\u0026nbsp;effects\u0026nbsp;including\u0026nbsp;arm\u0026nbsp;pain,\u0026nbsp;headaches,\u0026nbsp;fever\u0026nbsp;and\u0026nbsp;chills.\u003c/p\u003e\n\u003cp\u003eOne\u0026nbsp;respondent\u0026nbsp;(3%)\u0026nbsp;reported\u0026nbsp;JIIM\u0026nbsp;flare\u0026nbsp;post\u0026nbsp;vaccination\u0026nbsp;including\u0026nbsp;rash,\u0026nbsp;weakness\u0026nbsp;and\u0026nbsp;myalgia;\u003c/p\u003e\n\u003cp\u003ethis respondent did not report delaying JIIM medications in the context of COVID-19\u0026nbsp;vaccination.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedication\u0026nbsp;modifications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMedication modifications made in response to SARS-CoV-2 exposure (n=44), COVID-19\u0026nbsp;(n=27) or COVID-19 vaccination (n=37) included medications being held or delayed for 7-14\u0026nbsp;days\u0026nbsp;in 16%, 26%, 22% respectively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOverall\u0026nbsp;impact\u0026nbsp;of\u0026nbsp;the\u0026nbsp;COVID-19\u0026nbsp;pandemic\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSixteen out of 54 respondents (30%) reported concerns related to either delayed appointments\u0026nbsp;(n=10), difficulty obtaining medication (n=4) or avoidance of hospital care due to risk of\u0026nbsp;exposure (n=4). In addition, 21 out of 54 (39%) respondents reported psychosocial concerns\u0026nbsp;related to the COVID-19 pandemic including anxiety (n=18), depression (n=13), stress (n=12),\u0026nbsp;social withdrawal (n=8), irritability (n=4), anger (n=2) and two respondents endorsed suicidal\u0026nbsp;ideation.\u003c/p\u003e\n\u003cp\u003eThemes expressed in final free text comments of the survey most commonly included stressors\u0026nbsp;related to protective measures (such as masking and excessive cleaning) (n=4), medications\u0026nbsp;(n=2),\u0026nbsp;social isolation (n=3) and school closures (n=2). Themes also included concerns related\u0026nbsp;to JIIM flare (n=3) and COVID-19 vaccination (n=2), as well as overall reassurance that\u0026nbsp;COVID-19 resulted in mild illness in the JIIM patient (n=6). Two patients expressed frustration\u0026nbsp;regarding a lack of empathy from others.\u0026nbsp;Representative excerpt quotes include: \u0026ldquo;It was a\u0026nbsp;stressful\u0026nbsp;time\u0026nbsp;to\u0026nbsp;be\u0026nbsp;on\u0026nbsp;immunosuppressants\u0026rdquo;;\u0026nbsp;\u0026ldquo;The\u0026nbsp;isolation\u0026nbsp;was\u0026nbsp;the\u0026nbsp;worst\u0026nbsp;part\u0026rdquo;;\u0026nbsp;\u0026ldquo;although\u0026nbsp;she\u003c/p\u003e\n\u003cp\u003edid eventually contract covid-19\u0026hellip;.it did not have any negative impacts on her health and the\u0026nbsp;situation ultimately relieved a lot of stress for her and our family to know that she came through\u0026nbsp;it\u0026nbsp;fine\u0026rdquo;.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study to examine the overall impact of the COVID-19 pandemic on children and adolescents with JIIM and one of few studies to examine the pandemic from the perspectives of patients with JIIM and their caregivers. Based on our findings, patients with JIIM, including those on multiple immunosuppressive medications, had mild symptoms related to COVID-19 with none requiring hospitalization. Furthermore, only four patients out of 27 (15%) who tested positive for COVID-19 reported flare of their underlying disease after the infection. Three of the four patients who flared had withheld immunomodulatory medications in the context of active COVID-19, which could have contributed to the disease flare.\u003c/p\u003e \u003cp\u003eDespite initial concerns that children with rheumatic disease and/or those receiving immunomodulatory medications would be at increased risk of severe outcomes related to COVID-19, there has been limited data to suggest increased risk of hospitalization or severe illness (10\u0026ndash;12). Literature from the COVID-19 Global Rheumatology Alliance (GRA) indicates that adult patients with certain diseases (e.g. systemic lupus erythematosus), additional comorbidities (e.g. lung disease) or those receiving certain immunomodulatory medications (e.g. rituximab, cyclophosphamide, mycophenolate mofetil) may be at higher risk for worse outcomes (1, 2), however these findings are not consistent across studies and have not been replicated in children. Our survey results help to provide additional reassurance to patients with JIIM and their\u003c/p\u003e \u003cp\u003efamilies, demonstrating that no JIIM patients in this cohort reported severe outcomes from COVID-19 and none required hospitalization, including those on numerous immunosuppressive medications.\u003c/p\u003e \u003cp\u003eA few reports suggest an increased incidence of JIIM within the era of the COVID-19 pandemic (4, 13). Additional studies suggest increased risk of JIIM flare after COVID-19 infection (5, 6). In our study, 4 respondents (15%) reported flare of underlying JIIM, with one respondent reporting initial onset of JIIM, in the context of active COVID-19. Symptoms of JIIM flare included worsening rash, weakness, muscle/joint pain and one respondent reporting gastrointestinal involvement. Disease flares were more likely to be after first episode of COVID- 19 and more likely in those who were instructed to hold their immunomodulatory medications in the context of an active infection. Despite reassuring data suggesting that children and adolescents with rheumatic disease are not at increased risk of severe outcomes from COVID-19, conventional clinical practice has been for providers to withhold immunosuppressive medications in the context of active infection. Given that symptoms from active COVID-19 can vary widely and there is limited data regarding the impact of immunosuppressive medications on those symptoms, clinical guidance provided by the American College of Rheumatology (ACR) recommends that disease-modifying antirheumatic drugs be held in cases of confirmed symptomatic COVID-19 (14). It is suggested that medications may be restarted 7\u0026ndash;14 days after resolution of fever and respiratory symptoms. In our survey, 7 out of 27 (26%) of patients held their immunosuppressive medications in the context of active, symptomatic COVID-19, with three patients developing JIIM flare. Given our limited sample size, it is difficult to determine which factors may have led to JIIM flare, including immune activation from COVID-19\u003c/p\u003e \u003cp\u003einfection, delaying of immunosuppressive medications or other factors not identified in this study.\u003c/p\u003e \u003cp\u003eThere have been few case reports that describe new onset JIIM or disease flare after COVID-19 vaccination (15). No larger studies have been published to verify that people with autoimmune disease are at higher risk of adverse reactions from COVID-19 vaccination, and the ACR clinical guidance recommends that children with rheumatic disease receive COVID-19 vaccination in accordance with current US Food and Drug Administration (FDA), Center for Disease Control (CDC) and local recommendations (14, 16). In our survey, 69% of respondents report receiving the COVID-19 vaccination, with reports of minor side effects. One respondent (3%) reported JIIM flare after the 2nd dose of the Pfizer-BioNTech COVID-19 vaccine, requiring intensification of immunomodulatory medications to treat disease flare.\u003c/p\u003e \u003cp\u003eAccumulating evidence suggests an increased emotional burden experienced by patients with chronic disease throughout the pandemic (7, 17, 18). This burden has been compounded by limited access to medical care, fears related to underlying illness and risks related to COVID-19, as well as stressors related to quarantine and social distancing. In a prior study, Wilkinson et al. surveyed household members of families with JDM and found disruption of medical treatment in 40% of patients. Parents and caregivers expressed themes of stress, fear and anxiety throughout the course of the pandemic (17). Similarly, in our survey, disruption in medical care was reported in 30% of respondents and mental health concerns were reported by almost 40%, with caregivers most commonly discussing themes of stress related to protective measures and social isolation, as well as fears related to JIIM flare.\u003c/p\u003e \u003cp\u003eFinally, the respondents for this survey were made up of predominantly white and non-Hispanic patients, with 10% of respondents reporting black race and 31% reporting Hispanic ethnicity.\u003c/p\u003e \u003cp\u003eGiven that patients in black and Hispanic populations may have more complications related to JDM (19, 20) and were disproportionately impacted by the COVID-19 pandemic with higher risk for poor physical and mental health outcomes (7, 21), our study may be inadvertently biased to those with less severe outcomes. Larger investigation into a more diverse patient population would be beneficial in further evaluating these results.\u003c/p\u003e \u003cp\u003eThere are several limitations to our study. First, given the rarity of JIIM, we had a relatively small sample size with only 70 respondents consenting to participate and only 54 completing the full survey. Second, due to regulatory concerns, parents/caregivers were required to complete the survey for any children under 18 years of age, resulting in only 7% completion by individual patients. It has been demonstrated that discordance exists between patient and parental responses on patient experience surveys (22), and parental input may have impacted responses to measures, including the patient GAS and psychosocial impact questions. It is uncertain how these responses might vary with patient self-reporting.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings suggest that children and adolescents with JIIM, including those on numerous immunosuppressive medications, are not at increased risk of severe outcomes from COVID-19. Furthermore, very few patients experienced disease flare after COVID-19 or COVID-19 vaccination. Additional investigations are needed to examine the impact of COVID-\u003c/p\u003e \u003cp\u003e19 on a more diverse population of children and adolescents with JIIM and to further investigate strategies to reduce the mental health burden on these children and their families.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent \u0026ndash; Institutional Review Board approval was obtained from the Albert Einstein College of Medicine/Montefiore Medical Center IRB. Written consent was obtained prior to survey completion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publications \u0026ndash; N/A\u003c/p\u003e\n\u003cp\u003eData Availability \u0026ndash;\u0026nbsp;The data generated in this study is not publicly available due to individual privacy, but portions of the data may be made available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests \u0026ndash; N/A\u003c/p\u003e\n\u003cp\u003eFunding \u0026ndash; N/A\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions \u0026ndash;\u0026nbsp;Study design and initial data collection (DW, DJ, ER, BY, TR); Analysis and interpretation of data (DW, DJ, ER, BY, JD, ST, SK, TR); Drafting and revising article (all authors); Acceptance of final article (all authors)\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge the Cure JM Foundation, Childhood Arthritis and Rheumatology Research Alliance (CARRA) and the ongoing Arthritis Foundation financial support of CARRA.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUgarte-Gil MF, Alarcon GS, Seet AM, Izadi Z, Montgomery AD, Duarte-Garcia A, et al. Association Between Race/Ethnicity and COVID-19 Outcomes in Systemic Lupus Erythematosus Patients From the United States: Data From the COVID-19 Global Rheumatology Alliance. Arthritis Care Res (Hoboken). 2023;75(1):53\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrangfeld A, Schafer M, Gianfrancesco MA, Lawson-Tovey S, Liew JW, Ljung L, et al. Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2021;80(7):930\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGianfrancesco M, Hyrich KL, Al-Adely S, Carmona L, Danila MI, Gossec L, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2020;79(7):859\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGokhale Y, Patankar A, Holla U, Shilke M, Kalekar L, Karnik ND, et al. Dermatomyositis during COVID-19 Pandemic (A Case Series): Is there a Cause Effect Relationship? J Assoc Physicians India. 2020;68(11):20\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodero MP, Pelleau S, Welfringer-Morin A, group, Fs, Duffy D, Melki I et al. Onset and Relapse of Juvenile Dermatomyositis Following Asymptomatic SARS-CoV-2 Infection. J Clin Immunol. 2022;42(1):25 \u0026ndash; 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiquidano-Perez E, Garcia-Romero MT, Yamazaki-Nakashimada M, Maza-Morales M, Rivas-Calderon MK, Bayardo-Gutierrez B, et al. Juvenile Dermatomyositis Triggered by SARS- CoV-2. Pediatr Neurol. 2021;121:26\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaldonado D, Tu E, Mahmood SN, Wahezi DM, Darapaneni R, Sima N, et al. Association of Medication Access Difficulty and COVID-19-Related Distress With Disease Flares in Rheumatology Patients During the COVID-19 Pandemic. Arthritis Care Res (Hoboken). 2021;73(8):1162\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatu ED, Lamot L, Sag E, Ozen S, Uziel Y. How the COVID-19 pandemic has influenced pediatric rheumatology practice: Results of a global, cross-sectional, online survey. Semin Arthritis Rheum. 2020;50(6):1262\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartins CA. Transition to parenthood: consequences on health and well-being. A qualitative study. Enferm Clin (Engl Ed). 2019;29(4):225\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFilocamo G, Minoia F, Carbogno S, Costi S, Romano M, Cimaz R, et al. Absence of Severe Complications From SARS-CoV-2 Infection in Children With Rheumatic Diseases Treated With Biologic Drugs. J Rheumatol. 2021;48(8):1343\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarlais M, Wlodkowski T, Vivarelli M, Pape L, Tonshoff B, Schaefer F, et al. The severity of COVID-19 in children on immunosuppressive medication. Lancet Child Adolesc Health. 2020;4(7):e17\u0026ndash;e8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSengler C, Eulert S, Minden K, Niewerth M, Horneff G, Kuemmerle-Deschner J et al. Clinical manifestations and outcome of SARS-CoV-2 infections in children and adolescents with rheumatic musculoskeletal diseases: data from the National Paediatric Rheumatology Database in Germany. RMD Open. 2021;7(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMovahedi N, Ziaee V. COVID-19 and myositis; true dermatomyositis or prolonged post viral myositis? Pediatr Rheumatol Online J. 2021;19(1):86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWahezi DM, Lo MS, Rubinstein TB, Ringold S, Ardoin SP, Downes KJ, et al. American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 2. Arthritis Rheumatol. 2021;73(8):e46\u0026ndash;e59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang S, Noumi B, Malik F, Wang S. A Rare Case of MDA-5-Positive Amyopathic Dermatomyositis with Rapidly Progressive Interstitial Lung Disease Following COVID-19 mRNA Vaccination - a Case Report. SN Compr Clin Med. 2023;5(1):18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGil-Vila A, Ravichandran N, Selva-O'Callaghan A, Sen P, Nune A, Gaur PS, et al. COVID-19 Vaccination in Autoimmune Diseases (COVAD) study: Vaccine safety in idiopathic inflammatory myopathies. Muscle Nerve. 2022;66(4):426\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilkinson MGL, Wu W, O'Brien K, Deakin CT, Wedderburn LR, Livermore P. A survey to understand the feelings towards and impact of COVID-19 on the households of juvenile dermato myositis patients from a parent or carer perspective. Rheumatol Adv Pract. 2021;5(3):rkab058.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIhara BP, Lindoso LM, Setoue DND, Tanigava NY, Helito AC, Simon JR, et al. COVID-19 quarantine in adolescents with autoimmune rheumatic diseases: mental health issues and life conditions. Clin Rheumatol. 2022;41(10):3189\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillippi K, Hoeltzel M, Byun Robinson A, Kim S, Childhood A. Rheumatology Research Alliance Legacy Registry I. Race, Income, and Disease Outcomes in Juvenile Dermatomyositis. J Pediatr. 2017;184:38\u0026ndash;44. e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerron MM, Vasquez-Canizares N, Tarshish G, Wahezi DM. Myositis autoantibodies in a racially diverse population of children with idiopathic inflammatory myopathies. Pediatr Rheumatol Online J. 2021;19(1):92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVicetti Miguel CP, Dasgupta-Tsinikas S, Lamb GS, Olarte L, Santos RP. Race, Ethnicity, and Health Disparities in US Children With COVID-19: A Review of the Evidence and Recommendations for the Future. J Pediatr Infect Dis Soc. 2022;11(Supplement4):132\u0026ndash;S40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHargreaves DS, Sizmur S, Pitchforth J, Tallett A, Toomey SL, Hopwood B, et al. Children and young people's versus parents' responses in an English national inpatient survey. Arch Dis Child. 2018;103(5):486\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"618\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: Demographics and JIIM baseline features (n=70)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e49 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e20 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Prefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent age of JIIM patient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Under 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e5 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;6-10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e22 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;11-14 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e20 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;15-17 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e11 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;18-21 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e12 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace (n=68)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e50 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Black/African American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e7 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;American Indian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Other Race\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Prefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Hispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e22 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Non-Hispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e45 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Prefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eJIIM Subtype (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;JDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e59 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;JPM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eJIIM clinical manifestations at diagnosis (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Skin Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e52 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Muscle Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e54 (87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Gastrointestinal Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e7 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Lung Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e9 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Heart Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e6 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Joint Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e16 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eJIIM autoantibodies (n=63)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;P155/140 (TIF-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e8 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;MJ (NXP-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e5 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Jo-1 (anti-synthetase)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Mi-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;MDA-5 (CADM-140)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Negative Antibodies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Unknown or not done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e37 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedications during 6 months prior to COVID-19 exposure/infection (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Steroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e25 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Methotrexate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e34 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Hydroxychloroquine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e26 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Intravenous immunoglobulin (IVIG)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e25 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Mycophenolate mofetil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e17 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Rituximab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e11 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Anti-TNF agent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Calcineurin Inhibitors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Other**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e6 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;None of the above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e8 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number of immunosuppressive medications prior to exposure/infection with COVID-19 (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e9 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;One\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Two\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e24 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.94822006472492%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Three or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.051779935275082%\" valign=\"top\"\u003e\n \u003cp\u003e26 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e*N= 70 participants, except where otherwise indicated. **Other medications include abatacept (n=1), leflunomide (n=1) and tofacitinib (n=2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Features of JDM patients who reported flare of underlying disease post COVID-19 (n=4; all were female, white, and non-Hispanic)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.649122807017545%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease duration\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMSA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline medication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOVID vaccine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient GAS prior to COVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient GAS post COVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOVID-19 positive \u0026nbsp;more than once\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeds held for COVID-19 (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.649122807017545%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6-10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e7.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eMJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\" valign=\"top\"\u003e\n \u003cp\u003eMTX, HCQ, IVIG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eYes, Milder 2\u003csup\u003end\u003c/sup\u003e time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003eYes (7 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.649122807017545%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e11-14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e2.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\" valign=\"top\"\u003e\n \u003cp\u003eSteroids, MTX, HCQ, IVIG, MMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eYes, Milder 2\u003csup\u003end\u003c/sup\u003e time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003eYes (14 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.649122807017545%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e18-21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003ep155/140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\" valign=\"top\"\u003e\n \u003cp\u003eHCQ, IVIG, Orencia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003eYes (14 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.649122807017545%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e19-21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eMDA-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.157894736842104%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\"\u003e\n \u003cp\u003eYes, diagnosed after first episode\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pediatric rheumatology, juvenile idiopathic inflammatory myopathies","lastPublishedDoi":"10.21203/rs.3.rs-3070382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3070382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eThroughout the COVID-19 pandemic, there have been concerns regarding the risks of infection in patients with autoimmune disease. In this study, we investigated the impact of the pandemic on patients with juvenile idiopathic inflammatory myopathies (JIIM).\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eData were collected using a patient/caregiver survey via Research Electronic Data Capture (REDCap) database. Eligibility included JIIM diagnosis and current age less than 21 years old. Surveys were distributed via the CureJM organization, social media, Childhood Arthritis and Rheumatology Research Alliance (CARRA) network and Dr. Peter Dent Pediatric Rheumatology Bulletin Board.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eEighty-four respondents accessed the survey, 70 (83%) consented to participate, and 54 out of 70 completed the full survey (77%). Twenty-seven out of 57 patients (47%) tested positive for COVID-19, with 7 (12%) testing positive more than once. Despite broad usage of immunosuppressive medications, 24 out of 27 (89%) reported mild symptoms with none requiring hospitalization. Four patients reported a flare of JIIM symptoms after COVID-19; three of whom held immunomodulatory medications during their infection. Thirty-seven out of 54 respondents (69%) reported vaccination against COVID-19, with 9 out of 37 (24%) reporting minor vaccine side effects and one reporting JIIM flare post vaccination. Twenty-one out of 54 (39%) respondents reported psychosocial concerns related to the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003ePatients with JIIM, including those on multiple immunosuppressive medications, had mild symptoms related to COVID-19. Most patients tolerated COVID-19 vaccination well. Few patients had disease flare post-COVID-19 or vaccination. Mental health concerns were demonstrated in JIIM patients during the COVID-19 pandemic.\u003c/p\u003e","manuscriptTitle":"The impact of the COVID-19 pandemic on patients with juvenile idiopathic inflammatory myopathies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-05 15:19:36","doi":"10.21203/rs.3.rs-3070382/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2023-07-24T02:00:05+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2023-07-03T15:44:54+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-07-03T09:04:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-06-20T23:40:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Rheumatology","date":"2023-06-16T00:14:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e6c3047-a4c1-4082-ae84-ef653f4d11fd","owner":[],"postedDate":"July 5th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-09-18T15:04:36+00:00","versionOfRecord":{"articleIdentity":"rs-3070382","link":"https://doi.org/10.1186/s12969-023-00873-0","journal":{"identity":"pediatric-rheumatology","isVorOnly":false,"title":"Pediatric Rheumatology"},"publishedOn":"2023-09-12 15:01:01","publishedOnDateReadable":"September 12th, 2023"},"versionCreatedAt":"2023-07-05 15:19:36","video":"","vorDoi":"10.1186/s12969-023-00873-0","vorDoiUrl":"https://doi.org/10.1186/s12969-023-00873-0","workflowStages":[]},"version":"v1","identity":"rs-3070382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3070382","identity":"rs-3070382","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}