Rheumatology research output in the Arab World: despite the challenges

Rheumatology is a field in which diagnostic, pathophysiological, and therapeutic advancements occur daily. These developments are the result of research in basic sciences, translational sciences, and clinical sciences. Physical and financial support, provided by individuals and institutions, is essential for all types of research. The political and economic instability in the Arab world has impacted the advancement of healthcare and the output of research. This review seeks to evaluate the quantity and quality of rheumatology-related research conducted in the Arab world. This review examined the number of rheumatological clinical publications produced by Arab countries between 2017 and 2021 and cited by PubMed/MEDLINE. Publications with authors from multiple nations were disqualified. Publications were then categorized by type, including randomized controlled trials (RCTs), cohort studies, cross-sectional studies, systematic reviews, narrative reviews, and case reports. Publications were also organized according to the regions of the Arab world: North and East Africa, the Middle East, and the Arabian Peninsula. The review also used data from the world bank to evaluate the gross domestic product (GDP) and total population of Arabian nations in order to calculate a ratio of publications to GDP and publications to population. Egypt had the highest number of publications among north and east African countries and Arab countries in general, with 261 publications, including the highest number of RCTs, which were 23. With 81 publications, Saudi Arabia had the highest number of publications on the Arabian peninsula. However, no individual country on the Arabian peninsula published an RCT. Lebanon had the most publications in the Middle East, but the majority were reviews and case reports. Tunisia had the highest ratio of publications to GDP. Notably, the number of publications increased during the coronavirus disease 2019 era in some countries. The Arab world is still able to produce clinical rheumatology publications despite its political instability and lack of resources. The influence of such publications on the daily practice of rheumatology is still debatable.

The psychological impact of Behçet's disease

BACKGROUND

Bechet's disease (BD), a chronic multiorgan involving disease, has a significant impact on quality of life in spite of effective treatment modalities. Disease manifestations such as arthritis, orogenital ulcerations, rashes, angiitis, and neurological involvement affect health-related quality of life (HRQoL) through its impact on depression, anxiety, and fatigue.

OBJECTIVES

We aimed explore the psychological impact of BD, taking into consideration the effect on the HRQoL, as well as the association with depression, anxiety, wellbeing, and fatigue.

METHODS

This is a narrative review of the literature that looks into the association of BD on the HRQoL including all studies that have assessed such as association.

RESULTS/FINDINGS

Depression and anxiety are prevalent among patients with BD, and contribute significantly to fatigue, a common symptom among BD patients. In addition, the psychological wellbeing is affected by the disease, however, more studies are needed to assess this relationship.

CONCLUSION

Depression and anxiety are strongly associated with BD, and contribute significantly to fatigue, a common symptom among BD patients. In addition, the psychological wellbeing is affected by the disease, however, more studies are needed to assess this relationship. Besides, the controlling factors of the psychological impact are still to be deciphered.

Henoch-Schönlein purpura: Another COVID-19 complication

Whether affecting children or adults, SARS-CoV-2 infection (COVID-19) can have multi-organ involvement mediated by an inflammatory cascade. Immunoglobulin A (IgA) is one of the key components of the inflammatory cascade that can lead to endothelial injury and inflammation. IgA vasculitis or Henoch-Schönlein purpura (HSP) has been rarely reported in the context of COVID-19. In this report, we highlight a case of HSP occurring 2 days after diagnosis of COVID-19 in a 16-year-old boy, who presented with palpable purpura of the lower extremities and buttocks, diffuse abdominal pain, hemoptysis, and hematochezia. He was treated with oral prednisolone with rapid clinical improvement.

Comment on: Patient physician communication

[No Abstract Available].

Severe localised granulomatosis with polyangiitis (Wegener's granulomatosis) manifesting with extensive cranial nerve palsies and cranial diabetes insipidus: a case report and literature review

Background

Granulomatosis with polyangiitis (GPA, formerly Wegener’s granulomatosis) is a multisystem vasculitis of small- to medium-sized blood vessels. Cranial involvement can result in cranial nerve palsies and, rarely, pituitary infiltration.

Case presentation

We describe the case of a 32 year-old woman with limited but severe GPA manifesting as progressive cranial nerve palsies and pituitary dysfunction. Our patient initially presented with localised ENT involvement, but despite treatment with methotrexate, she deteriorated. Granulomatous inflammatory tissue around the skull base resulted in cavernous sinus syndrome, facial nerve palsy, palsies of cranial nerves IX-XII (Collet-Sicard syndrome), and the rare complication of cranial diabetes insipidus due to pituitary infiltration. The glossopharyngeal, vagus and accessory nerve palsies resulted in severe dysphagia and she required nasogastric tube feeding. Her neurological deficits substantially improved with treatment including high dose corticosteroid, cyclophosphamide and rituximab.

Conclusions

This case emphasises that serious morbidity can arise from localised cranial Wegener’s granulomatosis in the absence of systemic disease. In such cases intensive induction immunosuppression is required. Analysis of previously reported cases of pituitary involvement in GPA reveals that this rare complication predominantly affects female patients.  

Serum Sclerostin Levels in Patients with Human Immunodeficiency Virus Infection and Their Association with Bone Turnover Markers and Bone Mineral Densitometry

Background

The aim of the study was to compare serum sclerostin levels in human im-munodeficiency virus (HIV)-infected patients and healthy controls, and to evaluate their relationship with bone turnover markers (BTM) and bone mineral density (BMD).

Methods

We prospectively studied 33 HIV treatment-naive patients and 63 healthy individuals; matched for age and sex. Serum sclerostin levels, BTM, BMD were measured. Viral load and cluster of differentiation 4 (CD4) levels were also assessed in HIV-infected patients.

Results

The mean±standard deviation (SD) age of sample was 37.6±10.3 years (range, 19 to 59 years). Of the 96 subjects, 58 (60.4%) were male and 38 (39.6%) were female. Infection with HIV is associated with significant reduction in serum sclerostin levels (HIV-infected: 39.4±28.3 vs. non HIV: 76.6±15.7 pmol/L; P<0.001) and a decrease in BMD at femoral neck and lumbar spine compared to healthy controls. Sclerostin however was not correlated with BMD and was not related to age, generally a strong correlation. There were no significant correlations between sclerostin and BTM (P>0.05).

Conclusions

These findings suggest that untreated HIV and the resulting immune deficiency and/or systemic inflammation could be an important regulator of serum sclerostin in this population.

Musculoskeletal manifestations of diabetes mellitus

The prevalence of Type 1 and Type 2 diabetes are increasing significantly worldwide. Whilst vascular complications of diabetes are well recognized, and account for principle mortality and morbidity from the condition, musculoskeletal manifestations of diabetes are common and whilst not life threatening, are an important cause of morbidity, pain and disability. Joints affected by diabetes include peripheral joints and the axial skeleton. Charcot neuroarthropathy is an important cause of deformity and amputation associated with peripheral neuropathy. A number of fibrosing conditions of the hands and shoulder are recognized, including carpal tunnel syndrome, adhesive capsulitis, tenosynovitis and limited joint mobility. People with diabetes are more prone to gout and osteoporosis. Management of these conditions requires early recognition and close liaison between diabetes and rheumatology specialists.

Calcific periarthritis of the elbow presenting as acute tennis elbow

A 28-year-old woman presented with sudden acute lateral epicondylitis. There was no history of preceding trauma or repetitive use of the arm. Because of the acute onset and signs of acute inflammation, an X-ray was arranged. The X-ray showed a hyperdense calcified elongated globule distal to the lateral epicondyle. A diagnosis of calcific periarthritis (calcium apatite) of the elbow was made. Calcific periarthritis has rarely been reported as a cause of acute elbow pain.

PET/CT imaging in inflammatory myopathies

Inflammatory muscle diseases are a group of muscle disorders characterized by muscle weakness, fatigue, and an association with malignancy and paraneoplastic syndrome. A diagnosis of idiopathic inflammatory myopathy is suggested by abnormal myometry and rising creatine kinase, but tissue diagnosis is also needed. Magnetic resonance imaging (MRI) helps localize the appropriate site of biopsy, demonstrate the extent of muscle involvement, and monitor the response to therapy. However, the sensitivity of magnetic resonance (MR) is limited, and whole-body imaging is still far from routine. [(18) F]Fluoro-desoxy-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) is currently the ultimate metabolic imaging technique for the management of cancer. It has also been shown to detect inflammatory conditions and to monitor their response to treatment. The use of FDG PET in screening for underlying malignancies is widely reported and recommended in patients with paraneoplastic syndrome. Unfortunately, only a few reports have been published to show the value of FDG PET in inflammatory muscle diseases, which as we show herein, deserve further pursuit.

Transient osteoporosis associated with pregnancy: use of bisphosphonate in treating a lactating mother

Transient osteoporosis is a rare condition causing regional pain, immobility and functional compromise. The authors present the case of a pregnant lady with multiple sites of transient osteoporosis, including a stress fracture, successfully treated with intravenous pamidronate and a physical rehabilitation programme. The authors discuss the mechanisms for the syndrome and its overlap with complex regional pain syndrome type I; as well as the implications of bisphosphonate administration to a nursing mother. The authors also highlight the advantages of MRI over standard radiography when investigating unexplained foot pain.

Drug treatment modalities in patients with chronic osteoarthritis of the hip or knee

OBJECTIVE

A survey was conducted to determine drug treatments taken by patients with chronic osteoarthritis (OA) of the hip or knee.

METHODS

Data was collected at outpatient clinics at the Royal London and Newham University Hospitals, Bancroft Road, London between November 2001 and February 2003.

RESULTS

Two hundred patients (mean age of 65.8 years, mean OA duration of 4.4 years) completed the survey; 175 with OA of knee and 25 with OA of hip. The majority of patients (64%) required a combination of drug treatments, either prescribed or self-medicated, to manage their disease. Of the total patients, 76% were taking paracetamol, 40% were taking an NSAID and 39% were taking complementary therapy (such as cod liver oil or glucosamine) either as monotherapy or in combination with other drugs. Of this patients 39% who previously used an NSAID had discontinued, primarily due to side effects, especially those of the gastrointestinal tract.

CONCLUSION

The survey results demonstrate that there is a need to individualize treatment for each patient, which is consistent with published recommendations for the management of OA.

Measurement of S-nitrosothiols in extracellular fluids from healthy human volunteers and rheumatoid arthritis patients, using electron paramagnetic resonance spectrometry

In human tissues, S-nitrosothiols (RSNOs) are generated by the nitric oxide (NO.)-dependent S-nitrosation of thiol-containing species. Here, a novel electron paramagnetic resonance spectrometry assay for RSNOs is described, together with its application to studies of human health and disease. The assay involves degrading RSNOs using N-methyl-d-glucamine dithiocarbamate (MGD) at high pH and spin trapping the NO. released using (MGD)2-Fe2+. Because dietary nitrate might contribute to tissue RSNOs, the assay was used to monitor the effect of Na15NO3 ingestion on plasma and gastric juice RSNOs in healthy human volunteers. Na15NO3 ingestion (2 mmol) increased gastric RS15NO concentrations (p<0.01), but there was no significant effect on plasma RS15NO concentrations. Having established that dietary nitrate was not a confounding factor, we applied the RSNO assay to matched plasma and knee-joint synovial fluid (SF) from rheumatoid arthritis (RA) patients, with healthy subjects as controls. Clinical markers of RA inflammatory disease activity were quantified, as were plasma and SF NO2- and NO3-. Median RSNO concentrations were 0 (interquartile range 68) nM, 109 (282) nM, and 309 (470) nM in normal plasma, RA plasma, and SF, respectively. The median RSNO concentration was significantly elevated in RA SF compared with RA plasma (p<0.05) and in RA plasma compared with normal plasma (p<0.05). SF RSNO concentrations correlated positively with SF neutrophil counts (rs=0.55, p<0.05) and inversely with blood hemoglobin concentrations (rs=-0.52, p<0.05), but not with NO2- or NO3-. Thus the raised levels of RSNOs in RA SF correlate with some established markers of inflammation, suggesting the described RSNO assay may have applications in rapid clinical monitoring of NO metabolism in human inflammatory conditions.

Analgesics and Osteoarthritis: Are Treatment Guidelines Reflected in Clinical Practice?

Osteoarthritis (OA) treatment is complex and multifactorial, with pharmacological regimens requiring sufficient flexibility to be adapted to individual disease progression, flare ups, and response to treatment. Coexisting conditions are common and can lead to problems regarding polypharmacy. Several guidelines have been published for the management of OA pain. While differences exist, most recommend paracetamol as the initial oral drug for OA, based on its efficacy, tolerability, and cost; in patients who respond inadequately to paracetamol, supplementary or replacement analgesics should be recommended. This article considers the reality of analgesic use for OA in clinical practice and the extent to which guidelines are followed both in primary and secondary care. An international survey of rheumatologists (n = 610) found that paracetamol was recommended as first-choice analgesic for OA by 82% of those surveyed. Similarly, in a survey of French GPs, 90% of those surveyed recommended paracetamol first line; NSAIDs were recommended more frequently for stronger pain relief but were also recommended alongside paracetamol as a first-line treatment of mild to moderate pain by 43% of GPs. Finally, a UK patient survey, conducted at a London hospital (n = 200), found that 64% of patients were taking more than 1 drug for treatment of painful OA of the knee or hip; 76% were taking paracetamol and 40% were taking an NSAID. A further 39% had used an NSAID in the past but switched treatment, primarily due to side effects. These findings reinforce the case for the simple analgesic paracetamol to be seen as the cornerstone of pharmacological OA treatment, both as a first-line analgesic and as a foundation to which additional treatment modalities, including NSAIDs, can be added if and when necessary.