Coalition for Health and Gender Equity (CHANGE)-a protocol for a global cross-sectional survey of health and gender equity in rheumatology

Objectives

The primary aim of the CHANGE survey is to determine the current state of gender equity within rheumatology, and secondarily, to review the physician perspective on bullying, harassment and equipoise of opportunities within rheumatology.

Methods

The CHANGE e-survey is a cross-sectional self-reported questionnaire adapted from EULAR's gender equity in academic rheumatology task force. The survey was launched in January 2023; it is available in six languages and distributed widely via rheumatology organizations and social media. Eligible participants include rheumatologist physicians and rheumatology health-care professionals. Survey responses will undergo descriptive analysis and inter-group comparison aiming to explore gender-based discrimination using logistic regression, with subgroup analyses for country/continent variations.

Conclusion

This e-survey represents a comprehensive global initiative led by an international consortium, aimed at exploring and investigating the gender-related disparities and obstacles encountered by rheumatologists and rheumatology health-care professionals across diverse communities and health-care environments. By pursuing this initiative, we aim to take the broader rheumatology community a step closer to understanding the underlying origins of inequities and their determinants. Such insights are pivotal in identifying viable interventions and strategies to foster gender equity within the field. Ultimately, our collective objective is to ensure equitable access to opportunities for every individual, irrespective of gender, thereby promoting inclusivity and fairness across the entire spectrum of professional practice and career development.

An international survey of current management practices for polymyalgia rheumatica by general practitioners and rheumatologists

OBJECTIVES

To explore current management practices for polymyalgia rheumatica (PMR) by general practitioners (GPs) and rheumatologists including implications for clinical trial recruitment.

METHODS

An English language questionnaire was constructed by a working group of rheumatologists and GPs from 6 countries. The questionnaire focused on: 1: Respondent characteristics, 2: Referral practices, 3: Treatment with glucocorticoids, 4: Diagnostics, 5: Comorbidities, and 6: Barriers to research. The questionnaire was distributed to rheumatologists and GPs worldwide via members of the International PMR/giant cell arteritis Study Group.

RESULTS

In total, 394 GPs and 937 rheumatologists responded to the survey. GPs referred a median of 25% of their suspected PMR patients for diagnosis and 50% of these were returned to their GP for management. In general, 39% of rheumatologists evaluated patients with suspected PMR >2 weeks after referral, and a median of 50% of patients had started prednisolone before rheumatologist evaluation. Direct comparison of initial treatment showed that the percentage prescribing >25 mg prednisolone daily for patients was 30% for GPs and 12% for rheumatologists. Diagnostic imaging was rarely used. More than half (56%) of rheumatologists experienced difficulties recruiting people with PMR to clinical trials.

CONCLUSION

This large international survey indicates that a large proportion of people with PMR are not referred for diagnosis, and that the proportion of treatment naïve patients declined with increasing time from referral to assessment. Strategies are needed to change referral and management of people with PMR, to improve clinical practice and facilitate recruitment to clinical trials.

Gender equity in rheumatology leadership in the Asia-Pacific

Objectives

This study aimed to explore gender equity in rheumatology leadership in the Asia-Pacific region as represented by the member national organizations (MNOs) of the Asia-Pacific League of Associations for Rheumatology (APLAR).

Methods

We conducted a retrospective cross-sectional review of gender representation among the presidents of MNOs of APLAR in April 2022. We used the official website of each organization to acquire names and terms in the office of current and past presidents of each organization. The binary gender of each president was estimated using the name-to-gender inference platform Gender API (https://gender-api.com/). Proportions of male and female presidents were estimated for each organization. Data were compared for presidencies commencing before and in/after the year 2000.

Results

We found a significant gap in gender parity, with most presidents in the region being men (210 of 252, 83%). More than one-third (7 of 19, 36.8%) of the MNOs had all male presidents, although the proportion of women improved from 7 to 25% in/after 2000 (P = 0.0002). A statistically significant increase in female representation was observed in Australia (P = 0.0268, from 7 to 39%) and New Zealand (P = 0.0011, where the proportion of female presidents increased from 0 to 45%), but not in other countries.

Conclusion

A significant gap in gender parity exists in rheumatology leadership in the MNOs of APLAR. Trends suggest improvement over the last two decades, although statistically significant improvement is limited to a small number of countries.

AB0584 MANAGEMENT OF REFERRALS, TREATMENT STRATEGY, AND RESEARCH CHALLENGES IN POLYMYALGIA RHEUMATICA AMONGST RHEUMATOLOGISTS WORLDWIDE: A QUESTIONNAIRE BASED STUDY

Background

Polymyalgia rheumatica (PMR) is diagnosed and treated by both general practitioners (GP) and rheumatologists. How rheumatologists around the world manage the referral process of patients with PMR from GP’s has not been described. EULAR/ACR guidelines recommend initial prednisolone doses between 12.5 and 25 mg, but it is unknown if guidelines are followed in daily clinical practice1. In addition, the understanding of challenges for recruitment to clinical trials in PMR is currently limited.

Objectives

This study aims to describe the management of referrals, treatment strategy, and recruitment to clinical trials in PMR among rheumatologists worldwide.

Methods

An English language questionnaire was drafted by a working group of rheumatologists and GP’s from 6 different countries. Questions concerned: 1: respondent, 2: referrals, 3: prednisolone, and 4: barriers to research. Questionnaires were distributed to rheumatologists via members of the International PMR/GCA study group. Answers were collected via an online survey tool (Redcap), from 2nd of November 2021 to 27th of January 2022. Countries were grouped by income and geographical region based on the World bank classifications. Data were weighted by number of inhabitants in a country, based on the United Nations age specific population count, divided by number of respondents in a country. Countries with more than 20 respondents were included.

Results

Results from 27 countries were analysed including 1000 responders in total (Figure 1). There was large variation in time from referral to first assessment, initial dose of prednisolone was high, duration of treatment was relatively short, and a large proportion of patients with newly diagnosed PMR received prednisolone prior to rheumatological evaluation (Table 1). Concerning the 15% of respondents who performed research in PMR, 52% had participated in clinical trials and 56% of the responders experienced difficulties with recruitment.

Table 1.

Characteristics of reponders, referrals, and treatment.

Geographical regionIncomeThe worldEurope and Central AsiaNorth AmericaLatin AmericaEast Asia and PacificSouth AsiaMiddle East and AfricaHigh- income countriesLow- and middle- income countriesRespondersResponders (n), Completed questionnaire (total)875 (1000)294 (304)78 (81)136 (152)53 (53)53 (72)261 (338)446 (458)429 (542)Experience as rheumatologist (years)11 (6-20)12 (6-20)7 (4-20)11 (6-23)21 (10-30)7 (4-10)9 (5-18)11 (5-22)8 (5-12)ReferralsGP’s can discuss patients prior to referral, %647979575860677461Referred patients seen (%)100 (90-100)100 (90-100)100 (100-100)100 (100-100)100 (95-100)100 (100-100)100 (60-100)100 (100-100)100 (90-100)Evaluation > 2 weeks after referral, %26498060216185815PrednisoloneStarted prior to rheumatological evaluation (%)50 (20-50)60 (30-80)70 (50-80)50 (10-50)30 (20-50)50 (20-80)20 (0-50)50 (30-80)50 (10-70)Initial dose (mg)20 (15-40)20 (15-20)20 (15-20)20 (20-40)15 (15-15)20 (15-40)20 (15-40)15 (15-20)20 (15-40)Initial dose > 25 mg, %32964104143642Duration of treatment (months)12 (6-12)12 (12-18)12 (10-18)6 (3-12)18 (12-18)12 (6-12)6 (3-12)12 (12-18)9 (6-12)

Data presented as weighted median (interquartile range) unless otherwise stated.

GP: general practitioner

Conclusion

This is the first description of current practice in managing referrals and treatment of PMR by rheumatologists worldwide. In general, median treatment duration was according to EULAR/ACR guidelines, but initial dose of prednisolone was often higher than recommended in many parts of the world. PMR patients were often seen more than two weeks after referral, and treatment had started prior to first rheumatological evaluation.

References

[1]Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the rheumatic diseases 2015; 74(10): 1799-807.

Acknowledgements

This study was endorsed by the international PMR/GCA study group.

Disclosure of Interests

Agnete Overgaard Donskov: None declared, Sarah Mackie: None declared, Ellen-Margrethe Hauge Speakers bureau: AbbVie, Sanofi, Sobi, MSD, UCB, Consultant of: AbbVie, Sanofi, Sobi, MSD, UCB, Grant/research support from: Novo Nordic Foundation, Danish Rheumatism Association, Danish Regions Medicine Grants, Roche, Novartis, Celgene, MSD, Pfizer, Roche, Sobi, CARLOS TORO GUTIÉRREZ: None declared, Ib Hansen: None declared, Andrea Hemmig: None declared, Aatke van der Maas: None declared, Tamer A Gheita: None declared, Berit Dalsgaard NIelsen Paid instructor for: Roche, Karen Douglas: None declared, Richard Conway Speakers bureau: Janssen, Roche, Sanofi, Abbvie,, Elena Rezus: None declared, Bhaskar Dasgupta: None declared, Sara Monti: None declared, Eric Matteson Consultant of: Boehringer-Ingelheim,, Grant/research support from: Boehringer Ingelheim,, Sebastian E. Sattui Grant/research support from: AstraZeneca, Mark Matza: None declared, Vanessa Ocampo Speakers bureau: Abbvie, Andrea Bran: None declared, Simone Appenzeller Grant/research support from: GSK, Annelise Goecke Speakers bureau: Abbvie, Boehringer Ingelheim, Recalcine. Consultant Abbvie, Boehringer Ingelheim, NELLY COLMAN MC LEOD Speakers bureau: Laboratorios FAPASA (Farmacéutica Paraguay), Helen Keen Speakers bureau: Roche, Abbvie, Masataka Kuwana: None declared, Latika Gupta: None declared, Babur Salim: None declared, Ghita Harifi Speakers bureau: Abvie, Johnson and johnson, Lilly, Novartis, Mariama Erraoui: None declared, Nelly Ziade Speakers bureau: Abbvie, Eli Lilly, Janssen, Pfizer, Pierre Fabre, Roche, Novartis, Sanofi-Aventis, Paid instructor for: Abbvie, Eli Lilly, Sanofi-Aventis, Pfizer, Janssen, Novartis., Consultant of: Abbvie, Eli Lilly, Janssen, Pfizer, Roche, Novartis, Sandoz, Grant/research support from: Abbvie, Celgene - Algorithm, Bristol-Myers Squibb - NewBridge, Pfizer, Nizar Abdulateef Al-Ani: None declared, Adeola Ajibade: None declared, Johannes Knitza: None declared, Line Frølund: None declared, Max Yates: None declared, Victor Pimentel-Quiroz: None declared, Andre Lyrio: None declared, Maria Sandovici: None declared, Kornelis van der Geest Speakers bureau: Roche, Toby Helliwell Grant/research support from: Valneva, Elisabeth Brouwer Speakers bureau: Roche, Christian Dejaco Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Consultant of: Abbvie, Eli Lilly, Janssen, Roche, Galapagos and Sanofi, Kresten Keller: None declared

AB1194 PREVALENCE OF FIBROMYALGIA IN THE RHEUMATOLOGY OPDS DURING COVID19 LOCKDOWN: A CROSS-SECTIONAL STUDY

Background

In the challenging times of Covid 19, anxiety increased among the general population. Fibromyalgia patients are more at risk of developing anxiety in these difficult times. This might result in more frequent visits to the rheumatology clinics with an exacerbation of their chronic pain syndrome.

Objectives

The main objective of this study is to compare the prevalence of FM in the rheumatology outpatients’ clinics during the Covid 19 lockdown period (2020) and during the same period in the previous year (2019).

Methods

A cross-sectional study is conducted through 5 rheumatology clinics located in the 3 biggest emirates of the country (3 in Dubai, 1 in Abu Dhabi and 1 in Sharjah) to detect the number and charachteristics of fibromyalgia from March 15 to May 15th2019, and March 15 to May 15th2020.

Results

Total number of patients seen from march to May 2019 was 3480 out of them 55 were fibromyalgia patients with frequency 0.0158%. While from march to May 2020 total number of patients seen were 1355 out of them 66 were fibromyalgia patients with frequency 0.0487%. Figure 1

Figure 1.

Total and fibromyalgia patients in March-May 2019 and March-May 2020

Descriptive analysis of fibromyalgia patients seen in the lockdown time March to May 2020 shows that; gender was 64 females 97%, 2 males 3%, profession 36 unemployed 54.5%, 28 white collar 42.4%, 2 blue collar 3%, Age minimum was 25 years, maximum 77 years, with mean 48.3±13 years. Table 1

Table 1.

Descriptive analysis of the fibromyalgia paients

Gender(Frequency)Female64 (97%)Male2 (3%)Profession(Frequency)unemployed36 (54.5%)White collar28 (42.4)Blue collar2 (3%)Fibromyalgia severity(Mean±SD)Tender Points15.7±3Pain6.5±2.1Fibromyalgia associates(Frequency)Headache32 (48.5%)Sleep Disturbance47 (71.2%)Fatigue65 (98.5%)IBS26 (39.4%)Anxiety43 (65.2%)Depression37 (56.1%)

Tender points were 15.7±3, VAS for pain 6.5±2.1, sleep disturbance was present in 47 patients 71.2%, fatigue 65 patients 98.5%, irritable bowel syndrome in 26 patients 39.4%, headache in 32 patients 48.5%, anxiety in 43 patients 65.2%, and Depression in 37 patients 56.1 %.

Comparing frequencies of fibromyalgia between March to May 2019 and 2020 shows a significantly higher frequency of fibromyalgia in March to May 2020, 3.1-fold more than 2019.

Conclusion

The prevalence of patients with fibromyalgia seen in the Rheumatology clinics significantly increased during the lockdown time in comparison to the same period of 2019.

References

[1]Elsevier. “Novel Coronavirus Information Center”. Elsevier Connect. Archived from the original on 30 January 2020.

[2]Reynolds, Matt (4 March 2020). “What is coronavirus and how close is it to becoming a pandemic?”. Wired UK. ISSN 1357-0978. Archived from the original on 5 March 2020. Retrieved 5 March 2020.

[3]Turak, Natasha (29 January 2020). First Middle East cases of coronavirus confirmed in the UAE CNBC.com. Retrieved 19 March 2020.

[4]Coronavirus: UAE confirms 294 new cases, 19 recoveries”. Khaleej Times. Retrieved 5 April 2020.

[5]Psychological impact of fibromyalgia: current perspectives. GalvezSánchez CM, Duschek S, Reyes Del Paso GA. Psychol Res Behav Manag. 2019 Feb 13;12:117-127.

[6]Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the Multicenter Criteria Committee. Arthritis and Rheumatism. 1990;33(2):160–172.

[7]Wolfe F, Clauw DJ, Fitzcharles M, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care and Research. 2010;62(5):600–610.

Disclosure of Interests

None declared

POS0275-HPR CONCORDANCE BETWEEN THE PHYSICIAN’S AND THE NURSE’S ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS USING DAS-28, CDAI AND SDAI IN SEVEN MIDDLE EASTERN ARAB COUNTRIES

Background:

Managing patients with chronic rheumatic diseases is increasingly relying on the collaboration of a multidisciplinary team, including the rheumatology nurse who can aid assessment of disease activity among other healthcare tasks.

However, this practice, although common in Europe and North America, is still poorly implemented in the Middle eastern Arab countries (MEAC).

Objectives:

To evaluate the concordance between the physician’s and the nurse’s assessment of disease activity in patients with rheumatoid arthritis (RA) in the MEAC.

Methods:

During a routine patient visit to one of 9 rheumatology clinics located in 7 Middle Eastern Arab countries, the physician and the rheumatology nurse (who was already working in the clinic) performed the disease activity score 28 (DAS), Clinical Disease Activity Index (CDAI) and Simple Disease Activity Index (SDAI) in a blinded manner. The concordance regarding the 3 continuous scores was calculated using paired t-test. The agreement between physician- and nurse-DAS categories (remission, low, moderate and high disease activity) was calculated using weighted kappa for category comparison. Predictive factors of positive concordance between physician- and nurse-DAS were identified using binary logistic regression.

Results:

The study included 373 patients’ measurements over a period of two years (2018 to 2019). The mean age of the patients was 49.6 years (±28.2), 82.6% were females, and the mean disease duration was 11.3 years (±7.5).

The mean physician-DAS was slightly higher (3.97 (±1.52)) than the nurse-DAS (3.90 (±1.54)) (p=0.002), with a mean difference of +0.08 [95%CI 0.03; 0.12] (Table 1). The difference in the DAS individual items, the CDAI and the SDAI were not statistically significant.

Table 1.

Comparison of the disease activity measures reported by the physician and by the nurse.

PhysicianNursep-valueTotal Joint Count4.87 (2.26)5.02 (6.20)0.152Swollen Joint Count2.13 (3.88)2.15 (3.83)0.790Global Assessment3.30 (2.41)3.32 (2.43)0.702DAS-283.97 (1.52)3.90 (1.54)0.002CDAI14.26 (12.53)14.38 (12.59)0.515SDAI21.51 (23.57)21.61 (21.66)0.527

When analyzing DAS as a categorical 4-items variable, the agreement between the physician and the nurse was present in 79.36% of the cases (weighted kappa was 0.77 [95%CI 0.73;0.83] which is considered as excellent, and was higher in patients with high disease activity (Figure 1).

A positive concordance between the physician- and the nurse-DAS was associated with the country (higher in Egypt, p<0.001) and the status of higher disease activity (p<0.001).

Conclusion:

The agreement between the DAS-28 performed by the physician and by the nurse was excellent and was associated with the country and a higher disease activity. The present study confirms that the support of a trained nurse for evaluating disease activity in RA is feasible in the Arab countries and may save some valuable time in the clinic, whilst maintaining the quality of care for patients with RA.

Figure 1.

Agreement between physician- and nurse-DAS categories

Acknowledgements:

The authors would like to acknowledge the patients for participating in the study and the assistants/ students/ nurses who assisted in the data collection: Dr. Fatima Abdul Majeed Al Hawaj, M. Atef Ahmed, M. Mohammad Alhusamiah, Ms Raquel De Guzman, Ms Lina Razzouk.

Disclosure of Interests:

None declared

AB0104 CONCORDANCE BETWEEN THE PHYSICIAN’S AND THE PATIENT’S ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: RESULTS OF THE AUTODAS-MEAC STUDY AT ONE YEAR

Background:

Involving the patients with rheumatoid arthritis (RA) in the assessment of their disease may increase their adherence to treatment, improve the disease outcomes and facilitate the application of telehealth. We previously reported an excellent concordance between the Disease Activity Score (DAS-28) performed by physicians and patients at the baseline visit of this prospective study (1).

Objectives:

To evaluate the persistence of the concordance between the physician’ and the patient’s assessment of disease activity in RA using DAS-28 after one year.

Methods:

At the baseline visit, patients with RA from 7 Middle Eastern Arab Countries (MEAC) were briefed about DAS-28 by their rheumatologist during a routine consultation and given smartphone access to a video in Arabic language explaining the performance of DAS-28. At 3, 6 and 12 months (± 3 months), the patients were asked to self-report DAS-28, blinded to the physician’s assessment. Concordance between the continuous DAS-28 at each visit was calculated using paired t-test numerically and the Bland-Altman method graphically. Agreement between physician- and patient-DAS categories (remission, low-, moderate- and high disease activity) was calculated at each visit using weighted kappa for category comparison. Weighted kappa of the different agreements were compared over time using their respective confidence intervals (CIs). Predictive factors of positive concordance between physician and patient-DAS were identified using binary logistic regression.

Results:

The study included 428 patients over a period of three years (2018 to 2020). The mean age of participants was 49.8 years, 82.5% were females, 44.3% had a university degree and the mean disease duration was 11.4 years.

At baseline, the average patient-DAS was higher (4.06 (±1.52)) than the physician-DAS (3.97 (±1.52)). The mean difference was -0.09 [95%CI -0.14; -0.04] and most of the pairs were within the limit of agreement in the Bland-Altman graph, indicating a good concordance, particularly in cases of remission.

During the study follow-up, 299 patients consulted for visit 2 (69.9% of the total population), 232 for visit 3 (54.2%) and 199 for visit 4 (46.5%). The weighted kappa was 0.80 [95%CI 0.76;0.85] at visit 1 and 0.79 [95%CI 0.72;0.88] at visit 4 (Figure 1 showing kappa for DAS-28, CDAI and SDAI as well). A minor numerical decrease in kappa was observed over time; however, the CIs were overlapping over the four visits and the agreement was considered stable, remaining in the excellent range. At visit 4, a positive concordance between the physician- and the patient-DAS was associated with the profession (lower in blue collar, p=0.001), the educational level (higher in high school and university, p=0.034) and the baseline physician’s DAS (higher in high disease activity, p=0.46).

Conclusion:

The agreement between the DAS-28 performed by the physician and by the patient was excellent at baseline and remained stable over one year. A positive concordance was associated with the profession, the educational level and the level of disease activity. The present study can help the rheumatologist make informed decisions about the patients who may be suitable for a remote evaluation of their disease activity, that can be of particular interest in the context of the COVID-19 pandemic.

References:

[1]Ziade N, Saad S, al Mashaleh M, et al. Perceptions of Patients with Rheumatoid Arthritis about Self-Assessment of Disease Activity after Watching an Educational Video: Qualitative Pilot Results from the Auto-DAS in Middle Eastern Arab Countries Study [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10).

Acknowledgements:

The authors would like to acknowledge the patients for participating in the study and the assistants/ students/ nurses who assisted in the data collection: Dr. Fatima Abdul Majeed Al Hawaj, M. Atef Ahmed, M. Mohammad Alhusamiah, Ms Raquel De Guzman, Ms Lina Razzouk.

Disclosure of Interests:

None declared

Development of an Educational Video for Self-Assessment of Patients with RA: Steps, Challenges, and Responses

Objectives:

The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges.

Methods:

Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified.

Results:

Twenty-three rheumatologists from MEAC identified unmet needs in patients’ education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician’s visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix.

Conclusion:

Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.

Perceptions of patients with rheumatoid arthritis about self-assessment of disease activity after watching an educational video: a qualitative pilot study from the AUTO-DAS in Middle Eastern Arab countries project

To evaluate the perceptions of patients with rheumatoid arthritis (RA) about self-assessment of their disease activity after watching an educational video. Consecutive patients with RA consulting their rheumatologist in six Middle Eastern Countries were invited to watch an educational video developed to teach self-assessment using Disease Activity Score (DAS-28). Then, a rheumatology nurse conducted a semi-structured interview and collected the patients’ perception about the understanding of the video, feasibility, capability and confidence in performing self-assessment using Likert-type items. The degree of confidence with self-assessment was correlated to the patients’ socio-demographic characteristics. Sixty-two patients were included and had an overall positive reaction to the video. It was easy to understand in 96% and helped facilitate self-assessment in 92% of cases. Self-assessment was considered totally feasible in 74%, and 66% of patients were capable of always doing it, with a confidence of 60% (always) to 34% (sometimes). Confidence was associated with a higher educational level. Nevertheless, 77% of patients felt that the self-assessment would not fully replace the physician’s visit. Open-ended questions identified five themes: better understanding of the disease, easier communication with the rheumatologist, less consultation time, difficulty with the scoring part and importance of practice. Patients with RA felt that self-assessment was feasible and helpful in understanding RA, improving communication with the rheumatologist and shortening the visit time.

Arterial stenosis in antiphospholipid syndrome: Update on the unrevealed mechanisms of an endothelial disease

First described in 1983, antiphospholipid syndrome (APS) is an autoimmune condition characterized by the occurrence of recurrent arterial and/or venous thrombosis, and/or pregnancy morbidity, in the setting of persistent presence of antiphospholipid antibodies (aPL). While thrombosis is the most well-known pathogenic mechanism in this disorder, the relevance of some other mechanisms such as arterial stenosis is being increasingly recognized. Arterial stenosis has been first described in the renal arteries in patients with APS, however intracranial and coeliac arteries can also be involved with various and treatable clinical manifestations. The underlying pathophysiology of this stenotic arterial vasculopathy is not fully understood but some recent studies revealed new insights into the molecular mechanism behind this endothelial cell activation in APS. In this review, we discuss these newly discovered mechanisms and highlight the diagnostic and therapeutic modalities of the APS related arterial stenosis.

Pathogenic role of platelets in rheumatoid arthritis and systemic autoimmune diseases. Perspectives and therapeutic aspects

Well-recognized for their role in vascular homoeostasis, platelets may play a major role in inflammation and immunomodulation. Substantial data are emerging on the pathogenic involvement of platelets in inflammatory arthritis and autoimmune diseases, indicating the existence of crosstalk between the coagulation and inflammation system. Upon activation, platelets release pro-inflammatory platelets microparticles, which interact with leucocytes leading to joint and systemic inflammation in rheumatoid arthritis. Platelets activation by immune complexes activate dendritic cells promoting the secretion of interferon alpha, which has a key role in the development of systemic lupus erythematous. In this review, we discuss the current data on the role of platelets in the pathophysiology of inflammatory arthritis and various autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis.

Hughes syndrome and epilepsy: when to test for antiphospholipid antibodies?

Epilepsy and seizures are reported among the neurological manifestations of antiphospholipid syndrome (APS) at a prevalence rate of approximately 8%, which is nearly 10 times the prevalence of epilepsy in the general population. The association of seizures with antiphospholipid antibodies (aPL) is even more significant in the presence of systemic lupus erythematosus (SLE). In this review, we discuss the epidemiological, pathophysiological, laboratory, clinical, and radiological aspects of this association, and derive suggestions on when to consider testing for aPL in epileptic patients and how to manage seizures secondary to APS based on literature data. Epilepsy due to APS should be considered in young patients presenting with seizures of unknown origin. Temporal lobe epilepsy seems to be particularly prevalent in APS patients. The pathogenesis is complex and may not only involve micro-thrombosis, but also a possible immune-mediated neuronal damage. Patients with seizures and positive aPL tend to develop thrombocytopenia and livedo racemosa more frequently compared with those without aPL. Magnetic resonance imaging (MRI) remains the imaging modality of choice in these patients. The presence of SLE and the presence of neurological symptoms significantly correlate with the presence of white matter changes on MRI. In contrast, the correlation between aPL positivity and the presence of white matter changes is very weak. Furthermore, MRI can be normal in more than 30–40% of neuropsychiatric lupus patients with or without aPL. aPL testing is recommended in young patients presenting with atypical seizures and multiple hyper-intensity lesions on brain MRI in the absence of other possible conditions. New MRI techniques can better understand the pathology of brain damage in neuro-APS. The therapeutic management of epileptic APS patients relies on anti-epileptic treatment and anticoagulant agents when there is evidence of a thrombotic event. In the absence of consensual recommendations, the decision of lifelong anticoagulation is discussed on a case-by-case basis. The anti-thrombotic benefit of hydroxychloroquine and statins is supported by several studies.

Prevalence of chronic pain with neuropathic characteristics in the Moroccan general population: a national survey

OBJECTIVE

We conducted a telephonic survey to determine the prevalence of chronic pain with neuropathic characteristics (NC) in the Moroccan general population.

DESIGN

We performed a large nationwide telephonic survey based upon a random sampling of households in the 16 administrative regions of Morocco to determine the prevalence of chronic pain with NC in the general population. We used a stratified sampling taking into account the number of residents in each region. A sample of households was drawn for each of the 16 regions using systematic sampling.

OUTCOME MEASURES

A questionnaire aimed at identifying chronic pain (defined as daily pain for at least 3 months), evaluating its intensity, duration, and body locations was used. The Moroccan validated version of DN4 questionnaire was used to identify neuropathic characteristics.

RESULTS

A total of 5,328 respondents participated in the survey. 21% of the respondents (1,074) (95%CI: 19,9-22,2), reported chronic daily pain for more than 3 months. The point prevalence of chronic pain with NC, was 10.6% (95% CI: 9,75-11,45). The prevalence was higher in women and individuals older than 60. Chronic pain with NC was significantly more prevalent in women, elderly, illiterate respondents, and respondents from lower social class. It was more frequently located in the lower limbs, and its intensity and duration were higher in comparison with chronic pain without neuropathic characteristics.

CONCLUSION

Chronic pain with neuropathic characteristics is probably more prevalent in the general population than was previously thought and is generally more severe than other chronic pain.

Prostaglandin transporter mutations cause pachydermoperiostosis with myelofibrosis

Pachydermoperiostosis, or primary hypertrophic osteoarthropathy (PHO), is an inherited multisystem disorder, whose features closely mimic the reactive osteoarthropathy that commonly accompanies neoplastic and inflammatory pathologies. We previously described deficiency of the prostaglandin-degrading enzyme 15-hydroxyprostaglandin dehydrogenase (HPGD) as a cause of this condition, implicating elevated circulating prostaglandin E(2) (PGE(2)) as causative of PHO, and perhaps also as the principal mediator of secondary HO. However, PHO is genetically heterogeneous. Here, we use whole-exome sequencing to identify recessive mutations of the prostaglandin transporter SLCO2A1, in individuals lacking HPGD mutations. We performed exome sequencing of four probands with severe PHO, followed by conventional mutation analysis of SLCO2A1 in nine others. Biallelic SLCO2A1 mutations were identified in 12 of the 13 families. Affected individuals had elevated urinary PGE(2), but unlike HPGD-deficient patients, also excreted considerable quantities of the PGE(2) metabolite, PGE-M. Clinical differences between the two groups were also identified, notably that SLCO2A1-deficient individuals have a high frequency of severe anemia due to myelofibrosis. These findings reinforce the key role of systemic or local prostaglandin excess as the stimulus to HO. They also suggest that the induction or maintenance of hematopoietic stem cells by prostaglandin may depend upon transporter activity.

[Comparison of the calcium intake during and before Ramadan in Marrakesh, Morocco]

We studied the effect of Ramadan fasting on calcium intake in 2 groups of 500 healthy subjects from Marrakesh using the colloquial Arabic version of the Fardellone questionnaire. The first group was investigated 5 months before Ramadan and the second during Ramadan. No significant difference was observed between the 2 groups. However, comparison of the pre-Ramadan and Ramadan periods for each age group showed a significant increase in calcium intake in subjects over 60 years. During Ramadan, consumption of milk was significantly higher, while consumption of other dairy products was not different. Overall, no significant difference in calcium intake was noted between pre-Ramadan and Ramadan periods.

A novel homozygous splice site mutation in the HPGD gene causes mild primary hypertrophic osteoarthropathy

OBJECTIVES

Homozygous mutations in HPGD gene, encoding 15-hydroxyprostaglandin dehydrogenase, have recently been associated with primary hypertrophic osteoarthropathy (PHO). So far, only 7 HPGD alterations are known. In order to expand this mutational spectrum and better delineate the HPGD-related phenotype, we report the clinical and molecular characterisation of a 13-year-old boy and compare his features to known mutated patients.

METHODS

The HPGD gene exons 1-7 and exon-intron junctions were analysed by direct sequencing. Previously published HPGD-mutated patients were systematically reviewed based on the original clinical description.

RESULTS

A novel homozygous c.217+1G>A mutation affecting the obligatory donor splice site of HPGD exon 2 was identified in our proband who showed a mild form of PHO. Review of HPGD-mutated patients outlined all patients manifested digital clubbing, periostosis and acro-osteolysis. Hyperhidrosis (92%), arthralgia (65%) and eczema (33%) were variably associated features. Pachydermia (54%) was mild and mostly limited to palms and sole; cutis vertigis gyrata, blepharoptosis and severe skin thickening were never observed. Besides digital clubbing, PHO infants often presented patent ductus arteriosus (PDA) (32%) and delayed cranial sutures closure (55%).

CONCLUSIONS

The present findings broaden the allelic spectrum of HPGD gene to include a novel c.217+1G>A mutation. Mutated patients display a homogeneous phenotype mainly consisting in digital clubbing, periostosis, acro-osteolysis, hyperhidrosis and mild pachydermia. Earliest manifestations include delayed closure of the cranial sutures and PDA. In conclusion, the information reported herein would facilitate the diagnosis of PHO due to HPGD mutations.

[Evaluation of the calcium intake in population of Marrakesh and its region: 1000 cases]

OBJECTIVES

The aim of our work is to evaluate the calcium intake in population of Marrakesh and its region by the translated version in Moroccan Arabic dialect of Fardellone questionnaire.

SUBJECTS AND METHODS

The version translated into Arabic dialect Fardellone questionnaire is tested on a sample of 1000 subjects. The subjects aged less than 15 years accounted for 30.9% (n=309), those aged 15 to 59 62% (n=620) and those aged over 60 years 7.1% (n=71). The distribution by age group is calculated on the distribution of the Moroccan population.

RESULTS

The study population includes 60.6% women (n=606), 39.4% of men (n=394). The mean calcium intake was respectively 5875 mg by week (that means 839 mg/day), 4899 mg by week (that means 699 mg/day), 3053 mg by week (that means 436 mg/day), in subjects aged less than 15, those aged 15 to 59, and those aged over 60 years. The average consumption of calcium per day is significantly lower than the recommended daily amount for the three age groups. Patients aged over 60 years is the age group most under nourished calcium. The comparison of both gender found a deficit higher among women than among men.

CONCLUSION

Evaluation of the calcium intake is an essential tool for better management of metabolic bone diseases.