Expert Opinion Guidance on the Detection of Early Connective Tissue Diseases in Interstitial Lung Disease

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts.

Association between Diabetes and Rheumatoid Arthritis: A Systematic Literature Review

Objective

To examine the risk of diabetes mellitus (DM) in patients with rheumatoid arthritis (RA) and whether the risk is related to conventional risk factors, RA disease activity, and treatment.

Methods

A systematic literature review (SLR) query was conducted using specified MeSH terms, searching PubMed and EMBASE databases from inception to March 2020. Both cohort or case-control design studies assessing the incidence or prevalence of DM in RA patients were included.

Results

Of the 1948 articles, 43 peer-reviewed observational studies were selected. A high degree of heterogeneity in study design and reporting was observed, precluding final conclusions.

Based on the studies included, it was observed that DM prevalence ranged between 1% and 20% in RA patients, which was similar to controls (1–29%). The cumulative incidence of DM in RA patients ranged between 1.3% and 11.7% over different time frames. DM incidence rates in patients with RA per 1000 person-years ranged from 5.2 to 16.7.

RA patients may be at higher risk of DM, particularly among those receiving glucocorticoids (GC), while patients on hydroxychloroquine and biological disease-modifying anti-rheumatic treatments (DMARDs) may be at lower risk.

Conclusion

DM incidence may be increased in patients with RA as a result of more concomitant traditional risk factors and GC exposure. It is unclear whether biologics may have a true protective effect or provide a GC-sparing effect. High-quality studies in large cohorts of RA patients with appropriate adjustment for covariates are warranted to fully investigate the interplay between DM and RA.

Cricoarytenoid joint arthritis: a possible complication of dermatomyositis

Cricoarytenoid joint arthritis is most frequently reported in Rheumatoid Arthritis and in other systemic diseases such as Sjogren's syndrome, Systemic Lupus Erythematosus, Ankylosing Arthritis, Juvenile Chronic Arthritis, and autoimmune hepatitis but it has not been reported in dermatomyositis. In this paper, we report the case of a 43 years-old woman treated for dermatomyositis who presented with hoarseness and severe odynophagia. The laryngoscopy revealed the presence of an extensive white swelling of the left cricoarytenoid joint with reduced mobility of the left vocal cord, consistent with left cricoarytenoid joint arthritis, which has not previously been described in dermatomyositis to our knowledge. Treatment with high doses of prednisone produced a complete resolution of the laryngeal symptoms.

Adherence to systemic therapies for immune-mediated inflammatory diseases in Lebanon: a physicians' survey from three medical specialties

BACKGROUND

Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that may cause tissue damage and disability, reduced quality of life and increased mortality. Various treatments have been developed for IMIDs, including immune modulators and targeted biologic agents. However, adherence remains suboptimal.

METHODS

An adherence survey was used to evaluate physicians' beliefs about adherence to medication in IMID and to evaluate if and how they manage adherence. The survey was distributed to 100 randomly selected physicians from three different specialties. Results were analyzed by four academic experts commissioned to develop an action plan to address practical and perceptual barriers to adherence, integrating it into treatment goals to maximize outcomes in IMID, thereby elevating local standards of care.

RESULTS

Eighty-two physicians participated in this study and completed the questionnaire. Most defined adherence as compliance with prescribed treatment. Although the majority of surveyed physicians (74%) did not systematically measure adherence in their practice, 54% identified adherence as a treatment goal of equal or greater importance to therapeutic endpoints. Lack of time and specialized nursing support was reported as an important barrier to measuring adherence. The expert panel identified four key areas for action: 360° education (patient-nurse-physician), patient-physician communication, patient perception and concerns, and market access/cost. An action plan was developed centered on education and awareness, enhanced benefit-risk communication, development of adherence assessment tools and promotion of patient support programs.

CONCLUSION

Nonadherence to medication is a commonly underestimated problem with important consequences. A customized target-based strategy to address the root causes of non-adherence is essential in the management of chronic immune-mediated diseases.

Use of complementary and alternative therapy among patients with rheumatoid arthritis and osteoarthritis

AIMS AND OBJECTIVES

We wanted to assess the prevalence of complementary and alternative therapy use among patients suffering from rheumatoid arthritis or osteoarthritis in the Lebanese population and to determine the perceived efficacy and side effects of complementary and alternative therapy in the treatment of these diseases.

BACKGROUND

Complementary and alternative therapy has become popular among patients with chronic illnesses because of its widespread use. Rheumatoid arthritis and osteoarthritis are two diseases associated with severe pain, inflammation and limited activity. Although both are quite common in Lebanon, no studies were conducted in our country to portray complementary and alternative therapy use in their treatment.

DESIGN

Descriptive cross-sectional study.

METHODS

Conducted individualised questionnaire-based interviews among 250 adult patients, ranging between the ages of 20-90 years and diagnosed with either rheumatoid arthritis or osteoarthritis. The questionnaire included demographic information, clinical information, use of conventional therapies and complementary and alternative therapy, and the disease status before and after complementary and alternative therapy use.

RESULTS

Fifty-eight (23·2%) patients used complementary and alternative therapy in addition to their conventional medications in the treatment of either rheumatoid arthritis or osteoarthritis. Most herbal medicine users (63·8%) believed that complementary and alternative therapy was beneficial. The disease status measured by the intensity of pain, sleeping pattern and level of activities was significantly improved after using complementary and alternative therapy (p =0·01). Forty-eight (82·75%) patients were using herbals as complementary and alternative therapy, 14 (24·1%) of whom have sought medical care because of potential concomitant drug-complementary and alternative therapy side effects. However, these side effects were not serious and reversible.

CONCLUSION AND RECOMMENDATIONS

Although complementary and alternative therapy might have beneficial effects in rheumatoid arthritis and osteoarthritis, patients should be cautious about their use and should necessarily inform their health care providers about the consumption of any products other than their conventional medicines.

RELEVANCE TO CLINICAL PRACTICE

It is quite essential for health care professionals to be knowledgeable about the use of complementary and alternative medicine therapies when providing medical care to patients with arthritis.

First update of the Lebanese guidelines for osteoporosis assessment and treatment

With the demographic explosion, the human, social, and economic costs of osteoporosis in developing countries, including the Middle East, will continue to rise. In 2002, the Lebanese Guidelines for Osteoporosis Assessment and Treatment were developed to optimize quality of osteoporosis care in Lebanon and the region. They were endorsed by 5 Lebanese medical scientific societies, and by the Eastern Mediterranean Regional Office branch of the World Health Organization (WHO). In April 2006, the Lebanese Society for Osteoporosis and Metabolic Bone Disorders (OSTEOS) led an initiative to update several recommendations detailed in the original document, based on relevant new local and international data. Data from a population-based sample of elderly Lebanese validated the following recommendations: fracture risk assessment, expressed as relative risk per standard deviation (RR/SD) decrease, was comparable in Lebanese subjects to similarly derived estimates from Western studies; the use of the NHANES database (hip), and the densitometer American database (spine) was as good, if not superior to the use of a Lebanese database for identifying subjects with prevalent vertebral fractures. The original recommendation regarding the use of a gender-specific western database, densitometer for spine and NHANES for T-score derivation for men, remains unchanged. For skeletal site selection, the update recommends measuring the spine and hip for women < or =65 yr, hip only for subjects >65 yr, and adding the forearm in conditions associated with cortical bone loss or in the case of inability to measure axial sites. The original recommendations for conservative management in premenopausal women were reiterated. This First Update of the Lebanese Osteoporosis Guidelines validates previous recommendations using evidence from a population-based sample of elderly Lebanese, and lays the ground for transitioning the Lebanese Osteoporosis Guidelines to the WHO global fracture risk assessment model.

Vertebral fracture risk and impact of database selection on identifying elderly Lebanese with osteoporosis

The International Osteoporosis Foundation recommends using a universal database i.e. the NHANES database for the diagnosis of osteoporosis. Population-based databases for T-score calculation are still debated in terms of clinical and public health relevance. The current study aimed at estimating the prevalence of vertebral fractures in the Lebanese elderly, determining BMD-fracture relationship, and assessing the effect of database selection on osteoporosis prevalence and fracture risk assessment. Apparently healthy subjects were randomly selected from the Greater Beirut area - one-third of the Lebanese population at large - using a multilevel cluster technique. Subjects with medical conditions likely to affect bone metabolism i.e. history of major chronic disease, intake of medications that affect bone metabolism were excluded. Presence of vertebral fracture was estimated by a semi-quantitative assessment. Bone density was measured by central DXA. Clinical risk factors included age, gender, height, weight, body mass index, smoking, exercise, falls, previous fragility fracture and family history of fragility fracture. Impact of database selection was assessed by: (1) Comparison of sensitivity and specificity for prevalent vertebral fractures of the T-score <or= - 2.5 threshold using local versus NHANES database. (2) Comparison of estimates for fracture risk (RR/SD decrease in BMD) using local versus NHANES database. Prevalence of vertebral fractures was estimated at 19.9% [15.4-25.0] in women and at 12.0% [7.3-18.3] in men. Prevalence of osteoporosis by DXA using total hip was 33.0% [27.5-38.8] in women and 22.7% [16.2-30.2] in men. The NHANES database provided higher sensitivity for vertebral fracture than our population-specific database. RR of vertebral fracture per SD decrease in BMD remained unchanged across the two databases. In women, RR/SD were 1.61 [1.17-2.23] and 1.49 [1.14-1.95] in the NHANES and the local database, respectively, and in men 1.59 [0.94-2.72] and 1.43 [0.95-2.16]. In conclusion, our findings were in concordance with the IOF recommendations for the use of a universal database and could be used for the implementation of a unified fracture risk assessment paradigm along with the WHO initiative.

Régression du névrome de Morton après infiltration de corticostéroïdes

Morton neuroma is a non neoplastic lesion corresponding to perineural fibrosis encircling the common interdigital plantar nerve. Several therapeutic approaches are possible: conservative treatment or surgery. We report a case treated by local steroid injection where follow-up MR showed near complete regression of the lesion. Although local injection of steroid is a classical treatment, it is the first time to our knowledge that resolution or such a striking diminution of size is reported after infiltration.

An audit of bone densitometry practice with reference to ISCD, IOF and NOF guidelines

INTRODUCTION

The impact of osteoporosis guidelines on clinical practice has not been fully evaluated.

OBJECTIVES

To estimate the positive predictive value (PPV) of the National Osteoporosis Foundation (NOF), the International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) guidelines for osteoporosis and compare it to the PPV of clinical judgement alone.

METHODS

All subjects tested for bone mineral density during the fall of 2001 in three teaching hospitals in Beirut were invited to participate. The reference databases used for the calculation of the T-score were the NHANES database for the hip and the manufacturer's database for the spine. The impact of using guidelines was measured by the increment in PPV. Osteoporosis was defined as a T-score < or =-2.5 at either the spine or hip.

RESULTS

A total of 307 post-menopausal women were tested with dual-energy X-ray absorptiometry (DXA). In current practice (clinical judgement alone), the PPV for osteoporosis was 42.4%; using NOF guidelines, 236 women would have been tested, and the PPV would have been 46.2%. Similarly, using IOF or ISCD guidelines, 236 women would have been tested, and the PPV would have been 47.1%.

CONCLUSION

Compared to current clinical practice, application of the ISCD, IOF and NOF guidelines may increase the predictive value of a central DXA for osteoporosis.

Severity of rheumatoid arthritis: the SEVERA study

This study aims to assess the severity of rheumatoid arthritis (RA) in rheumatology practice in our population. All outpatients and inpatients with RA seen by registered rheumatologists over a 1-year period were included. Severity was measured using the Larsen score for hands and wrists and the Modified Health Assessment Questionnaire (M-HAQ). Two hundred ninety-eight RA cases were included. Mean age was 51.5 years. Among them, 261 (87.6%) were females. Disease duration was less than a year in 26 subjects (8.7%) and 10 years and above in 108 (36.2%) with a mean of 8.9. There were 220 (73.8%) subjects who had M-HAQ score <1. In 61 (20.5%) subjects, M-HAQ score was > or =1 and <2, and 17 (5.7%) had M- HAQ score > or =2. In relation with disease duration, M-HAQ starts with an average (SD) value of 0.7 (0.6) during the first year, decreases to 0.4 (0.4) at 5-year disease duration and increases after 10 years of disease progression to an average of 0.9 (0.8). Mean (SD) Larsen score was 51.9 (29.5) and median was 45. A total of 25% had a Larsen score > or =50% of maximum. Larsen score increased significantly (p<0.0001) with disease duration, starting at an average (SD) of 36.1 (14.9) during the first year, rising to 42.5 (15.8) around 5 years and reaching 73.9 (36.9) after 10 years. RA severity in our practice is comparable to that reported in Western populations in terms of radiological damage; however, functional status differs, possibly reflecting cultural differences.

Lebanese guidelines for osteoporosis assessment and treatment: who to test? What measures to use? When to treat?

With the demographic explosion of the population worldwide, the human, social, and economic costs of osteoporosis will continue to rise. It is estimated that the magnitude of the problem might be even larger in developing countries, including those in the Middle East. Although several organizations and countries have developed or adapted guidelines to their local needs, as of today there are no guidelines for osteoporosis assessment in the Middle East. In April 2002, a panel of osteoporosis experts met and discussed practice guidelines for osteoporosis assessment and treatment in Lebanon. The process, which involved an overview of international guidelines as well as local data on osteoporosis, resulted in a draft for Lebanese guidelines that addressed three main questions: "Who to test?" "What measures to use?" and "When to treat?". Representatives from five major Lebanese societies (Endocrinology, Rheumatology, Orthopedics, Obstetrics and Gynecology, and Radiology) subsequently reviewed, discussed, and officially endorsed the guidelines after revisions. The Lebanese guidelines were also endorsed by the Eastern Mediterranean branch of the World Health Organization.

Clinical, radiological, and laboratory findings in Lebanese spondylarthropathy patients according to HLA-B27 status

To evaluate clinical, radiologic, and laboratory features in Lebanese spondylarthropathy patients according to HLA-B27 status.

METHODS

We retrospectively compared demographic, clinical, radiologic, and severity data in 40 HLA-B27-positive and 58 HLA-B27-negative patients. All 98 patients met Amor's or European Spondylarthropathy Study Group criteria for spondylarthropathy, and 51.7% met New York modified criteria for ankylosing spondylitis.

RESULTS

Onset before 16 years of age, hip involvement, and an elevated mean erythrocyte sedimentation rate were significantly associated with the presence of the HLA-B27 (32.5 vs 13.8%, P=0.02; 45 vs 7.5%, P=0.001; and 47.7 vs 25.4, P=0.02; respectively). The two groups were comparable for age, sex ratio, prevalence and distribution of spondylarthropathy types, family history, sacroiliitis, bamboo spine, syndesmophytes, peripheral joint involvement, enthesopathies, extra-articular involvement, response to nonsteroidal anti-inflammatory drugs, and need for other medications.

CONCLUSION

In Lebanon, spondylarthropathy patients positive for HLA-B27 experience disease onset at an earlier age, are more likely to develop hip involvement, and have laboratory evidence of more severe inflammation than their HLA-B27-negative counterparts. None of the other clinical and radiologic parameters are modified by HLA-B27 status.

[Incidence of fractures after the age of 50 years in the Lebanese population and implications in terms of osteoporosis]

BACKGROUND

No comprehensive population-based data is available on the incidence of fractures in Lebanon and the Middle-East. The aim of this study was to estimate the incidence of osteoporotic fractures in the Lebanese population aged 50 years and over.

METHODS

In 1997, a cross-sectional population-based random sample of individuals aged 50 years and over was selected using a multiple level cluster sampling technique. Selected individuals responded to an Arabic version of the EULAR questionnaire. A fracture was defined as incident if it had occurred within the last year. The lifetime risk of osteoporotic fracture was estimated using the incidence rate by ten-year age groups assuming that each individual counts on the average for half the interval.

RESULTS

1003 individuals were included. There were 496 men (49.5%) and 507 women (50.5%). Mean age was 61.3 years (CI: 60.8-61.8) with a maximum of 88 years. The observed number of fractures was 111, giving an absolute risk of osteoporotic fractures of 11.1% (CI: 9.1-12.9). It was higher in women, 13.0% (CI: 10.9-15.1) than in men, 8.6% (CI: 6.9-9.3). Female to male ratio was 1.6. The estimated annual incidence was 2.6% (CI: 2.0-3.2), higher in women, 3.8% (CI: 2.2-5.5) than in men, 1.4% (CI: 0.4-2.5). Incident cases were distributed as follows: 4-hip, 4-forearm, 3-spine, and 15 other sites. Annual incidence was higher in women than in men for all sites. Estimated lifetime risk of osteoporotic fracture was 9.3% (CI: 6.7-11.9) in men and 16.7% (CI: 13.4-19.9) in women.

CONCLUSION

Our figures are lower than those found in Northern Europe but are higher than in Asian countries, possibly reflecting a west-east gradient in risk factors.

Validation of the European Spondylarthropathy Study Group and B. Amor criteria for spondylarthropathies in Lebanon

OBJECTIVES

1) To validate European Spondylarthropathy Study Group (ESSG) and B. Amor's criteria for spondylarthropathies in Lebanon. 2) To evaluate the frequency of spondylarthropathies in rheumatological practice in Lebanon.

PATIENTS AND METHODS

Cases of definite and probable spondylarthropathy were diagnosed based on the clinical judgement of participating rheumatologists, without reference to the two criteria sets under study. The first two patients without spondylarthropathy seen after each spondylarthropathy case were included into the control group. Criteria in the ESSG and B. Amor sets were looked for in the patient and control groups. The frequency of spondylarthropathy meeting each criteria set was determined.

RESULTS

Of the 841 patients evaluated during the study period, 68 met B. Amor's criteria and 72 met ESSG criteria. There were 29 cases of ankylosing spondylitis (40.3%), ten of peripheral psoriatic arthritis (13.8%), two of reactive arthritis (2.8%), two of enteropathic arthropathy (2.8%), and 29 of undifferentiated spondylarthropathy (40.3%). In the definite spondylarthropathy group, sensitivity and specificity were 77.19% and 97.55% for B. Amor's criteria versus 91.23% and 100% for ESSG criteria. The frequency of spondylarthropathy was 8.1% (95% confidence interval [CI], 6.3-9.9) or 8.56% (CI 6.6-10.5) according to B. Amor and ESSG criteria, respectively.

CONCLUSION

Our data validate both criteria sets in the Lebanese population, demonstrating that they are useful in populations that are genetically different from the European populations used to develop them. Spondyloarthropathy is the most common in our rheumatology practice.