Validation of the Arabic version of the early inflammatory arthritis detection tool.

OBJECTIVE: To evaluate the reliability and validity of the Arabic version of the Early Inflammatory Arthritis Questionnaire (EIAQ-A), a detection tool for screening for early inflammatory arthritis (EIA) in Arabic-speaking populations. SUBJECTS AND METHODS: A cross-sectional study was conducted among 30 consecutive participants (21 female and 9 male) attending the Internal Medicine Outpatient Clinic at Mubarak Al-Kabeer Hospital. They completed the self-administered EIAQ-A twice within a 2-week period. Their disease activity was evaluated during the visits based on clinical and laboratory variables. Cross-cultural adaptation was performed using forward and backward translations of the original questionnaire. Test-retest reliability of the EIAQ-A was evaluated using the measure of agreement, kappa (κ), between the response of participants in the two interviews. Internal consistency of the EIAQ-A was measured using the Kudar-Richardson-20 coefficient (KR-20), a binary response equivalent to Cronbach's α. External construct validity was assessed by Spearman's rank correlation coefficient (rs) between the score of EIAQ-A and both clinical and laboratory variables of disease activity. RESULTS: The test-retest reliability for EIAQ-A was good (κ = 0.558) for the overall score and between 0.841 and 0.368 for the subscale scores. Internal consistency had an acceptable value of KR-20 = 0.869. The construct validity for EIAQ-A was high for all disease activity variables tested, rs was between 0.727 (swollen joint count) and 0.896 (visual analog scale pain score). CONCLUSION: The EIAQ-A was a reliable and valid tool for population screening for EIA. Its use may accelerate the early detection of EIA in Arabic-speaking communities.

Back to basics: ankle reflex in the evaluation of peripheral neuropathy in type 2 diabetes mellitus.

BACKGROUND: Ankle reflex is a simple screening tool frequently used in the detection of peripheral neuropathy. AIM: The purpose of this study is to assess the performance characteristics of ankle reflex in detecting diabetic peripheral neuropathy (DPN) by evaluating the sensitivity, specificity and the predictive ability of the ankle reflex, a component of Neuropathy Disability Score (NDS) with reference to Nerve Conduction Studies (NCS). METHODS: A total of 151 patients with type 2 diabetes were assessed (47 males, 104 females). Grading of neuropathy was done using Neuropathy Symptom Score (NSS), NDS and NCS. Patients were divided into two groups, those with abnormal NCS (Group 1) and those with normal NCS (Group 2). Demographic characteristics, biochemistry, NSS and NDS were assessed between the two groups. Taking NCS as the gold standard, sensitivity, specificity and predictive ability of the ankle reflex were calculated and compared with other tests included in NDS, namely vibration sense, superficial pain and temperature sensation. RESULTS: There were 59 (39.1%) patients in Group 1 and 92 (60.9%) in Group 2. NSS and NDS demonstrated strong positive association with NCS. Taking NCS as the gold standard, ankle reflex yielded the highest sensitivity and specificity (91.5 and 67.4%, respectively), closely followed by that of vibration sense. CONCLUSION: Ankle reflex is a powerful screening tool with high sensitivity and negative predictive value, but a combination of ankle reflex and vibration sense has superior sensitivity and specificity compared with either of them done alone for the detection of DPN in clinical settings.

Does Vitamin D deficiency play a role in peripheral neuropathy in Type 2 diabetes?

AIM: Despite recent reports linking vitamin D deficiency with increased risk of diabetes mellitus and complications, there is limited data on patients with diabetic peripheral neuropathy. We aimed to evaluate the incidence and associations of vitamin D deficiency in 210 patients with Type 2 diabetes with and without diabetic peripheral neuropathy. METHODS: Renal, liver, lipid profile and HbA(1c) were measured. Vitamin D status was determined by measuring 25-dihydroxyvitamin D. Presence or absence of coronary heart disease was determined and early-morning urine microalbumin:creatinine ratio was measured. All patients were assessed clinically using neuropathy symptom score, neuropathy disability score and nerve conduction study. RESULTS: Eighty-seven patients had diabetic peripheral neuropathy and these patients had significantly longer duration of diabetes and higher HbA(1c). Age, gender, incidence of retinopathy and coronary heart disease were not significantly different from those without neuropathy. Mean (SD) vitamin D was significantly lower in those with neuropathy [36.9 (39.9) nmol/l] compared with those without [58.32 (58.9) nmol/l] and 81.5% of patients with neuropathy had vitamin D deficiency compared with 60.4% of those without. Vitamin D showed significant (P < 0.05) correlations with total cholesterol, LDL-cholesterol and urine microalbumin:creatinine ratio. Binary logistic regression analysis showed that diabetic peripheral neuropathy was significantly associated with vitamin D deficiency (odds ratio = 3.47; 95% CI = 1.04-11.56, P = 0.043) after inclusion of potential confounders such as duration of diabetes, HbA(1c) and LDL-cholesterol. CONCLUSION: Vitamin D deficiency is an independent risk factor for diabetic peripheral neuropathy, and further studies are required to confirm if Vitamin D supplementation could prevent or delay the onset.

The dentist workforce in Kuwait to the year 2020.

AIM: To project the future demand for dentists in Kuwait for the years 2007 to 2020 based on the period 1994 to 2006. The study addresses the supply of and demand for dentists in Kuwait in the light of emerging variables such as increasing population, economic growth, changes in dental care, education strategies, and changes in demographics of dentists. BASIC RESEARCH DESIGN: Population projections for the years 2007 to 2020 were derived using the average annual natural increase rate of the 1994-2006 populations. The future demand for dentists for the years 2007 to 2020 was projected using the average dentist to population ratios of the years 1994-2006. RESULTS: The average annual growth rate of indigenous Kuwaiti dentists during the period 1994-2006 was 5.58% compared to 31.9% for non-native expatriot dentists. There is a gap between the numbers of native and foreign dentists. In 2006, native dentists constituted 44.4% of the dental workforce in Kuwait, this is likely to affect the quality of provided dental care owing to language, religious and sociocultural barriers between foreign dentists and patients. The disparity between the total number of dentists needed and the number of native dentists is expected to decline from 54.41% in 2007 to 24.67% in 2020. CONCLUSIONS: The supply of native dentists is likely to remain insufficient to meet the projected demand until the year 2020. The supply of indigenous dentists should be increased through improvement in recruitment and retention of Kuwaiti national dentists and dental students.

The nursing workforce in Kuwait to the year 2020.

BACKGROUND: The study addresses the supply and demand for nurses in Kuwait in the light of emerging variables such as increasing population, economic growth, changes in healthcare strategies and expansion of healthcare facilities. OBJECTIVE: To project the future demand for nurses in Kuwait for the years 2007-2020 based on the period 1994-2006. METHODS: Population projections were derived using the average annual natural increase rate of the 1994-2006 populations. The future demand for nurses was projected using the average nurse to population ratios for the years 1994-2006. FINDINGS: The number of Kuwaiti indigenous nurses is declining at an average decrement rate of 3.3% per annum. There is a gap between the numbers of native and migrant nurses, which will be wider with time. In 2006, native nurses constituted only 6.6% of the nursing workforce; this affects the quality of provided health care owing to language, religions and socio-cultural barriers between foreign nurses and patients. CONCLUSIONS: The supply of indigenous nurses in Kuwait should be increased in order to deliver effective nursing care with shared culture and language in the modern healthcare system of Kuwait. This can be achieved through an improvement in recruitment and retention of indigenous nurses and nursing students.

Prevalence of angiotensin-converting enzyme gene insertion-deletion polymorphism in patients with primary knee osteoarthritis.

OBJECTIVE: Angiotensin converting enzyme (ACE) plays an important role in a number of inflammatory and immune related disorders. This study was undertaken to investigate an association between Angiotensin converting enzyme (ACE) gene insertion- deletion (I/D) polymorphism and primary knee osteoarthritis (OA) in Kuwait and to explore a correlation between clinical subgroups of OA and ACE I/D polymorphism genotypes. PATIENTS AND METHODS: The prevalence of ACE gene I/D polymorphism was determined in 115 patients with primary knee OA and 111 ethnically matched healthy controls by using polymerase chain reaction (PCR) of the genomic DNA. The association of ACE gene I/D polymorphism genotypes was also studied with age of disease onset, function and radiological grading. RESULTS: No significant difference was detected in the frequency of ACE gene I/D polymorphism genotypes and alleles between knee OA patients and the controls. The frequency of ACE gene polymorphism genotypes was also studied in subgroups on the basis of clinical parameters of age of onset of disease, function and radiological grading and no significant difference was detected between subgroups of OA patients and the controls. This is in sharp contrast to a previous report from Korea in which a significant association has been reported between ACE gene polymorphism and knee OA. CONCLUSION: This study did not find an association between ACE gene I/D polymorphism genotypes in Kuwaiti patients with primary knee osteoarthritis and the onset or severity of the disease, which is very different from Korean knee OA patients in which an association has been reported.

Musculoskeletal pain, disability and health-seeking behavior in adult Kuwaitis using a validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire.

OBJECTIVE: The WHO-ILAR Community Oriented Program for Control of Rheumatic Diseases (COPCORD) primarily aims to estimate the burden of musculoskeletal symptoms/disorders. We investigated data on musculoskeletal pain, disability and health-seeking behavior in the first community-based COPCORD study in Kuwait. METHODS: The validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire was used in 2,500 randomly selected Kuwaiti households. The target population comprised Kuwaiti nationals aged 15 years and older. Twenty-four trained field workers completed the survey in 8 weeks. Those subjects reporting musculoskeletal pain were identified (Phase 1), and were asked to complete a self-evaluation questionnaire (Phase 2) prior to rheumatological examination (Phase 3). Phase 2 included questions on the site and severity of pain, traumatic events, functional disability, and treatment. Patients marked their pain sites on a mannequin during their interviews. "Sufferers" were defined as those with musculoskeletal pain and no history of trauma. RESULTS: A total of 7,670 adults were interviewed (response rate 88%), of whom 2,057 had musculoskeletal pain not related to trauma. Knees, back, and shoulders were the common sites of pain. Most of the sufferers reported the severity of pain as being moderate to severe. Functional disability was reported in 39.1% of the sufferers. The age-sex population adjusted prevalence rate for musculoskeletal pain was 35.7% in females and 20.2% in males. The most common sources for advice on treatment were physicians in hospitals (68.8%) and general practitioners (30.4%). 82% had prescriptions for their medications, while 19.4% had self prescribed tablets. CONCLUSION: Musculoskeletal pain is a major health problem among Kuwaitis and deserves intense government attention.

Urine levels of type 1 collagen cross-linked N-telopeptides and deoxypyridinoline correlate with disease activity in rheumatoid arthritis.

OBJECTIVES: The aim of this study was to find out whether spot urinary concentrations of type 1 collagen cross-linked N-telopeptides (NTx) and deoxypyridinoline (Pyrilinks-D) can differentiate between active and inactive disease in rheumatoid arthritis (RA) and to investigate the extent to which they correlate with indices of disease activity. METHODS: Using enzyme-linked immunosorbent assays, the concentrations of NTx and Pyrilinks-D were estimated in spot urine samples from 25 females with active disease, 25 females with inactive disease, and in 25 controls. RESULTS: In Patients with active disease, urinary concentrations of NTx and Pyrilinks-D were significantly higher (p < 0.01) than in those with inactive disease or in healthy controls. In active disease there were significant positive correlation between urinary NTx and ESR, the swollen joint count, the tender joint count, and the patient's global assessment.

Systemic lupus erythematosus in Kuwait--hospital based study.

The present study describes the clinical characteristics of patients with systemic lupus erythematosus (SLE), from the rheumatology service of the two main teaching hospitals in Kuwait. It was a retrospective-cum-prospective clinical study of 108 SLE patients. There were 98 females and 10 males, with a median age of 31.5y. Kuwaitis constituted 69%, while 31% were expatriates. The mean disease duration was 62 months. The main clinical features were: musculoskeletal involvement (87%), photosensitivity (48%), malar rash (43%), discoid lesions (10%), oral ulcers (33%), vasculitic skin lesions (10%), haematological features (53%), constitutional symptoms (51.4%), neuropsychiatric manifestations (23%), renal involvement (37%), serositis (29%), clinical manifestations of antiphospholipid syndrome (21%), cardiac involvement (10%) and pulmonary manifestations (19%). In conclusion, the clinical features of SLE in Kuwait were similar to most major studies from developed countries. Main differences included prominent haematological and mucocutaneous manifestations and possibly a low prevalence of anti-Sm antibodies. Whether these differences are due to the environment or genetic factors, remains to be studied.

Characteristics of osteoarthritis among Kuwaitis: a hospital-based study.

Sixty-nine Kuwaiti patients with osteoarthritis (OA) were studied. Primary knee OA was seen in 65 (94.2%) patients. The mean age of this group was 53.18 years with a range of 39-97 years. The female to male ratio was 2.82:1. OA was bilateral in 84.62% and predominantly involved the medial tibiofemoral joint. According to Kellgren's grading of knee OA, grade 1 changes were present in 40.0%, grade 2 in 32.5%, grade 3 in 22.5% and grade 4 in 5.0%. Grade I obesity was seen in 13%, grade II in 64% and grade III in 23% of patients. Generalised primary nodular OA was seen in only four patients, all of whom were women. Primary OA of the hip joint and chondrocalcinosis were conspicuous by their absence.

Rheumatic manifestations and immunological abnormalities in patients with chronic hepatitis C. A study in the Middle East.

Hepatitis C virus infection and rheumatic disorders are both common in the Middle East and share many clinical and immunological manifestations, raising diagnostic problems. We compared the prevalence of extrahepatic clinical manifestations and immunological disorders in 40 patients with chronic hepatitis C and in 42 carefully matched healthy controls. Polyarthralgia or polyarthritis was the most common rheumatic manifestation (35%) in the cases, followed by cutaneous vasculitis (15%). Glomerulonephritis and xerophthalmia were uncommon, and none of the cases had systemic vasculitis. Immunological abnormalities included serum rheumatoid factor (47.5%), cryoglobulins (30%), and one or more antitissue antibodies (37.5%). The prevalences of polyarthralgia, cutaneous vasculitis, rheumatoid factor, cryoglobulinemia, and anti-tissue antibodies were significantly higher in the hepatitis C group than in the control group. Our data suggest that patients in the Middle East who present with features of rheumatic or autoimmune diseases should be screened for hepatitis C.

Validation of the Arabic version of the Health Assessment Questionnaire (HAQ) in patients with rheumatoid arthritis.

UNLABELLED: Several instruments for measuring functional status in rheumatic diseases have been developed and validated. However, none is as yet available in Arabic. OBJECTIVE: To translate the Health Assessment Questionnaire (HAQ) from English to Arabic and to test the metrological properties, reliability, and validity of the Arabic version. METHODS: The study included 41 consecutive patients seen at the outpatient rheumatology clinic of a large teaching hospital in Kuwait for rheumatoid arthritis meeting 1987 American College of Rheumatology criteria. The HAQ was translated from English to Arabic by three translators who were aware of the intended use of the questionnaire. The translated questionnaire was administered to each patient during two clinic visits seven to ten days apart. Test-retest reliability was assessed based on the intraclass correlation coefficient. Internal consistency of individual items with the overall score was assessed using Cronbach's alpha coefficient. Construct validity was evaluated by determining Spearman's correlation between the Arabic HAQ score and disease activity variables. RESULTS: There were 34 women and seven men, with a median age of 38 years and a median disease duration of 5.3 years. Test-retest reliability was 0.81, internal consistency was 0.93, and construct validity ranged from 0.5 (erythrocyte sedimentation rate) to 0.75 (pain). CONCLUSION: The HAQ-A retains the characteristics of the original American version, and is a reliable and valid instrument for measuring functional disability in Arabic-speaking patients with rheumatoid arthritis.

Hughes syndrome: a common problem in Kuwait hospitals.

The objective was to study antiphospholipid antibody syndrome (APS or Hughes syndrome) in two major teaching hospitals in Kuwait. patients with suspected Hughes syndrome were investigated with tests for anticardiolipin antibodies (aCL) and lupus anticoagulants (LAC) over 1 yr. Diagnosis was considered confirmed if significant levels of either or both antibodies with no obvious cause (primary), or with systemic lupus erythematosus (SLE) or SLE-like illness (including SLE serology) (secondary) were present. Twelve (37.5%; seven females, 58%) primary and 20 (62.5%; 18 females, 90%) secondary Hughes syndrome patients were seen during this period. patients were Kuwaiti, Middle-Eastern and North-African Arabs (29). Filipinos (2) and White (1). None were from the Indian subcontinent. The main presentation was thrombosis in 75% (arterial in 25% and venous in 50%), and recurrent abortions in 50% of married women. Haematological and dermatological manifestations were limited entirely to the secondary variety, seen in 25% and 19%, respectively. Clinical manifestations were severe, leading to death in one, intensive-care management in 31% and with partial or complete warfarin resistance or brittleness in 25%. Neurological/eye and cardiac manifestations were not seen, as these patients may be attending separate speciality hospitals for these diseases in Kuwait. The approximate prevalence of this syndrome was 2.66/1000 admissions in medical wards. Projected to the total referral areas of the two hospitals, an approximate figure of 52 patients/million population/year was obtained. Hughes syndrome was a common problem among Arabs, Filipinos and possibly Whites in Kuwait. Its manifestations were severe, often requiring intensive-care management, and in one case it was fatal. Patients from the Indian subcontinent were conspicuous by their absence, despite the fact that they were well represented in all other rheumatic disease groups. Ethnic and/or geographical factors could be important in this syndrome. To the best of our knowledge, this is the first report of Hughes syndrome from the Middle East.

Seronegative rheumatoid arthritis and HLA-DR4.

OBJECTIVE: To investigate the prevalence of HLA-D region antigens in patients with seronegative rheumatoid arthritis (RA). METHODS: The distribution of HLA-D region antigens was studied in 33 patients with seronegative RA. All patients were followed for at least 3 years, during which tests for IgM rheumatoid factor were negative on at least 3 occasions. HLA-D region antigens were defined by serological and molecular techniques (oligonucleotide typing). RESULTS: Our data demonstrate that DR4 was significantly (p < 0.021) increased in patients (45.5%) compared to normal controls (22.9%). Although the prevalence of DR1 was essentially the same in patients (15.2%) as in healthy controls (14.3%), the frequency of DR1 and/or DR4 was significantly (p < 0.018) increased in patients (60.6%) compared to healthy subjects (35.7%). The prevalence of remaining DR antigens and of DQ and DP specificities in patients with seronegative RA was not different from that in healthy controls. CONCLUSION: Our results together with those published by other investigators suggest that both seropositive and seronegative RA are associated with DR4 and may therefore share the same immunogenetic bases.

Immunogenetics of polymyalgia rheumatica.

The distribution of HLA-D region antigens was studied in 17 patients with well-documented polymyalgia rheumatica (PMR). HLA-D region antigens were defined by the oligonucleotide typing of polymerase chain reaction (PCR)-amplified genomic DNA. The results demonstrate that the prevalence of DR4 was significantly higher (p < 0.0002; RR = 8.10) in patients (70.6%) compared to normal controls (22.9%), and the frequency of DR1 and/or DR4 in patients (82.4%) was also higher (p < 0.0006; RR = 8.40) than that in normal healthy controls (35.7%). Of the subtypes of DR4,Dw13 was significantly higher (p < 0.002; RR = 9.30) in patients (29.4%) than in normal controls (4.3%). However, these data must still be confirmed by other investigators. The distribution of the remaining DR antigens and of the DQ and DP alleles in patients did not differ significantly from those in controls. The results suggest immunogenetic similarity between PMR and late onset rheumatoid arthritis in elderly populations.

Rheumatic complications of alcohol abuse.

The purpose of this report is to review rheumatic complications associated with alcoholism. Data were collected by an English-language literature search using MEDLINE (1966 to December 1991) and references from identified articles. Studies in humans, including case reports of joint disease and allied disorders associated with alcoholism, were reviewed. According to the data identified, alcoholism is associated with many rheumatic problems, including neuropathic arthropathy, hyperuricemia with gouty arthritis, septic arthritis, and joint hypermobility. Osteoporosis, osteonecrosis, and myopathy also are common. Several other rare musculoskeletal complication have been described. Early recognition of these problems is important for management. Further studies are needed to examine the effect of alcohol on connective tissue components in joints.