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.

'It's about time'. Dissemination and evaluation of a global health systems strengthening roadmap for musculoskeletal health - insights and future directions.

Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions-the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A 'roadmap' for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents 'agreed' or 'strongly agreed' the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated.

Tofacitinib versus methotrexate as the first-line disease-modifying antirheumatic drugs in the treatment of rheumatoid arthritis: An open-label randomized controlled trial.

OBJECTIVE: To compare tofacitinib and methotrexate (MTX) as first-line disease-modifying antirheumatic drugs (DMARDs) for rheumatoid arthritis (RA). METHODS: This open-label, randomized controlled, parallel-group, 3-month trial randomly assigned 100 RA patients to tofacitinib 10 mg daily (49 patients) or MTX 25 mg subcutaneously weekly (51 patients). The primary end point was low disease activity (LDA) measured with Disease Activity Score-28 with C-reactive protein (DAS28-CRP), and the secondary end point was LDA and remission measured by DAS28-erythrocyte sedimentation rate (ESR), Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI). Health Assessment Questionnaire Disability Index (HAQ-DI) response and mean reduction of core set of outcomes from baseline at 12 weeks were also analyzed as secondary end points. In addition, acute-phase reactants and composite measurements among groups were examined. RESULTS: LDA in DAS28-CRP was achieved in 17 (34.7%) tofacitinib patients and 18 (35.3%) MTX patients (p = .95). Fourteen (28.6%) and 11 (21.6%) tofacitinib and MTX patients, respectively, achieved LDA by DAS28-ESR (p = .42). Tofacitinib and MTX groups achieved LDA similarly in CDAI (36.7% against 37.3%; p = .96) and SDAI (38.8% vs. 39.2%; p = .96). There was no significant difference in achieving remission between the groups. At 12 weeks, tofacitinib reduced ESR and CRP (p < .05). Composite measures and functional status decreased within groups but not between groups (p > .05). Five (13.51%) tofacitinib patients developed hypertension. MTX caused gastrointestinal problems in 12 (30%) individuals. Two MTX (5%) and two tofacitinib (5.4%) patients had increased liver enzymes and renal impairment, respectively. Tofacitinib had 5.4% infection compared with 5% for MTX. CONCLUSIONS: As tofacitinib may be more effective than MTX according to previous reports such as the ORAL Start study, high-dose MTX (25 mg/week, subcutaneously) used in this study may be as efficacious as tofacitinib in patients with established RA who were DMARD naive or had not received a therapeutic dose of DMARDs. However, adverse effects differed between groups. Registered on: ClinicalTrials.gov; ID: NCT04464642.

Tofacitinib for the treatment of inflammatory bowel disease-associated arthritis: two case reports.

BACKGROUND: Musculoskeletal manifestations are common extraintestinal manifestations of inflammatory bowel disease. Tofacitinib is a Janus kinase inhibitor approved for treating rheumatoid arthritis and ulcerative colitis. There are limited data on the efficacy of tofacitinib in managing inflammatory bowel disease-associated arthritis. Here we report two patients with ulcerative colitis- and Crohn's disease-associated arthritis successfully responding to tofacitinib. CASES: A 34-year-old Bangladeshi woman presented with lower limb polyarthritis for 7 years. Six months after the onset of polyarthritis, she developed abdominal pain with rectal bleeding. Colonoscopy and rectal biopsy findings confirmed ulcerative colitis. Ulcerative colitis associated arthritis was diagnosed. Treatment with sulfasalazine, etanercept, adalimumab, infliximab, and methotrexate gave no long-lasting remission. Methotrexate with mesalazine gave a partial response, and tofacitinib 5 mg twice per day was added. Her articular and abdominal symptoms improved within a month, and remission persisted till 24 months of follow-up, except a short-lasting mild flare at the seventh month. A 52-year-old Bangladeshi man had Crohn's disease for 5 years. He presented with a swollen left knee and pain in other joints. Laboratory showed positive HLA-B27. He was intolerant to sulfasalazine and experienced poor response to methotrexate. Due to his inability to afford anti-tumor necrosis factor, tofacitinib was initiated. His arthritis improved within a month, and he remained in remission up to the sixth month. CONCLUSIONS: In a woman with ulcerative colitis associated arthritis, refractory to biologic therapy, both arthritis and colitis improved with tofacitinib. A patient with Crohn's disease-associated arthritis went into remission with tofacitinib. Tofacitinib may be effective in inflammatory bowel disease-associated arthritis.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies.

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

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.

Relationship Between Vitamin D Status and Brain Perfusion in Neuropsychiatric Lupus.

Purpose: Neuropsychiatric manifestation of lupus (NPSLE) is related with vitamin D (vit-D) deficiency which is possibly amenable to supplementation. This study was done to explore link of serum vit-D level and clinical mini-mental state examination (MMSE) with brain perfusion SPECT (BS) in patients with NPSLE. Methods: Patients who underwent BS with the diagnosis of NPSLE and had serum levels of vit-D and MMSE within a span of 1 month were retrospectively included. The BS DICOM data were used to generate 3D surface images of brain for visual identification of regional hypoperfusion, and the z-scores from eZIS software and then to perform voxel-based regression analysis in order to explore association between serum vit-D level and cerebral perfusion deficit using SPM8. Distribution of serum vit-D level was checked across MMSE and BS z-score using R. Results: A total 19 patients with means ± SD age of 28.4 ± 9.2 years, having mean levels of serum vit-D of 18.7 ± 9.8 ng/ml and mean MMSE scores 24.2 ± 1.6, had undergone BS. The eZIS-derived z-score fall in the category of normal in six (31.6%), mild perfusion deficit (PD) in 10 (52.6%) and moderate PD in three (15.8%) with the means ± SD of z-score being 0.52 ± 0.2, 1.72 ± 0.2, and 2.33 ± 0.2. Voxel-based analysis revealed significant positive correlation between vit-D level and hypoperfusion in brain regions related to cognitive function (p<0.05). Serum vit-D levels were significantly lower in NPSLE patients with lower MMSE scores as well as in higher eZIS z-score (p < 0.01). Conclusions: Our results may support the utility of vit-D supplementation in NPSLE and applicability of BS as a clinical adjunct for monitoring response to vit-D supplementation.

Risk factors of knee osteoarthritis in Bangladeshi adults: a national survey.

BACKGROUND: Knee osteoarthritis was reported as the second most prevalent condition in the national musculoskeletal survey. The purpose of this extended study was to identify risk factors for knee osteoarthritis in Bangladeshi adults. METHODS: This cross-sectional study was conducted in rural and urban areas of Bangladesh using stratified multistage cluster sample of 2000 adults aged 18 years or older recruited at their households. The Modified Community Oriented Program for Control of Rheumatic Disorders (COPCORD) questionnaire was used to collect data. The diagnosis of knee osteoarthritis was made using the decision tree clinical categorization criteria of the American College of Rheumatology. Univariate and multivariate logistic regression analyses were done to identify the risk factors for knee osteoarthritis. RESULTS: A total of 1843 individuals (892 men and 951 women) participated, and 134 had knee osteoarthritis yielding a prevalence of 7.3% (95% confidence interval (CI) 4.9 to 9.6%). The mean (standard deviation) age of the knee osteoarthritis patients was 51.7 (11.2) years. Multivariate logistic regression analysis found a significant association with increasing age (≥38 years OR 8.9, 95% CI 4.8-16.5; ≥58 years OR 13.9, 95% CI 6.9-28.0), low educational level (OR 1.7, 95% CI 1.0-2.7) and overweight (OR 1.9, 95% CI 1.2-2.9) with knee osteoarthritis. Knee osteoarthritis patients had a high likelihood of having work loss preceding 12 months (age and sex-adjusted OR 2.3; 95% CI 1.4-3.8; P < 0.01). CONCLUSIONS: Knee osteoarthritis is a commonly prevalent musculoskeletal problem among Bangladeshi adults having link to work loss. Increasing age, low education and overweight are significant risk factors of knee osteoarthritis.

Digital Gangrene: An Unusual Manifestation of Non-Hodgkin Lymphoma.

Background: Non-Hodgkin lymphomas (NHLs) comprise a group of haematologic malignancies with different histologic subtypes. The clinical picture varies from indolent to aggressive presentation and nodal (lymphadenopathy) to extranodal (central nervous system, gastrointestinal, cutaneous plaque, or ulcer) involvement. Digital gangrene is seldom reported. Here, we describe a patient with pain and blackening of all fingers and toes as presenting symptoms of NHL. Case Presentation. A 32-year-old male weaver had been smoking three to five cannabis-containing cigarettes daily for about ten years and methamphetamine four to five tablets daily for five years. He had no history of Raynaud's phenomenon, fever, cough, weight loss, skin rash, joint pain, and atherogenic or thrombogenic risk factors. We found normal blood pressure and absent peripheral pulses in arms and legs, dry gangrene of all fingers and toes, generalized lymphadenopathy, and hepatomegaly with ascites. The chest X-ray was normal, as were blood sugar, lipid profile, and hepatic and renal function. Rheumatoid factor, antinuclear and antiphospholipid antibodies, C-ANCA and P-ANCA, hepatitis B and C, and HIV were negative. CT abdomen revealed hepatosplenomegaly with multiple intra-abdominal lymphadenopathies. The peripheral angiogram showed 90-99% stenosis of radial and dorsalis pedis arteries with normal proximal vessels. Diagnosis of non-Hodgkin lymphoma was confirmed by histopathology of cervical lymph node (diffuse type), immunohistochemically subtyped as peripheral T cell lymphoma (not otherwise specified). The digital ischemia worsened despite cessation of cannabis and methamphetamine and starting CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) treatment, making amputation necessary. Conclusion: We present, to our knowledge, the first report of peripheral T cell lymphoma, NOS presenting with gangrene in all digits complicated by methamphetamine and cannabis abuse. This uncommon vascular manifestation of non-Hodgkin lymphoma may cause a diagnostic dilemma and delayed initiation of treatment.

2021 Asia-Pacific League of Associations for Rheumatology clinical practice guideline for treatment of gout.

BACKGROUND: Gout is the most prevalent inflammatory arthritis in the Asia-Pacific region and worldwide. This clinical practice guideline (CPG) aims to provide recommendations based on systematically obtained evidence and values and preferences tailored to the unique needs of patients with gout and hyperuricemia in Asia, Australasia, and the Middle East. The target users of these guidelines are general practitioners and specialists, including rheumatologists, in these regions. METHODS: Relevant clinical questions were formulated by the Steering Committee. Systematic reviews of evidence were done, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation methodology. A multi-sectoral consensus panel formulated the final recommendations. RESULTS: The Asia-Pacific League of Associations for Rheumatology Task Force developed this CPG for treatment of gout with 3 overarching principles and 22 recommendation statements that covered the treatment of asymptomatic hyperuricemia (2 statements), treatment of acute gout (4 statements), prophylaxis against gout flare when initiating urate-lowering therapy (3 statements), urate-lowering therapy (3 statements), treatment of chronic tophaceous gout (2 statements), treatment of complicated gout and non-responders (2 statements), treatment of gout with moderate to severe renal impairment (1 statement), and non-pharmacologic interventions (5 statements). CONCLUSION: Recommendations for clinically relevant scenarios in the management of gout were formulated to guide physicians in administering individualized care.

Low back pain in the Bangladeshi adult population: a cross-sectional national survey.

OBJECTIVE: Low back pain (LBP) is a common musculoskeletal disorder. This study aims to determine the residence-specific and sex-specific prevalence and the factors associated with LBP in Bangladesh. METHODS: The study subjects (aged ≥18 years) were identified from 20 primary sampling units of the national census following a cross-sectional multistage stratified sampling design. We considered the mechanical type of LBP for this study. A Bangla version of the modified Community Oriented Programme for Control of Rheumatic Disorders questionnaire was used. A team of trained field workers, rheumatology residents and rheumatologists collected the data. Analysis was done using weighted data. RESULTS: Two thousand subjects were approached, but 1843 could be screened. Among them, 561 had musculoskeletal disorders, and 343 were diagnosed with LBP. The weighted prevalence of LBP was 18.5% (95% CI: 11.8% to 25.2%) and age-standardised prevalence of LBP was 19.4% (95% CI: 14.0% to 24.8%), which was higher in women (27.2%, 19.3% to 35.1%) than men (14.0%, 8.7% to 19.3%). The prevalence persistently increased from age group 18-34 years (10.5%, 5.7 to 15.4) to ≥55 years (27.8%, 16.1% to 39.5%). People with no education had the highest prevalence (31.3%, 22.3% to 40.4%). The prevalence did not differ between urban and rural residential locations. Four factors were significantly associated with LBP: age (adjusted odds ratio: 2.4, 95% CI: 1.7 to 3.4), female sex (2.2, 1.5 to 3.3), absence of formal education (2.3, 1.6 to 3.3) and hypertension (1.7, 1.1 to 2.6). CONCLUSION: LBP is a common problem in Bangladeshi adults. The factors identified are age, female sex, no formal education and hypertension. These should be addressed adequately to prevent and treat LBP.

Cross-cultural adaptation and validation of revised WHO-ILAR-COPCORD core English questionnaire translated to Bangla.

BACKGROUND: The Community-Oriented Program for Control of Rheumatic Diseases (COPCORD) is intended to reduce the information deficit about the epidemiology of rheumatic diseases, particularly in rural communities in high-income countries. Multiple studies have been conducted using the WHO-International League of Associations for Rheumatology (ILAR)-COPCORD core questionnaire in Bangladesh using the translated version in the Bangla language. Cross-cultural adaptation and validation of the questionnaire are important to achieve better outcomes. AIM: To develop a culturally adapted, valid, and reliable Bangla version of the WHO-ILAR-COPCORD Core English Questionnaire to use as a rheumatic screening instrument among Bangla-speaking people. METHODS: The original English WHO-ILAR-COPCORD questionnaire was translated into Bangla and adapted in the local socio-cultural context maintaining idiomatic, semantic, experiential, and conceptual equivalence between the English and Bangla versions. Pretesting was carried out among 30 patients and healthy attendants, following standard international recommendations. Content validity of the adapted Bangla version was assessed by the item- and scale-level content validity indices (I-CVI and S-CVI). The adapted Bangla version of the WHO-ILAR-COPCORD questionnaire was used to assess 120 patients with rheumatic problems and healthy individuals. Test-retest reliability was assessed using intraclass correlation coefficients. RESULTS: The Bangla version of the WHO-ILAR-COPCORD questionnaire showed excellent content validity (I-CVI = 1, S-CVI = 1). The test-retest reliability was also acceptable (intraclass correlation coefficient > 0.7). CONCLUSION: The adapted Bangla version of the WHO-ILAR-COPCORD questionnaire demonstrated acceptable psychometric properties, in terms of content validity and test-retest reliability, for evaluating rheumatic problems in Bangladeshi patients.

Updated APLAR consensus statements on care for patients with rheumatic diseases during the COVID-19 pandemic.

AIM: To update previous guidance of the Asia Pacific League of Associations for Rheumatology (APLAR) on the management of patients with rheumatic and musculoskeletal diseases (RMD) during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Research questions were formulated focusing on diagnosis and treatment of adult patients with RMD within the context of the pandemic, including the management of RMD in patients who developed COVID-19. MEDLINE was searched for eligible studies to address the questions, and the APLAR COVID-19 task force convened 2 meetings through video conferencing to discuss its findings and integrate best available evidence with expert opinion. Consensus statements were finalized using the modified Delphi process. RESULTS: Agreement was obtained around key aspects of screening for or diagnosis of COVID-19; management of patients with RMD without confirmed COVID-19; and management of patients with RMD with confirmed COVID-19. The task force achieved consensus on 25 statements covering the potential risk of acquiring COVID-19 in RMD patients, advice on RMD medication adjustment and continuation, the roles of telemedicine and vaccination, and the impact of the pandemic on quality of life and on treatment adherence. CONCLUSIONS: Available evidence primarily from descriptive research supported new recommendations for aspects of RMD care not covered in the previous document, particularly with regard to risk factors for complicated COVID-19 in RMD patients, modifications to RMD treatment regimens in the context of the pandemic, and COVID-19 vaccination in patients with RMD.

Development of a Bangla version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI).

AIM: Development of a Bangla version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI). METHODS: This biphasic observational study performed the translation and adaptation of the questionnaires carried out in 5 steps with pre-testing in 30 AS patients followed by the psychometric validation of the pre-final Bangla version utilizing content and construct validity in 115 AS patients. The reliability was examined through internal consistency and test-retest reliability involving 23 AS patients. RESULTS: After pre-testing of the pre-final Bangla version of both indices, the psychometric validation found that the convergent validity of Bangla version of BASDAI showed strong correlation with C-reactive protein (r = .75) and the Maastricht Ankylosing Spondylitis Enthesitis (r = .64), and moderate correlation with erythrocyte sedimentation rate (r = .49). Again, the Bangla BASFI showed significant correlation with occiput-to-wall distance (OWD) (r = .50), mentum-to-sternum distance (MSD) (r = .50), chest expansion (CE) (r = -.40), finger-to-floor (FFD) (r = .55), number of swollen joints (r = .69), and number of enthesitis (r = .68). The divergent validity demonstrated weak correlations between BASDAI and OWD (r = .43), MSD (r = .34), CE (r = -.44), FFD (r = .47). The divergent validity of BASFI could not be assessed due to lack of a suitable comparing parameter. The instruments revealed acceptable internal consistency as Cronbach's alpha was 0.86 for BASDAI and 0.93 for BASFI. A 7-day test-retest reliability measured by the intraclass correlation coefficient were 0.80 (CI at 95% = 0.58-0.90) for BASDAI and 0.83 (CI at 95% = 95% 0.64-0.92) for BASFI respectively. CONCLUSIONS: Bangla version of BASDAI and BASFI may be useful in disease activity and functional ability assessment in AS patients.

AL amyloidosis presenting as inflammatory polyarthritis: a case report.

Amyloidosis is a condition characterised by extracellular tissue deposition of fibrils causing a wide range of clinical manifestations. This protein deposition can occur in any tissue, most commonly in the kidney, heart, skin, peripheral nervous system, and gastrointestinal tract. However, the deposition of amyloid fibrils in the synovium is seldom reported. Musculoskeletal manifestations are subtle, subclinical and rarely the patient presents with symptoms that resemble rheumatic diseases. Here, we describe a 55-year-old man with AL (amyloid light chain) amyloidosis who presented with inflammatory polyarthritis with significant morning stiffness, inflammatory low back pain, and painful thickened tongue. The patient had anaemia, macroglossia with lateral scalloping of the tongue, papules, and plaques in the periocular, perioral and perinasal area, bilateral carpal tunnel syndrome, localised soft tissue swelling over the joints, restricted movement in different joints with flexion contractures in some joints. Rheumatoid factor and ACPA were negative and the X-ray of the sacroiliac joints was normal. We confirmed amyloidosis by biopsy of an affected skin lesion. In the urine, no Bence Jones protein was found and bone marrow study and x-ray of the skull were normal. Plasma immuno-electrophoresis and serum free light chain (FLC) assay confirmed lambda light chain type monoclonal gammopathy. Take home message: Although AL amyloidosis is a rare condition, it should be considered while evaluating atypical symptoms in patients presenting with rheumatic complaints. A high index of suspicion is necessary for proper diagnosis as delay in diagnosis will yield a poorer treatment outcome.

Prevalence of musculoskeletal conditions and related disabilities in Bangladeshi adults: a cross-sectional national survey.

BACKGROUND: Nationally representative data on burden of musculoskeletal conditions (MSK) in Bangladesh are not available. The objective of this study was to determine the prevalence of MSK conditions and related disabilities in the adult population of Bangladesh. METHODS: A total of 2000 individuals aged 18 years or older were targeted from 20 primary sampling units (urban and rural) of all former seven divisions of Bangladesh in 2015. Structured interviews were done using the modified Community Oriented Program for Control of Rheumatic Disorders questionnaire to detect positive respondents. Standard criteria were used for diagnosing MSK conditions by rheumatology residents. In case of uncertainty, opinion was taken from senior rheumatologists. A Bangla version of the Health Assessment Questionnaire was used to determine disability. RESULTS: A total of 1843 (92.1%) participated. Among them, 892 men and 951 women participated from rural (n = 716) and urban (n = 1127) areas. Their mean age was 40.5 (standard deviation 14.7) years. Almost a third did not have any formal schooling. Overall, 30.4% (95% confidence interval, 28.3-32.5) had MSK conditions. Low back pain (18.6%, 16.9-20.5), knee osteoarthritis (7.3%, 6.1-8.5) and soft tissue rheumatism 3.8% (2.9-4.7) were the three top-ranking MSK conditions. Rheumatoid arthritis (1.6%, 1.0-2.1), spondyloarthritis (1.2%, 7-1.8) and adhesive capsulitis (1.4%, 0.9-1.9) were relatively uncommon. Among those who had MSK conditions, 24.8% (21.3-28.6) had some degree of disability. Of them, 24.4% (21.0-28.1) had history of work loss during last 12 months. CONCLUSIONS: The high burden of MSK conditions and related disabilities in Bangladesh warrants greater attention of the health system. Further studies are needed to estimate the impact of this group of conditions particularly addressing related disabilities and loss of work.

Translation, cross-cultural adaptation and validation of the English Lequesne Algofunctional index in to Bengali.

BACKGROUND: This study was focused on translation and cultural adaptation of the English Lequesne Algofunctional index (LAI) into Bengali for patients with primary knee osteoarthritis (OA) and testing reliability and validity of the Bengali version of the LAI. METHODS: This study was carried out in the Department of Rheumatology, BSM Medical University, Dhaka, Bangladesh. Using the forward-backward method the English LAI was translated into Bengali including cultural adaptation. For pretesting, A sample of 40 patients with primary knee osteoarthritis were screened using the Bengali version of LAI. Following the pretest, 130 consecutive patients with symptomatic knee OA completed the interviewer administered Bengali LAI, the validated Bengali version of SF-36, Visual Analogue Scale for Pain, Distance Walked and Activities of Daily Living. For the retest 60 randomly selected patients from the cohort were administered the Bengali LAI 7 days later. An item by item analysis was performed. Internal consistency was assessed by Cronbach's alpha, test-retest reliability by intraclass correlation coefficient (ICC) and Kappa coefficient, construct validity was measured using the Spearman rank correlation coefficient. RESULTS: It took 3.25 ± 0.71 min to complete the Bengali LAI and the mean score was 9.23 ± 4.58. For the Bengali LAI Cronbach's alpha score was 0.88, test-retest reliability assessed by ICC was 0.97. For construct validity, excellent convergent validity was achieved (ρ = 0.93) but the divergent validity was moderate (ρ = 0.43). CONCLUSIONS: The Bengali LAI showed excellent convergent validity, internal consistency and test-retest reliability, only the divergent validity was moderate. So, the Bengali LAI can be applied as a HRQoL assessment tool for primary knee OA patients.

Translation, cross-cultural adaptation and validation of the Pain Catastrophizing Scale (PCS) into Bengali in patients with chronic non-malignant musculoskeletal pain.

AIM: To develop a culturally adapted and validated Bengali Pain Catastrophizing Scale (BePCS). METHODS: The English PCS was translated, adapted and back-translated into and from Bengali, pre-tested by 30 adult patients with chronic non-malignant musculoskeletal pain. The BePCS was administered twice with 14 days interval to 90 patients. Convergent validity was measured by comparing the BePCS score with scores of the domains physical functioning and mental health of the Bengali Short Form 36, through Spearman's correlation coefficient. Test-retest reliability was assessed by intraclass correlation coefficient (ICC) and Spearman's rank correlation coefficient and internal consistency by Cronbach's alpha. Content validity was assessed by index for content validity (ICV) and floor and ceiling effects. RESULTS: The BePCS was well accepted by the patients in the pre-test. The content validity was excellent, both item ICV and scale ICV were 1. Construct validity: the convergent validity was -0.424 for physical functioning and -0.413 for mental health, indicating a moderate negative correlation. Total BePCS score showed excellent internal consistency with a mean Cronbach's α = 0.92. Internal consistency for subscales rumination, magnification and helplessness, were Cronbach's α 0.903, 0.72 and 0.872 respectively. The test-retest reliability of total BePCS was 0.78 (P < .001) and for the subscales rumination 0.872 (P < .001), magnification 797 (P < .001) and helplessness 0.927 (P < .001), showing excellent test-retest reliability. CONCLUSIONS: The interviewer-administered BePCS appears to be an acceptable, reliable and valid instrument for measuring health-related quality of life in Bengali speaking patients with chronic non-malignant musculoskeletal pain. Further evaluation in the general population and in different medical conditions should be done.