Telehealth in rheumatology: the 2021 Arab League of Rheumatology Best Practice Guidelines.

To develop Best Practice Guidelines (BPG) for the use of Telehealth in Rheumatology in the Arab region, to identify the main barriers and facilitators of telehealth, and to provide rheumatologists with a practical toolkit for the implementation of telehealth. Guidelines were drafted by a core steering committee from the Arab League of Associations for Rheumatology (ArLAR) after performing a literature search. A multidisciplinary task force (TF), including 18 rheumatologists, 2 patients, and 2 regulators from 15 Arab countries, assessed the BPG using 3 rounds of anonymous online voting by modified Delphi process. The statements were included in the final BPG without further voting if ≥ 80% of TF members indicated high agreement. The voting on barriers and facilitators was performed through one voting round. The toolkit was developed based on available literature and discussions during the Delphi rounds. Four General Principles and twelve Statements were formulated. A teleconsultation was specifically defined for the purpose of these guidelines. The concept of choice in telehealth was highlighted, emphasizing patient confidentiality, medical information security, rheumatologist's clinical judgment, and local jurisdictional regulations. The top barrier for telehealth was the concern about the quality of care. The toolkit emphasized technical aspects of teleconsultation and proposed a triage system. The ArLAR BPG provide rheumatologists with a series of strategies about the most reliable, productive, and rational approaches to apply telehealth.

One-year direct costs of biological therapy in rheumatoid arthritis and its predictive factors: data from the Moroccan RBSMR registry.

The aim of the study was to estimate the annual direct costs of biological therapies in rheumatoid arthritis (RA), and to establish possible factors associated with those costs. The main data source was the Moroccan registry of biological therapies in rheumatic diseases (RBSMR Registry). We included patients with available 1-year data. Variables related to socio-economic status, disease and biological therapy were collected. Direct costs included prices of biologics, costs of infusions, and subcutaneous injections. Differences in costs across groups were tested by Mann-Whitney and Kruskal-Wallis tests. Correlations analysis was performed in search of factors associated with high costs. We included 197 rheumatoid arthritis patients. The mean age was 52.3 ± 11 years, with female predominance 86.8%. Receiving one of the following therapies: rituximab (n = 132), tocilizumab (n = 37), or TNF-blockers (n = 28). Median one-year direct costs per patient were €1665 [€1472-€9879]. The total annual direct costs were € 978,494. Rituximab, constituted 25.7% of the total annual budget. TNF-blockers and tocilizumab represented 27.3% and 47% of this overall budget, respectively. Although the costs were not significantly different in terms of gender or level of study, the insurance type significantly affected the cost estimation. A positive correlation was found between the annual direct cost and body mass index (r = 0.15, p = 0.04). In Morocco, a developing country, the annual direct costs of biological therapy are high. Our results may contribute to the development of strategies for better governance of these costs.

Therapeutic Maintenance Level of Methotrexate in Rheumatoid Arthritis: A RBSMR Study.

Objectives: The aim of this study was to determine the therapeutic maintenance level of methotrexate for rheumatoid arthritis patients enrolled in the Moroccan biotherapy registry and to identify predictive factors for discontinuing MTX treatment. Methods: A cross-sectional study was conducted using the baseline data of the Moroccan biotherapy registry for RBSMR (a multicentric study that aims to evaluate tolerance of biological therapy on patients affected with rheumatic diseases). Demographics and disease features were compared using descriptive statistics. Therapeutic maintenance levels were determined according to a Kaplan-Meier survival curve and a univariate Cox proportional hazards regression model was used to compare the strength of potential factors, followed by a multivariate Cox model to identify significant predictors of MTX discontinuation. Statistically significant results were considered for p values less than 0.05. Results: 224 patients with rheumatoid arthritis were included in this study. The mean age of patients was 51.83±11.26 years with a majority of females (87.50%). The median duration of disease was 12 [1.66-41.02] years. The therapeutic maintenance level of MTX was 91.1% at 1 year, 87.1% at 2 years, and 68.3% at 5 years. The median of treatment duration was 2, 02 [0, 46-27,76] years. Causes of treatment interruption were side effects (66/88=75%), inefficiency (12/88=13.63%), and other reasons (10/88=11.36%). Predictive factors for stopping MTX were presence of rheumatoid factor (HR 2.24; 95% CI 1.14-5.15; p=0.02) and the access to education (HR 0.37; 95% CI 0.16-0.88; p=0.02). Conclusion: The therapeutic maintenance level of MTX in our study was satisfactory and comparable to other series, and influenced by many factors such as the occurrence of a side effect. It is necessary to sensitise medical practitioners on symptomatic prevention and management of side effects.

Active tuberculosis infection in moroccan patients with rheumatic diseases under biologic therapy: A multicenter national study.

Background: The aim of this study was to evaluate the prevalence of active tuberculosis (TB) infection in Moroccan patients with rheumatic diseases under biologic therapy, and to describe the demographic characteristics of these patients as well as to explore potential risk factors. Methods: This 14-year nationally representative multicenter study enrolled Moroccan patients with rheumatic diseases who had been treated with biologic therapy. Patient medical records were reviewed retrospectively for demographic characteristics, underlying rheumatic diseases, associated comorbidities, and TB-related data. Results: In total, 1407 eligible patients were studied, detailed records were obtained for only 130 patients; 33 cases with active TB were identified at an estimated prevalence rate of 2.3%. The mean age was 42.9 ± 12 years and 75.8% were males. Ankylosing spondylitis accounted for 84.8% of active TB cases, and the majority of the cases (31/33) occurred among antitumor necrosis factor-alpha (TNF-α) users. A total of 8 out of 33 patients were positive at initial latent TB infection (LTBI) screening by tuberculin skin test and/or interferon-gamma release assay. Consumption of unpasteurized dairy products (odds ratio [OR], 34.841; 95% confidence interval [CI], 3.1-389.7; P = 0.04), diabetes (OR, 38.468; 95% CI, 1.6-878.3; P = 0,022), smoking (OR, 3.941; 95% CI, 1-159.9; P = 0.047), and long biologic therapy duration (OR, 1.991; 95% CI, 1.4-16.3; P = 0.001) were identified as risk factors for developing active TB. Conclusion: Moroccan patients with rheumatic diseases under anti-TNF-α agents are at an increased TB risk, especially when risk factors are present. Strict initial screening and regular monitoring of LTBI is recommended for patients living in high TB prevalence areas.

Targeting Acquired Hemophilia A with Rheumatoid Arthritis by a Rituximab Shot: A Case Report and Review of the Literature.

BACKGROUND Acquired hemophilia A (AH) is a rare hemorrhagic diathesis, characterized by the presence of autoantibodies directed against the pro-coagulant activity of factor VIII. It is associated with rheumatoid arthritis (RA) in 4% to 8% of cases and its prognosis remains severe. CASE REPORT A 66-year-old patient has been followed up for 20 years for deforming and severe RA, which was in low-disease activity. However, the patient presented a polyarticular flare involving the metacarpophalangeal and the proximal interphalangeal joints, the left elbow, and the right knee, which was warm and swollen. Articular puncture of this knee yielded a hematic fluid that did not coagulate. Its cytological analysis showed significant presence of red blood cells, which were also abundantly present in the other cell lines. Activated partial thromboplastin time was lengthened and not corrected by the addition of control plasma. Prothrombin time (Quick's test), fibrinogen level, and vitamin K-dependent factors were without abnormalities. In contrast, factor VIII was collapsed at 7% and the anti-factor VIII antibody was positive. The diagnosis of AH with anti-factor VIII inhibitor was thus retained. With regard to RA, the Disease Activity Score was 6.32 and exhibited a very active RA. Rituximab with methotrexate was begun and the evolution was favorable. After 6 months, the reappearance of the anti-factor VIII inhibitor was found, thus justifying a second cycle of rituximab. CONCLUSIONS AH is not exceptional in RA. Rituximab remains a relevant alternative for managing simultaneous AH with inhibitor and RA.

Protracted fever of unknown origin as the presenting symptom of Behçet's disease. Report of a case.

We report a case of Behçet's disease that presented as protracted fever of unknown origin. The diagnosis was established when a thromboembolic event and ora3l aphthous ulcers occurred simultaneously. Antibiotics had no effect on the fever, which resolved when glucocorticoid and anticoagulant therapy was given. Among causes of protracted fever of unknown origin, Behçet's disease is exceedingly rare but should be considered together with the other vasculitides. Above all, the presence of a fever should prompt a search for a thromboembolic complication.

Multifocal pyomyositis in an immunocompetent patient.

Pyomyositis is defined as suppurative infection of the skeletal muscle and usually occurs in immunocompromized patients. We managed a 23-year-old man admitted for myalgia and evidence of infection, with onset after a strenuous physical activity. Numerous muscles were involved. Multiple abscesses were visualized by ultrasonography and computed tomography, with predominant involvement of the pelvic muscles. Examination of the aspirate from a forearm abscess recovered Staphylococcus aureus. No factors associated with immunodeficiency were found. Appropriate antimicrobial therapy ensured complete resolution of the infection. Pyomyositis is rare in immunocompetent individuals. Myalgia, fever, and rhabdomyolysis should suggest pyomyositis. Computed tomography and magnetic resonance imaging are the best investigations for confirming the diagnosis.

Lead-related gout. A case report.

Gout secondary to lead-induced nephropathy is a long-term complication of occupational lead exposure. We report a case of this now-rare condition. The patient was a 63-year-old man who had been a miner from 1950 to 1970. Thirty years after cessation of his exposure to lead, he experienced onset of inflammatory symmetric polyarthritis with joint deformities. Hyperuricemia, moderately severe renal failure, and tubular acidosis were found, indicating gouty polyarthritis. Blood lead levels were high, establishing that the cause was lead poisoning. EDTA chelation therapy was effective. Lead poisoning is frequently under-recognized because the clinical manifestations are often minimal and the diagnosis difficult to establish. We suggest that lead bound to bone may result in continued exposure to lead after cessation of industrial or environmental exposure. Chelating agents are valuable for the diagnosis and can ensure a full recovery.

Osteoid osteoma multifocally located and recurrent in the carpus.

The authors report a case of osteoid osteoma located simultaneously at the right carpitate and at the proximal part of the right third metacarpian. A 31-year-old man presented in 1997 an osteoid osteoma involving the right capitate. One year after the surgical excision of the tumor, a second osteoid osteoma reappears to the same place requiring a 2nd intervention. A 3rd osteoid osteoma was discovered 16 months later at the proximal part of the right third metacarpian. After every excision, the pathological aspect was compatible with a nidus of osteoid osteoma. Osteoid osteoma of capitate are very rare. Multifocal forms are exceptional. If relapses of the tumor are sometimes explained by the incomplete excision of the nidus, the pathogenesis of the true recurrence remains unclear.