Sinonasal immunoglobulin G4-related disease: a case report of an atypical and rare entity.

BACKGROUND: Immunoglobulin G4-related disease is marked by extensive inflammation and fibrosis of an unknown autoimmune component, with an overall incidence ranging from 0.78 to 1.39 per 105 person-years. Sinonasal immunoglobulin G4-related disease is atypical and exceedingly uncommon in the existing literature, frequently manifesting clinically as chronic rhinosinusitis, epistaxis, and facial pain. CASE PRESENTATION: This report describes a 25-year-old Iraqi female who has been suffering from symptoms of chronic rhinosinusitis for 8 years. Despite undergoing several surgeries, there has been no improvement in her symptoms. A tissue biopsy that revealed dense lymphoplasmocytosis with noticeable plasma cell infiltration, storiform fibrosis, and obliterative angitis, along with positive immunohistochemical staining for Immunoglobulin G4 plasma cells, finally confirmed the diagnosis of sinonasal immunoglobulin G4-related disease. The patient responded well to oral prednisolone and methotrexate treatments. CONCLUSIONS: The main objective of the current report is to raise awareness among physicians about the significance of promptly identifying and diagnosing this rarity, thus preventing the adverse consequences linked to delayed diagnosis and treatment initiation.

Safety of COVID-19 Vaccine in Patients with Rheumatic and Musculoskeletal Diseases.

Objectives: The main purpose of this study was to determine the frequency of COVID-19 vaccine side effects in patients with rheumatic diseases and to examine any potential associations with medications, disease type, or comorbidities. Methods: A multicentre cross-sectional study from rheumatology units in different hospitals in Iraq was carried out between 8th of August 2021 and 4th of August 2022. Patients were eligible for inclusion if they have a rheumatic disease and have taken one or more doses of any COVID-19 vaccine. Results: A total of 661 (57.8% female, mean age 46.51± 12.97 years) patients with rheumatic illnesses who received the "COVID-19" vaccination were included in this study. Rheumatoid arthritis was the most frequent diagnostic group. The Pfizer vaccine was given to the majority of patients (74.6%), followed by Sinopharm (16.2%), and AstraZeneca (9.2%). Side effects were detected in 661(100%) and 528 (100%) patients following the first and second vaccination doses, respectively; among which the most frequent were injection site pain in 57.8% following the first dose and 47.6% after the second dose, followed by fatigue and fever. According to multivariate logistic regression models, age (B=-0.204, p = 0.000), had a significantly inverse correlation coefficient with the experience of greater side effects. Rheumatic disease flares reported in 9.9%, 10.3%, and 8.2% of patients who received the Pfizer, Sinopharm, and AstraZeneca vaccines, respectively. Conclusion: The "COVID-19" vaccination has a reassuring safety profile with no greater risk of adverse events in any specific illness or pharmacological therapy.

Unusual cause of inflammatory backache: SAPHO syndrome.

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) is a rare chronic inflammatory disease that develops in adults. We present a case of SAPHO syndrome in a 37-year-old male presenting with gradually worsening back and neck pain for a 7-year period. The episodes were preceded by a history of pustular skin eruptions, which first appeared on the upper trunk and then involved his face and were pustular and scarring. The purpose of presenting this case report from Iraq is to raise awareness about this rare condition, which is frequently misdiagnosed and under-recognized.

A case report of an extremely rare association of ankylosing spondylitis with pachydermoperiostosis.

Key Clinical Message: We describe a case of a young man with features of pachydermoperiostosis and spondyloarthropathy. By describing this rarity, we aim to help build a database for future studies and construct a management plan that rheumatologists and clinicians can use. Abstract: This is the first case report in Iraq describing the combination of pachydermoperiostosis and ankylosing spondylitis. We report this interesting association in a 23-year-old male who presented with inflammatory back pain, coarse facial features, clubbing, signs of enthesitis, limitation of spine movement, and clinical and radiographic signs of sacroiliitis.

Unusual presentation of rheumatoid arthritis in a 106-year-old woman: A rare case report.

By reporting this case, we hope to encourage medical professionals to concentrate on diagnosing old patients with unusual presentation of rheumatoid arthritis.

A 5 item version of the Workplace Activity Limitation Scale successfully identifies impaired work productivity in rheumatoid arthritis patients: A split-sample factor analysis approach.

BACKGROUND: There is a growing interest in studying the effects of arthritis on a person's work productivity using a growing variety of outcome indicators. OBJECTIVES: To develop a valid and reliable shortened version of the Workplace Activity Limitation Scale 12 (WALS-12) for assessing work productivity limitations in rheumatoid arthritis (RA) patients. METHODS: A cross-sectional study involving 277 RA patients was conducted. An exploratory factor analysis on WALS-12 was used for item reduction on the first sample. Then confirmatory factor analysis (CFA) was run to establish the best fit indices of the reduced version. On the second sample, CFA and linear discriminant analysis were performed to assess the diagnostic performance and discriminant ability of the reduced form. A Bland-Altman method was used to find the agreement between the WALS-12 and the reduced one. RESULTS: The WALS-12 was reduced to 5 items. The Cronbach α was 0.817, with a composite reliability of 0.715. The Spearman rho correlation coefficient ranged between 0.675 and 0.795 for WALS-5, which was higher for the scale items with their domains than the correlation of WALS-5 with the domains of Work Limitations Questionnaire-25. Also, the root square of the average variant extracted from WALS-5 was 0.802. WALS-5 showed excellent discriminant ability with an area under the curve of 0.98 (P < .001), sensitivity of 97%, specificity of 82%, and accuracy of 94%. The reduced version WALS-5 was in agreement with the original version WALS-12. CONCLUSIONS: WALS-5 is a valid and reliable tool to assess the work productivity limitations in RA patients.

A case report of H-syndrome from Baghdad Medical City treated with tocilizumab.

This case report presents the first H-syndrome rarity in Iraq, a 12-year-old female patient who was attending the Rheumatology out clinic for progressive hands joint deformities. She has a history of a multi-systemic collection of diseases with various clinical features that include beta thalassemia minor, sensorineural deafness, and celiac disease.

Long-Term Adherence to Etanercept in Treatment Effectiveness of Patients with Spondyloarthritis: 7-Year Data from the Iraq National Registry.

INTRODUCTION: The diagnosis and treatment of spondyloarthritis (SpA) is a global challenge, with no cure available. Adherence to treatment with biologic disease-modifying antirheumatic drugs, such as the tumor necrosis factor-α inhibitor etanercept, varies among patients with SpA. Inadequate or poor adherence to treatment may have a negative effect on clinical outcome and quality of life and may lead to greater health-related expense. METHODS: This observational, retrospective study used real-world patient data from the Iraq National Center of Rheumatology database to retrospectively assess long-term adherence to etanercept, specifically evaluating 1- and 7-year adherence to etanercept among Iraqi patients with SpA. RESULTS: In total, data from 763 patients were included in the analysis. The majority of patients were men (82.2%). Mean disease duration at baseline was 5.85 years; 84.0% of patients received concomitant steroids, and 14.2% were treated with concomitant methotrexate. Measures of disease activity and functional status (mean ± SD) at baseline based on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) were 8.06 ± 0.83 (range 6.0-9.5) and 7.75 ± 1.12 (range 4.1-9.7), respectively. Around 30% of patients initiated etanercept treatment within 1 year of diagnosis. After 1 and 7 years, 91.7% (700/763) and 60.6% (80/132) of patients were adherent to etanercept treatment. Mean (± SD) changes from baseline in BASDAI and BASFI scores for adherent versus non-adherent patients at 1 year were 6.73 (± 1.90) versus 4.20 (± 1.85) (p = 0.0001) and 6.43 (± 2.04) versus 4.18 (± 1.88) (p = 0.0001), respectively. CONCLUSIONS: These results suggest that Iraqi patients with SpA benefit from long-term adherence to etanercept treatment; however, additional analyses are needed to further assess the reasons for treatment discontinuation, which may include disease remission. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04507776.

Disturbance in Serum Levels of IL-17 and TGF-ß1 and in Gene Expression of ROR-γt and FOX-P3 Is Associated with Pathogenicity of Systematic Lupus Erythematosus.

To investigate the disturbance in serum levels of interleukin-17 (IL-17) and transforming growth factor-beta1 (TGF-ß1) and gene expression of retinoic acid-related orphan receptor-gamma t (ROR-γt) and forkhead box-P3 (FOX-P3) in patients with systemic lupus erythematosus (SLE) and to study their association with disease pathogenicity and activity. Newly diagnosed active patients with SLE (n=88) and healthy volunteers (n=70) were included. Serum IL-17 and TGF-ß1 were measured using enzyme-linked immunosorbent assay. Gene-expression profiles of ROR-γt and FOX-P3 were screened using real-time polymerase chain reaction. The IL-17/TGF-ß1 and ROR-γt/FOX-P3 levels were also calculated. The mean age of the patients was 30.96±8.25 years; they were 82 women and 6 men. Of the patients, 11.4% manifested mild disease while 88.6% had severe disease. The serum level of TGF-ß1 was significantly lower (70.2±34.9 vs. 200.23±124.77 pg/ml), while both IL-17 (614.7±317.5 vs. 279.76±110.65 pg/ml) and IL-17/TGF-ß1 (18.5±30.1 vs. 1.66±0.9) levels were significantly higher, in patients than in controls (p<0.0001). The gene-expression level of FOX-P3 (0.6±0.8 vs. 13.68±39.35) was reported to be lower, while ROR-γt (3.9±3.5 vs. 1.99±2.09) and ROR-γt/FOX-P3 (18.6±21.1 vs. 7.63±17.19) levels were significantly higher, in patients than in controls (p<0.0001). Disturbance in serum levels of IL-17 and TGF-ß1 in T helper-17 and T-regulatory cells proliferation was highlighted through an imbalance in the gene expression of FOX-P3 and ROR-γt, as both are signature genes for the two cell types, respectively. These findings underscore the critical role of IL-17 and TGF-ß1 in SLE development, rendering them potential targets for developing novel immunotherapeutic strategies.

The Clinical Impact of Seropositivity on Treatment Response in Patients with Rheumatoid Arthritis Treated with Etanercept: A Real-World Iraqi Experience.

Purpose: To assess the clinical impact of rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA)'s seropositivity on treatment response in patients with rheumatoid arthritis (RA) treated with etanercept. Patients and Methods: A retrospective analysis of patients with RA registered in Baghdad Teaching Hospital Registry from May 2012 to August 2019 was conducted. Patients aged ≥18 years, meeting the ACR/EULAR 2010 criteria for RA, being treated with etanercept, and followed up at ≥1 year after etanercept initiation were included; patients who received any other biologics for RA were excluded. Patients were classified as seropositive (RF- and ACPA-positive), seronegative (RF- and ACPA-negative), RF-positive, RF-negative, ACPA-positive, and ACPA-negative. The primary outcomes included Clinical Disease Activity Index (CDAI) and Disease Activity Score 28 (DAS28) which were measured at one year after treatment initiation. Results: At baseline, a total of 1318 (88.3%) patients were seropositive; 1122 (75.2%) and 1054 (70.6%) patients were RF- and ACPA-positive, respectively. Baseline mean CDAI scores were significantly (P = 0.001) higher among seropositive patients compared with seronegative patients. The baseline mean DAS28 score was also significantly higher in ACPA-positive group compared with the ACPA-negative group (P = 0.021). At baseline, the number of patients who had high CDAI scores was significantly higher among the seropositive, RF-positive, and ACPA-positive groups (P = 0.001, P = 0.001, and P = 0.002, respectively). After one year of treatment with etanercept, among seropositive versus seronegative and ACPA-positive versus ACPA-negative groups, there was a significant improvement in terms of the mean CDAI score (P = 0.004 and P = 0.017, respectively) and CDAI response (P = 0.011 and P = 0.048, respectively). At one year, the proportion of patients among the seropositive versus seronegative group who reached remission were 566 (42.9%) versus 78 (44.6%) and 642 (47.3%) versus 83 (47.4%), for CDAI and DAS28 response, respectively. Conclusion: The results imply that seropositivity and ACPA-positivity may influence the treatment response in patients with RA, who were treated with etanercept.

Randomized controlled trial of colchicine add on to the standard therapy in moderate and severe corona virus Disease-19 infection.

Background: COVID19 complications cause inflammatory storm. Colchicine is a potent anti-inflammatory medication that has been proposed as a possible treatment option for COVID-19. Objective: to assess effectiveness and safety of add on use of colchicine to the standard treatment in moderate and severe COVID-19. Patients and methods: In this randomized controlled open label clinical trial, 160 patients hospitalized equally divided between moderate and severe COVID19 categories were randomized to 4 study groups in a 1:1:1:1 allocation (n = 40 for each group) according to type of treatment. Patients were randomly assigned to receive the standard treatment for 14 days (control group) or colchicine add on to the standard treatment 1 mg daily orally for 7 days then 0.5 mg daily for another 7 days. Survival rate, time to cure in days, and side effects were assessed. Results: Colchicine add on treatment was associated with a significantly shorter time to cure (referring to start of first symptom) by an average of 5 days in severe disease and 2 days in moderate disease (log-rank P=<0.001). In addition, the Colchicine add on significantly increased the risk of cure per unit of time by 2.69 times compared to controls after adjusting for disease severity, age, and time since the start of the disease to start of treatment. A severe COVID19 disease, a longer time for starting treatment, and the older age notably reduced the risk of cure (HR = 0.72, p = 0.07; HR = 0.74, p < 0.001; and HR = 0.59, p = 0.015 respectively). Possible side effects reported due to colchicine were 8/40 (20%) of severe COVID19 patients and 3/40 (7.5%) of moderate COVID19, non of which warranted stopping treatment by the data monitoring board. Generally, the side effects were 8/11 (72.73%) gastrointestinal disturbances. No immediate or late allergic reactions were observed. Conclusions: Colchicine add on treatment reduced significantly time to recovery in severe COVID19 (by five days) and in moderate cases (by two days) but did not lower the death rate. Side effects were mild, well tolerated and confined to gastrointestinal adverse events.

A randomised controlled trial of effectiveness and safety of Niclosamide as add on therapy to the standard of care measures in COVID-19 management.

BACKGROUND: COVID-19 pandemic has ignited the urge for repurposing old drugs as candidate antiviral medicines to treat novel challenges of viral infections. Niclosamide (NCS) is an anti-parasitic drug of known antiviral potential. Therefore, this study attempts to investigate the antiviral effect and safety of NCS on SARS-CoV-2 caused COVID-19 patients. METHODS: Randomized controlled open label clinical trial encompassed 75 COVID-19 patients treated with standard of care plus NCS were included as experimental group and 75 COVID-19 patients treated with only standard of care therapy as control group. Survival rate, time to recovery, and side effects were the main endpoints for the assessment of the therapeutic effect and safety of NCS. RESULTS: No significant difference between the two study groups in the incidence of death Vs recovery within 30 days of follow up(p = 1).Median survival time to cure in the NCS addon group was significantly less than controls (5 Vs 7days, Log rank p = 0.005).All the recoveries took place within 20 days in the NCS add on group, which is 10 days shorter than that in the controls (30 days), NCS add on treatment increased the risk of cure by 60% per day compared to control group (adjusted HR = 1.6,p = 0,007) after adjusting for the count of comorbidities. Additionally, two or more comorbidities reduced the risk of cure to 33% (p < 0.001).Male gender increased the risk of cure by 42% (p = 0.046). Older age group decreased the risk of recovery per day to 0.58 and 0.53 for 50-59 and 60+ years of age. Hyypertension (HT) and diabetes mellitus (DM) significantly reduced the risk of being cured per day to 0.56 (p = 0.003)and 0.65 (p = 0.039) respectively. No significant signals of safety in NCS add on therapy compared to control group. CONCLUSION: adding NCS to the standards of care measures increased the risk of the cure and had shorter time to stay in the hospital compared with controls., male gender increased the risk of cure, while older patients>40 years, HT, and DM decreased the risk of cure. Also, NCS add on therapy was relatively safe; hence, NCS is of clinical benefit for freeing hospital beds for more patients in pandemic crisis.

Presarcopenia in Patients with Vitiligo: A Case Control Study.

BACKGROUND: Sarcopenia is a muscle disease with significant morbidity and mortality. Vitiligo is a common autoimmune inflammatory disease which results from absence, deficiency, or dysfunction of melanocytes. Links between sarcopenia and autoimmune inflammatory processes were reported. However, no previous reports on association between sarcopenia and vitiligo were identified. OBJECTIVE: To assess presarcopenia in patients with vitiligo and to evaluate the effect of sociodemographic and clinical characteristics of vitiligo patients of sarcopenia if present. SUBJECT AND METHODS: This case control study included 63 patients with Vitiligo and 63 apparently healthy control group matched in age and gender. Sarcopenia was diagnosed by measuring the Appendicular Lean Mass Index. Cut off point required for sarcopenia is <6 for women and <7 for men. Sociodemographic and clinical characteristics were recorded. Sarcopenia was diagnosed according to the 2018 revised European consensus on definition and diagnosis of sarcopenia. RESULTS: Mean age of vitiligo patients was 38.7 ± 14.0 years (range: 20-69 years) and for controls 39.9 ± 11.6 years (range: 20-70 years) (p=0.604). Female were 34 (54.0%) and 29 (46.0%) males, while in the controls 30 (47.6%) were females and 33 (52.4%) males (p=0.604). Presarcopenia was significantly higher in Vitiligo compared to controls. Vitiligo increases the risk of having presarcopenia by about five-fold (OR [95%CI]=4.706[1.26-17.61], p=0.013).Only BMI was significantly negatively correlated with presarcopenia. BMI decreases the risk of having presarcopenia by odds ratio of 0.837 (0.032). other baseline characteristics had no significant impact of presarcopenia in vitiligo (P model<0.01, R2 =0.46 Accuracy= 0.57 AUC=0.92). CONCLUSIONS: Vitiligo was significantly positively correlated with presarcopenia and increased the risk of presarcopenia by about five-fold.

Fibromyalgia in Iraqi patients with asthma and its impact on asthma severity and control.

BACKGROUND: Fibromyalgia (FM) is common with significant impact on patients quality of life. Limited reports on coexistence of FM with asthma. OBJECTIVES: To assess the prevalence of FM in asthmatic patients and its impact on asthma severity and control. PATIENTS AND METHODS: This case-control study included 103 patients with asthma and 102 apparently healthy controls matched in age and sex. Sociodemographic and clinical characteristics of FM and controls were recorded. FM was diagnosed according to the 2016 revision of American College of Rheumatology criteria. Asthma diagnosis and severity were performed by the pulmonologist according to Global Initiative for Asthma (GINA) guidelines and asthma control was assessed by Asthma Control Test (ACT) score. RESULTS: The mean age of asthmatic patients was 41.1 ± 12.7 years and for controls was 39.8 ± 12 years (p = 0.453). Females were more prevalent in asthmatic patients and controls although statistically were not significant (p-value = 0.532). Prevalence of FM was significantly more in asthmatic patients compared to controls [18 (17.6%) vs 7 (6.8%), p = 0.018] and asthmatic patients had three folds risk of having FM (ranging from 1.2 to 7.4 times. FM increased the risk of severe asthma by 4.91 folds (P < 0.005). Also, only FMS and glucocorticoids were significant independent predictor of having poor asthma control. FM was significantly and negatively correlated with low ACT score (ß standardized regression coefficient = -0.291, p = 0.005). CONCLUSIONS: fibromyalgia was common in asthmatic patients and was significantly associated with more severe and poorly controlled asthma.

Impact of disease activity on health related quality of life in patients with Behçet's disease: A cross-sectional study.

BACKGROUND: Behçet's syndrome (BD) is a systemic inflammatory vasculitis of unknown aetiology, affecting vessels of different types, sizes and locations and characterized by recurrent episodes of acute inflammation, including mucocutaneous manifestations (oral aphthous ulcers, genital ulcers and skin lesions) and gastrointestinal, musculoskeletal, neurological, ophthalmic and vascular involvement which lead to a significant morbidity and impaired health related quality of life (HRQoL). Few studies reported impact of disease activity on HRQoL. OBJECTIVE: To assess the impact of BD activity on HRQoL. PATIENTS AND METHODS: This cross sectional study included patients with Behçet's disease diagnosed according to the International Study Group criteria 1990 for BD. Age of the patients, sex, smoking status, educational level, disease duration, organ involvement, age at disease onset, and medications used were recorded. Behçet's Disease Disease activity was assessed using Behçet's Disease Current Activity Form (BDCAF) and HRQoL was evaluated using The Short Form-36 (SF-36). RESULTS: A total of 71 patients (45 males, 26 females) with Behçet's disease were enrolled in this study. Mean age of patients was 36.0 ± 10.8 years, Males represented the majority of patients (63.4%). BDCAF was significantly and negatively correlated with total SF-36 score (standardized ß = - 0.520, p < 0.0001). The mean BDCAF was significantly more in females compared to males (6.154 ± 2.444 vs 4.467 ± 2.785, p = 0.012). While the mean SF36 was significantly more in males compared to females (57.722 ± 21.627 vs 41.435 ± 18.993, p = 0.002). After multiple linear stepwise regression analysis, still BDCAF significantly and negatively affected HRQoL in BD (partial r = -0.255, p = 0.043). Male gender, cyclosporine users, infliximab users, and Adalimumab users had significant positive impact on total SF-36 score (partial r = 0.293, p = 0.020; partial r = 0.256, p- = 0.043, partial r = 0.414; p = 0.00, partial r = 0.399, p = 0.001 respectively). While disease duration, and MMF users (partial r = -0.295, p = 0.019; partial r = -0.250, p = 0.043) had significant negative impact on total SF-36 score, and there was weak positive correlation between vascular involvement and total SF36 score (partial r = 0.244,p = 0.053) and a negative weak correlation between the use of anticoagulant with total SF-36 score (partial r = -0.233, p = 0.066). CONCLUSIONS: Behçet's disease activity has a significant negative impact on HRQoL This may suggest that treating activity of disease may improve HRQoL.

Prevalence of sarcopenia in sample of Iraqi patients with type 2 diabetes mellitus: A hospital based study.

BACKGROUND AND AIMS: Damage to the skeletal muscles, with a pronounced and accelerated decline in muscle quality have been described as a new complication of diabetic patients, so this study was conducted to assess the prevalence of sarcopenia in sample of Iraqi patients with type 2 diabetes mellitus. METHODS: This was a case-control study conducted at Baghdad Teaching Hospital from September 2018 to April 2019. Participants were men and women aged between (40-70) years with type 2 diabetes mellitus diagnosed by an Internist/Endocrinologist doctor and on treatment for at least 6 months earlier. Sixty-five patients and 65 matched healthy controls in age, gender and body mass index were studied. Diagnosis of sarcopenia was done according to revised European consensus on the definition and diagnosis of sarcopenia 2018. Glycemic control was evaluated by mean of hemoglobin A1c (HbA1c) test. RESULTS: The mean age of the patients was 57.0 ± 7.7 years, and mean disease duration was 7.2 ± 6.0 years. The prevalence of sarcopenia was 10 (15.4%) in diabetic patients and 5 (7.7%) in controls while the prevalence of presarcopenia was 7 (10.8%) in diabetic patients and 3 (4.6%) in controls (p-value = 0.133).: The mean age of the patients was 57.0 ± 7.7 years, and mean disease duration was 7.2 ± 6.0 years. The prevalence of sarcopenia was 10 (15.4%) in diabetic patients and 5 (7.7%) in controls while the prevalence of presarcopenia was 7 (10.8%) in diabetic patients and 3 (4.6%) in controls (p-value = 0.133). CONCLUSIONS: Patients with type 2 diabetes mellitus had a higher prevalence of sarcopenia compared with healthy controls although statistically was not significant.

An observational descriptive cross sectional multicenter study of health related quality of life among Iraqi patients after total hip replacement.

BACKGROUND: Hip replacement is highly effective procedure to decrease pain and disability in patients with hip arthritis and accordingly can affect health related quality of life (HRQOL). Globally, limited studies have reported impact of total hip replacement (THR) on HRQOL and there is no previous reports of HRQOL among Iraqi patients after THR. OBJECTIVE: To evaluate HRQOL in patients after THR and to assess impact of sociodemographic characteristics on it if present. PATIENTS AND METHODS: A multicenter cross sectional study was conducted on 96 patients with THR in Iraq. Sociodemographic characteristics were measured. HRQOL after THR was evaluated using Harris hip score (HHS). RESULTS: The mean age of patients was 56.76, (13.88) years with a range of 23-90 years. Most of patients were females (52 patients (54.2%). Mean BMI was 44.87(8.07) kg/m2 with a range of 28.1-56.7 kg/m2. The mean(SD) of HHS was 84.39 (7.25) with minimum score of 61.7 and maximum score 93.8. Sociodemographic characteristics had no statistically significant effect on HRQOL measured by HHS except BMI. For each 1 unit increase in BMI, there is significantly and independently decrease in HHS by -0.276. CONCLUSIONS: THR improved HRQOL. BMI was the only significant independent factor that was negatively correlated with HRQOL.

Review of biologics, biosimilars, and intended copies in rheumatology, and current practice in Iraq.

Biologic therapies are an important option in the treatment of patients with rheumatic disease. As the development of potential biosimilars increases, many countries are following the guidelines developed by the WHO, European Medicines Agency, or US Food and Drug Administration to create country-specific regulations for the review and approval of these products. Iraq does not yet have such regulations, and this presents a potential safety concern for patients. The analytical, nonclinical, and clinical data requirements for approval of a potential biosimilar are specific and scientifically rigorous. In some countries, products are available that have not met the stringent criteria for biosimilars; they are usually referred to as "intended copies". Frequently, the available data are not sufficient to demonstrate that they are similar in efficacy and safety to the reference product. Thus, safety issues may arise once the product is in use, as was the case with Kikuzubam, an intended copy of rituximab that was withdrawn from the market in Mexico following reports of severe adverse reactions. It is important to implement scientific, evidence-based guidelines for the review, approval, therapeutic use, and monitoring of biosimilars, and to provide training on this topic to healthcare professionals and patients. In this review, we discuss issues related to the use and regulation of biosimilars, and the differences between biosimilars and intended copies. We also provide suggestions for including biosimilars as a treatment option in Iraq.

Unusual Presentation of Galactosemia in a Child: Musculoskeletal Manifestations.

Galactosemia is an autosomal recessive inherited disease of galactose metabolism. In this report, a galactosemia case with unusual presentation has been presented. We reported a child boy with galactosemia presented with arthralgia, hands deformity and decreased bone mineral density.

Fibromyalgia Syndrome and Vitiligo: A Novel Association.

OBJECTIVES: This study aims to assess the relationship between fibromyalgia syndrome (FMS) and vitiligo in Iraqi patients and evaluate the predictors of this relationship, if present. PATIENTS AND METHODS: The case-control study included 100 Iraqi patients (46 males, 54 females; mean age 30.4±14 years; range 15 to 65 years) with vitiligo and 200 age- and sex-matched healthy controls (74 males, 126 females; mean age 30.3±9.4 years; range 15 to 62 years). Baseline characteristics of patients and controls were recorded. The 2012 Canadian Guidelines criteria were used for the diagnosis of FMS and applied to all patients and controls. RESULTS: Prevalence of FMS in vitiligo patients and controls was 12% and 7%, respectively (p=0.15, odds ratio=1.8, 95% confidence interval=0.8-4.08). FMS symptoms in vitiligo patients were fatigue (46%), diffuse body pain (34%), sleep disturbance (33%), cognitive dysfunction (30%), and mood disorders (23%), while visceral involvements were central nervous system (52%), skin (35%), gastrointestinal tract (32%), cardiovascular system- respiratory system (16%), genitourinary tract (8%), and ear nose throat (7%). Of vitiligo patients, FMS was significantly more common among females (22.2%) compared to none among males (0%) (p<0.05). Prevalence of FMS was restricted to female sex only and a significantly higher prevalence rate of FMS was found among female vitiligo patients (22.2%) compared to controls (9.5%). Receiving phototherapy significantly increased the risk of having FMS by 5 times compared to female patients not receiving phototherapy. Use of any steroid reduced the risk of having FMS by 2.5 times (inverse of odds ratio=0.4) among females patients (p>0/05). No significant association was found between FMS in vitiligo patients and age, disease duration, type of vitiligo, use of any immunosuppressant and body mass index (p>0.05). CONCLUSION: Fibromyalgia syndrome was more prevalent in vitiligo patients compared to controls, which was clinically important but statistically not significant. There was a significant association between FMS in vitiligo patients and female sex, severe form of vitiligo, and receiving phototherapy. This may suggest that early diagnosis of FMS in vitiligo patients may help in early treatment and subsequently improve patients' quality of life.