2023 Management Recommendations of Bangladesh Rheumatology Society on Pharmacological Treatment of Rheumatoid Arthritis With Synthetic and Biologic Disease-Modifying Drugs.

Rheumatoid arthritis (RA) is the most common inflammatory polyarthritis in Bangladesh. Bangladesh Rheumatology Society (BRS) proposes these management recommendations to treat the considerable burden of RA in the resource-constrained situation based on the best current evidence combined with societal challenges and opportunities. BRS formed a task force (TF) comprising four rheumatologists. The TF searched for all available literature, including updated American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and Asia-Pacific League of Associations for Rheumatology (APLAR) and several other guidelines, and systematic literature reviews until October 2023, and then a steering committee was formed, which included rheumatologists and internists. We followed the EULAR standard operating procedures to categorize levels of evidence and grading of recommendations. This recommendation has two parts -- general (diagnosis of RA, nomenclature of disease-modifying anti-rheumatic drugs [DMARDs], disease activity indices) and management portion. The TF agreed on four overarching principles and 12 recommendations. Overarching principles deal with early diagnosis and disease activity monitoring. Recommendations 1-5 discuss using glucocorticoids, NSAIDs, and conventional synthetic DMARDs (csDMARD). Recommendations 6-9 stretch the use of targeted synthetic DMARDs (tsDMARDs) and biological DMARDs (bDMARDs). The suggested DMARD therapy includes initiation with methotrexate (MTX) or another csDMARD (in case of contraindication to MTX) in the first phase and the addition of a tsDMARD in the second phase, switching to an alternative tsDMARDs or bDMARDs in the subsequent phases. The TF included the Padua prediction score for the thromboembolism risk estimation. Recommendations 10-12 cover infection screening, vaccination, and DMARD tapering. Bangladesh has a higher prevalence of RA. This recommendation will serve as a tool to treat this high burden of patients with RA scientifically and more effectively.

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.

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.

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.

The knowledge level of rheumatoid arthritis patients about their disease in a developing country. A study in 168 Bangladeshi RA patients.

OBJECTIVES: To assess disease-related knowledge of rheumatoid arthritis (RA) patients PATIENTS AND METHODS: Consecutive RA patients were invited from the rheumatology departments of BSMM University, Dhaka, Bangladesh. The Bangla version of the Patient Knowledge Questionnaire (B-PKQ) was used. Correlations between the B-PKQ scores and clinical-demographic data were measured using Pearson's correlation coefficient. Impact of independent variables on the level of knowledge about RA was analyzed through multiple regression analysis. Possible explanatory variables included the following: age, disease duration, formal education level, and Bangla Health Assessment Questionnaire (B-HAQ) score. Analysis of variance (ANOVA) was used to test the difference between demographical, clinical, and socioeconomic variables. For statistical analysis, SPSS statistics version 20 was used. RESULTS: A total of 168 RA patients could be included. The mean B-PKQ score was 9.84 (range 1-20) from a possible maximum of 30. The mean time for answering the questionnaire was 24.3 min (range 15-34). Low scores were observed in all domains but the lowest were in medications and joint protection/energy conservation. Knowledge level was higher (15.5) in 6 patients who had RA education before enrollment. B-PKQ showed positive correlation with education level (r = 0.338) and negative correlation with HAQ (r = -0.169). The B-PKQ showed no correlation with age, disease duration, having first degree family member with RA, education from other sources (neighbor, RA patient, nurses), or information from mass media. CONCLUSIONS: Disease-related knowledge of Bangladeshi RA patients was poor in all domains. Using these findings, improved education and knowledge will result in better disease control.Key Points• Little is known about the knowledge of RA patients regarding their disease and its treatment in Bangladesh and in developing countries in general.• We found that the knowledge of Bangladeshi RA patients regarding their disease was poor in all domains; it correlated positive with education level and negative with function (HAQ), but showed no correlation with age or disease duration.• The findings of this study can be used for improving current patient education programs by health professionals and through mass media.• Better disease control of RA may be achieved by improving patient knowledge in a developing country like Bangladesh, but also in other parts of the world.

Musculoskeletal symptoms and disorders among 350 garment workers in Bangladesh: A cross-sectional pilot study.

OBJECTIVE: To study the prevalence of musculoskeletal (MSK) symptoms and disorders among garment workers in Bangladesh, to look for possible relationships between pain location and type of work performed and to estimate the prevalence of rheumatological diagnoses. METHODS: A cross-sectional pilot study among 350 garment workers using the COPCORD (Community Oriented Program for Control of Rheumatic Disorders) methodology. Subjects with musculoskeletal pain were examined by rheumatologists for rheumatological diagnosis. The workers were classified into cutting, sewing, finishing and quality control operators. RESULTS: Most of the workers were aged below 35 years (88%) and females (82.9%) and the majority had only primary education (74.6%). The prevalence of MSK pain within 7 days of the interview was 77.1%, a much higher figure than in the general population. The most affected sites were: shoulder (17.9%), lower back (15.2%), neck (13.8%) and knee (10.8%). Multiple regional pain was the commonest finding in 173 of 350 workers. In this pilot study rheumatoid arthritis was diagnosed in 0.9%, undifferentiated arthritis in 1.1%, nonspecific low back pain in 4.6%, soft tissue rheumatism in 3.7%, osteoarthritis in 0.9% and lumbar spondylosis in 1.1%, figures comparable with those observed in the general population; spondyloarthropathy was seen more often, in 1.42%, possibly explained by the small numbers. CONCLUSIONS: Musculoskeletal pains are common among garment workers of Bangladesh and may cause morbidity, disability, and work loss. Our findings may be important to plan ergonomic measures preventing complaints and may be of interest for international companies ordering garments in Bangladesh.