Expert Opinion Guidance on the Detection of Early Connective Tissue Diseases in Interstitial Lung Disease.

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts.

Cricoarytenoid joint arthritis: a possible complication of dermatomyositis.

Cricoarytenoid joint arthritis is most frequently reported in Rheumatoid Arthritis and in other systemic diseases such as Sjogren's syndrome, Systemic Lupus Erythematosus, Ankylosing Arthritis, Juvenile Chronic Arthritis, and autoimmune hepatitis but it has not been reported in dermatomyositis. In this paper, we report the case of a 43 years-old woman treated for dermatomyositis who presented with hoarseness and severe odynophagia. The laryngoscopy revealed the presence of an extensive white swelling of the left cricoarytenoid joint with reduced mobility of the left vocal cord, consistent with left cricoarytenoid joint arthritis, which has not previously been described in dermatomyositis to our knowledge. Treatment with high doses of prednisone produced a complete resolution of the laryngeal symptoms.

Adherence to systemic therapies for immune-mediated inflammatory diseases in Lebanon: a physicians' survey from three medical specialties.

BACKGROUND: Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that may cause tissue damage and disability, reduced quality of life and increased mortality. Various treatments have been developed for IMIDs, including immune modulators and targeted biologic agents. However, adherence remains suboptimal. METHODS: An adherence survey was used to evaluate physicians' beliefs about adherence to medication in IMID and to evaluate if and how they manage adherence. The survey was distributed to 100 randomly selected physicians from three different specialties. Results were analyzed by four academic experts commissioned to develop an action plan to address practical and perceptual barriers to adherence, integrating it into treatment goals to maximize outcomes in IMID, thereby elevating local standards of care. RESULTS: Eighty-two physicians participated in this study and completed the questionnaire. Most defined adherence as compliance with prescribed treatment. Although the majority of surveyed physicians (74%) did not systematically measure adherence in their practice, 54% identified adherence as a treatment goal of equal or greater importance to therapeutic endpoints. Lack of time and specialized nursing support was reported as an important barrier to measuring adherence. The expert panel identified four key areas for action: 360° education (patient-nurse-physician), patient-physician communication, patient perception and concerns, and market access/cost. An action plan was developed centered on education and awareness, enhanced benefit-risk communication, development of adherence assessment tools and promotion of patient support programs. CONCLUSION: Nonadherence to medication is a commonly underestimated problem with important consequences. A customized target-based strategy to address the root causes of non-adherence is essential in the management of chronic immune-mediated diseases.

Use of complementary and alternative therapy among patients with rheumatoid arthritis and osteoarthritis.

AIMS AND OBJECTIVES: We wanted to assess the prevalence of complementary and alternative therapy use among patients suffering from rheumatoid arthritis or osteoarthritis in the Lebanese population and to determine the perceived efficacy and side effects of complementary and alternative therapy in the treatment of these diseases. BACKGROUND: Complementary and alternative therapy has become popular among patients with chronic illnesses because of its widespread use. Rheumatoid arthritis and osteoarthritis are two diseases associated with severe pain, inflammation and limited activity. Although both are quite common in Lebanon, no studies were conducted in our country to portray complementary and alternative therapy use in their treatment. DESIGN: Descriptive cross-sectional study. METHODS: Conducted individualised questionnaire-based interviews among 250 adult patients, ranging between the ages of 20-90 years and diagnosed with either rheumatoid arthritis or osteoarthritis. The questionnaire included demographic information, clinical information, use of conventional therapies and complementary and alternative therapy, and the disease status before and after complementary and alternative therapy use. RESULTS: Fifty-eight (23·2%) patients used complementary and alternative therapy in addition to their conventional medications in the treatment of either rheumatoid arthritis or osteoarthritis. Most herbal medicine users (63·8%) believed that complementary and alternative therapy was beneficial. The disease status measured by the intensity of pain, sleeping pattern and level of activities was significantly improved after using complementary and alternative therapy (p =0·01). Forty-eight (82·75%) patients were using herbals as complementary and alternative therapy, 14 (24·1%) of whom have sought medical care because of potential concomitant drug-complementary and alternative therapy side effects. However, these side effects were not serious and reversible. CONCLUSION AND RECOMMENDATIONS: Although complementary and alternative therapy might have beneficial effects in rheumatoid arthritis and osteoarthritis, patients should be cautious about their use and should necessarily inform their health care providers about the consumption of any products other than their conventional medicines. RELEVANCE TO CLINICAL PRACTICE: It is quite essential for health care professionals to be knowledgeable about the use of complementary and alternative medicine therapies when providing medical care to patients with arthritis.

First update of the Lebanese guidelines for osteoporosis assessment and treatment.

With the demographic explosion, the human, social, and economic costs of osteoporosis in developing countries, including the Middle East, will continue to rise. In 2002, the Lebanese Guidelines for Osteoporosis Assessment and Treatment were developed to optimize quality of osteoporosis care in Lebanon and the region. They were endorsed by 5 Lebanese medical scientific societies, and by the Eastern Mediterranean Regional Office branch of the World Health Organization (WHO). In April 2006, the Lebanese Society for Osteoporosis and Metabolic Bone Disorders (OSTEOS) led an initiative to update several recommendations detailed in the original document, based on relevant new local and international data. Data from a population-based sample of elderly Lebanese validated the following recommendations: fracture risk assessment, expressed as relative risk per standard deviation (RR/SD) decrease, was comparable in Lebanese subjects to similarly derived estimates from Western studies; the use of the NHANES database (hip), and the densitometer American database (spine) was as good, if not superior to the use of a Lebanese database for identifying subjects with prevalent vertebral fractures. The original recommendation regarding the use of a gender-specific western database, densitometer for spine and NHANES for T-score derivation for men, remains unchanged. For skeletal site selection, the update recommends measuring the spine and hip for women < or =65 yr, hip only for subjects >65 yr, and adding the forearm in conditions associated with cortical bone loss or in the case of inability to measure axial sites. The original recommendations for conservative management in premenopausal women were reiterated. This First Update of the Lebanese Osteoporosis Guidelines validates previous recommendations using evidence from a population-based sample of elderly Lebanese, and lays the ground for transitioning the Lebanese Osteoporosis Guidelines to the WHO global fracture risk assessment model.

Vertebral fracture risk and impact of database selection on identifying elderly Lebanese with osteoporosis.

The International Osteoporosis Foundation recommends using a universal database i.e. the NHANES database for the diagnosis of osteoporosis. Population-based databases for T-score calculation are still debated in terms of clinical and public health relevance. The current study aimed at estimating the prevalence of vertebral fractures in the Lebanese elderly, determining BMD-fracture relationship, and assessing the effect of database selection on osteoporosis prevalence and fracture risk assessment. Apparently healthy subjects were randomly selected from the Greater Beirut area - one-third of the Lebanese population at large - using a multilevel cluster technique. Subjects with medical conditions likely to affect bone metabolism i.e. history of major chronic disease, intake of medications that affect bone metabolism were excluded. Presence of vertebral fracture was estimated by a semi-quantitative assessment. Bone density was measured by central DXA. Clinical risk factors included age, gender, height, weight, body mass index, smoking, exercise, falls, previous fragility fracture and family history of fragility fracture. Impact of database selection was assessed by: (1) Comparison of sensitivity and specificity for prevalent vertebral fractures of the T-score

Severity of rheumatoid arthritis: the SEVERA study.

This study aims to assess the severity of rheumatoid arthritis (RA) in rheumatology practice in our population. All outpatients and inpatients with RA seen by registered rheumatologists over a 1-year period were included. Severity was measured using the Larsen score for hands and wrists and the Modified Health Assessment Questionnaire (M-HAQ). Two hundred ninety-eight RA cases were included. Mean age was 51.5 years. Among them, 261 (87.6%) were females. Disease duration was less than a year in 26 subjects (8.7%) and 10 years and above in 108 (36.2%) with a mean of 8.9. There were 220 (73.8%) subjects who had M-HAQ score <1. In 61 (20.5%) subjects, M-HAQ score was > or =1 and <2, and 17 (5.7%) had M- HAQ score > or =2. In relation with disease duration, M-HAQ starts with an average (SD) value of 0.7 (0.6) during the first year, decreases to 0.4 (0.4) at 5-year disease duration and increases after 10 years of disease progression to an average of 0.9 (0.8). Mean (SD) Larsen score was 51.9 (29.5) and median was 45. A total of 25% had a Larsen score > or =50% of maximum. Larsen score increased significantly (p<0.0001) with disease duration, starting at an average (SD) of 36.1 (14.9) during the first year, rising to 42.5 (15.8) around 5 years and reaching 73.9 (36.9) after 10 years. RA severity in our practice is comparable to that reported in Western populations in terms of radiological damage; however, functional status differs, possibly reflecting cultural differences.

Lebanese guidelines for osteoporosis assessment and treatment: who to test? What measures to use? When to treat?

With the demographic explosion of the population worldwide, the human, social, and economic costs of osteoporosis will continue to rise. It is estimated that the magnitude of the problem might be even larger in developing countries, including those in the Middle East. Although several organizations and countries have developed or adapted guidelines to their local needs, as of today there are no guidelines for osteoporosis assessment in the Middle East. In April 2002, a panel of osteoporosis experts met and discussed practice guidelines for osteoporosis assessment and treatment in Lebanon. The process, which involved an overview of international guidelines as well as local data on osteoporosis, resulted in a draft for Lebanese guidelines that addressed three main questions: "Who to test?" "What measures to use?" and "When to treat?". Representatives from five major Lebanese societies (Endocrinology, Rheumatology, Orthopedics, Obstetrics and Gynecology, and Radiology) subsequently reviewed, discussed, and officially endorsed the guidelines after revisions. The Lebanese guidelines were also endorsed by the Eastern Mediterranean branch of the World Health Organization.