Pattern of Uveitis in a Tertiary Hospital in North Jordan and the Impact of Behcet's Disease.

Aim: The purpose of this study is to assess the prevalence of autoimmune-mediated uveitis in relation to other diseases and to describe the clinical patterns of uveitis in a single tertiary hospital in north Jordan. Methods: A cross-sectional retrospective review was performed. We included all patients diagnosed with uveitis in King Abdullah University Hospital (KAUH) ophthalmology clinic and/or patients referred to KAUH rheumatology clinics for evaluation of suspected autoimmune mediated uveitis or for difficult to treat uveitis. This included patients from January 2015 to January 2019. Data collected about patients' age, sex, anatomical location of the disease, etiology, treatment, complications, and outcomes on vision loss were analyzed. Results: A total of 221 patients were included in our study. The mean (±SD) age was 36 (±16) years. A total of 111 patients were female and 110 were male with a ratio of 1 : 1. Noninfectious uveitis was found to be more common than infectious uveitis (95% vs. 5% respectively). Autoimmune-mediated uveitis accounted for 40% of the total cases. The most common causes of autoimmune-mediated uveitis included Behcet's disease (n = 41, 19%) and seronegative spondyloarthropathy (n = 29, 13%). The majority of patients (n = 207, 94%) were treated with ophthalmic eye drops, cDMARDs (n = 101, 46%), biologics (n = 33, 15%), and colchicine (n = 30, 14%). Conclusion: Autoimmune-mediated uveitis, most commonly associated with Behcet's disease and seronegative spondyloarthropathy, represents a high percentage of uveitis in our area. This implies the need for a high index of suspicion at the time of evaluation.

The Safety and Effectiveness of Infliximab Biosimilar in Managing Rheumatoid Arthritis: A Real-Life Experience from Jordan.

Background: Infliximab (IFX) biosimilar was the first biosimilar approved in Jordan in 2014, with limited evidence of its safety and effectiveness from the Middle East and North Africa (MENA) region. Thus, this study aimed to evaluate the safety and effectiveness of IFX biosimilar in active rheumatoid arthritis (RA) patients over 34 weeks by investigating (1) the adverse events (AEs), serious adverse events (SAEs), and therapy discontinuation and (2) the score changes of the 28-Joint Disease Activity Score (DAS28) and the Health Assessment Questionnaire Disability Index (HAQ-DI). Methods: This multicenter prospective cohort study collected clinical parameters within hospital settings every four weeks. The numbers and percentages of observed AEs and SAEs were informed. The DAS28 utilizing Erythrocyte Sedimentation Rate (ESR), HAQ-DI, and ESR were reported at baseline and 14th and 30th weeks; thus, they were reported as means (SD). Results: A total of 22 RA patients were enrolled and initiated IFX biosimilar, of which nine (41.0%) discontinued the study, but their data were analyzed up to the point of withdrawal. A total of 35 AEs were reported in 14 patients, including two (5.7%) SAEs. None of the participants discontinued treatment due to AEs. The mean (SD) score of DAS28-ESR significantly decreased from 6.55 (1.16) at baseline to 4.59 (1.45) at week 14 (p < 0.0001) and to 4.77 (1.09) at week 30 (p < 0.0001). Similarly, the mean (SD) HAQ-DI score significantly decreased from 0.95 (0.74) at baseline to 0.48 (0.62) at week 14 (p=0.008) and to 0.71 (0.78) at week 30 (p=0.483). The mean (SD) value of ESR decreased from 58.75 (26.94) at baseline to 47.92 (33.89) at week 14 (p=0.082) and to 39.83 (17.38) at week 30 (p=0.005). Conclusion: IFX biosimilar demonstrated safety and effectiveness in managing RA patients bringing real-world clinical support for biosimilars' role in rheumatology.

Prevalence of rheumatoid arthritis among hospital workers in the north of Jordan: Preliminary report of a hospital-based cohort study.

BACKGROUND: Rheumatoid arthritis (RA) is the most common autoimmune inflammatory arthritis in adults. Prevalence estimates of rheumatoid arthritis vary in the world. Occupational factors and geographical location might contribute to a higher risk of developing the disease, however the exact etiology remains unknown.The aim of our study was to estimate the prevalence of RA among hospital workers in the North of Jordan and to compare this prevalence with that in the general population. In addition to describing the characteristics of RA patients. METHODS: The study was performed in two stages; during the first stage a specially designed questionnaire was conducted by trained residents with 2569 hospital workers from 6 government hospitals to identify individuals with RA. Suspected individuals of having RA identified in stage one were invited and examined further by two rheumatologists for confirmation of the diagnosis. RESULTS: A total of 2569 employees were interviewed; among them 1240 (48.5%) were males and 1318 (51.5%) were females. The mean (SD) age was 34±(8.4) years. In the second stage the diagnosis of RA according to ACR criteria 1987 was confirmed in 8 individuals (2 males and 6 females). Male: Female (M: F) ratio was 1:3 with mean (SD) age 43.38 (7.52) years. The estimated prevalence of RA among hospital workers in the North of Jordan was 8/2569 = 0.00311, 31.1:10.000, 0.31%, (95% confidence interval, 9.6-52.7:10.000). CONCLUSION: The prevalence of RA among hospital workers in the North of Jordan is 0.31%, similar to that of other parts of Jordan and neighboring regions.

Renal dysfunction among rheumatoid arthritis patients: A retrospective cohort study.

BACKGROUND: Rheumatoid arthritis (RA) is a common rheumatological disease which can involve a variety of different renal manifestations. This may be explained by disease effect itself or by medications used for treatment that may lead to renal dysfunction and its complications.We aimed to identify the prevalence and factors that played a role in renal dysfunction among RA Jordanian patients. METHOD: 285 patients with RA visiting outpatient clinic between March 2016 and March 2017 were included in a retrospective study design. Age, gender, comorbidities, duration of the disease, medications and laboratory results were gathered and scoring of RA activity was done. RESULTS: Data gathered from the 285 patients showed a female predominance with 88.4% female and 11.6% male. The average disease duration was 6.7 years. Age, DM, HTN, and serum CRP were associated with worse renal function on univariate analysis. 44 patients (18.8%) presented with microscopic hematuria, 16 (6.9%) with proteinuria and only 5 (2.1%) patients presented with both microscopic hematuria and proteinuria. Patients with eGFR <60 ml/min had longer disease duration with a mean of 11 years (±7.7) in comparison to 6.4 years (±6.1) for those with eGFR>90 ml/min (P = 0.001). CONCLUSION: Renal dysfunction is not common in RA Jordanian population and has variable presentations. Age and the duration of illness play a major role in the progression of CKD if present. Future prospective studies evaluating renal biopsies in RA patients are needed.

Diaphragmatic Lipoma in a Woman with Rheumatoid Arthritis: A Case Report and Literature Review.

BACKGROUND A lipoma is a benign tumor made of fat tissue. Diaphragmatic lipomas are frequently reported in case studies. CASE REPORT This study presents a case of diaphragmatic lipoma in a woman with rheumatoid arthritis who was complaining of shortness of breath. A literature review of previously reported diaphragmatic lipoma cases was also carried out. In our patient, normal vital signs were detected, and laboratory results showed that antinuclear antibody, complete blood count, erythrocyte sedimentation rate, and C-reactive protein levels were high. A high-resolution CT scan showed pulmonary nodules and an incidentally found diaphragmatic lipoma. The patient was prescribed corticosteroids, methotrexate, folic acid, and chloroquine. The 3-month follow-up visit revealed symptomatic improvements in breathing difficulties and joint attacks. CONCLUSIONS Diaphragmatic lipoma should be identified to avoid misdiagnosis. Most cases of lipoma require observation. Surgical treatment is indicated only if the mass is symptomatic, increasing in size, or of uncertain nature.

Impact of body mass index on hemoglobin level and blood transfusion in total knee arthroplasty: A retrospective case control study.

BACKGROUND: Morbid obesity is a challenge in cases that require total knee arthroplasty, and several studies considered it a contraindication for the procedure due to associated risk of complications, including plummeting hemoglobin levels and subsequent need for a blood transfusion. This study investigated risk factors for blood transfusion in this patient group and considered their relationship to obesity. MATERIALS AND METHODS: Patients' data were extracted from medical records, including estimated blood loss and perioperative hemoglobin levels. Patients were weighed and measured, and their body mass index (BMI) was calculated and stratified according to international criteria. RESULTS: A total of 188 patients were included in this study; among them, 136 patients had obesity (72%), with a mean BMI of 33.54. The mean volume of blood lost was 1055.4 ml, with the mean postoperative hemoglobin decrease of 1.42 g/dl and 2.88 g/dl at 6 and 24 h after surgery, respectively. The pre-operative Hb level was the only significant risk factor for blood transfusion. BMI did not affect the risk of blood transfusion or amount of blood lost. CONCLUSION: Obesity (BMI > 30 kg/m2) did not increase the risk of needing a blood transfusion after total knee arthroplasty. A judicious transfusion strategy involving the pre-operative Hb optimization should be adopted in TKA to decrease transfusion rate, benefit patient outcomes, and increase healthcare system efficiency. This study shows that high BMI is not a risk factor for postoperative blood transfusion.

The importance of physical fitness for the relationship of BDNF with obesity measures in young normal-weight adults.

AIMS: Brain derived neurotrophic factor (BDNF) is essential for cognitive function. It is also found in non-neuronal tissues with various regulatory actions, including metabolic. Physical fitness (PF) is associated with improved synthesis and secretion of BDNF and reduced obesity. However, the importance of PF for the relationship of BDNF with obesity has not been investigated. This study aims at examining the relationship of PF with BDNF and obesity in 174 young (age = 25.30 ± 9.2 years) healthy adults. MAIN METHODS: Serum BDNF was evaluated using ELISA while obesity was determined using body weight (BW), BMI, and waist circumference (WC). Six minute walk distance (6MWD) test was used to estimate PF. KEY FINDINGS: Serum BDNF was greater (p = 0.000) in the participants with high (Hi6MWD) versus low (Lw6MWD) PF group. Additionally, 6MWD explained 6.8% of serum BDNF. Obesity measures were greater (p < 0.05) in the participants with low versus high BDNF. In regression analyses, serum BDNF explained 4.7% of BW (p = 0.004), 3.8% of BMI (p = 0.011), and 6.2% of WC (p = 0.001). However, when the participants were divided into Hi6MWD and Lw6MWD, BDNF explained 8.2% of BW (p = 0.009), 6.0% of BMI (p = 0.03), and 7.0% of WC (p = 0.013), only in the Hi6MWD, but not in the Lw6MWD (p > 0.05) groups. SIGNIFICANCE: The finding confirms the relationship of BDNF with obesity. Additionally, it further suggests the importance of PF level to this relationship among young adults. Future studies are needed to confirm these findings.

Possible Modulation of Vascular Function Measures in Rheumatoid Arthritis by Homocysteine.

The effect of homocysteine on cardiovascular diseases is still equivocal, especially in rheumatoid arthritis patients. In this investigation, the association between homocysteine with blood flow and vascular resistance in rheumatoid arthritis was examined. Serum levels of homocysteine were determined in thirty-one rheumatoid arthritis patients and nineteen apparently healthy subjects using ELISA. Additionally, strain-gauge plethysmography was used to determine both forearm blood flow and vascular function at rest and after occlusion. Forearm occlusion blood flow (patients: 21.9 ± 6.55 versus control: 25.5 ± 6.10ml/100mL/min) was lower (p < 0.05) while occlusion vascular resistance (patients: 4.77 ± 2.08 versus controls 3.05 ± 0.96U) was greater (p < 0.01) in rheumatoid arthritis than in the controls. Level of serum homocysteine was similar (p = 0.803) in rheumatoid arthritis group and healthy group. In addition, level of serum homocysteine was correlated with resting blood flow (r = -0.41; p < 0.02) and resting vascular resistance (r = 0.31, p < 0.05) in the patients group. The study confirms altered vascular function in rheumatoid arthritis. Uniquely, the results show that homocysteine was related to resting, but not postischemia, vascular measures. These relationships indicate that homocysteine might impact the vasculature in rheumatoid arthritis.

Immune thrombocytopenia among patients with cancer and its response to treatment.

OBJECTIVES: The aim of this study was to determine the rate of immune thrombocytopenia (ITP) in adult Jordanian patients diagnosed with cancer, to correlate this rate with the type of cancer and to assess the response of ITP in patients with cancer to treatment. METHODS: All adult patients aged 16 years or older who had been diagnosed with cancer at King Abdullah University Hospital (KAUH) between September 2002 and October 2017 were included in this study. Their medical records were reviewed for the diagnosis of ITP. RESULTS: The total number of patients diagnosed with cancer at KAUH between September 2002 and October 2017 was 8318. The majority of patients had solid cancers (87.0%), and hematological cancers constituted 13%. Fifteen (0.2%) patients with cancer had ITP. ITP was significantly more common in patients with lymphomas (1.3%) than in patients with solid cancers (0.1%) (P < .005). In the multivariate analysis and after adjusting for age and gender, patients with lymphomas were 15.2 times more likely to be diagnosed with ITP than were patients with solid cancer. CONCLUSIONS: Patients with lymphomas had higher rates of ITP than did patients with solid cancers. Treatment of ITP-associated cancer may improve the platelets count.

The prevalence of Behçet's disease in the north of Jordan: a hospital-based epidemiological survey.

OBJECTIVES: To estimate the prevalence of Behçet's disease (BD) in Jordan, with the additional aim of comparing this prevalence among hospital workers in other geographical areas. METHODS: In the first stage of our survey, 2,569 employees from 6 hospitals in north Jordan were interviewed using a screening questionnaire to identify individuals with recurrent oral ulcers (ROU), a previous diagnosis of BD (PDBD) and/or any major symptom related to BD. In the second stage, all individuals with ROU or PDBD identified at stage 1, were examined by 2 rheumatologists for the presence/confirmation of BD according to the International Study Group (ISG) criteria. Pathergy test was performed according to recommendations. RESULTS: ROU were present in 210 (8.2%) individuals. BD was confirmed in 10 employees with PDBD. Seven more BD patients were found. Mean age of 17 BD patients was 38.6±10.7 (range 26-65 y). M: F was 2.4:1. Pathergy test was positive in 8/17. A family history of ROU or BD was noted in 9 (52%) and 3 (25.0%), respectively, compared to 227 (8.9%) and 62 (2.6%) in the whole group, excluding the BD patients (p<0.001 and 0.008, respectively). The prevalence rate of BD in the north of Jordan was estimated as 66:10.000 (95% CI 34.8 to 97.5:10000). CONCLUSIONS: The results of this first ever survey indicated that the prevalence of BD in the north of Jordan is among the highest in the world. This prevalence can now be compared to hospital workers in other geographical areas.

Effects of antirheumatic drug underutilization on rheumatoid arthritis disease activity.

BACKGROUND: Following the recommended guidelines is crucial for achieving patient remission in rheumatoid arthritis. The aim of this study was to assess the effect of proper drug utilization of antirheumatic drugs on disease activity and drug safety in Jordan. METHODS: In a retrospective cross-sectional study, patient's demographics, clinical variables, drug regimens and side effects were recorded and the 28-joint disease activity scores were calculated. Patients were stratified into high, moderate, low disease activity or remission group. RESULTS: Around 80% of patients were using methotrexate which was under-dosed in 82% of them. Only 25% were using biologic drugs. Surprisingly, only 10% of patients had low disease activity and only 4% were in a remission state. Anaemia (32.3%) and mild renal impairment (27.6%) were the most common side effects. CONCLUSIONS: The low frequency of well-controlled disease activity is interpreted by high occurrence of methotrexate underdosing and biologic agent underprescription. Implementing the role of a clinical pharmacist could have a real impact on tight control of such disease issues in Jordan.

Comparison if the addition of multilevel vertebral augmentation to conventional therapy will improve the outcome of patients with multiple myeloma.

BACKGROUND: This was a prospective study to evaluate the effect of multilevel vertebral augmentation in addition to conventional therapy in multiple myeloma patients. METHODS: We treated 27 patients, whom were recently diagnosed to have multiple myeloma by two ways of treatment. Thirteen patients (group I) were treated with conventional therapy and 14 patients (group II) with adding vertebroplasty and kyphoplasty. Patients were evaluated pre-treatment and at half, one, two and 3-years post-treatment by using Oswestry Disability Index (ODI), the Stanford Score (SS) and the Spinal Instability Neoplastic Score (SINS). RESULTS: Mean values of ODI, SS and SINS were 31.9 (63.8%), 4.3 and 13.8 for group I and 33.2 (66.4%), 4.6 and 12.8 for group II before starting treatment. Group II showed improvement better than group I at all follow-up intervals with best results at first 6 months. P-values at the end of the study were ODI = 0.047, SS = 0.180 and SINS = 0.002. Mortality rates were equal of both groups (four patients of each group). CONCLUSION: Adding vertebral augmentation to conventional therapy improves multiple myeloma patients' quality of life, but didn't affect the mortality rate.

Low prevalence of malignancy in patients with idiopathic inflammatory myopathies in Jordan.

OBJECTIVES: To estimate the frequency of malignancy among patients with idiopathic inflammatory myopathies (IIM) in Jordan. METHODS: This was a retrospective review of case records of patients with IIM in Jordan. RESULTS: We identified 94 cases of IIM, (47 polymyositis (PM) and 47 dermatomyositis (DM)). Sixty-seven (71%) were females and 27 (29%) were males. The mean age at diagnosis was 39.7± 15.7 years (range 17-72), median 40 years and the mean follow-up was 5.05±4.03 years (0.2-19). Malignancy was diagnosed in only 4 patients (4.25%) with IIM. Among patients with DM, malignancy was found in three patients (6.4%).The age-standardised rate was 2.7% (95% confidence interval: 0. 6% to 7.1%). The standardised incidence ratio was 0.998. Diagnosis of associated malignancy was made close to the time of IIM diagnosis. Two male patients had nasopharyngeal carcinoma at the ages of 51 and 59 years, while the other two were female with breast and ovarian cancer at the ages of 40 and 45 years, respectively. CONCLUSIONS: Malignancy in association with IIM was found to be low in our cohort in comparison to reports from other countries. The observed number of cancer cases in this group of patients is similar to the expected number of cases that would occur in general population of Jordan. This could be related to younger age of disease onset. The benefits of long-term screening for malignancy in our population are not clear.

Vascular function and brain-derived neurotrophic factor: The functional capacity factor.

Brain-derived neurotrophic factor (BDNF) is essential for neurocognitive function. This study aims at establishing a plausible link between level of serum BDNF, functional capacity (FC), and vascular function in 181 young (age 25.5±9.1 years old), apparently healthy adults. Fasting blood samples were drawn from participants' antecubital veins into plain glass tubes while they were in a sitting position to evaluate serum BDNF using enzyme-linked immunosorbent assay (ELISA). Mercury-in-silastic strain-gauge plethysmography was used to determine arterial function indices, blood flow and vascular resistance at rest and following 5 minutes of arterial ischemia. The 6-minute walk distance (6MWD) test was used to determine FC, according to the American Thoracic Society Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories guidelines. It was conducted in an enclosed corridor on a flat surface with a circular track 33 meters long. The walking course was demarcated with bright colored cones. The 6MWD correlated with BDNF (r=0.3, p=0.000), as well as with forearm blood inflow (r=0.5, p=0.000) and vascular resistance (r = -0.4, p=0.000). Subsequent comparison showed that BDNF and blood inflow were greater (p<0.05) while vascular resistance was less (p<0.05) in participants who achieved a longer 6MWD. Similarly, BDNF correlated with forearm blood inflow (r=0.4, p=0.000) and vascular resistance (r = -0.4, p=0.000). Subsequent comparison showed improved vascular function (p<0.05) in the participants with greater BDNF. In conclusion, these findings might suggest that improved vascular function in individuals with greater FC is mediated, at least partially, by an enhanced serum BDNF level.

Two novel mutations of FBN1 in Jordanian patients with Marfan syndrome.

Marfan syndrome is an autosomal dominant inheritance disorder with a 1/5000-live-birth prevalence. More than 3000 mutations have been characterized thus far in the FBN1 gene. The goal of this study is to facilitate Marfan syndrome diagnosis in Jordanian patients using a molecular genetic testing. All of the 65 coding exons and flanking intronic sequences of the FBN1 gene were amplified using polymerase chain reaction and were subjected to sequencing in five unrelated Jordanian patients suspected of having Marfan syndrome. Four different mutations were identified, including two novel mutations: the c.1553dupG frame-shift (p.Tyr519Ilefs*14) and the c.6650G>A (p.Cys2217Tyr) missense mutations. Two other missense mutations, c.2243G>A (p.Cys748Tyr) and c.2432G>A (p.Cys811Tyr), have been previously detected. Patient number five was heterozygous for the synonymous substitution variant c.1875T>C (p.Asn625Asn; rs#25458). Additionally, eight variants in the intronic sequence of the FBN1 gene were identified, of which the c.2168-46A>G mutation was a new variant. The data provide molecular-based evidence linking Marfan syndrome to pathogenic mutations in the FBN1 gene among Jordanians for the first time. Thus, our results will contribute to the better management of the disease using molecular tools and will help in genetic counseling of the patients' families.

Challenges and opportunities in the early diagnosis and optimal management of rheumatoid arthritis in Africa and the Middle East.

Early diagnosis and early initiation of disease-modifying antirheumatic drug (DMARD) therapy slow the progression of joint damage and decrease the morbidity and mortality associated with rheumatoid arthritis (RA). According to the European League Against Rheumatism (EULAR) guidelines, treatment should be initiated with methotrexate and addition of biological DMARDs such as tumour necrosis factor (TNF) inhibitors should be considered for RA patients who respond insufficiently to methotrexate and/or other synthetic DMARDs and have poor prognostic factors. Africa and the Middle East is a large geographical region with varying treatment practices and standards of care in RA. Existing data show that patients with RA in the region are often diagnosed late, present with active disease and often do not receive DMARDs early in the course of the disease. In this review, we discuss the value of early diagnosis and remission-targeted treatment for limiting joint damage and improving disease outcomes in RA, and the challenges in adopting these strategies in Africa and the Middle East. In addition, we propose an action plan to improve the overall long-term outlook for RA patients in the region.

Adequate hemodialysis improves anemia by enhancing glucose-6-phosphate dehydrogenase activity in patients with end-stage renal disease.

BACKGROUND: We conducted this study to determine the erythrocyte glucose-6-phosphate dehydrogenase (G6PD) activity level in patients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) and to determine the effect of hemodialysis adequacy on G6PD activity levels and its impact on anemia. METHODS: Eighty-two patients (48 men and 34 women) receiving regular hemodialysis for ESRD through arteriovenous fistulae for at least one year prior to the start of the study were enrolled in this study. G6PD activity levels were measured in all patients and the average Kt/V was used as a parameter of HD adequacy. Patients were divided into two groups according to Kt/V values. Group 1 included 45 patients with Kt/V(˃)1.2 (adequate HD), and group 2 included 37 patients with Kt/V(˃)1.2 (inadequate HD). The average hemoglobin level and the weekly dose of an erythropoietin-stimulating agent, epoetin alpha (ESA), for each patient were calculated for one year. RESULTS: The mean (SD) erythrocyte G6PD activity for all patients on hemodialysis was 7.64 ± 1.85 U/g Hb. Patients who had received adequate hemodialysis had a significantly higher average erythrocyte G6PD (mean (SD) = 9.2 ± 0.7 U/g Hb) compared to patients who had inadequate hemodialysis (mean (SD) = 5.7 ± 0.7 U/g Hb) (P-value <0.005). The mean hemoglobin concentration was significantly higher in patients with adequate hemodialysis compared to those with inadequate hemodialysis. CONCLUSION: Our study demonstrated the beneficial effect of adequate hemodialysis in correcting anemia by enhancing the erythrocyte G6PD activity in patients.

Rheumatoid arthritis in Jordan: a cross sectional study of disease severity and associated comorbidities.

Treating rheumatoid arthritis (RA) to target is advocated using disease activity measures. The impact of RA on the general health status of affected patients in Jordan is not well described. This study reported the severity of RA in Jordan and its association with consequent disabilities and comorbidities. A cross-sectional, observational study was conducted at King Abdullah University Hospital in the north of Jordan. All patients who were diagnosed with RA were included. Patients' demographics, comorbidities, disease activity score (DAS 28), and clinical disease activity index (CDAI) were collected. Both DAS 28 and CDAI were utilized to categorize RA disease activity. A total of 465 patients with RA were included: 82% were females; mean age ± standard deviation (SD) was 47.62±14.6 years; and mean disease duration ± SD was 6±4.45 years. The mean ± SD for the DAS 28 and CDAI was 5.1±1.5 and 23±14.2, respectively. According to the DAS 28, 51% of the patients were in the high disease activity category and only 5% were in remission. On the other hand, according to the CDAI, 44% were in the high disease activity category and only 1% were in remission. In Jordan, patients with RA have a high severe disease rate and a low remission rate. The disease is often progressive and associated with comorbidities that need to be managed.

Anti-TNF therapy in Jordan: a focus on severe infections and tuberculosis.

BACKGROUND: A high rate of infection has been reported in patients receiving treatment with anti-tumor necrosis factor (anti-TNF). This study describes the rate of and risk factors for serious infections in patients receiving anti-TNF agents in Jordan. METHODS: This retrospective observational study was conducted at a large tertiary referral center in the north of Jordan. Between January 2006 and January 2012, 199 patients who received an anti-TNF agent (infliximab, adalimumab, or etanercept) were included. Patients received the anti-TNF treatment for rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, or other conditions. A serious infection was defined as any bacterial, viral, or fungal infection that required hospitalization, administration of appropriate intravenous antimicrobial therapy, and temporary withholding of anti-TNF treatment. RESULTS: The mean duration of anti-TNF treatment was 26.2 months. Steroids were used in 29.1% of patients, while 54.8% were given additional immunosuppressant therapy (methotrexate or azathioprine). Only one anti-TNF agent was given in 70.4% of patients, while 29.6% received different anti-TNF agents for the duration of treatment. Serious infections were documented in 39 patients (19.6%), including respiratory tract infections (41%), urinary tract infections (30.8%), and skin infections (20.5%), and extrapulmonary tuberculosis in three patients (7.7%). Exposure to more than one anti-TNF agent was the only factor associated with a significant increase in the rate of infection (relative risk 1.9, 95% confidence interval 1.06-4.0, P=0.03). CONCLUSION: Serious infections, including tuberculosis, were a common problem in patients receiving anti-TNF agents, and exposure to more than one anti-TNF agent increased the risk of serious infection.

Association between vitamin B12 level and anti-parietal cells and anti-intrinsic factor antibodies among adult Jordanian patients with Helicobacter pylori infection

OBJECTIVE: Evaluate the association of Helicobacter pylori infection with anti-parietal cell antibodies (APCA) and anti-intrinsic factor antibodies (AIFA) and their impact on vitamin B12 serum level. PATIENTS AND METHODS: One hundred patients (M/F: 43/57; age 46.5 ± 17.5 years) who underwent upper gastrointestinal endoscopy at King Abdullah University Hospital, Irbid, Jordan were enrolled in the study. The patients were grouped as H. pylori-infected (n = 81) or H. pylori negative (n = 19) by histopathological examination. Fasting serum vitamin B12 levels, antiparietal cell antibodies and anti-intrinsic factor antibodies for patients and controls were determined. RESULTS: Anti-parietal cell antibodies and anti-intrinsic factor antibodies were positive in 9.9% and 18.5% of H. pylori-positive patients respectively. None of the H. pylori negative subjects had anti-parietal cell antibodies or anti-intrinsic factor antibodies. Serum vitamin B12 level was lower in the H. pylori-infected patients (275 ± 70.4 pg/mL) than in controls (322.9 ± 60.7 pg/mL; p 0.05). H. pylori was positive in 94% of the low-vitamin B12 group compared with 64.6% of the normal-vitamin B12 group (p 0.5). CONCLUSION: Patients with H. pylori infection are more likely to have anti-parietal cell antibodies and anti-intrinsic factor antibodies. There was an association between H. pylori infection and lower vitamin B12 levels. H. pylori infection might be a significant factor in the pathogenesis of autoimmune gastritis.