Adaptation of the 2015 American College of Rheumatology treatment guideline for rheumatoid arthritis for the Eastern Mediterranean Region: an exemplar of the GRADE Adolopment

BACKGROUND: It has been hypothesized that adaptation of health practice guidelines to the local setting is expected to improve their uptake and implementation while cutting on required resources. We recently adapted the published American College of Rheumatology (ACR) Rheumatoid Arthritis (RA) treatment guideline to the Eastern Mediterranean Region (EMR). The objective of this paper is to describe the process used for the adaptation of the 2015 ACR guideline on the treatment of RA for the EMR. METHODS: We used the GRADE-Adolopment methodology for the guideline adaptation process. We describe in detail how adolopment enhanced the efficiency of the following steps of the guideline adaptation process: (1) groups and roles, (2) selecting guideline topics, (3) identifying and training guideline panelists, (4) prioritizing questions and outcomes, (5) identifying, updating or conducting systematic reviews, (6) preparing GRADE evidence tables and EtD frameworks, (7) formulating and grading strength of recommendations, (8) using the GRADEpro-GDT software. RESULTS: The adolopment process took 6 months from January to June 2016 with a project coordinator dedicating 40% of her time, and the two co-chairs dedicating 5% and 10% of their times respectively. In addition, a research assistant worked 60% of her time over the last 3 months of the project. We held our face-to-face panel meeting in Qatar. Our literature update included five newly published trials. The certainty of the evidence of three of the eight recommendations changed: one from moderate to very low and two from low to very low. The factors that justified a very low certainty of the evidence in the three recommendations were: serious risk of bias and very serious imprecision. The strength of five of the recommendations changed from strong to conditional. The factors that justified the conditional strength of these 5 recommendations were: cost (n = 5 [100%]), impact on health equities (n = 4 [80%]), the balance of benefits and harms (n = 1 [20%]) and acceptability (n = 1 [20%]). CONCLUSION: This project confirmed the feasibility of GRADE-Adolopment. It also highlighted the value of collaboration with the organization that had originally developed the treatment guideline. We discuss the implications for both guideline adaptation and future research to advance the field.(AU)

Enhancing the care of women with rheumatic diseases during pregnancy: challenges and unmet needs in the Middle East.

Pregnancy in women with rheumatic disorders is known to be associated with risks for both the mother and fetus; however, these risks can be minimized with proper planning and careful management of the disease. In the Middle East, there are specific cultural challenges that may have a negative impact on the care that women with rheumatic disorders receive. There is a need for cross-collaboration between specialist physicians, improved awareness of rheumatic disorders among the general public and more open discussion with patients about the potential complications of pregnancy. Women in the region are often unwilling to discuss their disease with their partner and are even less likely to seek advice regarding family planning from their physician. The objective of this review is to highlight the specific challenges of pregnancy management and to discuss why establishing specialist pregnancy clinics for women with rheumatic disorders could be an effective solution. Such clinics can provide high quality care before, during and after pregnancy as shown in several European and US centers. Additionally, such clinics could be useful for the collection of pregnancy outcomes data from the Middle East, which may currently be lacking in the region, in order to highlight where further improvements can be made. With specialist care and analysis of pregnancy outcomes, the standard of care for women with rheumatic disorders in this area could be significantly improved.

[Analysis of the quality of data issued from Beirut's hospitals in order to measure short-term health effects of air pollution]. / Analyse de la qualité des données issues des hôpitaux de Beyrouth Municipe pour mesurer les effets à court terme de la pollution atmosphérique.

BACKGROUND: The effects of air pollution on human health have been the subject of much public health research. Several techniques and methods of analysis have been developed. Thus, Beirut Air Pollution and Health Effects (BAPHE) was designed to develop a methodology adapted to the context of the city of Beirut in order to quantify the short-term health effects of air pollution. METHODS: The quality of data collected from emergency units was analyzed in order to properly estimate hospitalizations via these units. This study examined the process of selecting and validating health and pollution indicators. RESULTS: The different sources of data from emergency units were not correlated. BAPHE was therefore reoriented towards collecting health data from the emergency registry of each hospital. A pilot study determined the appropriate health indicators for BAPHE and created a classification methodology for data collection. CONCLUSION: In Lebanon, several studies have attempted to indirectly assess the impact of air pollution on health. They had limitations and weaknesses and offered no recommendations regarding the sources and quality of data. The present analysis will be useful for BAPHE and for planning further studies.

An audit of bone densitometry practice with reference to ISCD, IOF and NOF guidelines.

INTRODUCTION: The impact of osteoporosis guidelines on clinical practice has not been fully evaluated. OBJECTIVES: To estimate the positive predictive value (PPV) of the National Osteoporosis Foundation (NOF), the International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) guidelines for osteoporosis and compare it to the PPV of clinical judgement alone. METHODS: All subjects tested for bone mineral density during the fall of 2001 in three teaching hospitals in Beirut were invited to participate. The reference databases used for the calculation of the T-score were the NHANES database for the hip and the manufacturer's database for the spine. The impact of using guidelines was measured by the increment in PPV. Osteoporosis was defined as a T-score < or =-2.5 at either the spine or hip. RESULTS: A total of 307 post-menopausal women were tested with dual-energy X-ray absorptiometry (DXA). In current practice (clinical judgement alone), the PPV for osteoporosis was 42.4%; using NOF guidelines, 236 women would have been tested, and the PPV would have been 46.2%. Similarly, using IOF or ISCD guidelines, 236 women would have been tested, and the PPV would have been 47.1%. CONCLUSION: Compared to current clinical practice, application of the ISCD, IOF and NOF guidelines may increase the predictive value of a central DXA for osteoporosis.