Diaa Shehab

Are 25(OH)D levels related to the severity of knee osteoarthritis and function

Objective: To investigate the effect of 25-hydroxyvitamin D [25(OH)D] in Kuwaiti patients with primary knee osteoarthritis (OA) and to assess its relation with radiological grading and functional status. Subjects and Methods: In this cross-sectional study, 25(OH)D was measured using radioimmunoassay in 99 patients [90 women and 9 men; mean age 56.5 ± 9.1 years (range: 36–80)] with clinical and radiological findings of primary knee OA. X-ray grading using the Kellgren-Lawrence grading scale and the Osteoarthritis Research Society International (OARSI) Atlas grading scale and functional assessments using Lequesne’s indices were evaluated in relation to the 25(OH)D level. Other variables studied were age at onset of symptoms, body mass index and duration of disease. Results: The age of the patients at the onset and the duration of disease were 51.58 ± 7.14 and 3.88 ± 2.51 years, respectively. Mean scoring for functional assessment was 10.31 ± 4.35 and mean Kellgren-Lawrence radiological grading was 2.43 ± 0.85. Radiological finding according to the OARSI Atlas revealed joint space narrowing of grades 2–3 in 87 (87.9%) patients and the presence of osteophytes in 55 (55.6%) patients. The mean value of 25(OH)D level was 11.4 ± 6.07 ng/ml. Of the 99 patients, 92 (92.9%) were vitamin D deficient. Comparison of 25(OH)D levels to radiological findings and different functional classes showed no significant association. Conclusion: Most of our patients had vitamin D deficiency, but the level of 25(OH)D was not related to the severity of the knee X-ray grading or to the functional assessment in our patients with primary knee OA.

Musculoskeletal pain: Should physicians test for vitamin D level?

The aim of this study was to evaluate vitamin D levels using a reliable method in patients with regional and generalized musculoskeletal (MSK) pain in comparison to healthy controls.

Rheumatic complications of alcohol abuse

The purpose of this report is to review rheumatic complications associated with alcoholism. Data were collected by an English-language literature search using MEDLINE (1966 to December 1991) and references from identified articles. Studies in humans, including case reports of joint disease and allied disorders associated with alcoholism, were reviewed. According to the data identified, alcoholism is associated with many rheumatic problems, including neuropathic arthropathy, hyperuricemia with gouty arthritis, septic arthritis, and joint hypermobility. Osteoporosis, osteonecrosis, and myopathy also are common. Several other rare musculoskeletal complication have been described. Early recognition of these problems is important for management. Further studies are needed to examine the effect of alcohol on connective tissue components in joints.

Use of interaction cards to evaluate clinical performance

Currently in-training evaluation in Kuwait depends on the use of the global rating scale at the end of clinical rotation clerkships. Such a scale is inconsistent, subjective, and suffers from deficiencies such as positive skewness of the distribution of ratings and poor reliability. The aim of the study was to assess the inter-rater variation and the reliability of the recently introduced Interaction Card (IC) method for evaluating clinical performance and to measure the agreement between trainees’ overall performance evaluation by the currently used global rating scale and the IC summative evaluation. In the study, 370 evaluators encountered 50 trainees during their basic clinical training rotations (internal medicine, surgery, obstetrics and gynecology, and pediatrics) at six hospitals. A total of 9146 encounters were conducted focusing on six clinical performance domains: clinical skills (taking history, case sheet, and physical examination), professional behaviour, case presentation, diagnosis, therapy and handling of emergencies. The method demonstrated significant inter-rater variation in the overall IC ratings according to specialty, rank of evaluator and hospital (p < 0.001). The Interaction Card was found to be reliable, as shown by the internal consistency between the six domains (Cronbachs alpha = 0.914). There was low correlation (Spearman rank correlation coefficient, rs = 0.337), and low agreement (Kappa = 0.131) between the global rating scale and Interaction Cards summative evaluations. The IC method provided instantaneous formative feedback and summative evaluation for clinical performance to trainees. The method can be generalized to encompass training and examinations programmes for all categories of trainees in most clinical specialties.

Rheumatic complications of inflammatory bowel disease among Arabs: a hospital-based study in Kuwait

To investigate the rheumatic complications of inflammatory bowel disease (IBD) Arab patients in relation to the clinical manifestations of IBD using the Montréal classification system in a hospital‐based population in Kuwait.

Frequency and confidence in performing clinical skills among medical interns in Kuwait

Background: Several investigations suggest inadequate emphasis of basic clinical procedures during internship training. Many trainees had reported lack of competence, while some expressed confidence to manage conditions although not sufficiently experienced. Aims: This study aimed at ascertaining the perceptions of new medical graduates regarding the performance of core clinical skills during training and confidence of performing them later. It also aimed at determining any gender variability in the confidence in performing selected clinical skills in Obstetrics & Gynaecology. Methods: Interns trained during 2005/06 responded anonymously to a questionnaire that listed 48 core clinical skills. The 124 subjects eligible for the study comprised graduates from Kuwait (64), other Gulf Cooperation Council countries (29), Ireland (27) and Egypt. They indicated whether they felt confident to perform the skills in future, and the number of times they had performed them during training. We received 91 completed questionnaires. Results: The majority felt confident in performing routine skills (basic ECG and X-ray interpretations, insertion of intravenous line, inserting urethral catheter and nasogastric feeding). Approximately two thirds had performed generic skills related to emergency resuscitation, with a half of them confident in performing them in the future. A third felt confident in performing artificial ventilation and endotracheal intubation. The confidence to perform common skills in Obstetrics & Gynaecology varied, with no significant gender variation. Approximately a fifth was confident in performing lumbar puncture, needle aspiration of joints, insertion of thoracic drainage, insertion of central venous catheter, venous cut-down and indirect laryngoscopy. A small proportion reported confidence in performing different clinical procedures although they had not undertaken them during training. Conclusions: Substantial proportions of trainees lacked confidence in performing emergency resuscitative measures and some routine clinical skills. Training needs to be closely monitored and interns who are not competent identified early for taking remedial measures.

Validation of the Arabic Version of the Early Inflammatory Arthritis Detection Tool

Objective: To evaluate the reliability and validity of the Arabic version of the Early Inflammatory Arthritis Questionnaire (EIAQ-A), a detection tool for screening for early inflammatory arthritis (EIA) in Arabic-speaking populations. Subjects and Methods: A cross-sectional study was conducted among 30 consecutive participants (21 female and 9 male) attending the Internal Medicine Outpatient Clinic at Mubarak Al-Kabeer Hospital. They completed the self-administered EIAQ-A twice within a 2-week period. Their disease activity was evaluated during the visits based on clinical and laboratory variables. Cross-cultural adaptation was performed using forward and backward translations of the original questionnaire. Test-retest reliability of the EIAQ-A was evaluated using the measure of agreement, kappa (κ), between the response of participants in the two interviews. Internal consistency of the EIAQ-A was measured using the Kudar-Richardson-20 coefficient (KR-20), a binary response equivalent to Cronbachs a. External construct validity was assessed by Spearmans rank correlation coefficient (rs) between the score of EIAQ-A and both clinical and laboratory variables of disease activity. Results: The test-retest reliability for EIAQ-A was good (κ = 0.558) for the overall score and between 0.841 and 0.368 for the subscale scores. Internal consistency had an acceptable value of KR-20 = 0.869. The construct validity for EIAQ-A was high for all disease activity variables tested, rs was between 0.727 (swollen joint count) and 0.896 (visual analog scale pain score). Conclusion: The EIAQ-A was a reliable and valid tool for population screening for EIA. Its use may accelerate the early detection of EIA in Arabic-speaking communities.

Cytokine profiles in osteoporosis suggest a proresorptive bias

Objective: As the immune system is suggested to contribute to the pathophysiology of osteoporosis in menopause, we compared the levels of proresorptive and antiresorptive cytokines produced by peripheral blood mononuclear cells (PBMCs) from postmenopausal women with normal and low bone mineral density (BMD). Methods: Seventy-one postmenopausal women were studied; 25 had normal BMD and 46 had low BMD. Participants were categorized as normal (n = 25), osteopenic (n = 31), and osteoporotic (n = 15) based on T-scores. Levels of 10 cytokines produced by mitogen-stimulated PBMCs were measured by Multiplex ELISA. Results: PBMCs from women with low BMD produced higher levels of the proresorptive cytokines tumor necrosis factor-alpha, interleukin (IL)-6, IL-12, and IL-17 (P = 0.014, 0.012, 0.011, and 0.049), and lower levels of the antiresorptive cytokines IL-4, IL-10, and IL-23 (P = 0.003, 0.018, and 0.025) compared with women with normal BMD. Proresorptive cytokines were similar in osteopenic and osteoporotic women, but both had higher levels than women with normal BMD. Osteoporotic women produced lower levels of the antiresorptive cytokines IL-4, IL-10, IL-13, and IL-23 compared with the normal BMD group (P = 0.001, 0.05, 0.05, and 0.026), and lower levels of IL-4 as compared with osteopenic women (P = 0.05). Osteopenic women produced lower levels of IL-4 and IL-10 compared with the normal BMD group (P = 0.025 and 0.038). Ratios of proresorptive to antiresorptive cytokines suggest a stronger proresorptive cytokine bias in women with low BMD. Most of the ratios are lowest in the normal BMD group, modest in osteopenic women, and highest in the osteoporotic group. Conclusions: Women with low BMD have a proresorptive cytokine bias.

Ossification of Ligamentum Flavum in Middle East Arabs: A Hospital-Based Study

Objective: To investigate the frequency of ossification of the ligamentum flavum (OLF) in the spine among the Arab population in Kuwait using magnetic resonance imaging (MRI) surveillance of the whole spine. Subjects and Methods: A consecutive series of 102 patients with low back pain were recruited from the outpatient clinic of Mubarak Al-Kabeer Hospital, Kuwait. MRI of the whole spine in the sagittal plane was obtained in at least two sequences (T1 and T2). The OLF was defined as low signal intensity thickening of the ligament in both T1 and T2 sequences on the posterior margin of the spinal canal, causing indentation of the theca with or without cord compression. Results: Of the 102 cases, 19 (18.6%) patients had OLF. Of the 19 positive cases, 12 (63.2%) were present at a single level, and 7 (36.8%) at multiple levels. A total of 26 OLF segments were identified in the following anatomical distribution: cervical: 15 (57.7%); upper thoracic (T1–T4): 1 (3.8%); mid thoracic (T5–T8): 4 (15.4%); lower thoracic (T9–T12): 4 (15.4%), and lumbar region: 2 (7.7%). Of the 19 OLF patients, 2 (10.5%) had tandem ossification of the posterior longitudinal ligament in the cervical spine and were symptomatic. Conclusions: The frequency of OLF appears to be high among this hospital-based cohort of the Arab population. OLF should be kept in mind if a patient presents with radiculopathy, particularly in the cervical region, for which surgical intervention is contemplated.

Antibodies to mutated citrullinated vimentin and anti-cyclic citrullinated peptide antibodies in inflammatory bowel disease and related arthritis.

Background: Antibodies that react with citrullinated proteins (anti‐mutated citrullinated vimentin [anti‐MCV] and second‐generation anti‐cyclic citrullinated peptide antibodies [anti‐CCP2]) are markers for rheumatoid arthritis. Recent studies have demonstrated that these antibodies are present in other arthropathies including the spondyloarthritis, psoriatic arthritis, and juvenile idiopathic arthritis. Arthritis associated with inflammatory bowel disease (IBD) takes various forms, with some shared similarities with classic spondylarthropathies. Our objective was to investigate the role of anti‐MCV and anti‐CCP2 as potential biomarkers in IBD and related arthritis. Methods: In all, 125 IBD patients (71 males, 54 females) were compared to 81 age‐ and sex‐matched healthy controls. Anti‐MCV and Anti‐CCP2 IgG were measured using an enzyme linked immunosorbent assay. Results: In the 125 IBD patients (mean age 32.6 ± 12.3 years), 44 (35.2%) had ulcerative colitis and 81 (64.8%) had Crohns disease. Forty‐four (35.2%) IBD patients developed arthritic manifestations. Antibody positivity was observed in 24/125 (19.2%) IBD patients and in 18/81 (22.2%) healthy subjects. The proportion of anti‐MCV positivity among IBD patients and healthy individuals were similar: 16.8% vs. 16.0%, P = 0.887. Anti‐CCP2 positivity among IBD patients and healthy individuals was also comparable: 6.4% vs. 6.2%, P = 0.948. Similarly, the presence of anti‐MCV and anti‐CCP2 antibodies was not different among IBD patients with and without arthritis. The mean titers of antibodies were low: anti‐MCV (29.6 ± 7.5 U/mL) and anti‐CCP2 (27.6 ± 4.0 U/mL) in IBD patients with arthritis. Conclusions: Autoantibodies to citrullinated proteins were low in IBD‐related arthritis. These findings suggest that these antibodies are not useful biomarkers in IBD to predict who may develop IBD‐related arthropathy. (Inflamm Bowel Dis 2012)