Mohammed A. Omair

Effect of Gastrointestinal Manifestations on Quality of Life in 87 Consecutive Patients with Systemic Sclerosis

Objective. To assess the effect of gastrointestinal (GI) manifestation on the quality of life in patients with systemic sclerosis (SSc). Methods. The University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2 questionnaire was completed by 87 consecutive patients with SSc attending the scleroderma clinic at a single center. Their clinical features and current therapies were recorded; 100 patients with rheumatologic disorders other than SSc were used as controls. Individual scores were compared between SSc and controls, and between SSc subgroups. Results. Of 87 patients, 76 (90%) were women. Median age was 55 years and disease duration 105 months. Thirty-three (38%) had diffuse and 54 (62%) had limited SSc. Patients with SSc had a higher score than controls in all domains (p < 0.05). Numbers of patients who responded positively to individual questionnaire components are as follows: any GI symptom 86 (99%), reflux 77 (89%), distension 73 (84%), soilage 19 (22%), diarrhea 44 (51%), constipation 51 (59%), well-being 43 (49%), and social 43 (49%). There was no difference between the scores of patients with diffuse and limited disease subtypes. The use of calcium channel blockers did not significantly increase the constipation score (p = 0.99). Patients who responded positively to the reflux, distension, diarrhea, and constipation domains had lower scores in the well-being and social domains. Conclusion. GI manifestations, especially fecal incontinence (affecting 22% of patients), have a negative influence on the quality of life of patients with SSc. There was no difference between SSc disease subtypes.

Safety and Effectiveness of Mycophenolate in Systemic Sclerosis. A Systematic Review

Background Mycophenolate is increasingly being used in the rheumatic diseases. Its main adverse effects are gastrointestinal, myelosuppression, and infection. These may limit use in systemic sclerosis (SSc) since gastrointestinal involvement is common. The objective of this study is to evaluate gastrointestinal adverse events of mycophenolate in SSc. Secondarily we evaluated other adverse events, and the effectiveness of mycophenolate in skin and lung disease. Methods A literature search of Medline, Embase, Cochrane Central Register of Controlled Trials, and CINAHL (inception-2013) was performed. Studies reporting use of mycophenolate in SSc patients, adverse events, modified Rodnan skin score (MRSS), forced vital capacity (FVC), or diffusing capacity of carbon monoxide (DLCO) were included. The primary outcome was gastrointestinal events occurring after the initiation of mycophenolate. Secondary safety outcomes included myelosuppression, infection, malignancy, and death after the initiation of mycophenolate. Results 617 citations were identified and 21 studies were included. 487 patients were exposed to mycophenolate. The mean disease duration ranged between 0.8-14.1 years. There were 18 deaths and 90 non-lethal adverse events. The non-lethal adverse events included 43 (47.7%) gastrointestinal events, 34 (26%) infections, 6 (5%) cytopenias and 2 (2%) malignancies. The most common gastrointestinal events included diarrhea (n=18 (14%)), nausea (n=12 (9%)), and abdominal pain (n=3 (2%)). The rate of discontinuation ranged between 8%-40%. Seven observational studies reported improvement or stabilization in FVC, and 5 studies report stabilization or improvement in MRSS. Conclusion Mycophenolate-associated gastrointestinal adverse events are common in SSc, but not severe enough to preclude its use. Observational data suggests mycophenolate may be effective in improving or stabilizing interstitial lung disease, and skin involvement.

Autoimmune symptoms in idiopathic pulmonary fibrosis: clinical significance.

Information regarding autoimmune symptoms that do not meet the diagnostic criteria for connective tissue disease in patients with idiopathic pulmonary fibrosis (IPF) is limited. The aim of the present study was to investigate differences in the clinical characteristics and prognosis of IPF patients with and without autoimmune symptoms.

Gastric Antral Vascular Ectasia Unmasked by Alprostadil for Digital Ulceration in Scleroderma

To the Editor: We describe a 54-year-old woman with systemic sclerosis (scleroderma, SSc) of the limited subtype. Diagnosis in 1994 was based on tightness of the skin distal to the metacarpophalangeal joints, calcinosis, telangiectasia, esophageal dysmotility, and severe Raynaud’s phenomenon (RP) complicated by recurrent digital ulcers, gangrene and autoamputation. Her serology is significant for positive antinuclear antibody, and anticentromere antibody. During her disease course, she received different regimens of vasodilators including nifedipine, losartan, and topical nitroglycerin in addition to aspirin, with inadequate response. In May 2010 she presented with a refractory ulcer in the right third digit. Despite increase in her vasodilator therapy and addition of pentoxifylline, it progressed to diffuse ulceration of the digit, extending proximal to the distal interphalageal joint. Magnetic resonance imaging revealed no evidence of osteomyelitis. It was decided to admit her to hospital for intravenous (IV) prostaglandin. After she received a 3-day course of continuous IV alprostadil, the ulcer … [↵][1]Address correspondence to Dr. S. Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8. E-mail: Sindhu.Johnson{at}uhn.on.ca [1]: #xref-corresp-1-1

The Dorsal 4-finger Technique: A Novel Method to Examine Metacarpophalangeal Joints in Patients with Rheumatoid Arthritis

Objective. To describe the dorsal 4-finger technique (DFFT) in examining metacarpophalangeal (MCP) joints of patients with rheumatoid arthritis (RA) and compare it to the traditional 2-finger technique (TFT) using ultrasound (US) as a gold standard. Methods. Four rheumatologists evaluated 180 MCP joints of 18 patients with RA. All patients underwent US for greyscale (GSUS) and power Doppler US (PDUS). Agreements between rheumatologists, the 2 techniques, and US were evaluated using Cohen κ and the first-order agreement coefficient (AC1) κ methods. Results. The population comprised 17 females (94.4%) with a mean (SD) age and disease duration of 56.8 (14.4) and 21.8 (12.9) years, respectively. Eight patients (44.4%) were taking methotrexate monotherapy, while 10 patients (55.6%) were receiving biologics. US evaluation revealed 69 (38.3%) and 30 (16.7%) joints exhibited synovitis grade 2–3 by GSUS and PDUS, respectively. Effusion was documented in 30 joints (16.7%). The mean intraobserver agreement using the DFFT and TFT were 80.5% and 86%, respectively. The mean interobserver agreements using the DFFT and TFT were 84% and 74%, respectively. κ agreement with US findings was similar for both techniques in tender joints but was higher for the DFFT in nontender joints (0.33 vs 0.07, p = 0.015 for GSUS) and (0.48 vs 0.11, p = 0.002 for PDUS). The DFFT had a higher sensitivity in detecting ballottement by GSUS (0.47 vs 0.2, p < 0.001) and PDUS (0.60 vs 0.27, p < 0.001). Conclusion. The DFFT is a novel, reproducible, and reliable method to examine MCP joints, and it has a better correlation with US than the traditional TFT.

Recommendations for the management of rheumatoid arthritis in the Eastern Mediterranean region: an adolopment of the 2015 American College of Rheumatology guidelines

Clinical practice guidelines can assist rheumatologists in the proper prescription of newer treatment for rheumatoid arthritis (RA). The objective of this paper is to report on the recommendations for the management of patients with RA in the Eastern Mediterranean region. We adapted the 2015 American College of Rheumatology guidelines in two separate waves. We used the adolopment methodology, and followed the 18 steps of the “Guidelines 2.0” comprehensive checklist for guideline development. For each question, we updated the original guidelines’ evidence synthesis, and we developed an Evidence Profile (EP) and an Evidence to Decision (EtD) table. In the first wave, we adoloped eight out of the 15 original questions on early RA. The strength changed for five of these recommendations from strong to conditional, due to one or more of the following factors: cost, impact on health equities, the balance of benefits, and harms and acceptability. In the second wave, we adoloped eight out of the original 44 questions on established RA. The strength changed for two of these recommendations from strong to conditional, in both cases due to cost, impact on health equities, balance of benefits and harms, and acceptability. The panel also developed a good practice recommendation. We successfully adoloped 16 recommendations for the management of early and established RA in the Eastern Mediterranean region. The process proved feasible and sensitive to contextual factors.

Prevalence of fibromyalgia in physicians in training: a cross-sectional study

The prevalence of fibromyalgia (FM) in physicians in training (PIT) in Saudi Arabia is unknown. The aim of this study is to evaluate the prevalence of FM in PIT using different screening tools and factors associated with its development. We also aimed at evaluating the level of agreement and correlation between screening tools. This was a cross-sectional study conducted in a single academic institution. PIT were invited to fill three questionnaires: Fibromyalgia Rapid Screening tool (FirST), Fibromyalgia Survey Questionnaire (FSQ), and London Fibromyalgia Epidemiology Study Screening Questionnaire (LFESSQ). A total of 182 PIT completed the questionnaire. They were predominantly males (57.1%), single (56.0%), and at resident level (86.7%). The median age was 28 (interquartile range = 4). The average number of house-calls/month was 3.2 (SD = 2.3). The prevalence of FM using the FirST, FSQ, and LFESSQ was 6.0%, 8.2%, and 11.6%, respectively. Six (3.3%) fulfilled the three criteria concurrently. After adjusting for different variables using the FSQ, PIT with family history of FM had 23.6 times the odds for testing positive (95% CI = 3.12, 178.37), and every extra house-call/month was associated with a 50% increase in the odds for testing positive for FM (95% CI = 1.00, 2.25). Percent agreement between tools was high (all > 86%). Results for kappa coefficient showed moderate agreement between FSQ scores and each of FirST and LFESSQ. There was poor agreement between FirST and LFESSQ. FM is prevalent among PIT. There is a high percent agreement and poor to moderate correlation between the screening tools used.

Biological therapy in arthritis patients with hepatitis B or C infection: a multicenter retrospective case series

Objective Reactivation of viral hepatitis B (HBV) and C (HCV) has been reported in various case reports of patients with arthritis on biological therapy. The objective of this study was to describe the clinical characteristics and outcomes of arthritis patients with HBV or HCV treated with biological therapy. Material and Methods This is a retrospective case series including all patients above 13 years of age with arthritis patients from four centers in Saudi Arabia with concurrent chronic viral hepatitis infection (HBV or HCV) who received biological agents in the rheumatology clinics during their course of their disease from duration of the disease onset until last outpatient visit up to November 2015. Demographic information, full details about the hepatitis status of each patient, rheumatic disease diagnosis and different therapies used were reviewed. Results We identified 10 cases each with HBV and HCV on biological therapy. The mean age in the HBV group was 51 (34-85) years and 80% were females. Eight patients had rheumatoid arthritis (RA), one patient had RA/systemic lupus erythematosus, and one had human immunodeficiency virus related-arthritis. Seven were chronic inactive HBsAg carriers and three had chronic active HBV. Nine HBV patients received prophylactic antiviral therapy. Two cases with chronic HBV had reactivation with no elevation of the transaminases.The mean age in the HCV group was 54 (23-79) years and all were female RA patients. Three had detectable hepatitis C virus-ribonuecleic acid (HCV-RNA) before the start of biological therapy. Nine HCV patients received antiviral treatment and seven had a sustained virologic response (SVR) before start of biological treatment. Three patients had detectable HCV-RNA during the course of biological therapy. One of the three was a non-responder and two were relapsers. One of the patients with HCV relapse was started on sofosbuvir plus ribavirin and achieved SVR on follow-up. Conclusion We report the successful use of biological therapy in arthritis patients with hepatitis B infection with antiviral therapy with no detoriation of their viral status. Due to the lack of sufficient prospective studies demonstrating the rate of HCV flare on biological therapy, caution should be exercised and careful monitoring with liver enzymes and viral load is mandated in vulnerable HCV RNA patients. Treatment should be individualized by the rheumatologist in collaboration with the hepatologist to minimize complications.

Awareness and Misconceptions of Female Students in King Saud University on Systemic Lupus Erythematosus

Objectives: To determine the level of awareness of systemic lupus erythematosus (SLE) among preparatory year program female students enrolling in King Saud University. Methods: The authors developed a self-administered questionnaire to estimate the level of awareness on SLE. According to their scores, respondents are classified as knowledge adequate if they could answer 11 (35.5%) of the question. Descriptive statistics were calculated in terms of mean and standard. Chi-square and T tests were used to compare different subgroups for nominal and continuous variables respectively. Results: Six hundred thirty participants completed the questionnaire. Mean age ± (SD) was 18.6 ± (1.17), 591(93.8%) were of Saudi nationality, and 607(96.3%) were single. The number of respondents in each university section was as follows: Humanity 228(36.2%), Health 201(31.9%), and Science 201(31.9%). One participant (0.02%) reported the diagnosis of SLE. Seventy-nine (12.5%) knew someone diagnosed with SLE. Two hundred fifty two (40%) have previously heard the term SLE. Of those, 73(29%) had adequate knowledge on SLE with a superior knowledge in participants who knew someone with SLE (p=0.018). In regards to the etiology of SLE, 71 (28.2%) identified it as an autoimmune disease. While 39(15.5%) thought it is infectious, 56(22.2%) attributed it to evil eye and 12(4.8%) believed it is the result of an act of sorcery or witch crafting. When asked about the preferred future source of knowledge, 476(75.6%) have chosen to obtain it directly from health care providers, while 183(29%) preferred social media. Conclusion: The awareness on SLE among university participants is low. Future educational campaigns are needed to increase awareness and rectify misconceptions.