Najia Hajjaj-Hassouni

Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA)

Background Patients with rheumatoid arthritis (RA) are at increased risk of developing comorbid conditions. Objectives To evaluate the prevalence of comorbidities and compare their management in RA patients from different countries worldwide. Methods Study design: international, cross-sectional. Patients: consecutive RA patients. Data collected: demographics, disease characteristics (activity, severity, treatment), comorbidities (cardiovascular, infections, cancer, gastrointestinal, pulmonary, osteoporosis and psychiatric disorders). Results Of 4586 patients recruited in 17 participating countries, 3920 were analysed (age, 56±13 years; disease duration, 10±9 years (mean±SD); female gender, 82%; DAS28 (Disease Activity Score using 28 joints)–erythrocyte sedimentation rate, 3.7±1.6 (mean±SD); Health Assessment Questionnaire, 1.0±0.7 (mean±SD); past or current methotrexate use, 89%; past or current use of biological agents, 39%. The most frequently associated diseases (past or current) were: depression, 15%; asthma, 6.6%; cardiovascular events (myocardial infarction, stroke), 6%; solid malignancies (excluding basal cell carcinoma), 4.5%; chronic obstructive pulmonary disease, 3.5%. High intercountry variability was observed for both the prevalence of comorbidities and the proportion of subjects complying with recommendations for preventing and managing comorbidities. The systematic evaluation of comorbidities in this study detected abnormalities in vital signs, such as elevated blood pressure in 11.2%, and identified conditions that manifest as laboratory test abnormalities, such as hyperglycaemia in 3.3% and hyperlipidaemia in 8.3%. Conclusions Among RA patients, there is a high prevalence of comorbidities and their risk factors. In this multinational sample, variability among countries was wide, not only in prevalence but also in compliance with recommendations for preventing and managing these comorbidities. Systematic measurement of vital signs and laboratory testing detects otherwise unrecognised comorbid conditions.

Minimum clinically important improvement and patient acceptable symptom state in pain and function in rheumatoid arthritis, ankylosing spondylitis, chronic back pain, hand osteoarthritis, and hip and knee osteoarthritis: Results from a prospective multinational study

To estimate the minimum clinically important improvement (MCII) and patient acceptable symptom state (PASS) values for 4 generic outcomes in 5 rheumatic diseases and 7 countries.

High Prevalence of Hypovitaminosis D in Morocco: Relationship to Lifestyle, Physical Performance, Bone Markers, and Bone Mineral Density

OBJECTIVES We undertook this study to determine the prevalence of hypovitaminosis D, its determinants, and its relationships to physical performance, serum parathyroid hormone (PTH) concentration, bone mineral density, and biochemical markers of bone turnover in healthy, ambulatory, pre- and postmenopausal women. METHODS The group studied included 415 women aged 24 to 77 years. Between July and September, we assessed calcium intake and measured serum calcium, phosphorus, albumin, alkaline phosphate, 25-hydroxyvitamin D (25(OH)D), PTH, osteocalcin, and C-terminal cross-linking telopeptide of Type I collagen. We also measured bone mineral density (BMD) by dual-energy radiograph absorptiometry in the spine and total femur. Three tests were used to assess physical performance: timed get-up-and-go test, 5-times-sit-to-stand test, and 2.4 m speed walk. RESULTS The prevalence of vitamin D insufficiency (<30 ng/mL) was 91%. In multiple logistic regression, the main determinants of hypovitaminosis D were age >55 years (OR 2.14 [95% IC, 1.1-4.1; P = 0.026)], wearing a veil [OR 2 (95% IC, 1.1-4; P = 0.04)], time spent outdoors less than 30 min/d [OR 2.8 (95% IC: 1.4-5.7; P = 0.003)], and daily calcium intake less than 700 mg [OR 2.39 (95% IC, 1.2-4.7; P < 0.01)]. A significant inverse correlation between 25 OH and osteocalcin (r = -0,18, P < 0001), 25 OH, and Type I collagen (r = -0,15, P = 0003) were observed. By Locally Weighted Regression and Scatterplot Smoothing technique, there was an increase in PTH level when S-25(OH)D was below 30 ng/mL. After adjustment for age, both spine BMD and total femoral BMD failed to show any significant correlation with serum 25(OH)D and PTH. There was no correlation between any physical performance tests and 25(OH)D levels. CONCLUSIONS Our study showed that during the summer season, vitamin D insufficiency is very common in healthy adult Moroccan women. Lack of sun exposure and veiled clothing style were the most important factors that influenced hypovitaminosis D. Patients with hypovitaminosis D had a high bone turnover, whereas there was no effect on BMD and physical performance. Further research is needed to evaluate the clinical impact of the above findings.

Hydatid disease of bone. Review of 11 cases.

UNLABELLED Osseous hydatid disease is defined as development within bone of multiple cysts that are the larval form of the tapeworm Echinococcus granulosus. Bone cysts account for only 0.5-2.5% of all hydatid cysts in humans. We report on our experience. METHODS This retrospective study included patients managed between 1988 and 1998 for histologically documented hydatid disease of bone. RESULTS Eleven patients were included, six men and five women, with a mean age of 40.7 +/- 11.04 years (range, 27-60 years). Mean time to diagnosis was 22.7 +/- 18.2 months (range, 5-36). The pelvis was involved in six patients and a long bone in five (the femur in three, the tibia in one, and the fibula in one). Peripheral eosinophil counts were high in four patients and serological tests for hydatid disease were positive in five patients. Surgical treatment was used alone in 10 patients and with albendazole in one patient. The main complications were fistulization (n = 6) and suppuration (n = 4). Five patients experienced recurrences. CONCLUSION Hydatid disease still occurs in Morocco. The liver and lungs are the most common targets. Bone cysts are uncommon but severe. The behavior of osseous hydatid cysts resembles that of locally malignant lesions. Although immunofluorescent assays are useful, the final diagnosis depends on histology. The treatment rests on surgical excision. Recurrence is common, particularly at sites that are difficult to access.

Long-term effects of therapeutic education for patients with rheumatoid arthritis

INTRODUCTION The objective of this study was to assess the effects of an educational program on the course of rheumatoid arthritis (RA) after 3 years. METHODS From December 2002 to December 2003, 39 RA patients participated in a 3-day education program delivered to groups of four or five patients. Effects of the program were evaluated after 3 years in 33 patients, comparatively to baseline, based on the following variables: knowledge of RA (self-questionnaire), disease activity (DAS 28), functional impairment (health assessment questionnaire [HAQ]) and quality of life (arthritis impact measurement scale 2 [AIMS2], short-form). We also compared patient knowledge in the educational program participants and in 38 controls with RA. Direct questions were used to evaluate the program after 3 years. RESULTS Patient knowledge 3 years after the education program was significantly improved compared to baseline (P<0.0001) and was significantly better than in the controls (P<0.0001). Disease activity was significantly lower in the education group after 3 years than at baseline (DAS28, 3.1 vs. 3.8, P<0.005). Neither the HAQ nor the AIMS2 scores changed significantly after 3 years compared to baseline. The replies to the direct questions indicated a very high level of overall satisfaction with the educational program. CONCLUSION An educational program tailored to patient needs can produce lasting improvements in knowledge of the disease and may help to control the activity of RA. These results warrant the development of education programs for patients with chronic inflammatory joint disease.

The impact of clothing style on bone mineral density among post menopausal women in Morocco: a case-control study

BackgroundThe clothing style is an important factor that influences vitamin D production and thus bone mineral density. We performed a case-control study in order to evaluate the effect of veil wearing (concealing clothing) on bone mineral density in Moroccan post menopausal women.MethodsThe cases were osteoporotic women whose disease was assessed by bone mineral density measurement. Each patient was matched with a non osteoporotic woman for age, and body mass index. All our patients were without secondary causes or medications that might affect bone density. The veil was defined as a concealing clothing which covered most of the body including the arms, the legs and the head. This definition is this of the usual Moroccan traditional clothing style.Results178 post menopausal osteoporotic patients and 178 controls were studied. The mean age of the cases and the controls was 63.2 years (SD 7) and the mean body mass index was 32.1 (SD 8). The results of crude Odds Ratios analyses indicated that wearing a veil was associated with a high risk of osteoporosis: OR 2.29 (95% CI, 1.38–3.82). Multiparity or a history of familial peripheral osteoporotic fractures had also a significant effect on increasing the osteoporosis risk (ORs: 1.87 (95% CI, 1.05–3.49) and 2.01 (95% CI, 1.20–3.38)). After a multiple regression analysis, wearing the veil and a history of familial osteoporotic fractures remained the both independent factors that increased the osteoporosis risk (ORs: 2.20 (95% CI, 1.22–3.9) and 2.19 (95% CI, 1.12–4.29) respectively).Conclusionour study suggested that in Moroccan post menopausal women, wearing a traditional concealing clothing covering arms, legs and head increased the risk of osteoporosis. Further studies are required to evaluate the clinical impact of the above findings and to clarify the status of vitamin D among veiled women in Morocco.

Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study

Background Increased risk of some comorbidities has been reported in spondyloarthritis (SpA). Recommendations for detection/management of some of these comorbidities have been proposed, and it is known that a gap exists between these and their implementation in practice. Objective To evaluate (1) the prevalence of comorbidities and risk factors in different countries worldwide, (2) the gap between available recommendations and daily practice for management of these comorbidities and (3) the prevalence of previously unknown risk factors detected as a result of the present initiative. Methods Cross-sectional international study with 22 participating countries (from four continents), including 3984 patients with SpA according to the rheumatologist. Statistical analysis The prevalence of comorbidities (cardiovascular, infection, cancer, osteoporosis and gastrointestinal) and risk factors; percentage of patients optimally monitored for comorbidities according to available recommendations and percentage of patients for whom a risk factor was detected due to this study. Results The most frequent comorbidities were osteoporosis (13%) and gastroduodenal ulcer (11%). The most frequent risk factors were hypertension (34%), smoking (29%) and hypercholesterolaemia (27%). Substantial intercountry variability was observed for screening of comorbidities (eg, for LDL cholesterol measurement: from 8% (Taiwan) to 98% (Germany)). Systematic evaluation (eg, blood pressure (BP), cholesterol) during this study unveiled previously unknown risk factors (eg, elevated BP (14%)), emphasising the suboptimal monitoring of comorbidities. Conclusions A high prevalence of comorbidities in SpA has been shown. Rigorous application of systematic evaluation of comorbidities may permit earlier detection, which may ultimately result in an improved outcome of patients with SpA.

Cervical spine involvement in ankylosing spondylitis

Abstract Our objective was to study cervical spine involvement in a Moroccan population of ankylosing spondylitis (AS) patients and evaluate correlations with disease symptomatic and structural severity. Patients were prospectively enrolled for a 1-year period. Clinical, biological, and radiological data were collected. The risk of cervical spine involvement was estimated using the Kaplan–Maier method. Sixty-one patients were enrolled: 38 males (62.2%) and 23 females of mean (SD) age 35.1 years [11] (range 17–66). The mean disease duration was 10.6 years [7] (0.5–30). Forty-three patients (70.4%) had a history of neck pain. Radiological involvement was present in 33 cases (54%). The concordance between clinical and radiological involvement was statistically significant (κ=0.49; P<10−6). The risk of cervical spine involvement with regard to disease duration showed that 19.6% of patients had radiological involvement after 5 years, 29.9% after 10 years, 45.1% after 15 years and 70.0% after 20 years. Comparison between patients with and without cervical spine radiological involvement showed no difference in age of onset or sex. There was statistical difference in symptomatic severity parameters (Schöber, chest expansion, BASMI, BASFI, BASDI, BASG) and structural severity parameters (lumbar syndesmophytes score, BASRI). Our study confirms the greater severity of AS in North African countries. Cervical spine involvement increases with age and disease duration in AS and is more frequent in symptomatic and structural severe forms of the disease.

Gender and disease features in Moroccan patients with ankylosing spondylitis

This study was conducted to determine differences in ankylosing spondylitis (AS) between men and women in terms of clinical characteristics, biological features, structural severity and quality of life (QoL). A total of 130 consecutive AS patients fulfilling the modified New York criteria were included. Sociodemographic data were collected. The activity of disease was assessed by the Bath ankylosing spondylitis disease activity index (BASDAI) and the functional disability by the Bath Ankylosing spondylitis functional index (BASFI). Spinal mobility was measured using the occiput-to-wall distance, chest expansion, Schober index and the Bath Ankylosing Spondylitis Metrology Index (BASMI). The Bath Ankylosing Spondylitis Radiologic Index (BASRI) was used to evaluate structural damage. Fatigue was evaluated using a visual analogue scale and the QoL was measured by using the generic instrument SF-36. Laboratory tests included the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP). In our sample, there were 87 (66.9%) men and 43 (33.1%) women. Women had significantly lower educational levels but there were no differences in socioeconomic status, age at onset, diagnosis delay, disease duration or treatments. Also, women had higher clinical disease activity (morning stiffness and BASDAI score), higher number of tender joints, more severe enthesitis and higher scores of fatigue (for all p ≤ 0.05). Moreover, hip involvement was more prevalent in men and the impairment of spinal mobility was significantly worse compared to women (for all p ≤ 0.001). Men had worse radiographic damage and lower scores in physical and social domains of QoL, but there were no differences in functional impairment scores. In this study, we noticed that AS presents differently according to gender in our patients. More longitudinal studies seem to be necessary to identify gender-related parameters of disease, thing that may help in diagnosis and therapeutic management of our AS patients.

Low bone mineral density is related to atherosclerosis in postmenopausal Moroccan women

BackgroundSome studies have implicated several possible metabolic linkages between osteoporosis and vascular calcification, including estrogen deficiency, vitamin D excess, vitamin K deficiency and lipid oxidation products. Nevertheless, it remains unclear whether osteoporosis and atherosclerosis are related to each other or are independent processes, both related to aging. The aim of this cross-sectional study was to evaluate the correlation between arterial thickening and bone status in a sample of apparently healthy Moroccan women.MethodsSeventy-two postmenopausal women were studied. All patients were without secondary causes that might affect bone density. Bone status was assessed by bone mineral density (BMD) in lumbar spine and all femoral sites. Arterial wall thickening was assessed by intima-media thickness (IMT) in carotid artery (CA) and femoral artery (FA). Prevalent plaques were categorized into four groups ranging from low echogenicity to high echogenicity.ResultsThe mean age was 59.2 ± 8.3 years. 84.7% had at least one plaque. By Spearman Rank correlation, CA IMT was negatively correlated to Femoral total BMD (r = -0.33), Femoral neck BMD (r = -0.23), Ward triangle BMD (r = -0.30) and Trochanter BMD (r = -0.28) while there was no association with lumbar BMD. In multiple regression analysis, CA IMT emerged as an independent factor significantly associated with all femoral sites BMD after adjusting of confounding factors. FA IMT failed to be significantly associated with both Femoral and Lumbar BMD. No significant differences between echogenic, predominantly echogenic, predominantly echolucent and echolucent plaques groups were found concerning lumbar BMD and all femoral sites BMDConclusionOur results demonstrate a negative correlation between bone mineral density (BMD) qnd carotid intima-media thickness (IMT) in postmenopausal women, independently of confounding factors. We suggest that bone status should be evaluated in patients with vascular disease to assess whether preventive or therapeutic intervention is necessarry.