Syed Atiqul Haq

Osteoarthritis of the knees in the COPCORD world

This paper examines and summarizes data on knee osteoarthritis (AO) in Community Oriented Program For Control Of Rheumatic Disorders (COPCORD) publications. A literature search was made through PubMed, Google, Proceedings of Asia‐Pacific League of Associations for Rheumatology (APLAR) congresses, and Abstracts from APLAR congresses. Data were compiled to examine the prevalence of knee OA and knee pain, sex ratio, urban/rural differences and other risk factors. Data on knee pain and OA were available in a total of 36 COPCORD publications. The pooled prevalence of knee OA was 7.9% in adults above the age of 15 years. It was more common in women. Overweight, squatting and cycling appeared to be modifiable risk factors for knee OA. OA of the knee is the commonest rheumatic disease in studied communities. Further research is needed for identification of its modifiable risk factors and development of strategies for reduction of the community burden of this malady.

Efficacy and Safety of Methotrexate in Articular and Cutaneous Manifestations of systemic Lupus Erythematosus

Aim:  A prospective open‐label study comparing the efficacy and safety of methotrexate (MTX) and chloroquine (CQ) in articular and cutaneous manifestations of systemic lupus erythematosus (SLE).

Development of a questionnaire for identification of the risk factors for osteoarthritis of the knees in developing countries. A pilot study in Iran and Bangladesh. An ILAR-COPCORD phase III study.

Background:  Knee osteoarthritis (OA) is one of the most prevalent rheumatic disorders in the Asia‐Pacific region. Identification of modifiable risk factors is important for development of strategies for primary and secondary prevention of knee OA.

Treatment of diffuse systemic sclerosis with hyperimmune caprine serum (AIMSPRO): a phase II double-blind placebo-controlled trial

Objective The primary objective of the study was to explore safety and tolerability of hyperimmune caprine serum (AIMSPRO) in established diffuse cutaneous systemic sclerosis (SSc). Secondary objectives included assessment of potential efficacy and biological activity and exploration of candidate biomarkers. Methods This was a double-blind parallel group randomised placebo-controlled clinical trial. After informed consent 20 patients with established diffuse cutaneous SSc of greater than 3 years duration not receiving immunosuppressive therapy were randomised to receive either active (n=10) or placebo formulation (n=10) by subcutaneous twice weekly injection over 26 weeks. Clinical assessments were evaluated over 26 weeks. Results There were no safety concerns during this study. Frequency of adverse events was not different between active and placebo groups. Mean modified Rodnan Skin Score (mRSS) fell by 1.4±4.7 units with active treatment but increased by 2.1±6.4 units on placebo when baseline values were compared with 26 weeks and responder analysis showed clinically meaningful improvement in mRSS at 26 weeks in 5 (50%) of actively treated patients compared with 1 (10%) in the control group (p=0.062). PIIINP (µg/L) showed a comparatively larger increase in the treatment group compared with the placebo group, (p=0.0118). Conclusions These results confirm tolerability and safety of this novel biological agent in established diffuse SSc. The value of a placebo treated control group in small clinical trials evaluating skin disease in SSc is confirmed. Potential improvement in mRSS and changes in PIIINP in cases receiving active therapy suggest that this intervention may be of clinical benefit and warrants further evaluation.

Clinical Features of Fibromyalgia Syndrome in a Bangladeshi Population

Objective: The study was designed to describe various clinical features of fibromyalgia syndrome [FMS] in a Bangladeshi population seen at a university rheumatology clinic. Methods: Thirty consecutive patients with FMS were compared with the next patient with rheumatoid arthritis [RA] as well as a healthy painfree normal control [NC], of the same sex and similar age. All subjects were evaluated by a physician-administered questionnaire. Results: Virtually all clinical and psychological features were more common in FMS than NCs as well as RA. The frequency of clinical and psychological features of FMS, e.g., fatigue, sleep difficulties, swollen feeling, paresthesia, irritable bowel syndrome, tension-type headaches as well as global anxiety, stress, and depression were similar to those reported in Europe and North America. Conclusion: Characteristics of FMS in a Bangladeshi population are similar to those described in the West.

WHO‐ILAR‐COPCORD in the Asia‐Pacific: the past, present and future

The aim of the Community Oriented Program for Control of Rheumatic Disorders (COPCORD) is reduction of community burden of rheumatic disorders, particularly in developing communities. Stage I entails estimation of prevalence and incidence of musculoskeletal pain and rheumatic disorders. Stage II is dedicated to education of health workers, patients and the community. Stage III deals with identification of risk factors for common rheumatic disorders and development of strategies for their primary and secondary prevention. So far Stage I data have been reported from 15 countries in the Asia‐Pacific countries. The prevalence of musculoskeletal pain has varied from 11.6% to 45.4%. The commonest sites of pain were low back, knee, neck and shoulder. Commonest rheumatic disorders were osteoarthritis of knees, non‐specific low back pain and soft tissue rheumatism. A few scattered educational activities have been reported from Indonesia and India. Systematic case‐controlled or cohort studies aimed at finding out the risk factors for common rheumatic disorders were scanty. However, several associations were reported from cross‐sectional prevalence surveys. It is imperative that the COPCORD investigators in the Asia‐Pacific region focus on finding out the modifiable risk factors for rheumatic disorders with properly designed studies, develop preventive strategies on the basis of identified risk factors and carry out interventional studies to test the efficacy of the strategies with validated outcome instruments.

The Bengali Short Form-36 was acceptable, reliable, and valid in patients with rheumatoid arthritis

OBJECTIVE To develop a culturally adapted Bengali version of the Short Form-36 (SF-36) Health Survey and to test its acceptability, reliability, and validity in patients with rheumatoid arthritis (RA). STUDY DESIGN AND SETTING The US English SF-36 was translated into Bengali after established cross-cultural adaptation procedures. The questionnaire was interviewer administered to 125 consecutive outpatients with RA and readministered after 2 weeks to 40 randomly selected patients. RESULTS Most participants (86.4%) did not have any problem in understanding the Bengali SF-36 and 98.4% of the questionnaires were fully completed. Only the role-physical and role-emotional scales showed substantial floor and ceiling effects. Principal component analysis confirmed that the hypothesized two-factor structure and tests of scaling assumptions were 100% successful for all eight scales expect physical functioning (98.8%) and general health (77.5%). Cronbachs α was higher than 0.78 and the test-retest reliability was high (r>0.82) for all scales. Correlations with other disease activity parameters were generally as expected and summary scores were able to discriminate between relevant subgroups. CONCLUSION The interviewer-administered Bengali SF-36 appears to be an acceptable, reliable, and valid instrument for measuring health-related quality of life in Bangladeshi patients with RA. The questionnaire should be further evaluated in people from the general population and in patients with different medical conditions.

Incidence of musculoskeletal pain and rheumatic disorders in a Bangladeshi rural community: a WHO-APLAR-COPCORD study

Aim:  To estimate the incidence of musculoskeletal pain and rheumatic disorders in a Bangladeshi rural community.

Idiopathic inflammatory myopathies: from immunopathogenesis to new therapeutic targets.

Pathogenesis of idiopathic inflammatory myositis (IIM) involves strong interactions between dendritic cells (DCs), activated Th1 and Th17 cells, B cells, muscle cells, genes and environment. Local maturation of DCs permit the activation and polarization of CD4+ T cells into TH1 and TH17 that play a key role in maintaining chronic muscle inflammation. T‐cell mediated myocytotoxicity promotes the liberation of specific muscle autoantigens from regenerating muscle cells with production of myositis‐specific autoantibodies. Type I interferon signature is a key characteristic of IIM. Type I IFN that can be induced by immune complexes containing myositis‐specific autoantibodies is produced by scattered plasmacytoid DCs but also by muscle cells particularly regenerating muscle cells. These immature muscle precursors appear to be critical in the pathogenesis of IIM as they up‐regulate muscle autoantigens, type I IFN, HLA class I antigens and TLR3‐7, all together involved in maintaining chronic muscle inflammation. In addition to the role of immune and muscle cells, genome‐wide association studies have confirmed the importance of several MHC and non‐MHC genes in IIM. Environmental factors can contribute to the pathogenesis of IIM. In sIBM, distinct features suggest both degenerative and inflammatory processes. In addition to our better understanding of the pathogenesis, identify molecular pathway leads to consider new targeted therapies including cytokine inhibition, B‐cell and T‐cell costimulation blockade, type I IFN neutralization or inhibition of the ubiquitin proteasome pathway.

Treatment of osteoporosis: facing the challenges in the Asia‐Pacific

The prevalence of osteoporosis and fractures is projected to increase rapidly in the Asia‐Pacific region in coming decades. At the societal level, healthcare providers will face the challenges of paucity of information, lack of awareness among physicians, resource constraints, lack of organization, absence of policies of cost reimbursement, insufficient representation of the problem in curricula and lack of effective, inexpensive and convenient therapy. Poverty, illiteracy, lack of awareness and interest in future quality of life, and co‐morbidities with seemingly greater importance, will all act as challenges at the level of individual patients. Lack of compliance is a function of lack of awareness and motivation, cost, complexity of administration, side‐effects and absence of immediately perceivable benefit. The challenges may be overcome through systematic collection of data, formation or activation of national osteoporosis planning and coordinating groups, development of national guidelines, programs of education of healthcare providers, patients and the general public, adoption of a population‐based prevention strategy, cost‐effective opportunistic screening using clinical decision rules like the osteoporosis self‐assessment tool for Asians, use of the fracture risk assessment tool for therapeutic decision‐making, giving due emphasis to the problem in curricula and development of mechanisms for cost reimbursement. The Asia‐Pacific League of Associations for Rheumatology may take a lead in stimulating, organizing and coordinating these activities.