Burnout syndrome among rheumatologists and rheumatology fellows in Arab countries: an ArLAR multinational study

BACKGROUND

Burnout is frequent among physicians and seems to be underestimated among rheumatologists.

OBJECTIVE

To estimate the frequency of burnout in a sample of rheumatologists practising in the Arab countries and determine its associated factors.

METHODS

This was a descriptive cross-sectional study conducted by the Arab League of Associations for Rheumatology (ArLAR research group) using an anonymous electronic questionnaire set up on the Google Forms platform. All Arab rheumatologists and rheumatology fellows were invited to participate in the spring of 2022 via ArLAR social media accounts, societies' WhatsApp groups, and mass emails. Burnout was defined by at least one positive domain of the Maslach Burnout Inventory (MBI) (Emotional exhaustion, Depersonalization, and Personal accomplishment). The final score was correlated to socio-demographic factors using a multivariable binary logistic regression.

RESULTS

The study included 445 rheumatologists and rheumatology fellows with an average age of 45.2 years (SD 11.5); 61.8% were men. The frequency of burnout among rheumatologists was 61.3% and was driven by low personal accomplishment scores (58.1%). Younger age (OR 1.92 (95%CI 1.20-3.08)), dissatisfaction with the specialty (OR 2.036 (95% CI 1.20-3.46)), and low income (OR 2.26 (95% CI 1.01-5.10)) were associated with burnout.

CONCLUSION

The frequency of burnout in a sample of rheumatologists in Arab countries is very high, driven by low personal accomplishment scores and associated with a low income, dissatisfaction with the specialty and younger age. Some associated factors might be modifiable, thus reducing the burden of burnout on rheumatologists and on the healthcare system. Key Points • The frequency of burnout in a sample of Arab rheumatologists was 61.3% according to the MBI. • The score was mainly driven by low personal accomplishment scores (58.1%). • Younger age, dissatisfaction with the specialty, and low income were associated with burnout. • Acting upon modifiable risk factors would help reducing the burden of burnout on rheumatologists and on the healthcare system.

The rheumatology workforce in the Arab countries: current status, challenges, opportunities, and future needs from an ArLAR cross-sectional survey

The Arab League of Associations for Rheumatology (ArLAR) Research Group (ARCH) conducted this study to investigate the number of current practicing rheumatologists in the Arab countries, to estimate the projected number of rheumatologists in 10 years, and to evaluate the current workload, practice profile, consultation waiting time, and geographical mobilities of these rheumatologists. This cross-sectional survey study was conducted in 16 Arab countries in two parts. The first survey was addressed nominally to national societies to estimate the current and projected workforce. The second was an anonymous e-survey elaborated by the study steering committee on the Google Forms platform and distributed to Arab rheumatologists using social media, WhatsApp, and mass e-mails to evaluate their practice. The mean number of rheumatologists in Arab countries was 0.84 per 100,000 inhabitants (mean age 47.5 years, 55% females), ranging from 0.06 (Sudan) to 1.86 (Tunisia). The number of rheumatologists is expected to increase by 50% in 2032. Nevertheless, a 20% increase in population associated with an increase in demand is also expected. Data from 446 rheumatologists (mean age 43.9 years, 60.5% females) revealed that 72% worked full-time, and 53% were employed in the public sector only. The average waiting time for a rheumatology consultation was 19.9 days. Of 394 rheumatologists, 19% obtained their rheumatology diplomas from non-Arab countries, and 47% of Gulf rheumatologists were non-citizen physicians. Considering local demographic disparities, healthcare system differences, and geographical mobilities, national authorities are advised to implement effective intervention plans to optimize the rheumatology workforce.

How to optimize recruitment strategies of patients with rheumatic and musculoskeletal diseases for online surveys: experience from an international study

The use of online surveys as a recruitment tool for clinical research has recently expanded; nevertheless, optimal recruitment strategies remain poorly identified. Objectives. The study aimed to identify the most effective recruitment strategies for online research studies and to determine the optimal survey channels for obtaining patients' responses. This is a post-hoc analysis of the ARCOVAX (ArLAR COVID Vaccination) study. Multiple recruitment strategies were disseminated in Arabic, English, and French. The proportion of enrolled patients was correlated with each strategy. Channels used by patients to complete the survey were divided into three categories (social media (SoMe), doctor, and patients' associations). These channels were correlated with the patients' characteristics and the country's Gross Domestic Product (GDP). A total of 1595 patients from 19 Arab countries completed the survey. Patients' mean age was 39 years, 73.2% (1159) were females, 17.8% (284) had a university education level and 93.1% (1468) answered the survey in Arabic. The most effective recruitment strategies were personalized WhatsApp reminders to recruiters (30% of enrolled patients), technical support in response to access issues (27%) and sharing recruitment status by country on a WhatsApp group (24%). The channels used to complete the survey were: SoMe in 45% (711), doctor in 40% (647), and patients' associations in 8.5% (233), and correlated with age and GDP. To optimize recruitment, it is recommended to combine multiple strategies and channels, use the native language and be active (mobilize teams), reactive (provide prompt technical support), and proactive (share regular updates and reminders).

APLAR recommendations on the practice of telemedicine in rheumatology

INTRODUCTION

The COVID-19 pandemic led to rapid and widespread adoption of telemedicine in rheumatology care. The Asia Pacific League of Associations for Rheumatology (APLAR) working group was tasked with developing evidence-based recommendations for rheumatology practice to guide maintenance of the highest possible standards of clinical care and to enable broad patient reach.

MATERIALS AND METHODS

A systematic review of English-language articles related to telehealth in rheumatology was conducted on MEDLINE/PubMed, Web Of Science and Scopus. The strength of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach as well as the Oxford Levels of Evidence. The recommendations were developed using a modified Delphi technique to establish consensus.

RESULTS

Three overarching principles and 13 recommendations were developed based on identified literature and consensus agreement. The overarching principles address telemedicine frameworks, decision-making, and modality. Recommendations 1-4 address patient suitability, triage, and when telemedicine should be offered to patients. Recommendations 5-10 cover the procedure, including the means, data safety, fail-safe mechanisms, and treat-to-target approach. Recommendations 11-13 focus on training and education related to telerheumatology.

CONCLUSION

These recommendations provide guidance for the approach and use of telemedicine in rheumatology care to guide highest possible standards of clinical care and to enable equitable patient reach. However, since evidence in telemedicine care in rheumatology is limited and emerging, most recommendations will need further consideration when more data are available.

POS0275-HPR CONCORDANCE BETWEEN THE PHYSICIAN’S AND THE NURSE’S ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS USING DAS-28, CDAI AND SDAI IN SEVEN MIDDLE EASTERN ARAB COUNTRIES

Background:

Managing patients with chronic rheumatic diseases is increasingly relying on the collaboration of a multidisciplinary team, including the rheumatology nurse who can aid assessment of disease activity among other healthcare tasks.

However, this practice, although common in Europe and North America, is still poorly implemented in the Middle eastern Arab countries (MEAC).

Objectives:

To evaluate the concordance between the physician’s and the nurse’s assessment of disease activity in patients with rheumatoid arthritis (RA) in the MEAC.

Methods:

During a routine patient visit to one of 9 rheumatology clinics located in 7 Middle Eastern Arab countries, the physician and the rheumatology nurse (who was already working in the clinic) performed the disease activity score 28 (DAS), Clinical Disease Activity Index (CDAI) and Simple Disease Activity Index (SDAI) in a blinded manner. The concordance regarding the 3 continuous scores was calculated using paired t-test. The agreement between physician- and nurse-DAS categories (remission, low, moderate and high disease activity) was calculated using weighted kappa for category comparison. Predictive factors of positive concordance between physician- and nurse-DAS were identified using binary logistic regression.

Results:

The study included 373 patients’ measurements over a period of two years (2018 to 2019). The mean age of the patients was 49.6 years (±28.2), 82.6% were females, and the mean disease duration was 11.3 years (±7.5).

The mean physician-DAS was slightly higher (3.97 (±1.52)) than the nurse-DAS (3.90 (±1.54)) (p=0.002), with a mean difference of +0.08 [95%CI 0.03; 0.12] (Table 1). The difference in the DAS individual items, the CDAI and the SDAI were not statistically significant.

Table 1.

Comparison of the disease activity measures reported by the physician and by the nurse.

PhysicianNursep-valueTotal Joint Count4.87 (2.26)5.02 (6.20)0.152Swollen Joint Count2.13 (3.88)2.15 (3.83)0.790Global Assessment3.30 (2.41)3.32 (2.43)0.702DAS-283.97 (1.52)3.90 (1.54)0.002CDAI14.26 (12.53)14.38 (12.59)0.515SDAI21.51 (23.57)21.61 (21.66)0.527

When analyzing DAS as a categorical 4-items variable, the agreement between the physician and the nurse was present in 79.36% of the cases (weighted kappa was 0.77 [95%CI 0.73;0.83] which is considered as excellent, and was higher in patients with high disease activity (Figure 1).

A positive concordance between the physician- and the nurse-DAS was associated with the country (higher in Egypt, p<0.001) and the status of higher disease activity (p<0.001).

Conclusion:

The agreement between the DAS-28 performed by the physician and by the nurse was excellent and was associated with the country and a higher disease activity. The present study confirms that the support of a trained nurse for evaluating disease activity in RA is feasible in the Arab countries and may save some valuable time in the clinic, whilst maintaining the quality of care for patients with RA.

Figure 1.

Agreement between physician- and nurse-DAS categories

Acknowledgements:

The authors would like to acknowledge the patients for participating in the study and the assistants/ students/ nurses who assisted in the data collection: Dr. Fatima Abdul Majeed Al Hawaj, M. Atef Ahmed, M. Mohammad Alhusamiah, Ms Raquel De Guzman, Ms Lina Razzouk.

Disclosure of Interests:

None declared

AB0104 CONCORDANCE BETWEEN THE PHYSICIAN’S AND THE PATIENT’S ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: RESULTS OF THE AUTODAS-MEAC STUDY AT ONE YEAR

Background:

Involving the patients with rheumatoid arthritis (RA) in the assessment of their disease may increase their adherence to treatment, improve the disease outcomes and facilitate the application of telehealth. We previously reported an excellent concordance between the Disease Activity Score (DAS-28) performed by physicians and patients at the baseline visit of this prospective study (1).

Objectives:

To evaluate the persistence of the concordance between the physician’ and the patient’s assessment of disease activity in RA using DAS-28 after one year.

Methods:

At the baseline visit, patients with RA from 7 Middle Eastern Arab Countries (MEAC) were briefed about DAS-28 by their rheumatologist during a routine consultation and given smartphone access to a video in Arabic language explaining the performance of DAS-28. At 3, 6 and 12 months (± 3 months), the patients were asked to self-report DAS-28, blinded to the physician’s assessment. Concordance between the continuous DAS-28 at each visit was calculated using paired t-test numerically and the Bland-Altman method graphically. Agreement between physician- and patient-DAS categories (remission, low-, moderate- and high disease activity) was calculated at each visit using weighted kappa for category comparison. Weighted kappa of the different agreements were compared over time using their respective confidence intervals (CIs). Predictive factors of positive concordance between physician and patient-DAS were identified using binary logistic regression.

Results:

The study included 428 patients over a period of three years (2018 to 2020). The mean age of participants was 49.8 years, 82.5% were females, 44.3% had a university degree and the mean disease duration was 11.4 years.

At baseline, the average patient-DAS was higher (4.06 (±1.52)) than the physician-DAS (3.97 (±1.52)). The mean difference was -0.09 [95%CI -0.14; -0.04] and most of the pairs were within the limit of agreement in the Bland-Altman graph, indicating a good concordance, particularly in cases of remission.

During the study follow-up, 299 patients consulted for visit 2 (69.9% of the total population), 232 for visit 3 (54.2%) and 199 for visit 4 (46.5%). The weighted kappa was 0.80 [95%CI 0.76;0.85] at visit 1 and 0.79 [95%CI 0.72;0.88] at visit 4 (Figure 1 showing kappa for DAS-28, CDAI and SDAI as well). A minor numerical decrease in kappa was observed over time; however, the CIs were overlapping over the four visits and the agreement was considered stable, remaining in the excellent range. At visit 4, a positive concordance between the physician- and the patient-DAS was associated with the profession (lower in blue collar, p=0.001), the educational level (higher in high school and university, p=0.034) and the baseline physician’s DAS (higher in high disease activity, p=0.46).

Conclusion:

The agreement between the DAS-28 performed by the physician and by the patient was excellent at baseline and remained stable over one year. A positive concordance was associated with the profession, the educational level and the level of disease activity. The present study can help the rheumatologist make informed decisions about the patients who may be suitable for a remote evaluation of their disease activity, that can be of particular interest in the context of the COVID-19 pandemic.

References:

[1]Ziade N, Saad S, al Mashaleh M, et al. Perceptions of Patients with Rheumatoid Arthritis about Self-Assessment of Disease Activity after Watching an Educational Video: Qualitative Pilot Results from the Auto-DAS in Middle Eastern Arab Countries Study [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10).

Acknowledgements:

The authors would like to acknowledge the patients for participating in the study and the assistants/ students/ nurses who assisted in the data collection: Dr. Fatima Abdul Majeed Al Hawaj, M. Atef Ahmed, M. Mohammad Alhusamiah, Ms Raquel De Guzman, Ms Lina Razzouk.

Disclosure of Interests:

None declared

Development of an Educational Video for Self-Assessment of Patients with RA: Steps, Challenges, and Responses

Objectives:

The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges.

Methods:

Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified.

Results:

Twenty-three rheumatologists from MEAC identified unmet needs in patients’ education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician’s visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix.

Conclusion:

Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.

Perceptions of patients with rheumatoid arthritis about self-assessment of disease activity after watching an educational video: a qualitative pilot study from the AUTO-DAS in Middle Eastern Arab countries project

To evaluate the perceptions of patients with rheumatoid arthritis (RA) about self-assessment of their disease activity after watching an educational video. Consecutive patients with RA consulting their rheumatologist in six Middle Eastern Countries were invited to watch an educational video developed to teach self-assessment using Disease Activity Score (DAS-28). Then, a rheumatology nurse conducted a semi-structured interview and collected the patients’ perception about the understanding of the video, feasibility, capability and confidence in performing self-assessment using Likert-type items. The degree of confidence with self-assessment was correlated to the patients’ socio-demographic characteristics. Sixty-two patients were included and had an overall positive reaction to the video. It was easy to understand in 96% and helped facilitate self-assessment in 92% of cases. Self-assessment was considered totally feasible in 74%, and 66% of patients were capable of always doing it, with a confidence of 60% (always) to 34% (sometimes). Confidence was associated with a higher educational level. Nevertheless, 77% of patients felt that the self-assessment would not fully replace the physician’s visit. Open-ended questions identified five themes: better understanding of the disease, easier communication with the rheumatologist, less consultation time, difficulty with the scoring part and importance of practice. Patients with RA felt that self-assessment was feasible and helpful in understanding RA, improving communication with the rheumatologist and shortening the visit time.

The impact of COVID-19 pandemic on rheumatology practice: a cross-sectional multinational study

OBJECTIVE

To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on rheumatology practice.

METHOD

A cross-sectional web survey was designed by the members of the Arab League of Associations for Rheumatology (ArLAR), validated by its scientific committee and disseminated through e-mail and social media. It included close-ended questions about the impact of the pandemic on the rheumatology activities, including outpatient visits and hospitalizations (in percentage, 100% corresponds to complete suspension) and open-ended questions about unmet needs. Univariate and multivariable logistic regression analyses were used to evaluate the predictors of impact. Suggestions were developed to improve the practice.

RESULTS

A total of 858 rheumatologists were included in the analysis (27.3% of registered in ArLAR), 37% were 35-44 years old, 60% were females, and 48% worked in the private sector. The impact of COVID-19 was a decrease of 69% in hospitalizations, 65% in outpatient clinic, 56% in infusion centers, and 43% in income. It was associated with the region (highest in the Gulf), use of telemedicine, impact on income and practice sector (lowest in private). There was a hydroxychloroquine shortage in 47%. Telemedicine was mostly based on traditional telephone contacts and e-mails and reimbursed in 12%. Fifteen rheumatologists (1.8%) were infected and 156 cases of COVID-19 were reported among patients. The top-cited unmet needs in rheumatology practice were access to drugs and a telemedicine platform.

CONCLUSIONS

The negative impact of the COVID-19 pandemic on rheumatology practice may compromise rheumatic diseases control. Better access to drugs and providing telemedicine platforms are recommended to improve the practice. Key Points • The COVID-19 pandemic had a significant negative impact on the rheumatology practice, including access to outpatient clinic, hospitalization, and to anchor drugs. • The compromised access to rheumatology care may jeopardize the control of chronic rheumatic diseases and the long-term prognosis. • Better access to drugs and providing telemedicine platforms are strongly recommended.

Impact of the COVID-19 pandemic on patients with chronic rheumatic diseases: A study in 15 Arab countries

AIM

To evaluate the impact of the coronavirus disease 2019 pandemic (COVID-19) on the access to rheumatology care for patients with chronic rheumatic diseases (CRD) in the Arab countries.

METHOD

A web-based cross-sectional survey was designed by the Arab Adult Arthritis Awareness group (AAAA) consisting of 16 rheumatologists representing countries from the Arab League of Associations for Rheumatology (ArLAR) and was validated by the ArLAR scientific committee. The survey was disseminated online through social media and patients' association channels between May 8 and May 22, 2020. The steering committee developed recommendations to improve the care of patients with CRD during the COVID-19 pandemic.

RESULTS

A total of 2163 patients were included in the analysis; 72% were female; mean age was 40 years (SD 11.9). The Levant, the Gulf, and North Africa contributed almost equally to the sample. The pandemic had a significant negative impact on rheumatology visits in 82% of cases, access to hydroxychloroquine (47%), and chronic medication persistency (28%). The negative impact on rheumatology visits was associated with female gender, country, medication non-persistency, isolation due to COVID-19, and impact on mental health. Sixty-one patients (2.8%) stated that they had COVID-19, 5% said that a close contact was infected, and 47% were in isolation because of COVID-19.

CONCLUSION

The current study highlights the deleterious consequences of the COVID-19 pandemic on the continuity of rheumatology care. Therefore, an action plan, including establishing a telemedicine platform, securing drug availability, and promoting medication persistence through the appropriate communication channels, is strongly recommended.

Long-term results of tripolar constrained total hip arthroplasty in revision hip arthroplasty

Aims

We investigated the long-term performance of the Tripolar Trident acetabular component used for recurrent dislocation in revision total hip arthroplasty. We assessed: 1) rate of re-dislocation; 2) incidence of complications requiring re-operation; and 3) Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain and functional scores.

Patients and Methods

We retrospectively identified 111 patients who had 113 revision tripolar constrained liners between 1994 and 2008. All patients had undergone revision hip arthroplasty before the constrained liner was used: 13 after the first revision, 17 after the second, 38 after the third, and 45 after more than three revisions. A total of 75 hips (73 patients) were treated with Tripolar liners due to recurrent instability with abductor deficiency, In addition, six patients had associated cerebral palsy, four had poliomyelitis, two had multiple sclerosis, two had spina bifida, two had spondyloepiphyseal dysplasia, one had previous reversal of an arthrodesis, and 21 had proximal femoral replacements. The mean age of patients at time of Tripolar insertions was 72 years (53 to 89); there were 69 female patients (two bilateral) and 42 male patients. All patients were followed up for a mean of 15 years (10 to 24). Overall, 55 patients (57 hips) died between April 2011 and February 2018, at a mean of 167 months (122 to 217) following their tripolar liner implantation. We extracted demographics, implant data, rate of dislocations, and incidence of other complications.

Results

At ten years, the Kaplan–Meier survivorship for dislocation was 95.6% (95% confidence interval (CI) 90 to 98), with 101 patients at risk. At 20 years, the survivorship for dislocation was 90.6% (95% CI 81.0 to 95.5), with one patient at risk. Eight patients (7.2%) had a dislocation of their constrained liners. At ten years, the survival to any event was 89.4% (95% CI 82 to 93.8), with 96 patients at risk. At 20 years, the survival to any event was 82.5% (95% CI 71.9 to 89.3), with one patient at risk. Five hips (4.4%) had deep infection. Two patients (1.8%) developed dissociated constraining rings with pain but without dislocation, which required re-operation. Two patients (1.8%) had periprosthetic femoral fractures, without dislocation, that were treated by revision stems along with exchange of the well-functioning constrained liners.

Conclusion

Constrained tripolar liners used at revision hip arthroplasty provided favourable results in the long term for treatment of recurrent dislocation and for patients at high risk of dislocation. Cite this article: Bone Joint J 2019;101-B(6 Supple B):123–126.

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

In the original version of this article the first name of the co-author was incorrectly spelled as "Khaled A. Alnaqbi". The correct spelling should have been "Khalid A. Alnaqbi". This is now presented correctly in this article.

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.

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.

Pan Arab Osteoporosis Society Guidelines for Osteoporosis Management

Osteoporosis is the most common bone disease in humans. With its related fragility fracture, it represents a major public health problem in our region, with a significant medical and socio-economic burden. The high prevalence rate of vitamin D deficiency, the increase in life expectancy, the low socioeconomic level and the significant restriction to access to health care in some countries represent the major causes for the increasing prevalence of osteoporosis and incidence of fragility fractures in the Arabic countries. Bone mineral density (BMD) assessment is the gold standard to diagnose osteoporosis. However, a clinical diagnosis of osteoporosis may be made in the presence of a fragility fracture, without BMD measurement. Dual energy x-ray absorptiometry (DXA) is the preferred method for screening bone mineral density. For screening site of measurement, DXA of hip and spine is suggested. BMD assessment is recommended in all women 65 years of age and older and men 70 and older regardless of risk factors. Younger subjects with clinical risk factors and persons with clinical evidence of osteoporosis or diseases leading to osteoporosis should also be screened. These guidelines are aimed to provide to health care professionals in the region of an updated process for the diagnosis and treatment of osteoporosis. It includes risk factors for osteoporosis and the indications for screening, diagnosis of osteoporosis, treatment of osteoporosis in postmenopausal and premenopausal women, and men; in addition to prevention and treatment of glucocorticoid-induced osteoporosis.

Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ

Osteonecrosis of the jaw (ONJ) has been associated with antiresorptive therapy in both oncology and osteoporosis patients. This debilitating condition is very rare and advances in diagnosis and management may now effectively reduce the risk of its development and offer valuable treatment options for affected patients. This paper provides a case-based review of ONJ and application of the International Task Force on ONJ (referred to as the "Task Force") recommendations for the diagnosis and management of ONJ. The Task Force was supported by 14 international societies and achieved consensus from representatives of these multidisciplinary societies on key issues pertaining to the diagnosis and management of ONJ. The frequency of ONJ in oncology patients receiving oncology doses of bisphosphonate (BP) or denosumab is estimated at 1%-15%, and the frequency in the osteoporosis patient population receiving much lower doses of BP or denosumab is estimated at 0.001%-0.01%. Although the diagnosis of ONJ is primarily clinical, imaging may be helpful in confirming the diagnosis and staging. In those with multiple risk factors for ONJ for whom major invasive oral surgery is being planned, interruption of BP or denosumab therapy (in cancer patients) is advised, if possible, before surgery, until the surgical site heals. Major oral surgery in this context could include multiple extractions if surgical extractions are required, not simple forceps extractions. ONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate. Periodontal disease should be managed before starting oncology doses of BP or denosumab. Local debridement may be successful in disease unresponsive to conservative therapy. Successful surgical intervention has been reported in those with stage 3 disease; less severe disease is best managed conservatively. Teriparatide may be helpful in healing ONJ lesions and may be considered in osteoporosis patients at a high fracture risk in the absence of contraindications. Resumption of BP or denosumab therapy following healing of ONJ lesions is recommended, and there have not been reports of subsequent local recurrence.

Apelin receptors: From signaling to antidiabetic strategy

The G protein-coupled receptor APJ and its cognate ligand, apelin, are widely expressed throughout human body. They are implicated in different key physiological processes such as angiogenesis, cardiovascular functions, fluid homeostasis and energy metabolism regulation. On the other hand, this couple ligand-receptor is also involved in the development and progression of different pathologies including diabetes, obesity, cardiovascular disease and cancer. Recently, a new endogenous peptidic ligand of APJ, named Elabela/Toddler, has been identified and shown to play a crucial role in embryonic development. Whereas nothing is yet known regarding Elabela/Toddler functions in adulthood, apelin has been extensively described as a beneficial adipokine regarding to glucose and lipid metabolism and is endowed with anti-diabetic and anti-obesity properties. Indeed, there is a growing body of evidence supporting apelin signaling as a novel promising therapeutic target for metabolic disorders (obesity, type 2 diabetes). In this review, we provide an overview of the pharmacological properties of APJ and its endogenous ligands. We also report the activity of peptidic and non-peptidic agonists and antagonists targeting APJ described in the literature. Finally, we highlight the important role of this signaling pathway in the control of energy metabolism at the peripheral level and in the central nervous system in both physiological conditions and during obesity or diabetes.

Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus

This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.

Nasal photodisinfection and chlorhexidine wipes decrease surgical site infections: a historical control study and propensity analysis

BACKGROUND

Pre-operative decolonization therapy (DcTx) using chlorhexidine (CHG) body washes and/or intranasal mupirocin can reduce surgical site infections (SSIs), but compliance is often suboptimal.

AIM

To assess the effectiveness of immediate DcTx using a novel approach of intranasal antimicrobial photodisinfection therapy (PDT) combined with CHG body wipes for the reduction of SSIs.

METHODS

Between 1(st) September 2011 and 31(st) August 2012, 3068 elective cardiac, orthopaedic, spinal, vascular, thoracic and neurosurgical patients were treated with CHG in the 24h preceding surgery, and received intranasal PDT in the pre-operative area. SSI surveillance methodology remained unchanged from previous years and patients were followed for one year. Results were compared with those for a four-year historical control group of 12,387 patients as well as those for a concurrent control group of 206 untreated patients.

FINDINGS

A significant reduction in the SSI rate was observed between treated patients and the historical control group [1.6% vs 2.7%, P = 0.0004, odds ratio (OR) 1.73, 95% confidence interval (CI) 1.2815-2.3453]. This significant reduction was maintained on intent-to-treat analysis (P = 0.021, OR 1.37, 95% CI 1.0476−1.7854) [corrected]. Overall compliance with DcTx was 94%. A 1:4 propensity score analysis of matched treated and untreated patients demonstrated that DcTx reduced the risk of SSIs significantly (P = 0.00026, z = 3.65).

CONCLUSION

The combination of CHG wipes and PDT immediately before surgery reduced SSIs, achieved excellent compliance, and was easily integrated into the pre-operative routine.

Cement penetration and primary stability of the femoral component after impaction allografting

This study explored the relationship between the initial stability of the femoral component and penetration of cement into the graft bed following impaction allografting.

Impaction allografting was carried out in human cadaveric femurs. In one group the cement was pressurised conventionally but in the other it was not pressurised. Migration and micromotion of the implant were measured under simulated walking loads. The specimens were then cross-sectioned and penetration of the cement measured.

Around the distal half of the implant we found approximately 70% and 40% of contact of the cement with the endosteum in the pressure and no-pressure groups, respectively. The distal migration/micromotion, and valgus/varus migration were significantly higher in the no-pressure group than in that subjected to pressure. These motion components correlated negatively with the mean area of cement and its contact with the endosteum.

The presence of cement at the endosteum appears to play an important role in the initial stability of the implant following impaction allografting.

Middle East and North Africa consensus on osteoporosis

With the increasing life expectancy, osteoporosis is becoming a major worldwide health problem. The magnitude of the disease may become larger in developing countries, more particularly in the Middle East region where the prevalence of low bone mass is higher than in western countries. Although several local organizations and countries have developed guidelines for osteoporosis, no previous regional guidelines have been developed encompassing all Middle-Eastern and North African countries. The present document reviews all the regional published data on bone mineral density, risk factors, fracture prevalence and vitamin D status. It also gives simple recommendations applicable to all these countries. This document was endorsed by leading members of all the different regional countries including, Iran, Egypt, Tunisia, Jordan, Palestine, Syria, Iraq, Libya, Oman, Kuwait, Saudi Arabia and Bahrain.

Apelin signalling: a promising pathway from cloning to pharmacology

The discovery of new signalling pathways is always followed by the development of pharmacological agents as drugs that can be used in the treatment of diseases resulting from a dysfunction of the signalling pathway in question. Apelin signalling plays a role in the central and peripheral regulation of the cardiovascular system, in water and food intake, and possibly in immune function. Up-regulation of ligand and receptor is also associated with pathophysiological states such as cardiac dysfunction and neovascularisation. Finally, the apelin receptor is a coreceptor for the entry of several HIV-1 and SIV strains. In view of these features, the apelin receptor constitutes a very interesting target for the design of new drugs for treating the prime causes of human mortality.

Clinical practice guidelines for managing dyslipidemias in kidney transplant patients: a report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

The incidence of cardiovascular disease (CVD) is very high in patients with chronic kidney (CKD) disease and in kidney transplant recipients. Indeed, available evidence for these patients suggests that the 10-year cumulative risk of coronary heart disease is at least 20%, or roughly equivalent to the risk seen in patients with previous CVD. Recently, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) published guidelines for the diagnosis and treatment of dyslipidemias in patients with CKD, including transplant patients. It was the conclusion of this Work Group that the National Cholesterol Education Program Guidelines are generally applicable to patients with CKD, but that there are significant differences in the approach and treatment of dyslipidemias in patients with CKD compared with the general population. In the present document we present the guidelines generated by this workgroup as they apply to kidney transplant recipients. Evidence from the general population indicates that treatment of dyslipidemias reduces CVD, and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemias. Dyslipidemias are very common in CKD and in transplant patients. However, until recently there have been no adequately powered, randomized, controlled trials examining the effects of dyslipidemia treatment on CVD in patients with CKD. Since completion of the K/DOQI guidelines on dyslipidemia in CKD, the results of the Assessment of Lescol in Renal Transplantation (ALERT) Study have been presented and published. Based on information from randomized trials conducted in the general population and the single study conducted in kidney transplant patients, these guidelines, which are a modified version of the K/DOQI dyslipidemia guidelines, were developed to aid clinicians in the management of dyslipidemias in kidney transplant patients. These guidelines are divided into four sections. The first section (Introduction) provides the rationale for the guidelines, and describes the target population, scope, intended users, and methods. The second section presents guidelines on the assessment of dyslipidemias (guidelines 1-3), while the third section offers guidelines for the treatment of dyslipidemias (guidelines 4-5). The key guideline statements are supported mainly by data from studies in the general population, but there is an urgent need for additional studies in CKD and in transplant patients. Therefore, the last section outlines recommendations for research.

Metal artifact reduction sequence: early clinical applications

Artifact arising from metal hardware remains a significant problem in orthopedic magnetic resonance imaging. The metal artifact reduction sequence (MARS) reduces the size and intensity of susceptibility artifacts from magnetic field distortion. The sequence, which is based on view angle tilting in combination with increased gradient strength, can be conveniently used in conjunction with any spin-echo sequence and requires no additional imaging time. In patients with persistent pain after femoral neck fracture, the MARS technique allows visualization of marrow adjacent to hip screws, thus enabling diagnosis or exclusion of avascular necrosis. Other applications in the hip include assessment of periprosthetic soft tissues after hip joint replacement surgery, postoperative assessment after resection of bone tumors and reconstruction, and localization of unopacified methyl methacrylate cement prior to hip arthroplasty revision surgery. In the knee, the MARS technique allows visualization of structures adjacent to implanted metal staples, pins, or screws. The technique can significantly improve visualization of periprosthetic bone and soft-tissue structures even in patients who have undergone total knee arthroplasty. In patients with spinal fixation hardware, the MARS technique frequently allows visualization of the vertebral bodies and spinal canal contents. The technique can be helpful after wrist fusion or screw fixation of scaphoid fractures.

Malignant degeneration of an osteochondroma with unusual intra-bursal invasion

Multiple hereditary osteochondromatosis is an uncommon autosomal dominant condition in which patients are predisposed to the development of chondrosarcoma. We report a case of a patient who developed a secondary low-grade chondrosarcoma in this setting. The tumor was associated with an unusual multinodular invasive growth pattern into a pre-existing bursa that was present overlying the osteochondroma.

Malignant fibrous histiocytoma of soft tissue imaging with emphasis on MRI

Malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma in adults. This pictorial essay describes and illustrates the clinical, pathologic, and radiologic features of MFH. The cross-sectional imaging features on CT and MRI are emphasized in relation to the diagnosis and staging of MFH.

Soft tissue osteosarcoma with telangiectatic features: MR imaging findings in two cases

Extraskeletal osteosarcomas are rare tumors, and the telangiectatic variety is the least common histological variety in this group. This report describes the clinical and MR imaging findings in two cases arising in the pretibial soft tissues. Both tumors demonstrated marked inhomogeneity with T2-weighted spin echo and STIR sequences. One of the tumors revealed numerous fluid levels within the lesion. A review of the MRI features of these tumors is provided. Osteosarcoma with telangiectatic features should be considered in the differential diagnosis of a soft tissue mass with fluid-fluid levels in patients 40 years of age or older.

Valgus stress radiography in normal ankles

Deltoid ligament injury is thought to be rare. Signs of complete rupture of the deltoid ligament may be subtle or interpreted as another injury condition and thus are often missed acutely. No standardized method has been created to evaluate medial ligament insufficiency in acute or chronic laxity. To establish a diagnostic test for suspected isolated ruptures of the deltoid ligament, 32 subjects with no previous ankle injury underwent valgus stress radiography and nonstressed radiography of both ankles. Stress radiography in this study showed that there is a measurable but minimal range of talar tilt on valgus stress in previously uninjured ankles. This study provides the basis for diagnosis of the rare isolated rupture of the deltoid ligament of the ankle.