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Objectives The aim of this study was to investigate the association between individual-level and country-level socio-economic (SE) factors and health outcomes across SpA phenotypes. Methods Patients with axial SpA (axSpA), peripheral SpA (pSpA) or PsA from the ASAS-perSpA study (in 23 countries) were included. The effect of individual-level (age, gender, education and marital status) and country-level [e.g. Gross Domestic Product (GDP)] SE factors on health outcomes [Ankylosing Spondylitis Disease Activity Score (ASDAS) ≥ 2.1, ASDAS, BASFI, fatigue and the Assessment of SpondyloArthritis international Society Health Index (ASAS-HI)] was assessed in mixed-effects models adjusted for potential confounders. Interactions between SE factors and disease phenotype were tested. A mediation analysis was conducted to explore whether the impact of country-level SE factors on ASDAS was mediated through biologic/targeted synthetic (b/ts) DMARD uptake. Results In total, 4185 patients (61% males, mean age 45) were included (65% axSpA, 25% PsA, 10% pSpA). Female gender [β= 0.14 (95% CI: 0.06, 0.23)], lower educational level [β = 0.35 (0.25, 0.45)) and single marital status [β = 0.09 (0.01, 0.17)] were associated with higher ASDAS. Living in lower GDP countries was also associated with higher ASDAS [β = 0.39 (0.16, 0.63)], and 7% of this association was mediated by b/tsDMARD uptake. Higher BASFI was similarly associated with female gender, lower education and living alone, without the effect of country-level SE factors. Female gender and lower educational level were associated with worse ASAS-HI, while more fatigue was associated with female gender and higher country-level SE factors [lower GDP, β = −0.46 (−0.89 to −0.04)]. No differences across disease phenotypes were found. Conclusions Our study shows country-driven variations in health outcomes in SpA, independently influenced by individual-level and country-level SE factors and without differences across disease phenotypes.

Objectives The primary objective was to compare the clinical characteristics of SpA patients with and without root joint disease (RJD+ and RJD–). The secondary objectives were to compare the prevalence of RJD across various SpA subtypes and in different world regions, and to compare the SpA axial severity and SpA burden between RJD+ and RJD–. Methods This is a post hoc analysis of the Assessment of Spondyloarthritis International Society PerSpA study (PERipheral involvement in SpondyloArthritis), which included 4465 patients with SpA [axial (axSpA), peripheral (pSpA), PsA, IBD, reactive and juvenile] according to the rheumatologist’s diagnosis. RJD was defined as the ‘ever’ presence of hip or shoulder involvement related to SpA, according to the rheumatologist. Patient characteristics were compared between RJD+ and RJD–. Multivariable stepwise binary logistic regression analyses were conducted to identify factors associated with ‘RJD’, ‘hip’ and ‘shoulder’ involvement. Results RJD was significantly associated with the SpA main diagnosis (highest in pSpA), a higher prevalence of HLA-B27 positivity, enthesitis, tender and swollen joints, CRP, conventional synthetic DMARDs, loss of lumbar lordosis and occiput-wall distance >0. RJD was more prevalent in Asia, and occurred in 1503 patients (33.7%), with more hip (24.2%) than shoulder (13.2%) involvement. Hip involvement had a distinct phenotype, similar to axSpA (including younger age at onset, HLA-B27 positivity), whereas shoulder involvement was associated with features of pSpA (including older age at onset). Conclusion RJD+ SpA patients had a distinctive clinical phenotype compared with RJD–. Hip involvement, based on the rheumatologist’s diagnosis, was more prevalent than shoulder involvement and was clinically distinct.

Musculoskeletal disorders remain a major problem in hemodialysis patients. The aim of the study was to estimate the prevalence of musculoskeletal manifestations in hemodialysis patients and identify disease cluster profiles. We performed a cross-sectional study including all adult patients in the hemodialysis unit at Hotel-Dieu de France Hospital. We collected demographic characteristics, musculoskeletal symptoms, biologic parameters, and treatments. Musculoskeletal disorders were classified by a rheumatologist into predefined diagnostic categories. Prevalence was presented, and a cluster analysis was performed. Eighty-nine patients were included, mean age was 67.5 ± 12 years, and 43.8% were female. Dialysis vintage was 5.7 ± 5.37 years. Musculoskeletal symptoms were reported by 76.4% of the patients. Pain was the most frequent symptom (44.9%). The main diagnoses were osteoarthritis (53.9%) and fracture (27%). Musculoskeletal symptoms and disorders were significantly associated with dialysis vintage and age. Cluster analysis identified three patient profiles: younger with low calcium levels, younger but long dialysis vintage with osteoarthritis and carpal tunnel syndrome, and older with long dialysis vintage and fractures. The prevalence of musculoskeletal manifestations is high in the hemodialysis population and increases with dialysis vintage. Musculoskeletal disorders cluster according to age and dialysis vintage. Key Points• Musculoskeletal symptoms are highly prevalent among hemodialysis patients (76.4%).• All musculoskeletal disorders are associated with dialysis vintage and age.• Three clusters are identified among hemodialysis patients: young with low calcium levels, young but long dialysis vintage with osteoarthritis and carpal tunnel syndrome and old with long dialysis vintage with fractures.

ObjectivesTo characterise peripheral musculoskeletal involvement in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), across the world.MethodsCross-sectional study with 24 participating countries. Patients with a diagnosis of axial SpA (axSpA), peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The investigators were asked which diagnosis out of a list of six (axSpA, PsA, pSpA, inflammatory bowel disease-associated SpA, reactive arthritis or juvenile SpA (Juv-SpA)) fitted the patient best. Peripheral manifestations (ie, peripheral joint disease, enthesitis, dactylitis and root joint disease), their localisation and treatments were evaluated.ResultsA total of 4465 patients were included (61% men, mean age 44.5 years) from four geographic areas: Latin America (n=538), Europe plus North America (n=1677), Asia (n=975) and the Middle East plus North Africa (n=1275). Of those, 78% had ever suffered from at least one peripheral musculoskeletal manifestation; 57% had peripheral joint disease, 44% had enthesitis and 15% had dactylitis. Latin American had far more often peripheral joint disease (80%) than patients from other areas. Patients with PsA had predominantly upper limb and small joint involvement (52%).Hip and shoulder involvement was found in 34% of patients. The prevalence of enthesitis ranged between 41% in patients with axSpA and 65% in patients with Juv-SpA. Dactylitis was most frequent among patients with PsA (37%).ConclusionThese results suggest that all peripheral features can be found in all subtypes of SpA, and that differences are quantitative rather than qualitative. In a high proportion of patients, axial and peripheral manifestations coincided. These findings reconfirm SpA clinical subtypes are descendants of the same underlying disease, called SpA.

The coronavirus disease-2019 (COVID-19) pandemic continues to be a cause of unprecedented global morbidity and mortality. Whilst COVID-19 vaccination has emerged as the only tangible solution to reducing poor clinical outcomes, vaccine hesitancy continues to be an obstacle to achieving high levels of vaccine uptake. This represents particular risk to patients with autoimmune diseases, a group already at increased risk of hospitalization and poor clinical outcomes related to COVID-19 infection. Whilst there is a paucity of long-term safety and efficacy data of COVID-19 vaccination in patients with autoimmune diseases, the current evidence strongly suggests that the benefits of vaccination outweigh the risks of adverse effects and disease flares. Herein, we report the protocol of the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study, an ongoing international collaborative study involving 29 countries and over 110 investigators. Supplementary Information The online version contains supplementary material available at 10.1007/s00296-021-05046-4.

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. Supplementary Information The online version contains supplementary material available at 10.1007/s00296-021-04799-2.

Aim To calculate the prevalence of human leukocyte antigen (HLA)-B27 in axial spondyloarthritis patients (axSpA) compared to blood donors (BD) in Lebanon, to identify the clinical and radiological findings associated with HLA-B27 and to estimate the proportion of patients fulfilling the clinical arm of the Assessment of the Spondyloarthritis International Association (ASAS) criteria. Method Consecutive Lebanese adult axSpA patients fulfilling the ASAS classification criteria were included from 12 rheumatology clinics across Lebanon. BD served as controls. A binary logistic regression was used to study the association between HLA-B27 and the disease features. Results A total of 247 individuals were included (141 axSpA patients and 106 BD). The prevalence of HLA-B27 was 3.8% in BD and 41.1% in axSpA. Overall, 39.7% of the axSpA patients fulfilled the clinical arm of the ASAS classification criteria. Sensitivity of HLA-B27 for axSpA was 41.1%, specificity was 96.2%, positive predictive value was 93.6%, and negative predictive value was 55.13%. Positive likelihood ratio (LR) was 10.9 and negative LR was 1.63. We found a positive association of HLA-B27 with family history of SpA and psoriasis. Conclusion Our study confirmed a low prevalence of HLA-B27 in axSpA patients and BD in this Lebanese population, However, we found a high specificity and positive LR, as well as the same number of axSpA patients fulfilling the clinical arm of the ASAS criteria as in European studies. HLA-B27 is therefore valuable for identification of axSpA in Lebanese patients despite the overall low prevalence in this population. Our results may guide future evaluations the role of HLA-B27 in planning local referral strategies.

Increased risk of comorbidities has been reported in Rheumatic and Musculoskeletal Diseases (RMD). We aimed to evaluate the prevalence and pattern of comorbidities in RMD patients nationwide, to identify multimorbidity clusters and to evaluate the gap between recommendations and real screening. Cross-sectional, multicentric nationwide study. Prevalence of comorbidities was calculated according to six EULAR axes. Latent Class Analysis identified multimorbidity clusters. Comorbidities’ screening was compared to international and local recommendations. In 769 patients (307 RA, 213 OA, 63 SLE, 103 axSpA, and 83 pSA), the most frequent comorbidities were cardiovascular risk factors and diseases (CVRFD) (hypertension 36.5%, hypercholesterolemia 30.7%, obesity 22.7%, smoking 22.1%, diabetes 10.4%, myocardial infarction 6.6%), osteoporosis (20.7%) and depression (18.1%). Three clusters of multimorbidity were identified: OA, RA and axSpA. The most optimal screening was found for CVRF (> = 93%) and osteoporosis (53%). For malignancies, mammograms were the most optimally prescribed (56%) followed by pap smears (32%) and colonoscopy (21%). Optimal influenza and pneumococcus vaccination were found in 22% and 17%, respectively. Comorbidities were prevalent in RMD and followed specific multimorbidity patterns. Optimal screening was adequate for CVRFD but suboptimal for malignant neoplasms, osteoporosis, and vaccination. The current study identified health priorities, serving as a framework for the implementation of future comorbidity management standardized programs, led by the rheumatologist and coordinated by specialized health care professionals.

Fouad Fayad,1 Nelly R Ziade,1 Georges Merheb,2 Said Attoui,3 Alla Aiko,4 Kamel Mroue,3 Abdel Fattah Masri5 1Rheumatology Department, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon; 2Department of Rheumatology, Notre Dame des Secours University Hospital, Jbeil, Lebanon, Holy Spirit University, Kaslik, Lebanon; 3Rheumatology Department, Hammoud University Medical Center, Saida, Lebanon; 4Department of Medicine (Rheumatology), Saint George Hospital, Beirut, Lebanon; 5Department of Internal Medicine (Rheumatology), American University of Beirut Medical Center, Beirut, Lebanon Introduction: To investigate the treatment preferences of patients with rheumatoid arthritis (RA) and determine whether these preferences are related to specific disease characteristics. Method: A national survey was designed to collect demographic, disease, treatment, and preference data on RA patients enrolled in 7 private and university hospital clinics in Lebanon. Associations between patient factors and treatment preferences for RA were analyzed by χ2 or Mann–Whitney U test. Results: A total of 693 patients (83% female; 67% aged 41–70 years) consulting 7 trained rheumatologists completed the survey. Most patients (80%) had established RA >24 months, and approximately one-third (34%) were in remission according to the disease activity score in 28 joints (DAS28). Most (87%) were receiving oral agents (60% oral only). Almost two-thirds of patients (64%) expressed a preference for oral treatments, and more than half (53%) ranked doctor’s advice as the most influential factor when choosing treatment. In univariable analysis, health coverage, radiographic damage, disease duration, current therapy, and previous side effects were significantly associated with treatment preference. In multivariable analyses, only radiographic damage and current route of administration were independently associated with preference (both P

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)0.527When 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, pConclusion: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 categoriesAcknowledgements: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

Background: Adherence to therapy in chronic diseases such as inflammatory rheumatic diseases (CIRD), inflammatory bowel diseases (IBD) and psoriasis (Pso) is a major condition to achieve positive outcomes. Patient support programs (PSPs) were developed to improve the quality of care and enhance adherence to therapy. Objectives: To evaluate the perception of patients treated for inflammatory chronic diseases towards PSPs. Methods: All available PSPs were identified at the national level, and their services were classified into categories: financial, logistic, educational, and emotional support. Consecutive adult patients with CIRD, IBD and Pso, enrolled in a PSP for more than 3 months, were interviewed by a trained medical student. Demographic data, disease and treatment characteristics were collected at the physician’s clinic. Global satisfaction was estimated using a 5-points Likert scale, adherence to treatment was measured by the Compliance Questionnaire for Rheumatology (CQR), PSPs services were classified according to their importance to the patient using a 5-points Likert scale. An open questionnaire identified the patients’ perceptions qualitatively. Predictive factors of satisfaction were identified. Results: Forty-seven patients were included in the study, 53% were males, with a mean age of 49.8 years (SD 15.2) (Patients’ characteristics in Table 1). The majority declared that the PSP was very useful (95.7%) and were highly satisfied with the programs (97.9%). Higher attributes were assigned, by decreasing order, to: financial (copay program, providing of free samples), logistic (hotline, refrigerating box), educational (educational material) and emotional support. Nursing services and telephone reminders were rated as least important (Figure 1). Most open comments gave higher appreciation to financial support (54%), followed by education (38%) and logistics (8%). High appreciation of education was associated with lower age, type of treatment and PSP. Shorter treatment duration was associated with appreciation of educational material, emotional support and telephone reminders. Conclusion: Patients were highly satisfied with PSP programs, and ranked the financial support as the most important followed by logistics, whereas education, nursing services and telephone reminders were found less important. Lower age and shorter treatment duration were associated with higher appreciation of education and support. References [1] Rubin D, Mittal M, Davis M, et al. Impact of a Patient Support Program on Patient Adherence to Adalimumab and Direct Medical Costs in Crohn’s Disease, Ulcerative Colitis, Rheumatoid Arthritis, Psoriasis, Psoriatic Arthritis, and Ankylosing Spondylitis. J Manag Care Spec Pharm. 2017;23(8):859-67. [2] Gangi A, Clewell J, Shillington A. The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review. Patient Preference and Adherence 2016:10 711–725. [3] Van den Bosch F, Ostor A, Wassenberg S, et al. Impact of Participation in the Adalimumab (Humira) Patient Support Program on Rheumatoid Arthritis Treatment Course: Results from the PASSION Study. Rheumatol Ther (2017) 4:85–96. Disclosure of Interests: None declared

Background: Involving patients with rheumatoid arthritis (RA) in the assessment of their disease may increase adherence to treatment, improve disease outcomes and reduce consultation time. Objectives: To evaluate the concordance between physician and patient assessment of disease activity in RA using Disease Activity Score (DAS-28). Methods: During the routine consultation, patients were briefed about DAS-28 by their rheumatologist. Using a standard DAS-28 mannequin, physicians, patients and nurses reported the number of tender and swollen joint, inflammatory markers and global health on a 0-10 Likert scale. DAS-28, Clinical Disease Activity Index (CDAI) and Simple Disease Activity Index (SDAI) were calculated blindly by each participant. Agreement between physician- and patient-DAS categories was calculated using weighted kappa (WK) for category comparison. Concordance between physician- and patient-DAS was estimated using the Bland-Altman method. Predictive factors of positive concordance between physician and patient-DAS were identified using logistic regression. Results: Four hundred and twenty patients from 7 Middle-Eastern countries were included, with a mean age of 49 years (SD 12), 84% of females, disease duration of 11 years (SD 8). Mean physician-DAS-28 was 4.03 (SD 1.51). 65% had positive rheumatoid factor, 56% had positive ACPA, 30% had erosive disease and 34% were on biotherapy. Agreement between physician- and patient-DAS categories was 89%, WK was 0.84. WK were 0.80 for DAS physician-nurse, 0.79 for DAS patient-nurse, 0.83 for CDAI physician-patient and 0.88 for SDAI physician-patient agreements respectively. All activity measures were higher in patients compared to physicians, except for the swollen joints count. The mean difference between physician- and patient-DAS was -0.09 [95% CI -0.14; -0.04] and was smaller in patients in remission (Figure 1: Bland Altman plot). Concordance was statistically associated with CRP and patient SDAI. Conclusion: Concordance between patient and physician assessment of disease activity in RA was excellent and was higher using SDAI followed closely by DAS-28 and CDAI. Self-assessment of disease activity should be decided according to the physician’s clinical judgment. References: [1] Gossec L, et al. Arthritis Rheumatol 2016; 68 (suppl 10). [2] Smolen J, et al. Arthritis Research & Therapy (2016) 18:114. [3] Studenic Pet al. Arthritis Rheumatol. 2012;64(9):2814–23. The physician-patient DAS-mean is plotted on the X-axis. The physician-patient DAS-difference is plotted on the Y-Axis. The horizontal black line corresponds to the mean DAS difference (-0.09 [95% CI -0.14; -0.04]). The horizontal blue lines correspond to +/-1.96 SD. The vertical red line corresponds to the DAS-28 cut-off for remission (2.6). Disclosure of Interests: None declared

Background:Patients with a diagnosis of Spondyloarthritis (SpA) and Psoriatic Arthritis (PsA) may have predominant axial or peripheral symptoms, and the frequency and distribution of these symptoms may determine the clinical diagnosis by the rheumatologist (“clinical clusters”). Clustering analysis represents an unsupervised exploratory analysis which tries to identify homogeneous groups of cases (“statistical clusters”) without prior information about the membership for any of the cases.Objectives:To identify “statistical clusters” of peripheral involvement according to the specific location of these symptoms in the whole spectrum of SpA and PsA (without prior information about the diagnosis of the patients), and to evaluate whether these “statistical clusters” are in agreement with the “clinical clusters”.Methods:Cross-sectional and multicentre study with 24 participating countries. Consecutive patients considered by their treating rheumatologist as suffering from either PsA, axial SpA (axSpA) or peripheral SpA (pSpA) were enrolled. Four different cluster analyses were conducted: the first one using information about the specific location from all the peripheral musculoskeletal manifestations (i.e., peripheral arthritis, enthesitis and dactylitis), and thereafter a cluster analysis for each peripheral manifestation individually. Multiple correspondence analyses and k-means clustering methods were used. Distribution of peripheral manifestations and clinical characteristics were compared across the different clusters.Results:4465 patients were included in the analysis. Two clusters were found with regard to the location of all the peripheral manifestations (Fig. 1). Cluster 1 showed a low prevalence of peripheral manifestations in comparison with cluster 2; however, when peripheral involvement appeared in cluster 1, this was mostly represented by arthritis of hip, knee and ankle, as well as enthesitis of the heel. Patients from cluster 1 showed a higher prevalence of males (63% vs 44%), HLA-B27 positivity (69% vs 38%) and axial involvement (80% vs 52%), as well as more frequent diagnosis of axSpA (66% vs 21%) and more frequently fulfilling the ASAS axSpA criteria (69% vs. 41%). Patients from cluster 2 showed a higher prevalence of psoriasis (63% vs 25%), a more frequent diagnosis of PsA (61% vs 19%), and they fulfilled more frequently the peripheral ASAS (26% vs 11%) and the CASPAR criteria (57% vs 19%).Figure 1.Distribution of the peripheral involvement across clustersThree clusters were found with regard to the location of the peripheral arthritis. Clusters 2 and 3 showed a high prevalence of peripheral joint disease, although this was located more predominantly in the lower limbs in cluster 2, and in the upper limbs in cluster 3. Cluster 1 showed a higher prevalence of males, HLA-B27 positivity, axial involvement, a lower presence of psoriasis, a more frequent diagnosis of axSpA and fulfilling the ASAS axSpA criteria in comparison with clusters 2 and 3, respectively. Clusters 2 and 3 showed a higher prevalence of enthesitis and dactylitis in comparison with cluster 1, a more frequent diagnosis of PsA and fulfillment of the CASPAR criteria.Information about the location of enthesitis exhibited three groups: cluster 1 showed a very low prevalence of enthesitis, while cluster 2 and 3 showed a high prevalence of enthesitis, with a predominant involvement of axial enthesis in cluster 2 and peripheral enthesitis in cluster 3.Finally, the analysis of dactylitis also exhibited three clusters that showed a very low prevalence of dactylitis, predominantly toes and predominantly fingers involvement, respectively.Conclusion:These results suggest the presence of heterogeneous patterns of peripheral involvement in SpA and PsA patients without clearly defined groups, confirming the clear overlap of these peripheral manifestations across the different underlying diagnoses.Acknowledgements:This study was conducted under the umbrella of ASAS with unrestricted grant of Abbvie, Pfizer, Lilly, Novartis, UCB, Janssen and Merck.Disclosure of Interests:None declared

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

Background:Spondyloarthritis (SpA) and Familial Meditaerranean fever (FMF) may co-exist in certain populations, and have some overlapping manifestations (oligo-arthritis, hip involvement). Their association may impact disease phenotype and may affect disease management.Objectives:To evaluate the association of SpA and FMF and its impact on disease phenotype and management.Methods:A systematic literature search was conducted with the keywords spondyloarthritis and familial mediterranean fever from Janurary 1990 to January 2020 in PubMed and using manual cross-reference methods.Results:The search retrieved 74 articles, out of which 37 articles were relevant to the study question; most of the articles were case reports, with some large cohort studies of FMF and SpA (Flowchart in Figure 1).In large FMF cohorts, the prevalence of SpA was higher compared to the general population (7.5-13%, OR around 10). M694V was a risk factor for SpA. These FMF-SpA patients were older at diagnosis, had lower fever attacks, and higher disease duration, inflammatory back pain, chronic arthritis, enthesopathy, persistent inflammation and higher resistance to Colchicine. In case series, they were responsive to anti-TNF therapy.In large SpA cohorts, MEFV mutation, particularly M694V, was found in 15-35% (even without associated FMF). In most cohorts, MEFV mutation carriers didn’t have any distinct disease phenotype, except for some reports of higher ESR, more hip involvement, higher BASFI and higher BASDAI. Genome-wide association studies and case reports suggest an implication for IL-1 and thus a role for Anakinra therapy in these patients.Conclusion:In FMF or SpA patients with resistance to conventional therapy, the evaluation of disease association should be performed as it may have significant impact on disease management.References:[1]Li et al, Plos Genetics 2019. Watad et al, Frontiers Immunol 2019. Atas et al, Rheumatol Int 2019. Cherqaoui et al, JBS 2017. Zhong et al. Plos One 2017. Ornek et al, Arch Rheumatol 2016. Cinar et al, Rheumatol Int 2008. Durmur et al, JBS 2007.Figure 1.Flowchart of the systematic literature search (Spondyloarthritis, Familial Mediterranean Fever; January 1990-2020).Disclosure of Interests:Nelly Ziade Speakers bureau: Abbvie, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Aref Nassar: None declared

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.

Background Using a treatment target in rheumatoid arthritis (RA), such as DAS-28 and involving patients in their disease management can improve prognosis. Objectives To develop and implement an educational video that instructs patients with RA for self-assessment of disease activity using DAS-28. Methods Step 1:Initiation. Rheumatologists from some Middle Eastern Arab countries were invited to participate in this study. International experts and societies were contacted to access pre-existing educational material. Step 2: Development. Different material sources were synthetized and translated into Arabic and validated by the rheumatologists. The educational video was shot by a professional team with a real patient and a rheumatologist on set. Step 3. Validation. The final products (leaflets and video) were validated by the rheumatologists and tested with patients (figure 1). Obstacles were noted at the various study levels. Results 23 rheumatologists from 7 Middle Eastern Arab countries participated in the study. A one-page educational leaflet was developed in Arabic and English languages. An educational video presenting the treat-to-target concept and the basics of DAS performance was produced in Arabic language with English subtitles. Obstacles at the rheumatologist, patient, cultural and logistic levels were identified and the potential solutions were addressed by the study team. Conclusions Collaboration between several countries sharing the same language and similar cultural backgrounds was possible and able to produce an educational video aiming at the empowerment of RA patients for the self-assessment of their disease activity. The video will serve for future studies in the Arabic-speaking countries and will be available later for clinical use according to the rheumatologist’s clinical judgment. References [1] Smolenet al. Ann Rheum Dis2015;0:1–13. [2] Gossec, et al. Arthritis Rheumatol2016;68(suppl 10). [3] Studenic, et al. 2012;64(9):2814–23. www.nras.org.uk and www.das-score.nl Acknowledgements Professor Maxime Dougados, Paris. Disclosure of Interest None declared

Background The number of patients suffering from stage 5 Chronic Kidney Disease is constantly increasing and their life expectancy has improved due to the hemodialysis technique. Musculoskeletal disorders remain a major problem in long term hemodialysis patients. Frequency and severity of these manifestations increase with the length of the dialysis. Objectives To identify diseases clustering profiles of musculoskeletal disorders in hemodialysis patients. Methods All adult patients in the hemodialysis centre were included in this cross-sectional study. For each patient, we filled a data collection sheet including basic demographic characteristics, musculoskeletal symptoms, biologic parameters and treatments. Musculoskeletal disorders were classified by a rheumatologist into pre-defined diagnostic categories: Osteoarthritis, Fractures, Tendinopathies, Carpal Tunnel Syndrome, Crystal deposition disease and Others. Prevalences were presented and a cluster analysis was performed. Results Eighty-nine patients were included (table 1). Mean age was 67.5±12 years. 43.8% were female. Dialysis vintage was 5.7±5.37 years. Musculoskeletal symptoms were reported by 76.4% of the patients. Pain was the most frequent symptom (44.9%). The main disorders were osteoarthritis (53.9%), fracture (27%), tendinopathy (22.5%), carpal tunnel syndrome (18%), and chondrocalcinosis (9%). Musculoskeletal symptoms were significantly related to the dialysis vintage and age (p=0.044, p=0.035 respectively). All disorders categories were significantly associated with dialysis vintage, particularly increasing after the seventh year of dialysis. Cluster analysis identified three patient profiles: younger with low calcium levels, younger but long dialysis vintage with osteoarthritis and carpal tunnel syndrome, older and long dialysis vintage with fractures (figure 1). Conclusions The prevalence of the musculoskeletal manifestations is high (76.4%) in the hemodialysis population. Musculoskeletal disorders seem to cluster differently according to age and dialysis vintage. Acknowledgements Dr Ghada Abi Karam and Dr Fouad Fayad. Disclosure of Interest None declared

Background Axial spondyloarthritis (AxSpA) is a relatively frequent and debilitating disease, with a prevalence ranging from 0.1 to 2% in the Caucasian population. Current Assessment of Spondyloarthritis International Society (ASAS) classification criteria of AxSpA rely either on sacroiliitis on imaging plus one SpA feature or positive HLAB27 antigen plus two SpA features, in a patient with chronic low back pain and age at onset of less than 45 years. Therefore, HLA-B27 is a central feature in SpA classification and plays a pivotal role in referral strategies and early diagnosis. The primary objective of the study is to review the prevalence of HLA-B27 in normal and AxSpA populations in Middle Eastern and Arab Countries and to assess the strength of association between HLA-B27 antigen and AxSpA. The secondary objective is to identify the gaps in the methodology of the studies and suggest a framework for future research. Methods Studies were included in the analysis if they reported prevalence of HLA-B27 in AxSpA and/or general population and if they covered geographical location in the Middle East or Arab countries in the Mediterranean basin. Odds ratios (OR) were calculated for each country, as a measure of the strength of association between HLA-B27 and AxSpA, compared to the normal population, using the two-by-two frequency table. Available data from the literature were analyzed according to the following quality indicators: sample size, method of HLA-B27 testing, presence of control group and external validity. Results Twenty-seven studies were analyzed. HLAB27 prevalence in the normal population ranged from 0.3% (Oman) to 6.8% (Turkey). HLA-B27 prevalence in AxSpA ranged from 26.2% (Lebanon) to 91% (Turkey). HLA-B27 prevalence in all SpA ranged from 13.87% (Lebanon) to 69.43% (Kuwait). Peripheral SpA was less associated with HLA-B27 than AxSpA, indicating the need of differentiating between the two entities when calculating prevalence. When available (8 studies), the OR ranged from 21.63 (Morocco) to 105.6 (Syria). The high heterogeneity between the results can be due to differences in methodology: study sample size, different classification criteria, absence of control groups, HLA-B27 testing method. Conclusions The prevalence of HLA-B27 in the normal population is significantly lower in the Middle Eastern and Arab countries than in Western Countries. However, HLA-B27 testing can be useful for AxSpA positive diagnosis, given the high OR. Heterogeneity between countries may be due to methodological differences.

Background Rheumatic and musculoskeletal diseases (RMD) frequently coexist with other conditions, resulting in multimorbidity, which may compromise arthritis management and lead to diminished quality-of-life and increased mortality. In 2016, EULAR published “Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases”, used to guide this study. Objectives The primary objective is to evaluate the prevalence and pattern of comorbidities in selected RMD in Lebanese patients. The secondary objective is to evaluate the gap between recommendations and routine comorbidities9 screening. Methods COMORD is an observational, cross-sectional, multicentric national study. Consecutive RMD patients (Rheumatoid Arthritis (RA), Osteoarthritis (OA), Systemic Lupus Erythematous (SLE), Axial Spondyloarthritis (AxSpA) and Peripheral Spondyloarthritis (pSpA)) as diagnosed by the rheumatologist) were recruited at 6 practices from university hospitals and private clinics in Lebanon. Six axes of comorbidities (Cardiovascular, Malignancies, Infections, Gastrointestinal, Osteoporosis, Depression) were investigated using a case report form (patient interview). Optimal comorbidities screening was defined according to current recommendations and compared with monitoring in practice. Prevalences were presented descriptively. The number of comorbidities was correlated with predictive factors using Poisson Regression. Finally, Latent Class Analysis (LCA) was used to identify patterns of multimorbidity. All analysis were performed on IBM SPSS Statistics 23 and XLSTAT 18.07. Results 515 patients were recruited (196 RA, 161 OA, 75 AxSpA, 45 SLE, 40 pSA). Mean age was 56y, 76% were female. There was no difference in the disease distribution between centers. The most common comorbidities were cardiovascular risk factors and diseases, followed by depression and osteoporosis. The number of comorbidities was significantly associated with age (p Conclusions Comorbidities are prevalent in RMDs and follow specific multimorbidity patterns, with a predominance for cardiovascular, depression and osteoporosis. They are more frequent with age and obesity. Optimal screening needs to be improved. References Baillet et al. Ann Rheum Dis 2016. Dougados et al. Ann Rheum Dis 2014. Molto et al. Ann Rheum Dis 2016. Simoes et al. Arthritis Care & Research 2017. Disclosure of Interest None declared

Background For years, women with potentially serious systemic diseases, such as rheumatic diseases (RD), have been advised against getting pregnant. However, with careful clinical management, most of these women can have successful pregnancies. The use of RD drugs before or during pregnancy is problematic due to the lack of knowledge about their compatibility with pregnancy. Recently, the British Society of Rheumatology (BSR) and the European League Against Rheumatism (EULAR) published guidelines on prescribing drugs in pregnancy and breastfeeding. Objectives To evaluate the perceptions and clinical practices of rheumatologists and obstetricians in Lebanon regarding the use of medications prior and during pregnancy and breastfeeding. The secondary objective was to assess the variables that are significantly associated with the physicians9 adherence to guidelines. Methods A national, observational, cross-sectional physician survey was conducted among a representative sample of rheumatologists and obstetricians throughout Lebanon. Collected data included physicians9 information (age, gender, years of experience, practice setting and number of pregnant patients with RD seen per month), their opinion on pregnancy in RD patients (pre-conception status of RD and counseling, remission length before allowing pregnancy) and compatible RD drugs with pregnancy and lactation. Qualitative variables were analyzed using Chi-square or Fisher9s exact tests, while quantitative variables were analyzed using Wilcoxon or Student t tests. A total score of answers per physician in accordance with EULAR/BSR guidelines was calculated. Univariate and multivariate analysis assessed the variables significantly associated with this score. P value Results Thirty-nine (90.7%) rheumatologists participated in this survey. They had 22.2±11.6 years of practice. Ninety-four (41.4%) obstetricians participated in this survey. They had 26.0±12.8 years of practice. Figure 1 displays the percentage of physicians who consider the selected RD medications detrimental to/not compatible with fertility, pregnancy and breastfeeding. Average score of answers in accordance with EULAR/BSR guidelines was 0.654±0.154 and results were significantly different between specialties (p Conclusions Advices given to RD patients who plan on becoming pregnant in Lebanon vary largely, especially among the physicians9 specialty and experience in RD, which highlights the urgency of disseminating the EULAR/BSR guidelines among rheumatologists and obstetricians alike. References Flint J et al, Rheumatology 2016. Gotestam Skorpen C et al, Ann Rheum Dis 2016. Panchal S et al, Rheum Int 2013. Ruiz-Irastorza G and Khamashta MA, ACR 2014. Acknowledgements Sponsor: Newbridge Pharmaceuticals. MW support: KBP-Biomak. Disclosure of Interest None declared

Tumor necrosis factor alpha (TNF alpha), as its name would indicate, is an immunomodulatory cytokine shown to have anti-tumor activity [1]. The use of TNF alpha inhibitors in rheumatologic diseases has grown substantially, but debate has emerged regarding the administration of these agents to patients known to have a history of solid malignancies in remission [2, 3].We present here a case of systemic recurrence of low-risk colorectal cancer after the use of etanercept, a TNF alpha-sequestering agent.

In Middle-Eastern countries, more particularly in Lebanon, the incidence of vitamin D deficiency has been found to be surprisingly high in schoolchildren and young individuals. However, the prevalence and risk factors for vitamin D inadequacy amongst Lebanese osteoporotic women seeking medical health care has never been studied. We analysed vitamin D-inadequacy risk factors among the 251 Lebanese postmenopausal osteoporotic women (from both Muslim and Christian communities) who participated in a vitamin D international epidemiological study. Vitamin D inadequacy prevalence (25-hydroxyvitamin D (25(OH)D) r − 0·41; P r 0·37; P r 0·17; P r 0·48; P P P P P P = 0·002 and P = 0·02 respectively). There is an urgent need to increase vitamin D supplement use in Middle-Eastern osteoporotic women, more particularly in those from the Muslim community.

Resume La maladie de Behcet est definie par des ulcerations buccales recidivantes associees a deux des manifestations suivantes : ulcerations genitales recurrentes, lesions oculaires et cutanees et un test de Pathergy positif. Elle affecte l'adulte jeune entre la troisieme et la quatrieme decennie de vie et reste exceptionnelle apres l'âge de 60 ans. Nous rapportons deux cas de maladie de Behcet d'installation tardive, apres 70 ans. Le premier cas est celui d'un libanais âge de 70 ans, presentant une oligoarthrite asymetrique, une uveite, des ulcerations buccales, une chondrite auriculaire, une pseudofolliculite et une pustulose cutanee, toutes corticosensibles. Le second cas est celui d'une libanaise âgee de 72 ans ayant presente une uveite posterieure avec vasculite retinienne, des ulcerations cutaneomuqueuses bipolaires et une histoire familiale de maladie de Behcet, stabilisee par un traitement immunosuppresseur. Nous discutons les differents diagnostics differentiels et les particularites de cette installation tardive, tout en insistant sur la necessite d'evoquer le diagnostic de maladie de Behcet, meme a un âge avance, surtout dans les pays ou cette maladie est relativement frequente, et d'instaurer un traitement precoce afin d'eviter les complications ophtalmiques et systemiques graves.

Background Nurses work in a physically and emotionnally stressful envirnment, which could lead to increased fibromyalgia symptoms. Objectives To estimate the prevalence of fibromyalgia symptoms in nurses from Hotel Dieu de France and North Center Hospitals and to determine predictive factors. Methods The study was conducted using a questionnaire distributed to all registered nurses working in the two hospitals in November 2014. For fibromyalgia screening, we used the validated French version of London fibromyalgia epidemiology study screening questionnaire (LFESSQ). The screening was considered positive if a subject met four criteria of pain and two criteria of fatigue items (LFESSQ-6). To estimate the positive predictive value of LFESSQ-6, a sample of nurses screened positive were then examined by a rheumatologist to clinically confirm the diagnosis of fibromyalgia. The prevalence of fibromyalgia in nursing was estimated by applying the positive predictive value to LFESSQ-positive subjects detected by the questionnaire. They were also asked about their demographics, their work environment, personal and family history, as well as the frequency of episodes of depressed mood through the Patient9s Health Questionnaire-2 (PHQ-2). The statistical analysis was based on a logistic regression model used for the multivariate analysis to identify predictive factors of fibromyalgia. Results 485 questionnaires were distributed, with a response rate of 76.3%. 16.8% of the study sample met the criteria of LFESSQ-6. The subsequent rheumatology consultation confirmed the diagnosis of fibromyalgia in 57.14% of positively screened. Applying the positive predicted value in the nursing population, the prevalence of fibromyalgia was estimated of 9.6% using the screening by the LFESSQ -6. The factors that were significantly associated with a positive screening fibromyalgia were: the number of children and sports activities as protective factors on the one hand, and dissatisfaction with salary, lack of group cohesion, and the frequency of episodes of depressed mood as risk factors on the other hand Conclusions Our results suggest that fibromyalgia is prevalent in the nursing population. Some risk factors are modifiable: depression measured by the PHQ- 2, dissatisfaction with salary and a lack of group cohesion. Protective factors were the number of children and the sports activities. References White KP, Harth M, Speechley M, Ostbye T. Testing an instrument to screen for fibromyalgia syndrome in general population studies: the London Fibromyalgia Epidemiology Study Screening Questionnaire. J Rheumatol. 1999 Apr;26(4):880–4. Chaaya M, Slim ZN, Habib RR, Arayssi T, Dana R, Hamdan O, et al. High burden of rheumatic diseases in Lebanon: a COPCORD study. Int J Rheum Dis. 2012 Apr;15(2):136–43. Branco JC, Bannwarth B, Failde I, Abello Carbonell J, Blotman F, Spaeth M, et al. Prevalence of fibromyalgia: a survey in five European countries. Semin Arthritis Rheum. 2010 Jun;39(6):448–53. Acknowledgement Nursing administration. Hotel-Dieu de France Hospital, Beirut. Nursing administration. Centre Hospitalier du Nord. Lebanon. Disclosure of Interest None declared

Osteoporotic fractures are one of the leading causes of death in the elderly population, but mortality may have been reduced by the advances in management and prevention during recent decades. The authors analyzed the population-level impact of these fractures on mortality in France from 1968 to 2004. About 20 million death certificates registered in metropolitan France from 1968 to 2004 were analyzed. Osteoporotic fractures were identified by using a previously developed methodology. Age-specific and standardized mortality rates were calculated by site of fracture and sex, and time trends were evaluated. Associated causes of death were compared between the extreme periods of the study by the observed/expected pairs method; 440,890 (2.2%) death certificates reported an osteoporotic fracture. Osteoporotic fractures overall, particularly hip and skull fractures, declined by half during the study period, exceeding the decline in general mortality and resulting in fracture-deceased subjects being older. However, pelvis, vertebral, and rib fractures became more frequent. Associated causes of death increased with time, except for decubitus ulcers, indicating a change in the pattern of the death process. Despite a 50% decline, osteoporotic fractures still have a significant impact on mortality. The pattern of the death process has changed, with an increased role for comorbidities.

Background We developed a methodology using vital statistics to estimate the impact of osteoporotic fractures on the mortality of an entire population, and applied it to France for the period 2000-2004. Methods Current definitions of osteoporotic fractures were reviewed and their components identified. We used the International Classification of Diseases with national vital statistics data for the French adult population and performed cross-classifications between various components: age, sex, I-code (site) and E-code (mechanism of fracture). This methodology allowed identification of appropriate thresholds and categorization for each pertinent component. Results 2,625,743 death certificates were analyzed, 2.2% of which carried a mention of fracture. Hip fractures represented 55% of all deaths from fracture. Both sexes showed a similar pattern of mortality rates for all fracture sites, the rate increased with age from the age of 70 years. The E-high-energy code (present in 12% of death certificates with fractures) was found to be useful to rule-out non-osteoporotic fractures, and to correct the overestimation of mortality rates. Using this methodology, the crude number of deaths associated with fractures was estimated to be 57,753 and the number associated with osteoporotic fractures 46,849 (1.85% and 1.78% of all deaths, respectively). Conclusion Osteoporotic fractures have a significant impact on overall population mortality.

The impact of osteoporosis guidelines on clinical practice has not been fully evaluated.To estimate the positive predictive value (PPV) of the National Osteoporosis Foundation (NOF), the International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) guidelines for osteoporosis and compare it to the PPV of clinical judgement alone.All subjects tested for bone mineral density during the fall of 2001 in three teaching hospitals in Beirut were invited to participate. The reference databases used for the calculation of the T-score were the NHANES database for the hip and the manufacturer's database for the spine. The impact of using guidelines was measured by the increment in PPV. Osteoporosis was defined as a T-scoreor =-2.5 at either the spine or hip.A total of 307 post-menopausal women were tested with dual-energy X-ray absorptiometry (DXA). In current practice (clinical judgement alone), the PPV for osteoporosis was 42.4%; using NOF guidelines, 236 women would have been tested, and the PPV would have been 46.2%. Similarly, using IOF or ISCD guidelines, 236 women would have been tested, and the PPV would have been 47.1%.Compared to current clinical practice, application of the ISCD, IOF and NOF guidelines may increase the predictive value of a central DXA for osteoporosis.

Behcet's disease is characterized by recurrent mouth ulcerations associated with two of the following clinical manifestations: recurrent genital ulcerations, ophthalmic and cutaneous lesions and a positive Pathergy test. The young adult is the most affected, usually in the third and fourth decades, with an exceptional onset after the age of 60 years. We report two cass of late onset Behcet's disease, occurring after the age of 70 years. The first case is a 70-year-old Lebanese male complaining of asymmetrical oligoarthritis, uveitis, oral ulcerations, ear chondritis, pseudofolliculitis and pustular rash, all corticosensitive. The second is the case of a 72-year-old Lebanese female who presented with posterior uveitis and retinal vasculitis, bipolar cutaneous ulcerations and a positive family history of Behcet's disease; all the symptoms were stabilized by immunosuppressive therapy. We discuss the differential diagnoses and the particularities of this late onset and emphasize the necessity of establishing an early diagnosis of Behcet's disease, even at an older age, and the need to start an adequate treatment in order to prevent serious ophtalmic and systemic complications.

Pregnancy in women with rheumatic disorders is known to be associated with risks for both the mother and fetus; however, these risks can be minimized with proper planning and careful management of the disease. In the Middle East, there are specific cultural challenges that may have a negative impact on the care that women with rheumatic disorders receive. There is a need for cross-collaboration between specialist physicians, improved awareness of rheumatic disorders among the general public and more open discussion with patients about the potential complications of pregnancy. Women in the region are often unwilling to discuss their disease with their partner and are even less likely to seek advice regarding family planning from their physician. The objective of this review is to highlight the specific challenges of pregnancy management and to discuss why establishing specialist pregnancy clinics for women with rheumatic disorders could be an effective solution. Such clinics can provide high quality care before, during and after pregnancy as shown in several European and US centers. Additionally, such clinics could be useful for the collection of pregnancy outcomes data from the Middle East, which may currently be lacking in the region, in order to highlight where further improvements can be made. With specialist care and analysis of pregnancy outcomes, the standard of care for women with rheumatic disorders in this area could be significantly improved.