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Pachydermoperiostosis (PDP) is a rare autosomal disorder characterized by periostosis, clubbing, thickening of the skin (pachyderma) of the face and scalp, seborrhea and hyperhydrosis. It is the primary form of hypertrophic osteoarthropathy (HOA), the other name of which is Touraine- Solente-Golé syndrome. PDP has various organ involvements and there are some rare associations of PDP with other disorders. Here we describe a 16-year-old boy who presented with skin and skeletal manifestations typical of PDP who also had chronic diarrhea, abdominal pain and weight loss. After giving treatment with risedronate sodium and mesalazine he got significant improvement in his skeletal and abdominal complaints. Bangladesh Med J. 2021 Sept; 50(3): 52-55

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Journal of Bangladesh College of Physicians and Surgeons (JBCPS), all the go by ‘BCPS Journal’, is the official organ of BCPS inclusive of academic, extra-academic and official matters. The journal started its journey in August 1983, now in the fourth decades is embedded in the fanfare of Golden Jubilee of BCPS. It commensurate with the fellows’ desire that a supplement of the JBCPS shall be published as the official organ of the college on behalf of the education, training, research and publication to Showcase the college image in the academic arena. The special editorial board is tasked to marinate a document of the sojourn of the JBCPS, for now and then. The authors have tried to pick up pieces of information from all available local libraries and online resources to build up an edifice to be added on from time to time. It has been tried to fullfill the mandate through expanded and extended search and find the tenets of the emergence and evolution of the JBCPS with an endeavor to bring out a canvas of the paintings of the stories of the Odyssey. Bangladesh Medical Journal (BMJ) published by Bangladesh Medical Association (BMA) is the oldest journal of the country first published 50 years ago in July 1972. Then the Bangladesh Medical Research Council Bulletin (BMRC Bulletin), published in December 1975. JBCPS is the third in this sequence. Prof Golam Rasul was the first editor in chief and so far, fifteen chiefs navigated the journal so far. The first editorial board consisted of five members and present editorial board embracing almost all the subjects including editors from abroad. JBCPS is online since 2004 and is available in the Bangladesh Journals Online (BanglaJOL) since 2006. With Continued relentless untiring efforts of the editorial board and collaboration from the executive committee of BCPS the JBCPS is now one of the top ranked & prestigious peer reviewed journal of the country. The next endeavor shall be to enlist the journal in PubMed which is expected very soon. J Bangladesh Coll Phys Surg 2022; 40: 28-38

Background/Aims Primary Sjogren syndrome (pSS) is a chronic autoimmune multi-system disease characterized by inflammation of exocrine glands, particularly the lacrimal and salivary glands, as well as multiple extra-glandular involvements. Treatment is often challenging, and until now, no disease-modifying anti-rheumatic drugs (DMARDs) have been approved for this condition. There is a lack of data about the efficacy of Janus kinase inhibitors in pSS. Here we report a patient with pSS successfully responding to upadacitinib. Methods A 68-year-old woman presented with pain in multiple joints for 16 years with intermittent use of NSAIDs. She had no low back pain and no self or family history of psoriasis or red eye. She denied dry mouth but required frequent water drinking during meals to aid swallowing and occasionally used artificial tears. MTX was started for her two-month articular flare and positive rheumatoid factor (RF). MTX caused severe vomiting and hyponatremia, and she was hospitalized. After the correction of hyponatremia, she was put on tofacitinib. We reevaluated the case when she came to us. She had grade 2-3 tenderness of most peripheral joints and was bedridden. Immunological parameters revealed RF 127 IU/ml (reference value Results Her EULAR Sjogren Syndrome's Disease Activity Index (ESSDAI) was six at baseline, indicating moderate disease activity. Her joint pain improved significantly within two months with infrequent use of pilocarpine in the sixth month. Six months after treatment with upadacitinib, ESSDAI came down to 2; the Patient's Global Assessment score was 02 and achieved STAR (Sjogren's Tool for Assessing Response) response 7 (STAR responder if score ≥5). Conclusion To our knowledge, this is the first case report on the efficacy of upadacitinib in pSS. Further high-quality clinical trials are required to confirm the benefit of upadacitinib in pSS. Disclosure M. Momen Majumder: None. S. Haq: None.

PURPOSE: Neuropsychiatric manifestation of lupus (NPSLE) is related with vitamin D (vit-D) deficiency which is possibly amenable to supplementation. This study was done to explore link of serum vit-D level and clinical mini-mental state examination (MMSE) with brain perfusion SPECT (BS) in patients with NPSLE. METHODS: Patients who underwent BS with the diagnosis of NPSLE and had serum levels of vit-D and MMSE within a span of 1 month were retrospectively included. The BS DICOM data were used to generate 3D surface images of brain for visual identification of regional hypoperfusion, and the z-scores from eZIS software and then to perform voxel-based regression analysis in order to explore association between serum vit-D level and cerebral perfusion deficit using SPM8. Distribution of serum vit-D level was checked across MMSE and BS z-score using R. RESULTS: A total 19 patients with means ± SD age of 28.4 ± 9.2 years, having mean levels of serum vit-D of 18.7 ± 9.8 ng/ml and mean MMSE scores 24.2 ± 1.6, had undergone BS. The eZIS-derived z-score fall in the category of normal in six (31.6%), mild perfusion deficit (PD) in 10 (52.6%) and moderate PD in three (15.8%) with the means ± SD of z-score being 0.52 ± 0.2, 1.72 ± 0.2, and 2.33 ± 0.2. Voxel-based analysis revealed significant positive correlation between vit-D level and hypoperfusion in brain regions related to cognitive function (p

Background The Community-Oriented Program for Control of Rheumatic Diseases (COPCORD) is intended to reduce the information deficit about the epidemiology of rheumatic diseases, particularly in rural communities in high-income countries. Multiple studies have been conducted using the WHO-International League of Associations for Rheumatology (ILAR)-COPCORD core questionnaire in Bangladesh using the translated version in the Bangla language. Cross-cultural adaptation and validation of the questionnaire are important to achieve better outcomes. Aim To develop a culturally adapted, valid, and reliable Bangla version of the WHO-ILAR-COPCORD Core English Questionnaire to use as a rheumatic screening instrument among Bangla-speaking people. Methods The original English WHO-ILAR-COPCORD questionnaire was translated into Bangla and adapted in the local socio-cultural context maintaining idiomatic, semantic, experiential, and conceptual equivalence between the English and Bangla versions. Pretesting was carried out among 30 patients and healthy attendants, following standard international recommendations. Content validity of the adapted Bangla version was assessed by the item- and scale-level content validity indices (I-CVI and S-CVI). The adapted Bangla version of the WHO-ILAR-COPCORD questionnaire was used to assess 120 patients with rheumatic problems and healthy individuals. Test-retest reliability was assessed using intraclass correlation coefficients. Results The Bangla version of the WHO-ILAR-COPCORD questionnaire showed excellent content validity (I-CVI = 1, S-CVI = 1). The test-retest reliability was also acceptable (intraclass correlation coefficient > 0.7). Conclusion The adapted Bangla version of the WHO-ILAR-COPCORD questionnaire demonstrated acceptable psychometric properties, in terms of content validity and test-retest reliability, for evaluating rheumatic problems in Bangladeshi patients.

Aim To update previous guidance of the Asia Pacific League of Associations for Rheumatology (APLAR) on the management of patients with rheumatic and musculoskeletal diseases (RMD) during the coronavirus disease 2019 (COVID‐19) pandemic. Methods Research questions were formulated focusing on diagnosis and treatment of adult patients with RMD within the context of the pandemic, including the management of RMD in patients who developed COVID‐19. MEDLINE was searched for eligible studies to address the questions, and the APLAR COVID‐19 task force convened 2 meetings through video conferencing to discuss its findings and integrate best available evidence with expert opinion. Consensus statements were finalized using the modified Delphi process. Results Agreement was obtained around key aspects of screening for or diagnosis of COVID‐19; management of patients with RMD without confirmed COVID‐19; and management of patients with RMD with confirmed COVID‐19. The task force achieved consensus on 25 statements covering the potential risk of acquiring COVID‐19 in RMD patients, advice on RMD medication adjustment and continuation, the roles of telemedicine and vaccination, and the impact of the pandemic on quality of life and on treatment adherence. Conclusions Available evidence primarily from descriptive research supported new recommendations for aspects of RMD care not covered in the previous document, particularly with regard to risk factors for complicated COVID‐19 in RMD patients, modifications to RMD treatment regimens in the context of the pandemic, and COVID‐19 vaccination in patients with RMD.

Amyloidosis is a condition characterised by extracellular tissue deposition of fibrils causing a wide range of clinical manifestations. This protein deposition can occur in any tissue, most commonly in the kidney, heart, skin, peripheral nervous system, and gastrointestinal tract. However, the deposition of amyloid fibrils in the synovium is seldom reported. Musculoskeletal manifestations are subtle, subclinical and rarely the patient presents with symptoms that resemble rheumatic diseases. Here, we describe a 55-year-old man with AL (amyloid light chain) amyloidosis who presented with inflammatory polyarthritis with significant morning stiffness, inflammatory low back pain, and painful thickened tongue. The patient had anaemia, macroglossia with lateral scalloping of the tongue, papules, and plaques in the periocular, perioral and perinasal area, bilateral carpal tunnel syndrome, localised soft tissue swelling over the joints, restricted movement in different joints with flexion contractures in some joints. Rheumatoid factor and ACPA were negative and the X-ray of the sacroiliac joints was normal. We confirmed amyloidosis by biopsy of an affected skin lesion. In the urine, no Bence Jones protein was found and bone marrow study and x-ray of the skull were normal. Plasma immuno-electrophoresis and serum free light chain (FLC) assay confirmed lambda light chain type monoclonal gammopathy. Take home message: Although AL amyloidosis is a rare condition, it should be considered while evaluating atypical symptoms in patients presenting with rheumatic complaints. A high index of suspicion is necessary for proper diagnosis as delay in diagnosis will yield a poorer treatment outcome.

Ankylosing Spondylitis Disease Activity Score (ASDAS) is a very important tool for measuring disease activity in patients with axial spondyloarthritis (axSpA). This study was aimed to develop a culturally adapted, valid and reliable Bengali version of questionnaire for the ASDAS. The original English ASDAS was translated into Bangla and adapted in the local socio-cultural context, following standard international recommendations. Content validity of the adapted Bangla version was assessed by the item-level & scale level content validity indices (I-CVI & S-CVI). A total 120 patients with axSpA were assessed in the study. For construct validity, correlation between ASDAS with BASDAI, ESR, CRP, Maastricht enthesitis score, physician's global assessment and BASMI was assessed by Spearman's rank correlation coefficient. Internal consistency and test-retest reliability were assessed using Cronbach's alpha coefficient and intraclass correlation coefficient respectively. I-CVI for each item was 1 and S-CVI was 1. ASDAS-ESR and ASDAS-CRP showed strong correlation (Spearman's correlation coefficient >0.5) with BASDAI, ESR, MASES and physician global assessment of disease activity. The scale demonstrated excellent internal consistency (Crohnbach's alpha=0.703) and test-retest reliability (ICC=0.98). The adapted Bangla version of the ASDAS demonstrated acceptable psychometric properties (validity & reliability) in Bangladeshi patients with axSpA. Faridpur Med. Coll. J. Jul 2019;14(2): 62-66

Objectives This study aimed to explore gender equity in rheumatology leadership in the Asia-Pacific region as represented by the member national organizations (MNOs) of the Asia-Pacific League of Associations for Rheumatology (APLAR). Methods We conducted a retrospective cross-sectional review of gender representation among the presidents of MNOs of APLAR in April 2022. We used the official website of each organization to acquire names and terms in the office of current and past presidents of each organization. The binary gender of each president was estimated using the name-to-gender inference platform Gender API (https://gender-api.com/). Proportions of male and female presidents were estimated for each organization. Data were compared for presidencies commencing before and in/after the year 2000. Results We found a significant gap in gender parity, with most presidents in the region being men (210 of 252, 83%). More than one-third (7 of 19, 36.8%) of the MNOs had all male presidents, although the proportion of women improved from 7 to 25% in/after 2000 (P = 0.0002). A statistically significant increase in female representation was observed in Australia (P = 0.0268, from 7 to 39%) and New Zealand (P = 0.0011, where the proportion of female presidents increased from 0 to 45%), but not in other countries. Conclusion A significant gap in gender parity exists in rheumatology leadership in the MNOs of APLAR. Trends suggest improvement over the last two decades, although statistically significant improvement is limited to a small number of countries.

Background Knee osteoarthritis was reported as the second most prevalent condition in the national musculoskeletal survey. The purpose of this extended study was to identify risk factors for knee osteoarthritis in Bangladeshi adults. Methods This cross-sectional study was conducted in rural and urban areas of Bangladesh using stratified multistage cluster sample of 2000 adults aged 18 years or older recruited at their households. The Modified Community Oriented Program for Control of Rheumatic Disorders (COPCORD) questionnaire was used to collect data. The diagnosis of knee osteoarthritis was made using the decision tree clinical categorization criteria of the American College of Rheumatology. Univariate and multivariate logistic regression analyses were done to identify the risk factors for knee osteoarthritis. Results A total of 1843 individuals (892 men and 951 women) participated, and 134 had knee osteoarthritis yielding a prevalence of 7.3% (95% confidence interval (CI) 4.9 to 9.6%). The mean (standard deviation) age of the knee osteoarthritis patients was 51.7 (11.2) years. Multivariate logistic regression analysis found a significant association with increasing age (≥38 years OR 8.9, 95% CI 4.8–16.5; ≥58 years OR 13.9, 95% CI 6.9–28.0), low educational level (OR 1.7, 95% CI 1.0–2.7) and overweight (OR 1.9, 95% CI 1.2–2.9) with knee osteoarthritis. Knee osteoarthritis patients had a high likelihood of having work loss preceding 12 months (age and sex-adjusted OR 2.3; 95% CI 1.4–3.8; P Conclusions Knee osteoarthritis is a commonly prevalent musculoskeletal problem among Bangladeshi adults having link to work loss. Increasing age, low education and overweight are significant risk factors of knee osteoarthritis.

Gout is the most prevalent inflammatory arthritis in the Asia-Pacific region and worldwide. This clinical practice guideline (CPG) aims to provide recommendations based on systematically obtained evidence and values and preferences tailored to the unique needs of patients with gout and hyperuricemia in Asia, Australasia, and the Middle East. The target users of these guidelines are general practitioners and specialists, including rheumatologists, in these regions.Relevant clinical questions were formulated by the Steering Committee. Systematic reviews of evidence were done, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation methodology. A multi-sectoral consensus panel formulated the final recommendations.The Asia-Pacific League of Associations for Rheumatology Task Force developed this CPG for treatment of gout with 3 overarching principles and 22 recommendation statements that covered the treatment of asymptomatic hyperuricemia (2 statements), treatment of acute gout (4 statements), prophylaxis against gout flare when initiating urate-lowering therapy (3 statements), urate-lowering therapy (3 statements), treatment of chronic tophaceous gout (2 statements), treatment of complicated gout and non-responders (2 statements), treatment of gout with moderate to severe renal impairment (1 statement), and non-pharmacologic interventions (5 statements).Recommendations for clinically relevant scenarios in the management of gout were formulated to guide physicians in administering individualized care.

ObjectiveLow back pain (LBP) is a common musculoskeletal disorder. This study aims to determine the residence-specific and sex-specific prevalence and the factors associated with LBP in Bangladesh.MethodsThe study subjects (aged ≥18 years) were identified from 20 primary sampling units of the national census following a cross-sectional multistage stratified sampling design. We considered the mechanical type of LBP for this study. A Bangla version of the modified Community Oriented Programme for Control of Rheumatic Disorders questionnaire was used. A team of trained field workers, rheumatology residents and rheumatologists collected the data. Analysis was done using weighted data.ResultsTwo thousand subjects were approached, but 1843 could be screened. Among them, 561 had musculoskeletal disorders, and 343 were diagnosed with LBP. The weighted prevalence of LBP was 18.5% (95% CI: 11.8% to 25.2%) and age-standardised prevalence of LBP was 19.4% (95% CI: 14.0% to 24.8%), which was higher in women (27.2%, 19.3% to 35.1%) than men (14.0%, 8.7% to 19.3%). The prevalence persistently increased from age group 18–34 years (10.5%, 5.7 to 15.4) to ≥55 years (27.8%, 16.1% to 39.5%). People with no education had the highest prevalence (31.3%, 22.3% to 40.4%). The prevalence did not differ between urban and rural residential locations. Four factors were significantly associated with LBP: age (adjusted odds ratio: 2.4, 95% CI: 1.7 to 3.4), female sex (2.2, 1.5 to 3.3), absence of formal education (2.3, 1.6 to 3.3) and hypertension (1.7, 1.1 to 2.6).ConclusionLBP is a common problem in Bangladeshi adults. The factors identified are age, female sex, no formal education and hypertension. These should be addressed adequately to prevent and treat LBP.

IntroductionDespite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.MethodsDesign: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1–2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.ResultsPhase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening.ConclusionAn empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

A 65-year old Bangladeshi woman with Systemic Lupus Erythematosus (SLE) developed Parkinson-like movement disorder. Steroid pulse therapy followed by prednisolone was most effective in this case. Psychosis, seizure and meningitis are common central nervous system (CNS) manifestations in SLE patients, and Parkinson-like rigidity or tremors are rare. Bangladesh Med J. 2019 Jan; 48 (1): 50-53

Background Among many self-reported outcome measures, Western Ontario and McMaster Universities Arthritis Index (WOMAC) is one of the commonly used indexes for osteoarthritis patients. Despite high prevalence of musculoskeletal problems in Nepal, there is no validated tool available in the local language. Thus, this study aimed to translate the English WOMAC® into Nepali, and validate it for use in the future. Methods Guidelines by Beaton et al were followed for translation and cross-cultural adaptation of the original WOMAC into Nepali language. Diagnosed cases of knee osteoarthritis (OA) attending the rheumatology outpatient department of National Center for Rheumatic Diseases, Kathmandu were enrolled in the study. These patients were interviewed with the Nepali version. Internal consistency was measured by Cronbach's alpha and test-retest reliability by intra-class correlation coefficient (ICC). Correlation between domains of WOMAC was tested with visual analog scale (VAS) and numerical rating scale (NRS) of pain and stiffness. Results The test-retest reliability was good with ICC of >0.75 for all domains and items. Internal consistency was acceptable with Cronbach's alpha scores of 0.852, 0.704 and 0.955 for pain, stiffness and physical function domains, respectively. Strong correlation was observed between WOMAC stiffness domain and VAS for stiffness and NRS for stiffness with rho (ρ) values of 0.750 and 0.759, respectively. Moderate correlation was seen between WOMAC pain and VAS for pain and NRS for pain with ρ of 0.658 and 0.584, respectively. Conclusions Nepali WOMAC is a reliable and valid instrument for assessment of disease severity and its impact in Nepali-speaking patients with OA.

Co-existence of systemic lupus erythematosus and ankylosing spondylitis is not common. In this report, we present a 24-year-old woman with both the entities diagnosed in the course of time. Initially she presented with malar rash, photosensitivity, oral ulcer and polyarthritis. Her ANA and anti-Smith antibody were positive, but ant-ds DNA was negative. With these features, she was diagnosed as a case of systemic lupus erythematosus. Few months later, she was diagnosed with ankylosing spondylitis on the basis of inflammatory back pain and bilateral sacroilitis. Bangladesh Med J. 2017 Sep; 46 (3): 100-103

Background Nationally representative data on burden of musculoskeletal conditions (MSK) in Bangladesh are not available. The objective of this study was to determine the prevalence of MSK conditions and related disabilities in the adult population of Bangladesh. Methods A total of 2000 individuals aged 18 years or older were targeted from 20 primary sampling units (urban and rural) of all former seven divisions of Bangladesh in 2015. Structured interviews were done using the modified Community Oriented Program for Control of Rheumatic Disorders questionnaire to detect positive respondents. Standard criteria were used for diagnosing MSK conditions by rheumatology residents. In case of uncertainty, opinion was taken from senior rheumatologists. A Bangla version of the Health Assessment Questionnaire was used to determine disability. Results A total of 1843 (92.1%) participated. Among them, 892 men and 951 women participated from rural (n = 716) and urban (n = 1127) areas. Their mean age was 40.5 (standard deviation 14.7) years. Almost a third did not have any formal schooling. Overall, 30.4% (95% confidence interval, 28.3–32.5) had MSK conditions. Low back pain (18.6%, 16.9–20.5), knee osteoarthritis (7.3%, 6.1–8.5) and soft tissue rheumatism 3.8% (2.9–4.7) were the three top-ranking MSK conditions. Rheumatoid arthritis (1.6%, 1.0–2.1), spondyloarthritis (1.2%, 7–1.8) and adhesive capsulitis (1.4%, 0.9–1.9) were relatively uncommon. Among those who had MSK conditions, 24.8% (21.3–28.6) had some degree of disability. Of them, 24.4% (21.0–28.1) had history of work loss during last 12 months. Conclusions The high burden of MSK conditions and related disabilities in Bangladesh warrants greater attention of the health system. Further studies are needed to estimate the impact of this group of conditions particularly addressing related disabilities and loss of work.

Aim Development of a Bangla version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI). Methods This biphasic observational study performed the translation and adaptation of the questionnaires carried out in 5 steps with pre-testing in 30 AS patients followed by the psychometric validation of the pre-final Bangla version utilizing content and construct validity in 115 AS patients. The reliability was examined through internal consistency and test-retest reliability involving 23 AS patients. Results After pre-testing of the pre-final Bangla version of both indices, the psychometric validation found that the convergent validity of Bangla version of BASDAI showed strong correlation with C-reactive protein (r = .75) and the Maastricht Ankylosing Spondylitis Enthesitis (r = .64), and moderate correlation with erythrocyte sedimentation rate (r = .49). Again, the Bangla BASFI showed significant correlation with occiput-to-wall distance (OWD) (r = .50), mentum-to-sternum distance (MSD) (r = .50), chest expansion (CE) (r = -.40), finger-to-floor (FFD) (r = .55), number of swollen joints (r = .69), and number of enthesitis (r = .68). The divergent validity demonstrated weak correlations between BASDAI and OWD (r = .43), MSD (r = .34), CE (r = -.44), FFD (r = .47). The divergent validity of BASFI could not be assessed due to lack of a suitable comparing parameter. The instruments revealed acceptable internal consistency as Cronbach's alpha was 0.86 for BASDAI and 0.93 for BASFI. A 7-day test-retest reliability measured by the intraclass correlation coefficient were 0.80 (CI at 95% = 0.58-0.90) for BASDAI and 0.83 (CI at 95% = 95% 0.64-0.92) for BASFI respectively. Conclusions Bangla version of BASDAI and BASFI may be useful in disease activity and functional ability assessment in AS patients.

Objectives To assess disease-related knowledge of rheumatoid arthritis (RA) patients Patients and methods Consecutive RA patients were invited from the rheumatology departments of BSMM University, Dhaka, Bangladesh. The Bangla version of the Patient Knowledge Questionnaire (B-PKQ) was used. Correlations between the B-PKQ scores and clinical-demographic data were measured using Pearson’s correlation coefficient. Impact of independent variables on the level of knowledge about RA was analyzed through multiple regression analysis. Possible explanatory variables included the following: age, disease duration, formal education level, and Bangla Health Assessment Questionnaire (B-HAQ) score. Analysis of variance (ANOVA) was used to test the difference between demographical, clinical, and socioeconomic variables. For statistical analysis, SPSS statistics version 20 was used. Results A total of 168 RA patients could be included. The mean B-PKQ score was 9.84 (range 1–20) from a possible maximum of 30. The mean time for answering the questionnaire was 24.3 min (range 15–34). Low scores were observed in all domains but the lowest were in medications and joint protection/energy conservation. Knowledge level was higher (15.5) in 6 patients who had RA education before enrollment. B-PKQ showed positive correlation with education level (r = 0.338) and negative correlation with HAQ (r = −0.169). The B-PKQ showed no correlation with age, disease duration, having first degree family member with RA, education from other sources (neighbor, RA patient, nurses), or information from mass media. Conclusions Disease-related knowledge of Bangladeshi RA patients was poor in all domains. Using these findings, improved education and knowledge will result in better disease control.Key Points• Little is known about the knowledge of RA patients regarding their disease and its treatment in Bangladesh and in developing countries in general.• We found that the knowledge of Bangladeshi RA patients regarding their disease was poor in all domains; it correlated positive with education level and negative with function (HAQ), but showed no correlation with age or disease duration.• The findings of this study can be used for improving current patient education programs by health professionals and through mass media.• Better disease control of RA may be achieved by improving patient knowledge in a developing country like Bangladesh, but also in other parts of the world.

Background: Non specific low back pain (NSLBP) has been identified as one of the commonest rheumatic disorders in prevalence surveys in Asia-PacificObjective: Development of a core questionnaire for identification of risk factors of NSLBP at community level.Methods: Following steps were followed: 1) item generation from literature survey, existing Nordic questionnaires and patient focus group discussions, 2) development of a preliminary APLAR-COPCORD English questionnaire, 3) translation into target language, back translation and development of a synthetic target language version, 4) adaptation of the synthetic target language version through tests of comprehensibility, content validity test-retest reliability, and 5) finalization of the English questionnaire. .Results: 45 items were generated. A preliminary English questionnaire was developed.Conclusion: The developed English questionnaire will serve as an efficient tool for identification of risk factors of NSLBP in Asia-Pacific communities.TAJ 2011; 24(2): 85-90

Vasculitides are disorders characterized by inflammation of the vessel walls, often caused by autoimmunity, but sometimes as a result of microbial invasion. Almost all types of microbes including bacteria, viruses, protozoa and fungi have been incriminated in the pathogenesis of vasculitis. Accurate etiological diagnosis is important since immunosuppressive treatment may lead to further deterioration if infection is the cause of vasculitis. Clinical features sometimes provide clues to the etiology. Further evaluation requires a focused and cost-effective plan of laboratory investigation. The investigations aim at establishing the diagnosis of vasculitis and identify the causative organism. An accurate diagnosis of vasculitis optimally requires histological examination and imaging. For infection-associated vasculitis, the identification of the organism requires studies of stained specimens, cultures, and/or detection of antigens and antibodies. Ideally, the treatment involves administration of an appropriate antimicrobial. In non-self-limiting types of vasculitides, glucocorticoids are needed when the symptoms are progressive, with vital organs involvement, and sometimes, when there is no antimicrobial agent of proven efficacy against the incriminated agent. Additional immunosuppressive agents or interventions must be considered when the disease is severe and/or post-infective immune mechanisms are involved in the pathogenesis, e.g., severe HBV- or HCV-associated vasculitides. Available preventative vaccinations are also crucial. The incidence of HBV-associated vasculitides dramatically decreased following HBV vaccination campaigns, and other infection-associated vasculitides may as well in the future.

AIM Inflammatory back pain (IBP) is the earliest symptom of axial and other forms of spondyloarthritis (SpA). However, there are no published data on prevalence of IBP among patients suffering from chronic low back pain (CLBP) in Bangladesh. In this study, we estimated the prevalence of IBP and the subtypes of SpA in a tertiary hospital in Bangladesh. METHODS This 1 year cross-sectional study was conducted among 240 CLBP patients in a rheumatology outpatient clinic. Assessment of Spondyloarthritis International Society classification criteria of IBP and predefined recognized classification criteria were followed to define different subtypes of SpA. Means and standard deviations were reported for continuous variables. Descriptive and bi-variate analyses were accordingly performed. RESULTS Of 240 CLBP patients, 60 (25%) had IBP and 180 (75%) had mechanical back pain (MBP). Among the 60 IBP patients, 52 (86.6%) had predominantly axial SpA (axSpA) and eight (13.4%) had predominantly peripheral spondyloarthritis. In the axSpA group, 49 (94.2%) had radiographic axSpA (rd-axSpA) also known as AS and three (5.8%) had non-radiographic axSpA (nr-axspA). AxSpA patients could be divided into eight (15.35%) with psoriasis, two (3.8%) with reactive arthritis and one patient (1.9%) had arthritis associated with inflammatory bowel disease. Fifty (83.3%) IBP and 73 (40.6%) MBP patients had age at onset of back pain < 40 years. Forty-two (70%) of the IBP and 100 (55.6%) of the MBP patients had normal body mass index. All these differences were statistically significant (P ≤ 0.0001). CONCLUSIONS Inflammatory back pain is common among patients presenting with CLBP. The commonest cause of IBP is AS, followed by PsA and nr-axSpA.

Rheumatoid Arthritis (RA) has significant contributor to the global burden of disease and affects people in all communities across the world. It is a chronic inflammatory disease of the locomotors system that leads to substantial disability, loss of productivity and increased mortality. The Study was conducted among the RA patients based on broad objective of exploring the efficacy and adverse effects of triple combination therapy. This was an open, randomized, prospective study which followed qualitative research method. A total 61 patients were included in the trail. All subjects were randomly selected to combination therapy and MTX group. One patient from each group stopped the drugs due to adverse effects. Finally 59 patients completed the trail. 33 belonged to combination therapy group and 26 to MTX. Combination therapy is the best and easiest than others modifying anti-rheumatic drug used. Combination therapy with Methotrexate, Chloroquine and low dose Prednisolone is better than Methotrexate alone.Medicine Today 2017 Vol.29(2): 26-29

Paget’s disease of bone (PDB) is characterized by focal areas of increased and disorganized bone remodeling. The brain, spinal cord, cauda equina, spinal roots, and cranial nerves can be affected in Paget’s disease due to their anatomic relationship to the relevant bones and associated bony canals. We describe here a 58-year-old Bangladeshi male who presented with neurological complications of the disease. Before he was correctly diagnosed, his presentation was mistakenly ascribed to several other diseases by different physicians that resulted in prolongation of his sufferings. He responded promptly to bisphophonate therapy after being correctly diagnosed.Bangladesh J Medicine Jan 2017; 28(1) : 46-49

Management of refractory ankylosing spondylitis (AS) is often difficult due to scarcity of low cost treatment options. Several biologics have shown efficacy in AS [1,2], but many patients can’t aff...

Objective To study the prevalence of musculoskeletal (MSK) symptoms and disorders among garment workers in Bangladesh, to look for possible relationships between pain location and type of work performed and to estimate the prevalence of rheumatological diagnoses. Methods A cross-sectional pilot study among 350 garment workers using the COPCORD (Community Oriented Program for Control of Rheumatic Disorders) methodology. Subjects with musculoskeletal pain were examined by rheumatologists for rheumatological diagnosis. The workers were classified into cutting, sewing, finishing and quality control operators. Results Most of the workers were aged below 35 years (88%) and females (82.9%) and the majority had only primary education (74.6%). The prevalence of MSK pain within 7 days of the interview was 77.1%, a much higher figure than in the general population. The most affected sites were: shoulder (17.9%), lower back (15.2%), neck (13.8%) and knee (10.8%). Multiple regional pain was the commonest finding in 173 of 350 workers. In this pilot study rheumatoid arthritis was diagnosed in 0.9%, undifferentiated arthritis in 1.1%, nonspecific low back pain in 4.6%, soft tissue rheumatism in 3.7%, osteoarthritis in 0.9% and lumbar spondylosis in 1.1%, figures comparable with those observed in the general population; spondyloarthropathy was seen more often, in 1.42%, possibly explained by the small numbers. Conclusions Musculoskeletal pains are common among garment workers of Bangladesh and may cause morbidity, disability, and work loss. Our findings may be important to plan ergonomic measures preventing complaints and may be of interest for international companies ordering garments in Bangladesh.

Background: The World Health Organization (WHO) and the International League Against Rheumatism (ILAR) initiated the Community-Oriented Program for the Control of Rheumatic Diseases (COPCORD) project in 1981. The aim of this study was to translate the revised WHO-ILAR COPCORD questionnaire into Bengali and to test if the Bengali version could be reliably used for the identifying rheumatic diseases in Bangladeshi people.Methods: This was an observational study conducted in rheumatology wing, department of medicine, BSMMU from April to October, 2011. It was implemented in two stages: Translation and cross-cultural adaptation of questionnaire and testing of questionnaire. For translation into Bengali and cross-cultural adaptation, the recommendation by Beaton’s procedure was followed. Respondents were enrolled from rheumatology outpatient departments of medicine, BSMMU, household members and healthy patient’s attendants. Data were collected and analyzed using SPSS windows v16.Results: Thirty subjects completed the preliminary version of the questionnaire. Fifteen males (50%) and fifteen (50%) females were interviewed. Mean age of the respondents were 31.97±10.15 with age range 16-55 years. Test-retest reliability of the Bengali version of the questionnaire was tested by interviewing 70 subjects. To evaluate agreement between two measurement qualitative questions were analyzed using kappa test and quantitative question were tested by spearman’s correlation. Most of the questions (88.2%) showed high or good agreement (kappa agreement >0.6) and one (5.88%) question showed moderate agreement (0.4-0.6). In case of quantitative questions responses in test and re-test were found to have 50% good correlation and remainder poor correlation in Spearman’s correlation.Conclusions: Pretest and reliability has shown the questionnaire clear in wording and culturally appropriate. Process of translation and adaptation using Beaton’s procedure was user friendly, comprehensive and appears an essential method for translation of the questionnaire.

Introduction Rheumatoid arthritis (RA) is a chronic, systemic and autoimmune disease affecting 0.5-1% of the world population. Genetic and environmental factors are already established as being involved in the development of RA. Different human leukocyte antigen (HLA)-DRB1 alleles have major pathogenic effects to the development of RA. Objective To determine the HLA-DRB1 allelic frequency of RA in one Bangladeshi tertiary care center. Methods This case-control study was conducted at the Microbiology and Rheumatology Department of Bangabandhu Sheikh Mujib Medical University (BSMMU). Fifty-two patients diagnosed as having RA and 52 healthy controls were enrolled. Buccal swabs were collected from all subjects and HLA-DRB1 typing was carried out with polymerase chain reaction with sequence-specific primers (PCR-SSP) of low resolution. Blood was also collected for auto-antibodies (rheumatoid factor [RF] and anti-cyclic citrullinated peptide [anti-CCP]) detection from all subjects. RF was detected by nephelometry and anti-CCP was detected by using the enzyme-linked immunosorbent assay method. Statistical associations of HLA antigen between the groups were determined by chi-square test. Results In RA patients DR*04 and DR*10 were found at the DRB1 locus at higher frequencies (20.5%, P = 0.0035 and 18.3%, P = 0.0045, respectively). However, the frequency of DR*15 was significantly lower (P = 0.005) in RA cases (18.3%) than the control group (35.6%). The frequencies of autoantibodies (anti-CCP and RF) were compared between approximate shared epitope (SE) positive and SE negative patients, and no significant association was found. Conclusions In this study DRB1*04 and DRB1*10 alleles were significantly associated with RA patients while DRB1*15 was found more in the control group.

Calcineurin inhibitors added to standard-of-care induction therapy for lupus nephritis (LN) may increase complete renal remission (CRR) rates. The AURA-LV study tested the novel calcineurin inhibitor voclosporin for efficacy and safety in active LN. AURA-LV was a Phase 2, multicenter, randomized, double-blind, placebo-controlled trial of two doses of voclosporin (23.7 mg or 39.5 mg, each twice daily) versus placebo in combination with mycophenolate mofetil (2 g/d) and rapidly tapered low-dose oral corticosteroids for induction of remission in LN. The primary endpoint was CRR at 24 weeks; the secondary endpoint was CRR at 48 weeks. Two hundred sixty-five subjects from 79 centers in 20 countries were recruited and randomized to treatment for 48 weeks. CRR at week 24 was achieved by 29 (32.6%) subjects in the low-dose voclosporin group, 24 (27.3%) subjects in the high-dose voclosporin group, and 17 (19.3%) subjects in the placebo group (OR=2.03 for low-dose voclosporin versus placebo). The significantly greater CRR rate in the low-dose voclosporin group persisted at 48 weeks, and CRRs were also significantly more common in the high-dose voclosporin group compared to placebo at 48 weeks. There were more serious adverse events in both voclosporin groups, and more deaths in the low-dose group compared to placebo and high-dose voclosporin groups (11.2%, 1.1%, and 2.3%, respectively). These results suggest that the addition of low-dose voclosporin to mycophenolate mofetil and corticosteroids for induction therapy of active LN results in a superior renal response compared to mycophenolate mofetil and corticosteroids alone, but higher rates of adverse events including death were observed.

In 2017, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated guidelines on the definition of hypertension, and blood pressure thresholds for initiation of antihypertensive medication. Our objective was to assess the change in prevalence of hypertension, risk factors, and identify populations recommended for treatment among Bangladeshi adults, based on the 2017 ACC/AHA guidelines. Data for this analysis were collected from a population-based nationally representative sample of 1843 Bangladeshi adults, aged ≥18 years in 2015. Hypertension was defined based on two definitions: the JNC 7 guidelines (SBP ≥ 140 or DBP ≥ 90 mmHg), and the 2017 ACC/AHA guidelines (SBP ≥ 130 mmHg, or DBP ≥ 80 mmHg), or a self-reported diagnosis of hypertension. Based on the 2017 ACC/AHA guidelines, the prevalence of hypertension was 40.7% (95% CI: 38.5–43.0). The prevalence of JNC 7 definition of hypertension was 17.9% (95% CI: 16.2–19.7), indicating a 22.8% increase in prevalence. Based on both definitions, urban residents, older adults, adults with low physical activity, obese, abdominally obese, and diabetic adults were more likely to have hypertension. Based on current JNC 7 guidelines, only half of hypertensive adults were aware of having hypertension. Among those aware of their condition, 75% were taking medication based on self-report. Using the 2017 ACC/AHA guidelines, the prevalence of hypertension will more than double in Bangladesh. Newly diagnosed hypertensive adults will be considered high-risk for cardiovascular disease leading to a larger burden on Bangladesh’s health system. However, implementation of the ACC/AHA guidelines may improve prevention efforts where lifestyle changes are appropriate.

Aims and objectives. To identify the association of following variables with radiographic findings in rheumatoid arthritis cases in Bangladesh: Age at onset, Duration of suffering, Sex, Clinical indexes of disease activity & Rheumatoid factorMethods. In this observational study, 100 consecutive rheumatoid arthritis patients who met ACR criteria 1987 were enrolled from rheumatology OPD of BSMMU from the period of August 2009- April 2010. Clinical evaluations and laboratory investigations were done in all cases. Final evaluation was done on 96 patients, because 4 patients were dropped out, due to inconclusive radiological report. Radiographs of hands and wrists were scored by Van der Heijde modification of Sharp scoring method.Results. Out of 96 patients 73 were female and 23 male with female male ratio of 3.1:1. Age of onset was 41.0±11.0 (mean ± SD) in male and 37.7±12.9 in female. 90 patients had severe RA among them 21 (23.3%) were male and 69 (76.6%) were female. Rose Waaler (RW) test was positive in 68 cases. Bony erosions were observed in 58 cases, out of them 15 (65.2%) were male and 43 (58.9%) female. Bony erosions were observed in 60.3% cases of positive Rose Waaler and 69.8% in patients whose age at onset was < 45 yrs. Hemoglobin level (gm/dl) was 12.2±1.6 in male and 10.9±1.5 in female. Platelet count was 312142±111233 in male and was 379114±115574 in females.Conclusion: Hemoglobin levels were significantly lower among the anemic women than anemic men. Thrombocytosis was also more in women than men. Higher percentage of bony erosions was observed among the cases of positive RW and whose age at onset was < 45 but it was not statistically significant.Bangladesh J Medicine Jan 2015; 26 (1) : 13-17