Imad Uthman

Background/Objectives: Fibromyalgia is a chronic, symptom-defined condition whose recognition and management depend on sustained access to care. Recorded utilization during crises may therefore reflect disrupted access, diagnostic recognition, and longitudinal engagement rather than disease burden. Since 2019, Lebanon has experienced overlapping financial deterioration, the COVID-19 pandemic, the Beirut port explosion, and armed conflict. We characterized recorded fibromyalgia utilization and continuity across these six years. Methods: This retrospective cohort study analyzed all outpatient encounters with fibromyalgia as the primary diagnosis in electronic health records of the American University of Beirut Medical Center, January 2019–December 2024. Monthly encounter volume was the primary utilization outcome. Recorded continuity was evaluated as time from each patient’s index encounter to a subsequent fibromyalgia-coded encounter, with 180-day return as the principal standardized comparison across cohorts. Results: We identified 4969 encounters from 3237 patients (87.5% female; mean age, 46.7 years). Monthly encounter volume fell around the 2019 financial and banking disruption and remained below the preceding nine-month level (84.3 vs. 66.8 encounters/month; rate ratio, 0.76; 95% CI, 0.61–0.94), with a further exploratory reduction in mid-2024. The 180-day probability of a subsequent encounter declined from 22.8% in the 2019 cohort to 15.6% in 2024 (hazard ratio, 0.59; 95% CI, 0.45–0.76); lower return rates emerged from the 2022 cohort onward. Conclusions: Recorded fibromyalgia utilization and recorded return for subsequent fibromyalgia-coded care within the same institution changed at different times during Lebanon’s compounding crises. These findings describe recorded care, not disease occurrence: recovering patient numbers may coexist with persistently lower recorded return within the institution, so aggregate utilization alone may incompletely describe recovery for continuity-dependent chronic conditions.

Background/Objectives: Fibromyalgia is a chronic, symptom-defined condition whose recognition and management depend on sustained access to care. Recorded utilization during crises may therefore reflect disrupted access, diagnostic recognition, and longitudinal engagement rather than disease burden. Since 2019, Lebanon has experienced overlapping financial deterioration, the COVID-19 pandemic, the Beirut port explosion, and armed conflict. We characterized recorded fibromyalgia utilization and continuity across these six years. Methods: This retrospective cohort study analyzed all outpatient encounters with fibromyalgia as the primary diagnosis in electronic health records of the American University of Beirut Medical Center, January 2019–December 2024. Monthly encounter volume was the primary utilization outcome. Recorded continuity was evaluated as time from each patient’s index encounter to a subsequent fibromyalgia-coded encounter, with 180-day return as the principal measure. Results: We identified 4,969 encounters from 3,237 patients (87.5% female; mean age, 46.7 years). Monthly encounter volume fell around the 2019 financial and banking disruption and remained below the preceding nine-month level (84.3 vs. 66.8 encounters/month; rate ratio, 0.76; 95% CI, 0.61–0.94), with a further exploratory reduction in mid-2024. The 180-day probability of a subsequent encounter declined from 22.8% in the 2019 cohort to 15.6% in 2024 (hazard ratio, 0.59; 95% CI, 0.45–0.76); lower return rates emerged from the 2022 cohort onward. Conclusions: Recorded fibromyalgia utilization and longitudinal engagement changed at different times during Lebanon’s compounding crises. These findings describe recorded care, not disease occurrence: recovering patient numbers may coexist with persistently impaired longitudinal engagement, so aggregate utilization alone incompletely measures recovery for continuity-dependent chronic conditions.

Pain is the leading cause of disability worldwide, yet no harmonized self-reported reference framework exists to characterize how its burden is distributed across the lifespan and world regions. In this study, we harmonized individual-level self-reported pain data from 6,125,459 participants across 902 population-based data sources in 118 countries to establish global reference trajectories of pain. We implemented these trajectories in an open-access benchmarking platform for positioning external datasets against global pain norms. Pain prevalence ranged from roughly 2% for facial pain to 40% for back pain, was consistently higher in women across all 11 anatomical sites (risk ratio range: 1.08−1.83) and increased most steeply before age 55 years. Contrary to existing estimates that generally project higher prevalence of pain conditions in higher Human Development Index (HDI) regions, we found that individuals in the lowest HDI countries experienced a substantially higher late-life prevalence of any bodily pain than those in the highest (risk difference: 30.6 percentage points (95% confidence interval: 26.9−34.3)), with low back pain approaching twice the prevalence at the oldest ages. Globally, 18.3% of pain burden across anatomical sites was attributable to three modifiable risk factors (smoking, obesity and low income), but this varied from 12.6% in sub-Saharan Africa to 27.1% in eastern Europe, indicating that the factors underlying pain in lower-HDI settings remain poorly characterized. Together, these reference trajectories provide a common framework for defining and comparing pain burden and informing more equitable global surveillance and prevention.

Lebanon is one of the Arab countries historically known for its multiple regional referral hospital centers. With several principal investigators leading international randomized clinical trials, several Lebanese researchers have been devoted to advancing the quality of practice in the Arab world, ultimately improving patients’ quality of life. Rheumatology is not a stranger to these descriptions. Since the 1950s, the number of rheumatology providers has been substantially increasing. The Lebanese Society of Rheumatology was established in 1961 to attract ideas and organize collaborations. The prevalence of rare autoimmune/autoinflammatory diseases, such as Behcet’s disease and familial Mediterranean fever, partly shapes Lebanon’s research and clinical practice. Despite having no dedicated basic science autoimmune facilities, many groups work on the genetic and immunological aspects of systemic autoimmune rheumatic diseases. From a clinical research perspective, Lebanese rheumatologists collaborate on regional and international projects. Regarding clinical practice, the availability of serological and imaging facilities is an asset for rheumatologists. One of the significant challenges is the cost of novel antirheumatic therapies, such as biological agents. While national and private services try to aid dependent patients, the burden is still significant. Future challenges lie in attracting more expertise, making research funding available to investigators, and establishing dedicated centers of excellence, which frequently incorporate patient-reported outcomes.

Background Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies, which include lupus anticoagulant, anticardiolipin, and anti-β2 glycoprotein I. The updated 2023 ACR/EULAR classification criteria recognize microvascular features of APS but not orthopedic complications. Among these, avascular necrosis (AVN) is an uncommon and underrecognized manifestation, characterized by ischemic death of bone tissue, most often affecting the femoral head, knee, talus, and humeral head. The link between APS and AVN remains unclear and warrants further review. Objectives To explore the association between APS and AVN, focusing on its pathophysiology, prevalence, risk factors, clinical presentation, and management strategies. Methods A comprehensive search was performed across medical databases, including PubMed, Medline, and Google Scholar, using relevant keywords. Results AVN is a rare but significant complication of APS, with prevalence ranging from 0.9 to 20%, depending on the study design and population analyzed. The pathogenesis is primarily attributed to microvascular thrombosis and hypercoagulability caused by antiphospholipid antibodies. Identified risk factors include prolonged glucocorticoid use, thrombocytopenia, pregnancy, and underlying microvascular abnormalities. Early detection via MRI and timely interventions, such as anticoagulation therapy, lifestyle modifications, and surgical procedures, improve patient outcomes and prevent disease progression. Conclusions Understanding the multifaceted nature of AVN in APS is crucial for timely diagnosis and effective management. Further research is needed to establish clear preventative strategies and optimize long-term treatment protocols, ultimately improving patient care and clinical outcomes.

Letters to the Editor; Authors: V. Ghazi, B. Sleem, G. El Hasbani, C. Kesrouani, A.S. Jawad, I. Uthman

Madelung's deformity is characterized by an increased radial inclination and volar tilt of the distal radius, proximal migration of the lunate with triangulation of the carpus, and dorsal displacement of the ulna.[1] It typically arises due to the premature closure of the medial volar aspect of the distal radial physis.[2] The origins of this deformity can be traced back to 1878, when Otto Madelung first documented it.[3] A notable aspect is the female predominance in the occurrence of this condition.[1] The clinical presentation of Madelung's deformity is variable, spanning from asymptomatic cases to instances of radiocarpal pain and diminished grip strength that hinders daily activities.[2] In rarer cases, this deformity of a single joint can resemble other conditions, such as degenerative or inflammatory arthritis, particularly within specific age groups. In this case report, we emphasized the case of a young female patient who sought medical attention due to recurring left wrist pain and swelling that raised suspicions of monoarticular rheumatoid arthritis over a span of three years. Despite conducting comprehensive laboratory and serological investigations yielding normal results, a magnetic resonance imaging (MRI) of the affected wrist indicated potential signs of Madelung's deformity. A previously healthy 27-year-old female patient presented to the clinic with a three-year history of recurring pain and swelling in the left wrist. The pain was described as vague and had started suddenly three years before the presentation. The patient noted that nonsteroidal anti-inflammatory drugs and acetaminophen provided some relief. She denied any trauma to the wrist and hands. Additionally, she had no family history of inflammatory arthritis. The vital signs were within the normal range. Extensive laboratory tests, including complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, cyclic citrullinated peptide, and antinuclear antibodies, all yielded unremarkable results. An X-ray of the left wrist (Figures 1a, b) revealed significant narrowing and collapse of the radiocarpal joint space, accompanied by surface irregularities, subchondral sclerosis, and subchondral cyst formation. No posttraumatic bone fractures were detected, and the soft tissues appeared normal. Subsequent imaging with MRI showed a further increase in the pronounced narrowing and collapse of the radiocarpal joint space, along with bone marrow edema in the subchondral region. Osteophytes were detected, along with subchondral cystic changes. Notably, marked synovitis was observed in the radiocarpal and distal radial ulnar joints. Mild radiocarpal and ulnar deformity was present, characterized by increased radial length and an ulnar slant angle, mild distal ulnar subluxation, and hypertrophy of the ulnar styloid process, consistent with the features of Madelung's deformity (Figure 2). To manage inflammation, the patient was prescribed a short course of oral corticosteroids and was referred to the orthopedics department for further evaluation and management. Comprehensive genetic testing, including investigations for abnormalities, such as mutations in the short-stature homeobox gene (SHOX) associated with Léri-Weill dyschondrosteosis and the 45, X karyotype associated with Turner syndrome, yielded negative results. In the majority of cases, Madelung’s deformity involves the distal radius, although a minor portion of patients can have an involvement of the entire radius.[4] The involvement of the entire radius is usually more severe in terms of clinical presentation.[5] The severity of Madelung’s deformity can be also assessed radiologically by the presence of ulnar tilt, lunate subsidence, lunate fossa angle, palmar tilt, or palmar carpal displacement.[5] In our case, the patient presented with disabling chronic pain and swelling of the left wrist, suggesting a possibility of monoarticular rheumatoid arthritis. The presentation of both entities can rarely overlap, and the treatment of each is different from the other.[6] Plain X-rays can detect pathognomonic findings for Madelung’s deformity (Table 1).[7] The patient presented in this case had a severe form of Madelung’s deformity. Although advanced imaging are not necessary to confirm the diagnosis, an MRI delineates three-dimensional deformity, the extent of growth plate involvement, and the presence of a Vickers ligament.[8] Mild deformities are usually managed conservatively by sequential imaging.[7] On the contrary, moderate or severe forms or certain types of symptomatic deformities require surgical intervention. It is important to note that certain advanced asymptomatic deformity usually presents near skeletal maturity.[5] It is also important to note that Madelung’s deformity may be secondary to genetic defects, such as SHOX deficiency or Turner’s syndrome.[9] In summary, Madelung's deformity, whether congenital or acquired, can mimic other conditions such as monoarticular seronegative rheumatoid arthritis, particularly among the young population. This underscores the importance of considering this diagnosis in young female patients experiencing chronic wrist pain without a history of trauma or laboratory abnormalities. Treatment strategies for this condition vary according to its severity, which can be assessed through plain radiography.