Introduction The COVID‐19 pandemic led to rapid and widespread adoption of telemedicine in rheumatology care. The Asia Pacific League of Associations for Rheumatology (APLAR) working group was tasked with developing evidence‐based recommendations for rheumatology practice to guide maintenance of the highest possible standards of clinical care and to enable broad patient reach. Materials and methods A systematic review of English‐language articles related to telehealth in rheumatology was conducted on MEDLINE/PubMed, Web Of Science and Scopus. The strength of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach as well as the Oxford Levels of Evidence. The recommendations were developed using a modified Delphi technique to establish consensus. Results Three overarching principles and 13 recommendations were developed based on identified literature and consensus agreement. The overarching principles address telemedicine frameworks, decision‐making, and modality. Recommendations 1‐4 address patient suitability, triage, and when telemedicine should be offered to patients. Recommendations 5‐10 cover the procedure, including the means, data safety, fail‐safe mechanisms, and treat‐to‐target approach. Recommendations 11‐13 focus on training and education related to telerheumatology. Conclusion These recommendations provide guidance for the approach and use of telemedicine in rheumatology care to guide highest possible standards of clinical care and to enable equitable patient reach. However, since evidence in telemedicine care in rheumatology is limited and emerging, most recommendations will need further consideration when more data are available.

The global health crisis created by coronavirus disease in 2019, ie, COVID-19, is of serious concern to rheumatologists. The relationship of rheumatic diseases, their therapies, and COVID-19 with multiple genuine and malicious information available online can influence the knowledge and attitudes of rheumatic patients. This Google Forms study was conducted to understand the knowledge, attitudes, and practices of rheumatology patients with regard to COVID-19 in Nepal. Methods: A web-based cross-sectional study was conducted among patients with rheumatic diseases. A modified version of a questionnaire was used after consent had been obtained. It was then translated into Nepali for comprehensibility. The final questionnaire contained a total of 29 questions: six on demographic parameters and twelve, five, and six on knowledge, attitudes and practice, respectively. Simple descriptive statistics were used to describe the positive responses in each domain. Logistic regression analysis was done to observe demographic variables associated with knowledge, attitudes, and practice. Results: Among 380 participants, 63.2% were female, the majority (42.1%) aged 18-29 years, and all were literate. Most were aware of the clinical features of COVID-19 (91.6%), 71.5% had positive attitudes toward its control, some (31.5%) thought that they had a greater chance of contracting COVID-19 than others, and 18.9% believed that antirheumatic medications could increase their susceptibility to infection. A majority (>94.7%) of them practiced preventive measures. Conclusion: Patients with rheumatic diseases were aware of the general clinical features, routes of transmission, and general preventive measures regarding COVID-19 and did not significantly change their treatment practices.

Introduction/objectives: The global health crisis created by Coronavirus Disease (COVID-19) can be a serious concern to rheumatologists. The relationship of rheumatic diseases, their therapies, and COVID-19 with multiple genuine and malicious information available online can influence the knowledge and attitude of rheumatic patients. This web-based google-form study was conducted to understand the knowledge, attitude and practices of rheumatologic patients towards COVID-19 in Nepal. Methodology: A web based cross-sectional study was conducted among the patients with rheumatic diseases. Modified version of questionnaire prepared by Zhong BL et al was used after consent. It was then translated in Nepali language for comprehensibility. The final questionnaire contained a total of 29 questions; 6 for demographic parameters, 12, 5 and 6 for knowledge, attitude and practice behaviors, respectively. Simple descriptive statistics describing the positive responses in each domain. Multiple linear regression analysis done to observe demographic variables associated with the knowledge, attitude and practice. Results: Among 380 participants, 63.2% were female. Most of the participants were aware of the clinical features of COVID-19 (91.6 %), 71.5% had positive attitude towards its control, some (31.5 %) thought that they had greater chance of getting COVID-19 than others and 18.9 % believed that the anti-rheumatic medications could increase their susceptibility to infection. Majority (> 94.7%) practiced preventive measures.Conclusions: Patients with rheumatic diseases were aware of the general clinical features, route of transmission and general preventive measures regarding COVID-19.

Natural therapy modalities such as thermal therapy and balneotherapy are commonly being practiced for the management of chronic aches and pain all over the world. Nepal has many such natural hot water springs among which few are famous for therapeutic purposes. Thousands of people with some musculoskeletal problem visit those places in the hope of getting rid of their problems. This study aimed to understand their belief in such therapies, expectations, and satisfaction after treatment along with their knowledge of the safety of hot spring water bath. Among 126 participants interviewed, 31% had inflammatory arthritis, followed by degenerative disorders in 29.4% and soft-tissue rheumatism in 12.7%. Around three-quarters believed that hot spring water has natural healing power and thus can improve their pain. Many even believed that water in natural springs is devoid of any chemicals. So, it is a safe treatment option. Regarding the expectation of cure, they had mixed opinions. Naïve participants hoped they might find a permanent cure in thermal baths. However, repeated visitors said that the effect usually lasted for a few months and they have to visit there regularly. Almost two-thirds of people thought that such natural treatment does not have any side effects. Few stated that they had faced certain problems after the treatment. The water tested from the study site showed that it contained a higher amount of chlorine and sulfate in comparison to other hot water springs in Nepal. The minerals present in water might be a cause of temporary relief of pain. Also, outbreaks of infection from common spring baths have to be considered as such cases have been reported in the past. In conclusion, the medicinal benefits of such natural hot water springs have to be studied further and awareness regarding safety should be given to the people seeking treatment.

Abstract. Examination of urate crystal in synovial fluid (SF) remains the gold standard for diagnosis of gout, but is not universally available. SF uric acid (UA) level may be measured by the uricase method with an automated analyzer. The present study aimed to evaluate the utility of SF to serum UA ratio (SSR) for diagnosis of gout. A cross-sectional study was conducted at the National Center for Rheumatic Diseases, Nepal. Patients presenting with acute (<1 day) joint pain and/or swelling were included. Aspiration was performed in all patients and fluid was subjected to testing for urate level, pH and cell counts and microscopy. Serum samples were also assessed for urate levels, and the SSR was calculated for each patient. A receiver operating characteristic curve was plotted to determine the cutoff value for indicating diagnosis of gout. The difference in SSR between gout and non-gout effusion was evaluated by one-way analysis of variance. A total of 181 patients were included of which 77 had gout. The remaining cases included osteoarthritis, pseudogout, rheumatoid arthritis and ankylosing spondylitis. SSR was significantly higher in gout patients than in any other group (P<0.05). An SSR of ≥1.01 had the highest sensitivity and specificity at 89.6 and 66.3%, respectively, for identifying gout effusion. The present results indicated that SSR may be used as an aid for gout diagnosis when polarizing microscopy is not available. IntroductionGout is among the most common inflammatory arthritides, characterized by deposition of monosodium urate (MSU) crystals in and around the joint and soft tissue (1-3). Persistent hyperuricemia is an important factor in the development of gout, but not all hyperuricemic patients develop gouty arthritis (4). The risk of supersaturation and crystal formation increases with increasing urate concentration. Alteration in various factors including pH and temperature also aggravates crystal formation and deposition in joints such as the first metatarsophalangeal (MTP) joint, a normally lower-temperature joint (5). The release of these preformed crystals initiates an intense inflammatory response in the synovium causing acute gouty arthritis (6).Worldwide prevalence of gout ranges from 0.1 to 10%, with an incidence of 0.3 to 6 cases per 1,000 person-years (7). However, Asian countries including India (8), Bangladesh (9) and Pakistan (10) have been reported as having low gout prevalence, with prevalence rates below 0.5% according to data published by the Community Oriented Programme for Control of Rheumatic Diseases (7).Gout typically presents in middle-aged men as severe pain and/or swelling with redness around joints, which may last from hours to days. Acute gouty arthritis usually has monoarticular presentation with a predisposition to develop in joints of lower extremities, particularly the first MTP joint. Other joints including the ankle and wrist may also be affected. Oligo-or polyarticular presentation may also occur, albeit rarely, typically in conditions such as chronic untreated...