Expanding the Criteria of the Novel Middle East Pain Syndrome to Include More Rheumatologic and Orthopedic Conditions, Type 2 Diabetes Mellitus, and Advanced Age - Understanding Musculoskeletal Pains among Palestinian Patients with Rheumatoid Arthritis

Expanding the Criteria of the Novel Middle East Pain Syndrome to Include More Rheumatologic and Orthopedic Conditions, Type 2 Diabetes Mellitus, and Advanced Age - Understanding Musculoskeletal Pains among Palestinian Patients with Rheumatoid Arthritis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Expanding the Criteria of the Novel Middle East Pain Syndrome to Include More Rheumatologic and Orthopedic Conditions, Type 2 Diabetes Mellitus, and Advanced Age - Understanding Musculoskeletal Pains among Palestinian Patients with Rheumatoid Arthritis Yazan AlHabil, Nabil Koosa, Seema Hameedi, Johnny Amer, Ahmad Salhab, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4763944/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Methods A retrospective study was conducted at three Palestinian healthcare centers between February and December 2023. Targeting RA patients of both sexes and all ages, the clinical characteristics of 397 patients were categorized using a stratified sampling technique. Data were retrieved from each center’s respective archive modalities. An adjusted multiple logistic regression model was utilized to test the association between 1,25(OH) 2 VD 3 and Parathyroid levels with musculoskeletal pain severity. A p-value less than 0.05 was considered statistically significant. The Kolmogorov-Smirnov test was utilized to test the normality of continuous variable distribution. Results Many patients fulfill criteria for other conditions, with slow disease progression noted, despite correct RA diagnosis. Pain severity correlated with deficient 1,25(OH) 2 VD 3 (1.745 OR, P-value:0.05) and high PTH levels (PTH: 1.579 OR, P-value:0.027). Commonly reported pains include lower back, knees, cervical, and upper back areas. Muscular stiffness and bone tenderness are prevalent, with 41.03% reporting severe pain. Increased age correlates with severe pain (OR:1.53, P-value:0.015). Likewise, Type 2 Diabetes mellitus shows a significant positive association (OR:0.741, P-value:0.017). Despite the lack of significant associations, the high prevalence of smoking (47.1%) and hypertension (58.9%) requires intervention. Radiological reporting is unclear in 63.22% of cases, with 'bone spurs' commonly utilized. Additionally, 93.9% have low ionized calcium levels. Other lab results mostly fall within normal ranges, emphasizing the complexity of diagnosis and suggesting the importance of thorough radiological investigations and laboratory assays. Conclusions We recommend expanding MEPS criteria to include other conditions, highlighting the significant associations between 1,25(OH) 2 VD 3 deficiency, HPT, advanced age, and Type 2 Diabetes mellitus with musculoskeletal pains in diagnosed RA cases. Vitamin D Deficiency Hyperparathyroidism Middle East Pain Syndrome MSK Pain Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The musculoskeletal system is a core element that influences many human health aspects. Changes in a plethora of crucial biochemical elements can significantly alter the clinical manifestations of this system, primarily musculoskeletal pains. A novel yet understudied syndrome that tackles the intertwined relationship between the musculoskeletal system and alterations in the body’s biochemical stores is the Middle East Pain Syndrome (MEPS). Despite the lack of enough evidence to formulate a consensus on its definition, MEPS can be defined as a combination of chronic Vitamin D 3 deficiency, possible hyperparathyroidism (HPT), and Fibromyalgia in Middle Eastern patients that do not fulfill the criteria of Rheumatoid Arthritis (RA) ( 1 ). Alterations in the physiological levels and biochemical processes regarding 1,25(OH) 2 VD 3 is heavily tied to changes in the parathyroid hormone (PTH) levels. PTH is involved in bone resorption and the utilization of calcium in the bloodstream via binding to the osteoclasts’ receptors. 1,25(OH) 2 VD 3 deficiency can lead to HPT, manifesting as increased levels of the PTH. HPT is categorized into primary, secondary, and tertiary HPT. Primary HPT is a metabolic condition in which hypercalcemia and typical/hyperparathyroidism occur due to the benign overgrowth of one or more parathyroid glands ( 2 ). In contrast, secondary and tertiary HPT are induced by external stimuli. Secondary hyperparathyroidism (SHPT) is the body’s attempt to maintain calcium homeostasis in response to hypocalcemia by increasing secreted PTH. The main pathological background to SHPT is chronic kidney disease, in which the renal inability to yield adequate amounts of 1,25(OH) 2 VD 3 from 1,25(OH) 2 VD 2 ultimately leads to the inability of the body to excrete phosphate. Consequently, insoluble phosphate-calcium complexes form and hinder the utilization of calcium. Lastly, tertiary HPT is hypercalcemia within the context of autonomous over-secretion of PTH by hyperplastic parathyroid glands due to chronic secondary HPT ( 3 ). The Endocrine Society’s clinical practice guidelines outline those levels of 1,25(OH) 2 VD 3 above 30 ng/ml are optimal, less than or equal to 20 ng/ml as a deficiency, with levels between 21–29 ng/ml as insufficiency ( 4 ). 1,25(OH) 2 VD 3 deficiency increases the risk of fractures, pseudoarthrosis, and bony lesions ( 1 , 5 ). 1,25(OH) 2 VD 3 deficiency can occur due to malabsorption conditions, renal failure, reduced nutritional intake, or inadequate sun exposure. Consequently, hypocalcemia and subsequent HPT may occur ( 6 ). According to Elbeialy et al., the common clinical manifestations of HPT and 1,25(OH) 2 VD 3 deficiency include muscle cramps, bone pain, FMS, juxta-articular erosions, tenosynovitis, periarteritis, and pericapsural calcification ( 1 ). Moreover, combined HPT and 1,25(OH) 2 VD 3 deficiency causes musculoskeletal pain due to hypocalcemia-induced osteoporosis and calcium pyrophosphate deposition-induced degenerative arthritis and muscular weakness ( 7 ). Healthcare professionals continue to diagnose patients with arthritic conditions, such as RA, despite their failure to fulfill the entirety of their criteria. Consequently, patients experience slight improvement upon adhering to their treatment plans. MEPS is proposed as an HPT-induced RA-mimicking syndrome ( 1 ). Furthermore, MEPS is postulated to be correlated with cadmium toxicity, a proposed cause of chronic 1,25(OH) 2 VD 3 deficiency in the Middle East. Cadmium can be deposited in the kidneys, the leading site of converting 25(OH) 2 VD 3 to 1,25(OH) 2 VD 3 , leading to dysfunctions in the mitochondrial electron transport chain and NADPH oxidase. Subsequently, reactive oxygen species form and induce oxidative damage on epithelial cells, manifesting in a decline in kidney functions ( 8 – 10 ). Despite the novel scientific evidence proposed by Elbeialy et al. regarding MEPS, there needs to be reported evidence investigating the possibility of adding other orthopedic and rheumatologic conditions to the definition of MEPS, which focused on Fibromyalgia only. Thus, this paper aims to shed light on such a possibility, hoping to increase awareness among clinical practitioners and the general population regarding MEPS. Moreover, this paper may have an integral impact on clinical practice guidelines in orthopedics and rheumatology. This paper also investigates the prevalence, risk factors, severity, and variation in Palestinian patients considering musculoskeletal pains. Method Study design and setting A retrospective cohort study was conducted between February and December 2023 at the three largest public healthcare centers in the West Bank belonging to the Palestinian Ministry of Health (Palestinian Medical Complex in Ramallah, Rafidia Surgical Hospital in Nablus, and Thabet Thabet Hospital in Tulkarem). These centers were chosen because they are geographically widespread, allowing the research team to gain a thorough insight into the studied variables. Over two months, the research team collected data from the orthopedic and rheumatology departments’ databases, accessed via each center’s respective archive modalities. Population, sample size, and sampling technique Patients diagnosed with RA (n = 58). There is no reported evidence by the Palestinian Authority bodies regarding statistics concerning Palestinians with musculoskeletal pain. Therefore, a generalized calculation of the sample size was conducted. According to the Palestinian Central Bureau of Statistics, the Palestinian population in the West Bank is 3.25 million, with a 50% proportion, yielding a minimum sample size of 385 participants ( 11 ). A stratified sampling technique was utilized to group this study’s participants according to their clinical notes and laboratory panels’ backgrounds. Inclusion criteria : All patients suffering from active musculoskeletal pains, with untreated or mistreated RA, of any age, and having any of the following were included in the final sample: radiological imaging of bony structures, 1,25(OH) 2 VD 3 , Parathyroid (PTH), Rheumatoid Factor (RF), Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), total calcium, ionized calcium, albumin, or serum uric acid levels. Each patient’s history records, physician notes, and other valuable information were also recruited in this study. Exclusion criteria : Patients with concurrent conditions that interfere with radiological, or laboratory panel data were excluded, including the following: chronic kidney or liver diseases, autoimmune diseases, endocrine pathologies, malabsorptive conditions, hereditary 1,25(OH) 2 VD 3 resistant rickets or 1-alpha hydroxylase deficiency, those who are currently on p450-enzyme-inducing drugs, those with altered albumin levels, and those who have a history of prolonged hospital stays. Variables and operational definitions The dependent variable was Musculoskeletal pain severity (on a 10-point scale). The independent variables were Gender , a nominal variable, Age , and a continuous numerical variable (age groups post-grouping were below 18 years of age, ≥ 18 but less than 50 years of age, ≥ 50 but less than 70 years of age, and ≥ 70 years of age) to become ordinal variables, Location of Pain and Associated Symptoms : nominal variable data were taken from each patient’s respective profile, and later were grouped according to site (pain) and identifying characteristic (associated symptoms), Duration of Pain : discrete numerical readings were taken from each database’s reporting of recurrent visits or duration explicitly mentioned in each patient’s electronic medical history. This data was grouped and converted to ordinal variable readings. Smoking status: The smoking history (cigarettes or otherwise) was counted as a yes. As a nominal variable, Diabetes mellitus (type 2) and Hypertension statuses : diagnosed diabetes or hypertension histories were counted as a yes. Considered as a nominal variable, PTH and Vitamin D readings : two numerical readings were taken from the database for almost all patients and were later categorized and transformed into ordinal variables according to international guidelines, Thyroid stimulating hormone, total and ionized calcium, albumin, serum uric acid, and erythrocyte sedimentation rate readings : numerical readings were taken from the databases and converted to ordinal variables according to international guidelines, Rheumatoid Factor status : a nominal variable regarding each patient’s respective Rheumatoid Factor status (positive or negative) according to the databases, Therapies, and disease progression : nominal variable data were collected from the databases and then grouped according to therapy class (nominal) and progression scale (ordinal), Radiological findings : nominal variable data were collected from the databases and then grouped according to radiological characteristics (nominal). Data Analysis The research team utilized Statistical Product and Service Solutions (SPSS-IBM Cooperation version 22) to enter and analyze the collected data. The characteristics of the participants were described using standard deviations, percentages, means, medians, and interquartile ranges (IQR) wherever appropriate. A statistically significant p-value had to be less than 0.05. Moreover, the T-test (for parametric) and the Mann-Whitney test (for non-parametric) were used to compare means. An adjusted multiple logistic regression was used to test the association between the variables. In addition, the odds ratio (OR) was calculated to assess the association between 1,25(OH) 2 VD 3 deficiency and HPT with MSK pain with a 95% confidence interval (CI). Kolmogorov-Smirnov test was used to test the normality of continuous variable distribution. Results Recorded data of patients with various musculoskeletal pains diagnosed with RA were gathered. Patients with chronic kidney disease, endocrine pathologies, autoimmune disorders, malabsorptive conditions, hereditary 1,25(OH) 2 VD 3 resistant rickets, 1-alpha hydroxylase deficiency, drug regimens including p450-enzyme-inducing drugs, altered albumin levels, or have a prior history of prolonged hospital stays were excluded (n = 189). Statistical analytic testing was performed using the T-test modality for Tables 1 A- 5 due to this test’s ability to check for differences between the means of two groups. Figures 1 A-E visually represent Tables 1 A-B. Table 1 A : Complaint demographics of patients with musculoskeletal pains. The general characteristics of the population’s complaints. The final sample size (n = 397) included 71.7% females and 28.3% males. There was no significant difference between varying age groups (p-value: 0.778) between males and females. The median age (IQR) is 48 ( 26 ), where males had a median (IQR) of 38 (23.5) and females of 53 ( 21 ). In females, the most prominent location of pain was the lower back area (23.5%), followed by the knees (13%), various joints (12.3%), unspecified bone pain (11.6%), cervical area (10.2%), upper back area (8.4%), limbs (4.9%), wrists (3.5%), generalized back area (2.8%), ankles (2.5%), heels (2.1%), hands (1.8%), shoulders (1.8%), thighs (0.7%), feet (0.7%), elbows (0.4%), and unspecified muscular pain (0%). Likewise, the most prominent location of pain in males was the lower back area (32.1%) followed by knees (17%), cervical area (10.7%), upper back area (10.7%), joints (7.1%), unspecified bone pain (6.3%), shoulders (4.5%), limbs (2.7%), wrists (2.7%), unspecified muscular (1.8%), ankles (1.8%), elbows (0.9%), feet (0.9%), thighs (0.9%), hands (0%), and heels (0%). There was no significant difference in the location of pain between males and females (p-value: 0.163). Associated symptoms were mostly unreported or not documented by healthcare staff among both males (38.3%) and females (31.9%). In females, the most reported associated symptom was generalized fatigue (26.4%), followed by muscular stiffness (13%), bone tenderness (9.1%), gastrointestinal symptoms (3.9%), limb numbness (3.9%), limb swelling (2.5%), limb cramping (2.1%), paraesthesia (2.1%), limb weakness (1.1%), generalized muscular tenderness (1.1%), and bowing of legs (0.4%). In males, the most prominent associated symptom was muscular stiffness (20.5%), followed by generalized fatigue (19.6%), bone tenderness (3.6%), limb numbness (3.6%), bowing of legs (2.4%), gastrointestinal symptoms (2.4%), limb cramping (2.4%), paraesthesia (2.4%), limb weakness (1.8%), limb swelling (0.9%), and generalized muscular tenderness (0.9%). There was a significant difference in associated symptoms between males and females (p-value: 0.027). Variable Male Female Total P-value n % n % n % Value Description Part A Age (years) Less than 18 4 3.6 3 1.1 7 1.76 0.778 Not significantly different From 18 to less than 50 55 49.1 150 52.6 205 51.6 From 50 to less than 70 43 38.4 117 41.1 160 53.8 From 70 and more 10 8.9 15 5.3 25 6.26 Location of Pain Unspecified bone pain 7 6.3 33 11.6 40 10.07 0.163 Unspecified muscular pain 2 1.8 0 0 2 0.503 Unspecified joints 8 7.1 35 12.3 43 10.8 Unspecified limbs 3 2.7 14 4.9 17 4.28 Cervical area 12 10.7 29 10.2 41 10.32 Generalized back area 0 0 8 2.8 8 2.015 Upper back area 12 10.7 24 8.4 36 9.06 Lower back area 36 32.1 67 23.5 103 25.94 Shoulders 5 4.5 5 1.8 10 2.51 Elbows 1 0.9 1 0.4 2 0.503 Wrists 3 2.7 10 3.5 13 3.27 Hands 0 0 5 1.8 5 1.25 Thighs 1 0.9 2 0.7 3 0.755 Knees 19 17 37 13 56 14.10 Heels 0 0 6 2.1 6 1.51 Ankles 2 1.8 7 2.5 9 2.26 Feet 1 0.9 2 0.7 3 0.75 Associated Symptoms Unreported 43 38.3 91 31.9 134 33.7 0.027 Significantly different Generalized Fatigue 22 19.6 83 29.1 105 26.4 Bone tenderness 4 3.6 26 9.1 30 7.55 Bowing of Legs 3 2.7 1 0.4 4 1 Muscular stiffness (including morning stiffness) 23 20.5 37 13 60 15.11 Muscular tenderness 1 0.9 3 1.1 4 1 Limb cramping 3 2.7 6 2.1 9 2.26 Limb swelling 1 0.9 7 2.5 8 2.01 Limb weakness 2 1.8 3 1.1 5 1.25 Limb numbness 4 3.6 11 3.9 15 3.77 Paraesthesia 3 2.7 6 2.1 9 2.26 Gastrointestinal symptoms 3 2.7 1 0.4 4 1 Duration of Pain Less than one week (traumatic) 3 2.7 4 1.4 7 1.76 0.595 Not significantly different From one week to less than 6 months 1 0.9 5 1.8 6 1.51 From 6 months to less than 1 year 7 6.3 12 4.2 19 4.78 From 1 year to less than 5 years 12 10.7 36 12.6 48 12.09 From 5 years and more 89 79.5 228 80 317 79.84 The duration of symptoms among both males and females followed a similar pattern, with most of the population having pain for longer than five years with recurrent office visits (80% and 79.5% for females and males, respectively). This was followed by pain lasting between one and five years (12.6%), six to twelve months (4.2%), one and six months (1.8%), and less than one week - traumatic in origin (1.4%) in females. In contrast, the pattern among males was followed by pain lasting between one and five years (10.7%), between six and twelve months (6.3%), less than one week (2.7%), and less than six months (0.9%). There was no significant difference in the duration of pain between males and females (p-value: 0.595). Figure 1 A Patients’ age group distribution (in years). Figure 1 B Patients’ complaints regarding the location of pain. Table 1 B : Smoking, hypertension, and diabetes statuses. The comorbidities and smoking status of the population. In females, the majority were non-smokers (60%), with a diagnosis of hypertension (60.7%), with no diagnosis of diabetes of any type (57.9%). Likewise, the majority of males were smokers (65.2%), with a diagnosis of hypertension (45.5%), with no diagnosis of diabetes of any type (53.6%). There were no significant differences in smoking status (p-value: 0.341), hypertension (p-value: 0.257), or diabetes (p-value: 0.998) statuses between males and females. Variable Male Female Total P-value n % n % n % Value Description Part B Smoking Yes 73 65.2 114 40 187 47.1 0.341 Not significantly different No 39 34.8 171 60 210 52.89 Diabetes Yes 48 42.8 116 40.7 164 41.3 0.257 No 60 53.5 165 57.8 225 56.6 Hypertension Yes 61 54.46 173 60.7 234 58.9 0.998 No 51 45.5 112 39.29 163 41.05 Table 2 A : Parathyroid hormone and 1,25(OH) 2 VD 3 readings. Two readings of the population’s parathyroid hormone (PTH) and 1,25(OH) 2 VD 3 as present in the data records. Regarding the first PTH reading, both the male and female participants’ readings were within the normal range (55.4%). However, in the second reading, females’ readings shifted into abnormally high readings (56.5%), while males remained within the normal range (56.3%). There was no significant difference between males and females in the primary (p-value: 0.998) and secondary (p-value: 0.658) PTH readings. Regarding 1,25(OH) 2 VD 3 readings, primary readings were abnormally low in both females (84%) and males (75.2%). In the second reading, these readings remained abnormally low in both females (79.3%) and males (71.8%). Notably, 8.3% of females and 10.9% of males had higher-than-normal Vitamin D second readings. There was no significant difference between males and females in the primary (p-value: 0.089) and secondary (p-value: 0.176). Please note that Figs. 2 A-F represent Tables 2 A-B in a visual manner. Variable Male Female Total P-value n % n % n % Value Description Part A Primary PTH Reading Low 0 0 0 0 0 0 0.99 Not significantly different Normal 62 55.4 158 55.4 220 55.41 High 50 44.6 127 44.6 177 44.58 Primary 1,25(OH) 2 VD 3 Reading Low 82 75.2 237 84 319 80.35 0.08 Normal 16 14.7 26 9.2 42 10.57 High 11 10.1 19 6.7 30 7.55 Latter PTH Reading Low 0 0 0 0 0 0 0.65 Normal 57 50.8 124 43.5 181 45.5 High 55 49.1 161 56.4 216 54.4 Latter 1,25(OH) 2 VD 3 Reading Low 79 71.8 219 79.3 298 75 0.17 Normal 19 17.3 34 12.3 53 13.35 High 12 10.9 23 8.3 35 8.81 Figure 2 A Patients’ primary and later PTH readings. Figure 2 B Patients’ primary and later 1,25(OH) 2 VD 3 readings. Table 2 B displays other laboratory results (TSH, total and ionized calcium levels, serum uric acid, RF, albumin, serum uric acid, and erythrocyte sedimentation rate readings). Variable Male Female Total P-value n % n % n % Value Description Part B TSH Low 31 27.7 77 27 108 27.2 0.446 Not significantly different Normal 81 72.3 203 71.2 284 71.53 High 0 0 2 0.7 2 0.5 Total Calcium (mg/dl) Low 0 0 0 0 0 0 0.844 Normal 96 90.6 240 89.9 336 84.6 High 10 9.4 27 10.1 37 9.31 Ionized Calcium (mg/dl) Low 103 93.6 270 96.7 373 93.9 0.34 Normal 7 6.4 9 3.2 16 4.03 High 0 0 0 0 0 0 Rheumatoid Factor (RF) Negative 67 59.8 151 53 218 54.9 0.216 Positive 45 40.2 134 47 179 45 Albumin Low 12 11.2 28 9.8 40 10.07 0.983 Normal 76 71 210 73.7 286 72 High 19 17.8 47 16.5 66 16.6 Serum Uric Acid (SUA) (mg/dl) Males & premenopau-sal females Low 13 12.5 0 0 13 3.27 0.508 Normal 89 85.6 24 61.5 113 28.4 High 2 1.9 15 38.5 17 4.28 Menopausal females Low - - 14 11.2 14 3.52 Normal - - 111 88.8 111 27.9 High - - 0 0 0 0 ESR (mm) Below 50 years of age Low 0 0 0 0 0 0 < 0.001 Significantly different Normal 10 19.6 44 31.2 54 13.6 High 41 80.4 97 68.8 138 34.7 Above 50 years of age Low 0 0 0 0 0 0 < 0.001 Normal 11 25.6 68 58.1 79 19.89 High 32 74.4 49 41.9 81 20.4 Regarding TSH levels, most females (71.2%) and males (72.3%) had normal readings. In total calcium level readings, most females (89.9%) and males (90.6%) had normal readings. Notably, both females (100%) and males (100%) with reported ionized calcium had abnormally low levels. In addition, 59.8% of males and 52.6% of females were diagnosed with seronegative RA. Meanwhile, 40.2% of males and 47.4% of females were diagnosed with seropositive RA. Furthermore, most females (73.7%) and males (76%) had albumin readings within the normal limits. Regarding serum uric acid levels (SUA), most males (85.6%) had readings within the normal range. Moreover, most premenopausal females (61.5%) and menopausal females (88.8%) had SUA readings within the normal range. Regarding ESR readings, both males below (74.4%) and above (80.4%) 50 years of age had normal readings, as well as females below the age of 50 (68.8%). In contrast, females above 50 years of age had low ESR levels (58.1%). There were no significant differences in TSH (p-value: 0.466), total calcium (p-value: 0.844), ionized calcium (p-value: 0.216), RF (p-value: 0.638), and albumin (p-value: 0.983) readings between males and females. Notably, there was a significant difference in SUA (p-value: <0.001), or ESR (p-value: <0.001) readings between males and females. Table 3 Therapies, progression, and pain scales. The population’s reported symptom severity score, therapies prescribed, and progression. Variable Male Female Total P-value n % n % n % Value Description Symptom Severity Scale Unreported 5 4.46 79 27.71 84 21.15 0.427 Not significantly different Less than 5 1 0.89 17 5.96 18 4.53 5 23 20.5 21 7.36 44 11.08 6 12 10.71 10 3.5 22 5.54 7 6 5.35 45 15.7 51 12.84 8 0 0 15 5.26 15 3.77 9 65 58.03 80 28.07 145 36.5 10 0 0 18 6.31 18 4.53 Therapy Physical Therapy 5 4.46 29 10.17 34 8.56 < 0.001 Significantly different NSAIDs 20 17.85 149 52.28 169 42.5 1,25(OH) 2 VD 3 Supplement 30 26.7 90 31.57 120 30.22 Steroids 19 16.96 9 3.15 28 7.05 < 0.001 DMARDs 38 33.9 8 2.8 46 11.5 Progression Unreported 23 20.5 26 9.12 49 12.34 No change 43 38.39 212 74.38 255 64.23 Slow 38 33.9 31 10.87 69 17.38 Good 7 6.25 16 5.61 23 5.79 The majority of both males (58.03%) and females (34.38%) reported relatively high symptom severores – being 8/10. The majority of the females in this sample (52.28%) were prescribed NSAIDs, while males were mostly prescribed DMARDs (33.9%). Unfortunately, the majority of both males (38.39%) and females (74.38%) reported no significant improvement in their symptoms upon taking and adhering to their prescribed drug regimens. There were no significant differences in the symptom severity score (p-value: 0.427) between males and females. However, there was a significant difference in both therapies prescribed (p-value: < 0.001) and symptom progression (< 0.001) between males and females. Please note that Figs. 3 A-C represent Table 3 in visual manners. Figure 3 A Patients’ reported scale of pain. Table 4 Radiological findings reported in the databases. The population’s reported radiological findings within their respective healthcare centers. Most females (60.4%) and males (70.5%) have no or unclear reported findings. The term ‘Bone spurs’ was the most reported among female patients (14.7%), followed by ‘Joint narrowing’ (9.5%), ‘Vertebral changes’ (6.3%), ‘Nerve root compression’ (3.5%), ‘Wrist arthritis’ (3.2%), ‘Subperiosteal resorption’ (1.4%), and ‘Calceneal spurs’ (1.1%). In males, the most reported term was ‘Bone spurs’ (12.5%), followed by ‘Joint narrowing’ (9.8%), ‘Vertebral changes’ (4.5%), ‘Wrist arthritis’ (1.8%), ‘Nerve root compression’ (0.9%), ‘Subperiosteal resorption’ (0%), and ‘Calcaneal spurs’ (0%). It is worth mentioning that these terms varied across different healthcare centers. Still, an umbrella term was utilized throughout the data collection process to cover the core of the reported findings. In addition, all the reported radiological findings went hand in hand with the location of pain and its associated symptoms across all healthcare settings. There was no significant difference in reporting radiological findings (p-value: 0.135) between males and females across all healthcare centers. Please note that Fig. 4 represents Table 4 in a visual manner. Variable Male Female Total P-value n % n % n % Value Description Radiological Findings Unreported 79 70.5 172 60.4 251 63.22 0.135 Not significantly different Subperiosteal resorption 0 0 4 1.4 4 1 Vertebral changes 5 4.5 18 6.3 23 5.79 Calcaneal spurs 0 0 3 1.1 3 0.75 Wrist arthritis 2 1.8 9 3.2 11 2.77 Bone spurs 14 12.5 42 14.7 56 14.1 Joint narrowing 11 9.8 27 9.5 38 9.57 Nerve root compression 1 0.9 10 3.5 11 2.77 Table 5: Alternate diagnoses. Four different rheumatologic or orthopedic conditions that the population’s complaints, laboratory findings, radiological reports, and response to therapy were tested against to explore different diagnoses. Of the 397 patients diagnosed with RA, only 68.3% of males and 36.6% of females are correctly diagnosed with RA with reported slow or good response to the treatment provided. However, 19% of males and 27.5% of females have findings that are in keeping with Ankylosing Spondylitis. In addition, 1.6% of males and 2.8% of females have findings that go hand in hand with Polymyalgia Rheumatica. Furthermore, 11.1% of males and 33.1% of females have findings that suggest FMS. A significant difference exists in the diagnoses presented (p-value: < 0.001) between males and females. Please note that Figure 5 represents Table 5 visually. Variable Male Female Total P-value n % n % n % Value Description Condition’s Criteria Met Rheumatoid arthritis 43 68.3 52 36.6 95 23.9 5 points) on Symptom Severity Scores. A multiple logistic regression analysis of factors associated with symptom severity on a pain scale. It revealed that age (OR: 1.53, P-value: 0.015), above-normal PTH levels (OR: 1.579, P-value: 0.027), extremely low 1,25(OH) 2 VD 3 levels (OR: 1.745, P-value: 0.05), and diabetes (OR: 0.741, P-value: 0.017) are associated with increased pain reporting by patients upon a symptom severity scoring scale. Variable Odds Ratio Confidence Interval P-value Interpretation Age* - 1.543 0.244-1.097 0.015 Significant PTH Levels Low 0.438 0.056-0.439 0.201 Not significant Normal 0.853 0.027-0.089 0.063 Not significant High 1.579 0.020-0.40 0.027 Significant Vitamin D Levels Extremely Low 1.745 0.039-0.115 0.05 Significant Low 1.670 0.017-0.341 0.09 Not significant Normal 0.804 0.010-0.028 0.16 Not significant Smoking Status Yes 0.817 0.025-0.650 0.053 Not significant Diabetes Status Yes 0.741 0.013-0.409 0.017 Significant Hypertension Status Yes 1.069 0.026-0.576 0.064 Not significant Ionized Calcium Levels Low 1.879 0.321-1.245 0.067 Not significant * Age groups were divided into below and above 50 years of age in the conduction of this table. Discussion This study aimed to investigate the possibility of expanding the definition of the MEPS, which currently focuses on FMS only within the context of 1,25(OH) 2 VD 3 deficiency and possible HPT in patients with RA. It also aimed to investigate the prevalence, risk factors, severity, and variation in the Palestinian population regarding musculoskeletal pains. Several remarkable findings were noted in this study. Notably, most of these patients had abnormally low 1,25(OH) 2 VD 3 levels upon two readings as recorded in the databases, despite some patients' prescription of 1,25(OH) 2 VD 3 supplementation. Surprisingly, 8.81% of patients had higher-than-normal levels of 1,25(OH) 2 VD 3 in their secondary readings, raising concerns about healthcare professionals’ pattern in over-prescribing the supplement in those with 1,25(OH) 2 VD 3 deficiency. Moreover, a statistically significant association was found between low 1,25(OH) 2 VD 3 levels and musculoskeletal pain severity (OR:1.745, P-value:0.05). A national-scale study conducted in 2018 reported that the prevalence of 1,25(OH) 2 VD 3 deficiency in Palestine is 60.7% ( 12 ). On the other hand, the prevalence of 1,25(OH) 2 VD 3 deficiency among the general public in Canada, the United States, and Europe is 7.4%, 5.9%, and 13%, respectively ( 13 – 15 ). According to Holick, patient populations with 1,25(OH) 2 VD 3 deficiencies are more likely to present with generalized musculoskeletal pain involving primarily proximal muscles, with subsequent weakness and altered daily-life productivity ( 16 ). 1,25(OH) 2 VD 3 deficiency is known for its immunomodulatory properties, influencing both innate and adaptive immune responses, which are crucial in the pathogenesis of RA ( 17 , 18 ). Evidence suggests that 1,25(OH) 2 VD 3 deficiency may exacerbate RA symptoms, including joint pain, inflammation, and disease severity markers ( 19 ). While some studies advocate for 1,25(OH) 2 VD 3 supplementation as a potential adjunct therapy to mitigate RA progression and improve patient outcomes, results from clinical trials remain varied and inconclusive, necessitating further investigation into optimal dosing regimens and patient selection criteria ( 20 , 21 ). Overall, while the link between 1,25(OH) 2 VD 3 deficiency and RA continues to be explored, ongoing research aims to clarify its exact mechanisms and therapeutic implications in the management of this complex autoimmune condition. SHPT is characterized by elevated PTH levels and decreased ionized calcium levels. This condition can arise from a wide array of factors, with 1,25(OH) 2 VD 3 deficiency being one of them. Deficient 1,25(OH) 2 VD 3 levels reduce calcium levels, preventing the proper sensitization of the calcium-sensing receptor (Ca-SR) expressed on the parathyroid gland. The Ca-SR is essential for detecting serum calcium levels. When calcium levels are high, the receptor inhibits the secretion of PTH. However, when calcium levels are low due to insufficient 1,25(OH) 2 VD 3 , the Ca-SR fails to inhibit PTH secretion effectively. Prolonged activation of PTH release can result in hyperplasia of the parathyroid gland, ultimately leading to the establishment of SHPT ( 22 , 23 ). In our study, the majority of the population had abnormally high levels of the parathyroid hormone (PTH) upon two readings as recorded in the databases, with a statistically significant association between high PTH levels and musculoskeletal pain severity (OR: 1.579, P-value: 0.027). These findings prompt Palestinian healthcare professionals and centers to seek thorough diagnoses and follow-up plans with their respective patient populations. RA is a seropositive autoimmune and systemic inflammatory disease that affects the joints along with various organs, including the heart and lungs, potentially leading to malignancy and early mortality ( 24 ). The global prevalence of RA ranges from 0.5–2%, with a higher incidence in women, smokers, and those with a family history of RA ( 25 ). The diagnosis of RA is based on scoring ≥ 6 out of 10 according to the 2010 criteria established by the American College of Rheumatology/European League Against Rheumatism. Regarding joint involvement, one large joint corresponds to 0 points, 2–10 large joints (shoulder, elbows, hips, knees, and ankles) correspond to 1 point, 1–3 small joints (metacarpophalangeal joint, proximal interphalangeal joints, second to fifth metatarsophalangeal joints, thumb interphalangeal joint, and wrist) correspond to 2 points, and 4–10 small joints correspond to 3 points. Involvement of more than ten joints, with at least one being small, corresponds to 4 points. Regarding serology, negative rheumatoid factor (RF) and negative anti-citrullinated protein antibody (ACPA) correspond to 0 points, low positive RF or low positive ACPA corresponds to 1 point, and high positive RF or high positive ACPA corresponds to 2 points. Concerning acute phase reactants, average erythrocyte sedimentation rate (ESR) or customary C-reactive protein (CRP) corresponds to 0 points, while abnormal ESR or CRP corresponds to 1 point. In terms of duration, less than six weeks corresponds to 0 points, and more than six weeks corresponds to 1 point ( 26 ). The primary approach to managing RA involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids to alleviate the inflammatory processes associated with the disease. Aspirin, among the earliest and most effective treatments for RA, is favored over corticosteroids. Disease-modifying antirheumatic Drugs (DMARDs) come into play in the second line of management. DMARDs aim to decelerate the progression of articular damage, destruction, and deformity, thereby attenuating the likelihood of developing malignancies ( 27 ). Many patients diagnosed with RA also exhibit HPT, and at times, the latter can present with symptoms similar to RA ( 28 ). This similarity in presentation poses a challenge, as the coexistence of HPT and RA may lead to a failure in receiving appropriate treatment ( 29 ). Recognizing the pattern of joint involvement is crucial to distinguish between RA and HPT. RA predominantly affects proximal joints, such as the proximal interphalangeal joint, whereas HPT affects distal interphalangeal joints, metacarpophalangeal joints, and radioulnar joints ( 30 ). However, more than joint involvement is required for differentiation. Radiographs play a pivotal role in this process. HPT is characterized by high bone turnover, increased osteoclastic activity, and osteoclast proliferation. One of the earliest radiographic features is subperiosteal resorption. Findings such as resorption, new bone formation, and sclerosis indicate HPT. Disease progression may result in a bone-ground glass appearance due to extensive destruction ( 31 ). In contrast, RA exhibits osteoporotic lesions that differ from those seen in HPT, characterized by tuft spur-like swellings ( 32 ). Combining joint involvement patterns and radiographic features aids in accurately differentiating RA and HPT. Undeterred by the significant proportion of correct diagnosis and effective treatment plans for RA in Palestinian healthcare centers (23.9%), a substantial number of musculoskeletal patients were diagnosed with RA despite not fulfilling its criteria (76.1%). Instead, many of these patients’ presentations, laboratory analyses, and radiological findings fulfill the requirements of Ankylosing Spondylitis, Polymyalgia Rheumatica, and FMS (see Table 5 ). Furthermore, even in patients with correct RA diagnosis, a typical pattern of absent or slow disease progression or symptom resolution (81.61%) and presumable over-prescription of non-steroidal anti-inflammatory drugs (NSAIDs) were noted (42.5%). Ankylosing Spondylitis (AS) is a standard seronegative (negative RF) inflammatory rheumatic disease primarily affecting axial joints and their surrounding structures (33). The exact cause of AS is unknown, but it is associated with overexpression of interleukin-12, IL-17, TNF-α, and the presence of the Human Leukocyte Antigen (HLA)-B27 gene. AS is observed in 50% of patients with uveitis, 7% of those with psoriatic arthritis, and 1–2% of individuals with inflammatory bowel disease (IBD) ( 34 ). Diagnosis follows the Assessment in Spondylarthritis International Society (ASAS) criteria, requiring chronic back pain for at least three months with onset after age 45. Diagnosis is confirmed if there is sacroiliitis on imaging with at least one axial spondylarthritis (SPA)-feature symptom or HLA-B27 positivity with at least two SPA-feature symptoms. SPA features include inflammatory back pain, peripheral arthritis, dactylitis, enthesitis, family history, response to NSAIDs, uveitis, psoriasis, IBD, HLA-B27, and elevated CRP levels. Initial treatment involves NSAIDs, physiotherapy, and exercise. DMARDs like sulfasalazine may be added for peripheral arthritis. If needed, second-line treatment includes TNF inhibitors or IL-7 inhibitors. Surgical intervention is considered if there is no improvement ( 35 ). In our study, 12.4% of the population’s profiles go hand in hand with an AS diagnosis, with a significant difference between males and females (p-value: <0.001). FMS is a chronic condition characterized by widespread musculoskeletal pain and various nonspecific symptoms, including fatigue, mood issues, anxiety, sleep disturbances, and cognitive impairments. The primary clinical symptom is diffuse musculoskeletal pain, often accompanied by a hypersensitivity to touch known as tender points. Approximately 20–30% of FMS patients may experience tingling sensations (paraesthesia) in the upper and lower limbs and trunk. Fatigue and sleep disturbances are nearly universal among FMS patients, along with cognitive impairments such as short-term memory loss. Anxiety and mood disorders are common, with about 40% of patients experiencing depression at the time of diagnosis and 30% having anxiety. The lifetime prevalence of stress and depression is estimated at 60%. According to AAPT (ACTTION­American Pain Society Pain Taxonomy), the latest diagnostic criteria for FMS include multisite pain at least six sites, moderate to severe sleep and fatigue problems, and symptoms persisting for at least three months. Treatment for FMS is both non-pharmacological and pharmacological. Patient education is a crucial component, emphasizing understanding of the disease. Non-pharmacological interventions include physical activity and cognitive-behavioral therapy for associated mental disturbances. Pharmacological options involve antidepressants, antipsychotic medications, analgesics, and muscle relaxants tailored to the patient's specific symptoms ( 36 , 37 ). In our study, 13.6% of the population’s presentations suggest Fibromyalgia syndrome, with a significant difference between males and females (p-value: <0.001). Polymyalgia rheumatica (PMR) is an inflammatory disease primarily affecting individuals over the age of 50. It is characterized by proximal musculoskeletal pain, often bilateral in the arms and shoulders and occasionally in the thighs' pelvic girdle and proximal aspects. The peak incidence of PMR occurs between 70–75 years, with about two-thirds of affected individuals being females. Those of Scandinavian or Northern European descent have a higher prevalence of being affected ( 38 , 39 ). PMR patients typically experience a sudden onset of proximal musculoskeletal pain with morning stiffness lasting 45–60 minutes, limiting movement and restricting daily morning activities ( 40 ). Bilateral shoulder pain is the most common complaint, with neck and hip girdle involvement in 50–90% of cases. Due to associated nonspecific symptoms like low-grade fever, anorexia, and weight loss (occurring in 40–50% of cases), physicians may screen patients for malignancy ( 38 ). In 2012, the European Alliance of Associations for Rheumatology (EULAR) and the American College of Rheumatology (ACR) introduced provisional criteria for PMR classification. Each characteristic is assigned points, and a diagnosis requires a minimum of 4 points: morning stiffness duration > 45 minutes (2 points), limited range of motion (1 point), absence of RF and anti-citrullinated protein antibody (1 point), lack of other joint involvement (1 point), and specific shoulder and hip pathologies (0/1 point, confirmed with ultrasound if needed) ( 42 ). Laboratory tests, including CBC, inflammatory markers (ESR, CRP), thyroid function tests, kidney and liver function tests, creatine kinase, bone profile, and Rheumatoid factor and anti-citrullinated protein antibodies, are conducted to rule out alternative diagnoses ( 39 ). The first-line treatment for PMR is oral or intramuscular glucocorticoids. However, a steroid-sparing strategy with methotrexate or other DMARDs may be employed due to the potential side effects of long-term steroid use ( 40 ). In our study, 1.25% of our population’s presentations are in keeping with Polymyalgia Rheumatica, with a significant difference between males and females (p-value: < 0.001). In light of the population’s musculoskeletal pains, the most commonly reported area of pain was the lower back area, with knees, cervical, and upper back areas also frequently reported. Associated symptoms were often unreported either by the patients or healthcare providers. Regardless, morning muscular stiffness was the most commonly reported symptom in males and generalized fatigue in females, with bone tenderness following these two symptoms in both sexes. The majority of these patients reported significantly high subjective scaling of their pains. Furthermore, the timeline of these patients’ complaints and office visits, for the majority of patients, occurred for over five years. Notably, increased age was significantly tied to increased MSK pain severity (OR: 1.53, P-value: 0.015). In addition, lifestyle factors associated considerably with musculoskeletal pains included diagnosed Type 2 diabetes mellitus (T2DM) diabetes (OR: 0.741, P-value: 0.017). T2DM is characterized by insulin resistance and elevated blood glucose levels, primarily affecting the elderly with a global prevalence of 20%. Recent increases in 1,25(OH) 2 VD 3 deficiency have drawn attention to its impact on bone health and mental well-being, cardiovascular health, hypertension, and diabetes. Vitamin D is believed to influence T2DM through various mechanisms, including its effect on insulin receptors present in adipose and muscle tissue. Studies indicate that vitamin D receptors (VDR) stimulate insulin responsiveness by influencing the receptor gene. Additionally, the active form of 1,25(OH) 2 VD 3 , calcitriol, enhances the expression of peroxisome proliferator-activated receptor delta (PPAR-δ), co-expressed with VDR, impacting fatty cell accumulation and fatty acid oxidation. Calcitriol also plays a crucial role in activating pancreatic β-cells, promoting the biosynthesis and conversion of proinsulin to insulin. Beyond direct effects on β-cells, 1,25(OH) 2 VD 3 influence on extracellular and intracellular calcium levels may impact calcium flux in β-cells, potentially interfering with insulin production in cases of 1,25(OH) 2 VD 3 deficiency ( 41 – 45 ). Furthermore, 1,25(OH) 2 VD 3 has been associated with deactivating cytokines, which, when elevated, can contribute to β-cell destruction and the development of T2DM ( 46 , 47 ). In addition, hypertension and smoking status were also tackled. Despite the insignificant association between these variables and MSK pains, the high prevalence (smoking: 47.1%, HTN: 58.9%) of these conditions prompts serious intervention by the Palestinian healthcare system. The results of laboratory and radiological evaluations aiding in the diagnosis and follow-up of patients also revealed remarkable findings. Radiological reporting is noted to be absent or unclear regarding structure and wording in this study’s sample (63.22%). The term ‘bone spurs’ appeared to be commonly used in radiological reporting. The diverse range of radiological report terms (see Table 4 ) possibly accounts for the diverse range of pain locations and associated symptoms in this population. Additionally, 93.9% of patients had abnormally low levels of ionized calcium. For the most part, other laboratory findings fell within the normal ranges (see Table 2 B), plausibly yielding no aid in diagnosis. These results emphasize the complexity of the diagnostic workup and suggest thorough radiological investigations and ionized calcium assays as more relevant in this context. Numerous patients present with musculoskeletal pain (MSK), either localized or generalized, prompting the screening of various blood and inflammatory markers alongside imaging studies. Unfortunately, many physicians overlook the importance of adhering to established disease diagnosis criteria. This oversight can lead to the misdiagnosis of patients experiencing MSK pain, attributing it to rheumatoid diseases (RD), be they seropositive or seronegative, even in the absence of the necessary criteria. Some of these misdiagnosed patients exhibit conditions such as 1,25(OH) 2 VD 3 deficiency, elevated PTH, and, in some cases, criteria for FMS. Inspired by the work of Elbeialy, a new syndrome has emerged: MEPS. MEPS, at present, is a diagnosis of exclusion necessitating a comprehensive bone assessment, rheumatologic inflammatory marker testing, HPT evaluation, and radiographic examinations of affected joints. A thorough patient history, especially factors contributing to SHPT, is also crucial in the diagnostic process. Elbeialy et al. propose that SHPT in MEPS is not a consequence of kidney disease but rather is induced by exposure to environmental factors such as tobacco, carbonated beverages, and contaminated fried foods containing heavy metals like cadmium and lead due to their high density in the Middle East region ( 1 ). Cadmium is a pervasive environmental element found in mineral ores, soils, water, and air, contaminating consumables and breathable air. Although the utilization of cadmium has diminished in specific applications, it remains prevalent in manufacturing solar panels, plating baths, and electrode storage. Cadmium toxicity is characterized by the deposition of particles in the proximal convoluted tubules, leading to nephrotoxicity. The specific deposition site is believed to be where the conversion of 1,25(OH) 2 VD 2 to 1,25(OH) 2 VD 3 occurs, resulting in 1,25(OH) 2 VD 3 deficiency and, subsequently, SHPT. SHPT contributes to muscle, tendon, and joint pain like F and MS symptoms. According to Elbeialy et al., MEPS positively responds to FMS treatment, incorporating Selective Serotonin Reuptake Inhibitors (SSRIs), 1,25(OH) 2 VD 3 supplements, muscle relaxants, and antioxidant supplementation with vitamins E and C. In cases featuring arthritis, adding Plaquenil and sulfasalazine may be warranted ( 9 , 48 ). Overall, the significant association between 1,25(OH) 2 VD 3 deficiency, high PTH levels, increased age, and present T2DM with MSK pains in the context of diagnosed RA directs us to expand the definition of MEPS and include the variables above as integral elements of MEPS, as shown in Table 6 . In addition, according to the data, we can conclude that Ankylosing Spondylitis and Polymyalgia Rheumatica can also be added to Fibromyalgia Syndrome within the context of MEPS. We deem further studies as crucial, and we call for further investigation regarding the plausibility of adding more elements to the MEPS criteria, the significance of each of the variables above and their point-scoring, the interplay of cadmium toxicity in MEPS within the Palestinian society, and healthcare professionals to be aware of MEPS within the context of their respective work fields. Strengths and Limitations Our study possesses distinctive strengths and limitations inherent to any scientific investigation. Primarily, it contributes valuable insights into a novel and unique condition, offering updated statistical data on 1,25(OH) 2 VD 3 deficiency, Hyperparathyroidism, and patient characteristics in Palestine, a matter of considerable concern for the Palestinian medical community. Additionally, the study presents comprehensive data and perspectives that have the potential to influence the expansion of the definition of MEPS. Furthermore, it sheds light on reporting and treatment planning patterns among Palestinian healthcare workers, advocating for crucial changes in guidelines and protocols within the Palestinian Ministry of Health. However, the retrospective nature of our study poses limitations as it needed more access to thorough medical data, whether due to access to archived data or the need for more patient interviews. This limitation hindered a comprehensive, in-depth exploration of the fields of rheumatology and orthopedics in Palestine. In addition, the research team compiled various terms into umbrella terms based on location and character during the data entry process, potentially restricting the diversity of radiological findings. Despite the initial intention to include a study on 1,25(OH) 2 VD 3 receptors in select patients recruited on the ground, resource constraints rendered this unfeasible. Acknowledging both the strengths and limitations, we aspire that our study will benefit patients in Palestine and hopefully in other countries, as patient beneficence is the primary concern of all healthcare workers. By raising awareness among the general public and healthcare professionals, we anticipate that our findings will contribute to formulating new guidelines, ultimately enhancing patient care and medical practices. Conclusions In conclusion, this study has explored the complex relationship between MEPS, 1,25(OH) 2 VD 3 deficiency, HPT, and various musculoskeletal conditions in the Palestinian population. The findings underscore the prevalence of abnormally low 1,25(OH) 2 VD 3 levels and elevated parathyroid hormone (PTH) levels among patients experiencing musculoskeletal pain, suggesting a potential association with MEPS. The study has also highlighted the surprising occurrence of higher-than-normal 1,25(OH) 2 VD 3 levels in some patients, raising concerns about the pattern of over-prescription of supplements and NSAIDs among Palestinian healthcare professionals. Additionally, the significant association between low Vitamin D levels and musculoskeletal pain severity, as well as the correlation between high PTH levels and the severity of musculoskeletal pain, emphasizes the need for thorough diagnoses and follow-up plans in the Palestinian healthcare system. Furthermore, the study delves into the misdiagnosis of Rheumatoid Arthritis (RA) and the prevalence of conditions such as Ankylosing Spondylitis, Polymyalgia Rheumatica, and FMS in the studied population. This misdiagnosis poses challenges in providing appropriate patient treatment and calls for thorough diagnostic measures before diagnosis. The proposed expansion of the MEPS definition to include other rheumatologic and orthopedic conditions, older age groups, and T2DM status is a novel contribution. The study suggests that MEPS may involve a broader spectrum of musculoskeletal disorders beyond Fibromyalgia, emphasizing the importance of considering various factors in the diagnostic process. The paper also draws attention to lifestyle factors such as smoking and hypertension, which, although not significantly associated with musculoskeletal pains in this study, warrant intervention by the Palestinian healthcare system due to their high prevalence. This study capitalizes on the complexity of musculoskeletal pain presentations and the need for comprehensive diagnostic approaches. The proposed expansion of MEPS criteria opens avenues for further research and may have implications for clinical practice guidelines. Ultimately, these findings contribute to our understanding of the multifaceted nature of musculoskeletal disorders in the Middle Eastern population and call for a more nuanced approach to diagnosis and treatment. Abbreviations MEPS: Musculoskeletal and Extraintestinal Pain Syndromes FMS: Fibromyalgia Syndrome 1,25(OH) 2 VD 3 : Vitamin D HPT: Hyperparathyroidism PTH: Parathyroid Hormone SHPT: Secondary Hyperparathyroidism RA: Rheumatoid Arthritis NSAIDs: Non-steroidal anti-inflammatory Drugs DMARDs: Disease-Modifying Antirheumatic Drugs T2DM: Type 2 Diabetes Mellitus ESR: Erythrocyte Sedimentation Rate CRP: C-Reactive Protein RF: Rheumatoid Factor ACPA: Anti-Citrullinated Protein Antibody TNF-α: Tumor Necrosis Factor-alpha HLA: Human Leukocyte Antigen AS: Ankylosing Spondylitis IBD: Inflammatory Bowel Disease SPA: Spondylarthritis IL-17: Interleukin-17 IL-7: Interleukin-7 CBC: Complete Blood Count PPAR-δ: Peroxisome Proliferator-Activated Receptor delta SSRIs: Selective Serotonin Reuptake Inhibitors AAPT: ACTTION­American Pain Society Pain Taxonomy Declarations Ethics approval and consent to participate Approval was taken from An-Najah University’s institutional review board (IRB). In addition, approval was taken from the Ministry of Health’s research center. There are no risks to participants since they have no active role in this research. The team ensured that the privacy and confidentiality of the participants’ data were protected using password-protected files. Furthermore, any personal data regarding the identity of the participants was not published in any shape, way, or form. Finally, the collected data was safely disposed of after the research. Please note that informed consent was not obtained from the participants since it is deemed unnecessary for retrospective studies according to An-Najah National University’s institutional review board (IRB). Consent for publication Not applicable. Availability of data and materials Data is provided within the manuscript. Competing interests The authors declare no competing interests. Funding Is not applicable. Authors’ contributions Y.A.: the principal investigator optimized the study proposal and protocol, supervised the data analysis, and wrote most of the manuscript file. S.H. and N.K. participated in the study protocol writing, applied for IRB, data collection, and data analysis, and edited the manuscript file. J.A. and A.S. revised the final version of the manuscript, supervised the study, and assisted in the data analysis. M.A. and M.M. revised the study protocol and assisted in project supervision. All the authors read and approved the final manuscript. Acknowledgments We want to thank our esteemed professors for their unconditional love and endless support throughout our medical school journey. We dedicate this work to our beloved parents and dear friends who continue to support us in indescribable ways. References Elbeialy AA, Bauomi AM, Elnaggar BM, Elzomor HM. Middle east pain syndrome is a pollution-induced new disease mimicking rheumatoid arthritis. Sci Rep. 2021;11(1):22263. 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J Clin Endocrinol Metab. 2007;92(6):2017–29. Remelli F, Vitali A, Zurlo A, Volpato S. Vitamin D Deficiency and Sarcopenia in Older Persons. Nutrients. 2019;11(12). Gallagher JC. Vitamin D and aging. Endocrinol Metab Clin North Am. 2013;42(2):319–32. Hayat MT, Nauman M, Nazir N, Ali S, Bangash N. Chapter 7 - Environmental Hazards of Cadmium: Past, Present, and Future. In: Hasanuzzaman M, Prasad MNV, Fujita MBT-CT and T in P, editors. Academic Press; 2019. pp. 163–83. https://www.sciencedirect.com/science/article/pii/B9780128148648000073 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4763944","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":344630307,"identity":"74448f64-5257-4280-a202-c2e77d4b2544","order_by":0,"name":"Yazan AlHabil","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Yazan","middleName":"","lastName":"AlHabil","suffix":""},{"id":344630308,"identity":"cfd2b2a2-52cb-4db3-ab65-a0b7e1d6114e","order_by":1,"name":"Nabil Koosa","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Nabil","middleName":"","lastName":"Koosa","suffix":""},{"id":344630309,"identity":"38ee009f-6109-499d-aa72-eba6bfd7b094","order_by":2,"name":"Seema Hameedi","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Seema","middleName":"","lastName":"Hameedi","suffix":""},{"id":344630312,"identity":"cb5dc645-7a8b-49e6-8362-06cb741bdb13","order_by":3,"name":"Johnny Amer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYBACxgYwZQPEB9iABDPRWtJI0AIFh0EEkVqYG5ifbvi453wef+PhZw8YKqwTGwg7jM3s5oxnt4slDhwzN2A4k06MFgaz2zwHbic2HDhgJsHYdpgYLezfbv85cC5x/oHj3yQY/xGlhcfsNsOBA4kbDpwB2tJAjJZmnrKbPQeSEzceOFMmkXAs3ZigFsP29m03fhywS5x34/g2iQ811rKEtTTDWBIHGBgSCCkHAXk4i5+g8aNgFIyCUTBSAQBS+UeTcTbiUAAAAABJRU5ErkJggg==","orcid":"","institution":"An-Najah National University","correspondingAuthor":true,"prefix":"","firstName":"Johnny","middleName":"","lastName":"Amer","suffix":""},{"id":344630314,"identity":"b841830e-56d0-4c57-8ffb-e7fccdd6f47a","order_by":4,"name":"Ahmad Salhab","email":"","orcid":"","institution":"An-Najah National University","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"","lastName":"Salhab","suffix":""},{"id":344630316,"identity":"658d3cc3-bae3-4739-9857-a3b29fd6148b","order_by":5,"name":"Mazen A. Abdalla","email":"","orcid":"","institution":"An-Najah National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mazen","middleName":"A.","lastName":"Abdalla","suffix":""},{"id":344630317,"identity":"6da3ba08-0ad9-46b9-baa6-587cdc0e3168","order_by":6,"name":"Mohammad M. Jaber","email":"","orcid":"","institution":"An-Najah National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"M.","lastName":"Jaber","suffix":""}],"badges":[],"createdAt":"2024-07-18 16:21:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4763944/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4763944/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63810695,"identity":"c4b288d2-5525-40d4-9bb3-2e30abba3de0","added_by":"auto","created_at":"2024-09-02 13:57:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":123042,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e Patients’ age group distribution (in years).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB:\u003c/strong\u003e Patients’ complaints regarding the location of pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC:\u003c/strong\u003e Patients reported associated symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD:\u003c/strong\u003e Patients’ frequency of office visits (duration of symptoms).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE:\u003c/strong\u003e Patients’ comorbidities and smoking statuses.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4763944/v1/88a87a310f20443995f01e4d.png"},{"id":63808812,"identity":"7bb75252-8a02-4d32-a42a-217ebe3f9fc8","added_by":"auto","created_at":"2024-09-02 13:49:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":94949,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003ePatients’ primary and later PTH readings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003ePatients’ primary and later 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e \u0026nbsp;readings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC: \u003c/strong\u003ePatients’ other laboratory readings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD: \u003c/strong\u003ePatients’ rheumatoid factor statuses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE: \u003c/strong\u003ePatients’ serum uric acid (SUA) readings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF:\u003c/strong\u003e Patients’ erythrocyte sedimentation rate (ESR) readings.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4763944/v1/79b2146a0e43e09bd205c418.png"},{"id":63808816,"identity":"a4c40a10-66ef-4f75-b614-a8f90b66ac45","added_by":"auto","created_at":"2024-09-02 13:49:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":105265,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003ePatients’ reported scale of pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB: \u003c/strong\u003ePatients’ therapeutic plans.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC: \u003c/strong\u003ePatients’ symptomatic progression.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4763944/v1/26259a1e9b215141385288ad.png"},{"id":63808815,"identity":"97965860-3cb6-4039-8117-e03458101f11","added_by":"auto","created_at":"2024-09-02 13:49:27","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":81504,"visible":true,"origin":"","legend":"\u003cp\u003ePatients’ radiological reports.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4763944/v1/86709592300788d3835ba3fb.png"},{"id":63808813,"identity":"7442c4c6-366e-4aef-b484-9f770476cb6c","added_by":"auto","created_at":"2024-09-02 13:49:27","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":64076,"visible":true,"origin":"","legend":"\u003cp\u003ePatients’ alternate diagnoses.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4763944/v1/f583eaea661d8c84f9b07656.png"},{"id":64160217,"identity":"2d90623d-0447-436d-a31c-2a031081491f","added_by":"auto","created_at":"2024-09-09 07:17:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1828338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4763944/v1/4e71928a-fde1-4979-9989-30ea650a9a45.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Expanding the Criteria of the Novel Middle East Pain Syndrome to Include More Rheumatologic and Orthopedic Conditions, Type 2 Diabetes Mellitus, and Advanced Age - Understanding Musculoskeletal Pains among Palestinian Patients with Rheumatoid Arthritis","fulltext":[{"header":"Background","content":"\u003cp\u003eThe musculoskeletal system is a core element that influences many human health aspects. Changes in a plethora of crucial biochemical elements can significantly alter the clinical manifestations of this system, primarily musculoskeletal pains. A novel yet understudied syndrome that tackles the intertwined relationship between the musculoskeletal system and alterations in the body\u0026rsquo;s biochemical stores is the Middle East Pain Syndrome (MEPS). Despite the lack of enough evidence to formulate a consensus on its definition, MEPS can be defined as a combination of chronic Vitamin D\u003csub\u003e3\u003c/sub\u003e deficiency, possible hyperparathyroidism (HPT), and Fibromyalgia in Middle Eastern patients that do not fulfill the criteria of Rheumatoid Arthritis (RA) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlterations in the physiological levels and biochemical processes regarding 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e is heavily tied to changes in the parathyroid hormone (PTH) levels. PTH is involved in bone resorption and the utilization of calcium in the bloodstream via binding to the osteoclasts\u0026rsquo; receptors. 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency can lead to HPT, manifesting as increased levels of the PTH. HPT is categorized into primary, secondary, and tertiary HPT. Primary HPT is a metabolic condition in which hypercalcemia and typical/hyperparathyroidism occur due to the benign overgrowth of one or more parathyroid glands (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In contrast, secondary and tertiary HPT are induced by external stimuli. Secondary hyperparathyroidism (SHPT) is the body\u0026rsquo;s attempt to maintain calcium homeostasis in response to hypocalcemia by increasing secreted PTH. The main pathological background to SHPT is chronic kidney disease, in which the renal inability to yield adequate amounts of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e from 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e2\u003c/sub\u003e ultimately leads to the inability of the body to excrete phosphate. Consequently, insoluble phosphate-calcium complexes form and hinder the utilization of calcium. Lastly, tertiary HPT is hypercalcemia within the context of autonomous over-secretion of PTH by hyperplastic parathyroid glands due to chronic secondary HPT (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Endocrine Society\u0026rsquo;s clinical practice guidelines outline those levels of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e above 30 ng/ml are optimal, less than or equal to 20 ng/ml as a deficiency, with levels between 21\u0026ndash;29 ng/ml as insufficiency (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency increases the risk of fractures, pseudoarthrosis, and bony lesions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency can occur due to malabsorption conditions, renal failure, reduced nutritional intake, or inadequate sun exposure. Consequently, hypocalcemia and subsequent HPT may occur (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). According to Elbeialy et al., the common clinical manifestations of HPT and 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency include muscle cramps, bone pain, FMS, juxta-articular erosions, tenosynovitis, periarteritis, and pericapsural calcification (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Moreover, combined HPT and 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency causes musculoskeletal pain due to hypocalcemia-induced osteoporosis and calcium pyrophosphate deposition-induced degenerative arthritis and muscular weakness (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealthcare professionals continue to diagnose patients with arthritic conditions, such as RA, despite their failure to fulfill the entirety of their criteria. Consequently, patients experience slight improvement upon adhering to their treatment plans. MEPS is proposed as an HPT-induced RA-mimicking syndrome (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Furthermore, MEPS is postulated to be correlated with cadmium toxicity, a proposed cause of chronic 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency in the Middle East. Cadmium can be deposited in the kidneys, the leading site of converting 25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e to 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e, leading to dysfunctions in the mitochondrial electron transport chain and NADPH oxidase. Subsequently, reactive oxygen species form and induce oxidative damage on epithelial cells, manifesting in a decline in kidney functions (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the novel scientific evidence proposed by Elbeialy et al. regarding MEPS, there needs to be reported evidence investigating the possibility of adding other orthopedic and rheumatologic conditions to the definition of MEPS, which focused on Fibromyalgia only. Thus, this paper aims to shed light on such a possibility, hoping to increase awareness among clinical practitioners and the general population regarding MEPS. Moreover, this paper may have an integral impact on clinical practice guidelines in orthopedics and rheumatology. This paper also investigates the prevalence, risk factors, severity, and variation in Palestinian patients considering musculoskeletal pains.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted between February and December 2023 at the three largest public healthcare centers in the West Bank belonging to the Palestinian Ministry of Health (Palestinian Medical Complex in Ramallah, Rafidia Surgical Hospital in Nablus, and Thabet Thabet Hospital in Tulkarem). These centers were chosen because they are geographically widespread, allowing the research team to gain a thorough insight into the studied variables. Over two months, the research team collected data from the orthopedic and rheumatology departments\u0026rsquo; databases, accessed via each center\u0026rsquo;s respective archive modalities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePopulation, sample size, and sampling technique\u003c/h2\u003e \u003cp\u003ePatients diagnosed with RA (n\u0026thinsp;=\u0026thinsp;58). There is no reported evidence by the Palestinian Authority bodies regarding statistics concerning Palestinians with musculoskeletal pain. Therefore, a generalized calculation of the sample size was conducted. According to the Palestinian Central Bureau of Statistics, the Palestinian population in the West Bank is 3.25\u0026nbsp;million, with a 50% proportion, yielding a minimum sample size of 385 participants (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A stratified sampling technique was utilized to group this study\u0026rsquo;s participants according to their clinical notes and laboratory panels\u0026rsquo; backgrounds.\u003c/p\u003e \u003cp\u003e \u003cem\u003eInclusion criteria\u003c/em\u003e: All patients suffering from active musculoskeletal pains, with untreated or mistreated RA, of any age, and having any of the following were included in the final sample: radiological imaging of bony structures, 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e, Parathyroid (PTH), Rheumatoid Factor (RF), Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), total calcium, ionized calcium, albumin, or serum uric acid levels. Each patient\u0026rsquo;s history records, physician notes, and other valuable information were also recruited in this study.\u003c/p\u003e \u003cp\u003e \u003cem\u003eExclusion criteria\u003c/em\u003e: Patients with concurrent conditions that interfere with radiological, or laboratory panel data were excluded, including the following: chronic kidney or liver diseases, autoimmune diseases, endocrine pathologies, malabsorptive conditions, hereditary 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e resistant rickets or 1-alpha hydroxylase deficiency, those who are currently on p450-enzyme-inducing drugs, those with altered albumin levels, and those who have a history of prolonged hospital stays.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eVariables and operational definitions\u003c/h2\u003e \u003cp\u003eThe dependent variable was Musculoskeletal pain severity (on a 10-point scale). The independent variables were \u003cem\u003eGender\u003c/em\u003e, a nominal variable, \u003cem\u003eAge\u003c/em\u003e, and a continuous numerical variable (age groups post-grouping were below 18 years of age, \u0026ge; 18 but less than 50 years of age, \u0026ge; 50 but less than 70 years of age, and \u0026ge;\u0026thinsp;70 years of age) to become ordinal variables, \u003cem\u003eLocation of Pain and Associated Symptoms\u003c/em\u003e: nominal variable data were taken from each patient\u0026rsquo;s respective profile, and later were grouped according to site (pain) and identifying characteristic (associated symptoms), \u003cem\u003eDuration of Pain\u003c/em\u003e: discrete numerical readings were taken from each database\u0026rsquo;s reporting of recurrent visits or duration explicitly mentioned in each patient\u0026rsquo;s electronic medical history. This data was grouped and converted to ordinal variable readings. Smoking status: The smoking history (cigarettes or otherwise) was counted as a yes. As a nominal variable, \u003cem\u003eDiabetes mellitus (type 2) and Hypertension statuses\u003c/em\u003e: diagnosed diabetes or hypertension histories were counted as a yes. Considered as a nominal variable, \u003cem\u003ePTH and Vitamin D readings\u003c/em\u003e: two numerical readings were taken from the database for almost all patients and were later categorized and transformed into ordinal variables according to international guidelines, \u003cem\u003eThyroid stimulating hormone, total and ionized calcium, albumin, serum uric acid, and erythrocyte sedimentation rate readings\u003c/em\u003e: numerical readings were taken from the databases and converted to ordinal variables according to international guidelines, \u003cem\u003eRheumatoid Factor status\u003c/em\u003e: a nominal variable regarding each patient\u0026rsquo;s respective Rheumatoid Factor status (positive or negative) according to the databases, \u003cem\u003eTherapies, and disease progression\u003c/em\u003e: nominal variable data were collected from the databases and then grouped according to therapy class (nominal) and progression scale (ordinal), \u003cem\u003eRadiological findings\u003c/em\u003e: nominal variable data were collected from the databases and then grouped according to radiological characteristics (nominal).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe research team utilized Statistical Product and Service Solutions (SPSS-IBM Cooperation version 22) to enter and analyze the collected data. The characteristics of the participants were described using standard deviations, percentages, means, medians, and interquartile ranges (IQR) wherever appropriate. A statistically significant p-value had to be less than 0.05. Moreover, the T-test (for parametric) and the Mann-Whitney test (for non-parametric) were used to compare means. An adjusted multiple logistic regression was used to test the association between the variables. In addition, the odds ratio (OR) was calculated to assess the association between 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency and HPT with MSK pain with a 95% confidence interval (CI). Kolmogorov-Smirnov test was used to test the normality of continuous variable distribution.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eRecorded data of patients with various musculoskeletal pains diagnosed with RA were gathered. Patients with chronic kidney disease, endocrine pathologies, autoimmune disorders, malabsorptive conditions, hereditary 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e resistant rickets, 1-alpha hydroxylase deficiency, drug regimens including p450-enzyme-inducing drugs, altered albumin levels, or have a prior history of prolonged hospital stays were excluded (n\u0026thinsp;=\u0026thinsp;189). Statistical analytic testing was performed using the T-test modality for Tables\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e5\u003c/span\u003e due to this test\u0026rsquo;s ability to check for differences between the means of two groups. Figures\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-E visually represent Tables\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-B.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e: Complaint demographics of patients with musculoskeletal pains. The general characteristics of the population\u0026rsquo;s complaints. The final sample size (n\u0026thinsp;=\u0026thinsp;397) included 71.7% females and 28.3% males. There was no significant difference between varying age groups (p-value: 0.778) between males and females. The median age (IQR) is 48 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), where males had a median (IQR) of 38 (23.5) and females of 53 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In females, the most prominent location of pain was the lower back area (23.5%), followed by the knees (13%), various joints (12.3%), unspecified bone pain (11.6%), cervical area (10.2%), upper back area (8.4%), limbs (4.9%), wrists (3.5%), generalized back area (2.8%), ankles (2.5%), heels (2.1%), hands (1.8%), shoulders (1.8%), thighs (0.7%), feet (0.7%), elbows (0.4%), and unspecified muscular pain (0%). Likewise, the most prominent location of pain in males was the lower back area (32.1%) followed by knees (17%), cervical area (10.7%), upper back area (10.7%), joints (7.1%), unspecified bone pain (6.3%), shoulders (4.5%), limbs (2.7%), wrists (2.7%), unspecified muscular (1.8%), ankles (1.8%), elbows (0.9%), feet (0.9%), thighs (0.9%), hands (0%), and heels (0%). There was no significant difference in the location of pain between males and females (p-value: 0.163). Associated symptoms were mostly unreported or not documented by healthcare staff among both males (38.3%) and females (31.9%). In females, the most reported associated symptom was generalized fatigue (26.4%), followed by muscular stiffness (13%), bone tenderness (9.1%), gastrointestinal symptoms (3.9%), limb numbness (3.9%), limb swelling (2.5%), limb cramping (2.1%), paraesthesia (2.1%), limb weakness (1.1%), generalized muscular tenderness (1.1%), and bowing of legs (0.4%). In males, the most prominent associated symptom was muscular stiffness (20.5%), followed by generalized fatigue (19.6%), bone tenderness (3.6%), limb numbness (3.6%), bowing of legs (2.4%), gastrointestinal symptoms (2.4%), limb cramping (2.4%), paraesthesia (2.4%), limb weakness (1.8%), limb swelling (0.9%), and generalized muscular tenderness (0.9%). There was a significant difference in associated symptoms between males and females (p-value: 0.027).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart A\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLess than 18\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"20\" rowspan=\"21\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom 18 to less than 50\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e51.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom 50 to less than 70\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom 70 and more\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"16\" rowspan=\"17\"\u003e \u003cp\u003e\u003cb\u003eLocation of Pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnspecified bone pain\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"16\" rowspan=\"17\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnspecified muscular pain\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnspecified joints\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnspecified limbs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCervical area\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGeneralized back area\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUpper back area\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLower back area\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e25.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eShoulders\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eElbows\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWrists\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHands\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eThighs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eKnees\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHeels\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eAnkles\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFeet\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003e\u003cb\u003eAssociated Symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnreported\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e33.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eSignificantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGeneralized Fatigue\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBone tenderness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBowing of Legs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMuscular stiffness (including morning stiffness)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMuscular tenderness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLimb cramping\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLimb swelling\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLimb weakness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLimb numbness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eParaesthesia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGastrointestinal symptoms\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eDuration of Pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLess than one week (traumatic)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.595\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom one week to less than 6 months\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom 6 months to less than 1 year\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom 1 year to less than 5 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrom 5 years and more\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e79.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe duration of symptoms among both males and females followed a similar pattern, with most of the population having pain for longer than five years with recurrent office visits (80% and 79.5% for females and males, respectively). This was followed by pain lasting between one and five years (12.6%), six to twelve months (4.2%), one and six months (1.8%), and less than one week - traumatic in origin (1.4%) in females. In contrast, the pattern among males was followed by pain lasting between one and five years (10.7%), between six and twelve months (6.3%), less than one week (2.7%), and less than six months (0.9%). There was no significant difference in the duration of pain between males and females (p-value: 0.595).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u003c/strong\u003e \u003cp\u003ePatients\u0026rsquo; age group distribution (in years).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eB\u003c/strong\u003e \u003cp\u003ePatients\u0026rsquo; complaints regarding the location of pain.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e: Smoking, hypertension, and diabetes statuses. The comorbidities and smoking status of the population. In females, the majority were non-smokers (60%), with a diagnosis of hypertension (60.7%), with no diagnosis of diabetes of any type (57.9%). Likewise, the majority of males were smokers (65.2%), with a diagnosis of hypertension (45.5%), with no diagnosis of diabetes of any type (53.6%). There were no significant differences in smoking status (p-value: 0.341), hypertension (p-value: 0.257), or diabetes (p-value: 0.998) statuses between males and females.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart B\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e52.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e56.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e41.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eA\u003c/b\u003e: Parathyroid hormone and 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e readings. Two readings of the population\u0026rsquo;s parathyroid hormone (PTH) and 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e as present in the data records. Regarding the first PTH reading, both the male and female participants\u0026rsquo; readings were within the normal range (55.4%). However, in the second reading, females\u0026rsquo; readings shifted into abnormally high readings (56.5%), while males remained within the normal range (56.3%). There was no significant difference between males and females in the primary (p-value: 0.998) and secondary (p-value: 0.658) PTH readings. Regarding 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e readings, primary readings were abnormally low in both females (84%) and males (75.2%). In the second reading, these readings remained abnormally low in both females (79.3%) and males (71.8%). Notably, 8.3% of females and 10.9% of males had higher-than-normal Vitamin D second readings. There was no significant difference between males and females in the primary (p-value: 0.089) and secondary (p-value: 0.176). Please note that Figs.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-F represent Tables\u0026nbsp;\u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-B in a visual manner.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart A\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePrimary PTH Reading\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e44.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePrimary 1,25(OH)\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003eVD\u003c/b\u003e\u003csub\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sub\u003e \u003cb\u003eReading\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLatter PTH Reading\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e54.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLatter 1,25(OH)\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003eVD\u003c/b\u003e\u003csub\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sub\u003e \u003cb\u003eReading\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e79.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e2\u003c/span\u003eA\u003c/strong\u003e \u003cp\u003ePatients\u0026rsquo; primary and later PTH readings.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e2\u003c/span\u003eB\u003c/strong\u003e \u003cp\u003ePatients\u0026rsquo; primary and later 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e readings.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e displays other laboratory results (TSH, total and ionized calcium levels, serum uric acid, RF, albumin, serum uric acid, and erythrocyte sedimentation rate readings).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c3\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart B\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eTSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"19\" rowspan=\"20\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e71.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eTotal Calcium (mg/dl)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.844\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e89.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e84.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eIonized Calcium (mg/dl)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e96.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e93.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eRheumatoid Factor (RF)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNegative\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePositive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAlbumin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eSerum Uric Acid (SUA) (mg/dl)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003eMales \u0026amp; premenopau-sal females\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e61.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e38.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003eMenopausal females\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e88.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eESR (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003eBelow 50 years of age\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eSignificantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003eAbove 50 years of age\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding TSH levels, most females (71.2%) and males (72.3%) had normal readings. In total calcium level readings, most females (89.9%) and males (90.6%) had normal readings. Notably, both females (100%) and males (100%) with reported ionized calcium had abnormally low levels. In addition, 59.8% of males and 52.6% of females were diagnosed with seronegative RA. Meanwhile, 40.2% of males and 47.4% of females were diagnosed with seropositive RA. Furthermore, most females (73.7%) and males (76%) had albumin readings within the normal limits. Regarding serum uric acid levels (SUA), most males (85.6%) had readings within the normal range. Moreover, most premenopausal females (61.5%) and menopausal females (88.8%) had SUA readings within the normal range. Regarding ESR readings, both males below (74.4%) and above (80.4%) 50 years of age had normal readings, as well as females below the age of 50 (68.8%). In contrast, females above 50 years of age had low ESR levels (58.1%). There were no significant differences in TSH (p-value: 0.466), total calcium (p-value: 0.844), ionized calcium (p-value: 0.216), RF (p-value: 0.638), and albumin (p-value: 0.983) readings between males and females. Notably, there was a significant difference in SUA (p-value: \u0026lt;0.001), or ESR (p-value: \u0026lt;0.001) readings between males and females.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTherapies, progression, and pain scales. The population\u0026rsquo;s reported symptom severity score, therapies prescribed, and progression.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eSymptom Severity Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnreported\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e21.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.427\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLess than 5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e9\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e10\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eTherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePhysical Therapy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eSignificantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNSAIDs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e \u003cem\u003eSupplement\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSteroids\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eDMARDs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eProgression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnreported\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo change\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e64.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSlow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGood\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe majority of both males (58.03%) and females (34.38%) reported relatively high symptom severores \u0026ndash; being 8/10. The majority of the females in this sample (52.28%) were prescribed NSAIDs, while males were mostly prescribed DMARDs (33.9%). Unfortunately, the majority of both males (38.39%) and females (74.38%) reported no significant improvement in their symptoms upon taking and adhering to their prescribed drug regimens. There were no significant differences in the symptom severity score (p-value: 0.427) between males and females. However, there was a significant difference in both therapies prescribed (p-value: \u0026lt; 0.001) and symptom progression (\u0026lt;\u0026thinsp;0.001) between males and females. Please note that Figs.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-C represent Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e3\u003c/span\u003e in visual manners.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure \u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u003c/strong\u003e \u003cp\u003ePatients\u0026rsquo; reported scale of pain.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiological findings reported in the databases. The population\u0026rsquo;s reported radiological findings within their respective healthcare centers. Most females (60.4%) and males (70.5%) have no or unclear reported findings. The term \u0026lsquo;Bone spurs\u0026rsquo; was the most reported among female patients (14.7%), followed by \u0026lsquo;Joint narrowing\u0026rsquo; (9.5%), \u0026lsquo;Vertebral changes\u0026rsquo; (6.3%), \u0026lsquo;Nerve root compression\u0026rsquo; (3.5%), \u0026lsquo;Wrist arthritis\u0026rsquo; (3.2%), \u0026lsquo;Subperiosteal resorption\u0026rsquo; (1.4%), and \u0026lsquo;Calceneal spurs\u0026rsquo; (1.1%). In males, the most reported term was \u0026lsquo;Bone spurs\u0026rsquo; (12.5%), followed by \u0026lsquo;Joint narrowing\u0026rsquo; (9.8%), \u0026lsquo;Vertebral changes\u0026rsquo; (4.5%), \u0026lsquo;Wrist arthritis\u0026rsquo; (1.8%), \u0026lsquo;Nerve root compression\u0026rsquo; (0.9%), \u0026lsquo;Subperiosteal resorption\u0026rsquo; (0%), and \u0026lsquo;Calcaneal spurs\u0026rsquo; (0%). It is worth mentioning that these terms varied across different healthcare centers. Still, an umbrella term was utilized throughout the data collection process to cover the core of the reported findings. In addition, all the reported radiological findings went hand in hand with the location of pain and its associated symptoms across all healthcare settings. There was no significant difference in reporting radiological findings (p-value: 0.135) between males and females across all healthcare centers. Please note that Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e4\u003c/span\u003e represents Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003e in a visual manner.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eRadiological Findings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUnreported\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e63.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eNot significantly different\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSubperiosteal resorption\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eVertebral changes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCalcaneal spurs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWrist arthritis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBone spurs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eJoint narrowing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNerve root compression\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e Alternate diagnoses.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFour different rheumatologic or orthopedic conditions that the population\u0026rsquo;s complaints, laboratory findings, radiological reports, and response to therapy were tested against to explore different diagnoses. Of the 397 patients diagnosed with RA, only 68.3% of males and 36.6% of females are correctly diagnosed with RA with reported slow or good response to the treatment provided. However, 19% of males and 27.5% of females have findings that are in keeping with Ankylosing Spondylitis. In addition, 1.6% of males and 2.8% of females have findings that go hand in hand with Polymyalgia Rheumatica. Furthermore, 11.1% of males and 33.1% of females have findings that suggest FMS. A significant difference exists in the diagnoses presented (p-value: \u0026lt; 0.001) between males and females.\u003cem\u003e\u0026nbsp;Please note that Figure 5 represents Table 5 visually.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"750\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32%\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.6%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.6%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.8%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.588235294117647%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.411764705882353%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.627450980392156%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.019607843137255%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.019607843137255%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.980392156862745%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.058823529411764%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.8%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition\u0026rsquo;s Criteria Met\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.2%\"\u003e\n \u003cp\u003e\u003cem\u003eRheumatoid arthritis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.2%\" valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4%\" valign=\"top\"\u003e\n \u003cp\u003e68.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.866666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.133333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e36.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.133333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.466666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e23.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.4%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.4%\" rowspan=\"4\"\u003e\n \u003cp\u003eSignificantly different\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.941176470588236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAnkylosing Spondylitis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27450980392157%\" valign=\"top\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27450980392157%\" valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e12.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.941176470588236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePolymyalgia Rheumatica\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27450980392157%\" valign=\"top\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27450980392157%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.941176470588236%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eFibromyalgia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.235294117647058%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" valign=\"top\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.784313725490197%\" valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27450980392157%\" valign=\"top\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.27450980392157%\" valign=\"top\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.72549019607843%\" valign=\"top\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTable 6:\u003c/strong\u003e Risk factors associated with high (\u0026gt; 5 points) on Symptom Severity Scores. A multiple logistic regression analysis of factors associated with symptom severity on a pain scale. It revealed that age (OR: 1.53, P-value: 0.015), above-normal PTH levels (OR: 1.579, P-value: 0.027), extremely low 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u0026nbsp;\u003c/sub\u003elevels (OR: 1.745, P-value: 0.05), and diabetes (OR: 0.741, P-value: 0.017) are associated with increased pain reporting by patients upon a symptom severity scoring scale.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"738\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.80487804878049%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eConfidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\" valign=\"top\"\u003e\n \u003cp\u003e1.543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\" valign=\"top\"\u003e\n \u003cp\u003e0.244-1.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePTH Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\" valign=\"top\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\" valign=\"top\"\u003e\n \u003cp\u003e0.056-0.439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.14801444043321%\"\u003e\n \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.787003610108304%\" valign=\"top\"\u003e\n \u003cp\u003e0.853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.9927797833935%\" valign=\"top\"\u003e\n \u003cp\u003e0.027-0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.99638989169675%\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.075812274368232%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.14801444043321%\"\u003e\n \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.787003610108304%\" valign=\"top\"\u003e\n \u003cp\u003e1.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.9927797833935%\"\u003e\n \u003cp\u003e0.020-0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.99638989169675%\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.075812274368232%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eVitamin D Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003eExtremely Low\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\"\u003e\n \u003cp\u003e1.745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\"\u003e\n \u003cp\u003e0.039-0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.14801444043321%\"\u003e\n \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.787003610108304%\"\u003e\n \u003cp\u003e1.670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.9927797833935%\"\u003e\n \u003cp\u003e0.017-0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.99638989169675%\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.075812274368232%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.14801444043321%\"\u003e\n \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.787003610108304%\"\u003e\n \u003cp\u003e0.804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.9927797833935%\"\u003e\n \u003cp\u003e0.010-0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.99638989169675%\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.075812274368232%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\"\u003e\n \u003cp\u003e0.817\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\"\u003e\n \u003cp\u003e0.025-0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\"\u003e\n \u003cp\u003e0.741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\"\u003e\n \u003cp\u003e0.013-0.409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\"\u003e\n \u003cp\u003e1.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\"\u003e\n \u003cp\u003e0.026-0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.932249322493224%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIonized Calcium Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\"\u003e\n \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.601626016260163%\"\u003e\n \u003cp\u003e1.879\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.51219512195122%\"\u003e\n \u003cp\u003e0.321-1.245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.75609756097561%\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.32520325203252%\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u003cem\u003eAge groups were divided into below and above 50 years of age in the conduction of this table.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to investigate the possibility of expanding the definition of the MEPS, which currently focuses on FMS only within the context of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency and possible HPT in patients with RA. It also aimed to investigate the prevalence, risk factors, severity, and variation in the Palestinian population regarding musculoskeletal pains. Several remarkable findings were noted in this study.\u003c/p\u003e\n\u003cp\u003eNotably, most of these patients had abnormally low 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e levels upon two readings as recorded in the databases, despite some patients\u0026apos; prescription of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e supplementation. Surprisingly, 8.81% of patients had higher-than-normal levels of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e in their secondary readings, raising concerns about healthcare professionals\u0026rsquo; pattern in over-prescribing the supplement in those with 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency. Moreover, a statistically significant association was found between low 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e levels and musculoskeletal pain severity (OR:1.745, P-value:0.05). A national-scale study conducted in 2018 reported that the prevalence of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency in Palestine is 60.7% (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). On the other hand, the prevalence of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency among the general public in Canada, the United States, and Europe is 7.4%, 5.9%, and 13%, respectively (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). According to Holick, patient populations with 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiencies are more likely to present with generalized musculoskeletal pain involving primarily proximal muscles, with subsequent weakness and altered daily-life productivity (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency is known for its immunomodulatory properties, influencing both innate and adaptive immune responses, which are crucial in the pathogenesis of RA (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). Evidence suggests that 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency may exacerbate RA symptoms, including joint pain, inflammation, and disease severity markers (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). While some studies advocate for 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e supplementation as a potential adjunct therapy to mitigate RA progression and improve patient outcomes, results from clinical trials remain varied and inconclusive, necessitating further investigation into optimal dosing regimens and patient selection criteria (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Overall, while the link between 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency and RA continues to be explored, ongoing research aims to clarify its exact mechanisms and therapeutic implications in the management of this complex autoimmune condition.\u003c/p\u003e\n\u003cp\u003eSHPT is characterized by elevated PTH levels and decreased ionized calcium levels. This condition can arise from a wide array of factors, with 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency being one of them. Deficient 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e levels reduce calcium levels, preventing the proper sensitization of the calcium-sensing receptor (Ca-SR) expressed on the parathyroid gland. The Ca-SR is essential for detecting serum calcium levels. When calcium levels are high, the receptor inhibits the secretion of PTH. However, when calcium levels are low due to insufficient 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e, the Ca-SR fails to inhibit PTH secretion effectively. Prolonged activation of PTH release can result in hyperplasia of the parathyroid gland, ultimately leading to the establishment of SHPT (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). In our study, the majority of the population had abnormally high levels of the parathyroid hormone (PTH) upon two readings as recorded in the databases, with a statistically significant association between high PTH levels and musculoskeletal pain severity (OR: 1.579, P-value: 0.027). These findings prompt Palestinian healthcare professionals and centers to seek thorough diagnoses and follow-up plans with their respective patient populations.\u003c/p\u003e\n\u003cp\u003eRA is a seropositive autoimmune and systemic inflammatory disease that affects the joints along with various organs, including the heart and lungs, potentially leading to malignancy and early mortality (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). The global prevalence of RA ranges from 0.5\u0026ndash;2%, with a higher incidence in women, smokers, and those with a family history of RA (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). The diagnosis of RA is based on scoring\u0026thinsp;\u0026ge;\u0026thinsp;6 out of 10 according to the 2010 criteria established by the American College of Rheumatology/European League Against Rheumatism. Regarding joint involvement, one large joint corresponds to 0 points, 2\u0026ndash;10 large joints (shoulder, elbows, hips, knees, and ankles) correspond to 1 point, 1\u0026ndash;3 small joints (metacarpophalangeal joint, proximal interphalangeal joints, second to fifth metatarsophalangeal joints, thumb interphalangeal joint, and wrist) correspond to 2 points, and 4\u0026ndash;10 small joints correspond to 3 points. Involvement of more than ten joints, with at least one being small, corresponds to 4 points. Regarding serology, negative rheumatoid factor (RF) and negative anti-citrullinated protein antibody (ACPA) correspond to 0 points, low positive RF or low positive ACPA corresponds to 1 point, and high positive RF or high positive ACPA corresponds to 2 points. Concerning acute phase reactants, average erythrocyte sedimentation rate (ESR) or customary C-reactive protein (CRP) corresponds to 0 points, while abnormal ESR or CRP corresponds to 1 point. In terms of duration, less than six weeks corresponds to 0 points, and more than six weeks corresponds to 1 point (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). The primary approach to managing RA involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids to alleviate the inflammatory processes associated with the disease. Aspirin, among the earliest and most effective treatments for RA, is favored over corticosteroids. Disease-modifying antirheumatic Drugs (DMARDs) come into play in the second line of management. DMARDs aim to decelerate the progression of articular damage, destruction, and deformity, thereby attenuating the likelihood of developing malignancies (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). Many patients diagnosed with RA also exhibit HPT, and at times, the latter can present with symptoms similar to RA (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). This similarity in presentation poses a challenge, as the coexistence of HPT and RA may lead to a failure in receiving appropriate treatment (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). Recognizing the pattern of joint involvement is crucial to distinguish between RA and HPT. RA predominantly affects proximal joints, such as the proximal interphalangeal joint, whereas HPT affects distal interphalangeal joints, metacarpophalangeal joints, and radioulnar joints (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). However, more than joint involvement is required for differentiation. Radiographs play a pivotal role in this process. HPT is characterized by high bone turnover, increased osteoclastic activity, and osteoclast proliferation. One of the earliest radiographic features is subperiosteal resorption. Findings such as resorption, new bone formation, and sclerosis indicate HPT. Disease progression may result in a bone-ground glass appearance due to extensive destruction (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). In contrast, RA exhibits osteoporotic lesions that differ from those seen in HPT, characterized by tuft spur-like swellings (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). Combining joint involvement patterns and radiographic features aids in accurately differentiating RA and HPT. Undeterred by the significant proportion of correct diagnosis and effective treatment plans for RA in Palestinian healthcare centers (23.9%), a substantial number of musculoskeletal patients were diagnosed with RA despite not fulfilling its criteria (76.1%). Instead, many of these patients\u0026rsquo; presentations, laboratory analyses, and radiological findings fulfill the requirements of Ankylosing Spondylitis, Polymyalgia Rheumatica, and FMS (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). Furthermore, even in patients with correct RA diagnosis, a typical pattern of absent or slow disease progression or symptom resolution (81.61%) and presumable over-prescription of non-steroidal anti-inflammatory drugs (NSAIDs) were noted (42.5%).\u003c/p\u003e\n\u003cp\u003eAnkylosing Spondylitis (AS) is a standard seronegative (negative RF) inflammatory rheumatic disease primarily affecting axial joints and their surrounding structures (33). The exact cause of AS is unknown, but it is associated with overexpression of interleukin-12, IL-17, TNF-\u0026alpha;, and the presence of the Human Leukocyte Antigen (HLA)-B27 gene. AS is observed in 50% of patients with uveitis, 7% of those with psoriatic arthritis, and 1\u0026ndash;2% of individuals with inflammatory bowel disease (IBD) (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e). Diagnosis follows the Assessment in Spondylarthritis International Society (ASAS) criteria, requiring chronic back pain for at least three months with onset after age 45. Diagnosis is confirmed if there is sacroiliitis on imaging with at least one axial spondylarthritis (SPA)-feature symptom or HLA-B27 positivity with at least two SPA-feature symptoms. SPA features include inflammatory back pain, peripheral arthritis, dactylitis, enthesitis, family history, response to NSAIDs, uveitis, psoriasis, IBD, HLA-B27, and elevated CRP levels. Initial treatment involves NSAIDs, physiotherapy, and exercise. DMARDs like sulfasalazine may be added for peripheral arthritis. If needed, second-line treatment includes TNF inhibitors or IL-7 inhibitors. Surgical intervention is considered if there is no improvement (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e). In our study, 12.4% of the population\u0026rsquo;s profiles go hand in hand with an AS diagnosis, with a significant difference between males and females (p-value: \u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eFMS is a chronic condition characterized by widespread musculoskeletal pain and various nonspecific symptoms, including fatigue, mood issues, anxiety, sleep disturbances, and cognitive impairments. The primary clinical symptom is diffuse musculoskeletal pain, often accompanied by a hypersensitivity to touch known as tender points. Approximately 20\u0026ndash;30% of FMS patients may experience tingling sensations (paraesthesia) in the upper and lower limbs and trunk. Fatigue and sleep disturbances are nearly universal among FMS patients, along with cognitive impairments such as short-term memory loss. Anxiety and mood disorders are common, with about 40% of patients experiencing depression at the time of diagnosis and 30% having anxiety. The lifetime prevalence of stress and depression is estimated at 60%. According to AAPT (ACTTION\u0026shy;American Pain Society Pain Taxonomy), the latest diagnostic criteria for FMS include multisite pain at least six sites, moderate to severe sleep and fatigue problems, and symptoms persisting for at least three months. Treatment for FMS is both non-pharmacological and pharmacological. Patient education is a crucial component, emphasizing understanding of the disease. Non-pharmacological interventions include physical activity and cognitive-behavioral therapy for associated mental disturbances. Pharmacological options involve antidepressants, antipsychotic medications, analgesics, and muscle relaxants tailored to the patient\u0026apos;s specific symptoms (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e). In our study, 13.6% of the population\u0026rsquo;s presentations suggest Fibromyalgia syndrome, with a significant difference between males and females (p-value: \u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003ePolymyalgia rheumatica (PMR) is an inflammatory disease primarily affecting individuals over the age of 50. It is characterized by proximal musculoskeletal pain, often bilateral in the arms and shoulders and occasionally in the thighs\u0026apos; pelvic girdle and proximal aspects. The peak incidence of PMR occurs between 70\u0026ndash;75 years, with about two-thirds of affected individuals being females. Those of Scandinavian or Northern European descent have a higher prevalence of being affected (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e). PMR patients typically experience a sudden onset of proximal musculoskeletal pain with morning stiffness lasting 45\u0026ndash;60 minutes, limiting movement and restricting daily morning activities (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e). Bilateral shoulder pain is the most common complaint, with neck and hip girdle involvement in 50\u0026ndash;90% of cases. Due to associated nonspecific symptoms like low-grade fever, anorexia, and weight loss (occurring in 40\u0026ndash;50% of cases), physicians may screen patients for malignancy (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e). In 2012, the European Alliance of Associations for Rheumatology (EULAR) and the American College of Rheumatology (ACR) introduced provisional criteria for PMR classification. Each characteristic is assigned points, and a diagnosis requires a minimum of 4 points: morning stiffness duration\u0026thinsp;\u0026gt;\u0026thinsp;45 minutes (2 points), limited range of motion (1 point), absence of RF and anti-citrullinated protein antibody (1 point), lack of other joint involvement (1 point), and specific shoulder and hip pathologies (0/1 point, confirmed with ultrasound if needed) (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e). Laboratory tests, including CBC, inflammatory markers (ESR, CRP), thyroid function tests, kidney and liver function tests, creatine kinase, bone profile, and Rheumatoid factor and anti-citrullinated protein antibodies, are conducted to rule out alternative diagnoses (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e). The first-line treatment for PMR is oral or intramuscular glucocorticoids. However, a steroid-sparing strategy with methotrexate or other DMARDs may be employed due to the potential side effects of long-term steroid use (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e). In our study, 1.25% of our population\u0026rsquo;s presentations are in keeping with Polymyalgia Rheumatica, with a significant difference between males and females (p-value: \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eIn light of the population\u0026rsquo;s musculoskeletal pains, the most commonly reported area of pain was the lower back area, with knees, cervical, and upper back areas also frequently reported. Associated symptoms were often unreported either by the patients or healthcare providers. Regardless, morning muscular stiffness was the most commonly reported symptom in males and generalized fatigue in females, with bone tenderness following these two symptoms in both sexes. The majority of these patients reported significantly high subjective scaling of their pains. Furthermore, the timeline of these patients\u0026rsquo; complaints and office visits, for the majority of patients, occurred for over five years. Notably, increased age was significantly tied to increased MSK pain severity (OR: 1.53, P-value: 0.015). In addition, lifestyle factors associated considerably with musculoskeletal pains included diagnosed Type 2 diabetes mellitus (T2DM) diabetes (OR: 0.741, P-value: 0.017).\u003c/p\u003e\n\u003cp\u003eT2DM is characterized by insulin resistance and elevated blood glucose levels, primarily affecting the elderly with a global prevalence of 20%. Recent increases in 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency have drawn attention to its impact on bone health and mental well-being, cardiovascular health, hypertension, and diabetes. Vitamin D is believed to influence T2DM through various mechanisms, including its effect on insulin receptors present in adipose and muscle tissue. Studies indicate that vitamin D receptors (VDR) stimulate insulin responsiveness by influencing the receptor gene. Additionally, the active form of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e, calcitriol, enhances the expression of peroxisome proliferator-activated receptor delta (PPAR-\u0026delta;), co-expressed with VDR, impacting fatty cell accumulation and fatty acid oxidation. Calcitriol also plays a crucial role in activating pancreatic \u0026beta;-cells, promoting the biosynthesis and conversion of proinsulin to insulin. Beyond direct effects on \u0026beta;-cells, 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e influence on extracellular and intracellular calcium levels may impact calcium flux in \u0026beta;-cells, potentially interfering with insulin production in cases of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e). Furthermore, 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e has been associated with deactivating cytokines, which, when elevated, can contribute to \u0026beta;-cell destruction and the development of T2DM (\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e). In addition, hypertension and smoking status were also tackled. Despite the insignificant association between these variables and MSK pains, the high prevalence (smoking: 47.1%, HTN: 58.9%) of these conditions prompts serious intervention by the Palestinian healthcare system.\u003c/p\u003e\n\u003cp\u003eThe results of laboratory and radiological evaluations aiding in the diagnosis and follow-up of patients also revealed remarkable findings. Radiological reporting is noted to be absent or unclear regarding structure and wording in this study\u0026rsquo;s sample (63.22%). The term \u0026lsquo;bone spurs\u0026rsquo; appeared to be commonly used in radiological reporting. The diverse range of radiological report terms (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) possibly accounts for the diverse range of pain locations and associated symptoms in this population. Additionally, 93.9% of patients had abnormally low levels of ionized calcium. For the most part, other laboratory findings fell within the normal ranges (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB), plausibly yielding no aid in diagnosis. These results emphasize the complexity of the diagnostic workup and suggest thorough radiological investigations and ionized calcium assays as more relevant in this context.\u003c/p\u003e\n\u003cp\u003eNumerous patients present with musculoskeletal pain (MSK), either localized or generalized, prompting the screening of various blood and inflammatory markers alongside imaging studies. Unfortunately, many physicians overlook the importance of adhering to established disease diagnosis criteria. This oversight can lead to the misdiagnosis of patients experiencing MSK pain, attributing it to rheumatoid diseases (RD), be they seropositive or seronegative, even in the absence of the necessary criteria. Some of these misdiagnosed patients exhibit conditions such as 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency, elevated PTH, and, in some cases, criteria for FMS. Inspired by the work of Elbeialy, a new syndrome has emerged: MEPS. MEPS, at present, is a diagnosis of exclusion necessitating a comprehensive bone assessment, rheumatologic inflammatory marker testing, HPT evaluation, and radiographic examinations of affected joints. A thorough patient history, especially factors contributing to SHPT, is also crucial in the diagnostic process. Elbeialy et al. propose that SHPT in MEPS is not a consequence of kidney disease but rather is induced by exposure to environmental factors such as tobacco, carbonated beverages, and contaminated fried foods containing heavy metals like cadmium and lead due to their high density in the Middle East region (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Cadmium is a pervasive environmental element found in mineral ores, soils, water, and air, contaminating consumables and breathable air. Although the utilization of cadmium has diminished in specific applications, it remains prevalent in manufacturing solar panels, plating baths, and electrode storage. Cadmium toxicity is characterized by the deposition of particles in the proximal convoluted tubules, leading to nephrotoxicity. The specific deposition site is believed to be where the conversion of 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e2\u003c/sub\u003e to 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e occurs, resulting in 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency and, subsequently, SHPT. SHPT contributes to muscle, tendon, and joint pain like F and MS symptoms. According to Elbeialy et al., MEPS positively responds to FMS treatment, incorporating Selective Serotonin Reuptake Inhibitors (SSRIs), 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e supplements, muscle relaxants, and antioxidant supplementation with vitamins E and C. In cases featuring arthritis, adding Plaquenil and sulfasalazine may be warranted (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOverall, the significant association between 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency, high PTH levels, increased age, and present T2DM with MSK pains in the context of diagnosed RA directs us to expand the definition of MEPS and include the variables above as integral elements of MEPS, as shown in Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e. In addition, according to the data, we can conclude that Ankylosing Spondylitis and Polymyalgia Rheumatica can also be added to Fibromyalgia Syndrome within the context of MEPS. We deem further studies as crucial, and we call for further investigation regarding the plausibility of adding more elements to the MEPS criteria, the significance of each of the variables above and their point-scoring, the interplay of cadmium toxicity in MEPS within the Palestinian society, and healthcare professionals to be aware of MEPS within the context of their respective work fields.\u003c/p\u003e"},{"header":"Strengths and Limitations","content":"\u003cp\u003eOur study possesses distinctive strengths and limitations inherent to any scientific investigation. Primarily, it contributes valuable insights into a novel and unique condition, offering updated statistical data on 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency, Hyperparathyroidism, and patient characteristics in Palestine, a matter of considerable concern for the Palestinian medical community. Additionally, the study presents comprehensive data and perspectives that have the potential to influence the expansion of the definition of MEPS. Furthermore, it sheds light on reporting and treatment planning patterns among Palestinian healthcare workers, advocating for crucial changes in guidelines and protocols within the Palestinian Ministry of Health. However, the retrospective nature of our study poses limitations as it needed more access to thorough medical data, whether due to access to archived data or the need for more patient interviews. This limitation hindered a comprehensive, in-depth exploration of the fields of rheumatology and orthopedics in Palestine. In addition, the research team compiled various terms into umbrella terms based on location and character during the data entry process, potentially restricting the diversity of radiological findings. Despite the initial intention to include a study on 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e receptors in select patients recruited on the ground, resource constraints rendered this unfeasible.\u003c/p\u003e \u003cp\u003eAcknowledging both the strengths and limitations, we aspire that our study will benefit patients in Palestine and hopefully in other countries, as patient beneficence is the primary concern of all healthcare workers. By raising awareness among the general public and healthcare professionals, we anticipate that our findings will contribute to formulating new guidelines, ultimately enhancing patient care and medical practices.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study has explored the complex relationship between MEPS, 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency, HPT, and various musculoskeletal conditions in the Palestinian population. The findings underscore the prevalence of abnormally low 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e levels and elevated parathyroid hormone (PTH) levels among patients experiencing musculoskeletal pain, suggesting a potential association with MEPS. The study has also highlighted the surprising occurrence of higher-than-normal 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e levels in some patients, raising concerns about the pattern of over-prescription of supplements and NSAIDs among Palestinian healthcare professionals. Additionally, the significant association between low Vitamin D levels and musculoskeletal pain severity, as well as the correlation between high PTH levels and the severity of musculoskeletal pain, emphasizes the need for thorough diagnoses and follow-up plans in the Palestinian healthcare system. Furthermore, the study delves into the misdiagnosis of Rheumatoid Arthritis (RA) and the prevalence of conditions such as Ankylosing Spondylitis, Polymyalgia Rheumatica, and FMS in the studied population. This misdiagnosis poses challenges in providing appropriate patient treatment and calls for thorough diagnostic measures before diagnosis. The proposed expansion of the MEPS definition to include other rheumatologic and orthopedic conditions, older age groups, and T2DM status is a novel contribution. The study suggests that MEPS may involve a broader spectrum of musculoskeletal disorders beyond Fibromyalgia, emphasizing the importance of considering various factors in the diagnostic process. The paper also draws attention to lifestyle factors such as smoking and hypertension, which, although not significantly associated with musculoskeletal pains in this study, warrant intervention by the Palestinian healthcare system due to their high prevalence. This study capitalizes on the complexity of musculoskeletal pain presentations and the need for comprehensive diagnostic approaches. The proposed expansion of MEPS criteria opens avenues for further research and may have implications for clinical practice guidelines. Ultimately, these findings contribute to our understanding of the multifaceted nature of musculoskeletal disorders in the Middle Eastern population and call for a more nuanced approach to diagnosis and treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col class=\"decimal_type\"\u003e\n \u003cli\u003eMEPS: Musculoskeletal and Extraintestinal Pain Syndromes\u003c/li\u003e\n \u003cli\u003eFMS: Fibromyalgia Syndrome\u003c/li\u003e\n \u003cli\u003e1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e: Vitamin D\u003c/li\u003e\n \u003cli\u003eHPT: Hyperparathyroidism\u003c/li\u003e\n \u003cli\u003ePTH: Parathyroid Hormone\u003c/li\u003e\n \u003cli\u003eSHPT: Secondary Hyperparathyroidism\u003c/li\u003e\n \u003cli\u003eRA: Rheumatoid Arthritis\u003c/li\u003e\n \u003cli\u003eNSAIDs: Non-steroidal anti-inflammatory Drugs\u003c/li\u003e\n \u003cli\u003eDMARDs: Disease-Modifying Antirheumatic Drugs\u003c/li\u003e\n \u003cli\u003eT2DM: Type 2 Diabetes Mellitus\u003c/li\u003e\n \u003cli\u003eESR: Erythrocyte Sedimentation Rate\u003c/li\u003e\n \u003cli\u003eCRP: C-Reactive Protein\u003c/li\u003e\n \u003cli\u003eRF: Rheumatoid Factor\u003c/li\u003e\n \u003cli\u003eACPA: Anti-Citrullinated Protein Antibody\u003c/li\u003e\n \u003cli\u003eTNF-\u0026alpha;: Tumor Necrosis Factor-alpha\u003c/li\u003e\n \u003cli\u003eHLA: Human Leukocyte Antigen\u003c/li\u003e\n \u003cli\u003eAS: Ankylosing Spondylitis\u003c/li\u003e\n \u003cli\u003eIBD: Inflammatory Bowel Disease\u003c/li\u003e\n \u003cli\u003eSPA: Spondylarthritis\u003c/li\u003e\n \u003cli\u003eIL-17: Interleukin-17\u003c/li\u003e\n \u003cli\u003eIL-7: Interleukin-7\u003c/li\u003e\n \u003cli\u003eCBC: Complete Blood Count\u003c/li\u003e\n \u003cli\u003ePPAR-\u0026delta;: Peroxisome Proliferator-Activated Receptor delta\u003c/li\u003e\n \u003cli\u003eSSRIs: Selective Serotonin Reuptake Inhibitors\u003c/li\u003e\n \u003cli\u003eAAPT: ACTTION\u0026shy;American Pain Society Pain Taxonomy\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval was taken from An-Najah University\u0026rsquo;s institutional review board (IRB). In addition, approval was taken from the Ministry of Health\u0026rsquo;s research center. There are no risks to participants since they have no active role in this research. The team ensured that the privacy and confidentiality of the participants\u0026rsquo; data were protected using password-protected files. Furthermore, any personal data regarding the identity of the participants was not published in any shape, way, or form. Finally, the collected data was safely disposed of after the research. Please note that informed consent was not obtained from the participants since it is deemed unnecessary for retrospective studies according to An-Najah National University\u0026rsquo;s institutional review board (IRB).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIs not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.A.: the principal investigator optimized the study proposal and protocol, supervised the data analysis, and wrote most of the manuscript file. S.H. and N.K. participated in the study protocol writing, applied for IRB, data collection, and data analysis, and edited the manuscript file. J.A. and A.S. revised the final version of the manuscript, supervised the study, and assisted in the data analysis. M.A. and M.M. revised the study protocol and assisted in project supervision. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank our esteemed professors for their unconditional love and endless support throughout our medical school journey. We dedicate this work to our beloved parents and dear friends who continue to support us in indescribable ways.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eElbeialy AA, Bauomi AM, Elnaggar BM, Elzomor HM. Middle east pain syndrome is a pollution-induced new disease mimicking rheumatoid arthritis. 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Academic Press; 2019. pp. 163\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/B9780128148648000073\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/B9780128148648000073\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Vitamin D Deficiency, Hyperparathyroidism, Middle East Pain Syndrome, MSK Pain","lastPublishedDoi":"10.21203/rs.3.rs-4763944/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4763944/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted at three Palestinian healthcare centers between February and December 2023. Targeting RA patients of both sexes and all ages, the clinical characteristics of 397 patients were categorized using a stratified sampling technique. Data were retrieved from each center\u0026rsquo;s respective archive modalities. An adjusted multiple logistic regression model was utilized to test the association between 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e and Parathyroid levels with musculoskeletal pain severity. A p-value less than 0.05 was considered statistically significant. The Kolmogorov-Smirnov test was utilized to test the normality of continuous variable distribution.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMany patients fulfill criteria for other conditions, with slow disease progression noted, despite correct RA diagnosis. Pain severity correlated with deficient 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e (1.745 OR, P-value:0.05) and high PTH levels (PTH: 1.579 OR, P-value:0.027). Commonly reported pains include lower back, knees, cervical, and upper back areas. Muscular stiffness and bone tenderness are prevalent, with 41.03% reporting severe pain. Increased age correlates with severe pain (OR:1.53, P-value:0.015). Likewise, Type 2 Diabetes mellitus shows a significant positive association (OR:0.741, P-value:0.017). Despite the lack of significant associations, the high prevalence of smoking (47.1%) and hypertension (58.9%) requires intervention. Radiological reporting is unclear in 63.22% of cases, with 'bone spurs' commonly utilized. Additionally, 93.9% have low ionized calcium levels. Other lab results mostly fall within normal ranges, emphasizing the complexity of diagnosis and suggesting the importance of thorough radiological investigations and laboratory assays.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe recommend expanding MEPS criteria to include other conditions, highlighting the significant associations between 1,25(OH)\u003csub\u003e2\u003c/sub\u003eVD\u003csub\u003e3\u003c/sub\u003e deficiency, HPT, advanced age, and Type 2 Diabetes mellitus with musculoskeletal pains in diagnosed RA cases.\u003c/p\u003e","manuscriptTitle":"Expanding the Criteria of the Novel Middle East Pain Syndrome to Include More Rheumatologic and Orthopedic Conditions, Type 2 Diabetes Mellitus, and Advanced Age - Understanding Musculoskeletal Pains among Palestinian Patients with Rheumatoid Arthritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 13:49:22","doi":"10.21203/rs.3.rs-4763944/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f41bfa86-1254-43ec-9be6-5f1091fb8fd7","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T07:09:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-02 13:49:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4763944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4763944","identity":"rs-4763944","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}