Rheumatology-led pregnancy clinic: enhancing the care of women with rheumatic diseases during pregnancy

The autoimmune rheumatic diseases have a clear predilection for women. Consequently, issues regarding family planning and pregnancy are a vital component of the management of these patients. Not only does pregnancy by itself causes physiologic/immunologic changes that impact disease activity but also women living with inflammatory arthritic conditions face the additional challenges of reduced fecundity and worsened pregnancy outcomes. Many women struggle to find adequate information to guide them on pregnancy planning, lactation and early parenting in relation to their chronic condition. This article discusses the gaps in the care provided to women living with inflammatory arthritis in standard practice and how a rheumatology nurse-led pregnancy clinic would fill such gap, consequently enhance the care provided and ensure appropriate education is provided to these individuals who represent the majority of the patients attending the rheumatology outpatient clinics. Such specialist care is expected to cover the whole journey as it is expected to provide high-quality care before, during and after pregnancy

A Proposed Pathway For The Treatment of Giant Cell Arteritis: Experience From a District General Hospital in The United Kingdom

Introduction: Giant Cell arteritis can be difficult to diagnose clinically. In those cases, where there is no certainty, there is more reliance on a temporal artery biopsy and radiological imaging to confirm the diagnosis. The purpose of this article was to identify the standard of care in individuals with suspected Giant Cell Arteritis in a typical district general hospital and to offer a proposed pathway for treatment. Methods: Darent Valley Hospital has been managing Giant Cell Arteritis for many years but there has always been a need for an outlined pathway to identify those at risk of cranial complications like visual loss to improve patient care. We evaluated the management of 70 individuals that had a temporal artery biopsy and followed their treatment journey. We extracted clinical specialist, emergency admission, operation theatre and histological data. We collected clinic follow up data over the following years to identify those that relapsed on treatment, stayed in remission or had complications. We propose a pathway to manage those individuals with Giant Cell arteritis in line with the new advances in treatment. Results: Ten patients were identified that had a histologically positive biopsy. Reassuringly, most individuals with an obvious clinical diagnosis had high dose glucocorticoid treatment commenced before even being referred for a biopsy. Nine individuals had visual ischemia out of which five lost their vision. Conclusion: The presentation of a pathway will help streamline best medical and surgical practice and ensure the availability of urgent specialist treatment and to identify those at risk of ischemic complications. (Raza M, El Miedany Y. A Proposed Pathway For The Treatment of Giant Cell Arteritis: Experience From a District General Hospital in The United Kingdom. SEEMEDJ 2018; 2(2); 34-47

Socioeconomic deprivation and age are barriers to the online collection of patient reported outcome measures in orthopaedic patients

Introduction: Questionnaires are used commonly to assess functional outcome and satisfaction in surgical patients. Although these have in the past been administered through written forms, there is increasing interest in the use of new technology to improve the efficiency of collection. The aim of this study was to assess the availability of internet access for a group of orthopaedic patients and the acceptability of online survey completion. Methods: A total of 497 patients attending orthopaedic outpatient clinics were surveyed to assess access to the internet and their preferred means for completing follow-up questionnaires. Results: Overall, 358 patients (72%) reported having internet access. Lack of access was associated with socioeconomic deprivation and older age. Multivariable regression confirmed increased age and greater deprivation to be independently associated with lack of internet access. Out of the total group, 198 (40%) indicated a preference for assessment of outcomes via email and the internet. Conclusions: Internet access was not universal among the patients in our orthopaedic clinic. Reliance on internet collection of PROMs may introduce bias by not including results from patients in older age groups and those from the more deprived socioeconomic groups

Diagnostic and prognostic values of antikeratin antibodies (AKA) and collagen III propeptides (PIIINP) in juvenile rheumatoid arthritis

Background: The need for specific and sensitive diagnostic as well as prognostic markers for juvenile rheumatoid arthritis (JRA) has urged  scientific research toward this field.Objective: We sought to assess the diagnostic and prognostic values of serum and synovial fluid collagen III propeptides (PIIINP) and antikeratin antibodies(AKA) in JRA.Methods :Thirty-one JRA patients with a mean age of 10.6±4.2 years were enrolled in the study. They were compared to 10 SLE patients with arthritis and 15 age and sex matched healthy children as control groups. All  patients were subjected at enrollment to laboratory evaluation by CBC,  ESR, CRP, serum PIIINP and AKA. Patients with knee effusion were  subjected to AKA and PIIINP analysis in their synovial fluid samples. Clinical evaluation was done by examination of joint swelling, tenderness and limitation of movement scores. Also, radiological evaluation by plain X-ray films for hands, knees and feet using modified Larsen score (MLS) was performed. Laboratory, clinical and radiological evaluation methods were re-performed after 3 months of proper treatment. A third radiological evaluation was done one year after the first evaluation.Results: Serum PIIINP was significantly elevated in JRA patients  (12.8±8.7) ìg/L in comparison to healthy controls (7.0±1.9 ìg/L, p<0.05). However, no significant difference was observed when compared to SLE patients. Reduction of serum PIIINP was observed after 3 months of treatment with no significant difference between JRA patients (10.5±8.8 ìg/L) and the healthy controls. Synovial fluid PIIINP (56.4±6.6 ìg/L) was significantly higher than that of the serum (p<0.05). Neither serum nor synovial fluid PIIINP correlated with any of the laboratory, clinical or radiological parameters. The serum AKA positivity rate was significantly higher in JRA patients (77% at the study onset and 90% after three months) as compared to the control group (7%, p<0.001). Serum AKA values recorded a sensitivity, specificity and diagnostic efficiency in JRA patients of 77%, 93% and 83% at the study onset. These values increased after 3 months to 90%, 93% and 91% respectively. Synovial AKA levels displayed no significant difference in comparison to that of the serum.Conclusion :AKA is a specific and sensitive diagnostic marker for JRA. Meanwhile, PIIINP was significantly elevated during JRA disease activity particularly in the synovial fluid. Neither AKA nor PIIINP proved to have prognostic values in JRA.Key words: juvenile rheumatoid, arthritis, antikeratin antibodies, collagen III propeptides, SLE

The Egyptian Arabic version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR)

The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient-reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). We report the results of the cross-cultural adaptation and validation of the parent and patient versions of the JAMAR in the Egyptian Arabic language. The reading comprehension of the questionnaire was tested in ten JIA parents and patients. Each participating centre was asked to collect demographic, clinical data and the JAMAR in 100 consecutive JIA patients or all consecutive patients seen in a 6-month period and to administer the JAMAR to 100 healthy children and their parents. The statistical validation phase explored descriptive statistics and the psychometric issues of the JAMAR: the 3 Likert assumptions, floor/ceiling effects, internal consistency, Cronbach\u2019s alpha, interscale correlations, test\u2013retest reliability, and construct validity (convergent and discriminant validity). A total of 100 JIA patients (20.0% systemic JIA, 40.0% undifferentiated arthritis, 24.0% RF negative polyarthritis, 16.0% other categories) and 100 healthy children were enrolled in one paediatric rheumatology centre. The JAMAR components discriminated well healthy subjects from JIA patients. All JAMAR components revealed satisfactory psychometric performances. In conclusion, the Egyptian Arabic version of the JAMAR is a valid tool for the assessment of children with JIA and is suitable for use both in routine clinical practice and in clinical research

African League Against Rheumatism (AFLAR) preliminary recommendations on the management of rheumatic diseases during the COVID-19 pandemic

Objectives: To develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic. Method: A task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1-3, 4-6 and 7-9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a \u27low\u27 level of agreement. Results: A total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting. Conclusions: The preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges. Key Points • AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic. • COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists. • Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs. • Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk

Consensus evidence-based recommendations for treat-to-target management of immunoglobulin A vasculitis

IgA vasculitis (IgAV), formerly known as Henoch-Schönlein purpura, is the most common cause of systemic vasculitis in childhood. Given its potential life-threatening systemic complications, early and accurate diagnosis as well as management of IgAV represent a major challenge for health care professionals. This study was carried out to attain an evidence-based expert consensus on a treat-to-target management approach for IgAV using Delphi technique. The preliminary scientific committee identified a total of 16 key clinical questions according to the patient, intervention, comparison, and outcomes (PICO) approach. An evidence-based, systematic, literature review was conducted to compile evidence for the IgAV management. The core leadership team identified researchers and clinicians with expertise in IgAV management in Egypt upon which experts were gathered from different governorates and health centers across Egypt. Delphi process was implemented (two rounds) to reach a consensus. An online questionnaire was sent to expert panel (n = 26) who participated in the two rounds. After completing round 2, a total of 20 recommendation items, categorized into two sections were obtained. Agreement with the recommendations (rank 7–9) ranged from 91.7–100%. Consensus was reached (i.e. ⩾75% of respondents strongly agreed or agreed) on the wording of all the 20 clinical standards identified by the scientific committee. Algorithms for the diagnosis and management have been suggested. This was an expert, consensus recommendations for the diagnosis and treatment of IgAV and IgA vasculitic nephritis, based on best available evidence and expert opinion. The guideline presented a strategy of care with a pathway to achieve a state of remission as early as possible

Impact of Educational Stage in the Application of Flipped Learning: A Contrasting Analysis with Traditional Teaching

The effectiveness of flipped learning depends largely on student typology. This study analyzes the applicability of this approach, according to the characteristics inherent to students based on their educational stage. The objective of the research is to verify the effectiveness of flipped learning compared to a traditional methodology during the stages of preschool, primary, and secondary education. For this study, a descriptive and correlational experimental research design was followed, based on a quantitative methodology. Two types of analysis groups (control and experimental) were established in each of the mentioned educational stages. As a data collection instrument, a validated ad hoc questionnaire was applied to a sample of 168 students from the Autonomous City of Ceuta (Spain). The results show that the applicability of flipped learning is more positive in primary and secondary education when compared to a traditional teaching method. However, the results found in preschool education reflect the difficulties in adapting the model to the needs of the students of that stage, due to the difficulties in the autonomous management of digital teaching platforms and the requirement of a minimum level of abstraction to apply this approach

Egyptian consensus on treat-to-target approach for osteoporosis: a clinical practice guideline from the Egyptian Academy of bone health and metabolic bone diseases

Background: This study was carried out to achieve an Egyptian expert consensus on a treat-to-target managementstrategy for osteoporosis using Delphi technique. A scientific committee identified researchers and clinicians with expertise in osteoporosis in Egypt. Delphi process was implemented (2 rounds) to establish a consensus on 15 clinical standards: (1) concept, (2) diagnosis, (3) case identification, (4) whom to treat, (5) who should treat?, (6) case stratification and intervention thresholds, (7) falls risk, (8) investigations, (9) treatment target, (10) management, (11) optimum treatment duration, (12) monitoring, (13) drug holiday, (14) osteoporosis in men, and (15) post-fracture care and fracture liaison service. Results: The surveys were sent to an expert panel (n = 25), of whom 24 participated in the two rounds. Respondents were drawn from different governorates and health centres across Egypt including the Ministry of Health. Most of the participants were rheumatologists (76%), followed by internists (8%), orthopaedic doctors (4%), rehabilitation doctors (4%), primary care (4%), and ortho-geriatrics (4%) physicians. Seventy-two recommendations, categorised into 15 sections, were obtained. Agreement with the recommendations (rank 7–9) ranged from 83.4 to 100%. Consensus was reached (i.e. ≥ 75% of respondents strongly agreed or agreed) on the wording of all 15 clinical standards identified by the scientific committee. An algorithm for the management of postmenopausal osteoporosis has been suggested. Conclusion: A wide and representative panel of experts established a consensus regarding the management of osteoporosis in Egypt. The developed guidelines provide a comprehensive approach to the assessment and management of osteoporosis for all Egyptian healthcare professionals who are involved in its management