Consensus evidence-based clinical practice recommendations for the diagnosis and treat-to-target management of osteoporosis in chronic kidney disease stages G4-G5D and post-transplantation: An initiative of Egyptian Academy of Bone Health

The aim of this study was to reach a consensus on an updated version of the recommendations for the diagnosis and Treat-to-Target management of osteoporosis that is effective and safe for individuals with chronic kidney disease (CKD) G4-G5D/kidney transplant. Delphi process was implemented (3 rounds) to establish a consensus on 10 clinical domains: (1) study targets, (2) risk factors, (3) diagnosis, (4) case stratification, (5) treatment targets, (6) investigations, (7) medical management, (8) monitoring, (9) management of special groups, (10) fracture liaison service. After each round, statements were retired, modified, or added in view of the experts' suggestions, and the percent agreement was calculated. Statements receiving rates of 7-9 by more than 75% of experts' votes were considered as achieving consensus. The surveys were sent to an expert panel ( = 26), of whom 23 participated in the three rounds (2 were international experts and 21 were national). Most of the participants were rheumatologists (87%), followed by nephrologists (8.7%), and geriatric physicians (4.3%). Eighteen recommendations, categorized into 10 domains, were obtained. Agreement with the recommendations (rank 7-9) ranged from 80 to 100%. Consensus was reached on the wording of all 10 clinical domains identified by the scientific committee. An algorithm for the management of osteoporosis in CKD has been suggested. A panel of international and national experts established a consensus regarding the management of osteoporosis in CKD patients. The developed recommendations provide a comprehensive approach to assessing and managing osteoporosis for all healthcare professionals involved in its management. [Abstract copyright: Copyright © 2022 by The Author(s). Published by S. Karger AG, Basel.

Trigeminal nerve electrophysiological assessment in sickle cell anemia: correlation with disease severity and radiological findings

Purpose The aim of our study was to assess, electrophysiologically, the possibility of associated subclinical trigeminal neuropathy in sickle cell anemia (SCA) patients and correlate the Results with disease severity and findings of computerized tomography. Materials and methods Fifty patients with SCA were included; 20 of these patients had clinical unilateral trigeminal neuropathy (group II), whereas the others were asymptomatic (group I). Forty matched healthy individuals served as a control group. Trigeminal evoked potential (TEP) and inferior alveolar nerve (IAN) conduction studies were carried out for all patients and controls. Findings were correlated with the frequency of vaso-occlusive crisis, mental foramen (MF), and mandibular canal (MC) dimensions as measured by computerized tomography. Results There were highly significantly longer N13, 19, and 20 latencies and reduced N13-P19 amplitude in patient groups in comparison with the controls (P<0.001). There were delayed P19 latency, IAN latency, reduced IAN amplitude (P<0.05), and conduction velocity (P<0.001) in SCA patients with trigeminal neuropathy versus those without trigeminal neuropathy, and also in asymptomatic patients versus controls. The vaso-occlusive crisis frequency in group II was correlated positively with all TEP waves′ latencies and IAN latency and correlated negatively with IAN amplitude, conduction velocity, and N13/P19 amplitude. MF and MC dimensions were significantly reduced in group II in comparison with the controls (P<0.05). MF height and MC diameter were correlated negatively with ipsilateral P19 latency. Conclusion Subclinical trigeminal neuropathy may be associated with SCA. The trigeminal nerve could be affected along its peripheral or the central pathway. Central affection may occur as a result of lesions in its nuclei or at the somatosensory cortex. Electrophysiological assessment is recommended in SCA patients to diagnose trigeminal neuropathy and detect the level of its affection. This will provide new insights into its prevention and treatment

Verification of an ultrasonographic scoring system in discriminating rheumatoid arthritis from osteoarthritic and normal joints in an Egyptian cohorts

Background The use of musculoskeletal ultrasound in rheumatoid arthritis (RA) has been growing over the last decades mainly to monitor response to treatment and for early detection of erosions. Suggestions to include this technique in the diagnosis of RA have been made, but not yet been implemented (because of the lack of specific sonographic criteria for RA). Objectives To verify the performance of a proposed combined structural and synovial scoring system in differentiating RA from osteoarthritis (OA) and healthy sonographic findings in the small joints of the hand. Patients and methods Twenty RA patients, 20 patients with hand OA, and 10 healthy controls were subjected to musculoskeletal ultrasound of the metacarpophalyngeal and proximal interphalyngeal joints. The novel proposed scoring system was applied characterizing each joint as either RA supported or RA unsupported. Grading of synovitis as mild, moderate, or severe was also performed. In the RA group, disease activity was assessed by Disease Activity Score 28 (DAS28) and anticyclic citrullinated peptide serum levels were measured. Results When one or more RA-supported joints were detected using this scoring system, it had a sensitivity of 100.0% and a specificity of 83.0%, with a diagnostic accuracy of 90.0%, for the diagnosis of RA. If two or more joints were detected, it had a sensitivity of 95.0% and a specificity of 96.7%, with a diagnostic accuracy of 96.0% for the diagnosis of RA. Conclusion The novel suggested combined structural and synovial scoring system showed high performance in differentiating RA from OA and controls

Fecal incontinence: challenges in electrodiagnosis and rehabilitation

Abstract Background Pelvic floor disorders are a common, yet debatable medical challenge. The management of fecal incontinence (FI) has always been a puzzle as it is a multifactorial problem that needs a skilled specialized teamwork. Main body of abstract FI has complex etiology including altered rectal sensibility, dysfunction of the pelvic floor muscles, and damage to the anal sphincter complex. The most valuable tests for the evaluation of FI are anorectal manometry, endoanal ultrasound, MRI with or without defecography, and neurophysiological studies. Neurophysiological tests of the pelvic floor muscles represent a valid method for studying the functional integrity of neural pathways, localizing a pathological process, and possibly revealing its mechanism and severity. These tests include assessment of conduction of the pudendal nerve, electromyography (EMG) of the sphincter as well as pelvic floor muscles, sacral reflexes, somatosensory-/motor-evoked responses, and perineal sympathetic skin response. Different approaches are available for the treatment of FI. These include conservative measures such as lifestyle and dietary modifications, medications, and pelvic floor rehabilitation which are considered the preferred lines to avoid the risk of interventions. However, more invasive approaches as the use of perianal injectable bulking agents, sacral nerve stimulation, or surgery are also present. Conclusion Finally, management of FI is a true challenge that needs multidisciplinary approach. Integrated diagnostic work-up between the related subspecialities, as well as tailoring the management plan according to each case, would help to reach best outcome

Consensus evidence-based clinical practice guidelines for the diagnosis and treat-to-target management of osteoporosis in Africa: an initiative by the African Society of Bone Health and Metabolic Bone Diseases.

The objective of this consensus statement is to inform the clinical practice communities, research centres and policymakers across Africa of the results of the recommendations for osteoporosis prevention, diagnosis and management. The developed guideline provides state-of-the-art information and presents the conclusions and recommendations of the consensus panel regarding these issues. To reach an African expert consensus on a treat-to-target strategy, based on current evidence for best practice, for the management of osteoporosis and prevention of fractures. A 3-round Delphi process was conducted with 17 osteoporosis experts from different African countries. All rounds were conducted online. In round 1, experts reviewed a list of 21 key clinical questions. In rounds 2 and 3, they rated the statements stratified under each domain for its fit (on a scale of 1-9). After each round, statements were retired, modified or added in view of the experts' suggestions and the percent agreement was calculated. Statements receiving rates of 7-9 by more than 75% of experts' votes were considered as achieving consensus. The developed guidelines adopted a fracture risk-centric approach. Results of round 1 revealed that of the 21 proposed domains, 10 were accepted whereas 11 were amended. In round 2, 32 statements were presented: 2 statements were retired for similarity, 9 statements reached consensus, whereas modifications were suggested for 21 statements. After the 3rd round of rating, the experts came to consensus on the 32 statements. Frequency of high-rate recommendation ranged from 83.33 to 100%. The response rate of the experts was 100%. An algorithm for the osteoporosis management osteoporosis was suggested. This study is an important step in setting up a standardised osteoporosis service across the continent. Building a single model that can be applied in standard practice across Africa will enable the clinicians to face the key challenges of managing osteoporosis; furthermore, it highlights the unmet needs for the policymakers responsible for providing bone health care together with and positive outcomes of patients' care. [Abstract copyright: © 2021. International Osteoporosis Foundation and National Osteoporosis Foundation.

Health economics: direct cost of osteoporotic hip fracture in Egypt—an analysis for the Egyptian healthcare system by the Egyptian Academy of Bone Health

Abstract Mini abstract This work studies the direct cost of hip fractures in Egypt. The direct cost was calculated based on the incidence of hip fracture in Egypt retrieved from the national database. The result of this work raises red flags to the policy makers in Egypt that such fragility fractures are preventable, should appropriate approaches be implemented. Background This study provides an analysis for the healthcare system in Egypt. It was carried out to assess the direct annual cost incurred to the Egyptian healthcare system in 2023 as a result of fragility hip fractures in older adult Egyptians. Results The direct costs of hip fractures incurred during the first year after the injury were estimated at 1,969,385,000 Egyptian pounds (US $63,734,142.4). Time from fracture to surgery was 2.2 + 0.5 days. The average hospital stay after hip fracture surgery was 5.2 + 2.6 days. 4.5% of patients died after surgery, on average 2.3 + 0.4 months. After being discharged from the hospital, all patients needed home care. Conclusion Hip fractures have a significant clinical and financial impact on patients and the healthcare system. This study raises red flags for the healthcare policy makers in Egypt, as the financial burden due to the direct costs of hip fractures justifies extensive prevention programs for osteoporosis and fragility fractures. There is an urgent need to implement diagnostic approaches and validated management protocols for bone health disorders and its associated fractures in Egypt

Standards for structured reporting of dual-energy X-ray absorptiometry scans: best practice recommendations by the Pan Arab Osteoporosis Society

Abstract Background Dual-energy X-ray absorptiometry (DXA) is an important diagnostic test for bone mass status. The aim of this work was to set the standards for structured reporting of DXA measurements in adults within the context of fracture and fall risk assessment. Results Two rounds of Delphi were completed. The first Delphi round had a 68% response rate, while round two had a 100% response rate. After round 2, a total of 28 items were obtained, which were classified into three domains. The percentage of people who agreed with the recommendations (ranks 9–7) ranged from 76.5 to 100%. The wording of all 19 clinical standards determined by the scientific committee was agreed upon (i.e., 75% of respondents strongly agreed or agreed). Conclusion The DXA scan report is an independent document that contains sufficient information to enable optimal osteoporosis management advised by an experienced healthcare professional. Setting up quality standards for DXA scans not only supports healthcare professionals reporting/interpreting bone densitometry but also meets the parameters outlined in national as well as international guidelines or recommendations for the optimal management of osteoporosis and subsequent prevention of low trauma fractures

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

Abstract Background This study was carried out to achieve an Egyptian expert consensus on a treat-to-target management strategy 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

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit