Mervat Eissa

Egypt is one of the oldest civilizations in the world and the most populous Arab country, with an estimated population of 103 million people in 2022. Despite a free healthcare services policy, the healthcare system in Egypt faces some challenges, including a low level of government health expenditure (4–5% of gross domestic product, GDP) with a resultant high out-of-pocket expenditure (57.2% of total health expenditure). Although there are no formal screening programs for rheumatic diseases in Egypt, the estimated burden of rheumatic diseases was 0.04% of the total disease burden in Egypt in 2014. The laboratory and radiological investigations necessary for diagnosing rheumatic diseases, as well as the facilities required for their proper management, pose minor obstacles. Economic and financial constraints, however, present a significant challenge to ensuring equity in provided services. There are ongoing attempts to improve insurance coverage to face such challenges. With around 1200 rheumatologists and some rheumatology associations, including the Egyptian Society of Rheumatic Diseases, Egypt has an active pivotal role in research and managing rheumatic diseases in the Arab world.

Aim: This study aimed to evaluate the efficacy of carboxymethyl cellulose (CMC)-based natural mixture of aloe vera gel and coconut oil as a salivary substitute in comparison to the conventional CMC for the management of xerostomia in a sample of patients with Sjogren’s syndrome (SS). Methods: This crossover randomized clinical trial included 24 patients diagnosed with SS. Half the patients started with the study treatment (A-Gel) for 2 weeks, then went through a 7-day washout period, then received the control treatment (B-Gel), while the other half had the order reversed. The measured outcomes were subjective oral dryness (Bother 1’ xerostomia index), modified xerostomia quality of life scale (XeQoLS), clinical oral dryness (CODs), and salivary candidal load. Results: With a mean age of 46.96 ± 11.86 years, all patients were female and suffered from mouth dryness for 16.58 ± 25.32 months. In light of our findings, both groups’ Bother 1’ xerostomia index values recorded at different intervals showed significant improvements. There was a p < 0.001 difference between the mean value for groups A and B at baseline (7.33 ± 2.39 and 7.29 ± 2.66), one week later (4.17 ± 2.24 and 4.25 ± 2.57), and two weeks later (2.83 ± 2.08 and 2.88 ± 2.07). However, there was no significant difference between the groups. Likewise, for CODs and modified XeQoLS, no significant difference was found between groups; however, both groups showed a statistically significant improvement (p < 0.001). Improvement in the modified XeQoLS was observed in all domains (physical functioning, pain & clinical acceptance). Regarding candidal load, there was no statistically significant difference between groups or even within groups (p > 0.05). Conclusions: As salivary substitutes, the CMC natural mixture (aloe vera, coconut oil) and the conventional CMC-based oral gel are equally efficient at minimizing xerostomia symptoms and enhancing SS patients’ quality of life with minimal side effects. Saliva’s natural effect might be substituted with a natural mixture of coconut oil, aloe vera gel, and CMC. The trial is registered on clinicaltrials.gov, identifier: NCT04252209.

Single nucleotide polymorphisms (SNPs) of the protein tyrosine phosphatase non-receptor type 2 (PTPN2) gene have been documented to be linked with several autoimmune disorders including Behçet’s disease (BD). PTPN2 SNPs rs2542151 and rs7234029 have been assessed using real-time PCR in 96 BD patients and 50 controls matched by age and gender. Patients were categorized into groups according to the disease phenotypes and severity. A total of 94.8% of patients were males. The patients’ mean age at onset was 26.1 ± 8 years. The median (IQR) disease duration was 8.5(4–13) years. No difference was observed between the patients and controls concerning the frequency of the two SNPs’ different genotypes, models, and alleles. Moreover, neither disease phenotypes nor severity were associated with rs2542151 or rs7234029 SNPs. PTPN2 rs2542151 and rs7234029 SNPs do not seem to have associations with BD occurrence, phenotypes, or severity in the Egyptian patients. Key Points • PTPN2 rs2542151 and rs7234029 SNPs do not seem to have associations with BD occurrence, phenotypes, or severity in the Egyptian patients.• Further studies involving a larger sample size with variable clinical diversity are recommended to verify the results.

Objective: Our objective was to develop and validate cutoff values in the systemic Juvenile Arthritis Disease Activity Score 10 (sJADAS10) that distinguish the states of inactive disease (ID), minimal disease activity (MDA), moderate disease activity (MoDA), and high disease activity (HDA) in children with systemic juvenile idiopathic arthritis, based on subjective disease state assessment by the treating pediatric rheumatologist.Methods: The cutoff definition cohort was composed of 400 patients enrolled at 30 pediatric rheumatology centers in 11 countries. Using the subjective physician rating as an external criterion, six methods were applied to identify the cutoffs: mapping, calculation of percentiles of cumulative score distribution, the Youden index, 90% specificity, maximum agreement, and receiver operating characteristic curve analysis. Sixty percent of the patients were assigned to the definition cohort, and 40% were assigned to the validation cohort. Cutoff validation was conducted by assessing discriminative ability.Results: The sJADAS10 cutoffs that separated ID from MDA, MDA from MoDA, and MoDA from HDA were ≤2.9, ≤10, and >20.6, respectively. The cutoffs discriminated strongly among different levels of pain, between patients with and without morning stiffness, and among patients whose parents judged their disease status as remission or persistent activity or flare or were satisfied or not satisfied with current illness outcome.Conclusion: The sJADAS cutoffs revealed good metrologic properties in both definition and validation cohorts and are therefore suitable for use in clinical trials and routine practice.

Background: Despite the recent advances in the management of inflammatory arthritis, a considerable proportion of arthritis patients remain symptomatic. This cohort has recently been identified as ‘difficult to treat’ (D2T). In view of the limited evidence base, management of these patients has been a challenge particularly in view of its associated significant economic health burden. A better understanding of the D2T may help recognise or develop new therapeutic targets and facilitate earlier intervention in the disease course to prevent the progression of such condition. The aim of this work is to address the unmet needs in the management of D2T arthritis and develop a comprehensive approach towards the identification and proper assessment of those patients. Results: At the completion of round 3 Delphi process, a total of 20 items were obtained and divided into 5 domains. From 88.9 to 100% of respondents agreed with the recommendations (ranks 7–9). All 20 of the clinical standards that the scientific committee identified were agreed upon in terms of wording, recommendation grade, and level of evidence (i.e. 75% of respondents strongly agreed or agreed). Conclusion: D2T inflammatory arthritis remains a relevant clinical challenge, despite the endorsement of the treat-to-target approach and the availability of a broad range of targeted arthritis medications. This study provided a comprehensive definition of the condition to facilitate the identification of this patients’ group. It also highlighted the goals and principles aiming at providing an effective framework for D2T assessment, closely monitor and set up a strategy to intervene in standard clinical practice.

Background: Transition of care means the process of educating and empowering adolescents and young adults to take an active role in their own healthcare, develop decision-making skills, and eventually transition from paediatric to adult healthcare providers. Most people do not switch doctors until they are young adults, but it can be beneficial to start preparing children earlier. We aimed to develop a specific toolkit tailored to paediatric and adult rheumatologists to assist them in transitioning of care of young people with juvenile onset rheumatic musculoskeletal diseases from the paediatric to adult rheumatology care. Results: The expert panel was confined to an online survey (n = 18), all the experts completed the two rounds. At the conclusion of round 2, a total of 10 points were gathered. The range of respondents (ranks 7–9) who agreed with the recommendations was 88.9 to 100%. All 10 clinical standards identified by the scientific committee were written in the same way. Based on the answers to the structured key questions and the literature review, a structured template was developed presenting transition of care integrated pathway. Conclusion: The developed rheumatology-specific guideline offers adolescents and young adults a focussed, multidisciplinary transition of care approach with equity of access, quality of care and flexibility and set up standards for transitional care for young adults with juvenile rheumatological diseases.

Background: Vitamin D (vit D) controls inflammation and immunity. In Behçet’s disease (BD), microRNA-155 is recognized as a significant immune response regulator. We aimed to investigate the role of vit D on immunomodulation and downregulation of inflammatory pathways associated with BD and detect the role of miRNA-155 in BD. Methods: miRNA-155 expression by ...

Background: Kawasaki disease (KD) is an acute, self-limited febrile disease of unidentified cause that mostly affects children less than 5 years of age. This work aimed to provide an appropriate Egyptian evidence-based consensus on clinical practice recommendations for the management of Kawasaki disease. The main objective of this study, which employed the Delphi method, was to reach a consensus among experts on a treat-to-target management approach for KD. Results: The expert panel was confined to an online survey (n=26), and all the expert completed the three rounds. At the conclusion of round 3, a total of 17 recommendation items were gathered, which were divided into two sections. The range of respondents (ranks 7–9) who agreed with the recommendations was 92.3 to 100%. All 17 clinical standards identified by the scientific committee were written in the same way. There have been algorithms proposed for managing various KD conditions. Conclusion: The developed evidence-based consensus recommendations for the diagnosis and management of KD represent an up-to-date document that focuses on clinical management questions which are generally posed to health care professionals involved in the management of KD. This guideline was developed considering experience with and availability of treatment and diagnostic options in Egypt.

Background: Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by having varying clinical presentation, severity, unpredictable course as well as outcomes. Recent disease-modifying conventional and biologic agents have enhanced rates of attaining both short- and long-term management goals, including minimization of glucocorticoid dose and use. This study was carried out to develop an up-to-date evidence-based, consensus on clinical practice guidelines for treat-to-target management of systemic lupus erythematosus in adults. Results: The response rate to the online questionnaires, sent to the expert panel who participated in the three rounds, was 95.5%. At the end of round 3, a total of 14 recommendation sections were proposed for the T2T management of patients with SLE. Agreement with the recommendations (rank 7–9) ranged from 90.9–100%. Consensus was reached (i.e., ≥ 80% of respondents strongly agreed or agreed) on the proposed statements. Conclusion: These recommendations provide a consensus on the treat-to-target management of patients with SLE. They provide strategies to reach optimal outcomes in common clinical scenarios, based on a combination of evidence and expert opinion.

Background: Despite the associated high prevalence of morbidity and mortality, osteoporotic fragility fractures remain underdiagnosed and undertreated. Furthermore, those who sustain a fragility fracture are at imminent risk of sustaining subsequent fractures. Post-fracture care (PFC) programs are systematic, coordinated care programs that recognize, evaluate, and manage older adults who sustained a fragility fracture with the goal of managing all the risk factors and preventing succeeding fractures. Main text: This work was carried out to outline the PFC program adopted in Egypt and its applicability in standard clinical practice. A review of literature was conducted to identify an evidence-informed PFC strategies and protocols, which outlines the optimal manner to manage older adults living with fragility fractures. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist was used to guide the reporting of this review. Based on this, a PFC integrated model of care based on a patient-centered approach has been developed aiming to optimize the outcomes. Conclusion: This manuscript described the integrated model of care adopted in Egypt to provide care for older adults presenting with fragility fractures. This will pave the way to standardize patient identification and management. Additionally, to prevent occurrence of subsequent fractures and to enhance equity of care for patients with fragility fracture and osteoporosis, expansion of such service to rural and remote areas is highly recommended.