Wafa Hamdi

Objectives: Still disease, which includes systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still disease (AOSD), has historically had age-related treatment differences. With the advent of bDMARDs and evolving disease knowledge, management approaches have shifted. Our study aims to describe 2024 reported clinical practices for Still disease in France, and compare them with 2017 and 2024 national guidelines to identify practice gaps. Methods: This study is a French subanalysis of the European JIR-CliPS project, which evaluates reported prescribing practices for inflammatory diseases, taking into account recommendations and socio-economic factors in the participating countries. A detailed questionnaire was distributed to French physicians through professional societies and colleges. Results: Forty-seven physicians, mainly pediatric rheumatologists, internists, and rheumatologists, participated. While national guidelines influenced therapeutic decisions in most cases, only 26.7% followed them strictly, and 78.9% perceived no significant differences in the management of sJIA and AOSD. Treatment decisions were primarily guided by disease phenotype, severity, and relapse status. The use of bDMARDs as first-line treatment remained limited for several phenotypes, and glucocorticoid tapering strategies were heterogeneous, with most physicians adjusting tapering based on clinical response rather than following a standard schedule. Conclusion: This study highlights gaps between 2024 practice and current national guidelines for Still disease, particularly in first-line bDMARD use and glucocorticoid tapering. Understanding these gaps may support standardized practice and improved management of Still disease in the future.

The coronavirus pandemic 2019 (COVID-19) is the most significant public health concern in current times. In addition to its massive morbidity and mortality toll, the pandemic significantly impacted social interactions and global economies. As a group, the Arab countries ranked 12th in the list of most affected countries in terms of the total number of cases (31,304 cases/1,000,000 population) and ninth in the list of deaths worldwide (383 deaths per 1,000,000 population as of March 2023). Many disparities in epidemiology, infection rate, and clinical outcomes were observed within the Arab countries, which may be attributed to differences in the population’s age, ethnicity, vaccination rates, and healthcare systems. Patients with chronic rheumatic and musculoskeletal diseases (RMDs) were particularly affected, as many of them are generally immunocompromised and vulnerable to infection. Data from the Arab League of Associations for Rheumatology (ArLAR) highlighted the deleterious consequences of the COVID-19 pandemic on the continuity of rheumatology care, the persistence of chronic medication (particularly hydroxychloroquine), the patient’s mental health, and the overall income, which are all key predictors of disease prognosis. Studies also highlighted the negative impact on rheumatologists, with a significant reduction in outpatient and inpatient activities and an important effect on physicians’ mental health. In addition to the risk of infection, the main challenges in managing patients with RMDs during the pandemic included the difficulty of access to rheumatology care, lack of proper access to telehealth, shortage of essential anti-rheumatic drugs, and a negative impact on mental health and economic levels. All these factors were associated with a low persistence of chronic anti-rheumatic drugs and poor disease control. These challenges were addressed through a series of strategies, including the development and dissemination of the best practice guidelines for the use of telehealth in rheumatology by the ArLAR, the conduct of studies investigating the acceptability of the COVID-19 vaccination in patients with RMDs and healthcare providers, and the promotion of awareness campaigns targeting patients with RMDs and the general population. Rheumatologists were compelled to leave their comfort zone, adopt new technologies, promote public health, and fulfill their duties as role models to patients. These are crucial practice lessons that will remain in the future.

Objective To establish cutoff values for the Arabic version of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire and examine their applicability across different cultural and ethnic backgrounds in Arab countries. Methods This study is a sub-analysis of the TACTIC initiative, a multicentric, multinational cross-sectional study. A total of 553 patients diagnosed with PsA from 13 Arab countries were included. Demographic and clinical data were collected, and disease activity was assessed using the Disease Activity in Psoriatic Arthritis (DAPSA) score. Psychometric scores, including the Patient Global Assessment (PGA), Health Assessment Questionnaire (HAQ), Patient Health Questionnaire (PHQ-4), and Fibromyalgia Screening Tool (FiRST), were also evaluated. PsAID thresholds were determined using Ward’s method and the “Anchor-based Threshold Determination” according to changes in DAPSA categories. Results Five hundred fifty-three patients were included in the current analysis, with 59.0% being female. The mean age of the patients was 45.5 years (SD 13.15), and the mean disease duration was 8.8 years (SD 7.3). The mean PsAID was 3.8 (SD 2.3), and the mean DAPSA was 19.3 (SD 16.1). Two clusters were identified based on PsAID levels. Cluster 1 (n = 315) had a mean PsAID of 2.15, while cluster 2 (n = 238) had a mean PsAID of 6.12. Using Ward’s method, the cutoff value was established at 4.1. A strong positive correlation was observed between DAPSA and PsAID scores (r = 0.718, p < 0.001). The anchor-based threshold analysis—based on shifts in DAPSA disease activity categories—identified a cutoff value of 3.8, which demonstrated good sensitivity and specificity in distinguishing between different levels of disease activity with an AUC of 0.83. Conclusion The Arabic PsAID threshold was found to be consistent with the internationally established value of 4. These identified cutoff points can serve as valuable tools for evaluating the impact of psoriatic arthritis on patients' quality of life. Moreover, they can help guide more personalized treatment strategies across diverse populations and ethnic groups. Key Points • This study established cutoff values for the Arabic version of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, confirming their alignment with international thresholds. • Analysis of 553 patients from 13 Arab countries demonstrated robust correlations between PsAID and disease activity measures, with an optimal cutoff around 4. • These thresholds provide reliable tools for assessing disease impact and can support personalized treatment strategies across diverse Arab populations.

Objective To present updated evidence-based recommendations with a range of therapeutic options for children in Africa with oligoarticular juvenile idiopathic arthritis (JIA), adopting the treat to-target approach. Methods This study was conducted by the Paediatric Society of the African League Against Rheumatism (PAFLAR) to reach a consensus for recommendations regarding diagnosis and management of oligoarticular JIA suitable for application among different African countries. The Delphi technique was used to reach a consensus of 15 key questions identified by the steering committee. According to the PICO (patient/population, intervention, comparison, outcome) approach, a voting process among 22 African and international clinicians and experts in the field of pediatric rheumatology was performed after intensive systematic review of literature. Results A consensus was reached for 15 recommendations for diagnosis, monitoring, management of the disease, and its complications, intervention, and when to discontinue treatment of oligoarticular JIA patients with high level of agreement (ranging between 85 and 95%) who agreed or strongly agreed, and the response rate was 100%. Conclusion These recommendations focus on the early diagnosis and multidisciplinary management of oligoarticular JIA and its complications with high levels of consensus and agreement, improving practice consistency among healthcare providers. Key Points • A panel of experts created a consensus about the early diagnosis of oligoarticular JIA • Consensus-based recommendations to the management of oligoarticular JIA • These guidelines emphasized on the oligoarticular JIA-specific characteristics, severity factors, and treatment alternatives

Objective: Psoriatic arthritis (PsA) guidelines aim to provide consistent, evidence-based recommendations. Multiple regional guidelines exist, often based on similar evidence but with different methodologies and contexts. Our aim was to compare recent PsA treatment guidelines from the American College of Rheumatology, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, European Alliance of Associations for Rheumatology, and Pan American League of Associations for Rheumatology, identifying similarities, differences, and opportunities for global harmonization with regional adaptation. Methods: Narrative comparative review of guideline documents published between 2018 and 2024 by major rheumatology societies was performed. Data on methodology, panel composition, treatment domains, pharmacologic recommendations, and update strategies were extracted and synthesized. Results: Guidelines share core principles, including domain-based approaches, treat-to-target strategies, and the use of conventional synthetic disease-modifying antirheumatic drugs and biologics. Differences arise from methodological frameworks (eg, GRADE [Grading of Recommendations Assessment, Development, and Evaluation], domain-based, adolopment), stakeholder composition, and explicit consideration of regional drug access. Conclusion: A hybrid framework combining global core recommendations with modular regional adaptations may optimize resource use, improve guideline sustainability, and maintain local relevance. Living systematic reviews and artificial intelligence could support more timely updates.

That explores the experiences of parents caring for children with JIA at a tertiary referral hospital. Through in-depth interviews, the study identifies eight major challenges: medicalrelated difficulties, emotional distress, coping mechanisms, financial constraints, social challenges, interactions with healthcare personnel, and work-life disruptions. The findings highlight the critical need for a holistic, patient-centered approach that not only addresses the medical needs of children with JIA but also provides structured support for caregivers. Enhancing access to resources, developing targeted interventions, and increasing awareness among healthcare providers about the impact of JIA are essential steps toward improving outcomes for both patients and their families.experience to improve healthcare. Thereby, the realities of clinical practice can sometimes be difficult to confront, particularly when it comes to delayed diagnoses in pediatric rheumatology. A striking case report from Bouaké, Ivory Coast, highlights the diagnostic challenges of JSLE, illustrating a 12-year journey before an accurate diagnosis was established. Initially misdiagnosed as malaria, sickle cell disease, and tuberculosis, the patient endured years of untreated disease activity, leading to severe complications. The diagnosis at the age of 17, underscores the urgent need for increased clinical suspicion, enhanced physician training, and improved diagnostic infrastructure in African healthcare settings. This case serves as a powerful reminder that early recognition and timely intervention are critical in preventing disease progression and reducing morbidity. Addressing these challenges can pave the way for better pediatric rheumatology care and improved patient outcomes across the continent.Pathway for Pediatric Rheumatology. In fact, Nigeria's pediatric rheumatology landscape has witnessed gradual progress, yet significant gaps remain. This review provides a comprehensive look at the field's development, challenges, and future direction. While Lagos has made strides with the establishment of a dedicated pediatric rheumatology unit, specialized services remain scarce across most Nigerian states. Key obstacles identified in this review include low disease awareness, high diagnostic costs, a shortage of trained specialists, and limited research data. Addressing these challenges requires strategic investment in pediatric rheumatology training programs, expansion of specialized care units, and nationwide awareness campaigns.Essential Data with Clinical Implications. Thus, back pain in children and adolescents is often underestimated, yet it can serve as an early indicator of underlying rheumatic conditions (5). A retrospective study conducted in Douala, Cameroon, provides a decade-long overview of juvenile-onset back pain (JOBP), analysing clinical presentation and imaging findings. Among the 67 children diagnosed with JOBP, chronic mechanical lumbar pain was the most prevalent, related with imaging abnormalities such as disc disease and scoliosis. This study offers valuable long-term epidemiological data grounded in everyday clinical experience, reinforcing the need for early musculoskeletal assessment in pediatric patients with persistent back pain. These insights are crucial for shaping diagnostic strategies, improving clinical management, and guiding future research in pediatric rheumatology.In fact, accurate assessment tools are crucial for monitoring disease progression in JIA, especially in cases involving the hip joint. A Tunisian study in our collection examined the applicability and reliability of two hip scoring systems commonly used in pediatric rheumatology practice (6,7). The results showed moderate to good reliability in evaluating joint space narrowing, erosion, and growth abnormalities. However, certain parameters, such as subchondral cysts and sclerosis, revealed poor concordance among observers. Significantly, the study found that targeted training led to improved agreement in some areas, underscoring the need for standardized training for pediatric rheumatologists before these tools can be broadly implemented in clinical practice. This research emphasizes the importance of collaborative studies and standardized methodologies in strengthening the pediatric rheumatology research network.This collection of studies highlights the progress, challenges, and opportunities in pediatric rheumatology across Africa. From caregiver burdens and diagnostic hurdles to the implementation of innovative Therapeutic Patient Education (TPE) and educational programs, each contribution deepens our understanding of the field. Looking ahead, enhanced training, increased research collaboration, and patient-centered strategies will be essential for improving outcomes for children with rheumatic diseases across the continent. This collection serves as a call to action for healthcare providers, policymakers, and researchers to address existing gaps and drive meaningful change in pediatric rheumatologic care, moving towards a more effective and patient-centred approach.

Background: Juvenile idiopathic arthritis (JIA) is the most common rheumatologic disease of childhood. The Existing guidelines for polyarticular JIA are typically based on data from non-African populations and may not fully address the unique challenges faced in African settings. We aimed to produce updated African guidelines for the diagnosis and treatment of children and adolescents with polyarticular juvenile idiopathic arthritis (poly-JIA). Methods: This study was conducted with the aim of reaching a consensus among African experts on the diagnosis and treatment of poly-JIA using the Delphi technique. The first scientific committee identified a total of 15 key clinical questions according to the PICO (Patient/Population, Intervention, Comparison, Outcome) approach. A systematic review of the evidence-based literature was conducted for this work. The core steering group identified researchers and clinicians with expertise in pediatric rheumatology. A Delphi process was used to reach consensus. Results: An online questionnaire was sent to the expert panel that participated in the survey (100% response rate). A total of 15 recommendation points were identified, divided into two parts: five recommendations for diagnosis and ten recommendations for management. The percentage of those who agreed with the recommendations (fourth and fifth place) ranged from 80 to 100%. All 15 clinical recommendation statements that the scientific committee had identified had been agreed upon in wording (i.e., 75% of respondents agreed or strongly agreed). Conclusions: We successfully developed guidelines for children with polyarticular JIA, taking into consideration the African specific nature of limited resources and low income, also on the same time incorporating newly released data and using a treat to target approach.

The objective of this study is to develop evidence-based recommendations for the diagnosis and management of enthesitis-related arthritis (ERA) and juvenile psoriatic arthritis (JPsA) in the African context. The recommendations for ERA and JPsA were combined into a single document. The steering committee and task force identified 15 key questions and formulated 35 research questions. A comprehensive literature review, utilizing Medline and a manual search for African local data, was conducted to gather evidence. Following this synthesis, the task force developed draft recommendations and engaged in a Delphi process with an expert panel, including 17 African and three international experts, to reach a consensus and ensure alignment with global standards. The final recommendations were assigned a level of evidence and subsequently approved by the task force members, the expert panel, and the PAFLAR Board. Fifteen recommendations on the diagnosis and management of ERA and JPsA were developed, covering the role of the pediatric rheumatologist in multiple aspects of disease management, including diagnosis, monitoring of disease and extra-articular manifestations, determining treatment strategies, and guiding interventions. The level of evidence supporting these recommendations was variable, leading to the identification of a research agenda to address African particularities and answer pending questions. The final recommendations achieved a high level of agreement, with consensus ranging from 90 to 100%. These recommendations represent an important achievement for pediatric rheumatology in Africa, being the first of their kind, tailored specifically to the region. Developed through a rigorous methodology and collaboration between international and African experts, they aim to standardize care and address the unique challenges faced in African setting.

Introduction: Patient education is crucial in managing chronic diseases like Juvenile Idiopathic Arthritis (JIA). Traditional methods such as videos and brochures often fail to maintain long-term knowledge retention. Therapeutic Patient Education (TPE) offers a more effective, patient-centered approach.Objective: PAFLAR aimed to implement a TPE program with a “train the trainers” masterclass to ensure effective delivery and improve outcomes for children with JIA.Methods: PAFLAR's TPE program was designed through a focus group, involving a literature review and strategic planning for the implementation step. The program includes specialized training for healthcare professionals enhancing their abilities to deliver TPE workshops. Participants were selected based on volunteerism and commitment to the project. Evaluations were conducted through feedback assessment of both patients and participants.Results: PAFLAR launched a TPE program in 2023, aimed at training healthcare providers to implement TPE effectively. This initiative included both in-person and virtual masterclasses, resulting in five workshops conducted in Kenya, Tunisia, and Nigeria. These workshops covered various aspects of JIA management, such as patient and family education, self-esteem, physical activity, treatment adherence, and pain management. Early results showed significant improvements in patients’ and parents’ understanding and management of JIA, with positive feedback indicating a need for further sessions.Conclusion: PAFLAR has taken the initial step in implementing a TPE program for JIA across three countries, representing different regions of Africa. The TPE program offers a promising alternative to traditional patient education methods, significantly improving patient care, empowering healthcare providers, and advancing healthcare systems.

Pediatric osteoporosis (PO) is a condition that is currently gaining recognition. Due to the lack of official definitions over the past few decades, the exact incidence of PO is unknown. The research does not provide a specific prevalence of PO in different world regions. However, this is expected to change with the latest 2019 guidelines proposed by the International Society of Clinical Densitometry. Although adult osteoporosis (AO) has been postulated a pediatric disease because its manifestation in adulthood is a result of the bone mass acquired during childhood, differences between PO and AO should be acknowledged. AO is defined as low bone density; however, PO is diagnosed based on existing evidence of bone fragility (vertebral fractures, pathological fractures). This is particularly relevant because unlike in adults, evidence is lacking regarding the association between low bone density and fracture risk in children. The enhanced capacity of pediatric bone for reshaping and remodeling after fracture is another difference between the two entities. This contrast has therapeutic implications because medication-free bone reconstitution is possible under certain conditions; thus, background therapy is not always recommended. In this narrative review, differences between PO and AO in definition, assessment, and medical approach were investigated.