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Hwang J, Dzifa Dey I, Ayanlowo O, Flower C, King A, Johnson N, Ima-Edomwonyi U, Olasebikan H, Falasinnu T, Durairaj Pandian V, Blazer A. Addressing the research gap: access to care hinders genetic discovery in systemic lupus erythematosus patients throughout the African diaspora. Front Genet 2024; 15:1414490. [PMID: 39211738 PMCID: PMC11358083 DOI: 10.3389/fgene.2024.1414490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/24/2024] [Indexed: 09/04/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune condition that disproportionately impacts non-White ethnic and racial groups, particularly individuals in the African diaspora who experience heightened incidence, prevalence, and adverse outcomes. Genetic and epigenetic factors play significant roles in SLE risk, however these factors neither explain the whole of SLE risk nor the stark racial disparities we observe. Moreover, our understanding of genetic risk factors within African ancestry populations is limited due to social and environmental influences on research participation, disease presentation, and healthcare access. Globally, the African diaspora faces barriers in accessing essential SLE diagnostic tools, therapeutics, healthcare practitioners, and high-quality clinical and translational research studies. Here, we provide insights into the current state of genetic studies within African ancestry populations and highlight the unique challenges encountered in SLE care and research across countries of varying income levels. We also identify opportunities to address these disparities and promote scientific equity for individuals affected by SLE within the global African diaspora.
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Affiliation(s)
- Jihwan Hwang
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ida Dzifa Dey
- Department of Medicine, Division of Rheumatology, University of Ghana, Accra, Ghana
| | - Olusola Ayanlowo
- Department of Dermatology, College of Medicine University of Lagos, Lagos, Nigeria
| | - Cindy Flower
- Department of Medicine, Division of Rheumatology, The University of the West Indies, Cave Hill, Saint Michael, Barbados
| | - Amanda King
- Division of Rheumatology, Bay Medical Centre, Castries, Saint Lucia
| | - Nicole Johnson
- Department of Pediatrics, Division of Rheumatology, University of Calgary, Calgary, AB, Canada
| | - Uyiekpen Ima-Edomwonyi
- Department of Medicine, Division of Rheumatology, College of Medicine University of Lagos, Lagos, Nigeria
| | - Hakeem Olasebikan
- Department of Medicine, Division of Rheumatology, College of Medicine University of Lagos, Lagos, Nigeria
| | - Titilola Falasinnu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, CA, United States
| | - Vishnuprabu Durairaj Pandian
- Department of Medicine, Division of Rheumatology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ashira Blazer
- Department of Medicine, Division of Rheumatology, University of Maryland School of Medicine, Baltimore, MD, United States
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Garrido-Cumbrera M, Poddubnyy D, Sommerfleck F, Bundy C, Makri S, Correa-Fernández J, Akerkar S, Lowe J, Karam E, Navarro-Compán V. Regional Differences in Diagnosis Journey and Healthcare Utilization: Results from the International Map of Axial Spondyloarthritis (IMAS). Rheumatol Ther 2024; 11:927-945. [PMID: 38847994 PMCID: PMC11264652 DOI: 10.1007/s40744-024-00672-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/03/2024] [Indexed: 07/21/2024] Open
Abstract
INTRODUCTION To assess differences in the diagnosis journey and access to care in a large sample of patients with axial spondyloarthritis (axSpA) from around the world, included in the International Map of Axial Spondyloarthritis (IMAS). METHODS IMAS was a cross-sectional online survey (2017-2022) of 5557 unselected patients with axSpA from 27 countries. Across five worldwide geographic regions, the patient journey until diagnosis and healthcare utilization in the last 12 months prior to survey were evaluated. Univariable and multivariable linear regression was used to analyze factors associated with higher healthcare utilization. RESULTS Of 5557 participants in IMAS, the diagnosis took an average of 7.4 years, requiring more than two visits to HCPs (77.7% general practitioner and 51.3% rheumatologist), and more than two diagnostic tests [67.5% performed human leukocyte antigen B27 (HLA-B27), 64.2% x-ray, and 59.1% magnetic resonance imaging (MRI) scans]. North America and Europe were the regions with the highest number of healthcare professional (HCP) visits for diagnosis, while the lowest number of visits was in the Asian region. In the previous 12 months, 94.9% (n = 5272) used at least one healthcare resource, with an average of 29 uses per year. The regions with the highest healthcare utilization were Latin America, Europe, and North America. In the multiple linear regression, factors associated with higher number of healthcare utilization were younger age (b = - 0.311), female gender (b = 7.736), higher disease activity (b = 1.461), poorer mental health (b = 0.624), greater functional limitation (b = 0.300), greater spinal stiffness (b = 1.527), and longer diagnostic delay (b = 0.104). CONCLUSION The diagnosis of axSpA usually takes more than two visits to HCPs and at least 7 years. After diagnosis, axSpA is associated with frequent healthcare resource use. Younger age, female gender, higher disease activity, poorer mental health, greater functional limitation, greater spinal stiffness, and longer diagnostic delay are associated with higher healthcare utilization. Europe and North America use more HCP visits and diagnostic tests before and after diagnosis than the other regions.
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Affiliation(s)
- Marco Garrido-Cumbrera
- Universidad de Sevilla, Health & Territory Research (HTR), Seville, Spain.
- Spanish Federation of Spondyloarthritis Patient Associations (CEADE), Madrid, Spain.
| | - Denis Poddubnyy
- Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Rheumatology Research Centre, Berlin, Germany
| | | | | | - Souzi Makri
- Cyprus League for People with Rheumatism (CYLPER), Nicosia, Cyprus
| | | | | | - Jo Lowe
- Axial Spondyloarthritis International Federation (ASIF), London, UK
| | - Elie Karam
- Canadian Spondylitis Association (CSA), Toronto, Canada
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Kinara SN, Kimani HM, Ogweno GO. Prevalence and predictors of arthritis among adults in a rural set-up in Kenya: a cross-sectional study. Pan Afr Med J 2024; 47:158. [PMID: 38974697 PMCID: PMC11226762 DOI: 10.11604/pamj.2024.47.158.42890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction arthritis is a significant public health problem affecting many people globally. Exposure to various risk factors puts individuals at risk of developing arthritis. Therefore, this study aimed to assess the prevalence and predictors of arthritis among residents of a rural set-up in Nyamira County, Kenya. Methods a community-based cross-sectional study design was employed. Simple random sampling was utilized to select households from a household list. All the residents of the sampled household above 40 years were included. Descriptive analysis was done to describe the study population. Bivariate and multivariate analysis was also done to identify statistically significant arthritis-related variables. Results the prevalence of arthritis was 44.6%. Previous joint injury/infection [AOR=2.74; 95%CI=1.59-4.77; p<0.001], being unemployed [AOR=2.77; 95%CI=1.50-5.21; p=0.001], age above 51 years, and hypertension [AOR=1.90; 95%CI=1.03-3.53, p=0.040] were associated with an increased risk of arthritis. Conversely, being male [AOR=0.42; 95% CI=0.22-0.75; p=0.005], standing for > 2 hours [AOR=0.48; 95%CI=0.29-0.81; p=0.006], and constant shifting from sit to stand positions [AOR=0.45; 95% CI=0.26-0.76; p=0.003] were associated with a lower risk of arthritis. Most participants (75%) had an arthritis knowledge score of more than 66%. Conclusion the study found a high prevalence of arthritis in the community. Arthritis was strongly associated with various risk factors under study. Therefore, there is a need to take preventive measures for modifiable factors to enhance a reduced prevalence of arthritis.
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Affiliation(s)
- Shem Nyarunda Kinara
- Department of Family Medicine Community Health and Epidemiology, Kenyatta University, Nairobi, Kenya
| | - Harun Mbugua Kimani
- Department of Family Medicine Community Health and Epidemiology, Kenyatta University, Nairobi, Kenya
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Dey D, Katso B, Baah A, Isaaka S, Amoako E. Exploring paediatric rheumatology care: a ten-year retrospective analysis of the patient population in Ghana. Pediatr Rheumatol Online J 2024; 22:40. [PMID: 38515165 PMCID: PMC10956341 DOI: 10.1186/s12969-024-00975-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Rheumatic diseases can seriously impact children's general health, development, and growth. However, due to a lack of resources, paediatric rheumatology is a largely underdeveloped speciality in many African nations. Children with rheumatic disorders face obstacles in accessing specialized medical care, including lack of specialists, care centres, medication access, and limited research and education to increase understanding of paediatric rheumatic disease among healthcare practitioners. This study described the disease characteristics, prevalence, and challenges faced by paediatric rheumatic disease patients receiving care at a teaching hospital in Accra, Ghana. METHODS A retrospective record-based study was conducted among all paediatric cases presenting to the rheumatology clinic of the Korle Bu Teaching Hospital (KBTH) from January 2011 to December 2021. Data collected include clinical features, laboratory findings at disease presentation, andtherapeutic regimens prescribed per standard guidelines and experiences. RESULTS A total of 121 cases were identified as of 2021, indicating a point prevalence of 0.0011%. The majority (73%) were females with a mean age of 13.4 ± 3.2 years. The mean duration of symptoms in months experienced by patients before being successfully referred to a rheumatologist was 18 months. There were significant differences between referred and confirmed diagnoses, especially in cases involving mixed connective tissue diseases (MCTD), systemic lupus erythematosus (SLE), and juvenile dermatomyositis (JDM), suggesting that these conditions may be under-recognised. Arthralgia and arthritis were the most common presenting symptoms. More than three-quarters (86.8%) of the cases studied were treated with steroids (oral or intravenous). In cases requiring immunosuppressive therapy, methotrexate was the most commonly prescribed in 33.9% of instances. Mortality was recorded at 8.3%, with the majority involving SLE cases. Most (95.7%) of the primary caregivers expressed positive experiences regarding care received at the adult rheumatology clinic. CONCLUSION There were significant delays in diagnosis and diagnostic accuracy for patients with paediatric rheumatic disease (PRD). This highlights the pressing need for strengthening paediatric rheumatology services in Africa, including increasing awareness about these conditions among the public and healthcare providers to improve early diagnosis and quality of life for children with these conditions.
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Affiliation(s)
- Dzifa Dey
- Rheumatology Unit, Department of Medicine and Therapeutics, University of Ghana Medical School Legon-Accra, Accra, Ghana.
- Rheumatology Unit, Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, Accra, Ghana.
| | - Bright Katso
- Rheumatology Unit, Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Afia Baah
- Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Saudatu Isaaka
- Rheumatology Unit, Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, Accra, Ghana
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Han T, Chen W, Qiu X, Wang W. Epidemiology of gout - Global burden of disease research from 1990 to 2019 and future trend predictions. Ther Adv Endocrinol Metab 2024; 15:20420188241227295. [PMID: 38439915 PMCID: PMC10910883 DOI: 10.1177/20420188241227295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/14/2023] [Indexed: 03/06/2024] Open
Abstract
Background Understanding the global burden of gout in the past and future can provide important references for optimizing prevention and control strategies in healthcare systems. Objectives This study aimed to report variations in the global disease burden and risk factors of gout in 204 countries and territories from 1990 to 2019. Design We conducted a retrospective analysis of gout based on the latest Global Burden of Disease (GBD) 2019 database. Methods We collected data on the prevalence, incidence, and disability-adjusted life years (DALYs) of gout from 1990 to 2019. The data were then stratified by age, sex, and economic development level. Decomposition analysis, frontier analysis, and prediction models were used to analyze the changes and influencing factors influencing each indicator. Results Globally, there were 53,871,846.4 [95% uncertainty interval (UI): 43,383,204.6-66,342,327.3] prevalent cases, 92,228,86.8 (95% UI: 7419,132.1-11,521,165) incident cases, and 1673,973.4 (95% UI: 1,068,061.1-2,393,469.2) cases of DALYs of gout in 2019, more than double those in 1990. Moreover, the pace of increase in the age-standardized prevalence rate (ASPR), age-standardized incidence rate (ASIR), and age-standardized DALY rate (ASDR) accelerated during 1990-2019, with estimated annual percentage changes (EAPC) of 0.94 [95% confidence interval (CI): 0.85-1.03], 0.77 (95% CI: 0.69-0.84), and 0.93 (95% CI: 0.84-1.02), respectively, especially among men. The disease burden of gout has increased in all the other 20 GBD regions in the past 30 years, except Western Sub-Saharan Africa. The highest risk of high body mass index (BMI) and kidney dysfunction was in high-income countries such as North America and East Asia. The global prevalence rate, incidence rate, and DALYs rate of gout in 2030 will reach 599.86, 102.96 per 100,000 population, and 20.26 per 100,000 population, respectively, roughly the same as in 2019. Conclusion With the development of society, the disease burden of gout will become increasingly severe. It is very important to study the accurate epidemiological data on gout for clinical diagnosis and treatment and health policy.
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Affiliation(s)
- Tingfen Han
- Department of Traditional Chinese Medicine, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Wenli Chen
- Department of Ophthalmology, Zhejiang Chinese Medical University Affiliated Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, Zhejiang, China
| | - Xiasang Qiu
- Department of Traditional Chinese Medicine, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Weijie Wang
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, 310005, China
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Kibone W, Nansubuga AL, Okot J, Buule R, Bongomin F, Kaddumukasa M. Rheumatology Training for Undergraduate Medical Students in Uganda: A Need Assessment Survey. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205231222989. [PMID: 38204974 PMCID: PMC10775743 DOI: 10.1177/23821205231222989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/27/2023] [Indexed: 01/12/2024]
Abstract
Objectives Despite the rise in the common rheumatological and musculoskeletal disorders (RMDs) in Africa, rheumatology remains an under recognized field with limited training and exposure of medical students. We assessed the knowledge of undergraduate medical students in Uganda on RMDs occurring in our settings. Methods A descriptive cross-sectional study was conducted among clinical year medical students at 9 universities in Uganda offering undergraduate medical degrees in March and April 2022. A self-administered, semistructured questionnaire was used to collect data on sociodemographic characteristics and basic knowledge on RMDs online using KoboToolbox. Sufficient knowledge was defined as a score of ≥50% (pass mark for undergraduate students in Uganda). Multivariable logistic regression was performed using STATA 16 to determine factors associated with knowledge acquisition on RMDs. Results We enrolled 359 medical students from 9 medical training institutes across Uganda. Overall, 126 (35.1%) participants had sufficient knowledge and the overall mean score for all participants was 41.2%. Factors independently associated with sufficient knowledge were: being in fourth (adjusted odds ratio [aOR]: 2.6, 95% confidence interval [CI]: 1.49-4.64, P < .001) and fifth year (aOR: 2.2, 95% CI: 1.18-4.18, P = .013) compared to third year of study, awareness of the speciality of rheumatology (aOR: 4.0, 95% CI: 1.96-8.06, P < .001), formal classes on rheumatology (aOR: 2.0, 95% CI: 1.15-3.35, P = .012), prior bedside teaching on RMDs (aOR: 2.3, 95% CI: 1.49-3.69, P < .001), awareness of common RMDs (aOR: 3.2, 95% CI: 1.67-6.04, P < .001), and having seen a patient with an RMD (aOR: 1.8, 95% CI: 1.14-2.77, P < .01). Conclusion There was a significant knowledge gap among undergraduate medical students nationwide on rheumatology. There is an urgent need to increase exposure to RMDs for undergraduate medical students to address the rising burden of RMDs in Uganda.
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Affiliation(s)
- Winnie Kibone
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Angel Lisa Nansubuga
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jerom Okot
- Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Richard Buule
- Faculty of Clinical Medicine and Dentistry, Kampala International University, Ishaka, Uganda
| | | | - Mark Kaddumukasa
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Hakeem OB, Abubakar Y, Courage U, Joshua OG, Olujimi S, Abdulaziz U, Uyi IE, Ojo O, Adelowo O, Olusegun OA, Nwankwo H, Ibukunoluwa D, Ibrahim D, Ahmed H, Ajibade A, Ehi A, Dungwom PS, Okwara C, Harriet E, Osuagwu N, Uchechukwu T, Egbe T, Ako I, Idowu A, Akpabio AA, Tito A, Abdulhakeem A, Ochiagha O, Janetta I. Rheumatoid arthritis knowledge gap and intervention in Nigeria study. Int J Rheum Dis 2024; 27:e14993. [PMID: 38108585 DOI: 10.1111/1756-185x.14993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Family physicians are often the first healthcare providers to encounter patients with rheumatoid arthritis (RA) in Nigeria, given the paucity of rheumatology services nationwide. This study aimed to assess and address the knowledge gap regarding RA among family physicians in Nigeria. METHODS A cross-sectional survey involving 609 family physicians from all six geopolitical zones of Nigeria was conducted in October 2022. Pre-intervention questionnaires were administered to assess the participants' knowledge of RA. An investigator-led PowerPoint presentation on RA was then delivered as an intervention, followed by the same participants completing post-intervention questionnaires to evaluate knowledge improvement. Data were analyzed using the Statistical Package for Social Science, version 25. RESULTS The mean age of participants was 42 ± 15 years, predominantly male (63.9%). The median pre-intervention knowledge score was 3.2 (IQR: 2.0-4.5), with 77.0% scoring <5. After the intervention, the median score significantly improved to 7.1 (IQR: 4.3-8.6) (p = .001), with 62.6% scoring >7. Significant improvements were observed in several knowledge areas where gaps existed pre-intervention, including the understanding that NSAIDs are not the mainstay of management (p < .001), the effectiveness of glucosamine and chondroitin sulfate (p < .001), confidence in diagnosing RA (p = .016), the recognition of joint deformities as a characteristic feature (p < .001), and the understanding that rheumatoid factor is not definitive for diagnosis (p < .001). CONCLUSION This study highlights the importance of interventions in closing the knowledge gap about RA diagnosis and management. We recommend the implementation of a comprehensive approach to rheumatology education and services by policymakers.
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Affiliation(s)
- Olaosebikan B Hakeem
- Department of Medicine, Rheumatology Unit, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
| | - Yerima Abubakar
- Department of Medicine, Rheumatology Unit, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Uhunmwangho Courage
- Department of Medicine, Rheumatology Unit, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Odunlami Gbenga Joshua
- Department of Medicine, Rheumatology Unit, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Shodipo Olujimi
- Department of Family Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
| | - Umar Abdulaziz
- Department of Medicine, Rheumatology Unit, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
| | - Ima-Edomwonyi Uyi
- Department of Medicine, Rheumatology Unit, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Osaze Ojo
- Kubwa General Hospital, Abuja, Nigeria
| | - Olufemi Adelowo
- Department of Medicine, Rheumatology Unit, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
| | - Oguntona A Olusegun
- Rheumatology Unit, Olabisi Onabanjo University Teaching Hospital, Shagamu, Nigeria
| | - Henry Nwankwo
- Department of Medicine, Rheumatology Unit, Nnamdi Azikwe University Teaching Hospital, Nnewi, Nigeria
| | - Dedeke Ibukunoluwa
- Department of Medicine, Rheumatology Unit, University College Hospital, Ibadan, Nigeria
| | - Daiyabu Ibrahim
- Department of Medicine, Rheumatology Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Hamidu Ahmed
- Department of Medicine, Rheumatology Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Adenitan Ajibade
- Department of Medicine, Rheumatology Unit, Federal Medical Centre, Gombe, Nigeria
| | - Aigbokhan Ehi
- Department of Medicine, Rheumatology Unit, University of Benin Teaching Hospital, Benin, Nigeria
| | - Pam Stephen Dungwom
- Department of Medicine, Rheumatology Unit, Jos University Teaching Hospital, Jos, Nigeria
| | - Chibuzor Okwara
- Department of Medicine, Rheumatology Unit, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ezike Harriet
- Department of Medicine, Rheumatology Unit, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Njideka Osuagwu
- Department of Medicine, Rheumatology Unit, Federal Medical Centre, Owerri, Nigeria
| | - Tralagba Uchechukwu
- Department of Medicine, Rheumatology Unit, University of Port Harcourt, Port Harcourt, Nigeria
| | - Tamara Egbe
- Department of Medicine, Rheumatology Unit, Federal Medical Centre, Yenagoa, Nigeria
| | - Itam Ako
- Department of Medicine, Rheumatology Unit, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Alabi Idowu
- Department of Medicine, Rheumatology Unit, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
| | - Akpabio A Akpabio
- Department of Medicine, Rheumatology Unit, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Asekhame Tito
- Department of Medicine, Rheumatology Unit, Nnamdi Azikwe Teaching Hospital, Nnewi, Nigeria
| | - Awesu Abdulhakeem
- Department of Medicine, Rheumatology Unit, Federal Medical Centre, Katsina, Nigeria
| | - Olisa Ochiagha
- Department of Medicine, Rheumatology Unit, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Ikoro Janetta
- Department of Medicine, Rheumatology Unit, Federal Medical Centre, Yenagoa, Nigeria
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Furia F, Ndosi M. Diagnosing and treating rheumatic and musculoskeletal diseases in low resource settings: a review of the challenges and opportunities in Tanzania. Rheumatol Adv Pract 2023; 7:rkad079. [PMID: 37840626 PMCID: PMC10576200 DOI: 10.1093/rap/rkad079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Affiliation(s)
- Francis Furia
- School of Clinical Medicine, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
- Department of Pediatrics, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Mwidimi Ndosi
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
- Rheumatology Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Al Rayes H, Salah H, Hamad T, Soliman M, Bedaiwi M. The Impact of Spondyloarthritis on Health-Related Quality of Life and Healthcare Resource Utilization in Saudi Arabia: A Narrative Review and Directions for Future Research. Open Access Rheumatol 2023; 15:161-171. [PMID: 37705696 PMCID: PMC10497044 DOI: 10.2147/oarrr.s414530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/04/2023] [Indexed: 09/15/2023] Open
Abstract
Spondylarthritis (SpA) is an umbrella term that encompasses a wide range of rheumatological disorders. Several studies demonstrated that SpA is associated with increased healthcare resource utilization (HCRU) and a lower health-related quality of life (HRQoL). This review aimed to summarize the current literature regarding the multidimensional impact of SpA on HRQoL and HCRU in Saudi Arabia and explore the correlation of the extent of severity of SpA with HRQoL and HCRU. Although the prevalence of SpA varies across different populations and is correlated with HLA-B27 prevalence, the magnitude of SpA in the Saudi population has not been extensively evaluated. Few studies have investigated the impact of SpA on HRQoL and HCRU in Saudi Arabia and the Middle East. There is a need to study the cost-effectiveness of various SpA treatment strategies, including biologic disease-modifying anti-rheumatic drugs (bDMARDs), to prioritize healthcare spending in the Saudi healthcare system. Data on SpA in Saudi Arabia and the Middle East region are mainly based on expert views, with few population-based studies compared to other regions. Therefore, there is an imperative need to develop high-quality, national-level epidemiological studies that assess the following: (1) more accurate estimates of the current prevalence of SpA in Saudi Arabia, including the prevalence of axial SpA and psoriatic arthritis; (2) the phenotypes/clinical characteristics of SpA, including disease severity and extra-articular involvement; (3) the impact of SpA on the HRQoL of the patients and the factors that can predict the extent of impaired HRQoL in such population, which can represent the first step in developing psychological interventions that should be personalized to this patient population; (4) the impact of implementing formal assessment of disease activity on the management of the patients and, subsequently, their HRQoL; and (5) the HCRU and costs for patients with SpA, and how treatment patterns can affect this cost.
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Affiliation(s)
- Hanan Al Rayes
- Division of Rheumatology, Department of Internal Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Hany Salah
- Therapeutic Area Lead Rheumatology, Intercontinental, AbbVie Biopharmaceuticals GmbH, Dubai, United Arab Emirates
| | - Tharwat Hamad
- Medical Manager, Immunology, AbbVie Biopharmaceuticals GmbH, Jeddah, Saudi Arabia
| | - Mohab Soliman
- Medical Advisor, Rheumatology, AbbVie Biopharmaceuticals GmbH, Riyadh, Saudi Arabia
| | - Mohamed Bedaiwi
- Division of Rheumatology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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Taik FZ, Adnine A, Tbatou H, Amar A, Abourazzak FE. Would You Consider Becoming a Rheumatologist? A Survey Regarding the Attractiveness of Rheumatology as a Career Among Moroccan Medical Students. Mediterr J Rheumatol 2023; 34:349-355. [PMID: 37941866 PMCID: PMC10628880 DOI: 10.31138/mjr.20230727.wyc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/28/2023] [Accepted: 02/22/2023] [Indexed: 11/10/2023] Open
Abstract
Objective To assess the attractiveness of a career in rheumatology among Moroccan medical students and to study factors that motivate or demotivate them to choose rheumatology as a future career. Methods An electronic survey was distributed among students in medical training, interns, and graduates from the Faculty of Medicine at the University Hospital of Tangier. The questionnaire evaluated the level of clinical exposure to rheumatology, the interest in rheumatology as a specialty, and the motivation or demotivation for choosing or not choosing rheumatology as a career. Results 318 students responded to the survey. Of these, 57.5% reported that they had already completed a training period in a rheumatology department. Of Moroccan students, 35.6% would consider specialising in rheumatology and 8.5% of these stated that rheumatology was their first specialty choice. The uni- and multi-variate analysis determined that clinical exposure to rheumatology (OR=2.39 IC95% [1.46-3.91]) and female gender (OR=1.95 IC95% [1.2-3.2]) were the main statistically significant factors for the prediction of the choice of rheumatology. Intern status was statistically associated with not choosing rheumatology (OR=0.085 IC95% [0.03-0.24]. The main motivation factors for Moroccan medical students to choose rheumatology were the diversity of musculoskeletal diseases (54.5%) and the good balance work/life (46.6%). The main reasons for not choosing rheumatology were the limited therapeutic aspects of the discipline (30.3%) and an interest in surgical specialties (29.3%). Conclusion Rheumatology fascinates Moroccan medical students by the diversity of its pathologies and the good balance work/life. Greater clinical exposure to rheumatology is the strongest predictor of medical students choosing rheumatology as a future career.
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Affiliation(s)
- Fatima Zahrae Taik
- Department of Rheumatology, Tangier-Tetouan-El Hoceima University Hospital, Tangier, Morocco
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tetouan, Morocco
| | - Anass Adnine
- Department of Rheumatology, Tangier-Tetouan-El Hoceima University Hospital, Tangier, Morocco
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tetouan, Morocco
| | - Hatime Tbatou
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tetouan, Morocco
| | - Amine Amar
- Applied Mathematics and Data Science, School of Science and Engineering, Al Akhawayn University, Morocco
| | - Fatima Ezzahra Abourazzak
- Department of Rheumatology, Tangier-Tetouan-El Hoceima University Hospital, Tangier, Morocco
- Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tetouan, Morocco
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Headcraph E, Atukunda I, Kaddumukasa M, Nakiyingi L, Lusobya RC, Ampaire-Musika A, Otike C, Nagawa E, Juma P, Msonge F, Otiti-Sengeri J. Spectrum of and Factors Associated with Eye Disorders among Rheumatoid Arthritis Patients Attending Tertiary Hospital in Uganda. Open Access Rheumatol 2023; 15:103-111. [PMID: 37465162 PMCID: PMC10351586 DOI: 10.2147/oarrr.s413697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023] Open
Abstract
Background Ocular morbidities associated with rheumatoid arthritis (RA) have not received much attention in Africa, particularly in sub-Saharan Africa. They are among the commonest (40%) extra-articular organ involvement in RA. If undiagnosed, there is a potential risk of them causing visual impairment or blindness. There is no documented study in Uganda on the magnitude of eye disorders among RA patients. Aim To determine the spectrum of eye disorders and associated factors among patients with RA attending Mulago National Referral Hospital. Methods A hospital based cross-sectional study was conducted among adults with RA attending the rheumatology clinic between July 2021 and September 2021. Clinical and sociodemographic data were collected, and ophthalmologic examinations were performed on all consenting participants. Modified Poisson regression with robust standard error was used to determine factors associated with eye disorders. Results Overall, 105 patients with RA were enrolled, of which, 53 (50.5%) had eye disorders. The commonest disorder (54.7%, n=29) was dry-eye syndrome. Factors that were significantly associated with eye disorders were age 36-55 years (aPR 1.56, p=0.015), duration of RA >5 years (aPR 1.81, p=0.001), use of hydroxychloroquine >5 years (aPR 1.77, p=0.041), dose of oral steroids >10 mg/day (aPR 1.49, p=0.034), and history of both diabetes and hypertension (aPR 1.87, p=0.014). Conclusion The prevalence of eye disorders among patients with RA was high, with the commonest being dry-eye syndrome. We recommend that ocular examinations be performed on every patient at the time of RA diagnosis for early detection of eye disorders.
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Affiliation(s)
- Eunice Headcraph
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Immaculate Atukunda
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lydia Nakiyingi
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rebecca Claire Lusobya
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Anne Ampaire-Musika
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Caroline Otike
- Clinical Epidemiology Unit, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Nagawa
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Paul Juma
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fransisco Msonge
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Juliet Otiti-Sengeri
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Lebughe Litite P, Westhovens R, Nkodila A, Malemba JJ, de Vlam K. Development and validation of a screening tool for SPondyloArthritis Screening in Sub-Saharan Africa: SpASSS questionnaire. BMC Med Res Methodol 2023; 23:145. [PMID: 37344764 DOI: 10.1186/s12874-023-01966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 06/06/2023] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVE To develop and validate a screening tool to identify patients with a high likelihood for Spondyloarthritis (SpA) in the Democratic Republic of the Congo (DR Congo). METHODS The development of the SpA Screening questionnaire in Sub Saharian Africa (SpASSS) questionnaire followed 3 steps: The item generation was carried out by a systematic literature review according to the PRISMA guidelines on the clinical manifestations of SpA, interviewing clinical experts and the classification criteria for Spondyloarthritis. The candidate questions were tested in a population of 50 consecutive patients with confirmed diagnosis of spondyloarthritis, in a control population of rheumatic disease excluding SpA and in a group of 200 non-rheumatic participants, randomly chosen in the general population for question reduction and validation. Descriptive statistical analyses were performed to assess socio-demographic characteristics and response distribution for each item. Their diagnostic performance was investigated using ROC curves. For validation, principal component analysis was performed using factor analysis. Referral strategy score for SpA was determined by adjusted Cronbach's alpha coefficient. RESULTS Mean ± SD age of SpA cases was 41.8 ± 14.4 years, 56% were men compared to diseased controls 60.0 ± 12.5 years, 28.7% men (p < 0.001). 14/20 items showed a statistically significant difference (p < 0.05) between SpA cases and control groups. All items were factorable and 6 components were identified. Only the two first components (C1 with 8 items, C2 with 3 items) showed a significant threshold for reliability in detection of suspected SpA with a Cronbach's alpha of 0.830 and 0.708. All validated items of these two components showed the global reliability threshold with α-adjusted Cronbach calculated at 66.9%. The performance for correctly screening SpA was demonstrated with an area under the curve of 0.938 (0.884-0.991) and 0.794 (0.728-0.861) for C1 and C2 respectively. CONCLUSIONS This validation and item reduction of the SpASSS questionnaire for SpA might identify patients to refer for case ascertainment and will help conducting future epidemiological and clinical studies in the DR Congo. STRENGTHS AND LIMITATIONS OF THIS STUDY • To the best of our knowledge, this is the first study in Sub-Saharan Africa based on local data to develop a screening tool for SpA in the population for epidemiological and clinical use. • Referral strategies based on context-specific data are necessary to provide accurate case definition and epidemiological data, thus reducing methodological bias. • In the SpA group, no discrimination was made regarding SpA subtypes, disease duration, activity and severity.
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Affiliation(s)
- P Lebughe Litite
- Rheumatology Unit, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - R Westhovens
- Division of Rheumatology, University Hospitals Leuven, Louvain, Belgium
| | - A Nkodila
- Department of Public Health, Faculty of Family Medicine, Université Protestante Au Congo, Congo, Kinshasa, Democratic Republic of the Congo
| | - J J Malemba
- Rheumatology Unit, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - K de Vlam
- Division of Rheumatology, University Hospitals Leuven, Louvain, Belgium.
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Tian J, Kang S, Zhang D, Huang Y, Zhao M, Gui X, Yao X, Lu Q. Global, regional, and national incidence and prevalence of systemic sclerosis. Clin Immunol 2023; 248:109267. [PMID: 36804224 DOI: 10.1016/j.clim.2023.109267] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To estimate the global and country-specific unbiased epidemiological data of SSc. METHODS Epidemiological studies were systematically searched in four databases. A Bayesian hierarchical linear mixed model was constructed to estimate epidemiological data. RESULTS 82 studies were included and epidemiological data on SSc were missing for 83.9% of countries worldwide. The global SSc incidence and newly diagnosed population were estimated to be 8.64 per 100,000 person-years (1.78-23.57) and 0.67 million (0.14-1.84) people annually, respectively. Regarding prevalence, the global SSc prevalence and affected population were 18.87 per 100,000 persons (1.55-25.28) and 1.47 million (0.12-1.97) people, respectively. Relatively higher incidence and prevalence were observed in females, adults, and high-income level countries. CONCLUSIONS We provide a comprehensive synthesis of SSc epidemiology and fill data gaps in most countries. Especially in low- and middle-income countries, epidemiological studies of SSc are insufficient. Further large-scale and standardized reported epidemiological investigations of SSc are imperative.
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Affiliation(s)
- Jingru Tian
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China
| | - Shuntong Kang
- Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Dingyao Zhang
- Graduate Program in Biological and Biomedical Sciences, Yale University, New Haven, USA; Program in Computational Biology and Bioinformatics, Yale University, New Haven, USA
| | - Yaqing Huang
- Department of Pathology, Yale University, New Haven, USA
| | - Ming Zhao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China; Department of Dermatology, Hunan Key Laboratory of Medical Epigenomics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xianhua Gui
- Department of Respiratory Medicine, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
| | - Xu Yao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China.
| | - Qianjin Lu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, China; Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, China.
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Migowa A, Bernatsky S, Ngugi A, Foster HE, Muriuki P, Lusambili A, Luchters S. An iceberg I can't handle: a qualitative inquiry on perceptions towards paediatric rheumatology among healthcare workers in Kenya. Pediatr Rheumatol Online J 2023; 21:6. [PMID: 36681840 PMCID: PMC9862847 DOI: 10.1186/s12969-023-00790-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/15/2023] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Delay in diagnosis and access to specialist care is a major problem for many children and young people with rheumatic disease in sub-Saharan Africa. Most children with symptoms of rheumatic disease present to non-specialists for care. There is an urgent need to understand and scale-up paediatric rheumatology knowledge and skills amongst non-specialist healthcare workers to promote early diagnosis, prompt referral, and management. PURPOSE We evaluated the knowledge, attitudes and practices towards diagnosis and care of paediatric rheumatology patients among health care workers in Kenya. METHODS We conducted 12 focus group discussions with clinical officers (third-tier community health workers) nurses, general practitioners and paediatricians across 6 regions in Kenya. Interviews were conducted on zoom, audio-recorded, transcribed, and analysed using NVIVO software. RESULTS A total of 68 individuals participated; 11 clinical officers, 12 nurses, 10 general practitioners, 27 paediatricians and 7 others. Most (n = 53) were female, and the median age was 36 years (range 31-40 years). Fifty per cent of the participants (34 of 68) worked in public health facilities. Our study revealed gaps in knowledge of paediatric rheumatology amongst healthcare workers which contributes to delayed diagnosis and poor management. Healthcare workers reported both positive and negative attitudes towards diagnosis and care of paediatric rheumatology patients. Perceived complexity and lack of knowledge in diagnosis, management and lack of health system clinical pathways made all cadres of healthcare workers feel helpless, frustrated, inadequate and incompetent to manage paediatric rheumatology patients. Positive attitudes arose from a perceived feeling that paediatric rheumatology patients pose unique challenges and learning opportunities. CONCLUSION There is an urgent need to educate healthcare workers and improve health systems to optimize clinical care for paediatric rheumatology patients.
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Affiliation(s)
- Angela Migowa
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium. .,Department of Paediatrics and Child Health, Aga Khan University, Medical College East Africa, Nairobi, Kenya.
| | - Sasha Bernatsky
- grid.63984.300000 0000 9064 4811Department of Medicine (Division of Rheumatology and Epidemiology) McGill University Health Centre (MUCH), Montreal, Canada
| | - Anthony Ngugi
- grid.470490.eDepartment of Population Health, Aga Khan University East Africa, Nairobi, Kenya
| | - Helen E. Foster
- grid.1006.70000 0001 0462 7212Population and Health Institute, Newcastle University, Newcastle, UK
| | - Peter Muriuki
- grid.413355.50000 0001 2221 4219African Population and Health Research Centre, Nairobi, Kenya
| | - Adelaide Lusambili
- grid.470490.eDepartment of Population Health, Aga Khan University East Africa, Nairobi, Kenya
| | - Stanley Luchters
- grid.5342.00000 0001 2069 7798International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium ,grid.463169.f0000 0004 9157 2417Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe ,grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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The outlook of rheumatological care in Africa: Current state, challenges, and recommendation. Ann Med Surg (Lond) 2022; 82:104689. [PMID: 36186494 PMCID: PMC9519466 DOI: 10.1016/j.amsu.2022.104689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 11/29/2022] Open
Abstract
There is a gross lack of access to rheumatological access in Africa. For example, the most populous country in the continent, Nigeria, has just 30 rheumatologists serving a population of about 200 million. In Ghana, there are just 2 rheumatologists serving a population of about 28 million people. Unfortunately, the prevalence of rheumatologic and musculoskeletal diseases is on the rise in Africa. The main issues facing rheumatologic care in Africa are inadequate health professionals, inadequate research, and a weak health system. These factors have hindered the progress of rheumatologic care and treatment in the region. Prompt action must be taken in tackling these effects and to achieve better care for rheumatologic patients in Africa. This paper analyzes carefully the current state of rheumatologic care in Africa, identifying the needs for rheumatologic care, determinants of quality of rheumatologic care delivery, and the challenges currently facing rheumatology care in Africa. Also, this review gives some recommendations on ways by which the existing system of rheumatologic care in Africa can be improved.
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Merkeb Alamneh Y, Sume BW, Abebaw Shiferaw A. Musculoskeletal disorders among the population in Northwest Ethiopia. SAGE Open Med 2022; 10:20503121221085109. [PMID: 35321461 PMCID: PMC8935578 DOI: 10.1177/20503121221085109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
Objective: This study aimed to assess the magnitude and patterns of chronic musculoskeletal disorders among the population in East Gojjam zone, Northwest Ethiopia. Methods: A community-based cross-sectional study with 846 recruited study participants was done using a multistage sampling technique in conjunction with a simple and systematic random sampling technique. Face-to-face interviews, physical examinations, a semi-structured questionnaire adapted from the Community Oriented Program for Control of Rheumatic Diseases, and other literature were used to collect data. EpiData 3.1 was used to enter the data, which were then exported to STATA 14.0 for analysis. Result: The study had a response rate of 98.8%, with about 836 people out of a total of 846 expected to take part. The magnitude of musculoskeletal disorders was found to be 40.1%. Back pain was the most common musculoskeletal condition (16%) of the population, followed by osteoarthritis (10%) and other forms of arthritis (rheumatoid arthritis (8%), gout arthritis (6%)). The most common comorbidity (multimorbidity) patterns were hypertension (9.8%), diabetes (5.6%), obesity (3.9%), and others (2.2%). Conclusion: Almost one in four participants have at least one musculoskeletal disorder in Northwest Ethiopia. Rheumatoid arthritis, osteoarthritis, low back pain, and gout arthritis were the most common musculoskeletal disorders. The most common comorbidity patterns were hypertension, diabetes, obesity, and others. An in-depth investigation of the musculoskeletal burden at the national level will be critical for implementing evidence-based strategies, as well as early detection and screening, linking to health institutions, and direct interventions.
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Affiliation(s)
- Yoseph Merkeb Alamneh
- Department of Biomedical Sciences, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Bickes Wube Sume
- Department of Biomedical Sciences, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Abtie Abebaw Shiferaw
- Department of Medical Laboratory, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
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Giollo A, Fuzzi E, Doria A. Methotrexate in early rheumatoid arthritis: Is the anchor drug still holding? Autoimmun Rev 2022; 21:103031. [PMID: 34995761 DOI: 10.1016/j.autrev.2022.103031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 12/29/2022]
Abstract
Treat-to-target (T2T) is currently the most fashionable strategy for treatment-naïve, early rheumatoid arthritis (RA) patients. A T2T approach can lead to a complete and drug-free disease remission, whereas failure to obtain remission leads to damage early in the disease course. Hence, one should try to achieve high remission rates as early as possible, implementing the best therapeutic strategies available. Methotrexate (MTX) combined with glucocorticoid bridging is the mainstay of T2T. However, MTX is often used suboptimally in RA patients for many reasons, including poor tolerability, low compliance, and safety issues. Recent evidence has suggested that novel targeted synthetic DMARDs (tsDMARDs) such as the Janus-kinase (JAK) inhibitors in combination with glucocorticoids yielded better outcomes in early RA than conventional treatment. Such an approach may have advantages in terms of patients' outcomes, though some concerns about serious adverse events need to be addressed.
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Affiliation(s)
- Alessandro Giollo
- Division of Rheumatology, Department of Medicine, University of Padova Hospital Trust, Padova, Italy.
| | - Enrico Fuzzi
- Division of Rheumatology, Department of Medicine, University of Padova Hospital Trust, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova Hospital Trust, Padova, Italy.
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18
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Neurophobia in Africa: Survey responses from fifteen African countries. J Neurol Sci 2022; 434:120161. [DOI: 10.1016/j.jns.2022.120161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/03/2022] [Accepted: 01/15/2022] [Indexed: 11/23/2022]
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Zamparini J, Pattinson S, Makan K. Competence of medical and obstetric registrars in the management of systemic lupus erythematosus in pregnancy. Obstet Med 2021; 14:153-157. [PMID: 34646343 DOI: 10.1177/1753495x20964670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction Systemic lupus erythematosus has a predilection for women of childbearing age. Globally a shortage of rheumatologists exists resulting in general physicians and obstetricians treating systemic lupus erythematosus in pregnancy. Methods We conducted a survey amongst medical and obstetric registrars in South Africa to assess their subjective and objective competence in managing pregnant women with systemic lupus erythematosus. Results The pass rate for the objective section was 70.8% with no statistically significant difference in the pass rate between medical and obstetric registrars. Participants felt unprepared to manage pregnant women with systemic lupus erythematosus, with a mean overall score of 3.4 out of 7 for the subjective section, based on four Likert scale type questions. Conclusion Trainees are not able to accurately assess their own levels of competence in order to identify their learning needs. Due to the shortage of rheumatologists and lack of obstetric physicians in South Africa, general physicians and obstetricians must be equipped to provide adequate care to pregnant women with systemic lupus erythematosus.
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Affiliation(s)
- Jarrod Zamparini
- Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Parktown, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stuart Pattinson
- Unit for Undergraduate Medical Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kavita Makan
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Rheumatology, Department of Medicine, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
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Migowa AN, Hadef D, Hamdi W, Mwizerwa O, Ngandeu M, Taha Y, Ayodele F, Webb K, Scott C. Pediatric rheumatology in Africa: thriving amidst challenges. Pediatr Rheumatol Online J 2021; 19:69. [PMID: 33962643 PMCID: PMC8103667 DOI: 10.1186/s12969-021-00557-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pediatric Rheumatology is an orphan specialty in Africa which is gradually gaining importance across the continent. MAIN BODY This commentary discusses the current state of affairs in the sphere of Pediatric Rheumatology across Africa and offers practical strategies to navigate the challenges encountered in research, models of care, education and training. We outline the establishment, opportunities of growth and achievements of the Pediatric Society of the African League Against Rheumatism (PAFLAR). CONCLUSION This commentary lays the foundation for establishment of a formidable framework and development of partnerships for the prosperity of Pediatric Rheumatology in Africa and beyond.
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Affiliation(s)
- Angela N. Migowa
- grid.470490.eAga Khan University Medical College East Africa, Department of Paediatrics and Child Health, 3rd Parklands Avenue, P. O Box 30270, Nairobi, Kenya
| | - Djohra Hadef
- Batna 2 University, Faculty of Medicine, 05000 Ezzohor city, Batna Algeria
| | - Wafa Hamdi
- grid.12574.350000000122959819University of Tunis El Manar, Campus Universitaire Farhat Hached B.P. n° 94 Rommana Tunis, 1068 Tunis, Tunisia
| | - Oscar Mwizerwa
- grid.10818.300000 0004 0620 2260University of Rwanda, KG 11 Ave, Kigali, Rwanda
| | - Madeleine Ngandeu
- grid.412661.60000 0001 2173 8504University of Yaoundé, Boîte Postale 337, Yaoundé, Centre Region Cameroon
| | - Yassmin Taha
- Ahmed Gasim Children’s Hospital Khartoum, Sudan Bahri Street, Downtown, Tuti Island, Bahri, Khartoum State Sudan
| | - Faleye Ayodele
- grid.411278.90000 0004 0481 2583Lagos State University Teaching Hospital, Nigeria 1- 5 Oba Akinjobi Way, Street, Ikeja, Lagos Nigeria
| | - Kate Webb
- grid.7836.a0000 0004 1937 1151University of Cape Town, South Africa Rondebosch, Cape Town, 7700 South Africa
| | - Christiaan Scott
- grid.7836.a0000 0004 1937 1151University of Cape Town, South Africa Rondebosch, Cape Town, 7700 South Africa
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Abstract
Historically, rheumatic diseases have not received much attention in Africa, particularly in sub-Saharan Africa, possibly owing to a focus on the overwhelming incidence of infectious diseases and the decreased life span of the general population in this region. Global attention and support, together with better health policies and planning, have improved outcomes for many infectious diseases; thus, increasing attention is being turned to chronic non-communicable diseases. Rheumatic diseases were previously considered to be rare among Africans but there is now a growing interest in these conditions, particularly as the number of rheumatologists on the continent increases. This interest has resulted in a growing number of publications from Africa on the more commonly encountered rheumatic diseases, as well as case reports of rare diseases. Despite the limited amount of available data, some aspects of the epidemiology, genetics and clinical and laboratory features of rheumatic diseases in African populations are known, as is some detail on the use of therapeutics. Similarities and differences in these conditions can be seen across the multi-ethnic and genetically diverse African continent, and it is hoped that increased awareness of rheumatic diseases in Africa will lead to earlier diagnosis and better outcomes for patients. The prevalence of rheumatic diseases is increasing in African countries, leading to an increased need for specialist rheumatologists and disease-modifying drugs. In this Review, the authors outline what is currently known about the state of rheumatic diseases in Africa. In the past, there has been an emphasis on communicable diseases in Africa, but attention has now shifted towards non-communicable diseases such as rheumatic diseases. Common rheumatic diseases are seen in Africa and are both comparable and different from presentations seen outside of Africa. Diverse genetic and environmental factors affect the presentation of common rheumatic diseases among different African nations. A shortage of appropriately trained staff, laboratory testing capacity and effective medications exists across the whole continent. Advocacy and research are needed to increase awareness of the risk factors, presentations and management of rheumatic diseases in Africa. Specialized treatment guidelines are needed for resource-poor countries in Africa.
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Abstract
PURPOSE OF THE REVIEW To highlight the current challenges in diagnosis and clinical care of pediatric rheumatic disease and barriers to research and education of pediatric rheumatologists worldwide. RECENT FINDINGS Recent studies and reports demonstrate a paucity of studies on epidemiology, outcomes, and management guidelines from many regions of the world. There have been noteworthy efforts to bridge the gap in under resourced areas. An analysis of the global burden of rheumatic disease has demonstrated that while understudied, musculoskeletal diseases are prevalent and increasingly contribute to loss of years of healthy life. In juvenile idiopathic arthritis, two milestone publications in global pediatric rheumatology have recently been published. An international study evaluated the epidemiology, treatment, and outcomes of juvenile idiopathic arthritis and demonstrated global diversity in both clinical manifestations and outcomes. Notably, the first guidelines for managing pediatric rheumatic disease in a less resourced setting have been published for juvenile idiopathic arthritis. This document offers the first publication targeted to address challenges faced by pediatric rheumatology caregivers in low-resourced settings. These documents serve as exemplars for international collaboration in pediatric rheumatology and can be used as models for other pediatric rheumatic disease research. Other efforts are making progress in various arenas towards increasing access to care, education, and training in pediatric rheumatology. SUMMARY The global burden of rheumatic disease in the pediatric population is poorly understood but unrecognized disease greatly impacts the overall morbidity and mortality in this population. More studies in lesser resourced regions are needed to prioritize access to pediatric rheumatology care and prioritize a further increase in research capacity and education moving forward.
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Landewé RBM. The unsustainable bubble of disease-modifying antirheumatic drugs in rheumatology. THE LANCET. RHEUMATOLOGY 2021; 3:e306-e312. [PMID: 38279413 DOI: 10.1016/s2665-9913(21)00013-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/07/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
The high prices of biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) put pressure on the health-care budgets for patients with rheumatic musculoskeletal diseases. High prices appear to reflect added value. According to the value-based health-care model, value is proportional to patient-reported outcomes and experiences (satisfaction) and inversely proportional to health-care costs. The question addressed in this Viewpoint is whether the many novel DMARDs, all of which are similarly effective and safe but disproportionally expensive in comparison to conventional synthetic DMARDs, fulfil the promise of added value. It is proposed that the added value of the newest biological and targeted synthetic DMARDs is questionable at best, and that their added value is limited to patients who do not respond adequately to standard-of-care treatment. The added value for each novel DMARD decreases with each additional DMARD that obtains market authorisation, and the number of patients with treatment-refractory disease declines as a result of an ever-improving standard of care. Yet, the prices of DMARDs remain high and even tend to increase. Explanations for the perpetually high cost of these drugs despite a dubious added value relate to system characteristics, such as regulatory uncoupling of drug approval, pricing, and reimbursement; profuse and effective marketing of novel drugs; the existence of strategic patenting; and effective lobbying. To constrain DMARD expenses in rheumatology, to put more pressure on manufacturers, and to serve as many patients with rheumatic and musculoskeletal diseases as possible with affordable care, I propose that rheumatologists judge more critically which patients truly need expensive DMARDs and choose more wisely. Four simple behavioural measures are proposed to this end.
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Affiliation(s)
- Robert B M Landewé
- Department of Clinical Immunology and Rheumatology, Amsterdam University Medical Center, Amsterdam, Netherlands; Department of Rheumatology, Zuyderland Medical Center, Heerlen, Netherlands.
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Manyati TK, Mutsau M. Exploring the effectiveness of telehealth interventions for diagnosis, contact tracing and care of Corona Virus Disease of 2019 (COVID19) patients in sub Saharan Africa: a rapid review. HEALTH AND TECHNOLOGY 2021; 11:341-348. [PMID: 33585154 PMCID: PMC7870280 DOI: 10.1007/s12553-020-00485-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/01/2020] [Indexed: 12/23/2022]
Abstract
The efficacy of leveraging telehealth services on clinical outcomes remains scarcely documented. We conducted a rapid review to explore the effectiveness of telehealth interventions for the diagnosis, contact tracing and care of the corona virus disease of 2019 in sub Saharan Africa. Using MEDLINE, Science Direct and Cochrane Library databases, a review was conducted during the month of July 2020 of peer reviewed articles reporting on the use of telehealth interventions in sub-Saharan Africa. All the studies were assessed against the inclusion criteria by two independent reviewers. The 7 studies included in the synthesis were conducted in 2 countries [Nigeria (× 1), Zimbabwe (× 1)], and commentaries covering the entire sub Saharan Africa in general (× 4) and to Uganda (× 1). All the included articles and commentaries were published in 2020. We established that mobile applications are effective in providing information for referrals of potential patients infected by COVID 19 and provides convenient access to routine care without the risk of exposure through close contact. In countries such as Nigeria, mobile positioning data significantly improved decision making, capacity and scope of contact tracing and surveillance of known contacts of confirmed cases. We noted that collaborations between the government, mobile network operators and technology companies were utilised for successful mobile positioning data tracing interventions for COVID patients. Mobile applications such as the Vula platform in South Africa were also noted as effective in providing psychological support to health care workers attending to patients.
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Affiliation(s)
| | - Morgen Mutsau
- Centre for Applied Social Sciences, University of Zimbabwe, Harare, Zimbabwe
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Dey D, Sciascia S, Pons-Estel GJ, Ding H, Shen N. Health Disparities in Rheumatic Diseases: Understanding Global Challenges in Africa, Europe, Latin America, and Asia and Proposing Strategies for Improvement. Rheum Dis Clin North Am 2021; 47:119-132. [PMID: 34042051 DOI: 10.1016/j.rdc.2020.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Rheumatic diseases reach across continents with some similarities as well as unique challenges. The intersection between genetic factors, environmental exposures and socioeconomic factors, as well as challenges, with delays in access to subspecialty care and medications, manifest in different ways. By understanding both the challenges and successes in different countries, while also recognizing the significant diversity both within and across continents, unified strategies to improve rheumatic disease outcomes and decrease disparities among the most vulnerable groups can be developed and disseminated.
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Affiliation(s)
- Dzifa Dey
- Rheumatology Unit, Department of Medicine and Therapeutics, Korlebu Teaching Hospital, University of Ghana Medical School, College of Health Sciences, PO Box 4236, Korle-Bu, Accra, Ghana.
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, and SCDU Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Piazza del Donatore di Sangue 3, Turin 10154, Italy
| | | | - Huihua Ding
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Shen
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Akintayo RO, Akpabio AA, Kalla AA, Dey D, Migowa AN, Olaosebikan H, Bahiri R, El Miedany Y, Hadef D, Hamdi W, Oyoo O, Slimani S, Yerima A, Taha Y, Adebajo AO, Adelowo OO, Tikly M, Ghozlani I, Ben Abdelghani K, Fouad NA, Mosad D, El Mikkawy D, Abu-Zaid MH, Abdel-Magied RA. The impact of COVID-19 on rheumatology practice across Africa. Rheumatology (Oxford) 2021; 60:392-398. [PMID: 33020845 PMCID: PMC7665741 DOI: 10.1093/rheumatology/keaa600] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/18/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To identify the changes in rheumatology service delivery across the five regions of Africa from the impact of the COVID-19 pandemic. METHODS The COVID-19 African Rheumatology Study Group created an online survey consisting of 40 questions relating to the current practices and experiences of rheumatologists across Africa. The CHERRIES checklist for reporting results of internet e-surveys was adhered to. RESULTS A total of 554 completed responses were received from 20 countries, which include six in Northern Africa, six in West Africa, four in Southern Africa, three in East Africa and one in Central Africa. Consultant grade rheumatologists constituted 436 (78.7%) of respondents with a mean of 14.5 ± 10.3 years of experience. A total of 77 (13.9%) rheumatologists avoided starting a new biologic. Face-to-face clinics with the use of some personal protective equipment continued to be held in only 293 (52.9%) rheumatologists' practices. Teleconsultation modalities found usage as follows: telephone in 335 (60.5%), WhatsApp in 241 (43.5%), emails in 90 (16.3%) and video calls in 53 (9.6%). Physical examinations were mostly reduced in 295 (53.3%) or done with personal protective equipment in 128 (23.1%) practices. Only 316 (57.0%) reported that the national rheumatology society in their country had produced any recommendation around COVID-19 while only 73 (13.2%) confirmed the availability of a national rheumatology COVID-19 registry in their country. CONCLUSION COVID-19 has shifted daily rheumatology practices across Africa to more virtual consultations and regional disparities are more apparent in the availability of local protocols and registries.
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Affiliation(s)
- Richard O Akintayo
- Rheumatology Department, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Akpabio A Akpabio
- Internal Medicine Department, University of Uyo Teaching Hospital, Uyo, Nigeria
| | - Asgar A Kalla
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dzifa Dey
- Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, Accra, Ghana
| | - Angela N Migowa
- Department of Paediatrics and Child Health, Aga Khan University, East Africa, Kenya
| | - Hakeem Olaosebikan
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Rachid Bahiri
- Department of rheumatology, El Ayachi Hospital Medical University, Rabat, Morocco
| | | | - Djohra Hadef
- Department of Paediatrics, Batna 2 University, Batna, Algeria
| | - Wafa Hamdi
- Kassab Institute of Orthopedics, Tunis El Manar University, Tunis, Tunisia
| | - Omondi Oyoo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya
| | - Samy Slimani
- Rheumatology, Atlas Clinic of Rheumatology, Batna, Algeria
| | - Abubakar Yerima
- Department of Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Yassmin Taha
- Paediatrics Department, Ahmed Gasim Children's Hospital, Khartoum, Sudan
| | - Adewale O Adebajo
- Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Olufemi O Adelowo
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Mohammed Tikly
- Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Nermeen A Fouad
- Rheumatology and Rehabilitation, Fayoum University, Fayoum, Egypt
| | - Doaa Mosad
- Paediatrics Department, Mansoura University, Mansoura, Egypt
| | - Dalia El Mikkawy
- Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt
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Intracytoplasmic Expression of IL-6 and IL-17A in Circulating CD4+ T Cells Are Strongly Associated with and Predict Disease Activity in Rheumatoid Arthritis: A Case-Control Study in Ghana. Int J Rheumatol 2020; 2020:2808413. [PMID: 33101416 PMCID: PMC7568150 DOI: 10.1155/2020/2808413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Background T cell cytokines play important roles in the development and progression of rheumatoid arthritis (RA). Loss of Th1/Th2 and Th17/Treg balance has been reported in several inflammatory autoimmune diseases. However, their role in RA within hitherto rare Ghanaian context has not been explored. Here, we evaluated the intracytoplasmic CD4+ T cell cytokine patterns in rheumatoid arthritis patients in Ghana and determined their relationship with disease activity. Methods This case-control study included 48 newly diagnosed RA patients and 30 apparent healthy controls from two major hospitals in Ghana. Validated structured questionnaires were administered to obtain demographic data; blood samples were collected and processed for flow cytometric analysis. Results IFN-γ, TNF-α, IL-4, IL-6, IL-10, IL-17A, IL-6/IL-4, and IL-17/IL-10 expressions were significantly higher in RA cases compared to the healthy controls. The expression of IL-6 (0.00 (0.00-0.98) vs. 0.82 (0.34-1.10) vs. 1.56 (1.39-1.68), p < 0.0001), IL-17A (0.00 (0.00-0.02) vs. 0.19 (0.09-0.30) vs. 0.99 (0.64-1.25), p < 0.0001), and IL-17A/IL-10 (0.00 (0.00-0.39) vs. 0.15 (0.09-0.26) vs. 0.88 (0.41-1.47), p < 0.0001) increased significantly from the healthy controls through RA patients with low DAS scores to RA patients with moderate DAS scores. IL-6 (β = 0.681, r2 = 0.527, p < 0.0001), IL-17A (β = 0.770, r2 = 0.593, p < 0.0001), and IL-17A/IL-10 (β = 0.677, r2 = 0.452, p < 0.0001) expressions were significantly directly associated with DAS28 scores. IL-6 (cutoff = 1.32, sensitivity = 100.0%, specificity = 100.0%, accuracy = 100.0%, and AUC = 1.000) and IL-17A (cutoff = 0.58, sensitivity = 100.0%, specificity = 100.0%, accuracy = 100.0%, and AUC = 1.000) presented with the best discriminatory power in predicting moderate DAS scores from low DAS scores. Conclusion Th1- and Th17-related cytokines predominate in the pathophysiology of RA, with IL-6 and IL-17 being principally and differentially expressed based on the severity of the disease. IL-6 and IL-17A could serve as useful prognostic and disease-monitoring markers in RA in the African context.
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Abstract
This chapter describes the musculoskeletal (MSK) context in children and young people as an important contributor to the global non-communicable disease burden. Through selected MSK conditions, we describe the impact on patients, families and communities and highlight the challenges that need to be addressed. We focus on opportunities for better working together and describe exemplar initiatives to raise awareness, workforce capacity building, models of care and research agendas to have a greater global context.
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The management of gout in Africa: challenges and opportunities. Clin Rheumatol 2020; 40:3393-3400. [PMID: 32944884 DOI: 10.1007/s10067-020-05401-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/01/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
The rise in non-communicable diseases in Africa presents challenges for health systems that are burdened by infectious diseases. Gout is one of those diseases that has seen an increase in numbers worldwide, including Africa. Gout is commonly associated with comorbidities and mortality. It directly impacts the quality of life, increases health costs, decreases physical function, and significantly increases the time from work, much of which is potentially avoided if treatment is instituted early. Despite advances in understanding the pathophysiology and outcomes of gout, the quality of care delivered to patients in Africa is still suboptimal. Existing data on gout in Africa reveals a general low index of suspicion due to limited knowledge of the disease by healthcare workers resulting in late diagnosis, with severe polyarticular tophaceous gout being a common presenting feature. These late presentations are associated with avoidable disability and increase the direct and indirect costs of managing gout. The challenges are related to lack of government budgetary support for staff training, infrastructure for diagnosis, and availing medicines. The picture of gout in Africa largely mirrors the west concerning risk factors, comorbidities, and burden of disease, but with some unique presentations seen in HIV, sickle cell disease, and vertigo. We discuss the challenges of gout diagnosis and management in Africa and propose a roadmap to improve gout outcomes across Africa.
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Systematic review of recommendations on the use of methotrexate in rheumatoid arthritis. Clin Rheumatol 2020; 40:1259-1271. [PMID: 32876784 DOI: 10.1007/s10067-020-05363-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/21/2020] [Accepted: 08/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Most recommendations for the use of methotrexate (MTX) in rheumatoid arthritis (RA) are issued by developed countries. It is unknown whether they are relevant globally. We reviewed existing recommendations on the use of MTX for the treatment of RA and summarized areas of agreement that could be relevant for least developed countries (LDCs). METHODS Electronic databases and registries were searched for recommendations on MTX use in RA, duplicates were eliminated, and the most updated version adopted when there were several versions on the same recommendation. Reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for study quality assessment. Similarities and discrepancies of recommendations are reported. RESULTS After deduplication, 1693 unique citations were found; 25 full texts were screened and 12 included in the narrative synthesis. Average scores for the AGREE II domains ranged from 33.3 to 83.3%. Recommendations targeted rheumatologists and health care providers involved in RA care. Most covered some but not all of the following areas: baseline "pre-MTX" assessment (7/12;58%), prescription of MTX (10/12;83.3%), management of MTX side effects (6/12;50%), and special considerations (e.g., peri-operative management) (8/12; 66.7%). Recommendations agreed on baseline tests prior to starting MTX, monitoring, and need for folic acid supplementation. These aspects can serve as the foundation for the development of MTX recommendations relevant to LDCs. Recommendations disagreed on the MTX starting dose, optimal route, titration, and intervals to monitor toxicity. CONCLUSION Existing recommendations do not uniformly address all aspects related to the use of MTX and disagree in relevant aspects of MTX use. Adaptations to these recommendations are needed to facilitate their implementation in LDCs. Key Points • This paper summarizes current recommendations on the use of methotrexate for the treatment of rheumatoid arthritis. • Areas of agreement between recommendations include the following: pre-methotrexate patient assessment, need for folic acid supplementation, and toxicity monitoring. • Areas of disagreement relate to methotrexate starting and maximal dose, titration, and frequency of assessments.
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Akpabio A, Akintayo RO, Effiong U. Can telerheumatology improve rheumatic and musculoskeletal disease service delivery in sub-Saharan Africa? Ann Rheum Dis 2020; 81:e142. [PMID: 32723751 DOI: 10.1136/annrheumdis-2020-218449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 01/23/2023]
Affiliation(s)
- Akpabio Akpabio
- Internal Medicine, University of Uyo Teaching Hospital, Uyo, Akwa Ibom, Nigeria
| | | | - Utibe Effiong
- Central Michigan University, Mount Pleasant, Michigan, USA
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Navigating COVID-19 in the developing world. Clin Rheumatol 2020; 39:2039-2042. [PMID: 32462422 PMCID: PMC7251044 DOI: 10.1007/s10067-020-05159-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 12/14/2022]
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Rutter-Locher Z, Galloway J, Lempp H. Rheumatology care of migrants from sub-Saharan Africa: a literature review and qualitative pilot study of patients' perspectives. Clin Rheumatol 2020; 40:3429-3438. [PMID: 32335755 DOI: 10.1007/s10067-020-05099-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Rheumatologists practising in the UK National Health Service (NHS) are likely to treat migrant patients from sub-Saharan Africa. This study aimed to conduct a literature review about rheumatoid arthritis prevalence in Africa and understand the experiences of patients with rheumatological conditions, about their past healthcare in sub-Saharan Africa and their transition of care to the United Kingdom (UK). METHODS A systematic search and a pilot study using semi-structured interviews to gain the views of migrants from sub-Saharan Africa with rheumatological conditions was conducted. RESULTS Thirty-two studies reported on the prevalence of rheumatoid arthritis in Africa. Studies were small and out-of-date, and there was significant heterogeneity in prevalence rates. For the qualitative study, seven participants were recruited. Four themes were highlighted: (i) the physical and emotional impact of rheumatological conditions on participants; (ii) limited rheumatology care in sub-Saharan Africa with high costs, limited access to specialists, lack of investigations and treatments, the use of traditional medicines and poor communication by clinicians; (iii) barriers to rheumatology care in the UK such as migrants' poor understanding of rheumatological conditions and NHS entitlements; (iv) and ways to improve access to care such as patient, public and general practitioner education. CONCLUSION This study has highlighted the paucity of rheumatoid arthritis prevalence data in Africa and described, for the first time, the migrant's perspective of rheumatology care in sub-Saharan Africa and the transition of care to the UK. This description begins to allow healthcare providers in the UK to tailor management for this migrant population. Key Points • Rheumatological conditions are common in Africa, but there is a paucity of epidemiological data regarding the prevalence of specific conditions such as rheumatoid arthritis. • UK clinicians need to be mindful when treating migrants that access to rheumatologists and specialist investigations and treatment is limited in sub-Saharan Africa and that there is often limited public and patient understanding of rheumatological conditions. • Migrants continue to lack understanding of their NHS entitlements and fear data sharing with immigration services which can be a barrier to seeking care. • This study has exposed the lack of understanding about rheumatological conditions by the public and some general practitioners which needs to be addressed with effective education and awareness campaigns.
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Affiliation(s)
- Zoe Rutter-Locher
- Rheumatology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - James Galloway
- The Centre for Rheumatic Diseases, King's College London, Weston Education Centre, Cutcombe Road, London, UK
| | - Heidi Lempp
- The Centre for Rheumatic Diseases, King's College London, Weston Education Centre, Cutcombe Road, London, UK
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Epidemiology of rheumatoid arthritis in sub-Saharan Africa: a systematic review and meta-analysis protocol. Syst Rev 2020; 9:81. [PMID: 32303250 PMCID: PMC7164226 DOI: 10.1186/s13643-020-01342-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/30/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND So far, only one meta-analysis has estimated the prevalence of rheumatoid arthritis (RA) in Africa. Out of 10 studies included in that meta-analysis, nine came from sub-Saharan African countries and had been published between 1968 and 1988. We will conduct a new systematic review and meta-analysis to update their estimates and provide more consistent prevalence data on RA in sub-Saharan Africa. METHODS We will comprehensively search electronic databases to select observational studies addressing RA in sub-Saharan Africa and published as from 1 January 2000: PubMed, EMBASE, African Journals Online, Web of Science, and Global Index Medicus. Summary estimates will be derived through random-effects meta-analysis whenever possible. Alternatively, estimates will be reported through narrative synthesis when the random-effects meta-analysis will be impossible. The risk of bias will be assessed using standard methods. DISCUSSION This systematic review and meta-analysis shall quantify the magnitude of RA morbidity and mortality in sub-Saharan Africa. Results from this review will be disseminated in peer-reviewed journals, conferences and on social media platforms. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020153483.
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Furia FF, Godfrey E, Mwamanenge N, Swai P. Spectrum of paediatric rheumatic disorders at a tertiary hospital in Tanzania. Pediatr Rheumatol Online J 2020; 18:30. [PMID: 32245494 PMCID: PMC7126129 DOI: 10.1186/s12969-020-0418-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Paediatric rheumatic disorders are common in children and result in significant impairment in quality of life, morbidity and mortality. There is limited information on the burden of these disorders in lower income countries especially in sub-Saharan Africa. Few case reports have documented presence of paediatric rheumatic disorders in Tanzania. This study was conducted to determine the spectrum of rheumatic disorders among children at Muhimbili National Hospital (MNH). METHODS This was a retrospective study conducted among children who were attended at MNH between January 2012 and August 2019. Paediatric patients seen in the out-patient clinics and those admitted in the wards were eligible. All patients with diagnosis of rheumatic disorders were identified from admission books and outpatient clinic logbooks, and later data were collected from their case notes and were recorded in clinical research forms. Collected information included age, sex, clinical features and laboratory tests results. RESULTS A total of 52 children with mean age of 9.5 ± 4.3 years, 12 (40.4%) participants were aged above 10 years and 32 (61.5%) were females. Frequently reported clinical presentations were joint pain 44 (84.6%), joint swelling 34 (65.4%), fever 24 (46.2%) and skin rashes 21(40.4%). Juvenile idiopathic arthritis (JIA) was the predominant diagnosis reported in 28 (53.8%) participants followed by juvenile systemic lupus erythematosus 8 (15.4%), mixed connective tissue diseases 4 (7.7%) and juvenile dermatomyositis 4 (7.7%). Antinuclear antibody test was performed in 16 participants it was positive in 9 (56.2%). Nine participants were tested for anti-double stranded DNA test and 5 (55.6%) were positive for this test. C-reactive protein was tested in 46 participants out of which 32 (69.6%) had elevated levels. HIV was tested in 24 (46.2%) participants and results were negative. Thirty-five out of 52 (67.3%) participants had anaemia. Predominant drugs used for treatment of JIA include prednisolone and methotrexate. CONCLUSIONS Paediatric rheumatic disorders are not uncommon in Tanzania-and were noted to affect more female children in this study. Predominant conditions included juvenile idiopathic arthritis (JIA), juvenile systemic lupus erythematosus (JSLE) and juvenile dermatomyositis (JDM).
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Affiliation(s)
- Francis F. Furia
- grid.25867.3e0000 0001 1481 7466Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania ,grid.416246.3Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Evance Godfrey
- grid.25867.3e0000 0001 1481 7466Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania ,grid.416246.3Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Naomi Mwamanenge
- grid.25867.3e0000 0001 1481 7466Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Peter Swai
- grid.25867.3e0000 0001 1481 7466Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania ,grid.416246.3Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
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Lewandowski LB, Schiffenbauer A, Mican JM, Moses SJ, Fallah MP, Plotz P, Katz JD. Rheumatology capacity building: implementing a rheumatology curriculum for Liberian health-care providers in 2016. Clin Rheumatol 2020; 39:689-696. [PMID: 31960207 PMCID: PMC10461609 DOI: 10.1007/s10067-019-04817-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Liberia has no rheumatology providers for the nation's 4.7 million people. We proposed a short course format rheumatology curriculum to educate Liberian providers as an initial step in providing graduate medical education in musculoskeletal health. METHOD A 1-week training curriculum in rheumatology encompassing introduction to musculoskeletal exam and approach to rheumatology diagnosis and management was designed. The curriculum used multiple education methods including interactive lectures, bedside training, and hands-on learning. RESULTS A 1-week rheumatology training curriculum for 24 local physicians was feasible. The execution of the designed rheumatology curriculum in Liberia relied upon a mixed method format that was both didactic and case-based. A survey of the Liberian trainees revealed that the curriculum was salient to care of patients and barriers to optimal learning such as time and space limitations were identified. CONCLUSIONS A 1-week rheumatology training education program is possible and relevant to local providers, but training length and setting may need to be optimized. Future training will aim to minimize barriers to education and expand the cohort of providers with rheumatologic knowledge in Liberia.Key Points• Liberia, like many nations in sub-Saharan Africa, has no trained rheumatologists to serve the nation's population.• Education and capacity building for rheumatologic care in short course format are relevant and feasible to local health-care providers.• Further efforts are needed to develop and evaluate continuing rheumatology education in Liberia.
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Affiliation(s)
| | - Adam Schiffenbauer
- Environmental Autoimmunity Group, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, USA
| | - JoAnn M Mican
- NIAID, National Institutes of Health, Bethesda, MD, USA
| | - Soka J Moses
- John F. Kennedy Medical Center, Monrovia, Liberia
| | | | - Paul Plotz
- NIAMS, National Institutes of Health, Bethesda, MD, USA
| | - James D Katz
- NIAMS, National Institutes of Health, Bethesda, MD, USA
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Akinnuwesi BA, Adegbite BA, Adelowo F, Ima-Edomwonyi U, Fashoto G, Amumeji OT. Decision support system for diagnosing Rheumatic-Musculoskeletal Disease using fuzzy cognitive map technique. INFORMATICS IN MEDICINE UNLOCKED 2020. [DOI: 10.1016/j.imu.2019.100279] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Meyer PWA, Ally MMTM, Tikly M, Tintinger G, Winchow LL, Steel H, Anderson R. Tobacco-Derived Lipopolysaccharide, Not Microbial Translocation, as a Potential Contributor to the Pathogenesis of Rheumatoid Arthritis. Mediators Inflamm 2019; 2019:4693870. [PMID: 31780859 PMCID: PMC6874965 DOI: 10.1155/2019/4693870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
Microbial lipopolysaccharides (LPS) have been implicated in the pathogenesis of rheumatoid arthritis (RA), possibly driving a systemic inflammatory response that may trigger the development and/or exacerbation of the disease. To explore the existence of this mechanism in African RA patients, we have measured systemic levels of LPS and its surrogate, LPS-binding protein (LBP), as well as those of intestinal fatty acid-binding protein (I-FABP), pulmonary surfactant protein D (SP-D), and cotinine in serum to identify possible origins of LPS, as well as associations of these biomarkers with rheumatoid factor (RF) and anticitrullinated peptide (aCCP) autoantibodies and the DAS 28-3 clinical disease severity score. A cohort of 40 disease-modifying antirheumatic drug-naïve, black South African RA patients rated by compound disease scores and 20 healthy subjects and 10 patients with chronic obstructive pulmonary disease (COPD) as controls were included in this study. Levels of the various biomarkers and autoantibodies were measured using a combination of ELISA and immunofluorimetric and immunoturbidometric procedures. LPS levels were lowest in the RA group compared to the healthy controls (p = 0.026) and COPD patients (p = 0.017), while LBP levels were also significantly lower in RA compared to the healthy individuals (p = 0.036). Levels of I-FABP and SP-D were comparable between all three groups. Categorisation of RA patients according to tobacco usage revealed the following significant positive correlations: LBP with C-reactive protein (p = 0.0137); a trend (p = 0.073) towards an association of LBP with the DAS 28-3 disease severity score; RF-IgG antibodies with both LPS and LBP (p = 0.033 and p = 0.041, respectively); aCCP-IgG antibodies with LPS (p = 0.044); and aCCP-IgG with RF-IgM autoantibodies (p = 0.0016). The findings of this study, several of them novel, imply that tobacco products, as opposed to microbial translocation, represent a potential source of LPS in this study cohort of RA patients, again underscoring the risks posed by tobacco usage for the development and severity of RA.
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Affiliation(s)
- Pieter W. A. Meyer
- Department of Immunology, Tshwane Academic Division, National Health Laboratory Services, Pretoria 0001, South Africa
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Mahmood M. T. M. Ally
- Department of Internal Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Mohammed Tikly
- Division of Rheumatology, Chris Hani Baragwaneth Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Road, Johannesburg 2013, South Africa
| | - Gregory Tintinger
- Department of Internal Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Lai Ling Winchow
- Division of Rheumatology, Chris Hani Baragwaneth Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Chris Hani Road, Johannesburg 2013, South Africa
| | - Helen Steel
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
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Bedaiwi M, Al-Homood IA, El-Garf A, Uthman I, Sunna N, Nassier R, Mohamed H, Al Saleh J. Disease burden and treatment challenges of psoriatic arthritis in Africa and the Middle East. Rheumatol Int 2019; 39:1321-1329. [PMID: 31134289 DOI: 10.1007/s00296-019-04319-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/03/2019] [Indexed: 01/17/2023]
Abstract
Psoriatic arthritis (PsA) is a chronic, inflammatory arthropathy occurring in up to 30% of patients with psoriasis, and is characterized by multiple manifestations including peripheral arthritis, enthesitis, dactylitis, spondylitis, and psoriatic skin and nail disease. This complex and heterogeneous disease is poorly understood and its diagnosis and treatment are suboptimal, particularly in Africa and the Middle East, where very few studies into the impact of PsA have been carried out. This article aims to highlight the disease burden of PsA in the region as well as to identify unmet clinical needs. A non-systematic review was carried out in the PubMed database and the most relevant publications were selected. Expert rheumatologists practicing in Africa and the Middle East provide an insight into the challenges of treating PsA in daily practice, along with recommendations for improvements.
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Affiliation(s)
- Mohamed Bedaiwi
- Division of Rheumatology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Ibrahim A Al-Homood
- Department of Medical Specialties, Rheumatology Section, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ayman El-Garf
- Rheumatology Department, Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Imad Uthman
- Division of Rheumatology, American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | | | - Jamal Al Saleh
- Rheumatology Unit, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
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