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Abstract Background Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) frequently overlap, with each disease potentially presenting as a manifestation of the other. The strong relationship between PMR and GCA raises the question of whether it is a “co-occurrence of different diseases” or a “common spectrum of inflammatory diseases.” The objectives of the current study were to assess the applicability of using ultrasound (US) and clinical data as a monitoring tool to identify PMR patients with subclinical GCA and determine possible predictors of GCA among PMR patients. Results One hundred eight PMR patients and 62 GCA patients were included in this study. The study found that 20.4% of the PMR cohort had subclinical GCA, which later progressed to classical GCA, while 31.5% experienced a PMR relapse. The presence of intimal media thickening of the temporal/axillary artery at baseline was a very early predictor of GCA development; the OGUS score was significantly higher in the PMR group who developed GCA than the standard GCA cohort (p

Abstract Background The incidence of osteoporosis in children has increased dramatically during the last decade. This has been attributed to better survival rates of children living with chronic disorders, the increased use of medications known to have a negative impact on the children’s bones, and the increased preference for indoor activities and sedentary life in healthy children. Recent advances in pediatric osteoporosis definition, along with a lack of management recommendations or national consensus on its diagnosis and treatment, have led to a wide range of approaches being implemented to manage this illness. The aim of this work was to develop an optimal evidence-based consensus, target-oriented, on-steered therapeutic approach for children with osteoporosis. Based on 15 key clinical questions, a qualitative literature evaluation was conducted to provide evidence-based recommendations for the treatment of pediatric osteoporosis. An expert panel of 14 pediatric osteoporosis specialists conducted a Delphi survey. The level of evidence for each element was assessed using the Oxford Centre for Evidence-based Medicine (CEBM) System, when available, and/or based on the expert panel’s personal experience. All recommendations with an agreement rate of 75% or higher were included. Results Thirty-six recommendations, categorized into 13 domains, had evidence 4 or 5 and consequently were included in the Delphi survey. This was assessed online and a response rate of 82.4% was achieved. Delphi 2 round revealed that all the recommendations achieved 75% or more level of agreement and therefore have been accepted and included in this management recommendations. Based on that an algorithm showing an approach to pediatric osteoporosis management and maintenance of therapy has been developed. Conclusion For the management of children with osteoporosis, consulting a pediatric bone specialist is strongly advised, either by referral or by advice. This is extremely relevant because children are uniquely capable of recovering spontaneously or with the assistance of medication. This includes also vertebral fractures reshaping. Consequently, there is a huge opportunity to improve bone mass accretion and thus musculoskeletal health in children with osteoporosis.

Abstract Background With a focus on promoting healthy aging, the Egyptian Academy of Bone and Muscle Health followed a structured guideline development process to create the Egyptian 24-h movement clinical guideline for adults aged 18 to 50. This guideline is in continuation with the earlier published 24-h movement guidelines for children and older adults. Online databases (PubMed, Embase, and Cochrane Library) were searched for relevant peer-reviewed studies that met the a priori inclusion criteria. Results A large body of evidence was used to inform the guidelines as a total of 56 studies met the inclusion criteria. Leveraging evidence from the review of the literature led to the development of 30 statements answering the 7 key questions. Recommendations were also given for specific conditions including inactivity or insufficiently active adults, chronic conditions disability as well as pregnancy and postpartum. Based on this, the final guideline was developed providing evidence-based recommendations for a “Healthy 24-h day”, based on the integration of resistance training, aerobic activity, balance and flexibility activity, sleep pattern, and sedentary behavior. Conclusion The developed guidelines are meant to help in the decision-making process and are intended for use by adults both nationally and internationally; also, for endorsement by the policymakers. The developed 24-h movement guidelines provide specific targets for each movement behavior, towards which adult Egyptians can work to achieve better health.

Abstract Background The Egyptian Academy of Bone and Muscle Health in collaboration with the Egyptian College of Pediatric Rheumatology have identified two indicators to ensure optimum health outcomes among children: one is developmentally and nutritionally appropriate healthcare, and the second is the availability of an effective transition of care model from pediatric care to adult health services. Currently, there is no national guidelines on transition of care for children and adolescents with osteoporosis and metabolic bone disease. To close this gap, this work was carried out to develop the Egyptian guidelines for transition model of care. Results The final recommendation included 12 specific domains. These included the following: targeted population, transition age, transition readiness, patient-targeted care, and disease-specific knowledge, patient education, and optimum model for the transition of care, transition referral, management approach, high quality of care, documentation, and recent service approaches as well as standards and quality indicators. All the overarching principles and most voters agreed with the 12 amended recommendations. Conclusion Transitional care is the term used to describe services that seek to bridge this care gap. Based on the best available data and professional judgment, these consensus-based recommendations guide ways to achieve optimal outcomes in transitional care for adolescents with osteoporosis and metabolic bone disorders. Though focussed on transition of care of bone and muscle health, this article can be the bases for transition services for children with other chronic conditions. This could be used as a blueprint for additional national or internationally healthcare transition policies.

Abstract Background Gender differences in the diagnosis and treatment of osteoporosis is a relatively common phenomenon, particularly amongst those patients under 80 years of age presenting with fragility fractures. The clinical implications of these findings are that strategies, which tend to focus on osteoporosis management in women, should also pay enough attention to osteoporosis in men. However, there have been questions whether there is a gender difference when setting intervention thresholds for osteoporosis management. This work was carried out aiming to determine the fracture probabilities calculated by FRAX at which therapeutic intervention in older men and women can be considered. Results Assessment of fracture risk probability thresholds in men revealed that for hip fractures, ROC was 0.754 (95% CI: 0.69–0.817). The sensitivity was 80.5% for threshold probabilities of 2.5%. For the major osteoporosis fracture, ROC was 0.828 (95% CI: 0.694–0.963). The sensitivity was 87.5% for threshold probabilities of 10%. Assessment of fracture risk probability threshold in women ROC was 0.760 (95% CI: 0.691–0.83). The sensitivity was 76.1% for threshold probabilities of 3%. For major osteoporosis fracture, ROC was 0.848 (95% CI: 0.784–0.912). The sensitivity was 87.3% for threshold probabilities of 15%. Conclusion Operational aspects of osteoporosis management should consider gender specific fracture thresholds. Interventional thresholds were found to be different in men compared to women. This helps to optimise fracture prevention in older men.

Abstract Background With the vision of healthy aging, the Egyptian Academy of Bone and Muscle Health followed an established guideline development process to create the Egyptian 24-h movement clinical guideline for adults aged 50 years and older adults. This guideline highlights the significance of movement behaviors across the whole 24-h day. Online databases (PubMed, Embase, and Cochrane Library) were searched for relevant peer-reviewed studies that met the a priori inclusion criteria. Results A total of 53 studies met the inclusion criteria. Leveraging evidence from the review of the literature led to the development of 27 statements answering the 5 key questions. Results revealed a major change in the previous basic understandings as it shifts away from focussing on a sole movement behavior to the combination of all the movement behaviors. Based on this, the final guideline was developed providing evidence-based recommendations for a “Healthy 24-Hour Day”, comprising a mix of light-intensity and moderate-to-vigorous-intensity physical activity, sleep, and sedentary behavior. Conclusion The developed guidelines are meant to help in the decision-making process and are intended for use by adults and older both nationally and internationally; also, for endorsement by the policy-makers. Dissemination and implementation efforts would impact positively on both health professionals and researchers and would also be useful to interested members of the public sector.

Abstract Trabecular bone score (TBS) is a grayscale textural assessment resulting from a computed evaluation of pixel gray-level variations in previously obtained lumbar spine DXA images. It is an index of bone microarchitecture correlated with parameters of bone strength. Higher values of TBS indicate a better microarchitecture, whereas lower values indicate a degraded microarchitecture. TBS can be used alongside Fracture Risk Assessment tool “FRAX” and bone mineral density (BMD) to enhance the assessment of fracture risk and to inform treatment initiation and monitoring. A systematic review was carried out aiming to update the evidence on the clinical use of the TBS in the management of both primary and secondary osteoporosis. Results revealed that in both primary and secondary osteoporosis, TBS enhances the prediction of fracture risk, and when adjust with BMD and clinical risk factors, it is able to inform the decision-making process regarding initiating osteoporosis therapy and the choice of anti-osteoporosis medication. Evidence also implies that TBS provides valuable adjunctive information in monitoring osteoporosis therapy. In conclusion, this work provides an up-to-date evidence-based review and recommendations which informs the utility of trabecular bone score in standard clinical practice.

Abstract Background This work aims to develop clinical practice recommendations for the management of systemic sclerosis (SSc). Results Fourteen expert panels had completed the two rounds of surveys. After the end of round 2, recommendations were released and distributed on 11 domains. The percentage of the agreement on the recommendations was 92.3% to 100%. All 11 key questions were answered at the end of the second round with agreement. Conclusion This guideline tried to tackle the gaps in research that limit treatment options. Stratifying the patients according to their disease domains has helped to set up sequential management pathways for each domain.

Abstract Background By 2030, approximately 22.6 million individuals in Egypt will be older than 50 years and prone to develop osteoporosis and are at risk of sustaining a fragility fracture. Osteoporotic fragility fractures, and in particular hip fractures, are associated with enduring pain, physical disability, poor quality of life, and loss of independence. Mortality rates are also high in this cohort of patients. Over the coming years, the potential preventable burden is likely to surge, particularly with the aging of the Egyptian population. The aim of this work was to determine the age onset of screening for risk of fragility fracture among Egyptians. Results A convincing evidence was found that fracture risk assessments are accurate and can be applicable in standard practice to identify individuals at high/very high risk of developing fragility fractures. A tremendous increase in the risk of fragility fracture at the age of 60 (RR = 33.5 for men and 20.2 for women). As interventions to either treat osteoporosis or to modify behavioral risk factors in terms of healthy eating and physical exercise would take years to change this risk, it was recommended to start screening for fragility fracture at the age of 50 for both men and women. Conclusion All Egyptian men and postmenopausal women 50 years of age or older should be evaluated/screened for their risk of sustaining a fragility fracture risk. The consequences of failing to identify and treat women and men who are prone to sustain a fragility fracture are considerable. In contrast to DXA scanning, screening with FRAX is cost-effective (time and effort required by patients and the health care system).

Abstract Purpose To assess the relationship between the triad of obesity, fracture risk factors, and osteoporosis and its impact on fragility fractures. Results Osteoporosis was least prevalent (p

Abstract Background The aim of this work is to set up the standards for performing musculoskeletal ultrasound scans and reporting as an additional procedure in the rheumatology setting. We used two rounds of the Delphi approach to get the consensus on a musculoskeletal ultrasound reporting. Results Fifteen expert panels had completed the two rounds of surveys. After the end of round two, eighteen recommendations distributed upon eight domains were released. The percentage of the agreement on the recommendations was 93.3 to 100 %. All eighteen key questions were answered at the end of the second round with agreement. Conclusion A musculoskeletal ultrasound report template has been developed by this study, based on outcomes of a Delphi process, by an international participants’ panel. All domains met the 80% voting threshold set in this work. The reporting template can be used for both clinical research as well as standard practice to provide guidance and standardize the musculoskeletal ultrasound reporting.

Abstract Purpose (1) This was a multi-center, cross-sectional, observational study. Both old men and postmenopausal women over 50 years old who were admitted with an osteoporotic fracture (whether hip fracture or major osteoporosis) were consecutively recruited for this work and managed under the Fracture Liaison Service. All the patients were assessed for their sarcopenia risk (SARC-F), fracture risk (FRAX), and fall risk (FRAS) as well as functional disability (HAQ). The aim was to assess the prevalence of sarcopenia risk among older adult Egyptians presenting with fragility fractures. (2) To identify the relation between sarcopenia risk with the risk of falling as well as sustaining a fragility fracture. Results Two hundred and thirty-six patients (69 males, 167 females) were included in this work. The mean age was 70.1 (SD = 9.2) years. The prevalence of sarcopenia was 69.7%. The sarcopenia risk score was positively correlated with the FRAX score (p = 0.01). The prevalence of high sarcopenia risk was 78% of the patients presenting with a high 10-year probability of major osteoporosis fracture as well as a 10-year probability of hip fracture. The sarcopenia risk score was positively correlated with the increased fall risk (p = 0.01) as scored by the FRAS scale. There was a significant relation (p

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

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

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

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

Abstract Background Musculoskeletal disorders are common problems that affect the elderly. They severely restrict mobility and dexterity, resulting in early retirement from work, lower levels of well-being, and reduced ability to participate in society. With the increase in life expectancy, the older populations are dreaming of active, painless, and independent lives in the face of functional limitations that are the result of various comorbidities with age progression. Main text The aim of the study is to highlight aging changes in the musculoskeletal system, risk factors that may have a negative impact on musculoskeletal, as well as strategies to optimize musculoskeletal health in the elderly. A narrative review was conducted through a series of literature searches in the database MEDLINE/PubMed focusing on musculoskeletal health. The search terms used were “muscle building,” “bone building,” “osteoporosis,” “osteopenia,” “sarcopenia,” “osteosarcopenia,” “fractures,” “falls,” “functional ability,” “nutrition,” “diet,” “obesity,” “comorbidity,” and “medication.” Data extraction was carried out by the investigators using a standardized data collection form with subsequent discussion among the authors. Peer-reviewed observational controlled and non-controlled studies (case–control and cohort studies) were selected. The data collected in the selected articles were all related to musculoskeletal health. Conclusion Many of the changes in the musculoskeletal system result more from disuse than from simple aging. Less than 10% of the Egyptian population participate in regular exercise, and the most sedentary group is older than 50 years of age. Long-term regular exercises may reduce the loss of bone and muscle mass and prevent age-associated increases in body fat.

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

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

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

Abstract Background There is an evidence-practice gap in osteoarthritis (OA) management which has caused several patients living with the disease are receiving suboptimal medical care. Though there are several guidelines and treatment recommendations published, there is a real need to operationalise such evidence-based guidelines and facilitate their implementation by healthcare professionals in their local health systems Main text This work was carried out to outline a patient-centred multidisciplinary osteoarthritis care programme for knee and hip joint osteoarthritis that is applicable in standard clinical practice. A scoping review was conducted to identify an evidence-informed osteoarthritis management strategy, which outlines the optimal manner to treat patients living with osteoarthritis and can be implemented by healthcare professionals. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide the reporting of this review. Based on this, a “Model of Care” based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including non-pharmacological, pharmacological therapies, psychotherapy, rehabilitation as well as surgery) has been developed aiming to optimise the outcomes. The goals and principles have been identified as well as the key performance indices. An algorithm for the multidisciplinary management of osteoarthritis has been developed. Conclusion The developed osteoarthritis care programme (OACP) provided a “Model of Care” for people living with OA which can be implemented in standard practice. The results will give insight into the features, performance, results, and outcome measures assessed. It will also guide future research towards how “Model of Care” can be patient-centred and tailored to the individual medical status.

Abstract The overarching goal of treating osteoporotic patients is to reduce the incidence of fractures, yet interventions that support early detection of osteoporosis and prevention of osteoporotic fractures are underutilized. Osteoporosis and, specifically, the associated burden of fractures call for a screening strategy offering an opportunity to intervene early. Such strategy should be clinically feasible and cost-effective, aiming to identify and treat subjects at high or very high risk of fragility fracture. The low sensitivity of bone mineral density measurements in identifying high-risk patients is evidenced by the high number of osteoporotic fractures occurring in subjects with BMD values above threshold required for a diagnosis of osteoporosis. Consequently, DXA scanning is not considered appropriate as a public screening tool identifying patients at risk of sustaining fragility fractures and current efforts focus on identifying non-BMD-related risk factors. In Egypt, we are fortunate in having all modalities of osteoporosis therapy and assessment tools available, yet there remains a significant treatment gap in osteoporosis management. Furthermore, screening for fracture risk is not currently advocated nationally. This manuscript describes a national initiative for a population screening intervention to identify patients at risk of developing a fragility fracture aiming to reduce fragility fractures especially in older adults.

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

Abstract Background Busy rheumatologists, and busy patients as well as policy makers, require accurate, succinct, transparent, easily digested summaries of evidence and recommendations for management. Our objective was to develop an up-to-date evidence-based, consensus, clinical practice guidelines for treat-to-target management of rheumatoid arthritis in adults. Results Ninety-four (94.7%) of the expert committee completed the 2-round e-Delphi surveys. A total of 33 recommendation items, addressing the main rheumatoid arthritis (RA) domains, were identified. The level of agreement (rate 7–9), for the statements which reached consensus, ranged from 85 to 100%. Consensus was achieved on the wording of all the clinical practice guidelines identified by the scientific committee. A management algorithm for the management of rheumatoid arthritis have been developed. Conclusion These updated recommendations reflect the most recent evidence for the management of RA. It also outlines the multidisciplinary team role in enhancing the RA patients’ care. The recommendations offer strategies to achieve optimum treat-to-target outcomes. However, standards of care are defined based on the clinical data obtained for individual patients and are prone to modification. High-quality, broad scope evidence-based clinical practice guidelines offer a path for bridging the gap between best practice, policy, local settings and patients’ choice.

Abstract Background This is a Clinical Practice Guideline update released by the Egyptian Academy of Bone Health and Metabolic Bone Diseases. It does not replace the clinical practice guidelines published for the treatment of osteoporosis in 2021, but it entails specific recommendations and selective criteria for romosozumab as another pharmacological agent for treatment of postmenopausal osteoporosis. It has been issued, in part, due to the imminent approval of romosozumab in Egypt. Main text The guideline recommends the use of romosozumab, for up to 1 year, for the reduction of vertebral, hip, and non-vertebral fractures in postmenopausal women with severe osteoporosis at very high risk of fracture/imminent fracture risk: defined as T-score less than − 2.5 and a prior hip or vertebral fracture in the past 24 months or a very high fracture risk, as identified by FRAX (FRAX major osteoporosis fracture > 30%, FRAX hip fracture > 4.5%). The recommended dosage of romosozumab is 210 mg monthly by subcutaneous injection for 12 months. For osteoporotic postmenopausal women who have completed a 12-month course of romosozumab, treatment with an anti-resorptive osteoporosis therapy is recommended to maintain bone mineral density gains and reduce fracture risk. The treatment is not recommended for women at high risk of cardiovascular disease and stroke, which includes those with prior myocardial infarction or stroke. In conclusion, strategies to osteoporosis management have been highly diversified, with bone health specialists have become able to set up treatment plan tailored to the individual patient’s requirement. Patients with severe osteoporosis at very high fracture risk need stronger therapeutic regimens to start with. Romosozumab endorses bone formation and suppresses bone resorption, leading to a greater anabolic window and a superior positive impact on bone mineral density.

Abstract Background Lupus nephritis (LN) affects a substantial number of the patients living with Systemic lupus erythematosus (SLE), representing a major cause of morbidity and mortality. Patients with lupus nephritis should be referred to a lupus nephritis expert who can confirm the diagnosis, assess the level of disease activity, and offer guidance on treatment and monitoring of the disease, as well as its consequences and side effects. The aim of this guideline was to develop recommendations for the management of adult lupus patients, including lupus nephritis diagnosis, assessment, and monitoring. Nineteen key clinical questions were identified by scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. Literature review team performed a systematic review to summarize evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for LN. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations. Results An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 19 recommendation items, categorized into 11 sections to address the main LN categories, were obtained. The percentage of those who agreed with the recommendations (ranks 7–9) ranged from 90.5 to 100%. The phrasing of all 19 clinical standards identified by the scientific committee was agreed upon (i.e., 75% of respondents strongly agreed or agreed). Conclusion These recommendations provide an updated consensus on the pharmacological treatment of lupus nephritis and strategies to reach optimal treat to target outcomes in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient situation.

Abstract Background Nephritis is known to be one of the most serious complications of lupus and a strong predictor of poor outcome. This study was carried out aiming at setting up an up-to-date recommendation for the management of women living with lupus nephritis and planning for a family throughout conception, pregnancy, and the postpartum period. Ten key clinical questions were identified by the scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. The literature review team performed a systematic review to summarise evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for women living with lupus nephritis (LN) and planning for a family. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-Based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations. Results An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 20 recommendation items, categorised into 10 domains to address the main LN with pregnancy categories, were obtained. The percentage of those who agreed with the recommendations (rank 7–9) ranged from 88.5 to 100%. On the phrasing of all the clinical standards defined by the scientific committee, a consensus was reached (i.e., 75% of respondents strongly agreed or agreed). An algorithm for the management of LN with pregnancy has been suggested. Conclusion These recommendations provide an updated consensus on the pharmacological treatment of LN with pregnancy and strategies to reach optimal outcomes for both the mother and newborn in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient’s situation.

Abstract Background We aimed to provide up-to-date, evidence-based and consensus-based recommendations for Treat-to-Target management of psoriatic arthritis (PsA) and associated clinical manifestations. In this recommendations, 14 key clinical questions were identified by scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. Literature Review team performed a systematic review to summarize evidence advocating the benefits and harms of available pharmacologic and non-pharmacologic therapies for psoriatic arthritis. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 3-round Delphi process was conducted with 19 experts whom were drawn from different governorates and health centers across Egypt with diverse in their experiences, including private, governmental workplace, tertiary university hospitals, and insurance hospitals. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations. Results An online questionnaire was sent to an expert panel who participated in the three rounds (response rate 100%). At the end of round 3, a total of 51 recommendation items, categorized into 6 sections to address the main 6 psoriatic arthritis categories, were obtained. Agreement with the recommendations (rank 7–9) ranged from 89.5 to 100%. Consensus was reached (i.e., ≥ 75%of respondents strongly agreed or agreed) on the wording of all the 51 clinical standards identified by the scientific committee. Algorithms for the management of psoriatic arthritis have been suggested. Conclusion These recommendations provide an updated consensus on the pharmacological treatment of psoriatic arthritis and strategies to reach optimal treat-to-target outcomes in in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient situation.

Abstract Introduction New therapies, management approaches, and evidence regarding the management of gout have become available over the past years. This triggered the need for an updated recommendation for gout management. Through an up-to-date consensus evidence-based clinical practice guideline for the management of gout including recommendations for management of gout flares, optimum usage of urate lowering therapy for chronic gout, as well as patient education and lifestyle guidance. A wide systematic literature review was performed, and evidence-based recommendations were extrapolated, based on 16-key questions identified according to population, intervention, comparator, and outcomes (PICO) approach. These were evaluated by a panel consisted of 17 rheumatology experts via online surveys over a 2-round Delphi process. The purpose of this study is to offer an updated, consensus-evidence-based, and in the meantime patient-focused, expert recommendations for the treat-to-target approach of gout management. Results Results revealed that after round 2 ended, a total of 30-recommendation items, categorized into 10 domains, were obtained. Agreement with the recommendations (rank 7–9) ranged from 90 to 100%. Consensus was reached (i.e., ≥ 75% of respondents strongly agreed or agreed) on the wording, the grade of recommendation, and level of evidence of all the 30 clinical standards identified by the scientific committee. Conclusions This guideline provides updated evidence-based recommendations for the prevention and treatment of acute as well as chronic gout. This guideline provides an approach for physicians and patients making decisions on the management of gout. It will also facilitate improvement and uniformity of care.

Abstract Background Because of the subjective character of symptoms, absence of a diagnostic test, modest response to treatments, and, at times, patient reports of important functional disability, fibromyalgia remains a challenge for the treating health care professionals in the standard clinical practice. The aim of this study was to develop an up-to-date consensus and evidence-based clinical practice guidelines for a treat-to-target management of fibromyalgia. Fifteen key clinical questions were identified by a scientific committee according to the Patient/Population, Intervention, Comparison, and Outcomes (PICO) approach. A literature review team performed a systematic review to summarize the evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for fibromyalgia. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 3-round Delphi process was conducted with 16 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations. Results An online questionnaire was sent to an expert panel who participated in the three rounds (response rate 100%). At the end of round 3, a total of fifteen recommendation items, categorized into 10 sections to address the main fibromyalgia categories, were obtained. Agreement with the recommendations (ranks 7–9) ranged from 85 to 100%. Consensus was reached (i.e., ≥ 80% of respondents strongly agreed or agreed) on the wording of all the 15 clinical standards identified by the scientific committee. An algorithm for the management of fibromyalgia has been suggested. Conclusions These recommendations provide an updated consensus on both the non-pharmacological and the pharmacological treatments of fibromyalgia. The provided strategies to reach optimal treat-to-target outcomes in common clinical scenarios are based on a combination of evidence and expert opinions. Best treatment decisions should be tailored to each individual patient situation.

Abstract Background Despite a broad spectrum of effective anti-osteoporosis therapies and a growing number of older adults worldwide, the number of people receiving appropriate secondary fracture prevention is not yet optimum or achieved its expected target, i.e., avoiding refracture. Main body To close this gap in the patients’ care, and in concordance with the International Osteoporosis Foundation (IOF) as well as international organizations recommendations, the Egyptian Academy of Bone Health and Metabolic Bone Diseases has launched specialised healthcare system for fracture liaison services (FLSs). FLS is a small team of healthcare professionals who identify, investigate, initiate therapy and arrange for follow-up plan over time, for people aged 50 and above presenting with a fragility fracture. Such comprehensive service requires operative clinical standards which would help to standardise the service across the different centres to become effective and sustainable. An estimated 71.8% of the Egyptian population currently have access to a local FLSs. This article aims at setting up evidence-based standards of post-fracture care and provide the necessary index for efficient implementation of secondary fracture prevention in the different FLS centres in Egypt. Conclusion The Egyptian FLS clinical standards agree with the international protocols and are an effective approach to target interventions to the properly identified patients at risk. The Egyptian model has identified 19 key performance indicators to measure the effectiveness of fracture liaison services and guide quality improvement.

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

Abstract Background A fracture that occurs in people with low bone mass in the setting of minimal trauma—such as a fall from standing height—meets the criteria for the clinical diagnosis of osteoporosis and qualifies this particular individual for being at high risk of further fractures, particularly in the first 2 years after the index fracture. Therefore, it is vital to identify those individuals at very high and high fracture risk with the potential of instantly starting osteoporosis therapy. Main body Currently, there are unmet needs in the management of bone fragility and fracture prevention. Therefore, re-stratification of the people according to their risk of fracture, and, also, identify what is and is not achievable using different osteoporosis therapies, represent a major step forward. In 2020, the dichotomisation of high risk into high and very high-risk categories, which represent a new concept in osteoporosis assessment, was published by the IOF and the ESCEO. This coincided with proliferation of the available therapies with different modes of action and new therapeutic targets for treating osteoporosis. Fear of complications, even though rare, associated with long-term bisphosphonates and the positive impact of osteoanabolic agents on fracture reduction and bone quality, have changed the prescribing patterns and paved the way for sequential and combined therapy. Conclusion The incorporation of recent concepts in osteoporosis and the development of new interventional thresholds have positive implication on strategies for osteoporotic patients’ diagnosis and management.

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

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

An amendment to this paper has been published and can be accessed via the original article.