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Objectives: The primary aim of the CHANGE survey is to determine the current state of gender equity within rheumatology, and secondarily, to review the physician perspective on bullying, harassment and equipoise of opportunities within rheumatology., Methods: The CHANGE e-survey is a cross-sectional self-reported questionnaire adapted from EULAR's gender equity in academic rheumatology task force. The survey was launched in January 2023; it is available in six languages and distributed widely via rheumatology organizations and social media. Eligible participants include rheumatologist physicians and rheumatology health-care professionals. Survey responses will undergo descriptive analysis and inter-group comparison aiming to explore gender-based discrimination using logistic regression, with subgroup analyses for country/continent variations., Conclusion: This e-survey represents a comprehensive global initiative led by an international consortium, aimed at exploring and investigating the gender-related disparities and obstacles encountered by rheumatologists and rheumatology health-care professionals across diverse communities and health-care environments. By pursuing this initiative, we aim to take the broader rheumatology community a step closer to understanding the underlying origins of inequities and their determinants. Such insights are pivotal in identifying viable interventions and strategies to foster gender equity within the field. Ultimately, our collective objective is to ensure equitable access to opportunities for every individual, irrespective of gender, thereby promoting inclusivity and fairness across the entire spectrum of professional practice and career development., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions-the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A 'roadmap' for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents 'agreed' or 'strongly agreed' the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated., Competing Interests: Competing interests: AMB reports grant income from AO Alliance, Asia Pacific League of Associations for Rheumatology, Australian Rheumatology Association, Curtin University, Pan American League of Associations for Rheumatology, and World Federation of Chiropractic related to the current work. AMB reports grant funding from the Australian Government, Department of Health; Medical Research Future Fund (Australian National Health and Medical Research Council); Western Australian Government Department of Health; Bone and Joint Decade Foundation; Curtin University; Institute for Bone and Joint Research (Australia); Canadian Memorial Chiropractic College; and Arthritis and Osteoporosis Western Australia outside the submitted work. AMB reports consultancy fees and travel support from the WHO and speaker fees from the American College of Rheumatology outside the current work. JC: reports personal income from Curtin University related to the current work. MC: reports institutional income from the Bone and Joint Decade Foundation related to the current work; and Royalties from Up-to-Date unrelated the current work. NMA: nothing to disclose. LF: reports leadership roles with World Physiotherapy and the International Federation of orthopaedic Manipulative Physical Therapists. SAH: nothing to disclose. MJ: reports a leadership role with AO Alliance and personal fees. AAK: nothing to disclose. LM: reports institutional income from the Bone and Joint Decade Foundation related to the current work. LM reports grant income from Janssen Australia, NHMRC Australian Government CREE for Inflammatory Arthritis, MRFF Australian Government Adult Arthritis Biologic Tapering Trial, and MRFF Australian Government Juvenile Arthritis Biologic Tapering Trial outside the current work. LM reports data safety monitoring (unpaid) on an Australian Government funded trial for opioid medicines. LM reports leadership positions with the Global Alliance for Musculoskeletal Health and the Australian Rheumatology Association. FM: reports a leadership position with the International Federation of Musculoskeletal Research Societies. FR: nothing to disclose. SSarfraz: nothing to disclose. SSharma: reports fellowship funding from the International Association for the Study of Pain (IASP) and speaker fees and travel support from the IASP unrelated to the current work. SSharma reports leadership positions with the IASP. ERS: reports income from PANLAR, Abbvie, Elea and Pfizer outside the current work; testimony fees from Abbvie, Amgen, BMS, Glaxo, Janssen, Lilly, Novartis, Pfizer, Sandoz, UCB; and support for attening meetings from Abbvie, Janssen, Pfizer, UCB, Amgen. HS: reports grant income from AO Alliance, Asia Pacific League of Associations for Rheumatology, Australian Rheumatology Association, Curtin University, Pan American League of Associations for Rheumatology, and World Federation of Chiropractic related to the current work. HS reports grant funding from the Australian Government, Department of Health; Medical Research Future Fund (Australian National Health and Medical Research Council); Western Australian Government Department of Health; Bone and Joint Decade Foundation; Curtin University; Institute for Bone and Joint Research (Australia); and Canadian Memorial Chiropractic College outside the submitted work. HS reports travel support from the Australian Pain Society to attend a scientific meeting., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The prevalence of glucocorticosteroid-induced osteoporosis (GIOP) is well established in higher income countries. There are limited studies showing a wide prevalence of GIOP in Africa. Prospective studies are needed on GIOP in African rheumatology patients to implement appropriate management algorithms., Purpose: The prevalence of glucocorticosteroid-induced osteoporosis (GIOP) is well established in developed countries, but little is known about GIOP in African adult patients with inflammatory rheumatic musculoskeletal diseases (RMDs). This study aimed to determine the prevalence of GIOP and osteoporotic fracture risk in African patients with inflammatory RMDs according to radiographic and bone mineral density (BMD) findings., Methods: PubMed, Google Scholar, Scopus, and African Index Medicus were searched up to 31 December 2020. Heterogeneity was assessed using I 2 statistic across the included studies. A random-effects model was applied to estimate the pooled effect size across studies. All statistical analyses were performed using STATA™ version 14 software. The study was registered with PROSPERO, number CRD42021256252., Results: In this meta-analysis, a total of 7 studies with 780 participants, stratified by geographical region were included. The pooled prevalence of GIOP based on BMD data was 47.7% (95% CI 32.9-62.8) with 52.2% (95% CI 36.5-67.6) in North African countries and 15.4% (95% 1.9-45.4%) in South Africa with a high heterogeneity (I 2  = 93.3%, p = 0.018). There was no data from the rest of African countries. We were unable to complete the meta-analysis of osteoporotic fractures due to the lack of available data., Conclusion: This study revealed that the prevalence of GIOP varies significantly in Africa. There is no information, however, for most of Africa, and further prospective studies are needed to develop context-specific GIOP preventive strategies in patients with RMDs., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Competing Interests: We declare no competing interests. DD and FP are joint first authors. All authors were involved in planning and data collection. IH did the statistical analysis. DD, FP, and IH wrote the article. All authors edited and corrected the article. All authors had full access to all the data in the study and have seen and approved the final version of the article and accept responsibility to submit for publication. The survey data were from data that were already available in the public domain and no personal details collected, therefore ethics approval was not required. Data collected for the study, including individual country data will be made available to others on request from the authors on publication.

Rationale: Early surgery is recommended for hip fractures., Main Result: In this study only one-third of subjects with hip fractures were admitted within 24 h of the fracture, and surgery was delayed beyond 48 h in the majority., Significance: These findings highlight the need to improve access to care for hip fracture subjects., Purpose: There is limited data on the timing of admission and surgery following a low trauma hip fracture (HF) in South Africa (SA)., Methods: A prospective, observational study was conducted at public and private hospitals in three provinces, Gauteng (GP), KwaZulu-Natal (KZN) and the Western Cape (WC), in SA to determine time from fracture to admission and from admission to surgery in patients presenting with low trauma HF. Associations with delayed admission and surgery were explored using logistic regression., Results: The median age of the 1996 subjects was 73 years (IQR 63-81 years), the majority were women (1346, 67%) and 1347 (67%) were admitted to the public hospitals. In one-third of subjects (661, 33%), admission was delayed to beyond 24 h after the fracture. There was a significantly longer time to admission in public compared to private hospitals (21 h [IQR 10.0-48.5] versus 6 h [IQR 3.3-14.1], p < 0.001), in subjects < 65 years, the WC and when admission occurred on a weekday. Surgery was delayed beyond 48 h in the majority (1272, 69%) of subjects and was significantly longer in public compared to private hospitals (130 h [IQR 62.6-212.4] versus 45.4 h [IQR 24.0-75.5], p < 0.001), in KZN, and when admission occurred after hours., Conclusion: The burden of HFs is higher at public hospitals in SA, where there is a significant delay in admission after a fracture and surgery after admission. This highlights the need for a review of HF care pathways, resources and policies., (© 2022. International Osteoporosis Foundation and National Osteoporosis Foundation.)

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., (© 2020. International League of Associations for Rheumatology (ILAR).)

Spondyloarthritis (SpA) has been less well studied than rheumatoid arthritis in North Africa, due to a belief that it is rare and benign in certain populations. The main genetic trait of SpA is its association with human leukocyte antigen (HLA)-B27. The distribution of this allele largely explains the prevalence and severity of SpA. The prevalence of HLA-B27 in the general population of North Africa is estimated at about 4%, and rises to about 60% among people affected with SpA. Coxitis is one of the main features of North African SpA, but the response to treatment is comparable to the literature from the West. The major challenge in North Africa remains accessibility to specialized care and means of early diagnosis. Prevalent infections in North Africa do not seem to be a major obstacle to optimal treatment strategies., (© 2021. International League of Associations for Rheumatology (ILAR).)

Africa is experiencing an exponential increase in the number of older persons. The number of persons surviving with human immunodeficiency virus is simultaneously increasing due to improved availability of anti-retroviral therapy. The burden of non-communicable diseases, in particular, osteoporosis and its consequent fragility fractures, is also predicted to increase. Osteoporosis, however, remains a neglected disease and there are no age-standardized reference data available to accurately screen and diagnose individuals with osteoporosis. Epidemiological studies reporting the incidence of hip fracture or vertebral fractures are limited from Africa, especially Sub-Saharan Africa. The studies are usually limited as they are based on a retrospective data and small study numbers and often from a single study site. However, compared with early initial studies, the more recent studies show that osteoporosis and fractures are increasing across the continent. The overall incidence rates for osteoporosis and fractures still vary greatly between different regions in Africa and ethnic groups. Predisposing factors are similar with those in developed countries, but awareness of osteoporosis is sorely lacking. There is a lack of awareness among the population as well as health authorities, making it extremely difficult to quantify the burden of disease. There is great potential for research into the need and availability of preventive strategies. The FRAX® tool needs to be developed for African populations and may circumvent the shortage of bone densitometry., (© 2020. International League of Associations for Rheumatology (ILAR).)

Objectives: To develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic., Method: A task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1-3, 4-6 and 7-9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a 'low' level of agreement., Results: A total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting., Conclusions: The preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges. Key Points • AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic. • COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists. • Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs. • Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk., (© 2020. The Author(s).)

Introduction: Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health., Methods: Design: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions., Results: Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening., Conclusion: An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives., Competing Interests: Competing interests: AMB reports grants from the Bone and Joint Decade Foundation during the conduct of the study. CHS reports grants from Curtin University during the conduct of the study. HS reports grants from the Bone and Joint Decade Foundation during the conduct of the study; personal fees from AbbVie outside the submitted work. JEJ reports personal fees from Curtin University during the conduct of the study. SP has nothing to disclose. JJY reports grants from the Danish Foundation for Chiropractic Research and Post-graduate Education, grants from Canadian Memorial Chiropractic College, grants from Ontario Chiropractic Association, grants from National Chiropractic Mutual Insurance Company Foundation, grants from the University of Southern Denmark Faculty Scholarship outside the submitted work. SS has nothing to disclose. DK-G has nothing to disclose. SMishrra reports grants from Curtin University during the conduct of the study. KEA reports personal fees from Amgen, personal fees from UCB, personal fees from FAN, personal fees from Astellas pharma, personal fees from Chugai pharma outside the submitted work. NA has nothing to disclose. JB has nothing to disclose. NB reports personal fees from Amgen, personal fees from Grunenthal, personal fees from Lilly, personal fees from Pfizer, personal fees from Sanofi, personal fees from Global Alliance for Patient Access outside the submitted work. FMB has nothing to disclose. RB reports personal fees from World Federation of Chiropractic outside the submitted work. DD has nothing to disclose. KED has nothing to disclose. LF has nothing to disclose. HEF has nothing to disclose. FG has nothing to disclose. SH has nothing to disclose. SAH has nothing to disclose. BH has nothing to disclose. AJ has nothing to disclose. MJ has nothing to disclose. AAK has nothing to disclose. JL has nothing to disclose. SMatsuda has nothing to disclose. AM reports grants, non-financial support and other from Merck KGaA; grants, non-financial support and other from Kolon TissueGene; grants, non-financial support and other from Merck KGaA; grants from Pfizer; grants from European Commission-Innovative Medicines Initiative (IMI); grants from European Union Structural Funds administered by the Research Council of Lithuania (Lietuvos mokslo taryba); grants from European Union Structural Funds administered by the Research Council of Lithuania (Lietuvos mokslo taryba); grants from European Commission-Framework 7 (FP7-HEALTH); grants from European Commission-Framework 7 (FP7-PEOPLE) Marie Skłodowska-Curie Program; personal fees from Galapagos-Servier; personal fees from Image Analysis Group (IAG); personal fees, non-financial support and other from Artialis SA; personal fees and other from Aché (Aché Laboratórios Farmacêuticos); personal fees and other from Abbvie; personal fees from Guidepoint Global,; personal fees from Alphasights; personal fees from Science Branding Communications; personal fees and non-financial support from Pfizer Consumer Healthcare; non-financial support from GSK Consumer Healthcare; personal fees and other from Flexion Therapeutics; personal fees from Pacira Biosciences; other from Genacol; personal fees, non-financial support and other from Sterifarma; other from Henry Stewart Talks; non-financial support from GlaxoSmithKline (GSK); grants from Versus Arthritis (Arthritis Research UK); personal fees and other from Korean Society for Osteoarthritis and Cartilage Repair; personal fees from American College of Rheumatology; personal fees and other from Spanish Society of Rheumatology; personal fees and other from Heilongjiang Rheumatology Association; personal fees and other from Zhujiang Hospital of Southern Medical University; non-financial support and other from International Cartilage Regeneration and Joint Preservation Society (ICRS); non-financial support and other from Osteoarthritis Research Society International (OARSI); non-financial support from AxDev International; other from Gordian Biotechnology; other from UNITY Biotechnology; personal fees and other from Bioiberica; other from The Dutch Arthritis Society (ReumaNederland); other from Kolon Life Science; personal fees from SANOFI; personal fees from European Commission; other from BRASIT/BRASOS, Brazil; other from GEOS, Brazil; other from European Orthopaedic Research Society (EORS); other from Brazilian Society of Rheumatology (SBR); other from Society for Osteoarthritis Research (SOAR), India; other from MCI Group, Geneva outside the submitted work. LMwaniki has nothing to disclose. MCN has nothing to disclose. MP has nothing to disclose. FJJR has nothing to disclose. ERS reports grants, personal fees and non-financial support from Abbvie; personal fees from Amgen; personal fees from BMS; grants from Glaxo; grants and personal fees from Janssen; personal fees from Lilly; grants and personal fees from Novartis; grants, personal fees and non-financial support from Pfizer; grants and personal fees from Roche; grants, personal fees and non-financial support from UCB outside the submitted work. HT reports having authored two books: Life Beyond the Carpal Tunnel (2007) and Holistic Pain Relief (2014). JW has nothing to disclose. DW has nothing to disclose. ADW has nothing to disclose. LMarch reports personal fees from Lilly, personal fees from Pfizer, personal fees from Abbvie, grants from Janssen outside the submitted work. LMarch is an executive member of OMERACT which receives funding from 30 different companies., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The hip fracture rates in South Africa were used to create ethnic-specific FRAX® models to facilitate fracture risk assessment., Introduction: The aim of this study was to develop FRAX models to compute the 10-year probability of hip fracture and major osteoporotic fracture and assess their potential clinical application., Methods: Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for the White, Black African, Coloured and Indian population of South Africa. Age-specific 10-year probabilities of a major osteoporotic fracture were calculated in women to determine fracture probabilities at a femoral neck T score of -2.5 SD, or those equivalent to a woman with a prior fragility fracture. Fracture probabilities were compared with those from selected countries., Results: Probabilities were consistently higher in Indian than in Coloured men and women, in turn, higher than in Black South Africans. For White South Africans, probabilities were lower than in Indians at young ages up to the age of about 80 years. When a BMD T score of -2.5 SD was used as an intervention threshold, FRAX probabilities in women age 50 years were approximately 2-fold higher than in women of the same age but with an average BMD and no risk factors. The increment in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T score of -2.5 SD was no longer a risk factor. Probabilities equivalent to women with a previous fracture rose with age and identified women at increased risk at all ages., Conclusions: These FRAX models should enhance accuracy of determining fracture probability amongst the South African population and help guide decisions about treatment.

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., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Limited data exist on the incidence of hip fractures in South Africa (SA). We report gender and ethnic specific incidence rates of hip fractures in SA., Methods: In a multicentre prospective study, conducted in geographically defined municipalities of three provinces in SA, a structured questionnaire was administered to all subjects aged 40 years and over, presenting with a new atraumatic hip fracture, from 1 April 2017 to 31 March 2018. Gender and ethnic specific incidence rates (IR) of hip fractures were calculated using population statistics from Statistics SA., Findings: Of the 2767 subjects enrolled, 1914 (69·2%) were women and 853 (30·8%) were men. The majority of subjects were from the White population (40·9%) followed by those from the African (26·4%), Coloured (18·7%) and Indian (13·9%) populations. Men with hip fractures were significantly younger than women in the total group (69 [IQR 59-79] versus 77 years [IQR 68-84], p < 0·001) and in each ethnic group. White subjects were significantly older (p < 0·0001) and Africans significantly younger (p < 0·0001) than the other ethnic groups. In women, the highest IR was noted in the White population (176·0 per 100,000), followed by that in the Indian (147·7 per 100,000), Coloured (73·2 per 100,000) and African populations (43·6 per 100,000). A similar pattern was seen in men albeit at lower rates, with the highest rate in White men at 76·5 per 100,000. In the total study population and the African population, the IR was higher in men compared to women in subjects under 60 years. In the White population, the IR was higher in men compared to women in the 40-44 years age group. While in the Coloured and Indian populations the IR was higher in men compared to women in the 40-49 years and 45-54 years age groups, respectively. There was an increase in the relative risk ratios with age in the total study population, and in all ethnic groups in both women and men., Interpretation: Hip fractures occur in all ethnic groups in South Africa with higher IRs in the White and Indian populations compared to the Coloured and African populations. Consistent with the published literature, the overall hip fracture IR was higher in women than in men, except in the younger age groups, and increased with age., Funding: South African Medical Research Council and the University of KwaZulu-Natal Competitive Research Grant., Competing Interests: Declaration of competing interest Professor B Cassim received local travel grant from Servier Laboratories South Africa (Pty) Ltd. All other authors report no conflict of interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Immune-mediated necrotizing myopathies (IMNMs) are a group of acquired autoimmune muscle disorders which are characterized by proximal muscle weakness, high levels of creatinine kinase, and myopathic findings on electromyogram (EMG). Muscle biopsy in IMNM differentiates it from the other subgroups of Idiopathic Inflammatory Myositis (IIM) by the presence of myofibre necrosis and prominent regeneration without substantial lymphocytic inflammatory infiltrates. Anti-signal recognition particle (SRP) and anti-3hydroxy-3 methylglutarylcoenzyme A reductase (HMGCR) autoantibodies were found in two-thirds of IMNM patients. In terms of treatment, IMNM is more resistant to conventional immunosuppressive treatment, therefore, other modalities of treatment such as Intravenous Immunoglobulin (IVIG) and rituximab are often required., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

The aim of this study was to describe the clinical features of patients with psoriatic arthritis (PsA) in a South African cohort. This is a retrospective analysis of patients contributing to development of the international classification criteria for PsA, ClASsification criteria for Psoriatic ARthritis (CASPAR). Patients were all seen at the arthritis clinics at Groote Schuur Hospital, Cape Town. Demographic, clinical, laboratory and radiographic information was collected. This study describes the relevant findings relating to the clinical profile of the patients seen at our centre as well as the effect of family history and/or dactylitis in determining the severity of psoriatic arthritis. There were 45 patients with a male to female ratio of 1:1.25. The mean age of psoriasis onset was 38.34 years (SD 15.54), whilst that of arthritis onset was 43.86 years (SD 13.4). Polyarthritis was the commonest pattern and sacro-iliitis was uncommon. Dactylitis was present in 26%. The presence of family history or of dactylitis did not predict more severe disease. There was a significant correlation between tender and swollen joints. The mean Health Assessment Questionnaire (HAQ) score was 1.05. Eighty-three percent showed evidence of radiological changes, and distal interphalangeal (DIP) erosions were found in 54%. Arthritis mutilans was present in 31%. There were no black subjects in the cohort. The clinical patterns of PsA in our cohort are similar to those reported elsewhere. The paucity of blacks amongst this cohort requires further study. PsA-specific measures of disease activity need to be developed. PsA causes significant joint damage and disability.

Background Systemic lupus erythematosus (SLE) is a life-threatening multisystem autoimmune disease that is more severe in patients of African ancestry and children, yet pediatric SLE on the African continent has been understudied. This study describes a cohort of pediatric SLE (PULSE) patients in South Africa. Methods Patients with a diagnosis of SLE (1997 American College of Rheumatology criteria) diagnosed prior to age 19 years in Cape Town, South Africa, were enrolled in this cross-sectional study from September 2013 to December 2014. Information on clinical and serological characteristics was extracted from medical records. Results were compared to a well-described North American pediatric SLE cohort. Results Seventy-two South African patients were enrolled in the study; mean age 11.5 years; 82% were girls. The racial distribution was 68% Coloured, 24% Black, 5% White and 3% Asian/Indian. Most patients presented with severe lupus nephritis documented by renal biopsy (61%). Of patients with lupus nephritis, 63% presented with International Society of Nephrology/Renal Pathology Society class III or IV. Patients in the PULSE cohort were more likely to be treated with cyclophosphamide, methotrexate and azathioprine. The PULSE cohort had high disease activity at diagnosis (mean Systemic Lupus Erythematosus Disease Activity Index-2K (SLEDAI-2K) 20.6). The SLEDAI-2K at enrolment in the PULSE cohort (5.0) did not differ from the North American pediatric SLE cohort (4.8). Sixty-three per cent of the PULSE cohort had end organ damage with Systemic Lupus International Collaborating Clinics Damage Index (SLICC-DI) score >0 (mean SLICC-DI 1.9), compared to 23% in a previously reported US cohort. Within the PULSE cohort, nine (13%) developed end-stage renal disease with six (8%) requiring transplant, strikingly higher than North American peers (transplant rate <1%). Conclusions The PULSE cohort had highly active multiorgan disease at diagnosis and significant disease damage at enrolment in the South African registry. South African patients have severe lupus nephritis and poor renal outcomes compared to North American peers. Our study revealed a severe disease phenotype in the PULSE cohort resulting in poor outcomes in this high-risk population.

Approximately 20% of human cancers is attributable to DNA oncogenic viruses such as human papillomavirus (HPV), hepatitis B virus (HBV), and Epstein-Barr virus (EBV). Unrepaired DNA damage is the most common and overlapping feature of these DNA oncogenic viruses and a source of genomic instability and tumour development. Sustained DNA damage results from unceasing production of reactive oxygen species and activation of inflammasome cascades that trigger genomic changes and increased propensity of epigenetic alterations. Accumulation of epigenetic alterations may interfere with genome-wide cellular signalling machineries and promote malignant transformation leading to cancer development. Untangling and understanding the underlying mechanisms that promote these detrimental effects remain the major objectives for ongoing research and hope for effective virus-induced cancer therapy. Here, we review current literature with an emphasis on how DNA damage influences HPV, HVB, and EBV replication and epigenetic alterations that are associated with carcinogenesis.

Polyarteritis nodosa (PAN) of the urinary tract is rare. An unusual case of systemic PAN involving the bladder neck is described. A 27-year-old man, with known diastolic hypertension diagnosed 2 years earlier, was admitted with chronic urinary obstruction complicated by hydronephrosis. He had symptoms of myalgia and weight loss, was afebrile but had an elevated erythrocyte sedimentation rate and acute-on-chronic renal impairment. All virological and serological tests including hepatitis B and anti-neutrophil cytoplasmic antibody were negative. A computed tomography scan of the brain revealed small-vessel disease. A bladder neck mass was visualised on cystoscopy. Histological examination of this demonstrated a medium-sized necrotising vasculitis with small-vessel fibrinoid necrosis suggestive of PAN. At least six of the American College of Rheumatology criteria for PAN were met. The patient was treated with pulses of intravenous cyclophosphamide and oral corticosteroids with a good clinical response.

Prostate cancer (PCa) is the most prevalent urological cancer that affects aging men in South Africa, and mechanisms underlying prostate tumorigenesis remain elusive. Research advancements in the field of PCa and epigenetics have allowed for the identification of specific alterations that occur beyond genetics but are still critically important in the pathogenesis of tumorigenesis. Anomalous epigenetic changes associated with PCa include histone modifications, DNA methylation, and noncoding miRNA. These mechanisms regulate and silence hundreds of target genes including some which are key components of cellular signalling pathways that, when perturbed, promote tumorigenesis. Elucidation of mechanisms underlying epigenetic alterations and the manner in which these mechanisms interact in regulating gene transcription in PCa are an unmet necessity that may lead to novel chemotherapeutic approaches. This will, therefore, aid in developing combination therapies that will target multiple epigenetic pathways, which can be used in conjunction with the current conventional PCa treatment., Competing Interests: The authors declare no conflict of interests.

Lower back pain is one of the most common symptoms–and the most common musculoskeletal problem–seen by general practitioners. Iti s also a common cause of disability and an expensive condition in terms of economic impact because of absenteeism. This article discusses an approach to this common symptom and how to distinguish the benign, mechanical type of back pain from the more sinister, but less frequently encountered, inflammatory back pain.

Severe thrombocytopenia with bleeding associated with a life-threatening thrombotic manifestation in the setting of antiphospholipid syndrome is a major diagnostic and therapeutic challenge for the clinician. Hemorrhage is a less common complication than thrombosis in patients with APS, although severe thrombocytopenia can sometimes result in bleeding. There are no evidence-based guidelines regarding the management of a patient with severe thrombocytopenia associated with a major thrombotic manifestation. In this case report, we review the literature reporting the difficulties in management of such patient.

SUMMARY: The study describes the association between risk factors and quantitative ultrasound bone measures in black and mixed-race pre-menopausal South African women. Despite some differences between the two study groups, the findings generally lend support to the use of ultrasound for epidemiological studies of bone mass in resource-limited settings. INTRODUCTION: Quantitative ultrasound at the calcaneus is a convenient and inexpensive method of estimating bone strength well suited to community-based research in countries with limited resources. This study determines, in a large sample of pre-menopausal South African women, whether characteristics associated with quantitative ultrasound measures are similar to those shown to be associated with bone mineral density as measured by dual X-ray absorptiometry. METHODS: This cross-sectional study included 3,493 women (1,598 black and 1,895 mixed race), aged 18-44 living in Cape Town. Study nurses administered structured interviews on reproductive history, lifestyle factors, and measured height and weight. Calcaneus quantitative ultrasound measurements were obtained using the Sahara device. Adjusted means of ultrasound measures according to categories of risk factors were obtained using multivariable regression analysis. RESULTS: Associations between quantitative ultrasound measures and age, body mass index, age at menarche, parity, and primary school physical activity were similar to those known for bone mineral density as measured by dual X-ray absorptiometry. There were no clear associations between quantitative ultrasound measures and educational level, alcohol use, cigarette smoking, and current calcium intake. CONCLUSION: The data give qualified support to the use of quantitative ultrasound as an epidemiological tool in large studies of bone strength in pre-menopausal women.

Background: Women using injectable progestin contraceptives (IPCs) have lower bone mineral density than nonusers. We assessed whether bone loss is completely reversible after cessation of IPC use, whether different IPCs have different effects and whether effects vary by age at first use., Study Design: In a cross-sectional study in Cape Town, South Africa, 3487 premenopausal black and mixed race women aged 18-44 years were interviewed for information on contraceptive history and risk factors for decreased bone mineral density, and ultrasound measurements of the left calcaneus were taken. Adjusted means of the ultrasound measures for categories of IPC use were obtained using multivariable linear regression., Results: Current users of IPCs had the lowest ultrasound measures, while the measures of women who had ceased IPC use at least 2-3 years previously were similar to or greater than those of never users of IPCs. The effects of depot medroxyprogesterone acetate and norethisterone enanthate were similar. The calcaneus measures were unrelated to age at which use began after control for confounding factors., Conclusion: The data suggest that bone loss during IPC use is reversible and that this loss of bone is completely recovered several years after cessation of use.

Background: Takayasu's arteritis is a condition of unknown aetiology with an unpredictable natural history. Most of the literature available has originated from Asia, with a few contributions from Africa where the pattern of the disease may be different. This is a single institution's experience review., Methods: Data were obtained retrospectively from the angiographic and medical records of patients treated at Groote Schuur Hospital over the period 1952-2002. The criteria for inclusion were those proposed by the Aortitis Syndrome Research Committee of Japan and the American College of Rheumatology., Results: Two hundred and seventy-two patients were identified. The mean age at presentation was 25 years (range 14-66 years) and 75% were female. Only 8% were Caucasian. Hypertension was the most common presentation (77%) and was usually a consequence of renal artery stenosis or aortic coarctation. Cardiac failure was the most common problem. Cerebrovascular symptoms were recorded in 20%. Convincing evidence of tuberculosis was present in 20%. The entire aorta was involved in 70% of cases. Thirty per cent had aortic bifurcation involvement. Occlusions were noted in 93% and aneurysms in 46%. Vascular reconstruction was performed on 115 occasions in 99 patients, with an operative mortality of 4%. Cardiac failure was the usual cause of death. One hundred and six patients (39%) were followed for a minimum of 5 years. No further progression of disease was noted in 70 patients., Conclusion: The natural history and prognosis of Takayasu's arteritis still remain poorly defined.

The general impression is that rheumatoid arthritis (RA) has a lower prevalence and a milder course in developing countries. Epidemiological studies from different regions show that varying prevalence is possibly related to urbanization. The data suggest that where severe disability does occur, it presents a significant health challenge because of scarce medical and social resources. Disease-modifying anti-rheumatic drugs (DMARDs) remain the mainstay of therapy to alter the natural history of the disease. New therapies are unlikely to be of general benefit in the developing world because of financial constraints and increased risk of infections, particularly tuberculosis, associated with the use of tumour necrosis factor-alpha blockers. Instead, future research in poorer communities should be directed at assessing the burden of disease, the role of early aggressive therapy with DMARDs in combination with glucocorticoids for the majority of patients with RA, and finally, sourcing targeted biological therapies through clinical trials and grants for compassionate use in patients with refractory disease.

Objective: This study was undertaken to compare trabecular bone mineral density (BMD) in premenopausal rheumatoid arthritis (RA) patients and normal age-matched controls., Method: A protocol was designed to record age, duration of disease, use of corticosteroids (CS) and/or slow-acting antirheumatic drug (SAARD) therapy together with duration of such therapy. BMD was measured using the Hologic QDR 1,000 dual energy X-ray absorptiometer. The first four lumbar vertebrae and the left femur were measured in 56 RA patients and 165 controls. Height and weight were measured. Comparisons were made between RA patients and controls, as well as between subgroups of RA patients based on CS therapy., Results: Patients with RA had significantly lower BMD (P < 0.05) at all the sites than the normal controls. The mean duration of RA at the time of study was 60 months (standard deviation 58 months). Thirteen RA patients had used CS in doses less than 10 mg daily for 6 months or longer (mean 19 months), while 25 patients had been on SAARD for an excess of 6 months (mean 23 months). The CS-treated patients had significantly lower BMD than untreated subjects at the femoral neck and inter-trochanteric region (P < 0.05), but not at the lumbar spine. However, when compared with normal controls, the CS-treated subgroups had significantly lower BMD at the lumbar spine and all femoral areas. Trochanteric BMD was the best determinant of the RA group, with a sensitivity of 65% and specificity of 77%. The positive predictive value was 16%, while the negative predictive value was 10%. Using Bayes' theorem, the prevalence of osteopenia in RA was found to be 6%., Conclusion: We conclude that generalised bone loss is a systemic feature of RA and that loss at the spine and femur may be aggravated by CS therapy.

Objective: To determine the spectrum and ethnic differences of spondyloarthritis disease patterns in patients attending the Rheumatic Diseases Unit, University of Cape Town, South Africa., Methods: A retrospective survey of case records of 100 patients with spondyloarthritis seen between January 1988 and January 1995., Results: Of these 100 patients, 71 were male, 53 were Colored [mixed race descendants of Khoisan (Hottentot and Bushmen), Whites, Malays and Black Africans], 40 White, 5 Black and 2 Indian (descendants of immigrants from the Indian subcontinent). Our results show that the prevalence and disease patterns of spondyloarthritis in this South African cohort are comparable to those seen in Europe and North America with respect to clinical and radiological features, as well as therapeutic and orthopedic surgical requirements. No major ethnic differences in disease patterns were observed in White and Colored patients studied., Conclusion: The spectrum of spondyloarthritis in South Africa is similar to that seen elsewhere in the world. Our study confirmed the rarity of these conditions in Black South Africans.

The aim of this study was to assess the prevalence of and diagnostic role of metacarpal osteopenia in rheumatoid arthritis (RA) and to evaluate its detectability using receiver operating characteristic (ROC) analysis. Metacarpal bone mineral density was measured in 98 patients with classical RA using a computer-assisted measure of 6 metacarpal diameters (radiogrammetry) in patients aged less than 50 years. Sensitivity and specificity of the technique in discriminating the RA patients from 85 normal controls and osteopenic RA subjects from their normopenic counterparts, was determined by standard statistical techniques. Clinical, laboratory and radiological variables were compared in their ability to explain the variance of metacarpal bone density. The prevalence of metacarpal osteopenia in RA was 55%. Prolonged disease and reduced function significantly differentiated osteopenic from non-osteopenic RA patients. Discriminant analysis of RA and control groups showed that measurement of 6 metacarpals was more accurate than the 2nd metacarpal measurement alone in predicting the RA patients. The sum of 6 metacarpal combined cortical width (CCW) had a sensitivity of 61% and specificity of 68% in discriminating the RA patients from the controls. Receiver operating characteristics curves showed, not surprisingly, that objective measurement of bone diameters was superior to clinical or laboratory measures of disease activity in correctly classifying a randomly chosen RA patient as osteopenic or not. Metacarpal osteopenia is common in RA and it may be a useful measure of the disease in young patients.

This study compares functional changes to change in measures of disease activity following the introduction of slow-acting anti-rheumatic drugs (SAARD) in patients with active rheumatoid arthritis (RA). Clinical and laboratory variables were simultaneously monitored at 6-monthly intervals, over approximately 18 months. Function was measured by a performance testing, the Keitel function index (KFI), which was divided into sections representing small and large joints [hand (HFI); wrist (WFI) and limb function index (LFI)]. One-hundred-and-fifteen patients were studied, of whom 21 were male. The mean age of the subjects was 49 yr (S.D. +/- 12) and mean duration of disease 7 yr (S.D. +/- 7). The mean KFI at entry was 38 (S.D. +/- 18) while at the end of the study it was 31 (S.D. +/- 17) (P < 0.0001). The change in KFI following therapy correlated with the change in Ritchie articular index (RAI) (r = 0.4; P < 0.0001), early morning stiffness (EMS) (r = 0.3; P = 0.004), swollen joint count (JC) (r = 0.4; P = 0.0005), C-reactive protein (CRP) (r = 0.2; P < 0.05) and Lansbury systemic index (LSI) (r = 0.35; P = 0.002), but not with change in Westergren erythrocyte sedimentation rate (ESR) or change in time to onset of fatigue. Multiple regression analysis showed that 32% of the variation in KFI at the end of the study could be predicted by a combination of ESR, sulphasalazine therapy, RAI, disease duration and chloroquine treatment at onset (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

This study was designed to evaluate the effects of low-dose corticosteroid (CS) therapy for rheumatoid arthritis (RA) and of high-dose CS therapy for systemic lupus erythematosus (SLE) on metacarpal bone mass in young (premenopausal) subjects. Ninety-eight patients with RA, 63 patients with SLE and 85 healthy controls of comparable age, race, sex and nutritional status were studied. Metacarpal bone mass was measured by radiogrammetry using a digitiser. In the RA patients, mean bone mass of CS-treated subjects (27%) was 52.31 g/cm2, while that of untreated subjects was 56.69 g/cm2 (P < 0.02). In the SLE group, mean bone mass of CS-treated subjects (76%) was 61.47 g/cm2 and that of untreated subjects 62.36 g/cm2 (P > 0.1). Although patients with SLE required larger cumulative doses of CS for longer periods, their bone mass was higher than that of the RA subjects (P < 0.01). None of the patients had femoral neck or vertebral crush fractures. In RA, bone loss was probably a feature of severe disease rather than of CS therapy.

There is no ideal slow-acting antirheumatic drug. Therapy of rheumatoid arthritis (RA) is currently being modified, with strong recommendations to abandon the traditional pyramidal approach. The call is for a more aggressive, earlier approach to suppress inflammation. Combination therapy rather than the use of a single agent is advocated by some. Improved methods for assessing disease activity as well as measurement of outcome have been developed. Markers of poor prognosis have helped to define patients for earlier treatment. Comparison of toxicity among such a diverse group of drugs is probably best achieved with a toxicity index measuring the number of episodes expressed in terms of patient-years of exposure. Toxicity remains the commonest reason for discontinuing an agent, while remission beyond 36 months on therapy is uncommon, except with methotrexate. The profile of toxicity is clearly defined for individual agents, but combination therapy may reveal an entirely different set of toxic manifestations. There is an urgent need to develop a set of risk factors to predict toxicity in an individual patient. Juvenile chronic arthritis behaves differently from adult RA. Drug toxicity profiles are similar, but less common. Outcome is more difficult to measure, with the major impact of disease and therapy being on growth retardation.