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   Table of Contents - Current issue
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October-December 2018
Volume 45 | Issue 4
Page Nos. 125-187

Online since Thursday, November 1, 2018

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ORIGINAL ARTICLES  

Comparative study between early active and passive rehabilitation protocols following two-strand flexor tendon repair: can two-strand flexor tendon repair withstands early active rehabilitation? p. 125
Hala M Abdel Sabour, Amir Labib, Ahmed Abel Sallam, Mohey Elbanna
DOI:10.4103/err.err_15_18  
Background Restoration of full range of motion of digits as well as prevention of joint contracture following flexor tendon repair is a challenge. There is lack of solid evidence regarding the most suitable rehabilitation protocol following flexor tendon repair. This is owing to the limited number of studies comparing different rehabilitation protocols. Moreover, the present studies advocate a specific technique with no comparative group. Even the few controlled studies conducted vary in methods of repair and rehabilitation, and outcome assessment. To our knowledge, the only randomized controlled trial comparing early passive rehabilitation with early active rehabilitation is the one done by Trumble and colleagues in 2010, which was done on four-strand repaired tendon. These authors concluded that active rehabilitation program had better range of motion with less flexion contractures and greater satisfaction scores than those subjected to passive rehabilitation protocol. Aim This conclusion stimulated us to study the effect of early active mobilization versus early passive mobilization following two-strand repair. Patient and methods We conducted our study for 12 weeks comparing early active mobilization protocol ‘place and hold’ with early passive mobilization ‘modified Kleinert’ after standard two-strand modified Kessler repair in different hand zones. Results and conclusion We concluded that early active mobilization had better tendon gliding and excursion even with the two-strand repair as active motion will decrease adhesion formation, with significant difference compared with the passive group. Moreover, there was no significant difference in the rupture rate and significant difference for combined tendon lag and flexion deformity owing to the tenodesis mobilization between both the groups.
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Neutrophil-to-lymphocyte ratio: relation to disease activity and carotid intima-media thickness in Behçet’s disease p. 133
Mounir Serag Elden, Gamal Hmmad, Hesham Farouk, Rasha M Fawzy, Basma Abdelwhaba
DOI:10.4103/err.err_26_18  
Background Behçet’s disease (BD) is an autoinflammatory disorder. Disease activity could be detected by changes in peripheral blood cell components. The aim of this study was to assess the relationship between neutrophil-to-lymphocyte ratio (NLR) with disease activity and carotid intima-media thickness (cIMT) in patients with BD. Patients and methods This study was conducted on 20 adult patients with BD (group І). This group was subdivided according to cIMT into group Іa, which included patients with increased cIMT, and group Іb, which included patients with cIMT within normal ranges. Moreover, 20 age-matched and sex-matched apparently healthy volunteers were included as a control group (group ІІ). Patients with BD were subjected to full history taking, thorough clinical examination, and assessment of disease activity according to Behçet’s Disease Current Activity Form score. The white blood cell count, neutrophil count, and lymphocytes count were recorded, and NLR was calculated. cIMT assessment was done for all participants. Results There were statistically significant differences (P<0.05) regarding lymphocytes count and NLR and highly statistically significant difference (P<0.001) regarding neutrophil count, being higher in patients with BD. There was a statistically highly significant difference (P<0.001) regarding cIMT, being higher in group Іa patients (0.82±0.03) than group Іb patients (0.50±0.04) and healthy control group (0.47±0.04). There was a statistically significance positive correlation (R=639, P=0.005) between NLR and Behçet’s Disease Current Activity Form score. In conclusion, higher NLR values were recorded in patients with BD. Furthermore, patients with active BD had higher NLR values than inactive, and NLR is higher in patients with increased cIMT; thus, NLR may be an important bio-index for detecting BD activity and the presence of vascular affection.
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The value of neuromuscular ultrasound in relation to clinical and electrophysiological testing in the diagnosis of thoracic outlet syndrome p. 140
Nagwa M Nassar, Ahmed Z Yasaky, Dina A Farrag, Medhat M Magdy
DOI:10.4103/err.err_41_18  
Background Thoracic outlet syndrome (TOS) diagnosis has long been challenging and controversial with no available golden standard diagnostic test. Objectives To assess the value of NMUS as a new diagnostic tool for TOS and compare it with other clinical and electrophysiological studies. Patients and Methods This study was conducted on 20 patients with clinical TOS and 10 healthy controls. They were subjected to history taking, clinical examination, provocative tests, functional assessment using shoulder pain and disability index, electrophysiological and imaging studies including x-ray and NMUS. Pectoralis minor muscle deformation and brachial plexus compression was detected using NMUS by measuring the pectoral bowing ratio (PBR), PBR is significant if >10% on provocation with arm abduction. Results In this case control study, mean age of 20 patients was 34.20±9.52. Female:male ratio was 13:7 without significant difference between patients and controls regarding age or sex. Mean pain and disability scores were 73±13.42 and 55.30±15.68 respectively. Compound medial antebrachial cutaneous (MAC) nerve conduction and F-wave studies was positive in 85% of patients and none of the controls. Similarly, NMUS positive finding was detected in 75% of patients and none of the controls with highly significant difference between two groups, P<0.01. Diagnostic accuracy (DA) of NMUS for TOS was 83.3% comparable to x-ray and compound MAC, F-wave studies (DA=93.3%, 90% respectively). Conclusion Neuromuscular ultrasonography is an important, painless, sensitive tool for assessment of TOS. It is complementary to other imaging and electrophysiological studies and their combination could help in objective diagnosis of TOS.
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Incidence and characteristics of health care-associated infection in hospitalized patients with rheumatic diseases in Alexandria Main University Hospital p. 148
Abeer A Abdelati, Eman A Sultan
DOI:10.4103/err.err_30_18  
Introduction Health care-associated infection (HCAI) is an important cause of morbidity and mortality in patients with autoimmune diseases. Most previous reports investigated HCAI in the setting of systemic lupus erythematosus but lacked reports on other connective tissue diseases. Objectives We aimed to determine the incidence and characteristics of HCAI in patients with rheumatic diseases admitted to the Rheumatology Unit in Alexandria Main University Hospital in 2017. Patients and methods A 1-year duration prospective observational study was done to elucidate the incidence and characteristics of HCAI in patients with underlying rheumatic diseases who were admitted to our Rheumatology Unit between January 1 and December 31, 2017. Statistical analysis was performed using IBM SPSS Statistics 20. Data are presented as numbers and percentages for categorical variables and means and SDs for continuous variables. Results A total of 516 patients [423 (82%) female and 93 (18%) male] with underlying rheumatic diseases and disease duration of 6.03±4.18 years were admitted during the study period. The mean age was 32.18±9.54 years, and the mean length of hospitalization was 10.04±5.76 days. HCAI occurred in 14.9% (n=77) of patients, with 81 (15.69%) infection cases (four cases had more than one episode of infection in more than one site with a different organism during the same admission). Gram-negative bacilli were the most commonly isolated organisms (46.3%; n=38), and the urinary tract was the most commonly documented site of infection (39.5%; n=32). Klebsiella spp. (17.9%; n=15) was the most frequently identified infectious agent. Of the total cases with HCAI (n=77), 85.7% (n=66) were cured, 7.8% (n=6) deteriorated, 5.2% (n=4) died, and 1.3% (n=1) referred to another specialized hospital. Conclusion Despite the improvement in health care services, the incidence of HCAI infection in our inpatient population is still high and represents a burden on our resources. Although most cases were treated with appropriate antimicrobials, HCAI is still the cause of deterioration, and death occurred in a considerable percentage of patients with rheumatic diseases.
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Salivary CXCL13 in relation to scintigraphy in early detection of secondary Sjogren’s syndrome p. 153
Salwa G Moussa, Hanan E El-Hefnawy, Heba F El-Shishtawy, Dalia M.E El Mikkawy, Mennatallah H Shalaby
DOI:10.4103/err.err_39_18  
Background Sjogren’s syndrome (SS) is a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands. CXCL13 directs B-cell chemotaxis and is elevated in several autoimmune diseases. Objective To assess the role of salivary CXCL13 level as a screening tool in early detection of secondary SS patients. Patients and methods Salivary CXCL13 levels using ELISA technique, Schirmer paper test and/or Lissamine green staining, and quantitative salivary scintigraphy excretion fraction were measured in 45 selected patients with primitive connective tissue disease (rheumatoid arthritis, systemic lupus erythematosus, or systemic sclerosis) and according to the American-European Consensus Group criteria, they were classified to three equal groups: group I were having SS; group II were having dryness manifestations but not completing the criteria for SS diagnosis (suspected SS); group III were having no SS, and 15 age-matched and sex-matched apparently healthy controls. Results A significantly higher salivary CXCL13 level on comparing SS patients to suspected, non-SS groups and controls (P<0.001). Salivary CXCL13 had a significant negative correlation with scintigraphy (P<0.01), a significant positive correlation with eye dryness signs (P<0.01), cutoff value of CXCL13 to diagnose SS was more than 40 pg/ml and a cutoff value of salivary scintigraphy excretion fraction to diagnose SS was less than 33.1%. Conclusion Salivary CXCL13 is a sensitive biomarker for early detection of secondary SS.
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Functional capacity-based rehabilitation of patients with chronic stable left ventricular heart failure p. 159
Youssy S Gergius, Nehal E El-Sheshtawy, Nadia H El-Arousi, Mahmoud M Fathalla, Mohamed A Abdel Rahman, Ahmed M Gharib
DOI:10.4103/err.err_5_18  
Context Heart failure (HF) is a common and costly condition. Reduced endurance is the main limiting factor of exercise capacity in HF patients. Cardiopulmonary exercise testing (CPX) is considered the most objective method to assess exercise capacity in HF patients. Aim To study the degree of improvement among patients with chronic stable left ventricular HF with low and average functional capacity after functional capacity-based rehabilitation program. Settings and design Rehabilitation was done at department of cardiology, department of physical medicine and rehabilitation, Ain Shams university. CPX was done at the National institute of research. Patients and methods A total of 40 patients with chronic heart failure were randomized to either a control (received their medical treatment with no specific rehabilitation program) or a rehabilitation group. Symptom-limited CPX was performed at baseline and at discharge from the program. Rehabilitation group was further divided according to their functional capacity measures obtained from CPX into group 1 and group 2. Minnesota Living with Heart Failure Questionnaire was obtained from all participants. Group 1 received electric muscle stimulation (EMS) of both lower limbs 5 days/week for 5 weeks. Group 2 received a conventional aerobic rehabilitation program 2 or 3 times/week for ∼40 sessions. VO2 peak, VO2-VT, VE/VCO2, peak load, heart rate recovery, and Minnesota Living with Heart Failure Questionnaire values were compared before and after the treatment period. Statistical analysis used Statistical presentation and analysis of the present study was conducted using the mean, SD, Student’s t-test, paired t-test, χ2, linear correlation coefficient, and analysis of variance tests by SPSS, version 17. Results EMS produced significant improvement of functional capacity measures in addition to quality of life. It was comparable to the aerobic rehabilitation in group 2. Both rehabilitation protocols caused significant improvement when compared with the control group. Conclusion Functional capacity and quality of life were improved after either EMS or aerobic rehabilitation protocol when applied to selected patients with chronic heart failure when compared with control patients who did not receive any rehabilitation program.
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Periodontal microbiota in a cohort of Egyptian patients with rheumatoid arthritis and their relation to serum and gingival anticitrullinated peptide protein antibodies and different disease parameters p. 167
Eiman Soliman, Abeer Abdelati, Rania Fahmy, Mona Helmy
DOI:10.4103/err.err_29_18  
Objective The possibility of infectious trigger at the gingival site in rheumatoid arthritis (RA) was reported in previous studies. The aim of our study is to determine the organisms causing periodontitis (PD) in a cohort of Egyptian patients with RA and their relation to serum and gingival anticitrullinated peptide protein antibodies (ACPA) level and other disease parameters. Patients and methods A prospective cohort study was conducted on 100 consecutive Egyptian patients with RA. Disease activity was assessed by applying disease activity score-28, and functional status was measured using health assessment questionnaire. Dental examination, serum rheumatoid factor, ACPA in serum and gingival crevicular fluid (GCF), and radiograph of the hands were done for all patients. GCF culture was performed for all cases with PD for Porphyromonas gingivalis (Pg), Aggregatibacter actinomycetemcomitans (Aa), and Prevotella intermedia (Pi). Results Of the 100 patients, 66 patients had PD; of them, GCF culture was performed, and Pg, Aa, and Pi were found in 60.6, 15.2, and 30.3% of patients with RA with PD, respectively. Gingival ACPA showed significant higher level with Pg than Pi cases (P=0.047). No statistically significant difference was detected on comparing Pg with Aa or Aa with Pi. Aa-positive cases were associated with significantly higher level of C-reactive protein than Pi-positive cases (P=0.029), whereas no statistical significant difference was detected between Pg- and Aa-positive or Pi-positive cases. Conclusion Our findings support the relationship between PD and infectious trigger at the gingival site and RA. Pg is the most prevalent periodontal microbiota in our cohort of patients with RA with PD that is associated with significant higher level of gingival ACPA. None of the detected organisms correlated with the degree of RA activity or other disease parameters, apart from significantly higher C-reactive protein level with Aa.
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Renalase and lupus nephritis: disease activity and histopathological classification p. 175
Marwa Y Mahgoub, Ali I Foda, Ahmed Y Elshambaky, Amira MN Abdelrahman, Sarah N Nasif, Rania G El Sayed
DOI:10.4103/err.err_24_18  
Aim To measure the level of serum renalase and to clarify its relation to lupus nephritis (LN) activity and histopathological classification. Patients and methods This study was carried out on 40 patients with systemic lupus erythematosus (SLE), diagnosed according to systemic lupus international collaborating clinics classification criteria (SLICC) criteria, and 20 healthy controls. They were 20 patients without nephritis and 20 patients with LN (17 active and three inactive LN). Venous blood samples were taken from all participants for complete blood count, erythrocyte sedimentation rate, kidney function, anti-double-stranded DNA, C3, C4, and renalase level. The serum renalase levels were determined by enzyme-linked immunosorbent assay. Assessments of protein in 24-h urine collection and protein/creatinine (P/C) ratio were done. Renal biopsies were obtained from patients with LN, with staging and activity and chronicity indices assessment. SLE disease activity was measured by Systemic Lupus Erythematosus Disease Activity Index, and LN activity was estimated by renal Systemic Lupus Erythematosus Disease Activity Index. Results Renalase levels were higher in patients with LN than both patients with SLE without LN and control group. The serum renalase levels of patients with LN were positively correlated with P/C ratio, 24-h proteinuria and C3, but negatively correlated with Systemic Lupus Erythematosus Disease Activity Index. For patients with active LN, there was no significant correlation between their serum renalase levels and the indicators of renal activity, including erythrocyte sedimentation rate, proteinuria, P/C ratio, anti-double-stranded DNA, C3, C4, and activity index of renal biopsy. The median of renalase as a marker for diagnosis of LN was 134.65, with a cutoff value of 100 µg/ml. Conclusion Serum renalase may be involved in LN pathogenesis but was not a good predictor for either LN activity or various stages of LN histopathology.
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Role of tumor necrosis factor-like weak inducer of apoptosis/fibroblast growth factor-inducible molecule 14 pathway in lupus nephritis p. 182
Miriam R Bekhit, Nadia S Kamel, Manal O Mohammed, Nouran M Abaza, Somia A Saad El Din
DOI:10.4103/err.err_14_18  
Objectives To evaluate urinary tumor necrosis factor-like weak inducer of apoptosis (uTWEAK) levels as well as renal fibroblast growth factor-inducible molecule 14 (Fn14) expression by immunohistochemistry in patients with systemic lupus erythematosus (SLE) to assess the possible role of TWEAK level as an indicator of lupus nephritis (LN) and its relation to disease activity as well as pathological LN classification. Patients and methods Urinary levels of TWEAK using enzyme-linked immunosorbent assay and chemical and immunological markers of SLE were measured in 30 patients with SLE and 15 age-matched and sex-matched apparently healthy controls. Patients with SLE were divided into two subgroups: 15 patients with LN and 15 without LN. Disease activity was assessed using systemic lupus erythematosus disease activity index SLE disease activity index (SLEDAI). Fn14 was examined in renal biopsies from LN group by immunohistochemistry. Results A significantly higher uTWEAK level was found in patients having SLE with LN compared with those without LN and controls (F=149.2, P<0.001). uTWEAK had a highly significant positive correlation with proteinuria (r=0.755, P<0.001) and a significant positive correlation with tSLEDAI and rSLEDAI (r=0.217, P<0.037 and r=0.476, P<0.024, respectively). uTWEAK had a significant negative correlation with anti-dsDNA titer, C3, and C4 (r=−0.579, P<0.008; r=−0.456, P<0.011; and r=−0.552, P<0.002, respectively). Fn14 expression was detected in mesangial and tubular cells, mainly proximal tubular cells, in patients with LN. Conclusion uTWEAK is a specific and sensitive biomarker for detection of active LN.
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