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   Table of Contents - Current issue
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January-March 2018
Volume 45 | Issue 1
Page Nos. 1-41

Online since Tuesday, January 9, 2018

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ORIGINAL ARTICLES  

Effect of statins as modulators of CD39+ tregs in patients with rheumatoid arthritis who were unsuccessfully treated with methotrexate Highly accessed article p. 1
Mohammed H Abu-Zaid, Salwa El-Morsy Abdel Ghany, Rasha A Gaber
DOI:10.4103/err.err_20_17  
Objective The aim of this study was to determine the effects of combined atorvastatin (AV) with etanercept (ETA) in patients with active rheumatoid arthritis (RA), who were nonresponders to methotrexate (MTX) therapy, and its effect on disease activity and CD39+ regulatory T-cell (Tregs). Patients and methods This study included 50 patients with active RA. Patients with RA were divided into two groups. Group I (n=25) received MTX therapy plus ETA (50 mg/week) (ETA+MTX) and group II (n=25) received MTX and ETA plus AV therapy (20 mg/day) (ETA+MTX+AV). In addition, 25 healthy volunteers were used as controls. DAS-28, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, lipid profile, interleukin-6, CD39+ Tregs, ultrasonography 7 score (US7), carotid intima–media thickness, and flow-mediated dilatation (FMD) of the brachial artery were measured before and after 6 months of treatment. Results After 6 months of treatment, statin therapy combined with MTX and ETA significantly decreased disease activity variables, interleukin-6 and US7 synovitis, and tenosynovitis sum score. In addition, FMD% and CD39+ Tregs were significantly elevated. The increase in CD39+ Tregs was correlated with DAS-28 (P<0.001), FMD% (P<0.05), and US7 synovitis and tenosynovitis sum score (P<0.001). Conclusion Combination therapy with AV and ETA provides an added immunomodulatory benefit through enhancement of the immune suppression mediated by CD39+ Treg cells. Therefore, statins can be used safely with antitumor necrosis factor drugs to control disease activity and atherosclerotic changes in patients with RA, who are treated unsuccessfully with MTX.
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Value of electrophysiological testing in unilateral facial palsy p. 9
Nagwa M M Nassar, Iman M Ghanima, Eman A Tawfik, Noha M M Shaker Al Alfi
DOI:10.4103/err.err_9_17  
Objective The aim of this study was to assess the value of facial nerve temporal recording in the diagnosis and prognosis of facial nerve palsy. Patients and methods The study was conducted on 42 patients with acute unilateral Bell’s palsy (patients’ group) and 43 healthy volunteers who served as a control group. All patients and controls were subjected to clinical examination in the form of history taking and full general and neurological examinations, clinical scoring system using House–Brackmann facial nerve grading system (performed for the patients’ group only), electrophysiological assessment, which included electroneuronography (ENoG) and facial nerve temporal recording. Results The amplitude of the facial nerve temporal recording was significantly lower in the patients’ group compared with that in the control group, and there was statistically significant increase of the amplitude of facial nerve temporal recording, regaining its normal triphasic waves; as regards correlation study between the percent of degeneration of ENoG and the amplitude of the diseased facial temporal recording, there was positive correlation between them, and it was not reaching the level of statistical significance. Conclusion Facial nerve temporal recording detects the degenerative changes that occur in the intratemporal segment of the facial nerve; hence, it should be considered as a complementary tool for the ENoG test for early diagnosis and follow-up of Bell’s palsy.
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Electrophysiological Phalen’s provocation test in carpal tunnel syndrome p. 13
Dina A Farrag, Abeer K El-Zohiery
DOI:10.4103/err.err_39_17  
Objective Routine nerve conduction studies (NCS) are considered the golden standard for the objective diagnosis of clinically detectable carpal tunnel syndrome (CTS); however, fallacies can still befall. Clinically, phalen’s provocation test has proven reliability for screening CTS, yet, its use during NCS is still to be assessed. Thus, we aim to evaluate the role of our newly proposed electrophysiological Phalen’s provocation test (EPPT) in the diagnostic work-up of CTS. Patients and Methods One-hundred clinically suspected CTS hands and forty healthy hands were included in this study. Routine median motor and sensory NCSs were performed twice; once before and secondly, after provocation with wrist in 90 degrees flexion for 60 seconds (EPPT). Results All patients showed significantly delayed median distal motor and sensory latencies than controls (P<0.001). After EPPT, the percentage of change in median nerve distal sensory latency (MDSL) only was significantly higher in patients compared to controls (P<0.05). Moreover, the increased MDSL after provocation was more significant among clinically phalen’s positive hands (P=0.001). In addition, a cut off value of 3.2 msec could detect median sensory neuropathy at the thumb after provocation and it showed better performance than distal sensory recording before provocation. Conclusion EPPT might be promising for early detection of sensory neuropathic changes in CTS.
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Study of plasma levels of soluble triggering receptor expressed on myeloid cells-1 in rheumatoid arthritis and its correlation with disease activity and tumor necrosis factor-α p. 18
Abd El-Samed I El-Hewala, Samar G Soliman, Eman Badr, Heba A Esaily, Eman A Abd Allah
DOI:10.4103/1110-161X.222634  
Aim of the work The triggering receptor expressed on myeloid cells-1 (TREM-1) is a cell surface receptor expressed mainly on monocytes and neutrophils. It acts as an amplifier of inflammatory response in acute and chronic inflammatory states. The aim of this work was to study the plasma-soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in rheumatoid arthritis (RA) patients and its correlation with disease activity and tumor necrosis factor-α (TNF-α). Patients and methods This study included 80 patients with RA and 20 age-matched and sex-matched controls. All were subjected to demographic, clinical, laboratory, and radiological studies using the 28-joint Disease Activity Score, erythrocyte sedimentation rate, complete blood count, and radiograph of both hands. Plasma levels of sTREM-1 and TNF-α were measured with enzyme-linked immunosorbent assay. Results RA patients had significantly higher sTREM-1 and TNF-a levels compared with controls (206.32±125.75 and 17.83±11.88; P<0.001) and (190.82±69.46 and 54.75±9.46; P<0.001). In RA patients, sTREM-1 levels were found to be positively correlated with 28-joint Disease Activity Score, erythrocyte sedimentation rate, and TNF-a level (r=0.408, P=0.001; r=0.287, P=0.010; r=0.749, P=0.001). sTREM-1 level was significantly increasing as patients had increasing disease activity (F-test=20.62; P=0.001). Conclusion RA patients had higher sTREM-1 and TNF-a level compared with controls, and sTREM-1 level was correlated with disease activity, suggesting that sTREM-1 plays a role in the inflammatory process associated with TNF-a, and it may be a useful disease activity marker in RA. TREM-1 may be a safe therapeutic strategy for RA, as blocking TREM-1 signaling was found to suppress inflammatory responses without affecting the immune system to fight bacterial infection.
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Correlation of serum interleukin-10 level with disease activity and severity in systemic lupus erythematosus p. 25
Mervat I Abd Elazeem, Rabab A Mohammed, Nilly H Abdallah
DOI:10.4103/err.err_15_17  
Background Systemic lupus erythematosus (SLE, lupus) is a syndrome of multifactorial etiology, characterized by widespread inflammation, most commonly affecting women during the childbearing years. Virtually, every organ and/or system of the body may be involved. Interleukin-10 (IL-10) production is increased in SLE. Objective The aim of the study was to assess serum levels of IL-10 in SLE patients and their relationship with disease activity and severity parameters. Patients and methods Totally, 50 patients with SLE and 20 healthy controls were investigated in this study diagnosed according to Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for SLE. Clinical assessment of the disease activity was performed using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score. Assessment of SLE disease severity was carried out using the SLICC/American College of Rheumatology Damage Index and laboratory parameters, including erythrocyte sedimentation rate, C-reactive protein (CRP), 24 h urinary proteins, anti-dsDNA antibodies, complement 3, and complement 4 levels. The serum IL-10 levels were determined using enzyme-linked immune sorbent assay technique. Results The serum IL-10 levels were significantly higher in SLE patients (mean: 23.07±33.19 pg/ml) compared with the controls (0.52±0.86 pg/ml, P=0.000*). The increase in serum levels IL-10 significantly correlated with the SLEDAI scores (P=0.016*) and CRP (P=0.042*) in the studied patients. There were no significant correlations between IL-10 and SLICC, age, disease duration, erythrocyte sedimentation rate, 24 h urinary protein, anti-DNA, and complement 3–complement 4 (P=0.735; r=0.05, P=0.890, P=0.521, P=0.529; r=0.09, P=0.430; r=0.11, P=0.263; r=0.16, P=0.195; r=0.19, respectively). There was no significant difference between mean IL-10 levels in different classes of lupus nephritis (P=0.702). Conclusion The circulating IL-10 concentrations were significantly elevated in SLE patients and correlated with the SLEDAI score and CRP.
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Pattern of forefoot bursae in patients with rheumatoid arthritis and its effect on foot functions p. 34
Diaa F Mehasseb, Hamdy K Korayem, Manal Y Tayel, Ahmed H Afifi, Sarah S El-Tawab, Amira M Ibrahim
DOI:10.4103/err.err_24_17  
Aim of this work The aim of this study was to investigate the pattern and prevalence of forefoot bursae (FFB) and their effect on foot functions in Egyptian patients with rheumatoid arthritis (RA). Patients and methods The study included 100 patients with RA diagnosed according to the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria. The patients were recruited from the outpatient clinic of Physical Medicine, Rheumatology and Rehabilitation Department in Alexandria Faculty of Medicine. Musculoskeletal ultrasound (US) of the forefeet under the standardized EULAR guidance was done for all patients, and accordingly, the studied patients were further classified as those with US-detectable FFB (group I) and those without US-detectable FFB (group II). For group I patients, foot impact scale (FIS), foot anatomical changes assessment, and gait analysis were done. Results US-detectable FFB was found in 92% of the 100 patients with RA. The most frequent intermetatarsal bursa was the fourth one, and the most frequent submetatarsal bursa was the first one. There was a statistically significant relation between the total number of FFB on one side and its two subscales, meta-tarsophalangeal synovial hypertrophy, serum C-reactive protein level, visual analogue scale of foot pain, and step length on the other side. No statistically significant correlation was found between the total number of FFB and BMI, clinical disease activity index, or the foot deformities. Moreover, no statistical significant correlation was found between FIS and clinical disease activity index. Conclusion US-detectable FFB are highly prevalent in patients with RA and considered a significant contributory factor to foot disability among these patients. Foot disability may occur regardless of the RA activity state.
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CASE REPORT Top

Primary Sjögren’s syndrome with polymyositis, a rare amalgamation p. 39
Harpreet Singh, Deepak Jain, B Kiran, Neeraj Kumar
DOI:10.4103/err.err_25_17  
Sjögren’s syndrome is characterized by diminished lacrimal and salivary gland secretory function. This disorder is not strictly confined to the exocrine glands and its manifestations may extend to extraglandular sites, such as the lungs, kidneys, reticuloendothelial system, and the musculoskeletal system. Although muscular manifestations are very common with Sjögren’s syndrome, true myopathy is very rare. Here, we report a case of a 45-year-old woman who presented with complaints of bilateral progressive weakness of upper and lower limbs associated with difficulty in neck holding with a history of dryness of the mouth and the eyes. The diagnosis of polymyositis associated with Sjögren’s syndrome was established on the basis of clinical picture and diagnostic tests. True polymyositis is very rare in primary Sjögren syndrome and there are scarcely any cases of primary Sjögren’s syndrome with polymyositis reported in the literature.
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