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   Table of Contents - Current issue
Coverpage
April-June 2017
Volume 44 | Issue 2
Page Nos. 45-95

Online since Thursday, May 4, 2017

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ORIGINAL ARTICLES  

Study of serum sclerostin levels in association to entheseal ultrasonography in Egyptian psoriatic arthritis patients p. 45
El-Attar A.M Enas, Farrag A Dina, El-Mallah E Reem, Samaha Y Dalia
DOI:10.4103/err.err_63_16  
Introduction Serum sclerostin is a protein inhibitor of the wingless signaling pathway of bone formation whose role in osteoimmunology and inflammatory arthritides is still controversial. Aim The aim of the present study was to examine the relation of serum sclerostin as one member of the wingless signal protein inhibitors to arthritic and bony manifestation of psoriasis as a model of autoimmune inflammatory arthritis. Settings and design This was a cross-sectional, prospective study. Patients and methods The study included 30 psoriatic arthritis (PsA) male patients whose mean age was 43.3±8.3 years and had a disease duration of 3.8±2.6 years, and 15 age-matched and sex-matched apparently healthy controls. Serum sclerostin was measured using the enzyme-linked immunosorbent assay. Disease activity was measured using the Disease Activity Index for Psoriatic Arthritis. Ultrasonography of enthesis at Leeds enthesitis sites and dual energy X-ray absorptiometry at the lumbar spine were also carried out for all patients. Statistical analysis The independent t-test, Pearson’s correlation coefficient, and one-way analysis of variance were used for statistical analysis. Results The serum sclerostin level was significantly higher in PsA patients compared with controls, with a mean of 0.64 and 0.37 ng/ml, respectively. Serum sclerostin correlated significantly with Disease Activity Index for Psoriatic Arthritis, ultrasonography inflammatory and damage scores, and dual energy X-ray absorptiometry at the lumbar spine. Conclusion Serum sclerostin could have a significant role in the development of inflammation-associated bone damage in PsA. Further follow-up studies are recommended to confirm the role of serum sclerostin in inflammation and bone damage in PsA patients and the factors that could regulate this autoimmune pathological event.
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Study of brain-derived neurotrophic factor in the serum of patients with systemic lupus erythematosus p. 52
Rasha M Fawzy, Ahmed Y Elshambaky, Shwikar T Fahmy, Mona M Elbhesy, Basmh A Moustafa
DOI:10.4103/1110-161X.205659  
Objectives Brain-derived neurotrophic factor (BDNF) is an important mediator of neuronal development, survival, and function. It is related to the pathogenesis of several neuropsychiatric disorders. The aim of this study was to determine the relationship between serum BDNF (sBDNF) level and neuropsychiatric status in systemic lupus erythematosus (SLE) patients. Patients and methods This study included the following groups: group I included 35 SLE patients with neuropsychiatric systemic lupus erythematosus (NPSLE) manifestations, group II included 30 SLE patients without neuropsychiatric manifestations, group III included 15 patients with neuropsychiatric disorders due to causes other than SLE, and group IV included 15 apparently healthy volunteers. All groups were matched for age and sex. SLE disease activity was assessed using the SLE Disease Activity Index. A Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Axis I was used for the assessment of psychiatric disorders, whereas neurological disorders were assessed by an expert neurologist. sBDNF was measured by the enzyme-linked immunosorbent assay. Results There was a statistically significant increase (P<0.05) in the mean titer of sBDNF in group I compared with other groups (314.9±162.1, 151.1±188.2, 218.1±198.4, and 141.9±130.2 ng/ml in groups I, II, III, and IV, respectively), as well as in group III compared with groups II (P<0.05) and IV (P<0.05). The mean serum titer of BDNF was statistically significantly elevated in active NPSLE patients (320.7±156.2 ng/ml, P<0.05) compared with inactive NPSLE (210.6±141.89.6 ng/ml, P<0.05), active SLE (142.8±162.7 ng/ml, P<0.05), and inactive SLE (139.8±174.8 ng/ml, P<0.05) without neuropsychiatric manifestations. Conclusion Variation in sBDNF level between SLE patients with and without neuropsychiatric manifestations indicates that it has a particular role in NPSLE disease process. Likely, it could be used as a biological marker for determining NPSLE disease activity.
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Platelet-rich plasma versus dry needling of myofascial meridian trigger points in the treatment of plantar fasciitis p. 58
Reem El Mallah, Enas A Elattar, Howayda F Zidan
DOI:10.4103/1110-161X.205661  
Background Plantar fasciitis (PF) is the most common cause of heel pain, which results from repetitive trauma with degenerative changes in the plantar tissue. Platelet-rich plasma (PRP) and dry needling showed promising results as regards pain resolution and healing effect, and hence our aim was to compare their efficacy in the treatment of chronic PF. Patients and methods Thirty patients diagnosed with unilateral PF were subjected to full clinical assessment for foot function using the foot function index (FFI) and assessment of trigger points along the meridians. Ultrasonographic examination of plantar fascia thickness, echogenicity, and power Doppler was carried out. Patients were divided randomly into two groups of 15 each: group A received a single injection of PRP at the plantar fascia, and group B was treated with dry needling protocol in myofascial meridians trigger points along the superficial back line. Follow-up after 6 and 12 weeks included clinical re-evaluation, FFI determination, and ultrasonography. Our results showed a significant improvement in the clinical outcome of the FFI in group B (P<0.03) and a highly significant improvement in the clinical outcome within the PRP group by the 12th week (P<0.009). A significant decrease in thickness, heterogeneity, and Doppler signals (P<0.04, P<0.003, and P<0.03, respectively) was observed within the PRP group at the 12th week. Conclusion PRP injection is a promising line of treatment for chronic PF with documented ultrasonographic healing effect. Dry needling is a simple and safe technique for treating pain associated with PF, yet it is more invasive and less effective compared with PRP injection.
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Relation of anthropometric hand measurements to idiopathic carpal tunnel syndrome p. 69
Wafaa S El-Emary
DOI:10.4103/1110-161X.198426  
Context Certain individuals are more prone to developing idiopathic carpal tunnel syndrome (ICTS) than others, suggesting that certain personal factors can be implicated in its occurrence. Aim The aim of this work was to study anthropometric hand and wrist measurements in ICTS patients, and to correlate them with median nerve electrophysiologic study. Patients and methods The study included 50 patients with clinically diagnosed and electrophysiologically confirmed ICTS and 50 age-matched and sex-matched healthy volunteers as the control group. Both groups performed sensory and motor conduction studies of the median nerve. External hand and wrist anthropometric measurements were taken for both groups including wrist depth and width, wrist ratio (WR), palm length and width, third digit length, and hand ratio (HR). Results Patients had significantly higher wrist depth (P=0.000), higher WR (P=0.000), shorter palm length (P=0.002), shorter hand length (P=0.001), and lower HR (P=0.000). Patients had more square wrists and shorter hands. Some of these measurements correlated well with median nerve conduction study parameters. Wrist depth and WR were positively correlated with median motor and sensory latencies (P=0.000) and negatively correlated with median motor and sensory amplitudes (P=0.000), and sensory conduction velocity (P=0.000). HR was negatively correlated to median motor and sensory latencies (P=0.01) and positively correlated to median motor (P=0.001) and sensory amplitudes (P=0.039), and sensory conduction velocity (P=0.001). Palm width was negatively correlated with median motor amplitude (P=0.043). Conclusion Certain hand anthropometric characteristics predispose to ICTS. Short hand and square wrist configurations could predict the development of ICTS.
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Value of combined exercise and ultrasound as an adjunct to compression therapy in chronic venous leg ulcers p. 77
Rehab A.E Sallam, Atif I El Ghaweet, Samer A.H Regal
DOI:10.4103/1110-161X.205660  
Introduction Chronic venous leg ulcers are very difficult to treat and take very long time to heal. Compression therapy remains the mainstay of venous ulcer conservative treatment. Aim The aim of this study was to evaluate the effectiveness of combined therapeutic exercises and ultrasound as an adjunct to compression therapy for the treatment of chronic venous leg ulcers. Settings and design This study is a prospective randomized case-controlled one. Patients and methods Seventy-two patients with chronic venous leg ulcers were recruited from outpatient clinics. We allocated patients to four groups of 15 patients each. Group I was treated with therapeutic exercise program in addition to compression therapy. Group II was treated with underwater ultrasound and compression therapy. Group III was treated with therapeutic exercises as in group I and underwater ultrasound as in group II, in addition to compression therapy. Group IV was treated with compression therapy. The duration of follow-up was 12 weeks. Treatment outcome was assessed using the visual analogue scale for pain, ulcer size, the pressure ulcer scale for healing, maximum ankle dorsiflexion and plantar flexion using a plastic goniometer. Results Venous ulcer healing was greatest in patients receiving combined exercise and ultrasound in addition to compression therapy. Combined therapeutic exercises and ultrasound were well tolerated and no adverse reactions were noted. Patients receiving therapeutic exercises alone or ultrasound alone showed lesser degrees of improvements. No significant improvements were observed in any variable in patients who received compression therapy alone. Conclusion Combined prescription of exercises and ultrasound as an adjunct to compression therapy would be a more effective means of promoting chronic venous ulcer healing, when standard compression therapy have failed. It is safe, easy and well tolerated and should be considered as adjunctive therapy in patients with venous leg ulcers.
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Tumor necrosis factor-α is a novel biomarker for peripheral neuropathy in type II diabetes mellitus: a clinical and electrophysiological study p. 83
Mohja A El-Badawy, Dina A.B Farrag, Samia M.R Abd El-Rehem, Amira R El-Mahdi, Alyaa A El-Sherbeny, Emad A.M Abdel Hady, Hoda A Abdel-Sattar, Doaa M Abdelaziz
DOI:10.4103/1110-161X.205663  
Background Tumor necrosis factor-α (TNF-α) is an adipocytokine locally produced by Schwann cells and has a role in nerve regeneration and regulation of apoptosis. The role of TNF-α in the development of diabetic peripheral neuropathy (DPN) is controversial. Objective The objective of this study was to evaluate TNF-α serum level in a group of type II diabetes mellitus (DM) patients with and without neuropathy in comparison with healthy age-matched control group. Design This is a cross-sectional case–control study. Settings The study was conducted in outpatient clinics of the diabetes and physical medicine, rheumatology, and rehabilitation departments. Patients Ninety patients diagnosed with type II diabetes were included in the study. Main outcome measures All patients were assessed for clinical neuropathy using neuropathy symptom score and neuropathy disability score. All patients underwent nerve conduction studies of both upper and lower limbs. They were divided into two groups: group I with confirmed DPN (n=60) and group II with DM but no peripheral neuropathy (n=30). Serum TNF-α level was measured in all previous DM patients (90 patients) in addition to 48 healthy age-matched controls. Results A statistically significant difference was detected between serum TNF-α level in controls and diabetic patients. Similarly, a significant difference was detected between its level in non-DPN patients and confirmed DPN patients, being higher in the latter. A positive significant correlation has been detected between TNF-α level and patients’ age, as well as blood cholesterol level. A positive significant correlation has been found between TNF-α level and both neuropathy symptom score and neuropathy disability score. A significant negative correlation had been detected between TNF-α level and motor amplitudes of both tibial nerves. Conclusion Serum TNF-α level might be a potential biomarker for peripheral neuropathy in type II DM.
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CASE REPORT Top

Calcium pyrophosphate dihydrate and hydroxyapatite crystals in a patient with rheumatoid arthritis: Acase report p. 91
Shereen R Kamel
DOI:10.4103/1110-161X.205662  
The association between rheumatoid arthritis (RA) and calcium pyrophosphate dihydrate (CPPD) crystal deposits can now be easily identified by MSUS, which is a noninvasive technique that can be applied to patients with painful joints and enthesis that are unexplained by rheumatoid activity. In this paper, we report an Egyptian case of a 51-year-old man who had rheumatoid arthritis since 7 years and developed bilateral knee and heel pain of 1.5 months’ duration with gradual onset and progressive course. Radiography revealed features of RA in both hands, as well as features of severe osteoarthritis in both knees with no signs of chondrocalcinosis. Ultrasonography of the joints, Achilles tendon, and plantar fascia detected knee, Achilles tendon, and plantar fascia calcifications, which are characteristic of CPPD, and supraspinatus calcification, which is characteristic of hydroxyapatite (HA) deposition. Further investigations revealed no evidence of metabolic disorders. CPPD and HA crystals were identified in his synovial fluid. Subclinical affection with CPPD and HA crystals in RA can be easily detected by ultrasonography, which allows early management to prevent future attacks in RA patients that could lead to exacerbation of joint symptoms that may be missed as rheumatoid disease activity. Diet control and colchicine treatment may be more effective if started early before exacerbation.
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ERRATUM Top

Erratum: Musculoskeletal ultrasound on the hand and wrist in systemic sclerosis p. 95

DOI:10.4103/1110-161X.205665  
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