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   Table of Contents - Current issue
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July-September 2017
Volume 44 | Issue 3
Page Nos. 97-141

Online since Wednesday, August 2, 2017

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ORIGINAL ARTICLES  

Synovial fluid anti-citrulline-containing peptide antibody and its role in the diagnosis of rheumatoid arthritis p. 97
Ali I Fouda, Ibrahim Rageh, Nashwa I Hashaad, Sabreen Hamza
DOI:10.4103/err.err_5_17  
Objective This study aimed to measure the level of anti-citrulline-containing peptide (anti-CCP) antibody (ab) in the synovial fluid (SF) of rheumatoid arthritis (RA) patients to study its relations with anti-CCP ab serum level, RA disease activity, and severity parameters as well as to explore its diagnostic value in RA. Patients and methods This study was conducted on 60 RA and 60 osteoarthritis (OA) patients. Patients were subjected to thorough history taking and full clinical examination including locomotor system examination. The Health Assessment Questionnaire was used for the assessment of functional capacity. Complete laboratory investigations including a complete blood count, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, serum and SF anti-CCP ab levels were carried out. The Sharp score was calculated for the assessment of RA severity in posteroanterior plain radiographic views of both hands and feet. Results The mean SF anti-CCP ab level was highly significantly increased (P=0.0001) in RA patients (133.93±41.3 ng/l) in comparison with OA patients (5±13.2 ng/l). There were statistically significant correlations of SF anti-CCP ab level with rheumatoid factor (P=0.049), serum anti-CCP ab (P=0.0001), and Sharp score (P=0.037), whereas other clinical and laboratory parameters did not show any significant correlation (P>0.05). The specificity of SF anti-CCP ab and serum anti-CCP ab of RA patients was 100%. Besides, the sensitivity of serum anti-CCP ab was 90%, whereas the sensitivity of SF anti-CCP ab was 83.3%. The positive predictive value of both serum and SF anti-CCP abs was 100% in RA patients and their negative predictive value was 90.9% in the serum of RA patients and 85.7% in the SF. The cutoff value of anti-CCP ab was 65.4 ng/l in the serum and 63.35 ng/l in the SF. Conclusion SF anti-CCP ab is significantly increased in RA compared with OA and could be considered an appreciated diagnostic marker having a major role in the identification of RA patients not fulfilling the criteria for the RA disease diagnosis. Its relation to RA disease severity could not be established.
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The ultrasound 7 score in the assessment of synovitis in rheumatoid arthritis: correlation with clinical disease activity indices p. 103
Shereen R Kamel, Hanaa A Sadek, Fatma A Mohamed, Manal F Abu Samra, Haidy M Osman
DOI:10.4103/err.err_4_17  
Objective The aim of the paper was to assess value of ultrasound 7 score (US7) in the detection of synovitis in rheumatoid arthritis (RA) and its correlation with clinical disease activity indices. Patients and methods A total of 50 patients with RA were included. Disease activity was assessed by clinical disease activity indices. Erythrocyte sedimentation rate was measured, and simple erosion narrowing score was used for radiography scoring. Musculoskeletal US7 score was done which combines each joint score for synovial proliferation (gray-scale ultrasound ‘GSUS7’) and vascularization (power Doppler ultrasound ‘PDUS7’). Results Detailed joint region examination by US7 score was done. Dorsomedian aspect of wrist (94%), palmar aspect of metacarpophalangeal joint (MCP) II (96%), and palmar aspect of phalangeal interproximal (PIP) II and III (92%) were the most affected joint regions with synovitis by GSUS. However, for detection of synovitis by PDUS, dorsomedian aspect of wrist and dorsal aspect of MCP, PIP II, and PIP III were involved. Erosions were found most in radial aspect of MCP II (70%), lateral aspect of metatarsophalangeal joint V (72%), and dorsal aspect of PIP II (54%) and PIP III (44%). All clinical disease activity indices were correlated with GSUS7 and PDUS7 synovitis. Conclusion US7 was simple and practical sum scoring system for use in the detection of synovitis in patients with RA. The correlations between the clinical disease activity indices, erythrocyte sedimentation rate, duration of illness, radiographic score, and components of the US7 score reflects the value of US7 score in assessment of disease activity and severity.
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Evaluation of disease activity markers in relation to dry eye disease in patients with rheumatoid arthritis p. 111
Mohja A El-Badawy, Amira R El-Mahdi, Samia M Abd El Rehem, Weam M Ebeid, Rania S El-Kitkat, Doaa M Abdelaziz
DOI:10.4103/1110-161X.212040  
Purpose The aim of this study was to correlate the presence of anti-cyclic citrullinated peptide (anti-CCP) and anti-mutated citrullinated vimentin (anti-MCV) antibodies with rheumatoid disease activity and dry eye disease in patients with rheumatoid arthritis (RA). Patients and methods A total of 69 patients were evaluated for the activity of RA using the Disease Activity Score (DAS-28), erythrocyte sedimentation rate, and C-reactive protein. We used the Health Assessment Questionnaire-Disability Index to assess functional disability. Anti-CCP and anti-MCV antibodies were measured using enzyme-linked immunosorbent assay technique. We assessed dry eye symptoms using Ocular Surface Disease Index (OSDI) questionnaire. Clinical tests used for dry eye assessment included Schirmer’s test, tear breakup time test, and ocular surface fluorescein staining. Results Anti-CCP antibody serum levels significantly correlated with DAS (r=0.46, P=0.036), Schirmer’s test (r=0.40, P=0.038), and ocular surface fluorescein staining (r=0.6, P=0.04). Anti-MCV antibody serum levels correlated with DAS (r=0.5, P=0.04), ocular surface fluorescein staining (r=0.9, P=0.007), and OSDI score (r=0.3, P=0.03). DAS showed a nonsignificant correlation with OSDI score and all tests of dry eye. OSDI score significantly correlated with Schirmer’s test (P=0.036). Conclusion Dry eye is the most common ocular manifestation in our investigated patients with RA. Dry eye disease existence is not correlated with disease activity, hence all patients with RA should be regularly examined for dye eye regardless of disease severity. Rheumatologists could use the OSDI questionnaire for screening dry eye disease in patients with RA. The presence of anti-CCP and anti-MCV antibodies may denote the existence of dry eye disease and correlates with RA disease activity.
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Correlation between disease activity and serum interleukin-23 in rheumatoid arthritis p. 118
Samia H Fadda, Mervat I Abd Elazeem, Rabab A Mohammed, Marwa T Sayed
DOI:10.4103/err.err_11_17  
Background Interleukin-23 (IL-23) is a proinflammatory cytokine that is thought to be central to the development of autoimmune diseases. This study was conducted to determine whether or not serum concentration of IL-23 is elevated in patients with rheumatoid arthritis (RA) and to determine the relationship between the IL-23 level and disease activity in patients with RA. Patients and methods Serum samples were obtained from 100 patients with RA and 50 healthy controls. Clinical parameters of the disease were determined, including 28-Joint Disease Activity Score, Clinical Disease Activity Index, Health Assessment Questionnaires, C-reactive protein, rheumatoid factor levels, anti-cyclic citrullinated peptide antibodies, and degree of bony erosions based on radiographs. The levels of IL-23 were determined by enzyme-linked immunosorbent assay (ELISA). The correlations between the serum levels of IL-23 and disease activity parameters of patients with RA were determined. Results Serum IL-23 level was significantly elevated in patients with RA, 0.00–49.30 pg/ml (19.12±13.45 pg/ml) compared with healthy controls, 0.00–1.40 pg/ml (0.90±0.63 pg/ml) (P=0.0001). Serum IL-23 levels in patients with RA correlated with Clinical Disease Activity Index (r=0.952, P=0.000), Health Assessment Questionnaires (r=0.953, P=0.000), and 28-Joint Disease Activity Score (r=0.967, P=0.000). Moreover, serum IL-23 levels in patients with RA correlated with erythrocyte sedimentation rate (r=0.950, P=0.000), C-reactive protein (r=0.954, P=0.001), and rheumatoid factor (r=0.917, P=0.000). There was a statistically significant difference between IL-23 mean values associated with different radiograph classes in patients with RA (P=0.001). Conclusion Levels of serum IL-23 in patients with RA were significantly higher than in healthy controls. Moreover, elevated serum IL-23 levels were correlated with clinical and laboratory parameters of disease activity. It should be considered as a useful marker to detect active RA. IL-23 is involved in disease progression and bony erosions in patients with RA. Anti-IL-23 drugs could have a potential role in the treatment of RA.
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Functional outcome of cemented bipolar prosthesis in unstable trochanteric fractures in elderly p. 125
Mohd Faizan, Aamir Bin Sabir, Naiyer Asif, Latif Z Jilani, Ravindra Mohan, Chandrashekhar Channappanavar, Mazhar Abbas
DOI:10.4103/1110-161X.212038  
Background Hip arthroplasty in unstable trochanteric fracture warrants quick recovery with little risk of mechanical failure, avoids the risk associated with internal fixation, and enables the patient to maintain a good level of function immediately after surgery. Aim The aim of this study is to evaluate the clinical and functional outcomes of cemented bipolar prosthesis in unstable intertrochanteric fractures in the elderly. Patients and methods Twenty-four patients with unstable type of intertrochanteric fracture according to Association Osteosynthesis Classification were treated with hemiarthroplasty (cemented bipolar prosthesis) and reconstruction of trochanter. The average age of the patients was 79 years. We evaluated postoperative complications, mortality rate, functional outcome using the Harris hip score, time to return to preinjury level of activity, and radiological signs of healing and loosening or migration of implant. The range of period of follow-up was 2–5 years (mean: 3.5 years). Results Mobilization and full weight-bearing was started immediately within 1 week of surgery. The dislocation rate in our study was zero. Deep infection and loosening of the implant was not observed in any of the cases. The mean Harris hip score improved progressively with time of follow-up. The mean score was 45.30 on the third day. The final average Harris hip score at the last follow-up was 81.90. Limb length discrepancy was observed in seven patients and average shortening was 1.3 cm (range: 0.5–1.8 cm). Conclusion Hip arthroplasty in mobile and psychologically stable elderly patients with unstable intertrochanteric fracture is a valuable treatment option.
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Significance of antibodies to ribosomal P proteins in lupus nephritis patients and their relation to disease activity: clinical and laboratory study p. 130
Samia H Fadda, Mervat I Abd Elazeem, Rabab A Mohammed, Hanaa M Hasan
DOI:10.4103/err.err_21_17  
Background Lupus nephritis (LN) is a prominent feature in systemic lupus erythematosus (SLE), present in 15–30% of patients with lupus at the time of the initial diagnosis and in 30–50% during the disease progression. Objectives The aim of this study was to determine the significance of anti-ribosomal P protein (anti-P) antibodies and LN and their relation to disease activity and other SLE manifestations. Patients and methods Fifty active LN patients were subjected to full clinical examination (assessment of SLE disease activity using the systemic lupus erythematosus disease activity index and assessment of SLE disease severity using Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index), routine laboratory investigations, anti-dsDNA antibodies, and anti-P antibodies. Results Comparison between the data of LN in both groups (anti-P positive/anti-dsDNA negative and anti-P negative) shows that there was a statistically significant difference in age (P=0.042), hypertension (P=0.00), and psychiatric manifestations (P=0.004). On comparison of both groups as regards vasculitis, there was a borderline statistical significance (P=0.050). Comparison of both groups as regards creatinine level or biopsy class V showed a statistically significant difference with a higher percentage in the anti-P positive/anti-dsDNA negative group (P=0.024 and 0.040, respectively). Conclusion Anti-P antibody-positive patients have younger ages, lower creatinine level, lower incidence of hypertension, usually class V in renal biopsy, but more susceptible to have psychiatric manifestations compared with anti-P antibody negative patients.
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CASE REPORT Top

Gouty tophi without hyperuricemia, an interesting case diagnosed by fine-needle aspiration cytology p. 139
Debashish Bhattacharjee, Santosh K Mondal, Rudra Narayan Ray, Debjani Basu
DOI:10.4103/1110-161X.212041  
Gout is a disorder of uric acid metabolism characterized by deposition of monosodium urate crystals in joint spaces or soft tissues. Gouty tophi can be the presenting feature of gout and can occur despite normal serum uric acid levels. Periarticular nodules can be a diagnostic dilemma for both clinicians and radiologists. A 39-year-old man presented with a nontender, firm swelling in right medial malleolus. His serum uric acid level was normal. Computed tomography scan report gave a differential diagnosis of synovial sarcoma and pigmented villonodular synovitis. Fine-needle aspiration cytology from the swelling revealed abundant granular amorphous deposits with needle-shaped crystals in a background of chronic inflammatory infiltrate. Biopsy from the swelling demonstrated the presence of needle-shaped crystals in a radial arrangement along with foreign-body giant cells and histiocytes. On the basis of cytological and histopathological findings, a diagnosis of gouty tophi was rendered.
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