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   2016| July-September  | Volume 43 | Issue 3  
    Online since September 7, 2016

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Foot neuropathy in rheumatoid arthritis patients: clinical, electrophysiological, and ultrasound studies
Abd El-Samad I El-Hewala, Samar G Soliman, Alaa A Labeeb, Ashraf A Zytoon, Amira T El-Shanawany
July-September 2016, 43(3):85-94
Aim This study aimed to evaluate neuropathic foot pain in patients with rheumatoid arthritis (RA) using electrophysiological studies and musculoskeletal ultrasound (MSUS) to address the association between these findings and disease activity. Evaluation of the usefulness of this combination was undertaken. Design The present study was designed as a cross-sectional study. Patients and methods A total of 50 RA patients underwent a complete history-taking and rheumatologic examination. According to the cut-off point of Disease Activity Score in 28 joints, patients were divided into two equal groups (25 patients each): active and inactive. In total, 25 healthy individuals were included as controls. Routine tibial and peroneal nerve conduction studies, as well as electromyography of tibialis anterior and abductor hallucis muscles, were carried out. MSUS assessment of the ankle joint and extra-articular portion of the foot complex was also performed. Results Electrophysiological findings of foot neuropathy were observed in 78% of the patients, irrespective of the disease activity level. In total, 48% of the patients had mononeuropathies of a demyelinating pattern (entrapment neuropathies), whereas the other 30% had symmetrical polyneuropathy with axonal degeneration. Combined distal tibial and peroneal nerve entrapments were reported in 16% of the patients. A positive power Doppler signal and joint erosions showed a highly statistical significant prevalence among the active group in comparison with patients in remission (P ≤ 0.001). Conclusion Peripheral nerve affection is common in the rheumatoid foot, irrespective of the disease activity status. The most common neuropathies were posterior tarsal tunnel syndrome, peroneal nerve entrapment at the fibular neck, and pure sensory axonal neuropathy. A positive power Doppler signal and bone erosions of the ankle joint, detected by MSUS, were associated with RA disease activity. Electrophysiology was superior to MSUS for the diagnosis of posterior tarsal tunnel syndrome.
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Difference between early versus delayed postoperative physical rehabilitation protocol following arthroscopic rotator cuff repair
Samar M Fawzy, Ahmed Rizk Mohamed, Ahmed K Sameer, Ahmed S Foad
July-September 2016, 43(3):137-142
Background Early passive motion exercise has been the standard rehabilitation protocol following rotator cuff repair. However, recent research studies show that longer immobilization may enhance tendon healing. Aim The aim of this study was to compare early passive range of motion (ROM) exercise with a delayed rehabilitation protocol with regard to the effectiveness of stiffness reduction and functional improvements and rates of tendon healing in patients undergoing arthroscopic repair for torn rotator cuffs. Patients and methods This study was performed on 164 patients having a full-thickness tear of the supraspinatus muscle that was repaired using the arthroscopic single-row suture anchor technique along with subacromial decompression. The patients were divided into two groups, early (group 1) and delayed ROM (group 2). In group 1, 78 patients were started on passive elevation and rotation exercises on the second day after surgery. In group 2, 86 patients had their shoulder immobilized for 6 weeks, after which passive motion exercise was started. Patients were followed-up clinically for a minimum of 12 months, and rotator cuff healing was assessed using MRI. Results Both groups had a statistically significant difference between preoperative and postoperative results. As regards American Shoulder and Elbow Surgeon scores, the early group improved from 45.4 preoperatively to 90.9 postoperatively (P<0.0001) and the delayed group improved from 44.59 preoperatively to 91.6 postoperatively (P<0.0001). As regards Constant score, the early group improved from 35.7 preoperatively to 86.5 postoperatively (P<0.0001) and the delayed group improved from 37.8 preoperatively to 88.1 postoperatively (P<0.0001). However, there were no statistically significant differences in rotator cuff healing between the two groups. The follow-up mean of visual analog scale was significantly better in group 2 compared with group 1 at 6 weeks postoperatively but no difference was found after 3 months. In contrast, ROM was better in group 1 compared with group 2 at 6 months postoperatively but no difference was found after 1 year. Conclusion Significant improvement in pain, ROM, and function after arthroscopic rotator cuff repair was seen at 1 year postoperatively, regardless of early or delayed postoperative rehabilitation protocols. However, early motion increases pain scores and may increase the possibility of rotator cuff retear but with early regain of ROM. A delayed rehabilitation protocol with immobilization for 6 weeks would be better for tendon healing without risk for retear or joint stiffness and easily convalescence with less postoperative pain.
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Musculoskeletal ultrasound on the hand and wrist in systemic sclerosis
Rasha M Fawzy
July-September 2016, 43(3):95-101
Background Systemic sclerosis (SSc) is a chronic autoimmune connective tissue disorder. Musculoskeletal involvement represents a major cause of disability in SSc, which is localized especially at the level of the hands and feet. Musculoskeletal ultrasound (MSUS) had become a reference imaging tool in the evaluation of joint and soft-tissue abnormalities in rheumatic diseases. Aim of the work This study aimed to characterize ultrasonographic changes of the hand and wrist in patients with SSc as compared with patients with rheumatoid arthritis (RA), as well as determine the relation of these changes with clinical, laboratory, and radiographic findings in SSc. Patients and methods Twenty SSc patients and 20 control RA patients were included in this study. All patients underwent history taking, clinical examination, hand/wrist plain radiography, and MSUS performed on both hand and wrist joints. Results MSUS was more sensitive than radiographies in detecting soft-tissue calcifications in SSc patients and also in detecting erosions with no statistically significant difference (P > 0.05). In SSc patients, the prevalence of synovitis and tenosynovitis detected by ultrasound was found to be statistically significantly higher than that found by clinical examination (P = 0.025 and 0.011, respectively). Patients with higher values of erythrocyte sedimentation rate and C-reactive protein were more likely to have synovitis and/or tenosynovitis and inflammatory activity on power Doppler assessment. Conclusion Ultrasound was more accurate than clinical examination and conventional radiography in the detection of subclinical synovitis, tenosynovitis, and the underlying fibrotic changes of tendon friction rub. In SSc patients, on using MSUS, articular involvement was found to be less frequent compared with that in RA patients, with specific appearance of sclerosing tenosynovitis in SSc patients.
  1,822 179 -
Musculoskeletal ultrasonographic evaluation of lower limb enthesopathy in ankylosing spondylitis and Behçet’s disease: Relation to clinical status and disease activity
EA Baraka, WA Hassan
July-September 2016, 43(3):108-116
Aim of the work Using clinical and musculoskeletal ultrasonographic (MSUS) examination, we aimed to compare the frequency, pattern, and main sites of peripheral enthesopathies in the lower limbs of ankylosing spondylitis (AS) and Behçet’s disease (BD) patients, and to evaluate their relation with different clinical, laboratory, and functional parameters of both diseases. Patients and methods Fifteen AS patients (group I) and 22 BD patients (group II) were examined clinically and by carrying out MSUS for enthesopathy at five entheseal sites of the lower limbs. A control group of 20 apparently healthy male volunteers was also included. An enthesopathy score was calculated for each patient according to the Glasgow ultrasound enthesitis scoring system (GUESS). Disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index and the Behçet’s disease current activity form in both groups, respectively. Results The GUESS score was significantly higher (P < 0.05) in group I than in group II (7.27 ± 3.88 vs. 4.68 ± 3.67). In the two patients’ groups, tendon thickening was the most frequent finding detected. Bone erosions and enthesophytes were significantly (P < 0.05) more frequent in group I than in group II. The most commonly affected entheseal sites were the distal Achilles tendon, followed by the proximal plantar fascia. In group I, the GUESS scores significantly correlated with the fatigue scores (P < 0.05), peripheral joint pain scores (P < 0.05), and Bath Ankylosing Spondylitis Functional Index scores (P < 0.05), whereas it showed insignificant correlations with patients’ ages (P > 0.05), disease duration (P > 0.05), spinal pain scores (P > 0.05), local tenderness scores (P > 0.05), morning stiffness score (P > 0.05), total Bath Ankylosing Spondylitis Disease Activity Index (P > 0.05), Bath AS metrology indices (P > 0.05), AS quality of life scores (P > 0.05), radiographic scores (P > 0.05), erythrocyte sedimentation rate (P > 0.05), and C-reactive protein levels (P > 0.05). In group II, the mean GUESS score was significantly higher (P < 0.05) for BD patients with arthritis than for BD patients without arthritis, but it showed insignificant correlation (P > 0.05) with disease activity. Conclusion Ultrasonographic changes at the entheseal sites of the lower limbs are prevalent in both AS and BD. These changes are more frequently related to functional and articular involvement. MSUS is more sensitive than clinical examination in detecting enthesopathies of the lower limbs in both AS and BD patients.
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Potential role of calprotectin as a monitoring biomarker for clinical and sonographic activity and treatment outcome in recent-onset rheumatoid arthritis
Amal F Soliman, Basant M Elnady, Raneyah H Mahmoud Shaker, Amira I Mansour
July-September 2016, 43(3):143-149
Background Calprotectin is a protein released during the activation and turnover of leukocytes. It can be used as a biomarker of inflammatory diseases such as rheumatoid arthritis (RA). Aim The current study aimed to measure the serum level of calprotectin in RA patients, recently diagnosed and after initiation of treatment, to determine its association with clinical disease, synovial inflammation determined by Ultrasound (US), and its relation to therapy when compared with other inflammatory markers. Patients and methods A total of 32 patients with recent RA and 20 healthy individuals were assessed for serum calprotectin level (enzyme-linked immunosorbent assay). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were also measured in patients who were reassessed 4 months after initiation of therapy. Disease activity was evaluated by the disease activity score of 28 joints (DAS28), and US assessment was performed. Results The mean level of serum calprotectin was significantly higher (P<0.001) than that of controls. At baseline, there were significant (P<0.001) correlations of calprotectin serum level with DAS28, ESR, CRP, grayscale, and power Doppler (PD) synovitis scores. After therapy, all except DAS28 and ESR significantly correlated with calprotectin serum level. Calprotectin was shown to be better (P=0.001) than CRP (P=0.922) and ESR (P=0.104, r2=0.495) in predicting power Doppler synovitis score. Calprotectin results showed higher sensitivity in predicting disease activity at the stage of active inflammation. Conclusion Serum calprotectin level is strongly associated with clinical, laboratory, and US parameters of inflammation in recent-onset RA. Calprotectin is a confident biomarker for monitoring the treatment outcome in RA patients.
  1,369 174 1
Impact of an intensive dynamic exercise program on oxidative stress and on the outcome in patients with fibromyalgia
Amal F Soliman, Gehan G El-Olemy, Waleed A Hassan, Raneyah H.M. Shaker, Omminea A Abdullah
July-September 2016, 43(3):117-123
Objective The aim of this study was to investigate the effectiveness of intensive dynamic exercises on the oxidative status in patients with primary fibromyalgia (FM) and to explore the importance of these effects on the outcome of FM. Patients and methods We measured levels of stress oxidants (protein carbonyls, nitric oxide, and thiobarbituric acid reactive substances) and antioxidant parameters (thiols and catalase) in blood samples from 40 FM patients and from healthy controls (n = 25) at presentation and after 12 weeks of intensive exercise program that comprised aerobic and strengthening exercises (lasting 1 h three times per week). In the patients, pain was assessed using the visual analog scale and tender points counts, and the Fibromyalgia Impact Questionnaire and the Beck Depression Inventory were applied at presentation and after 12 weeks of exercise therapy. Results At presentation, the serum levels of the oxidative stress parameters were significantly higher (P < 0.001), whereas the serum levels of antioxidant parameters were significantly lower (P < 0.001) in patients with FM than in controls. There was a higher significant decrease (P < 0.001) in the oxidative stress parameters following the 12-week exercise regime, whereas the antioxidant parameter levels showed a higher significant increase (P < 0.001) after the exercise treatment. Tender points, visual analog scale, Fibromyalgia Impact Questionnaire, and Beck Depression Inventory showed a higher significant (P < 0.001) improvement with exercise therapy. Conclusion Twelve weeks of intensive dynamic exercise program should be recommended to patients with FM as it was effective in decreasing the oxidative stress parameters, increasing the antioxidant parameters, and improving the clinical outcome of this disease.
  1,337 152 -
Correlations between Serum prohepcidin level disease activity in rheumatoid arthritis and systemic lupus erythematous
Sahar S Ganeb, Gamal A.E. Hamad, Refaat M El-Tanawy, Nashwa I Hashaad, Inas A Ahmed, Dalia K Gomah, Arwa S Amer
July-September 2016, 43(3):102-107
Introduction The aim of this study was to determine whether there is a relation between serum prohepcidin level and disease activity of rheumatoid arthritis (RA) and systemic lupus erythematous (SLE), and to discover whether it has a role in the anaemia of chronic disease occurring in RA and SLE patients. Patients and methods This study was carried out on 30 patients suffering from RA and 30 patients suffering from SLE. In addition, 20 healthy volunteers were recruited as controls. All patients and controls were subjected to full history taking, thorough clinical examination, locomotor system examination, assessment of the disease activity in RA patients using the Disease Activity Score-28, assessment of the disease activity in SLE patients using Systemic Lupus Erythematous Disease Activity Index, laboratory investigations, including complete blood count, erythrocyte sedimentation rate (ESR), rheumatoid factor and C-reactive protein (CRP), and measurement of serum prohepcidin levels by the enzyme-linked immunosorbant assay. Results The mean serum prohepcidin concentration was 395.2 ± 551.4 ng/ml in RA patients, whereas it was 381.5 ± 88.07 in SLE patients and 121.4 ± 11.1 ng/ml in healthy volunteers. The prohepcidin concentration correlated with the rheumatoid factor, C-reactive protein, ESR, disease duration, morning stiffness, tender joint count, swollen joint count, Larsen score, haemoglobin level and Disease Activity Score-28 in RA patients .There were positive significant correlations between the mean serum prohepcidin concentration and platelets number, haemoglobin level and ESR in SLE patients and insignificant correlations between the mean serum prohepcidin concentration and Systemic Lupus Erythematous Disease Activity Index. Conclusion Prohepcidin could be considered as a useful marker for RA, but not for SLE. Prohepcidin may have a role in anaemia of chronic disease occurring in RA and SLE.
  1,303 149 -
Vitamin D status in hospitalized male patients in Ain Shams University Hospitals and relation to body composition
Menna El Araby, Heba Y Kamel, Tomader T Abdel Rahman, Wessam S Sayed, Ahmed K Mortagy
July-September 2016, 43(3):150-155
Background Vitamin D deficiency is highly prevalent worldwide; its effect on bone is well known and understood, but the effect of this deficiency is still not clear. Objective This study examines vitamin D status in Egyptian hospitalized elderly male patients and its relation to body composition, muscle strength, and performance. Design This was a cross-sectional study. Participants and methods Data collected from a previous cross-sectional study, in which a systematic random sampling technique was used where every third patient (skip interval) was included in the study and vitamin D was measured only to a selected number of patient who meets inclusion criteria, were selected for inclusion in the study on the basis of the exclusion criteria, which may have affected the parameters measured. Complete assessment of history and physical examination were performed. Measurements Body composition was measured using bioelectrical impedance analysis (Geratherm), hand grip was measured using a Jamar handheld dynamometer, performance was measured using the timed get up and go test, and 25-hydroxyvitamin D was measured by enzyme-linked immunosorbent assay. Results Our study included 88 elderly men 60 years of age or older; the mean age of the participants studied was 64.74 ± 4.6 years, and 86.3% were married, 22.7% were physically active, and 15.9% were nonsmokers. The mean BMI was 26.4 ± 7.2 kg/m2 and the mean vitamin D level was 12.15 ng/ml. The prevalence of vitamin D insufficiency was 19.3% and that of vitamin D deficiency was 79.5%. Vitamin D deficiency was not associated with age, occupation, marital status, smoking (type, duration, and quantity), hand grip, timed get up and go test, and parameters of body composition. Conclusion Vitamin D deficiency and insufficiency is highly prevalent among elderly Egyptian men, and its impact on body composition, muscle function, and strength is not significantly noticeable.
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Expression of the leukocyte-associated ig-like receptor-1 on B lymphocytes from systemic lupus erythematosus patients
Heba A Esaily, Wafaa M Radwan, Hany S Elbarbary, Azza A Taha
July-September 2016, 43(3):124-130
Background The leukocyte-associated immunoglobulin (Ig)-like receptor-1 (LAIR-1) is a transmembrane molecule belonging to the Ig superfamily. In B cells, LAIR-1 cross-linking leads to downregulation of Ig and cytokine production. Aim of the work The aim of the present study was to assess the expression of LAIR-1 on peripheral blood B lymphocyte from systemic lupus erythematosus (SLE) patients, and its correlation with disease manifestations. Patients and methods Twenty-two SLE female patients and 16 matched healthy controls were included in the study. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score was assessed. The expression of LAIR-1 was determined by using flow cytometry. Results The 22 SLE patients had a mean age of 25.59±4.22 years and disease duration of 5–24 months. The mean SLEDAI was 8±1.5. The percentage of CD19+ B lymphocytes lacking LAIR-1 was markedly increased in SLE patients (27.8±10.9%) compared with healthy controls (16.2±4.4%) (P<0.001). The mean fluorescent intensity ratio (MFIR) of LAIR-1 expression on CD19+ B cells was strongly decreased in SLE patients (44.1±12.6) compared with healthy controls (58.9±7.7) (P<0.001). The percentage of CD19+ LAIR-1 B cells significantly correlated with the complement (C4) (r=0.45, P=0.03) and the serum creatinine level (r=0.47, P=0.02), and negatively with the serum albumin level (r=−0.57, P=0.005). The MFIR of LAIR-1 significantly correlated with the serum albumin level (r=0.74, P<0.001) and negatively correlated with the serum creatinine level (r=−0.43, P=0.041). There was no significant association of LAIR (%) or the MFIR with the clinical manifestations of the patients. Conclusion This study points out that the lack of LAIR-1 expression on B cells from SLE patients could be a trigger for the dysregulation of antibody production in SLE, and is associated with the degree of renal affection as evidenced by the significant correlation with serum creatinine levels and negative correlation with the levels of serum albumin.
  1,098 116 -
Evaluation of serum undercarboxylated osteocalcin in premenopausal rheumatoid arthritis patients: its correlation with disease activity and bone mineral density
Heba A Esaily, Abd El Samad Al Hewala, Samar G Soliman, Eman A Galbat, Dalia H. Abo Al-Ela
July-September 2016, 43(3):131-136
Background There is a definite role of vitamin K and undercarboxylated osteocalcin (ucOC) on bone mineral density (BMD) in rheumatoid arthritis (RA). Up to our knowledge, no other work has discussed the relationship between ucOC and BMD in premenopausal RA patients and its correlation with disease activity. Patients and methods Sixty premenopausal RA female patients and 30 healthy premenopausal controls of matched age were included. All were subjected to clinical examination, laboratory investigations including serum level of ucOC, disease activity measurement using DAS-28 score, and BMD measurement using dual-energy X-ray absorptiometry. Results The level of ucOC was significantly higher in patients with RA than in controls (P<0.001). BMD in patients was found to be significantly lower compared with controls in the spine, femoral neck, and distal radius areas. The most frequent osteoporotic site according to Z-score was the spine (16.7%), followed by the femoral neck (8.3%) and distal radius (6.7%). The most common commonest osteopenic site according to Z-score was the spine (31.7%), followed by the femoral neck (21.7%) and the distal radius (16.7%). Our work showed that ucOC level was found to be high in premenopausal RA patients with higher DAS values than in those with lower DAS value (P<0.001). In our work, BMD measured by means of dual-energy X-ray absorptiometry scan was found to be lower with higher DAS values and vice versa. Conclusion Serum level of ucOC (which is a mirror of vitamin K deficiency) was found to be higher in premenopausal RA patients than controls and correlated positively with disease activity and inversely with BMD measurement.
  1,063 132 -