Rheumatology and Rehabilitation

Carotid artery atherosclerosis and ECG changes in patients with systemic lupus erythematosus: relation to disease activity and severity Samia M Abdel-Monem, Sahar S Ganeb, Rasha M Fawzy, Ahmed M Bendary, Zeinab N Elhawary Egyptian Rheumatology and Rehabilitation 2019 46(2):71-77 Aim This study aimed to detect atherosclerotic changes in the carotid arteries of systemic lupus erythematous (SLE) patients as an indicator of cardiovascular risk factors and to correlate the findings with disease severity and activity parameters as well as to study specific ECG changes in these patients to elucidate possible associations between these variables. Patients and methods This study included 30 SLE patients who met the Systemic Lupus International Collaborating Clinics (SLICC) criteria (group I), 30 rheumatoid arthritis (RA) patients diagnosed according to the American College of Rheumatology/European league against rheumatism (EULAR) 2010 criteria (group II), and 30 apparently healthy volunteers age and sex matched to the SLE patients’ group (group III). All patients were subjected to full history taking, thorough clinical examination, assessment of disease activity using the Systemic Lupus Erythematous Disease Activity Index (2 K) score and assessment of damage by the SLICC/American College of Rheumatology Damage Index (SDI). Laboratory investigations included: complete blood count, erythrocyte sedimentation rate, lipid profile, immunological profile (antinuclear antibodies, anti-double-stranded DNA antibody, anticardiolipin antibody, and complements C3 and C4). The right common carotid artery was scanned by ultrasound and the average of carotid intima media thickness (CIMT) was calculated (mean of four readings) for all participants participating in the study. ECG was also done for all participants. Results The mean CIMT was higher in RA patients (0.71±0.194 mm) with a nonsignificant difference compared with SLE patients (0.68±0.197 mm) and a high statistically significant difference (P<0.001) compared with healthy controls (0.34±0.09 mm). There was no statistically significant correlation of the mean CIMT (mm) with SLICC damage index (P=0.09) and disease activity score (P>0.05). Abnormal ECG findings were observed in 3/30 SLE patients (10%), 10/30 RA patients (33.3%), and one/30 healthy control (3.3%), with statistically significant difference (P<0.03) among groups. The presence or absence of abnormal ECG findings showed statistically insignificant differences regarding patients’ disease activity and mean CIMT. Conclusion Although ECG changes were present in 10% of our SLE patients, association of specific ECG changes could not be confirmed. A greater prevalence of increased CIMT was observed in SLE patients, emphasizing the important role of this disease in the development of premature atherosclerosis which did not correlate with disease activity or severity parameters.

Outcome of intensive rehabilitation following single-event multilevel surgery for crouch gait in children with cerebral palsy John F.H Amen, Dalia M.E El-Mikkawy, Ahmed H Yosry, Mohamed A El-Gebely, Mostafa H.A El-Sherbini Egyptian Rheumatology and Rehabilitation 2019 46(2):78-84 Background Crouch gait is one of the most common gait patterns in ambulatory children with cerebral palsy (CP) and is contributed by several factors. The literature reports wide variations in surgical practice and rehabilitation programs following single-event multilevel surgeries. Objective To evaluate the outcome of rehabilitation after single-event multilevel orthopedic surgery for crouch gait in children with CP. Patients and methods A total of 20 children with bilateral spastic CP and walked with a crouch gait, with gross motor function classification system levels II, III, and IV, were subjected to single-event multilevel surgery. Ten (20 limbs) patients were men and eight (14 limbs) were women. Their age ranged from 5.5 to 19 years. To assess the outcome of our rehabilitation program, we used clinical couch examination parameters, functional mobility scale, and instrumented three-dimensional gait analysis. Rehabilitation program included preoperative and postoperative rehabilitation at 1-year postoperatively. Results Highly statistically significant improvements in clinical parameters, which include hip abduction, femoral anteversion, fixed flexion deformity, popliteal angle, and extension lag, were demonstrated (P<0.01), whereas tibial torsion showed a statistically significant improvement (P<0.05). Functional mobility scale at 5, 50, and 500 m improved in 10 (55.6%) cases, 13 (72.2%) cases, and 11 (61.1%) cases, respectively. Instrumented gait laboratory parameters, namely, stride length, crouch angle at initial stance, and peak knee flexion in mid-swing, showed improvement but did not reach statistical significance. Conclusion The rehabilitation program we offered improves clinical and functional mobility of children with CP with crouch gait. Thus, it is viewed as an important contributor to the overall outcome together with multilevel orthopedic surgery.

Premature ovarian failure in systemic lupus erythematosus patients: is it related to cyclophosphamide treatment? Rasha M Ghaleb, Khaled A Fahmy Egyptian Rheumatology and Rehabilitation 2019 46(2):85-91 Introduction Systemic lupus erythematosus (SLE) is a chronic autoimmune systemic disease that mainly affects women during the childbearing period. Cyclophosphamide (CYC) is the drug of choice for severe SLE manifestations. However, many side effects had been reported. Premature ovarian failure (POF) is one of the serious complications that can occur in SLE patients. Aim The aim was to evaluate the prevalence of POF in female patients with SLE and whether it is related to CYC treatment or not. Patients and methods One hundred women with SLE satisfying the updated revised criteria for the classification of SLE were studied. The patients were allocated into two groups: CYC-treated group (n=55) and non-CYC-treated group (n=45). Patients were interviewed and demographic characteristics, clinical and serologic profiles, and menstrual histories were recorded. Disease activity was measured by the SLE disease activity index. Serum anti-Müllerian hormone was measured as a marker for ovarian reserve assessment in the two study groups. Results Ovarian failure occurred in 15 (27.3%) patients out of the 55 SLE patients treated with CYC. The cumulative CYC dose was significantly higher in patients with ovarian failure than in those without this condition (11.7 vs. 9.5 g; P=0.001). The cumulative dose of CYC and the older age at initiation were found to be associated more with POF. Conclusion In our population of female SLE patients, CYC-induced ovarian failure is a significant problem occurring in 27.3% of SLE patients receiving CYC. So, for SLE patients in whom the use of CYC is mandatory, a lower dosage and a shorter course of this agent should be considered. Co-treatment with gonadotropin-releasing hormone agonists might persevere the future fertility and ovarian function in young women. Ovarian banking before administration of CYC could be a possible solution in certain cases.

Neuromuscular ultrasound in ulnar neuropathy at the elbow: correlation with electrodiagnostic studies Esraa Muhammad Bastawy, Naglaa Ali Gad Allah, Ola Abd El Nasser, Eman Ahmed Tawfik Egyptian Rheumatology and Rehabilitation 2019 46(2):92-100 Introduction Ulnar nerve entrapment is the second most common entrapment neuropathy in the upper limb after carpal tunnel syndrome, and, if left untreated, it may lead to significant functional impairment and disability. Objective The aim of this study was to perform clinical, electrodiagnostic (EDX), and neuromuscular ultrasound assessment for patients with ulnar neuropathy at the elbow, to determine the possible roles of neuromuscular ultrasound in the localization of the neuropathy, in the detection of its possible etiologies and in the determination of its severity. Patients and methods A sample of 15 (22 elbows) patients was recruited and subjected to full medical history, neurological assessment, EDX studies, and neuromuscular ultrasound examination. Ten (20 elbows) age-matched and sex-matched healthy volunteers were also recruited and served as a control group. Results This study revealed significantly enlarged ulnar nerve cross-sectional area (CSA) at the ulnar groove and below the elbow and supracondylar sites in patients compared with the control group. receiver-operating characteristic curve analysis revealed high diagnostic accuracy of the absolute CSA at the ulnar groove, and below the elbow and supracondylar sites, with an area under the curve of 0.8, 0.8, and 0.9, respectively, and the cutoff values were >9, >8, and >8, respectively. The area under the curve for the ‘maximum CSA/midforearm CSA ratio’ was 0.9, with a cutoff value of more than 1.3. Conclusion Our study data suggest that neuromuscular ultrasound (NMUS) examination may play a potentially important role in the assessment of ulnar neuropathy at the elbow. It can localize the lesion and disease severity, and it can differentiate between patients and controls, given its high diagnostic ability. Abnormalities in ultrasonographic features of ulnar nerve entrapment with regard to CSA and ratio between ‘maximum CSA and midforearm CSA’ at the elbow was correlated with EDX findings.

Clinical significance of interleukin 27 serum concentration in patients with systemic sclerosis: relation to clinical, laboratory and radiological parameters Waleed A Hassan, Gamal A Hamaad, Emtethal A Sayed, Mona M El Behisy, Manal K Gomaa Egyptian Rheumatology and Rehabilitation 2019 46(2):101-107 Background Interleukin 27 (IL27) is a cytokine that belongs to IL12 family and it is mainly produced by antigen presenting cells. IL27 binding to its receptor leads to activation of many intracellular signaling pathways that can exhibit a wide variety of immunomodulatory actions. Aim of the work The current study aimed to determine IL27 concentrations in the sera of SSc patients and to assess the relation between these concentrations and the various clinical, laboratory and radiological disease parameters. Methods We measured serum IL27 concentrations in 31 SSc patients and 20 controls. The patients were subjected to detailed history and clinical evaluation. In SSc patients, modified Rodnan skin score (MRSS) was used to assess the skin thickness and pulmonary involvement was assessed by high resolution computerized tomography (HRCT) and forced vital capacity (FVC) assessment. Results IL27 serum concentrations in diffuse (median, 302.8; 101.6-1034.4 ng/L) and limited (median, 385; 109-826.3 ng/L) subtypes of SSc showed a significant elevation (P < 0.001) compared to its concentrations in the controls (median, 104.2; 51-184.2 ng/L). SSc patients with elevated IL27 serum concentrations had significantly lower forced vital capacity (FVC) than those with normal IL27 serum concentrations (p=0.04). Also, serum level of sCD163 significantly correlated with MRSS (r=0.48, p=0.0064) and FVC (r=-0.6, p=0.0005). Conclusion Patients with systemic sclerosis have significantly increased serum IL27 concentrations that remarkably associated with significant cutaneous and pulmonary involvement signifying that it could be a beneficial biomarker that reflects disease severity and implies a possible pathogenic role in SSc.

Relation of ischemia-modified albumin to disease manifestations and activity in Egyptian patients with Behҫet's disease Nermeen A Fouad, Tarek I Ahmed, Olfat G Shaker, Omayma O Abdelaleem Egyptian Rheumatology and Rehabilitation 2019 46(2):108-112 Aim of work To determine level of ischemia-modified albumin (IMA) in patients with Behçet’s disease (BD) and to assess its role in disease manifestations and activity. Patients and methods The study included 48 patients with BD and 38 matched controls. Disease activity was estimated by the BD current activity form. Serum IMA was measured. Results Mean age of the patients was 33.8±7.9 years. There were 42 males and six females, and the disease duration was 52.9±48.8 months. The serum IMA level was significantly increased in the patients with BD (50.9±12.9 U/ml) compared with the control (7.76±1.6 U/ml) (P<0.001). There was a statistically significant association between IMA level and disease activity, with high mean IMA level among active cases (P=0.01). There was no statistically significant association between IMA level and any of other clinical characteristics in patients with BD. Sensitivity and specificity test for IMA level in detection of cases illustrated accuracy of 98.5% with sensitivity 95.8% and specificity 78.9% at cutoff value of 9.4 U/ml. Conclusion There is growing evidence indicating the role of oxidative stress in BD. IMA is accepted as an essential marker of oxidative stress in patients with BD. It has a potential diagnostic value for the detection of the disease. Furthermore, it correlates with the disease activity.

Ultrasonographic features of tibialis posterior tendon in rheumatoid arthritis patients with pes planovalgus Hamdy Khamis Koraym, Wafaa S El-Emary, Sherine M Elsherif, Ahmed H Afifi, Samar A.S.M Olibah Egyptian Rheumatology and Rehabilitation 2019 46(2):113-120 Aim The aim of this study was to assess the relationship between ultrasonographic features of tibialis posterior (TP) tendon in rheumatoid arthritis (RA) patients and associated pes planovalgus (PPV) foot deformity. Patients and methods This study included 20 (40 feet) RA patients with PPV and ultrasound-proven TP tenosynovitis. The following variables were recorded for patients: the number of tender and swollen foot joints count, foot posture index (FPI), Health Assessment Questionnaire, and Disease Activity Score 28 (DAS28). FPI is a clinical tool used to quantify the degree to which a foot is pronated, neutral, or supinated using the set criteria. Patients underwent high-resolution ultrasound of the TP tendon. Measurement of tendon diameter was recorded in the retromalleolar region. The presence of fluid around the TP tendon and levels of power Doppler signal (PDS) were assessed. Results High disease activity was detected in patients (mean DAS28 of 5.89). Eighteen (45%) feet had thickened transverse diameter and 15 (37.5%) feet had thickened longitudinal diameter. Twenty-three feet showed PDS. Nineteen feet had fluid around the tendon, detected only in the retromalleolar region. Regarding FPI, 14 feet were mild to moderate pronated feet and 26 feet were highly pronated feet. There were direct correlation between FPI and both DAS28 (p=0.05) and transverse diameter thickness (p=0.01). Highly pronated feet had higher DAS28 (p=0.03), increased transverse diameter thickness (p=0.04), more detection of fluid around the TP tendon (p=0.005) as well as higher incidence of PDS around the TP tendon (p=0.002). Conclusion Higher degree of pronation in RA feet with PPV is associated with ultrasonographic increased tendon thickness, PDS, and fluid around TP tendon. Early diagnosis and intervention for TP tenosynovitis may prevent progressive PPV foot deformity.

Patellar tendon ultrasonographic properties and lower limb function in rheumatoid arthritis patients Samia Abd El Hamid Abd El Megid, Salwa Saeid El Gendy, Hussein Abd El Aziz Yassin, Marwa Mohamed Mohamed Ali Abd El Rahim, Mai Abd El Halim Abd El Razik Moussa Egyptian Rheumatology and Rehabilitation 2019 46(2):121-131 Aim of work The aim of this work was to investigate patellar tendon (PT) biomechanical properties in rheumatoid arthritis (RA) patients through changes in ultrasonographic tendon properties and its effect on lower limb function. Patients and methods Forty RA patients and 20 healthy participants were included in this study. The physical function was assessed by Health Assessment Questionnaire, the activity of RA by disease activity score 28 and range of motion for all knees by a manual goniometer. RA patients were divided into the following groups: group I comprised patients with low disease activity score 28, who were further subdivided according to the presence of knee flexion deformity into two subgroups (GIA and GIB) and group II patients in the remission stage. Ultrasonography was used for measuring PT elongation and cross-sectional area and quadriceps’ muscle strength was measured. The lower limb function was assessed clinically by 50-foot walk test and smart balance master system through unilateral stance test, step up and over and sit to stand tests. Results There was an increased elongation of PT of all RA groups relative to the control group (P=0.001); no significant difference was found in the PT (cross-sectional area). RA patients showed quadriceps’ muscle strength reduction (P=0.001) and delayed walking time of the 50-foot walk test (P=0.05). Unilateral stance test showed increased center of gravity sway velocity during either eye open or eye closed conditions in RA groups and deterioration in all parameters of step up and over and sit to stand tests (P=0.05–0.001). All physical function evaluation of RA patients showed impairment associated with a reduction of PT stiffness and quadriceps’ strength. Conclusion Inflammation of the PT and peritendinous tissues in RA alters its biomechanical properties; this impairs RA patients’ physical and lower limb functions.

Combined (physical and medical treatment) therapy versus physical treatment alone and medical treatment alone in the management of chronic pelvic inflammatory disease Dalia S Saif, Dina S Fotoh, Reem M EL Kholy, Dalia I Morsi, Heba M Farag Egyptian Rheumatology and Rehabilitation 2019 46(2):132-139 Context Pelvic inflammatory disease (PID) is the inflammation of the upper genital tract involving the fallopian tubes as well as the ovaries. Symptoms of PID are fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, uterine and adnexal tenderness, and irregular menstruation. Aim The aim was to determine the therapeutic efficacy of combined shortwave diathermy and medical treatment in the management of chronic PID in comparison to either therapy alone. Materials and methods Sixty participants were recruited and diagnosed as chronic PID for more than 6 months by history, clinical examination, cervical swab, and ultrasonography. They were divided into three groups: Statistical analysis Descriptive and analytic study by SPSS version 16 on IBM compatible computer. Results There was a statistically highly significant clinical improvement regarding itching, discharge and pain relief, laboratory improvement regarding the number of pus cells in cervical swab, and radiological improvement regarding US parameters in the first group of patients with PID compared with the baseline and compared with other groups. Conclusion The greatest therapeutic efficacy can be obtained from combined physical and medical treatment compared with each line alone in the treatment of chronic PID.