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   Table of Contents - Current issue
Coverpage
October-December 2017
Volume 44 | Issue 4
Page Nos. 143-184

Online since Tuesday, October 31, 2017

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ORIGINAL ARTICLES  

Intra-articular injection of hyaluronic acid for treatment of osteoarthritis knee: comparative study to intra-articular corticosteroids p. 143
Soad A Elsawy, Mona Hamdy, Manal S Ahmed
DOI:10.4103/err.err_55_16  
Objective Osteoarthritis (OA) is a chronic degenerative joint disease characterized by pain and progressive functional limitation. Although both corticosteroid and hyaluronic acid (HA) injections are widely used to palliate the symptoms of knee OA, few researches involving a comparison of two interventions have been conducted. The objective of the study was to compare the efficacy and safety of HA to corticosteroid injections for the treatment of knee OA. Patients and methods We enrolled 60 patients with knee OA who were randomized to receive intra-articular injection of either HA or the corticosteroid. The therapy was followed for 6 months. The patients treated with HA received one course of injections per week for 3 weeks and the other group received single injection of corticosteroid. The two groups were compared as regards pain and functional improvement using the Western Ontario and McMaster University Osteoarthritis Index and visual analog scale. Results The study included 60 patients, with age ranging from 36 to 65 years with a mean of 51.8 years. All of them were diagnosed with knee OA using ACR clinical classification criteria. Patients were recruited between May and December 2015. After 6 months of the treatment, both groups showed functional improvement. HA group showed significant improvement compared with the corticosteroid group as regards the Western Ontario and McMaster University Osteoarthritis Index and visual analog scale (P=0.01). Conclusion Both HA and corticosteroid groups showed improvement in pain and knee function, but the intra-articular HA was superior to corticosteroid on long-term follow-up. This supports the potential rate of intra-articular HA as an effective long-term therapeutic option for patients with OA of the knee.
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Medial calcaneal neuropathy: a missed etiology of chronic plantar heel pain p. 147
Emmanuel Kamal Aziz Saba, Sarah Sayed El-Tawab, Hussein Al-Moghazy Sultan
DOI:10.4103/err.err_16_17  
Introduction Medial calcaneal neuropathy had been implicated as a source of chronic plantar heel pain. Aim The aim was to determine the presence of medial calcaneal neuropathy as a cause of chronic plantar heel pain. Patients and methods The present study included 43 heels obtained from 38 patients with chronic plantar heel pain and 30 apparently healthy volunteers as a control group. Clinical examination was done. Sensory nerve conduction study of the medial calcaneal nerve was performed. This was a single-center, public hospital-based study. It was designed as a cross-sectional examination of consecutive patients with chronic plantar heel pain. Results There were 27 (62.79%) heels, from 23 (60.52%) patients, who had medial calcaneal neuropathy. From them, unobtainable medial calcaneal nerve response was present in 10 (37.03%) heels of nine (39.13%) patients. Medial calcaneal neuropathy was the solitary cause of chronic plantar heel pain in 10 (37.03%) heels from 10 (43.48%) patients. However, it was associated with other local heel pathologies in the remaining patients. The majority of them were having plantar fasciitis in nine (33.34%) heels from five (21.73%) patients. Conclusion Medial calcaneal neuropathy is present in a considerable number of patients with chronic plantar heel pain. It should be taken into consideration during the assessment of any patient with chronic plantar heel pain.
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Electrophysiological study of Martin–Gruber anastomosis in a sample of Egyptians p. 153
Emmanuel Kamal Aziz Saba
DOI:10.4103/err.err_12_17  
Introduction Martin–Gruber anastomosis (MGA) is one of the most common anomalous innervations present in the body. Missing these anomalous innervations may easily be mistaken for technical pitfalls or even for actual pathology. Aim The aim of the current study was to determine the presence and the frequency of MGA by electrophysiological examination in a sample of Egyptian subjects. Subjects and methods It is a cross-sectional study of consecutive apparently healthy volunteers. The study included 200 forearms from 100 apparently healthy Egyptian volunteers in a single-center public-hospital-based electromyography laboratory. Electrophysiological studies in the form of motor conduction study for the median and ulnar nerves were performed by recording the hypothenar, first dorsal inerosseous, and thenar muscles. Qualitative data were analyzed using Pearson’s Chi-square test and Fisher’s exact test. Results The present study included 69 (69%) women. MGA was found in 39 (19.5%) forearms of 26 (26%) subjects electrophysiologically. There was no statistical significant difference between the occurrence of MGA in men versus women (P=0.127). The most common form was MGA to the first dorsal interosseous muscle. It was present in 30 (15%) forearms of 24 (24%) subjects. MGA to thenar muscles was present in 13 (6.5%) forearms of 12 (12%) subjects. MGA to the abductor digiti minimi muscle was present in five (2.5%) forearms of five (5%) subjects. Conclusion Martin–Gruber anastomosis is present in Egyptians. The frequency of occurrence of MGA in a sample of Egyptian subjects was found to be 26% in electrophysiological examination.
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Study of interleukin 33 in rheumatoid arthritis versus osteoarthritis patients p. 159
Aliaa M. Abd El-Aziz Farag, Nagat M El-Gazzar, Marwa A.Abo El Hawa, Mohamed A.Saad Attia
DOI:10.4103/err.err_8_17  
Aim of the work To compare the expression of serum interleukin 33 (IL33), a new member of the interleukin1 (IL-1) cytokine family, in rheumatoid arthritis (RA) versus osteoarthritis (OA) patients and to correlate it with clinical, laboratory and radiographic parameters. Subjects and methods 20 RA and 20 primary knee OA patients. The levels of serum IL-33 were measured by enzyme-linked immunosorbent assay (ELISA) while anticyclic citrullinated peptide (Anti-CCP), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured by standard laboratory techniques. Plain x-ray of both hands and wrists were evaluated using the modified Larsen score 1995 (MLS) in RA patients. Knee OA grading was performed according to the KellgrenLawrence classification. The correlation of IL-33 level with clinical, laboratory and radiological data of RA and OA was analyzed. Results Serum IL-33 level was significantly higher in RA than in OA patients (P < 0.001). This level was positively correlated with disease duration, clinical and laboratory markers of disease activity, impaired functional status and radiographic severity in RA while not in OA patients. Conclusions These findings support that IL-33 could have an essential proinflammatory role in the pathogenesis of RA and that IL-33 level may be a monitor of disease activity and severity. IL-33 may become therapeutic target for RA.
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Risk factors for acute coronary events in patients with rheumatoid arthritis p. 164
Abdulsalam Noorwali, Narges Omran, Samah H Elmedany, Amal M El-Barbary
DOI:10.4103/err.err_14_17  
Objectives The aim of this study was to assess the role of disease activity, line of treatment, and carotid atherosclerosis in the risk for acute coronary syndrome (ACS) in rheumatoid arthritis (RA) patients. Patients and methods In this prospective study, we ascertained ACS on 124 patients with RA. Disease activity score 28 was used for the assessment of RA activity. Insulin resistance was evaluated using homeostasis model assessment-insulin resistance. Carotid atherosclerosis was measured using high-resolution ultrasound. We used Cox’s proportional hazards models to estimate the association between ACS and atherosclerosis, cardiovascular (CV) risk factors, and RA line of treatment. Results Among the 124 RA patients without a history of previous ACS, 16 incident ACS events occurred over 30 months. Old age, long RA disease duration, high BMI, and 10-year cardiovascular disease risk were associated with an increased risk for ACS. High mean disease activity score 28, rheumatoid factor, and anticitrullinated peptide antibodies (ACPA) levels were significantly associated with ACS risk. Treatment with disease-modifying antirheumatic drugs or biological disease-modifying antirheumatic drugs (DMARDs) did not alter the ACS risk. Logistic regression analysis showed that carotid plaques were a good predictor for ACS in RA patients. Conclusion The main finding of this study was a general tendency toward an association of disease activity, rheumatoid factor, and ACPA with the risk for ACS. In addition, subclinical atherosclerosis detected by means of carotid intima-media thickness and the presence of carotid plaques were good predictors for RA patients with ACS. Treatment with any DMARD or biologic DMARDs was not linked to an altered risk for ACS.
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Objective assessment of cortical activity changes in stroke patients before and after hand rehabilitation with and without botulinum toxin injection p. 172
Omnia A Abu-Bakr, Nagwaa M.M Nassar, Amal M Al-Ganzoury, Khaled Abo-Elfotouh Ahmed, Eman A Tawfik
DOI:10.4103/err.err_38_16  
Background Upper limb spasticity is a disabling condition and may result in severe functional limitation. The peripheral action of botulinum toxin (BTX) injection on spasticity is well known, but there are debates around its possible central action. Aim The aim of this study was to assess the clinical, functional, and cortical activation outcome of two antispastic treatments for stroke of the hand and wrist. Thirty patients with upper limb poststroke spasticity were recruited in this study. Patients and methods They were randomly allocated to two groups: group A and group B. Both groups received rehabilitation program, whereas group B received additional BTX injection. All patients were assessed at baseline and 8 weeks after treatment using the Modified Ashworth Scale, the Action Research Arm Test and Nine-Hole Peg Test, and somatosensory-evoked potential study of the median nerve. Results Group B showed a higher percentage of change in Modified Ashworth Scale of the wrist flexors and long flexors of fingers and in Action Research Arm Test compared with group A. Conclusion BTX injection in spastic muscles of the wrist and hand, followed by a rehabilitation program led to greater clinical and functional improvement compared with implementing the rehabilitation program alone.
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CASE REPORT Top

Recurrent diabetic muscle infarction, a rare complication of diabetes: a case report p. 181
Tariq Bhat, Muzafar Naik, Mohd Farooq Mir, Jangbhadur Singh, Aijaz Shah
DOI:10.4103/1110-161X.217439  
Diabetic muscle infarction is a rare complication of diabetes mellitus that presents as a localized, exquisitely painful swelling and limited range of motion of the involved extremity. The onset is usually acute, persists for several weeks and resolves spontaneously over several weeks to months without the need for intervention. However, as diabetes mellitus is an immunocompromised state and any painful swelling in the limbs is often taken as infectious in aetiology, the patient is inadvertently investigated with invasive procedures and is started on unnecessary antibiotics, adding to the burden of management. Keeping in view the low threshold for starting antibiotics in painful limb swelling in diabetes mellitus in our setting, we hereby describe a case of recurrent painful diabetic muscle infarction, first involving the right upper and later the right lower limb, managed with physical rest and analgesics. This case emphasizes that the treating physician keep this rare complication of diabetes mellitus in consideration in the respective clinical scenario and adopt a less aggressive (a noninvasive method like ultrasound) rather than a more aggressive (an invasive method like muscle biopsy) approach in diagnosis and take a similar approach towards management.
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