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   Table of Contents - Current issue
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July-September 2019
Volume 46 | Issue 3
Page Nos. 141-210

Online since Monday, July 15, 2019

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ORIGINAL ARTICLES  

Shockwave therapy versus local steroid injection in chronic supraspinatus tendinopathy Highly accessed article p. 141
Mona Zamzam, Ahmed El Yasaki, Nermin ElGarabawy, Lamiaa Emad E El Ghandour
DOI:10.4103/err.err_16_18  
Objective To evaluate the efficacy of shockwave therapy versus ultrasound-guided steroid injection in the treatment of chronic supraspinatus tendinopathy. Patients and methods This study was carried out on 30 patients with calcific and noncalcific supraspinatus tendinopathy for more than 3 months. A clinical assessment was performed for all patients including pain scoring by the visual analog scale and full shoulder examination at the start of the study and 6 weeks later. Shoulder ultrasound was performed at the start of the study. Fifteen patients received four sessions of radial shockwave therapy (Intelect Radial Shockwave, UK) 3 bar pressure, 2000 pulses, 20 Hz. Fifteen patients received a single ultrasound-guided subacromial steroid injection (1 ml triamcinolone 40 mg and 1 ml lidocaine). Results Both groups showed a statistically significant improvement in pain relief (visual analog scale) and clinical examination: tenderness, shoulder range of motion, and muscle power. There was no statistically significant difference between both groups. Conclusion Radial shockwave therapy has no additional benefit over ultrasound-guided steroid injection in the short term in patients with chronic supraspinatus tendinopathy.
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Diastolic dysfunction in patients with rheumatoid arthritis p. 148
Rasha M. Ghaleb, Mervat I. Abd Elazeem, Osama A Amin
DOI:10.4103/err.err_6_19  
Objective The aim of this study was to evaluate left ventricular diastolic function parameters as an early predictor of cardiac involvement in patients with rheumatoid arthritis (RA) without any evidence of hypertension, diabetes mellitus, rheumatic fever or underlying cardiac disease, detected by Doppler echocardiography and to correlate diastolic function in RA patients with different RA disease characteristics. Patients and methods Seventy-five RA patients were diagnosed according to the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA and another 38 age-matched and sex-matched healthy participants were included. All patients and the control groups were submitted to M-mode, two-dimensional, Doppler (continuous and pulsed wave) echocardiography. Diastolic dysfunction was defined as when transmitral flow E/A ratio is less than one. Results Left ventricular diastolic dysfunction was found in 28 (37.3%) of 75 RA patients and four (10.5%) of 38 controls with a P value of less than 0.05. In the patients’ group, a statistically significant correlation was found between diastolic dysfunction and duration of the disease (P<0.05), and disease activity was assessed by 28 Joint Disease Activity Score (P<0.05). Conclusion Among those without a history of cardiac disease, patients with RA have a higher prevalence of diastolic dysfunction than those without RA. Diastolic dysfunction in RA was associated with disease duration and disease activity. Thus, early identification of diastolic dysfunction in asymptomatic RA patients by the use of echocardiography may provide an opportunity to manage the underlying etiology to prevent progression to diastolic heart failure.
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Assessment of tendon involvement in chronic hemodialysis patients: an ultrasonographic study p. 154
Samia M Abdelomnem, Sami E Egila, Rasha M Fawzy, Mohamed A Mohamed, Nora A Abdelkader
DOI:10.4103/err.err_60_18  
Aim of the work The aim of this study was to detect changes occurring in some tendons, for example, Achilles, quadriceps, and supraspinatus tendons, using musculoskeletal ultrasound (MSUS) imaging in patients with chronic kidney disease (CKD) on regular hemodialysis and to evaluate associations of these changes with patients’ clinical status, parathyroid hormone (PTH) level as well as other laboratory parameters. Patients and methods This study was carried out on 35 patients and a group of 25 age-matched and sex-matched apparently healthy participants as a control group. All patients underwent history taking; clinical examination; and shoulder, knee, and ankle plain radiography. Laboratory investigations including PTH level were done. MSUS was performed on the selected tendons for all patients and controls. Results The ankle was the most clinically affected joint. US abnormalities most commonly affected the Achilles tendon (15.2%) having calcific deposits, abnormal peritendon tissue, increased thickness, and abnormal structure, followed by the quadriceps tendon (2.9%), whereas the supraspinatus tendon was the least affected (2.3%). There were highly statistically significant differences between patients with CKD and controls regarding mean tendon thickness, with the quadriceps tendon and supraspinatus tendons being thicker in the study group (P<0.001). Significant positive correlations of PTH level with age, the duration of dialysis, and PO4 level were observed. Conclusion There were significant tendon involvements among patients with CKD with the Achilles tendon mostly involved having calcific deposits, abnormal peritendon tissue, increased thickness, and abnormal structure. Tendon abnormalities occurred mainly in older patients with longer durations of dialysis, hypercalcemia (Ca), hyperphosphatemia (PO4), and a higher Ca×PO4 product. MSUS is a simple, noninvasive, and a substantial tool in the diagnosis and follow-up of tendon involvement among patients with CKD.
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Articular and skeletal affection in regularly dialyzed patients with end-stage renal disease p. 162
Hisham E Abd El Wahab, Tarek M Abd Elaziz, Mohammad M Alsayyad, Mahmoud S Berengy
DOI:10.4103/err.err_57_18  
Background Patients on regular hemodialysis (HD) are vulnerable to develop different articular and skeletal problems that interfere with life quality and affect morbidity and mortality in these patients. To, properly, overcome or even prevent the development of these complications, early detection, especially of the commonly affected parts, is required. Aim The aim was to detect articular and skeletal manifestations in patients with end-stage renal disease on regular HD, their relation to duration of dialysis, and which is more affected. Patients and methods A total of 50 patients (34 males and 16 females) with end-stage renal disease on regular HD, who were attendants of the dialysis unit of Internal Medicine Department at Al-Azhar University hospital, New Damietta, with duration of dialysis ranging between 3 and 15 years and age ranging from 26 to 70 years old were recruited for the study. They were classified into three groups: group I: mild, group II: moderate, and group III: severe joint affection. Full history taking, thorough clinical examination, especially for uremic and rheumatologic manifestations; laboratory investigations (inflammatory and metabolic markers); synovial fluid analysis and culture; and radiological investigations (radiography, dual-energy X-ray absorptiometry scan, ultrasound, computed tomography, and MRI of the affected parts) were done. Results There was a significant association between the duration of dialysis and the presence of joint affection. The most common affected joints were knee joints [n=23 patients (46%)] and shoulder joints [n=10 (20%)]. There was a statistically significant association between the severity of joints involvement and the prolonged duration of dialysis. The most common crystals present were the urate crystals (26%) followed by calcium pyrophosphate dihydrate (12%), and lastly oxalate crystals (8%). Carpal tunnel syndrome was diagnosed in 12 patients, with high significant association between the duration of dialysis and presence of carpal tunnel syndrome. There was increase in the level of parathyroid hormone with increase in the duration of renal dialysis. Moreover, 64% of patients had hyperparathyroid bone disease. The mean alkaline phosphatase level was increased in all groups of patients but was more in patients with severe joint affection. Serum albumin was maintained within normal level in HD patients. Radiological study of our HD patients showed that the most frequent radiological findings were signs of secondary hyperparathyroidism (subperiosteal resorption; acroosteolysis in the terminal tufts; pathological fracture, with two fractures in the spine, one in the neck of femur, and one fracture in the rib; and periarticular calcification, with one was found in the hand, and two were found in the pelvis). The incidence of these radiological findings increased with the increase of duration of HD. In addition, 18 patients had normal bone mineral density values, 18 patients had osteopenia, whereas 14 patients had osteoporosis. Conclusion The increased duration of dialysis is associated with increased incidence of articular and skeletal complications mainly renal osteodystrophy in the form of crystal-induced arthritis, osteoporosis, and periarticular calcification. Knee and shoulder joints, spine, neck of femur, wrist joints, and ribs are the main targets for complications and then for proper prophylaxis.
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Asymptomatic left ventricular diastolic dysfunction in diffuse systemic sclerosis patients: conventional echocardiography and left atrial speckle tracking p. 170
Ahmed Aboughanima, Abdelaziz Gomaa, Gehan El Olemy
DOI:10.4103/err.err_15_19  
Objective Our objective was to assess asymptomatic left ventricular diastolic dysfunction (LVDD) in diffuse systemic sclerosis (SSc) patients using both conventional and two-dimensional speckle tracking echocardiography in correlation to disease variables. Patients and methods Twenty-two patients with diffuse SSc without symptoms of LVDD and 22 controls were included in a comparative cross-sectional study. Skin fibrosis was assessed by modified Rodnan skin thickness score and disease severity by Medsger’s score. Parameters related to diastolic functions of the left ventricle were obtained by conventional echocardiography. Assessment of left atrium (LA) functions was by two-dimensional speckle tracking echocardiography as a predictor of LVDD. Results There were significant differences between patients and controls regarding E-wave deceleration time (194.8±27.3 vs. 157.1±20.3; P<0.001), E/E’ (8.85±1.98 vs. 6.99±0.69; P=0.008), positive peak LAε (11.4±2.9 vs. 18.8±2.28; P<0.001), and sec. positive peak LAε (17.5±3.9 vs. 25.5±2.7; P<0.001). All LA strain parameters were significantly correlated with disease duration, disease severity, N-terminal pro b-type natriuretic peptide, E/E’, and E-wave deceleration time, while positive peak LAε was correlated with the modified Rodnan skin thickness score. Receiver operating characteristic curve analysis identified a positive peak value of less than or equal to 10.8 and sec. positive peak of less than or equal to 17.5 as predictors for the detection of E/E’ more than or equal to 8. Conclusion LA reservoir and conduit functions were significantly affected in SSc patients than controls and were associated with longer disease duration and more severe disease, while only reservoir function was associated with more fibrotic skin changes. All LA strain parameters correlated significantly with E/E’ ratio, while positive peak LA and sec. positive peak LA were demonstrated as LVDD predictors in patients with diffuse SSc.
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Role of interleukin-35 in rheumatoid arthritis pathogenesis and its relation to disease activity and joint damage p. 177
Nahed El-sayed El-sayed Akl, Soheir Mohammed Abd El-Halim, Maaly Mohamed Mabrouk, Doaa Shawky Ashkar, Shymaa Ahmed Hablas
DOI:10.4103/err.err_37_18  
Aim This study aimed to discuss the role of interleukin-35 (IL-35) in the pathogenesis of rheumatoid arthritis (RA) and its relation to disease activity and radiological severity. Patients and methods Thirty patients diagnosed with RA were selected from the outpatient clinic and inpatient unit of Physical Medicine, Rheumatology and Rehabilitation Department, Tanta University Hospitals fulfilling the American College of Rheumatology/European League Against Rheumatism 2010 criteria for the diagnosis of RA, and 20 apparently healthy individuals who were matched in age and sex participated as controls. Patients with other autoimmune diseases, malignancy, or any current infections were excluded. Disease activity score in 28 joints was assessed for all patients. Rheumatoid factor, anticyclic citrullinated peptide, complete blood count, erythrocyte sedimentation rate and C-reactive protein and serum level of IL-35 measured by enzyme-linked immunosorbent assay were evaluated. The degree of joint destruction was assessed by Larsen score. Results Of the RA patients, 73.3%showed low serum levels of IL-35 with significant difference compared with controls, and its levels showed negative association with disease activity. IL-35 serum levels were significantly correlated with hemoglobin level, erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor and not correlated with anticyclic citrullinated peptide antibodies. Also IL-35 serum levels significantly correlated with radiological disease severity were assessed by Larsen score. Conclusion IL-35 had an immunoregulatory role in RA pathogenesis as its serum level is significantly low in RA patients and correlated with different parameters of disease activity and radiological severity.
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Spinal decompression therapy as an alternative modality for management of low back pain and radicular pain caused by lumbar disc herniation or protrusion p. 183
Ahmed R El-Zayat, Wael Gomah, Ahmed H Aldesouky
DOI:10.4103/err.err_34_18  
Background Recent studies have suggested that motorized nonsurgical spinal decompression AQ5 can reduce chronic low back pain (LBP) due to lumbar disc herniation or protrusion. Aim The purpose of this study was to evaluate the efficacy of motorized nonsurgical spinal decompression by the DRX9000 device in the reduction of LBP and radicular pain caused by lumbar disc herniation or protrusion and whether it correlated with MRI changes in disc height or not. Patients and methods This study was carried out on 73 patients with chronic LBP attributed to disc protrusion selected from outpatients of rheumatology and rehabilitation clinics at Abdul Latif Jameel Hospital for Medical Rehabilitation, Jeddah, Saudi Arabia; these patients were divided into two groups. The first group comprised 39 patients who underwent a 6-week treatment protocol of motorized nonsurgical spinal decompression via the DRX9000, and the other group comprising 34 patients underwent a 6-week physiotherapy with deep heat modalities and ordinary traction; pain assessment using a visual analog scale with MRI was carried out before and after treatment. Paired t-test or linear regression was used, as appropriate, with P less than 0.05 considered to be statistically significant. Results The main outcomes were a significant improvement in LBP in both groups using visual analog scale, but radicular pain and disc height using MRI were significantly improved in group 1 compared with group 2. Conclusions The study concluded that nonsurgical spinal decompression was associated with a reduction in back pain and radicular pain and with an increase in disc height and can be used as an alternative modality for discogenic LBP.
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The effects of lateral wedge insoles on primary knee osteoarthritis patients p. 189
Amal M.S. Eldin Abbas Hamed, Mona L Zamzam, Mona A El-Sebaie, Sahar F Ahmed
DOI:10.4103/err.err_46_18  
Background Osteoarthritis is the most common degenerative joint disease. Knee osteoarthritis (KOA) is the most common disability due to pain and dysfunction; it typically affects the medial tibiofemoral joint compartment. Objectives The use of orthosis as lateral wedge insoles (LWIs) helps in the reduction of symptoms and improvement of function and can reduce many of the biomechanical risk factors for disease development in osteoarthritis patients. Aim The study aimed to determine the possible mechanical and clinical effects of the different LWIs to assess their role in the management of the medial compartment KOA. Method The study included 48 knees divided into three groups, group A received only conventional physiotherapy, group B received LWI and group C received subtalar strapped (STS) LWI for 4 months. Results The Western Ontario and McMaster Universities osteoarthritis index score showed high significance, P value less than 0.001, for most subscales, femorotibial angle and plantar pressure peaks at the five metatarsal areas (M1, M2, M3, M4, M5), midfoot, medial heel and lateral heel areas, and center of pressure showed high significance, P value less than 0.001 for both insoles. Conclusion The positive outcomes suggested that LWI and STSLWI insert are viable alternatives in the conservative management of patients with medial KOA. The use of LWI and STSLWI helps to prevent the progression of medial KOA if used. In early grades of medial KOA as grades 2 and 3. The results not only suggested clinically symptomatic improvement with an inexpensive conservative therapy, but also a less complicated comfortable orthosis of alignment benefit to KOA.
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Proximal neuropathies in patients with poststroke shoulder pain p. 195
Tarek S Shafshak, Mowaffak M Abdelhamid, Marwa A Amer
DOI:10.4103/err.err_58_18  
Background Poststroke shoulder pain (PSSP) could be due to proximal neuropathy or upper trunk brachial plexus lesion. Aim The aim was to detect any electrophysiological abnormality in the proximal nerves supplying shoulder structures that could contribute to PSSP. Settings and design Cross-sectional study at institution: a university hospital, tertiary level of clinical care. Materials and methods Nerve conduction studies of the axillary, musculocutaneous, suprascapular, and lateral antebrachial nerves were done on both sides. In addition, electromyography of the deltoid, biceps brachii and infraspinatus on the hemiplegic side was performed on 30 stroke survivors with PSSP. Statistical analysis used Statistical Package for the Social Sciences (SPSS ver.20). Description and analysis of the obtained data were done using appropriate tests. Results Axillary and musculocutaneous motor nerve latencies on the hemiplegic side were significantly prolonged compared with the normal side (P=0.012, 0.029, respectively). Moreover, axillary and suprascapular nerve amplitudes on the hemiplegic side were significantly lower than those on the normal side (P=0.008, 0.002, respectively). Twelve (40%) patients had electrophysiological abnormalities. Upper trunk brachial plexopathy was the most common abnormality which occurred in six (20%) patients. In addition, isolated axillary or suprascapular nerve lesion occurred at a similar frequency (10%). Conclusion Proximal nerve lesions are not uncommon in PSSP patients.
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Comparison of platelet-rich plasma and laser therapy in treatment of chronic lateral epicondylitis p. 202
Amr E Okasha, Amany S El-Bahnasawy, Ola M Gharbia, Sherief E Farrag
DOI:10.4103/err.err_1_19  
Background Lateral epicondylitis (LE) is the most frequent cause of chronic lateral elbow pain in adults that represents an encumbrance on social and professional life of patients. Many treatment modalities that have been used in the management of LE have recently come into question. Platelet-rich plasma (PRP) and low-level laser therapy (LLLT) have been tried for management of chronic tendinopathies but with some debate about their effectiveness. Objectives This study compared the effectiveness of local injection of PRP and LLLT in pain reduction and functional improvement in chronic LE. Patients and methods This randomized double-blinded, prospective study included 104 eligible patients with chronic LE. Fifty-two patients were treated with local PRP injection and 52 were treated by intermittent LLLT. They were evaluated at 3 and 6 months for subjective pain using visual analog scale (VAS), functional outcome, and grip strength. Results Pain was assessed using the subjective VAS which was improved in both PRP and LLLT groups, DASH score and grip strength revealed improvement in both groups. This improvement was of highly statistical significance in both groups when compared with baseline evaluation (P<0.001). On comparing the PRP group with the LLLT group, there was significant improvement in VAS at 6 months only, whereas there were significant improvements in functional outcome and grip strength evaluation at 3- and 6-month follow-up for PRP group. Conclusion Treating patients with LE with PRP injection improves pain and function more effectively compared with LLLT.
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LETTERS TO THE EDITOR Top

Magnetic resonance diagnosis of adhesive capsulitis of the shoulder p. 208
Reddy Ravikanth, Kanagasabai Kamalasekar
DOI:10.4103/err.err_49_18  
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Association between microalbuminuria and metabolic syndrome in patients with rheumatoid arthritis p. 210
Mahmood D Al-Mendalawi
DOI:10.4103/err.err_42_18  
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