Background: Ulnar neuropathy at elbow (UNE) is the 2nd most common compressive neuropathy in the upper extremities, following carpal tunnel syndrome.It occurs when compression and traction are applied to the ulnar nerve (UN) at the elbow.Aim: This study aimed to assess and compare the therapeutic effects of ultrasound-guided deep perineural platelet rich plasma (PRP) against injection of corticosteroid (CS) among individuals with ulnar neuropathy at elbow (UNE).Subjects and methods: This randomised prospective study was performed on sixty adult participants with mild to moderate UNE who were categorized into 2 groups.Group I received single US-guided perineural PRP injection, and group II underwent single US-guided perineural corticosteroid injection.Results: In comparison with baseline, almost all primary outcome measures in groups II and I significantly improved after the first-and third-months post-injection, respectively.Almost all participants in the two groups under study had successful results with ultrasound guided perineural injection of either PRP or corticosteroid with no adverse effects.Linear regression of tested variables showed that ulnar nerve cross-sectional area (CSA) and nerve conduction velocity (NCV) slowing across elbow were among the potential predictors for favorable outcomes after corticosteroid and /or PRP injection.Conclusions: Ultrasound guided deep perineural PRP and corticosteroid injection are a safe and effective tool for mild to moderate cases of UNE without any difference in outcome measures.Milder cases of UNE were identified to predict better recovery with regard to nerve healing after PRP more than corticosteroid injection as a long-term therapy.

Background: Neutrophil extracellular traps (NETs) are chromatin complexes of cell-free DNA and histones, with attached neutrophil granular proteins which trap and kill infectious microbes. NETs are essential in host defense, and also linked to inflammation and autoimmunity, including systemic lupus erythematosus (SLE) and recently emerged as contributor to arterial and venous thrombosis. Common carotid intema media thickness (CIMT) used commonly as indicator for subclinical atherosclerosis and myocardial infarction in rheumatic diseases. In the current study, we investigated, the role of NET and CIMT in human SLE and their association with disease activity and cardiovascular complications.Methods: Levels of NETs (human myeloperoxidase-DNA complexes) were analyzed in plasma from 40 SLE patients and 40 healthy individuals using MPO ELISA kit, and subclinical cardiovascular risk was assessed in these groups by using CIMT.Results: Comparison between both groups showed significant difference in the level of NETs (human MPO) and CIMT (p< 0.01), and positive correlation with disease activity and cardiovascular complications.Conclusion: NETs and CIMT could be good predictors for disease activity and cardiovascular risk in SLE patients.

Background Cubital tunnel syndrome is a common compressive neuropathy, its conservative and surgical treatments results are not satisfactory; the need for a novel, safe, and effective therapeutic modality is highly required. Patients and methods 30 patients (30 elbows) in the intervention group received 3 sessions of rESWT (radial extracorporeal shock wave therapy) one session/week, and placebo control group (17 patients - 20 elbows) received sham treatment. Clinical, functional, electrophysiological and ultrasonography morphological assessment were done at baseline, 2 weeks after last session, and after 3 months of follow up. Results Patients of intervention group showed significant improvement of clinical, functional, electrophysiological and ultrasonography morphological assessment parameters relative to control group either after treatment or at follow up period. Conclusion rESWT is an effective and safe treatment for relieving symptoms of compressive ulnar neuropathy at the elbow.

Background: Systemic lupus erythematosus (SLE) is an autoimmune illness with variable clinical symptoms and disease course.We aimed to identify the Syndecan-1(SDC-1) role in SLE patients with renal involvement, and to determine its correlation with the disease activity & severity.Patients and Methods: This case control research was performed on 30 SLE patients with renal involvement; they fulfilled the 2019 EULAR/ACR SLE Classification Criteria and were collected from outpatient and inpatient clinics of Department of Rheumatology, Rehabilitation, and Physical Medicine at Tanta University Hospitals.Twenty apparently healthy volunteers of matched age and sex were included as controls.Results: Serum level of SDC1 was significantly increased in SLE patients compared to controls.There was a significant negative correlation between SDC1 & C3 level, a significant positive correlation between SDC1 & WBCs, ESR, CRP, blood urea, serum creatinine, 24 h urinary protein, A/C ratio, Anti-dsDNA, SLEDI & illness duration.Conclusions: The SDC1 serum level was significantly higher than controls, and positively correlated with disease activity In SLE patients with LN.

Objective: The main objective of this study was to evaluate the association of IL6-174 G/C gene polymorphisms and the response to tocilizumab (TCZ) in patients with systemic juvenile idiopathic arthritis (s-JIA). Methods: Sixty patients with s-JIA (37 males and 23 females with median age at onset of 5.2 years) who received TCZ were recruited. Basic demographic, laboratory and clinical data were collected alongside the IL-6 haplotype status. The overall response to treatment with TCZ was assessed according to a number of variables including the extent of disease activity reduction, the achievement of clinically inactive disease, the necessity to switch to another biologic disease modifying anti-rheumatic drug (bDMARD) and the achievement of a glucocorticoid-free state. Results: Three IL6 -174 genotypes, including, GG, GC, and CC were found with higher frequencies of GC genotype. These genotypes had non-significant association with the response of s-JIA patients to IL-6 blockade in this cohort study. However, a longer time frame from disease onset to diagnosis was associated with poorer long-term treatment response. Conclusion: We observed no significant impact of IL6 -174 G/C gene polymorphisms on treatment response to TCZ in s-JIA Egyptian patients. The observation that a shorted timeframe between symptom onset and diagnosis is associated with better long-term response to TCZ provides evidence for a therapeutic “window of opportunity” in patients with s-JIA.

Results Serum14-3-3η levels were significantly higher in all RA patients than in controls (P < 0.001), its sensitivity was 86.7% and 88.3% in early and established RA patients with a significant difference with RF and ACCP at early disease, and the specificity was 96.7%. There was a significant reduction of 14-3-3η levels 6 months after treatment in the first group (p=0.004), and there was a significant positive correlation between serum 14-3-3η levels and parameters of disease activity and severity. Conclusion 14-3-3η could be a novel, potent, and efficacious diagnostic, and prognostic marker for RA with high sensitivity, that may become a new therapeutic target for RA.

Objective To detect the prevalence of hyperuricemia in Egyptian rheumatoid arthritis (RA) patients as well as to assess its association with the severity of joint inflammation and disease-modifying antirheumatic drugs (DMARDs) in those patients. Methods A total of 150 RA patients were recruited; all patients were subjected to (1) clinical and functional assessment by disease activity score in 28 joints (DAS28) and modified health assessment questionnaire (MHAQ). (2) Laboratory investigations: serum uric acid (SUA) level, complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), tumor necrosis factor α (TNF-α), interleukin 1 (IL1), and interleukin 6 (IL6) levels. (3) Radiological evaluation: (A) plain X-ray of both hands and feet; (B) musculoskeletal ultrasound (MSUS) of both wrists, hands, shoulder, ankle, and knee joints. Results SUA was significantly correlated with disease activity by DAS28. Acute-phase reactants and inflammatory markers (IL1β, IL6, and TNF-α) were also significantly elevated in RA patients with low and high hyperuricemia compared to those with normal SUA. A total of 90% of RA patients with low hyperuricemia had synovial proliferation with power Doppler (1+ and 2+), and 30 patients had mild effusion (1+), while nearly all patients with high hyperuricemia had hypoechoic synovial proliferation (2+ and 3+), and 20 patients had moderate effusion. However, 70% RA patients with normal serum uric acid showed mild synovitis and effusion (1+). No significant association was found between the administered DMARDs and levels of SUA as well as inflammatory markers; however, high-dose steroid treatment was associated with high SUA level. Conclusion Elevation of serum uric acid levels in Egyptian RA patients was prevalent and might be an inflammatory marker for severity of joint inflammation. Moreover, higher doses of steroids could be considered a cause of hyperuricemia.

Background Stroke patients often present with upper limb spasticity which impairs the functional status of patients. Recently, extracorporeal shock wave therapy (ESWT) is reported to be a safe, non-invasive, alternative treatment for spasticity. Many articles have been published on the effect of ESWT on lower limb spasticity, but only few of them had focused on upper limb spasticity, so the aim of this study is to evaluate the clinical and electrophysiological effect of ESWT on wrist and hand spasticity of chronic stroke patients and its impact on functional performance. In this monocentric study, forty chronic stroke patients with upper limb spasticity were recruited and randomly allocated into two groups. Both groups continued to receive conventional stroke rehabilitative program, while group I received three sessions of radial extracorporeal shock wave therapy (rESWT) 1 week apart. Results There was a significant decrease in wrist and hand spasticity after treatment and at follow-up in group I compared to group II (Modified Ashworth Scale after rESWT 1.45 ± 0.16, 2.90 ± 0.18 and follow-up 1.55 ± 0.13, 3.00 ± .0.15 in groups I and II, respectively). Also, there was a significant improvement of wrist control and hand function after treatment and at follow-up in group I compared to group II ( p < 0.001). The improvement of pinch grip was noticed at follow-up with a significant difference relative to baseline in group I ( p < 0.05). Hmax/Mmax ratio was significantly decreased at follow-up in group I compared to group II ( p < 0.001). Conclusion ESWT is a valuable adjuvant treatment for spasticity of the hand and wrist in stroke patients which is reflected as improvement of functional activity. Trial registration ClinicalTrials.gov, NCT04312581 . Registered on 18 March 2020.

Aim To evaluate the efficacy of botulinum toxin A on relieving the clinical symptoms caused by median nerve compression in patients with carpal tunnel syndrome. Patients and methods An imbalanced randomization (3 : 1) placebo-controlled parallel group study for efficacy and safety was conducted in Tanta University, Egypt. Group I received Botox injection. Group II received the same amount of normal saline as Botox injection and at the same injection points as group I. All patients were subjected to clinical assessment and electrophysiological assessment of the median nerve before and after 12 weeks. Results Highly significant improvements were noted in group I regarding clinical symptoms and electrophysiological study of the median nerve, whereas group II showed significant improvement in clinical symptoms but no improvement in the electrophysiological study, with significant difference between the two groups. Conclusion Botox injection can be used safely as a treatment option in moderate carpal tunnel syndrome.

Aim of the work: To evaluate the diagnostic utility of high resolution ultrasound in comparison to nerve conduction study (NCS) in patients with idiopathic carpal tunnel syndrome (CTS). Patients and methods: 40 patients with CTS (56 hands) and 30 matched controls (30 hands) were included. Patients and controls were assessed by clinical examination, ultrasonographic parameters including cross sectional area (CSA), flattening ratio 1 (FR1) at pisiform and FR2 at hamate and NCS including distal motor latency (DML), motor (MCV) and sensory (SCV) conduction velocity, sensory latency and amplitude. Results: The mean age of the patients was 36.02 +/- 8.4 years; 39 females and 1 males. This study included 37 right (92.5%) and 3 left-handed (7.5%) patients. Right-hand affection was detected in 17 (42.5%) patients, left-hand in 3 (7.5%) while bilateral hands affection was detected in 20 (50%). CSA and FR2 were significantly associated with CTS severity. CSA significantly correlated with all electrophysiological parameters including DML, sensory amplitude, sensory latency and SCV. FR1 significantly correlated with sensory latency and FR2 with SCV. Regarding sensitivity of ultrasonographic parameters, FR2 was the highest (91.3%) while CSA and FR1 were 80.3% and 50% respectively. Specificity of all ultrasonographic parameters was 100% and the highest sensitivity was for SCV (94.6%). Conclusions: There was an insignificant difference between nerve conduction study and high resolution ultrasound in diagnosis of idiopathic CTS. However, high resolution ultrasound had a superior diagnostic utility in CTS, and is valuable for exclusion of secondary CTS and anatomical variants of the median nerve. (C) 2018 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V.

De Quervain disease (DQVD) is one of the most common causes of lateral wrist pain and can lead to significant disability. The current case involves a right-handed, middle-aged, female patient with severe lateral wrist pain due to DQVD. Her pain was not responsive to oral non-steroidal anti-inflammatory drugs, rehabilitation, and repeated corticosteroid injections. Because she refused surgical intervention, we performed ultrasound-guided methotrexate injections (four times). After the injections, dramatic pain relief, functional improvement, and reduction of the thickness of the retinaculum and tendons in the first dorsal extensor compartment of the wrist were noted. This case report highlights the potential usefulness of ultrasound-guided methotrexate injection for recalcitrant DQVD of the wrist.

Objectives: To compare the effect of pulsed electromagnetic field (PEMF) extracorporeal shock wave therapy (ESWT) on healing of delayed as well as non-united tibial fractures. Methods: This study was carried out on 60 adult patients suffering from delayed or non-union tibial fractures in spite of previous conservative treatment by (closed reduction and casting), or operative treatment by: ORIF by (IMN, plate and screws or gliding nail), or external fixation. They were divided according to line of treatment into 2 equal groups. The first group received (PEMF) therapy at the site of fracture of 12 Hz, 3 mT for 60 minutes per session, for 3 months, the patient of the second group were treated by focused (ESWT) at the site of fracture 3 sessions of 2500-3000 impulses each given at 0.25-0.84 mJ/mm2, at interval of 48-72 h between sessions, a maximum of 3 cycles of treatment was given at 3 months intervals. Clinical and radiological assessments were done before, after and then 6 months later as follow up. However functional assessment was done after treatment and 6 months later as follow up. Results: Our results showed better and earlier improvement of clinical, radiological as well as functional scores in group II more than group I. Conclusion: The best significant as well as more rapid clinical, radiological and functional improvement in cases of delayed or non-united tibial fractures was obtained with ESWT compared to PEMF therapy.

Context Rheumatoid arthritis (RA) is an inflammatory autoimmune disease involving joints and other systems. Nitric oxide (NO) participation is recognized in numerous physiological and pathological processes. The role of NO in the pathogenesis of RA is still unknown. Aim The aim of this work was to evaluate serum nitrite as a disease marker in patients with RA and its correlation with different parameters of disease activity and severity. Patients and methods A total of 30 RA patients and 15 healthy controls were included. Clinical and functional assessments with routine laboratory investigations were carried out, and serum level of nitrite was measured using enzyme-linked immunosorbent assay. Plain radiographies of both hands and feet were performed for radiological status scoring using the Larsen score. Statistical analysis The collected data were coded, tabulated, and statistically analyzed using SPSS program, version 16.0. Student's t-test and Pearson's correlation coefficient were used for statistical analysis. Results Serum nitrite level in patients with RA was statistically significantly high compared with controls. A statistically significant positive correlation was found between serum nitrite levels and different clinical and laboratory markers of disease activity as well as radiographic joint status assessed using Larsen score. Conclusion There was an increase in serum nitrite levels in patients with RA that significantly correlated with the clinical and laboratory markers of disease activity and radiological joint status.

Aim of the work: The objectives of this study were to evaluate the use of anti-cyclic citrullinated peptide high sensitive (anti-CCP hs) in the differentiation between rheumatoid arthritis (RA) and chronic hepatitis C virus (HCV) associated arthropathy and its correlation with disease activity and the degree of liver cirrhosis in RA associated with chronic HCV infection.Patients and method: This study was carried out on 90 chronic HCV infection patients, 90HCV negative RA patients and 90HCV positive RA patients, in addition to 90 healthy volunteers. Hepatic assessment, rheumatological examination, quantitative HCV RNA test and abdominal ultrasonography were assessed in all HCV patients. Disease activity score (DAS-28) was assessed in RA patients. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), antinuclear antibodies (ANA), cryoglobulins, rheumatoid factor (RF), anti-CCP3, anti-CCP hs test were assessed for all patients.Results: The higher frequency of anti-CCP hs was found in RA (HCV+ve) (88.9%) compared to RA (HCV-ve) (75.5%) and HCV patients (14.4%), its sensitivity in RA patients was 75.6% and specificity was 85.6%. InHCV patients anti-CCP hs significantly correlated with cryoglobulinemia and scoring for liver fibrosis (p<0.001). In RA patients, anti-CCP hs significantly correlated with RF, anti-CCP3, DAS-28, ESR and CRP (p<0.001).Conclusions: Serumanti-CCP hs is sensitive but not a specific marker for RA patients and cannot be used as a diagnostic marker to differentiate between RA and chronic HCV associated arthropathy, in addition it cannot be used as a marker of activity in RA especially when associated with HCV. (C) 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases.