Egyptian Rheumatology and Rehabilitation
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Tocilizumab in management of refractory juvenile idiopathic arthritis, 10 years of experience at tertiary university hospital
Egyptian Rheumatology and Rehabilitation - - 2021
Juvenile idiopathic arthritis (JIA) is the most prevalent pediatric rheumatic disorder. Progress in modalities of therapy improves the disease outcome. We aimed to determine the efficacy and safety of tocilizumab (TCZ) in the management of systemic (sJIA) and polyarticular (pJIA) in children who are resistant to conventional as well as other biological therapies. In this retrospective study, we selected JIA patients according to the International League of Association for Rheumatology (ILAR) criteria and were treated with TCZ. Response to TCZ was assessed using Juvenile Arthritis Disease Activity Score-10 (JADAS-10) and also outcomes were assessed according to the American College of Rheumatology (ACR) remission criteria. Safety of the drug was assessed by documenting possibly related adverse effects (AE). Statistical analysis using SPSS version 25 with statistical significance is considered if p ≤ 0.05. We included 16 JIA patients aged ≤ 18 years but 2 of them were excluded as they developed severe reaction during the TCZ 1st dose, so finally, 14 patients were included. The median age of our patients was 12 years. Of these 14 patients, 9 (64.3%) had sJIA and 5 (35.7%) had pJIA. TCZ use led to significant improvement in the JADAS-10 from mean 22.4 (± 7.9) when it was initially assessed and then 3, 6, 12, and 24 months after TCZ initiation with means 5.7 (± 3.9), 4.4 (± 3.7), 3.5 (± 3.1), and 2.7 (± 2.2), (P = 0.001, 0.001, 0.005, 0.012), respectively. Five patients exhibited TCZ possibly expected side effects. Neutropenia and infusion-related reactions were the most frequent AE. Tocilizumab seems to be generally effective and safe drug in the management of sJIA and pJIA especially in cases refractory to conventional as well as other biologic agents.
Knowledge, attitudes, practices, and compliance of rheumatic disease patients toward COVID-19 during the late pandemic
Egyptian Rheumatology and Rehabilitation - Tập 50 - Trang 1-9 - 2023
Rheumatic disease (RD) patients are liable for severe coronavirus disease 2019 (COVID-19). It is noticeable that RD patients’ practices have changed during the late COVID-19 pandemic. This study aimed to assess the knowledge, attitudes, practices, and compliance of RD patients during the late pandemic. This study included 188 patients with various RDs. The majority were female (61.7%) and were rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients (40.4% and 30.9%, respectively). We found knowledge deficiencies regarding some symptoms, contact isolation, and transmission. Negative attitudes toward COVID-19 final control were detected in a large proportion (50%). Furthermore, the majority did not think they were at risk of COVID-19 due to either RD (61.7%) or their drugs (66%). Their practices were also negative; the majority stopped wearing masks (56.4%) and went to crowded places recently (83%). Moreover, most did not stop or reduce their drugs for fear of COVID-19 but for availability issues (5.3% and 9.6% vs. 37.2%). Male gender and higher education and socioeconomic levels were significantly associated with better knowledge. In addition, RDs such as reactive arthritis, steroid use, lower steroid doses, COVID-19 vaccination, high education and socioeconomic levels, and Internet use as main knowledge sources had a significant association with better attitudes. Conventional disease-modifying anti-rheumatic drugs (DMARDs) use, biologics non-use, high education, severe functional impact, and compliance before the pandemic were significantly associated with higher practice scores. Knowledge was positively correlated with attitudes and practice (P = 0.0001 and 0.003, respectively). Moreover, attitudes were negatively correlated with age (P = 0.016). In multiple linear regression analysis, education, socioeconomic status, and practice were significant positive predictors of knowledge (P = 0.002, 0.001, and 0.046, respectively). Good knowledge, COVID-19 vaccination, younger age, and lower steroid doses were significant predictors of better attitudes (P = 0.02, 0.001, 0.02, and 0.002, respectively). Furthermore, non-use of biologics and functional disability were significant predictors of good practice (P = 0.002 and 0.015, respectively). Improving knowledge and educating RD patients about the importance of protective measures is essentially needed to decrease the pandemic fatigue consequences and prevent serious COVID-19 complications in those patients.
Predictive factors for progression of adolescent idiopathic scoliosis: a 1-year study
Egyptian Rheumatology and Rehabilitation - Tập 42 Số 3 - Trang 111-119 - 2015
The cause of scoliosis remains unknown in 80–85% of adolescent patients. Treatment of adolescent idiopathic scoliosis (AIS) remains a complex challenge. The goal of this study was to evaluate the predictive value of different factors [age, initial Risser’s score and initial Cobb’s angle, surface electromyography (SEMG), activity of both paraspinal muscles at the apex of the curve] in the progression of AIS. This study included 30 patients with AIS. Full history taking and spinal and neurological examinations were carried out. Initial Cobb’s angle and Risser’s staging were determined, together with SEMG of paraspinal muscles at the curve’s apex. Reassessment of Cobb’s angle and Risser’s score was done 1 year later. Analysis of data was carried out with an IBM computer using statistical program for social science (version 18) software and services. Quantitative data were presented as mean, SD, minimum and maximum values, and range. Qualitative data were presented as number and percentage, analyzed with the χ2-test. Analytic statistics were calculated using Student’s t-test to compare two independent means. A receiver-operating character curve was constructed using Medcalc program 3.5. Twenty-six girls and four boys with dorsal and dorsolumbar scoliosis were included in this study. There was significant increase in Cobb’s angle and Risser’s score. Age, Risser’s score, and SEMG results on the convex side were significantly correlated with progression of the curve. Cobb’s angle was the most sensitive predictor, followed by SEMG, whereas age, initial Risser’s score, and SEMG had the highest specificity as predictors. Cobb’s angle, Risser’s score, and SEMG are specific, sensitive, and positive predictors for progression of AIS.
Subclinical heart failure in juvenile idiopathic arthritis: a consequence of chronic inflammation and subclinical atherosclerosis
Egyptian Rheumatology and Rehabilitation - Tập 43 - Trang 78-83 - 2016
Chronic inflammation is the basis of juvenile idiopathic arthritis (JIA). Hence, it is expected that JIA may produce harmful effects on the cardiovascular system. The aim of this study was to explore the presence of subclinical atherosclerosis and subclinical heart failure in JIA patients without manifest cardiovascular disease and to examine the risk factors that may be associated with the subclinical heart failure. Fifty JIA patients and 50 healthy matched controls were enrolled in this study. Inflammatory markers in the serum, together with intima-media thickness (IMT) and flow-mediated dilation (FMD) of brachial arteries as surrogate markers of subclinical atherosclerosis, were assessed and compared between patients and controls. Echocardiographic parameters of heart failure, including the Tei index and ejection fraction%, were also evaluated. JIA patients had significantly increased IMT and impaired endothelial dysfunction as measured by FMD% of the brachial artery in comparison with controls. JIA patients had significantly higher Tei index and significantly lower ejection fraction% in comparison with controls. In regression analysis only systemic JIA, FMD%, and IMT were significantly associated with the presence of subclinical heart failure among patients with JIA. Our findings indicate the presence of subclinical heart failure in these patients. JIA patients with subclinical atherosclerosis, with systemic disease, and with active disease are at greatest risk of developing subclinical heart failure.
Impact of obesity on functional and laboratory parameters in patients with rheumatoid arthritis
Egyptian Rheumatology and Rehabilitation - Tập 43 - Trang 21-26 - 2016
Overweight patients with rheumatoid arthritis (RA) have more disease activity, lower rates of remission, and twice as likely to require a tumor necrosis factor inhibitor. Provided that the prevalence of obesity is increasing, this may significantly affect RA incidence. An association between obesity and RA is logic, as biologic mechanisms of inflammation are present in fatty tissue, and it may be a trigger to chronic systemic inflammation. Human obesity is characterized by increased plasma leptin levels, which if elevated in morbidly obese patients may enhance constitutive immunological stimuli and increased levels of inflammatory marker. The aim of this study was to assess the impact of obesity and serum leptin level on disease activity and functional outcome in RA patients. This study was carried out at Minia University Hospital, Egypt. Patients were recruited from Rheumatology Outpatient Clinic from October 2012 to June 2013. It included 36 RA patients, fulfilling the 2010 ACR/EULAR classification criteria. They were divided into two groups: obese patients with a BMI of 25 or greater and nonobese patients (BMI ≤ 25). A total of 12 healthy individuals were included as controls. All patients were subjected to history taking and clinical examination; patient’s functional status and disease activity were assessed using the Health Assessment Questionnaire (HAQ) disability index and DAS-28, respectively. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factor (RF) were determined. Serum level of leptin was measured using enzyme-linked immunosorbent assay. Data were analyzed using SPSS for Windows, version 16.0. RA obese patients showed a higher duration of morning stiffness (P = 0.02), HAQ index (P = 0.001), DAS-28 (P = 0.0001), visual analogue scale (VAS) of pain (P = 0.0001), and articular index (P = 0.001) compared with nonobese ones. They showed higher ESR (P = 0.003), serum leptin (P = 0.008), CRP (P = 0.0001), and RF (P = 0.002). There was a positive correlation between BMI and each of ESR (P = 0.003), CRP (P = 0.0001), and RF (P = 0.01). There was a positive correlation between waist circumference and each of ESR (P = 0.03), serum leptin (P = 0.03), CRP (P = 0.0001), and RF (P = 0.04). There was a positive correlation between BMI and HAQ index (P = 0.0001), DAS-28 (P = 0.001), articular index (P = 0.003), and VAS of pain (P = 0.0001). There was a positive correlation between waist circumference and HAQ index (P = 0.001), DAS-28 (P = 0.03), and VAS of pain (P = 0.0001). Moreover, there was a positive correlation between VAS of pain and serum leptin (P = 0.04). Serum leptin was correlated with CRP (P= 0.01). Linear regression analysis showed that the VAS was the first and most significant risk factor (β = 0.73; P = 0.01) and that HAQ was the second (β = –0.53; P = 0.04) to affect serum leptin levels. Obese RA patients had higher disease activity parameters, clinical scores and laboratory indices, and worse functional outcomes compared with nonobese patients. Higher serum leptin levels were associated with higher disease activity scores.
Risk factors for acute coronary events in patients with rheumatoid arthritis
Egyptian Rheumatology and Rehabilitation - Tập 44 - Trang 164-171 - 2017
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. 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. 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. 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.
Health economics: direct cost of osteoporotic hip fracture in Egypt—an analysis for the Egyptian healthcare system by the Egyptian Academy of Bone Health
Egyptian Rheumatology and Rehabilitation - Tập 50 - Trang 1-8 - 2023
This work studies the direct cost of hip fractures in Egypt. The direct cost was calculated based on the incidence of hip fracture in Egypt retrieved from the national database. The result of this work raises red flags to the policy makers in Egypt that such fragility fractures are preventable, should appropriate approaches be implemented. This study provides an analysis for the healthcare system in Egypt. It was carried out to assess the direct annual cost incurred to the Egyptian healthcare system in 2023 as a result of fragility hip fractures in older adult Egyptians. The direct costs of hip fractures incurred during the first year after the injury were estimated at 1,969,385,000 Egyptian pounds (US $63,734,142.4). Time from fracture to surgery was 2.2 + 0.5 days. The average hospital stay after hip fracture surgery was 5.2 + 2.6 days. 4.5% of patients died after surgery, on average 2.3 + 0.4 months. After being discharged from the hospital, all patients needed home care. Hip fractures have a significant clinical and financial impact on patients and the healthcare system. This study raises red flags for the healthcare policy makers in Egypt, as the financial burden due to the direct costs of hip fractures justifies extensive prevention programs for osteoporosis and fragility fractures. There is an urgent need to implement diagnostic approaches and validated management protocols for bone health disorders and its associated fractures in Egypt.
Comparative effectiveness of extracorporeal shock wave therapy, local corticosteroid injection, and conventional physiotherapy in treatment of chronic lateral epicondylitisAbstract Background Results Conclusion
Egyptian Rheumatology and Rehabilitation - Tập 47 Số 1 - 2020
Lateral epicondylitis (LE) is a popular overuse syndrome involving the forearm’s extensor tendons. Corticosteroid (CS) injection is the popular injection used for management of LE. Extracorporeal shockwave therapy (ESWT) is a noninvasive alternative inducing the neovascularization, tendon repairing, and decreasing pain. Our study aimed to compare the effectiveness of ESWT versus local CS injection versus conventional physiotherapy (PT) in management of chronic LE.
Our results revealed that the three groups displayed a significant decrease of VAS score, decrease of PRTEE score, and increase of grip strength compared to baseline (
ESWT, local CS injection, and conventional PT were efficient in management of chronic LE at 12 weeks of follow-up but ESWT had a higher effect decreasing pain and improving functional disability in daily life activity at short and long term follow-up.
Healing effects of prolotherapy in treatment of knee osteoarthritis healing effects of prolotherapy in treatment of knee osteoarthritis
Egyptian Rheumatology and Rehabilitation - Tập 43 - Trang 47-52 - 2016
Pelotherapy is an injection therapy for chronic musculoskeletal pain. We conducted a two-arm controlled trial to assess the efficacy of prolotherapy for knee osteoarthritis (OA). A total of 104 adults with at least 6 months of painful primary knee OA were treated with dextrose prolotherapy (group I). They were divided into two subgroups: Ia and Ib. Subgroup Ia was treated with both techniques of prolotherapy (Hackett technique – classic, traditional prolotherapy – and Lyftgot technique – neural prolotherapy), whereas subgroup Ib was treated with the Hackett technique only. Extra-articular and intra-articular injections were administered at 1, 2, and 3 months, with as needed additional treatments at months 4 and 5. A total of 24 adults with at least 6 months of painful primary knee OA were treated with physiotherapy (group II). Outcome measures included the following: clinical assessment; visual analogue scale (VAS), 10; Western Ontario McMaster University Osteoarthritis Index (WOMAC), 96 points; plain radiographs; and musculoskeletal ultrasound. Postprocedure hot packs were applied, and at-home massage and exercises were taught. 128 Patients enrolled in the study were matched with each other for sex, age, disease durations, and BMI. Subgroups Ia and Ib reported a significant improvement as regards the clinical assessment, VAS, WOMAC, and radiological assessment at 12 months, compared with their baseline at month 0 and compared with group II (P ≤ 0.001). At 12 months, the mean ± SD of VAS was 0.32 ± 0.27 for subgroup Ia, 0.44 ± 0.5 for subgroup Ib, and 9.9 ± 1.65 for group II, and the mean ± SD of WOMAC was 11.32 ± 10.3 for subgroup Ia, 18.5 ± 10.25 for subgroup Ib, and 79.5 ± 22.63 for group II. Postprocedure application of hot packs, massage, and paracetamol resulted in diminution of injection-related pain. There were no adverse events. Prolotherapy resulted in clinically sustained improvement of pain, function, and radiological assessment, which means that the healing effects of prolotherapy is better than that of physiotherapy. The combination of the two prolotherapy techniques results in quicker and better improvement for patients in terms of the clinical assessment, VAS, and WOMAC.
Association between carpal tunnel syndrome and trigger finger: a clinical and electrophysiological studyAbstract
Background
Results
Conclusions
Egyptian Rheumatology and Rehabilitation - Tập 48 Số 1 - 2021
Carpal tunnel syndrome is a prevalent mononeuropathy. Trigger finger is a flexor stenosing tenosynovitis. The aim of the study was to assess the concomitant occurrence of carpal tunnel syndrome and trigger finger in the same hand among patients presented with idiopathic carpal tunnel syndrome or idiopathic trigger finger. The study included 110 hands (75 patients) presented with carpal tunnel syndrome or trigger finger and 60 asymptomatic hands (46 apparently healthy individuals). Clinical assessment and neurophysiological evaluation were done.
Regarding the presenting clinical complaints, there were 76 hands (69.1%) from 48 patients (64.0%) presented with idiopathic carpal tunnel syndrome. There 34 hands (30.9%) from 27 patients (36.0%) presented with idiopathic trigger finger. Classification of the patients into three groups depending on the final diagnosis: (I) carpal tunnel syndrome group, 57 hands (51.8%) with only carpal tunnel syndrome from 36 patients (48.0%); (II) trigger finger group, 25 hands (22.7%) with only trigger finger from 22 patients (29.3%); and (III) carpal tunnel syndrome with trigger finger group, 28 hands (25.5%) with both conditions from 24 patients (32.0%); and among them, seven patients had contralateral hand carpal tunnel syndrome only. The duration of complaints among the carpal tunnel syndrome with trigger finger group was significantly shorter than that in the other two groups. There were statistically significantly higher values of patient global assessment of hand symptoms and effect of hand symptoms on function and quality of life among the carpal tunnel syndrome with trigger finger group versus the other two groups. There was no statistically significant difference between the carpal tunnel syndrome with trigger finger group versus the carpal tunnel syndrome group regarding different classes of the Padua neurophysiological classification scale. The most common digit to have trigger finger was the middle finger in 19 hands (35.8%).
The concurrent presentation of idiopathic carpal tunnel syndrome and idiopathic trigger finger in the same hand is common. Each of them could be associated with the other one. The symptoms of one of them usually predominate the patient’s complaints. The identification of this association is essential for proper diagnosis and comprehensive management of patients presented with these conditions.
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