Ali Saad, M., H. Ahmed, R. Elgohary, and H. I. E. Gendy, "IgG4 related pericardium and lung disease in pediatric patient complicated with fatal massive hemoptysis: a case report and review of literature.", Pediatric rheumatology online journal, vol. 21, issue 1, pp. 16, Submitted. Abstract

BACKGROUND: IgG4-related disease (IgG4-RD) is a progressive and sometimes fatal disease that rarely affects pediatric age group. It may affect the orbits, lacrimal and salivary glands, pancreas, kidneys, peritoneum and other organs. Lung and pleura are not commonly reported in IgG4-RD. We here present a rare case of pediatric IgG4-RD with rare involvement of pericardium, pleura and lungs.

CASE PRESENTATION: A 13-year-old girl presented with intrathoracic IgG4-RD with pleuropericardial involvement. She showed initial improvement on prednisolone. Azathioprine and then mycophenolate failed to control relapses during steroid tapering. Her last relapse was treated by rituximab however, the patient developed acute fatal massive hemoptysis.

CONCLUSIONS: Pediatric IgG4-RD is a rare entity with pericardio-pulmonary affection as the rare of the rare. Usual treatment of prednisolone and steroid sparing agents should be used, with rituximab used as a rescue therapy, but fatal complications may occur.

Elgohary, R., M. Magdy, E. Sobhy, M. Mansour, and A. Fayed, "Ultrasonographic assessment of muscle layer thickness and its relation to patient outcome in a medical intensive care unit.", Clinical nutrition ESPEN, vol. 55, pp. 128-135, 2023. Abstract

AIM: Low skeletal muscle mass in ICU patients is associated with poor clinical outcome. Ultrasonography is a noninvasive method that can measure muscle thickness at the bedside. We aimed at studying the relation of the ultrasonography measured muscle layer thickness (MLT) at time of ICU admission with the patients' outcome namely mortality, duration of mechanical ventilation (MV) and ICU length of stay (LOS). In addition to define the best cut-off values that can predict mortality in medical ICU patients.

METHOD: this observational prospective study was conducted on 454 adult critically ill patients admitted to the medical ICU of a university hospital. At the time of admission, MLT of the anterior mid-arm and lower 1/3 thigh were assessed using ultrasonography with and without transducer compression. The clinical scores for assessment of disease severity; Acute Physiology and Chronic Health Evaluation score (APACHE-II) and Sequential Organ Failure Assessment score (SOFA) in addition to nutrition risk; modified Nutrition Risk in Critically ill score (mNUTRIC) were estimated for all patients. ICU LOS, duration on MV and mortality were reported.

RESULTS: The mean age of our patients was 51 years ± 19. The ICU mortality rate was 36.56%. The baseline MLT was negatively associated with APACHE-II, SOFA and NUTRIC scores but not with duration of MV or ICU-LOS. The non-survivors had lower values of baseline MLT. A cut-off value of 0.895 cm (AUC: 0.649, 95% CI of 0.595-0.703) using the mid-arms as a reference point with maximum probe compression showed the highest sensitivity (90%) to predict mortality compared to other techniques however with low specificity (22%).

CONCLUSION: the baseline ultrasonography measured mid-arm MLT is a sensitive risk assessment tool that can reflect disease severity and predict ICU mortality.

Wahba, M. M., Mona Selim, M. M. Hegazy, R. Elgohary, and M. S. Abdelsalam, "Eccentric Versus Concentric Exercises in Patients With Rheumatoid Arthritis and Rotator Cuff Tendinopathy: A Randomized Comparative Study.", Annals of rehabilitation medicine, vol. 47, issue 1, pp. 26-35, Submitted. Abstract

OBJECTIVE: To determine the efficacy of concentric vs. eccentric exercise in improving shoulder function, pain, and tendon characteristics for patients with rheumatoid arthritis and rotator cuff tendinopathy.

METHODS: Forty patients with rheumatoid arthritis and rotator cuff tendinopathy were divided into either concentric or eccentric exercise groups, with 20 patients in each group. Patients received 12 sessions at a pace of 3 sessions per week. Shoulder Pain and Disability Index (SPADI), the visual analogue scale (VAS), supraspinatus and subscapularis thickness, echo pixels, and the Disease Activity Score-28-erythrocyte sedimentation rate (DAS-28-ESR) were assessed at baseline and post-treatment.

RESULTS: There was a significant difference between the concentric and eccentric groups regarding SPADI and VAS scores in favor of the eccentric group. However, there was no significant difference between the two groups regarding tendon thickness, echo pixels, or DAS-28-ESR.

CONCLUSION: Eccentric exercises were more effective than concentric exercises in improving shoulder function and pain intensity. However, neither of the two types of exercises was superior in improving tendon characteristics or disease activity.

Sobhy, E., M. M. Kamal, Y. Saad, D. A. Saleh, R. Elgohary, and M. S. Hassan, "Effect of branched-chain amino acid supplementation and exercise on quadriceps muscle quantity and quality in patients with cirrhosis as assessed by ultrasonography: A randomized controlled trial.", Clinical nutrition ESPEN, vol. 61, pp. 108-118, Submitted. Abstract

BACKGROUND/AIM: Sarcopenia and myosteatosis are common in patients with cirrhosis. The study aimed to evaluate efficacy of ultrasound to monitor muscle status during branched-chain amino acid (BCAA) supplementation and/or muscle exercise interventional approaches.

PATIENTS AND METHODS: A randomized controlled study, included 220 liver cirrhosis patients with Child- Pugh B and C, randomized into a control group (55 patients) received only the standard care, and interventional groups (165 patients) equally distributed into three subgroups, in addition to standard care, they received BCAA, programmed exercise, or BCAA and programmed exercise. At baseline and after 28 days, all participants were subjected to ultrasound-measured quadriceps muscle thickness and echo-intensity, muscle strength using handgrip, performance using short physical performance battery (SPPB), Model for End-Stage Liver Disease (MELD) score and nutritional assessment using 7- point Subjective Global Assessment Score (SGA) and laboratory assessment.

RESULTS: All interventional groups showed a significant improvement in the ultrasound detected quadriceps muscle thickness (p = 0.001) and echo intensity, in addition to muscle strength, muscle performance, and SGA. Hematological parameters (hemoglobin and platelet count), biochemical parameters (ALT, AST, bilirubin, creatinine, urea and INR) and MELD score were also improved in the interventional groups. In Child-Pugh B patients BCAA combined with exercise showed an add-on effect.

CONCLUSION: BCAA supplements, programed muscle exercise and both are useful interventional methods in improving muscle quality and quantity in cirrhosis patients, which can be monitored by ultrasound. The best results can be achieved by combined intervention in Child-Pugh B, while in Child-Pugh C single intervention may lead to an acceptable improvement. The trial was registered retrospectively in the Clinical Trials Registry (registration number NCT06088550).

Menyawi, M. A. E. M. E., G. Gamal, H. Abdelbadie, and R. Elgohary, "Assessment of validity, reliability, and feasibility of OMERACT ultrasound knee osteoarthritis scores in Egyptian patients with primary knee osteoarthritis.", Clinical rheumatology, vol. 43, issue 12, pp. 3913-3923, Submitted. Abstract

BACKGROUND: Ultrasound (US) can evaluate all joint components affected by knee osteoarthritis (KOA); however, standardized scoring of US-detected pathology is needed to improve its diagnostic and monitoring capabilities.

OBJECTIVES: To examine the validity, reliability, and feasibility of the Outcome Measures in Rheumatology (OMERACT) ultrasound scoring for KOA, comparing with clinical and radiography measures, using predefined cutoff values.

METHODS: This cross-sectional study included 75 Egyptian patients with primary KOA. All patients had Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, bilateral knee radiography, and ultrasonography. Inter-observer reliability of ultrasound was evaluated in 30 knees by another newly trained operator.

RESULTS: Most of the OMERACT-US KOA scores showed significant associations with WOMAC clinical scores, except for femoral cartilage damage and effusion. The synovitis score was significantly associated with WOMAC-pain score (p-value 0.046), while medial meniscus extrusion (MME) and medial osteophytes were significantly associated with WOMAC-stiffness score (p-value 0.009 and 0.023, respectively). MME and synovitis were significantly associated with WOMAC-physical score (p-value 0.035 and 0.020, respectively). The ultrasound scores also showed a strong correlation with radiographic scoring. Inter-observer reliability ranged from moderate to excellent agreement (k = 0.58 to k = 0.83); it was highest for lateral osteophytes (k = 0.83), good agreement for synovitis (k = 0.72), any osteophytes (k = 0.71), damage of femoral cartilage (k = 0.70), and moderate agreement for medial osteophytes (k = 0.58) and MME (k = 0.59).

CONCLUSION: OMERACT-US scoring system for KOA demonstrated validity, reliability, and feasibility for evaluating both structural and inflammatory components. Using cutoff values improved the scoring reliability for osteophytes and MME. Key Points • OMERACT-US scores provide a valid assessment of inflammatory and structural components of knee osteoarthritis. • The following changes may improve the performance of the OMERACT-US scores. a. The binary score for effusion and synovial hypertrophy can be omitted, as they have no added value. b. A semi-quantitative grading for effusion may capture the impact of effusion on clinical outcomes. c. Added cutoff values to score medial meniscal extrusion, osteophytes, and pathological effusion improved the respective scores' reliability. d. Applying the updated OMERACT definition of synovitis. • OMERACT-US scores are reliable to be used with a newly trained operator, particularly when cutoff values are included, and proper training time is provided. • The OMERACT-US score is feasible to be used in clinical practice, as the time taken to perform was short, even for a newly trained operator.

Elshaarawy, G. A., I. I. Salama, S. I. Salama, A. H. Abdelrahman, M. Hassan, E. Eissa, S. Ismail, S. E. Eldeeb, D. E. Ahmed, H. Elhariri, et al., The association between ADAMTS14/rs4747096 gene polymorphism and some risk factors and knee osteoarthritis., , Submitted. Abstract

Knee osteoarthritis (KOA) is an important cause of disability in the world and it denotes a public health defiance of the upcoming years.Aim To examine the connection between ADAMTS14 gene rs4747096 polymorphism and KOA and to assess risk factors associated with KOA.Methods A case control study was conducted on 158 patients with KOA and 120 controls with comparable age and sex randomly recruited from National Research Centre employees. All participants were subjected to full history taking, assessment of KOA severity using WOMAC scoring system, and thorough clinical examination. Blood sample was collected for detection of ADAMTS14/rs4747096 gene polymorphism.Results The frequency of ADAMTS14 gene rs4747096 genotypes among patients with KOA was 73.5% for AA, 25.7% for AG, and 0.7% for GG compared to controls 963%, 31.3%, and 5.6% respectively and the frequency of alleles among patients was 86.4% for A and 78.7% for G compared to controls (78.7% and 21.3% respectively, P < 0.05. The study found that the median levels of total WOMAC score and its domains were significantly higher among KOA patients than controls. The logistic regression analysis revealed that age ≥ 50 years, BMI ≥ 35, and long standing at work were predictive factors for KOA (P < 0.05). Regarding different genetic patterns, only the A recessive pattern of inheritance was found to be a predictive risk factor for KOA.Conclusion For ADAMTS14 rs4747096 genotype, the AA and AG genotypes significantly increased the risk of KOA. The recessive pattern of inheritance, older age, morbid obesity, and prolonged standing at work were the predictive risk factors for KOA. Further studies with larger sample size are encouraged to investigate the mechanism by which this genotype can affect the development of KOA.

Fayed, A., A. Soliman, and R. Elgohary, "Measuring Serum Sclerostin in Egyptian Patients With Systemic Lupus Erythematosus and Evaluating Its Effect on Disease Activity: A Case-Control Study", JCR Journal of Clinical Rheumatology, vol. 27, issue 4, pp. 161-167, 2021.
El-Gohary, R., A. Diab, H. El-Gendy, H. Fahmy, and K. H. Gado, "Using intra-articular allogenic lyophilized growth factors in primary knee osteoarthritis: a randomized pilot study.", Regenerative medicine, vol. 16, issue 2, pp. 113-115, 2021. Abstract

Investigating the safety in addition to clinical and structural efficacy of allogenic lyophilized growth factors (L-GFs) in patients with symptomatic primary knee osteoarthritis. A prospective, open-label pilot study. A total of 31-patients randomized into non-intervention and intervention groups. The intervention group received two intra-articular doses at baseline and after 2-months. Post-injection complications were documented, and the efficacy was assessed by Western Ontario and McMaster Universities Osteoarthritis Index scores and ultrasonography. One dropout from the intervention group. The percentage of improvement of mean Western Ontario and McMaster Universities Osteoarthritis Index-scores and ultrasonography-detected effusion were statistically significant in the intervention group compared with the non-intervention. A brief, mild, post-injection pain was reported by all intervention group. This study provides the safety of intra-articular injection of allogenic L-GFs in knee osteoarthritis. The conclusion of efficacy was limited by small sample size and lack of control injection. NCT04331327 (ClinicalTrials.gov, retrospectively registered).

El-Gohary, R., A. Diab, H. El-Gendy, H. Fahmy, and K. H. Gado, "Using intra-articular allogenic lyophilized growth factors in primary knee osteoarthritis: a randomized pilot study.", Regenerative medicine, vol. 16, issue 2, pp. 113-115, 2021. Abstract

Investigating the safety in addition to clinical and structural efficacy of allogenic lyophilized growth factors (L-GFs) in patients with symptomatic primary knee osteoarthritis. A prospective, open-label pilot study. A total of 31-patients randomized into non-intervention and intervention groups. The intervention group received two intra-articular doses at baseline and after 2-months. Post-injection complications were documented, and the efficacy was assessed by Western Ontario and McMaster Universities Osteoarthritis Index scores and ultrasonography. One dropout from the intervention group. The percentage of improvement of mean Western Ontario and McMaster Universities Osteoarthritis Index-scores and ultrasonography-detected effusion were statistically significant in the intervention group compared with the non-intervention. A brief, mild, post-injection pain was reported by all intervention group. This study provides the safety of intra-articular injection of allogenic L-GFs in knee osteoarthritis. The conclusion of efficacy was limited by small sample size and lack of control injection. NCT04331327 (ClinicalTrials.gov, retrospectively registered).

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