c:\work\Jor\vol691_1 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1553-1557

Effect of Sildenafil Citrate on the Outcome of in vitro Fertilization after
Multiple IVF Failures Attributed to Poor Endometrial Development: A
Randomized Controlled Trial
Mekled A.K.H, Abd El-Rahim A.M, El-Sayed A.
Department of Obstetrics and Gynecology, Ain Shams University
Corresponding author Dr amr elsayed, email: dramrelsayed34@yahoo.com

Aim of the work:
this study aimed to evaluate the effect of sildenafil citrate on endometrial development in
women with history of recurrent implantation failure after IVF.
Setting: This study was conducted in obstetrics and gynecology department of Ain Shams University.
Patients and methods: this is a randomized controlled trial on 80 women with previous two or more failed
IVF. Women in group A (N=40) took oral sildenafil citrate at dose 25mg tab /6h daily from day six of
induction of ovulation until day of HCG administration; while those in group B (N=40) took placebo tablets.
Outcome measuers: The primary outcome was change in endometrial thickness before and after intervention.
Results: Endometrial thickness in both groups was statistically insignificant between the two groups when
measured in day 6 with p-value 0.070.Endometrial thickness on day of HMG injection measured and found
that it was higher in group A(Sildenafil Group) than group B(Placebo Group) with significantly increased
statistically difference between the two groups with p-value <0.001.
Conclusion: sildenafil citrate leads to smooth muscle relaxation and vasodilation. This may enhance
endometrial development and increased pregnancy rate in females undergoing IVF which may be attributed to
the increase in the endometrial thickness.
Keywords: endometrial thickness, IVF, sildenafil.

A) Detailed medical history including:
Embryo implantation depends on the quality of the
Personal history.
ovum and endometrial receptivity. Endometrial
Menstrual history.
receptivity is a temporally unique sequence of factors
Past and obstetric history.
that make the endometrium receptive to embryonic
B) Physical examination:
implantation. Implantation window is a period during
After history taking and fulfillment of both
which the endometrium is optimally receptive to
inclusions and exclusion criteria, clinical
implanting blastocyst(1).
examination were done including: general
Observations suggested that prospective
abdominal and pelvic examination.
assessment of the quality of decidualization
response in the endometrium may be an important
C) Laboratory investigations:
tool for predicting the likelihood of successful
Routine investigations including: fasting and
implantation and pregnancy outcome. Since its
postprandial blood sugar and complete blood count.
introduction into the clinic, ultrasound has been

used widely to assess uterine features such as
D) Intervention:
endometrial thickness; endometrial pattern and that
Women in group A took oral sildenafil citrate
may be predictive of pregnancy, especially in the
at dose 25mg tab /6h daily from day six of
context of assisted reproductive technology (2).
induction of ovulation until day of HCG
Sildenafil citrate is a newly developed, type 5-
administration; while those in group B took
specific PDE inhibitor that prevents the breakdown
placebo tablets.
of cGMP and potentiates the effects of NO on the
E) Induction of ovulation:
vascular smooth muscle. Since its introduction in
- On day 3 of spontaneous cycles, all patients had
1997, sildenafil has been used with great success in
basal hormonal profile (FSH, LH, E2, TSH and
treatment of the vascular smooth muscle through a
cGMP-mediated pathway (3). This work aimed to
- Transvaginal (TV) ultrasound (U/S) on day 3 of
evaluate the effect of sildenafil citrate on endometrial
non-stimulated cycles was done by transvaginal
development in women with history of recurrent
probe of 5-9 MHZ. Any patient found to have
implantation failure after IVF.
uterine abnormalities was excluded.
- Ovarian hyper stimulation protocol was held

All participants were subjected to the
according to a long GnRH agonist protocol starting
from midluteal phase by daily subcutaneous

Received:11/6/2017 accepted:20/6/2017 1554 DOI: 10.12816/0040099

Full Paper (vol.691 paper# 1)

Serum level of Visfatin in psoriasis and its relation to disease severity The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1558-1562
Serum level of Visfatin in Psoriasis and its Relation to Disease Severity
Nehal Mohamed Zu Elfakkar, Marwa Kamal Asaad, Hoda Ezz El-Arab Abdul Wahab,
Waleed Mohamed Abd Elfattah
Department of Dermatology, Venereology and Andrology, Faculty of Medicine,
Ain shams University
Corresponding author: Waleed Dahab, email: waleeddahab01@gmail.com

psoriasis is a chronic, debilitating, autoimmune disease that adversely affects the
individual's quality of life; the disease progresses with periods of flare-ups and remission. Psoriasis
affects approximately 2% of the global population. Psoriasis can begin at any age, however, the mean
age of onset was 15-20 years old and the second peak period was 55-60years of age .
Aim of the Work: this study aimed to evaluate the serum level of visfatin in psoriatic patients and its
relation to duration and severity of psoriasis.
Subjects and Methods: the present study represents a case-control study which was carried out on 20
patients with psoriasis vulgaris and 20 age and sex matched healthy volunteers as the controls.
Results: in the present study, serum level of visfatin in patients group was statistically significant higher
than serum level of visfatin in the control group. There was a significant positive correlation between
visfatin level and PASI score proposing visfatin as a marker of psoriasis severity.
Conclusion: Visfatin is one of adipokines that may have a role in the pathogenesis of psoriasis and its
severity in addition to its role in the cardiovascular system diseases, which may explain the relation
between psoriasis and cardiovascular complications and their severity in the psoriatic patients.
Keywords: Psoriasis, Visfatin, Serum,Severity, Psoriasis area severity index.


Psoriasis is a chronic, debilitating,
The role of visfatin in psoriasis might
autoimmune disease that adversely affects an
include modulation of inflammatory or immune
individual's quality of life; the disease
response as it induces chemotaxis and increases
progresses with periods of flare-ups and
the production of IL-1_, L-6, TNF- and
remission. Psoriasis affects approximately 2% of
costimulatory molecules by CD14+ monocytes.
the global population. Psoriasis can begin at any
This enhances their ability to induce
age, however, the mean onset age was 15-20
proliferative responses (5).
years old and the second peak period was 55-
Another explanation is that visfatin level
60years of age (1). Psoriasis is due to a complex
might be upregulated during inflammation and
interplay between genetic and environmental
in response to inflammatory cytokines (6).
factors. Over 40 genetic mutations have been
This study aimed to investigate the role of
associated with psoriasis, and among these
visfatin in the pathogenesis of psoriasis and its
mutations, psoriasis susceptibility locus 1
relation to the duration, severity of the disease, and
(PSORS1) and PSORS2 appear to play a major
body mass index (BMI).
role. In addition to genetic susceptibility,

environmental factors as stress, infection,
trauma, or medications. Exposure to triggers in a
genetically predisposed individual creates a
The present study is a case-control
deregulated immune response producing the
study. It was carried out on 20 patients with
characteristic lesions of psoriasis (2).
psoriasis vulgaris and 20 age and sex matched
Visfatin [also known as pre B-cell-
healthy volunteers as the controls. They were
colony-enhancing factor (PBEF)] is a 52-kDa
enrolled from Dermatology Outpatient Clinic of
protein mainly produced by macrophages in
Mostafa Kamel Military Hospital between the
visceral adipose tissue (3). Various cells of innate
period of 1/11/2016 to 3/5/2017. All subjects
immunity such as neutrophils, monocytes,
gave consent to participate in this work after an
macrophages as well as epithelial and
explanation of the steps of the study. The study
endothelial cells can be a source of visfatin after
was approved by research ethical committee of
induction with inflammatory stimuli (4).
Received: 13 / 6/2017 DOI: 10.12816/0040100
Accepted: 22 / 6 /2017

Full Paper (vol.691 paper# 2)

c:\work\Jor\vol691_3 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1563-1569

Value of Pre-Procedural Multi-Detector Computed Tomography
Angiography Prediction Outcome in Retrograde Approach
Recanalization for Coronary Chronic Total Occlusion
1Ahmed Ahmed Khashaba, 2Khaled Abdel Azeem Shokry, 1Yaser Gomaa,
1Diaa El Din Ahmed Kamal, 1Thanaa Maghraby Ogeal Awad
1Department of Cardiology, Faculty of Medicine - Ain Shams University
2Professor of Cardiology, Military Medical Academy


Background: Computed tomography coronary angiography(CTCA) can be useful in procedure planning
for CTO PCI by identifying factors known to influence PCI success rates, such as calcification, severe
tortuosity and length of the occluded segment. Percutaneous coronary intervention for CTO is considered
to be one of the most challenging procedures of interventional cardiology, and in the earlier studies,
successful recanalization rates of CTO ranged from 51% to 74%. However, with improved operator
experience and the development of novel equipment and techniques, procedural success rates have been
increased, which brings an increasing number of CTO into a treatable category.
Patients and Methods: An exploratory pilot study was conducted on 40 patients using retrograde wire
approach with various strategies by highly experienced CTO operators in Ain Shams University hospitals
and in Kobry Elkobba Military hospital from August 2015 to 2017.
Results: According to the results CTOs were divided into two groups, group1 with successful retrograde
PCI in 32 pts. (80%), and group 2 with failed-retrograde PCI in 8 pts. (20%) All CTOs were correctly
identified by MIP,MPR,cMPR images. Most of the CTOs were located in the proximal 21 patients 52.5%
then mid 14 patients 35% ostial 3 patients 7.5% and lastly distal 2 patients 5%. In failed group there were
more calcified plaques. There was more calcification in the CTOs segments (p=0.005). Ten arc-calcified
and two circular-calcified lesions were identified only 4 from ten patients (40%) had arc calcified Plaques
which were successfully recanalized and 6 patients 60% failed. In circular-calcified lesions one patient
(50%) succeeded and one failed. Proximal artery tortuosity between two groups showed a significant
difference (p=0.000). Conclusion: Complex CTO lesion morphology is still an important issue for CTO-
PCI procedural success, and further improvement of technologies (MDCT) and medical devices, such as
guide wires and catheters are required to improve the success rate.
Keywords: Multi-Detector, Computed Tomography, Coronary Chronic Total Occlusion


Chronic total occlusion (CTO) recanalization
pool can be visualized, which is fibrous,calcified,
still represents the final frontier in percutaneous
and heavily laden with cholesterol [8,9]. CT coronary
coronary intervention (PCI).
angiography is a useful tool to optimize PCI
Jeroudi et al. reviewed 1699 consecutive
strategy as it is possible to characterize the length,
patients who underwent coronary angiography at a
course, and composition of an occluded artery and
Veterans Affairs hospital and reported that the
allow visualization of the distal runoff and side
prevalence of CTO among coronary artery disease
branches [10].
(CAD) patients with and without prior coronary
Retrograde approach has been described initially
artery bypass graft (CABG) surgery was 89% and
via the bypass grafts [11], and more recently the use
31%, respectively [1] higher than that reported in a
of septal collaterals has been described to be safe
recent large Canadian registry (54% and 18.4%,
and effective [12]. Retrograde approach for
respectively),2] but similar to other prior studies
recanalization of CTO has gained popularity
[3,4]. Successful recanalization of CTO lesions in
recently with improved success rates as shown in
patients with viable myocardium not only
several case reports and small series of selected
facilitates the reduction of angina symptoms,
patients [13].
avoid bypass surgery and decrease incidence of
Aim of the Work
myocardial infarction, but also may improve long
The goal of this study is to evaluate the imaging
­term survival [5,6]. An analysis of 25 years of
experience in the Mayo Clinic showed that the
Tomography angiography (MDCT) in chronic
procedural success rate for CTO remained around
coronary total occlusion (CTO) before retro grade
70%[7]. Multi ­detector computed tomography
approach in percutaneous coronary intervention
(MDCT) can visualize the coronary artery lumen,
artery wall, and atherosclerotic plaque; even the lipid

Received: 3 / 7 /2017 DOI: 10.12816/0040101
Accepted: 14 /7 /2017

Full Paper (vol.691 paper# 3)

c:\work\Jor\vol691_4 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1570-1575

Prevalence of Intake of Dietary Supplements in the
Population of Saudi Arabia­ Jeddah
Ibrahim Abdullah Albakri1, Mayssan Hussein Almalki2, Samaher Maher Bukhari2, Shahad Sami
Ekram3, Abdulrahman Khalid Aldhubayi4, Marium Mohammed Iqbal2, Yosra Abdallh Frag Al-Aloy5,
Aljoharah Mohammed Almazrou6, Abdullah Saud Alotaibi7, Madihah Nafea S Alruwaili8, Nourah Ali

Alshamrani9, Zahra Jaber Hussein10
1 Najran University, 2 Batterjee Medical College,3 Um Alqura University, 4 Qassim University, 5 Taibah
University, 6 Almaarefa College, 7 King Faisal University, 8 Northern Border University, 9 Taif university, 10
Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Several studies have shown micro-nutrient deficiencies in the Middle East region. Prominent
defects in vitamin D, folate, and iron were especially noted. There are not many studies currently that tell us
about the prevalence of dietary supplement intake in Saudi Arabia.
Aim: The aim was to observe the current prevalence of dietary supplement use in Saudi Arabia. We will also
attempt to elicit the reason they take the supplements, and how it affects their overall quality of life.
Method: Cross-sectional study among 489 Saudi patients was without any exclusion criteria using a standard
questionnaire. The study was held at the endocrinology department of King Abdul Aziz Hospital & Oncology
Center in Jeddah, Saudi Arabia.
Results: The overall prevalence of multivitamin, mineral and supplement intake in the Saudi population was
found to be 22%. Among them 16% were male and 24% were female.
Conclusion: Healthcare providers must spread more awareness about the potential benefits of dietary
supplements in preventing non-communicable diseases.
Keywords: multivitamin and mineral intake; dietary supplements; food fortification; Saudi Arabia public health

Food and Nutrition Board of the IOM, and they must
The US Food and Nutrition Board of the Institute
be free of herbs, hormones, or drugs [7]. Using this
of Medicine (IOM) defines Dietary Reference
Intakes (DRI) for 29 vitamins and minerals (table 1)
compositions are classified as multivitamin and
[1]. Experts recommend obtaining the essential
mineral supplements. Food fortification, as defined
micronutrients by eating a varied and balanced diet
by the World Health Organization, is "a process of
[2]. Nevertheless, persistent or periodic nutritional
deliberately increasing the content of an essential
gaps are not uncommon in the general population [3],
micronutrient in a food irrespective of whether the
and people who don't consume adequate amounts of
nutrients were originally in the food before
certain foods may fall short on nutrients. Throughout
processing or not, so as to improve the nutritional
the life cycle there are times when the body requires
quality of the food supply and to provide a public
more nutrients than the typical diet may provide, for
health benefit with minimal risk to health" [26].
instance iron during pregnancy and vitamin B12
Dietary supplements are capable of providing
after the age of 50 years [4]. Deficiencies in one or
large amounts of micro-nutrients to the diet.
more nutrients may sometimes contribute to serious
Multiethnic Cohort Study showed that dietary
health issues [5].
supplement users consumed higher amount of
Diet supplementation is relatively common in the
thiamin, riboflavin, niacin, vitamins A, B-6, B-12, E,
United States. It was noted by the National Health
and folate from the supplements alone [8]. Evidence
and Nutrition Examination Survey (NHANES) that
has also suggested that eating patterns that include
approximately half of the people living in the United
high intakes of vegetables, fruits, nuts, and whole
States take some form of dietary supplements, the
grains are linked to a significantly lower risk of
most common being multivitamin and mineral [6].
cancer, heart disease, and stroke [9, 10]. Therefore, use
The US National Institutes of Health defines
of dietary supplements can be a preventive measure
multivitamins and minerals as supplements that
to lower the prevalence of many non-communicable
consist of at least 3 or more micronutrients at doses
diseases and micronutrient deficiency [11]. However,
less than Tolerable Upper Level determined by the
Received: 3 / 9 /2017 DOI: 10.12816/0040102
Accepted: 14 /9 /2017

Full Paper (vol.691 paper# 4)

c:\work\Jor\vol691_5 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1576-1581

Role of MRI Assessment of the Patellar Instability
Mariana Fikry Nashed, Mohammed Amin Nassef, Amir Louis Louka
Radiology Department, Faculty of Medicine, Ain-Shams University
Corresponding author: Mariana Fikry Nashed, Mobile: +201221584200, E-mail: marianafikrynashed@gmail.com

Patello-femoral stability is principally influenced by anatomic factors. Understanding the
anatomy and biomechanics of the patello-femoral joint provides insight into the etiology and management
of patellar instability. Magnetic resonance imaging (MRI) has emerged as an auxiliary method for
investigating patello-femoral instability, particularly for detecting osteochondral lesions and for evaluating
the medial patello-femoral ligament (MPFL). Objective: descriptive study including analysis of MRI knee
done for patients with patellar instability suspected clinically with or without history of trauma.
Patients and Methods: Thirty patients were included in the study, all with suspicious patellar instability
from Ain-Shams University orthopedic clinic and other private clinics. A cross-sectional study was held
where all the patients under-went MRI routineknee protocol. MRI knee images were interpreted for
identification of different pathologies contributing to patellar instability.
Results: Sixty percent of the patients included in our study had MPFL injury, 43% showed patella alta,
83% showed trochlear dysplasia (by different measurements) and 43% showed lateral displacement of TT.
Conclusion: MRI the modality of choice in diagnosing different pathologies of patellar instability, for its
value in assessing soft tissue structures, detailed imaging of the cartilage and applying all measurement
Keywords: Medial patello-femoral ligament (MPFL), Tibial tubercle to trochlear groove distance (TT-TG
distance), Vastus medialis obliquus (VMO), Quadriceps angle (Q-angle).


Magnetic resonance imaging (MRI), providing
The patello-femoral joint (PFJ) enhances our
thinner and higher-resolution scans, allows a
ability of knee flexion and extension and is
more accurate study of the patello-femoral joint
assumed to have evolved through men's ability of
cartilage surface than CT does. Furthermore, it
having adopted a bipedal gait. This articulation
does not involve the use of ionizing radiation, and
between patella and femur is relatively complex
allows measurements to be taken at the level of
and displays a complicated biomechanical
the cartilage rather than only at that of the
behavior (1).
subchondral bone (as in conventional radiology
The biomechanical characteristics of the
patello-femoral joint are the result of a complex
Routine MR imaging protocols are sufficient
interplay of components. The statics and
for most pathology related to the extensor
dynamics of this articulation involve the
mechanism. The proton density fat suppression
geometries of the patella and the trochlea, the
sequence, which is universally included in routine
passive soft tissue restraints of capsule and
knee protocols, is sensitive for tendon, bone, and
retinaculum, and the coordination of the
articular cartilage pathology. The sagittal and
quadriceps. Additionally, angular and rotational
axial planes are the most useful for assessing
limb alignment can affect patello-femoral
patello-femoral dysplasia (5).
mechanics and kinematics. Bottom line - it is all
Increased patellar height (patella alta) is a key
about balance; balance of the extensor
factor causing patellar instability and is present in
mechanism of the knee (2).
30% of patients with recurrent patellar
The etiologies of patello-femoral disorders
dislocation. The importance of increased patellar
may be intra-articular (trochlear dysplasia,
height in the study of patello-femoral (PF)
patellar dysplasia), peri-articular (hypoplasia of
disorders lies on the reduced ``engagement''
vastus medialis, patella alta, increased external
between the two articulating bones: the patella
rotation of the proximal tibia with lateralization
and the femoral trochlea, which is necessary to
of the patellar tendon insertion) and extra-
provide to the patella the required mechanical
articular (increased valgus positioning of the
stability throughout the range of motion,
distal femur, sometimes in combination with
normally the ratio between the patellar tendon
genu recurvatum and increased anterior torsion of
length and the maximal diagonal measurement of
the femoral neck (3).
the patella is between 0.76 and 1.49 (6).
Received: 7 /7 /2017 DOI: 10.12816/0040103
Accepted: 16 / 7 /2017

Full Paper (vol.691 paper# 5)

Decidual Natural Killer Cells (CD56+) population In the Placental Bed in Accidental Haemorrhage The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1582-1588

Decidual Natural Killer Cells (Cd56+) Population in the Placental
Bed in Accidental Hemorrhage
Hassan Tawfik Khairy, Sherif Fathi El-Mekkawi, Mohammed Saeed Eldin Elsafty,
Aml Shawqi Kamal El Shial
Department of Obstetrics and Gynecology, Faculty of Medicine - Ain Shams University

Accidental hemorrhage is defined as abnormal complete or partial separation of normally
implanted placenta after 20 weeks of gestation and prior to birth. Risk factors which have been found
associated with accidental hemorrhage include maternal age, parity, smoking, hypertension, past history of
accidental hemorrhage, thrombophilic disorders, abdominal trauma and polyhydramnios. Aim of the Work:
The aim of our study was to find if there is any role for decidual natural killer cells in cases with placental
abruption. Patients and Methods: This is a case control study in which 60 pregnant women recruited from
Obstetric Department of Ain Shams University Maternity Hospital. Patients were subjected to emergency
cesarean section. Multiple tissue biopsies (5 mm thick) were taken from the decidua basalis of the placental
bed and immunostained for decidual CD 56+ve bright natural killer cell marker.
Results: Our results show that there was a highly statistically significant difference between the study and
control group as regard immunohistochemical scores (according to CD 56+ %), In control group: score 0 =
0.0%, score 1+ = 0.0%, score 2+ = 18.5%, score 3+ = 29.6%, score 4+ = 51.9% while in the study group:
score 0 = 25.9%, score 1+ = 40.7%, score 2+ = 29.6%, score 3+ = 3.7%, score 4+ = 0.0%; (Chi square
42.133 FE) and (P. value = 0.000). Also there was a highly statistically significant difference between the
study and control group as regard dNK cells density (uNK cells as a percentage of total stromal cells), in
control group: low density = 18.5% and high density = 81.5% while in the study group: low density =
96.3% and high density = 3.7%; (Chi square 33.400 FE) and (P. value = 0.000). Conclusion: These findings
suggest that low dNK score and density was associated with cases of placental abruption.
Keywords: Placental abruption, Natural killer cells, CD56+bright, Cesarean section, Immunohistochemistry.

thrombosis(5).Normal placentation requires trophoblast
Accidental hemorrhage is defined as abnormal
invasion of maternal spiral arteries, and development
complete or partial separation of normally implanted
of a high-flow, low-resistance uteroplacental
placenta after 20 weeks of gestation and prior to
birth(1). Risk factors which have been found
Abruption is often discovered when bright red
associated with accidental hemorrhage include
or dark clotted blood is discharged from the vagina.
maternal age, parity, smoking, hypertension, past
However, bleeding from the vagina is not always
history of accidental hemorrhage, thrombophilic
present (7). Bleeding and pain consist the classical
disorders, abdominal trauma and polyhydramnios.
symptoms of placental abruption but the clinical
Placental abruption seems to be multifactorial. Its
picture varies from asymptomatic, in which the
etiology is not fully understood but impaired
diagnosis is made by inspection of the placenta at
placentation, placental insufficiency, intrauterine
delivery, to massive abruption leading to fetal death
hypoxia, and uteroplacental underperfusion are
and severe maternal morbidity(8).
considered the key mechanisms causing abruption(2).
Natural killer (NK) cells are part of the innate
Abruption results from a rupture of maternal
immune system, and are found in both peripheral
decidual artery causing dissection of blood at the
blood and endometrium. Although both peripheral
decidual-placental interface, around placental
NK (pNK) and uterine NK (uNK) cells express the
margin, or behind the membranes. Acute vasospasm
surface antigen CD56, pNK cells are phenotypically
of small vessels may be one event immediately
and functionally different from uNK cells and <10%
preceding placental separation. Thrombosis of the
of pNK cells resemble uNK cells(9),Furthermore
decidual vessels with associated decidual necrosis
90% of pNK cells are CD56dim and CD16+
and venous hemorrhage also are often present(3).
whereas 80% of uNK cells are CD56bright and
Immunological defects may well play a role in
CD16- (10,11).
the origin of placental abruption(4). These defects
The maternal immunologic state is maintained
may lead to maternal inflammatory response with
by local secretion of T helper-2 (Th2) cytokines
cytokine release resulting in a chain of events such
while the pregnancy complications such as
as shallow trophoblast invasion, defective spiral
spontaneous miscarriage, preterm delivery and
artery remodeling, placental infarctions, and
preeclampsia, seem to be associated with a
Received: 11 /6 /2017 DOI: 10.12816/0040104
Accepted: 20 /6 /2017

Full Paper (vol.691 paper# 6)

c:\work\Jor\vol691_7 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1589-1594
Using Serum Beta Trace Protein to Estimate Residual Kidney
Function in Hemodialysis Patients
Hesham M. El-Sayed, Hussein S. Hussein andAhmad M. Elarnosy
Nephrology Department, Faculty of Medicine, Ain Shams University
Corresponding author: Ahmad M.Elarnosy, Tel:01158445513, email: ahmadelarnosy@gmail.com

Aim of the work:
residual kidney function (RKF) in end stage kidney disease (ESKD) patients contributes
significantly to solute clearance. This improves survival as well quality of life in these patients. Kidney
Diseases Outcomes Quality Initiative (KDOQI) guidelines suggest that hemodialysis (HD) dose can be safely
reduced in those with RKF in the form of residual urea clearance (KRU) of 2 ml/min/1.73 m2 or more.
However, measurement of RKU is difficult as it requires regular inter-dialytic urine collections. Simpler
methods for measuring KRU and thus RKF are needed. Beta trace protein (BTP)have been proposed as
alternative markers of RKF and RKU. Dialysis specific equations to estimate KRU based on serum BTP
wererecentlydeveloped. This study aimed to compare measured KRU using inter-dialytic urine collection and
estimated KRU using serum BTP.Patients and Methods: we included 60 ESKD patients in this study;they
were divided into 2 groups. Group-1(G-1) had daily urine output <500ml and group-2(G-2) haddaily urine
output >500ml. We estimated and measured KRU in both groups. Correlation between measured and estimated
KRU in each group was done using Pearson correlation coefficient. Results: the estimated and measured KRU
was strongly correlated in G-1 with r=0.746 at p<0.01 , but it was week in G-2 with r=0.44 and p<0.05.Mean
bias between estimated and measured KRU was 0.7 mL/min in G-1. In G-2 the mean bias was -0.54mL/min.
Conclusion: KRU and thus RKF can be better estimated using serum BTP in patients with urine output
ability to remove uremic toxins and maintain body
Chronic kidney disease (CKD) is a major health
euvolumia. They should be referred to a
issue as it is considered as a major cause of
nephrologist care. The patient and his family should
mortality. The risk of mortality increases
be educated about the possible RRTs which
exponentially with decreasing renal function (1).The
includes hemodialysis(HD), peritoneal dialysis(PD)
Kidney Disease Outcome Quality Initiatives
(K/DOQI) classifies CKD into 5 groups according
Hemodialysis(HD) carry out some functions of
to the glomerular filtration rate (GFR).Stage 5 is
the kidneys in ESKD patients .It removes many
End Stage Kidney Disease (ESKD) and patients in
uremic toxins like urea and creatinine, normalize
this stage require renal replacement therapy(RRT)
electrolytes such as potassium, calcium and
to carry out some functions of the failed kidneys(2).
phosphate as well as removing excess fluid gains
Table1:CKD staging according to K/DOQI(2)
between sessions also known as ultrafiltration(4).
Stage Description
GFR: Related Items
Residual kidney function(RKF) is the remaining
minimal GFR in patients diagnosed as ESKD who
require RRT.Patients with RKF suffer less adverse
damage >90
cardiovascular and anemia; they also tend to have
with normal kidney
RKF is generally expressed as urinary clearance
damage 60-90
of urea(KRU). Current guidelines recommend
with mild reduction
assessment of RKF at regular intervals.KRU is
of GFR
included in hemodialysis adequacy if it is >2
GFR 30-60
However, there are no simple methods for
GFR 15-30
assessing RKF that are similar to GFR estimation
from serum creatinine in non dialysis patients. RKF
Renal failure
is assessed by timed 24 to 48 hour urine collection
with calculation of KRU. Urine collection is

Once CKD patients approach ESKD they lose
Received: 19/ 6 /2017 DOI: 10.12816/0040105
Accepted: 28 / 6 /2017

Full Paper (vol.691 paper# 7)

c:\work\Jor\vol691_8 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1595-1602

Awareness About the Role of Bariatric Surgery in Mortality and
Morbidity among General Population of Albaha City
Ali M.A. Alamri, Raed A.M. Alzahrani, Fares A.M. Alzahrani, Abdulrahman A. Alghamdi,
Abdulrahman H.A. Alghamdi, Osama H.A. Alhabi, Saeed Y.S. Alghamdi
Faculty of Medicine, Albaha University, Albaha, KSA

Obesity is an emerging health concern worldwide and in Saudi Arabia. Until now bariatric
surgery is the most effective treatment for morbid obesity.
Objective: The aim of this study was to measure awareness about the role of bariatric surgery in mortality
and morbidity among general population in Albaha city in Saudi Arabia.
Methods: A questionnaire was distributed among the general public in Albaha city, Saudi Arabia. The
questionnaire consisted of two parts, the first one included personal data and the second one was concerned
with awareness and knowledge of people regarding effectiveness and complications of bariatric surgery. Only
completed questionnaires without missing data were subjected to statistical analysis.
Results: The majority of respondents opposed surgery and didn't believe in its effectiveness compared with
other treatment lines. There were false beliefs about the regaining of weight after surgery and exaggeration of
its complications. The most common causes for refusal of surgery were lack of need and fear of complications
while the most common motives for acceptance were desire of more weight loss and health benefits.
Conclusion: Health education is necessary to increase patients' awareness and knowledge about bariatric
surgery. The topics to be focused upon are the expected benefits after surgery, the maintenance of weight and
the nature and incidence of surgical complications.
Keywords: bariatric surgery; obesity; body mass index.


Obesity is a growing health problem
surgery. Other patients regain substantial amounts
worldwide. In Saudi Arabia one out of three adults
of weight, even within the first 1-2 years after
suffers from obesity and at least one out of ten
surgery (6).
adults has morbid obesity (1). In the United States
Studies have found bariatric surgery to
approximately 30 percent of adults are obese, and
have more positive health impacts on many
the prevalence of obesity has increased rapidly in
obesity-related diseases than traditional weight-
recent decades. Increasing numbers of children are
loss tactics. Obese individuals with diabetes, high
overweight, which contributes to the high
blood pressure, high levels of uric acid and other
projections of obese adults in the future. Obesity
obesity-related conditions who received bariatric
leads to 30-50 % more chronic medical problems
surgery showed greater improvement in these co-
than heavy smoking or drinking (2). It contributes to
morbidities at two and 10 years than those who did
coronary artery disease, cancer (breast, cervix,
not receive surgery. Despite clinical outcomes
colon, esophagus, kidney, pancreas, prostate and
improvement, bariatric surgery is not without risk.
uterus), diabetes, hypertension, pancreatitis, gall
Common risks include infection, ulcers, dumping
bladder problems, gout, infertility, liver problems
(involuntary vomiting or defecation), hemorrhage,
and stroke. Obesity alone causes 100,000 cancers
wound reopening, blood clots, heart attacks and
each year in the United States (3).
hernias (4). On the other hand, Elder and Wolfe (7)
Demand for bariatric surgery has increased
assessed that nutrient deficiencies or GI pathology
(4). It is estimated that 15,000 bariatric operations
considered as a complications that may follow any
are performed annually in Saudi Arabia (1).
of the bariatric surgical procedures.
Between 2003 and 2011, 735 bariatric procedures
Buckley and Marlowe (4) reported that
were performed at Imam Abdulrahman Al-Faisal
experience and proven outcomes are essential
Hospital (IAFH) and 452 standard biliopancreatic
components for a successful surgical program.
diversion (BPD) (5). Typically patients lose
While one of the most important determinants of
between 20 and 50 kg within the first 1-2
high-quality bariatric surgery outcomes is
postoperative years, and maintain the bulk of this
experience, there exists a huge range of experience
weight loss for up to 10 years and longer. While,
between hospitals and surgeons. On the other hand,
up to 25% of patients fail to achieve adequate
Al-Khaldi (1) reported that in many medical
weight loss, typically defined as > 50% excess
centers, operations have been done under
weight lost and maintained for at least 5 years after
questionable surgical circumstances and a lacking
Received: 2/ 9/2017 DOI: 10.12816/0040106
Accepted: 13 / 9 /2017

Full Paper (vol.691 paper# 8)

c:\work\Jor\vol691_9 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1603-1606

Spontaneous Spinal Epidural Hematoma in Pregnancy
Ali Malik Alahmed1*, Faisal Alabbas2, Majdi Saleh Alzahrani3
1- Imam Abdul-Rahman Bin Faisal University, 2-King Fahad university of Dammam,
Faculty of Medicine, 3- Umm Al-Qura University, Makkah , Saudi Arabia.

Spinal epidural hematoma (SEH) is an uncommon condition. Spontaneous SEH, accounting for 0.3­0.9%
of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft
trauma or coagulation abnormalities).The pathophysiology of spontaneous and idiopathic SEH is still under
debate: There are only a few reports in literature of spontaneous evolving SEH with progressively increasing
pain and neurological impairment.
Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present a 38-years
old female on the 2nd trimester of her pregnancy preset with spontaneous spinal epidural hematoma with a
sudden onset of weakness and back pain fallowed by a sudden paraplegia. MR imaging showed high intensity
irregular dotted lesion seen in the lower thoracic region (T12), in addition, MRI revealed an intervertebral
disk prolapse with a cord compression between (L3-L4) (L4-L5).
The Surgical treatment of the case, the patient underwent laminectomy and an evacuation of the hematoma
by the neurosurgical team allowed a correct diagnosis but still paraplegic. Our aim is to discuss the clinical
and radiological features and the treatment options.
Keywords: spontaneous spinal epidural hematoma, epidural hematoma, pregnancy.


Spontaneous spinal epidural hematoma (SSEH) is
with SSEH. She does not have any of the following
an uncommon condition. Since the first- reported
chronic illnesses: hypertension, diabetes mellitus or
case by Jackson in 1869, around 400 cases of SSEH
coagulopathy. There was no history of trauma,
have been reported with only 11 cases happened
headache or anti-coagulant treatment. On
through pregnancy [1] .The diagnosis of SSEH is
examination, the patient was conscious, oriented
difficult due to its atypical symptoms, rarity, and
and alert but tachycardiac and tachypneic. Her
unclear etiology. Here, we describe a rare case of
blood pressure was 155/96 mmHg and the
an acute SSEH during pregnancy and discuss the
temperature was 38.3C. The upper limb power was
etiology, presentation and management.
normal but the lower limb was bilaterally 0/5 with

an absence of reflexes.

A 38-years old female on the 2nd trimester of her
A magnetic resonance imaging (MRI) was
pregnancy referred from other hospital to our
requested and showed high intensity irregular
hospital after one week of undiagnosed spinal
dotted lesion seen in the lower thoracic region
hematoma on the 6th of May 2016. She presented
(T12) as shown in Figure 1. In addition, MRI
with a sudden onset of weakness and back pain
revealed an intervertebral disk prolapse with a cord
fallowed by a sudden paraplegia and was diagnosed
compression between (L3-L4) (L4-L5) (Figure 2).

Received:2 / 7/2017 DOI: 10.12816/0040107
Accepted: 11 / 7/2017

Full Paper (vol.691 paper# 9)

c:\work\Jor\vol691_10 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1607-1613

Study of Relationship between G894T Variant of Endothelial Nitric
Oxide Synthase Gene and Acute Ischemic Stroke
Eman A. EL Gohary, Adel A. El Azab,Manal M. M.Kamal EL-Din,Shaimaa K.Mohammed.*
Clinical Pathology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
*Corresponding authors: Shaimaa Khalil Mohammed, shaimaakhalil2@gmail.com, Phone: +201001784064

Background: Cerebral stroke (CS) is considered as one of the major causes of death and disability
worldwide. Ischemic stroke is the most common type of stroke in Egypt, as in other countries, accounting for
43% to 79% of all stroke types .There are some traditional factors that increase the risk of ischemic stroke such
as hypertension and smoking, but genetic risk factors, suggested by evidence from inheritance-based studies,
might contribute to predisposition to ischemic stroke.Among investigated genetic variations of eNOS is G894T
polymorphism that leads to a change of glutamate to aspartate at site 298 and is said to have increased
susceptibility to cleavage of eNOS enzyme which contribute to the development of stroke.
Patients and methods: The study was conducted on a group of thirty (30) Egyptian patients admitted to the
Neurology Department and Stroke Units of Ain Shams University hospitals (Al-Demerdash hospital).They
were presented with acute ischemic stroke in the first 48 hours and diagnosed according to clinical
neurological and radiological examinations. Oral informed consents were obtained either from the patients or
their relatives before enrollment in the study according to the Ethical Committee of Faculty of Medicine, Ain
Shams University. In addition, ten (10) Egyptian apparently healthy, age and sex- matched subjects were
investigated as control group. All individuals included in this study were subjected to full history taking,
thorough general, neurological and radiological assessment. The laboratory investigations included complete
blood count, coagulation profile, and blood glucose level assay. Furthermore, eNOS G894T gene
polymorphism was assessed by PCR- RFLP. Results: In this study, we couldn't find a significant association
between eNOS G894Tgene polymorphism and acute stroke Egyptian patient.
Keywords: acute ischemic stroke , endothelial nitric oxide.


Cerebral stroke (CS) is considered as one of the
indicated that the (eNOS) gene plays a crucial role
major causes of death and disability worldwide
in thepathogenesis of many diseases including
(1).Ischemic stroke is the most common type of
stroke, essential hypertension and it has an
stroke in Egypt, as in other countries, accounting
important role in development of coronary artery
for 43% to 79% of all stroke types (2).There are
disease (5,6). The eNOS gene is situated on
some traditional factors that increase the risk of
chromosome 7 (7q35­q36), it consists of 26 exons
ischemic stroke such as hypertension and smoking,
and codes for an enzyme that produces Nitric
but genetic risk factors, suggested by evidence
from inheritance-based studies, might contribute to
endothelium(7).Different genetic variations of
predisposition to ischemic stroke(3).Endothelium
eNOS were identified to be associated with
derived nitric oxide (NO) is critical to vascular
development of stroke as (4b/ a, 786T>C, A-922G
homeostasis. NO has potent vasodilator and anti-
and Glu298Asp) gene polymorphisms (8).Among
proliferative effects, as well as antithrombotic
investigated genetic variations in eNOS is G894T
properties. It stimulates smooth muscle cell
polymorphism that leads to a change of glutamate
relaxation and inhibits platelet aggregation and
to aspartate at site 298 and is said to have increased
leukocyte adhesion. Impaired endothelium-
susceptibility to cleavage of eNOS enzyme which
dependent vasodilation is a general attribute of
contribute to the development of stroke (9).
atherosclerotic vessels, which to some extent could
be due to the reduction in the activity of vascular
Explore the relationship between G894T
endothelial nitric oxide synthase (eNOS). This
polymorphism of endothelial nitric oxide synthase
impaired NO-dependent vasomotor reactivity has
gene and acute ischemic stroke.
been implicated in the patho-physiology of

Received:14 / 6 /2017 DOI: 10.12816/0040108
Accepted: 23 / 6 /2017

Full Paper (vol.691 paper# 10)

c:\work\Jor\vol691_11 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1614-1623

Awareness about Cruciate Ligament Injury among General
Population of Albaha City
Fares A.M. Alzahrani, Raed A.M. Alzahrani, Abdulrahman A. Alghamdi, Abdulrahman H.A.
Alghamdi, Saeed Y.S. Alghamdi, Mashhour M.H. Alghamdi, Ali M.A. Alamri
Faculty of Medicine, Albaha University, Albaha, KSA

Anterior cruciate ligament (ACL) injury is very common in young and active individuals who
have continued active participation in sports. This injury might cause functional disability with many
economic and social consequences. So, there is a need to raise awareness of the general population about this
type of injury in order to decrease its incidence and complications.
Objective: This cross sectional study was undertaken to investigate the awareness of the general population
in Albaha city, Saudi Arabia towards ACL injury.
Methods: A self-administered questionnaire was randomly distributed to individuals aged 18-60 years of
both sexes, 464 subjects agreed to participate, answered the questionnaire and were involved in the study.
Results: Findings showed that 77.8% of the study participants were aware of ACL injury and ranked it as a
serious disease. Great percent (36.0%) of the studied persons realized the role of sports as a risk factor of
ACL injury. The majority (60.8%) proposed an interaction between two or more of; incorrect technical
movements, lack of self- protection awareness, insufficient preparation and overload of exercise. Low
percentages of all participants considered prolonged walking, prolonged standing, going up and down stairs,
prolonged sitting, getting up from a sitting position, kneeling or squatting or running actions that might
increase the incidence of ACL injury.
Conclusion: Findings showed reasonable awareness of the general population in Albaha city about the
seriousness of ACL injury, but there was lacking in their information about risk factors other than sports,
dangerous actions that increase incidence of ACL injuries and their characteristic symptoms. There is a need
for increasing health education and raising awareness and more implementation of prevention programs for
ACL injuries.
Keywords: anterior cruciate ligament; injury; sports.


Cruciate ligament consists of two large
of the main causes of injury (8,9). Al Mutawa et al.
ligaments each about the size of little finger inside
(10) reported that the total incidence of the injuries
the knee that cross deep inside the joint. They are
that are associated with football is high in Saudi
called the anterior cruciate ligament (ACL) and
Arabian athletes. Anterior cruciate ligament
posterior cruciate ligament (PCL) and they go from
injuries in athletes are common, with female
the femur to the tibia. Cruciate ligaments stabilize
athletes having a two to eight times higher
the knee and allow it to glide through a smooth
incidence of ACL injuries compared with male
range of motion as the leg bend and straighten. The
athletes (11).
ACL is the ligament in the front. It is one of the
About 85% of all ACL injuries occur
main static and functional stabilizing structures of
during training and competitions. Bispo et al. (12)
the knee and the one most commonly injured (1). It
reported that road traffic accidents have also been
creates the connection between the femur and the
considered as a cause to certain cases of ACL
tibia, and serves to prevent anterior translation of
injury. Agel et al. (13) assessed that non-contact
the tibia relative to the femur (2).
injuries such as stopping after fast running; cutting
ACL injury is associated with sports and
to a different direction; and sudden deceleration
leisure activities (3). von Porat et al. (4) and Lyman
prior to a change of direction or landing motion
et al. (5) reported that this form of injury is very
from a jump all are responsible about 60% of ACL
common in individuals who have continued active
injuries. By contrast, contact injuries account for
participation in sports, which affect young and
approximately 40% of ACL injuries. Generally,
active individuals in the majority of cases. ACL
they occur when the knee joint is placed in valgus
injury is common among athletes and occur
collapse following direct contact with another
primarily in individuals involved in sports with
player (3,14). ACL rupture can lead to a considerable
knee pivoting movements such as soccer, football,
loss of knee function and disability, and therefore,
team handball, basketball and alpine skiing (6,7). In
a reduction in a person's quality of life and has
particular, playing football on a regular basis is one
serious clinical and economic consequences (15,16).
Received:3 /9 /2017 DOI: 10.12816/0040109
Accepted: 14 / 9 /2017

Full Paper (vol.691 paper# 11)

c:\work\Jor\vol691_12 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1624-1627

Role of Intervention Radiology in Renal Vascular Injuries
Amr Ahmed Hanafy Mahmoud Abdelkader, Sameh Mohamed Abd EL Wahab,
Rasha S. Hussien, Karim Ahmed Abd El-Tawab
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Amr Abdelkader, Mobile: +201002522405, E-mail address:Dr.amr@hotmail.co.uk

Background: Trans-catheter renal artery embolization has a role in the management of iatrogenic and traumatic
renal vascular injuries. Objective: To assess the technical success and short term clinical efficacy of renal artery
Embolization in patients with iatrogenic and traumatic renal vascular injuries. Methodology: All cases were
done at interventional radiology unit Ain Shams University. Conclusion: Renal artery embolization plays a great
role in the management and treatment of renal vascular injuries either traumatic or iatrogenic.
Keywords: Renal vascular injuries, Renal artery embolization (RAE), Renal Pseudo-aneurysm, Renal Arterio-
venous fistula (AVF).


lower segmental arteries arise from the anterior
The kidney is the third most common abdominal
division, and a posterior segmental artery arises from
organ to sustain injury, with renal trauma evident in
the posterior division. Segmental arteries branch at
approximately 1­5% of all trauma cases. Trauma is
the level of the fornix to form interlobar arteries,
either blunt representing almost 80% of traumatic
which continue in the interlobar septae between the
renal injuries such as motor vehicle accident, falls and
pyramids. Each interlobar artery branches at the
sports accidents or penetrating trauma due to stab
cortico -medullary junction into 5-7 arcuate arteries,
wounds and gunshot wounds (1). The prevalence of
which then branch into interlobular arteries. These
Interlobular arteries give supply to the afferent
interventions such asrenal biopsy, placement of a
glomerular arteries and capsular perforating arteries (3).
percutaneous nephrostomy tube, or laparoscopic or
The venous system begins with the peritubular
open surgical procedures reaches 8.0%, with less than
capillary venous plexus draining into the arcuate veins
2.0% patients requiring intervention (1).
through the venae rectae which in turn drain into the
Aim of The Work The aim of this work was to
interlobular veins leading to arcuate veins and then
assess the technical success and short term clinical
interlobar veins which forms multiple trunks (2 in 50%,
efficacy of trans-catheter renal artery embolization as a
3 in 30% of cases) that ultimately unite as the renal
vein located anteriorly to the renal pelvis. The right
The study was approved by the Ethics Board of Ain
renal vein drains directly into the IVC with no
Shams University.
tributaries while the left renal vein is longer than the
right one with multiple tributaries draining into it (3).
The study was done after approval of ethical
board of Ain Shams University.
Anatomy of the renal vasculature (Fig. 1)

Arterial supply consist of a single renal artery
arising bilaterally from the lateral aspect of the
abdominal aorta just inferior to the origin of the
superior mesenteric artery at level of L1/L2in 75% of
cases. In 25% of cases there are duplicate renal arteries
which are more common on the right side. The right
renal artery usually has a long downward course
towards the inferior position of the right kidney and it
passes posterior to the inferior vena cava (IVC) and is
usually postero-superior to the right and left renal
veins. The renal artery is subdivided outside the renal
hilum into an anterior and posterior division, carrying
75% and 25% of the blood supply respectively (2).
The arterial divisions are further divided into five
segmental arteries where an apical, upper, middle and
Fig. 1: Image showing renal vascular supply

(Quoted from Fox) (4).
Received:14 / 6 /2017 DOI: 10.12816/0040110
Accepted:23 /6 /2017

Full Paper (vol.691 paper# 12)

c:\work\Jor\vol691_13 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1628-1633
Granulocyte-Colony Stimulating Factor Prevents Motor Dysfunction and
Histological Damages In A Rat Model Of Parkinson's Disease
Mariama S. Azmy, Esther T. Menze*, Reem N. El-Naga, Mariane G. Tadros
Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
*Corresponding author: Esther T. Menze, E-mail address: Esther.menze@gmail.com

Aim of the work
: Parkinson's disease is the most common neurodegenerative movement disorder worldwide.
The main motor clinical manifestations of Parkinson's disease are resting tremors, bradykinesia, rigidity, and
postural instability. In the present study, we aimed to evaluate the effects of granulocyte-colony stimulating
factor (G-CSF) on the body weight, motor function, and brain histology of rotenone-treated rats.
Material and methods: Rats were divided into four groups, as follows: Group 1 the control rats, Group 2 the
rotenone-treated rats (2 mg/kg, 28 days), Group 3 the rotenone + G-CSF (20 µg/kg, 28 days)-treated rats and
Group 4 the rotenone + G-CSF (40 µg/kg, 28 days)-treated rats. Body weight was measured on weekly basis.
Postural instability was evaluated at the end of the study and the motor behavior was monitored. Then, rats were
decapitated and brain histology was examined. Results: Rotenone resulted in body weight loss,
bradykinesia/akinesia, rigidity, postural instability, and histological damages. All these deficits were prevented
by G-CSF at 40 µg/kg. Therefore, G-CSF may be a potential neuroprotective agent in Parkinson's disease.
Keywords: G-CSF, rotenone, body weight, postural instability


Parkinson's disease, the most common
constitute a major risk factor for Parkinson's
neurodegenerative movement disorder, remains a
disease(4-6). One of these pesticides related to
major disabling progressive condition affecting
Parkinson's disease is rotenone(4). Rotenone is the
mainly elderly people. The clinical manifestations of
most potent member of the rotenoid family of
Parkinson's disease can be divided into motor and
neurotoxins(7). It is a well-characterized inhibitor of
mitochondrial complex , an activity that results in
ATP depletion and oxidative stress(8). Owing to its
instability are the main motor symptoms of
lipophilicity, rotenone can readily cross the blood-
Parkinson's disease(1). The nonmotor symptoms
brain barrier. Betarbet et al. first showed that chronic
include cognitive impairment (mainly dementia),
systemic rotenone exposure could induce almost all
the features of Parkinson's disease in rats(9). In the
(depression), psychosis, sleep disturbance (such as
present study, a rat model based on administration of
excessive daytime sleepiness, disturbed nocturnal
low-dose rotenone (2 mg/kg) for 28 days was used
sleep, and rapid eye movement sleep behavior
to reproduce the features of Parkinson's disease.
disorder [RBD])(2).

Similar to erythropoietin, whose receptors
The two major neuropathological hallmarks of
were found to be expressed by the neurons and
Parkinson's disease are dopaminergic neuronal loss
which displayed neuroprotective effects(10, 11),
in the substantia nigra and accumulation of -
granulocyte-colony stimulating factor (G-CSF)
synuclein-positive intraneuronal inclusions, namely
receptors (G-CSFR) were found to be expressed by
Lewy bodies (LB)(3). The non-motor symptoms are
neuronal cells; in addition, G-CSF displayed
likely related to pathology in brain areas rather than
neuroprotective effects in numerous neurological
the nigrostriatal projection, particularly the
conditions(12-14). With regard to Parkinson's disease,
hippocampus and cerebral cortex. Currently, most
G-CSF was shown to increase tyrosine hydroxylase-
expressing nigral neurons and striatal dopamine
content in the acute 1-methyl-4-phenyl-1,2,3,6-
symptom control. However, none of these treatments
tetrahydropyridine (MPTP) mouse model(15). In this
can delay the disease progression.
study, we aimed to assess the effects of two doses of
Epidemiological studies have suggested that
G-CSF on the motor function and brain histology of
environmental factors, such as pesticide exposure,
rotenone-treated rats.
Received: 5 / 6 /2017 DOI: 10.12816/0040111
Accepted:14 /6 /2017

Full Paper (vol.691 paper# 13)

Maternal serum vascular endothelial growth factor in patients with preeclampsia The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1634-1640

Maternal Serum Vascular Endothelial Growth Factor in
Patients with Preeclampsia
Mohammed Salah El-Sokkary, Tamer Ahmed El-Refaie, Noha Bassiouny Hassan Mostafa,
Mona Mohamed Soliman Elaassar
Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University

Background: Vascular endothelial growth factor and placental growth factor levels were significantly lower in
patients of sever or early onset (34 weeks or less gestational age at onset of PET) pre-eclampsia than in controls.
Aim of the Work: Will there be a rise in serum vascular endothelial growth factor in pregnant women suffering
from preeclampsia than in normotensive pregnant women.
Patients and Methods: 150 pregnant women from 28 weeks of gestation till term will be enrolled into this
comparative clinical trial at the time of their antenatal visit to the outpatient department of obstetrics and
gynecology Ain Shams University maternal hospital. Results: We recruited 150 pregnant women after 28 weeks
of gestation and they were classified into 3 groups: Group1:50 pregnant women with mild preeclampsia from 28
weeks of gestation till term, Group2: 50 pregnant women with severe preeclampsia from 28 weeks of gestation till
term and Group 3: 50 normal pregnant women serving as controls. Conclusion: We conclude that serum VEGF
level measured after 28 weeks of gestation can be used as a predictor for preeclampsia and its degrees (mild and
severe) with high sensitivity and specificity.
Keywords: Nulliparous, Gastroesophageal, Hypochondrium, Cerebrovascular.


Pre-eclampsia is a hypertensive disease that is
enhanced formation of endothelin, thromboxane,
characterized by the onset of high blood pressure
and superoxide, increased vascular sensitivity to
and proteinuria after 20 gestational weeks; it
angiotensin II, and decreased formation of
complicates 3­8% of all pregnancies (1).
vasodilators such as nitric oxide and prostacyclin.
Vascular endothelial growth factor and
proliferation of extra villous throphoblasts, forming
placental growth factor levels were significantly
a cell column beneath the chorionic (anchoring)
lower in patients of sever or early onset (34 weeks
villi. The extravillous trophoblasts invade the
or less gestational age at onset of PET) pre-
deciduas and extend down the inside of the spiral
eclampsia than in controls. Soluble vascular
arterioles. This results in replacement of the
endothelial growth factor receptor 1 (sVEGFR-1),
endothelium and the muscular wall of the blood
which antagonizes VEGF functions, has been found
vessels (2).
to increase in preeclamptic patients. These
observations suggest the participation of VEGF and
pathophysiology of the disease remains unclear,
sVEGFRI in the pathaphysiology of pre-eclampsia
abnormal vascular growth and impaired endothelial
function have been thought to be the major cause of
VEGF is an endothelial cell-specific mitogen in
the pathology (3).
vitro and an angiogenic inducer in a variety of in
The pathophysiological considerations in the
vivo models. Hypoxia has been shown to be a
development of pre-eclampsia, include: the
major inducer of VEGF gene transcription. The
existence of initiators e.g. genetic factors,
tyrosine kinases'FlT-1 (VEGFR-l) and Flk-l/KDR
immmunological factors, inflammatory factors,
(VEGFR-2) are high-affinity VEGF receptors (7).
maternal vascular disease, faulty implantation (4).

The initiators cause the endovascular
VEGF is a well-known promote of
trophoblastic injury (acute atherosis) of the
angiogenesis; it also induces nitricoxide and
decidual blood vessels through certain mediators
vasodilatory prostacyclins in endothelial cells
like: vascular endothelial growth actor (VEGF),
suggesting a role in decreasing vascular tone and
prostaglandins, nitric oxide (previously termed,
blood pressure (8).
endothelium- derived relaxing factor), endothelins,
Other proteins are related in structure and
cytokines, lipid peroxidases (5).
receptor specificity to vegf-a. The VEGF family
Reduced uteroplacental perfusion as a result of
consists of VEGF-A, VEGF-B, VEGF-C, VEGF-D,
abnormal cytotrophoplast invasion of spiral
VEGF-E, and placental growth factor (P1GF) (7).
arterioles leads to placental ischemia which is
Exogenous VEGF was shown to ameliorate
thought to cause a wide spread dysfunction of the
maternal vascular endothelium which results in
endothelial dysfunction, and nephropathy (9).
Received: 13 / 6 /2017 DOI: 10.12816/0040112
Accepted:22 /6 /2017

Full Paper (vol.691 paper# 14)

c:\work\Jor\vol691_15 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1641-1645

Laser-Assisted New Attachment Procedure ­ LANAP
Ahmad Farid atteya, Reem Mohammad Shafei, Abrar Aqeel A Jefri, Mohammad Abdulsalam Alhindi
Ibn Sina national College for Medical Studies

The LANAP process is a protocol that compacts with inflammation, the infectious procedure, occlusion,
tooth mobility, and an osseous component. The LANAP protocol is rather simplistic. Utilized by a certified
and trained periodontist or dentist, it is a surgical laser procedure intended for the treatment of periodontitis
through regeneration rather than resection. The definitive objective is to set up the periodontal condition to
advance self-regeneration of the lost attachment and osseous structure that result from periodontal ailment.
Regeneration is a fairly complex event and, as observed with guided tissue regeneration or scaling and root
planning alone, can be very unpredictable. LANAP is predictable. This article introduces a general depiction
of the LANAP protocol (laser-assisted new attachment procedure) and the advantages of its utilization to
Keywords: LANAP, Periodontal Attachment Loss, Nd-YAG Lasers, Periodontal Pocket, Periodontal

to imitate outcomes of a laser of an alternate
There is a need among patients and clinicians to
wavelength notwithstanding when used to
treat periodontal ailment adequately with minimally
implement a comparable treatment. Periodontal
invasive treatments [1]. Recent journals have
treatment using a laser has been reported as a
concentrated on surgical treatment with minimally
monotherapy, as an adjunct to scaling and root
intrusive flap approaches [2]. Many patients and
planning, for root debridement combined with
clinicians decline to utilize these successful regular
surgical or non-surgical treatment [11], and to
surgical strategies because of apparent and genuine
perform surgical laser ­ assisted new attachment
side effects, for example, as root exposure, gingival
procedure 'LANAP` [12].
recession, and postoperative distress. This
The essential objective of periodontal therapy is
frequently prompts the determination of nonsurgical
to set up periodontal health with pocket lessening
treatments for treatment of advanced periodontal
and connection attachment gain, ideally through
ailments, bringing about deficient determination of
periodontal regeneration. Periodontal regeneration
the ailments [3]. Laser-Assisted New Attachment
defined as building up a new attachment apparatus
Procedure (LANAP) therapy, having been at first
on a formerly diseased root surface through new
presented over 16 years ago, is winding up more
cementum, new periodontal ligament (PDL), and
generally acknowledged among clinicians as extra
new bone [13]. Numerous regenerative treatments
research emerges [4]. An underlying histologic report
have shown sufficient documentation of new
gave confirmation of new connection to LANAP-
periodontal structures regenerated adjacent to a
treated teeth with new cementum and inserting
calculus notch to meet these criteria [14, 15]. All these
Sharpey's fibers [5]. This was affirmed by a current
treatments use surgical bone replacement graft
report documenting human evidence of standard for
material (autogenous , allogenic or xenogenic ) or a
periodontal regeneration with new cementum,
biologic agent (growth factor or amelogenins) with
periodontal ligament, and alveolar bone adjacent to
or without the arrangement of barrier membrane . A
previously diseased root surfaces. Notwithstanding
large portion of these reports incorporate the
histologic documentation, it is important to
utilization of periodontal surgical flap processes [16].
comprehend the clinical reaction to treatment [6].
The search for the holy grail of periodontal
Laser treatment stays dubious in the field of
regeneration remains. Nevertheless all of progresses
periodontics [7]. Lasers of fluctuating wavelengths
referenced above, predictable regeneration of
(635 to 10,600nm) utilized for nonsurgical and
periodontal tissues remains to be an enigma within a
surgical periodontal and peri- implant treatment
conundrum. Puzzling, incongruous, and debateable
include: diode, neodymium: yttrium-aluminum-
as a consequence of an incomplete understanding of
garnet (Nd:YAG), carbon dioxide, Erbium: yttrium-
its mechanism, it remains a lightning rod of on-
aluminium­ garnet (Er:YAG) [8, 9]. It is significant to
going dispute. For more than a generation, dentists
note that lasers of changing wavelengths have
have utilized lasers for a variation of applications in
diverse levels of tissue infiltration relying upon
clinical dental practice. Gregg and McCarthy
reflection, scatter and retention [10]. Along these
introduced research on the use of a specific free -
lines, every treatment must be separately explored
running pulsed neodymium: yttrium­ aluminium ­
with a particular laser. Every laser can't be expected
garnet (Nd:YAG) laser for the management of
Received: 4 / 8/2017 DOI: 10.12816/0040113
Accepted: 13 /8 /2017

Full Paper (vol.691 paper# 15)

c:\work\Jor\vol691_16 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1646-1654

Comparative Study between Measuring FSH, LH and E2 on
Day Two and on Any Day of the Cycle
Shereif A. Hameed, Ahmed H. Salama, Dina H. Salama, Shaimaa M. Ali
Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University
Corresponding author: Shaimaa mohamed <shaimaa1361985@gmail.com>

evaluation of ovarian reserve has become an essential part of the treatment assessment of
woman to undergo assisted reproductive technique. Aim of the Work: this work was conducted to measure
FSH, LH and E2 at any day of the whole menstrual cycle compared to day2 with measurement and
establishing an actual negative correlation between FSH & E2. Patients and methods: observational
analytical prospective study on 50 women attending the Gynecology Outpatient Clinics of Maternity Hospital,
Ain-Shams University in 2016. Results: there was a significant negative correlation between E2/FSH on the 3rd,
5th and 10th days of the cycle. Also there was insignificant negative correlation on day 21. Conclusion: there was
negative correlation between basal day2 E2/FSH which was equivalent or similar to that ratio on days
(5,10,21) so there was no need to wait for hormonal analysis to the next cycle (day 2 or 3) to save time
specially in patients >35years; for them there was importance of cycle day3 for evaluation of ovarian reserve
and prior ovulation induction and subsequent pregnancy potential during the infertility work up.
Recommendations: during the infertility work up, rigid adherence to cycle day3 collection, no longer seems
necessary ,no need to wait for hormonal analysis to Estradiol and FSH to the next cycle as there was
equivalent negative correlation between E2/FSH on menstrual cycle days (3,5,10,21) aiming for saving time.
Key words: FSH, LH, E2, menstrual cycle.

The importance of cycle day 3 FSH for
The concept of ovarian reserve as assessed by
evaluation of ovarian reserve and subsequent
follicle stimulating hormone (FSH) measurement
pregnancy potential has recently been emphasized in
has been proven useful in predicting pregnancy
women >35 years during the infertility workup (1).
outcome (1). Determination of cycle day 3 FSH has
Basal FSH values have been utilized to decide on
evolved as the standard for predicting oocyte
treatment protocols and to counsel patients as to their
quality and the likelihood of conception in assisted
potential pregnancy success (4). Many authors attest to
reproductive technology programmers. The
the importance of cycle day 3 testing (8, 9,10). The
information obtained from cycle day 3 FSH testing
emphasis on cycle day 3 testing seems to have
is invaluable in counselling patients as to their
evolved in part from convenience, based on the cycle
chances of achieving a pregnancy and deciding on
day 3 starts of most stimulation protocols (5).
options for stimulation protocols (2).
According to Hodgen's work (11), early follicular
Muasher et al. (3) demonstrated that basal
growth and recruitment occur in the beginning of the
cycle day 3 concentrations of FSH reflected the
cycle prior to cycle days 5-7. By day 7 the one
reproductive potential of that menstrual cycle. This
follicle destined to ovulate has been selected. Since
could be applied further to discriminate between
the objective in ovarian hyperstimulation for assisted
patients who would be more likely to respond to
reproductive technology is to recruit more than one
ovarian stimulation and those who would not (4).
dominant follicle, stimulation must be initiated prior
Cycle day 3 testing has emerged as a dictum from
to the loss of this multipotentiality of the follicles.
this study because most stimulation protocols were
Before the widespread use of GnRHa, stimulation
initiated on cycle day 3, 4 or 5 (5,6). The validity of
protocols traditionally began on cycle day 3 or 4.
testing on other days has not yet been explored.
Thus, basal testing had to be performed by cycle day
Early follicular phase oestradiol concentrations
3. According to the data of Hansen et al. (12) testing
may reflect die stage of follicular development,
FSH on any of cycle days 2-5 will give equivalent
with higher concentrations associated with
results, regardless of patient age.
asynchrony of follicular development. An abrupt
Ovarian reserve tests (ORT) help to predict
early rise of oestradiol may be a subtle sign of the
the response to exogenous gonadotrophin
shortened follicular phase often seen prior to
stimulation and the likelihood of success with IVF
menopause. The purpose of this study was to
and they are widely accepted as an essential
evaluate the intra- and inter-cycle variability of
element of the evaluation of IVF (13).
serum values of FSH and oestradiol in the early
ORT can roughly be divided into three
follicular phase (cycle days 2-5) (7).
groups: (14)
Received:10 / 6 /2017 DOI: 10.12816/0040114
Accepted: 19 /6 /2017

Full Paper (vol.691 paper# 16)

c:\work\Jor\vol691_17 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1655-1660

Role of MRI Assessment of the Patellar Instability
Mariana Fikry Nashed, Mohammed Amin Nassef, Amir Louis Louka
Radiology Department, Faculty of Medicine, Ain-Shams University
Corresponding author: Mariana Fikry Nashed, Mobile: +201221584200, E-mail: marianafikrynashed@gmail.com

Patello-femoral stability is principally influenced by anatomic factors. Understanding the
anatomy and biomechanics of the patello-femoral joint provides insight on the etiology and management of
patellar instability. Magnetic resonance imaging (MRI) has emerged as an auxiliary method for investigating
patello-femoral instability, particularly for detecting osteochondral lesions and for evaluating the medial
patello-femoral ligament (MPFL).
Objective: descriptive study including analysis of MRI knee done for patients with patellar instability
suspected clinically with or without history of trauma.
Patients and Methods: thirty patients were included in this study, all with suspicious patellar instability
from Ain-Shams University, orthopedic clinic and other private clinics. A cross-sectional study was held
where all the patients under-went MRI routine knee protocol. MRI knee images were interpreted for
identification of different pathologies contributing to patellar instability.
Results: sixty percent of the patients included in our study had MPFL injury, 43% showed patella alta, 83%
showed trochlear dysplasia (by different measurements) and 43% showed lateral displacement of TT.
Conclusion: MRI the modality of choice in diagnosing different pathologies of patellar instability, for its
value in assessing soft tissue structures, detailed imaging of the cartilage and applying all measurement
Keywords: medial patello-femoral ligament (MPFL), tibial tubercle to trochlear groove distance (TT-TG
distance), vastus medialis obliquus (VMO), quadriceps angle (Q-angle).


The patello-femoral joint (PFJ) enhances our
higher-resolution scans, allows a more accurate
ability of knee flexion and extension and it is
study of the patello-femoral joint cartilage surface
assumed to have evolved through men`s ability of
than CT does. Furthermore, it does not involve the
having adopted a bipedal gait. This articulation
use of ionizing radiation and allows measurements
between patella and femur is relatively complex
to be taken at the level of the cartilage rather than
and displays a complicated biomechanical
only at that of the sub
- chondral bone as in
behavior (1).
conventional radiology (4).
The biomechanical characteristics of the
Routine MR imaging protocols are sufficient
patello-femoral joint are the result of a complex
for most pathology related to the extensor
interplay of components. The statics and dynamics
mechanism. The proton density fat suppression
of this articulation involve the geometries of the
sequence, which is universally included in routine
patella and the trochlea, the passive soft tissue
knee protocols, is sensitive for tendon, bone and
restraints of capsule and retinaculum, and the
articular cartilage pathology. The sagittal and axial
coordination of the quadriceps. Additionally,
planes are the most useful for assessing patello-
angular and rotational limb alignment can affect
femoral dysplasia (5).
patello-femoral mechanics and kinematics. Bottom
Increased patellar height (Patella alta) is a key
line, it is all about the balance of the extensor
factor causing patellar instability and is present in
mechanism of the knee (2). The etiologies of
30% of patients with recurrent patellar dislocation.
patello-femoral disorders may be intra-articular
The importance of increased patellar height in the
(trochlear dysplasia, patellar dysplasia), peri-
study of patello-femoral (PF) disorders lies on the
articular (hypoplasia of vastus medialis, patella
reduced engagement`` between the two
alta, increased external rotation of the proximal
articulating bones: the patella and the femoral
tibia with lateralization of the patellar tendon
trochlea, which is necessary to provide to the
insertion) and extra-articular (increased valgus
mechanical stability
positioning of the distal femur, sometimes in
throughout the range of motion, normally the ratio
combination with genu recurvatum and increased
between the patellar tendon length and the
anterior torsion of the femoral neck (3). Magnetic
maximal diagonal measurement of the patella is
resonance imaging (MRI), providing thinner and
between 0.76 and 1.49 (6).
Received: 7 /7 /2017 DOI : 10.12816/0040115
Accepted: 16/ 7/2017

Full Paper (vol.691 paper# 17)

c:\work\Jor\vol691_18 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1661-1667

Evaluation of Tuberculosis Awareness in Eastern and Western Saudi Arabia
Mahdi M Almuhanna1, Mohammed J Busaleh1, Hassan A Alkhalaf1, Yousif T AlMalak1, Zahra A

Alhussain1, Meshal A Almustafa1, Nshwa M Ashor2, Tameem A Alhomaid3, Muhannad M
Aldubaykhi3, Muath S Alshammasi3, Saleh A alghadouni3, Muna J Alhuthali4, Hassan M Alradhwan5,
Mohammed D Alharbi6, Hadeel A AlZiyadi7, Anas S alsamaani8

1King Faisal University, 2KAUH, 3Qassim University, 4Umm Alqura University,
5Wroclaw Medical University, 6Al Imam Mohammad Ibn Saud Islamic University,
7Taif University, 8Qassim Mental Health Hospital

Background: Previously, and specifically at the last period of 20th century, TB was one of the major
leading cause of death. However, the incidence of TB has been decreased. Around ten million cases have
been reported in 2015, 61% of them are recorded in Asia. The yearly incidence rate of TB that is recorded in
Saudi Arabia is 12/100,000. Eradicating TB is the future plan for the entire world, and WHO are intending
to get free TB world. This plan can't be real if general populations are not aware of TB.
Aim: The aim of this study is to assess knowledge, attitude and practice with TB among eastern and
western Saudi Arabia community. Method: That was cross-sectional study. So, participants have been
selected by random sample from public places in eastern and western Saudi Arabia. The tool that we used to
collect data is Self-administrated questionnaire contains demographic part and awareness of TB evaluation
part. Then we compare evaluations results according to many variables specifically the region by Chi-Square
Test. We consider the result of the comparison is significant level once P-value < 0.05.
Result: Around 750 participants in this study (Response rate 93.75%) by mean age 32. Only 3.6% have a
history of TB and 16.8 % have relative with a history of TB. Only 18.1% of participants have good
knowledge, only 15.1% have favorable attitude and most of the participants have a good practice (63.7%).
People with high degree educational level have better knowledge than others. People who have relative with
a history of TB have better knowledge. Females are better in attitude more than male, western populations
have a better attitude than eastern, and people who have relative with a history of TB have a better attitude.
People with high degree education have a better practice than others and people who have relative with a
history of TB have a better practice.
Conclusion: Eastern and western region in Saudi Arabia have a very poor knowledge and Attitude
towards TB, and Western populations have better attitude compared to that of Eastern. Participants have
high percentage of a good practice which still needs to be improved Level of education is an important
factor that may control the level of knowledge about TB.
Keywords: Saudi Arabia, Awareness, Tuberculosis, TB.


Mycobacterium tuberculosis is the bacteria
last record on 2016 done by Saudi General
that cause infectious disease that is mostly
Authority for Statistics) [5,6]. The yearly incidence
affecting lungs called Tuberculosis (TB) [1].
rate of TB that is recorded in Saudi Arabia is
Previously, and specifically at the last period of
12/100,000 according to WHO (World Health
the 20th century, TB was one of the major leading
Organizations) [7]. Like what happened all over
cause of death. And that due to many causes such
the world, TB incidence has been decreased in
as the spread of HIV/AIDs (Human Immune
Saudi Arabia from 2000 AD tell in the present
time. For all that what Saudi government does to
alterations, the growth of populations, migration
fight TB, it is still not fully adequate and
and many other factors [2]. For the time being, the
sufficient. In which WHO's success rate of the
world is still in challenging to control of TB,
treatment target is 85%, and success rate in Saudi
however, the incidence of TB has been decreased
Arabia is 62% recorded in 2014 [5,7,8]. Eradicating
[3,4]. Around ten million cases have been reported
TB is the future plan for the entire world, and
in 2015; 61% of them are recorded in Asia [4].
WHO is intending to get free TB world. And they
When we talk about Saudi country, it is
are intending to reduce TB mortality cases 95%
considered as the third largest country in the
and 90% protecting from new cases between the
Middle East, and has a large number of population
years 2015 AD to 2035 AD [9].
in which they are around 31 million (this is the
Received:5 / 8 /2017 DOI : 10.12816/0040116
Accepted:14 /8 /2017

Full Paper (vol.691 paper# 18)

c:\work\Jor\vol691_19 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1668-1673

Role of Surveillance CT in Detection of Pre-Clinical Relapse in Patients with B-
Cell lymphoma: A Retrospective Study
Ahmad Hassan Soliman ,Shorouq Sabry Rizq Aly
Department of Radiodiagnosis, Faculty of Medicine
Ain Shams University
Corresponding author: Dr.Ahmad Hassan Soliman, MD, Telephone No.:01110009147 e-mail: DrSoliman@hotmail.com

with the evolution of curative treatment regimen, the rate of complete remission achieved in
patients with diffuse aggressive non-Hodgkin lymphoma is continuously rising. It is achievable at the end of
primary treatment in about 60-80%. On the other hand relapse is very common in the 1st two years after end of
primary treatment in diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma, that is to say, about
20-25% of patients relapse after complete response. Use of routine surveillance imaging for relapse detection
is still an area of controversy. Evidence is still lacking to support the utility of routine imaging (namely CT
scan) in detection of pre-clinical relapse in diffuse aggressive non-Hodgkin lymphoma (NHL). This work aims
at adding further evidence to the pool of studies available in the literature which might encourage, or
disapprove the rule of CT as a routine imaging procedures in lymphoma patients who achieved CR.
Objectives: I. To clarify whether surveillance CT scan has a significant role in early detection of asymptomatic
relapse in B-Cell lymphoma patients. II. To assess the contribution of image-based relapse detection to the
overall survival of B-Cell lymphoma patients.
this is a retrospective cohort study in which 50 Patients with B-Cell lymphoma diagnosed between
2014 and 2016 were selected from the PACS of Radiology Department at Ain Shams University Hospitals.
Age ranges between 20 and 70 year-old. All diagnoses were confirmed by histopathology studies. All patients
underwent treatment and follow-up strategy as planned by their treating oncologist/hematologist, after which
they entered CR or SD according to IWG Cheson criteria of treatment response. Disease progression was
retrospectively reviewed over a period of 6 months up to 2 years. Surveillance CT scan was performed on the
neck, chest, abdomen and pelvis on each of the planned follow-up visits. Relapses were defined as
"asymptomatic" if there were no reported symptoms and a normal examination was recorded.
Results: the most common cause of relapse detection was patient-reported symptoms alone (41%) or in
combination with abnormal blood tests and/or physical examination (23%). Routine imaging was responsible
for relapse detection in 27% of the patients. The unadjusted median OS for patients with imaging-detected
relapse was 90 months versus 38 months for patients non imaging-detected relapse (P = 0.0008). Although
surveillance imaging proved no significance in detection of pre-clinical relapse, our regression analysis
showed that it remained significantly associated with reduced risk of death.
Conclusion: clinical symptoms remain the leading factor in diagnosing recurrent lymphoma in the era of
modern imaging, and this study questions the clinical relevance of current practice. A possible survival
advantage was seen for patients with image-detected relapse.
Non-Hodgkin lymphoma, Relapse, CT scan.


detection, staging and response assessment is
Non-Hodgkin lymphoma (NHL) is a fairly
always making the highlights, with relapse detection
common tumor that accounts for 4.3% of all new
being of major concern, especially with the new
cancer cases per year in USA. Its incidence is
curative methods made available for relapsed cases.
almost doubling annually (1). In Egypt, lymphoma is
The high risk of radiation induced malignancies
the fourth most common tumor in adults, with B-
associated with frequent radiological follow-up
Cell lymphoma being the commonest subtype of
scans for those long term survivors also raised the
NHL accounting for about 49% of all NHL cases
red flag for re-establishing a risk-benefit oriented
presenting to NCI (2).
follow-up plan for those patients (3).
With such a disease burden, and about one
Careful history taking, thorough physical
third relapsed NHL patients after complete
examination and good clinical judgment are the
remission, on-going research on new methods of
cornerstones of an appropriate follow-up. Many
Received:8 / 4 /2017 DOI : 10.12816/0040117
Accepted:17 / 4 /2017

Full Paper (vol.691 paper# 19)

c:\work\Jor\vol691_20 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1674-1679

Radioembolization in Treatment of Hepatocellular Carcinoma with
Portal Vein Invasion
Elsahhar Ahmed Hetta, Osama Mohamed Abdel Hameed, Aly Haggag Aly Noreldien
Radiodiagnosis Department, Faculty of Medicine, Ain Shams University
Corresponding author: Ahmed Elsahhar,Ahmedelsahhar90@gmail.com,Telephone: 01007770738

Aim of work:
this study aimed assess the efficacy of radioembolization (Yttrium-90) therapy in
Hepatocellular carcinoma (HCC) patients with portal vein thrombosis.
Patients and methods: this study included 24 patients diagnosed with HCC and portal vein invasion to be
treated with Transarterial Radioembolization (TARE). They were 17 males and 7 females. Patients received
a single course of treatment.
Results: tumor radiological response assessment revealed that the tumor was controlled in 92% of the
patients. Complete response was observed in 21 % of the patients, partial response in 29 % of the patients,
stable disease in 42 % of the patients and progressive disease in 8% of the patients.
Conclusion: Yttrium-90 radioemblization appeared to be an effective, safe and feasible treatment option for
patients with hepatocelluar carcinoma with portal vein invasion.
Keywords: radioembolization, Yttrium-90, hepatocellular carcinoma, portal vein thrombosis.


Hepatocellular carcinoma (HCC) is one of the
most common cancers. Overall incidence is more
This study included 24 patients diagnosed with
than a million cases every year and it is
HCC with portal vein invasion to be treated with
increasing over the last decade (1). Portal vein
tumor thrombosis (PVTT) is a poor prognostic
Patients provided written informed consent
factor for HCC. PVTT is present in 10%-40% of
before treatment.
HCC at the time of diagnosis(2).
Management of hepatic malignancy is a
Inclusion criteria
challenging clinical problem involving several
patients with: (1) HCC by imaging or pathology
different medical and surgical disciplines.
(2) nonsurgical candidate; not fit for
Because of the wide variety of potential
radiofrequency or TACE (3) noncompromised
therapies, treatment protocols continue to evolve.
pulmonary function (assessed by the history of
Consequently, development of appropriate
severe chronic obstructive pulmonary disease,
therapeutic algorithms necessitates consideration
physical examination); (4) able to undergo
of medical options, such as systemic
chemotherapy; surgical options, such as resection
catheterization; (5) Portal vein thrombosis (6)
or transplantation; and locoregional therapies,
tumor less than 70% of the total liver volume (7)
such as thermal ablation and transarterial
embolization. Internal radiation therapy through
count 1.5 × 109/L,
platelets 50 × 109/L),
transarterial delivery of beta-emitting yttrium-90
renal function (serum creatinine 2.0 mg/dL);
(90Y)-loaded microspheres, is an emerging
technique for the treatment of patients with
bilirubin 2.0 mg/dL).
unresectable primary liver tumors.
Exclusion criteria
The microspheres lodge preferentially
(1) other planned therapy systemic/locoregional
within the neovessels of the tumor(s) and deliver
therapy for their HCC (2) liver cell failure (serum
high-energy radiation over a limited range (mean
total bilirubin > 2.0 mg/dL); (3) evidence of any
penetration of radiation into tissues is 2.4 mm),
uncorrectable flow to the gastrointestinal tract
thereby minimizing the radiation exposure to
observed on angiography or technetium-99m
normal liver parenchyma(2). Radioembolization
macroaggregated albumin scan; (4) greater than
may be used for the treatment of unresectable
30 Gy (16.5 mCi) estimated to be delivered to the
HCC in patients with branch/partial portal vein
lungs in a single administration or 50 Gy on
thrombosis (3).
Received: 10 / 7/2017 DOI : 10.12816/0040120
Accepted: 19/ 7/2017

Full Paper (vol.691 paper# 20)

c:\work\Jor\vol691_21 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1680-1691

Role of Diffusion Weighted MRI Sequence in Evaluation of
Ahmed H. E. Ismail1, Yasser A. M. Abd El Mawla2, Amr M. Abd El Samad2, Mohamed F. Hussein1
1Theodor Bilharz Research Institute, 2Faculty of Medicine, Ain Shams University
Corresponding author: Ahmed Hamdy El Sayed dr.ahmed.hamdy.elsayed@gmail.com

: cholangiocarcinoma requires accurate diagnosis, which relies on appropriate imaging and
image-guided biopsy. Diffusion weighted MRI is a relative new and increasingly used technique. It can be
obtained during a single breath-hold, there is no need to use contrast media and it provides information that
reflects tissue cellularity and organization. ADC maps can provide quantitative measurements of tissue water
diffusivity. It proved to be helpful in the characterization of cholangiocarcinoma.
Keywords: magnetic resonance imaging; diffusion weighted imaging; biliary tract, cholangiocarcinoma,

resonance cholangiopancreatography (MRCP) has
Diffusion-weighted magnetic resonance imaging
been found to be accurate for diagnosis of
(DWI) provides information on the random
biliopancreatic diseases. The role of DWI for the
(Brownian) motion of water molecules in the body.
evaluation of biliopancreatic diseases is not yet well
It is well established that DWI is a useful tool for
established. However, because DWI yields
the evaluation of intracranial diseases, such as acute
qualitative and quantitative information reflecting
stroke. The development of phased-array surface
cell membrane integrity and tissue cellularity, DWI
coils, high-gradient amplitudes and rapid imaging
can be used to differentiate normal and abnormal
techniques such as echo planar imaging (EPI) and
structures of tissues better, and thus may help in the
parallel imaging have been instrumental in allowing
characterization of various abnormalities in the
the extracranial application of DWI(1-3). The degree
biliopancreatic tract when added to conventional
of restriction to water diffusion in biological tissues
MRI [11]. In this article, we briefly reviewed the
is directly proportional to tissue cellularity and the
basic concepts for the biological basis of DWI and
integrity of cell membranes. In tissues with a high
its technical considerations.
cell density and associated with many intact cell
Additionally, we illustrated clinical applications
membranes, such as malignant tumors, the motion
of DWI for the following: evaluation of the
of water molecules is more restricted than in less
biliopancreatic tract, including stone-related
cellular tissue. The degree of water motion is found
complications such as acute cholangitis, hepatic
to be proportional to the degree of signal
abscesses, and acute gallstone pancreatitis;
attenuation in DWI. Thus, more cellular solid
characterization and diagnosis of gallbladder
tumors show relatively higher signal intensities and
exhibit lower apparent diffusion coefficient (ADC,
expressed in mm2/s) values on DWI using two or
characterization of intrahepatic biliary lesions and
more b values than do less cellular tissues.
diagnosis of malignant lesions in the intrahepatic
Recently, this utility of DWI has been expanded to
bile ducts; and characterization of extrahepatic
examination of abdominal organs; the ADC values
biliary lesions and diagnosis of malignant lesions in
of malignant masses are significantly lower than
the extrahepatic bile ducts, including extrahepatic
those of benign masses in the liver, pancreas,
cholangiocarcinoma, pancreatic carcinoma, and
kidney, and prostate, although there is a small
focal pancreatitis.
degree of overlap [4-9]. Most previous studies on

DWI have been limited to the evaluation of diffuse
parenchymal abnormalities and focal lesions in
In biological tissue, the diffusion of water
abdominal organs, whereas there are few studies
molecules is impeded or restricted by natural
about DWI for the evaluation of the biliopancreatic
barriers, such as cell membranes, large protein
tract [10]. To date, contrast-enhanced magnetic
molecules, and tissue cellularity. Pathological
resonance imaging (MRI) combined with magnetic
conditions, such as tumors, cytotoxic edema,
Received: 12 / 6 /2017 DOI : 10.12816/0040118
Accepted:21 /6 /2017

Full Paper (vol.691 paper# 21)

c:\work\Jor\vol691_22 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1692-1697

Effect of Sublingual Misoprostol on Intraoperative Blood Loss During
Abdominal Hysterectomy: Randomized Controlled Trial
Makled A K, Alsaied A, Ismail O , Farhan S.
Department of obstetrics and gynecology- Ain Shams University

To investigate whether the use of preoperative misoprostol can reduce blood loss during total
abdominal hysterectomy (TAH).
Methods: In a randomized single-blind placebo-controlled trial at Ain Shams university maternity hospital,
between May 2016 and June 2017, women (n = 118) undergoing TAH with or without bilateral salpingo-
oophorectomy for symptomatic myomas were randomly allocated to receive either 400 g of misoprostol or
placebo 30 minutes before surgery.
The primary outcome measure was postoperative drop in hemoglobin.
The secondary outcomes were intraoperative blood loss, need for blood transfusion, and incidence of adverse
effects. Results: The 2 groups were similar with regard to demographic and clinical characteristics. There was a
significant reduction of blood loss during TAH after sublingual administration of misoprostol compared with
placebo before surgery (355.1 mL vs 531.4 mL; P < 0.001). The mean postoperative hemoglobin concentration
was higher (11.1g/dL vs 10.7 g/dL; P < 0.015) and the postoperative drop in hemoglobin was smaller (1.2 g/dL
vs 1.8 g/dL; P < 0.001) in the misoprostol group than in the placebo group.
No significant adverse effects occurred in either group.
Conclusion: The results showed that a single dose of misoprostol administered before abdominal hysterectomy
resulted in a significant reduction of blood loss with minimal adverse effects.
Keywords: Blood loss, Misoprostol, Total abdominal hysterectomy.

Although injection of vasopressin in the lower
Hysterectomy is the surgical removal of the
uterine segment was found to be beneficial in
uterus. It is the most frequently performed major
gynaecological surgical procedure, with millions of
hysterectomy, serious complications such as
procedures performed annually throughout the
hypotension, myocardial infarction, and cuff
world (1).
cellulitis have been reported after use of this drug
Hysterectomy can be performed for benign and
Misoprostol, a synthetic analogue of
malignant indications. Approximately 90% of
prostaglandin E1, has been extensively evaluated as
hysterectomies are performed for benign
an uterotonic agent in obstetrics mainly for
conditions, such as fibroids causing abnormal
prevention and management of postpartum
uterine bleeding; other indications include
hemorrhage and reduction of bleeding during
cesarean delivery (6).
dyspareunia and prolapsed (2).
The misoprostol tablet is very soluble and can
Hemorrhage requiring blood transfusion is one
be dissolved in 20 minutes when it is put under the
of the most frequently cited complications of total
tongue. The peak concentration is achieved about
abdominal hysterectomy, occurring in 2%­12% of
30 minutes after sublingual administration, a
cases (3).
sublingual dose achieves a higher peak
Various methods had been adopted by
concentration than that of oral and vaginal
researchers to lessen blood loss during TAH.
administration. This is due to rapid absorption
Preoperative administration of gonadotropin-
through the sublingual mucosa as well as the
releasing hormone (GnRH) analogs have been
avoidance of the first-pass metabolism via the liver
found to be effective in reducing the size and
(7). Among non-pregnant women, misoprostol has
vascularity of large myomas; however, significant
been used for cervical priming before trans-cervical
adverse effects like hot flushes and osteoporosis
procedures (8), and for reducing blood loss in
have been reported after its use (4) .
myomectomy (9) and laparoscopy-assisted vaginal
hysterectomy with promising results (10).
Received: 9 / 7/2017 DOI : 10.12816/0040119
Accepted:18 /7 /2017

Full Paper (vol.691 paper# 22)

c:\work\Jor\vol691_23 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1698-1705

Review of Microtia: A Focus on Current Surgical Approaches
Nujaim H. Alnujaim1, Mohammed H. Alnujaim2
1Division of Plastic and reconstructive surgery, Department of Surgery,
King Saud University, Riyadh, Saudi Arabia
2College of Medicine, King Saud University, Riyadh, Saudi Arabia
Corresponding author: Dr. Nujaim Hamad Alnujaim, Tel: +966506688244, Email: Nujaimhs@gmail.com

A wide spectrum of anomalies may involve the auditory system. As a visible structure, auricular
malformations constitute a great burden. A wide set of anomalies may affect the ear including the microtia
spectrum, protruding ears (bat ear), constricted ear (Lop and Cup ears), Stahl ear, and cryptotia. In plastic
surgery practice protruding ears and microtia are common presentations. Microtia literally means small ears.
Microtia is a spectrum of anomalies of the auricle that range from disorganized remnant of cartilage attached
to soft tissue lobule to complete absence of the ear (anotia). Ear reconstructive procedures has made in impact
in the lives of these patients. The early attempts to surgically restore the ear in microtia was in 1920 using a
rib cartilage. Up to 49% of microtia cases are associated with other anomalies or a known syndrome. The
most common syndromic associations are hemifacial microsomia, Towens Brocks syndrome, Treacher
Collins, Goldenhar and Nager syndrome.
Oculo-auriculo-vertebral spectrum (OAVS). Generally, the ear can
be retrieved by two possible methods: Surgical reconstruction using autologous or alloplastic cartilage and
the use of prosthesis which could be adhesive or implant retained. Surgical reconstruction proved to be
superior to other methods due to its longevity and less complications. The only limitation is the skill of the
surgeon. Ear prosthesis are reserved for special cases including traumatic anotia in adults.
Microtia, Reconstruction, Malformation, Nagata, Brent.

affect the size, number and configuration of the
Congenital deformities may involve any part
ossicles. In addition, middle ear space and
of the body, of which those involving the
configuration are occasionally malformed 4. Minor
craniofacial skeleton constitute a much greater
Middle ear anomalies are exclusive to the middle
burden. A study by Weerda et al. 1states that the ear
ear and do not involve the tympanic membrane or
is more likely to be congenitally malformed
the external ear and are classified by Teunissen
compared to the nose and throat due to the complex
and Cremers in 1993 based on surgical approach
embryology of the ear. Ear malformation may
into four main groups: isolated stapes ankylosis,
involve the outer auricle, external auditory canal,
stapes ankylosis associated with other ossicular
middle and inner ear. Most of outer and middle ear
malformations, deformity of the ossicular chain
malformations are right sided and unilateral, while
with mobile stapes footplate, and severe aplasia or
inner ear malformations can be unilateral or
dysplasia of oval or round windows 5. Inner ear
bilateral 1, 2, 3 . Different parts of the human ear
malformations are either due to arrested or
develop separately as such a combination of outer,
abnormal development and include Michel
middle and inner ear deformities are quite rare. A
combined ear deformity described by Swartz and
aplasia/hypoplasia, common cavity, incomplete
Fearber et al. 2 known as atresia auris congenita
partition, and large vestibular aqueduct (LVA)
where the outer and middle ears are malformed and
syndrome 6 .
occasionally the inner ear. A wide spectrum of
Despite the morbidity associated with middle
anomalies may involve the auditory system. The
and inner ear congenital anomalies in terms of
auricle may be malformed in terms of orientation,
effect on hearing, the auricle a visible part of the
size and position. The external auditory canal can
auditory system contributes significantly to facial
be aplastic or hypoplastic. The middle ear
beauty. Therefore, a normal structure and position
structures including the ossicles, round and less
of the auricle is preferred to maintain a desirable
likely the oval window can be malformed.
appearance. Various congenital malformation may
Congenital ossicular malformation are described to
affect the auricle and cause a long-lasting
Received:1 /7 /2017 DOI : 10.12816/0040136
Accepted: 10/7 /2017

Full Paper (vol.691 paper# 23)

c:\work\Jor\vol691_24 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1706-1712
Awareness Level of Parents about Antibiotics Those Are Given to
Children in Riyadh Region 2017
Ali H Alhawaj1, Fay S Al-Dossari2, Najd R AlMudaiheem2, Mohammed N ALMusaad3, Mohammed
D Alharbi3, Hassan A Alkhalaf4, Mohammed A Al-Taweel4, Muath S Alshammasi5, Mohammed F
ALMujalli3, Esraa M Bakhsh2, Nawal S Alosaimi6, Asma A Altalhi7, Aminah H AlAli6, Naif A
Alajji8, Hadeel A AlZiyadi7, Nourah A Alsumairi7, Maram M Aljohani9.
1Ibn Sina National College for Medical Studies, 2Princess Nourah Bint Abdulrahman University,
3AL Imam Mohammad Ibn Saud Islamic University, 4King Faisal University, 5Qassim University, 6Umm
AlQura University, 7Taif Universty, 8King Saud University, 9King AbdulAziz University

Defect of use of antibiotics is bothering pediatricians. This defect is participating in the
prevalence of one of global health problem called antibiotic Resistance. Many articles are supporting the
idea that use of antibiotics is positively related to antibiotic resistance and this problem is increasing and
growing up. By the way, incorrect use of antibiotics has many factors that contribute on, like patient
attitude and deficiency of education from the physician who prescribed the antibiotic. Also, patient's
knowledge and practice with the antibiotic like self-prescription. What is patient expecting from antibiotic
and previous experience with antibiotics? Parents are responsible to give medications to children. So, we
need to increase parents' knowledge, attitude and practice (KAP) toward antibiotics to reach new
generation without antibiotic resistance. Regarding Saudi Arabia, antibiotic resistance already exists and
the rate of resistance is increased in the last decade. Aim of the work: To assess how parents are aware of
antibiotics those given to their children by evaluating knowledge, attitude, and practice of parents in
Riyadh region, central Saudi Arabia.
Methods: This is questionnaire based cross-sectional study. Authors were circulating on Riyadh Region to
find volunteers to fill questionnaires among parents of children in public places by selecting parents of
children up to 12 years old by choosing random samples from each place. The questionnaire has two parts:
the first part, as usual, is containing demographic data. While the second part: is the part that is evaluating
KAP of parents towards antibiotics. Then we compared the final results by Chi-Square test and p-values
less than 0.05 was considered as significant value.
Results: around 1058 parents volunteered to participate in this study (response rate was 88.16%) by mean
age of 38. Around 89.6% used antibiotics for their children before. There are 9.5% of parents were believe
that their children need antibiotics each time they get sick. More than 35% of our participants don't
complete period of antibiotic use to their child as what is mentioned on prescription. About 82.3% believe
that antibiotics can harm children. There are 41.7% of parents bought antibiotics to their children from the
previous prescription. Around 61.1% don't know the term antibiotic resistance. There are 28.4% of
participants could change their doctors if they don't prescribe antibiotics easily, while only 642(60.7%)
could change their doctors if they prescribe antibiotics excessively. About 68.1% of participants believe
that doctors prescribe antibiotics excessively. Nearly 49% have good KAP, 41% of participants have
intermediate KAP and remaining 10% have poor KAP. Females are better than male in KAP, people with
high degree education are better than other and parents who used antibiotics before are better than those
who didn't (p-value < 0.05).
Conclusion: Level of knowledge, attitude, and practice of people in Riyadh region is ranging between
good to moderate, and tends to be good. We can expect antibiotics resistance to happen among new
generation in Riyadh region. There is an unacceptable idea that is highly prevalent among parents that
doctors excessively prescribe antibiotics. Moreover, mothers have better awareness than fathers. People
with high degree level of education have better awareness than others.
Keywords: Antibiotic, AMR, Saudi Arabia, KAP, Antibiotic resistance.

their children from getting harm by anyway.
We can begin our study by considering
Antibiotics (AB) can be one of these harms. In
pediatric clinics as educational classes for parents
which the treatment of children depends on
more than clinics. So, we (as doctors) are
perceptions of parents. Even though, antibiotics
responsible to educate parents how to protect
are one of best and biggest discovery of century
Received: 6 / 7/2017 DOI : 10.12816/0040137
Accepted:15 /7 /2017

Full Paper (vol.691 paper# 24)

Summary The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1713-1722

Corneal Endothelial Changes after Iris-Claw Anterior Chamber Phakic
Intraocular Lens Implantation
Magdy E. Khallaf1, Hassan M. Bayomi2, Taha A. Farouk3
1,2,3Department of ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Compared to other refractive surgeries, implantation of phakic intraocular lenses (pIOL) have
more desirable results and are potentially reversible procedures due to the possibility of explanting these
lenses. These methods usually do not require expensive or special surgical equipment and most
ophthalmologists are able to perform these procedures., however disabilities resulting from pIOL are more
severe compared to corneal refractive surgery. Due to the potential risk of damage to anterior segment
structures, especially corneal endothelial cell loss, pIOL implantation is subjected to debate.
Aim of the Work:
To evaluate the endothelial cell count changes in eyes implanted with the iris-claw phakic
lens for treatment of moderate to high myopia as regard changes in cell density.
Patients and Methods: This study included Ten eyes of patients with moderate to high myopia implanted
with The Iris-Claw Anterior Chamber Phakic Intraocular Lens at Al-Hussein University Hospital, In this
prospective randomized study we did Preoperative specular microscopy and serial postoperative specular
microscopy (Topcon SP- 1P, Topcon Medical Inc., Japan).) were performed to evaluate endothelial cell count
changes over 6 months. Endothelial cell images were collected in the central region of the cornea before
surgery and 1 and 6 months after surgery. The main outcome measures were central corneal ECD and the
percentage of corneal endothelial cell loss. Secondary outcome measures were UCVA, BCVA, manifest
refraction, and complications.
Results: Preoperative mean endothelial cell count was 3198.50 ± 444.67 cells/ mm² (range, 2715.00 ­
3846.00 cells/ mm²)., it was 3074.50 ± 410.76 cells/ mm² (range, 2609.00 ­ 3686.00 cells/ mm²) at 1 month
after surgery., 3003.00 ± 411.91cells/ mm² (range, 2532.00 ­ 3610.00cells/ mm²) at 6 months after surgery.
The mean endothelial cell loss was 6.07% at the end of the follow up period with 3.79% at one month
postoperative, 2.37% from one to six months postoperative. The mean BCVA improved from 0.27 ± 0.09
preoperatively to 0.44 ± 0.12 postoperatively and the mean UCVA, from 0.02 ± 0.01 to 0.33 ± 0.09
postoperatively, the mean SE was -0.93 ±0.57 D Postoperatively.
Conclusion: Artisan phakic IOL had excellent results including., their suitability for high myopes,
reversibility, high optical quality, predictability, safety, efficacy, potential gain in visual acuity in myopic
patients and did not produce significant corneal endothelial cell loss 6months after surgery.
Keywords: phakic intraocular lenses, endothelial cell loss, high myopia.

Thus, in the absence of contraindications, the
safest and most effective procedure for treating
management challenge. Surgical options such as
young patients with moderate-to-high refractive
refractive lens exchange are less desirable in younger
errors and/or low corneal thickness is phakic
patients as they result in the total loss of
intraocular lens (pIOL) implantation. This is a
accommodation and a higher risk of retinal
detachment. Another option is excimer laser
accommodation and corneal architecture, is
treatment, effective in the correction of low-to-
potentially reversible, and has outcomes that are
moderate myopia. However, high refractive errors
more predictable, with faster recovery than excimer
are beyond the boundaries of safety and effectiveness
surgery (1). The iris-claw or lobster-claw lens was
of corneal surgery. Even with wavefront-optimized
first designed by Worst in 1977 for aphakic eyes(3).
and wavefront-guided treatment, common concerns
Later, in1986, Worst and Fechner modified this
include lower predictability of the refractive
IOL to a biconcave anterior chamber lens for the
outcome, postoperative refractive instability, and the
correction of myopia. To increase the safety of this
risk of postoperative ectasia(1) .
IOL and minimize the possibility of IOL-cornea
A healthy corneal endothelium is essential to
contact(4), in 1991 the biconcave design was
maintain corneal clarity. Corneal endothelial safety
changed to a convex- concave model with a
has been a main concern not only regarding
lower shoulder, a thinner periphery, and a larger
intraocular refractive procedures, namely phakic
optic diameter (5.0mm) to reduce photopic
intraocular lens (pIOL) implantation, but also
phenomena. This lens, called the Worst myopia
regarding corneal refractive surgery (2).
claw lens, has been implanted successfully since
Received:10 /6 /2017 DOI : 10.12816/0040138
Accepted: 19/ 6 /2017

Full Paper (vol.691 paper# 25)

c:\work\Jor\vol691_26 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1723-1737

Clinicoepidemiological Study and Survival Analysis of Right versus Left Sided
Colon Cancer Patients
Rokaya. M. Regeai*, Amr. L. Faraj**, Amr. S. Tawfik***, Nesreen. A. Mosalam****
Clinical Oncology and Nuclear medicine department, Ain Shams University Hospitals. Egypt.
Corresponding Author:Rokaya.M.Regeai: tele; 00218923313490, E-mail; Salem200612@gmail.com

Recently, there is a great attention, about the clinicopathological differences between right
and left colon cancer, and how much these differences will affect the outcomes of colon cancer patients.
Many epidemiological studies have demonstrated, that tumor at the right and left colon, respectively,
occur with different incidence in diverse region of the world. Differences in clinical presentation,
patient's demographics, and tumor biology between right- and left- sided colon cancers have long been
reported in the literatures.
Methods: The current study was conducted in Clinical Oncology and Nuclear medicine department, Ain
Shams University Hospitals, during the period from January 2011 to December 2015, data on all patients
histologically confirmed with colon cancer, were evaluated right-and left-sided cancers were compared
with regard to epidemiological, clinical and pathological parameters as well as survival data.
Results: The study showed that, there was 129 patients, 70(54.2%) patients had left-sided colon cancers
and 59(45.7%) patients had right-sided colon cancers, most of the cases were aged above 50 years 61.2%.
Histopathological type was mainly adenocarcinoma 72.09%, moderately differentiated 79.8%, the
mucinous carcinoma was more in right sided colon 56.25%. Comparison of progression free survival in
stage IV, showed higher progression rate (58.3%) in right sided patients, than left sided patients (41.6%),
this difference was not statistically significant. We also found that patients with right-sided colon cancer
had a statistically significantly worse overall survival (OS) P value=0.019, than patients with left-sided
colon cancer. We demonstrated that the differences in OS were significant only in patients with stage IV
colon cancer.
Conclusion: In conclusion, our results support evidence that there are differences in the biology and
outcomes for right- and left-sided colon cancers. Significantly better survival is seen for metastatic colon
cancer with a left-sided, and this was confirmed by multivariate analysis. This might have been due to
several environmental and lifestyle factors, which contributed to this anatomical shift. The differences in
genetic and molecular pathologic profiles in each side of the colon were observed. Stratification based on
the primary site should be considered in the future for trials assessing survival for colon cancer.
Keywords: Right colon cancer; Left colon cancer; Differences; Outcome.

genes, environmental mutagens, and gut flora,
Colorectal cancer (CRC) is the third most
little is known on how these differences may
common tumor in men and the second in women,
affect mechanisms of tumorigenesis side specific
accounting for 10% of all tumor types worldwide,
therapy response or prognosis(3,4).
CRC is the fourth most common cancer-related
The data show that patients whose primary
cause of death in the world. In Egypt (CRC) is
tumors originate on the left side of the colon (the
approximately the 8th most common cancer, and
descending colon, sigmoid colon, and rectum)
according to the estimated results of national
survive significantly longer than those whose
population based registry program the estimated
tumors originate on the right side (the cecum and
number for colon and rectal cancer cases in 2015
ascending colon), Even in KRAS-Mutated
is 3.055 and 922 respectively (1,2).
Tumors, Left-Sided Tumors Are Associated With
The left and right colon have different
Improved Survival . Several recent studies
embryologic origins, the left colon being from the
have reported that the location of CRCs is
foregut and the right from the midgut, and
associated with response to anti- epidermal
different blood supplies, Therefore, left- and
growth factor receptor (EGFR) antibody. All
right-sided colon cancers are distinct genetic
these studies found that left-sided CRCs are
entities . Background differences exist between
associated with more favorable responses and
the proximal and distal colon in terms of
prognosis than are right-sided. However, the
developmental origin, exposure to patterning
mechanism(s) for this phenomenon has not been

identified (5,6).

Received:4 / 7 /2017 DOI : 10.12816/0040139
Accepted: 13/ 7 /2017

Full Paper (vol.691 paper# 26)

c:\work\Jor\vol691_27 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1738-1747
Role of Transvaginal Contrast Enhanced MRI in Early Detection and Staging
of Cervical Cancer: A Review
Nermeen Mostafa Abd Elmonam Ali, Faten Mohmed Mahmoud Kamel,
Mennatallah Hatem Shalaby
Department of Radio Diagnosis, Faculty of Medicine, Ain Shams University

Cervical cancer is the second most common gynecologic malignancy. It usually takes years for pre-cancerous changes to
turn into cervical cancer. This pre-cancerous changes when detected is 100% treatable. Accurate cervical cancer staging is
crucial for appropriate treatment selection and treatment planning. The greatest difficulties in the clinical staging are the
estimation of tumor size, especially if the tumor is primarily endocervical in location. MRI has excellent soft-tissue contrast
resolution, which exceeds that of CT and US. Consequently, MRI is significantly more valuable in the assessment of the size
of the tumor, the depth of cervical invasion, and the local-regional extent of the disease.

Aim of the Study: to highlight the role of transvaginal contrast enhanced MRI in the early detection&
staging of cervical cancer to guide for accurate management.
Conclusion: High-resolution MRI is accepted as optimal for evaluation of the main prognostic factors and
selection of therapeutic strategy for cervical cancer.
Keywords: Cervical cancer, MRI, oncologic imaging, gynecologic carcinoma.

is slightly extending into the proximal vagina. Use
Cervical cancer is the most frequent gynecologic
carcinoma in women under 50 years of age and the

third most common gynecologic malignancy in
vaginal contrast medium is an easy, well tolerated,
postmenopausal women following endometrial and
and effective method to better delineate the borders
ovarian cancer (1).
of the tumor. It increases the specificity and
Staging and early detection of cervical
accuracy of MR staging by showing the exact
carcinoma have a great importance in management.
relation of the tumor with the vaginal wall (5).
The most widely used staging system is the FIGO
Application of endovaginal coil MRI is useful
(International Federation of Gynecology and
for obtaining high resolution images of the cervix,
Obstetrics), which distinguishes four stages of
important in defining tumors less than 1cm3
cervical cancer This staging system was introduced
volume and clarifying the extent of tumor invasion
before the advent of modern imaging modalities
and hence differs from all other classifications of
Using high-resolution magnetic resonance
gynecologic tumors in which it is still based on the
imaging (MRI) with a special vaginal coil was
results of bimanual palpation(2).
designed specifically to image the cervix and
MRI has been shown by a number of studies to
enabled measurement of diffusion of water within
be the most reliable imaging modality in the
the tissue cells. The researchers found that the
evaluation of cervical cancer and in treatment
diffusion of water was reduced in cancerous tissue
planning. It has the advantages of direct tumor
compared to normal tissue . This remarkably eases
visualization, accurate assessment of the depth of
the early detection of early stage cervical cancer (7).
stromal invasion , tumor volume, and lymph node
The study was approved by the Ethics Board of
Ain Shams University.
MRI has been considered to play a significant

role for more detailed and non-invasive mapping. It
Pathology of Uterine Cervical Carcinoma
has increasingly been utilized in cervical cancer
Incidence statistics
staging ,MRI presents an excellent imaging
Worldwide, uterine cervical carcinoma is
resolution for the different densities of pelvic
structures, does not require ionizing radiation is
malignancy. The incidence of invasive cervical
comfortable for the patient improves the staging,
cancer is higher in low-income countries due to
allowing the early detection of recurrence(4).
lack of screening programs. In developed
MRI staging in early cervical cancer may be
countries (8) .The incidence of invasive cervical
difficult and overestimated, especially if the tumor
cancer dropped after implementation of the
Received: 16 / 7 /2017 DOI : 10.12816/0040140
Accepted:25 / 7 /2017

Full Paper (vol.691 paper# 27)

c:\work\Jor\vol691_28 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (1), Page 1748-1756
Magnetic Resonance Spectroscopy in Evaluation of Multiple Sclerosis
Mustafa Al Hassan Abdou Heidar, Iman Soliman Metwally, Tougan Taha
Department of Radio Diagnosis, Faculty of Medicine, Ain Shams University

MS is a diffuse immune-mediated inflammatory disease that evolves over time; it's characterized by the presence
of CNS lesions disseminated in space and time. Plaques of inflammatory demyelination within the CNS are the
pathologic hallmark of MS. 1H-MRS is a noninvasive imaging technique that's promising as diagnostic technique
for MS as well as a good marked for immune-modularity therapy response and as a predictor for clinical disability
in MS. Aim of the Study: To highlight the value of MR spectroscopy in evaluation & monitoring patients with
multiple sclerosis and how MR spectroscopy can add valuable information to conventional MR.
Keywords: Multiple sclerosis, MR, MS, 1H-MRS.


Multiple sclerosis (MS) is a complex autoimmune
1H-MRS permits the in-vivo study of certain cerebral
disease with a heterogeneous presentation and diverse
metabolites thus it offers the possibility of
disease course.
greater pathological specificity in lesional areas of MS
Recent studies indicated a rising prevalence of MS
as well as in normal appearing white matter and even
in the Middle East, MS affects individuals during the
in the gray matter(4).
most productive time of their lives, and directly limits
The 1H-MRSI sequence allows an in- vivo evaluation
their work capacity, leading to major social and
of different cerebral metabolites associated with
economic consequences; The mean age at MS onset is
cellular and functional processes. Among the
26.61±7.82 years, With female dominance. With
metabolites determined with this technique are the
(female: Male) ratios of (2.14:1) (1).Multiple sclerosis
following: (1) N-acetylaspartate (NAA), which is
(MS) is characterized by loss of motor and sensory
synthesized in the neuronal mitochondria and is
function that results from immune-mediated
considered a marker of neuronal body and axonal
inflammation, demyelination and subsequent axonal
integrity depending on transient (mitochondrial
damage. MS is one of the most common causes of
dysfunction) or permanent reduction of NAA
neurological disability in young adults (2).
(irreversible neuronal and/or axonal injury) (5).
Magnetic resonance imaging (MRI) has
The extended use of 1H-MRS in clinical
revolutionized the diagnosis and management of
settings has been hampered by its technical demands.
patients with multiple sclerosis (MS). Metrics derived
However, because of its ability to assist in
from conventional MRI are now routinely used to
simultaneous evaluation of different events involved in
detect therapeutic effects and extend clinical
MS pathogenesis that cannot be determined by cMRI,
observations. Conventional MRI measures have
1H-MRS could become an important tool to decipher
insufficient sensitivity and specificity to reveal the true
the sequence of the immunologic cascade and to
degree of pathologic changes occurring in MS. T2-
evaluate the response to new disease-modifying agents,
weighted and T1-weighted imaging cannot distinguish
including neuroprotectants. The use of the
between inflammation, edema, demyelination,
abovementioned nonconventional MRI biomarkers
Wallerian degeneration, and axonal loss.
could lead to a better understanding of different aspects
Nonconventional MRI techniques are now
of the disease process and play a key role in early
emerging and proving to be more related with the most
diagnosis and prognosis of the disease, assessment of
disabling features of MS. Advanced MRI techniques
therapeutic response, and the understanding of
provide a better understanding of the pathologic
different MS phenotypes(6).
processes that most likely are related to disease activity
The study was approved by the Ethics Board of
and clinical progression. Such metrics are able to reveal
Ain Shams University.
a range of tissue changes that include demyelination,

axonal loss, iron deposition, and neurodegeneration
and they provide the evidence that important occult
Multiple sclerosis (MS) is an inflammatory
pathology is occurring in the normal appearing white
demyelinating CNS disease frequently starting in
and gray matter(3).
young adulthood. It expresses itself in four clinical
Received: 18/ 07/2017 DOI : 10.12816/0040141
Accepted: 27/07 /2017

Full Paper (vol.691 paper# 28)

Microsoft Word - 29 Vol 69 (2).docx The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1757-1763

Study of the level of Copeptin in patients with Diabetic Retinopathy
Mohamed Reda Halawa*, Ayman Abdel Moneim Gaafar**, Abeer Ahmed Abdullah*, Evit Ezzat
Eid Iskandar*
*Department of Internal Medicine, Endocrine Unit, and **Department of ophthalmology School of
Medicine, Ain Shams University, Cairo (Egypt)
Corresponding author: Evit E. E. Iskandar, Tel:01066885672 Email: evit.iskandar@gmail.com

The prevalence of Diabetic retinopathy in Egypt among adult diabetic patients in
2010 was around 20.5%. 90 percent of all cases of blindness from diabetes can be prevented.
Copeptin, a novel biomarker (a surrogate to arginine vasopressin was found to increase with
diabetic nephropathy.
Objectives: to study the level of copeptin in patients with diabetic retinopathy.
Methods: The study was conducted on 96 individuals divided into 4 groups. Group I 24 patients
with proliferative diabetic retinopaty (PDR), Group II 24 patients with non proliferative diabetic
retinopathy (NPDR), Group III 24 diabetic patients with no evidence of retinopathy and Group
24 healthy non diabetic individuals. All participants were subjected to full medical history
taking, slit lamp biomicroscope fundus examination and measurement of serum fasting blood
sugar, 2 hour post prandial blood sugar, glycated hemoglobin, serum creatinine, serum copeptin
and urinary albumin creatinine ratio.
Results: the study shows a statistically significant rise in the level of copeptin in patients with
PDR (Group I) and NPDR (Group II) when compared with those with no diabetic retinopathy
(Group III) and the control group (Group IV) P value < 0.001. There was a statistically
significant positive correlation with duration of diabetes (r = 0.589) and level of
albumin/creatinine ratio (ACR) (r = 0.540) P value < 0.001.
Conclusion: : Copeptin was found to be higher in proliferative diabetic retinopathy and non
proliferative diabetic retinopathy when compared to diabetics with no retinal complications and
healthy individuals with a statistically significant difference. It was found to be significantly
higher in diabetic patients in comparison with the normal population. There was a statistically
significant positive correlation with ACR and duration of diabetes.
Keywords: Copeptin, proliferative diabetic Retinopathy, non proliferative diabetic retinopathy,
diabetes mellitus, biomarkers

accurately. It is equimolar to vasopressin in
Diabetes Mellitus is a group of metabolic diseases
secretion and hence directly reflects its serum
characterized by hyperglycemia resulting from
levels. It could be used as an early and adequate
defects in insulin secretion, insulin action, or both.
marker for organ damage(3)A study done in
The chronic hyperglycemia of diabetes is
Denmark revealed a positive correlation between
associated with damage, dysfunction and failure of
serum copeptin levels and renal impairment and
different organs (1). Diabetic retinopathy is the
peripheral arterial disease in type 2 diabetic
leading cause of blindness in patients aged 20 to 74
patients(4). This study aimed to detect levels of
years. Chronic hyperglycemia affects the retinal
copeptin in patients with diabetic retinopathy.
vessels resulting in diabetic retinopathy. The risk of
development and progression of diabetic
Any patient aged 20-60 years with diabetes and no
retinopathy is closely associated with the type and
other co-morbidities was included in the study.
duration of diabetes (2). Copeptin is the C-terminal
This study included 96 individuals and they were
part of the vasopressin prohormone. It is relatively
divided into 4 groups. Group I consisted of 24
stable in the serum and its levels can be measured
patients with proliferative diabetic retinopathy
Received: 17 /7 /2017 DOI :10.12816/0040142
Accepted:26 /7 /2017

Full Paper (vol.691 paper# 29)

c:\work\Jor\vol691_30 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69(1), Page 1764-1769

Neutrophil/Lymphocyte and Platelet/Lymphocyte Ratios and Their Relation
with Disease Activity in Systemic Lupus Erythematosus Patients
Hanan Mohammed Farouk, Maryam Ahmed Abdel Rahman,
Naglaa Afify Mohamed, Omnia Bahaa Attia
Department of Intenal Medicine, Faculty of Medicine, Ain Shams University
Corresponding Author: Omnia Bahaa ,email:dr.omnia.bahaa91@gmail.com

Background: systemic lupus erythematosus (SLE) is a chronic disease which had diverse clinical
manifestations, course and prognosis. Search for diagnostic markers is continuous process to enhance the
diagnostic and treatment process.
Aim of the study: this study aimed to investigate correlation between both of neutrophil/lymphocyte
and platelet/lymphocyte ratios and disease activity in SLE patients who did not receive any treatment.
Patients and Methods: a case control study involving 60 adult SLE patients and 40healthy controls was
performed. NLR and PLR levels between SLE patients and healthy controls were compared, and
correlations between these indices and clinical characteristics were analyzed.
Results: increased NLR and PLR were observed in SLE patients. NLR was positively correlated with
erythrocyte sedimentation rate (ESR) (r=0.621, p<0.001) ,SLEDAI scores(r=0. 0.774, p<0.001) and
SLICC score(r=0.638, p<0.001). PLR was positively correlated with with erythrocyte sedimentation rate
(ESR) (r=0.500, p<0.001),SLEDAI scores(r=0.445, p<0.001). and SLICC score(r=0.377, p<0.001) SLE
patients with nephritis had higher NLR and PLR levels than those without nephritis (p<0.001).
Conclusion: NLR and PLR could reflect inflammatory response and disease activity and disease damage
in SLE patients.
Keywords: Neutrophil/lymphocyte, platelet/lymphocyte, systemic Lupus erythematosus.


Systemic lupus erythematosus (SLE) is an
subclinical inflammation and has been used in
combination with other inflammatory markers to
autoantibody production, immune complex
determine inflammation in both auto- and non-
deposition and multiple target organ damage. The
autoimmune diseases(3). Previous studies have
disease can affect any part of the body and the
shown that Neutrophil/lymphocyte ratio (NLR) is
course of the disease is diverse and unpredictable.
In SLE, organs and cells undergo damage
Platelet/lymphocyte ratio (PLR) is also an
inflammatory index in routine blood test. PLR
autoantibodies and immune complexes. In most
change may be associated with inflammation and
patients, autoantibodies are present for a few
cytokines levels (5). NLR and PLR can be
years before the first clinical symptom appeared
calculated easily and less costly as compared with
(1). Many clinical and laboratory methods can be
detection of other inflammatory cytokines that
used to assess the disease activity.
could be used as biomarkers for inflammatory
The laboratory indicators of disease activity are
response or disease activity in SLE patients(6).
increased as deoxyribonucleotide (DNA) binding,

thrombocytopenia. The problem is how to
Patients: that is a case control study included 60
evaluate disease activity with simple laboratory
SLE patients fulfilling diagnosis according to
indicators that is available in almost every health
Systemic Lupus International Collaborating Clinics
care facility. White blood cell and its differential
(SLICC) classification criteria for SLE ,none of
count can be done as part of routine
them received any treatment either newly
investigations (2). The circulating white blood cell
diagnosed SLE patients or non-compliant on
(WBC) classification undergoes relative changes
treatment .It had been conducted on SLE patients
in systemic inflammation, typically represented
attending the Rheumatology Outpatient Clinic or
by lymphopenia and neutrophilia. WBC and
admitted to Internal Medicine and Rheumatology
subtype counts have been identified as
Department at Ain Shams University Hospitals.
This study consisted of 52 female patients
lymphocyte ratio (NLR) is a marker of
(86.67%) and 8 males with age ranged from 14 to
Received: 16 4/ /2017 DOI : 10.12816/0040143

Accepted: 25/4 /2017

Full Paper (vol.691 paper# 30)