c:\work\Jor\vol693_1 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 1978-1988

Role of Urinary Chitinase 3 Like Protein 1 for Early Detection of Acute
Kidney Injury in Adult Critically Ill Patients
Osama Mahmoud Mohamed*, Hesham Mohamed Abo Elleil**, Hussein Sayed Hussein***,
Fatma Mohamed Abbas Amin****
Department of Internal Medicine and Nephrology, Faculty of Medicine- Ain Shams University
Corresponding author:Fatma mohamed ,f.mohamed8609@gmail.com

AKI is a common problem in ICU patients and is mostly multifactorial. Also, it is known to
increase mortality, duration of ICU and hospital stay and increase the cost of care in critically ill patients.
Early diagnosis in these settings helps in decreasing the outcome of AKI. Multiple biomarkers have developed
concentrating on early diagnosis of acute kidney injury. Urinary Chitinase 3 like protein 1 is a novel
biomarker studied for early detection of acute kidney injury.
Objectives: the current study was aimed to assess the role of urinary chitinase 3 like protein 1
(CHI3L1) as an early biomarker for detection of acute kidney injury in adult critically ill patients.
Patients and methods: this was a prospective cohort study that was conducted in Ain Shams
University Hospital. This study included 30 adult critically ill patients with normal kidney function
and they were observed for 48 hours. The development of Acute Kidney Injury was based on
serum creatinine and urine output criteria according to KDIGO criteria. Urine samples, for
assessment of urinary CHI3L1, urine creatinine and urine CHI3L1/Cr ratio were collected under
aseptic techniques at 3 times intervals ( 0, 12 and 24hrs).
Results: our results showed that, of these 30 patients, 15 patients developed acute kidney injury using
KDIGO criteria and 15 patients had normal kidney function. Our results showed the percentage of patient
who developed AKI according to KDIGO, stage 60.0%, stage 33.3% and stage 6.7%. Of these patients
80% developed AKI based on serum creatinine and 20% based on serum creatinine and urine output. Our
results showed that there is statistically significant difference between AKI group and non-AKI group as
regards urine chitinase 3 like protein 1(CHI3L1) at 0hour, 12 hours and 24hours (P0.05). As the higher level
of urine CHI3L1 was found in AKI group which ranges from 35-135ng/ml with mean 94±34.02 at 0 hour,
from 70-200ng/ml with mean 126.80±43.77 at 12 hours and from 105-200ng/ml with mean 160.57±28.02
which means that urine CHI3L1 level increases with AKI. Our results showed that there is statistically
significant difference as regards urine CHI3L1 between non-AKI group and the 3 stages of AKI in AKI group
at 0hr, 12hrs and 24hrs (P0.05).
Conclusion: Urinary chitinase 3 like protein 1 is a highly sensitive early marker in prediction of acute kidney
injury in adult critically ill patients.
Key words:
acute kidney injury, biomarkers, chitinase 3 like protein 1, critically ill patients.


concentration and urine output, both of which are
Acute Kidney Injury is a clinical syndrome
indicators of renal function but not kidney injury.
with sudden decline in kidney function that occurs
SCr is an integrator of multiple intrarenal and extra-
over a period of hours to days leading to retention
renal functions, and its concentration shows the
of nitrogenous and metabolic waste products (1).
balance between creatinine generation and
AKI is common in patients in the ICU. AKI is
excretion. SCr not only is a late and insensitive
mostly multifactorial, but it is known to increase
biomarker of changes in kidney function, but its
mortality, duration of ICU and hospital stay and
concentration does not distinguish between
increase the cost of care in critically ill patients. It
changes the outcome of patients, especially those
hemodynamic triggers and could be affected by
needing RRT (2). AKI is considered a prevalent and
various factors. Also, patients with decreased
serious problem worldwide. The incidence ranges
muscle mass may not have a vigorous rise in SCr
from 3-20% in hospitalized patients and 30-60% in
despite a substantial kidney injury (4).
ICU patients. The mortality rates among AKI
Over the past decade there has been a
patients are still high despite the efforts done for
massive expansion in discovery and validation of
elucidating the mechanism and introduction of RRT
specific biomarkers of kidney disease. The ideal
(3). Now, the standard diagnostic tools for AKI
biomarker is one that can predict and detect AKI,
diagnosis are observation of serum creatinine
identify the site of injury, the type and cause of
Received: 11/ 7/2017 DOI : 10.12816/0041032
Accepted:19 /7 /2017

Full Paper (vol.693 paper# 1)

c:\work\Jor\vol693_2 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 1989-1997

Effect of Apocynin on Liver Toxicity Induced by Microwaves in Rats
Passant Medhat Hewady, Rizk Mahmoud Elkholy,
Ghada Mahmoud Esmaeil, Abeer Abed Abo Zeid
Department of Physiology, Faculty of Medicine, Tanta University

Background: electromagnetic waves could cause oxidative stress and generate ROS that lead to free
radical production and lipid peroxidation which damage liver tissue. Apocynin (APO) exerts its antioxidant
effect by reducing ROS production via inhibition of NADPH oxidase. The present study intended to
demonstrate effects of microwaves exposure on hepatic pro-oxidant/antioxidant systems and to investigate
protective effects of APO against microwaves induced hepatotoxicity. Aim of the work: The aim of the
present work is to evaluate the effect of Apocynin on liver toxicity induced by exposure to microwaves in
rats of local strain. Subjects and Methods: Thirty local strain rats were randomly assigned into three equal
groups: a) control group; b) microwave exposed group (frequency of 2.45 GHz for 15 minutes once daily for
a period of 16 days); c) apocynin treated prior to microwave exposure group (apocynin 20 mg/kg
intraperitoneally injected 1 hour before microwave exposure and continued during the other 16 days). Liver
tissue was biochemically assessed in all groups biochemically through the determination of tissue MDA,
MPO, GPx and iron in liver tissue. Also, serum alanine transaminase (ALT), aspartate transaminase (AST),
alkaline phosphatase (ALP) and Tumor necrosis factor alpha (TNF) levels were estimated in all groups.
Results: The microwave exposed group showed that there was a significant increase in serum ALT, AST,
ALP, TNF-, as well as significant increase in the level of MPO, MDA and iron in the liver tissue. However,
there was a significant decrease in the GPx and zinc level in the liver tissue. These results Were estimated
and calculated in comparison with those of control group. Moreover, Apocynin treated group showed a
significant decrease in serum ALT, AST, ALP, TNF- , in addition to a significant decrease in the level of
MPO, MDA and iron, along with a significant increase in the GPx level in the liver tissue, as compared with
microwave exposed group.
It is possible to conclude considering the abovementioned results that apocynin has a
significantly protective effect against hepatotoxicity induced by microwaves exposure.
Keywords: apocynin, hepatotoxicity, microwaves, oxidative stress.


Microwaves (MWs) are electromagnetic
oxygen species (ROS) are neutralized by highly
waves with wavelengths ranging from one
efficient antioxidant systems that catalyzes the
millimeter to one meter or equivalently, with
decomposition of hydrogen peroxide to water and
frequencies between 0.3 GHz and 300 GHz.
oxygen, therefore preventing generation of highly
During the last few decades, there has been an
toxic hydroxyl radicals[3]. Trace elements play an
increase in the number of devices that emit
important role as activators of enzyme systems or
microwaves. Such devices are used predominantly
as constituents of organic compounds. For
in telecommunications, but also in other society
example, zinc and copper play a role in quenching
sectors and in households[1].
of free radicals through reduction of the
Nowadays, we are facing growing public concerns
peroxidation ratio and breaking the free-radical
regarding the potential hazard to man from
production chain. On the other hand, iron and
exposure to microwaves. By far the greatest public
copper possess the ability to generate reactive
concern has been that exposure to microwaves
radicals, resulting in cellular damage like
may cause cancer. However, most of the studies
depletion of enzyme activities, damage to lipid
on animals regarding the in vivo effect of MW
bilayer and DNA[4].
exposure have reported evidence of changes in
Apocynin, also known as acetovanillone
cellular biochemistry such as increased reactive
(4-hydroxy- 3-methoxy-acetophenone), is the
oxygen species generation[2].
major active constituent of Chinese medicinal herb
Reactive oxygen species (ROS) are generated
Picrorhizakurroa. Traditionally P. kurroa has been
as products of cellular metabolism, primarily in
used to treat hepatic diseases, respiratory tract
the mitochondria. When cellular production of
disorders, diarrhea, epilepsy and fever. Apocynin
ROS overwhelms its antioxidant capacity, damage
is a specific inhibitor of nicotinamide adenine
to cellular macromolecules such as lipids, proteins,
dinucleotide phosphate (NADPH) oxidase and
and DNA may ensue. Normally, the reactive
exhibits potent anti-inflammatory activity[5].
Received: 29 /7 /2017 DOI : 10.12816/0041033
Accepted: 8/8 /2017

Full Paper (vol.693 paper# 2)

c:\work\Jor\vol693_3 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (2), Page 1998-2007

Role of Diffusion MRI in Evaluation of Renal Masses
Medhat Atef Morsy, Rania Ali Maarouf, Ahmed Mohammed Abd Rabou
Department of Radio-diagnosis, Faculty of Medicine, Ain Shams University
*Corresponding author: Medhat Atef Morsy, Mobile No. +201007120072 E-Mail: medhat_atef007@hotmail.com

renal masses are being exposed more frequently in the last decades due to advances in cross
sectional imaging such as CT and MR. Accurate characterization of renal masses is essential to ensure
appropriate case management, to assist in staging and prognosis and to differentiate surgical lesions from
nonsurgical lesions. However, in some cases there is an overlapping between the ADC values of benign and
malignant masses. Thus, the use of ADC values alone may lead to inaccurate assessment of renal masses.
Aim of the Study:
to assess the roles of DWI in combination with quantitative ADC measurements the
differentiation between benign and malignant renal masses. Conclusion: The combination of conventional MRI
and ADC value in the diagnosis of renal masses can increase the diagnostic accuracy and considered of most
value in cases where IV contrast agents are contraindicating.
Keywords: MRI, DWI, carcinoma, renal masses, kidney cancer.

images, the ADC value can reflect the pathological

changes of tissues and is very useful in the clinical
diagnosis of central nervous system disease, various
adenocarcinoma and Grawitz tumor) is a kidney
abdominal lesions, and especially renal disease [6].
cancer that initiates in the lining of the proximal

The ADC value is inversely proportional to
convoluted tubes, which is a part of the small tubes
cellular density because increased cellular density
present in the kidney that carry waste particles from
limits water diffusion in the interstitial space. In the
blood to urine. RCC is the furthermost common type
past few decades, a large body of evidence has
of kidney cancer in adults, accountable for nearly 90-
suggested that DWI with quantitative ADC
95% of the cases[1]. Epidemiological evidence
measurements can act as predictor in differentiating
supported the fact that renal cancer is estimated to be
malignant renal lesions from normal kidney and
the 13th most common cancer in the world, with
benign renal lesions [7].
about 270,000 new cases identified in an annual basis

The aim of the present study is to evaluate the
with approximately 116,000 people dying from the
recent role of Diffusion MRI in the evaluation of
disease [2]. In general, the common symptoms of
renal masses.
renal cancer are: flank and back pain, fatigue,
Aim of the present study was to assess the roles of
anaemia, haematuria, weight loss, and so forth.
DWI in combination with quantitative ADC

Nevertheless, there is consensus that MRI
measurements the differentiation between benign and
diffusion-weighted imaging technique plays a more
malignant renal masses.
important role in the differential diagnosis of benign
The study was approved by the Ethics Board of Ain
and malignant renal tumors [3]. Diffusion-weighted
Shams University.
imaging (DWI) evaluates random movement of
water molecular diffusion process in vivo, which can
Cancer of the kidney amounts to 2% of the
provide information on the spatial structure and
total human cancer burden, with approximately
biophysical characteristics of tissue such as cellular
190,000 new cases diagnosed each year. They occur
structure, cellular density, microstructure, and
in all world regions, with a preference for developed
microcirculation [4]. In general, most neoplasm show
countries. Etiological factors include environmental
restricted diffusion owing to the dense cellular
carcinogens (tobacco smoking) and lifestyle factors,
packing of solid tumors and increased cell
in particular obesity [8].
membranes per unit volume, leading to the restriction
The recently introduced 2004 World Health
of water molecular movement and corresponding
Organization (WHO) classification of the adult renal
high signal intensity on DWI . The degree of water
epithelial neoplasms is meant to replace the previous
molecules diffusion can be evaluated quantitatively
1998 WHO classification. The 2004 WHO
by the apparent diffusion coefficient (ADC) value [5].
classification is based on pathology and genetic
As a quantitative parameter calculated from the DWI
abnormalities. The description of categories has been
Received: 3 / 8 /2017 DOI : 10.12816/0041047
Accepted: 12 /8 /2017

Full Paper (vol.693 paper# 3)

c:\work\Jor\vol693_4 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2004-2011

Corneal Endotheleal Cells Changes After Phacoemulsification in
Type II Diabetes Mellitus
Mohamed S. ELKady, Mahmoud M. Saleh, Ahmed S. Aboalhamd
Department of ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Corneal endothelial cells are responsible for the clarity of the cornea; however, endothelial cells
have limited cell division ability. Studies have proven that cornea is more vulnerable to chronic changes
affecting endothelial cells in diabetic patients. Cataract extraction by phacoemulsification is one of the most
ophthalmic surgeries having a negative effect on the corneal endothelial cells especially in elders. Age of the
patient and diabetes mellitus have a negative effect on the outcome of phacoemulsification. The aim of the
study is to compare the changes occur in corneal endothelium pre and post cataract extraction by
phacoemulsification in diabetic patients in aspects of BCVA, CCT, CD, CV and HEX. Aim of the work: To
assess endothelial cells changes following cataract extraction by phacoemulsification and posterior chamber
IOL implantation in type II diabetic patients. Methods: The study included 20 eyes of 20 patients scheduled
for cataract surgery by phacoemulsification at Al Azhar university hospitals. The patients were assigned
to 2 groups. Group 1: Ten patients without diabetes were used as a control group, and a casual blood glucose
test and glucose tolerance test were undertaken in accordance with the recommendations of the American
Diabetes Association to disclose undetected diabetes. Group 2: Ten patients diagnosed with type II diabetes
based on medical history and all were on oral anti-diabetic medication or subcutaneous treatment with insulin.
Serum glycosylated hemoglobin (HbA1c) was obtained in all patients with diabetes to evaluate their glycemic
status.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 thickness
(CCT), cell density (CD), coefficient of variation (CV), hexagonality (HEX) and best corrected visual acuity
(BCVA). Results: In term of CCT, in group 1 the CCT mean ±SD in preoperative is 510.7 ±35.13,
in 1 month postoperative is 522.1 ±35.91 and in 6 months postoperative is 512 ±34.91,
the difference between preoperative CCT and 6 months postoperative is 1.3 ±0.95.
In group 2 the CCT mean ±SD in preoperative is 497.45 ±25.82, in 1 month postoperative 515.64 ±26.59 and
in 6 months postoperative is 500.18 ±25.5, the difference between preoperative CCT and 6 months
postoperative is 2.73 ±1.64. In term of CD, in group 1 the CD mean ±SD in preoperative is 2678 ±390,
in 1 month postoperative is 2599 ±378 and in 6 months postoperative is 2571 ±355,
the difference between preoperative CD and 6 months postoperative is -107.17 ±15.53.
In group 2 the CD mean ±SD in preoperative is 2872 ±335, in 1 month postoperative is 2703 ±326 and in 6
months postoperative is 2441 ±284, the difference between preoperative CD and 6 months postoperative is -
430.8 ±50.31. In term of CV, in group 1 the CV mean ±SD in preoperative CV is 34.4 ±2.95, in 1 month
postoperative is 35.2 ±3.05 and in 6 months postoperative is 35 ±2.6, the difference between preoperative CV
and 6 months postoperative is 0.7 ± 1.34 which is statistically insignificant. In group 2 the CV mean ±SD in
preoperative CV is 36 ±3, in 1 month postoperative is 37 ±3.16 and in months postoperative is 36 ±3.2, the
difference between preoperative CV and 6 months postoperative is -0.3 ±1.64 which is statistically
insignificant. In term of HEX, in group 1 the HEX mean ±SD in preoperative is 34 ±8, in 1 month
postoperative 29 ±7 and in 6 months postoperative 28 ±7, the difference between preoperative and 6 months
postoperative is -6.2 ±1.55 which is statistically significant. In group 2 the mean HEX mean ±SD in
preoperative is 33 ±10, in 1 month postoperative is 25 ±7 and in 6 months postoperative is 24 ±7, the
difference between preoperative HEX and 6 months postoperative is -8.7 ±2.58 which is statistically
In term of BCVA, in group 1 the BCVA mean ±SD in preoperative is 0.15 ±0.05, in 1 month postoperative is
0.38 ±0.11 and in 6 months postoperative is 0.5 ±0.07, the difference between preoperative BCVA and 6
months postoperatively is statistically significant. In group 2 the BCVA mean ±SD in preoperative is 0.128
±0.034, in 1 month postoperative is 0.285 ±0.0369 and in 6 months postoperative is 0.392 ±0.093, the
difference between preoperative BCVA and 6 months postoperatively is statistically significant.
Conclusion: The endothelium in diabetic subjects is more vulnerable to surgical trauma and has a lower
capability in the process of repair.
Keywords: phacoemulsification, endothelial cell loss, central corneal thickness.
Received:10 / 6 /2017 DOI : 10.12816/0041050
Accepted:19 / 6 /2017

Full Paper (vol.693 paper# 4)

c:\work\Jor\vol693_5 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2016-2024

Role of MRI in Evaluation of Traumatic Ankle Injuries
Mervat Mohamed Ibrahim Ali Elgohary*, Susan Adel Ali Abdul Rahim*,
Thura Aamer Ahmed Ibrahim**
Department of Radiology, Faculty of Medicine - Ain Shams University*, Almosel University**
„Corresponding author: Susan Adel Ali, Mobile :00201116237200, E-Mail: dr.susanadil@hotmail.com

MR imaging has become the diagnostic modality of choice for the evaluation of
traumatic ligamentous, tendinous injures of the ankle and occult bony trauma. This article reviews
the current applications of MR imaging for the evaluation of most of these lesions. Ankle sprains are
considered the most common lower limb injuries (incidence between 5 - 7 per 1000 persons/year in
Europe), affecting more frequently young athletes; the most common mechanism of injury is
represented by inversion of the foot (less frequently eversion).
Aim of the Work: The aim of the current study is to emphasize the value of Magnetic Resonance
Imaging (MRI) in evaluation of patients with ankle pain caused by traumatic injury.
Patients and Methods: A descriptive study, conducted from March 2017 till June 2017. Sixty
patients underwent MRI examination (patients with traumatic ankle pain) during this period. Twenty
patients have normal MRI examination and not included in the study while forty patients have
positive MRI findings. All patients were performed MRI in radiology department, Ain Shams
University Hospital. The examination carried out after signing the informed consent by the patient
himself or his guardian if the patient is incapacitated by any means.
Results: According to the data collected from our study, we have 70 pathologies diagnosed by
MRI after traumatic ankle injuries.
- 17 (24.3%) of them were ligamentous injuries.
16 (22.9%) were tendon injuries.
- 14 (20%) were bone injuries [3 (21.43%) of them were fractures and 5 (35.71%) of them
were osteochondral lesions and 6 (42.86%) of them were Bone contusions].
- 23 (32.8%) from the seventy pathology have joint effusion.
Conclusion: MRI is modality of choice in evaluating ankle injuries due to its high soft tissue contrast
resolution, and multi-planar capabilities. It provides a non-invasive tool for the diagnosis of Ankle
injuries, which are often difficult to diagnose with alternative modalities. MRI is particularly
advantageous for assessing soft tissue structures around the ankle such as tendons, ligaments, nerves,
and fascia and for detecting occult bone injuries.
Keywords: MRI, Traumatic Ankle Injuries.

day in the U.S., 25,000 people sprain their
Magnetic resonance imaging (MRI)
ankle. And more than 1 million people visit
has become the diagnostic modality of choice
emergency rooms each year because of ankle
for the evaluation of traumatic ligamentous,
injuries. The most common ankle injuries are
tendinous injures of the ankle and occult bony
sprains and fractures, which involve ligaments
trauma. This article reviews the current
and bones in the ankle. But you can also tear
applications of MR imaging for the evaluation
or strain a tendon (3).
of most of these lesions (1).
Ankle sprains are considered the most
Since, traumatic injuries of the ankle
common lower limb injuries (incidence
and hind foot are the most common
between 5 - 7 per 1000 persons/year in
musculoskeletal injuries and account for
Europe), affecting more frequently young
approximately 10% of all visits to emergency
athletes; the most common mechanism of
departments (2).
injury is represented by inversion of the foot
Ankle injuries can happen to anyone
(less frequently eversion) (5).
at any age. However, men between 15 and 24
MRI is particularly suited for
years old have higher rates of ankle sprain,
evaluation of the complex bone and soft tissue
compared to women older than age 30 who
anatomy of the foot and ankle because of its
have higher rates than men. Half of all ankle
superior soft tissue contrast and the ability to
sprains occur during an athletic activity. Every
image in multiple planes. In addition new fast
Received: 31/7 /2017 DOI : 10.12816/0041051
Accepted:10 /8 /2017

Full Paper (vol.693 paper# 5)

c:\work\Jor\vol693_6 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2025-2029

Prevalence of Pulmonary Manifestations in a Cohort of the Egyptian
Patients with Rheumatoid Arthritis
Mohamed S. Abdel Baky a, Dalia F. Mohamed a, Sherin M. Hosney a, Dalia A. ElSherbiny a,
Ashraf A. Gomaa b, Mohamed Rezka
a Internal Medicine and Rheumatology,b Department of Chest Diseases,
Ain Shams University, Cairo, Egypt
Corresponding author: E-mail: drrezk2016@gmail.com -Tel: 00201092626942

: rheumatoid arthritis can affect the lung in many ways including lung parenchymal affection
(Interstitial lung disease), pleural inflammation, upper and lower airways affection and pulmonary
vasculature. Aim of the work: this study aimed to estimate the prevalence of pulmonary manifestations in
Egyptian RA patients. Patients and methods: this study included seventy patients with RA. All patients were
subjected to detailed medical history taking, general examination including chest examination, local
musculoskeletal examination, laboratory investigations including CBC, ESR, CRP titre, ALT, AST, BUN
and creatinine, rheumatoid factor titer (RF), Anti-CCP antibodies titer, radiological investigations including
chest X ray, HRCT and PFT. Results: pulmonary manifestations were prevalent in 50% of patients.
Spirometric abnormalities were detected in 45.7%, while HRCT abnormalities were detected in 42.85%.
HRCT severity score was correlated with age, tender joint count (TJC), swollen joint count (SJC) and ESR.
There was a statistically significant negative correlation between HRCT and FVC, FEV1. There was no
correlation regarding other parameters. Conclusion: pulmonary affection was prevalent in RA and can be
detected by radiological and pulmonary functions. There was correlation with age, ESR and pulmonary
Keywords: RA, RA-ILD, HRCT, PFT,TJC and SJC


Rheumatoid arthritis is considered as one of the
inflammatory diseases. The joints are the main
local musculoskeletal examination
target of the disease producing articular
Laboratory Investigations:
manifestations; meanwhile other systems can be
CBC, ESR, CRP titre, ALT, AST, BUN and
involved producing extraarticular manifestations
(1). The lung is one of the most common involved
Rheumatoid factor titer (RF) by using latex
organs in RA contributing to morbidity and
agglutination test kit
mortality affecting lung parenchyma, airways,
pleura and vasculature (2). This study aimedo
Anti-CCP antibodies titer using ELISA
manifestations in the Egyptian RA patients.

Radiographic evaluation:
1. Plain chest x ray posterior-anterior (PA) view
This study was an observational cross sectional
2. Pulmonary
study and it included seventy patients with RA
tomography scan (HRCT): It was done using both
fulfilling the American Colleague of Rheumatology
techniques GE Light Speed Plus MSCT 4
channels set and Toshiba Aquilion MSCT 64
(ACR/EULAR) 2010 classification criteria (3). They
channels set. HRCT films were done in supine
were selected from Rheumatology Outpatient Clinic
position with full inspiration without contrast
and Internal Medicine Department of Ain Shams
University Hospital. The study was conducted in
1. Spirometric
the period 7/2015-7/2017.
Spirometry was performed according to American

Thoracic Society guidelines (ATS) with
All patients were subjected to the following
assessment of vital capacity, forced vital capacity
Detailed medical history taking with special
(FVC), Forced expiratory volume in 1 second
emphasis on age, smoking, articular symptoms and
(FEV1), FEV1/FVC ratio.
detailed chest symptoms

Received: 6 / 8 /2017 DOI : 10.12816/0041054
Accepted: 15 /8 /2017

Full Paper (vol.693 paper# 6)

Frequency of Low Bone Mineral Density and Osteoporosis in a Cohort of Egyptian Women with Systemic Lupus Erythematosus The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2030-2035
Frequency of Low Bone Mineral Density and Osteoporosis in a Cohort of
Egyptian patients with Systemic Lupus Erythematosus
Abdel-Azeim Mohammad Elhefny, Sherin Mohamed Hosny Hamza,
Dalia AbdelHamid ElSherbiny, Rehab Fathy Ibraheem
Department of Internal Medicine, Rheumatology and Immunology
Faculty of medicine - Ain-Shams University
*Corresponding author: Rehab Fathy Ibraheem, Mobile No. 01002866976, E-Mail: rehabfathi65@gmail.com

several studies have found an increase in bone loss and risk of fracture in patients with
systemic lupus erythematosus. Objectives: To determine the frequency of low bone mineral density and
osteoporosis in a cohort of Egyptian patients with systemic lupus erythematosus and their relation to disease
activity. Patients and Methods: This is a cross sectional study which was carried out on 60 patients fulfilling
SLICC classification criteria for systemic lupus erythematous. All patients were attending the Rheumatology
Outpatient Clinic and Internal Medicine and Rheumatology Inpatient Department at Ain Shams University
Hospital from April (2016) to august (2016). Results: Mean values of lumbar spine, femoral neck BMD were
1.0 ± 0.15 and 0.9 ± 0.15 g/cm2, respectively, with mean T-score values at each site of -1.4 ± 1.3 and -0.8 ± 1.0,
the frequency of osteopenia among the studied 60 SLE patients was 40.0% and the frequency of osteoporosis was
25.0%. Conclusion: We found that there is increased frequency of low bone mineral density and osteoporosis
among SLE patients.
Keywords: Systemic lupus erythematosus, bone mineral density, frax.


Systemic lupus erythematosus (SLE) is a
enhance prediction of hip fractures and other major
systemic autoimmune disease that often affects
osteoporotic fractures over the use of BMD alone
young women (1). It is characterized by periods of
especially in SLE patients (11).
acute exacerbations that can affect any organ system

(2).SLE is associated with significant comorbidities
which can impair quality of life. SLE is also
To determine the frequency of low bone
associated with increased rates of infection and
mineral density and osteoporosis in a cohort of
increased risk of atherosclerosis and
cardiovascular diseases (3). The risk of malignancy
erythematosus and their relation to disease activity.
in people with SLE is controversial (4).

Recent studies have highlighted the high
prevalence of osteoporosis and bone fractures in a
A) Patients:
relatively young population of patients suffering
This is a cross sectional study which was
from SLE (5).The etiology of reduced bone mass in
carried out on 60 patients fulfilling SLICC
SLE is multifactorial and includes a variety of
intrinsic factors to the disease itself and treatments
erythematous (12).
side effects (6). Older age, postmenopausal status,
Exclusion Criteria
smoking, disease duration, glucocorticoid (GC)
Patients below 40 years of age and above 50
treatment, renal insufficiency, Raynauds syndrome,
years of age, Postmenopausal females, SLE patients
lupus anticoagulant and reduced BMD have all been
with a history of previously diagnosed osteoporosis,
reported as risk factors of osteoporosis and fractures
Patients receiving treatment for osteoporosis,
in SLE (7).SLE itself may result in low BMD,
Patients with diabetes mellitus and chronic kidney
especially in patients with high systemic lupus
diseases (not SLE related), Patients with other co-
erythematosus disease activity index (SLEDAI)(8).
existing autoimmune diseases or metabolic bone
However, some recent studies have shown that there
diseases and Smokers and alcohol consumers.
are no predictors of bone loss in relation to the

disease activity (6).
Ethical issues
Although BMD from DXA is widely used
An informed consent had been obtained
for fracture prediction, its accuracy is Limited (9).
from each participant in the study and the approval
Fracture risk assessment tool (FRAX) is used for
of the Ain Shams medical ethical committee had
estimation of individualized 10-year probability
been obtained. All patients were subjected to the
fracture (10). The use of this tool has been shown to
following: Full history taking including: SLE
Received: 26 /7 /2017 DOI : 10.12816/0041055
Accepted:5 / 8 /2017

Full Paper (vol.693 paper# 7)

c:\work\Jor\vol693_8 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2036-2042
Antral Follicle Count versus Basal Follicle Stimulating Hormone as Predictors of
Ovarian Response in Women Undergoing Superovulation with Long Protocol for
Assisted Reproduction
Karim Hassanin Abd El-Maeboud, Ahmed El-Sayed Hassan El-Bohoty,
Mohamed Abd El-Alim, Abeer Maged Ali El-Sopky
Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University

the prediction of ovarian response before undertaking the expensive IVF treatment is quite
important; it seemed that Patient characteristics, rather than the stimulation protocol are the determinant of the
individual response. Advance identification of patient who will elicit a poor response or hyper response to
standard treatment would be of great clinical advantage. Several parameters have been postulated as
predictors of the ovarian response. Aim of work: to compare between bFSH and AFC in predicting the
ovarian response in women undergoing super-ovulation with long protocol for assisted reproduction.
Patients and Methods: this is an observational cohort study that included 80 infertile women who performed
IVF/ICSI. It took place at Assisted Reproductive Technology (ART) Unit. Ain shams University Maternity
hospital. No extra interventional measures were taken in the study apart from routine investigations and
procedures done during ART therapy, being already approved in signed consent to undergo treatment. Patients
who are fulfilling the inclusion and exclusion criteria were enrolled in the study. They all underwent
superovulation with long GnRH agonist. They were followed up through the stimulation protocol steps, then
data were analysed. Results: all basal measured data such as Age p. value =0.035, AFC p. value =0.000, basal
FSH p. value =0.000 and basal E2 p. value =0.020 showed statistical significant difference between the good
responders and poor responders when both groups were compared, When we apply ROC curve to compare
between AFC and basal FSH as regards both (good and poor responders) to detect which one of them is
better, there was no statistical significance difference between them with p. value = 0.371, the best cut off
point for AFC as a predictor for good responders was found > 3 follicles with sensitivity of 90.5%, specificity
of 94.1% and area under curve (AUC) of 97.5%, while while the best cut off point for basal FSH level was
found 8 with sensitivity of 77.78%, specificity of 100% and AUC of 93.7%.
Conclusion: AFC and basal FSH are good predictors of ovarian response in women undergoing
superovulation with long protocol. There was no absolute superiority of AFC on basal FSH in predicting
ovarian response. Age and basal E2 are also considered good predictors of ovarian response.
Keywords: Antral Follicle Count, Basal Follicle Stimulating Hormone, Ovarian Response, Superovulation,
Long Protocol for Assisted Reproduction.

Several parameters have been postulated as
The prediction of ovarian response before
predictors of the ovarian response (8) all of which
undertaking the expensive IVF treatment is quite
stripe to assist ovarian reserve (9). Ideal ovarian
important (1) especially with assisted reproduction
reserve parameter should be easily measurable,
program in which the response of ovulating woman
minimally invasive, inexpensive, and should have a
to exogenous gonadotropin therapy is often
good predictive value (10).
inconsistent(2). Patient characteristics, rather than
Ultrasonographic measurements of antral
the stimulation protocol seem to determine the
follicle count (AFC) and ovarian volume have also
individual response (3). In young ovulating women
been explored as predictors of response to ovulation
undergoing in vitro fertilization treatment, the
induction (11). The antral follicle count (AFC) is a
standard stimulation protocol can result in either
minimally invasive, easily performed test provides a
poor response or ovarian hyper stimulation
representation of remaining follicular pool levels to
syndrome (4), the later, however, is one of the
assess the probability of a positive response to
challenging complications (5).
controlled ovarian hyper stimulation (COH) and
Poor ovarian response to gonadotropin
success of IVF (12).
stimulation results in small number of oocytes
Antral Follicle Count is the sum of antral
collected and thus a smaller number of embryos
follicle in both ovaries, as observed with
available for transfer, which therefore reduces the
transvaginal ultrasonography during the early
success rate of IVF (6). Advance identification of
follicular phase. Most studies have defined antral
patient who will elicit a poor response or hyper
follicles as those measuring 2-10 mm in mean
response to standard treatment would be of great
diameter in the greatest 2-dimensional (2-D) plane;
clinical advantage (7).
some have defined antral follicles as those
Received: 2 / 4 /2017 DOI : 10.12816/0041056
Accepted: 11 / 4 /2017

Full Paper (vol.693 paper# 8)

c:\work\Jor\vol693_9 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2043-2051

First Trimester Placental Volume and Vascular Indices by 3D
Ultrasonography and 3D Power Doppler in Pregestational
Diabetic and Non-Diabetic Pregnant Patients
Magd E. Mohamed, Amr M. Elhelaly, Mahmoud H. Abdelfattah
Department of Obstetrics and Gynecology,Faculty of Medicine - Ain Shams University

3D power Doppler ultrasonography enables the quantitative analysis of the region observed
through vascular indices as VI (vascularization index), FI (flow index) and VFI (vascularization flow index),
which show the quantity of vessels, the local blood flow and their combination and placental volume. These
indices can be calculated using VOCAL program. Aim of the Study: This study aimed at comparing
placental volume and vascular indices using 3D ultrasonography and 3D power Doppler in pregestational
diabetic and non-diabetic pregnant women at the first trimester (11th week and 13th week). Patients and
This current study was conducted at Antenatal care Clinic in cooperation with "the feto-maternal
Unit for ultrasound assessment", Ain-Shams University Maternity Hospital during the period between
November 2015 and April 2017, on 46 women at the eleventh 11th week and thirteen 13th week of
gestation. They were divided into two groups: Group (A) included 23 women with pregestational diabetes
mellitus and group (B) included 23 non-diabetic pregnant women as a control group after respecting certain
inclusion and exclusion criteria. Results: There was no statistically significant difference between
pregestational diabetic and non - diabetic group as regard placental volume and vascular indices (VI, FI and
VFI). Conclusion: There was no statistically significant difference as regard placental volume and vascular
indices (FI,VI and VFI) in pregestational diabetic compared to non-diabetic pregnant patients at the first
trimester of pregnancy especially with good glycemic control but changes may be present with poor
glycaemic control. Recommendations: Further studies are recommend as regard evaluating placental
volume and vascular indices (FI,VI and VFI) in pregestational diabetic at the second and the third trimester
of pregnancy giving more time for the pathological effect of diabetes mellitus to appear.
Keywords: first trimester placental volume, vascular indices, 3D ultrasonography, 3D power Doppler.

unique non - invasive technology for investigating
Diabetes mellitus is a group of metabolic
the circulatory system. Doppler ultrasound
diseases characterized by hyperglycemia and
velocimetry has been extensively used to
caused by defects in insulin secretion and /or
investigate fetal, feto-placental and utero placental
insulin action (1). Diabetes mellitus is a major
circulation. There is ample evidence associating
public health problem worldwide. Its prevalence
abnormal Doppler findings with complication of
has been used as one of the parameters in the
pregnancy and an adverse perinatal outcome
assessment of the quality of health care by the
(6).The advent of three-dimensional (3D) power
world health organizations (WHO)(2) .In 1842, an
Doppler ultrasound has begun a new era in tissue
Austrian professor of mathematics and geometry
and organ vascularization research Therefore, we
Dr. Christian John Doppler first described in
can calculate vascular indices using the specially
detail the effect that now bears the name.
Designed VOCAL TM software(7). Doppler
Satomura was the first describing clinical
examinations of intra placental blood circulation
application of Doppler ultrasound technology in
appear to be an efficient method for diagnosing
1959 (3).The placenta is an essential link between
and managing pregnancies complicated by fetal
the mother and the developing fetus, and
intrauterine growth restriction (IUGR), because
histological studies have evidenced characteristic
the changes in maternal Doppler findings (i.e.,
changes in the placental vascular structures of
uterine artery) and in fetal Doppler (i.e., umbilical
diabetic mothers(4). The umbilical artery was the
artery) are secondary to the changes in the
first vessel studied by obstetric Doppler
placental vascular tree(8).
examination. Flow velocity waveforms from the
Objective and non-invasive quantification
umbilical artery represent the downstream or
of vascularization of a given tissue volume holds
placental resistance to flow. Umbilical artery
much promise, particularly because this method has
resistance decreases progressively throughout
proved to be highly reproducible between observers
gestation, reflecting the increase and dilation in
(thereby overcoming one of the main limitations of
villous vascularization(5). Doppler US offers a
conventional Doppler ultrasound)(9).
Received: 14 / 7/2017 DOI : 10.12816/0041057
Accepted: 23 / 7 /2017

Full Paper (vol.693 paper# 9)

c:\work\Jor\vol693_10 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2052-2058

Role of Intravenous Hyoscine Butylbromide Injection on The Duration
and Progress of First Stage of Labour in Primigavidae
Gebril M. M. ,Farhan A. M., Arfat A. M. M.*
Obstetrics and Gynecology Departmant, Al Azhar University, Cairo Egypt,
*Agouza Hospital. Giza. Egypt.
Corresponding author:Ahmad Muhammad

Background: Labour is a physiologic process that results in expulsion of the products of conception outside the
uterus throughout 3 stages. It is achieved with changes in the biochemical connective tissue and with gradual
effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient
frequency, intensity, and duration. Hyoscine butylbromide (HBB) belongs to the parasympatholytic group of
drugs and is a semisynthetic derivative of scopolamine. It is a quaternary ammonium derivative, which exerts a
spasmolytic action on the smooth muscle of the gastrointestinal, biliary, and genitourinary tracts. Methods: A
case control study conducted on 150 women coming to Al Azhar University Maternity Hospital.Patients who
meet the inclusion criteria were asked to participate in the study and a verbal consent was obtained from each
patient. Patients were divided into three equal groups (A, B, C). A single dose of the drug (placebo or HBB
20mg or HBB 40 mg) was injected intravenously slowly to groups A, B, C respectively. Labouring mothers
were monitored in bed. Vaginal examination was conducted every two hours. The duration of the first stage was
calculated from the time of cervical dilatation of three to four centimeters in active labour until a fully dilated
cervix was observed Results: showed significant difference between the three groups regarding the progress of
labour. There was a significant decrease in the duration of the active phase of first stage of labour in study
groups who received hyoscine butylbromide compared to placebo group. The decrease in the duration of active
phase of first stage of labour was not related to the drug dose. There was no significant difference between the
three groups regarding the second stage duration. There were no significant adverse effects of hyoscine
butylbromide on either mothers or neonates. Conclusion: Hyoscine butylbromide helps to decrease the duration
of active phase of labour in primigravdae with no side effects on either the mother or the neonate. This decrease
is not related to the dose of the drug. Hyoscine butylbromide (HBB) belongs to the parasympatholytic group of
drugs and is a semisynthetic derivative of scopolamine. It is a quaternary ammoniu m derivative, which exerts a
spasmolytic action on the smooth muscle of the gastrointestinal, biliary, and genitourinary tracts. Role of
intravenous hyoscine butylbromide injection on the duration and progress of first stage of labour in
Keywords: normal labour, augmentation of labour, hyoscine butylbromide.

by t
he acti


of labour, which usually
Normal labour is a continuous process which
begins at about three to four em of cervical
has been divided into three stages for the
dilation and is characterized by rapid cervical
purposes of study, with first stage further
dilatation and descent of the presenting fetal part
subdivided into two phases.The first stage of
(2). Measurement of the length of labour is
labour is the interval between the onset of labour
inherently imprecise for several reasons. The
and full cervical dilatation. The second stage of
starting point cannot be identified by objective
labour is the interval between full cervical
means. The cervix undergoes various structural
dilatation and delivery of the fetus. The third
alterations in late pregnancy, and women do not
stage of labour is the period between the
begin labour with identical cervical anatomy.
delivery of the fetus and delivery of the
Labour onset is a self- diagnosis, and women
vary in their recognition and response to painful
The first stage begins with regular uterine
contractions. As such, the duration of the latent
contractions and ends with complete
phase is particularly difficult to quantify.
cervical dilatation at 10 cm. First stage is divided
Therefore, cervical dilatation on admission
according to Friedman's landmark studies of
to the hospital is often used as the first data
500 nulliparous women, into an early latent
point (3).The principle of active management of
phase and an ensuing active phase. The
labour was introduced in Dublin to shorten
latent phase starts with mild, irregnlar uterine
the length of labour while achieving or
contractions that soften and shorten the
maintaining a low rate of caesarean delivery, the
cervix.The contractions become progressively
active management of labour refers to active
more rhythmic and stronger. This is followed
control, rather than passive observation over the
Received:2 / 4/2017 DOI : 10.12816/0041058
Accepted:11 / 4 /2017

Full Paper (vol.693 paper# 10)

c:\work\Jor\vol693_11 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2059-2062

Total Hip Replacement after Acetabular Fracture: A Review Article
Osama M. Elsayed , Ahmed M. Mohassab ,Magdy G. Mazeed
Department of Orthopedics, Faculty of Medicine, Ain Shams University, Egypt
Corresponding author: Magdy gamil mazeed, Mobil No. 01228927947, E-Mail: Drmagdygamil88@yahoo.com

Total hip replacement (THR) after acetabular fracture is a complex procedure and presents the
surgeon with unique challenges. THR maybe indicated in two distinct clinical scenarios; firstly, if an acute
acetabular fracture would result in a predictably poor outcome if treated with open reduction and internal fixation
(ORIF), and secondly (and most commonly) after a patient develops post-traumatic arthritis after either non-
operative or operative treatment of an acetabular fracture.
Purpose: Purpose of this article wad to assess the outcome of total hip replacement in the management of
selected acetabular fractures among adult with traumatic hip arthritis.
Methods: Prospective and retrospective studies of 494 patients who underwent primary total hip arthroplasty for
acute Acetabular fractures. The study was done in different places. Collected during the period from 1990 to Jan
2015. Results: in our series of primary total hip replacement for acute acetabular fractures
we had excellent/good results. Mean Harris Hip Score = 82.5.
Conclusion: primary total hip replacement is a reasonable method of treatment of selected acetabular fractures
and good method for treatment neglected acetabular fracture. Outcomes may not be as good as total hip
replacement done for other conditions.
Keywords: Acetabular fracture, Post traumatic arthritis, Harris hip score, total hip replacement after acetabular

total hip arthroplasty was performed to manage an
The hip is a weight bearing joint and is
acetabular fracture. The diversity of the results is not
involved approximately in all movements of the
surprising in the view of the heterogeneity of the
fracture patterns and the diverse methods of primary
In the past, acetabular surgery and its fixation
fracture management. In most studies the primary
was not as common as today. Many patients were
problem was the premature loosening of cups(4).
treated with long time skeletal traction (about 3
A lot of complications could be found also
months), this type of treatment has some
after total hip arthroplasty as infection, recurrent
complications as malunion, nonunion in some region
dislocation, sciatic nerve palsy and Heterotopic
of acetabulum, bed sores, muscle atrophy and
weakness around hip and knee joint, kidney stones,
Sciatic nerve palsy can occur iatrogenically
GIT malfunction and the most serious complication
from total hip arthroplasty, regardless of the
from long standing bed set is deep venous
operative approach used ; reported one sciatic nerve
thrombosis(1). With Open reduction and internal
palsy in a study involving 21 acetabular fractures
fixation of acetabular fracture, patient can mobilize
treated with a delayed cementless total hip
earlier, that's why fixation of acetabular fracture is
arthroplasty using a modified anterior approach.
getting popularity in recent years.
However, the authors did not specify whether this
Associated complications of these surgeries
nerve palsy was present pre- or postoperatively(6).
could be infection, sciatic nerve injury, avascular
That's why good planning for total hip
necrosis, Some of these complications have no
replacement is needed and that depends on patient,
definitive treatment like sciatic nerve injury.
implant, approach and muscle status(7).
Other complications as degenerative joint

disease and avascular necrosis can be managed by
total hip replacement(2). Total hip replacement after
The aim of this review is to collect and analyze the
pervious operations for internal fixation of fractured
existing evidence related to results of total hip
acetabulum is not a simple and straight forward
arthroplasty after acetabular fracture surgery and its
operation(3). Many authors have reported highly
prerequirments and possible complications
diverse clinical and radiographic outcomes after a
published in literature in English from 1990 to 2015,
Received: 29 / 7 /2017 DOI : 10.12816/0041059
Accepted:8 /8 /2017

Full Paper (vol.693 paper# 11)

c:\work\Jor\vol693_12 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2063-2067

Effect of Low Dose Aspirin Therapy on Pregnancy Rate in Women Undergoing
in vitro Fertilization: A Randomised Controlled Trial
Radwa Abd-Elshafy Ali Ahmed *Khaled Saiid Mohammed Moussa**, Noha Abd El-Sattar Afify Sakna**
* Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University
** Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University
Ahmed Salah <Ahm_sala7@hotmail.com
: acetylsalicylic acid was synthesized in 1897. The product was called aspirin. In 1971, Vane
described the mechanism of action of aspirin and showed that it inhibited the enzyme cyclooxygenase, thus
avoiding prostaglandin (PG) synthesis. Aspirin (acetylsalicylic acid) is well known to have analgesic, anti-
inflammatory and antipyretic properties. Since aspirin has been shown to increase uterine perfusion, it was not
unreasonable to assume that aspirin administration may increase endometrial receptivity and blastocyst
implantation. Aim of the work: this study aimed to assess the efficacy of low dose aspirin treatment in
increasing the clinical pregnancy in infertile women undergoing IVF /ICSI.
Patients and methods
: this study included 200 infertile women undergoing IVF/ICSI who recruited from the
Infertility Clinic of Ain-Shams University, Maternity Hospital and a Private Center.
Results: there was no statistically significant difference between both groups (Aspirin and Placebo) as regard
age, cumulus, MII, fertilization rate, grade 1 embryo, grade 2 embryo and total ET. There was statistically
non-significant difference between both groups as regard clinical pregnancy. There was statistically non-
significant difference between both groups as regard living birth. There was statistically non-significant
difference between both groups as regard miscarriage.
Conclusion: in the total of 200 women were recruited. The clinical pregnancy rate of the Aspirin group
showed no statistically significant difference from that of the placebo group (39% compared to 35%).
Recommendations: the use of Aspirin before IVF is not associated with a higher pregnancy rate. Therefore,
no need for Aspirin to be added before IVF, However, further studies are needed to confirm our study.
Keywords: acetylsalicylic acid, follicular stimulating hormone.

of 80­160 mg daily(1). It has been demonstrated that
Acetylsalicylic acid was synthesized in 1897.
low-dose of aspirin increased the weight of
The product was called aspirin. In 1971, Vane
newborns in pregnant patients with fetal growth
described the mechanism of action of aspirin and
retardation, it was also used to prevent recurrent
showed that it was inhibiting the enzyme
idiopathic fetal growth retardation and to improve
cyclooxygenase, thus avoiding prostaglandin (PG)
placental and fetal blood flow in women with pre-
synthesis. Low-dose acetylsalicylic acid (Aspirin)
eclampsia(3). Low-dose aspirin may improve uterine
irreversibly inhibits the enzyme cyclo-oxygenase in
and ovarian perfusion and it may enhance
platelets, preventing the synthesis of thromboxane
endometrial receptivity and ovarian responsiveness
which is a potent vaso-constrictive agent (1).
as well, which could result in better implantation
Aspirin's antiplatelet activity has led to its use
and pregnancy rates after IVF or ICSI treatment. It
with investigation of a variety of disorders. The
has also been suggested in the literature that low-
combination of low-dose aspirin and unfractionated
dose aspirin would lead to an increased number of
heparin appeared to be of benefit in pregnant
oocytes in IVF/ICSI as well as a higher pregnancy
women with antiphospholipid antibodies and
rate (4). Our institution at one time used aspirin
recurrent pregnancy if loss not be related to other
routinely during IVF cycles, based on the work of
causes. Pre-eclampsia is associated with deficient
studies which showed that low-dose aspirin
intravascular production of prostacyclin and
increased implantation and pregnancy rates in
excessive production of thromboxane. The
women undergoing IVF(4). A study was performed
administration of low-dose aspirin to women at risk
to determine whether aspirin inhibits the replication
led to a significant reduction in the likelihood of
of human immunodeficiency virus and also whether
developing pre-eclampsia, preterm birth, fetal or
aspirin diminishes the incidence of mortality in
neonatal death and small gestational age babies(2).
patients with colon cancer. Furthermore, it has been
The daily administration of aspirin in low doses
demonstrated that low-dose aspirin increased the
induced a shift in the balance away from
weight of newborns in pregnant patients with fetal
thromboxane A2 and towards prostacyclin, leading
growth retardation; it is also used to prevent
to vasodilatation and increased blood. Aspirin has
recurrent idiopathic fetal growth retardation and to
been found both experimentally and clinically to be
improve placental and fetal blood flow in women
cardio-protective, with few adverse effects in doses
with preeclampsia (5). Since aspirin has been shown
Received:9 / 8 /2017 DOI : 10.12816/0041060
Accepted:18 /8 /2017

Full Paper (vol.693 paper# 12)

c:\work\Jor\vol693_13 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2068-2074

Impact of Diabetes Duration on The Extent and Severity of
Coronary Atheroma Burden in Type 2 Diabetic
Patients: Evaluation by Coronary CT Angiography
Mona Ibrahim Abul Soud , Ahmad El Sayed Yousef, Diaa El Din Ahmad Kamal , Khaled Mohamed Sayed
Department of Cardiology, Faculty of Medicine, Ain Shams University
Corresponding author: Khaled Sayed, email:masry.fares@gmail.com

Aim of the work:
this study aimed to explore the association between diabetes duration on both the extent and
severity of coronary atheroma burden using coronary computed tomography angiography (CCTA) in type 2
diabetic patients.
Patients and methods: we analyzed 105 symptomatic type 2 diabetic patients without known CAD who
underwent CCTA from August 2016 to June 2017. Patients were categorized into two groups according to the
duration of diabetes: < 10 years, and 10 years. Stenosis by CCTA was scored as none (0%), non-obstructive (1­
49%), or obstructive (50%) for each coronary artery segment. For these patients, we compared the prevalence,
extent, and severity of CAD, including coronary artery calcium score (CACS), atheroma burden obstructive score
(ABOS), segment involvement score (SIS), segment stenosis score (SSS) and syntax score.
Results: patients with longer duration of type 2 diabetes possessed higher rates of obstructive CAD. Patients with
longer duration of diabetes also manifested greater degree of CACS, ABOS, SIS, SSS and syntax score (P < 0.001
for all).
Conclusion: in symptomatic type 2 diabetic patients, longer diabetes duration was associated with a higher
prevalence, extent, and severity of CAD so, increased risk of developing atherosclerotic cardiovascular disease
including major events as myocardial infarction or even sudden cardiac death.


those without [4]. Although the incidences of
Reducing atherosclerotic cardiovascular
diabetes mellitus­related complications including
disease (ASCVD) burden in diabetes mellitus (DM)
cardiovascular disease have decreased over the past
is a major clinical imperative that should be
2 decades, patients with diabetes mellitus continue to
prioritized to reduce premature death, improve
have significantly increased risk for vascular
quality of life and lessen individual and economic
complications in comparison with individuals
burdens of associated morbidities, decreased work
without diabetes mellitus [5]. An estimated 382
productivity, and high cost of medical care [1].
million people worldwide have diabetes mellitus and
Atherosclerotic cardiovascular disease remains the
this number is expected to reach 592 million by the
principal cause of death and disability among
year 2035 [6]. Key manifestations of ASCVD in
patients with diabetes mellitus, especially in those
diabetes mellitus included advanced atherosclerosis
with type 2 diabetes mellitus in whom it typically
manifest as coronary artery disease (CAD), ischemic
occurs 14.6 years earlier [2], with greater severity,
stroke, peripheral vascular disease, and heart failure.
and with more diffuse distribution than in
Understanding the mechanisms, strategies for and
challenges with managing ASCVD and heart failure
Furthermore, about two-thirds of deaths in people
risk in diabetes mellitus, as well as the potential
with diabetes mellitus are attributable to
cardiovascular risks and benefits of glucose-
cardiovascular disease: of these, 40% are from
lowering drugs, is important for managing
ischemic heart disease, 15% from other forms of
cardiovascular disease in diabetes mellitus [1].
heart disease, principally congestive heart failure,
Coronary computed tomography angiography
and 10% from stroke. Among those with diabetes
(CCTA) has emerged as a non-invasive imaging
mellitus, excess risks of death from any cause and of
modality for the detection or exclusion of CAD, with
ASCVD mortality are particularly prominent in
prior studies observing a high prevalence of CAD in
those with younger age, higher burden of glycaemia,
asymptomatic type 2 diabetic patients using CCTA
and greater renal complications, in comparison with
that is associated with worsened outcomes [7]. A
Received: 5 /8 /2017 DOI : 10.12816/0041061
Accepted: 14 / 8 /2017

Full Paper (vol.693 paper# 13)

c:\work\Jor\vol693_14 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2075-2081

Rubella and Congenital Rubella Syndrome in Pediatric
Ashwaq Ali Absalem1, Rola Mohammed Alanazi2, Sajida Hassan Alkhawajah3,
Ohoud Ahmed Hijazi4, Fahad Abdulaziz Jarad5, Bassmah Hassan Alrowaithi6,
Zahra Jaber Hussein7, Faris Hussain Al-Ameer7, Afnan Ahmed Aljehani6,
Amina Bashir Shikeh Adam8
1 Tabuk University,2 King Fahad Armed Forces Hospital ­Jeddah,
3 Maternity and Child Hospital (MCH) Dammam,4 Taif University, 5 King Khalid University,
6 Ibn Sina National College for Medical Studies,7 Imam Abdulrahman Bin Faisal University,
Dammam, Saudi Arabia,8 Banadir University
Corresponding Author: Ashwaq Ali Absalem - as.aL93@hotmail.com

The name rubella is derived from a Latin expression signifying "minimal red". Rubella is, for the most
part, a benign transferable exanthematous disease. It is caused by rubella virus, which is an affiliate of the
Rubivirus class of the family Togaviridae. About half of people contaminated with rubella are
asymptomatic. Clinical indications and severity of disease fluctuate with age. For example, contamination
in children is portrayed by mild constitutional symptoms, suboccipital adenopathy, and rash; on the other
hand, in adolescents and adults, rubella might be complicated by arthritis, thrombocytopenic purpura, and
arthralgia. Uncommon cases of rubella encephalitis have likewise been depicted in children. The main
complication of rubella is its teratogenic impacts when pregnant ladies get the disease, particularly in the
early weeks of pregnancy. The virus could be transmitted to the fetus through the placenta and is equipped
for causing genuine congenital defects, stillbirths, and abortions. Fortunately, as a consequence of the
successful vaccination program, rubella contamination and congenital rubella syndrome infrequently are
seen today. We conducted this review using a comprehensive search of MEDLINE, PubMed, EMBASE,
Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from
January 1, 1970, through February 28, 2017. The following search terms were used: rubella, rubella
syndrome, congenital, paediatric rubella, vaccination, rubella-containing vaccine, and rubella immunization
Keywords: rubella, rubella syndrome, congenital, children, vaccination.


Rubella infection is generally mild with
rubella reconnaissance is being directed in
nonspecific symptoms and is hence regularly
many nations in conjunction with measles
undiagnosed or misdiagnosed. Though, the rubella
virus remains a significant public health problem
observation exercises for CRS, especially in
because of the teratogenic effects and danger of
creating nations, have ended up being all the more
miscarriage and stillbirth that can result from
difficult. Out of 194 part states, just 75 nations
congenital infection, mostly when the mother
started detailing in 2000, which expanded to 114 of
becomes infected throughout the first period of
every 2014 except just 14 nations revealed positive
pregnancy [1, 2, 3]. With the utilization of viable
case recognizable proof [4, 5]. In this way, the
rubella vaccines, rubella was focused for
genuine weight of CRS remains underestimated [6].
elimination in two districts of the World Health
Since 2003, the Western Pacific Region of the
Organization (WHO) by 2015. However by the end
World Health Organization (WHO) has determined
of 2015, just the Region of the Americas was
to accelerate the control of rubella and avoidance
proclaimed to be free of endemic rubella
of CRS through integration with measles
transmission. Around the world, utilization of
elimination activities [7]. In 2014, the Western
rubella-containing vaccine (RCV) is expanding in
Pacific Region involved rubella including CRS
spite of RCV presentation in 74% of 194 WHO
elimination as one of eight regional immunization
part states, in 2014, worldwide new-borns
objectives quantified by the Regional Framework
vaccination scope stayed low at 46% [4].
for Implementation of the Global Vaccine Action
Surveillance for rubella and CRS is pivotal in
Plan in the Western Pacific [8]. Surveillance for
checking the effect of inoculation projects to
rubella was incorporated into the measles
survey infection trouble previously, then after the
surveillance in 2010; though passive laboratory-
fact RCV presentation. In spite of the fact that
confirmed surveillance for rubella has been
Received: 22 / 7 /2017 DOI : 10.12816/0041062
Accepted: 1 /8 /2017

Full Paper (vol.693 paper# 14)

c:\work\Jor\vol693_15 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2082-2087

Knowledge, Attitude and Practicetowards Stroke Risk Factors and Warning
Symptoms in Saudi Arabia, 2017
Kholoud Abdullah Aldebasi1, Noof Mofareh Alamri2,Asma Mohammad Alqahtani2
Ahmed Alsadah3, Ghaedaa Saad Alzahrani4,Abdulrahman Mubarak Almutairi 5,
Saleh Saad T Alotaibi6, Waad Saud Albalawi1
1-Tabuk University,2-King Khalid University,3-Maastricht University,
4-King Abdulaziz University,5-Majmaah University, 6-Taif university

Background:stroke is a neurological defect that could result in death thus adequate knowledgeof stroke is a
must for correct treatment andprevention of stroke consequences and disability.
Objectives:assessing theknowledge, attitude and practice(KAP) of Saudi population toward stroke risk
factors and warning symptomsin Kingdom of Saudi Arabia (KSA).
Methods:2021 adult Saudi subjects were enrolled in the study who were chosen from different parts of KSA.
This cross sectional study was conducted using a structuredquestionnaire designed to examine KAP of
participants about stroke risk factors.
Results: most of subjects were 41-50 years old, females, employed and had a college degree.About 9% of the
participated subjects were suffering from stroke while, 28% had relatives who suffered from stroke. The
majority of subjects had insufficient knowledge regarding the risk factors and warning symptoms of stroke
thus, resulting in inadequate KAP in 63.8% of the respondents while only 36.2% had good KAP. The good
KAP was significantly associated with younger age participants and highly educated.
Conclusion: The level of KAP toward stroke risk factors and warning symptoms wasinadequate among the
majority of participants. Good KAP was associated with high educational degree and young age.
KAP, Stroke, Cross-Sectional, Risk Factors, warning symptoms, KSA.


time (11). This study was assessed to evaluate the
Stroke is a worldwide health disease that
knowledge, attitudes, and practices (KAP) of adult
result in high morbidity and disability rates. Two
Saudi subjects regarding risk factors, warning
types of stroke were identified, ischemic and
symptoms for stroke that intended to develop
hemorrhagic types(1). The risk factors of stroke are
strategies for controlling the stroke risk factors.
conditionsincluding diabetes and hypertension and - Study design
heart diseases. Alcohol consumption and smoking
A cross sectional study was conducted during the
are also most common risk factors for stroke (2, 3).
period from January to April 2017 in KSA after
According to the severity of stroke, it can
obtaining an approval from the ethical committee of
result in different effects on mood, functional
faculty of medicine and a written informed consent
abilities, cognitive function and quality of life (4).
from all participants included in the study.
Also, it bosses a great burden on caregiver, national - Sample size and population
and individual economic stress (5).
A representative sample of Saudi adult
The treatment of stroke in acute type could
population was selected by multistage clustered
reverse the paralysis in most of patients (6, 7) but
random sampling technique. The inclusion criteria
thromobolytic therapies could be useful during the
were adult Saudi population aged from 20 to 50
first four hours of signs (8). Due to the fact that most
years old then were asked to fill up a questionnaire
of patients arrive late after the golden hours for
and after collecting the data from participants and
using therapies thus using preventive measures and
exclusion of questionnaires with incomplete data
modifying lifestyle are the most effective type of
thus 2021 subjects were included in the study from
management of stroke (9, 10).
different parts of KSA.
Adequate general knowledge about stroke - Study tools:
could result in a quick and correct identification of
A self-administrated questionnaire was used for
stroke thus good management within the estimated
evaluating the KAP of participants rereading stroke.
Received:18 /7 /2017 DOI : 10.12816/0041063
Accepted:27 /7 /2017

Full Paper (vol.693 paper# 15)

c:\work\Jor\vol693_16 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2088-2092

Assessment of Osteoporosis Knowledge among Saudi Females in Riyadh, KSA
Basim Khalid AlHarthi1 , Abdulmalik Alkhodair2, Amro Youssef Elias3, Saud Nasser Aleisa4
Faisal Abdullah ALMoumen5 , Mohammed Yahya Hassan Al-yami6
1-Taif University,2-Imam Mohammed bin Saud University,3-King Abdulaziz University,
4-Imam Mohammed bin Saud University,5-Imam Abdulrahman Bin Faisl University,
6-Najran University
Background: osteoporosis is considered as a major worldwide health problem. Little is known about its
definition, risk factors and prevalence in Kingdom of Saudi Arabia (KSA).
Objectives: Evaluating the general knowledge of Saudi females in Riyadh about osteoporosis.
Subjects and Methods: this was an analytical and descriptive study. A reliable osteoporosis knowledge
assessment tool (OKAT) questionnaire was published online for considering the levels of osteoporosis
awareness from February 2017 to July 2017.
Results: The majority of females were educated, married, had college degree and living in medium economic
state. Only ten patients reported having osteoporosis. The majority of participants (%) had high OKAT score
indicating high prevalence of good knowledge among included subjects. The young age, being highly educated
and good economic status were significantly associated with good awareness.
Conclusion: a good level of knowledge about osteoporosis was found among included subjects. Although
having good awareness about osteoporosis in Riyadh, the majority of subjects obtained their knowledge from
relatives and physicians. Thus, authorities should create educational programs at all health care facilities to
assess a preventive programs for osteoporosis.
Keywords: Osteoporosis, Awareness, Saudi Females, Riyadh.


Osteoporosis is the most common and worldwide
public health silent disease in postmenopausal
Study design and setting
women. This disease is a systemic disease of thin
This is a descriptive and analytical study that was
bone disease where the bones had weakening of its
conducted among Saudi females in Riyadh region
micro-architecture tissue, low bone mass, fragile
during the period from February 2017 to July 2017.
bones with a high vulnerability to fractures (1, 2).
Sample size and study population:
According to the International Osteoporosis
The total number of Saudi females in Al-Riyadh
Foundation, the symptoms of osteoporosis are not
region was 2204529 females as estimated by the
clear till the occurrence of the first fracture and it
KSA General Authority for Statistics in 2017 (13).
significantly affect old women (3-6). The risk factors
The response rate to all questions was estimated to
for osteoporosis are female gender, old age, low
be 87.7% according to previous studies that was
levels of sex hormones, smoking, low levels of
conducted in KSA for assessment of knowledge
vitamin D and menopause (3, 7). Also, bad life style
about osteoporosis (14, 15). The minimum sample size
habits and low exposure to sunshine are also
by the Raosoft sample size calculator (16) using a
important predisposing factors for osteoporosis (8, 9).
confidence interval of 95% and a margin of error of
In KSA, there is a great concern about the
5%was 166. A larger sample of 200 females was
knowledge of osteoporosis and its risks and
taken to cover missed and uncompleted
preventive measures. However, many studies have
questionnaires. The inclusion criteria were Saudi
reported a poor knowledge score about osteoporosis
females older than 20 years old. The exclusion
criteria were non-Saudi females, age less than 20,

and uncompleted data in the questionnaire.

This study aimed to investigate the level of
Study tools
awareness of Saudi females about osteoporosis and
An online questionnaire was designed according to
finding the association between the subject's
the questionnaire of osteoporosis knowledge
demographics and level of knowledge.
assessment tool that was implemented from
Received:15 /7 /2017 DOI : 10.12816/0041064
Accepted:24 / 7 /2017

Full Paper (vol.693 paper# 16)

c:\work\Jor\vol693_17 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2093-2099

Treatment Options for Relapsing-Remitting Multiple Sclerosis
Yara Mohsen Albalawi1, Sultan Sameer Alhunbusi2, Meshari Sultan Alsudayri3, Neda Ali Al-Bati4,
Ahmad Hamza Omar Khalid2, Talal Hamid Alfallaj5, Elham Hamid Al Fallaj6, Abdulrahman Zaid
Alshamrani7, Adilah Hamoud Al Turaifi8, Abdulrahman Mubarak Almutairi9
1 Tabuk University,2 Taif University,3 Hail University,4 Immam Abdulrahman Bin Faisal University
(IAU),5 Dow University of Health Sciences - Pakistan ,6 Almaarefa Colleges for Science & Technology
(MCST),7 Jeddah University,8 Ibn Sina National College for Medical Studies,9 Majmaah University
Corresponding Author: Yara Mohsen Albalawi , email: Yara.1993_9@live.com

Multiple sclerosis (MS) is a chronic inflammatory autoimmune demyelinating disease of the central
nervous system that usually affects young adults, particularly women. The pathobiology of multiple
sclerosis contains inflammatory and neurodegenerative mechanisms that affect both white and grey matter.
These mechanisms cause the relapsing, and frequently progressive, course of multiple sclerosis, which is
heterogeneous; confident prediction of long-term individual prognosis is not yet promising. Though, as
revised MS diagnostic criteria that include neuroimaging data facilitate early diagnosis, most patients are
encountered with making important long-term treatment decisions, most particularly the utilization and
selection of disease modifying therapy. Presently, there are numerous approved MS disease modifying
therapy with changing degrees of efficacy for decreasing relapse risk and preserving neurological function,
but their long-term benefits stay imprecise. Furthermore, available disease modifying therapy vary with
regard to the route and frequency of management, common adverse effects, tolerability and possibility of
treatment adherence, risk of major toxicity, and pregnancy-related risks. Thorough understanding of the
benefit risk profiles of these therapies is essential to establish logical and safe treatment procedures for
patients with multiple sclerosis.
Keywords: Relapsing-Remitting, Multiple Sclerosis, Treatment.

frequently recover unexpectedly and completely.
Multiple sclerosis (MS) is a putatively
Current preventive disease-modifying therapies for
autoimmune, idiopathic, chronic inflammatory
MS principally target assaults, diminishing their
demyelinating disease of the central nervous
recurrence and seriousness. Brain magnetic
system with genetic and environmental effects [1, 2].
resonance imaging (MRI) can distinguish
The average age of clinical start of MS is nearly 29
numerous new asymptomatic sores for each
years, and the male/female ratio in this group
clinically clear attack and is utilized as a sensitive,
approaches 1:3 and might be growing [3]. Multiple
objective, and quantifiable instrument for the
sclerosis causes worrisome or disabling physical
estimation of multiple sclerosis movement in both
symptoms including vision problems, mobility
clinical practice and remedial trials [8].
problems, pain, problems with coordination,
85% of the patients have relapsing-remitting
fatigue, and cognitive dysfunction.
multiple sclerosis (RRMS), in which a clinical
Quality of life may be reduced by mood
attack proclaims the beginning of the disease [9]. If
disorders and restrictions in employment and social
inadequate brain MRI indication is present at first
functioning [4, 5]. Lesions of CNS white issue with
clinical presentation, an impermanent diagnosis of
loss of myelin, neuronal axons, and myelin creating
clinically isolated syndrome might be functional,
oligodendrocytes portray the multifocal pathology
inferring high hazard for future affirmed MS,
of multiple sclerosis [6]. Recent research has
anticipating confirmation of further clinical
additionally featured an overlooked association of
relapses or new MRI lesions (dissemination in time
gray matter, which might be particularly applicable
and space). The lasting 15% of the patients have
to irreversible disability [7]. Acute inflammatory
primary progressive multiple sclerosis (PPMS),
Lesions are started by actuated peripheral
characterized as gradually progressive and
leukocytes that enter the central nervous system
incessant loss of neurological function for more
through a ruptured blood- brain boundary. The
than 1 year. It typically shows as a gait disorder, is
clinical correspond of this procedure is a clinical
related with less proof of inflammatory action than
assault (equivalent words incorporate exacerbation,
RRMS, and possibly signifies a neurodegenerative
relapse, or flare), which comprises of subacute
procedure. Differentiating RRMS from PPMS is
neurological manifestations that worsen over days
critical as all available MS disease modifying
to a few weeks and, primary in the disease,
therapies have displayed adequacy for attack
Received: 24 / 7/2017 DOI : 10.12816/0041065
Accepted: 3 /8 /2017

Full Paper (vol.693 paper# 17)

c:\work\Jor\vol693_18 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2100-2104

Assessment Level of Awareness about Risk of Using Chronic Steroid Causing
Cataract in Saudi Arabia, 2017
Saad Saud Aljuaid1, Wala Hassan Bakhamees2, Samah ali alharbi3,
Ibrahim Ahmed Alkulaybi4, Khaled Freeh Aoudah Alnawaimiss5, Abdullah Hisham Al-Mulla6,
Faisal Abdullah ALMoumen7
1-Taif University, 2-King Abdulaziz University, 3-Ibn Sina National College, 4-Umm Alqura University,
5-Hail University, 6-King Faisal University, 7-Imam Abdulrahman Bin Faisal University

the risk of cataract was increased in patients using steroid therapy for long periods in a
dose dependent manner.
Objectives: assessing the knowledge of Saudi population toward chronic use of steroid therapy impact on
Subjects and Methods: this is a cross sectional study conducted from February 2017 to June 2017
among 918 adult subjects randomly chosen from 15 primary health care centers in KSA. All subjects
were asked to fill up a questionnaire that included their demographics and questions about using steroid
therapy and it effects.
Results: the mean age of included subjects was 58.7 years old, 52% of were males and 48% were
females. More than half of included subjects had college degree (51.2%) and 66.8% were working. Only
7.8% of subjects had cataract and 20% of subjects received steroid therapy for more than 4 months per
year. The knowledge score was good in 23.3% of subjects and poor in 76.7% of subjects. There was no
association between age, gender, and working status but the higher education was significantly associated
with good knowledge.
Conclusion: there was inadequate knowledge about cataract induced by using steroid therapy among
adult Saudi population and no significant impact of age, gender and working status has been evidenced.
But the higher education was associated with higher levels of good knowledge.
Keywords: KSA, Awareness, Cataract, Steroid Therapy.


Medicine and a written consent was obtained from
Corticosteroids have been widely used
all subject included in the research. This was a
since its discovery for various types of autoimmune
cross sectional study conducted from the period of
disorders and other inflammatory disease(1). Also,
February 2017 to June 2017 in a randomly chosen
steroids could be used for replacement of adrenal
15 primary health care centers in KSA using the
insufficiency, treatment of many ophthalmic,
stratified random sampling technique.
Saudi adult subjects who are 50 years old
gastrointestinal ophthalmologic, rheumatologic,
or more either receiving steroid therapy are for
hematologic, pulmonary and disorders (2-4).
more than 4 months during one year or not and who
Many complications are related to the
accepted to participate in the study then 918
increasing use of steroids in various conditions
subjects were enrolled in the study. All subjects
especially those related to ocular diseases as
were asked to fill up a questionnaire that included
increasing the intraocular pressure, glaucoma and
their demographics and questions about using
cataract (5, 6). Cataract could result in visual
steroid therapy and it effects. Another part of the
impairment which lead to low vision ability and
questionnaire included questions about cataract and
partial or total loss of vision. Aging, diabetic-
its prevalence among the studied groups.
retinopathy and glaucoma are the most common
According to our knowledge this is the first
risk factors for cataract (7, 8). Also, using steroid
study assessing the knowledge about cataract and
therapy for long periods could result in (9). The
steroids among Saudi subjects thus the
objective of the study was to evaluate the
questionnaire was collected from previous studies
knowledge of Saudi population toward chronic use
dealing with the pathology of cataract in patients
of steroid therapy impact on cataract.
using steroid therapy then the questionnaire was

translated into Arabic and tested in a pilot study
among 40 Saudi subjects older than 50 years old
This study is conducted after obtaining the
during 2 weeks for testing the reliability and
approval from the ethical committee of Faculty of
validity of the questionnaire. The questionnaire
Received:17 /7 /2017 DOI : 10.12816/0041066
Accepted:26 /7 /2017

Full Paper (vol.693 paper# 18)

c:\work\Jor\vol693_19 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2105-2108

Assessment of The Effectiveness of Lifestyle on BMI in Adult People in
Saudi Arabia, 2017
Tahani Abdullah Doshi1, Hind Fahad Alqubali2, Aqeela Najim Al-khamis3,
Amnah Essa Abu lahsah1, Rahma Ibrahim Mohzari1, Mohammed Hadi Assiri4,
Nouf Mohammed Mari1, Layla Ali Hussin Mohammed1, Khetam hamod moafa1
Abdulrahman Fahad AL-Aql 5
1-Jazan University 2-Tabuk University 3-Imam Abdulrahman Bin Faisal University
4-Armed Forces Hospital, South Region
5-Imam Muhammad Ibn Saud Islamic University

Background: food habits and lifestyle significantly affect the prevalence of overweight and obesity thus impact
the body mass index (BMI) among Saudi population.
Objectives: assessments of the impact of lifestyle on the BMI among the adult population in Kingdom of Saudi
Arabia (KSA). Subjects and Methods: a cross sectional study conducted on 1055 adult Saudi subjects aged
between 20-40 years old. A predesigned questionnaire was distributed among included subjects from January
2017- May 2017consisted of questions about subject's demographics, anthropometric measures, and lifestyle.
Results: this study included 1055 subjects from which 40.9% normal, 5.9% were underweight, 25% were
overweight, 17.1% were obese, 8.4% were severely obese and 2.7% were morbidly obese. Being female, older
age and smoking were significantly related to overweight and obesity. The bad lifestyle habits, lack of exercise
and watching TV and video games were significantly associated with a high prevalence of obesity and
overweight among studied subjects.
Conclusion: bad lifestyle habits, smoking, not practicing physical exercise and using entertainment means for a
long time significantly increased the BMI thus revealing high rates of overweight and obesity.
Lifestyle, BMI, Obesity, Adult, KSA.

index (BMI), obesity has been rising dramatically
Obesity is considered as a serious health
over the past 30 years due to modernization and the
problem that increased in both developed and
obvious economic growth that affected the lifestyle
developing countries all over the world(1). The
and resulted in bad dietary habits (6, 7).
imbalance between food consumption and the
Also, many studies have proposed the
energy loss was considered an important factor
impact of physical activity, dietary habits, food
implicated obesity problems with the presence of
consumption as well as the economic status as
environmental and genetic factors(2).
modifiable factors on the prevalence of obesity (8, 9).
The implications of obesity and its role in
Aim of the study
jeopardizing human race drew a lot of attention as it
The present study aimed to estimate the
is considered the sixth most important risk factor for
effectiveness of lifestyle on the BMI among Saudi
several diseases problems affecting human beings
adult population.

nonalcoholic fatty liver disease, and diabetes (3, 4).
In 2014, WHO(5) stated the prevalence of - Study design
overweight was found in 39% of adults, but KSA
This was a cross sectional study that was based
showed higher rates in 68.2% of adults. The
on a reliable questionnaire that was conducted after
worldwide prevalence of obesity was found in 13%
obtaining the approval of the ethical committee of
of adults while in KSA it was 33.7% with a higher
Faculty of Medicine among adult Saudi population
prevalence among females (39.5%) than males
from January to May 2017 in KSA.
(29.5%). The percent of obese adults in KSA was - Sample size and population:
2.6Ś higher than the world's population (33.7% vs.
This study included 1055 adult Saudi subjects
13%). Also, many studies conducted among Saudi
who were chosen randomly from the 13
population showed that according to the body mass
governorates of KSA using the stratified random
Received: 14 / 7 /2017 DOI : 10.12816/0041067
Accepted:23 / 7 /2017

Full Paper (vol.693 paper# 19)

Effect of Maternal Diabetes on Cord Blood Concentrations of Iron Status Parameters The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2109-2114

Effect of Maternal Diabetes on Cord Blood Concentrations of Iron
Status Parameters
Nehal Mohamed El-Raggal, Rania Mohamed Abdou, Mohamed Tarif Hamza,
Shorouk Mostafa Hassan El Oufy
Department of Pediatrics, Faculty of Medicine-Ain Shams University
Corresponding author: Shorouk Eloufy ,sho_eloufy@yahoo.com

iron is essential element involved in a broad range of biologically important reactions critical
for cellular function and also plays a role in oxygen transferring and despite its low daily requirements iron
deficiency is the most common nutritional disorder in the world. Increased serum concentration of TfR is a
sensitive and quick response to the development of iron deficiency. Conversely, the serum TfR concentration
decreases in response to treatment with iron before a change in hemoglobin occurs, so the response to iron
can be monitored by changes in serum TfR. TfR-F index is proposed to be a more accurate reflection of
tissue iron status than ferritin. Many factors can influence the iron status of the fetus at birth, Maternal
diabetes mellitus was thought to be associated with depletion of fetal iron stores in proportion to the degree
of maternal control and presence or absence of complications of diabetes, but not maternal iron status.
Aim of the work: in this study we aimed to assess the effect of maternal diabetes on neonatal cord blood
iron stores. Patient and Method: this case-control study was conducted on 100 maternal/cord blood pairs
who were randomly included in the study from Obstetrics and Gynecology Department at El- Nile Insurance
Hospital, Shubra El Khema, during the period from November 2015 to July 2016.
Results: this study was done on the fetal iron status in the diabetic mothers and the control group using the
transferrin receptos-ferritin index(TfR-F index) as a measure of cellular iron status and results showed that
infants of the diabetic mothers(IDM) had significantly lower iron stores represented as lower s.ferritin
(P=0.000) and significantly higher serum transferring receptors(STfR)levels than infants born to the control
mothers (P=0.038) and also higher sTfR level in insulin dependent diabetes mellitus (IDDM) mothers ; this
was suggesting a state of increased erythropoiesis.
: this study confirmed that iron stores are lower at birth in infants of women with diabetes
mellitus. This appeared to be due to the effects of increased erythropoiesis secondary to chronic intrauterine
hypoxia. Fetal iron stores were affected by maternal glycemic control and not related to maternal iron
maternal diabetes , TfR-F index , STfR, ferritin , neonatal cord blood, iron stores.


Iron is essential to many cellular processes
Conversely, the serum TfR concentration
and transport across the cell membrane is
decreases in response to treatment with iron before
facilitated by the transferring receptor (TfR) on the
a change in hemoglobin occurs, so the response to
cell surface. The number of surface transferrin
iron can be monitored by changes in serum TfR.
receptors is inversely proportional to intracellular
TfR-F index is proposed to be a more accurate
iron. Cellular iron homeostasis is regulated
reflection of tissue iron status than ferritin (1).
through the action of iron regulatory proteins
Maternal diabetes mellitus was thought to be
(IRPs). The IRPs bind to the mRNA of both
associated with depletion of fetal iron stores in
ferritin and transferrin receptors and as
proportion to the degree of maternal control and
intracellular iron concentration falls the IRPs
presence or absence of complications of diabetes,
upregulate the expression of transferrin receptors,
but not maternal iron status. Infants of mothers
while simultaneously reducing serum ferritin (3).
with type 1 diabetes were found to have higher
Ferritin concentration is an important
fetal iron demands at least partly explained by
indicator of total body stores and its concentration is
increased erythropoiesis secondary to intra-uterine
taken to indicate deficient iron stores. However, the
hypoxia (11).
synthesis of ferritin is stimulated by infection, which
This study was performed to reveal the
may obscure an iron deficiency or indicate a larger
effect of maternal diabetes on fetal iron status
iron store that truly exists (11).Increased serum
parameters: STfR, ferritin levels and their ratio
concentration of TfR is a sensitive and quick
(TfR-F index), in cord blood samples of infants
response to the development of iron deficiency.
with and without maternal diabetes.
Received:8 /8 /2017 DOI : 10.12816/0041068
Accepted: 17 /8 /2017

Full Paper (vol.693 paper# 20)

c:\work\Jor\vol693_21 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2115-2127
Morpho-Functional Adaptations of the Lingual Epithelium of
Two Bird Species Which Have Different Feeding Habits
Ali G. Gadel-Rab1, Nahed A. Shawki2, Samy A. Saber3
1- Department of Zoology, Faculty of Science, Al-Azhar University, Assuit, 2-Department of Zoology, Faculty of
Science, Assuit university 3- Department of Zoology, Faculty of Science, Al-Azhar University, Cairo, Egypt
Corresponding author: Ali G. Gadel-Rab, Aligamal200992@yahoo.com


The dorsal epithelium of the free portion of tongue of laughing dove, Streptopelia senegalensis
(granivorous) is characterized by presence of well-developed keratinized epithelium with desquamate
parakeratinized one which is covering the anterior part of the free portion. Highly keratinized and stratified
epithelium is covering the ventral surface of the anterior third of the free portion of the tongue and forming the
lingual nail. Laryngeal area is covered dorsally by non-keratinized squamous epithelium. Frenulum is covered by
a transitional-like epithelium. Both the dorsal and ventral surfaces of the free portion of the tongue of the
common hoopoe, Upupa epops (insectivorous) are covered by thin non-keratinized squamous epithelium except
that covered the areas of lingual tubercles, lingual wings and lingual papillae, which are covered by epithelium
furnished dorsally by detached keratin. The laryngeal area is covered by non-keratinized squamous epithelium.
The frenulum is covered by non-keratinized stratified squamous epithelium. It has been summarized that the
differences in the structures of the avian tongue reflecting the differences in the feeding habits. The epithelium
covering the tongue of the laughing dove is constructed for high mobility (up-down movement) in comparison
with the epithelium of the common hoopoe that depends on its first action of feeding on the movement of the jaws
and beak.
Keywords: laughing dove, common hoopoe, lingual epithelium, salivary glands, and adaptations.

Columbiformes, which is avian granivorous have
The feeding mechanism is an important
an elongated and narrow tongue with short and
factor that determines the success of adaptations of
curved bill, exhibit great difference in the shape and
vertebrates to their environment and of their
volume of their tongues as well as the shape and
persistence through procreation (1). During feeding
volume of their bill than that of bucerotiformes
process, the lingual apparatus plays a principal role,
which feeds on insects and possess short and broad
together with other organs within and near the oral
tongues with a very elongated and straight bill. Thus,
cavity, in particular in tetrapods.
the questions are "are the lingual epithelium and its
All birds are adapted to their different
derivatives of papillae, tubercles and salivary glands
environments with respect to food resources.
in the two bird species modified to perform their
Reflecting their different life styles, birds have
action according to their feeding behavior? This
different feeding behaviors with corresponding
question attracts the attention of the authors of the
differences in the size and structures of their lingual
present study. The laughing dove, Streptopelia
apparatus)2(. The structural adaptations of the lingual
senegalensis (Columbifromes) and the common
apparatus of birds vary greatly among the different
Hoopoe, Upupa epops (Bucerotiformes) which are
species project an interesting subject for functional
sympatric species in most areas of Egypt were
morphological studies and attracted the attention of
chosen for this investigation.
many investigators)3-7( on the various feeding
Aim of the work: the study of functional
behaviors and types of food, frequent structural
morphology of the lingual epithelium of both the
modifications of the lingual system (Mucosa;
laughing dove and the common hoopoe attempts to
distribution of mechanical papillae and the area and
correlate the structure of the lingual epithelium of
degree of keratinization of the stratified epithelium)
the different components with contemplate
can be observed in birds)8(. Such modifications result
mechanical performance during the feeding process.
in different tongue mobility and the ability to slide
The present study included a morphological
the tongue out, extract food and manipulate food in
description of the tongue of the two chosen birds as
the beak cavity.
well as histological investigation and scanning
Received: 9 /8 /2017 DOI : 10.12816/0041069
Accepted:18 /8 /2017

Full Paper (vol.693 paper# 21)

c:\work\Jor\vol693_22 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2128-2132

Study of Analgesic Intake among Patients with Chronic Low Back Pain
and their Side Effects
Molook Shebeeb Alotibi1, Abdullah Ibrahim Saeed1, Hussam Sunaid Dhaher Almuzaini2, Ghadah Meshaal
Al-Rubaya3, Bara'ahSohaib Anwar Butt4, Alzahrani Rashad Mohammed5, Nedaa Mohammed A Alromaili1,
Abdullah Atallah Al-Enezi6, Meshari Ahmad Aali Al-Malki5, Hanan Abdulwahab Al-Hawaj7
1 King Saud University, 2 Al-Imam Muhammad Ibn Saud Islamic University, 3 Imam Abdulrahman Bin Faisal
University, 4 Ibn Sina National College for Medical Studies, 5 Taif University, 6 Majmaah University, 7 Arabian
Gulf University
*Corresponding Author: Molook Shebeeb Alotibi, e-mail: Molook2011@live.com

chronic low back pain is one of the most common causes of chronic pain. Low back pain can have
many causes but most cases have nonspecific etiology. There are many approaches in the management of chronic
low back pain. Methodology: we carried out a systematic review on observational (nonrandomized) of 43
studies using PUBMED. Aim: to evaluate the use of analgesics, mainly Non-Steroidal Anti-inflammatory Drugs
and opiates, compare their efficacies for symptomatic treatment of low back pain, and study the side effects
briefly for both category of drug.
Conclusion: management of chronic low back pain aims mainly to improve function, and quality of life, and to
decrease level of disability, and therefore, it remains as a big challenge for the general practitioner. More studies
must be done to compare efficacies of various lines of management for both short and long term.
Keywords: chronic low back pain, analgesic, NSAIDs, Anti-inflammatory Drugs, opioids, side effect of NSAID,
side effects of opioids, chronic pain therapy

sociodemographic factors, psychosocial factors,
Low back pain is a common global health
occupational factors, respiratory disorders, heart
problem, and is one of the leading causes of years
disease, rheumatological disorders, and other
lived with disability, with more than 80% of adults
comorbid conditions(4, 6).
experiencing it at least once in their lifetime (1). It is
Chronic low back pain is defined as low back pain
also considered the most common cause of chronic
lasting for more than 3 months (7). It is estimated that
pain (2). It is mostly prevalent among females and
a large population of patients will develop chronic
people aged 40-80 years, and its prevalence has been
low back pain after an attack of acute low back pain.
increasing in the past few years (3). Low back pain can
A systematic review of 11 studies concluded that only
have many causes, but is mostly nonspecific, with
one-third will recover from an acute low back pain
less than 10% of cases with an identifiable cause (4, 5).
attack within the first three months, while the others
There are many known etiologies of chronic low back
will have chronic pain and continue to suffer for at
least a year after the initial presentation (6, 8).
spondylolisthesis, fracture, tumor and metastatic
Managing chronic low back pain can be very
disease, infection, aortic aneurysm, sickle cell crisis,
challenging, most importantly due to its non-specific
etiologies; the fact that is causing a large
endometriosis, lumbar spinal stenosis, Paget disease,
inconsistency among physicians(4). The main target of
treatment is to relive the pain on the long term. Along
with treating the cause - if possible - many
spondylitis, etc.). The differential diagnosis of
approaches are important in the treatment of chronic
chronic low back pain is very broad, thus proper
low back pain; Non-steroidal anti-inflammatory drugs
history taking and physical examination are essential
for detecting the presence of a specific medical cause;
medications (9). Many guidelines recommend the
this is extremely important as some causes - as
initial use of acetaminophen followed then by
tumors and metastasis - are serious and may only
NSAIDs (6, 10). Other medications include opioids,
present initially with back pain.Predisposing factors
antidepressants (TCAs, SNRIs, and SSRIs), skeletal
for developing chronic low back pain include:
Received: 23 /7 /2017 DOI : 10.12816/0041070
Accepted:2 /8 /2017

Full Paper (vol.693 paper# 22)

c:\work\Jor\vol693_23 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2133-2136

Urinary Tract Infection in Patients with Diabetes Mellitus
Faisal Abdullah Alrwithey1*, Abdullah Eid Ayyadah Alahmadi1, Ali Mohammed Fayez Alshehri2, Ibrahim
Abdullah Abalhassan3, Fatimah Mohammed Salman Alhamad4, Yousef Zaki Khedher5, Alaa Mohammed
Aldehry6, Shaima Tariq Mansoor Beig6, Awatif Ahmed Althubyani6, Reham Ahmed Al Ghamdi6
1 Taibah University, 2 King Khalid University, 3 Prince Sattam Bin Abdulaziz University
4 Imam Abdulrahman Bin Faisal University, 5 King Abdulaziz University, 6 Ibn Sina National College
*Corresponding Author: Faisal Abdullah AlRwithey- drfaisal97@gmail.com
urinary tract infections (UTI) are one of the most common types of bacterial infection in patients
with diabetes mellitus (DM). There are certain aspects to diabetes that makes it a risk factor for getting urinary
tract infection and additionally, diabetes may also predispose to certain complications.
Methodology: in this paper we aim to carry out a systematic review on observational (nonrandomized) studies on
PUBMED. Aim: to evaluate the prevalence, pathogenesis, diagnosis, management and complications of UTI in
patients with DM. Conclusion: the proper management of UTI in diabetics is crucial, as prompt diagnosis and
correct use of antibiotics is vital for treatment. Future research in this regard will hopefully decrease the burden of
UTI in diabetic patients.
: Urinary tract infections, diabetes mellitus, UTI in DM, risk factors of UTI, diagnoses of UTI,
treatment option of UTI in diabetic patient, complication of UTI in diabetic patient

hyperosmolar hyperglycemia, diabetic ketoacidosis,
Urinary tract infection (UTI) can be roughly
coma or death, and chronic ones are nephropathy,
classifiedbased on anatomy as upper UTI and lower
opthalmopathy, foot ulcers, and cardiovascular
UTI, or both. UTI can be symptomatic or
diseases (6, 7). It was recorded in 2015 that worldwide
asymptomatic, but is defined as presence of
415 million people had diabetes, 90% of which was
bacteriuria with a quantitative count of more than or
type II DM. This number is estimated to rise to 552
equal to 105 colony forming unit of bacteria per
millionin 2030 (8). It was reported to be the cause of
milliliter (1). The most common causative pathogen
1.5 to 5 million deaths each year, and budgets a
for both uncomplicated and complicated UTIs is
global economic cost of 612 billion US dollars for its
Escherichia coli (2). Other organisms that cause UTI
management (9). There is an increased risk of UTI in
patients with DM, especially DM type II, therefore in
saprophyticus, Proteus mirabilis, Enterococcus
this study we aim to review the literature for
faecalis, group B Streptococcus, Pseudomonas
aeruginosa, Candidaspp, and Staphylococcus aureus
management of UTI in diabetics.
(3). National Ambulatory Medical Care Survey

reported UTI to be the most common bacterial
infection worldwide (1). Among the most common
We carried out a systematic review on observational
risk factors of UTI are female anatomy, sexual
(nonrandomized) studies by evaluating 37 articles,
after exclusion, using search on PUBMED (January
vesicoureteral reflux, blockage anywhere in the
1983 to December 2016) to identify the prevalence,
urinary tract, catheter use, and a suppressed
pathogenesis, management, and complication of UTI
immunity state such as diabetes (4, 5).
in patients with DM type II. The keywords used for
Diabetes mellitus (DM) is a group of metabolic
the search were: Urinary tract infections, diabetes
disorders characterized by high blood sugar levels
mellitus, UTI in DM, risk factors of UTI, diagnoses
over a prolonged period. DM is classified as type I or
of UTI, treatment option of UTI in diabetic patient,
type II based on the pathology. Type I results due to
complication of UTI in diabetic patient
failure of the pancreas to produce insulin, while type

II is resistance of insulin by the cells of body (6). Both
Prevalance of UTI in Patients with DM vs.
types of DM can have acute or chronic
Patients without DM
complications. Some acute ones include
Many studies have stated the general incidence of

UTI among patients with DM. An observationalstudy
Received: 25 / 7/2017 DOI : 10.12816/0041071
Accepted: 4 / 8 /2017

Full Paper (vol.693 paper# 23)

c:\work\Jor\vol693_24 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2137-2142

Effect of Egyptian Red Cabbage on Some Physiological Parameters in
Hyperthyroidimic Rats
Eman G.E. Helal, Rasha A. A. El Sayed, Sara Ebrahiem
Department of Zoology, Faculty of Science, Al-Azhar University (Girls), Cairo, Egypt.
*Corresponding authors: Eman G.E. Helal, E-mail: emanhelal@hotmail.com, mobile: 00201001025364

: this study aimed to illustrate the protective effect of red cabbage extract against hyperthyroidism
induced by L-thyroxine in male albino rats. Materials and methods: Eighteen animals were divided randomly
into three groups. Group A: healthy rats, Group B: hyperthyroidimc rats were given an oral dose of 500 ”g/kg
body weight/day L-thyroxine once daily for two weeks to induce hyperthyroidism and group C: hyperthyroid
rats received red cabbage extract. At the end of the experiment, blood samples were collected for biochemical
analysis. Results: hyperthyroid rats induced by L-thyroxine had significant increase (P<0.05) in serum levels of
triodothyronine (T3), thyroxin (T4), TG,VLDL,AST,ALP,BUNand uric acid as well as a significant decrease in
TSH, LDL,LDL/HDL,HDL and TC compared to the normal control group. Oral administration of red cabbage
extract ameliorated most of the tested parameters.
Keywords: hyperthyroidism- red cabbage- rat- kidney function.


Thyroid hormones (TH) are required for the
Among natural plants, red cabbage (RC)
normal function of most tissues of the body, playing
(Brassica oleracea) has been found to have
antioxidant, ant hyperglycemic,anticancer, and
differentiation, and metabolism, with major effects
hypocholesterolemic(5) properties. Cabbage is an
on O2 consumption and metabolic rate (1).
excellent source of vitamin C and also contains
Hyperthyroidism is associated with an increased
significant amounts of glutamine, an amino acid that
metabolic rate due to increased rate of oxygen
has anti-inflammatory properties.The principle
consumption in target tissues. Acceleration of

aerobic metabolism by thyroid hormones enhances
(glucosinolate), vitamins A, B, C and anthocyanins
the generation of oxidative stress(2).
which is a group of phenolic natural pigments that

found to have the strongest antioxidizing power of
Despite the fact that day-by-day herbal drugs
150 flavonoids . RC extract has also preventive
are gaining much importance for their affordable and
oxidative stress induced in livers(6)
safe nature, scientific investigations towards the

mitigation of thyroid disorders by the plant extracts
are meager (3). Large number of these plants and
Preparation of RED CABBAGE extract
their isolated constituents have shown beneficial
Red cabbage leaves were sliced into smal
therapeutic effects, including anti-oxidant, anti-
inflammatory, anti-cancer, anti-microbial and
extracted in 1000 ml of 70% aqueous ethanol using
immunomodulatory effects. Cruciferous vegetables
ultrasonic treatment at an intensity of 70 W/ cm2 and
are the only source of sulfur-containing compounds
oscillation frequency at 20 kHz for 5 min. Ultrasonic
called glucosinolates that are responsible for their
irradiation was applied by means of a Branson 450
bitter flavor(4). Glucosinolates are digested into
digital sonifier (20 kHz, 450 W) equipped with a
isothiocyanates that reduce inflammation and fight
cylindrical titanium alloy probe (12.7 mm in
bacteria. The red pigment comes from a flavonoid,
diameter). After overnight maceration, the extract
cyanidin, that functions as an antioxidant. In
was filtered through gauze and ethanol was
addition to these important phytochemicals, cabbage
evaporated under reduced pressure at 50șC by using
contributes to overall health with fiber and a range
a rotary evaporator. The remaining water extract was
of vitamins and minerals(4) .
dried using a freeze dry system under reduced
Received: 16 /8 /2017 DOI : 10.12816/0041072
Accepted: 25 / 8 /2017

Full Paper (vol.693 paper# 24)

c:\work\Jor\vol693_25 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2143-2148

Lidocaine Infusion on Hysteroscopic Media versus Oral Diclofenac for Pain
Relief during Outpatient Hysteroscopy: A Randomized Controlled Trial
Hatem Hussein El-Gamal, Ahmed Elsayed Hassan Elbohoty Mortada Elsayed Ahmed,
Ahmed Hamdy Gouda Aboutabl
Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Ahmed Hamdy Gouda Aboutabl,ah_tabl@hotmail.com

Aim of the work:
this work aimed to assess the analgesic efficacy of lidocaine dissolved in the distension
medium compared to oral diclofenac before outpatient diagnostic hysteroscopy
Patients and methods: this randomized controlled trial included 44 nulliparous women schedules to
undergo diagnostic office hysteroscopy.
The participants were randomly categorized into two groups; group D (n=22) received diclofenac 100 mg
oral tablets and group L (n=22) received 10 ml of lidocaine 2% dissolved in saline (The distension medium).
Pain was evaluated during hysteroscope insertion and 5, 10, 15 and 30 minutes after using visual analog
scale (VAS). The patient was considered in pain if the VAS score was 4. Results: hysteroscope insertion
was associated with pain in 35 patients (79.5%); more frequently in group L (p = 0.021). Severe pain was
reported by 13 patients (29.5%); more in group L (p = 0.099). All patients were pain-free 15 minutes after
procedure start. Group L showed significantly higher pain scores with hysteroscopic insertion (p = 0.017).
The two groups had comparable pain scores 5, 10 and 15 minutes from the procedure start. Few adverse
reactions were recorded. The two drugs were hemodynamically stable.
Conclusion: oral treatment with 100 mg diclofenac one hour before office hysteroscopy was a safe and more
effective in pain control during the procedure compared to lidocaine dissolved in saline used as the
distension medium.
Keywords: Lidocaine, Hysteroscopic, Diclofenac, Pain Relief.

distension medium compared to oral diclofenac
Office hysteroscopy is preferred by most
before outpatient diagnostic hysteroscopy.
gynecologists for diagnosis and frequently for

management of intrauterine pathology. It has the
advantage of saving time and costs of hospital
This randomized controlled trial was carried
admission and escaping anesthesia when compared
out in the Early Cancer Detection Unit in Ain
to operative procedures (1). However, many reports
Shams University Maternity Hospital during the
highlighted more or less high frequency of pain
period from April 2016 to January 2017. This
and discomfort in association with anesthesia-free
study included nulliparous women schedules to
diagnostic hysteroscopy. Moderate to severe pain
undergo diagnostic office hysteroscopy for various
was reported in 30% and 70% of cases (2,3). Pain
indications. This study was approved by the
and low patient acceptance are the main
Council of Obstetrics and Gynecology Department
constraints of widespread use of office
and the Ethics Research Committee, of Faculty of
hysteroscopy. It has been suggested that in
Medicine, Ain Shams University. All participants
experienced hands, analgesics are only needed in
have provided written informed consents.
the selected cases as in women with previous
Inclusion criteria were: age between 18 and 35
cesarean section, anxiety and history of chronic
years and body mass index (BMI) raging between
pelvic pain (4). Several analgesic methods have
18.5 and 30 kg\m2. Exclusion criteria included:
been reported in literature for outpatient
any contraindication to hysteroscopy, cervical
hysteroscopy. These include nonsteroidal anti-
stenosis, polyps and ulcers, patients receiving any
inflammatory drugs (NSAIDs) and opioid
form of analgesia and history of previous cervical
analgesics, administered orally or intravenously in
surgery. This study comprised 44 nulliparous
addition local anesthetics through intrauterine,
women randomly categorized into two groups:
paracervical, transcervical, or uterosacral routes
group D (n=22)was received oral diclofenac and
and topically as a spray, gel or cream(5).This
group L (n=22) was received lidocaine.
randomized controlled trial aimed to assess the
Randomization was performed using computer
analgesic efficacy of lidocaine dissolved in the
generated codes. The codes were kept in sealed
envelopes to be open 30 minutes before the
Received: 12 /8 /2017 DOI : 10.12816/0041073
Accepted: 21/ 8 /2017

Full Paper (vol.693 paper# 25)


Outcomes of Patients with Morbidly Adherent Placenta in Ain Shams Maternity
Hospital: a Retrospective Study
Amr Hassan El-Shalakany , Amr Abdel Aziz Elsayied , Ahmed Mohammed Ragab
*Department of Obstetrics and Gynecology, Faculty of Medicine Ain Shams University
Corresponding author: Ahmed Mohammed Ragab, bodyatef07.ba@gmail.com

morbidly adherent placenta is defined as an abnormal adherence of all or part of the placenta to the
underlying uterine wall. Aim of the work: this study aimed to evaluate the management of morbidly adherent
placenta in Ain Shams Maternity Hospital during the 5-year period from January 2012 to December 2016.Study
this is a retrospective study. Study Setting: Ain Shams University Maternity Hospital.
Patients and Methods: records of hospital admissions during the planned time frame with the diagnosis of
antepartum hemorrhage or placenta accreta/increta/percreta were reviewed.
Results: Ain Shams University Maternity Hospital (ASUMH) is a major tertiary referral hospital in Egypt. In
evaluation of the management and short term maternal and perinatal outcomes of morbidly adherent placenta
offered to women at ASUMH, the hospital archives were examined for hospital records fulfilling the criteria of
this study population during the 5-year period from January 2012 to December 2016. During the 5-year period of
the current study, there were 58,529 deliveries; 29,282 cases; they were delivered by CS (50.03%). MAP was
diagnosed in 429 cases 0.7 % of total deliveries with an incidence of 1 in 136, 1.5% of total CS. These results
indicated a high incidence of MAP, as a result of high rates of CS.
Conclusion: morbidly adherent placenta was highly associated with the existence of placenta previa, especially
in cases with previous cesarean section. When morbidly adherent placenta was diagnosed or suspected
antenatally, the patient must be referred to a tertiary center. Generally, the recommended management is
cesarean hysterectomy. However, this approach might not be considered first-line treatment for women who
have a strong desire for future fertility. Therefore surgical management of morbidly adherent placenta may be
Keywords: morbidly adherent placenta ­ in vitro fertilization - alpha feto protein.

morbidly adherent placenta's 18% were placenta
The morbidly adherent placenta is now a
incretas and 7% were placenta percretas. Morbidly
significant obstetric challenge. Morbidly adherent
adherent placenta can be subdivided into total
placenta is often used as a general term, but it is
morbidly adherent placenta, partial morbidly
defined by the levels of invasion of chorionic villi
adherent placenta and focal morbidly adherent
into maternal myometrium. Once a rare diagnosis, it
placenta based upon the amount of placental tissue
is now the leading cause of postpartum hemorrhage
involved in their attachment to the myometrium (4).
and indication for a gravid hysterectomy.
The incidence of morbidly adherent placenta
Traditionally, abnormal placentation has been
has been steadily increasing specially during the last
classified into accreta, increta and percreta based on
two decades, mirroring increased rates of caesarean
the depth of myometrial invasion: superficial, deep,
section (5). The incidence varies from 1 in 533 to 1 in
and through the uterine serosa respectively and the
2500 (6- 8).
greater the invasion, the greater the risks for
In the event of morbidly adherent placenta,
hemorrhage and maternal morbidity (1).
the third stage of labor may be complicated by
The basic histopathological disorder lies on
severe uterine hemorrhage that may lead to the need
the absence of both the decidua basalis and the
of extensive life-saving surgical interventions such
Nitabuch's layer, which result in a direct attachment
as hysterectomy and ligation of major pelvic vessels.
of the chorionic villi to the myometrium. The most
The average blood loss volume at delivery was
severe manifestations of this process result in
3,000-5,000 ml (9). As a consequence of placental
placenta increta when chorionic villi invade into
invasion to adjacent organs, reconstruction of the
myometrium and placenta percreta when chorionic
urinary bladder or bowel may be necessary. Massive
villi invade to or through the uterine serosa (2, 3).
blood and blood products transfusions were the rule
About 75% of morbidly adherent placentas are
in these dramatic cases, and maternal morbidity is
Received: 13 /8 /2017 DOI : 10.12816/0041074
Accepted:22 / 8/2017

Full Paper (vol.693 paper# 26)

c:\work\Jor\vol693_27 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2159-2164

Oxidative Stress in Segmental Versus Non Segmental Vitiligo
Nader Fouad Ragab*, Mahmoud Abdel-Rahim- Abdallah*, Manal Louis Luka*,
Noha Sobhy Abd El Wahab**
*Dermatology and Venereohiilogy Department, Faculty of Medicine - Ain Shams University,
Corresponding author: Noha Sobhy Abd El Wahab,nahnoha_nonna@yahoo.com

vitiligo is a coetaneous autoimmune disease, cosmetically non-acceptable to patients with
higher Fitzpatrick skin type because of the contrast between lesional and non-lesional skin. Oxidative stress
through H2O2 that is converted by superoxide dismutase (SOD) into H2O and super oxide anion (O.-) which
affects directly on preopiomelanocortin (POMC) system in the epidermis of vitiligo patients which plays the
key role in melanogenesis.
Aim of the work: this study aimed to measure H2O2 in segmental vs. non-segmental vitiligo. This was done
through colorimetric evaluation of H2O2 in the epidermis of patients with vitiligo and it was focused on the
role of the oxidative stress in the pathogenesis of vitiligo.
Patients and methods: this pilot study was included 30 patients recruited from the outpatient clinic of
Dermatology and Venereology at Ain Shams University Hospital and outpatient clinic of Al Haud Al
Marsoud Hospital. They were all suffered from vitiligo. Fifteen of them had non-segmental and the other 15
had segmental vitiligo. Each group was subdivided into active and stationary. The active disease was defined
as appearance of a new lesion and/or extension of preexisting lesions in less than one year.
there was a significant increase of H2O2 level in the lesional vs. non-lesional skin in all number of
patients, NSV patients, NSs patients, NSa, and SVs, but not in SVa patients. The H2O2 raised in NSV
patients when compared to SV patients. There was a non-significant rise of H2O2; also in patients with SVa.
There was a significant increase in the epidermal H2O2 level in the NSV patients above that of SV patients.
Conclusion: this study suggested that oxidative stress was present in both SV and NSV. This might open a
window for several studies concerning the patients of SV and whether the oxidative stress is primary or
secondary. Also whether these patients might benefit from antioxidant medications or not.
Keywords: oxidative stress, segmental versus, non segmental vitiligo, H2O2.


Vitiligo is a cutaneous autoimmune
occurs (6). The high epidermal catecholamines
disease, cosmetically non-acceptable to patients
especially norepinephrine causes vasoconstriction
with higher Fitzpatrick skin type because of the
of the vitiliginous skin resulting into hypoxia
contrast between the lesional and non-lesional skin
which predisposes to more oxidative stress (7). The
(1). The major theories discussing the pathogenesis
increased internal and external phenol/catechol
of vitiligo are :1- the biochemical theory, 2- the
concentration competes with tyrosine on
neural theory, 3- the autoimmune theory (2) and 4-
tyrosinase. This results into liberation of reactive
the oxidative stress theory which implies that there
quinones. These reactive quinones bind to
is defect in free radical defense, interfering with
tyrosinase giving rise to a new antigen that is
the synthesis of melanin (2,3).
carried by Langerhans cells to the regional lymph
The pathogenesis is complicated and
nodes and stimulates the proliferation of cytotoxic
involves multiple factors; however, the exact
T cells. These cytotoxic T cells are the first step in
pathogenesis is not known. Lerner et al. firstly
melanocytes killing (8).
supposed the neural theory and then theory
Oxidative stress through H2O2 that is
involved reactive oxygen species (ROS), the
converted by superoxide dismutase (SOD) into
autoimmune theory and the melanocytorrhagy
H2O and super oxide anion (O.-) affects directly on
theory have been proposed (4). Patients with vitiligo
preopiomelanocortin (POMC) system in the
were found to have marked elevation of GTP-
epidermis of vitiligo patients which plays the key
cyclohydrolase activity, that leads to excessive
role in melanogenesis (9).
production of 6-tetrahydrobiopterin (6BH4) which
Dammak et al.(10) reported higher
results in increased epidermal catecholamine
epidermal levels for markers of oxidative stress in
synthesis (5). Catecholamines compete with
patients with active course of non-segmental
tyrosine on the enzyme tyrosinase, then become
vitiligo (NSV) than in those with stationary course.
hydrolyzed during this process liberation of H2O2
The former study assessed catalase (CAT), SOD,

and glutathione peroxidase (GPx).
Received:14 / 8 /2017 DOI : 10.12816/0041075
Accepted: 23 / 8 /2017

Full Paper (vol.693 paper# 27)

c:\work\Jor\vol693_28 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2165-2170

The Prognostic Value of the Prechemotherapy
Neutrophil - Lymphocyte Ratio in Gastric Cancer
Tarek Hussein, Ahmed Ezzat, Ahmed Gaballah, Monika Magdy Youssef

Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University
Corresponding author: Monika Magdy,email:monika_rcg@yahoo.com

gastric cancer is the 5th most common cancer worldwide, with about one million newly
diagnosed cases annually. It causes one of the highest cancer burdens, as measured by disability-adjusted
life years lost. It is the third-leading cause of cancer-related death worldwide, after lung and liver
malignancies. It is increasingly recognized that variations within clinical outcomes in cancer patients are
influenced by not only the oncological characteristics of the tumor, but also the host-response factors.
Aim of the work: this study aimed to investigate the prognostic value of prechemotherapy NLR in the
gastric cancer patients and also to assess the association between high NLR and clinicopathological features;
e.g. tumor stage, site, gross morphology ...etc. Patients and methods: this retrospective study included
patients, diagnosed with gastric or gastroesophageal cancer, who presented to Oncology Department in
Ain Shams University Hospital from January 2013 till December 2016. 61 patients were included in this
study. Results: we found a significant correlation between presence of ascites and high NLR. This relation
wasn't discussed in any previous study as far as we know. There was a significant correlation between
NLR and each of the following: - overall survival and event-free survival. This was consistent with the
results of previous studies worldwide. Therefore, our study proved that the prechemotherapy NLR is a
prognostic factor in gastric cancer.
Conclusion: the prechemotherapy NLR was significantly correlated with presence of ascites at diagnosis
of gastric cancer. It is an independent prognostic factor in gastric cancer. It affects both event free survival
and overall survival.


inherited cancer predisposition syndromes. The
Gastric cancer is the 5th most common
most common hereditary cancer predisposition
cancer worldwide, with about one million
syndromes are: hereditary diffused gastric cancer,
(952,000) new cases diagnosed annually (1).
Lynch syndrome, juvenile polyposis syndrome,
More than 70% of gastric cancers occur
in the developing countries, particularly in
adenomatous polyposis (5). Treatment strategies
Eastern Asia. The peak age for gastric cancer is
were determined by TNM staging system.
60-80 years (2).According to the GLOBOCAN
However, many patients of the same TNM stage
database, gastric adenocarcinoma (GC) is the
had different prognoses (6). Gastric Cancer
third leading cause of cancer-related death
exhibits diverse prognoses according to various
worldwide, after lung and liver malignancies,
resulting in around 723,000 deaths in 2012 (2,3).
development of efficient treatment strategies for
Although there have been advances in diagnosis
the various prognostic groups within GC is
and management, most GC patients present with
important. Thus, Chan-Young et al. (7) tried to
locally advanced or metastatic disease, with a 5-
understand the biological mechanisms of each
year survival rate of <10% (4). In Egypt, gastric
subtype of GC, to effectively individualize each
cancer is the 12th most common cancer in both
treatment strategy. Several prognostic factors in
sexes, representing 1.6 % of total cancers. It's the
GC have been reported such as: performance
12th leading cause of cancer death, representing
status, tumor burden, tumor markers such as
2.2 % of total cancer mortality. Median age of
carbohydrate antigen 19-9 (CA-19-9), the high
gastric cancer in Egypt is 56 years (2).
metabolic landscape of the tumor and weight loss
Environmental risk factors include Helicobacter
pylori (H. pylori) infection, smoking, high salt
independently correlated with a poor prognosis
intake and other dietary factors. Though most
gastric cancers are considered sporadic, it was
It is increasingly recognized that
estimated that 5 % to 10 % have a familial
variations within clinical outcomes in cancer
component and 3 % to 5 % were associated with
patients are influenced; by not only the
Received:10 /8 /2017 DOI : 10.12816/0041076
Accepted:19 / 8 /2017

Full Paper (vol.693 paper# 28)

c:\work\Jor\vol693_29 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2171-2175

Role of Diffusion Weighted MRI Imaging in Detection of
Liver Metakstases
Khalid E. Allam, Mennatallah H. Shalaby, Israa A. Moulood
Department of Diagnostic Radiology, Faculty of Medicine, Ain Shams University
Corresponding author: Israa A. Moulood, email:d.eabdlhameed@yahoo.com

Aim of the work:
diagnosis of liver metastases is of essential importance in the staging of patients with a
known primary tumor. So, the present study aimed to evaluate role of DWI in diagnosis of liver metastasis.
Patients and methods:
twenty patients were included in this study. The cases were evaluated over 6
months at Ain Shams University Hospital with a 1.5 Tesla Phillips (MR System Achieva) whole body
imager. Results: in the sample of the study which was composed of 20 patients, there were two patients
who presented with negative lesion in DW MRI with sensitivity 100%, specificity 90% and accuracy 95%.
Conclusion: DWI alone performed equally well as Gd-MRI in the diagnosis of liver metastases. In cases
where gadolinium injection was not allowed, dynamic contrast-enhanced imaging can be replaced by a
protocol based on unenhanced T1- and T2-weighted imaging combined with DWI.
Recommendations: further studies on larger scale of patients are needed to confirm the results of the study.
Keywords: diffusion, weighted MRI imaging, liver metastasis.


Liver cancer is one of the leading causes of all
to be of relatively high signal intensity (restricted
cancer related deaths. In fact, the secondary
diffusion) at DWI (6). DWI is being applied for the
hepatic malignancies (liver metastases) are more
detection of liver metastases. In the liver, low b-
common than the primary ones. Almost all solid
value images (e.g., b = 50­150 s/mm2) that
malignancies can metastasize to liver (1). Accurate
suppress the high-signal flow from the hepatic
diagnosis of liver metastases is essential for
vessels, resulting in black blood images, have
appropriate management of these patients.
been found to be useful for lesion detection.
Metastases appeared as high-signal-intensity foci
ultrasound, computed tomography (CT), positron
at DWI. Some of the challenges encountered in
emission tomography and MRI are available for
DWI of the liver are cardiac motion and
the evaluation of patients with suspected or
susceptibility artifacts that can obscure or
known liver metastases (2). There is growing
diminish visualization of the left lobe .The
interest in the applications of diffusion-weighted-
susceptibility effects may result from air in the
imaging (DWI) in oncologic area. DWI has
adjacent stomach or colon. Artifacts resulting
important advantages because it does not require
from cardiac motion can be reduced by triggered
contrast medium, a very quick technique and it
acquisition by ECG or a peripheral pulse unit,
provides qualitative and quantitative information
thus improving image quality and signal-to-noise
that can be helpful for tumor assessment (3). DWI
ratio in the left lobe of the liver .Images may also
is an imaging technique which provides tissue
be acquired with the aid of respiratory triggering
contrast by the measurement of diffusion
to minimize inadvertent breathing motion.
properties of water molecules within tissues.
However, these techniques increase the image
Diffusion is expressed in an apparent diffusion
acquisition time, which can render the
coefficient (ADC), which reflects the diffusion
examination more susceptible to bulk motion (6).
properties unique to each type of tissue (4). Both
This study aimed to evaluate the role of DWI in
low and high b-value DWI are effective in
diagnosis of liver metastasis.
suppressing vascular structures that may mimic or

obscure liver lesions, but low b-value DWI
provides a higher signal to noise ratio, is less
Twenty patients were included in this study. The
prone to cardiac motion-induced signal loss and
cases were evaluated over 6 months duration at
suffers less from eddy current-induced distortions.
Ain Shams University Hospital with a 1.5 Tesla
A previous study had already shown that low b-
Phillips (MR System Achieva) whole body image.
value DWI was more sensitive than high b-value
Inclusion Criteria
DWI in detecting malignant liver lesions (5).
Any patient who was known to have proven
Tumors are frequently more cellular than the
primary extra hepatic cancer of any age with
tissue from which they originate and thus appear
proved metastases to liver by history ,examination
Received: 15 /8 /2017 DOI : 10.12816/0041077
Accepted: 24 / 8 /2017

Full Paper (vol.693 paper# 29)

c:\work\Jor\vol693_30 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (3), Page 2176-2180

Assessment of Osteoporosis Knowledge Test among
Community Population in Abha City, KSA
Alanazi, Munif Saleh1, Abdullah Eid Alahmadi2, Ahmed Ali Jaafari3,
Taef Hassan Al-Hussan4, Mohammad Ali Alfaifi4, Mohammed Abobakr Alammari5,
Malik Abdul Rahman Almalki2, Abdullah Ismail Alsharif6
1Northern Border University ,2TaibahUniversity,3Jazan University,4King Khalid University,
5Batterjee Medical College,6Tabuk University

Background: there is a high prevalence of osteoporosis in KSA indicating a low preventive measures and a
lack of knowledge about radiological investigations importance and hazards.
Objectives: assessing the general knowledge of osteoporosis risks, screening, treatment and physical activity
as well as evaluating the awareness about radiological investigations timing and effects.
Methods: a community survey study based on a reliable questionnaire that was distributed among general
community in Abha city from March 2017 to June 2017.
Results: most of subjects were young, females and have college degree. Only 17% of subjects reported
having osteoporosis. Most of participants (52%) have good overall general knowledge but only 42% had good
knowledge regarding the calcium recommendations and 21% have good knowledge about importance of
physical activity in prevention of osteoporosis. 60% of subject shave good knowledge about the risk factors of
osteoporosis and 75% had good knowledge regarding the symptoms and radiological investigations.
Conclusion: The overall knowledge in Abha City was good in 52% of subjects however, the levels of
knowledge about preventive measures were poor while the majority had adequate knowledge regarding the
risk factors, symptoms and radiological investigations. Although, a moderate prevalence of good knowledge,
educational programs must be adopted by health authorities to motivate healthy behaviors for prevention of
osteoporosis in our community.
Osteoporosis, Awareness, Radiology, Abha.


knowledge could aid in prevention of the disease
According to the WHO, osteoporosis is
and increasing the concern of KSA health
classified as the 10th most common worldwide
authorities about the educational campaigns of
disease that linked to civilization in the modern
osteoporosis (3, 12).
world (1,2). The entire population is at risk of

osteoporosis at any age but post-menopausal
women and old people are more susceptible to
This study aimed at exploring the awareness of
development of this disease (3, 4).
Saudi population about osteoporosis risks, physical
Falling is a major symptom for osteoporosis as
activities and preventive measures as well as
the disease may remain silent till the first fracture
assessing the general knowledge about importance
occur after even minor falls (5). The process of
of routine radiological investigations.
osteoporosis is complex as it takes long time and in

early stages the patients many had no symptoms or
little pain of bones, then the bones become fragile,
- Study design and setting:
lost its architecture and make the bones easily
This was a community survey study conducted
fractured (6, 7).
among general adult population during the period
The knowledge of osteoporosis risks, preventive
from January 2017 to April 2017.
behaviors as well as importance of early diagnosis
- Sample size and population
is the focus of many studies in KSA resulting in
This study included 300 Saudi adult subjects
good preventive programs and decreasing the
aged 20-60 years old living in Abha city. Non-
prevalence of this silent disease (8);although many
Saudi subjects and adolescents were excluded from
studies in KSA revealed a poor knowledge about
the study. The study population were selected using
osteoporosis (9-11). Thus the assessment of
multi-stratified randomizing technique from
Received: 16 /7 /2017 DOI : 10.12816/0041078
Accepted:25 /7 /2017

Full Paper (vol.693 paper# 30)