c:\work\Jor\vol694_1 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (4), Page 2181-2190

Protective Effect of Date Palm Extracts on Cadmium-Induced
Infertility in Male Rats
El-Sayed Mohamed El-Habibi; Magda Mahmoud El-Komy and
Heba Osama Saad
Physiology Division, Zoology Department, Faculty of Science,
Mansoura University, Mansoura, Egypt
Corresponding author: Heba Osama Saad, heba_osama2014@hotmail.com

Background: Infertility is a problem which affects one in six couples. However, male factor considers
solely responsible in about 20% of infertile couples and contributory in another 30­40%. Objective: The
aim of this study was to elucidate the effect of date palm pollen (DPP) and date palm seed extract (DPS) on
cadmium-induced infertility in male rats. Materials and Methods: Thirty six male albino rats were
divided into six groups (n=6) and received their treatment orally for 30 days: group 1, control; group 2,
(DPP): (240mg/kg) daily, group 3, (DPS): (100mg/kg) daily, group 4, (CdCl2): (5mg/kg) every other day,
group 5, (CdCl2 + DPP): CdCl2 as group 4, followed by DPP as group 2 (each dose given 2 hours after
CdCl2); group 6, (CdCl2 + DPS): CdCl2 as group 4, followed by DPS as group 3 (each dose was given 2
hours after CdCl2). Results: The current data exhibited significant decrease in the sperm quality, T, E2,
FSH, LH, aromatase enzyme, TAC, GSH, SOD and CAT, with marked increase in MDA& XO and severe
destruction in testis histoarchitecture in CdCl2 treated rats. However, there was a significant improvement
in all these parameters with DPP& DPS administration. Conclusion: consumption of DPP or DPS might
be considered as a functional treatment for retarding risks of infertility associated with cadmium exposure.
Keywords: Male infertility; Cadmium; Date palm pollen; Date palm seed; Antioxidants; Testis.


Infertility is commonly defined as the
hepatic, respiratory and reproductive systems
failure of conception after at least 12 months of
including the ovary and testes12, red blood cells13,
unprotected intercourse1. It is a major health
the heart14, bone diseases15 and the skeletal
problem which affects approximately 15% of all
muscles of rats16. Renal tubular damage is
couples2, however, male factor considers
probably the most common adverse effect 12,15.
responsible in about 20% of infertile couples and
Herbal medicines are gaining importance
contributory in another 30­40%3.
and nowadays are being studied to find the
Factors like diabetes, bronchiectasis, high
scientific basis of their therapeutic actions17. Date
grade fever, long term medication, urinary tract
palm (Phoenix dactylifera L., Palmae) is native to
the Middle East region over centuries ago18. In
epididymitis, testicular injury, un-descended testis,
traditional medicine, a suspension of date palm
mumps, orchitis, excessive alcohol, smoking,
pollen (DPP) is widely used as a folk remedy for
exposure to heat and certain chemicals affect
curing male infertility19,20. DPP mainly contains
cholesterol, rutin, carotenoids, and estrone which
Cadmium (Cd) and other heavy metals
are known to exhibit gonadotrophin activity in the
and estrogenic-based compounds (e.g., bisphenols)
rat21. Its extracts contain oestrogenic compounds,
may account for the recent declining fertility in
oestrones, gonad stimulating compounds that can
men by reducing sperm count and testis function5.
improve male infertility and elicit gonadotrophin
Cadmium can affect human health through several
activity in rat models. The antioxidative effect of
sources such as drinking water, food6,
DPP is mainly due to phenolic components, such
manufacturing of batteries and pigments that
as flavonoids22,23, phenolic acids, and phenolic
utilize Cd7, cigarette smoke8, pesticides, rubber
diterpenes24, anthocyanins, procyanidins and
coumaric acid25.
Studies have been increasingly showing
that date seeds possess significant nutritional
Cadmium acts as an endocrine disruptor
value, especially in terms of their fiber and
and oxidative stress inducer in humans and
antioxidant content26,27. Date seed contain different
rodents5,11. It has long been known to damage the
chemical compounds such as saturated fatty acids

as stearic and palmitic acid, unsaturated fatty acids
Received: 5 / 8 /2017 DOI : 10.12816/0041514
Accepted:15 /8 /2017

Full Paper (vol.694 paper# 1)

REVIEW OF LITERATURE The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (4), Page 2191-2198
Comparison between Corneal Biomechanics in Normal and Keratoconic
Corneas Using Ocular Response Analyzer
Shaker A. Khedr, Amany A. El-Shazly, Ossama T. Nada, Kareem A. Abouelezz
Ophthalmology Department, Faculty of Medicine, Ain Shams University
Corresponding author: Kareem A. Abouelezz,email:kareem.ezz1@hotmail.com

keratoconus (KC) is an idiopathic degenerative eye disease characterized by localized thinning
and conical protrusion of the cornea, which typically develops in the inferior-temporal and central zones.
Consequently, visual acuity is reduced due to irregular astigmatism and high myopia resulting from
asymmetric topographical changes in the corneal surface. KC is the most prevalent form of corneal ectasia
and affects all ethnicities. However, higher incidence has been reported in Asians when compared to
caucasians. Aim of the work: this study aimed to compare the biomechanical properties of the cornea
between topographically normal individuals with topographically keratoconic patients.
Patients and methods:
this prospective study was carried out from January 2017 to July 2017 on 40 eyes of
patients attending outpatient clinic of Ain Shams University Hospitals and Ophthalmology Department of
Research Institute of Ophthalmology in Giza.
All participant names were hidden and were replaced by code numbers to maintain privacy of the patients.
Ocular response analyzer (ORA) values were obtained from 20 eyes of keratoconus patients and 20 eyes of
non keratoconus subjects both topographically tested.
Results: corneal hysteresis (CH) was found to be higher in normal group than keratoconus group; the values
were found to be 10.9 ± 1.5 in normal group and 7.88 ± 1.23 in keratoconus group. Corneal resistance factor
(CRF) was found to be higher in normal group than keratoconus group, the values were found to be 12.7 ±
1.05 in normal group and 6.7 ± 1.7 in keratoconus group. Goldmann correlated intraocular pressure
(ORA_IOPg) was found to be higher in normal group than keratoconus group, the values were found to be
13.13 ± 2.91 in normal group and 10.31 ± 2.99 in keratoconus group. Corneal compensated intraocular
pressure (ORA_IOPcc) was found to be 14.17 ± 3.44 in normal group and 14.23 ± 2.01 in keratoconus
group, there was no difference between normal group and keratoconus group.
Conclusion: corneal biomechanical properties, characterized by corneal hysteresis and the corneal resistance
factor, provide new indicators for the diagnosis of keratoconus.
Recommendations: this study recommended to follow up IOP in keratoconus patients by ORA due to false
low results which may be taken by using the Goldman applanation intraocular pressure. Large studies should
be done to detect the prevelance of keratoconus in Egypt as this information was missing from peerviewed
studies we researched.
Keywords: corneal biomechanics, keratoconic corneas, ocular response, topographically, corneal hysteresis.

of proteolytic enzymes and a decrease in their
Keratoconus (KC) is an idiopathic degenerative
inhibitors (5). Increased proteoglycan (PG) content
eye disease characterized by localized thinning
and altered distribution PG filaments had also
and conical protrusion of the cornea, which
been reported (6). A progressive reduction in
typically develops in the inferior-temporal and
collagen-producing corneal keratocytes has been
central zones (1). Consequently, visual acuity is
observed (7) , as well as a disruption to the highly
reduced due to irregular astigmatism and high
organized orthogonal arrangement of collagens (8).
myopia resulting from asymmetric topographical
Further, a decrease in the mean fibril diameter
changes in the corneal surface. KC is the most
and interfibrillar spacing of individual collagens
prevalent form of corneal ectasia and affects all
and undulation of collagen lamellae have been
ethnicities (2). However, higher incidence has been
reported (6).
reported in Asians when compared to caucasians
A genetic predisposition to keratoconus is well
(3).While the etiology and pathology of the disease
documented with increased incidence in some
is still not fully understood, various biochemical,
familial groups and numerous reports of
cellular and microstructural differences have been
correspondence between monozygotic twins.
reported in the literature. For instance,
Approximately, 6% - 23.5% of patients with
biochemical changes included increased activity
keratoconushave a positive family history (9).
Received: 16/ 8 /2017 DOI : 10.12816/0041515
Accepted:24 /8 /2017

Full Paper (vol.694 paper# 2)

c:\work\Jor\vol694_3 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (4), Page 2199-2203

Knowledge, Attitude and Practice About
Allergic Rhinitis in Saudi Arabia, 2017
Faris Mohammed Alreshidi1, Abdullah Saleh Alrashidi1, Fayez Nashi Motlaq Alshammari1,
Alya Bakr A. Qadi 2, Ali Ghannam Mohammed Alrashidi1, Saud Mohammed Saud Aleisa3,
Saleh Muflih Srai Alghaythi1, Fouad Taiwilaa Alshammari1
1-University of Hail 2-Medical University of Lód, 3-Taif University
allergic rhinitis (AR) is considered a worldwide health disease therefore the lack of knowledge
would result in poor adherence to management and preventive protocols and increasing the prevalence of AR.
Objectives: evaluating the knowledge, attitude and practice(KAP) of Saudi adult subjects toward AR in
Kingdom of Saudi Arabia (KSA).
Methods: a cross sectional study conducted on 900 Saudi adult subjects admitted to primary health care
centers. The subjects were interviewed and filled up a questionnaire including the respondent's demographics,
questions related to knowledge, attitude and practice.
Results: most of the respondents aged from31-45 years old, 59.7% were females and 49% were graduated
from college.30% of participants had a family history of allergic rhinitis and 34% suffered from allergic
rhinitis. Inadequate KAP was found among the participants with higher KAP scores related with higher
educational degree. But there were no association between KAP level and gender or age.
Conclusion: an inadequate knowledge was found among most of respondents thus resulting in poor attitude
and practice pattern. Also, higher educational levels were associated with higher KAP scores.
Keywords: KSA, Knowledge, attitude, practice, Allergic Rhinitis (AR).


Allergic rhinitis (AR) is a non-contagious
After approval of the Faculty of Medicine
disease of nasal hypersensitivity tha toccurs in
and ethical committee of Health Care Facilities
response to an offending allergen that mediate the
included in the study, this cross sectional study was
immunological inflammation. The major symptoms
conducted on a random sample of Primary Health
of AR are sneezing, nasal obstruction, rhinorrhea,
Care Centers (PHCCs) in KSA from March 2017 to
and itching postnasal drip. The symptoms reveal
July 2017. Fourteen Primary health care centers
spontaneously or after using medication (1, 2).
were randomly chosen using the stratified random
Allergic rhinitis is a global health disease
sampling technique where a representative sample
that affect from 10 up to 20% of population
of 900 adult subjects admitted to PHCC for seeking
however this is not the true prevalence as many
health care during the period of study.
patients don't consider AR as a disease (3).
The inclusion criteria were age older than
Despite being non severe disease, it
18 years, both sexes, patients presenting with
impacts the social life, work productivity as well as
classic cold symptoms or signs of allergic rhinitis.
academic performance (4, 5).
Patients with chronic sinusitis were excluded from
The most effective treatment for AR is to
the study. All subjects gave a written informed
identification of the allergen and preventing its
consent for their approval to participate in the
occurrence. A gap was found between the
knowledge about RA and the practice resulting in

poor quality of life (6).
Study tools

The awareness of allergic rhinitis related
A self-administrated questionnaire with
mush comprise the understanding of the etiological
simple Arabic from was administrated among the
factors, treatment and preventive measures.
participants. The questionnaire was designed after

reviewing the online database then the items were
Adequate knowledge would significantly
collected and revised then was validated after
affect the attitude and practice level that include
conducting a pilot study among 40 subjects who
good relation with the doctor and appropriate
weren't included in the present study. The final
management and enhancing the quality of life(7, 8).
questionnaire was comprised of four items

including the demographics, knowledge, attitude
Aim of the study
and practice pattern of participants about allergic
This study aimed at assessing the KAP of
adult population toward allergic rhinitis.

Statistical analysis
Received:19 /7 /2017 DOI : 10.12816/0041516
Accepted:28 /7 /2017

Full Paper (vol.694 paper# 3)

c:\work\Jor\vol694_4 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (4), Page 2204-2208

Relationship between Obesity and Iron Deficiency
Tahany A El-kerdany1, Wafaa A Fahmy2, Doaa G Eissa1, Maha Hassan1
Department of Clinical Pathology, Faculty of Medicine, Ain Shams University1,
National Nutrition Institute2, Cairo, Egypt
Corresponding author: Maha Hassan ,dr.mooha86@hotmail.com

obesity and iron deficiency anemia are major health problems that are increasing in Egypt
especially in females.
Aim of work:
this study aimed to evaluate the iron status in obese Egyptian females in comparison to normal
weight females. Patients and Methods: forty four obese adult female patients and 44 normal weight healthy
females as control group were included in this study. They were all tested for iron profile and CRP using semi
quantitative rapid latex agglutination test. Results: the patient group in this study showed a significant lower
serum Fe and TSI than the control group, while ferritin was higher in patients than the control group. The
comparison between the three groups of obesity showed that the grade III patients had the lowest median
value in serum iron and the highest median value in TIBC and ferritin, however no statistical significant
differences were detected between the three groups of patients (P>0.05). Our results showed that 70.4%) of
patients had positive CRP with positive correlation between CRP and BMI.
Conclusion and Recommendations: obesity is a low inflammatory disease which affects iron profile and
increases CRP. Further, study on larger number of cases is recommended to analyze the exact mechanism of
iron deficiency anemia in obese female patients.
Keywords: iron deficiency, anemia and obesity.


evaluate the iron status in obese Egyptian females
Iron deficiency remains the most common
in comparison with normal weight females.
nutritional deficiency and cause of anemia

worldwide. Populations in the developing
countries, premenopausal females, pregnant
This study was conducted on 44 obese adult
women, children, vegetarians and frequent blood
female patients attending the outpatient clinics in
donors are largely affected by iron deficiency due
the National Nutrition Institute (NNI). Diagnosis
to low dietary intake, inadequate bioavailable iron,
of obesity was based on anthropometric
increased iron demand required for growth and
measurements (weight, height and accordingly the
development, iron losses and changes in blood
BMI). Participants were classified as grade I
volume (1). WHO recognized obesity as disease,
obesity (if BMI =30.0 kg/m2 to 34.9 kg/m2), grade
which is prevalent in both developing and
II obesity (if BMI =35.0 kg/m2 to 39.9 kg/m2) and
developed countries. Overweight and obesity are
grade III obesity (if BMI 40.0 kg/m2) (4). Patients
now so common and thereby replacing the more
were excluded if they were on iron therapy or
traditional public health concerns (under nutrition
consuming dietary supplements or vitamins
and infectious diseases) as some of most
containing iron, received non-steroidal anti-
significant contributors to ill health (2).
inflammatory drugs 48h prior to blood sampling,
Obese individuals who develop ID have an
had a history of blood donation or transfusion, and
increased health burden. Initially presenting with
had chronic or hematologic diseases or during the
iron depletion, ID can progress to iron-deficient
menstrual and post-natal period.
erythropoiesis, eventually leading to iron
All patients were subjected to:
deficiency anemia (IDA) (3). The mechanism
1- Weight measurement using a digital weighting
explaining the relationship between iron status and
scale with light clothing on and without shoes.
obesity remains unclear; this may be due to lower
2- Height measurement via standing on a fixed
iron intakes and/or increased iron requirements in
overweight individuals. In addition, the chronic
3- BMI is calculated by taking a person's weight in
inflammation and increased leptin production
kilograms divided by square of person's height in
characteristic of obesity increase hepcidin
meter (kg/m²).The normal range is 18.5-24.9,while
secretion from the liver, which, along with
overweight is 25-29.9 and obese is 30 and above
hepcidin produced by adipose tissue, could reduce
(4). Complete blood count (CBC) using automated
dietary iron absorption (1).This study aimed to
blood counter, (Diagon D-CELL-60) with
Received:16 /8 /2017 DOI : 10.12816/0041517
Accepted: 25 /8 /2017

Full Paper (vol.694 paper# 4)

c:\work\Jor\vol694_5 The Egyptian Journal of Hospital Medicine (October 2017) Vol.69 (4), Page 2209-2214

Infection with Genital Herpes Virus and Its Treatment in
Relation to Preterm Delivery
Ahmad Ayed Derham1, Hanadi Hezam AL-Thobiati2, Mohannad ali alghamdi1,
Nasir Ahmad Alsubai2, Lamees Hatim Aldoobie1, Razan Hussain Alhasawi3, Sara Falah Alsahafi3
1 King Abdulaziz University, 2 Umm AL-Qura University,
3 Batterjee Medical College for Science and Technology
Corresponding Author: Ahmad Ayed Derham, email: Ahmad_aaasda@hotmail.com

Infection with herpes simplex is a standout amongst the most well-sexually transmitted infections. As
the infection is common in women of reproductive age it may be contracted and transmitted to the fetus
amid pregnancy and the new-born. Herpes simplex virus is a significant cause of neonatal infection,
which could lead to death or long-term disabilities. Infrequently in the uterus, as it happens frequently
during the transmission delivery.
The most serious danger of transmission to the fetus and the new-born happens in case of an early
maternal infection contracted in the second half of pregnancy. The danger of transmission of maternal-
fetal-neonatal herpes simplex could be diminished by applying a treatment with antiviral medicines or
depending on a caesarean section in some particular cases. The aim of this paper is to provide
recommendations on the management of herpes simplex infections in pregnancy and approaches to
decrease perinatal transmission of herpes simplex virus.
Keywords: Genital Herpes, Herpes Simplex Virus, Caesarean, Perinatal Transmission.


Genital herpes is a main public- health
repeat rate is four to six scenes for each year
concern as a result of its recurrent nature, its
[7]. Pregnant ladies with untreated genital herpes
ability to be transmitted asymptomatically, and
amid the first or second trimester seem to have a
its potential for complications [1]. This sexually
more noteworthy than two-overlap danger of
transmitted disease is initiated by herpes
preterm conveyance contrasted with ladies not
simplex virus types 1 and 2 (HSV-1 and HSV-
exposed with herpes, especially in connection to
2), in most cases by HSV-2 [2]. HSV-2 is the
premature rupture of membrane and early
reason of most genital herpes and is nearly
preterm conveyance (less than or equal 35 week
always sexually transmitted. HSV-1 is generally
of gestation) [8]. Pregnant women who get
transmitted in childhood through non-sexual
antiherpes treatment have a lower danger of
contacts. Nevertheless, HSV-1 has emerged as a
preterm conveyance than untreated ladies, and
principle causative agent of genital herpes in
their preterm conveyance chance is like that
several developed countries [3, 4]. The highest
seen in unexposed women.
occurrence of HSV infections occurs in women
The study was approved by the Ethics Board
of reproductive age, the danger of maternal
of King Abdulaziz University.
transmission of the virus to the foetus or

neonate has become a main health concern [5].
Women recently diagnosed with genital herpes
Data sources and search terms
will habitually experience psychological distress
We conducted this review using a
and concern about future sexual relationships
comprehensive search of MEDLINE, PubMed,
and pregnancy.
EMBASE, Cochrane Database of Systematic
Demographically, HSV-2 infection is more
Reviews, and Cochrane Central Register of
typical in women than in men, and in the non-
Controlled Trials from January 1, 1980, through
Hispanic black populace, there is an expanded
February 28, 2017. The following search terms
predominance in both genders. Even between
were used: Genital Herpes, Herpes Simplex
people with comparative quantities of lifetime
Virus, Caesarean, Perinatal Transmission, HSV-
sexual accomplices, this difference between the
1, HSV- 2, and Disseminated Herpes Infection.
ethnicities remains [3]. Most individuals with
Data extraction
symptomatic genital herpes will encounter
Two reviewers independently reviewed studies,
repetitive contaminations inside the principal
abstracted data, and resolved disagreements by
year of the essential disease, and the middle
Received:30 / 7/2017 DOI : 10.12816/0041518
Accepted: 9/ 8 /2017

Full Paper (vol.694 paper# 5)

c:\work\Jor\vol694_6 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2215-2218

Update on Congenital Glaucoma
Abdel Mongy E. Ali 1, Abdulla M. El Amin, Tag Eldin M. Ahmed, Alaa H. Labib 2
Department of Ophthalmology, Faculty of Medicine, 1Al Azhar (Cairo) University and
2Aswan University, Aswan, Egypt.

primary infantile glaucoma, commonly termed congenital glaucoma or trabeculodysegenesis, is
an unusual, inherited congenital anomaly of the trabecular meshwork and anterior chamer angle which leads
to obstruction of aqueous outflow, increased intraocular pressure, and optic nerve damage. Primarycongenital
glaucoma is a worldwide diagnostic and therapeutic challenge. Although medical management is often a
temporizing measure, early surgical intervention is the definitive treatment.
Keywords: Congenital glaucoma, Goniotomy, Trabeculotomy, Trabeculectomy, Glaucoma drainage
implants, Cyclodestructive procedures, Deep sclerotomy.

transcription factors involved in the eye's
It is thought that goniotomy was first
development. Genetic testing is available for all
described in 1893 by Carlo de Vincentiis; however it
three genes. A novel therapy for aniridia is being
was performed without visualization of the angle
investigated that is based on the molecular biology
and resulted in poor outcomes(1).It was not until
of PAX6 genetic mutations(5).
1938 when Otto Barkan performed the first
Ataluren is an investigational new drug that
goniotomy utilizing gonioscopy and a knife to incise
works by reducing ribosomal sensitivity to
the trabecular tissue(2). Although goniotomy was
premature stop codons. Postnatal topical application
difficult or impossible in eyes with signification
of a drug formulation containing ataluren can
corneal edema, it became the standard of treatment
reverse corneal, lenticular, and retinal defects in a
for PCG. Trabeculotomy, which could be performed
mouse model of aniridia, which suggests that
in the presence of corneal opacity, was later
ataluren may be available therapeutic option for
developed by Smith in 1960(3).
patients with PAX6 genetic mutations(6-7).
Laser therapy has a limited role in
developmental glaucomas. The most effective and
a-Medical therapy:
definitive from of treatment of most developmental
As discussed, medical therapy usually plays a
glaucoma is surgical trabeculotomy, although
supportive role.
combined trabeculotomy with trabeculectomy may
Beta-blockers: Beta-blockers reduce IOP by
be useful in certain populations with a high risk of
decreasing aqueous secretion. Timolol in 0.25% and
failure of goniotomy or trabeculotomy. Refractory
0.5% solutions maybe used cautiously in young
pediatric glaucomas may be managed by
glaucoma patients. The drug should be used
trabeculectomy with anti-fibrosis drugs, glaucoma
withextreme caution in neonates due to the
drainage implants and cyclodestructive procedures(4).
possibility of apnea and other systemic side effects.
Deep sclerotomy non penetrating surgery has
Cardiac abnormalities and bronchial asthma should
attracted moreinterest during last two decades for its
be specifically excluded before its use. Use of
potential to decrease IOP without some of
0.25%, rather than 0.5%, is recommended in
immediate postoperative hypotony and long term
childrenin order to reduce its side effects; however,
belb complication of tradition filtering surgery(4).
the 0. 25% formulation is not widely available.
The study was approved by the Ethics Board
Hence, 0.5% timolol can be used with punctual
of Al-Azhar University.
occlusion. For this reason ,selective beta-blocker

(e.g., betaxolol) is preferred over non selective
Developmental Glaucoma:
Axenfeld-Rieger syndrome and aniridia are
Carbonic anhydrase inhibitors (CAIs): are
both inherited in an autosomal dominant manner.
chemically related tosulfonamides. They lower IOP
Approximately 50% of individuals who carry
by inhibiting aqueous secretion. Systemic CAIs
genetic mutations will develop early-onset
would be expected to have similar side effects in
glaucoma. Mutations in the PITX2 and FOXC1
children as compared to adults. In addition, growth
genes are associated with Axenfeld-Rieger
suppression in children has been associated with oral
syndrome, and PAX6 mutations cause aniridia and
acetazolamide therapy, and infants may experience a
Peters anomaly. Each of these genes encodes
severe metabolic acidosis. Topical versus oral CAI

therapy has been evaluated forpediatric glaucoma in
Received: 13 / 8 /2017 DOI : 10.12816/0041519
Accepted: 22 / 8 /2017

Full Paper (vol.694 paper# 6)

c:\work\Jor\vol694_7 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2219-2221
Early versus Delayed Initiation of Continuous Renal Replacement
Therapy in Critically Ill Patients with Acute Kidney Injury
Abdel-Basset El-Shaarawy Abdel-Azeem, Walid Anwar Abdel-Mohsen,
Maha Abd El Moneim Behairy, Ibrahim Al-Sayed Ibrahim Omar
Internal Medicine and Nephrology Department, Faculty of Medicine - Ain Shams University
Corresponding author: Ibrahimst Namei Omar, email: ibr.omar@yahoo.com

Aim of the work this study aimed to evaluate the impact of early versus late initiation of continuous
renal replacement therapy on clinical outcomes in critically ill patients with AKI. Results regarding our
retrospective cohort study and after prolonged exhaustive analysis of all the related data, some variables
were found to be significantly related to the outcome of these critical ICU patients. These variables were
systolic BP, WBCs, albumin, magnesium, PTT and INR at the start of CRRT. Some patients with AKI
were associated with sepsis; there was a little benefit of early CRRT, in terms of ICU mortality. This
needs further clarification by larger and high-powered studies.
Conclusion finally, the decision for early or late CRRT, in patients with AKI, should be individualized
according to the clinical and laboratory parameters of each patient. It should also include the opinion of
senior nephrologists, experienced in management of AKI. The decision should be sensitively
communicated to the patients and/or their relatives, explaining the actual role of CRRT in management of
their critical disorder.
Keywords: kidney Injury, replacement therapy, CRRT.


However, two observational studies
Acute Kidney injury (AKI) is a well-
reported high survival rates among patients who
recognized complication of critical illness with a
did not receive RRT (7). One study reported
large effect on morbidity and mortality. AKI is a
adverse outcomes in association with very early
common condition among patients in the
RRT in patients with sepsis (8) . CRRT is a
intensive care unit (ICU). Forty percent of ICU
dialysis modality used to treat critically ill,
patients developed evidence of AKI. Five
hospitalized patients in ICU who developed
percent of ICU patients received acute renal
AKI. It differs significantly according to the
replacement therapy (ARRT) (1). Despite
mechanism of solute transport, the type of
increased knowledge of the management of
membrane and the type of vascular access.
critically ill patients, mortality associated with
CRRT provided slower solute clearance per unit
AKI remains (2). Although the need for RRT in
time as compared to intermittent therapies. But
patients with severe AKI and life threatening
over 24 h or more it may even exceed clearances
complications is unequivocal, the optimal timing
with intermittent hemodialysis. Solute removal
of RRT initiation in patients with severe AKI
with CRRT was achieved either by convection
without life threatening complications has not
(hemofiltration), diffusion (hemodialysis), or a
yet been defined (3). Earlier initiation of RRT
may produce benefits by avoiding hypervolemia,
(hemodiafiltration) (9).
elimination of toxins, establishing acid-base

homeostasis, and preventing other complications
attributable to AKI. However, early initiation of
This was a retrospective observational
RRT may unnecessarily expose some patients to
cohort study, including 100 adult patients, who
potential harm because some patients were
were admitted to ICU with acute kidney injury
spontaneously recoverd renal function (4).
(AKI), in Saudi German Hospital-Jeddah, Saudi
Delaying RRT initiation unlikely had
Arabia, from 2013 to 2016, and received
any immediate benefit per se. However, a delay
treatment by CRRT.
may allow time for the stabilization of a patient

condition before RRT was initiated and might
Inclusion criteria
avoid the need for such support, which was not
Adult patients (Age>18 years) were
devoid of risk (5). Current evidence suggested
admitted to ICU, either due to medical or
reduced mortality and better renal recovery with
surgical cause with AKI.
earlier RRT initiation (6).
Received:16 / 8 /2017 DOI : 10.12816/0041520
Accepted:25 / 8 /2017

Full Paper (vol.694 paper# 7)

c:\work\Jor\vol694_8 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2222-2231

The Ameliorative Effect of Cleome droserifolia (Samwa) on Myocardial Injury
Associated with Diabetes in Male Rats
El-Komy MM, Serag MH and Emsalam AA*
Faculty of Science, Mansoura University Egypt
*Corresponding author: Ahmed Mohamed Emsalam*, Mobile No.+201120140623,
email: Ahmedemsalam@gmail.com

Diabetes is an imperative risk factor for cardiac complications development. Cleome
(Cd) is used in Egyptian traditional medicine for treatment of diabetes mellitus. Aim: The aim of
the present study was to measure the possible protective effects of ethanolic extract of Cd against
cardiacmyopathy in Streptozotocin (STZ) induced diabetic rats. Materials and Methods: Experimental
diabetes was induced by intrapritoneal injection with a single dose of STZ (45 mg/kgbw). Oral dose Cd
extract was administered daily for four weeks (310 mg/kg bw). Results: Diabetic rats exhibited an increase in
glucose level and lipid profile as well as cardiacpro-inflammatory, pro-apoptotic markers and oxidative stress,
while a decrease was recorded in antioxidant enzymatic activities. On the other hand the administration of
diabetic rats with Cdextract for four weeks resulted in a significant amelioration in the most of the parameters
mentioned above when compared with diabetic rats. Conclusion: The data clearly indicated that the treatment
with Cleome droserifolia exerts a therapeutic protective nature in cardiac complications due to diabetes by
decreasing oxidative stress and cardiac damage which may be attributed to its antioxidative potential.
: Diabetic rats, Streptozotocin, Heart injury, Cleome droserifolia.


Diabetes mellitus is a rapidly growing
Globally, there is renewed interest in natural
disease world-wide that is estimated to be present
products (NPs) as a starting point for drug
in 6.6% of the international population and
discovery and development for different diseases(7).
projected to be increased by 7.8% in 2030,(1).
NPs are structurally diverse and serve as a valuable
Treating diabetic patients is multifaceted in all
source for novel molecular scaffolds in drug
aspects and they require objectives and optimum
development(8). Traditional anti-diabetic plants
information in order to obtain the maximum
might provide a useful source of new oral
hypoglycemic compounds for development as
complications. It is considered of clinical and
pharmaceutical entities, or as simple dietary
public health significance, as it adversely affects
adjuncts to the existing therapies(9).Cleome
personal health, health-related quality of life, life
droserifolia (Cd) is used by herbalists in Egypt as a
expectancy and has significant implications on the
hypoglycemic agent, and its decoction is widely
health care system(2). Epidemiological evidence
used by the Bedouins of the southern Sinai for the
shows that diabetes frequently results in severe
treatment of diabetes. It is also used in treatment of
complications, such as cardiovascular disease,
various disorders such as diarrhea, fever,
cerebro-vascular disease, micro-vascular disorders
inflammation, liver diseases, bronchitis, skin
(e.g. nephropathy, retinopathy, neuropathy, sexual
diseases, malaria fever and in the treatment of
dysfunction) and diabetic foot disorders(3).
scabies and rheumatic fever. It is rich in bioactive
Heart muscle injury has been reported in
compounds as flavanoids, flavonol glycosides,
both human and animal models of diabetes. Results
alkaloids, tannins and steroids(10). So far as plant
from clinical and experimental diabetes mellitus
phenolics constitute one of the major groups of
indicate that free radical induced oxidative stress
compounds acting as primary antioxidants or free
play a significant role in organelle transformation
radical terminators. Flavonoids as a one of the
and cardiac dysfunction(4). Both type 1 and 2
most diverse and widespread group of natural
diabetes cause damage to myocyte which occurs
compounds are probably the most important
through the pathways utilizing reactive oxygen
natural phenolics as they possess radical
species (ROS)(5).
scavenging properties(8).
In human and experimental diabetes, heart

sickness is associated with a marked apoptosis.
This loss of cells can leads to fibrosis,
The present study is objected to investigate the
contractile deficiency, and subsequent heart
probable hypoglycemic, hypolipidemic and anti-
dysfunction(6) .
inflammatory effects of Cleome droserifolia on
Received: 13 / 7 /2017 DOI : 10.12816/0041521
Accepted:22 /7 /2017

Full Paper (vol.694 paper# 8)

c:\work\Jor\vol694_9 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2232-2237
Knowledge, Opinions and Attitude of Surgeons in Saudi Arabia
toward Informed Surgical Consent
Ali M Alsaihati1, Amer B alotaibi2, Ali M Alhawaj3, Areej M Alabdulsalam4, Nourah A Alajmi4,
Mohamed T Boukhet4, Waleed H Altulayqi4, Ali S Alkahtani4, Nawaf A Almarek4, Zahra A alhussain5,
Ali S Al-Sultan5, Mohammed B al khalaf5, Hani A AlAbdullah5, Abdulhalim B Hafizallah6, Fahad F
Almutairi7, Bothayna A Alanzan8, Mohammed S Alrashed
1Qatif Central Hospital, 2King Abdullah Hospital, 3Ibn Sina National College For Medical Studies, 4King
Saud University, 5King Faisal University, 6Taibah University, 7MCST, 8Princess Nora Bint Abdulrahman
University, 9Imam Muhammad Ibn Saud Islamic University9
Background: Informed consent has become a vital factor for the clinical treatment of modern practice in the
medical field, it is participating in legal, ethical and administrative compliance side. However, informed
consent is variably applicable and rarely fulfills its theoretical ideal. Disclosure of adequate information is very
important before signing informed consent. It is important to make patient enable to take a proper decision
with good knowledge about his/her case. Informed consent for the surgical procedure is consent that taken
from the patient before surgical operations and invasive procedures after explaining advantages and
disadvantages. Getting patient's signature for the consent of operations and the surgical procedure is surgeon's
job. The opinion of the surgeon about informed consent is important, as that may affect the performance of
surgeon in explaining procedure with its risks and benefits. Aim: Assessment of knowledge, opinion, and
attitude of surgeons towards informed consents. Find out how to improve the quality of informed consent from
surgeons' suggestions . Method: This cross-sectional study is questionnaire-based study. Our target was to
reach many surgeons in Saudi Arabia with different specialties, different status and from different hospitals.
We take our sample using random sampling technique. We selected surgeons from each hospital that our data
collector can reach and enter easily. Collection of data was done by interview. Our questionnaire contained
four parts in addition to demographic data part. The first part was asking about surgeons' opinions regarding
informed surgical consent process. The second part was responsible for inquire about obtaining informed
surgical consent. The third part is about the refusal to sign informed surgical consent. Last part is to ask about
surgeons' suggestions to improve informed surgical consent. Result: Total number of respondents was 140
(Response rate is 93.3%). Around 34% of participants agreed that surgeons don't give adequate information
about the surgical procedure. 33.6% insisted to know about their surgery. After asking each surgeon about the
importance of informed surgical consent they selected the following answers in descending order; informing
patients about advantages, hazards and alternatives (81.4%), Medico-legal importance (79.3%), decision taking
about procedure (72.1%), hospital policy (50.7%) and surgical tradition (19.3%). Most of the doctors (85%)
complained that sometimes, their patients refused to sign consent. Fear was the most common cause of singing
consent refusal according to opinions of 62.9% of surgeons. Conclusion: Surgeons in Saudi Arabia have
acceptable knowledge about informed surgical consent and how to obtain it. But still there were some opinions
of surgeons opposite to what is practiced, and also some of them practiced something not ideal while obtaining
informed surgical consents. However, most of the surgeons know the importance of consent and what is
important to be disclosed in it. In general, the frequency of consent refusal was low.
Keywords: Informed Consent, Surgeons, Saudi Arabia, surgical consent.


In our practice in surgery and the medical field
ongoing and dynamic exchange of information
in general, the term informed consent means hall
between the patient and his or her healthcare
discussion between patients and physicians about
provider. However, informed consent is variably
applicable and rarely fulfills its theoretical idea (2).
consequences of treatment, advantages, harms,
Disclosure of adequate information is very
risks, and alternatives (1). It has become a vital factor
important before signing informed consent. It is
for the clinical treatment of modern practice in
important to make patient enable to take a proper
medical fields; it is participating in different things
decision with good knowledge about his/her case.
in different context: legally, it prevents unwanted
However, use of non-scientific term and language
procedure and protects patients from assault.
that can be understood by the patient are significant,
Ethically, it protects the patient from freelance
and information must be accurate, sufficient and
decision making and supports patient-defined goals.
relevant (3). Clinical practice has been shifted over
The process of informed consent should involve an
past few decades to the modern way that gives
Received:26 /7 /2017 DOI : 10.12816/0041522
Accepted: 5/8 /2017

Full Paper (vol.694 paper# 9)

c:\work\Jor\vol694_10 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2238-2244

Relapse in Patients with Non-Hodgkin's Lymphpma
Azza Mohammed Adel, Amr Shafik Tawfik, Nesreen Ahmed Mosalam and
Rana Mohamed El Shishtawy
Clinical Oncology and Nuclear Medicine department, Ain Shams University
Corresponding author: Rana Mohamed El Shishtawy, email:dr.ranaelshishtawy@hotmail.com

non Hodgkin Lymphoma is the most common hematologic malignancy and it is the 6th
leading cause of cancer death. Relapses still occur in the majority of patients; overall, more than 30% of
DLBCL will ultimately relapse. Aim of study: primary objective was to retrospectively correlate the
occurrence of relapsed, refractory and in remission diffused large B cell lymphoma patients to both clinic-
pathological features of the disease and line of treatment received.
Patients and Method: a total of 116 patients with aggressive high grade NHL patients (DLBCL)
representing 86.6% of all patients presented to Clinical Oncology Department, Ain Shams University in
the period between January 2009 and December 2015. Data were collected between January 2017 until
Marsh 2017.
the mean age at diagnosis of the studied patients was 45 years. The incidence in male was higher
than female (52.6% vs. 47.4%), the majority of the cases didn't have B symptoms (57.7%), high LDH
level was measured among the cases (37%)and in only 36 patient's files,16.37% of the cases had positive
HCV.The most common stage at diagnosis was stage IV (33.6%)followed by stage III (29.3%).
Based on response to the 1st line chemotherapy, DLBCL patients were further statistically analyzed into
three categories:24 refractory patients (20.07%), 43 relapsed patients (37.1%) and 49 patients in remission
(non relapsed) (42.2%). Regarding 1st line treatment regimen by R-Chop, complete response rates were
significantly higher in patients who received R-CHOP than in the group who received CHOP alone
(57.1% vs 42.8%). The median disease freesurvival in the relapsed groupwas 8 months. The median
survival time for the DLBCL patients was 24 months. The survival rate after 1 year was 83.7%, while
Conclusion: relapsed and refractory disease continues to represent the most significant challenge in
treating NHL, the addition of rituximab to the CHOP regimen increased the CR rate and prolonged event-
free and overall survival.
non Hodgkin's lymphoma, DLBCL, relapsed refractory patients, CHOP vs. R-CHOP and

The cause of most cases of NHL is obscure,
The Non-Hodgkin lymphoma (NHL) is a
however some strong risk factors have been
variation gathering of lymph proliferative
malignancies with different patterns of
environmental agents, and infectious agents)
behavior and responses to treatment.
have been related with the development of
Generally, NHL originates in lymphoid tissues
lymphoma(3).In 2008 The International Agency
for Research on Cancer (IARC) published the 4th
edition of the WHO classification of tumors of
al.(2)recognized the following significant
hematopoietic and lymphoid tissues reflecting
differences in the epidemiology of NHL in
better understanding of disease entities and their
developing countries, in contrast with the
relationship to the immune system(4). DLBCL is
developed countries:
the most widely recognized type of NHL in the
Higher rates of males.
world, and accounts for 30%­40% of all adult
Lower median age at time of presentation for
NHLs. Although potentially treatable, 40% of
both low- and high-grade B-cell lymphoma.
patients with DLBCL were died of relapsed or
Lower frequency of B-cell lymphoma and a
refractory disease(5).
higher frequency of T- and NK-cell (Natural
The Ann Arbor staging system was utilized to
Killer-cell) lymphoma.
create rational treatment strategies and was
Approximately 20% more cases of high-grade
recommended for all NHLs, This system depended
B-cell lymphoma furthermore 10% fewer
on the number and site of nodal and extranodal
cases of low-grade B-cell lymphoma.
areas and took symptoms into account(6).The

Lugano modification of the Ann Arbor staging
Received:17 / 8 /2017 DOI : 10.12816/0041523
Accepted: 26 / 8 /2017

Full Paper (vol.694 paper# 10)

c:\work\Jor\vol694_11 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2245-2249

Wound Treatment in Relation to Surgical Site Infections
Abdullah Mohammed Alkhamri1, Zainab Mohammed Al Sulaiman2, Nojood Hassan A Turkey3,
Abdullah Rashed Alaboudi4, Sarhabdulhadi M Fallata5, Khaled Saad Aljedaani3, Sarah Abdullah
Altarouti6, Zahra Ali A Ahussain7, Alaaeid Aljohani8, Amr Mohammed Aldrees9, Yousef Safar
Alsahli10, Ahmed Abdulaziz Alrajhi11, Sama Mohammed Al Sulaiman3, Meshary Saad Alsohim12,
Anwar Abdullatif S Alhulaibi7
1 King Saud University, 2 Gulf Medical University­ Ajman, 3 King Abdulaziz University,
4 Qassim University,5 Batterjee Medical College, 6 B.A.U , Lebanon ,7 King Faisal University, 8 Ohud
Hospital, Medina ,9 Imam Muhammad Ibn Saud University,10 PHC Riyadh,11 Imam University,
12 Imam Muhammad Ibn Saud University

Surgical wounds heal by essential purpose in all the elective and emergency surgical processes.
Current practice is to place dressing over the closed wound before the patient leaves the sterile environment of
the operating theatre. Dressing is a material used to protect a wound and help its healing. On the other hand,
to leave wound open in direct contact to environment following any procedure by only applying some
ointment on it, the purported open wound treatment is yet debatable one. In the current study we have
compared open wound treatment versus occlusive dressings in elective surgical cases with respect to surgical
site infections. Materials and Methods: The current study was directed on 50 patients experienced for
elective general surgery. Patients were divided randomly in to two equal groups each containing of 25
patients. In Group 1, patients had occlusive dressing till removal of stitches and in Group 2, patients wounds
were retained exposed to environment after the surgical procedure. The study was done after approval of
ethical board of King Abdulaziz university
Results: In the current study, we perceived total 7% of postoperative wounds were infected of all the clean
and clean contaminated wounds we studied. In Group 1, patients had occlusive dressing and these patients
had 8% infection rate whereas in Group 2 patients, wounds were kept exposed to the environment and these
patients had 6% infection rate. Conclusion: It is thus, concluded that in the elective surgical cases there was
no damage in leaving the wounds open postoperatively. This process not only supports in arresting the
infective pathology at a reduced stage but likewise saves surgeon's time and patient's cash.
Keywords: Surgical site infection, Dressing, Infection, Surgical wound.

This practice take on that the risk of Surgical Site
Infection at or near surgical notches within
Infections is diminished by giving an obstruction to
30 days of an operative procedure, called surgical
ecological pollution. In addition, dressing's aids to
site infection, adds considerably to surgical
manage wound exudates, protects wounds and their
morbidity and mortality every year. Surgical site
staples or sutures, and reduces patients' anxiety by
infection (SSI) represents for 15% of every single
concealing the wound[4, 5]. Techniques for dressing
nosocomial disease and, amid surgical patients,
ranges from the injury being totally secured by glue
signifies the most widely recognized nosocomial
plaster to sterile bandage. Dressing is a material
infection [1]. SSIs are allied not only with increased
connected to secure an injury and it favours wound
morbidity but also with considerable mortality. In a
recuperating. That may be to leave twisted open in
study, 77% of the deaths of surgical patients were
guide contact to condition following any system by
allied to surgical wound infection [2]. Kirkland et al.
simply applying some balm on it, the purported open
considered a comparative danger of death of 2.2
injury treatment is as yet questionable one.In spite of
attributable to SSIs, in contrast with corresponding
the fact that reviews in the past have exhibited the
surgical patients without infection.Surgical wounds
safety of the exposure of surgical wounds [6, 7],
heal by essential expectation in all the optional and
however, there are examines which didn't bolster
emergency surgical procedures[3].
this practice [8, 9, 10]. It is as yet regular practice to
Current practice is to put dressing over the
dress injuries postoperatively, a system which
closed wound before the patient leaves the sterile
includes the cost in the two materials and nursing
condition of the operating place. The purpose of the
time. Subsequently, it is essential to survey whether
dressing is to avert wound infection. It had been and
wound dressings have a potential part in diminishing
is the practice in most of the hospitals to frequently
the danger of SSI. Such data can illuminate
dress surgical wound until stitches are removed.
designation of assets to medications. In the present
Received: 9 / 8 /2017 DOI : 10.12816/0041524
Accepted:18 /8 /2017

Full Paper (vol.694 paper# 11)

c:\work\Jor\vol694_12 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2250-2253

Four Petal Evisceration: Pros and Cons
Rehab M. Kamel
1, Doaa A. Mahmoud1, Ahmed M. Amin2
1Department of Ophthalmology, Al-Azhar University University, Faculty of Medicine for Girls,
2Department of Ophthalmology, Al-Azhar University University, Faculty of Medicine for Boys,

To evaluate four petals evisceration as one of the best modifications in evisceration surgery, allowing
the use of large orbital implant with low incidence of complications.
Methods: We conducted a retrospective, interventional study on evisceration with placement of spherical non
porous orbital implant after four petal evisceration. Preoperative examination included full history,
ophthalmological examination, indication for surgery, B-scan ultrasonography, axial length in cases of atrophic
and socket surface in secondary cases. All patients were operated a four petal evisceration with spherical non
porous implant of size 18 to 22. Postoperative, all patients were followed for at least 6 months for presence of
complications, implant and prosthesis motility and the final cosmetic results.
Results: 18 eyes were included. Diagnosis necessitating evisceration was atrophia bulbi in 8 patients,
endophthalmitis in 2 patients, and implant exposure in 4 patients, corneoscleral melting due to caustic exposure
in 1 patient, self-eviscerated globe due to severe trauma in 1 patient and anopthalmic socket following
evisceration without implant in 2 patients. Implant size was 18 in 1 patient, 20 in 6 patients, and 22 in 11
patients. No implant exposure occurred; superior sulcus deformity occurred in 3 patients, downward implant
migration occurred in 1 patient. Regarding implant motility, it was good with mean of 75% in 14 patients;
moderate with mean of 66% in 4 patients. The prosthesis motility was fair with mean of 35% in 12 patients
(66.6%) and poor with mean (10%) in 6 patients.
Conclusion: Four petals evisceration facilitates the use of large sized implant in all cases even in implant
exposure with deficient sclera with good post-operative final cosmetic results, very low rate of complications
and moderate prosthesis motility.
Keywords: four petal evisceration, implant exposure, atrophia.


completed fellowship training are more likely to
Evisceration and enucleation are commonly
perform eviscerations than their senior counterparts
performed procedures in conditions associated with
The evisceration technique has undergone several
a blind painful eye [1], in phthisis for cosmetic
modifications with the goals of achieving a lower
appearance and aesthetics and in microphthalmia to
rate of exposure and allowing colonization of the
enhance bony orbital development [2]. In the past,
biointegratable implant by the receptor tissue, as the
enucleation has been preferred by most surgeons for
fibrovascular ingrowth in the implant begins at the
various reasons, including the fear of sympathetic
sclerotomies[8] and to allow implantation of larger
ophthalmia (SO) after evisceration. However, after
orbital implants, which are effective in preventing
recent studies demonstrating the high safety of
volume loss after evisceration surgery. However, at
evisceration and low risk of SO, interest in
the same time, tension on the wound should be
evisceration has increased because of its advantages
minimized to reduce implant exposure. Several
[3]. Evisceration is technically easier surgery than
investigators have described sclerotomy techniques
enucleation , has better functional and aesthetic
to enlarge the scleral entry and expand the internal
outcomes over enucleation with more favorable
surface area of the sclera. The resultant increase in
fornix outcomes, better sulcus contour and allow
the scleral capacitance allows placement of larger
more greater motility of the implant due to less
orbital implants with superior functional and
disruption of orbital anatomy particularly the pulley
cosmetic results and decreased rates of extrusion [9].
system[4] . Also enucleation is associated with a

higher rate of postoperative complications like
implant exposure and enophthalmus [5], [6]. Shah et al
This study included eighteen patients who
[7] in a national survey assessed the practice patterns
underwent placement of spherical non porous
regarding eye removal among oculoplastic
orbital implant after four petal evisceration.
surgeons. They found that surgeons who recently
Preoperative examination including diagnosis
Received: 23 /7 /2017 DOI : 10.12816/0041525
Accepted: 2 / 8/2017

Full Paper (vol.694 paper# 12)

c:\work\Jor\vol694_13 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2254-2257

MRI Enhancement as A Predicator of Uterine Fibroid Volume
Reduction after Embolism
Amor Abdullah Al Mehdar1, Alaa Ibrahim Tukruna2, Abdulaziz Raja Najim Alotaibi3, Alaa
Mohammed Ali Alshahrani4, Fatimah Nasser Alsaad5, Zahra Adel Ali Jaffal6, Azharmuslimsarhan
Aljohani7, Zahra Ibrahim Alqarrash5, Hajarayad Alluhaybi7, Afnan Omer Aludaini8, Luayesam
Hakami9, Amnah Abdullah Alanzi10, Abdullah Abdulrahman I Muharib 11, Abdulsalam Ibrahim A.
Althumairy4, Atheer Raja Alyami12
1 Ministry of Health, 2 Batterjee Medical College, 3 King Faisal Medical Complex, 4 King Khalid University, 5 Imam
Abdulrahman Bin Faisal University, 6 Almaarefa Colleges, 7 Taibah University, 8 King Abdulaziz University, 9 Umm Al-Qura
University, 10 University of Tabuk, 11 King Saud Bin Abdulaziz University for Health Sciences, 12 Najran University

Aim of the Study:
To evaluate the response of necrotic fibroids to UAE and to identify whether pre-UAE
enhancement or other factors are predictors of fibroid shrinkage.
Materials and methods: This is a retrospective review of all women who underwent UAE for symptomatic
fibroids from January 2013 till July 2017, who experienced a follow-up MRI 5-6 months after UAE were
included. There were 54 fibroids (37 non-enhancing and 17 enhancing) among 24 women with a mean age of
56 (range 40-59) years. All fibroids were assessed for size, position, enhancement on subtraction images, and
Apparent Diffusion Constant (ADC).
Results: Enhancing fibroids had an average decrease in diameter by 23 ± 6%, not significantly different
compared to that non-enhancing fibroids which decreased by 19 ± 3% (p=0.491). Multiple linear regression
with percent change in fibroid diameter as the dependent variable and patient age, fibroid position, and pre-
UAE fibroid diameter, enhancement, and ADC as independent variables, showed that ADC (p<0.005) and
pre-UAE diameter (p<0.005) were the only significant independent variables.
Conclusion: Pre-UAE size and ADC, but not contrast enhancement, predicted fibroid diameter reduction.
Enhancing and non-enhancing fibroids had similar size reduction after UAE. Non-enhancement should not be
considered a contraindication to UAE.
Keywords: MRI, diffusivity, uterine artery embolization, fibroid.

response to UAE was judged insufficient in
Uterine artery embolization (UAE) is an
patients with a large fibroid, >8 cm, with a higher
accepted alternative to surgery in the
rate of need for additional therapy after UAE (4).
management of symptomatic patients with uterine
In addition, there is general unspecified fear of an
fibroids. UAE has been accepted as a safe and
excessive effect after embolization in these
effective alternative treatment for symptomatic
patients due to rapid ischemia and necrosis. This
fibroids firstly reported by Ravina in 1995 (1).
fear is based on several early case reports
Uterine fibroids (also called leiomyoma or
describing rare but serious complications shortly
myoma) are one of the most common benign
after UAE for large fibroids, such as unbearable
tumors which occur in about 40% of women by
pain, infection, septic uterine necrosis, and lethal
age 35 years (2).
sepsis (5).
Although many of women with fibroids are
The criteria for successful endovascular
asymptomatic, some of them have annoying
treatment are not universally accepted, although
symptoms. These symptoms include prolonged
patient satisfaction and fibroid shrink are
and heavy menstrual bleeding, pelvic pain, pelvic
essential. Most symptoms (especially those that
pressure, urinary frequency and reproductive
are bulk-related) are related to fibroid volume (6).
dysfunction. The costs for annual health care for
There have been several studies presenting a
a woman with uterine fibroids are 3.2 times
fibroid volume reduction rate of approximately
higher than a woman without fibroid in united
50­55% after embolization (7).
stated (3). However, the role of UAE in
symptomatic women with a large fibroid burden
procedures are increasingly preferred over
is a subject to debate. In several small studies,
hysterectomy in the management of symptomatic
Received:8 / 8/2017 DOI : 10.12816/0041526
Accepted: 17 /8 /2017

Full Paper (vol.694 paper# 13)

c:\work\Jor\vol694_14 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2258-2265

Impact of Dysphagia Therapy in Parkinson's Disease
Faisal Ahmed M. Abu Shaigah1, Ahlammohammed Zabbani2, Alya Bakr A. Qadi3, Abdulrahman
Mohammed M Aloufi4, Anmar Ahmed T Sultan5, Hussain Abdullah Aljuwayd6, Ahmed Ali H
Ghawas7, Ahmed Mohammed Alawadh8, Fayezaemadaldeen Alam9, Mohammed Abdullah
Alghamdi9, Nourhanwaleed Jastaniah9, Ghadeer Ahmed Mahdi2, Riyadh Jamil M Ajzaji9, Reem
Salem M Alenzi10, Fatimah Nader Al Jishi11
1Dammam Medical Complex, 2 Batterjee Medical College, 3 Medical University of Lodz, 4 King Khalid
University,5 King Salman Hospital, 6 Maastricht University, Netherlands, 7 King Faisal University, 8 Arabian
Gulf University,9 King Abdulaziz University, 10 Northern Border University, 11 Qatief Central Hospital

Dysphagia is a common symptom in Parkinson's disease (PD) which indicates a difficulty in
swallowing. It has been accompanied with poor quality of life (QoL), anxiety and depression.
Aim of the Study: to assess the effects of dysphagia treatment in Parkinsons disease.
Materials and methods: Studies published up to July 2017 were found via a systematic comprehensive electronic
database search using PubMed, Embase, and The Cochrane Library.Two reviewers independently assessed the
studies using strict inclusion criteria. Results: Thirteen studies were enrolled in the present study and qualitatively
analyzed using critical appraisal items. The review includes rehabilitative (exercises, electrical stimulation, bolus
modification etc.) and pharmacologic treatment. Some well-designed controlled trials were included. However,
none of the included studies fulfilled all criteria for external and internal validity. Thus, a meta-analysis was not
carried out as most of the studies were not of sufficient quality. Conclusion: Rehabilitative treatment including
Expiratory Muscle Strength Training (EMST) may be effective for dysphagia treatment solely coupled with
dopaminergic therapy for PD. Recently developed other treatment methods such as implant-prosthodontic
treatment and percutaneous injection of botulinum neurotoxin type A in the cricopharyngeal muscle on dysphagia
is rather promising. Nevertheless, these preliminary results warrant further investigation concerning their clinical
applicability, and further research should be conducted.
Dysphagia; Swallowing disorder, Parkinson's disease, Therapy outcome.

PD, demonstrating the importance of speech-
Parkinsons Disease (PD) can lead to
language pathologist (SLP)-based intervention for
problems with swallowing in between 31%-100% of
individuals, at any time during disease[1]. Normally,
symptom[4].Within this context, a growing number of
the disturbance is linked with bulbar structure
studies have been collected to assess the efficacy and
dysfunction affecting movements, with possible
efficiency of therapeutic interventions made by SLP
tongue tremor, food bolus flow weakening, prolonged
for this signs and symptom of dysphagia in PD, as
time during bolus transit, delayed swallowing reflex,
described above[5]. These studies have demonstrated
poor palate elevation, weakening of epiglottis
the benefits of several treatment strategies in
motility, regurgitation, tracheal penetration and
decreasing signs and symptoms of dysphagia and
aspiration[2]. Despite all these clinical symptoms, a
improving swallow safety in patients with PD,
parkinsonian individual´s initial alterations in
including food consistency modification, thermal­
swallowing ­ also called dysphagia ­ are normally
tactile stimulation, and expiratory muscle strength
undetected. By the time the patient starts worrying
training (EMST) [6].
about swallowing difficulties, frequently dysphagia is
The present study aimed at evaluating the effects
already in an advanced stage [3]. with a functional
of treatment for dysphagia in Parkinsons disease,
decline able to critically damage quality of life (QL).
Thus, an early swallowing functioning assessment in
incorporates all therapies available for oropharyngeal
PD is necessary, as well as measuring its impact on
dysphagia in Parkinsons disease, including an update
quality of life, to promote better results from the use
on rehabilitative therapies. The different types of
of therapeutic resources and optimize treatment.
therapy are grouped into four main therapy groups:
rehabilitative, surgical, pharmacologic, and other.
pneumonia is the main cause of death in patients with

Received:7 / 8 /2017 DOI : 10.12816/0041527
Accepted: 16 /8 /2017

Full Paper (vol.694 paper# 14)

c:\work\Jor\vol694_15 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2266-2270

Chronic Daily Headache Disorders and Their Management- A Study
Adilah Hamoud Al Turaifi1, Salem Mohammed Al-Qarni2, Ashwaq Fathi Nasser AL-Dossary3,
Khalid Abdulrahman Alsagaihe4, Fatimah Ibrahim Alshabeeb5, Dareen Hussain Alhendi6,
Sokinh Ahmed Almaghaslah7, Abdullah Mohammad Alsufi1, Zamil Jamil Alyamani,
Fatimah Taqi Almozayin9, Bassam Sameer Molawi10
1 Ibn Sina National College, 2 Almajaridah Health Care Center, 3 University of Imama Abdurhman Bin Faisal,
4 Almaaraefa Colleges, 5 Yemen University of Science And Technology, 6 Taibah University, 7 Pavol Jozef
Safarik University, 8 Hamdard University, 9 Arabian Gulf University, Umm Alqura University
Corresponding Author: Adilah Hamoud Al Turaifi ­

headaches account for 10% of all consultations with the general practitioner, and the third leading
cause of emergency department visits. The current prevalence of headache can go from 7.4% to 22.7% and may
be associated with much comorbidity, and can cause significant disabilities in an individual's quality of life.
Methodology: in this paper we carried out a systematic review on 32 observational (nonrandomized) studies
using PUBMED. Aim: our aim in the study is to evaluate the prevalence, associated risk factors, pathogenesis,
Conclusion: chronic headache adds to a huge burden in overall health care system, and a very frequent general
practice visit. Treatment of this type of headache is very challenging due to its chronicity as well as its risk of
conversion into medication onset headache. More researches that can promise better quality of life for
Keywords: chronic headache, migraine, tension type headache, new daily persistent headache, hemicranias,
medication induced headache, headache effect on lifestyle.

CDH are difficult to diagnose, manage, and
Chronic Daily Headache (CDH) is defined
are severely disabling and are recorded among one
as headache for more than 15 days in a month,
of the most frequent symptoms seen in general
lasting at least 4 hours, for a period of three months
practice. They are also associated with/ or may be a
(1). CDH is classified by the International Headache
cause of other comorbid disorders like depression,
Society into four major types: chronic migraine,
anxiety, mood disorders, and other chronic pain
chronic tension, hemicranias continua, and new daily
disorders. In fact, migraines can affect the health
persistent headache (2). The National Health and
related quality of life worse than diabetes and
Nutrition Examination Survey noted in 2011 that
22.7% of people reported having migraine or other

severe form of headaches in the past 3 months. The
Therefore, in this study, we aim to review the
burden of headache was highest in women of age
literature for the major types of CDH with respect to
18-44, reporting a 3-month prevalence of severe
their prevalence, pathology, management, and their
headache to be 26.1%. It was also noted that
effect on the quality life.
headache was the third leading cause of ED visits (3).

CDH are often preceded by gradual episodic
headache, which over several years transform to
We carried out a systematic review on
chronic type, as was noted by Fayyaz A et al. (4) in
observational (nonrandomized) studies by evaluating
3-6% of episodic headache cases. Other risk factors
32 articles, after exclusion, using search on
that lead to CDH are categorized as modifiable vs.
PUBMED (January 1994 to June 2017) to identify
non-modifiable. The modifiable ones included
the different types of CDH, their prevalence,
medication overdose, obesity, snoring, caffeine,
pathogenesis, management, and impact on
smoking, and psychiatric co-morbidity as depression
individual's quality of life. The keywords used for
or anxiety. The non-modifiable risk factors included
the search were: chronic headache disorders, chronic
Caucasians, female gender, low socio-economic
headache disorder & prevalence, pathogenesis, risk
factor, and previous head or neck injury (5).
factors, epidemiology, causes, management, impact
on life, and cost analysis; migraine, tension type
Received: 5 / 8 /2017 DOI : 10.12816/0041528
Accepted: 14/ 8/2017

Full Paper (vol.694 paper# 15)

INTRODUCTION The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2271-2277

Role of Pet/Ct in Assessment of Post Therapeutic Hepatocellular Carcinoma
Omar Hussain Omar, Mohamed Elgharib Abo Elmaaty, Ayman Mohamed Ibrahim,
Sherif Sameh Soliman
Radiodiagnosis Department, Ain Shams University, Cairo, Egypt
Corresponding author: Sherif Sameh Soliman Hassan, email: sherifsameh2000@yahoo.com.Tel.01005601993

Aim of the work:
this study aimed to highlight the role of PET/CT in evaluation of post-therapeutic
hepatocellular carcinoma, hence guiding the clinician to proper management strategy.
Patients and methods: 35 patients (32 male and 3 female) were included in this study. All patients had
history of local treatment of HCC; most of the cases were treated with TACE or RFA. They had undergone
18F-FDG PET/CT for evaluation of the therapeutic effect after the end of the therapy.
Results: our study demonstrated that 18F-FDG PET/CT is a significant prognostic factor for tumor recurrence
in post-therapeutic HCC with a cutoff TSUVmax/LSUVmax value of 1.3.
Conclusion: 18F-FDG PET/CT imaging have a prognostic significance in evaluation of patients with post-
therapeutic HCC and provide valuable information that can be used in the treatment response evaluation and
clinical decision making process.
Keywords: FDG, PET, PET/CT, post-therapeutic, HCC, Hepatocellular carcinoma.


HCC is the leading cause of death now among
history of local treatment, including transarterial
patients having liver cirrhosis (1). Surgical
chemoembolization (14 patients), radiofrequency
treatment, including hepatic resection and liver
ablation (13 patients), combination of these
transplantation is considered as the most effective
treatment of HCC. Patients with inoperable HCC
radiofrequency ablation in 2 patients) and surgical
were treated via interventional treatment (2).
resection in 6 patients.
18F-FDG PET /CT has been applied routinely for

assessment of patients with HCC before liver
All patients underwent PET/CT imaging in the
transplantation, also after transplantation it can
supine position after a 6 h fast. A combined
provide additional information beyond that
PET/CT scanner (Philips Ingenuity TF - PET/CT,
provided by conventional modalities and
128 MDCT) was used. Scans were acquired 60
contribute to the clinical management of HCC
min after intravenous injection of 5.5 MBq/kg of
recurrence ,especially in patients with extra
body weight of 18F-FDG (275~528 MBq, 7.43
hepatic recurrence (3). The reported increased
mCi~14.27 mCi). A low dose non contrast CT
sensitivity of 18F-FDG PET/CT over CT & MRI
acquired within a short period of time for
was attributed to its ability for detection of
attenuation correction and anatomic localization
followed by PET scan covering a field of view
morphological changes by CT (2). Based on gene
from the skull base to the mid thighs followed by
expression profiles of HCCs, high 18F-FDG uptake
injection of I.V. non-ionic contrast (with dose
HCCs are reported as more aggressive than low
1mg/kg patient body weight) and then a diagnostic
18F-FDG uptake HCCs. Moreover, baseline
128 MDCT examination of the same regions was
PET/CT have great prognostic value in HCC
done. Lesions were identified by presence of
patients who were treated with resection,
metabolically active tumor tissue with high FDG
radiotherapy, chemotherapy and TACE (1,4).
accumulation and correlate this activity to its

anatomical site in the combined PET/CT images.
The images were interpreted both visually and
From January 2015 to March 2017, thirty five
semi quantitatively for the regions with pathologic
patients (32 male and 3 female), their age ranged
tracer accumulation using standardized uptake
from 30 to 73 years with a median age 56 years,
value (SUV). The SUV is a semi quantitative
were referred to the radiology unit with
assessment of the radiotracer uptake from a static
hepatocellular carcinoma and had underwent
(single point in time) PET image. We rely on
interventional treatment for assessment by 18F-
visual inspection and use SUV in assessing
FDG PET/CT. Examination was conducted in a
questionable lesions or in the follow-up of FDG-
private radiology center in Cairo. Patients had a
avid masses. Typically, malignant tumors have an
Received: / /2017 DOI : 10.12816/0041529
Accepted: / /2017

Full Paper (vol.694 paper# 16)

c:\work\Jor\vol694_17 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2278-2285

Management of Diabetic Ketoacidosis in Patients with Diabetes Type I
Basam Zuhaer Sindi1, Naif Mishkhas Alazwari2, Abdulaziz Mohammed Khateeb2, Aqil Abdulmonem
Alzaher3, Mohammad Abdulaziz M Alkhawajah 3, Atheer Khalid Almutairi3, Najd Abdulrahman Al-

Mutairi3, Zainab Reda Alghanim3, Ameera Ahmad Nemer3, Hazim Abdulkarim Khatib2
1 Umm Alqura University, 2 King Abdulaziz University, 3 Imam Abdulrahman Bin Faisal University
Corresponding Author: Basam zuhaer sindi, email:Basam.sindi@gmail.com

DKA is the leading cause of mortality among pediatric age and young adults with T1D,
responsible for almost 50% of all fatalities in diabetic patients younger than 24 years of age. Goals of DKA
management include optimization of volume status, hyperglycemia and ketoacidosis, electrolyte abnormalities,
and potential precipitating factors. Methodology: we conducted this review using a comprehensive search of
MEDLINE, PubMed, and EMBASE, January 1987, through February 2017. The following search terms were
used: ketoacidosis, management of diabetic ketoacidosis, type I diabetic patients' emergency complication,
fluid replacement in DKA, insulin therapy approach. Aim: in this review, we aim at evaluating the various ways
of approaching patients who suffer from type-one diabetes during ketoacidosis and keto-acidotic coma. We will
try to understand the triggers and pathophysiology behind this condition, and explore ways to prevent them.
Conclusion: prompt diagnoses, aggressive treatment, and education of patient and their care providers about
prevention strategies must be implemented. Also, more studies are required in the area of preventing health
complications due to these types of diseases to effectively manage DKA in the future.
Keywords: diabetic ketoacidosis approach, insulin therapy in diabetic ketoacidosis, fluid replacement in
diabetic ketoacidosis.

2. Hyperglycemia and ketoacidosis.
Diabetic ketoacidosis (DKA) is a common
3. Electrolyte abnormalities.
cause of morbidity and mortality in type-1 diabetics;
4. Potential precipitating factors [4].
though, infrequently it also occurs in type-2

diabetics. Type 1 diabetes mellitus (T1D) affects
The majority of patients with DKA present to the
children and adults worldwide, with an increasing
emergency room. DKA-related ICU and hospital
incidence between young people. The incidence of
deaths have stayed steady for nearly fifteen years
DKA has risen by 30% through the past decade,
and no improvement in mortality was observed [5].
with greater than 140,000 hospital admissions every
In this review, we aimed evaluation of the
year in the United States alone [1]. Patients with the
various aspects to approach a patient with type-one
highest risk comprised those with high hemoglobin
diabetes during ketoacidosis and keto-acidotic coma.
A1C, longer diabetes length, adolescents, and
We tried to understand the triggers and
females. DKA is the chief cause of mortality amid
pathophysiology behind such conditions, and learn
children and young adults with T1D, adding up to
how to prevent them.
nearly 50% of all deaths in a young diabetic patient

of age less than 24 years [2]. Inside United States, the
overall inpatient DKA mortality is only 1%, but an
· Data Sources and Search terms
advanced rate is stated for elderly patients who also
We conducted this review using a comprehensive
have other life-threatening illnesses [1].
search of MEDLINE, PubMed, and EMBASE,
There were 140,000 hospitalizations for
January 1987, through February 2017. The
DKA with an average length of stay of about 3.4
following search terms were used: ketoacidosis,
days in the year 2009. The annual cost of DKA
management of diabetic ketoacidosis, type I diabetic
hospitalizations adds up to 2.4 billion US dollars [3].
patients' emergency complication, fluid replacement
The therapeutic aims of DKA management comprise
in DKA, insulin therapy approach
optimization of:
· Data Extraction
1. Volume status.
Received:2 / 8 /2017 DOI : 10.12816/0041530
Accepted: 11 /8 /2017

Full Paper (vol.694 paper# 17)

c:\work\Jor\vol694_18 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2286-2293

Orthodontic Management for Class III Malocclusion
Shaimaa Gamal Tagrida1, Alanoud Turki Alhelali1, Sarah Nassar Hasan Almadani1,
Dhay Abdullah Al ­Tawi2, Laura Jamal Musairy2, Abrar Mohammed Alghamdi3,
Fawaz Atteq Alsumiry3, Abdulrahman Saleh Aldamook4, Majed Sonitan Alharbi5

Alfarabi Private College-Jeddah1, Batterjee Medical College2, Ibn Sina Collage3,
King Abdulaziz University4, Alfarabi Private College-Reyadh5
Corresponding author: Shaimaa Gamal Tagrida, eso000qi@gmail.com,mobile:+966 56 285 6248

Class III malocclusion influences between 5% and 15% of the population. The 2 most common
quandaries encompassing Class III management are the planning of treatment and the type of appliance.
Various appliances have been utilized to correct a Class III skeletal discrepancy; however there is little proof
accessible on their adequacy in the long term. Additionally, early management of Class III malocclusion has
been practiced with expanding interest. Nevertheless, there has been no strong confirmation on the advantages
in the long term. Aim of the study: we conducted this systematic review to assess the adequacy of
orthodontic techniques utilized in the early treatment of Class III malocclusion in the short and long terms.
Methods: A systematic search was performed in the scientific database independently of language,
particularly MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, and
individual orthodontic journals were searched to November 2016. The selection criteria included randomized
controlled trials (RCTs) and prospective controlled clinical trials (CCTs) of children between the ages of 7 and
12 years on early treatment with any type of orthodontic/orthopaedic appliance compared with another
appliance to correct Class III malocclusion or with an untreated control group. The primary outcome measure
was correction of reverse overjet, and the secondary outcomes included skeletal changes, soft tissue changes,
quality of life, patient compliance, adverse effect, Peer Assessment Rating score, and treatment time. Results:
Ten studies, 6 RCTs and 4 CCTs, are involved in this review. In the RCT group, only 2 of 6 studies were
assessed at low risk of bias, and the others were at high or unclear risk of bias. All 4 CCT studies were
classified as high risk of bias. Two RCTs involving 109 participants looked at the comparison between
protraction facemask and untreated control. The results for ANB angle (mean difference, 3.40; 95% CI, 2.6-
3.15; P <0.0001) and reverse overjet (mean difference, 2.5 mm; 95% CI, 1.21-3.79; P< 0.0001) were
statistically significant favouring the facemask group. All CCTs validated a statistically significant advantage
in favour of the use of each appliance. Nonetheless, the studies had high risk of bias. Conclusions: There is a
moderate amount of evidence to show that early treatment with a facemask results in positive improvement for
both skeletal and dental effects in the short term. Though, there was absence of evidence on long-term benefits.
There is certain evidence regarding the chin cup, removable mandibular retractor, and tandem traction bow
appliance; however the studies had a high risk of bias. Additional high-quality, long-term studies are assessing
to evaluate the early treatment effects for Class III malocclusion patients.
Keywords: Class III malocclusion, orthodontic management, risk of bias, Facemask, chin cup.

the occlusal relationship such as facial esthetics and
Early management of Class III malocclusion
correcting the crossbite [6]. Many orthopedic
has been endeavoured with differing achievement.
appliances have been investigated including
The primary preferred standpoint of early treatment
protraction facemask, removable mandibular
Class III malocclusion is to prevent surgical
retractor, class III elastics, reverse Twin-block, FR-
interference and therefore decrease the morbidity of
3 appliance of Frankel, bionator, chincup, double-
the surgery [1]. The planning of early treatment is
piece corrector, and mandibular headgear to attain
critical for an effective result. Some studies have
this aim. Between these, the protraction facemask is
reported that treatment ought to be carried out in
favoured by many to correct a retronagthic maxilla.
patients less than 10 years of age to improve the
Alternatively, the chincup is believed to retard or
orthopaedic impact [2, 3]. Conversely, different
redirect the growth of a prognathic mandible. The
examinations have discovered that patient age had
previous Cochrane systematic review determined
little impact on treatment response and result [4, 5].
that even though there was some indication for the
Therefore, there is no solid proof to help that early
effectiveness of the facemask appliance in the short
management would be beneficial. The principle
term, there is no indication that the outcomes are
objectives of early involvement are to offer a more
preserved in the long term [7]. When there are not
favourable environment for growth and to develop
many high-quality RCTs in the literature, it is
Received: 9 /8 /2017 DOI : 10.12816/0041531
Accepted: 18 /8 /2017

Full Paper (vol.694 paper# 18)

c:\work\Jor\vol694_19 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2294-2300

Role of Magnetic Resonance Imaging and Ultrasonography in Diagnosis and
Follow Up Rheumatoid Arthritis in Hand and Wrist Joints
Ahmed Mohamed Safwat Zaki, Waleed Mohamed Abd El Hamid Hetta,
Omar Hussein Omar, Ahmed Fathy Abdel Ghany
Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Ahmed Fathy Abdel Ghany ,email: monaabdelaal2005@yahoo.com


Aim of the work: to compare the role of ultrasonography and magnetic resonance imaging in the diagnosis
of wrist joint affection in patients with rheumatoid arthritis. Patients and methods: this study included 50
patients diagnosed as rheumatoid arthritis (41 females and 9 males) with mean age 43 years; they were
subjected to high resolution ultrasound and MRI of the wrist joint for the dominant affected wrist clinically.
Comparison and correlation between both modalities was done. Results: our results showed agreement
between ultrasound and MRI in the assessment of synovial inflammation, activity and bone erosions in
wrist joint in rheumatoid arthrtis patients. Conclusion: we concluded that both modalities were comparable
and close to each others as regards the bony erosions and synovial hypertrophy and inflammation in the
wrist joints in patient with rheumatoid arthritis and the ultrasound was useful tools in detection of erosions
and synovial inflammation so can be used in patients without erosions on conventional x ray and also can
be used in follow up and monitoring the patients with established diagnosis of rheumatoid.

subluxation, and marginal erosions are all
Rheumatoid Arthritis (RA) is a chronic
features that may be seen. However, information
systemic autoimmune disorder of unknown
regarding the synovium is much more difficult to
etiology characterized by symmetrical joint
assess on radiographs. Both ultrasound and MRI
synovitis and pain. RA has a wide clinical
are sensitive for the detection of synovitis and
spectrum and may vary from mild non-erosive
both are superior to radiography (4) .
disease to severe inflammation and joint damage
MRI had excellent results in evaluation of
with extra-articular manifestations. The wrist and
early RA. MRI wrist demonstrated bone erosions,
hand joints were affected early in the disease
synovial hypertrophy, synovitis and tenosynovi-
process, with some deformities occurring in the
tis. Other signs include tendinitis, enthesitis,
first two years of the disease (1) .
ligament and tendon tears, bone marrow edema
Rheumatoid arthritis is characterized by
and joint effusions (5) .
Ultrasonography is an imaging technique
resulting in bone erosion, cartilage damage, joint
that has attracted much interest in the field of
destruction and long-term disability. The absence
rheumatology in recent years. As a result of
of effective treatment to prevent joint destruction
technological improvements and wide availabil-
has limited the need for more sensitive imaging
ity, ultrasonography has the potential to facilitate
techniques. Availability of these powerful and
diagnosis of RA and improve the assessment of
expensive drugs has created new demands on
disease activity (10). This study aimed to compare
radiologists to identify patients with aggressive
the role of ultrasonography and magnetic
rheumatoid arthritis at an early stage to affect the
resonance imaging in the diagnosis of wrist joint
therapeutic management of these patients (2) .
affection in patients with rheumatoid arthritis.
In rheumatoid arthritis (RA), hyperemia

caused by vasodilatation is one of the earliest
detectable pathologic alterations at the beginning
Fifty rheumatoid arthritis (RA) patients were
of joint inflammation, and angiogenesis, as one of
included in this study, from the Rheumatology
the key prerequisites for pannus formation, plays
and Rehabilitation outpatient clinic from private
a crucial role in the initiation and perpetuation of
centers. This study was conducted during the
period 2015 to 2017and included 41females and
Radiographs have traditionally been the
9males with a mean age of 43.
mainstay for imaging patients with rheumatoid
The inclusion criteria: clinical diagnosis of
arthritis; findings such as soft-tissue swelling,
rheumatoid arthritis (RA) according to The
periarticular osteopenia, joint space loss, joint
American Rheumatism Association 1987 revised
Received:19 /8 /2017 DOI : 10.12816/0041532
Accepted: 28 / 8 /2017

Full Paper (vol.694 paper# 19)

c:\work\Jor\vol694_20 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2301-2307
A study of Intratympanic Dexamethasone Injection in Meniere's
Disease (Continuation study)
Adel A.M Nassar, Ahmed E.F. Chedid, Rasha H. El-Kabarity and Sameh M.A. Beshry
ENT Dept. ­ Audiology Unit, Faculty of Medicine, Ain Shams University, Military Medical Academy
Corresponding author: Sameh M.A. Beshry .email: semsembeshry@gmail.com

Meniere's disease is a condition that is thought to arise from abnormal fluid and ion
homeostasis in the inner ear. The disease is named for Prospere Meniere, a French physician who was first
known victim of this disease and reported that the inner ear could be the source of a syndrome manifesting
episodic vertigo, tinnitus and hearing loss. The origin of Meniere's disease is presently controversial. While,
in the past, it was felt that endolymphatic hydrops (excess fluid) in the inner ear were responsible for the
disease, the most current opinion is that hydrops are just a marker for the Meniere's disease, rather than
absolutely being responsible for the symptoms.
Aim of the work: this study aimed to follow up (2 and 2.5 years) the effect intratympanic (IT)
dexamethasone in the prognosis of Meniere's disease (MD) with two different concentrations (4 and 10
mg/ml). Patients and methods: twenty patients with unilateral Meniere's disease received intra tympanic
dexamethasone injection were included in this study .The studied subgroups were categorized according to
the concentration of dexamethasone (4 and 10 mg/ml) used into two subgroups. Detailed history was taken
from all patients. They were exposed to Dizziness Handicap Inventory scale, basic audiological evaluation
and cervical-vestibular evoked myogenic potential assessment. The presence or absence of spontaneous,
post-head-shaking, and positional nystagmus was evaluated using a video-nystagmography system. The
patients in the two groups were followed -up for 2 and 2.5 years.
Results: the dosage of 10mg/ml dexamethasone showed more stability in signs and symptoms of Meniere's
disease than the dose of 4 mg/ml dexamethasone in follow up study. The long term study of intratympanic
(IT) dexamethasone injection in both subgroups shows nearly no improvement as regard pure tone average,
speech reception thresholds, word discrimination scores, subjective hearing loss, tinnitus, aural fullness,
vertigo interruption with daily activities and vertigo associated symptoms compared to the previous study
thesis. Conclusion: the long-term study of intratympanic (IT) Dexamethasone injection in both subgroups
showed nearly no improvement in most assessments performed.
Keywords: long-term study of intratympanic dexamethasone injection, Menieres disease, Dizziness
Handicap Inventory scale.


endolymphatic structures and vascular (circulation)
Meniere's disease is a condition that is thought
irregularities (3). A wide variety of conservative
to arise from abnormal fluid and ion homeostasis
approaches were established for the initial
in the inner ear. The disease is named for Prospere
treatment of Meniere's disease. These included
Meniere, a French physician who was first known
medical therapies in the form of low-salt diet and
victim of this disease and reported that the inner
administration of diuretics, steroids, calcium
ear could be the source of a syndrome manifesting
channel blockers, and vasodilators, and they were
episodic vertigo, tinnitus, and hearing loss(1). The
useful in regulating the symptoms in 50­70% of
origin of Meniere's disease is presently
patients. For medically intractable Meniere's
controversial. While in the past, it was felt that
disease, various surgical techniques had been
endolymphatic hydrops (excess fluid) in the inner
developed. They had been criticized because of
ear were responsible for the disease, the most
their poor results with respect to the long-term
current opinion is that hydrops are just a marker for
control of vertigo, the definite hearing damage that
the Meniere's disease, rather than absolutely being
may be induced, and the morbidity associated with
responsible for the symptoms (2).
the procedure (4).
The use of local intratympanic delivery of
endolymphatic hydrops (excess fluid) in the inner
aminoglycosides or corticosteroids has been
ear. The most common causes were: auto-immune
recommended in an attempt to minimize the
reactions, dietary deficiencies, viral infections,
complications and risks involved in the 3 surgical
allergic responses, autonomic nervous system
procedures. The sensorineural hearing loss in
imbalances, blockage and/or damage to the
Meniere's disease is typically fluctuating and
Received:18 /8 /2017 DOI : 10.12816/0041533
Accepted: 27 /8 /2017

Full Paper (vol.694 paper# 20)

c:\work\Jor\vol694_21 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2308-2314

The Accuracy of Three-Dimensional Ultrasound Imaging in
Detection of Lip and Palate Clefts
Sarah Saeed Alshahrani, Roa Fahad Alshabanah, Tahani Saeed Almohayya,
Ebtesam Mohammed Alahmari
Faculty of Medicine, King Khalid University, Abha, Saudi Arabia
Corresponding author: Dr. Sarah Saeed Alshahrani, email:dr.research222@gmail.com


Background: Although there is a lack of robust evidence from prospective cohort studies that supporting using
3D ultrasound, it becomes widely used in the clinical practice of obstetrics. This review aimed At evaluating the
evidence assessing the accuracy of 3D ultrasound, in the detection of cleft lip and palate in different populations
at different trimesters. Methods: In July 2017, we conducted a systematic search of the databases (MEDLINE,
EMBASE and Science Direct databases) as demonstrated in table 1. The titles and abstracts of the detected
articles were screened to exclude irrelevantly and duplicated, in addition to articles of case reports and reviews.
Finally, articles were finally included in this review and subjected to data extraction and qualitative data
analysis. Results: The detection rates of cleft lip ± alveolar bone cleft by 3D ultrasound imaging were found
very high by many of the included studies. A range of 85%-100% detection rate of cleft lip only and cleft lip
with cleft alveolus was reported by many studies. The detection rate of cleft palate with or without cleft lip
varied between 50%-100%. This review revealed a detection rate of cleft lip and palate in low-risk populations
ranged between 80-100%, while in high-risk populations the detection rate varied widely between 50% -100%.
: Although there is a wealth of evidence demonstrated the high accuracy of 3D imaging in the
detection of cleft lip and palate, the available studies had a poor methodology with a high risk of bias in their
Keywords: Accuracy, Ultrasound, Cleft, Lip, Palate, Three-dimensional.


The prenatal screening of congenital anomalies
have introduced to the prenatal screening methods (7).
becomes a major research area in obstetrics.
The benefits of using 3D ultrasound imaging include
Ultrasound has been used as an important tool for
the provision of depth and volume, which explore
prenatal detection of congenital anomalies including
more details than those available in two-dimensional
facial clefting (1). Facial clefts resulted from the failed
(2D) ultrasound imaging (8). There is a current belief
fusion of yaw arch maxillofacial and nasal processes
that 3D ultrasound is a time-saving technique that can
in the embryogenesis stage. The cleft lip plus or
play an important role the future. However, it is not
minus cleft palate are the most common facial clefts,
obvious what is the clinical significance of the
which could occur as an isolated anomaly or
additional data provided by 3D ultrasound imaging.
associated with other global anomalies and
Although there is a lack of robust evidence from
syndromes (2). Cleft lip and palate incidence have
prospective cohort studies that supporting using 3D
reported reaching 2.19/ 1000 live births in the central
ultrasound, it becomes widely used in the clinical
province of Saudi Arabia, which is a higher incidence
practice of obstetrics (7). The main problem occurs
when compared to other countries such the UK where
when using 3D ultrasound is the deviation from the
incidence rate was 182/1000 live births (3, 4).
initial plane, which can reduce the quality of the
When using ultrasound, the detection rate of
images. In addition to the problem of acoustic
these clefts differed greatly according to the skills of
shadowing, that may also occur in 2D ultrasound (9).
the operator and the design of the study. It ranges
Recently, it becomes possible to update the 3D image
from as low as 13% in a prospective study conducted
at a rate of 24/second which leads to living view of
by Stoll et al. (5) to as high as 90% in a retrospective
the 3D volumes or what is known as 4D ultrasound
study conducted by Benacerraf et al. (6). Proper
imaging (10).
prenatal screening associated with early detection of
This review aimed at evaluating the evidence
facial clefts, especially in a low-risk population, can
assessing the accuracy of 3D ultrasound, in the
improve the management plan. Recently, the three-
detection of cleft lip and palate in different
dimensional (3D) ultrasound imaging techniques
populations at different trimesters.
Received: 30 / 7 /2017 DOI : 10.12816/0041534
Accepted: 9 / 8 /2017

Full Paper (vol.694 paper# 21)

c:\work\Jor\vol694_22 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2315-2322

Quantitative Morphometric Study of The Chorionic Villi in
Hypertensive Mothers
Abdulrhman Saleh Dairi1, Wagih Gamal Elbarrany2, Amna Abdul Rahim Moulana3,
Ahmad Sami A Himayda1, Iyad M.Hakeem1
1Medical Intern, Faculty of Medicine and Surgery, Umm Al-Qura University, 2Professor of Anatomy,
Faculty of Medicine and Surgery, Umm Al-Qura University, 3Consultant of Anatomical Pathology,
Maternity and Children's Hospital, Ministry of Health, Makkah, Saudi Arabia.
Corresponding Author: Abdulrhman Saleh Dairi, email:askdairi@gmail.com, mobile:+966558306306

Background: Several
studies have reported that mothers with pregnancy induced hypertension or those
suffering from hypertensive disorders have abnormalities in histological features of the placenta. The fetus
connection with the mother is through chorionic villi. Besides several other histological features changes in
the chorionic villi have also been reported. This lead to the reduced supply of the necessary nutritional
elements for the fetus.
The aim of the Study: The principal objective of this study was to evaluate morphometric changes in the
placenta of expecting mothers have hypertensive disorders of pregnancy and women without any symptoms
of hypertension. As the placenta is capillary-rich region and any physiological change can adversely affect
the fetal health.
Patients and Methods: In this study, a total of 84 expecting mothers were recruited. Among these 42 have
hypertensive symptoms before pregnancy whereas the other 42 have their blood pressure in normal ranges.
Among the 42 hypertensive women, only 13 met the study inclusion criteria,i.e., blood pressure in the range
of 140/90 mmHg in the 30th week of the pregnancy. The quantitative morphometric parameters included
shape and size of the placenta, damage to the blood vessels mainly in the chorionic villi and an overall
number of blood vessels.
Results: A comparative evaluation of placenta from the hypertensive and normotensive expecting mothers
showed that blood vessels area in the hypertensive mothers was significantly reduced when compared to
normotensive mothers, same holds from the blood vessels in the perimeter areas. These findings have
important implications as far as the fetal development among hypertensive mothers is concerned.
Conclusions: Higher blood pressure associated changes in the placenta are manifested in the form of
several histological and morphological changes mainly in the chorionic villi structures involved in fulfilling
nutritional requirements of the fetus.
Keywords: Placenta, Chorionic villi, Hypertension, Pregnancy.

regions in the placenta known as primary villi
Foetal development is a well-orchestrated
4,5.The formation of the primary villi is followed
and highly complex developmental process
by the emergence of the mesenchymal core that is
involving the formation of several membranes
embedded into the progressively expanding
linking fetus to the mother1. The most common
villus6. Presumably, this has been noted to be
fetal membranes are the amnion and chorion
during the fourth or fifth week of embryonic
ultimately forming the amniotic sac that encircles
development even though some studies have
the fetus and has a major protective function2.
pointed out that it is a few days after the formation
Mainly the small projections or villi of the
of the primary villi. The secondary villi, develop
chorionic membrane play a significant role in
into tertiary villus when the blood vessels
providing fetal to mother contacts an appropriate
penetrate the mesenchymal core and the branches
supply of maternal blood supply to the fetus3. Few
that have been newly formed7.
studies have described the timing of the
This happens during the third and the
development of the chorionic villi, but it is
fourth week of pregnancy.
believed that the development of the vill ibegins at
The chorionic villi are differentiated into
the end of the second week to the third week of
four critical layers each with a distinct function in
embryonic development. Late in the second week
the maintenance of the embryo. These include the
of the development of the embryo, projections of
outer syncytiotrophoblast (multinucleated), the
the proliferating cytotrophoblast cells appear to be
inner layer cytotrophoblast stems cells, stroma
evaginating into the syncytiotrophoblast in several
and blood vessels8-10. As the fetal development
Received:4 / 8 /2017 DOI : 10.12816/0041535
Accepted:13 / 8 /2017

Full Paper (vol.694 paper# 22)

c:\work\Jor\vol694_23 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2323-2328

Management of Pain in The Intensive Care Unit
Fatimah Abdulwahab Alhawaj1, ZohairRadi Alghazal1, Mohammed Saleh Alonazi2, Nura Nasser
Alahmadi3, AlmutariAbdulmajed4, Ali Mohammed Alhijab1, Imtinan Abdulrahman Malawi5,
Sohaib Osama Baarimah6, Abdulhadi salem Towairqi7
1 Imam Abdulrahman Bin Faisal University, 2 Imam Muhammad Bin Saud University, 3 Taibah
University, 4 Semmelwies University, 5 Batterjee Medical College, 6 Umm Al-Qura University, 7
University of Jeddah
Corresponding Author: Fatimah AbdulwahabAlhawaj­ 00966546644766
Pain assessment in ICU patients turns out to be a daily challenge for the attending teams,
particularly in those patients who are intubated endotracheally; on mechanical ventilation or
analgosedated as such patients are unable to self-assess existence and intensity of pain. Guidelines to
identify pain in these patients are crucial for physicians for effective management.
Methodology: We conducted this review using a comprehensive search of MEDLINE, PubMed, and
EMBASE, January 1994, through March 2017. The following search terms were used: pain management
in ICU, pain in ICU, pain assessment by behavior, pain assessment in intubated patients.
Aim: Our aim in this study was to understand how to assess and manage pain in an intensive care unit
Conclusion: Physical clues given by comatose or intubated patients in critical care unit must be used as a
method to identify existence of pain, and must be managed effectively to decrease discomfort and prevent
short and long term adverse effects.
Keywords: Intensive care unit pain assessment, ICU pain management, guidelines to pain management.

Pain is defined by the International
comprehensive search of MEDLINE, PubMed,
Association for Study of Pain (IASP) as "an
and EMBASE, January 1992, through March
unpleasant sensory and emotional experience
2017. The following search terms were used:
associated with actual or potential tissue damage
pain management in ICU, pain in ICU, pain
or described in terms of such damage"[1]. The
assessment by behavior, pain assessment in
description highlights that pain is of subjective
intubated patients
nature, and also highlights that only the person
Data Extraction
experiencing the pain can assess its intensity.
Two reviewers have independently reviewed the
However, unfortunately, as many of the patients
studies, abstracted data, and disagreements were
who are treated in intensive care units (ICUs),
resolved by consensus. Studies were evaluated
especially, those who are intubated and on
for quality and a review protocol was followed
mechanical ventilation, do not fit this definition
as they are unable to self-report pain sensations
The study was done after approval of ethical
nor assess the pain intensity. Pain assessment in
board of King Abdulaziz University.
ICU patients turns out to be a daily challenge for

the attending teams, particularly in those patients
Incidence of pain in ICU patients
who are intubatedendotracheal, on mechanical
The World Health Organization (WHO)
ventilation or analgosedated. Adding to those
show us that nearly 83% of the
challenges are other co-existing mental and
people in the world live in nations with either
neurological disorders such aspsychoses,
deprivedaccess, or no access at all to pain
management [3]. However, pain experienced by
patients of ICU is a common finding and is well

documented. In the course of treatment in ICU,
up to 40­70% of patients have experienced
Data Sources and Search terms
moderate to severe pain. According to some
studies, around 30% of patients have
Received: 14 /8 /2017 DOI : 10.12816/0041536
Accepted: 23 /8 /2017

Full Paper (vol.694 paper# 23)

c:\work\Jor\vol694_24 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2329-2333

Assessment of Preoperative Anxiety among Patients
Undergoing Elective Surgery
Mohammed Saleh Almalki (1), Othman Ahmed Othman Hakami (2), Areej Mohammed Al-Amri(3)
1College of Medicine, Umm Al-Qura University; 2Faculty of Medicine, Jazan University;
3College of Medicine, Taibah University

Introduction: Although patients undergoing elective surgery are assumed to have a lower level of
preoperative anxiety, studies reported a high level of anxiety among those patients.
. This study aimed at assessing the level of preoperative anxiety and its predictors in adult patients
undergoing elective surgery.
Methods: This study is a cross-sectional design conducted among patients admitted for elective surgery.
A total of 278 patients with non-life-threatening surgeries were included and those who had mental or
psychological problems were excluded from this study. Sample type and sample size. The data collected
through a questionnaire about demographics, preoperative knowledge and anxiety in the preoperative
room 24 hours before the operation. The frequencies, percentages, mean and SD were calculated, and t-
test was used to detect significant associations.
Results: The overall preoperative anxiety score had a mean ±SD of 18.2±5.8 and the questions regarding
knowledge component reported higher scores than those about anxiety component. The components of
anxiety about surgery reported higher scores than those of anxiety about anesthesia. Age, gender,
availability of family support and type of surgery were found as significant predictors for preoperative
anxiety prior to elective surgery. However, the association between preoperative anxiety and marital
status and previous experience of surgery were found statistically non-significant.
: This study concluded that patients underwent elective surgery had high preoperative anxiety.
The patients with younger age, female gender, patients under general anesthesia, or those who had no
family support showed a higher level of preoperative anxiety.
Keywords: Anxiety, Surgery, Elective, Anesthesia, Fear.


activation of central nervous system and
Anxiety is an emotional state of fear,
suppression of immunological response, which
nervousness, and worry about threatening events
increases the vulnerability to diseases and
associated with the physiological alertness (1).
postoperative complications (8). Methods those
Surgery is a traumatic treatment that usually
found to reduce the level of preoperative anxiety
associated with bleeding, pain, the risk of
include pharmacological therapy and non-
morbidity or sometimes death. Thus, the
pharmacological methods such as spiritual
preoperative anxiety is common and the reported
practices, music, provision of information, and
prevalence of preoperative anxiety among
social support (9-11). The elevated levels of
patients underwent various types of surgery was
preoperative anxiety have serious outcomes and
found as high as 60% to 90% (2).
can increase the risk of postoperative
The elevated levels of preoperative
complications such as pain, prolonged recovery,
anxiety have serious outcomes and can increase
longer hospitalization, and death (3). Furthermore,
the risk of postoperative complications such as
the high level of preoperative anxiety is
pain, prolonged recovery, longer hospitalization,
associated with the increased need of anesthesia
and death (3). Furthermore, the high level of
(4). The methods used to assess the preoperative
preoperative anxiety is associated with the
anxiety either subjective self-assessment of
increased need of anesthesia (4). The common
anxiety by the patients or objective evaluation
causes for elevated preoperative anxiety include
using visual analog scales (VAS) (12, 13). The
fear of pain, physical injury, complications, and
death. In addition, concerns about loss of physical
overestimate the level of anxiety, while the
capacity and worry about family members and
objective assessment using VAS was found more
children (5, 6). The psychological hypotheses have
accurate (1). The aggravating factors that lead to
postulated that surgical intervention is a
increasing the preoperative anxiety include
psychological stress that needs an intervention (7).
female gender, young age, married status, and
The psychological stress is associated with
low educational level (5, 14, 15). In addition, the type
Received:28 / 7 /2017 DOI : 10.12816/0041537
Accepted: 7 / 8 /2017

Full Paper (vol.694 paper# 24)

c:\work\Jor\vol694_25 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2334-2339

Physical Activity Profile in Adult Patients Attending Family Medicine Clinics
Yousef Hussain Al Zahib
Family Medicine Resident, Saudi Board of Family Medicine Program, Abha, Saudi Arabia

Background: Scientific evidence has been accumulated about the health benefits of physical activity and
exercise on the health of adults in the last decades. However, few studies attempted to study the physical
activity profile among adults in Saudi Arabia. Thus, this study aimed to identify the physical activity profile
among patients who attend family medicine clinics in Jeddah city, Saudi Arabia.
Methods: The cross-sectional design with 382 patients attended family medicine clinics in King Faisal
residential city clinics and King Khalid residential city clinics were surveyed using a validated structured
questionnaire. The short form of IPAQ questionnaire, which was used in this study, consists of 7 items
questioning physical activity, in addition to questions about time spent (minutes per day and days per week)
and intensity of physical activity (moderate or vigorous). The data collected in the paper forms of
questionnaire then coded and introduced into computers, and then they analyzed using the Statistical
Analysis System (SAS), Version 9. Results: In the study participants, only 12.6% reported that they were
highly active, 28.5% were moderately active, 17.85% lightly active, and 41.1% were inactive. A highly
significant difference (P <0.001) was found between age groups (72.3% of participants with age <40 years
were physically active compared to 52% with age 40 years). The percentage of physically active males
were significantly more than females (57% compared to 53.3%). Participants with normal BMI were
significantly more physically active than participants with abnormal BMI (69.9% compared to 53.7%).
: The majority of the study population did not reach the recommended values of physical
activity. In addition, no differences between the different types of the educational level were found
regarding physical activities.
Keywords: Physical activity, exercise, family medicine, Saudi.

significant effect of active physical activities on
Physical activity is a term represents a wide
the health of children (7), adolescence, adults (8) and
range of body movements that generated by the
even elderlies (9). The recommendations for the
skeletal muscles and utilize energy above the
minimum time of active physical activity differed
baseline level. It includes routine daily activities,
according to the age. In children, the standard is a
exercise, and active sports (1). Exercise is an active
minimum of 60 minutes of moderate activity per
repetitive form of physical activity that designed
day (10), while in elderlies it is 150 minutes per
to improve the body fitness (2). Physical activity,
week (2). In adults, 30 minutes of moderate
particularly exercise, enhances health and well-
physical activity has been found to maintain
significant health benefits. Physical inactivity was
strengthening muscles, increasing the capacity of
found more dangerous
the cardiovascular
and reducing
In Saudi Arabia, studies showed low physical
depression and anxiety (3, 4). Scientific evidence
activity and tendency to a sedentary lifestyle,
has supported introducing of the exercise as the
which leads to increases rates of obesity, diabetes
essential components of health promotion
mellitus, and cardiovascular diseases (11-16). The
programs directed towards the general population
cultural factors represent the main obstacle for
(1). There are several types of exercise include
adults to exercise and to sustain the physically
aerobic exercise, when large muscles trained in a
active lifestyle, although many health education
repetitive manner for determined period;
campaigns have been conducted. A study found
resistance exercise is the training of muscle
only 15% of Saudi college males practice adequate
against continuous stretching, traction or weight
physical activity to gain substantial health benefits
force; flexibility exercise is the training of joints
(17). Another study conducted in Riyadh city found
by extended movements; balance exercise is any
19% of Saudi male adults have exercised,
training aims to decrease chance of falling (5).
regularly for 30 minutes, twice or more weekly (18).
Many factors influence the availability and
Other study found very high inactivity prevalence
practicing of exercise including socio-economic
of 96% because it used a different standard in the
variables, governmental policies, and cultural
definition of physical inactivity (19).
factors (6). Regarding the exercise, no age limits
In the last two-decade, scientific evidence has
have been reported and studies have found the
accumulated about the health benefits of physical
Received: 29 / 7/2017 DOI : 10.12816/0041538
Accepted: 8/ 8 /2017

Full Paper (vol.694 paper# 25)

c:\work\Jor\vol694_26 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2340-2345

Helicobacter Pylori Infection in Patients with HCV Related Liver Cirrhosis and
Its Association with Portal Hypertensive Gastropathy Severity
Tarek Elsakaty, Marcel William and Nabil Abdelgawad
Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: nabil abdelgawad, Nabil_135@yahoo.com
Aim of the work: Helicobacter pylori infection is a major health problem because about 50% of all
humans worldwide are infected with Helicobacter pylori. Portal hypertensive gastropathy (PHG), a term
used to describe the endoscopic appearance of gastric mucosa with a characteristic mosaic-like pattern
with or without red spots is a common finding in patients with portal hypertension. The role of H. pylori
infection on PHG severity is controversial so we try to prove if there is any role of H. pylori infection and
severity of PHG. Patients and methods: eighty consecutive patients with HCV-related liver cirrhosis
were enrolled in the study. Diagnosis of H. pylori infection was done by detection of H. pylori Ag in the
stool by ELISA test. 80 consecutive patients with HCV-related liver cirrhosis were enrolled. Patients and
Methods: all patients were subjected to an upper gastrointestinal endoscopy and ELISA test of H. pylori
Ag in the stool. The diagnosis and the severity of portal hypertensive gastropathy (PHG) were evaluated
on doing endoscopy. Child-Pugh and MELD scores were calculated to assess the severity of liver cirrhosis.
Results: H. pylori infection was reported in 46 patients with overall prevalence 57.5%. PHG was found in
57 patients (71.25%); 36 (63.15%) of them had mild and 21 (36.15%) had severe PHG. H. pylori was more
prevalent among patients with PHG than those without PHG (57.5% vs. 42.5%; p<0.001). No significant
relation was found between H. pylori infection and severity of liver cirrhosis as regards Child-Pugh score
(p= 0.383) and MELD score (p= 0.666). Conclusion: our results showed a significant association between
H. pylori infection and the occurrence and also the severity of PHG in patients with HCV-related liver
cirrhosis. Yet, the severity of liver cirrhosis itself did not correlate with H. pylori or the severity of PHG.
Thus, eradication of H. pylori may be beneficial to ameliorate PHG.
Keywords: portal hypertensive gastropathy, Helicobacter pylori, liver cirrhosis.


or more of the following condition was excluded
Cirrhosis is a major health problem with
from the study: patients with primary or
high incidence and prevalence worldwide. It is
secondary hepatic malignancy, history of gastric
associated with alterations in the gastrointestinal
surgery, liver cirrhosis of any etiology other than
mucosa, with increased risk for peptic ulcer
HCV, upper GI bleeding or previous endoscopic
disease(1). Portal hypertensive gastropathy (PHG)
management for portal hypertension either
is one of the clinically important gastric mucosal
prophylactic or therapeutic, history of antibiotics
lesions because it may cause acute or chronic
intake (up to 1 month) or prior therapy for
gastrointestinal blood loss leading to anemia. It is
eradication of H. pylori or proton pump inhibitors
characterized by endoscopic appearance of the
or H2 blockers within 4 weeks of endoscopic
gastric mucosa that is classically described as a
examination and patients on medical treatment
mosaic-like pattern that resembles snake skin,
for portal hypertension (e.g. non-selective
with or without red spots (2). Infection by H.
blockers, carvidalol). All patients included in this
pylori is highly prevalent, especially in low
study were subjected to complete medical history
socioeconomic strata of developing countries (3),
taking, full clinical examination, laboratory
being responsible for lesions like gastroduodenal
investigations for evaluation of hepatic state and
erosions and ulcers. In patients with liver
assure diagnosis of HCV infection, abdominal
cirrhosis, their prevalence is controversial, as
ultrasound performed for all patients using
well as the existence of associations with PHG (4-
Toshiba real-time scanner instrument with a 3.5
MHz convex transducer for the assessment of the
liver, spleen, portal vein diameter, presence of
Eighty (80) consecutive patients with HCV-
collaterals and presence or absence of ascites and
related liver cirrhosis attending the Endoscopy
its degree. The severity of liver disease was
Unit of Ain Shams University Hospital were
enrolled in the present study. This study was
including total bilirubin, albumin, international
performed in the period between March 2015 and
normalized ratio (INR) or prothrombin time,
February 2016. An informed consent was
hepatic encephalopathy, and ascites, is the most
obtained from each patient. Any patient had one
commonly used scoring system for evaluating the
Received: 18 / 8/2017 DOI : 10.12816/0041539
Accepted:27 / 8 /2017

Full Paper (vol.694 paper# 26)

Hodgkin Lymphoma: A Retrospective Clinical and Pathological Analyses with correlation to The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2346-2354

Hodgkin Lymphoma: A Retrospective Clinical and Pathological Analyses with
Correlation to Treatment Outcome
Elleithy MM, Mustafa MY, Mohamed DA, AlShahawy NS
Clinical Oncology and Nuclear Medicine Department, Ain Shams University
Corresponding author: Nour Sulaiman ,email:nour.sulaeman@gmail.com

Aim of the work:
the aim of the study was to analyze the correlation between several clinico-pathological
prognostic factors in classical type Hodgkin lymphoma and its effect on response to treatment and survival
rates (PFS and OS). The primary endpoint is response rate and secondary endpoints are survival rates.
Patients and methods: this study was performed on 76 patients diagnosed as classical Hodgkin lymphoma
that were recruited retrospectively from January 2010 to December 2015 in Nasser Institute Oncology
Centre and Ain Shams Clinical Oncology Department. Patients' risk factors in the whole group were
analyzed using univariate and multivariate regression analysis. They included age, sex, pathological type, B
symptoms, performance status, stage, extranoadal disease, bulky disease, inflammatory markers and their
correlation on complete response rate (CR), progression free survival (PFS) and overall survival (OS).
Results: nodular sclerosing type was the most common in 44.7% of patients followed by mixed cellularity
in 21.1% of patients followed by lymphocyte predominant in14.4% of patients, while unclassified classical
constituted 19.7%. Early disease (Stage I, II) constituted 68.4% of patients and late disease (Stage III, IV)
was found in 31.6% of patients. Bulky and extranodal diseases were found in 28.9% and 21.05% of patients
respectively. All of patients received first line ABVD with 59.2% of patients received consolidative or
palliative radiotherapy. CR rate was 65.8% being 71.2% in the early versus 52% in the advanced stage
(p=0.07) with a relapse rate of 7.8%. The CR was negatively correlated with pathological type being worse
in nodular sclerosing subtype than mixed cellularity (p=0.02), poor performance status (p=0.016), bulky
disease (p=0.004), extranodal disease (p=0.0381), elevated LDH (p=0.045) and leucocytosis and
lymphopenia (p=0.005). Median PFS was 17.5 months with a range of 1 to 75 months. 5 year PFS was
negatively correlated with advanced stage than early stage (p=0.019), Bulky disease than non bulky
(p=0.003), extranodal disease than nodal (p=0.014), leucocytosis and lymphopenia (p= 0.002). Median
overall survival is 28 months with a range of 6-81 months with 5 years survival rate of 82.9% and mortality
rate of 17.1%. 5 year overall survival was negatively associated with bulky rather than non bulky (p=0.05)
and extranodal more than nodal (p=0.007).
Conclusion: this study concluded that both overall and progression free survival and response rates were
negatively affected by stage, bulky and extranodal disease mainly. Pathological subtype and elevated ESR
and LDH negatively affected CR rate. Leucocytosis and lymphopenia had a significant negative effect on
response rate and progression free survival. This allowed the use of risk adapted treatment at several stages
tailoring treatment to each patient separately.
Keywords: Hodgkin lymphoma, leucocytosis, consolidative.


Hodgkin lymphoma is an uncommon type
same time optimizing treatment efficacy (2).
of lymphoid malignancy comprising 11% of all
Certain prognostic factors have been introduced
lymphomas. In Egypt, age specific incidence rates
for this purpose to help individualizing treatment.
(ASR) are approximately 1.5/100000 per year with
They are used to classify patients to early stage
Male to female ratio (1.93/1.11) nearly
favourable, early stage unfavourable, advanced
approaching 250-300 case annually with a
stage each with different treatment mode (3).
mortality of 0.9 per 100000 in 2012 (1).
Traditionally, the International Prognostic
Hodgkin lymphoma is a highly curable
Index Score has been developed to predict the
disease, with modern treatment strategies more
outcome of treatment in advanced stage lymphoma.
than 95% of patients can be cured in early stages
A study had validated its usefulness. It is a 7 points
and 80-90% of patients in intermediate and late
score with each point known to reduce 5 year
stages. Therefore, it is important to tailor treatment
freedom from progression survival by 7% to 8% per
according to risk factors to minimize the toxicity
year. It consisted of: serum albumin < 4 g/dl,
and avoid unnecessary complications while in the
hemoglobin < 10.5 g/dl, male sex, stage IV disease,

Age 45, white cell count 15,000, lymphocyte
Received:20 / 8 /2017 DOI : 10.12816/0041540
Accepted: 29 / 8/2017

Full Paper (vol.694 paper# 27)

c:\work\Jor\vol694_28 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2355-2360

Retrograde Intrarenal Surgery and Percutaneous Nephrolithotomy for The
Treatment of Renal Stones Greater Than 2 Cm
Alaa Hussain Ahmed Alhamrani1, Abdulla Abduljaleel Alkhalifa1, Ibrahim Abdullah Abalhassan2,
Hussain Ali Alramadhan1, Moaz Hassan H Alharbi2, Abdulmalik AbdulAziz Alkhamis1,
Ahmad Khaled M Alshangiti3, Ahmed Maithem Alnasser4, Hatim Saeed T Alshahrani5,
Hassan Mohammed Aljadaani6, Abdulrahman Ahmed H Aman7, Iyad Mashhoor Hakeem8,
Hassan Hamza A Almir9, Khalid Ayed Abdullah ALahmari5, Mohammed Ayed Almuzini10
1King Faisal University, 2 Prince Sattam Bin Abdulaziz University, 3 King Saud Bin Abdulaziz University
for Health Sciences, 4 Dammam Medical Complex, 5 King Khalid University,
6 Ibnsina National Medical College,7 Batterjee Medical College, 8 Umm Al-Qura University,
9 Imam Abdulrahman Bin Faisal University,10 October 6th University

Background: S
tone size is a key factor in the determination of the success of treatment modalities. Recently,
there has been a great advancement in technology for minimally invasive management of urinary stones such
as percutaneous nephrolithotomy, ureteroscopy, shockwave lithotripsy, and retrograde internal Surgery.
Aim of the Study: to assess and compare the efficacy of retrograde intrarenal surgery (RIRS) in the treatment
of kidney stones greater than 2 cm versus percutaneous nephrolithotomy (PCNL).
Patients and methods: A retrospective analysis was carried out for a total of 118 patients, of which 46 patients
underwent RIRS while 72 patients underwent PCNL between May 2013 and May 2017.
Results: The mean duration of operation was 96.39±41.11 min in the RIRS group and 69.51±19.3 min in the
PCNL group (p<0.001). Hospital stay was significantly shorter in the RIRS group (1.32±0.6 vs. 4.19±1.9
days) in the RIRS and PCNL groups respectively (p<0.001). Stone-free rates after one session were 67.4%
and 90.3% of the RIRS and PCNL groups, respectively. Blood transfusions were required in two patients in
the PCNL group. Complication rates were generally higher in the PCNL group.
Conclusion: The present study concluded that RIRS can be a successful substitute to PCNL in the treatment of
kidney stones with a diameter of 2­4 cm particularly in patients with comorbidities.
Percutaneous nephrolithotomy, retrograde intrarenal surgery, renal stones, flexible ureteroscopy.


Renal calculi are formed when the urine
is supersaturated with salt and minerals such as
laparoscopic surgery are reserved for rare, special
calcium oxalate, struvite (ammonium magnesium
cases [4].
phosphate), uric acid and cysteine [10].60-80% of
Once the decision to treat the stone has been made
stones contain calcium[2].They vary considerably in
there must be a decision on which technique to use.
size from small 'gravel-like' stones to large staghorn
This is based on the success and the morbidity of
calculi. The calculi may stay in the position in which
any individual procedure, which in turn is based on
they are formed, or migrate down the urinary tract,
the location and size of the stone, as well as the
producing symptoms along the way. Studies suggest
patient's comorbidities. The preferred approach for
that the initial factor involved in the formation of a
stones >1 cm is SWL, whereas for stones <2 cm, it is
stone may be the presence of nano -bacteria that
PCNL, but the management of stones of 1-2 cm is
form a calcium phosphate shell[3].
still controversial[5].
The primary goal while treating renal
Percutaneous nephrolithotomy (PCNL) is
stones is to achieve maximum clearance of stone,
the mainstay of management for large (> 2 cm) or
while causing minimal morbidity to the patient.
complicated renal stones [6]. Although this technique
The treatment of urinary calculi has advanced
affords high success rates and accelerated stone
considerably with the development of instruments
clearance, regardless of stone composition and size
and techniques. Most patients with renal and
[7], it is an aggressive treatment with severe
ureteric calculi presenting to a urologist require
complications especially for patients with solitary
treatment. The currently available options include
kidney. Such patients are likely to have increased
ESWL, percutaneous nephrolithotomy (PCNL), and
thickness of the renal parenchyma as a consequence
Received:6 / 8 /2017 DOI : 10.12816/0041541
Accepted:15 /8 /2017

Full Paper (vol.694 paper# 28)

c:\work\Jor\vol694_29 The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (4), Page 2361-2365

Incidence of Fat Embolism after Long Fracture Fixation
Operations: Review Article
Sami Amer M Alqarni1, Lama Ibrahim Aloraini2, Mohammed Salman AlHabib2,
Awath Fahim Alsulami3, Abdulaziz Muhammed AlEssa4, Zohor Abdullah Alamri1,
Rakan Fraih Jarallah Almuazzi5, Hala Mohammed Bin Zaid,6 Yousif Ali Brshoum Almutairi7,
Mohammed Ahmed H Ageeli8, Saleem Othman Rafi Alamri9, Omar Abdulmohsen Alshadokhi10,
Saeed Hamed Alzahrani11, Sulaiman Dawoud Dashti12, Ahmed Atiah Awwadh Alsalmi13
Department of Orthopedic
1 King Khalid University, Abha, Saudi Arabia 2,Imam Abdulrahman bin Faisal University, Dammam, Saudi
Arabia, 3Umm Al-Qura University, Mecca, Saudi Arabia, 4King Faisal University, Hofuf, Saudi Arabia, 5Hail
University, Hail, Saudi Arabia, 6Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia, 7October
6 University, Cairo, Egypt,8Jazan University, Jazan, Saudi Arabia, 9Ohud Hospital, Medina, Saudi Arabia,
10Imam Muhammad ibn Saud Islamic University, Riyadh, Saudi Arabia, 11Najran University, Najran, Saudi
Arabia, 12University of Malta, Malta, 13Taif University, Taif, Saudi Arabia
Corresponding author: Sami Amer M Alqarni, King Khalid University, Abha, Saudi Arabia

In spite of being rare, fat embolism syndrome is considered a fatal complication after bone fracture and
orthopedic procedures. It was suggested that early immobilization might reduce the incidence of fat embolism
syndrome. However, no enough data are available to justify this finding. Objectives: The aim of this review is to
determine the incidence of fat embolism among patients who had long fracture fixation. Methods: A systematic
review of Medline and Cochrane library was conducted on their database. This search yielded 34 papers, 13 of
which were related. Results: The incidence of fat embolism syndrome after long fracture fixation ranged from
2.7% and 11%. More specifically, the incidence among long bone fracture patients who were operated early
(within the first 24 hours after injury) ranged from zero% in some studies (16,19) to 1.8% in others. As regards
late operation, after 24 hour of bone fracture, the incidence of fat embolism syndrome (FES) ranged from 3.5%
to 10.4. Conclusions: The incidence of fat embolism in post long fracture fixation is very low. Several research
works indicate that early fixation significantly reduce the incidence of FES compared to late fixation.
Keywords: Fat Embolism, Long Bone Fracture, Long bone Fixation, Immobilization.

In spite of being rare to happen, fat embolism
coagulation theory. Mechanical theory supposes that
syndrome (EFS) is a fatal complication that may
fat globules are moved from intramedullary bony
occur after pelvic or long bone fractures as well as
cavity after fracture during manipulation due to
after orthopedic operations(1). It was estimated that the
mechanical pressure gradient, whereas the free fatty
incidence of fat embolism was 0.78% among patients
acid/lipase theory proposes that the elevation of those
with fracture femur, 0.15% among patients with tibial
chemicals in the blood initiates an inflammatory
fractures and 2.4% among patients multiple
cascade resulting in vasculitis and systemic
fractures(2). The overall incidence of fat embolism
manifestations. Coagulation theory, on the other hand,
among long-bone fractures was 0.9%(3,4). Fat
accuse the sluggish circulation encountered in trauma
embolism syndrome results from the presence of fat in
patients of platelet activation that adhere to bone
the arterial circulation. The exact mechanism by
marrow fat. This will eventually initiate a clotting
which the fat emboli reach the arterial circulation
process and thromboembolism(8).
remains elusive. It is suggested that a paradoxical
The classical triad of fat embolism syndrome
embolism process is involved. Fat is thought to
consists of respiratory manifestations, cerebral
traverse from the venous system to an arterial system
symptoms and cutaneous petechiae. Because the
through a patent foramen ovale or left to right
diagnosis is sometimes challenging, Wilson proposed
shunts(5­7). Three theories were proposed to explain
diagnostic criteria for fat embolism. The criteria
the pathophysiology of fat embolism; the mechanical
include 3 major, 5 minors, and 2 laboratory criteria
theory, the free fatty acids lipase theory, and the
(shown in table 1). The diagnosis of fat embolism
Received: 3 / 8 /2017 DOI : 10.12816/0041542
Accepted: 12 /8 /2017

Full Paper (vol.694 paper# 29)


Types and Management of Chronic Intestinal Ischemia
Hesham Abd El Raouf El Akkad , Ahmed Adel Ain Shoka , Khaled Ibrahim Mohammed El Beltagy
* Department of General Surgery, Faculty of Medicine, Ain Shams University
Corresponding author: Khaled Ibrahim Mohammed El Beltagy, email: ra5987747@gmail.com

chronic intestinal ischemia is unusual but important cause of abdominal pain. Although this
condition accounts for only 5% of all intestinal ischemic events, it can have significant clinical consequences
Aim of the Work: the objective of this systematic review was to assess the value of different types of management
of chronic intestinal ischemia (Open surgery versus endovascular interventions). PubMed and EBSCOHost
electronic databases were methodically searched for English-language articles published between 1996 and 2015.
Conclusion: chronic mesenteric ischemia is a condition characterized by postprandial abdominal pain, which is
ascribed to intestinal hypoperfusion. Patients were frequently malnourished and develop significant weight loss
due to sitophobia. Traditionally, open surgery has been the treatment of choice; however, endovascular surgery
was gaining wider acceptance. Based on the data, open surgeries surpass endovascular procedures in terms of
symptom amelioration and long-term vessel patency, along with less significant symptomatic recurrence. Patients
undergoing open procedures do, however, have a higher rate of complications. Nonetheless, there was no
statistically significant difference in mortality rates between the two approaches.
Keywords: celiac artery, mesenteric vasculitis, chronic mesenteric ischemia.


Chronic intestinal ischemia is uncommon
Diagnosis can often be made by non- invasive
condition that accounts for about 2% of
methods such as computerized axial tomographic
revascularization procedures in patients with
angiography, magnetic resonance angiography, and
atheroma. Most patients are older than 60 years;
duplex ultrasonography as well as by invasive
women are affected three times more often than men.
(4). Angiography was
Ischemia occurs when the blood supply to the
traditionally the gold standard for the diagnosis of
intestines is inadequate as a result of lesions affecting
intestinal ischemia. The development of multidetector
one or more of the three mesenteric arteries: the
row computed tomography (CT), however, has
celiac artery, the superior mesenteric artery and
permitted detailed analysis of vascular flow that was
inferior mesenteric artery (1).The most common cause
never before possible (5).
of chronic intestinal ischemia is atherosclerotic
The use of endovascular therapy for intestinal
occlusion or severe stenosis of the mesenteric
ischemia is predominantly limited to treatment of
arteries. A stenosis of >50% is present in 18% of
chronic form the disease (5).Various surgical
patients older than 65 years, but very few were
symptomatic (2).The clinical presentation was seen in
patient mostly between 60 and 80 years old, with or
endarterectomy, antegrade or retrograde bypass
without concurrent disease in other vascular beds.
grafting, angioplasty with or without stenting (6).
This manifestation of systemic arteriosclerosis carries

the risk factors of: smoking, hypertension,
dyslipidemia and coronary artery disease. Some of
Search strategy
these patients have associated comorbidities
The PubMed and EBSCOHost electronic databases
including chronic obstructive pulmonary disease,
were methodically searched for English-language
diabetes, aortic artery aneurysm and peripheral
articles published between 1996 and 2015.
vascular disease. The severity of clinical presentation

depends on:
1. The site, grade, and cause of vascular obstruction.
Inclusion Criteria
2. The degree of collateralization.
1. Only series with >10 patients undergoing
3. The stage of the disease (3).
endovascular therapy or open revascularization were

used for data analysis.
Received: 9 / 8 /2017 DOI : 10.12816/0041543
Accepted: 18 /8 /2017

Full Paper (vol.694 paper# 30)