c:\work\Jor\vol704_1 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 520-525

The Prevalence of Dysmenorrhea among Women
Sarah Abdulaziz Fallatah 1 , Afnan Mohmmed Mulla Ebrahim Khan 2 , Hannin Mohammed Al Reqei 3 ,
Zahra Ahmed Alalshaikh 4 , Jabir Mohammed A Alnabhani 5 , Mashail Ali Alomari 6 , Ruzanah
Abdulaziz Almarzugi 5 , Abdulaziz Faisal M Khyat 7 , Umklthom Mohmmad A Masmali 8 , Noha
Mohammed I Hawsawi 9 , Manal Mohamed A Khayat 10 , Basma Hamed M Alhawiti 10
1- King Abdulaziz Hospital, 2- Since and Technology University, Sana'a, 3- Maternity and Children Hospital
in Buraydah, 4- Soochow University, 5- King Abduaziz University, 6- King Khalid University,
7- University of Jeddah, 8- Jazan University, 9- Maternitya Children Hospital in Makkah,
10- Cairo University, Egypt
Menstrual disorders and abnormal uterine bleeding are common worries of young women. Complaints
comprise menses that are: too painful (dysmenorrhea), prolonged and heavy (menorrhagia, or excessive
uterine bleeding), or absent or arise irregularly (amenorrhea or oligoamenorrhea). In providing optimal
reproductive care, the medical provider should be capable of distinguishing between normal developmental
patterns or symptoms necessitating education and reassurance from pathologic conditions needing early
evaluation and management. This article discusses the normal menstrual patterns seen in adolescent females
and provides treatment and management approach to primary and secondary dysmenorrhea.
Keywords: Menorrhagia, Excessive uterine bleeding, Dysmenorrhea, Menstrual problems.


Dysmenorrhea is defined as difficult menstrual
The following risk factors are associated with
flow or painful menstruation. It is one of the most
more severe episodes of dysmenorrhea [6] :
common gynecologic complaints in young women
who present to clinicians[1]. Optimal treatment of
Earlier age at menarche
these symptoms rely on an understanding of the
Positive family history
underlying causes. Dysmenorrhea can be divided
Long menstrual periods
into 2 broad categories: primary (spasmodic) and
Heavy menstrual flow
secondary (congestive)[2]. Primary dysmenorrhea is
Some (not all) studies have found obesity and
defined as menstrual pain that is not allied with
alcohol intake to be linked with dysmenorrhea[7, 8].
macroscopic pelvic pathology (ie, occurs in the
Physical activity and the length of the menstrual
absence of pelvic disease). It normally occurs in
cycle do not appear to be related with increased
the first few years after menarche [3] and influences
menstrual pain. Even though dysmenorrhea is not
as many as 50% of post pubertal females [4].
life-threatening, it can be debilitating and
Secondary dysmenorrhea is defined as menstrual
psychologically taxing for many women. Some
pain resulting from anatomic or macroscopic
choose to self-medicate at home and never pursue
pelvic pathology[3, 5], as is seen in women with
endometriosis or chronic pelvic inflammatory
Dysmenorrhea is accountable for substantial
disease. It is most regularly perceived in women
absenteeism from work, and it is the most common
aged 30-45 years.
cause for school absence amid youths [9].
Table 1. Differential diagnosis of primary and
Risk factors
secondary dysmenorrhea
Risk factors for primary and secondary
dysmenorrhea include the following:

Within 3 yr after More than 5 yr
Table 2. Risk factors for primary and secondary
after menarche
15­25 yr old
Over 30 yr old
primary dysmenorrhea
Gradually improve Become worse
No change
Early age at menarche
(< 12 years)
or other time if
Heavy or prolonged
Tubo-ovarian abscess
Findings of
menstrual flow
Ovarian torsion
fibroma, etc.
Positive family history
No change
Pelvic inflammatory
4­48 h
1­5 d
Received: 28/10/2017 DOI: 10.12816/0043793
Accepted: 8/11/2017

Full Paper (vol.704 paper# 1)

c:\work\Jor\vol704_2 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 526-531

The Relation Between Diabetes Type II and Anemia
Abdulmajeed Hassan Aljohani 1 , Methaq Abdullah Alrubyyi 2 , Abdulrahman Bader Alharbi 3 ,
Abdullatif Mohammed Alomair 4 , Abdulrahim Abdullatif Alomair 5 , Nourah Ali Aldossari 5 ,
Saleh Khader Alghamdi 6 , Sulaiman Abdullah Alawaji 3 , Samar Ali Sager Alamri 7 , Leena
Abdulaziz Y Alsaiari 8 , Jehad Jamil T Qashqari 8 , Omar Talal M Tallab 7
King Saud bin Abdulaziz for health science in Riyadh , MCH ( Dammam )
Pedia resident service , Qassim University , King Fahad hospital , King Faisal University ,
King Saud Medical City , King Khalid University , King Abdulaziz University

Background: Anemia is defined as a decrease in the hemoglobin concentration of blood, which
accordingly decreases the oxygen-carrying capacity of red blood cells such that they are unable to meet
the body's physiological requirements. Numerous reports have specified that anemia customarily occurs
in patients with diabetes with renal insufficiency whereas limited studies have described the occurrence
of anemia in people with diabetes prior to indication of renal impairment. Other studies have similarly
recognized anemia as a risk factor for the need for renal replacement treatment in diabetes.
Understanding the pathogenesis of anemia allied with diabetes can lead to the development of
interventions to optimize results in these patients.
The purpose of this study was consequently to determine the pervasiveness of anemia among
patients with type 2 diabetes.
Materials and Methods:
A total of 50 (25 with type 2 diabetes and 25 controls) participants were
enlisted for the current study. Participants' blood samples were analyzed for fasting blood glucose, full
blood count and renal function tests among others. The pervasiveness of anemia was then determined
A high incidence of anemia was perceived in the cases. Of the patients with diabetes, 85 % had
a hemoglobin concentration that was significantly less (males 10.88±1.78 and females 10.32±1.52)
compared to that of controls (males 14.16±1.82 and females 12.49±1.11). A significantly increased
fasting blood glucose, urea, sodium, potassium, and calcium ions were observed in the cases (8.02±1.28,
5.21±2.01, 141.08±7.01, 4.84±0.49 and 1.51±0.28 respectively) as compared to the controls (4.57±0.52,
3.61±2.09, 134.86±6.75, 4.38±0.61 and 1.31±0.31 respectively). Finally, a significant association
between hemoglobin concentration and fasting blood glucose was also observed in the cases.
The findings suggest that a high incidence of anemia is likely to occur in patients with
poorly controlled diabetes and in patients with diabetes and renal insufficiency.
Anemia, Hemoglobin concentration, Diabetes, Renal insufficiency.


life, particularly in pregnant women and
capacity of blood as a result of a reduced
children. Globally, 1.62 billion people are
erythrocyte mass or reduction in the
anemic, consistent to 24.8 % of the global
hemoglobin (Hb) concentration of the blood
population. The highest prevalence of 47.4 % is
might specify anemia [1].
in preschool-age children while the lowest
This insufficient blood supply to meet the
prevalence of 12.7 % is in men [2].
body's physiological requirements. It is caused
Diabetes mellitus (DM) is a non-
by either an excessive destruction or reduced
infectious sickness that correspondingly has a
production of red blood cells. Anemia is allied
high occurrence worldwide [3]. It is a
with increased perinatal mortality, child
carbohydrate metabolism disorder which results
in hyperglycemia due to either absolute insulin
susceptibility to lead to poisoning, immune
deficiency or reduced tissue response to insulin
incompetence, impaired mental development,
or both. Diabetes, particularly when poorly
and decreased performance at work. Anemia
controlled, leads to complications such as
has a high pervasiveness and is considered a
retinopathy, nephropathy, and neuropathy in
public health problem affecting developing and
addition to numerous disordered metabolic
developed countries. It occurs at all stages of
processes including oxidative stress which

causes oxidative damage to tissues and cells [4].

Anemia is one of the commonest blood
Received: 19/11/2017 DOI: 10.12816/0043795
Accepted: 29/11/2017

Full Paper (vol.704 paper# 2)

c:\work\Jor\vol704_3 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 532-538

The Correlation between Depression and Folate Deficiency
Ahmad Sami A Himayda 1, Ahmed Fouzi Abdulkader 2, Nora Ayman Brazanji 3 ,
Sultan Ali M Alshehri 4 , Suha Salah Ibrahim Alqayn 5 , Hasan Sharif H Bukhari 1 , Fadia A
AbuZaid (1,2 ) 6 , Muhannad Azim Ghareeb ALanazi 7 , Ahmed Mohammed Abdulsalam
Alhayani 8 , Shima Ali Albather 9 , Ameen Nafi Roeie Aljabri 10 , Ahmad Abdulkarim Alanizi 11
1- Umm Al Qura University , 2- Khalid Primary Health Care Center ,MOH , 3- Muhammadiah
Primary Health Care Center , 4- Almujardah General Hospital , 5- Princess Nora Bint Abdul
Rahman University , 6- Anatomy Department, Faculty of Medicine, King Abdulaziz University,
Jeddah, Saudi Arabia1, Histology Unit, King Fahad Medical Research Center, King Abdulaziz
University Jeddah, Saudi Arabia 2 ) , 7- Aljouf University ,
8- Khulais Primary Health Care Center, Moh , 9- Hofuf Primary Health Care ,MOH ,
10- Qassim University, 11- King Saud Bin Abdulaziz University for Health Science

Folate is a naturally occurring B vitamin, is needed in the brain for the synthesis of
norepinephrine, serotonin, and dopamine. Thus, previous researches suggested that folate levels play an
important role in the etiology and course of depression. However, the literature has been inconsistent
regarding differences in folate level between individuals with and without depression. The present meta-
analysis synthesized the results of previous studies to examine whether individuals with depression had
lower levels of folate than individuals without depression.
Aim of the Study: to assess the relationship between Depression and Folate deficiency.
Methods: A review of the scientific literature (PubMed Search 1994 to 2017)
Pubmed, Embase and CENTRAL were searched to identify randomized controlled trials that investigated
The Correlation between Depression and Folate Deficiency as the primary outcome. Identification of
papers and data extraction was performed by two independent researchers.
We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the
Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to October
Results: 8 studies were included enrolling 173000 participants; 1813 patients with depression and 15487
control subjects. Pooling of all estimates showed a significant correlation between folate status and
depression (OR pooled unadjusted=1.41; 95% CI 1.19 to 1.82), (OR pooled adjusted=1.39; 95% CI 1.04
to 1.76).
Conclusion: Low folate and B12 serum levels seem to be associated with depression Folate has been linked
to depression and there is a strong body of evidence suggesting the introduction of folate supplement in the
prevention and treatment of depression at the population and individual levels.
Keywords:folate, vitamin B12, depression, meta-analysis, gender, geriatric.

necessary for the production of monoamine
Depression has a major impact on public
transmitters. Several case-control studies since
health . even though possible role of nutritional
the 1960s have shown high prevalences of folate
factors are involved in the pathogensis of neuro -
and vitamin B12 deficiency in depression (3).More
psychiatric disorders have been in question, some
recently, the total plasma homocysteine level was
clinical studies have shown a significant
shown to be a sensitive marker of folate and
vitamin B12 deficiency, and higher concentrations
of homocysteine were observed in depressed
Folate plays a crucial role in the one-
patients (4).
carbon metabolism for physiological nucleic acid
Both low folate and low vitamin B12 status
synthesis and cell division, regulation of gene
have been found in studies of depressive patients,
expression, amino acid metabolism and
and an association between depression and low
neurotransmitter synthesis(2). Folate and vitamin
levels of the two vitamins is found in studies of the
B12 are involved in the one-carbon metabolism
general population. Low plasma or serum folate

has also been found in patients with recurrent
Received: 19/11/2017 DOI: 10.12816/0043798
Accepted: 29/11/2017

Full Paper (vol.704 paper# 3)

c:\work\Jor\vol704_4 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 539-543

Wear Effect of Different Abrasive Materials on
Tooth Enamel: A Comparative Study
Ahmed Alzahrani*, Ihab Moussa ,Omar Saleh , Sulaiman Alarifi
College of Dentistry, King Saud University, Riyadh, Saudi Arabia
*Corresponding author: Ahmed Alzahrani, email: ksu.alzahrani@gmail.com
The purpose of the study was to measure and compare mean enamel loss caused by microabrasion
treatment of different abrasive materials under a fixed variable.
Materials and methods:
In this laboratory study, three commonly used abrasive materials were compared: Dental
Pumice, Zircate® Prophy Paste, Opalustre® and a controlled group (distilled water). Hundred extracted human
premolars were randomly allocated into four groups; each group was subjected to fixed pressure, time and
rotational speed mimicking dental office setting. Results: Data was collected and statistically analyzed. The
results of the study (p < 0.01) was statistically significant and showed that Opalustre® caused the highest mean
difference in enamel loss. Followed by dental Pumice and Prophy paste in order with minimal difference between
them. And the controlled group (distilled water) had the least mean enamel loss. Conclusion: microabrasion offers
a great approach in treating enamel defect/staining in a minimally invasive procedure in order to achieve
acceptable aesthetic results while preserving the tooth's microstructure as much as possible. As shown in the
result; Combined chemical acid with mechanical abrasive particles produce most effective results.
Keyword: Enamel microabrasion, Enamel surface, Wear, hydrochloric acid (HCl), pumice, prophy.


Patients seek and demand aesthetics in the
safe and effective procedure". Another study done
dental office. One of the most common complaints
by Balan et al. (4) demonstrated that even mild
in aesthetic demanding patient is teeth staining.
fluorosis can be treated conservatively with
Stains are divided into three categories (intrinsic,
combinations of microabrasion with bleaching lead
extrinsic, combination of both). management of such
to acceptable results. So even with the advancements
cases vary depending on several factors such as
of modern day dentistry, the effectiveness and
location, etiology of the stain and severity of the
efficiency of multiple materials and techniques to
stain (1). Regarding extrinsic staining, significant
produce a satisfying outcome is being studied and
improvements in the past years have been achieved
evaluated in laboratory investigation and in clinical
in less invasive, safe and conservative method such
as dental bleaching and enamel microabrasion using
Wear Effect of Different Abrasive Materials
different abrasive materials which is the focus of this
on Tooth Enamel is a true experimental comparative
research. First introduction of "mechanical
study aimed to identify the wear effect of different
application with a low-rotation micro motor was
materials on teeth enamel loss in weight in order to
indicated in the 1970s, using a mixture of 18%
understand furthermore different wear effect of
hydrochloric acid, hydrogen peroxide and ether (2).
multiple materials against enamel microstructure.
Enamel Microabrasion treatment has been
The results can improve knowledge in aesthetic
known as a conservative, safe and relatively low cost
dentistry field.
procedure to enhance enamel surface appearance by
minimal removal of staining/enamel defects in the
enamel outer layer. A previous study done by

Sundfeld et al. (3) briefly described "performing
enamel microabrasion with hydrochloric acid mixed
Three different abrasive materials were used
with pumice and other techniques employing a
Dental Pumice (Interdent, Inc., CA, USA), Zircate®
commercially available compound of hydrochloric
Prophy paste (Dentsply Sirona. Inc., NY, USA) and
acid and fine- grit silicon carbide particles in a
Opalustre® (Ultradent Prod. Inc., Utah, USA) in this
water-soluble paste" result as "highly satisfactory,
study and a control group used distilled water.
(Table 1) shows the manufactural, acid used,

particle size of the abrasive particles.
Received: 25/10/2017 DOI: 10.12816/0043802
Accepted: 5/11/2017

Full Paper (vol.704 paper# 4)

c:\work\Jor\vol704_5 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 544-548

Public Awareness towards Renal Stone Causes, Symptoms and
Management amongst Saudis
Ahmed Mousa Almuhanna 1, Mohammad Alomar 1, Hussain Khaled Alsalman2,
Abdulaziz Ahmed Al-Mutayliq2, Khalid Abdulrahman Alnasser2
KKUH, Riyadh; King Saud University, Riyadh
Corresponding Author: Ahmed Mousa Almuhanna, Phone: 0562111244, E-Mail: a.almuhanna4@hotmail.com
Primary investigator: Mohammad Alomar
: renal stone is an important health problem in the world and is the most common disease in urinary
tract system. It is particularly a common problem in areas of hot climate like Saudi Arabia. Knowledge and
lifestyle attitude of individuals towards renal stone plays a role in delivering optimum management.
Aim: to determine the public awareness of renal stones causes, symptoms and management amongst Saudis.
Patients and Methods: the data of this quantitative cross-sectional study was collected from participants from
two regions in Saudi Arabia. Participants were given a self-administered questionnaire written in Arabic from
October 2017 till November 2017. Individuals under the age of 18, tourists, medical staff and people unable to
read Arabic were excluded. Data were analyzed using SPSS.
Results: four hundred and seven participants with a mean age of 35 filled the questionnaire. About half of them
had experienced renal stones either personally or in a direct family member. 91.4% of them are aware that
increased water intake decreases the formation of renal stones. As for symptoms of urinary stones, 65.36% of
them thought that pain and other urinary symptoms would occur when having urinary stones. Radiology imaging
was the most chosen mode of diagnosing urinary tract stones especially amongst participants above the age of 35
(p-value= 0.002) with surgical intervention as the best treatment according to the participants. 57.2% of the
participants believe that drinking parsley water prevents the formation of renal stones. Individuals who
experienced renal stones before were more knowledgeable about the commonest type of renal stones (p-value=
0.005) and the quantity of recommended daily fluid intake (p-value= 0.008).
Conclusion and Recommendation: this data indicates that the participants are to some degree aware of some
aspects of renal stone prevention, symptoms and modes of diagnosis and treatment. Individuals who experienced
renal stones were more knowledgeable in some aspects. Further emphasis on public awareness of renal stones is
Keywords: Kidney diseases, renal stones, public awareness, urinary tract system.

increase community's awareness and screening to
Renal stone is an important health problem
detect the early renal stone would be a contributing
in the world and is the most common disease in
factor to decrease the number of cases. Furthermore,
urinary tract system. In addition to that, urinary tract
increased awareness of symptoms, causes, and
stones are common worldwide healthcare problem
management methods will help in decreasing the
with high prevalence (20%) in Saudi Arabia. Also,
number of morbidities and stop disease progression.
renal stones are more common in men than women
The aim of this study is to determine the public
with ratio (3.2:1) and most of the cases are
awareness of renal stone causes, symptoms,
idiopathic with ratio (4:1) stones in men reaching the
screening and management in Al-Riyadh and Al-
age of 60 is over 20% (1).
Hassa cities in Saudi Arabia.
The treatment of urinary tract stones has

dramatically changed over the last 20 years. Today,
the vast majority of stone pass spontaneously with
Study Design and Setting
conservative management while the rest of stone can
This is a quantitative cross-sectional study
be treated effectively with minimal surgical
which focused on determining the public knowledge
intervention such as shock wave lithotripsy (SWL)
and awareness towards renal stone in Al-Riyadh and
and endourological techniques. However, a major
Al-Hassa cities in Saudi Arabia. Data have been
problem is the high recurrence rate even after
collected from Saudis with the age group of 18 years
surgery or SWL (2). Implementing new methods to
and above both male and female who lives in Riyadh
Received: 20/10/2017 DOI: 10.12816/0043804
Accepted: 30/10/2017

Full Paper (vol.704 paper# 5)

c:\work\Jor\vol704_6 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 549-553

Bankart Repair in Traumatic Anterior Shoulder Instability
Mohammed Saad Alkhathami 1 , Abdulelah Ahmed AL-Ahdal 2 , Mohannad Ali S Alomari 3 ,
Ziad saleh alhomidan 4 , Mahdi Dhafer M Al- zulayq 5 , Mustafa Taher Ali AL Essa 6 ,
Abdullah Rashed Alaboudi , Abdulrahman Anis Kh. Khan 8 , Ahasen Ali Q Aldosary 9 ,
Faisal Saud Yousuf 10, Mohammed Thamer S Alghalibi 11 , Alyamani, Rakan Ali A 12
1- KAAH , Jeddah , 2- BMC , 3- Najran University Hospital , 4- Suliman Alrajhi Colleges ,
5- University of Jeddah , 6- Prince Saud bin Jalawy Hospital( Al Ahsa ) , 7- Qassim University ,
8- King Abdulaziz hospital Jeddah , Orthopaedic Resident , 9- King Khalid University ,
10- University of Jeddah , 11- Taif university , 12- PHC Asfaan

Latest studies have shown effective clinical outcomes after arthroscopic Bankart repair (ABR)
but have shown some risk factors for re-dislocation after surgery. We assessed whether patients are at a risk for
re-dislocation during the first year after ABR, examined the recurrence rate after ABR, and sought to recognize
new risk factors.
Materials and Methods: We performed ABR utilizing bioabsorbable suture anchors in 51 consecutive
shoulders (50 patients) with traumatic anterior shoulder instability. Average patient age was 26.5 (range, 15­40)
years. We assessed re-dislocation after ABR using patient telephone interviews (follow-up rate, 100%) and
correlated re-dislocation with several risk factors.
Results: Re-dislocation after ABR occurred in five shoulders (9.8%), of which 4 sustained re-injuries within
the first year with the arm elevated at 90° and externally rotated at 90°. Of the remaining 46 shoulders without
re-dislocation, 4 had re-injury under the same conditions within the first year. Consequently, re-injury within
the first year was a risk for re-dislocation after ABR (P < 0.001, chi-squared test). Using multivariate analysis,
large Hill-Sachs lesions (odds ratio, 6.75; 95% CI, 1.35-64.5) and <4 suture anchors (odds ratio, 9.45; 95% CI,
1.88-72.5) were significant risk factors for re-dislocation after ABR.
Conclusion: The recurrence rate after ABR was not associated with the time elapsed and that repair strategies
should augment the large humeral bone defect and use >3 anchors during ABR.
Keywords: Risk factor, Arthroscopic Bankart repair, Re-dislocation.


Hospital. The average patients age were 26.5 (range,
Arthroscopic Bankart repair (ABR) deliver stolerable
15­40) years. Inclusion criteria: recurrent anterior
outcomes for recurrent anterior shoulder instability.
shoulder instability after an apparent traumatic
Nevertheless, latest studies have shown recurrent
episode, at least three dislocation/subluxations
rates of 4%­19% [1-3]. Numerous factors, comprising
before the surgery, a Bankart lesion or anterior labral
a young age at the time of surgery, male gender,
periosteal sleeve avulsion lesion confirmed during
participation in collision sports,shoulder instability
arthroscopy, and an arthroscopic capsulolabral repair
on both sides, joint hyperlaxity, early return to
contact sports, the size of the humeral defect (Hill-
anchors.Exclusion criteria included: multidirectional
Sachs lesion), and bone defects have been linked
instability, revision Bankart repairs, and full-
with the recurrent instability [4­6]. Moreover, a recent
thickness rotator cuff tears.Preoperative radiographic
study showed that 55% of the re-dislocations after
imaging, consisting of anteroposterior, scapular Y,
ABR occurred within the first year, and afterward,
and axillary views, was acquired to assess the
the recurrence rate decreased for up to 5 years [7].
glenoid shape of the glenoid and the presence of any
Consequently, these outcomes prompted us to assess
bony (i.e., Bankart or Hill-Sachs) lesions. Contrast
whether the patients with primary ABR are at risk
magnetic resonance imaging of the affected shoulder
for re-dislocation during the first year after the
was assessed for the occurrence of a Bankart lesion
surgery. Moreover, the current work studied the
and any other shoulder injury before surgery.
recurrence rate after ABR and sought to recognize
We successfully contacted all the 50 patients who
new risk factors.
underwent ABR in our institution via telephone. A

re-visit for postoperative evaluation was requested
although most of the patients declined the visit.
Fifty-one consecutive shoulders (50 patients)
Consequently, the patients' present status, including
using ABR for traumatic anterior shoulder instability
postoperative injury and re-dislocation with either
from January2015 to January2017 at King Abdulaziz
subluxation or complete dislocation, was inquired
via phone.
Received: 20/11/2017 DOI: 10.12816/0043805
Accepted: 30/11/2017

Full Paper (vol.704 paper# 6)

c:\work\Jor\vol704_7 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 554-558

Diabetic Nephropathy among Adult Patients with Type 2
Diabetes Mellitus in Saudi Arabia
Ahmed Dakhel Alrehaili 1, Khaled Mohammed Almuraydhi 2, Mustafa Taher Ali AL Essa 3,
Abdullah Mohammed A Aljabir 4, Yaser Yousef Khogheer 5, Mohammed Walid Adham 6,
Musaab Mohammad A. Alshanqeeti 7, Ibrahim Mohammed I Eid 8 , Sultan Ahmed M. Alburayk 9 ,
Mohammed Alean Albalawi 10 , Moath Mohammad Alothman 11 , Ahmad Abdullah Algarni 12
1-King Faisal University, 2- King Fahad Hospital Alhofof , 3-Prince Saud Bin Jalawy Hospital ( Al Ahsa ) ,
4- Khamis Mushit Ben Sina PHC , 5- East Jeddah Hospital , 6- King Fahad Hospital Jeddah , 7- Umm
Alquraa University , 8- King Saud Bin Abdulaziz University for Health Sciences , 9- King Salman Hospital,
Saudi Arabia, Riyadh , 10- Madinah PHC ,11- PHC at Dammam City, 12- King Abdulaziz Hospital

: the occurrences of diabetes mellitus and diabetic nephropathy have increased quickly in the
past few decades and have become an economic burden to the healthcare system in KSA. Diabetic
nephropathy is a major complication of diabetes mellitus and is a primary cause of end-stage renal disease
(ESRD). The occurrence of non-diabetic renal disease (NDRD) in diabetic patients has been increasingly
recognized in recent years. It is generally believed that it is difficult to reverse diabetic nephropathy, whereas
some cases of non-diabetic renal disease are readily treatable and remittable. However, diabetic nephropathy
is known to co-exist with non-diabetic renal disease in a poorly defined population of patients with type 2
diabetes mellitus. This study estimated the pervasiveness of co-existing diabetic nephropathy and non-
diabetic renal disease in Saudi patients.
Methods:data were retrospectively analyzed from 122 patients with type 2 diabetes mellitus who had
experienced a renal biopsy between February 2014 and June 2017 at King Abdulaziz Hospital, region(s),
KSA. Male patients numbered 75 (61.5%) of the study population. The biopsies were performed as urinary
abnormalities or renal functions were atypical of a diagnosis of diabetic nephropathy. Biopsy samples were
examined using light, immunofluorescence (IF) and electron microscopy (EM). Clinical parameters were
recorded for each patient at the time of biopsy.
Results: nineteen of 122 diabetic patients (8%) had co-existing diabetic nephropathy and non-diabetic renal
disease. These patients showed clinical features and pathologic characteristics of diabetic nephropathy,
containing a high prevalence of diabetic retinopathy (88.8%), a long duration of diabetes, increased thickness
of the glomerular basement membrane (GBM) and mesangial expansion. Nonetheless, they similarly
presented with clinical findings which were inconsistent with diabetic nephropathy, such as hematuria,
rapidly progressive renal failure and marked proteinuria. Immunoglobulin A (IgA) nephropathy was apparent
in 5 out of the 10 patients (50%), tubulointerstitial lesions were found in two patients (20%), membrano-
proliferative glomerulonephritis (MPGN) in two patients (20%) and membranous nephropathy (MN) in one
patients (10%).
Conclusion: retrospective analysis of biopsy data suggests that approximately 8% of Saudi patients with type
2 diabetes mellitus may have co-existing diabetic nephropathy and non-diabetic renal disease. The most
common histological diagnosis in our small series was IgA nephropathy.
Keywords: Diabetic nephropathy, Renal histopathology, Non-diabetic renal disease, Renal biopsy, Diabetes

outcomes. These are regularly patients with a 7 to
The occurrence of diabetes mellitus (DM)
10-year history of type I DM, who have
and diabetic nephropathy (DN) have increased
demonstrable diabetic retinopathy and a history of
quickly in the past few decades and have become an
microalbuminuria. These patients present no
economic burden to the healthcare system in KSA.
indication of a sudden start of marked proteinuria,
Diabetic nephropathy, also known as diabetic
abnormal kidney size, hematuria, or other renal
glomerulosclerosis or diabetic kidney disease, is a
disease [4, 5]. Renal biopsy in this setting will not be
major complication of DM and is a leading cause of
diagnostically useful, whereas it will be inferred as
end-stage renal disease (ESRD). Persistent and
diabetic nephropathy (3).Most of our knowledge
slowly progressive proteinuria is a characteristic of
regarding the nature of kidney illness in patients
DN and diabetic renal failure (1-3). The diagnosis of
with type 2 diabetes mellitus (T2DM) is derived
diabetic nephropathy is regularly inferred in cases
from studies of patients with type I diabetes mellitus
where renal biopsy has not produced definitive
[1]. Nonetheless, biopsy data from patients with type
Received: 21/11/2017 DOI: 10.12816/0043806
Accepted: 1/12/2017

Full Paper (vol.704 paper# 7)

c:\work\Jor\vol704_8 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 559-569

The Role of Topical Nasal Steroid in Treatment of Otitis Media with Effusion
in Children: Systematic Review
Mohamed Alamein Mohamed, Hassan Alaa Aleabiary, Mohamed Amir Hassan,
Hesham Abelaty Elsersy
Department of Otorhinolaryngology, Faculty of Medicine, Ain Shams university
Corresponding author: Mohamed Alamein Mohamed , Mobile NO , 01148160705,E-Mail: mohamedzbeda05@gmail.com

Background: otitis media with effusion is common in children and the treatment is still controversial
issue. Objective: this study aimed to evaluate the role of topical nasal steroid in treatment of otitis media
with effusion in children.
Patients and Method: this was a systematic review of the literature to collect data through searching the
Medoline data base (www.pubmed .com) until March 2017 concerning the effectiveness of topical nasal
steroids in treatment of otitis media with effusion in children using the different keywords in different
Results: meta analysis by relative risk for persistence of OME of 0.551 with 95% CI of 0.314 to 0.966 ,
meta analysis by risk difference for persistence of OME of -0.229 with a 95% CI of -0.569 to -0.030 and
meta analysis by odds ratio for persistence of OME of 0.214 with a 95% CI of 0.049 to 0.936, which
was statistically significant favoring topical steroid over control .
Conclusion : topical nasal steroid is an effective treatment for otitis media with effusion without the
complications of oral steroid , nasal steroid spray can be used for longer period, with much greater safety.
It can also be helpful in controlling nasal allergy and the adenoid size, which are contributing factors in
developing and recurring otitis media with effusion.
Kay words: otitis media with effusion, nasal steroid, tympanometry, otitis media with effusion treatment.

Standard treatments for OME, such as hearing
Otitis media with effusion (OME) is defined as
aids and ventilation tube insertion are not trouble-
the presence of fluid in the middle ear without
free. Ventilation tube insertion involves a general
signs or symptoms of acute ear infection¹. OME
anesthesia. It is associated with an improvement
may occur during an upper respiratory infection,
in the mean hearing levels of 4 to 10 dB in
spontaneously because of poor Eustachian tube
children with bilateral tubes during the first six
function, or as an inflammatory response
months of follow up, but this diminishes with
following AOM. It happens most often between
time. Oral and topical nasal steroids have been
the ages of 6 months and 4 years .
used to treat otitis media with effusion. Use of
In the first year of life, >50% of children have
oral steroids is associated with behavioral
OME, increases to >60% by age 2 years².When
changes, increased appetite, weight gain, adrenal
children aged 5 to 6 years in primary school they
suppression, and a vascular necrosis of the
are screened for OME, about 1 in 8 are found to
femoral head. Topical steroids have fewer
have fluid in one or both ears. The prevalence of
adverse effects because of minimal systemic
OME in children with Down syndrome or cleft
absorption.Topical intranasal steroids may be
palate, however, is much higher, ranging from
safer than systemic preparations because the
60% to 85%³. One potential etiologic factor for
glucocorticoid is rapidly degraded in the nasal
otitis media with effusion is inflammation, which
mucosa to less active metabolites and any
may be reduced with steroids.
unchanged drug that is absorbed is metabolized in
Other potential mechanisms of action included:
the first pass through the liver. Systemic adverse
directly shrinking tissue around the Eustachian
effects are therefore less likely, while the desired
tube, improving Eustachian tube surfactant
anti-inflammatory effects may be similar.
secretion, and reducing middle ear effusion
This study was systematic review of the
Treatment of OME is still a controversial
literature to collect data through Medline search
issueas conventional treatment approaches fail
to evaluate the role of topical nasal steroid in
to provide satisfactory and permanent relief of
treatment of otitis media with effusion.
otologic symptoms.

Received: 19/10/2017 DOI: 10.12816/0043807
Accepted: 29/10/2017

Full Paper (vol.704 paper# 8)

c:\work\Jor\vol704_9 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 570-576

Non-Alcoholic Fatty Liver Disease
Roula Hadyan Mohammed AlHadyan1, Albader Abdulhameed Y Khojah2, Abdulaziz Ghareeb
AbdullahAlanazi3, Ahmed Nasser A Alharbi4, Saeed Aqeel S Al-Zubaidi5, Ziad Khodr Traboulsi6,
IbrahimAli I. Alasseri7, Ahmad Yeanallah Algarni6, Hassan Ali A Al-Mubarak8, Ahmed Abdullah Y
Alzahrani9, Bashaier Abdalrazaq Al Saeed10, Hamoud Jadan M Alruwaili11
1- Al-Maarefa Collages, 2- King Fahd General Hospital Jeddah, 3- Najran
University, 4- Qassim University, 5- Batterjee Medical College, 6- King Abdulaziz University,
7- Majardah General Hospital, MROD, 8- Imam Abdulrahman Bin Faisal University,
9- University of Jeddah, 10- Ibn Sina National College, 11- Aljouf University


Background: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease that
exposes patients to a great risk of emerging cardiovascular diseases and could develop to cirrhosis or
hepatocellular carcinoma if left unmanaged.
Objective of the Study: this article is intended to provide an overview and explore the optimal intervention
for management of NAFLD in the short and long term.
Methods: Electronic search in the scientific database from 1966 to 2017­ (Medline, Embase, the Cochrane
Library as well as NHS center websites were searched for English Publications were obtained from both
reprint requests and by searching the database. Data extracted included authors, country, year of publication,
age and sex of patients, epidemiology, geographical distribution, pathophysiology, risk factors, clinical
manifestations, investigations and types of surgical treatment.
Conclusion: It was concluded from the extensive review of the literature that Lifestyle modification including
diet, physical activity and controlling metabolic disorders are the cornerstone in current management of
NAFLD. Nevertheless, Insulin-sensitizing agents and antioxidants, particularly thiazolidinediones and vitamin
E, seem to be a very promising pharmacologic treatment for non-alcoholic steatohepatitis, yet further long-
term multicenter studies need to be conducted for confirmation and assessment.
Keywords: Cirrhosis, steatosis; steatohepatitis; metabolic syndrome, NAFLD, NASH.

other causes of liver disease. The treatment is
Non-alcoholic fatty liver disease (NAFLD) is
centered on management of comorbidities (life
defined by the presence of hepatic macrovesicular
style modification, weight loss, antidiabetic
steatosis in the presence of less than 20 g of
medication) (5).
alcohol ingestion per day (1).Non-alcoholic fatty
For the meantime, no drugs have been approved
liver disease (NAFLD) is a spectrum of disease
by the American agency for Food and Drug
from land steatosis (NAFLD) to steatohepatitis
Administration (FDA) for treatment of NAFLD.
(NASH) to progressive fibrosis and, ultimately,
Safe and effective medication and noninvasive
cirrhosis with portal hypertension to irreversible
biomarkers that could distinguish patients at risk
cirrhosis (2).
of progression to advanced disease are urgently
At the least advanced end of the spectrum, non-
needed (6).
alcoholic fatty liver (NAFL) is an excess of fat in
It's important to first understand the predisposing
the liver (steatosis) present in 20-30% of the
factors of NAFLD before concluding on the
general population and is largely asymptomatic (3).
appropriate intervention.
Most people with NAFLD have simple fatty liver.

Only a small number of people with NAFLD have
Predictors of Progressive Fibrosis in Non-
NASH. Experts estimate that about 20 percent of
Alcoholic Fatty Liver Diseases
people with NAFLD have NASH (4). Between 30

and 40 percent of adults in the United States have
1. Genetic Polymorphisms
NAFLD. About 3 to 12 percent of adults in the
United States have NASH (4).
the PNPLA3 and TM6SF2 genes are common in
the general population with minor allele
manifestations for many years. The symptoms can
frequencies of 20%­50% and 10%, respectively
be unspecific (for example, fatigue, elevated liver
(7).The rs738409 and rs58542926 single
injury markers). The diagnosis is typically
nucleotide polymorphisms (SNP's) of these
established though liver biopsy and exclusion of
respective genes have been identified by

genome-wide association studies to be
Received: 21/11/2017 DOI: 10.12816/0043808
Accepted: 1/12/2017

Full Paper (vol.704 paper# 9)

c:\work\Jor\vol704_10 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 577-583

Carbon Dioxide Role in GI Endoscopy
Mohanad Obaid Mohsen Alkhamash 4, Hussam Musallam Alfarsi 2, Abdullah Khalid Aljadi 5,
Maan Khaled B Baamer 2, Abdulmajeed Abdulaziz A Saeedi 2, Mohammed Abdullah Abaaljaysh 6,
Hussain Ali A Algharrash 7, Amal majed aldawish 8, Abdulrahim Mohammed Alamoudi 9
1- East Jeddah Hospital, Jeddah, 2- King Abdulaziz University, Jeddah, 3- Prince Saud Bin jalawi Hospital,
4- Taif University, 5- Qassim University, 6- Imam Abdulrahman Bin Faisal University, 7- Wroclaw
Medical University, Poland, 8- Almaarefa colleges, 9- King Abdulaziz University, Rabigh.

Sufficient distension of the GI lumen is needed for safe advancement of endoscopes and for
careful visualization of the mucosa. Carbon dioxide (CO2) has been proposed as an alternative to room air
for insufflation.
Aim of the Study: To assess the merits and demerits of the use CO2 insufflation for endoscopy in terms of
safety and efficacy.
Methods: Electronic and manual searches were combined to search RCTs (Randomized controlled trials).
After methodological quality assessment and data extraction, the efficacy and safety of CO2 insufflation
were systematically assessed.
Ten RCTs met the eligibility criteria and included in the present study; six of which on
colonoscopy, two on endoscopic retrograde cholangiopancreatography (ERCP) and two on double-balloon
enteroscopy (DBE). Postprocedural pain was assessed. Overall, pain was lower in the CO2 insufflation group
compared with the air group. Two RCTs found decreased flatus in the CO2 group compared with the air
group, and 3 RCTs showed there was decreased bowel distention on abdominal radiography in the CO2
group compared with the air group. Moreover, CO2 insufflation revealed no consistent advantages in the
RCTs of DBE, yet it was still indicated safe as air insufflation in stomach/ oesophagus endoscopic
submucosal dissection. PCO2 level showed no significant variation during these procedures.
Conclusion: CO2 insufflation is proven to be associated with decreased postprocedural pain, flatus, and bowel
distention. CO2 insufflation also appears to be safe in patients without severe underlying pulmonary disease.
Keywords: insufflation, Colonoscopy, Carbon dioxide, Transcutaneous partial CO2 pressure, GI Endoscopy.

is the most commonly used gas for creating a
In the last decade, endoscopy has become an
pneumoperitoneum during laparoscopic surgery due
essential diagnostic and therapeutic instrument in
to its incombustibility, high diffusibility, and rapid
daily clinical practice. As a consequence, the
rate of absorption and excretion. Insufflation with
number of endoscopic examinations has increased
carbon dioxide (CO2) instead of air has been shown
continuously, in particular, as a result of constant
to reduce pain and discomfort because CO2 is
efforts to improve patient's acceptance and
rapidly absorbed from the intestinal lining (5).
compliance to participate in bowel cancer screening

programs. However, some patients still have a fear
For the past three decades, a series of investigations
of undergoing colonoscopy, as they associate it with
have examined the safety and efficacy of
considerable pain and discomfort (1).
CO2 insufflation during various GI endoscopic
The introduction of moderate or deep sedation has
modalities. Based on previously published randomised
certainly been an essential step to increase its
and non-randomised trials, the most recent systematic
attractiveness and to reduce the anxiety and
review by Dellon et al. revealed that CO2 insufflation
concerns of the patients (2).Recent evidence
is associated with decreased postprocedural pain,
demonstrates that sedation can be safely
flatus and bowel distension, and appears to be safe in
administered in colonoscopy without increasing the
patients without severe underlying pulmonary disease
risk of respiratory or abdominal complications (3).

Another technique that has emerged in the last few
Nevertheless, the use of air insufflation to distend
years is the use of carbon dioxide (CO2) as an
the lumen has been suspected to be a cause of the
alternative insufflation gas (4). Carbon dioxide (CO2)
Received: 22/11/2017 DOI: 10.12816/0043809
Accepted: 2/11/2017

Full Paper (vol.704 paper# 10)

c:\work\Jor\vol704_11 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 584-593
Assessment of Follicular-Fluid Neurotrophin Levels as Predictor for
Ovarian Reserve in Women Undergoing Assisted Reproductive
Technology for Different Etiologies of Infertility
Magdy H. Koleib, Fekrya A. Salama, Nashwa E. Hassan, Hanan S. Mohammed
Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University
Corresponding author: Hanan Shehata Mohammed, email: hananshehata10121981@gmail.com,
mobile: 01020688539
brain-derived neurotrophic factor (BDNF) is a27-kDa polypeptide that belongs to the neurotrophin
family binding with high-affinity protein kinase receptors (Trk) and the unselective p75NGFR receptor. The BDNF
gene has a complex structure with multiple regulatory elements and four promoters that are differentially expressed
in the central or peripheral tissue. Aim of the Work: this study aimed to detect affection of follicular fluid
neurotrophin level in different types of infirtility and its using as peredictor for ovarian reserve.
Patients and Methods: this crosssectional study was carried out in Ain Shams University, Maternity Hospitals
Assisted Reproductive Technology Unit (ART unit) in the period from Septemper2016 to June 2017.
Results: the present study showed a cut-off value of BDNF for the patients who underwent this study was 2.7 pg/ml
with sensitivity of 74.2%, specificity 95.5%, PPV 85.2% and NPV 91.4%. Conclusion: FF-BDNF measurement on
the d-OPU in women with different types of infertility underwent COH for IVF-ET, had positive correlation with
ovarian reserve and positive predictor of pregnancy which occurred in 25.8% of cases. Recommendations: BDNF
has positive correlation with ovarian reserve and positive correlation with pregnancy outcome so we recommend to
measure serum BDNF before starting IVF cycle as predictive factore and cost effective.
Keywords: follicular-fluid neurotrophin, predictor, ovarian reserve, ART, infertility.


development into preimplantation embryos because it
Growing evidence indicated that Brain-Derived
promotes the
Neurotrophic Factor (BDNF) was a27-kDa

polypeptide that belonged to the neurotrophin family
nuclear and cytoplasmic maturation of oocyte (8).
binding with high-affinity protein kinase receptors
These findings demonstrate that neurotrophins are
(Trk) and the unselective p75NGFR receptor. The
expressed in human ovaries and strongly suggest that
BDNF gene has a complex structure with multiple
they play a role in folliculogenesis and cytoplasmic
regulatory elements and four promoters that are
competence of oocytes (6).
differentially expressed in central or peripheral
This is further supported by a study which
tissues (1). It is well known to play an important role
showed that plasma BDNF levels change during the
in the survival, differentiation and outgrowth of
menstrual cycle and that concentrations fall steadily
select peripheral and central neurons during
after menopause (9).
development and in adulthood (2,3).
Follicular fluid BDNF levels are different for
Neurotrophins are a family of growth factors
each etiological factor of infertility as patients with a
that are involved in the development of the central
history of endometriosis had significantly lower
and peripheral nervous system (4. Although they were
mean levels of follicular fluid BDNF compared to the
initially thought to be restricted to the nervous
control group. Patients with diminished ovarian
system, it is well known that they affect non-
reserve had lower levels of BDNF compared to the
neuronal cells, as cells of the endocrine system (5).
control group. Follicular fluid BDNF levels were not
Brain-derived neurotrophic factor (BDNF), is a
different between the control groups either in women
major member of the neurotrophin family and
with PCOS or unexplained infertility (10).
together with its receptor, it is found in both rodent
and mammalian (including human) ovaries. It has a
This study aimed to detect affection of
wide range of functions in the ovary, from support of
follicular fluid neurotrophin level in different types
early survival of germ cells to control of
of infirtility and its using as peredictor for ovarian
steroidogenesis and extrusion of polar bodies, as well
as ovulation (6). Moreover, it has been shown that in
BDNF treatment of bovine oocytes leads to the
development of more parthenogenetic embryos
This cross-sectional study was carried out in
compared to the case of controls (7). Similarly, BDNF
Ain Shams University Maternity Hospitals, Assisted
has been shown to be important in mouse oocyte
Reproductive Technology Unit (ART unit) in the
period from Septemper 2016 to June 2017.
Received: 1/9/2017 DOI: 10.12816/0043810
Accepted: 10/9/2017

Full Paper (vol.704 paper# 11)

c:\work\Jor\vol704_12 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 594-600

Assessment of Vitamin D Levels in Women with
Polycystic Ovarian Syndrome
Sanaa SH. Elkholy(1), Rowaa A. Mostafa(1), Amr A. Riad(1), Heba M. AbouZaghla(2)
1- Department of Obstetrics and Gynecology, 2- Department of Clinical Pathology
Faculty of Medicine, Ain Shams University
Corresponding author: Sanaa SH. Elkholy; Mobile: 01092986604; Email: sanaaelkholy@yahoo.com

polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of
reproductive age, with a prevalence of 6­10% in the general population. PCOS is characterized by the
following: ovulatory dysfunction resulting in oligo-amenorrhea and/or anovulation, hyperandrogenism and/or
hirsutism and the presence of polycystic ovarian morphology by ultrasound. Vitamin D also plays a
physiologic role in reproduction including ovarian follicular development and luteinization via altering anti-
Müllerian hormone (AMH), signaling, follicle-stimulating hormone sensitivity and progesterone production
in human granulosa cells. Aim of the Work: this study aimed to compare levels of vitamin D in women with
PCOS and healthy fertile women. Patient and Methods: this case control study was conducted in Ain Shams
Maternity hospital in outpatient infertility clinics and family planning clinic during the period from March
2017 to October 2017. It was included 40 women diagnosed with PCOS based on Rotterdam criteria and 40
fertile women without PCOS who were recruited from family planning clinic. Results: 25(OH) vitamin-D
level was significantly lower in PCOS group than in the control group. Conclusion: 25(OH) vitamin-D was
significantly lower in PCOS group than in the control group, but not sufficient to be a diagnostic tool for
PCOS. Recommendation: larger studies are still needed to clarify the rule of vitamin D in infertility.
Keywords: polycystic ovary syndrome (PCOS), vitamin D, anti-Müllerian hormone (AMH).


Polycystic ovary syndrome (PCOS) is the most
presence of a vitamin D response element in the
common endocrine disorder in women of
human insulin gene promoter (5). It also increases
reproductive age, with a prevalence of 6­10% in the
insulin synthesis and secretion and regulation of
general population. PCOS is characterized by the
steroidogenesis in the human ovarian tissue (6).
following: ovulatory dysfunction resulting in oligo-
Vitamin D deficiency is quite common in the
amenorrhea and/or anovulation, hyper-androgenism
general population. In fact, in several studies,
and/or hirsutism, and the presence of polycystic
vitamin D levels were found to be below 20 ng/ml
ovarian morphology by ultrasound (1). It may also
in 10-60% of the adults (7).
create long-term health risks, such as type 2
Serum 25-hydroxy vitamin D (25-OH D)
diabetes, endometrial cancer and cardiovascular
concentrations below 20 ng/ml were considered as
disease as it is associated with anovulation,
vitamin D deficiency and serum 25-OH D
hyperinsulinemia and central obesity (2). Vitamin D
concentrations of 20-30 ng/ml were considered as
has important roles in various parts of the body,
vitamin D insufficiency (8). There are many causes
especially in the bones. The active form of vitamin
of vitamin D deficiency, including reduced skin
D plays an important role in bone metabolism,
synthesis and absorption of vitamin D and acquired
regulation of calcium-phosphorus equilibrium and
and heritable disorders of vitamin D metabolism
cell differentiation and proliferation (3).Vitamin D
and responsiveness. Use of sunscreen, presence of
also plays a physiologic role in reproduction
pigment in the skin, patients with skin grafts for
including ovarian follicular development and
burns will cause a reduction in the synthesis of
luteinization via altering anti-Müllerian hormone
vitamin D. Obesity can cause decreased
(AMH) signalling, follicle-stimulating hormone
bioavailability due to reduced availability of vitamin
sensitivity and progesterone production in human
D. The presence of liver failure and kidney disease
granulosa cells (4). It also affects glucose
can also affect the metabolism of vitamin D (8). The
homeostasis through several roles. The potential
underlying pathogenesis of PCOS included insulin
influences of vitamin D on glucose homeostasis
resistance and compensatory hyperinsulinemia (9).
included the presence of specific vitamin D receptor
Increased insulin resistance causes an increase in
(VDR) in pancreatic -cells and skeletal muscle, the
weight which triggers hyperandrogenism and, thus,
expression of 1--hydroxylase enzyme which can
results in clinical symptoms. Although insulin
catalyze the conversion of 25-hydroxy vitamin D
resistance more frequently appears in obese patients
[25(OH)D] to 1,25-dihydroxyvitamin D and the
(65%), it is less frequent in lean patients with PCOS
Received: 4/10/2017 DOI: 10.12816/0043811
Accepted: 14/10/2017

Full Paper (vol.704 paper# 12)

c:\work\Jor\vol704_13 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 601-609
Efficacy of Intravenous Tenoxicam as an Analgesic during the First
Stage of Labor: A Randomized Controlled Trial
Hatem S.Shalaby, Hosam M.Hemada, Mohamed A.Faris
Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University
Corresponding Author: Nagham H.Ali, Email: dr.nagham_hu@yahoo.com, Mobile:00201110106843

childbirth is one of the most painful events of a woman's life. The experience of labor pain is a
complex, multidimensional response to sensory stimuli generated during parturition and its intensity can vary
greatly. Unlike other acute and chronic pain experiences, labor pain is not associated with pathology, but with
the most basic and fundamental of life's experiences
Aim of the work: this work aimed to study the efficacy of intravenous tenoxicam for labor analgesia.
Patient and methods: this was two-arm, randomized controlled trial. The first arm (Group T) represented
subjects who received tenoxicam. The second arm (Group R) represented subjects who received routine
analgesic pethidine and it is given at a dose of 50 mg diluted over 10 ml of normal saline. The parturient woman
was given 3-4 cm of diluted pethidine whenever she has intolerable pain.
Results: this study included 260 subjects that were allocated into two arms: tenoxicam arm (n=118) and
pethidine arm (n=142) as the control group. Tenoxicam group included 118 subjects and the pethidine group
included 142 subjects. Maternal age was 23.74 ± 3.76 in tenoxicam group vs 23.99 ± 3.5 in pethidine group.
Gestational age was 39.04 ± 1.42 in tenoxicam group vs 38.93 ± 1.5 in pethidine group. Birth weight was 3.43 ±
0.26 in tenoxicam arm vs 3.41 ± 0.26 in pethidine arm, average fetal heart rate was 140.1 ± 17.12 in tenoxicam
arm vs 138.1 ± 16.39 pethidine arm, cervical dilatation was 4.19 ± 0.77 in tenoxicam arm vs 4.25 ± 0.7 and
interval to delivery was 5.89 ± 1.29 in tenoxicam arm vs 6.2 ± 1.62 in pethidine arm.
tenoxicam (40 mg iv), a long acting NSAID that induces analgesia by inhibiting peripheral
prostaglandin synthesis, reduced postpartum uterine contraction pain without apparent maternal or neonatal
adverse effects. Furthermore, tenoxicam exhibits superior analgesic properties over the routinely used pethidine
as labor analgesic. Further studies should evaluate analgesic effects vs side effects of iv tenoxicam as a function
of dosage or as part of combination therapy with different opioid analgesics.
Keywords: tenoxicam, labor analgesia.


The sensation of pain is undeniably subjective.
are taken over a long period of time (for chronic
Personality, recollections of painful events, emotional
pain), then they could damage the lining of the
state, age, culture, context and other factors influence
gastro-intestinal tract or the kidneys or more rarely
an individual's responses to, and description of, pain
other organs (4).
(1-2). Pain during the early first stage of labor arises
Non-opioid analgesic agents are divided into
from dilation of the lower uterine segment and cervix.
two groups:
Pain during the late first stage and second stage of
The first group included substances which have
labor arises from descent of the fetus in the birth
anti-inflammatory effects in addition to their analgesic
canal, resulting in distension and tearing of tissues in
and antipyretic activities and are called non-steroidal
the vagina and perineum (3).
anti-inflammatory drugs (NSAIDs). The members of
Most women in labor require pain relief. Pain
this group, with the exception of almost all selective
management strategies include non-pharmacological
inhibitors of cyclooxygenase 2 (COX-2), are acids.
interventions that aim to help women cope with pain
Acidic NSAIDs, which include salicylates, derivatives
in labor and pharmacological interventions that aim
of acetic acid ,propionic acid and oxicams among
to relieve the pain of labor (4). Non-opioid analgesics
others, comprise molecules containing a lipophilic and
can effectively relieve mild to moderate pain and for
a hydrophilic region and are more than 99 % bound to
moderate to severe pain, they can be used in
plasma proteins (5).
combination with other drugs to enhance pain relief.
The second group of non-opioid analgesics,
Most non-opioids are quite safe when used for
which are not classified as NSAIDs, consists of
temporary acute pain; problems may arise when they
substances that lack anti-inflammatory properties, such
Received: 17/10/2017 DOI: 10.12816/0043812
Accepted: 27/10/2017

Full Paper (vol.704 paper# 13)

c:\work\Jor\vol704_14 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 610-620

Correlation of Age Related Changes of Nasal Tip Support
Mechanisms with Anthropometric Measurements
Mohamed M Abdel Halim (1), Ahmed M El Badawy (1),
Manal H Mousa (2), Hesham A Helal (1)
1- Department of Plastic and Reconstructive Surgery, 2- Department of Histology,
Faculty of Medicine ­ Ain Shams University
Corresponding author: Mohamed M Abdel Halim; Mobile: 01001089966; Email: drmm_mamdouh@hotmail.com

age-related changes of the face have been an area of intense interest and the focus of
considerable researches. The facial skeleton and overlying soft tissue undergo a gradual transformation
throughout the aging process and there are several consistent age-associated changes of the nose. Aim of the
this study aimed to evaluate the age related cellular and architectural changes of nasal tip support
mechanisms, in correlation to its anthropometric measurements. Patients and Methods: this prospective
study was conducted in Plastic and Reconstructive Surgery and Histology Departments, Ain-Shams
University Hospitals, Cairo, Egypt. Forty-five patients were included in this study. They had undergone
aesthetic rhinoplasty operations, 10 males (25%) and 30 females (75%) with mean age 35.42±15.15 years
and age range 19­60 years. Results: LLC is the most nasal tip support mechanism affected by aging as every
1 year increase in age; correspond to weakness in LLC by percent -1.077 followed by ULC, SC, SCA, IDA,
ICA, NLA, and projection respectively (P value <0.001). Conclusion: aging patients present unique
technical challenges in rhinoplasty that warrant a comprehensive approach to restore and preserve tip
support. Recommendations: medial crural septal suture should be performed in all elderly patients
undergoing aesthetic rhinoplasty, both to prevent further exaggeration of the already existed acute nasolabial
angle and to maintain the nasal tip projection and rotation.
Keywords: age, nasal tip support, anthropometric measurement.

line is drawn adjacent to the most projecting part
The nose is the center of the face and it has
of upper lip. To achieve adequate tip projection,
a central role in the harmony of the facial features.
50-60% of the horizontal line should lie anterior to
It can cause serious impacts with the facial image.
the vertical line. The nasolabial angle is defined as
This alone makes it clear that it is commonly
the angle formed by a line drawn from the anterior
believed that changes to the nose have
to the posterior nostril apices and that intersects
psychological and social impact on the person (1).
with the vertical facial plane. It determines the
The unique anatomy of the nose is
amount of cephalic rotation of the tip (4). In an
reflected by the complex nomenclature used to
aesthetically pleasing nose, the columella projects
describe it as well as the efforts made to
as a gentle curve below the alar margin as seen on
characterize the geometric proportions of the ideal
lateral view. The columella and infratip lobule
nose. The lobule can be defined as an area
projection are influenced by the configuration of
including the tip of the nose and bounded by a line
the medial and middle crura. Because of the thin
connecting the upper edge of the nostrils, the
and adherent skin; asymmetries or prominences in
supratip breakpoint, and the anterior half of the
these structures are easily visible in external
lateral alar wall. The lobule is subdivided into the
configuration (5). Tip support mechanisms play a
tip, supratip and infratip segments (2). The tip of the
central role in tip stability and positioning. Janeke
nose is the apex of the lobule and ideally the most
and Wright (6) demonstrated the most crucial
defined element on the profile. The infratip lobule
factor in nasal tip support mechanisms and they
lies inbetween the tip and the apex of the nostrils.
published hypothesis that fibrous connection
The configuration of the infratip lobule depends on
between the upper and lower lateral cartilages play
the shape, size, and angulation of the medial and
a vital r ole in the nasal tip support mechanism.
middle crura of the alar cartilage. The supratip
Ghavami and his colleagues (7) stated that the
lobule lies inbetween the pronasalae and the
lower lateral cartilages together with the
supratip breakpoint (3). The nasal tip is a dynamic
ligamentous attachments between these paired
structure, hinged by the upper lateral cartilages and
structures (Interdomal sling) are critical in
by the recurvature of the lower lateral cartilages. It
supporting the nasal tip, while Xavier (8)
is evaluated for projection, definition, rotation,
mentioned that the scroll area is mandatory and
symmetry and support. Tip projection can be
should be preserved to prevent weakening of tip
evaluated by drawing a line from the alar-cheek
support. Quatela and Pearson (9) mentioned that
junction to the tip of the nose and another vertical
the medial crural footplates play an important role
Received: 17/10/2017 DOI: 10.12816/0043813
Accepted: 27/10/2017

Full Paper (vol.704 paper# 14)

c:\work\Jor\vol704_15 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 622-624
Dermoscopic Features of Keloid versus Hypertrophic Scar
Mahmoud Abdallah¹, Marwa Yassin¹, Noha Saber².
¹Dermatology Department, Faculty of Medicine, Ain Shams University,
2Dermatology Department, El Talaba Hospital
*Corresponding author: nohasaber, drnohasaber@gmail.com. Tele: 0201117549990

: Hypertrophic scars and keloids can be described as variations of typical wound healing.
Aim of this study was to find out the dermoscopic differentiating features between keloids and hypertrophic
scars in their recent phases of development in Egyptian population.
Patients and Methods: An observational cross-sectional design of 30 cases that assigned according to
histopathological analysis into two groups; Keloids and Hypertrophic scars. Then the polarized non-contact
mode of a Dermlite© DL3 "Gen, USA" at a magnification of 10 × was used to capture dermoscopic images
for both groups. The surface morphology and the dermoscopic criteria were recorded directly from the
patients and included vascular structures (Arborizing, linear and comma shaped vessels), erythematous or
white patches. Results: Statistical analysis revealed that patients with keloids are more likely to be associated
with the presence vascular structures on dermatoscopy. The analysis of types of vascular structures showed
that arborizing vessels, in particular, were significantly related to keloids. In contrast, the dominant
dermoscopic feature in Hypertrophic scarring was the presence of scarring as presented in the form of
erythematous or white patches with scanty or absent vascularization. Conclusions: Dermatoscopy should be
considered as a routine investigation of any case with abnormal scarring for a better differentiation between
keloids and hypertrophic scars, and hence a better evaluation and treatment of each type.
Keywords: Keloid, Hypertrophic scar, vascular structures, handheld dermatoscopy.


Wound healing is a natural restorative response to
to the high cost and lengthy preparation time;
a tissue injury. It is the interaction of a complex
studied the dermoscopic features of keloids and
cascade of cellular events that generates
hypertrophic scars to differentiate them based on
resurfacing, reconstitution, and restoration of the
their characteristic dermoscopic features and they
tensile strength of injured skin1. Hypertrophic scars
could demonstrate distinctive dermoscopic features
and keloids can be described as variations of typical
especially in keloids where vascular structures
wound healing. As the scar matures, it becomes
including arborizing, linear irregular and comma
hyperemic and it may be thickened; however, it
shaped vessels were frequently seen5.
tends to subside gradually until a flat, white,

pliable, possibly stretched, and mature scar
develops. When an imbalance during the healing
This study was conducted on 30 patients with
process occurs, more collagen is produced than is
recent scars who were selected from the Outpatient
degraded, and the scar grows in all directions2. A
Dermatology clinic of Ain Shams University
keloid is an abnormal proliferation of the scar tissue
Hospitals during the period of September 2015 to
that forms at the site of cutaneous injury. It does not
February 2017. Inclusion criteria were a clinical
regress and grows beyond the original margins of
and histological diagnosis of Keloids and
the scar3. On the other hand, the hypertrophic scar
hypertrophic scars. We excluded all cases who had
is a widened or unsightly scar that does not extend
received previous treatment and patients with old
beyond the original boundaries of the wound.
scars (more than 6 month). The subjects were
Unlike keloids, the hypertrophic scar reaches a
classified into 2 groups (15 subjects with keloid
certain size and subsequently stabilizes or
scars and 15 subjects with hypertrophic scars)
regresses4. Dermoscopy is a widely used non-
according to histopathology. Then dermoscopic
invasive diagnostic technique which provides up to
images had been captured with a Dermlite© DL3
a ten times greater magnification than the unaided
"Gen, USA" at a magnification of 10 × for both
eye and can show the structure of the upper layer of
keloids and hypertrophic scar groups. The
the dermis, and therefore yielding many
dermoscope used in the polarized non-contact mode
diagnostically relevant findings5. Because of the
because, the blood vessels that are located in the
dermis collapse easily by the pressure applied when
hypertrophic scars clinically and the unpractical
performing contact dermoscopy. This causes
application of histopathological differentiation due
blanching of the lesion and loss of important
Received: 19/10/2017 DOI: 10.12816/0043814
Accepted: 29/10/2017

Full Paper (vol.704 paper# 15)

c:\work\Jor\vol704_16 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 625-629
Epidemiology, Bacteriology and Risk Factors of Surgical
Wound Infections: A Systematic Review
Mustafa Tawfiq Almuhanna1 and Mahacen Egal Alnadwi2

1Medicine College, King Faisal University and 2College of Medicine, Umm Al-Qura University
*Corresponding author: Mustafa Tawfiq Almuhanna, E-Mail: dr.expert333@gmail.com.


Introduction: Surgical wound infections are a main cause of hospital associated infections in low income and the
second most common cause in high income and resource rich countries. This review aiming at exploring
epidemiology, bacteriology and risk factors associated with surgical wound infections.
Methods: The systematic search was conducted in the Medline, Science direct, CINAHL databases using search
terms of (Wound Infection OR Nosocomial Infections OR Surgical Wound) AND (Epidemiology OR
Bacteriology OR Risk Factors). The relevant information was extracted from eligible studies. The irrelevant,
duplicated studies were excluded. The findings of the included studies were summarized in a narrative manner.
Results: Surgical wound infections have taken an alarming position as the third most common hospital acquired
infection. SSIs continue to be a huge challenge to healthcare institutions where they add costly implications for
surgery and health cost in general. Although gram-positive cocci hold the greater guilt for SSIs, there is an
increased risk of SSIs from gram-negative bacilli after GI tract surgical procedures.
Conclusions: Detecting risk factors preoperatively, classifying patient's risk and using a multidisciplinary
approach, all are of great importance to determine the appropriateness of the surgical procedure, designing a
tailored education session for the patient on the risk of possible complications, and last but not least, determining
an effective plan for expected postoperative complications.
Keywords: Bacteriology, Epidemiology, Wound Infections, Prevalence.


A surgical wound is defined as a cut or an
HAIs in low income areas (low and middle-income
opening in the skin. However, it is usually caused
countries 5.6%) and the second most common cause
during surgery, but it can be a result of a drain
in high income and resource rich countries (USA
placed during surgery. Surgical wounds vary in
2.6% and Germany 1.6%) (11,12,13). This review
respect to their size, and usually closed with
aiming at exploring epidemiology, bacteriology and
stitching, but sometimes are left open so as to heal
risk factors associated with surgical wound
(1). Wound infections are classified into two main
groups, skin infections and soft tissue infections, and

they often overlap as a result of disease sequence
(2,3). Since hospital-acquired wounds represent a
The systematic search was conducted in the
major part of morbidity due to nosocomial infections
Medline, Science direct, CINAHL databases using
and a rise in medical expenses, such wounds need to
search terms of (Wound Infection OR Nosocomial
be routinely surveyed as recommended by the
Centers for Disease Control and Prevention (4) as
(Epidemiology OR Bacteriology OR Risk Factors).
well as by the Surgical Infection Society (5).
The relevant information was extracted from eligible
One of the most common hospital acquired
studies. The irrelevant, duplicated studies were
infections are surgical site infections (SSIs). They
excluded. The findings of the included studies were
hold the third place among all hospital acquired
summarized in a narrative manner. The protocol of
infections, posing a great challenge to institutions as
the review was approved by the technical and ethical
they have become a leading cause in hospital
associated infections (HAIs) and have been found to
The study was done after approval of ethical board
have financially debilitating effects on surgical
of King Faisal university.
practices in both human and veterinary practice (6,7,8).
They have been linked to poor patients' outcomes
The findings of the included studies revealed
with increased mortality, morbidity and a high
that surgical wounds classified according to level of
healthcare expenditure (9,10). SSIs are a main cause of
contamination. They are classified into four classes
Received: 4/11/2017 DOI: 10.12816/0043815
Accepted: 14/11/2017

Full Paper (vol.704 paper# 16)

c:\work\Jor\vol704_17 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 630-633

Prevention of Infective Endocarditis Following Dental Practices
Zainab Jaffar Alghazal1 and Abdullah Ahmad Basheer Alghamdi2
1Dentistry College, Al-Farabi Colleges and 2College of Medicine, Umm Al-Qura University, Saudi Arabia
*Corresponding author: Zainab Jaffar Alghazal, E-Mail: dr.expert222@gmail.com

Different guidelines and different regimens for prevention of infective endocarditis following
operative procedures have been recommended. The purpose of this review was to explore the effectiveness of
using antibiotics as prophylaxis in the prevention of IE in dental practice.
Methods: The systematic search was conducted in the Medline, Science direct, CINAHL databases using
search terms of (Infective endocarditis) AND (Epidemiology OR Bacteriology OR Prevention) AND (Dent*).
The relevant information was extracted from eligible studies. The irrelevant, duplicated studies were excluded.
Results: The antibiotic prophylaxis efficacy to prevent IE has never been assessed in a randomized controlled
trial (RCT), and the profession has hedged far from such investigation on the grounds of numbers of patients
required and ethical concerns. Perhaps the time has come for address this issue, a staged approach could be
useful that is focusing a specific cardiovascular condition such as mitral valve prolapse in relation to operative
dental procedures with low risk include endodontics and supragingival scaling.
Conclusions: A multi-center approach will be required, but at least an RCT would confirm whether antibiotic
prophylaxis is required and also assess the (risk/benefits) of the antimicrobial administered.
Keywords: Infective Endocarditis, Dental, Prevention, Antibiotic, Prophylaxis.


Infective endocarditis (IE) or Bacterial endocarditis
treatment of defects or abnormalities and the increase
is an infection of the lining epithelium tissue of the
of the organisms' number resistant to drugs put some
heart champers (endocardium) or heart valves. It may
difficulties in the treatment of IE(3).
involve one or more valves, mural endocardium, or a
Bacteria in the oral cavity may cause IE
septal defect. Whilst IE is a rare and uncommon, it is
especially among those who at high risk. Blood from
a life-threatening infection (1). During the past 50
oral cavity, therefore, is the only way for bacteria to
years the incidence of IE increased significantly (2-4
reach the heart. Dental treatment which results in
cases per 100,000 individuals per year). However,
blood in the oral cavity (oral surgery, periodontal
from 1998-2009 the rate increased 2.4% per year and
treatment, endodontics, or even anesthesia) can lead
in the year 2009 the incidence of IE was 12.7 cases
to IE in susceptible patients if necessary precautions
per 100,000 individuals annually. More than 50% of
have been neglected(4).
patients with IE are older than 50 years. Females are
Prophylaxis with antibiotic has been suggested
3 times less likely to have IE than males. However,
as a preventive measure to decrease the tendency of
no association between race and IE has been
having infective endocarditis. Different guidelines
predicted (2).
and different regimens have been followed. The
Despite advances in the diagnostic measures,
purpose of this review was to explore the
instruments, and devices, antimicrobial therapy and
effectiveness of using antibiotics as prophylaxis in
surgical techniques, infective endocarditis still has a
the prevention of IE in dental practice.
substantial role in morbidity and mortality. Although

any one can be infected with this disease, it is much
more common in subjects who have a risk to develop
The systematic search was conducted in the
IE (certain heart defects/diseases, biomechanical
Medline, Science direct, CINAHL databases using
devices implanted in the heart, have had IE before).
search terms of (Infective endocarditis) AND
Intravascular devices lines have been determined as
(Epidemiology OR Bacteriology OR Prevention)
the primary risk factor for bloodstream infections
AND (Dent*). The relevant information was
(BSIs). Staphylococcus aureus, however, has become
extracted from eligible studies. The irrelevant,
the primary pathogen of IE (10). Extensive use of the
duplicated studies were excluded. The findings of the
biomechanical devices implanted in the heart for
included studies were summarized in a narrative
Received: 4/11/2017 DOI: 10.12816/0043816
Accepted: 14/11/2017

Full Paper (vol.704 paper# 17)

c:\work\Jor\vol704_18 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 634-637

Treatment of Urinary Tract Infection during Pregnancy
Abdullah Ahmad Basheer Alghamdi
College of Medicine, Umm Al-Qura University, Saudi Arabia
*Corresponding author: Name Abdullah Ahmad Basheer Alghamdi, E-Mail: dr.expert333@gmail.com

Pharmacotherapeutic treatment strategies of urinary tract infections (UTIs) in pregnancy
needs legitimate diagnostic investigation and comprehensive knowledge of antimicrobial medications.
This review aiming at obtaining the evidence about the effectiveness of antibiotic treatment for UTI
among pregnant women that evaluated by included randomized controlled trials.
Methods: An Electronic search was conducted in Medline and Researchgate databases using simple
search terms include (Pregnan* AND Infection AND Treatment). The search of the literature, after
exclusion of irrelevant, duplicated and review studies, revealed 8 studies met the inclusion criteria.
Most of the included studies used cephalosporins family of antibiotics. The cure rate of
ceftibuten was 95.2% compared to 90% in fosfomycin. A cure rate of 96% after treatment by ceftriaxone
and 94% after administration of cephazolin were reported. When gentamycin plus ampicillin used for the
treatment of UTIs a cure rate of 93% was reported. Conclusions: This review found high effectiveness
and cure rate of the antibiotics used in treatment of UTIs, however the recurrence rate varied between
studied antibiotics. Nitrofurantoin and intravenous antibiotics reported very low recurrence rate in
comparison to fosfomycin and cephazolin with a clinically significant recurrence rate.
Keywords: Urinary Tract, Infections, Treatment, Antibiotics, Pregnancy.


A definition UTIs is "the augmentation
and multiplication of bacteria in the urinary
Pharmacotherapeutic treatment strategies of UTIs
tract," while the presence of bacteria in a
in pregnancy needs legitimate diagnostic
collected urine sample is known as bacteriuria.
investigation and comprehensive knowledge of
Although all women are at risk to the
antimicrobial medications to guarantee best
advancement of UTIs, pregnant ladies are at
maternal outcome, ensure wellbeing to the fetus,
higher risk than non-pregnant as a result of
and avert drawbacks that lead to huge morbidity
anatomical and hormonal differences which lead
and mortality in both the woman and her fetus (7).
to ureteral dilatation and urinary stasis (1). The
Thu, schedule bacterial culture and
hormonal changes that associated with pregnancy
antibiotic sensitivity test of mid-stream urine
may elevate the chance of getting UTIs include
samples of pregnant ladies and other patients are
progesterone-mediated ureteral and vesicular
recommended to be measured before the
smooth muscle relaxation (2).
provision of the medications for the management
As pregnancy continued, from the sixth
of UTIs (8). In this manner, development of
week to 22th to 24th week, around 90% of
uncommon microbial resistance among these
pregnant women infected by ureteral dilatation,
strains could effortless be recognized, and thus,
which will continue to labor (pregnancy
helped in better treatment and management of
hydronephrosis) (3). Elevated volume of bladder
those contaminated by these bacteria (9). This
and reduced tone of bladder, along with reduced
review aiming at obtaining the evidence about the
tone of ureters, lead to ureterovesical reflux and
effectiveness of antibiotic treatment for UTI
elevated urinary stasis (4). Urinary tract infections,
among pregnant women that evaluated by
including pyelonephritis, are the most frequent
included randomized controlled trials.
health issues during pregnancy (5). They occur in

17% to 20% of pregnancies. Pyelonephritis is the
most frequent acute bacterial infection that
Electronic search was conducted in
Medline and Researchgate databases using simple
inconveniences like premature labor, infants with
search terms include (Pregnan* AND Infection
low birth weight, fetal mortality, preeclampsia,
AND Treatment). The search of the literature,
after exclusion of irrelevant, duplicated and
thrombocytopenia, and transient renalinadequacy
review studies, revealed 8 studies met the
(6). Enterobacteriaceae contribute to 90% of
inclusion criteria. The relevant data were
UTIs and the most effective antibiotics used are
extracted from these articles using data extraction
Received: 5/11/2017 DOI: 10.12816/0043817
Accepted: 15/11/2017

Full Paper (vol.704 paper# 18)

c:\work\Jor\vol704_19 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 638-643

Lumbar Puncture: Indications, Complications, Technique and
CSF Analysis in Pediatric Patients
Mahdi Hassan Alsuwailem, Ahmed Hassan Alkhatem, Abdullah Ahmed Alshabib,
Mohammed Hussain Aldraisi, Abdullah Khalid Al Jughiman, Mohammed Hussain Al-Turaifi,
Samirah Munther Al-Ali, Ali Hussain Al Nujaydi
King Faisal University
Corresponding Author: Mahdi Hassan Alsuwailem - MHS_1992@HOTMAIL.COM - 0561893332

The subarachnoid space is filled with cerebrospinal fluid, which circulates through the entire
central nervous system aiding in providing nutrition, fighting microbes, and acts as a buffer. Additionally, the
cerebrospinal fluid also helps in diagnosis of various pathologies affecting the central nervous system ranging
from infection, trauma, and tumor in the pediatric population with the help of lumbar puncture.
Methodology: We conducted this review using a comprehensive search of MEDLINE, PubMed, and EMBASE,
January 2001, through February 2017. The following search terms were used: lumbar puncture, pediatric
indication for lumbar puncture, contraindications to lumbar puncture, technique procedure, CSF analysis.
Aim: In this review, we aim to study the indications, contraindication, and complications of lumbar puncture.
We will also study the correct technique, as well as the analysis of cerebrospinal fluid.
Conclusion: The lumbar puncture procedure is highly effective in diagnostics as well as therapeutically,
however it can be fatal if gone wrong. There are several complications which can result from performing the
procedure incorrectly, as well as some underlying pathologies can make it contraindicated.
Keywords: pediatric indication for lumbar puncture, contraindications to lumbar puncture, technique procedure,
CSF analysis.


The subarachnoid space is filled by the cerebrospinal
· Data Sources and Search terms
fluid (CSF). An adult produces around 500 mL of
We conducted this review using a comprehensive
CSF every day, at a frequency of about 0.5 mL/min.
search of MEDLINE, PubMed, and EMBASE,
In children of 4­13 years of age, the static CSF
January 2001, through February 2017. The
volume varies between 65 to 150 mL. It is
following search terms were used: lumbar puncture,
completely replenished every 4­6 hours. The
volume extracted by a routine lumbar puncture (LP)
contraindications to lumbar puncture, technique
is about 3­5 mL, and is replaced in < 1 hour[1].
procedure, CSF analysis
LP is a vital diagnostic and therapeutic tool. It is
· Data Extraction
performed in order to obtain a sample of CSF. In
Two reviewers have independently reviewed the
children, the most common purpose for a LP is to
studies, abstracted data, and disagreements were
diagnose an infection within the central nervous
resolved by consensus. Studies were evaluated for
system (CNS) such as meningitis or meningo-
quality and a review protocol was followed
Lumbar puncture is also essential for the diagnosis

of various other non-infectious diseases in children
Cerebrospinal fluid (CSF)
including inflammatory disease like transverse
CSF is a dynamic, metabolically active body fluid
myelitis, hematological-oncological conditions in
that does numerous important functions. It offers
case of CNS leukemia or lymphoma, as well as
buoyancy to the brain, decreasing functional brain
when subarachnoid hemorrhage is suspected, or in
weight by around 75%; and also aids to buffer
case of other metabolic disease. Besides, LP is
nervous tissues from trauma. Since there are no
necessary to confirm CSF opening pressure which
lymphatics inside the central nervous system (CNS),
CSF provides an essential fluid medium for
hypertension. Less frequently, LP can aid for
chemicals and nutrients to sustain intercellular
therapeutic reasons to administer chemotherapeutic
spaces, and works as a reservoir for neural
or antimicrobial agents straight into the CSF.
metabolites to be given back to the venous
Received: 6/11/2017 DOI: 10.12816/0043818
Accepted: 16/11/2017

Full Paper (vol.704 paper# 19)

c:\work\Jor\vol704_20 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 644-651

An Assessment of Knowledge towards Acute Cholecystitis among
General Population of Albaha City
Mohammed O.M. Alghamdi, Fawaz A.F. Alghamdi, Abdullah A.A. Alzahrani, Abdullmajeed A.A.
Alghamdi, Saad A. Manakrawi, Ghazi S.A. Alghamdi, Mohammed H.S. Alzahrani
Faculty of Medicine, Albaha University, Albaha, Saudi Arabia
Background: Acute cholecystitis is an acute inflammation of the gallbladder, and it is the most common
cause of acute pain in the right upper quadrant. It is a critical clinical problem representing up to 5% of
emergency room visits. Objective: The aim of the present study was to assess the knowledge of the general
population of Albaha City, Saudi Arabia towards acute cholecystitis (AC). Methods: A representative sample
of 634 subjects from both sexes, aged from 18-80 years who completed a standardized questionnaire was
involved in the study. Results: Only 48 subjects had history of the disease with a prevalence rate of 7.57%.
More than half of the participants (58.7%) recorded family history of AC in one of their direct relatives. Great
percent of the study participants considered obesity, high cholesterol and high triglycerides responsible for
increased incidence of AC (59.9%, 54.3% and 66.9%). A high percentage of the participants (55.2%, 48.3%,
38.2%, 62.8%, 36.9% and 54.3%) did not know whether their food or habits could predispose to AC. Higher
percentages considered intolerance to fatty meals, nausea and vomiting as symptoms of AC (55.5%, 48.9
%and 46.7% respectively). Most of the participants (75.7%) did not receive any information about AC
prevention. Their established information was highly or to some extent effective in changing the participants'
life style (39.0% and 42.9% respectively). Conclusion: This survey has been useful in determining the
current regional knowledge towards AC among general population in Albaha city. Such study emphasizes the
need for more efforts that focus on novel preventive strategies to overcome the onset of gallstones. Further
much bigger collaborative national studies are recommended.
Keywords: acute cholecystitis; gall stone; risk factor; survey; Saudi Arabia.


Acute cholecystitis (AC) is an inflammatory
abdominal pain. However, pediatric population may
disease of the gall bladder, and it is the most
present without many of the classic findings. Signs
common cause of acute pain in the right upper
of peritoneal irritation may be present, and in some
quadrant (RUQ). It has been reported that
patients, the pain may radiate to the right shoulder
cholecystitis represents one of the most common
or scapula. Frequently, the pain begins in the
emergency admissions in surgical practice. More
epigastric region and then localizes to the RUQ.
than 90% of AC cases are associated with
Although the pain may initially be described as
gallstones. Gallstones are the primary triggering
colicky, it becomes constant virtually. Nausea and
factors of cholecystitis, and they are present in
vomiting are generally present, and patients may
more than 10% of the population and their
report fever(5).High prevalence of AC has been
presence increases with age. It is the most
reported in Saudi Arabia. Reda et al.(5) reported that
common indication for abdominal surgery in the
summer season is a major aggravating factor for
elderly, with a prevalence of 21.4% in the age group
acute cholecystitis. The frequency and severity is
of 60-69 years and 27.5% in individuals over 70
significantly higher during summer as compared to
years(1-3). Diabetes mellitus, pregnancy, cirrhosis,
other seasons of the year. People should be aware
and hemolytic disease are considered key factors for
regarding practices used for prevention of
the formation of gallstones. Risk factors for
gallbladder stones formation and inflammation. Diet
gallstones include family history and genetic
plays a key role in gallstones formation. Sugar, high
predisposition. Obesity, rapid weight loss, and a
fat diet, and alcohol intake increase the incidence of
high calorie diet are considered to be modifiable
gallstone formation. In contrast, monosaturated fat
risk factors. In addition, certain drugs, such as
found in nuts and olive oil, fibre, and vegetables
estrogen replacement therapy and thiazide diuretics,
decrease the risk. Similarly, weight loss and
can promote gallstone formation(3).Children who are
exercise prevent the formation of gallstones and
at a higher risk for developing cholecystitis include
protect against inflammation(6). Good understanding
seriously ill children, those with sickle cell disease,
of the causes, symptoms, and risk factors associated
those on prolonged total parenteral nutrition, those
with AC would play an important role in preventing
with hemolytic conditions, and those with
or decreasing its complications. Hence, this study
congenital and biliary anomalies(4). The most
was done to assess the knowledge about AC, and to
common presenting symptom of AC is upper
evaluate the awareness and attitudes towards the
Received: 26/10/2017 DOI: 10.12816/0043819
Accepted: 6/11/2017

Full Paper (vol.704 paper# 20)

c:\work\Jor\vol704_21 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 652-657
Head and Neck Malignancies are Mostly from Dermatological Origin
Sakhr Ahmed Dawari1, Thamer Hassan Mobarki2, Muteb Saad Alqhtani3,
Najmah Khalaf Allah Altwairgi4, Anas M Makhdoum5, Alhassan Ali Alghamdi5,
Ibrahim Abdulaziz Alzahim1, Duaa Salem Balkhi6, Noora Ahmed Alhammadi7,
Fatema Khalifa Bindayna7, Mayada Salem Alwafi6, Jenan Abdulfatah Alfehaid8, Omar Khalid
Alghamdi1, Rana Abualqasim Kudam9.
1 Imam Muhammad Ibn Saud University, 2 Jazan University, 3 King Saud Bin Abdulaziz University for
Health Sciences, 4 King Abdulaziz University, 5 Taibah University, 6 Umm Alqura University, 7 Ama
International University Of Bahrain, 8 Imam Abdulrahman Bin Faisal University, 9 King Fahad Hospital
Corresponding Author: Sakhr Ahmed Dawari - Dr.Sakhrdawari@Gmail.Com - 0543110737

Head and neck cancer includes epithelial malignancies of the upper aerodigestive tract (UADT),
including the paranasal sinuses, nasal cavity, oral cavity, pharynx, and larynx; and, as the sixth most
common cancer worldwide, head and neck cancer represents about 6% of solid tumors. Advances in surgery,
radiation therapy, and chemotherapy have improved locoregional control, survival, and quality of life. The
outcomes of these treatment modalities have shifted the focus of curative efforts from radical ablation to
preservation and restoration of function. This evolution has been documented in the pages of Cancer for the
past 6 decades. The median age of diagnosis is in the sixth decade of life, and there is a large male-to-
female predominance. Although there has been a slight decrease in overall incidence of head and neck
cancer over the past two decades, an increase in base of tongue and tonsillar cancer recently has been
Keywords: head and neck cancer, head and neck squamous cell carcinoma, head and neck surgery,


Head and neck cancer comprises
one report validated a reversal of the typical male-
epithelial malignancies of the upper aerodigestive
to-female ratio in favor of women within the 35-
tract, including the paranasal sinuses, nasal cavity,
year-old or younger age group [7]. Moreover, these
oral cavity, pharynx, and larynx; and, as the sixth
cohorts of
most common cancer worldwide, head and neck
young women lack the typical related risk factors
cancer represents about 6% of solid tumors.
of alcohol, tobacco, and betel nut exposure and
Approximately 650,000 new head and neck
might represent a unique subset even within young
cancers are diagnosed annually, and there are
HNSCC patients[6-8].
350,000 deaths yearly worldwide [1].
Many of the studies comparing young
Nearly 66% of patients present with
patients who have HNSCC with old patients with
advanced-stage disease. The median age of
HNSCC use tumor stage as a matching criteria for
diagnosis is in the sixth decade of life, and there is
creating the older, control cohort, consequently
a large male-to-female predominance. Even
limiting the data comparing stage at presentation.
though there has been a slight decrease in overall
Only those studies looking at whole populations
occurrence of head and neck cancer over the past 2
can reliably comment on differences in stage at
decades [2], an increase in base of tongue and
presentation. Schantz and Yu (9) reviewed the
tonsillar cancer recently has been observed [3].
1973-1997 SEER database and found younger
Head and neck squamous cell carcinoma
patients to be more expected to present with
(HNSCC) normally develops in the sixth to
seventh decade of life. Since Byers recognized this
Correspondingly, Funk's review(6) of the 1985-
subset of patients in 1975, clinicians have become
1996 NCDB established younger patients to
gradually more aware of patients who develop
current at an earlier stage across all types of
HNSCC at a young age, variably defined as age 30
histology, and a statistically significant higher
years and younger, 40 years and younger, or 50
proportion of stage I disease among young patients
years and younger [4].
when analyzed only for squamous cell carcinoma
These patients may represent a distinct
(SCC). Conflicting to these discoveries, in small
cohort with different risk factors and disease
single-institution studies, Verschuur et al.(10) and
behavior. Even though HNSCC normally residues
Veness et al. (11) both found a higher rate of nodal
more common in males, even among young
metastases at presentation in younger patients.
patients, some studies have reported a higher
Nonetheless, Veness et al.(11) likewise found
relative occurrence in females[5, 6]. Additionally,
older patients to be more probable to present with
Received: 8/11/2017 DOI: 10.12816/0043820
Accepted: 18/11/2017

Full Paper (vol.704 paper# 21)

c:\work\Jor\vol704_22 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 658-663

Post-Operative Pain: Mechanisms and Management
Habib Khalifah Al-Radhi1, Alaa Ahmed Akef2, Ali Adnan Al Khamis1, Mohammed Jawad Alsaeed1,
Mohammed Ali Alshehri2, Hamed Ghazi Muslih Alhusayni3, Ayman Mohammad Alswayh4, Israa
Mohammed Alhajji1, Bashaer Osama Abdu5, Hamad Mohammed Al Selaimy6, Yousef Ahmed H
Alesaeed7, Bassam Sameer Molawi2, Almutairi Fayez Farajallah S8, Rawan Rafat Ismaeel Badr9, Ola
Mohammed Bakhsh10, Siddiqa mahmoud Bahaziq11
1 King Faisal University, 2 Umm Al-Qura University, 3 Primary Health Care Shehar Center,
4 Prince Sattam Bin Abdelaziz University, 5 Heraa General Hospital, 6 King Saud Bin Abdulaziz
University for Health Sciences, 7 Gdansk Medical University, 8 Pavol Jozef Safarik University in Kosice,
9 Maternity and Children Hospital in Makkah, 10 Ibn Sina National College, 11 international Medical Center
Corresponding Author: Habib Khalifah Al-Radhi - Bo-Radhi1413@Hotmail.Com ­ 0541619609

Proper postoperative pain management, which can be advanced using a multimodal approach,
results in pain relief with minimal side effects. Newer recovery protocols, along with minimally invasive surgeries
add to the better management of post-operative complication. Many factors play a role in failure of proper
postoperative pain management, which mainly include insufficient education, fear of complications associated
with analgesic drugs, poor pain assessment and inadequate staffing.

we conducted this review using a comprehensive search of MEDLINE, PubMed, and
EMBASE fromJanuary 1987 toMarch 2017. The following search terms were used: post-operative pain
mechanism, post-operative pain management, non-opioid pain management
Aim of the work: In this study we aimed to understand the mechanism and the management of post-operative
pain, along with shining some light upon the recent advances.
Conclusion: Various combinations and modalities of pain management exist, and their use depends largely on the
case, the patients, and their perception of pain. Enhanced recovery protocols have significantly improved
perioperative and postoperative pain management, making the decrease in opioids need a priority.
Keywords: post-operative pain, complication after surgery, post-operative pain mechanism, post-operative pain
management, non-opioid pain management.


The American Society of Anesthesiologist

defined acute pain as pain in a surgical patient after a
include: insufficient education, fear of complications
procedure. Long-term rehabilitation, and other
associated with analgesic drugs, poor pain assessment
complications like chronic pain with decreased
and inadequate staffing.In this paper, we reviewed the
quality of life can result from poor management of
mechanisms of acute postoperative pain and its
postoperative pain. Whereas, satisfactory pain relief
management, and discuss enhanced recovery
will result in reduced hospital costs, and improved
protocols that addressed pain management[2].
quality of life. Therefore, pain relief is considered as

a human right by the World Health Organization
`WHO', and the management of postoperative pain is
· Data Sources and Search terms
measured continuously to assure quality and patients'
We conducted this review using a comprehensive
satisfaction. Patients' satisfaction with in-hospital
search of MEDLINE, PubMed and EMBASEfrom
pain management can be estimated using the Hospital
January 1987 to March 2017. The following search
Consumer Assessment of Health Providers and
terms were used:post-operative pain mechanism,
Systems (HCAHPS) questionnaire[1].
post-operative pain management, non-opioid pain
Proper postoperative pain management, which
can be improved using a multimodal approach, results
· Data Extraction
in pain relief with minimal side effects. Enhanced
Two reviewers have independently reviewed the
recovery protocols, along with minimally invasive
studies, abstracted data and disagreements were
surgeries. Many factors play a role in failure of
resolved by consensus. Studies were evaluated for
proper postoperative pain management. These factors
Received: 8/11/2017 DOI: 10.12816/0043821
Accepted: 18/11/2017

Full Paper (vol.704 paper# 22)

c:\work\Jor\vol704_23 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 664-669

Primary Immuno-Deficiencies in Pediatrics
Nouf Abdullah Aljehani1, Thamer Fahad Sallum2, Abdulghaffar Talal Halawani3, Alwah
Mohammed Alqahtani1, Khaled Dakhel Alahmadi1, Hassan Mohammed AL Awadh4,
Abdullah Mohammed Alkhawajah5, Ahmed Abdulhadi Alhajji4, Faisal Abdullah Malwi5,
SulaimanMohammed Aldhalan6, Sara Falah Alsahafi7, Salmah Mojeer Aljahdli3, Mayada
Salem Alwafi3, Hassan Habeeb Alamer4, Anmar Ahmed Sultan8, Maria Mohammed Al-Shehab9.
1 King Abdulaziz University, 2 Majmaah University, 3 Umm Al-Qura University, 4 King Faisal University,
5 Maternity and Children Hospital ­Alhasa, King Khalid University, 6 King Saud University,
7 Battarjee Medical Collage, 8 King Salman bin abdulaziz hospital, Primary Health care
Corresponding Author: Nouf Abdullah Aljehani - Dr-nouf.alj@hotmail.com - 0506968999

There are many different types of primary immunodeficiency syndromes, with an overall
prevalence of one in every 2,000 children in the United States. These syndromes are broadly classified as B-
cell, T-cell, phagocytic, complement, or combined immunodeficiency disorders, mainly affecting children from
a very young age.
Methodology: We
conducted this review using a comprehensive search of MEDLINE, PubMed, and EMBASE
from January 1987 to March 2017. The following search terms were used: immunodeficiency syndromes, B-cell
disorder, T-cell disorder, complement disorder, phagocytic diseases, diagnosis of primary immunodeficiency,
newborn screening
Aim of the work: In this study we aimed to understand the various common types of primary
immunodeficiency syndromes, and also study their diagnosis and screening methods.
Conclusion:Early diagnosis with the help of newborn screening and data recording can help in reducing
significant mortality and morbidity of children born with such disorders. Primary health care providers and
pediatricians must keep a high degree of suspicion as many times the presentation can be subtle.
Keywords: B-cell disorder, T-cell disorder, complement disorder, phagocytic diseases, diagnosis of primary
immunodeficiency, newborn screening


Over 180 primary immunodeficiency diseases
had been identified, and that number is increasing as
immunodeficiency syndromes, B-cell disorder, T-
the genetic technology advances allowing further
cell disorder, complement disorder, phagocytic
identification of detailed defects of immunity. The
diseases, diagnosis of primary immunodeficiency,
prevalence of these diseases differs. In the United
newborn screening.
States, the overall prevalence of confirmed and
Data Extraction
diagnosed primary immunodeficiency disease is
Two reviewers have independently reviewed the
assessed to be one in 1,200 persons; while among
studies, abstracted data and disagreements were
individuals younger than 18 years of age, it is
resolved by consensus. Studies were evaluated for
rounded to be one in 2,000[1]. The most common
quality and a review protocol was followed
types of primary immunodeficiency disease in
pediatric population in the United States are
The study was done after approval of ethical
antibody disorders, and then followed by combined
board of King Abdulaziz University
B-cell and T-cell disorders, phagocytic defects, and

lastly complement disorders[2].
B-cell/Antibody Disorders

Across the world, antibody disorders are the
most prevalent type of primary immunodeficiency
· Data Sources and Search terms
disease. Antibody disorders constitute 55% of
primary immunodeficiency diseases amongst
comprehensive search of MEDLINE, PubMed and
patients who are entered in the European Society for
EMBASEfrom January 1973 to March 2017. The
Immunodeficiency's (ESID) registry; in the United

States, 78% comprise an antibody disorder.
Received: 9/11/2017 DOI: 10.12816/0043822
Accepted: 19/11/2017

Full Paper (vol.704 paper# 23)

c:\work\Jor\vol704_24 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 670-680

Enhanced Depth Imaging Optical Coherence
Tomography: A Study of the Choroid in High Axial Myopia
Samar O Zayed, Sherif Z Mansour, Ayman A Gaafar, Abdel Rahman G Salman
Department of Ophthalmology, Faculty of Medicine, Ain Shams University
Corresponding author: Samar O Zayed, Mobile: 01001729041; Email: samar_os_zayed@hotmail.com

High myopia is one of the main causes of visual impairment worldwide. About 1% of the
population has high myopia. There is significant evidence from research with animal models and humans
that the development of refractive errors is associated with changes in the structural characteristics of the
choroid. Studies from a range of different animal species, including chicks, macaque monkeys, indicate that
alterations in choroidal thickness (CT) can precede and accompany the development of myopic refractive
errors. Aim of the Work: The aim of this study was to evaluate the choroid by Enhanced Depth Imaging
OCT, as regards to its morphology and thickness in high axial myopic patients. Patients and Methods: The
controlled cross sectional study that was conducted on a consecutive series of subjects attending outpatient
clinic of Ophthalmology Department, Ain Shams University. The patients were divided into two groups:
Study group (group I): includes 100 high axial myopic eyes (more than -6.00 diopters) and Control group
(group II): includes 100 emmetropic eyes. Results: According to ANOVA test and Tukey HSD post
ANOVA test), choroidal thickness changed significantly with different measurement location, with the
thinnest choroid observed in the 3 mm nasal and the thickest choroid in the 3 mm upper. CT varied
significantly across the myopic subgroups and the emmetropic control group at all the locations (^P
Ia,b,c,d,II <0.001 and #P I/II <0.001 for all locations).By plotting multiple regression analyses for myopic
patients to show which factor in the study was the most important determinant of subfoveal CT and CT in
different positions. It was found UCVA (LogMar) was the most important determinants for SFCT and all
other locations in all study groups.SFCT ( =162.66), (p<0.001) and (95% CI=147.62­177.70), CT 2 mm
nasal ( =156.29), (p<0.001) and (95% CI=141.40­171.18), CT 2 mm temporal ( =122.88) (p <0.001) and
the (95% CI = 109.83­135.92), CT 2 mm upper ( = 183.27 ), (p<0.001) and (95% CI=168.30­198.24) and
CT 2 mm lower ( = 164.5), (p<0.001)and the (95% CI=149.74­179.39). Conclusion: Our study along with
the comprehensive meta-analysis showed that the choroidal thickness is significantly lower in high myopic
eyes than control emmetropic eyes. UCVA, AL and the presence of posterior staphyloma are the significant
predictors of CT in high myopia and must be taken into account when interpreting the data on CT. Given the
large number of people with myopia in the world, these findings seem to have widespread implications.
Keywords: enhanced depth imaging, OCT, choroid, axial myopia.


High myopia (defined as -6.00 diopter or
choroidal thinning is due to significant thinning of
more) is one of the leading causes of visual
the choriocapillaris and focal lack of vessels (6).
impairment in the world (1). The prevalence of
Choroidal thickness is important for
high myopia, varies according to ethnic groups
understanding and evaluating various choroidal
and countries. It is more common in Asian
pathologies. With increasing knowledge and
population with rates of 9-12% in comparison to
technological advances, SD-OCT becomes an
2-4 % in white population (2).
important imaging modality used in routine
In high myopia, excessive high axial
practice. Choroidal pathology has been shown to
elongation of the globe can cause biomechanical
be part of some common diseases in
stretching and thinning of choroid and RPE
ophthalmology, such as diabetic retinopathy and
(retinal pigmented epithelium (3). The axial length
age related macular degeneration, which is the
is a parameter that rarely changes after growth
leading cause of irreversible severe central visual
period, around 20 years of age, whereas posterior
acuity loss in people older than 50 years in the
staphyloma can increase with high myope at
developed world (7).It was reported the successful
adulthood (4).It was found that the choroidal
examination and measurement of choroidal
thickness is related to high myopia, the choroid in
thickness in normal and pathological states (8).
high myopia has been demonstrated to be
They also demonstrated the ability of the SD-OCT
markedly thinner compared to normal eye (170-
to show an inverted OCT image by moving image
220 um) both histologically (5) and with Spectral
closer to the patient eye. Since the SD-OCT
Domain-Ocular Coherence Tomography (SD-
detection has the highest sensitivity near zero
OCT). Histologic studies demonstrated that this
delay, the choroid is closer to the zero delay line
Received: 14/10/2017 DOI: 10.12816/0043823
Accepted: 24/10/2017

Full Paper (vol.704 paper# 24)

c:\work\Jor\vol704_25 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 681-685
Etiologies and Management of Postural Tachycardia
Syndrome in Children
Nasser Salem M Alanazi1, Ahmed Salem M Alanazi1, Khalid Hashim J Alanazi1,
Hamad Mohammed Al-Selaimy2, Eman Abdulrahim A Alfaraj3, Fatimah Hamad S Alfeheid1, Safa
Abdulaziz Sharaf Qasem1, Ismail Nizar O Kraiz4, Rakan Ahmed I Alshuwaier4,
Noor Khalid Abdulrazaq Aljarba5, Abdullah Omar Abdullah Al-Orabi6
1Arar Maternity & Pediatric Hospital, Arar, 2 King Abdulaziz Medical City, National Guard Health Affairs,
Riyadh,3 Almaarefa Medical College, Riyadh, 4 King Khaled University Hospital, Riyadh,5 Ibn Sina National
College for Medical Studies, Jeddah, 6 Al-Iman General Hospital, Riyadh, KSA.
*Corresponding author: Name: Nasser Salem M. Alanazi, E-Mail: nasser-0077@hotmail.com
Postural tachycardia syndrome (POTS) is a chronic condition with frequent symptoms of orthostatic
intolerance or with sympathetic activation and excessive tachycardia while standing, without significant
hypotension. The aim of this review was to discuss the pathogenesis and to outline the diagnosis and treatment
guidelines. We conducted a literature review of articles published up to 2017, in following databases; PubMed,
and Embase investigating postural tachycardia syndrome in children. We restricted our search to only English
published articles with human subjects concerning children under 16 years. POTS is a disorder of the autonomic
nervous system that could create considerable disability amongst previously healthy people. Patients with POTS
show a HR rise of 30 bpm within 10 min of standing (or greater in kids), are typically hyperadrenergic, and
tend to have a reduced blood volume. The pathophysiology of POTS is complex and the result of a variety of
separate systems producing a common pattern of signs. The specific pathogenesis of POTS has yet not been
completely clear. A variety of uncommon factors might be involved in the pathogenesis. Selecting the correct
therapy according to the detailed pathogenesis could absolutely enhance the efficiency of medicine. Treatments
targeting the hypovolemia and the excess sympathetic nervous system activation may assist eliminate symptoms.
Keywords: Tachycardia, Etiology, Children.


(for ages 13 years and younger), or 120 beats/min
Postural tachycardia syndrome (POTS) is
(for ages 14 years and older) within 5 min of head-up
among the most common types of orthostatic
tilt, along with the symptoms of orthostatic
intolerance in kids (1). The main indication of POTS
intolerance for pediatric POTS. In a cross-sectional
is sinus tachycardia pertaining to the position change.
study, consisting of 1449 children and adolescents
The clinical orthostatic symptoms vary, such as
aged 6- 18 years, Zhao et al.(5) suggested that POTS
dizziness, headache, chest tightness, chest pain, pale
need to be suggested in kids and adolescents when
skin, tiredness, presyncope, and syncope. For the
the orthostatic HR increment 40 beats/min, or
medical diagnosis of POTS, previous standards,
absolute orthostatic HR 130 beats/min (for ages 12
which was also related to the medical diagnosis of
years and younger), or 125 beats/min (for ages 13
grown-up patients, postulated the visibility of an
years and older) within 10 min relocating from
orthostatic heart rate (HR) increment of at least 30
supine to upright setting. The data of the existing
beats/min or an absolute orthostatic HR of a
prevalence of POTS in kids and adolescents at a
minimum of 120 beats/min within 10 minutes of
variety of age are still doing not have; nevertheless,
active standing or passive head-up tilt, connected
Lin et al. (6) carried out a cross-sectional investigation
with orthostatic signs and symptoms (2). Nonetheless,
in Kaifeng City, Henan Province, China, where 600
there have been researches recording a bigger HR
Chinese children and adolescents aged 7-18 (11.9 ±
changes during the orthostatic progress in
3.0) years were analyzed via questionnaires and the
adolescents than adults (3). Therefore, the orthostatic
upright examination. Their outcomes suggested that
HR requirement for the medical diagnosis of adult
the prevalence rate of POTS in Chinese children and
POTS might not be appropriate for children and
adolescents was 6.8%, and there was no considerable
adolescents and need to be reviewed. Singer et al. (4)
sex difference in patients.
recommended that it appertained to use the
Postural tachycardia syndrome (POTS) is a
requirements that the orthostatic HR increment 40
chronic condition with frequent symptoms of
beats/min or absolute orthostatic HR 130 beats/min
orthostatic intolerance or with sympathetic activation
Received: 25/10/2017 DOI: 10.12816/0043824
Accepted: 05/11/2017

Full Paper (vol.704 paper# 25)

c:\work\Jor\vol704_26 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 686-691

Assessment of Knowledge and Adherence of Pediatric Residents to
Saudi Initiative Asthma (SINA) Guidelines in Saudi Arabia
Ismail Hassan H Almakrami *, Emad Ali M Alzahrani, Saad Ahmed Alqarni
King Abdul Aziz University
Background: Asthma is a chronic disease that infect adults and children. It results in chronic symptoms of
airflow obstruction. Developing and developed countries showed increase in asthma prevalence. The Saudi
Initiative for Asthma (SINA) was developed in 2009 with attention to non-asthma specialists.
To evaluate the knowledge and attitude of pediatric residents to Saudi Initiative Asthma (SINA)
guidelines. Methods: This study is a cross sectional study included 153 residents from different residency
levels. Results: The female participants represented 60.1%, while males represented 39.9%. There were
79% had low knowledge and 21 % had high knowledge. The prevalence of attitude represented 57.51%.
Knowledge was low between residents, while attitude was moderate.
SINA guidelines, initiative asthma, pediatric residents.


Asthma is one of the most chronic diseases in
regarding the National Asthma Protocol and 39%
both adults and children [1]. It causes chronic
only met the standards of the national guidelines
symptoms of airflow obstruction [2]. Over the last
in management of asthma. A study by
three decades, the prevalence of asthma has been
Abudahish and Bella [12] showed that the
increased in developing and developed countries
knowledge of primary health care physician in
[1], it was estimated that 8% of the world
Saudi Arabia, Asser region was poor (37%). In a
population are suffering from bronchial asthma
study by Mobureek ,et al. [13], it was reported that
four of Riyadh major hospitals didn't follow the
There are several countries that have been
Saudi National Asthma Protocol guidelines.
reported to have the highest asthma rates

including New Zealand, Australia and the United
In 2009, the Saudi Initiative for Asthma
Kingdom, while lowest rates were reported for
(SINA) was developed with special attention to
India and Indonesia [1]. Several studies were
non-asthma specialists including general practice
established in Saudi Arabia to estimate the
physicians and primary care physicians [14,15].
prevalence of asthma, one of them [4] showed that
SINA guidelines were updated in 2016 [16]. As
prevalence of asthma increased from 8% to 23%
several studies showed low knowledge and
in the period from 1986 to 1995. Another Saudi
adherence to guidelines, so the aim of this study
study [5] reported that the asthma prevalence in
is to assess the knowledge and attitude of
urban and rural children was 13.9% and 8%
pediatric residents to Saudi Initiative Asthma
(SINA) guidelines.
The prevalence rate of asthma in Saudi

Arabia has been reached to 10-24% [6]. The
increase in prevalence, mortality and morbidity of
This study is cross ­sectional study on
asthma may attributed to increased exposure to
pediatric resident in Saudi Arabia which
indoor allergens, urbanization, occupational
performed by sending them an electronic
exposure [7], improper use of medications [8],
questionnaire that assess their knowledge and
incompetent medical care and delay in asthma
adherence to SINA guidelines. The data collected
diagnosis [9,10]. Proper diagnosis and management
from Saudi Thoracic Surgery Society and several
of bronchial asthma patients can save their
hospitals in the period from June 2017 to
suffering and medical cost [11].
September 2017. An ethical approval was taken.

Data were analyzed by using Statistical Package
In order to improve the quality of asthma
for Social Studies (SPSS 22; IBM Corp., New
care, clinical guideline for its diagnosis and
York, NY, USA). Categorical variables were
expressed as percentages. Chi square test was
knowledge and adherence levels to guidelines are
used for categorical variables. P-value <0.05 was
low, in a Saudi study [2] by Al-Kabbaa et al. it
considered statistically significant.
was found that the level of awareness between
The study was done after approval of
the primary care physicians was low (52%)
ethical board of King Abdulaziz university.
Received:23/11/2017 DOI: 10.12816/0043825
Accepted: 03/12/2017

Full Paper (vol.704 paper# 26)

c:\work\Jor\vol704_27 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 682-698

Congenital Extra-Cardiac Vascular Anomalies as Detected on Multislice
Computed Tomography Angiography
Taisir J Alsalihi, Samer Malak, Nermeen N Halim
Department of Radio-diagnosis Faculty of Medicine, Ain Shams University
Corresponding author: Taisir J Alsalihi, Mobile: 01011569494, Email: dr.taiseer2009@gmail.com

Accurate evaluation of extra cardiac and intra cardiac anomalies in congenital heart diseases
(CHD) is vital for diagnosis and treatment. Trans-thoracic echocardiography (TTE) is the classical choice
for children suspected to have CHD because TTE is safe, readily available and its capacity to perform
Doppler flow studies therefore can measure hemodynamic parameters. Plus its ability to evaluate intra
cardiac abnormalities like atrial septal defect and ventricular septal defect. Therefore, owing to its lower
spatial resolution and limited acoustic window; it is not precise in evaluation of extra cardiac abnormalities.
Aim of the Work: to evaluate the advantage of recent advances of ECG gated MDCT in diagnosis of
congenital heart disease in pediatrics and assessment of associated extra cardiac abnormalities within the
great vessels in comparison with echocardiography findings. Patients and Methods: The current study
was carried out on 36 patients in Radio-diagnosis Department, Faculty of medicine, Ain Shams University
and specialized private radiology centers. The patients were referred from pediatric hospital, cardiology
clinic with their echocardiographic reports to radio-diagnosis department, cardiac imaging unit with a view
to execute ECG- gated multi-slice CT of the heart & extra-cardiac great vessels. Results: In this study
aortic anomalies represent the most common extra-cardiac anomalies accounting for 36.5% of our cases
while comprising: Supravalvular aortic stenosis; 4.3%, Aortic CoA; 26.1%, arch anomalies with vascular
rings; 52.2% and finally anomalous coronary arteries; 17.4%. By Using MDCT we were able to delineate
eight cases of right aortic arch (RAA).Two of them with aberrant left subclavian artery (ALSCA) adding to
two cases of left aortic arch with an aberrant right subclavian artery (ARSCA). On the other hand ,TTE
failed to identify 6 cases of RAA with a sensitivity 75%, specificity 100%, NPV 96.61% and one case of
ALSCA with a sensitivity 50.0%, specificity 100%, NPV 98.41% .Regarding coronary anomalies , Cardiac
CTA succeeded in characterization of origin and course of all coronary abnormalities encountered in our
study encompassing 4 cases specifically anomalous LAD from right coronary sinus running a prepulmonic
course anterior to RVOT , RCA from LAD and single coronary artery adding to LCX- RV coronary fistula.
While TTE failed to depict two cases of the coronary anomalies with a sensitivity of 50%, specificity
100%, PPV 100% and NPV 96.83%.
Conclusion: CTA can provide the confident detection and exclusion of extra- cardiac vascular
abnormalities with superb anatomical description which was feasible with a sensitivity 98.41%, specificity
99.76%, PPV 96.88% and NPV 99.88%.
Keywords: Congenital heart disease, extra-cardiac vascular anomalies, multislice CTA.


Congenital heart diseases (CHD) are the most
accuracy in characterizing extra cardiac thoracic
frequent types of birth defects. For the moderate
structures like the aorta and the aortic arch
and severe forms, the incidence of CHD is
branches, the pulmonary arteries and their
branches, the pulmonary veins, or associated other
(1).Comprehensive anatomic assessment in
vascular structures and airways (2).
complex CHD is crucial for adequate patient
Cardiac catheterization provides most of the
management. Trans-thoracic echocardiography
ancillary requisite information, but it is invasive in
(TTE) along with cardiac catheterization serves as
nature and therefore entails inherent complications
the cornerstone modalities in complex CHD
aside from the exposure to ionizing radiation and
primary evaluation. A high proportion of extra-
iodinated contrast administration. Moreover,
cardiac vascular and non- vascular malformations
cardiac catheterization is not informative
are peculiar for CHD. Those further common
regarding associated airway pathology (3).
abnormalities may influence the precise planning
The capability of electrocardiography-gated
of corrective or palliative surgical or non-surgical
computed tomography-angiography (ECG-gated
therapy. In patients with complex CHD, TTE with
CTA) to accurately volumetrically image the
color Doppler provides excellent delineation of the
morphologic features of complex CHD has been
intracardiac anomalies comprising hemodynamic
well portrayed in adults and young patients (4).
evaluation as well. However, TTE had less
Moreover, retrospectively ECG-gated helical CT
Received: 17/10/2017 DOI: 10.12816/0043826
Accepted: 27/10/2017

Full Paper (vol.704 paper# 27)

c:\work\Jor\vol704_28 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 699-702

Assessment of The Awareness toward Cancer Cervix, Early Detection and
Prevention of Risk Factors among Saudi Males and Females
1 Abdulrahman S. Almajnuni, 1Abdulaziz S. Balubaid, 1Abdulaziz S. Alzhrani,
1Mohammad S. Alkayyal, 2 Hassan saleh allam , 1Abdulaziz S Alghamdi ,
3Abdel Magid Aly Abdou *, 3 Mamduh Abdel Fatah Sheba *
1- King Abdul-Aziz University Hospital,2- King Abdul-Aziz University, Faculty of Medicine,
Rabigh Branch,3-* Faculty of Medicine, Rabigh, Jeddah

Cervical cancer is the third most common malignancy in women worldwide, and it remains a
leading cause of cancer-related death for women in developing countries
Aim and objectives:
the aim of the paper is to assess and increase the awareness toward cancer cervix, early
detection and prevention of risk factors among Saudi males and females.
Materials and Methods:
a cross-sectional descriptive study was carried out among 740 Saudi males and
females above the age of 16 years. The participants were randomly enrolled in this study.
the participants 446 (60.3%) females and 294 (39.7%) males were included in the study. Majority
of the participants (n= 547, 73.9%) have heard about cervical cancer but most of them didn't know that it is a
preventable disease (n= 359, 48.5%). We found that; only 17.6% of the study group has heard about HPV
Vaccine. It could be attributed to low level of knowledge about the virus itself, since only 19.9% of the
population knew about the virus.
there is a great need to increase the educational standards of the society and improve the
information and knowledge about this important disease to reduce the number of patients as well as raising
the health status of the populations.
Cancer Cervix, Prevention, HPV Vaccine.


a structured questionnaire was designed to assess
Cervical cancer is the third most common
the awareness of cervical cancer, early detection,
malignancy in women worldwide, and it remains a
and prevention of risk factors in both male and
leading cause of cancer-related death for women in
developing countries (1).Over 500,000 new cases
Pre-testing of the questionnaire was done on 10
are diagnosed each year. Approximately 80 percent
respondents, after which necessary changes were
of cervical cancer cases occur in low
made, and the questionnaire was re-administered.
socioeconomic countries where it is the most
The questionnaire was translated from English to
common form of cancer (2). Cervical cancer ranks
Arabic language and distributed as electronic form
as the 12th most frequent cancer among women in
and hard copies .
Saudi Arabia (3).The association between cervical
IBM-SPSS version 21 used to generate statistical
cancer and Human Papilloma Virus (HPV)
infection have been clearly documented, so
The study was done after approval of ethical
prevention of HPV infection will lead to prevention
board of King Abdul-Aziz University.
of cervical cancer. Vaccination against HPV should

be used for both males and females (4). Survey
studies previously done on awareness towards
Four hundred and sixty-four (60.3%) of the
cancer cervix and the role of HPV vaccine were
participants were females and 294 (39.7%) males
more focused on females (5).
were included in the study. Regarding level of

education of the participants most of them were
university level 537 (72.6%). Regarding the
a cross-sectional descriptive study was carried
question, Do you work or study in a medical field,
out among 740 Saudi males and females above the
492 (66.5%) answered by No, while 248 (33.5%)
age of 16 years. The participants were randomly
answered by Yes. Regarding the Age of the
enrolled in this study.
participants, the minimum age was 16 years old,
the maximum was 59 and the mean was 25.9.

Received: 2/9/2017 DOI: 10.12816/0043827
Accepted: 30/9/2017

Full Paper (vol.704 paper# 28)

c:\work\Jor\vol704_29 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 703-707

Prevalence and Risk Factors for Gallstone Disease in Hail Region
Saleh Muflih Alghaythi, Jaber Hathloul Alshammri, Fouad Taiwilaa Alshammari, Fayez Nashi

Alshammari, Abdulrahman Yousef Al-Muzaini, Meshari Sultan Turki Alsudayri, Aqeel Jazaa Alshammari
University of Hail
Corresponding Author: Saleh MuflihAlghaythi ,+966508073018,email: q1pe54@gmail.com
Aim of the work:
this study was carried out to determine the prevalence and risk factors of the occurrence of
gallstone disease among the Saudi Arabian population. Patients and methods: a retrospective survey was done
among 100 patients with gallstone disease from November 2016 to March 2017 using a structured data collection
tool. Results: The results showed that 60% of those with the disease were women, while only 40% were men and
29% belonged to age group 30-39 years old. Among the risk factors studied, there was a statistically significant
association between the disease and fever and lipid profile, total cholesterol, LDL, and TAG (p-value,<.01). In
addition to fever, majority of the patients also complained for right upper quadrant pain. Perhaps primary health
care physicians should consider fever with right upper quadrant pain as warning signs for gallstone disease which
should warrant more sensitive procedures like ultrasonography for early detection of the disease. Fundamental
knowledge of gallstone disease is essential for clinicians so as proper management be offered to ailing patients.
Keywords: gallstone disease, cholelithiasis, cholecystectomy.


Gallstone disease or cholelithiasis is prevalent
is of increasing health importance. There is scarcity of
worldwide and is a major cause of morbidity and
studies on the prevalence of gallstone at a community
sometimes mortality among the affected individuals. A
level in Saudi Arabia. Looking at the public health
study in Western countries revealed that the
standpoint, it is not only important to study the
prevalence of gallstone disease reportedly ranged from
background prevalence of gallstone disease, but also to
approximately 7.9% in men to 16.6% in women(1).In
explore the demographic and biological markers
Asians it ranged from approximately 3% to 15%, it is
related to its development. As gallstone disease can
nearly non-existent among Africans (less than 5%) and
result in serious outcomes, such as acute gallstone
ranged from 4.21% to 11% in China(2). Gallstone
pancreatitis and gallbladder cancer, knowing the
disease became increasingly prevalent in Saudi Arabia,
factors that can contribute to its development may help
where cholecystectomy was among the most common
people to modify their lifestyle and other relevant
abdominal operations (3).A study in Asir Region, KSA
activities. Hence, this study was carried out to
documented 320 cholecystectomy procedures per year
determine the prevalence of the disease among the
which only reflected the magnitude of symptomatic
Saudi population and to explore the potential risk
gallstone disease cases in this region (4).
factors for gallstone disease and to improve the
In other reports, more than 70% of individuals
understanding of the overall pathogenesis of this
had asymptomatic gallstone disease (5,6).From a
medical economic perspective, gallstone disease was
among the most common reason for hospitalization
This study utilized a retrospective study design
.Many studies reported that gallstone disease was
where data of patients with diagnosed gallstone were
related to age, sex and metabolic disorders, such as
extracted and collated using the structured data
obesity, dydlipidemiaand type 2 diabetes (8-10).
collection tool. A total of 100 cases were reviewed
A study among female teachers in Northern
during the months of November 2016 to March 2017.
Jordan revealed that gallstone disease was positively
The study was done after approval of ethical board
associated with age and body mass index (BMI)
of Hail university.
.The pathogenesis of gallstone disease was
suggested to be multifactorial and probably developed
from complex interactions between many genetic and
environmental factors (12,13).With the change in
characteristics of the patients with gallstones. Sixty
lifestyle such as the Westernization of dietary habits
percent (60%) were females, while the remainder
and a decrease in physical activity among Saudis in
(40%) were males; 28% belongedto age-group 30 to
recent years, it can be suggested that gallstone disease
39, 23% belonged to age-group 40-49; 98% were

Saudis and 88% were married.
Received: 21/9/2017 DOI: 10.12816/0043829
Accepted: 30/9/2017

Full Paper (vol.704 paper# 29)

c:\work\Jor\vol704_30 The Egyptian Journal of Hospital Medicine (January 2018) Vol. 70 (4), Page 708-712

Role of Systematic Steroids in Sepsis and Septic Shock Treatment
Outcome: A Systematic Review
Jumana Sahal Malibari
College of Medicine, Umm Al-Qura University, Saudi Arabia
*Corresponding author: Jumana Sahal Malibari, E-Mail: jumana.melebari@gmail.com

The use of restorative corticosteroids in very ill patients with sepsis is disputable. This study
aiming at evaluation of evidence supporting use of corticosteroids therapy for prevention of septic shock in
patients with severe sepsis. Methods: The electronic search was conducted in Medline and Embase
databases using specific search terms. The search resulted in 106 relevant articles. The primary screening
for relevance of this articles lead to exclude of 101 titles and only 5 studies were finally included in this
review. Results: The review included 5 double-blind randomized clinical trials, 4 of them were prospective,
and one retrospective study. Overall sample size (n= 1157 patients) in the prospective studies and (n=328
patients) in the retrospective study. Mean age ranged from (50 to 65 years) in the prospective studies and it
was 65 years in the retrospective study.
Conclusions: This review could not support the evidence of using corticosteroids in the management of
patients of sepsis especially those at risk for development of septic shock.
Keywords: Steroids, Sepsis, Septic Shock, Management.


The corticosteroid therapy role in the
have more immunosuppressive effects, and some
management of septic shock has been argued for
more than fifty years. As septic shock stays a
mineralocorticoid and vasoactive effects. This,
common condition resulted in substantial
morbidity, mortality, and economic cost, there is
glucocorticoids are emitted in a pulsatile way in
proceeded with enthusiasm for recognizing novel
health, major surgery and critical illness justified
operators or new uses of existing medications that
further investigation of the impacts of the
may enhance result of therapy (1). In spite of the
individual medications and the doses utilized(7).
many demonstrated mitigating properties of
The low-dose hydrocortisone (200-300
mg/d) used in the treatment of patients with very
investigations using different non-human models
severe sepsis and septic shock not evident. The
of septic shock, and numerous episodic positive
updated guidelines for the use of hydrocortisone
reports in clinical sepsis, multicenter clinical trials
based on 14 randomized clinical trials (RCTs)(8).
have not succeeded to help this type of treatment.
In the study by Annane et al.(9) in patients with
Clinical trials again raise the likelihood that
relative adrenal insufficiency hydrocortisone
corticosteroids may enhance results from severe
decline mortality and increase reversal of septic
sepsis (2). These new investigations, may contrast
shock. In the CORTICUS study (10), septic shock
past methods, since relative low doses of
was managed in a lesser period of time but
corticosteroids are used over long time (3).
survival rate was not improved. The elevated risk
The use of restorative corticosteroids in
of death and septic shock degree in the study by
very ill patients with sepsis is disputable. Tow
Annane et al.(8) brought about more prohibitive
essential inquiries still exist in this type of
suggestions for hydrocortisone utilize just in
patients. First, is there a very ill patients group
patients with insufficient reaction to fluid and
who have inadequate corticosteroids, and if this is
vasopressor resuscitation. However, septic shock
the case, how to managed them (3)? Second, do all
reversal in the CORTICUS study was accounted
very ill patients benefit from steroids? These
for to be fundamentally quickened by the
inquiries have been researched fundamentally in
organization of hydrocortisone regardless of the
those patients with septic shock, also, adequate
adrenal reaction to corticotropin. A global accord
investigations have been directed to permit
articulation suggested changing the terminology
numerous Meta -analyses(4-6), counting the late
relative or absolute adrenal insufficiency, which
Cochrane review (4). However, not all
mean only adrenal cortisol secretion, by the
corticosteroids are similar. Even at dose
critical illness­related corticosteroid deficiency
equivalency, some of them (e.g., dexamethasone),
(CIRCI) concept(11). This study aiming at
Received: 5/11/2017 DOI: 10.12816/0043830
Accepted: 15/11/2017

Full Paper (vol.704 paper# 30)