c:\work\Jor\vol711_1 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2214-2216

Serum Procalcitonin and C-reactive Protein Level as Markers of
Bacterial Infection
Fahad Hassan Alami Hakami
MOH Public Health Center, Gizan City, KSA,email: boss7711@hotmail.com

C-reactive protein (CRP) and procalcitonin (PCT) are useful diagnostic tools used to estimate
the risk of bacterial infection and the severity of the infection. The accurate diagnosis of bacterial infection is
crucial to avoid unnecessary antibiotic use and to focus on the appropriate therapy.
Aim of the work:
this study aimed to summarize the sensitivity and specificity of both PCT and CRP and
their serum levels as markers in bacterial infection
Methods: scientific websites were used to search for articles such as Pubmed and Google Scholar. Several
keywords were used to obtain all possible articles about the subject.
Conclusion: overall accuracy of PCT markers is higher than that of CRP markers in differentiation of
bacterial infections
Keywords: prolactonin, C - reactive protein, markers, bacterial infection


Bacterial infection is primarily a clinical
medical costs. There is a need for an effective and
concept that may require the use of supportive
accurate biochemical marker to support, or
bedside or laboratory tests to confirm or exclude.
exclude the diagnosis of infection.
There are two broad factors that are always

necessary to confirm the diagnosis: inflammation
Bacterial resistance
or systemic dysfunction and direct or indirect
Emerging bacterial resistance to antimicrobial
evidence of a compatible bacterial pathogen.
therapeutics calls for more stringent efforts to
Inflammation may be localized or result in a
reduce antibiotic overuse [5]. Towards this aim,
systemic inflammatory response syndrome
there has been considerable interest in antibiotic
(SIRS). However, these definitions have recently
stewardship programs aimed to reduce antibiotic
been criticized; e.g. in one study of >100 000
overuse by tailoring antibiotic therapy to
patients with confirmed infection and organ
individual needs of patients [6, 7]. Despite the
failure, 12% did not meet the criteria for SIRS[1].

biomarkers in different fields of medicine (for
example, D-dimers in pulmonary embolism,
In the current review, we used the internet to
natriuretic peptides in acute heart failure, troponin
get the articles related to our subject, we used
in myocardial infarction), accurate and timely
several key words like prolactonin, C - reactive
diagnosis of bacterial infections remains a
protein, markers, bacterial infection. Scientific
web sites were used for researching for articles
microbiological parameters from easy to obtain
such as Pubmed, Google Scholar and research
specimens that may be used to diagnose bacterial
Gate. We obtained 23 articles between 1992-2017.
infections and rule out other infections not in need

of antibiotic therapy have been largely lacking.
Bacterial infection and Sepsis
The main disadvantages of many current
Bacterial infection can cause sepsis [2]. Sepsis
microbiological methods are diagnostic delays
with acute organ dysfunction, namely severe
(for example, culture methods), suboptimal
sepsis is a major threat to life [2,3]. Early institution
sensitivity (for example, blood cultures) and low
of an appropriate antimicrobial regimen in
specificity due to contamination (for example,
infected patients is associated with a better
sputum cultures), whereas others are not amenable
outcome [4] and hence early diagnosis of bacterial
to routine diagnostics due to their invasive nature
infection is of primary importance. However,
(for example, lung biopsy).
some patients with an infection have minimal or

even no symptoms or signs. Not all patients who
Serum Procalcitonin and C - reactive Protein
had septic demonstrated an infection and the
Level as Markers of Bacterial Infection
widespread administration of antibiotics to all
Among several markers of inflammation and
these patients carries problems of antibiotic
sepsis, procalcitonin (PCT) and C-reactive protein
resistance, of drug toxicity and of increased
(CRP) markers are being studied to investigate
their accuracy for the diagnosis of bacterial
Received: 20/12/2017 DOI: 10.12816/0045292
Accepted: 30/12/2017

Full Paper (vol.711 paper# 1)

c:\work\Jor\vol711_2 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2217-2225

Review on Dental Implantology
Wedad Qassadi1, Tahani AlShehri 1, Amani Alshehri 1, Kholud ALonazi 1, Ibtihal Aldhayan 2
1-Alfarabi College of Dentistry, 2- Riyadh College of Dentistry

Aim of the work:
in this review, we tried to show all details about dental implant, its components, types in
the market, usage, case selection and diagnosis, indications and contraindications.
Patients and method:
Pubmed, Google Scholar have been used to search for papers that addressed dental
implantology, preoperative diagnosis of the cases and both of their medical and dental history were
considered during searching. Results: it was obvious that dental implant has been the first choice by patients
for replacing their missed teeth because of their numerous advantages specially in preserving the adjacent
teeth and esthetics, but it may be more expensive than fixed bridges or removable prosthodontics.
dental implant is a root-like structure made of titanium. It is composed of three main parts
(fixture, abutment, crown). Case selection is the main point for implant success, so, before implant surgical
procedure, the dentist asks the patient for full mouth x-ray, medical history and dental history.
: implant, types of implants, case selection.


During the last decade, implantology has
obstacles for the majority of the busy dentist
become an indispensable part of mainstream
practitioners who want to offer implant treatment
dentistry, helping dentists to improve the quality
in their practices. In this review the literature
of life of large patient populations.While implant
will make an overview on dental implant types,
treatment could often be a convenient alternative
indications and contraindications.
to conventional treatment options, in certain cases,

it is the treatment of the first choice for the
What is dental implant?
rehabilitation of severe functional, anatomical or
A dental implant is a surgical component that
aesthetic problems arising from tooth lost. This is
interfaces with the bone of the jaw or skull to
probably most striking in the treatment of the
support a dental prosthesis such as a crown,
severely atrophic mandible (1).
bridge, denture, facial prosthesis or to act as an
A couple of decades ago implant treatment was
orthodontic anchor. The basis for modern dental
reserved for specialist dental teams working at
selected universities or specialist centers who
osseointegration, in which materials such as
treated severely atrophic edentulous patients. In
titanium form an intimate bond to bone. The
the 90s, indications for implant treatment
implant fixture is first placed so that it is likely to
gradually changed from that of fully edentulous to
osseointegrate, and then a dental prosthetic is
the partially edentulous cases.
added. A variable amount of healing time is
With increasing demand, this has resulted in
required for osseointegration before either the
the process of unprecedented research and
dental prosthetic (a tooth, bridge or denture) is
development in implantology culminating in rapid
attached to the implant, or an abutment is placed
technological advances and paradigm changes in
which will hold a dental prosthetic(3).
implant design, materials and components as well
Success or failure of implants depends on the
as relative ease of the delivery of treatment across
health of the person receiving the treatment, drugs
all its stages: the patient assessment and treatment
which affect the chances of osseointegration, and
planning, implant placement and integration
the health of the tissues in the mouth. The amount
phase, the restorative treatment and the
of stress that will be put on the implant and fixture
maintenance phases (2).
during normal function is also evaluated. Planning
Although implant dentistry has evolved to
the position and number of implants is play an
become an important part of clinical practice,
important role to the long-term health of the
unfortunately the coverage of this subject both in
prosthetic since biomechanical forces created
the undergraduate and postgraduate curriculum
during chewing can be significant.
has been rather slowing, unstructured and
The position of implants is determined by the
certainly limited. Lack of recognized academic
position and angle of adjacent teeth, by lab
standards and training pathways has generated
simulations or by using computed tomography

with CAD/CAM simulations and surgical guides
Received: 20/12/2017 DOI: 10.12816/0045293
Accepted: 30/12/2017

Full Paper (vol.711 paper# 2)

c:\work\Jor\vol711_3 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2226-2231

The Effectiveness and Tolerability of Budesonide in Treatment of
Autoimmune Hepatitis: A Systematic Review
Mohammed Ahmed Alahmari, Mohammed Bakr Bazayd, Salem Hamed Alshuoqayh,
Turki Abdullah Alsulami, Hasan Hayaza Albarqi, Mohammed Hassan Al Tahnoon
Debrecen University, Maastricht University, Debrecen University, Debrecen
University, King Khalid University, Debrecen University
Corresponding author: Mohammed Ahmed Alahmari, Email: dr.resaerch222@gmal.com

Budesonide was effective in treating and keeping short-term remission with a fewer steroid-
specific side effects in contrast to prednisone. Contradicting outcomes were detailed on the efficiency of
budesonide in the management of Autoimmune Hepatitis. This review aiming at evaluating the use of
budesonide for the treatment of autoimmune hepatitis.
Methods: An electronic search was conducted in MEDLINE and EMBASE using these keywords steroids,
autoimmune, liver, effectiveness, and side effects. The search was limited to clinical setting which resulted
in 24 clinical studies.
Results: The total number of AIH patients included in this review were 386 of which 304 females (78.7%),
the sample size ranged from 9 patients to 207 and the mean age ranged from 13 years in to 54. Concerning
the efficacy of Budesonide, it ranged from 15% to 78% as the end points were different among the included
studies. Regarding the tolerability and side effects like Moon faces or cushingoid features, acne, heartburn,
hirsutism, alopecia, osteoporosis, diabetes mellitus and easy bruising. Side effects reported in X studies and
the incidence ranged from 28% to 56%.
Conclusion: Budesonide could be a promising treatment option especially in patients prone to corticosteroid
side effects like elderly individuals and postmenopausal women with high risk for osteoporosis or children
with risk for impaired growth.
Keywords: Hepatitis, Autoimmune, Liver, Treatment, Tolerability, Effectiveness


case, up to 44% of patients experience the adverse
Autoimmune hepatitis (AIH) is an
effects of symptoms prompted by prednisolone
inflammatory disorder characterized by high
when it utilized alone as, and furthermore when
combined with azathioprine still in no less than
immunoglobulin G occurs mainly in females, the
10% of patients causes prednisolone-particular
presence of autoantibodies serologically, and by
reactions (5). Ten to 15% of patients estimated are
interface hepatitis histologically, of an unknown
resistant to standard treatment and stay as
etiology (1). This inflammatory condition can cause
refractory patients with a requirement for other
cirrhosis and also increments the chance of
treatrment agents (7). There are restricted
hepatocellular carcinoma (2). Diagnosis of AIH is
information concerning the significance of
depend on histologic, biochemical, and serologic
cyclosporine (8), mycophenolate mofetil (9),
findings, in addition to signs and symptoms (3).
ursodiol (10), tacrolimus (11), Cyclophosphamide (12),
AIH has good response to immunosuppressant's
methotrexate (13), and mercaptopurine in AIH (14).
and the response is outcome dependent (4).
glucocorticoid effective as topical therapy of
(prednisolone or prednisone) alone or as
rhinitis, asthma, and inflammatory bowel disease
combination with azathioprine comprises the
(15). Since that it is 15 to 20 times higher
current standard treatment and has a high
glucocorticoid receptor binding affinity, the
remission rate in almost 80% of patients 3 years
efficacy of budesonide on liver inflammatory
later (5). Sixty-five percent to 80% of patients have
activity is much more than that of prednisolone
an effective reaction to the therapy, and while few
(16). Budesonide is derived from 16-
patients are able to stay in remission after drug
hydroxyprednisolone as a synthetic corticosteroid
discontinuation, the majority of patients,
(17) and effective in the liver as anti-inflammatory
particularly those already have cirrhosis, need
agent with lower systemic adverse effects (18), as it
long-term maintenance therapy (2). Prednisolone is
has a hepatic first-pass clearance of > 90%
the first line corticosteroid as it is very effective in
following oral use (3). In three previous pilot
reversing intrahepatic inflammation (6). In any
studies, contradicting outcomes were detailed on
Received: 20/12/2017 DOI: 10.12816/0045294
Accepted: 30/12/2017

Full Paper (vol.711 paper# 3)

c:\work\Jor\vol711_4 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2232-2237

Effectiveness of Psychological Intervention in Management of
Postpartum Depression
Abdulrahman Abdulkhaliq Abdullah Alshehri (1), Husam Mohsen Bin Alhasel (2),
Hiba Salah Abdelgadir (3)
(1) The faculty of Medicine, Albaha University, (2) Ibn Sina National College for Medical Studies,
(3) Family Medicine, UMST University
Corresponding author: Abdulrahman Abdulkhaliq Abdullah Alshehri, Email: a.a.a.z.1412@hotmail.com

: In order to prevent postpartum depression many primary preventive programs were done.
Psychological interventions are thought to be effective in decreasing the incidence of postnatal depression.
Many studies aimed to evaluate the effect of Psychotherapy in treatment of postpartum depression.
Methods: An electronic search was obtained in MEDLINE and EMBASE databases with search terms such as
psychology, postpartum, depression, intervention, effectiveness. The primary search resulted in 128 studies
which have been screened for eligibility. After exclusion of irrelevant, duplicated and review studies, 11
studies were included in the review as they met the inclusion criteria.
Results: Psychotherapy decrease the likelihood of PPD and decrease postpartum depressive symptoms,
increased awareness, depression reduction, general improvement and psychological health and prevention of
PPD, improve depression, functioning and anxiety. Training for health visitors (HVs) intervention was found
to be cost-effective in reducing the proportion of women at risk. It was only noted that there was no outcome
difference between the CBA and the PCA groups. Health visitor (HV) training was noted to have preventive
effect for depression.
Conclusions: There is evidence to recommend that interventions carried in pregnancy can be effective in
preventing postnatal depression. Interventions are mainly effective when grounded on psychological
treatments and provided to women suffering from antenatal depression.
Keywords: Psychology, Postpartum, Depression, Intervention, Effectiveness


Postpartum depression (PPD) also known as
families are less likely to develop PPD, and the vice
postnatal depression, is a mood disorder that can
versa (9-11).
occur in women associated with childbirth (during
Both counseling and medications are used in
the six weeks of the puerperium) (1). Symptoms of
the treatment of PPD. selective serotonin reuptake
PPD include anxiety, irritability, guilt, feelings of
inhibitors (SSRIs) is a drug of choice in the
extreme sadness, exhaustion, sleep disorders and
treatment of PPD. Many types of counseling and
somatic symptoms that affect the mother, children
psychological therapy were used in treatment of
and the whole family (1, 2). PPD is a global
PPD such as; cognitive behavioral therapy (CBT),
phenomenon that affect large number of women
every year. In 2013 about 8.5% ­11% of women
psychodynamic therapy (12, 13).
were diagnosed with depression during pregnancy
In order to prevent PPD many primary
preventive programs were done. Psychological
The exact cause of PPD is unknown, but it
interventions are thought to be effective in
thought that combination of physical and emotional
decreasing the incidence of postnatal depression (5).
factors which play an important role in its etiology (1,
Many studies were conducted aiming to evaluate the
4). PPD has many risk factors such as lack of partner
effect of Psychotherapy in treatment of PPD (14).
support, single marital status, recent stressful life
Interestingly, it was noted that postpartum
events, low levels of social support and few number
interventions to prevent and treat PPD were more
of children. In addition, the previous major
effective than interventions that done in the prenatal
depression is considered a risk factor to develop
and antenatal periods (15).
postnatal attack of depression (5-8). Many studies
The aim of the present systematic review is to
found that mothers who were satisfied with their
assess all randomized controls trials that studied the
Received: 20/12/2017 DOI: 10.12816/0045295
Accepted: 30/12/2017

Full Paper (vol.711 paper# 4)

c:\work\Jor\vol711_5 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2238-2242

The Risk of Renal Injury in Infants Associated with
Ibuprofen Use: A Systematic Review
Salem Hamed Alshuqayh, Mohammed Ahmed Alahmari, Abdullah Mohammed Beneissa,
Nouf Abdullah Alkhattaf, Saad Mohammed Alqahtani, Abdulaziz Aati Alharbi, Wejdan Ahmed AlBarqi
Debrecen University, Debrecen university, Debrecen University, Batterje Medical College,
King Khalid University, Ibn Sina National Collage, King Khalid University
Corresponding author: Salem Hamed Alshuqayh, Email: Alshuqayh@hotmail.com

: More recently ibuprofen, was used for the indication of the patency of ductus arteriosus closure
in preterm infants; this drug is associated similar side effects include cerebral, renal, and mesenteric circulation.
Methods: An electronic search was carried out using search terms such as "renal failure", "kidney failure",
"renal injury", ibuprofen, "side effects", "adverse effect", complications. The search in MEDLINE and
EMBASE through PubMed search engine resulted in 31 articles. These articles were screened for eligibility
criteria included studies aimed to assess renal injury caused by ibuprofen use in infants.
Results: After exclusion of irrelevant duplicated and review studies, 12 studies were included in this review.
Eight studies were randomized control, 3 retrospective evaluation and 1 retrospective cohort study. the effect of
the treatment on the renal function there are two outcomes reported either reduction in serum creatinine or
incidence of acute renal failure. Incidence of acute renal failure reported in 4 studies.
Conclusion: Although renal failure was more common in infants receiving Indomethacin compared to
Ibuprofen, oral Ibuprofen was less toxic to the kidneys than intravenous and the serum creatinine levels after
treatment did not differ, this is not significant.
Keywords: Ibuprofen, Kidney, Failure, Infants, Creatinine

of the risks related to the surgery. In a recent large
Ibuprofen is an over-the-counter non-steroidal
Canadian cohort (n = 3779) of very low birth weight
anti-inflammatory drug (NSAID) most commonly
(VLBW < 1500 g) infants, 28% required treatment
used to treat pain and fever in children (1). Like other
for a PDA; 75% were treated with indomethacin
NSAIDs, ibuprofen cause acute kidney injury (AKI)
alone, 8% with surgical ligation alone, and 17%
by decreasing renal plasma flow through its
required both indomethacin and surgical ligation.
inhibition of prostaglandin synthesis, especially in
Infants with lower birth weight were more likely to
hypovolemic patients. NSAIDs may also induce
be treated surgically (5).
kidney damage by triggering acute interstitial
Prostaglandins play a significant role in keeping
nephritis (AIN) (2).
the ductus arteriosus patent. PDA-related morbidity
The placenta and the patency of the ductus
and mortality have been shown to be reduced with
arteriosus (PDA) determine normal fetal circulation.
the use of indomethacin, which acts as an inhibitor of
After separation of the placenta and initiation of
prostaglandin forming cyclo-oxygenase enzymes (6).
breathing following birth, the closure of the ductus
However, indomethacin use has been associated with
starts and circulation changes promptly (3). However,
transient or permanent derangement of renal
in about a thirty percent of low birth weight ((LBW)
function, NEC, gastrointestinal hemorrhage or
< 2500 g) infants the PDA stays open, especially
perforation, alteration of platelet function and
during first days of life. In preterm infants, the PDA
impairment of cerebral blood flow/cerebral blood
often fails to close. The haemodynamic instability
flow velocity (7). These negative effects of
caused by the left to right shunt and associated run
indomethacin are possibly related to mechanisms
off has been shown to cause renal or gastrointestinal
other than inhibition of prostaglandin synthesis. This
effects including spontaneous perforation and
review aimed to obtain the scientific evidence about
necrotizing enterocolitis (NEC), chronic lung disease
the presence or absence of renal injury associated
and, if not managed, may lead to death. The presence
with use of ibuprofen in infants.
of a PDA is associated with reduced middle cerebral

artery blood flow velocity (4).
The surgical closure of the symptomatic PDA
An electronic search was carried out using search
reduces duration of mechanical ventilation, improves
terms such as "renal failure", "kidney failure", "renal
haemodynamics and improves lung compliance.
injury", ibuprofen, "side effects", "adverse effect",
However, medical treatment is still considered the
complications.. The data were collected for items
treatment of choice in the majority of cases because
such demographic characteristics of patients, sample
Received: 20/12/2017 DOI: 10.12816/0045296
Accepted: 30/12/2017

Full Paper (vol.711 paper# 5)

c:\work\Jor\vol711_6 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2243-2249

Prevalence of Depression among Diabetic Patients in Makkah
Adel Ahmed Alshehri1, Muath Ahmed Al-Gadouri1, Feras Majed Abdulrahim1,
Bayan Zaid Fatani1, Amal Joiber Alsaedi1, Daham Al-Daham2, Fahad D. Alosaimi3
1Umm Al-Qura University, Makkah, 2Department of Biostatistics and Bioinformatics,
King Abdullah International Medical Research Center, Riyadh,3Department of Psychiatry,
King Saud University, Riyadh, Saudi Arabia
Corresponding Author: Adel Alshehri, E-mail: Adelalshe93@gmail.com
Diabetes mellitus (DM) is a major health problem that is associated with psychological, as well
as physical, complications particularly depression. Depression is well-known to be prevalent among diabetic
patients and to be associated with poor glycemic control, poor adherence to medication, increased diabetic
complication and higher risk of mortality. Objectives: The purpose of the study is to determine the prevalence
rate of depression among diabetic patients in primary health care units and diabetic centers at Makkah city ­
Saudi Arabia, and to explore the associated factors that co-exist with depression among diabetic patients.
Methods: This was a descriptive cross-sectional study conducted on 382 diabetic patients (both type I and II)
recruited from diabetic centers at Al-Noor hospital, Hera'a hospital, and East of Al-aziziah hospital in Makkah,
KSA. Data were collected via a self-administered questionnaire including demographic variables and the Arabic
translation of Patient health questionnaire the Tunisian version (PHQ-9). The data collected were analyzed
using SAS 9.4. Results: After data analysis of the 382 participants 43.19% were males and 56.81% were
females, with a mean age of 50.28±11.43 years. The prevalence of depression was 20.68%, with 12.83%,
7.07%, and 0.79% having moderate, moderately severe, and severe depression, respectively. Hypertension,
duration of hypertension, number of co-morbidities, and high education level were significantly associated with
depression (p=0.0111, 0.0029, 0.0491, and 0.0158, respectively). The odd's ratio of number of co-morbidities
was 1.565 (p=0.0039). Conclusions: Depression and suicidality are prevalent among diabetic patients in
Makkah. When diabetes co-exists with hypertension and/or other comorbid illnesses the prevalent doubles.
Hypertension, increased number of associated co-morbidities, and high educational level are significantly
associated with depression in diabetic patients.
Keywords: Depression, prevalence, diabetes, KSA, Makkah.


Diabetes is the most common chronic
Subjects and study design
metabolic disease and one of the most common
This was a quantitative research model aimed
causes of psychological as well as behavioral
at collecting numerical data from human Participants
changes[1]. The prevalence of diabetes is
(diabetic patients) in Makkah, and the data was
progressively increasing in developing as well as
transformed to available and usable statistics. The
developed countries. Researchers have reported a
project was carried out in 10 months and
significant association between depression and
commenced in 30 December 2016. The study was
diabetes. Depression in diabetic patients is often
carried out in Makkah city Saudi Arabia. It was a
associated with poor glycemic control, poor
descriptive cross-sectional study of patients recruited
adherence to medication, increased diabetic
from diabetic centers and primary health care
complication, and higher risk of mortality[2].
facilities in the city. The hospitals the study was
Diabetes and depression are thought to be
conducted in were the diabetic center of Al Noor
bidirectional. Patients with diabetes have high
Hospital, the diabetic center of Hera 'a hospital and
incidence of depression with poor glycemic control
East of Alaziziah outpatient clinic.
and low inflammatory reaction being accused of
The study included 382 diabetic patients both
depression development, and depression worsening
types (Type I DM & Type II DM) attending diabetic
diabetic control[3]. The aim of this study was to
centers and the primary health cares. Those included
estimate the prevalence of depression among
were both males and females aged from 18 to 64
diabetic patients in Makkah city of Saudi Arabia.
years old who accepted to join the research and
The main objectives of the study were to determine
given both oral as well as written consents. Those
the prevalence rate of depression among diabetic
who were excluded were participants below the age
patients in primary health care units and diabetic
of 18, patients with gestational diabetes, patients
centers at Makkah city ­ Saudi Arabia, and to
with any endocrinopathies, patient recently
explore the associated factors that co-exists with
diagnosed with depression or treated for depression
depression among diabetic patients.
and patients with long-term corticosteroid use.

Received: 20/12/2017 DOI: 10.12816/0045297
Accepted: 30/12/2017

Full Paper (vol.711 paper# 6)

c:\work\Jor\vol711_7 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2250-2252

Causes, Diagnosis, and Management of Hypothyroidism
Mahmoud Shehab Halawani1, Ruaa Omar Nughays2, Alwaleed Fahad Altemani2, Nihal Mubarak
Mohamed Hussien3, Nuha Mohamad Alghamdi4, Farah Haytham A Alasadi2, Lina Ahmed Wasfi2,
Muath Aziz Alrehaili5, Asim Abdullah Alharbi5, Manal Mohammad Siraj6
1Ohud Hospital,2King Abdulaziz University, 3University Of Bahri, 4King Fahad Hospital,
5Taibah University, 6 AlMaarefa Colleges of Science & Technology
Corresponding Author: Mahmoud Shehab Halawani - Mahmoudsh@Moh.Gov.Sa - 0567306565

Among hormone deficiency, hypothyroidism is considered to be the most common disease, and is
subdivided into congenital or acquired, based on the onset. The exact site of dysfunction can further classify the
disease into primary and secondary. It is crucial to determine the level of severity of the disease as severe cases
may end up in a coma. On the other hand, mild cases may be asymptomatic. Diagnosis is mainly based on serum
thyroid hormones levels, and the treatment depends on thyroxine administration with an excellent prognosis.
Aim of this review: was to explore the types of hypothyroidism, its diagnosis, and study the best course of
management that must be followed.
We conducted this review using a comprehensive search of MEDLINE, PubMed, and EMBASE,
January 1985, through February 2017. The following search terms were used: hypothyroidism, myxedema,
classification of thyroid diseases, investigation of hypothyroidism, management of hypothyroidism.
Conclusion: Hypothyroidism is a common disease that usually affects females more than males. Populations at
higher risk include, old women, pregnant women, dyslipidemic patients, and patients with a history of radiation
exposure. Diagnosis is based on measurement of TSH along with the thyroid hormone levels. Management
includes administration of thyroxine, and must be done early.
Keywords: hypothyroidism, myxedema, manifestation of hypothyroidism, thyroid diseases, management of

The hypothalamaic-pituitary-thyroid axis works
· Data Sources and Search terms
as a feedback loop that plays as the main system
We conducted this review using a comprehensive
regulating thyroid hormone secretion normally. This
search of MEDLINE, PubMed, and EMBASE,
loop starts with the hypothalamus that secretes the
January 1988, through February 2017. The following
thyrotropin-releasing hormone (TRH), which in turn,
search terms were used: hypothyroidism, myxedema,
induces secretion of thyrotropin from the anterior
classification of thyroid diseases, investigation of
hypothyroidism, management of hypothyroidism
Thyrotropin will induce secretion of tri-iodothyronine
· Data Extraction
(T3) and thyroxine (T4) from the follicular cells of
Two reviewers have independently reviewed the
the thyroid. When T3 and T4 serum levels become
studies, abstracted data, and disagreements were
sufficient, this will suppress the release of TRH and
resolved by consensus. Studies were evaluated for
thyrotropin from the hypothalamus and the pituitary.
quality and a review protocol was followed
Most T3 present in the serum is the result of
peripheral deiodination of T4, with only twenty

percent secreted from the thyroid [1].
Among hormonal deficiencies, hypothyroidism
Primary hypothyroidism
is considered to be the most common disease, and is
When the pathology is in the thyroid gland itself, it
subdivided into congenital or acquired, based on the
is considered primary hypothyroidism. About half
onset. The exact site of dysfunction can further
primary hypothyroidism cases are due to autoimmune
classify the disease into primary and secondary
destruction (like chronic autoimmune thyroiditis).
(central). Hypothyroidism is also divided according
The other half is due to other etiologies or exposures.
to severity into subclinical (mild) or severe (clinical)
Silent thyroiditis and postpartum thyroiditis are
hypothyroidism. It is crucial to determine the level of
classified as a result of chronic autoimmune
severity of the disease as severe cases may end up in
thyroiditis [3].
a coma, whereas mild cases may be asymptomatic.
The prevalence and incidence if chronic
Diagnosis is mainly based on serum thyroid
autoimmune thyroiditis is about five times higher in
hormones levels, and the treatment depends on
women than men, and usually affects middle aged
thyroxine administration with an excellent prognosis
women as well as elderly and children. On histology,
diffuse infiltrates of lymphocytes are present with the
Received: 20/12/2017 DOI: 10.12816/0045298
Accepted: 30/12/2017

Full Paper (vol.711 paper# 7)

c:\work\Jor\vol711_8 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2253-2256

Methods to Improve Quality of Life in Diabetics
Mohammed Sheker Al-Kalif1, Bader Hulayyil Almansouri2, Haneen Anees Moumina3, Hussam
Mahmoud O Baeissa4, Faris Hassan Aljewayed1, Anas Mohammed Alessa5, Magran Saad Zahi Almutairi6,
Sara Mohammed Kayal3, Amal Ibrahim Alghabban7, Malik Dham Alanazi8, Zahra Issa A Al Ali9
1 Imam Abdulrahman Bin Faisal University, 2 Security Forces Hospital, 3 King Abdulaziz University,
4 King Abduallah Medical Complex, 5 King Saud University, 6 Badr Primary Care Center, 7 Ibn Sina National
College, 8 King Faisal University, 9 Maternal And Children Hospital
Corresponding Author: Mohammed Sheker Al-Kalif - Mohmed1426@Gmail.Com - 0568090896

: Severe complications and morbidities are associated with diabetes, especially with poor control of
the disease. Diabetes is thought to be the most common cause of renal failure and responsible for about half
cases of end stage kidney disease, coronary artery disease, myocardial infarctions, congestive heart failure,
strokes, foot problems and eye damage. The presence of any chronic illness with diabetes causes deterioration
clinical status which makes tight glycemic control a necessity to improve quality of life and prevent these serious
and potentially fatal complications.
Aim: This review was aimed to shine light upon measures that must be taken to improve the quality of life in a
patient with diabetes mellitus.
Methodology: We conducted this review using a comprehensive search of MEDLINE, PubMed, and EMBASE,
January 1997, through February 2017. The following search terms were used: diabetes mellitus, chronic
disorders, management of chronic diabetes, quality of life in diabetic patients, weight control, diabetic diet
Conclusion: Many factors affect the quality of life in diabetic patients including glycemic control, prevention of
complications, and socioeconomic/demographic factors. Lifestyle modifications like weight loss and good
dietary habits can help patients manage their disease better. Insulin pumps have eased the management of this
disease and improved patients' quality of life drastically. Patients should be educated about the importance of
support groups that may lead to a better quality of life.
Keywords: diabetes mellitus, chronic disorders, management of chronic diabetes, quality of life in diabetic
patients, weight control, diabetic diet.


In both developed and developing countries, the
diabetes causes further worsening in the clinical
prevalence and incidence if diabetes mellitus have
status. All this made tight glycemic control a
been increasing throughout the last forty years. The
necessity to improve quality of life and prevent these
reason behind this is thought to be the increase of
serious (and potentially fatal) complications [2].
food intake in unhealthy manners, along with

significantly decreased physical activities. The
international diabetes federation reported that about
· Data Sources and Search terms
415 million adults around the world have diabetes
We conducted this review using a comprehensive
(about one in every eleven individuals) [1]. It is
search of MEDLINE, PubMed, and EMBASE,
estimated that this number will continue to increase to
January 1997, through February 2017. The following
reach more than 600 million diabetics worldwide.
search terms were used: diabetes mellitus, chronic
Severe complications and morbidities are associated
disorders, management of chronic diabetes, quality of
with diabetes, especially with poor control of the
life in diabetic patients, weight control, diabetic diet.
disease. Diabetes is thought to be the most common

cause of renal failure and responsible for about half
· Data Extraction
cases of end stage kidney disease. Moreover, a
Two reviewers have independently reviewed the
relatively large proportion of diabetics will suffer
studies, abstracted data, and disagreements were
from coronary artery disease, myocardial infarctions,
resolved by consensus. Studies were evaluated for
congestive heart failure, strokes, foot problems and
quality and a review protocol was followed
eye damage. The presence of any chronic illness with
Received: 20/12/2017 DOI: 10.12816/0045299
Accepted: 30/12/2017

Full Paper (vol.711 paper# 8)

c:\work\Jor\vol711_9 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2257-2261

Management Approaches to Hairy Cell Leukemia; Overview
Akeelah Abdullah Al-Haddad, Batool Saad Alsalim, Huriyyah Alawi AlJarrash,
Halah Ahmad Alfaraj, Ranim Yahya Nasr
King Salman Hospital, Riyadh, Saudi Arabia
Corresponding author: Akeelah Abdullah Al-Haddad, E-mail: Akeelah.hdd@hotmail.com,
Mobile number: 00966567989356

Hairy cell leukemia is a rare disease comprising about 2% of lymphoid neoplasms. In this review, the
biology, diagnostic criteria, and current therapeutic options in HCL-V and HCL-JV are presented. We
conducted a database; PubMed and Embase comprehensive search up to December 2017, we search a relevant
trail to our concern topic (hairy cell leukemia). HCL-V is a distinct clinico-pathological entity. However,
differentiating HCL-V from classical HCL and splenic marginal zone lymphoma (SMZL), which are both
connected with noticeable splenomegaly and circulating neoplastic cells with 'hairy' projections remain a
problem. Patients with HCL-V are usually older, splenomegaly is less typical and leucopenia with
granulocytopenia and monocytopenia are generally not seen. Bone marrow is usually easily aspirable, hyper-
cellular with mild myelofibrosis.
Keywords: Hairy cell leukemia, treatment, irradiation, leukemia, management.


Hairy-cell leukemia variant (HCL-V) is an

unusual B-cell neoplasm accounting for 10-20% of
search a relevant trail to our concern topic
HCL patients and 0.4% of chronic lymphoid
(hairy cell leukemia); using following Mesh words:
malignancies, representing around 60-75 new HCL-
hairy cell leukemia;
V patients every year in the US [1].The disease
impacts the elderly populace without sexual
predominance. Its features are intermediate in
between those of classic HCL (HCL-C) and
prolymphocytic leukemia [2].The mean age of the
To identify the most related articles in the literature.
patients is 71 years. HCL-V was initially identified
To discuss more supported evidence-based review.
by Cawley et al. [1] and was later called
In addition, we scanned the references list of each
prolymphocytic variation of HCL. Unlike HCL-C,
identified articles for more relevant studies. Search
HCL-V is immune to most conventional therapies,
was restricted to English language articles and only
consisting of interferon-a (IFN-a) and purine
human subjected studies.
nucleoside analogs (PNA). Recently; HCL-V has

been included in the World Health Organization
(WHO) classification as a provisional entity, and it
is no longer considered to be biologically associated
HCL-V patients are defined by splenomegaly, a
to HCL-C [3]. HCL-V is more aggressive disease
high leukocyte count without neutropenia or
than classic form of HCL [3]. A research showed
monocytopenia and hyper-cellular marrow that can
that median survival was roughly 9 years with only
be easily aspirated [5]. Morphologically, HCL-V
15% survival over 15 years. It also revealed that
cells are similar to leukemic cells of B-cell
42% of patients died of unrelated reasons [4]. Final
prolymphocytic leukemia and HCL-C cells [6]. It
result showed that typical survival of HCL-V
consists of abundant villi, an extremely basophilic
patients is considerably much shorter compared to
cytoplasm and central, rounded, sometimes bilobed,
that of HCL-C.
indented hyperchromatic nuclei with noticeable
Hairy cell leukemia is a rare disease comprising
nucleoli [7]. HCL-V cells are smaller sized, have
about 2% of lymphoid neoplasms [1]. In this review,
greater nuclear cytoplasmic ratios and no ribosome-
the biology, diagnostic criteria, and current
lamella complexes [6]. On the other hand, leukemic
therapeutic options in HCL-V and HCL-JV are
cells of patients with HCL-V just infrequently
demonstrate reactivity to tartrate resistant acid

phosphate (TRAP) [6]. The immunephenotype of the
leukemic cells in HCL-V is CD11c+, CD10,
We Conducted a database; PubMed and Embase
CD23, CD24, CD25, CD27 and CD5 and have
comprehensive search up to December 2017, we
variable expression of CD103. Furthermore,
Received: 20/12/2017 DOI: 10.12816/0045300
Accepted: 30/12/2017

Full Paper (vol.711 paper# 9)

c:\work\Jor\vol711_10 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2262-2265

Risk Factors of Dyslipidemia among Saudi Population, 2017
Ghaedaa Saad Alzahrani, Saja Mohammad Aljehani , Jana Jamalaldeen Al-Johani
King Abdelaziz University

the dyslipidemia and its associated risk factors and co-morbid diseases are the focus of many
studies in KSA, however the data regarding the prevalence are very little. Objectives: this study aimed to
assess the risk factors of dyslipidemia and its association with the subject's demographics and life style
pattern in Kingdom of Saudi Arabia (KSA). Methods: this was a cross-sectional study based on a check list
and questionnaire sheet conducted for 6 months among 840 Saudi adults. Results: about 33%of the subjects
were suffered from dyslipidemia after checking their lipid profile and anthropometric measures. The subjects
were divided into two groups: group I included dyslipidemic subjects and group II included control subjects.
The older age and jobless subjects showed a significant association with the prevalence of dyslipidemia.
Group I showed a significant association between dyslipidemia and comorbid conditions than group II. The
irregular physical activity, consuming less healthy food and consuming more fast food are significantly
related to Group I than group II.
Conclusion: dyslipidemia is common among Saudi subjects and associated with health problem as
hypertension, diabetes and obesity as well as bad lifestyle habits.
Keywords: risk factors, dyslipidemia, Saudi population, KSA.


The dyslipidemias is defined as a multiple
Also, another study showed that dyslipidemia
syndromes in the metabolism of lipoprotein
was most frequent in diabetic patients
asdecrease or overproduction of lipoproteins. It is
characterized by high LDL in males and low HDL
considered as a significant risk factor for chronic
in females, with a subsequent increased risk of
non-communicable diseases and cardiovascular
CHD (10).
diseases (CVD) which contribute to high morbidity
Subburam et al.studiedthe association
and death rates worldwide (1). Dyslipidemia also
between dyslipidemia in diabetic patients,
impacts the health and economic status and
atherosclerosis and higher risk of coronary vascular
increased the worldwide medical costs (2, 3).
diseases and concluded that LDL dyslipidemia is
The dyslipidemia could be assessed using
widespread in T2DM patients and highlighted the
anthropometric measurements and assessing serum
urgent need for managing LDL dyslipidemia to
increase in the concentrations of triglycerides, total
suppress their risk on CVD (11).
Other studies focused on the treatment of
cholesterol (LDL-C) concentrations, with a marked
dyslipidemia have used therapeutic and lifestyle
reduction in level of the high-density lipoprotein
interventions to target additional risk factors
(HDL-C) (4, 5).In KSA the situation of dyslipidemia
associated with dyslipidemia. By improving lipid
is intensely increased with studying the economic
profile the global risk of CVD in the diabetic
impacts, dietary factors, life style habits and
patients can be reduced (12-14). Hence, many studies
demographics and showed an obvious reduction in
supported good global management and better
the encumbrance of infectious diseases (4,
control of dyslipidemia in patients with diabetes
5).However, there is no evident on an exact
type 2 which are essential in reducing the risk of
prevalence of dyslipidemia in KSA yet, but it
CVD (15, 16).
differs with different gender, distinct populations,
The hypothesis of this study was that
demographics and cultural features (6).
dyslipidemia is associated with hypertension,
The approach for evaluating the predictors,
obesity, T2DM, bad physical and life style habits.
prevalence as well as risk factors is a principal for
This study allowed to estimate the major risk
controlling and preventing this disease and
factors and pattern of dyslipidemia in KSA
contributing to decreasing it's comorbid impacts (7,
population. This study aimed to assess risk factors
8). Being overweight or obese and T2DM were
of dyslipidemia among Saudi Arabia population.
associated with high prevalence of dyslipidemia.
Also, to determine the association between
Also, changing the life style and physical activity
dyslipidemia and subject's demographics, risk
habits are linked with decreasing the risks and
factors and life style pattern.
prevalence of dyslipidemia (9).

Received: 20/12/2017 DOI: 10.12816/0045301
Accepted: 30/12/2017

Full Paper (vol.711 paper# 10)

c:\work\Jor\vol711_11 retracted


Full Paper (vol.711 paper# 11)

c:\work\Jor\vol711_12 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2274-2279

Relation of Serum Albumin Level and C- reactive Protein to
Hypotensive Episodes during Hemodialysis Sessions
Mohammed Z Hafez, Wael A Abd El Aziz, Sally M Abd El Wahab
Department of Internal Medicine, Aswan University Hospital
Corresponding author: Sally A Abd El Wahab, Mobile: 01001870782; Email: sally1111986@gmail.com

Intradialytic hypotension (IDH) remains the most common complication of hemodialysis (HD)
with potentially devastating consequences despite the technological advances regarding the hemodialysis
techniques of the last decades. The increasing number of advanced-age patients, diabetics and patients with
cardiovascular comorbidities undergoing hemodialysis emphasizes the need on implementation of new IDH
avoidance tactics. Aim of the Work: Our work aimed to evaluate serum albumin (Alb) level and C-reactive
protein level in hemodialysis patients and their correlation with dialysis-induced hypotension (DIH).
Patients and Methods: This prospective study was conducted based on data collected from HD patients
treated at Aswan University Hospital, dialysis unit, in a period from 1/1/2017 to 30/5/2017. It included 40
chronic HD patients with no history of endocrine tumors, diabetes mellitus, liver failure, heart failure, or
unstable coronary artery disease. Patients with hemoglobin less than 9 mg/dL, feverish patients, and patients
with any source of apparent infection were excluded. The age of the patients ranged from over 18 to less than
75 years. Results: : the mean value of serum albumin level in group (A) was (2.97 ± 0.71) with the highest
serum albumin was 4.4 and the lowest serum albumin was 2.1, while in Group (B) the mean value of serum
albumin level was (4.53 ± 0.74) with the highest serum albumin was 5.5 and the lowest serum albumin was
2.8. There was a significant decrease in serum albumin level in patients in group (A) who had developed
hypotensive episodes during hemodialysis ( P value < 0.001), in group (A) also there were 18 patients had
positive C-reactive protein (90 %) and 2 patients had negative C-reactive protein (10 %) with a mean value
(15.67 ± 13.27), while in group B : there were 2 patients had positive C-reactive protein level (10 %) and 18
patients had negative C-reactive protein level ( 90 %) with a mean value (2.07 ± 1.48) , So, there was a
significant increase in C-reactive protein level in patients in group (A) who had developed hypotensive
episodes during dialysis ( P value < 0.001). Conclusion: Serum Alb. levels and high levels of CRP may
predict an increased risk of DIH in regular HD patients and this was the main issue for our study, however we
also found that there were some other biochemical markers, which can come inbetween with our two main
markers, which confirm our results. Recommendations: Further studies on a larger scale of patients are
needed to confirm these results.

of hemodialysis. Hypotension during dialysis (DIH)
Chronic kidney disease (CKD), also known
could be directly related to a reduction in blood
as chronic renal disease, is a progressive loss in
volume or to a decrease in cardiovascular activation
kidney function over a period of months or years.
as a response to decreased cardiac filling (3).
The symptoms of worsening kidney function are
Dialysis-induced hypotension (DIH) is a
not specific, and might include feeling generally
very serious clinical problem. It is one of the most
unwell and experiencing a reduced appetite. Often,
frequent complication in renal replacement therapy
chronic kidney disease is diagnosed as a result of
which diminish patient's quality of life, and
screening of people known to be at risk of kidney
increases mortality in the dialyzed population. The
problems, such as those with high blood pressure or
main mechanism of DIH is rapid reduction of blood
diabetes and those with a blood relative with CKD.
volume owing to ultrafiltration and decrease in
This disease may also be identified when it leads to
extracellular osmolarity during the dialysis session.
one of its recognized complications, such as
Coexisting illnesses, especially cardiovascular
cardiovascular disease, anemia, pericarditis or renal
diseases, particularly common in older and diabetic
osteodystrophy (1).
patients, have an essential meaning in the episodes
CKD is a long-term form of kidney disease;
of dialytic hypotension (4).
thus, it is differentiated from acute kidney disease
Intradialytic hypotension is a well-
(acute kidney injury) in that the reduction in kidney
recognized HD complication, occurring in 10­70%
function must be present for over 3 months. CKD is
of treatments, depending on the definition. Patient
an internationally recognized public health problem
and clinical characteristics associated with
affecting 5­10% of the world population
intradialytic hypotension include older age, female
(2).Hypotensive episodes are a major complication
sex, longer dialysis vintage, diabetes, lower pre-
Received: 20/1/2018 DOI: 10.12816/0045303
Accepted: 30/1/2018

Full Paper (vol.711 paper# 12)

c:\work\Jor\vol711_13 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2280-2286
Self-reported Unintentional Injuries in Families Visiting the
`Childhood Safety Campaign' in Saudi Arabia
Mosa Ali Al-Zahrani, Mohamad-Hani Temsah, Fahad Al-Sohime, Badr Solayman Al-Mosned,
Muath Abdulaziz Al-Soliman, Mohammed Saleh Abaalkhail,
Mohannad Saeed Al-Zahrany and Faisal Nasser Al-Shuwair
Pediatric department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Corresponding author: Mosa Ali Al-Zahrani, email: Mosa.alzahrani.a@gmail.com, Phone: 00966554262939


Background: As a consequence of unintentional injury or trauma, children may develop permanent
disabilities such as limb amputations or disfigurement; and in severe cases these injuries can lead to death or
severe neurological disabilities.
The aim of this study was to identify the most frequently reported type of unintentional injury sustained by
children in Saudi Arabia, as well as the most common locations in which such injuries take place. This paper
will also examine the long-term consequences of children's unintentional injuries on their parents and the
different types of care that are needed post-injury
Methodology: This research was carried out in the form of a cross-sectional survey that was intended to be
used as an evaluation tool during the first `Childhood Safety Campaign' in Riyadh, Saudi Arabia. The
campaign was conducted over 4 days (14 - 17 March 2017) and provided parents with free childhood safety
educational resources. The campaign also aimed to capture the personal experiences of families using pre-
designed electronic surveys that were completed both before and after attending the campaign. Data was
subsequently analyzed using SPSS® version 21.0 basic descriptive software.
Out of the 374 parents who were surveyed, 32% (N=122) reported that at least one child of theirs
had sustained an injury of some sort in the 12 months preceding the campaign.
The most common type of unintentional injuries that were reported were falls (50.9%), whilst the most
common location for the occurrence of such injuries was at home (66%).
Parents also reported that, as a consequence of the injuries, most children endured a contusion/abrasion
(28.7%). The families that took part in this survey also reported that most of the medical care needed as a
consequence of injury took place in the Emergency Department. However, hospitalization was needed in
(2.3%) of cases.
Conclusion: Accidental injuries are most commonly reported by the parents of children in Saudi Arabia,
Incidentally, the majority of these accidents occur at home and can be easily treated in the ER Department.
Occasionally, however, certain serious types of injury toke place thereby requiring hospitalization. By raising
awareness of these types of preventable injuries via the use of educational awareness campaigns, the risks
posed to vulnerable young children may be greatly reduced.
Unintentional, injury, pediatric, self-reported.


of unintentional injuries among 0­19 year old in the
Children explore their environment as part of their
United States from 2000 ­ 2006 using data from the
normal development, thereby expanding their
National Vital Statistics Systems as well as the
knowledge and skills as children grow and develop,
National Electronic Injury Surveillance System ­
so do their risks for injury. With the time children
All Injury Program, to provide an overview of
developing better perceptual and cognitive abilities
unintentional injuries in this age group [3].
to evaluate these risks and the motor skills to avoid
According to this report, 12,175 children death each
injuries [1]. Injury is defined wither it intentional or
year from unintentional injuries. These injuries were
unintentional "a body lesion at the organic level,
related to: drowning, falls, fires or burns, poisoning,
resulting from an acute exposure to energy
suffocation, and transportation.
(mechanical, thermal, electrical, chemical or
radiant) in amounts that exceed the threshold of
unintentional injuries sustained by children in
physiological tolerance. In some cases, (e.g.
Bangladesh, Colombia, Egypt and Pakistan found
drowning, strangulation, freezing), the injury results
that approximately half of all the children who
from an insufficiency of a vital element [2].
sustained such injuries needed emergency room
The center for the disease control and prevention
treatment and were left with some form of disability
(CDC) Childhood Injury Report described patterns
as found [4].
Received: 20/12/2017 DOI: 10.12816/0045304
Accepted: 30/12/2017

Full Paper (vol.711 paper# 13)

c:\work\Jor\vol711_14 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2287-2293

Dinoprostone Versus Misoprostol for Cervical Ripening before Diagnostic
Hysteroscopy in Nulliparous Women: A Randomized Controlled Trial
Ayman Abd El-Razek Abulnour*, Mohamed El-Mandooh Mohamed*,
Waleed Mohamed Khalaf*, Shady Ali Tarek**
*Obstetrics & Gynecology Department, Ain Shams University;
** M.B.B.Ch. October University
Corresponding author: Shady Ali Tarek,email: shaditarek@gmail.com, mobile:00201226600770

Hysteroscopy has revolutionized the field of Gynecology and the management of many
gynecological conditions. It has now become a standard part in the diagnosis of postmenopausal bleeding by
the gynecological surgeons. Cost, convenience, accuracy, and patient acceptability of these procedures are
clearly superior to those of traditional surgeries. As gynecologists have grown better acquainted with the
benefits and techniques of operative hysteroscopy, it has become the method of choice for treatment of
intrauterine pathology.
Cervical ripening is a complicated process, being mediated by cytokines, growth factors, hormones and other
biochemical compounds.
Both dinoglandin and Misoprostol can be used for cervical ripening before introduction of hysteroscopy and
hence reduce the incidence of complications.
Objects: This study aims to assess the efficacy of dinoprostone compared to misoprostol in cervical ripening
in nulliparous women undergoing diagnostic hysteroscopy.
Methodology: a randomized controlled clinical trial comparing dinoprostone versus misoprostol for cervical ripening
before diagnostic hysteroscopy in nulliparous women, it included 2 groups, 33 patients each. In the first group named
(group D) dinoprostone 3 mg was applied vaginally 6 hours before diagnostic hysteroscopic procedure while in the
second group named (group M) 400 mcg misoprostol was applied vaginally at the same timing.
Results: There was no statistically significant difference between the groups that received misoprostol or
dinoprostone with regard to age, duration of marriage, medical disorder, history of gynecological operations and type
of gynecological operations. However, the use of misoprostol caused slightly less pain compared to dinoprostone but
more side effects occurred with the use of misoprostol.
Conclusion: There was no significant difference between dinoprostone and misoprostol in priming of cervix before
diagnostic hysteroscopy in nulliparous women regarding ease of hysteroscope entry, pain or side effects.
Keywords: Dinoprostone, Misoprostol, Diagnostic hysteroscopy


Hysteroscopy is one of the diagnostic
For easy passage of hysteroscope, cervical
methods that developed recently in gynecology. The
ripening and cervical canal widening to a specific
whole uterine cavity is explored through
diameter should be done(3).
hysteroscope. In the presense of any pathologic
Many methods including medications have
lesion, biopsy is taken and treatment is performed
been introduced for cervical ripening. The most
through hysteroscopy if needed (e.g. removal of
commonly used medication is misoprostol, a
submucosal myoma or endometrial polyp).
synthetic prostaglandin E1 (PGE1) analogue that is
Hysteroscopy has been proved to be a totally reliable
administered frequently in obstetrics and gynecology
method for the study of postmenopausal bleeding(1).
for cervical ripening, medical abortion, induction of
Although hysteroscopy has been identified as a safe
labor, dilatation and curettage, endometrial biopsy,
and less invasive procedure, some complications
intrauterine device insertion, postpartum hemorrhage
such as cervical tear, bleeding, uterine perforation,
and myomectomy(4).
pain and discomfort may occur during the procedure.
Prostaglandins have been widely used for
Many women need dilatation prior to hysteroscopy
induction of labor, particularly if the cervix is not
to make the procedure more simple(2).
The incidence of these complications may
dinoprostone) appears to be the prostaglandin of
decline if we use cervical ripening before the
choice when used vaginally in the form of tablets,
procedure. Cervical ripening is a complicated
gel or pessaries. Oral prostaglandins administration
process, being mediated by hormones, cytokines,
is less effective and has been virtually abandoned,
growth factors and other biochemical compounds.
mainly due to its side effects on gastrointestinal
Received: 11/12/2017 DOI: 10.12816/0045305
Accepted: 21/12/2017

Full Paper (vol.711 paper# 14)

c:\work\Jor\vol711_15 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2294-2303

Validation of The Modified Falls Efficacy Scale ­International
(FES-I) in Egyptian Geriatric Population
Nagwa Hazzaa1, Fathy Naeem1, Heba Gamal Eldin2, Lamiaa Abd El Fattah3
1Audiology Department, Faculty of Medicine, Ain Shams University.
2 Geriatric Medicine Department, Faculty of Medicine, Ain Shams University.
3 Department of Audiology, Mansheyat Al Bakry Hospital.


Background: Falls are a common and complex geriatric syndrome. The fear of falling has negative
consequences for older adults. Fall Efficacy Scale-International (FES-I) is one of the questionnaires that assesses
fear of falling and its Arabic version has established validity. Aim of the work: To evaluate the validity of the
modification on original Arabic FES-I to be suitable for the Egyptian culture.
Materials and Methods: 100 geriatric patients participated in this research. All participants were subjected to
full medical history taking, application of the modified Arabic Falls Efficacy Scale­International (FES-I), Mini
mental state examination, Time Up and go test. Results: The present study group included 100 participants 46 men
and 54 women with female predominance, with a mean age of 66 years, the minimum age was 60 years and maximum
was 85 years. Most of participants age lies between 60ys & 69ys. Medical history revealed that 67 % of participants had
no history of falling and 33% with positive history of falling once or more; also 31 % with history of imbalance and 69 %
without history of imbalance. From the participants in our study there were 40% below cut off value of TUG (14 sec)
(low risk of falling), and 60% above or equal cut off value of TUG (14 sec) (high risk of falling). Also according to Mini
Mental Status Examination (MMSE), 59% with mild cognitive impairment (21 to 26 points) and 41% with normal
cognitive function. As regards the categories of modified Arabic FES-I; 16% in low concern category, 22% in moderate
concern category, 62% in high concern category. In the current study, the validity and reliability of the modified Arabic
FES-I have been proved, there was a statistically significant difference between the two ROC curves in favor of the
modified FES-I regarding sensitivity (90.9% compared to 72.7%) and in favor of original FES-I regarding specificity
(68.7% compared to 58.2%). Modified Arabic FES-I showed significant positive correlation with age and Time Up and
go test, history of falling and history of imbalance and a negative correlation with the MMSE. Conclusion: The
validated modified Arabic FES-I can be used in assessment of risk of falling among Egyptian geriatric population. The
modified Arabic FES-I is more sensitive than the original Arabic FES-I.
Keywords: Arabic FES-I, modified Arabic FES-I, TUG, MMSE.

falls with one or more balance abnormalities are
Falls among older adults are recurrent and
even more likely to express fear [6].
multifactorial episodes. Examining an individual at
The most frequently used scale for fear of falling,
risk of falling by considering only the physical risk
which measures different levels of concern about
factors is in a sense to neglect other important
falling, is the Falls Efficacy Scale-International
aspects that cause falls, such as the fear of falling [1].
(FES-I), FES-I is reliable and valid in determining
Fall risk factors can be classified as intrinsic and
concern about falling in older adults across cultures
extrinsic risk factors [2]. Intrinsic factors are related
as well as in persons with and without cognitive
to clients' functional and health status, Extrinsic
impairment [1].
factors are related to environment [3].
The Arabic FES-I has established concurrent
Fear of falling has been defined as a lasting concern
validity and may be helpful for measuring an
about falling that leads to an individual avoiding
individual's concern of falling in people with
activities that he/she remains capable of performing
vestibular and balance disorders [7].

The fear of falling has negative consequences for
older adults' physical and functional well-being,
This study included 100 geriatric patients randomly
degree of independence, ability to perform activities
selected from the geriatric out-patient clinic and
of daily living (ADLs) and restriction on physical
vestibular unit, ENT department, Ain Shams
activity [5]. Furthermore, those who have a history of
university hospitals.
Received: 20/1/2018 DOI: 10.12816/0045306
Accepted: 30/1/2018

Full Paper (vol.711 paper# 15)

c:\work\Jor\vol711_16 The Egyptian Journal of Hospital Medicine (april 2018) Vol. 71(1), Page 2304-2309
Awareness of Risk Factors of DKA among Diabetic Adults in KSA
1Ahmed Maashi Alanazi, 1Abeer Jalawi Alotaibi, 1Hussein Ali Albakheit,
1Sarah Naif Aldewish,2Maram Khalf Ayad Alenzi, 3Alhanouf Abed Salim
1Faculty of Medicine, Almaarefa College, 2Northern Border University,3Taif university,Saudi Arabia
Corresponding author: Ahmed Alanazi, E-mail: dr.maashi@hotmail.com, Tel: +966538121009

Diabetic ketoacidosis (DKA) is a complication of Diabetes mellitus (DM) that lingers to have
high rates of morbidity and mortality regardless of advances in the management of DM. DKA mainly results
from insulin deficiency from new-onset diabetes, insulin noncompliance and increased insulin need because
of infection. Most persons with DKA have type 1 diabetes however, a subgroup of type 2 diabetes patients
might as well have ketosis-prone diabetes. Aim of the work: To assess the level of awareness of the risk
factors of DKA as well as the adherence of DM patients with drugs.
Methods: This is a questionnaire-based cross-sectional study enrolling a total of 100 randomly selected
diabetic Saudi adults ensuring diversity in age range and educational stages. Descriptive analysis was done
using Statistical Package for Social Sciences (SPSS) 23. Awareness levels for DKA were calculated as
absolute frequencies and were reported as overall percentages.
a total of 100 randomly selected diabetic Saudi adults (81 females and 19 males), 56% were
diagnosed with DM-1 while 44% had DM-2 and only 11% were active sport practitioners. Moreover, only
62% reported a robust adherence to DM medications.
The majority of the respondent scored low knowledge on DKA (54%). Regarding awareness of predisposing
risk factors: 9% and 29% of the participants have related DKA to infection and febrile illness respectively.
While, 50% of them suggested that there was an association between physical stress and DKA.
Conclusion: Our results revealed a compelling need to bridge the disparity in awareness of DKA among
Saudi adults with both types. The current knowledge gap doesn't only incur a significant cost burden on the
patients and their sponsors because of the high cost treatment and rehabilitation but also and more severely
the complications that can be life-threatening if not spotted and treated quickly.
Accordingly, we recommend the launch of education and awareness programs for the public at large, in the
hope that this will lead to improved quality of life particularity for DM patients and their caregivers as well
as establishing nutrition and sports programs at schools and universities that can teach children and young
adults the preventive measures and appropriate management of DKA early on in life. Other public
Awareness raising campaign through TV & Radio spots, culture and art activities and informational events
would add a great value.
Keywords: diabetic ketoacidosis, DKA, type 1 diabetes mellitus, type 2 diabetes mellitus, Cross section,
awareness, risk factors.
Abbreviations: DKA: Diabetic ketoacidosis, GDP: Gross domestic product.

rapid, deep breathing" Kussmaul respiration ", a
Diabetic ketoacidosis is an acute metabolic
strong, fruity breath odor" acetone ", loss of appetite,
complication of diabetes which the body cells can't
belly pain, and vomiting, confusion, hypotension,
use glucose for energy because there is not
tachycardia, volume depletion is always present [3].
enough insulin which lead to increase the glucose
Diagnostic criteria for DKA include presence of
then the body uses ketones or fatty acids source
blood glucose >250 mg/dL, arterial pH of 7.30,
for energy , using the chemical imbalance (metabolic
bicarbonate level of 18 mEq/L, and adjusted for
acidosis) called diabetic ketoacidosis [1].
albumin anion gap of >10­12.3. Positive serum and
It is commonly associated with type 1 diabetes,
urine ketones may further support the diagnosis of
nevertheless, it can also occur with type 2 diabetic
DKA [4].
patients where very little of their own insulin
Mortality rates have fallen significantly in a period
secreted. It can also be triggered by infection or
of 20 years - from 7.96% to 0.67%. The mortality
other illness, severely dehydration, cardiovascular
rate is still high in developing countries and among
diseases such as stroke or myocardial infarction [2].
non-hospitalised patients [5].
Clinical features of DKA include flushing, hot, dry
The frequency of DKA at diagnosis ranges from
skin, blurred vision, polydipsia, polyuria, polyphagia,
12.8% to 80%, and is lowest in Sweden, the Slovak
weakness, drowsiness or difficulty waking up. Young
Republic and Canada and highest in the United
children may lack interest in their normal activities,
Arab Emirates, Saudi Arabia and Romania. The
Received: 20/12/2017 DOI: 10.12816/0045307
Accepted: 30/12/2017

Full Paper (vol.711 paper# 16)

c:\work\Jor\vol711_17 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2310-2314

Ewing`s Sarcoma of Temporal Bone: Case Report
(1) Alakeel, Abdurahman Mansour, (2) Aldajani N, (2) Shami I M, (3) Orz Y
1. College of Medicine, King Saud University, 2. King Fahad Medical City (KFMC), Riyadh,
3.Alexandria University and King Fahad Medical City (KFMC), Riyadh
Corresponding author: Abdurahman Alakeel, E-mail: abdulrahman.alakeel@gmail.com

Primary Ewing`s Sarcoma (ES) is a small round tumor, more likely to present in long bones and rarely in skull
bones. ES commonly present in the second decade of life, and it is usually treated by multimodality including
surgery, chemotherapy, and radiotherapy. In this case, a 13 years old boy presented with left facial palsy and
hearing loss for two weeks, treated with steroid but no improvement. MRI was done and showed left jugular
foramen and cerebellopontine mass measuring 4.8*4.4* 3 cm. Debulking surgery of the tumor was done with
multiple biopsies reported by histopathology as malignant small round cell tumor consistent with Ewing sarcoma.
Keywords: Ewing`s Sarcoma, Temporal Bone, Case Report.


Primary Ewing Sarcoma (ES) is small round cell
CT scan showed left jugular foramen and
tumor of neuroectodermal origin 1,2. the second most
cerebellopontine mass with bony erosion (Figure 1,2)
common malignant bone tumor in young patients 3,4,5.
and sunburst appearance in soft tissue window
It is more likely to affect long bones, pelvic bones,
(Figure 3). MRI showed left jugular foramen and
ribs, and vertebrae 1,2,5,6,7,8 and present most
cerebellopontine mass measuring 4.8*4.4* 3 cm in
commonly in the second decade of life 2,3,4,5,7.
maximum dimension. It was isointense on T1 and T2
Primary ES of the skull is rare 3,4,6,7,9 and appears in
weighted images with avid post contrast enhancement
different bones, the most common site is temporal
with evidence of restricted diffusion within the mass
bone 2,3, as in this present case.
(Figure 4-7). The mass destroyed the petrous apex

and medial portion of the jugular foramen with the
extension into the petroclival junction and anteriorly
Our patient is 13 years old boy who was referred to
along the dura with compression of the Meckel's
our tertiary hospital with a history of left facial palsy
and hearing loss for two weeks. He was treated in the
MR angiogram of the intracranial vasculature appears
referring hospital with systemic steroid with no
unremarkable with patent vessels and normal
improvement on follow up. There were no associated
perfusion on MR perfusion scan. The radiological
symptoms of dizziness, tinnitus, otalgia, headache,
differential diagnosis was going with aggressive
change of voice or chocking. On the examination of
tumor such as hemangiopericytoma, round blue cell
the left ear, there was a reddish intact tympanic
category tumor, and least likely glomus jugulare
membrane with a normal external auditory canal.
tumor. CT chest, abdomen and pelvis together with
Cranial nerve examination showed normal II-VI, IX,
PET scan showed no metastasis.
XI, and XII cranial nerves; VII cranial nerve showed
We took the patient to the operating room together
left facial palsy grade 6 on House Brackmann grading
with our colleague from neurosurgery, and we
system. X cranial nerve exam showed left vocal cord
perform left transcochlear approach type A and
paralysis. His hearing assessment showed normal
debulking of the tumor with intraoperative fresh-
hearing in the right ear with a profound hearing loss
frozen biopsy which showed Ewing sarcoma.
in the left ear. Middle ear function using
Intraoperatively the tumor was infiltrating the bone in
tympanogram showed type C in the diseased ear with
the mastoid cavity, middle and inner ear.
normal type A on the non-affected side. Stapedial
We took multiple biopsies from the middle ear,
reflexes showed present right ipsilateral reflex and
jugular foramen, brain tumor and mastoid bone and
absent right contralateral, left ipsi- and contralateral
the final histopathology came as malignant small
round cell tumor consistent with Ewing sarcoma for

all (Figure 8,9). Postoperatively patient received

concurrent chemoradiotherapy.
Received: 20/12/2017 DOI: 10.12816/0045308
Accepted: 30/12/2017

Full Paper (vol.711 paper# 17)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2315-2321

Role of MRI in Assessment of Hepatocellular Carcinoma (HCC) after TACE
(Trans-arterial Chemoembolization) with Persistent High Alfa Fetoprotein (AFP)
Omar Hussein Omar, Mohamed Sobhy Hassan, Ahmed Mohamed Tawfik
Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University
Corresponding author: Ahmed Tawfik, E-mail: tawfeekahmed89@gmail.com

evaluation of treatment success after TACE is essential for making therapeutic decisions, e.g., to
repeat, interrupt or completely terminate TACE. An understanding of the various therapeutic strategies and
their post therapy imaging appearance is essential for accurately assessing treatment response. Evaluation of
tumor response should include not only tumor markers, but also imaging modalities. Evaluation of the
therapeutic effect of HCC after TACE is primarily based on the findings of imaging studies. CT is the standard
imaging technique for monitoring the effectiveness of TACE. MRI is complementary to CT in the evaluation
of the therapeutic response. To know the advantages and limitations of each imaging technique in the
evaluation of the therapeutic effect of HCC is important in determining if the treated tumor is completely
necrotic or requires additional treatment. Objective: the purpose of this work was to study the MRI appearance
of the HCC lesion after TACE in patients with high persistent AFP in cases when hyper-attenuating iodized oil
impairs the assessment of residual tumor enhancement on contrast enhanced CT.
Patients and Methods:
the age of patients ranged between 50 to 73 years with a mean age 58 years. All
patients were diagnosed as HCC patients on a background of liver cirrhosis. Twelve patients were positive for
HCV and three patients were positive for HBV infection.
our study included 15 patients, 12 males and 3 females with age 51 and 73 years with a mean age of
58years. All patients included were diagnosed with HCC by a previous triphasic CT and alfa feto protein. The
patients underwent TACE and the patient's response to embolization was assessed by AFP and CT or MRI
within 1-3 months post chemoembolization. All the selected candidates showed persistent elevation of alfa feto
protein after the procedure and within the 1-3 months post TACE. MRI was performed to these patients and
their MRI results were either negative or positive explaining the persistent rise of AFP where 13 patients
showed positive results and 2 patients showed negative MRI findings. The positive patients were further
categorized into groups according to their post tace MRI findings. 4 patients had de novo new lesions, 6
patients had recurrence and 3 residual tumor patients.
diffusion-weighted MR imaging was found to be a reliable predictor along with contrast
enhanced MR imaging when CT was not conclusive.
hepatocellular carcinoma, hepatitis B virus (HBV) or hepatitis C virus, transarterial


The Barcelona Clinic Liver Cancer
(BCLC) and the American Association for the
hepatocellular carcinoma (HCC), which is the
Study of Liver Diseases guidelines consider serum
third most common source of cancer fatalities
of >400 ng/mL to be diagnostic for HCC (4) or a
worldwide. The main etiologies of HCC are
solid mass >2 cm in diameter with typical features
infection of the liver by hepatitis B virus (HBV) or
of HCC on at least one imaging modality in a
hepatitis C virus (HCV), and alcohol abuse (1).
patient with liver cirrhosis (2).
Alpha-fetoprotein (AFP) is an oncofetal protein
High serum AFP levels occur in 60­70% of
produced by fetal hepatocytes, yolk-sac cells and
HCC patients. However, Serum sFP levels remain in
normal gastrointestinal cells immediately after
the normal range in 15­30% of HCC patients (4).
birth. Serum AFP level decreased gradually after
High serum AFP level correlates with more
birth to <10 ng/mL within 300 days (2). Normal
aggressive behaviour and poorer prognosis of HCC
adult serum AFP level is <20 ng/mL. Serum AFP
(5). Transarterial chemoembolization (TACE) of
level may be high in patients with drug or alcohol
hepatocellular carcinoma (HCC) is used as a
abuse or with chronic liver disease such as hepatitis or
bridge to liver transplantation. It is also used for
cirrhosis, but in these cases, the level is usually <100
patients with unrespectable HCC, and has been
ng/mL (3).
shown to improve survival (6).
Received: 5/1/2018 DOI: 10.12816/0045309
Accepted: 15/1/2018

Full Paper (vol.711 paper# 18)

c:\work\Jor\vol711_19 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2322-2350

Maternal and Fetal Toxicity of Carisoprodol
Magdy H. Abouel-Magd
Narcotic Research Department, the National Center for Social and Criminological Research, Cairo, Egypt

Aim of the work:
this study aimed to detect the histological and histochemical changes in liver tissue of
pregnant rats and their fetuses after treatment with carisoprodol. Material and methods: thirty pregnant female
rats were randomly categorized into three groups (ten pregnant female rats in each group). The first was
administered oral doses of distilled water and was served as control. The other two groups were administered
oral doses of carisoprodol in the distilled water equivalent to 10.8 mg and 21.6 mg/100g body weight/day
respectively for 15 days from the 6th day to the 20th day of gestation. Numerous histological and histochemical
studies were done to detect the histopathological and histochemical changes. Results: maternal and fetal liver
tissue of both treated groups showed lots of degenerative changes post-treatment with carisoprodol. The
severity of these changes was more obvious in fetal liver tissue of both groups this was accompanied with
numerous histochemical changes. Conclusion: treatment of pregnant rats with carisoprodol led to numerous
dystrophic changes in maternal and fetal liver tissue.
carisoprodol, mammals, pregnant rats, fetuses, histopathology and histochemistry.


There is an evidence that meprobamate produces its
clinical effects by barbiturate like activating activity
propyl-1,3-propanediol dicarbamate; N-isopropyl-
at GABAA receptors {The GABA receptors are a
meprobamate) is a commonly prescribed centrally
class of receptors that respond to the neuro-
acting skeletal muscle relaxant indicated as adjunct
transmitter gamma-amino butyric acid} (7). A
therapy to rest, physic therapy and other measures
research had showed that carisoprodol itself may
for the relief of discomfort related to painful
activate GABAA receptors independent of the action
of meprobamate (8). How much of the clinical effect
The drug is widely used in primary care settings.
observed in a patient taking carisoprodol is due to
Carisoprodol compound is marketed under a variety
carisoprodol alone and how much is contributed by
of brand names such as Somadril, Soma, Somalgit,
the meprobamate metabolite is not currently known.
Vanadam, Sodol, Carisoma, Sonoma, Somacid,
In Egypt, carisoprodol is available as somadril
Scutamil C, Relacton-C, Mio Relax, Relaxibys, Rela
compound which contains carisoprodol 200mg,
and Soridol (2).
paracetamol 160mg and caffeine 32mg. It is a
prescribed drug produced by Mina Pharm for
pharmaceutical regulations by the decision of the
mol-1) is a white crystalline powder that has a mild
Minister of Health and Population No.172 of the
characteristic odor and a bitter taste. Carisoprodol
year 2011, while meprobamate the active metabolite
begins to act within 30 minutes of oral ingestion and
of carisoprodol (9) is a schedule 111 controlled
has a half-life of approximately 1.5 hours. Adverse
substance on Anti-drug law No. 182 of the year
effects of carisoprodol mainly involve the central
1960. Carisoprodol has a narrow therapeutic range
nervous system (CNS) and include drowsiness,
(10) and when carisoprodol is ingested with other
dizziness, ataxia, tremor, blurred vision and
medications it may be a contributing factor in death,
headache (3). Carisoprodol is converted to three
even when present at therapeutic concentrations (11).
primary metabolites in the liver: hydroxyl
Paracetamol (Acetaminophen) is widely used over
the counter drug for analgesic and antipyretic
meprobamate (2), which are excreted by the kidneys
effects. Its use in suicidal or accidental or with
(4). The exact mechanism of action of carisoprodol is
chronic alcohol abuse causes fulminant liver failure
unknown, but the drug is thought to act centrally by
(12). Paracetamol induced hepatic failure is the
causing sedation rather than by direct skeletal
second leading cause of liver transplantation (13).
muscle relaxation; it may act by inhibiting
Caffeine is a central nervous system and metabolic
interneuron transmission in the descending reticular
stimulant and is used both recreationally and
formation and spinalcord (5). A part of the apparent
medically to reduce physical fatigue and to restore
effect of carisoprodol may be due to the
alertness when drowsiness occurs (14). Caffeine
meprobamate metabolite which has a half-life of
overdose can result in a state of central nervous
approximately 11 hours (Although this may be
system over-stimulation called caffeine intoxication
prolonged to up to 48 hours with chronic usage) (6).
(15).Liver injury caused by toxic chemicals and
Received: 20/12/2017 DOI: 10.12816/0045310
Accepted: 30/12/2017

Full Paper (vol.711 paper# 19)

c:\work\Jor\vol711_20 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2351-2357
Screening of Some Drugs of Abuse in Outpatient Clinics in
Al-Azhar University Hospitals
Fouad H Eldabah*, Nagy M Alfadaly, Essam S Amer,
Wael M Fathy,Mohammed S Mohammed*
Department of Forensic Medicine and Clinical Toxicology
Faculty of Medicine, Al-Azhar University
*Corresponding Author: Mohammed S Mohammed, Phone Number: 0106895406,
Email: Mohamudsadawy@gmail.com


Background: Substance, which use among the youth worldwide is a major problem that has elicited
concern from different individuals and groups. In Egypt, drug dependence is considered one of the serious
problems that worry both the people and government; however, epidemiological data on drug dependence
are still few. Drug addiction is one of the serious problems that worry the Egyptian government, as it deals
with young people within the age of work and productivity. It may lead to many problems such as bad
social adaptation, decreasing productivity at work or dismissing from job.
Aim of the work: The study aims to give an information about the degree of prevalence of a social
problem like drugs of abuse in ages more than 18 years in the Egyptian society from May 2016 to April
Methods: This study was a cross sectional study which done on random urine sample of 500 persons in age
of more than 18 years coming to outpatient clinics of Al-Azhar university hospitals namely El-Hussein and
Bab Elshaaria university hospitals after taking full history for each one (patient sheet) with informed
written consent.
Results: This study found that prevalence of drugs abuse among all studied sample, negative were 215
(43.0%), and positive were 285 (57.0%). Regarding prevalence of types of drugs abuse among all studied
sample; negative were 215 (43.0%), THC 105 (21.0%), THC & Opiate 15 (3.0%), THC & tramadol were
40 (8.0%), THC, tramadol & opiate 20 (4.0%), tramadol 55 (11.0%) and tramadol & opiate were 50
(10.0%). Percent of males was significantly higher among the studied groups positive than negative
(100.0%, 95.3% respectively, p =0.000). Mean value of age was significantly lower among the studied
groups positive than negative (37.96, 43.88 respectively, p <0.000).
Conclusion: prevalence of drugs abuse among all studied sample, negative were 215 (43.0%), and positive
were 285 (57.0%).
Keywords: Drugs abuse - Prevalence ­Social problems.

1.79% abused stimulants, and 2.26% abused
The 20th century ended with the
hypnotics (3).
conviction that drug abuse is a worldwide
Substance which use among the youth
problem and thus worldwide solutions were
worldwide is a major problem that has elicited
required. The apparently neat boundary between
concern from different individuals and groups (4) .
producer, transit, and consumer countries has
In Egypt, drug dependence is considered
clearly broken down (1) .
one of the serious problems that worry both the
A 2007 National Survey report stated that
8.5% of Egyptians - or six million people - are
epidemiological data on drug dependence are still
addicted to drugs, the majority of them are
few (5).
between 15 and 25 years old and the addicts are
Drug addiction is one of the serious
considered as criminals rather than patients in
problems that worry the Egyptian government, as
need for treatment (2).
deals with young people within the age of work
Soueif et al. (3) found that 20% of
and productivity. It may lead to many problems
Egyptian male students have used drugs at some
such as bad social adaptation, decreasing
time in their life, and among them, 25% have
productivity at work or dismissing from job (5).
continued to do so. Among secondary school
Drug testing has a number of purposes in
male students, 5.05% abused hashish, 0.84%
clinical practice, each of which requires a clear
abused opiates, 2.72% abused tranquilizers,
testing strategy. Urine is generally "the best"
biologic specimen for determining the presence
Received: 8/1/2018 DOI: 10.12816/0045311
Accepted: 18/1/2018

Full Paper (vol.711 paper# 20)

c:\work\Jor\vol711_21 The Egyptian Journal of Hospital Medicine (April2018) Vol. 71(1), Page 2358-2364

Causes and Outcomes of Hospitalization among Systemic Lupus
Erythematosus Patients in Aseer Central Hospital,
Saudi Arabia: A Retrospective Study
Mansour Somaily,1 Saeed Asiri2, Lamia Aseery,2 Bader Asiri,2 Nora Gammash,2 Razan Alhumayed,2
Ali Alasmari,2 Alhusain Asiri,3 Fatema Althabet,2 Abdullah Alsabaani4
1 King Khalid University Medical City, King Khalid University, Abha, 2 College of Medicine, King Khalid
University, Abha, 3 Ministry of Health, 4 Department of Family and Community Medicine, College of
Medicine, King Khalid University, Abha, Saudi Arabia
Corresponding Author: Saeed Yahya Asiri, email:syogran@gmail.com,mobile:00966546677161

Objective: To identify frequency, causes and outcomes of hospitalisations among adult patients with
systemic lupus erythematosus (SLE).
Methods: A record-based retrospective study was conducted at Aseer Central Hospital for a period of four
and half years from January 2012 to June 2016. The study includes adult SLE patients who were diagnosed
according to the 1997 SLE criteria.
Results: A total of 155 patients (8 males and 147 females) with 251 hospital admissions were included. The
average admission rate for all cases was about 2.0 ± 1.0 times. The most commonly recorded causes of
admissions were SLE nephritis flare (33.9%), and infections (16.3%). Mortality rate for SLE patients is
almost 7.7% and the recorded main causes of death were pulmonary hemorrhage (33.3%), sepsis (25%),
bilateral massive pulmonary oedema and pneumonia (8.3% for each).
Conclusion: Almost half of adult SLE patients are frequently hospitalized. Female patients and those with
associated chronic co-morbidity have more frequent admissions. Consequences of SLE remain the most
frequently recorded causes for hospital admission. Pulmonary complications are the main cause for death.
Therefore, prompt and aggressive management of pulmonary consequences could markedly reduce disease
mortality. Adopting preventive measures such as using prophylactic antibiotics and pneumococcal
vaccination, early in the disease course, should be accentuated.
Keywords: Systemic lupus erythematosus, Hospitalization, Complications, Saudi Arabia, Retrospective

estimated to be 4.6 times higher than general
Systemic lupus erythematosus (SLE) is a
worldwide autoimmune disorder with significant
Most SLE cases become hospitalised to
morbidity and mortality1. It is a persistent long-
receive treatment for disease manifestations,
term disorder which is more common in women2-3.
infections or associated medical health problems13.
The underlying cause of autoimmune diseases is
Several reports on hospital utilisation in SLE
not fully understood, but the hidden process in SLE
studied patients' characteristics associated with
is that the immune system mistakenly attacks
initial hospitalisation or predictors of mortality.
healthy tissues by using complexes or cytotoxic
Identifying both risk factors associated with early
antibodies which impact on body organs1,4.
readmission and variation in readmission rates for
Therefore, SLE has unevenness at onset that
SLE could potentially direct efforts to improve the
renders correct and early diagnosis quite
quality of care during initial hospitalisations as
well as during ambulatory care transitions14-16.
The concept of SLE has changed from
It is essential to better understand the SLE-
being signed as a rare disease with increased
associated comorbidities that leads to frequent
mortality rate to a more known disease with benign
healthcare utilisation, such as emergency
consequences6-9. Morbidity from the disease
department visits and/or hospitalisation. Moreover,
remain high; the treatment outcome is highly
up to the best of our knowledge, there is no study
variable, ranging from complete remission to
that investigated causes of admission and outcome
death10. During the last few decades, there has been
of hospitalisation of adult SLE patients in Aseer
great improvement in SLE patients' survival, with
Region, Saudi Arabia. Therefore, there is a
more than 90% of SLE patients showing 5-year
pressing need to investigate causes of admission
survival rate and 87.4% showing 10year survival
and outcome of hospitalisation in our region,
rate11-12. However, despite improvement of survival
which will lead to improving the service provided
rate, mortality rate among SLE patients was
to SLE patients.
Received: 20/12/2017 DOI: 10.12816/0045312
Accepted: 30/12/2017

Full Paper (vol.711 paper# 21)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2365-2369

Assessment of Pelvic Parameters before and after Postero-lateral Interbody
Fusion Surgery in Patient with Lumbo-sacral Instability
Kamal Abdelrahman Abd Elhafez, Mohamed Abd Elmonem Negm, Abdelrhman Gamal Ramadan
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University

pelvic incidence (PI) is a fundamental pelvic anatomic parameter that is specific and constant for
each individual and determines pelvic orientation as well as the size of lumbar lordosis (LL). Pelvic incidence (PI)
is a descriptor of pelvic morphology and not of pelvic orientation: therefore, its angular value is unaffected by
changes in human posture. The pelvic tilt (PT) and the sacral slope (SS) are position-dependent variables and are
very useful to characterize the spatial orientation of the pelvis. Pelvic incidence, sacral slope and pelvic tilt are
particularly useful because it can be demonstrated that pelvic incidence (PI) is the arithmetic sum of the
sacral slope (SS) + pelvic tilt (PT). Objective: this study aimed to determine the effect of Postero-Lateral Inter
Body Fusion Surgery (PLIF) in 25 patients with Lumbo-Sacral instability by measuring these three pelvic parameters
by plain x- ray before and after surgery. Patients and Methods: when compared to normal populations, pelvic
incidence (PI) is significantly higher in spondylolisthesis and the difference in PI tends to increase in a direct linear
fashion as severity of the spondylolisthesis increases. The cause effect relationship between pelvic morphology and
spondylolisthesis remains to be clarified. Taking into consideration the pelvic parameters stimulated a renewed
interest for the radiological evaluation and classification of spino-pelvic alignment in L5-S1 spondylolisthesis.
Results: we found that Postero-Lateral Inter Body Fusion Surgery (PLIF) is sucssessful operation for treatment
of lumbo sacral instability such as degenerative spondylolisthesis, isthmic spondylolisthesis and post
laminectomy instability. In comparison with lateral view x-ray before and after the operation, the pelvic
incidence increased and pelvic tilt decreased. Conclusion: PLIF is successfully used to treat degenerative and
isthmic spondylolisthesis. PLIF is successful regardless of age, sex and concomitant morbidities such as
diabetes mellitus, hypertension and ischemic heart disease.
Keywords: antero-posterior, lateral, pelvic incidence, posterior lumbar interbody fusion.


Spinal instability was defined as an
to stability of the lumbar spine[4,5]. The high
abnormal response to applied loads, characterized
mobility of the hip joint affects pelvic positioning,
by movement in the motion segment beyond normal
so that, with bipedalism, the sacral plateau began to
constraints [1]. Lumbar spinal instability may be
act as a base to support the weight of the spine.
caused by: degenerative disease, post operative
Degenerative diseases of the spine are influenced by
status, trauma to spine or its surrounding structures,
its spatial positioning during the lifetime of the
developmental disorders, like scoliosis and other
individual[6] .There is concern about analyzing the
congenital spine lesions and infection and tumors.
sagittal alignment of the spine. It is now known that
Instability of the lumbar spine occurs often and
sagittal alignment directly influences an individual's
mostly affects the region of L4-L5 or L5-S1 [2]. The
energy expenditure[7]. The C7-sacrum plumb line,
clinical symptoms and signs are non-specific and
thoracic kyphosis, and lumbar lordosis serve as
can be described as `low back pain with or without
parameters for evaluating sagittal alignment. The
radiculair pain'[3] .
shape of the pelvis and the sacral slope influence the
The stabilizing system can be represented
lumbar lordosis of each individual [8].There are
by means of three subsystems. The passive
some parameters that are used as references for the
subsystem consisting of vertebrae, facet joints, inter
evaluation of pelvic alignment.
vertebral discs, spinal ligaments, joint capsules and
The pelvic incidence (PI) is defined as the
passive muscle support. The neural feedback system
angle between a line perpendicular to the midpoint
is containing force and motion transducers and the
of the sacral plateau and a line from this point to the
neural control centers. The third system is the active
center of the femoral head. This angle most reliably
subsystem including the muscles and tendons
represents the transmission of load by the sacral
surrounding the spinal column.
plateau. The average value of the angle of incidence
Thus, the spine needs the integrated
was 55°±10[7,9-12].
function of the three subsystems, mentioned above,

to control stability and movement. Instability is
found when one of the systems fails to fulfill his
The aim of this study was to assess pelvic
task and disturbs the balance[3] .The important thing
parameters before and after postero- lateral inter
is to consider that all the lumbar muscles contribute
Received: 22/1/20178 DOI: 10.12816/0045313
Accepted: 3/2/2018

Full Paper (vol.711 paper# 22)

c:\work\Jor\vol711_23 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2370-2372

Squamous Cell Carcinoma Presenting as Cutaneous Horn: A Case Report
Samaher Alaauldeen1, Khalid Al Hawsawi2, Haneen Al Sufyani3, Lina Bugis4,
Ayat Al Dosari5, Taghreed Al Hetairshi6
1- Al-Noor Specialist Hospital, Makkah, Saudi Arabia, 2- Dermatology Department King Abdul Aziz
Hospital Makkah, Saudi Arabia, 3- King Abdul Aziz Hospital Makkah, Saudi Arabia, 4- Umm Al Qura
University Makkah, Saudi Arabia, 5- Makkah, Saudi Arabia, 6- Makkah, Saudi Arabia

Cutaneous horn is a clinical term used to describe a hard, keratotic conical lesion. Its base
may be a papule, plaque or nodule.
Objectives: An approach for how to diagnose and manage a cutaneous horn.
Materials and methods: Here-in we report an aged male 85-years old presented with a history of painful
slowly progressive skin lesion over his right foot 7 months ago.
Results: The past medical history revealed that the lesion was preceded by presence of a cutaneous horn
(CH) at the same site of the current skin lesion. That CH was persistent for a year before it spontaneously
fell down. Skin biopsy from the base of the CH was taken at that time, it was consistent with underlying
actinic keratosis. He did not receive any treatment for his CH . Currently skin examination revealed
fungating ulcer measuring 6X6 cm on the dorsum of the right foot. There was no inguinal
lymphadenopathy. Punch skin biopsy was taken from the edge of the ulcer for histo-pathological
Conclusion: On the basis of the above clinicopathological findings, a diagnosis of well differentiated
Squamous Cell Carcinoma was made. The patient was referred to Oncologist for appropriate management.
Keywords: Cutaneous horns, Cornu Cutaneum, Squamous Cell Carcinoma, Ulcer.

the same site of the current skin lesion. That horn
Cutaneous horn is a clinical term for a hard,
was persistent for a year before it spontaneously
keratotic conical lesion. It occurs commonly in
fell down. Skin biopsy from the base of the CH
sun exposed sites such as face, eyelid, ear, neck
was taken at that time. It was consistent with the
and dorsal aspects of hands[1]. The histopathology
underlying actinic keratosis. He did not receive
of horn is unique in its vertically oriented column
any treatment for his CH. Review of systems was
of massive hyperkeratosis, parakeratosis and
unremarkable. Family history revealed no history
variable acanthosis usually in association with
of malignancy in the family. Skin examination
atypical keratinocytes of an actinic keratosis[2].
revealed fungating ulcer measuring 6X6 cm on
Other lesions that are associated with cutaneous
the dorsum of the right foot (figure 1). No
horns include such seborrheic keratosis,
inguinal lymphadenopathy was detected.
Punch skin biopsy was taken from the edge
contagiosum, epithelial neoplasms especially
of the ulcer. The epidermis revealed full-
tricholemmomas, Bowen's disease, squamous cell
thickness atypical keratinocytes with downward
carcinoma (SCC), Basel cell carcinoma, granular
proliferation of lobules of atypical keratinocytes
cell tumor, metastatic renal carcinoma, sebaceous
deep into the dermis. The nuclei of these
carcinoma or Kaposi sarcoma [1-5].
The study was done after approval of
pleomorphism and mitoses. Also, there were
ethical board of King Abdulaziz Hospital.

lymphohistiocytic cellular infiltrates in-between
the epithelial lobules in the dermis (figure 2).
An aged male 85-years old presented with a
On the basis of the above clinicopathological
history of painful slowly progressive skin lesion
findings, a diagnosis of well differentiated
over his right foot 7 months ago.
squamous cell carcinoma was made. The patient
The past history revealed that the lesion was
was referred to Oncologist for appropriate
preceded by presence of a cutaneous horn (CH) at

Received: 20/12/2017 DOI: 10.12816/0045314
Accepted: 30/12/2017

Full Paper (vol.711 paper# 23)

c:\work\Jor\vol711_24 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2373-2379

Mean Platelet Volume versus Total Leukocyte Count and C-reactive Protein as
an Indicator for Mortality in Sepsis
Hazem M. Abd El Rahman, Sanaa F. Mahmoud, Ahmed W. Ezzat, Alaa E. Roshdy
Department of Anesthesia, Intensive Care and Pain Management
Faculty of Medicine, Ain Shams University
Corresponding author: Alaa E Roshdy; Mobile: 01010600091; Email: alaaroshdy86@gmail.com

sepsis is a major cause of morbidity and mortality, and the incidence is rising, probably due
to the growing elderly population, antibiotic resistance, immunosuppressive medication and, invasive
surgery. Pneumonia is the most common infection leading to sepsis, followed by urinary tract infections
and abdominal infections. These infections are usually localized and controlled by the immune system, but
they can sometimes spread and cause sepsis. Mean platelet volume (MPV) is a measurement that describes
the average size of platelets in blood. MPV is ordered routinely as part of the complete blood count panel
by an automated flow cytometry machine. In septic shock, most of the coagulation factors are depleted and
platelet count is decreased, a close relationship between sepsis severity and thrombocytopenia has already
been documented. Aim of the Work: this work aimed to find a relation between the mean platelet volume
and mortality in patients with sepsis in correlation with C-reactive protein and total leukocyte count.
80 adult critically ill patients of both sexes with sepsis and sever sepsis who admitted to the units
of Critical Care Medicine Ain Shams University Hospitals. The mean platelet volume (MPV) evaluated
and correlated to both total leukocyte count (TLC) and C-reactive protein (CRP) on a daily basis starting
from the day of admission and over 14 days. In addition, patients observed regarding outcomes including
mortality and discharge from ICU. Results: MPV was able to detect sepsis prognosis with high statistical
significance from admission, CRP also was a good predictor and on the contrary TLC had poor prognostic
value on admission and after 24 hours, but for the whole hospital stay a significant association was found.
elevated MPV on admission is an important marker for sepsis diagnosis and prognosis.
Progressively elevated MPV during hospital stay correlates well with mortality. Decreased platelet count
after admission is significantly associated with mortality in septic patients. MPV and platelet count can be
used as prognostic markers for sepsis and indicators of mortality on daily basis.
Keywords: sepsis, sepsis markers, mean platelet volume (MPV) .

"sepsis" comes from the word ń, (sipsi),
Infectious diseases are a global health
which in original Greek means decomposition of
problem, causing many deaths per year.
organic matter. During the late 19th and the 20th
Respiratory infections as well as diarrhea,
centuries, sepsis was described as a systemic
malaria, measles and HIV/AIDS are major causes
infection supposedly caused by the invasion of
of morbidity and mortality worldwide (1). Many
the blood stream by pathogenic microorganisms.
of the signs and symptoms that are associated
However, patients still died of sepsis even when
with infectious diseases are a direct manifestation
the microorganisms had been eradicated with
of the host immune response. For many years,
antibiotics (3).
physicians have recognized the hallmarks of a
Sepsis and septic shock are major
localized bacterial infection: dolor, rubor, calor
healthcare problems, affecting millions of people
and tumor. These signs result from different
around the world each year and killing as many
leukocytes and their metabolites in the immune
as one in four and often more (4).
system, which attempt to kill the invading
Similar to polytrauma, acute myocardial
pathogen. For the host, the challenge with
infarction, or stroke, early identification and
infections is to recognize the foreign invaders
appropriate management in the initial hours after
and to direct the appropriate immune response
sepsis develops improved outcomes (5).
effectively without inflicting self-damage. The
Mean platelet volume (MPV) describes the
body uses different mechanisms to avoid such
average size of platelets in a blood sample and
inappropriate responses, but occasionally this
routinely measured by automated hematology
mechanism fails causing severe tissue damage
analyzers using either electrical impedance or
and death (2).
optical fluorescence method (6). A rise in

Sepsis was first mentioned in Homer's
during sepsis caused by increased platelet
poems around 2,700 years ago. The word
destruction and increased production of larger
Received: 20/1/2018 DOI: 10.12816/0045315
Accepted: 30/1/2018

Full Paper (vol.711 paper# 24)

c:\work\Jor\vol711_25 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2380-2386

Road Traffic Accident: What Is Being Practiced on The Scene to
RTA Casualties in Al-Ahsa City, Saudi Arabia?
Mohammed Abdullah Alsaeeda*, Abdulrhman Mohammed Aljohera, Abdulaziz Khalid Althafar,
Abdullatif Abdulaziz Alarifia, Abdulalbary Mohammed Aljohera, Mohammed Nineaa, Iheb Bougmiza
a College of Medicine, King Faisal University, Alahsa, Saudi Arabia
*Corresponding author: Mohammed Abdullah Alsaeed, Saudi Arabia, Telephone +966506622264,
E-mail: m.alsaeed.94@gmail.com

In Saudi Arabia, road traffic accidents (RTA) is a burden to health, economy and community
because of the increasing number of deaths and disabilities. Many victims of RTA had poor pre-hospital care
undertaken by untrained lay people. Provision of first aid to RTA victims has helped in reduction the related
morbidity and mortality.
To assess how the car drivers' attitude and practice in case of RTA in Al-Ahsa city, Eastern Province,
Saudi Arabia.
Methods: This is a descriptive cross-sectional study between March and May, 2017 among drivers in Al-Ahsa
city situated in the eastern part of Saudi Arabia. Using pretested interview-based questionnaires. More than 252
responses have been collected by trained medical students, and 249 responses have been included.
Results: All the participants were male. 44.2% were bachelors and 45.4% students. A large number of the
participants are non-first aid trained (73.9%). 70.7% of the participants do not have willingness to provide first
aid for road traffic accident victim. The majority (71.1%) have witnessed an RTA sustaining injured individuals
and 36.9% have intervened. 67.5% of the responders have been involved in RTA themselves, and 29.3% of
them have sustained at least one injury.
Conclusion: There is an insufficient experience in dealing with RTA. The knowledge of the drivers about
first aid should be sought further and explored. RTA in Saudi Arabia is a major problem that require an
action and consideration from both the community and the government by increasing awareness and putting
strict rules to enhance the community to assume a safe driving and improve their skills.
Road traffic accident, RTA, Saudi Arabia, First Aid, Car, Drivers, Attitude, Practice,
Resuscitation, Pre-hospital Care, Emergencies, Injuries.


Road traffic accidents (RTA) burden is not only
In Kingdom of Saudi Arabia (KSA), cars are the
limited to injury and health, but also on economy and
main method of transportation either inside or outside
community [1, 2]. RTA is a major concern for most of
cities [6]. Saudi Arabia extends for more than 2
the countries because of the increasing number of
million Km2 in the south west of Asia [6]. A
deaths and disabilities occurred on the roads [3]. Issam
population of more than 27 million lives in KSA in
Barrimah defined RTA as "any crash on a road
13 administrative provinces, one-fourth of them are
involving at least one moving vehicle irrespective of
non-Saudi [6].
it was resulting in an injury" [4]. The World Health
The authorities in Saudi Arabia reported that more
Organization (WHO) defined Road Traffic Injury
than 6 million cars are there on the road of the
(RTI) as "a fatal or non-fatal injury incurred as a
country [6]. In KSA, fatalities caused by RTA
result of a collision on a public road involving at least
represents 4.7% of all mortalities, compared with a
one moving vehicle " [5].
rate not exceeding 1.7% in Australia, United

Kingdom (UK), and United States (US) [6].
Globally, injuries caused by RTA are considered
Unfortunately, the number of road mortalities in KSA
among the major causes of death and disability [1].
has increased in the last decade from 17 to 24 deaths
The problem is rising rapidly and reports indicate that
per 100,000 populations that is higher than the
by 2020, RTI will be the third leading cause of
numbers recorded in US and UK [6]. RTA fatalities
disability and the leading cause of death by the year
are considered to be the main cause of death in males
2030 [1]. According to the WHO reports, RTA caused
aged 16-30 years [6].
1.24 million deaths on the road and approximately 50
RTA is a serious problem in KSA with accident to
million people have been injured worldwide. It is
injury ratio of 8:6 in comparison with 8:1 worldwide
important to mention that RTI is a burden to hospitals
[6], and accident to death ration of 32:1 compared with
being on the top of the trauma admission causes.
283:1 in USA [6].
Received: 20/12/2017 DOI: 10.12816/0045316
Accepted: 30/12/2017

Full Paper (vol.711 paper# 25)

c:\work\Jor\vol711_26 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (1), Page 2387-2393

Evaluation of Inhaler Use Techniques among Asthmatic Patients in
King Faisal Medical Complex, Taif, Saudi Arabia
Faizah Abdullah Alghamdi 1, Maha Olayan Alsufyani 1, Amjad Awwadh Althobaiti 3 1, Bader Al Harthi2
Raad Nassif 2, Nadeem S. Butt 3, Ahmad A. Malik 3, Marwan A. Bakarman3
1-Medical interns, Taif Univeristy, 2- King Faisal Medical Complex,
Taif, 3- Rabigh Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Corresponding author: Faizah Abdullah Alghamdi, E-mail: faizah.111@hotmail.com

bronchial asthma is a prevalent health problem globally. Inhaled route is commonly used over
other routes to manage asthmatic patients. Despite the efficacy of inhalers, the poor inhaler technique used by
asthmatic patients leads to decrease drug delivery to lungs and poor asthma control. Objective: the main
objective of this study was to evaluate the proper use of inhaler devices by asthmatic patients according to the
standard recommended steps and to identify the factors related to the inaccurate or poor inhaler use among
asthmatic patients at King Faisal Hospital in Taif, Saudi Arabia. Methods and Materials: this was a cross-
sectional observational study conducted among Saudi asthmatic patients using inhaler devices and visiting out-
patient's respiratory clinic. Patients were asked to use their inhaler devices and their inhaler technique and using
a validated checklist. MDI, TurboHaler and Handihaler were the most commonly used whether alone or in
combinations. Results: around 74% and 92% responded to receive any education for asthma and asthma
devices respectively. Of those who received any education, mostly reported that they received education about
asthma and/or devices from their physicians. Breathing out, breath holding pattern and position of head during
inhaling condition were three critical steps that led to improper use. Conclusion recommendation: inhalation
technique in asthma patients was unsatisfactory and was accompanied with errors, especially in patients with
low education levels. This study suggested prioritizing and establishing the proper practice of inhaling devices
to better manage asthmatic patients and quality of life.
Keywords: bronchial asthma, inhaler devices, inhaler technique, compliance, Saudi Arabia.

patients committed at least one critical error while
Bronchial asthma is a prevalent health problem
showing inhaler technique(5). A previous study done
globally. In the last 20 years global prevalence of
in Saudi Arabia showed that the common error
asthma has increased to 5-10% and 20-25% among
committed by patients who were using MDI without a
Saudi patients (1). Inhaled route is the most commonly
spacer was not tilting the head backwards slightly and
preferred route used in management of asthmatic
breathing out residual volume, followed by not
patients. The main reason being due to its less
breathing in slowly. While the common errors in
systemic side effects and rapid onset of
patients using an MDI with a spacer, were not tilting
action(2).Inhalers are hand-held portable devices that
the head back slightly and breathing out slowly
deliver medication to the lungs for the treatment of
residual volume, and not holding the breath for 10
respiratory diseases such as asthma(3). Despite the
seconds(8). In another study conducted, 45% of
efficacy of inhalers, poor inhaler technique used by
asthmatic patients used the inhaler devices
asthmatic patients leads to decreased drug delivery to
improperly. Common factors affecting the proper use
lungs and poor asthma control(1).A study conducted in
of these devices were: irregular follow ups, lack of
2015 found that 93% of metered-dose inhaler (MDI)
asthma medication education, asthma itself as a
users demonstrated poor inhaler technique, 63% of
disease, uncontrolled asthma and three or more ED
them committed 3 or more errors, and the remaining
(Emergency department) visits. Around 40%of them
7% showed perfect technique(4). Another study in
received no proper education by any health care
India showed that 6% of MDI users, 16.12% of dry-
professionals due to a lack of asthma education
powder inhaler (DPI) users and 20.8% of MDI with
programs(1). Despite the importance and magnitude,
spacer were using their inhalers correctly. Around
limited studies have explored the issue particularly in
83% and 16% of the patients received training from
Saudi Arabia.
healthcare workers and general people respectively,
showed that training had a very positive effect on
The paper aimed to evaluate the proper use of inhaler
decreasing errors even by non-professionals(5). Study
devices by asthmatic patients according to the
in Nigeria in 2014 for MDI and DPI, found that
standard recommended steps and to identify the
increased age had association with misuse of these
factors related to the inaccurate or poor inhaler use
inhalers(6).However a study in Riyadh, Saudi Arabia
among asthmatic patients at King Faisal Hospital in
on asthmatic and COPD patients found that 70% of
Taif, Saudi Arabia.
Received: 20/12/2017 DOI: 10.12816/0045317
Accepted: 30/12/2017

Full Paper (vol.711 paper# 26)

The New Era in the Surgical management of Tetrology of Fallot in Pediatric Patients The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (1), Page 2394-2404
The New Era in the Surgical Management of Tetrology of
Fallot in Pediatric Patients: A Meta-Analysis
Tarek Mounir El-Sayegh, Hamdy Abdel Wareth Singab,
Mohamed Ali Elghanam, *Mina Nathan Zaki
Cardiology Department, Ain Shams University, Faculty of Medicine, Cairo, Egypt
*Corresponding author Dr. Mina Zaki Email: dr.mina.zaki86@gmail.com , mob.002 01003162324

Provided the high incidence of Tetrology of Fallot, a compelling need for different surgical
management techniques have been raised. Thus, a new era was developed in this field that gave favorable results,
however a debate still exists on the optimal technique to relieve the Right Ventricular Outflow Tract Obstruction
that could lead to less mortality and morbidity, hence it was necessary to analyze data that compare these
different techniques.
Moreover, there is a controversy between cardiac surgeons about the best technique to correct the RVOT in
infants with Tetrology of fallot and so this study was done to compare between two frequent techniques
according to their mortality and morbidity.
Aim of the work: Assess the outcome after surgical repair of tetrology of fallot in pediatric patients comparing
between transannular patch and valve sparing techniques.
Methods: The present study was planned in accordance with current guidelines for performing comprehensive
systemic reviews and meta-analysis including the PRISMA (Preferred Reporting Items For Systemic Review
Meta-Analysis), MOOSE (Meta-analysis of Observational Studies in Epidemiology) and guidelines for
randomized and nonrandomized studies.
In this study a meta-analysis was done to compare between the two most common techniques (21-32) that are
used to relieve the RVOT that are Transannular patch VS Valve Sparing Repair the variable chosen include:
Mortality the Indexed Right Ventricular Volumes, QRS duration, incidence of pulmonary regurgitation, Right
ventricular Ejection Fraction, Left Ventricular Ejection Fraction and incidence of Reoperation. The principal
summary measures were difference in means with 95% confidence interval and p value (to be of significant if p <
0.005 ) . The difference in means were combined across studies with MedCalc© version 15.8 (MedCalc©
Software bvba, Ostend, Belgium.
A total of 72 citation were identified of which 20 studies were potentially relevant and retrieved in full
text only 12 studies fulfilled the eligibility criteria There was 74% of patients had a TAP and 26% of patients had
VSR. Mortality was 291 among patients with patch repair and 104 among valve sparing repair. Reoperation was
detected in 7 patients with TAP VS 6 patients in VSR. Occurrence of PR was detected in 14 patients in TAP VS
12 patients in VSR. The study detected favorable measures in Indexed right ventricular volumes, RV ejection
fraction and QRS duration in patients with VSR than those with TAP. This study detected that both group of
patients had approximately equal results of LV ejection fraction.
Conclusion: Our results reflected that Valve Sparing Repair for pediatric patients has better outcome in
Mortality to relieve pulmonary stenosis, occurrence of pulmonary valve regurgitation as well as a less harmful
effect on the right ventricular ejection fraction, better Indexed right ventricular volume and QRS duration than
using transannular patching technique.
Both transannular patching and valve sparing repair have approximately the same effect on the left ventricular
ejection fraction that may need further studies.
Keywords: Tetralogy of Fallot, Surgical Correction. Transannular patch, Valve Sparing Repair.


Tetralogy of Fallot, one of the most common
chromosomal abnormalities such trisome 21,18 and
congenital anomalies of the heart consisted of right
ventricular outflow tract obstruction (RVOTO),
Risk of occurrence in families is 3% it can
ventricular septal defect (VSD), aorta overriding
be easily diagnosed with Echocardiography that can
and right ventricular hypertrophy, This combination
give sufficient information for planning of surgical
of lesions occurs in 3 of every 10.000 live births,
treatment (2).
and account for 7-10 % of all congenital cardiac
On November 29,1945 Alfred Blalock
malformations. Patients are usually presented during
performed the first systemic to pulmonary artery
neonatal period with cyanosis. The aetiology of
shunt procedure to palliate Tetralogy of Fallot in a
Fallot's Tetralogy is multifactorial including
child by increasing pulmonary blood flow it was
untreated maternal DM, Phenylketonuria, and intake
named the Blalock-Taussing shunt (BT shunt) and
of retinoic acid. Its also associated with
this was the first truly successful palliation of
Received: 13/1/2018 DOI: 10.12816/0045318
Accepted: 23/1/2018

Full Paper (vol.711 paper# 27)

c:\work\Jor\vol711_28 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (1), Page 2405-2410

Role of Multi-Detector Computed Tomography in Assessment of
Pulmonary Arterial Hypertension
Aya Essam, Omnia Ahmed Kamal, Ahmed Mohamed Osman
Radiology Department, Ain Shams University
Corresponding author: Aya Essam, email: ayaessam894@gmail.com

Pulmonary arterial hypertension (PAH) may be suspected based on the clinical history, physical examination
and electrocardiogram findings but imaging is usually central to confirming the diagnosis, establishing a cause
and guiding therapy. The diagnostic pathway of PAH involves a variety of complimentary investigations of
which computed tomography pulmonary angiography (CTPA) has established a central role both in helping
identify an underlying cause for PAH and assessing resulting functional compromise. In particular, CTPA is
considered as the gold standard technique for the diagnosis of thromboembolic disease.
This article reviews the CTPA evaluation in PAH, describing CTPA techniques, a systematic approach to
interpretation and spectrum of key imaging findings.
Keywords: Pulmonary arterial hypertension (PAH); computed tomography (CT); echocardiography.


Pulmonary arterial hypertension (PAH) is
Inclusion criteria
defined as an increase in mean pulmonary arterial
Both sexes were included.
pressure greater than 25 mmHg at rest, or greater than
Adult patients (age from 20-75).
30 mmHg during exercise 1. It's a serious condition
Patients suspected clinicaly to have pulmonary
that can damage the right side of the heart.
The walls of the pulmonary arteries become
thick and stiff, and can't expand as well to allow
Exclusion criteria
blood through. The reduced blood flow makes it
Patients are known to have contraindication of
harder for the right-hand side of the heart to pump
contrast e.g. renal failure, pregnancy.
blood through the arteries so the right-hand side of
Patient's with non-reliable Echo.
the heart has to continually work harder, it can

gradually become weaker; this can lead to heart
failure2. Transthoracic echocardiography (TTE)
Patients were subjected to:
provides a useful initial screening tool, in which the
1- Full history taking.
pulmonary arterial pressure is indirectly assessed via
2- All patients underwent Doppler
calculation of tricuspid regurgitation jet velocity 3 .
echocardiographic indices for the evaluation of
TTE also provides valuable information
patients with clinical suspicion of pulmonary arterial
regarding cardiac morphology and function and in
some cases may elicit the cause, e.g., atrial septal
3- All patients underwent contrast enhanced CT
defect (ASD). Right heart catheterization (RHC) is
the gold standard method of quantifying the
The study was done in the CT Unit in Radiology
pulmonary artery pressures and can also be used to
Department at Ain shams University Hospitals.
measure the pulmonary capillary wedge pressure in

suspected left heart disease. RHC provides very
Patient preparation
limited information regarding the underlying cause of
Explanation of the study to patients or his/ her
PAH11 .
care giver and obtaining an informed consent.

Checking serum creatinine before contrast
This study included 36 patients with clinical and
Measuring patient body weight for calculation of
echocardiographic diagnosis of pulmonary
amount of contrast media and sedative material if
hypertension referred for multidetector computed
tomography (MDCT) examination . The study was
Fasting for 6 hours.
performed in Radiology Department at Ain Shams

University Hospitals using Toshiba machine.
Procedure duration
The study was approved by the Ethics Board of
The study took 10 -15 minutes.
Ain Shams University.

Received: 21/1/2018 DOI: 10.12816/0045319
Accepted: 1/2/2018

Full Paper (vol.711 paper# 28)

Role of Diffusion Weighted MRI in Diagnosis The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (1), Page 2411-2421
Role of Diffusion Weighted MRI in Diagnosis
of Cervical Cancer
Sherif H Abo Gamra, Mohamed G Abdel Mutaleb, Haydar M Sinjawi
Department of Radiodiagnosis
Faculty of Medicine, Ain shams University
Corresponding author: Haydar M Sinjawi, Mobile: 01016267636; Email: haydar_sinjawi@yahoo.com

Diffusion weighted magnetic resonance imaging (DW-MRI) is a functional, non-invasive
imaging technique which generates tissue contrast from differences in mobility of water molecules that occurs
during an MR pulse sequence. Information regarding the integrity of cellular membranes and tissue cellularity
can be obtained, so that DW-MRI can now be included in routine patient assessment. Aim of the Work: The
aim of this study is to evaluate the role of DW-MRI in the diagnosis of cervical carcinoma, with pathological
diagnosis was taken as the reference. Patients and Methods: This is a retrospective study that included 20
patients in whom cervical cancer had been suspected clinically or by transvaginal ultrasound (U/S) and the
control group consisted of 20 patients in whom cervical cancer had not been suspected and MRI was
performed because of other Pelvic diseases. The study was conducted in El-Demerdash Hospital. The patients
were referred from the Gynecology Department to the Radiology Department (Women's imaging unit) for
further MRI assessment with diffusion weighted images (DWIs). Results: Lesions in all cases show restricted
diffusion, however on apparent diffusion coefficient (ADC) map, only one case showed high signal proved to
be chronic cervicitis on histopathology. Also, the mean ADC values for malignant lesions were (0.82 x10-3
mm2/sec), while the mean ADC value in the control group was (1.58x10­3 mm2/sec). Therefore ADC value of
(1.04 x10-3 mm2/sec) is a cut off between normal cervical tissue and malignant cervical lesion by sensitivity
95% and specificity 95 %. DWIs had elicited the same accuracy to Dynamic contrast-enhanced (DCE)
sequences (95%) when added to the non-contrast MRI in the estimation of cancer cervix.
Conclusion: Our results proved that (DW­MRI) was significantly beneficial in terms of diagnostic
performance that increases the radiologist's confidence in image interpretation. So it implies a non-invasive
technique which can be used especially if contrast intake is avoided as in pregnancy. Thus, we suggest that
DWI should be included in the routine pelvic MRI protocol. The ADC value in case of cervical carcinoma was
significantly lower than in the normal cervical tissue. The ADC threshold of (1.04 x10-3 mm2/sec) was a cut off
value, which was detected when differentiating between cancer-affected and non-affected cervical tissues
Keywords: MRI, DW-MRI, cervical cancer.

Diffusion-weighted imaging (DWI) is one of
Cervical cancer is the third most common
the evolving imaging technologies. It carries the
cancer in women worldwide and is diagnosed in over

12,000 women in the United States each year (1). Most
potential to improve tissue characterization when
women with cervical cancer are diagnosed before the
findings are interpreted together with conventional MR
age of fifty. However; older women remain at risk.
imaging sequences (5).
Cervical cancer is both preventable and, if identified
DW-MRI is a functional, non-invasive
early, treatable (2).
imaging technique which generates tissue contrast
Cervical cancer is usually staged and
from differences in mobility of water molecules that
managed on the basis of criteria proposed by the
occurs during an MR pulse sequence. Information
International Federation of Gynecology and
regarding the integrity of cellular membranes and
Obstetrics (FIGO) which is based on clinical
tissue cellularity can be obtained, so that DW-MRI can
examination, rather than surgical findings. Early
now be included in routine patient assessment (6). DW-
diagnosis and accurate staging of the disease is
MRI enables the radiologist to move from
crucial in planning the optimal treatment strategy (3).
morphological to functional assessment of diseases of
MRI is an ideal non-invasive technique
the female pelvis (7), adding the possibility of
and superior to other imaging modalities in the
discriminating between benign and malignant lesions.
evaluation of pelvic abnormalities. The anatomical
Cervical cancer has shown to have significantly lower
relation of the visceral organs, the differential
ADC values as compared to normal cervical tissue (8).
zonal anatomy of the corpus uteri, and the cyclical
DWI and ADC map help in differentiation
endometrial changes during the menstrual cycle are
of benign from malignant zones of cervix without
well depicted with MRI (4).
exogenous contrast (9). The measurement of ADC
value in patient with cervical cancer is an
Received: 7/1/2018 DOI: 10.12816/0045320
Accepted: 17/1/2018

Full Paper (vol.711 paper# 29)

c:\work\Jor\vol711_30 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (1), Page 2422-2428

General Background and Attitude of the Saudi
Population owards Mental Illness
* Malik Jelaidan, *Lamees AbuAlkhair, *Tafani Thani, *Abdulqader Susi, Raafat Shuqdar
* Taibah University, Medinah, Psychiatrist, Taibah University, Medinah
Mental illnesses or psychiatric disorders are very common worldwide although, a lot of patients might go
undiagnosed and untreated due to the stigma towards mental illness that drives the patients away from seeking
medical help. Aim of the work: this study aimed to evaluate the background and attitude of the general
population throughout Saudi Arabia about mental illnesses. Method: a cross sectional study analyzed data from
5850 participants aged 18 and up. From all 13 districts of Saudi Arabia. The data were collected using self-
administered anonymous electronically distributed questionnaire, between the months of April- May of 2017.
The data were analyzed using the statistical analysis system (SAS version 9.1; SAS Institute, Cary, NC). Crude
associations were assessed using Pearson Chi -square test. P value of less than 0.05 was used to indicate
statistically significant differences. Result: the mean age of the studied subjects was 28.7 ± 9.8 years. Subject's
background about the general nature of psychiatric disorders was high and exceeding 90% regarding the nature
of psychiatric disorders and whether they were similar or not, a very low percent (7%) showed that psychiatric
patients cannot socially adapt, while 96.9% believed that psychiatric patients were considered insane. (52%)
believed psychiatrists are affected by their patients on long term exposure. Conclusion: he background of Saudi
population regarding mental illnesses is considered fair, the attitude towards psychiatric patients need further
education to minimize the stigma towards them.
Keywords: Saudi Arabia, stigma, mental illness,general background.


background of the population about mental illness in
Mental illnesses are health conditions involving
the society.
changes in thinking, emotion or behavior (or a

combination of these). Mental illnesses are associated
with distress and/or problems functioning in social,
This study aimed to evaluate the general background
work or family activities. Mental illnesses are likely
and attitude of the general population of Saudi Arabia
to have multiple causes, including genetic, biological
about mental illness and to determine the reasons
and environmental factors (1). Mental illnesses are
behind the stigma surrounding mental health in
prevalent in Saudi Arabia, especially among the
elderly (2) and almost one fifth of primary health care

patients have mental illness(3).
Abdel-Fattah and Asal identified a systematic
A cross sectional study analyzed data from 5850
sample of 490 secondary school students in Taif,
participants. The data were collected using a self-
assessing depressive symptoms using the 21-item
administered, electronically distributed questionnaire.
Beck Depression Inventory (BDI) and high rates of
A pilot study was conducted on 54 individuals to test
symptoms were reported(4). In another study which
the validity and reliability of the questionnaire. The
was done on high school students ages 14 to 19,
study took place between the periods of May-April of
psychiatric symptoms were examined, fifty-nine
2017. Ethical approval was obtained from Taibah
percent of boys sample had significant levels of either
University College of Medicine Research Ethics
depression, anxiety or stress(5),
while the girl sample reported overall, 16% had one
The study investigated the background and attitude of
or more type of symptom, 9% had two or more
the Saudi population toward psychiatric disorders and
symptoms, 6% had three symptoms and 4% had all
mental illness, with question discussing the attained
four symptoms(6).And a prevalence estimate of the
background of the nature, practice and management
most common DSM-IV disorders was as high as 48%
of psychiatric disorders, the compliance of psychiat-
of the general population(7). Shahrour and Rehmani
ric patients and the social stigma toward both patients
tried to explore why are patients not seeking medical
and physicians.
help (8) and the reasoning behind the stigma. As the
The background about psychiatric disorders was
stigma is very prevalent in the Saudi society (9-11)
based on 8 questions. There have been 3 answers for
specifically and the Muslim community in general (12)
each of the background question (yes, no and do not
and there are doubts towards the legitimacy of mental
know). For simplification "no" and "don't know"
illness (13).We wanted to evaluate the general
were grouped as "no". The background was assessed

and categorized into good, fair and poor according to
Received: 1/1/2018 DOI: 10.12816/0045321
Accepted: 10/1/2018

Full Paper (vol.711 paper# 30)