c:\work\Jor\vol713_1 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2633-2635

Bilateral Foraminal Stenosis in Patient with Dandy-Walker
Malformation: Hiding Pathology
Hieder Al-Shami1, Farah Sameer Othman2, Ahmed Hegazy3, Mohammed Fathy Adel Ali3
1 Department of Neurosurgery, Al-Ahly Bank Hospital, Cairo, Egypt,
2 Department of Pediatric, Faculty of Medicine, Mousl University, Mousl, Iraq, 3 Department of
Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
Corresponding Author: Hieder Al-Shami, email:Adamhouse73@gmail.com

Etiologies of hydrocephalus are many and sometimes it can be attributed to be multifactorial in
origin. Presence of known cause of hydrocephalus like fourth ventricular pathology may mask foramenal
stenosis. Diagnosis of unilateral and bilateral stenosis of foramen of Monro should be included in the treatment
plan in hydrocephalus
A case report of a 9 months-old boy presented with delayed milestones of development and an increase in head
circumference. The patient has been diagnosed as hydrocephalus and associated Dandy-Walker malformation.
Ventriculoperitoneal shunt was inserted successfully but drained only one lateral ventricle. The association of
isolated lateral ventricle with Dandy-Walker malformation is due to stenosis of foramen of Monro. Our case
report is unique due to association between foramen occlusion and Dandy-Walker malformation.
Keywords: foramen of Monro, Dandy-Walker malformation, VP shunt.


Etiologies of hydrocephalus are many and
enlarged and showing no drainage as well as a cyst
sometimes it can be attributed to be multifactorial
in the posterior fossa. The diagnosis was bilateral
in origin (1). Presence of known cause of
foraminal stenosis at the level of the foramen of
hydrocephalus like fourth ventricular pathology
may mask foramenal stenosis (2). Diagnosis of
unilateral and bilateral stenosis of foramen of
Patient was prepared for endoscopic dilatation
Monro should be included in the treatment plan in
of foramen of Monro and fenestration of the
hydrocephalus to prevent shunt malfunctioning (3).
septum pellucidum.
Our case reported bilateral stenosis of foramen of
Operation. The patient was under general
anaesthesia in supine position with head fixation by
Mayfield head holder. A burr hole was made in the

left Kocher's point as the left lateral ventricle was
slightly wider than right one and directed to
A 9-month male patient complaining of
contralateral frontal horn for later on septostomy.
failing or delayed milestones development and an
The left foramen was occluded by thin membrane.
increase in skull circumference (HC=42 cm)
The right foramen of Monro was stenosed with
presented to our clinic. He was diagnosed as
no evidence of neoplastic activity and normal
obstructive hydrocephalus.
choroid plexus. The left foramen was dilated by a
He was prepared for ventriculo-peritoneal
Fogarty catheter and balloon to dilate the opening.
shunt. No specific operative findings other than
By using bipolar and monopolar, large fenestration
high pressure of cerebrospinal fluid (CSF) were
of septum pellucidum (septostomy) was made.
After completing of foramenoplasty, visualization
unremarkable with relaxation of the anterior
of third ventricle was made. An additional third
fontanelle after 24 hours.
ventriculostomy was not made due to small sized
Follow up CT brain (see Figure 1) showed that
the lateral ventricle of the same side was drained
Postoperative care. The patient was monitored
completely while the contra-lateral ventricle was
in ICU and discharged on Day 2 with no

Received:17 /2 /2018 DOI: 10.12816/0045818
Accepted:27 / 2 /2018

Full Paper (vol.713 paper# 1)

c:\work\Jor\vol713_2 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2636-2642

Evaluation of The Accuracy of Sub Bowman's Keratomileusis (SBK)
Microkeratome in Flap Creation during Lasik Surgery
Hager K Elsaiid*, Tamer M El Mekkawi *, Mouamen M Seleet* and Rania S Elkitkat **
The department of Ophthalmology **, Faculty of Medicine, Ain Shams University
Corresponding author: Hager Khaled Mohamed, mobile:01092156291,email: dr_gogo_2931989@hotmail.com

To evaluate the accuracy of SBK microkeratome in flap creation during myopic LASIK surgery using
anterior segment optical coherence tomography (AS-OCT).
Design: A Prospective non-randomized noncomparative interventional clinical study.
Methods: Flaps were created using the One Use-Plus SBK microkeratome (intended flap 90 µm) in 40 eyes of
20 patients. Flap thickness was measured using AS-OCT one month after surgery.
Results: The mean achieved central corneal flap thickness in both eyes was 88.67±7.19, 1.33 µm thinner than
the intended 90 µm thickness (difference from intended thickness -1.33±7.19) with a p value of 0.067 which is
statistically insignificant (p>0.05). The mean achieved central corneal thickness in the right eye was 88.56 ± 7.95
m (ranging from 70 m to 112µm), 1.44 µm thinner than the intended 90 µm (difference from intended
thickness -1.44 ±7.95) thickness with a p value of 0.206 which is statistically insignificant ( p>0.05). The mean
achieved central corneal flap thickness in the left eye was 88.78 ± 6.41 m (ranging from 77µm to 105 µm)
showing a difference from intended thickness of -1.22±6.41 µm deviation from the intended thickness that is
statistically insignificant (p value of 0.185, p>0.05).
Conclusion: Using the one use ­plus SBK microkeratome is a safe, accurate and effective modality for creating
a thinner SBK flap, hence increasing the available residual stromal bed and preserving corneal tissue.
It has excellent predictability and reproducibility when it comes to flap thickness with minimal intra operative
There was several limitations to our study. The tool of measurement (AS-OCT), is that the boundaries
between the flap and stroma become ambiguous with time, increasing the examiner's subjectivity.
Keywords: LASIK, SBK Microkeratome, Femtosecond laser, Ectasia, Myopia.


crucial for decreasing the possibility of ectasia
Over the past decades, laser in situ
occurrence. Also it has been shown that the thinner
keratomileusis (LASIK) has become the most
the flap, the less risk for ectasia. Accuracy of the
common refractive procedure for the correction of
flap thickness produced using mechanical
microkeratomes is mandatory in this calculation.
predictability of the corneal flap thickness is crucial
Percentage of tissue altered (PTA) greater than
in producing successful LASIK outcomes. The
40% at the time of LASIK is significantly
corneal flap thickness is directly related to LASIK
associated with the development of ectasia in eyes
safety; therefore, methods that improve the
with normal preoperative topography [5].
precision and minimize the degree of variation in
Earlier studies using microkeratomes showed
corneal flap thickness are worthy of attention [2].
that there was a high deviation from the marked
Today, a variety of microkeratomes, as well as
thickness for a given blade. Hence the development
femtosecond lasers, are in clinical use for flap
of SBK microkeratome with 90 µm thickness has
creation [3].Good microkeratomes are associated
shown high reproducible accuracy in different
with accurate cuts, less flap thickness variation,
recent studies. This has made this type of
easy manipulation, and fewer complications[4].
mechanical microkeratome a competitor for
One of the most feared complications is post
femtolaser flap creation that has gained popularity
LASIK corneal ectasia. Among many other factors,
in recent years, with the main advantage of creating
the residual corneal thickness after the ablation is
accurate thin sub-Bowamn flaps[6-8].
Received:12 /3 /2018 DOI: 10.12816/0045820
Accepted: 22/ 3/2018

Full Paper (vol.713 paper# 2)

c:\work\Jor\vol713_3 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2643-2650

Epidemiology of Tinea Capitis among Population of
Arar city, Northern Saudi Arabia
Alshalan,Maha Hazzaa F1, Wesam Mohamed Tharwat 2, Alruwaili , Anwar Eid M1 ,

Alfuhigi ,Zuhur Dhaher M1, Alanazi , Yasamiyan Mohammed A1, Alenazy , Asmaa Enad S1,

Alrowili,Amjad Saud Mhrb1, Alsharif , Shahad Ahmed S1, Alshammari, Nada Naif Z1,
Alshammari , Manal Nashi O1, Alenazy , Maram Khalf A1.
1 Students, Faculty of Medicine, Northern Border University, Arar, KSA
2 Dermatology and Venereology, Prince Hospital, Arar city, KSA
Tina capitis is a mycosis caused by dermatophytes that invade the keratinized tissues such as
skin, nails, and hair. It is important to know the prevalence, route of transmission and risk factors of these
infections for prevention and treatment of this disease. The objective of this study was to determine the
prevalence rate and risk factor associated with tinea capitis in the general population of Arar city, Northern
Saudi Arabia. Methods: Cross sectional hospital based study. Data collected from 180 participant aged 5- 60
years, attending three randomly selected primary healthcare centers in Arar city during the period from 1st
January to 30th June 2017. Participants selected using a systemic random sampling procedure as we take every
second person attending the PHC during the study period. Each participant interviewed separately, and
confidentiality assured. Data was collected by means of personal interview with the sampled person using a
predesigned questionnaire covering the needed items. Results: The overall prevalence of tinea capitis among
the studied population was 31.1%. Males were more affected (56.7%) than females (P value>0.05) and 35% of
cases aged from 16-21 years (P value>0.05). Conclusion: The overall prevalence of tinea capitis among Arar
population was 31.1%. This indicates the high tendencies of spread of tinea capitis through human-to-human
mode of transmission and possible animal contact. Community health education on the cause, mode of
transmission, prevention, and prompt treatment of tinea capitis is recommended.
Keywords: Epidemiology; prevalence; Tinea capitis; Arar city; Northern Saudi Arabia.


Tinea capitis is a mycosis caused by
to prompt treatment following clinical presentation
dermatophytes that invade the keratinized tissues
and standard of living [5, 6]. It is the most common
such as skin, nails, and hair [1]. Dermatophytic
dermatophytosis in children aged between six
fungi causing tinea capitis can be divided into
months and prepubertal age [7, 8], and its prevalence
in Africa among children is 14­86% [5].
Anthropophilic fungi grow preferentially on
In some urban areas in North America, Central
humans and the most common type forms large
and South America, tinea capitis is widespread and
conidia of approximately 3-4 m in diameter
it is still very common in parts of Africa and India
within the hair shaft. Zoophilic fungi are acquired
through direct contact with infected animals.
According to the literature, there has been a
Smaller conidia of approximately 1-3 m in
significant increase in the incidence of tinea capitis
diameter typically are present, extending around
and a change in the pattern of infectious agents in
the exterior of the hair shaft [2]. The prevalence of
tinea capitis and the predominance of its etiological
It is important to know the prevalence, route of
agents are different according to the geographical
transmission and risk factors of these infections for
distribution [3].
prevention and treatment of this disease [10, 11] .
It has a worldwide distribution but is endemic to
It is generally spread through direct or indirect
tropical regions as its growth is facilitated by the
rout, the direct transmission via direct contact with
warm and moist conditions [4] . Until recently, tinea
an infected person or indirect transmission by
capitis was thought to have a high prevalence
mainly in the developing world because of poor
hairbrushes, towels, combs or other personal items
hygiene, overcrowding and low socio-economic
and backs of seats which is common between
family members in low socioeconomic areas. The
Also other factors can affect it distribution such
spores are long lived and can infect another
as population migration patterns, lifestyle, primary
individual months later [12]. The aim of the study is
host range, secondary host immunity, presence of
to obtain a general overview of the current state
immunodeficiency diseases, and patients' attitude
and changing pattern of tinea capitis in Arar city.
Received:11 / 1 /2018 DOI: 10.12816/0045822
Accepted:21 / 1 /2018

Full Paper (vol.713 paper# 3)

c:\work\Jor\vol713_4 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2651-2655

Congenital Hydrocephalus in Arar, Northern Saudi Arabia
Adel Turki Alenezi 1, Nagah Mohamed Abo El-Fetoh2, Malik Azhar Hussain3,
Osama Mazha Mutkhan Alanazi1, Aldaghmi, Ahmed Saud A1, Bader Arar Shadad Alruwaili1,
Muaz Bilal Wali1, Munif Saleh Alenezi1, Alanazi Abdullah Saad1, Abdulaziz Salamah Alanazi1, Wael
Abdullah Alanazi1, Mohammed Khalil Al Shakarh1
1 Faculty of Medicine, Northern Border University, 2 Community Medicine Department, Faculty of Medicine,
Sohag University, Sohag, Egypt and Northern Border University, Arar, KSA, 3Assistant Professor,
Department of Surgery, College of Medicine, Northern Border University, Arar, Saudi Arabia

Congenital hydrocephalus, an important cause of neurologic morbidity and mortality in children,
is a medical condition characterized by an abnormal accumulation of cerebrospinal fluid in the brain.
Objectives: To estimate the prevalence and the recent progresses in diagnosis of hydrocephalus as well as the
changes in epidemiology and treatment outcomes of the disease. Methods: This is a descriptive study involved
all neonates born in Maternity and child hospital in Arar city, Northern Saudi Arabia, KSA, during the period
from 1 January to 31 December 2017. Among 6000 delivered infant in 2017; there was 23 cases of
hydrocephalus. Data was collected by using predesigned questionnaire which include questions designed to
fulfill the study objectives. Results: the prevalence of hydrocephalus among studied infants was 0.38%.
Consanguinity between parents was reported among 60.9% of the cases. Other congenital anomalies reported,
cardiac anomalies 39.1%, spina bifida 17.4% and cleft palate 8.7%. Cause of hydrocephalus was 65.2%
hereditary and 34.8% infection (secondary cause). Swelling of the eyelid, increased vascular clarity on the skull,
transparent skin in the head, the child's tendency to sleep, disorientation, irritability and nervousness, high
crying, weakness of feeding and vomiting, delayed child skills, convulsions, increased size of the head, the sun's
sign in the eye and the child is always looking down were the symptoms reported by the cases. 56.5% of the
cases had shunt insertion and 43.4% had ordinary medical treatment. 30.4% of the shunt cases were complicated
(17.4% had shunt blockage with infection and fever, 13% shunt blockage and 69.6% had other complications).
Outcome of the case; 39.1% were stable, 13% worsen and 47.8% died (34.7% died by complications, 8.7%
during operation and 4.3% did not receive treatment). Conclusion: The prevalence of hydrocephalus is
comparable to that of other countries. More research is recommended because it is probable that the real
prevalence of congenital hydrocephalus was underestimated and no account of how often abortions are
performed among mothers of hydrocephalic fetuses. So more efforts from the ministry of health is needed.
Keywords: Hydrocephalus; prevalence; outcome; Arar; Northern Saudi Arabia.


ventriculostomy (ETV), but it was not a success
Hydrocephalus is broadly defined as a
because of technical problems and complications
disturbance of formation, flow, or absorption of
and for many decades ETV was not used [4]. Around
CSF that often is detected when it becomes
(1960) the use of ventricular shunts became more
symptomatic as a result of increased intracranial
common, as materials and techniques had improved,
pressure [1]. Morbidity and mortality rates
the use of modern shunts resulted in a reduction
vary internationally but in general rising
in mortality from 50% to about 10%during the last
throughout the world, the highest incidence rates
decade [5].
are found in Africa and Asia. In infants,
A previous study conducted in Sohag
hydrocephalus without an obvious extrinsic cause is
governorate, Egypt [6] reported that; incidence of
usually referred to as congenital hydrocephalus,
hydrocephalus was 6.76/1000 living births.
since it is often present at birth. When
Consanguinity was present in 58% , family
hydrocephalus occurs as a complication of another
history was detected in 20.8%, drugs intake in
condition such as hemorrhage, infection or
63.8%, fathers above 50 years at time of
neoplasm, it is usually called acquired or secondary
conception was detected in 30.4% of them
hydrocephalus [2]. Prevalence estimates for infantile
(85.28%) were nonprofessionals, no antenatal
hydrocephalus vary between one and 32 per 10,000
care (51.7%), polyhydramnios (7.5%),
births, depending on the definition used and the
oligohydramnios(7.1%), early vaginal bleeding
population studied [3]. Management was described in
(14.2%), preeclampsia (7.5%), twins was
(1923) by the use of endoscopic perforation of the
recorded (7.9%), breech presentation in (12.9%).
floor of the third ventricle, endoscopic third
Congenital hydrocephalus was treated by shunt
Received:12 / 1 /2018 DOI: 10.12816/0045824
Accepted: 22/ 1 /2018

Full Paper (vol.713 paper# 4)

c:\work\Jor\vol713_5 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2656-2663
Pattern of Gastrointestinal Diseases among Elderly Patients in Arar City,
Kingdom of Saudi Arabia (KSA)
Sara Emad Alrayya1, Muharib Mana Alshammari1, Mushref Saeid Alshammari1, Bdoor Attaulla
Alenezi1, Sarah Musharraf Alanazi1, Shouq Saud Alanazi1, Deema Faleh Alanazi1,
Abdulaziz Sael Alshammari1, Sultan Theyab Alshammari1, Jazzaa Hammad Alshammari1,
Abdullah Zidane Alshammari1, Raghad Aladham Alanazi1
1Faculty of medicine, Northern Border University, Arar, KSA

The world's population is aging and the number of people who are 60 years old increased worldwide. The
elderly population is susceptible to various benign and malignant diseases. Gastrointestinal diseases are
among the common health problems that affect the elderly. Aim of the study: to identify the pattern of
gastrointestinal diseases among elderly patients in Arar city (KSA) and the relation with gender in the study
population. Subjects and methods: a cross sectional study was conducted in five randomly selected primary
healthcare centers in Arar city (KSA), from September 2016 to March 2017. It included 118 elderly patients.
A questionnaire was designed for data collection about socio-demographic variables, smoking, BMI, chronic
diseases and types of gastrointestinal diseases among participants. Results: findings showed that all
participants suffered from dental problems and 24.6% had gum problems. Other diseases affected various
proportions of the studied elderly population including loss of appetite, gastric regurgitation, chronic
constipation, irritable bowel syndrome, chronic colitis, peptic and duodenal ulceration, liver cirrhosis, viral
hepatitis, cholecystitis, gall stones, pills, anal fissure and GIT tumors. Statistically significant differences
were found between males and females regarding having piles, gall stones and anorexia. On contrary, all
other GIT diseases showed insignificant differences between males and females. Conclusion: different types
of GIT diseases were found among the participants with varying rates. Significant gender differences were
observed in some diseases (piles, gall stones and loss of appetite) while most of the studied GIT diseases
showed insignificant differences between both sexes.
Keywords: gastrointestinal diseases; pattern, elderly.

secretion, and/or
The world's population is aging and the
absorption may develop giving rise to functional
number of people who are 60 years old
digestive diseases; while others may develop
increased worldwide and expected to reach 21.1%
diseases that are more frequent and/or more
of the population by 2050[1]. Ageing is a complex
severe [6].
process [2] and as age advances there is an
increased risk for developing various diseases due
gastrointestinal diseases affecting the elderly.
to the progressive deterioration of many organs
About 30 % of the general population had
and systems [3].
constipation during life time[7, 8], with elderly
The elderly population is susceptible to various
people and women being mostly affected.
benign and malignant diseases. Prevalence of
Constipation is more common among elderly
arterial hypertension and diabetes and cancer
patients who admitted to hospital or nursing
mortality rates increase with age. Additionally,
homes for long periods[8, 9].
osteoarthritis, infections and upper gastrointestinal
Gallstone disease is another problem which is
diseases are common in the elderly [2].
age-associated [10, 11] and elderly patients are
Furthermore, aging is frequently accompanied by
frequently affected by gallstone disease.
decreased taste acuity, deteriorating dental health,
According to a cross-sectional survey in Italy, the
and a decline in physical activity, all of which
overall prevalence of gallstone disease was 26.7%
may result in poor nutrition [4].
in the elderly and multiple gallstones were
Gastrointestinal diseases are among the
particularly frequent, occurring in 62.7% of
common health problems that affect the elderly.
They are also likely to be taking many
cholecystitis-associated gallbladder and common
medications which can also affect bowel function
bile duct stones are present in 16% of elderly
[5]. There is a wide variation in the gastrointestinal
patients undergoing cholecystectomy[12, 13].
function in the old age where basic digestive
Regarding irritable bowel syndrome (IBS),
functions may remain efficient; or functional
patients are commonly between the ages of 30 and
Received:13 / 1/2018 DOI: 10.12816/0045826
Accepted:23 / 1/2018

Full Paper (vol.713 paper# 5)

c:\work\Jor\vol713_6 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2664-2666

A Traveler to Holland With a Benign Killer: A Case Report of a
Sickle Cell Trait Male with Splenic Infarction
Ghadeer S. Alabbadi,Osama Alsultan, Aqeela M. Alredwan, Ghadeer M. AlHajjaj, Eiman S. Alajyan
King Fahad Hospital of the University AL Khobar
Corresponding Author: Ghadeer S. Alabbadi, Mobile: +966543276165, Email: rose- 2018@hotmail.com.

Sickle cell trait is highly prevalent in Saudi Arabia. However, most of the patient are asymptomatic, only few
present with symptoms of the complications of the disease. We report a case of 24-year-old male who
presented to the hospital with history of dull left upper quadrant, nausea and vomiting while he was on the
airplane. Investigation showed a picture of sickle cell trait with hemoglobin S of 40%. Peripheral blood smear
was within normal. CT scan of the abdomen confirmed the presence of splenic infraction. This case
emphasized on the need to increase the level of threshold to recognize the rare complications of sickle cell trait
and how to manage them appropriately.
Keywords: altitude; sickle cell trait, splenic infarction.


We labeled a patient as sickle cell trait when he
vomitus was food content with no history of
inherited heterogenetic genes of hemoglobin Hb A.
hematemesis. During the flight, he noticed some
The percentage of Individuals with SCT is high,
change in his urine color. It became deep yellow-red.
especially in equatorial Africa and in African-
He also had a history of dyspnea along the onset of
Americans. It reached up to 50% in some enclaves of
the pain. He tolerated the pain till landing. After
Africa and up to 10% in African-Americans [1-3]. 20%
landing he sought medical advice at a private
of the eastern province population of Saudi Arabia
hospital's emergency department where he was
are SCT. The sickle cell trait in general lives
managed with intra-venous fluid hydration, given
normally like other people [4]. However, Sickle cell
some analgesics and was discharged home after eight
trait is not completely benign state. usually the trait
hours in good condition with the impression of a
remains a silent condition. But when the SCT person
gallbladder disease. He stayed at Amsterdam for four
leaves his original place and went to higher altitudes,
days. During his stay, he had an on and off left upper
where high oxygen is needed, he may face many
quadrant abdominal pain, the pain was partially
complications one of them is the splenic infarction [5].
relieved by analgesics, but it was triggered by deep
We reported here a case of sickle cell trait patient
breathing, coughing, and laughing. He arrived back to
complaint of upper abdominal pain of 3 weeks
Saudi Arabia on the 23rd of October 2013. He
duration after a trip to Holland. In all patients, the
immediately visited King Fahad Hospital of the
diagnosis of splenic syndrome secondary to SCT
University. In the emergency department, routine
gene after exposure to high altitude were made
laboratory work-up was done and he was given
analgesics. His past medical history was significant
for an appendectomy three year back, and a
M. M. is a 24 years-old Saudi gentleman who was
septorhinoplasty three months back with no
referred to the hematology clinic at King Fahad
complications. He also had a family history of sickle
Hospital of the University complaining of upper
cell trait mother and four siblings. He was on high
abdominal pain for three weeks duration after a trip to
protein diet and shakes as a part of a fitness program.
Holland. He was in his usual state of health till one
He has been a cigarette smoker for the last seven
night prior to his trip when he started to do some
years, two packs per day. Regarding his occupation,
strenuous exercise in the form of heavy weight lifting
he was a heavy field worker. He was discharged
and treadmill jogging. He slept for eight hours then
home from the emergency department with an
headed to the airport thereafter. The flight was a
appointment follow up at the hematology clinic.
seven hours trip. He had a heavy meal served on the
At the clinic, he was complaining of mild left
flight then he napped for almost four hours.
upper quadrant abdominal pain. On examination, he
Eventually, he was woken-up from his sleep because
was vitally stable. He looked well, not pale or
of a sudden onset, severe, generalized abdominal
jaundiced. Systemic examination was unremarkable
pain, more pronounced on the left upper quadrant.
apart from abdominal examination.
The pain was constant, dull-aching in nature, and
Abdominal examination showed tenderness in
radiating to his left shoulder. It was associated with
epigastric and left hypochondriac area upon
nausea and he vomited almost four times. The
Received:20 / 12 /2017 DOI: 10.12816/0045827
Accepted:30 /12 /2017

Full Paper (vol.713 paper# 6)

c:\work\Jor\vol713_7 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2667-2680

Continuous versus Interrupted Suturing in Repair of Lateral and
Mediolateral Episiotomy: A Randomized Controlled Trial
Maged Ramadan Abu Seada*, Tamer Farouk Borg*, Mohammed Mahmoud Samy*,
Aliaa Abdelrazek Mohamed**
*Obstetrics and Gynecology Department - Ain Shams University** Cairo University
Corresponding author: Aliaa Abdelrazek Mohamed, email: draliaa89@gmail.com; mobile:002-01123373356

Episiotomy is the surgical enlargement of the posterior aspect of the vagina by an incision to
the perineum during the last part of the second stage of labor. The incision is performed with scissors or
scalpel and is lateral or mediolateral in location.
Aim: This study aims to compare postoperative pain following repair of episiotomy between continuous or
interrupted suturing technique.
Methodology: In the second stage of labor, 260 pregnant women received a mediolateral and lateral
episiotomy 130 each in Ain Shams University, Maternity Hospital were chosen to participate in the study
after obtaining a verbal consent.
They were randomly allocated into two groups A and B, randomization was done using opaque sealed
envelopes. Group A: was repaired by interrupted suturing technique and include 130 pregnant women 65
with mediolateral and 65 with lateral episiotomies. Group B: was repaired by continuous suturing technique
and include 130 pregnant women 65 with mediolateral and 65 with lateral episiotomies.
Result: This study was carried out on (260) women who were randomly selected to receive a mediolateral or
lateral episiotomy in the second stage of labor repaired by either continuous or interrupted suture technique.
There was significant difference detected between continuous and interrupted groups as regard pain 6 hours
after delivery and dyspareunia. We found that the interrupted group had higher VAS pain score and
dyspareunia scale. Conclusion and Recommendations: The use of a continuous knotless technique for
perineal repair is associated with less perineal pain at 6 hours, less need for analgesia, lower VAS scores,
lower dyspareunia scale and less wound complication than interrupted sutures techniques. For that, the
introduction of a continuous suturing policy would provide more comfortability, less analgesia, less perineal
pain, less dyspareunia and less wound complications are needed for the interrupted method of repair.
Keywords: Episiotomy, perineal pain, dyspareunia.

included episiotomy as a mandatory step in
Episiotomy is the surgical enlargement of
vacuum delivery. Rather, the guidelines
the posterior aspect of the vagina by an incision to
recommend the restrictive use of episiotomy,
the perineum during the last part of the second
using the operator's individual judgment.
stage of labor. The incision is performed with
Unfortunately, indications for the selective
scissors or scalpel and is typically midline
performance of this procedure are not clearly
(median) or mediolateral in location(1).
defined, and episiotomy is still sparingly used
The use of episiotomy decrease trauma to
during vacuum deliveries in many institutions, up
the fetus, decrease the frequency of extensive
to 100% in certain medical centers (including the
perineal tears, and protect the soft maternal
first author's department), whereas the avoidance
tissues, yet disagreement persists about its actual
of this procedure has resulted in malpractice
Episiotomies benefits; include reducing the
Numerous studies have noted that
rate of obstetric anal sphincter injuries (OASIS)
episiotomy use is related to increased rates of
and hastening the labour process in cases of fetal
several obstetric complications, including urinary
distress, this procedure has been considered a
and anal sphincter incontinence, and postpartum
necessary constituent of vacuum delivery.
hemorrhage and pain. Moreover, this procedure
However, because of a lack of robust evidence for
can be related to a higher, rather than lower,
the value of episiotomy, none of the accepted
incidence of advanced perineal tears. (3)
national guidelines, including those from the
Episiotomy is incision of the pudenda. The
incision may be made in the midline, creating a
Gynecologists (ACOG), the Council of the
median or midline episiotomy, or it may begin in
Society of Obstetricians and Gynecologists of
the midline but be directed laterally and
Canada (SOGC), and the Royal College of
downward away from the rectum, termed a
Obstetricians and Gynecologists (RCOG), have
Received:4 / 2 /2018 DOI: 10.12816/0045828
Accepted: 14/ 2 /2018

Full Paper (vol.713 paper# 7)

Discussion The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2681-2688

Assessment of Pulmonary Embolism Severity and Scoring Using Multi Slice
CT in Correlation with Clinical Presentation and Echocardiography
Mohamed Mahmoud Noser, Maha Abdel Meguid El-Shinnawy, Ahmed Mohamed Osman.
Radiology department, Ain Shams hospitals
Corresponding author: Mohamed Noser, email: m_noser@rocketmail.com


Aim of the work: The aim of this study is to evaluate the correlation between pulmonary embolism
severity and scoring obtained using multi slice CT (MSCT) and the clinical presentations and
echocardiography in patients with pulmonary embolism (PE). Patients and method: this study was carried
out in the Radiology Department of Ain Shams University Hospitals. 21 patients with PE. The CT obstruction
index (OI) using Qanadli score and the RV/LV diameter Right ventricle dysfunction ratio (RVD-ratio) using
the four-chamber view of the heart were calculated for all patients. The cut-off for the OI to detect RVD was
constructed using ROC curve. They were 13 (61.9%) females and 8 (38.1%) males. Their age was ranged
from 22 -83 years old. Results: Dyspnea and RVD (RVD-ratio >1) were significantly more common in
patients with severe pulmonary embolism. Regarding the echo findings with PE high Right ventricular
systolic pressure (RVSP) was the commonest echo finding among our studied patients. The cutoff point of
obstruction index (OI) >15 (Qanadli score >37.5 %) has the highest prediction value of right ventricular
dysfunction, indicating that most of the patients with a score of more than 37.5% had RVD that was agreed
with echo findings.
Keywords: MSCT, OI, ECHO.


The advantage of multidetector computed
Acute pulmonary embolism (PE) is a common
tomography (MDCT) pulmonary angiography,
and potentially fatal disease with mortality ranging
particularly 16- and 64-slice made volumetric
from 2% to 7%, even when treated with
acquisition of images of the entire chest in a single
breath-hold with isotropic resolution possible. This
Symptoms and signs of PE are often non-
capability enables multiplanar viewing and
specific, and clinical presentation of patients with
assessment of pulmonary vessels to sub-segmental
suspected PE varies widely making it hard to
levels. All these advantages made MDCT
diagnose or exclude PE. Although PE cannot be
angiography the most commonly used procedure
diagnosed or excluded on clinical grounds, clinical
for the diagnosis of PE(4).
suspicion (pretest probability) of PE guides the
It is important to show the relationship
further diagnostic process(2) .
between the CT obstruction index (OI) and other
Echocardiography can be used as an easy,
parameters (e.g. those recently used in
inexpensive, devoid of complications and, for the
stratification of patient risk, such as the right
most part, universally available tool for the risk
ventricular dilatation). The presence of RVD may
stratification of patient with acute pulmonary
indicate a high likelihood of recurrent and possibly
embolism. Because of its low sensibility, an
fatal PE, despite an adequate anticoagulation
echocardiogram is best indicated in a patient in
therapy. The degree of pulmonary vascular
whom hypotension and or shock are suspected to
obstruction is considered the most important factor
be due to pulmonary embolism. Pertinent findings
determining the right ventricular impairment in
in the echocardiogram can justify the use of
patients with PE(5) .Computed tomography
pulmonary angiography (CTPA) is the current
echocardiographic findings in acute pulmonary
reference standard for confirming suspected acute
embolism are: dilatation of the right ventricle,
PE. Thus, CTPA is performed in nearly all patients
right ventricular dysfunction in some cases with
preservation of the motility of the apex, dilatation
contraindications to iodinated contrast agents. In
of the inferior vena cava with lack of collapse
addition to detecting emboli, CTPA enables
during inspiration flattening of the interventricular
evaluation of right ventricular (RV) dysfunction,
septum suggesting right ventricular pressure
including the right-to-left ventricular (RV/LV)
overload and pulmonary hypertension based on the
diameter ratio, and interventricular septal bowing,
jet of tricuspid regurgitation if available(3).
some of which are associated with high mortality
rates and PE-related adverse events(6).
Received:6 / 1 /2018 DOI: 10.12816/0045829
Accepted:16 / 1 /2018

Full Paper (vol.713 paper# 8)

c:\work\Jor\vol713_9 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2689-2696

Low Profile Ilizarov Frame in Correction of Varus Deformity in
Patients with Adolescent Blount's Disease
Mustafa F. Abd Alkader, Mootaz F. Thakeb, Ahmad S. Aly
Department of Orthopedic, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Mustafa F. Abd Alkader . phone :01020033418 email: mustafafarook@yaoo.com

: Adolescent Blount disease or late onset tibia vara constitutes the most common cause of pathologic
genu varum in late childhood and adolescence. It is a developmental condition characterized by disordered
endochondral ossification of the posteromedial part of the proximal tibial physis resulting in multiplanar
deformities of the lower limb.
Objective: the aim of This work was to evaluate the results of treatment of acute correction of varus deformity in
patients with Blount disease by using low profile Ilizarov frame.
Patients and Methods: It is a retrospective and a prospective study for 10 patients who had adolescent Blount
disease treated by acute correction using low profile Ilizarov frame. We looked principally into the following
variables to evaluate the results of the treatment: Deformity correction (expressed as mechanical axis restoration),
the average normal values were used as a reference (medial proximal tibial angle, 85­90; posterior proximal tibial
angle, 77­84; thigh­foot angle, +10 external rotation)
Results: the patients were 9 boys (90%) and one girl (10%). The mean age at presentation was 13.60 years, range
( 11- 17 years) , 6 patients (60%) presented with unilateral affections and 4 patients (40%) presented with bilateral
affection. Mean preoperative to postoperative changes of MPTA from 74.57 (range 65-80) improved to 89.21
(range 86-95), Mean preoperative to postoperative changes of PPTA from 74.21 (range 66-80) improved to 79.07
(range 77-82) , Mean preoperative to postoperative changes of MAD from 31.14 mm (range 18-45 mm) improved
to 3.64 mm (range 0-8 mm). Mean preoperative to postoperative changes of TFA from -23.57 (range -30 -15) of
internal tibial torsion improved to 5.36 (range 0-10) of external tibial torsion
Conclusion: Management of adolescent Blount disease by acute correction strategy using a low profile Ilizarov is
a safe technique offering excellent results with low incidence of complications.
,Low profile Ilizarov is lighter and less bulky so more comfortable for patients than classic Ilizarov external
fixation , Acute correction technique can achieve the same result of correction as gradual correction technique in
patient with no limb length discrepancy , Acute correction offers a shorter time in frame as compared to gradual
correction with fewer follow-up visits and exposure to radiation.
Keywords: Blount disease, Low profile Ilizarov , acute correction.


condition also referred to as "tibia vara" in the
Adolescent Blount disease or late onset
literature, is often referred to as Blount disease.
tibia vara constitutes the most common cause of
Langenskiold (4) made significant early
pathologic genu varum in late childhood and
contributions to the identification and management
adolescence. It is a developmental condition
of infantile Blount disease in 1964. He described a
prognostic radiographic classification system.
ossification of the posteromedial part of the
Although Blount coined the term tibia vara
proximal tibial physis resulting in multiplanar
implying a solely frontal plane deformity,
deformities of the lower limb(1).
In 1922, Erlacher (2) is credited with the
deformities are commonly seen with this condition.
first description of progressive tibial varus deformity
Secondary to the asymmetrical growth with relative
in otherwise healthy children.
inhibition of the posteromedial portion of the
In 1937, Blount (3) reviewed previous
proximal tibial growth plate, a three dimensional
reports adding his own cases. He was the first to
deformity of the tibia with varus, procurvatum (apex
identify two forms of this disorder; infantile and
anterior), and internal rotation develops, along with
adolescent (late onset) and coined the term
possible limb shortening in unilateral cases (5,6).
"osteochondrosis deformans tibiae". However, the
Received:6 / 3 /2018 DOI: 10.12816/0045830
Accepted:16 / 3 /2018

Full Paper (vol.713 paper# 9)

c:\work\Jor\vol713_10 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2697-2700

Matrix Metalloproteinase 7 in Rheumatoid Arthritis
Patients with Interstitial Lung Disease
Howaida Elsayed Mansour, Sherin Mohamed Hosny, Nermeen Samy Khalel,
Hana Muhammed Abdulsalam
Faculty of Medicine­Ain Shams University
Corresponding author: Hana Muhammed Abdulsalam,email: H.mohamed2013@hotmail.com

The study aim: The purpose of this study is to measure the matrix metalloproteinase 7 (MMP7) in
rheumatoid arthritis (RA) patients with interstitial lung disease (ILD) and to assess for any correlation with
RA-disease activity. Research design: A cross sectional study. Sample: a purposive sample included 40
rheumatoid arthritis patients from Ain Shams University Hospitals Inpatient Department of Rheumatology
and Outpatient Clinic. The results revealed that serum (S) MMP7 was significantly higher among RA
patients with interstitial lung disease than patients without. Conclusion: The study documented that
S.MMP7 may be used as a screening test for detection of interstitial lung disease in patients with rheumatoid
arthritis. The study recommended: Measurement of serum MMP7 level to RA patients may be used as
screening test for detection of ILD
Keywords: RA: Rheumatoid arthritis. MMP7: Matrix metalloproteinase 7. ILD: Interstitial lung disease

enzymes involved in remodeling of the extracellular
Rheumatoid arthritis (RA) is a systemic
matrix (ECM) in physiological
inflammatory disorder that most commonly affects
and pathological situations (e.g. arthritis, cancer,
the joints, causing progressive, symmetric, erosive
atherosclerosis, and periodontal disease) 4.
destruction of cartilage and bone, which is usually
associated with autoantibody production. Although
metalloproteinase-7 (MMP-7) is a potential
joint disease is the main presentation, there are a
diagnostic and prognostic marker of interstitial
number of extra-articular manifestations including
pulmonary fibrosis (IPF). MMP-7 has been shown
to be upregulated in the lungs in IPF, particularly in
inflammatory eye disease and lung disease. Of these
alveolar macrophages and hyperplastic epithelial
manifestations, lung disease is a major contributor
cells. Bronchoalveolar lavage fluid (BALF) and
to morbidity and mortality 1.
serum levels of MMP-7 are significantly higher in
Among the most significant factors contributing to
patients with IPF compared with those in healthy
this excess mortality is interstitial lung disease
subjects. Elevated levels of serum MMP-7 are
(ILD), the most common subtype of lung
associated with impaired lung function and poorer
involvement in RA. In fact, the risk of death among
survival in IPF patients 5.
individuals with clinically evident RA-associated

ILD is 3 times higher than that among RA patients
without ILD. Recent studies have further
The purpose of this study was to measure
demonstrated that even though overall mortality
the (MMP7) in RA patients with ILD and to assess
rates in RA are declining, the rate of death due to
for any correlation with RA-disease activity.
RA-ILD has increased significantly 2.

The mechanism of pulmonary fibrosis occurring
in ILD is not well understood. Patients with
1Study design and sample:
rheumatoid arthritis typically have circulating
This study was cross sectional study included 40
autoantibodies, the most common being rheumatoid
RA patients fulfilling the American College of
factor and anti-cyclic citrullinated peptide (CCP).
Rheumatology and European League against
These antibodies may be present in the serum for
Rheumatism (ACR / EULAR) 2010 classification
several years before clinical disease onset. Both
criteria 1 Patients were selected from Ain Shams
rheumatoid factor and anti-CCP have been linked to
University Hospitals Outpatient Rheumatology
the development of ILD. There is growing evidence
Clinic and Inpatient Rheumatology Department.
that rheumatoid arthritis begins in the lungs, a
The study was approved by the Ethics Board of
theory supported by a subgroup of patients who are
Ain Shams University.
anti-CCP positive with lung disease but have no

The patients were divided into 2 groups:
metalloproteinases (MMPs) are thought to be key
Group (1): 20 RA patients with ILD.
Received:4 / 2/2018 DOI: 10.12816/0045831
Accepted:14 / 2 /2018

Full Paper (vol.713 paper# 10)

c:\work\Jor\vol713_11 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2701-2711

Assessment of Multidetector CT Virtual Hysterosalpingography as a Reliable
Modality for the Evaluation of Female Genital System Abnormalities
Sara Ramadan Morsi Mohamed, Sherine George Moftah,
Mohamed Gamal El Din Abdel Mutaleb
Department of Radio-diagnosis, Faculty of Medicine, Ain Shams University
Corresponding author: Sara Ramadan, E-mail: sea_doll@msn.com
virtual hysterosalpingography is a novel, noninvasive modality that combines the capabilities of
multidetector CT with the established technique of hysterosalpingography to allow a simultaneous non-invasive
evaluation of the entire uterine wall, uterine cavity, cervix and Fallopian tubes. The evaluation of the para-uterine
pelvic structures is considered as a great advantage of the procedure that can be an alternative diagnostic
technique in the infertility workup algorithm. Virtual hysterosalpingography with the reconstruction of two-
dimensional, three-dimensional, and virtual endoscopic views allows a comprehensive evaluation of the female
reproductive system with a single imaging test, it gives well-appointed anatomic information and a detailed
characterization of the different pathologic processes. In comparison with HSG, US and MR imaging techniques
that have been used for the diagnostic work-up of female infertility; virtual hysterosalpingography provides more
detailed information about abnormalities of the cervix, uterus, Fallopian tubes and other pelvic structures and it
may allow a more accurate evaluation of tubal patency. However, the resultant exposure of the patient to ionizing
radiation is a relative disadvantage that must be weighed against the clinical purpose.
Aim of the work: this study aimed to evaluate the role of virtual CT hysterosalpingography as a new noninvasive
modality for the assessment of the uterus and the Fallopian tubes abnormalities. Conclusion: VHSG has the ability to
integrate most of the advantages of the diagnostic studies methods in the diagnosis and evaluation of the infertile
female. Whether it should completely replace the use of standard conventional HSG among the infertile females, or be
used as a back up to HSG and indicated when questionable or abnormal findings are encountered.
Keywords: hysterosalpingography, multidetector CT, female genital system, abnormalities.

qualities give a significant improvement in the
Evaluation of the uterus and Fallopian tubes with
visualization and assessment of fallopian tubes, one of
diagnostic imaging procedures is classically carried
the major goals in the evaluation of the infertile
patients (4). The high spatial resolution and variety of
hysterosalpingography (HSG) and magnetic resonance
post processing algorithms available at multidetector
imaging (1). The development of multidetector
CT allow a more precise characterization of
computed tomography technology with a capacity for
elevated lesions of different sizes than is possible even
exceptionally high spatial and temporal resolution has
at hysteroscopy (6). Distinct advantages over
revolutionized the examination of the heart, colon and
conventional x-ray HSG, convert the VHSG into a
airways (2). Virtual hysterosalpingography (VHSG) is a
valuable alternative diagnostic technique in the
novel, less invasive modality that combines the
infertility work up algorithm. All these qualities give a
capabilities of multidetector CT with the established
significant improvement in the visualization and
technique of hysterosalpingography to allow a
assessment of the uterus and Fallopian tubes in the
simultaneous evaluation of the entire uterine wall,
infertile females (7).
uterine cavity, cervix and Fallopian tubes. Evaluation
Pathology of Uterine and Tubal Abnormalities
of the parauterine pelvic structures is a great advantage
(I)Uterine Abnormalities
of the procedure that could be an alternative diagnostic
A) Congenital uterine malformations: (Behr et al. (8))
technique in the infertility workup (3). First evaluation
Interruption of normal development of the Müllerian
performed using 16-row multidetector CT (MDCT)
ducts can result in formation of müllerian duct
scanners are promising, with good results for
anomalies (MDAs).
identification of uterine pathologies, but with
Classification of Müllerian duct anomalies
limitations for the Fallopian tubes assessment (4).
The American Society of Reproductive Medicine
The introduction of 64- row CT scanners enables
system is most commonly used to classify Müllerian
isotropic spatial resolution, thinner collimation, better
duct anomalies . This system which is based on
image quality, as well as temporal and contrast
embryology, comprises seven classes (Fig. 1)(8).
resolutions, ensuring a better voxel profile (5). All these
Received:2 /2 /2018 DOI: 10.12816/0045832
Accepted:12 /2 /2018

Full Paper (vol.713 paper# 11)

c:\work\Jor\vol713_12 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2712-2714

Tandem Mass Spectrometry in Patients with Drug Resistant Epilepsy
Osama Nour Alden 1, Rania Hamed Shatla1, Esraa Elsayed Ragab2
1Pediatric Neurology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
2 Mansheit Abakry Hospital, Cairo, Egypt
Corresponding author: Esraa Elsayed Ragab,email: esraaelsayed167@yahoo.com

Inherited metabolic abnormality was a common influential factor in the pathogenesis of intractable
epilepsy. Screening of inborn metabolic abnormality in children with intractable epilepsy should be conducted as
early as possible, to achieve early treatment and improve their prognosis.
Methods: Descriptive study was conducted in Outpatient Neurology Clinic ­Ain Shams University Pediatric
Hospital. It included 30 (12 male and 18 female) patients with intractable epilepsy during the period from
February 2017 to December 2017. All patients presented with drug resistant epilepsy.
subjected to full history talking , clinical examination and were investigated by serum lactate, serum ammonia,
arterial blood gases, Extended Metabolic Screen using tandem mass spectrometry, urinary organic acids, fundus
examination, EEG and neuroimaging.
Abnormal urinary organic acid analysis was present in 5 patients as follows: 3-hydroxyglutaric acid in
one patient, increase lactic acid in three patients and 2-oxoglutaric in one patient. Plasma amino acid analysis
results were alanine elevation in 4 patients, elevated C5-DC in one patient, abnormal co-carnitine in three
patients, 2 of them had low concentration and one had high concentration, elevated glycine in two patients and
phenylalanine elevation in only one .Conclusion: Inherited metabolic abnormality was a common influential
factor in the pathogenesis of intractable epilepsy.
Tandem mass spectrometry, intractable epilepsy.


Although these disorders are individually
Drug resistant epilepsy may be defined as
rare, collectively they account for a significant
failure of adequate trials of two tolerated and
portion of childhood disability and deaths. Most of
appropriately chosen and used antiepileptic drug
the disorders are inherited as autosomal recessive
(AED) schedules (whether as monotherapies or in
whereas autosomal dominant and X-linked disorders
combination) to achieve sustained seizure freedom.
are also present. The clinical signs and symptoms
It is important to note that no seizure frequency
arise from the accumulation of the toxic substrate,
requirement is necessary to meet the definition.
deficiency of the product, or both. Depending on the
Thus, an individual with one seizure per year can be
residual activity of the deficient enzyme, the
regarded as treatment resistant 1.
initiation of the clinical picture may vary starting
Inherited metabolic abnormality was a
from the newborn period up until adulthood 9.
common influential factor in the pathogenesis of
The following clues should raise the
intractable epilepsy (IE), especially in infantile
suspicion of an inherited metabolic disorder: the
spasms. Screening of inborn metabolic abnormality
marriage is consanguineous; there is a history of
in children with IE should be conducted as early as
recurrent abortion; there is a history of unexplained
possible, to achieve early treatment and improve
neonatal death in siblings especially associated with
their prognosis 2.
acidosis, coma and convulsions, picture like
Inborn error of metabolisms are a collection
encephalopathy, and a sibling has been diagnosed as
of rare genetic diseases that generally result from a
suffering from an inborn error of metabolism (IEM)
deficiency of an intracellular component (e.g., an
8. In certain developed and developing countries,
enzyme or transporter) of a metabolic pathway,
neonatal screen for metabolic disorders allows
resulting in an accumulation of a substrate or
diagnosis and treatment in the pre-clinical phase, so
intermediate in a pathway and/or reduced ability to
that the adverse consequences of such disorders can
synthesize essential compounds. Often the central
be prevented. Metabolic disorders for which
nervous system (CNS) is affected, leading to
neurological disease 3.
phenylketonuria (PKU), galactosaemia, maple syrup
Received:9 / 3/2018 DOI: 10.12816/0045833
Accepted19: / 3 /2018

Full Paper (vol.713 paper# 12)

c:\work\Jor\vol713_13 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2715-2717
Case Report: Transverse Vaginal Septum in A Down's Syndrome Patient
Buthaina Alwafi 1, Sarah Al-Sharief 2, Nada Abdulqader 2
1Consultant at department of Ob-Gyn, Maternity and Children's Hospital, Jeddah, KSA,
2Ibn Sina National College for Medical Studies, Jeddah, KSA.
Corresponding author: Nada Abdulqader, E-mail: Nada.j.abdelqader@gmail.com


Transverse vaginal septa are relatively rare anomalies. It has been shown to occur at different depths within
the vagina. It results from vertical fusion or canalization disorder between the vaginal components of
Müllerian ducts and urogenital sinus during embryological development of the vagina and can present with or
without obstruction. The condition was initially described by Delaunay in 1877.
The authors describe a rare case of a middle-aged female with Down's syndrome, presented with secondary
amenorrhea for 3 years. Initial examination and imaging investigation revealed the presence of a transverse
vaginal septum. The diagnosis was facilitated using a combination of abdominal and transvaginal ultrasound
scanning and CT. And it has been revealed that she has a high rising microperforate transverse vaginal
septum. Surgery and follow up was also done.
Keywords: Transverse vaginal septum, Hypothyroidism, Down's syndrome.


A vaginal septum results from incomplete
Treatment for a transverse vaginal septum is
fusion of the separating tissue between the fused
generally surgery, where it can be removed.
Müllerian ducts and the urogenital sinus [1]. This is
Postoperative complications, such as vaginal
estimated to occur to 1 per 30,000-84,000 women
stenosis and reobstruction can occur, especially
[2]. It occurs in any portion of the vagina and can be
when the septum is thick.
transverse, longitudinal, or oblique.

Transverse vaginal septum is considered as one
of the most rare female urogenital tract congenital
A 45-year-old woman, a known case of Down's
abnormalities, and a low septum is even rarer. The
syndrome who has normal secondary sexual
etiology is unknown and is as a result of a female
characteristics, is nulliparous, obese, has bronchial
sex limited autosomal recessive transmission [3].
asthma, and hypothyroidism for which she is taking
And it is known as a fibrous membrane of
L-thyroxine, she was referred from Rabigh
connective tissue with vascular and muscular
Hospital, Saudi Arabia to Maternity and Children's
components, It can occur at almost any level of the
Hospital, Jeddah. After complaining of secondary
vagina; superior, mid or inferior vagina.
amenorrhea for 3 years and acute urinary retention
The external genitalia appear normal, but the
for which a catheter was fixed. On per vaginal
vagina is shortened and blocked resulting in
examination, it was found that she has a short
cryptomenorrhea. Women with this condition may
vagina of 2 cm in length with a mass obstructing it
suffer pain during intercourse (dyspareunia).
that the fingers can't go around. No adnexal masses
Numbers are suitably vague, because it can go
and no abnormalities were detected in pouch of
unnoticed if the septum doesn't trap menstrual
blood behind it in a complete obstruction.
Abdominal ultrasound showed a normal sized
Generally, these septa are not associated with other
empty uterus about 55x30x38 mm, soft tissue and
reproductive abnormalities but it may be combined
normal endometrium of 5 mm thickness with a
with other Müllerian duct anomalies such as uterus
cystic mass below it. There was collection of blood
didelphys. Clinical presentation depends on
inside this cyst which measured 5.9 x 5 cm [Fig.1] .
whether it is complete or partial.
Received:20 / 12 /2017 DOI: 10.12816/0045834
Accepted:30 /12 /2017

Full Paper (vol.713 paper# 13)

c:\work\Jor\vol713_14 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2718-2726
Ankle Arthroscopy versus Conservative Modalities in Management of Ankle
Impingement Syndrome: A Systematic Review of Literature
Ahmed Ruby AbdelHamid, Atef Mohamed Fathy El-beltagy,
Ahmed Salem Eid*
Orthopedic Department, Faculty of Medicine, Ain Shams University-Egypt.
*Corresponding author: Ahmed Ruby AbdelHamid. Phone: 00201025156155.Email: ahmad.a.amer101@gmail.com

it has been well established that chronic ankle pain negatively affects the lives of patients.
Surgical techniques for ankle pain have evolved dramatically over the past decade, as arthroscopic
equipment has improved to allow excellent exposure to the ankle joint and surrounding anatomic areas. Soft-
tissue and osseous impingement syndromes are now increasingly recognized as a significant cause of chronic
ankle pain, The exact cause of this condition is debated but seems to involve osteophyte formation due to
either repetitive microtrauma or macrotrauma associated with major injuries. Careful analyses of patient
history and signs and symptoms at physical examination can suggest a specific diagnosis in most patients.
Aim of the work: this systematic review aimed to assess the outcome of ankle arthroscopy versus
conservative modalities in management of ankle impingement syndrome.
Methods: a systematic literature search of the PubMed, Embase (classic), and Chochrane library databases,
for articles that published from January 1990 to June 2017 was performed using the following inclusion
criteria English language puplications, human clinical trials, studies that reported on at least one of the
chosen outcome measures which are patient satisfaction, time to return to full activity, AOFAS score, visual
analog scale (VAS) score for pain, and complications, we found 9 studies met our inclusion criteria, data
extraction was done which is consisted of population characteristics, in addition to the outcome measures.
Results: nine articles were included in this systematic review. Overall, good results were found for
arthroscopic treatment in patients with ankle impingement syndrome, patient satisfaction rates was reported
in 5 studies, we reported high percentages of good to excellent satisfaction rates, ranging 74% to 94%,
especially in patients treated with arthroscopy, Complication rates were 14.1%, as regard to patients treated
with arthroscopy the rate was 13.2%, on the other hand the rate was 17.6% in those patients treated with
injection therapy technique, conventional conservative modalities reported to be ineffective in treating ankle
impingement except injection therapy technique in case of ankle soft tissue impingement.
Conclusion: our systematic review showed that Patients may respond to conservative treatment modalities,
especially ultra-sound guided injection mainly in soft tissue impingement type, arthroscopic debridement is
the treatment of choice for patients of ankle impingement syndrome of both osseous and soft tissue nature
with least morbidity and early return to function, and also it is noted to be superior to conservative
Keywords: ankle arthroscopy; Ankle impingement; Bony, Soft tissue impingement; Chronic ankle pain;
Sport injury; Os trigonum, Osteophytes; Treatment, Conservative.


Chronic ankle pain is a common clinical
Impingement syndromes have been well
problem with a wide differential diagnosis. Soft-
described in the anterolateral, anterior, and
tissue and osseous impingement syndromes are
posterior ankle, with more recent orthopedic and
now increasingly recognized as a significant cause
radiologic studies describing the less well-
of chronic ankle pain(1).
The ankle impingement syndromes are defined
posteromedial impingement(5).
as pathologic conditions causing painful restriction
Ankle impingement is a common cause of
of movement at the tibiotalar joint caused by
ankle pain in athletic patients and is frequently
osseous or soft tissue overgrowth or by the
associated with sporting activities involving
presence of accessory ossification centers. First
repetitive forced dorsiflexion or plantar flexion of
described by Morris(2) in 1943 and then by
the ankle. The exact cause of this condition is
McMurray(3) in 1950, who termed the condition
debated but seems to involve osteophyte formation
``footballer's ankle,'' ankle impingement is now
due to either repetitive microtrauma or
an established cause of ongoing ankle dysfunction,
macrotrauma associated with major injuries(6).
often following seemingly trivial trauma(4).
Received:18 / 3 /2018 DOI: 10.12816/0045835
Accepted:28 / 3 /2018

Full Paper (vol.713 paper# 14)

c:\work\Jor\vol713_15 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2727-2737

General Public Perceptions and Knowledge on Tooth Bleaching in Riyadh, KSA
Abdul Qadir Abdul Wahid1, Abdulkarim Mansour T Alshamrani2
1Lecturer Dental biomaterials, BDS, MSc, Riyadh College's of Dentistry and Pharmacy
Riyadh City,2General Dentist in Ministry of Health-Tabuk City

To assess the perceptions and knowledge on tooth bleaching among general public in 5 different areas
in Riyadh, KSA.
Method: We assessed a population sample of 300 individuals aged between 15 and 65 years old resident in
Riyadh region (2016). We used frequency distribution and Chi-square test to investigate the association between
socio-demographic factors and knowledge/use of bleaching products.
Results: The sample is consisted of 66.7% of males and 33.3% of females. 83.3% of the respondents reported
knowing bleaching products and advertisements seemed to be the most popular source of information (65.2%).
However only 53.1% reported using bleaching products. Most respondents tried using bleaching products at
home (86%), while only 9% undergone tooth bleaching treatment in dental clinics. The commonest reason
reported for bleaching was to improve esthetics (66.7%). Data analysis showed that knowledge of bleaching in
Riyadh City is not related to gender, nationality, education and occupation (p >0.05).
Conclusion: Large majority of patients were not happy with the appearance of their teeth, the main complaint
being the color. Most of the patients knew that bleaching is a treatment option to improve dental aesthetics, and
those who knew only half tried the treatment. More efforts are needed by the dental professions
Keywords: Bleaching products, knowledge, use

Today the cosmetic dentistry has become an
It is a cross-sectional survey based study. The
important part of restorative dentistry as the patients
samples were selected based on a two stage
perception of teeth appearance is associated with
convenience sampling technique.
their general health and well being (1).Two recent
The first stage comprised of selection of study
studies reported that most of the subjects considered
sites. The study sites are five different locations of
tooth color to be a major factor with regard to dental
Riyadh City as following: Hayat Mall-North,
esthetics. Also they wanted to improve their tooth
AlAziziah Mall-South, Panorama Mall-in the
appearance and whiten their teeth. Their general
Middle, AlOthaim Mall-East and AlBadiah
satisfaction with tooth appearance was influenced
mainly by tooth color, followed by malalignment and
The second stage comprised of selection of
caries. Therefore it was suggested that when planning
subjects. The subjects were males and females
treatment, dentists should consider, patient's esthetic
general public arriving in the above mentioned areas.
objectives in addition to function, structure and
The sample size was 300, 200 males and 100 females.
biology. This can lead to a higher level of patient
The subjects were interviewed face to face in open
satisfaction (2,3). To improve esthetics bleaching is
area .
considered to be the least invasive method to treat the
An informed consent were taken before interview.
discolored teeth (4). Also the popularity of teeth
The interview was structured, based on a
whitening has increase many-fold with the
questionnaire which was available with the
availability of over the counter bleaching agents (5).
interviewer. The questionnaire is based on a study
Patient's perceptions and expectations from tooth
published by R Ahmad, E.H.Z.M. Ariffin, I.
bleaching must be assessed before the patients
Vengrasalam, N.H.A. Kasim et al 2005(7). The
undergo the treatment. The expected outcome must
questionnaire has been modified and translated to
be made clear to the patient as discrepancies between
meet the requirements of our study. The
the patient's and dentist's perceptions of esthetic
questionnaire is of three parts . Part A is based on
treatment needs have been reported (6).
socio-demographic questions, Part B is based on
This study aims to assess the general public
general public perception of their oral health and Part
perceptions and knowledge on tooth bleaching so that
C is based on their knowledge of dental bleaching
the discrepancies between the general public and
agents. Interviewers were dental interns . The average
the dental surgeon's perception regarding tooth
time of the interview was 10 minutes. The interview
whitening are identified and a comprehensively better
was comprised of showing the patient Vita Shade
dental care is delivered to the general public.

Guide to aid them in selecting the desired shade for

Received:14 /1 /2018 DOI: 10.12816/0045836
Accepted:24 /1 /2018

Full Paper (vol.713 paper# 15)

c:\work\Jor\vol713_16 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2738-2741

Febrile Convulsions in Children, Arar, Northern Saudi Arabia
Alaa Jameel A Ahmed1, Adel Turki ALenezi1, Areej Muteb S Alanazi1,
Sara Ghazi Eid Alenezi1, Shumukh Fahad Aish Alshammari1, Futun Fahad Alabdali1,
Reem Muharib R Alruwaili1, Maetham Almusawi2
1 Students, Faculty of Medicine, Northern Border University, Arar, 2 Resident, Emergency Department,
Prince Saud Bin Jalawi Hospital, Al Hasa, KSA

Febrile seizure is one of the most common types of seizure in children aged between
5 months and 5 years and accounts for 30% of all childhood seizures, but it is generally considered benign.
The objective of the study was to determine the percentage of febrile seizures in Pediatrics Emergency,
Maternity and Children's Hospital of Arar City and to study some of the clinical and demographic
characteristics of those children. Methods: This was a cross-sectional study conducted during 6 months
period, from 1 January to 30 July 2017. All admitted cases (0­12 years) presenting with seizures, both
unprovoked and symptomatic (acute and remote), were enrolled. All children 0 to 12 years of age who
were hospitalized at the emergency department with seizures were included in this study. Data was
recorded in predesigned proforma including age, sex, nature of seizure, fever, history of head trauma,
epilepsy, infectious diseases, previous history and family history of seizures and the final diagnosis was
fulfilled. Results: Among the studied children presented to the emergency department with attack of
convulsions 72.2% of cases had febrile convulsions and 27.8% of cases had convulsions due to other
causes. The majority (49.1%) of cases were 1-3 years old. Most (87.7%) of the cases of febrile convulsions
had generalized convulsions and in 84.2% it was the first attack but there was a history of repeated attacks
in 15.8%. Family history of febrile convulsions was found in 15.8% of the cases.
Febrile convulsions was the main etiology of convulsions in children admitted to emergency
department of Maternity and Children's Hospital in Arar city. We suggested other researchers to follow the
patients to show the recurrence of seizure and the prognosis in them, physical and neurological
examinations and good history taking may provide important information for primary emergency
physicians when evaluating children with attack of febrile convulsions.
Keywords: Febrile convulsions; children; Emergency department of Maternity and Children's Hospital;
Arar city.

lasting between a few seconds and 15 minutes,
Febrile convulsions are the most common type
followed by a period of drowsiness. Febrile
of seizure in children, but it is generally
seizures tend to occur in families, although the
considered benign [1]. These convulsions are
exact mode of inheritance is unknown, children
associated with a rapidly rising temperature and
who have febrile seizure more often tend to have
usually develop when the core temperature
a history of febrile convulsions in close relatives
reaches 39oC or higher. As they may indicate a
[3]. The exact role of fever in the etiology of
serious underlying acute infection, such as sepsis
febrile convulsion is not clear but there is a
or bacterial meningitis, child must be examined
positive family history in 7-31% of cases [1]. The
and investigated to see if there is associated cause
definitive degree of fever is uncertain. At the time
for the fever [2]. In practice they are rarely seen
of convulsions, 75% of patients had a
before the age of 9 months and after 5 years old.
temperature over 39 0C. Viruses are the most
It usually occurs between the age of 3 months and
common cause of illnesses in children admitted to
5 years [2]. Febrile convulsions occur in 2- 4% of
the Hospital with a first febrile seizure [4]. It is
young children in the United States, South
very rare that death or permanent motor disability
America, and western Europe. It occur more
will occur due to febrile seizure although 0.4%
frequently in Asian countries. They are slightly
experienced a transient focal weakness or Todd's
more common in males than females. The mean
paralysis following the seizure [5]. Children with
age is 17-23 months [1]. The typical febrile
febrile seizures are at no greater risk of
convulsion is a generalized tonic clonic seizure
intellectual impairments than their peers [6]. Fifty
Received:15 / 1 /2018 DOI: 10.12816/0045837
Accepted:25 / 1 /2018

Full Paper (vol.713 paper# 16)

c:\work\Jor\vol713_17 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2742-2750

Role of dynamic MRI in assessment of Pelvic Floor Dysfunction in Females
Nada Ahmed Hussein, Naglaa Hussein Shebrya, Nermeen Nasry Keriakos
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Nada Ahmed Hussein, E-mail: nada306@hotmil.com

Pelvic floor dysfunction is a major medical and social problem. Dynamic MR imaging of the
pelvic floor is an excellent tool for assessing functional disorders of the pelvic floor. Findings reported at
dynamic MR imaging of the pelvic floor are valuable for selecting patients who are candidates for surgical
treatment and for choosing the appropriate surgical approach.
Aim of the work:
To highlight the role of dynamic MRI as a non-invasive method in the assessment of
pelvic floor dysfunction in females. Methods: Dynamic and static MRI were performed in 20 female
patients complaining of pelvic organ prolapse and/or stress urinary incontinence or defecation disorder. Full
history was taken and clinical examination performed and findings compared with MRI results.
Results: Good concordance was found between dynamic MRI and clinical examination in all three
compartments, it was 75% in the anterior compartment, 80% in the posterior compartment, 65% in
enteroceles and 75.0% in the middle compartment.
Conclusion: MR imaging provides excellent soft tissue contrast to ensure adequate diagnosis of the muscular
and fascial defects responsible for pelvic floor dysfunction.
Keywords: Dynamic MRI, Pelvic organ prolapse, Incontinence, Pelvic floor.

treatment. Clinical evaluation based on detailed
Pelvic floor dysfunction (PFD) is a term
physical, neurologic, and digital rectal examination
applied to a wide variety of clinical conditions,
is the cornerstone of diagnosis. However, clinical
including Stress urinary incontinence (SUI), pelvic
examination is limited in several ways: (a) it can
organ prolapse (POP), defecatory dysfunction,
lead to underestimating or misdiagnosing the site of
sensory and emptying abnormalities of the lower
prolapse; (b) it does not permit assessment of
urinary tract, sexual dysfunction, and several
evacuation disorders; and (c) it cannot detect a
chronic pain syndromes. The first three are the most
peritoneocele, a finding that indicates the need for
common clinical conditions (1).
abdominal rather than vaginal surgery (4).
Whereas exact mechanisms are subject to
Several imaging techniques may be used as
debate, risk factors include age, multiparity,
adjuncts to physical examination. Traditional
complicated vaginal deliveries, obesity, collagen-
imaging procedures (e.g., urodynamic study,
related disorders, hysterectomy, and menopause.
voiding cystourethrography, and fluoroscopic
Possible causes include injury to the pelvic floor
cystocolpodefecography) remain practical and cost-
from surgery or childbirth, denervation of the
effective methods for evaluating uncomplicated
musculature, fascial defects, and abnormal
anorectal and pelvic dysfunction (5). Magnetic
synthesis or degradation of collagen (2).
resonance (MR) imaging of the pelvic floor is a
It has been attributed both to damage to the
two-step process that includes analysis of anatomic
levator ani muscle and to an endopelvic fascial
damage on axial fast spin-echo (FSE) T2-weighted
defect, however, some believe that it is still unclear
images and functional evaluation using sagittal
which of these factors is more responsible.
dynamic single-shot T2-weighted sequences during
Similarly, SUI has been attributed to urethral
straining and defecation (4).
hypermobility, to unequal movement of the urethral

walls, and to defects in the urethral supporting
structures. Because of these controversies,
treatment is often started regardless of the specific
This study is a diagnostic prospective study which
anatomic lesion involved (3).
was carried out in the Department of Radio-
Evaluation of women with pelvic floor
diagnosis at Ain Shams University Hospital from
failure requires a comprehensive approach that
August 2017 to February 2018. Twenty women
includes clinical assessment, physiologic testing,
with pelvic organ prolapse / stress urinary
and counseling about conservative versus surgical
incontinence and/or defecatory disorder were
Received:5 / 3 /2018 DOI: 10.12816/0045838
Accepted:15 /3 /2018

Full Paper (vol.713 paper# 17)

c:\work\Jor\vol713_18 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2751-2758

Prevalence And Demographic Features of Miscarriages at Baljurashi

General Hospital, Albaha, Saudi Arabia
1 Abdullah Hameed Saleh Alghamdi*, 1 Fahad Ali Abdullah Dokhaikh, 1 Osama Hamdan Ahmed Alhabi,
4 Mohammed Abobakr Hassan Balkheir, 2 Taj Elsir Mohamed Ali**
1Medical interns, Faculty of Medicine, Albaha University; 2 Obstetrics & Gynecology Department,
Faculty of Medicine, Albaha University; Saudi Arabia
*Corresponding author: Abdullah Hameed Saleh Alghamdi, E-mail: ahsgh94@gmail.com
Miscarriage is the most common encountered complication of pregnancy. It may be repeated for 3 or
more times; a condition called habitual or recurrent miscarriage.
Aim: To determine the incidence of miscarriage at Baljurashi General Hospital, the demographic characteristics of
women who presented with miscarriage, and the most common gestational age at time of miscarriage.
Materials and methods: A self-administered questionnaire was distributed to women attending Baljurashi General
Hospital who suffer from miscarriage.
Results: The incidence of miscarriage was 10%. Ninety-two women responded to the questionnaire. Most of the
respondents aged more than 25 years, had no job, and were in their first trimester. Half of the respondents had
secondary education. Approximately one tenth suffered from repeated miscarriages.
Conclusion: The incidence of miscarriage, among patients presenting to Baljurashi hospital, was comparable to those
reported in other regions. However, the percentage of repeated abortion is high and these cases were not appropriately
investigated. We recommend for the introduction of routine genetic studies into the work up of repeated miscarriages.
Keywords: repeated miscarriage; abortion; pregnancy; survey.


The fetal factors that may result in miscarriage
Miscarriage is defined as the loss of clinically
include: abnormal development of the zygote, embryo,
recognized pregnancy, prior to 20 weeks gestation or
fetus or placenta (resulting in blighted ovum); or
less than 500 g ]1[. It is the most common complication
chromosomal abnormalities such autosomal trisomies
of pregnancy affecting 10 to 15 % of clinically
(the most frequent), monosomy X, and triploidy (results
recognized pregnancies. The incidence is much higher
in partial hydatiform mole) ]6[. Some risk factors have
if losses before the next menstrual cycle are considered;
been recognized for miscarriage and these include:
approaching 50 to 75% of all fertilized ova ]2[.
increased maternal and/ or paternal age, prior
Miscarriages may be repeated for three or more times; a
miscarriage, and infertility. Other risk factors were
condition termed "habitual abortion" or "repeated
proposed, yet still controversial, such as smoking,
miscarriage" ]3[.
alcohol and caffeine intake, and stressful life and work

More than 80 % of all miscarriages take place
conditions ]7[.
before 12 weeks of gestation (i.e. in the 1st trimester)

Up to the best of the authors' knowledge, no
and nearly half of them occur due to chromosomal
previous studies have assessed the incidence and
abnormalities. Less than 20 % of all miscarriage occur
epidemiology of miscarriages in Saudi women residing
between the 12th and 20th weeks of gestation (in the 2nd
in Albaha region. The aim of this study was to
trimester) and are more likely to be caused by
determine the incidence of miscarriage at Baljurashi
anatomical anomalies of the uterus rather than by
General Hospital, Albaha region; the demographic
chromosomal anomalies ]1[.
characteristics of women who presented with

Miscarriage may occur either due to maternal or
miscarriage, and the most common gestational age at
fetal causes. Maternal factors that predispose to
time of miscarriage.
miscarriage include uterine defects such as septate

uterus, leiomyomas, and intrauterine adhesions;
infections; endocrinal disturbances such as thyroid
Ethical considerations
disorders ]4[, poorly controlled diabetes mellitus,
This study was approved by the Research Ethics
polycystic ovarian syndrome, luteal phase defect;
Committees of Albaha University and Baljurashi
environmental conditions such as exposure to pesticides
General Hospital. An informed consent was obtained
and other chemical pollutants and immunological
from each participant.
disorders ]5[.

Received: 20/ 12 /2017 DOI: 10.12816/0045839
Accepted: 30/ 12/2017

Full Paper (vol.713 paper# 18)


Comparative Randomized Controlled Blind Study of the Anti-Shivering
Effect of Hydrocortisone, Granisetron and Meperidine in Post-Spinal
Anesthesia in Patients Undergoing Cesarean Section
Mohamed Sidky Mahmoud Zaki, Ahmed Mohamed El Sayed El Hennawy,
Yahia Mamdouh Hassan Mekki, Moustafa Atef Moustafa Hamouda
Department of Anesthesiology, Intensive Care Medicine & Pain Management
Faculty of Medicine, Ain shams University
Corresponding author: Moustafa Atef Moustafa Hamouda, Email: moustafaatef.13b@gmail.com
it was observed that a considerable proportion of patients undergoing surgery experience
intraoperative and postoperative hypothermia and it was found that misregulation of body temperature due to
anesthesia as well as the cold temperature of the operation room were the main cause.
Purpose: to compare the anti-shivering effect of meperidine, hydrocortisone and granisetron after spinal
anesthesia during elective cesarean section. Patients and Methods: this study presents a placebo-controlled
prospective randomized blind study. Included patients were randomly (using computer generated
randomization table) allocated into four equal groups each group consists of 28 patients. Results: in our
study, age, sex, and ASA grade distribution of patients were nearly identical in the four groups. Furthermore,
the duration of surgery and amount of irrigation fluid used in the four different groups were also similar. We
did not observe a change in temperature gradient between the four groups. A study with a more prolonged
duration of postoperative temperature monitoring is needed to note if core-periphery temperature changes
occur with passage of time. Conclusion: the results indicate that IV granisetron 40 µg/kg was effective as IV
meperidine 0.4 mg/kg and both are slightly effective than IV hydrocortisone 2 mg/kg in reducing the
incidence and intensity of shivering during spinal anesthesia compared to control group.
Keywords: Anti-shivering - Hydrocortisone - Granisetron ­ Meperidine - Cesarean Section - Post-spinal


most commonly indicated for cesarean section due to
Shivering is a common problem encountered
lower rates of maternal morbidity and mortality and
by an anesthesiologist during intraoperative as well
less neonatal depression compared with general
as in postoperative period. Shivering occurs during
anesthesia. The combination of lipophilic opioids
both general anesthesia and regional anesthesia.
with hyperbaric bupivacaine during spinal anesthesia
Incidence of shivering is up to 33% in the patients
for cesarean section provides reduced latency, longer
undergoing surgery under regional anesthesia and up
duration, and better quality of anesthesia without
to 56­66% under general anesthesia. A number of
increasing the incidence of neonatal depression.
factors including age, duration of surgery,
Another known effect of opioids is the prevention
temperature of the operating room, type of regional
and treatment of postoperative shivering (3).
anesthesia (spinal or epidural), and infusion solution
Various methods have been used to prevent
are risk factors for hypothermia and shivering (1).
and treat shivering in patients who receive spinal
Perioperative shivering causes patient
anesthesia, one of these, meperidine appears to be the
discomfort because of severe muscle movements, it
most effective treatment agent for perioperative
also induces elevated blood pressure and tachycardia,
shivering, although meperidine is the best studied
aggravates wound pain by stretching incision,
drug in the treatment of post anesthetic shivering,
increase intra ocular pressure and increase
other drugs like tramadol, hydrochloride, ketamine
intracranial pressure. Shivering may also increase
and magnesium sulfate infusion were used (4).
tissue oxygen demand by as much as 150% and

accompanied by increase in minute ventilation and
cardiac output to maintain aerobic metabolism this
Compare the anti-shivering effect of
eventually leads to increased oxygen consumption,
meperidine, hydrocortisone and granisetron after
increased carbon dioxide synthesis that results in an
spinal anesthesia during elective cesarean section.
increased pulmonary ventilation capacity and cardiac
workload, and an increase in the metabolic rate by up
After approval of Ethics Committee and
to 400%. Shivering may also interfere with the
obtaining written informed consent from eligible
monitoring of patients by causing artifacts of
parturients, the study was conducted on 112 full
electrocardiography, blood pressure and pulse
term pregnant patients classified according to
oximetry (2). Neuraxial anesthetic techniques are the
American Society of Anaesthesiologist (ASA)
Received:20 / 3 /2018 DOI: 10.12816/0045840
Accepted: 29/3 /2018

Full Paper (vol.713 paper# 19)

c:\work\Jor\vol713_20 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2765-2769

Prevalence of Hypothyroidism and Its Associated Risk
Factors in Arar City, Saudi Arabia

Alruwaili , Anwar Eid M, Alshalan, Maha Hazzaa F , Alfuhigi , Zuhur Dhaher M,
Abdulhamid, Mohmoud A. Alshaheen, Alanzi, Najah Dhaher Y, Alanazi, Ahmed Nidaa K,

Razan Mohmoud A. Alshaheen, Waad Salamah Alaleimi, Noor Ghazy Johiman Alenezy,

Asem Matrouk Zayed Alrowaili, Alanazi, Mona Abdulaziz M,
Mohammad Humood Meshref Alenezi, Amjad Mufarh Alrwuaili, Amer Ahmed Balla Ahmed
Faculty of Medicine, Northern Border University
: Hypothyroidism is a common endocrine disorder worldwide. The prevalence of hypothyroidism
depends on many factors, such as age, sex and geographical factors.
This study is carried out to assess the prevalence of hypothyroidism and the related etiology and
risks in the general population of Arar city, northern border of Saudi Arabia. Methods: A cross-sectional study
was conducted in Arar, Northern Saudi Arabia. A multistage stratified random sampling technique was used. A
pre-designed online questionnaire was distributed among the targeted population and filled by participants after
a brief introduction or explanation of the idea of the research to the public. Sampled participants filled out the
self-reported predesigned questionnaire to collect socioeconomic and thyroid diseases related data.
Results: In our study, the prevalence of hypothyroidism was 25.5% (116/454), females are more affected than
males, as 57.7% of the cases were female, most of them (80%) aged 21-60 years old and 40% of the cases has a
family history of the disease. 64.7% of the cases were on medical treatment but only 16% of them responded.
While surgical treatment were found in only 8% of the cases. Conclusion: Hypothyroidism is prevalent in Arar,
Northern Saudi Arabia, females were more affected than males. Knowledge of factors influencing thyroid
dysfunction help the public to guard against these prevalent diseases. More studies should be carried out in Arar
city to stress on the individual thyroid disorder. The studies should be community based with clinical and
laboratory diagnosis of cases.
Keywords: Hypothyroidism; risk factors; manifestations; Arar, Northern Saudi Arabia.


developed world is about 4-15% [6,8], while the
Thyroid disorders (hyper and hypo thyrodism);
prevalence of hypothyroidism is about 4-5% [6,7]. It
are amongst the most prevalent of medical
affects many systems, such as cardiovascular,
conditions. Hypothyroidism is a common endocrine
Hypothyroidism is associated with high levels of
hypothyroidism depends on many factors, such as
LDL, total cholesterol, triglycerides obesity,
age, sex and geographical factors [1]. It's also a diet
metabolic syndrome and high blood pressure [9-10].
related disorder and it's usually seen when the daily
It also has widespread systemic manifestations
intake of iodine falls below 25g. Hypothyroidism
including their effects on bone and mineral
can be classified according to the gland function into
metabolism. Some studies reported decreased serum
primary and secondary [2].
calcium and phosphorus levels in hypothyroidism
In primary hypothyroidism the defect is in the
[11]. Iodination programs are of proven value in
thyroid gland itself and the hypo activity of the
treatment of hypothyroidism and in preventing
gland, while secondary hypothyroidism is due to a
goitre development, however; some rare cases need
defect in the posterior pituitary gland which secretes
a surgical treatment. Due to asymptomatic nature of
the thyroid stimulating hormone or TSH [2]. Several
subclinical hypothyroidism, it's recommended to do
studies have been reported from different parts of the
a routine TSH screening at the age of 35 for both
world showing the prevalence of hypothyroidism.
sexes and every 5 years thereafter.
The prevalence of spontaneous hypothyroidism
is between 1% and 2%, and it is more common in
The present study carried out to assess the
older women and ten times more common in women
prevalence of hypothyroidism and its related risk
than in men [3]. Hypothyroidism is characterized by a
factors in the general population of Arar city,
broad clinical spectrum ranging from an overt state
northern border of Saudi Arabia.
of myxedema, end-organ effects and multisystem
failure to an asymptomatic or subclinical condition
with normal levels of thyroxine and triiodothyronine
A cross-sectional study was conducted in Arar,
and mildly elevated levels of serum thyrotropin[4,5].
Northern Saudi Arabia. A multistage stratified
The prevalence of subclinical hypothyroidism in the
random sampling technique was used. A pre-
Received:17 / 1/2018 DOI: 10.12816/0045841
Accepted:27 / 1 /2018

Full Paper (vol.713 paper# 20)

c:\work\Jor\vol713_21 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2770-2774

Correlation of Average Retinal Nerve Fiber Layer Thickness Using
OCT with The Perimetric Staging in Primary Open Angle Glaucoma
Hosny Hassan Mohammad, Abd Elghany Ibrahim Abd Elghany,
Ibrahim Mohamed Ibrahim El Karmout
Department Ophthalmology Faculty of Medicine - Al Azhar University
*Corresponding author: Ibrahim Mohamed Ibrahim El Karmout, Email:ibramo1990@gmail.com ,Tel no: 01000901850

Primary open angle glaucoma (POAG) is the most common type of glaucoma which is
considered chronic progressive optic neuropathy, accompanied by a characteristic cupping and atrophy of the
optic disc, visual field loss, open angle and no obvious systemic or ocular cause.
Subjects and Methods: In this study all cases were examined in the period extending from December, 2016 to
august, 2017, including 46 eyes of 30 subjects, the eyes were classified according to disease severity into 22
cases with early glaucoma, 16 cases with moderate glaucoma and 8 cases with severe glaucoma according to
Hodapp, Parrish, and Anderson classification.
Objectives: Inclusion criteria included: All cases have primary open angle glaucoma, presence of at least one
reliable visual field, controlled IOP within range 12-21 mm/Hg. Exclusion criteria included: Cases with
closed angles or any angle abnormality on gonioscopy, any other retinal or choroidal insult, including other
causes of optic atrophy, patients with affected visual field due to any cause rather than POAG, secondary
glaucomas. Results: This study included 46 eyes of 30 subjects which were classified according to disease
severity into: Early glaucoma: included 22 eyes. Moderate glaucoma: included 16 eyes. Severe glaucoma:
included 8 eyes. Conclusion: There is significant direct correlation between average retinal nerve fibre layer
thinning and visual field mean deviation.
EMGT, Early manifest glaucoma trial; GPA, Guided progression index; IOP, Intraocular pressure


As glaucoma is the second leading cause of
including 46 eyes of 30 subjects, the eyes were
blindness in the world, the main goal of glaucoma
classified according to disease severity into 22
management is to diagnose the disease when it is
cases with early glaucoma, 16 cases with moderate
asymptomatic. Visual field (VF) testing is essential
glaucoma and 8 cases with severe glaucoma
in the diagnosis and monitoring of glaucoma.
according to Hodapp, Parrish, and Anderson
However, it is known that standard perimetry
cannot detect visual field defects until 20% - 40%
of ganglion cells have been lost. Retinal nerve fiber
This study included 46 eyes of 30 subjects that
defects have been objectively demonstrated earlier
were classified according to disease severity into:
than VF defects with new investigative
Early glaucoma: included 22 eyes.
technologies. Measuring retinal nerve fiber layer
Moderate glaucoma: included 16 eyes.
Severe glaucoma: included 8 eyes.
tomography (OCT) enables an objective and
Demographic data: The thirty subjects of this
quantitative assessment of glaucomatous structural
study were distributed as follow, the female
loss (3). (OCT) is an innovative medical diagnostic
(23.33%) and male (76.67%)(fig 1) , family history
imaging technology which can perform micron
positive (23.33%) and negative (76.67%), while age
resolution cross-sectional or tomographic imaging
ranged from 43 to 76 years old with mean
in biological tissues. OCT is especially suited for
62.4±8.51.(table 1)
diagnostic applications in ophthalmology because

of the ease of optical access to the anterior and
Table (1): Demographic data distribution of the study
posterior segments of the eye (2). Spectral domain or
Fourier domain OCT (SD-OCT) uses a
spectrometer as a detector of OCT signal. Which

has benefits over time domain OCT (TD-OCT)
Total (N=30)
such as higher axial resolution, faster scanning
7 (23.33%)
speed and better reproducibly (2).
23 (76.67%)

(years) Mean ± SD
62.4 ± 8.51
In this study all cases were examined in the period
Family Positive
7 (23.33%)
extending from December, 2016 to august, 2017,
history Negative
23 (76.67%)
Received:20 / 3 /2018 DOI: 10.12816/0045842
Accepted:30 / 3 /2018

Full Paper (vol.713 paper# 21)

c:\work\Jor\vol713_22 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2775-2779

Study of Accuracy of Corneal Flap Thickness by
Using Femtosecond Laser Technology
Ahmed Hassan Samir Assaf, Rania Gamal Eldin Zaky,
Bassem Fayez Aziz Riad, George Adel Aziz Mansour
Department of Ophthalmology School of Medicine, Ain Shams University, Cairo (Egypt)
Corresponding author: George A. A. Mansour, Tel:01091482886 Email: drgeorgemansour@gmail.com

LASIK is the most popular surgery to correct the refractive errors nowadays. It is proved to be
safe, effective and well predictable. It is important to produce a uniform flap with a narrow SD from the
intended thickness. The Integrated optical pachymetry is a convenient and useful feature of the EX500
excimer laser which can be used to measure flap thickness intraoperatively.Objectives: this study aimed to
detect the accuracy of Allegretto Wavelight FS200TM platform in creation of different corneal flap
thicknesses. Patients and Methods: sixty eyes of 30 myopic patients were included in our study, the
patients were operated by 2 different surgeons from June 2017 till December 2017. The patients were
distributed randomly into 3 studied groups. Group I (20 eyes with intended fs flap 100um), group II (20
eyes with intended fs flap 110um) and group III (20 eyes with intended fs flap 120um). All participants
were subjected to full medical history taking, uncorrected distance visual acuity, slit-lamp microscopy,
corneal topography using oculus® pentacam device, manifest and cycloplegic refraction, corrected distance
visual acuity, fundus bio-microscopy examination using 90 D lens.
Results: in this study 100m thickness group (Group A) showed the lowest difference between the mean
result and the intended flap (-0.35um) followed by the 120um group (Group C) with difference of (-2.9um)
between the mean result and the intended flap thickness followed by the 110m group (group B) with the
highest difference (-3.45um) from the intended flap thickness.
Conclusion: the flaps made with the Wavelight FS200 femtosecond laser were predictable and uniform
more predictable in group A than in group C and B, but with no statistical significance between the three
studied groups (P=0.402).
Keywords: femtosecond laser, LASIK, allegretto Favelight FS200TM , EX500 optical pachymetry.


Laser in situ keratomileusis (LASIK) has become
a resection plane (6). It is important to produce a
the most popular approach in the world for the
uniform flap with a narrow standard deviation
correction of refractive errors including the
(SD) from the intended thickness to obtain an
correction of myopia, hyperopia, and astigmatism
appropriate residual stromal thickness during
(1).The first phase of LASIK, the creation of
LASIK (7). Sufficient residual stromal bed (RSB)
corneal flap, is the most critical step of LASIK,
thickness is Important to reduce the likelihood of
and it affects the visual outcome of the whole
corneal ectasia (8). Femtosecond-LASIK flaps that
are too thin may be prone to gas breakthrough or
The technological evolution of flap creation has
lifting complications, such as flap tears, striae, or
emerged from automated microkeratomes to most
buttonhole formation (9).
recently femtosecond (FS) laser technology (3).The
Corneal thickness can be measured by several
corneal flap thickness is directly related to LASIK
predictability and safety, therefore, methods that
pachymetry, pentacam and optical coherence
improve the predictability and minimize the
tomography (10). Intraoperative measurements may
degree of variation in corneal flap thickness are
help surgeons determine the accuracy of
worthy of attention (4). Recently the femtosecond
programmed versus achieved flap thickness (FT)
laser technology has been widely used , which has
provided an alternative option for flap creation
Laboratories, Fort Worth, TX, USA) has built-in
since the introduction of the IntraLaseTM (Abbott
optical pachymetry that is generally quick, easy to
Medical Optics, Santa Ana, CA, USA) in 2001 (5).
use, and does not interrupt the cadence of surgery.
In the femtosecond (FS) laser technology, FS laser
Previous studies have shown similar residual
photodisrupts tissue at a preset depth and
stromal bed (RSB) values when comparing
produces microcavitation bubbles consisting of
water and carbon dioxide. The expansion of these
pachymetry and ultrasound pachymetry (11).
bubbles separates the corneal lamellae and forms

Received:18 /3 /2018 DOI: 10.12816/0045843
Accepted:28 / 3 /2018

Full Paper (vol.713 paper# 22)

c:\work\Jor\vol713_23 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2780-2787

Awareness of Risk Factors of Hernia among Adults in Riyadh, KSA
Abdulwahab Abdulhaq Abdulwahab Alkhars, Hussein Ali Albakheit, Fahad Abdullah Al-Anazi, Saud
Mohammed Alharbi, Ahmed Hassan Alsomali, Bandar Mohammed Albukairi, Ahmed Maashi Alanazi
1Faculty of Medicine, Almaarefa College
Corresponding author: Abdulwahab Alkhars, E-mail : Hoopa55555@gmail.com, Tel: +966 504533313

: Abdominal wall hernias are a very common surgical condition affecting all ages and both
genders. The main predisposing factors of hernias include pregnancy, weight lifting, constipation, weight gain
as well as some chronic diseases such as Asthma Diabetes Mellitus.
Aim of the study: was to assess the awareness of the risk factors of abdominal hernias among adults of both
genders and different BMI ranges in Riyadh population (Saudi Arabia).
Methods: This is a questionnaire-based cross-sectional study enrolling a total of 100 randomly selected high-
risk to development Hernia 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 Hernia were
calculated as absolute frequencies and were reported as overall percentages.
Results: overall results showed that only 48% of the respondents could relate hernia to the key underlying
risk factors while 22% denied the correlation and 30% claimed no knowledge on the risk factors and the
association with hernia development. However, majority of participants (87%) suggested a correlation
between hernia and heavy lifting. Moreover, more than half of the study group (65% and 62%) related
pregnancy and surgery as a contributing factor for hernia. While a lack of awareness was obvious on other
risk factors such as smoking, chronic, constipation prostate enlargement, asthma and DM with a knowledge
score of 37%, 36%, 32%, 32% and 29% respectively.
Conclusion: Our study revealed lack of public knowledge on the predisposing factors for hernia among the
study group of young Saudi female and male adults regardless to the age and BMI range. Despite the fact that
87% related hernia to heavy lifting, less than 65% of participants could correlate hernia to pregnancy and
surgery while not more than 36% could correlate hernia with other key predisposing risk factors such as
smoking, enlarged prostate, asthma, DM and chronic constipation. This indicates that proper intervention is
needed to broadly raise the awareness of hernia risk factors among Saudi adults. This can be achieved by
mass media awareness campaigns such as TV and radio health education programs as well as campaign at
schools, universities and health centers.
adult, hernia, inguinal, prospective studies, risk factors, KSA, Riyadh.


A hernia is defined as the protrusion of an organ
inguinal hernia repairs constituting nearly 770,000
or tissue through an abnormal opening. occurs
of these cases; approximately 90% of all inguinal
when an organ or fatty tissue squeezes through a
hernia repairs are performed on males [3]. Most
weak spot in a surrounding muscle or connective
abdominal hernias are asymptomatic. A hernia is
tissue called fascia. The most common types of
reducible when its contents can be replaced within
hernia are inguinal (inner groin), incisional
the surrounding musculature, and it is irreducible
(resulting from an incision), femoral (outer groin),
or incarcerated when it cannot be reduced. A
umbilical (belly button), and hiatal (upper
strangulated hernia has compromised blood supply
stomach) [1].
to its contents, which is a serious and potentially
The abdominal wall is made up of muscles that
fatal complication. Strangulation occurs more
mirror of each other from right to left. These
often in large hernias that have small orifices. In
include rectus abdominis, external oblique,
this situation, the small neck of the hernia
internal oblique and the transversalis. Hernia is
obstructs arterial blood flow, venous drainage, or
derived from a Latin word means "rupture" [2]. The
both to the contents of the hernia sac. Adhesions
definition of a hernia of the abdominal wall is an
between the contents of the hernia and peritoneal
abnormal protrusion of the abdominal contents
lining of the sac can provide a tethering point that
through an acquired or congenital area of
entraps the hernia contents and predisposes to
weakness or defect in the wall [2].
Abdominal wall hernias are among the most
Incarcerated or strangulated hernias cause pain and
common of all surgical problems .More than 1
require immediate surgery [4].
million abdominal wall hernia repairs are
The time a hernia takes to develop depends on its
performed each year in the United States, with
causes, which relate to muscle weakness and
Received:18 / 1 /2018 DOI: 10.12816/0045844
Accepted: 28/ 1 /2018

Full Paper (vol.713 paper# 23)

c:\work\Jor\vol713_24 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2788-2791

Hydatid Disease with Water Lily Sign Manifesting as a Soft-Tissue Mass in The
Soleus Muscle of an Adult Woman- Case Report
Fares Abdullah Alaskar and Mohammed Aldameg
Medical Imaging Department, King Fahad Medical City, Riyadh. Saudi Arabia

Due to the high lactic acid levels and the contractility of the muscle soft-tissue hydatid disease is unusual even
in endemic areas, and skeletal muscle involvement is extremely rare. Here we discuss an extremely unusual and
rare case of hydatid disease found in the medial aspect of the soleus muscle in 46 years old female.
MRI imaging is essential for identification and differential diagnosis.
Keywords: Hydatid cyst, skeletal muscle hydatosis, Water Lily Sign, echinococcosis.

Hydatid disease is a parasitic disease of
A 46 years old woman was presented to the
tapeworm of the echinococcus type. The most
medical imaging department at King Fahad Medical
common forms found in humans are cystic and
City with the complaint of swelling of the right leg
alveolar echinococcosis caused by echinococcus
with a slowly growing mass.
granulosus and multilocularis respectively (1). It is
Her history was not relevant with trauma or septic
most prevalent in sheep and cattle breeding areas,
disease. She did not have pain that localized on the
where the first step in the chain of transmission of
abdomen and chest.
this infestation occurs. The causative agent is
First off, we started with Physical examination
introduced to the sheep dog through the feces of
which revealed a 5 x 3 x 11 cm fixed, firm and
livestock. Similarly, in humans, E. granulosus is
tender mass in anterolateral and distal parts of the
contracted by ingestion of eggs contained in the
right thigh. There was no ecchymosis, erythema,
feces of the dog after ingestion (2).
increased warmth or lymphadenopathy.
Hydatid cysts can appear anywhere in the body;
Secondly, Conventional radiography of the knee
however, the liver and lungs are the primary sites of
was then performed and it revealed soft tissue
involvement because of their role as a capillary filter
swelling at the posterior aspect of the proximal right
station. Other regions where hydatid cysts might
leg (Figure 1).
occur include the bones, kidney, spleen, pancreas,
Lastly, Magnetic resonance imaging (MRI) was
peritoneum, heart and brain (2).
performed for further imaging. MRI showed an
Soft-tissue hydatid disease is unusual even in
oval cystic mass interposed between the far medial
endemic areas, and skeletal muscle involvement is
fibers of the medial gastrocnemius muscle and the
extremely rare, with a reported prevalence of 0.5%­
soleus (4.6 x 2.8 x 10.9 cm). The lesion iso/mildly
bright signal intensity on T1 with serpiginous linear
Skeletal muscle is an unfavorable site for the
low-signal-intensity membrane (Figure 2).
growth of infection because the hydatid cyst needs
On the fluid-sensitive sequences revealed the
oxygen but the muscles usually contain high lactic
lesion had a high-signal-intensity matrix associated
acid levels. It is also hard for the cyst to grow within
with the serpiginous linear low-signal-intensity
skeletal muscles because of their contractility (4).
septations (Figure 3,4).
In this report, we present a very rare case of
Axial view of the right leg after contrast
muscular hydatid disease in an adult Saudi woman.
administration images there is mainly peripheral
It is critical to suspicious clinical diagnosis for
thick enhancement (Figure 5,6).
preoperative diagnosis of this disease.

Received:18 /1 /2018 DOI: 10.12816/0045845
Accepted:28 /1 /2018

Full Paper (vol.713 paper# 24)

c:\work\Jor\vol713_25 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2792-2804

Histopathological and Ultrastructural Studies on Biomphalaria
alexandrina Snails Infected with Schistosoma mansoni miracidia and
Treated with Plant Extracts
Hanaa M.M. El-Khayat 1, Karima M. Metwally2, Nouran A. Abououf,2 Hend M. El-Menyawy 2
1- Environmental Research and Medical Malacology Department, Theodor Bilharz Research Institute,
Imbaba, Giza, 2- Department of Zoology, Faculty of Science (Girls), Al-Azhar University, Cairo, Egypt.
Corresponding author: Hend Elmenyawy, email: end191517@yahoo.com

Biomphalaria alexandrina snails are the intermediate host of Schistosoma mansoni in Egypt.
Aim of the work: this study aimed to evaluate the molluscicidal activity of the methanol extract of the plants
Anagallis arvensis and Viburnum tinus against B. alexandrina (Normal and S. mansoni infected). Results: the
present results proved high activity for both plant extracts (LC50 & LC90 which reached 45& 60 ppm and
38&59 ppm for A. arvensis and V. tinus, respectively). The effect of sub-lethal concentration, ½ LC5, of the
two plant extracts (26 and 11 ppm, respectively) affected B. alexandrina survival rate to be in the following
order, control > V. tinus treated > A. arvensis treated > infected > infected-A. arvensis treated > infected- V.
treated. On the other hand, exposure to those sub-lethal doses caused considerable reduction in the
infection percentages. In addition, the histopathological effects of the examined sub-lethal concentrations on
hepatopancreatic tubules of the treated snails showed cells vacuolation, presence of hyaline substances filled
the lumens of the tubules and necrotic focal areas in case of A. arvnsis and vacuolar degeneration with the
necrotic changes in case of V. tinus. While, alterations in the hermaphrodite glands of the treated snails
included: degeneration and necrotic changes in the acini. The severity of lesions was progressed with
infection as a result of invading of snail tissue by developmental stages of the S. mansoni cercariae. The
ultrastructural micrographs were used to explain and confirm the recorded histopathological alterations in the
hermaphrodite glands of the infected-treated snails. In comparison with the control and infected snail groups,
infected-treated snails showed degeneration with severe deformation and destruction in their reproductive
units, degeneration in developmental stages tissues of S. mansoni cercariae and accumulation of the toxic
agents.Conclusion: the two examined plants, A. arvensis and V. tinus plant extracts showed high activity
against B. alexandrina and provide a considerable scope in exploiting local indigenous resources for snail's
molluscicidal agents. The sub-letal concentrations, ½ LC5, of the two plant extracts caused a considerable
reduction in survival rate and infection rate among S. mansoni infected snails. Histopathological changes in
the digestive glands showed cells vacuolation, hyaline substance filled lumens of the tubules and necrotic
focal areas in the digestive glands. Histopathological effects explained and confirmed by TEM images
showed degeneration with severe deformation and destruction in the reproductive units.
Keywords: Biomphalaria alexandrina, snail control, Anagallis arvensis, Viburnum tinus, Schistosoma
infection, histology, Transmission Electron Microscope (TEM).

compounds that may reach water sources during
Biomphalaria alexandrina snails are the
the agricultural
intermediate host of Schistosoma mansoni in

Egypt, they had colonized The River Nile from
activities such as herbicides, fungicides and
the Delta to Lake Nasser then extended their
pesticides which may kill snails or make their
distribution from the Nile Delta throughout the
environmental conditions unsuitable for their life
country resulted in an increase in schistosomiasis
[3] . For about two decades, increasing trails are
given to the study of plant molluscides in hope
Use of molluscicides in snail control showed
that may prove less toxic, cheaper, readily
a significant effect in reducing both incidence and
available and easily applicable by simple
technique, but the ideal applicable molluscicide
molluscicides are inexpensive and have a
did not proposed yet [4-6].Also, El Emam[7] used
potential to be biodegradable in nature and
relatively high concentrations of dry powder of A.
appropriate technology for focal control of the
arvensis (125 and 100 ppm) to indnce death of
snail vectors [2]. There are other chemical
snails in two field trials carried out in Sharkia
Received: / /2018 DOI: 10.12816/0045846
Accepted: / /2018

Full Paper (vol.713 paper# 25)

c:\work\Jor\vol713_26 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2805-2819

Serum Neopterin Level in Children with Juvenile Idiopathic Arthritis
Mohamed Hesham Mohamed Ezzat Abdelhameed1, Sahar Samir Abd El Maksoud2, Hanan
Mohamed Abd El Lateef1, Sara Mohammed Sayed Ahmed Dower1
Departments of 1Pediatrics, 2Clinical Pathology, 1Pediatrics
Faculty of Medicine, Ain Shams University
*Corresponding author: Sara Mohammed Sayed Ahmed Dower, Mobile: 01005838621; Email: saramdower@hotmail.com

Juvenile idiopathic arthritis (JIA) is generally considered a clinical syndrome involving
several disease subsets, with a number of inflammatory flows, leading to an eventual common pathway in
which persistent synovial inflammation and associated damage to articular cartilage and underlying bone
are present. Neoptrin is a reliable marker in the assessment of the rate of IFN- production. Levels of
neoptrin increase in direct proportion with the level of interferon. Measurement of neopterin level is useful
because of its relative stability also it is a prognostic indicator for cell-mediated immunity.
Aims: This study aims to assess serum level of neopterin in patients with Juvenile Idiopathic Arthritis
(JIA) in relation to the disease activity, severity and response to conventional and biological therapy.
Methodology: The study was conducted on 30 patients (Group A) previously diagnosed as SoJIA, they
were divided into two subgroups according to their therapy into Group AI on biological therapy (15
patients) and Group AII on conventional therapy (15 patients). These in addition to 20 healthy controls
(Group B).
Results: Basic clinical evaluation and laboratory investigations were done. We found that JIA patients had
significantly higher levels of serum neopterin than healthy controls. We also found a highly significant
difference between neopterin levels in the activity and remission states among all patients (Group AI and
Group AII).
Conclusion: We concluded that serum neopterin is a useful marker for cellular immune activation and
also indicative of the activity of JIA. Our findings are supported by positive correlations between serum
neopterin levels and other markers of activity as TLC, PLT counts, ESR, and CRP. We also concluded
that serum neopterin is a sensitive and accurate predictor of disease activity where sensitivity of that test
was 93.3% and accuracy was 72.5%.
Recommendations: Investigating the serum neopterin measurement in other autoimmune collagen
diseases. Assessment the influence of biological therapy on neopterin levels in relation to disease
Keywords: Serum Neopterin, Juvenile Idiopathic Arthritis.

of therapy, the use of biologics and DMARDs in
Juvenile idiopathic arthritis (JIA) is
high-risk RA patients(3).
generally considered a clinical syndrome
Neopterin is a pyrazino-pyrimidine
involving several disease subsets, with a number
compound that is synthesized by monocytes and
of inflammatory flows, leading to an eventual
macrophages in response to interferon (IFN)
common pathway in which persistent synovial
which is produced by activated T-cells. It is a
inflammation and associated damage to articular
marker of cellular immune response, and levels
cartilage and underlying bone are present(1).
are elevated in conditions of T-cell or
Many biological therapies are now
macrophage activation, including autoimmune
available for patients with rheumatoid arthritis
diseases such as systemic lupus erythematosus
(RA) who have an inadequate response to
and JIA(1).
synthetic disease modifying anti-rheumatic drugs
Neopterin is found at increased levels in
(DMARDs) especially methotrexate(2).
biological fluids from individuals with
The 2015 American College of
inflammatory disorders. Due to its capacity to
Rheumatology (ACR) treatment guideline
increase hemeoxygenase-1 content, it has been
addresses the use of DMARDs, biologics,
proposed as a protective agent during cellular
tofacitinib, and glucocorticoids in early and
established RA. It is also recommended to use
Neopterin is a biologically stable
various treatment approaches in frequently
metabolite, which gives an advantage of its
encountered clinical scenarios, including treat-
detection in assessing the activity of the immune
to-target, switching between therapies, tapering
response(5). An association between CRP and
ESR levels as well as neopterin concentrations
Received:16 / 3 /2018 DOI: 10.12816/0045847
Accepted:26 / 3 /2018

Full Paper (vol.713 paper# 26)

c:\work\Jor\vol713_27 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2820-2825
Abdominal Teratoma, A Case Report and Review of Cases
Reported from Saudi Arabia
Maram R. Shami1, Jamal Kamal 2, Nizar J. Kamal 3
1- King Abdulaziz University, Department of Medicine and Surgery ,2- King Abdulaziz University,
Department of Pediatric Surgery, 3- King Abdulaziz University, Department of Basic science

: teratomas is defined as germ cell tumors that derived from totipotent cells, some are
entirely benign (mature) and some are malignant (immature) account for 80%, 3%, respectively.
The majority of teratomas are found in gonads (ovary, testis) followed by extra-gonadal sites
(sacrococcygeal, retroperitoneal, gastric, etc.).
Aim of the study: this study aimed to report a rare cases of teratoma in Saudi Arabia.
this study was a case of a one-year old child with abdominal teratoma, which was discovered
incidentally, and on reviewing the literature we found that only two cases of extragonadal abdominal
teratomas reported from Saudi Arabia and this is the third one. Data were collected from patient's medical
file after approval has been taken from bioethics department and the patient's family.
Result: abdominal teratoma is rare and should be taken into consideration as one of the differential
diagnosis of abdominal mass. Total excision is the mainstay of treatment.
Abdominal teratoma is rare and should be taken into consideration as one of the differential
diagnosis of abdominal mass, it is usually benign. Total excision is the mainstay of treatment. Careful
histopathological examination and close follow-up is mandatory, only two cases were reported from
Saudi Arabia and our case could be the third one.
Keywords: abdominal teratomas, incidental finding; rarely reported from Saudi Arabia.

different from cases which contain recognizable
Teratoma comes from two Greek words,
organs immaturely developed within the mass,
teraton meaning (monster) and Onkoma
as a result of separation from the fertilized ovum
(swelling).This name was first given by Rudolph
in the early of pregnancy called fetus [1,2].
Virchow in 1869 due to diversity of the
Benign type is the most common one and
anatomical component in the sacrococcygeal
malignant transformation may rarely occur
type. It arise early in embryonic cell division
and it has been reported to be between 1% and
from totipotent cells, by definition it should
12.5% for sacrococcygeal lesions[3]. The most
contain all three germ cell layers; ectoderm,
common malignancies arising in teratomas are
endoderm and mesoderm, however majority of
squamous cell carcinoma, carcinoid tumor and
pathologists do not require the presence of cells
adenocarcinoma [4].
from these germinal layers, the best current
Teratomas commonly arise in the gonads
definition nowadays is the one given by Willis ;
and sacrococcygeal region, followed by the
"teratomas is a tumor or neoplasm formed of
mediastinum, stomach, liver and retroperitoneal
several foreign tissues arising in abnormal
space [4].
location, this is different from cases which
Clinically teratomas present as a mass
noticed during clinical examination or mass
developed within the mass, as a result of
effect symptoms related to pressure on the
separation from the fertilized ovum early in
adjacent structure, hematemesis, melena and
pregnancy called fetus in feto"[1].
secondary anemia could be the presenting
Some teratomas are entirely benign, some
features of gastric teratomas. Symptoms due to
are all malignant and others may contain a
malignant invasion of the adjacent structures
mixture of benign and malignant tissues. A third
may also occur.
group was added; where there is a histological
Hormonal production by teratomas is rare;
benign tissue which has not been progressed to
cases of hypoglycemia, and precocious puberty
recognizable organ, called embryonal, its
were reported. High level of beta chorionic
metastatic potential is uncertain [2], this is
gonadotrophin indicates transformation into
Received: 20/ 12 /2017 DOI: 10.12816/0045848
Accepted: 30/12 /2017

Full Paper (vol.713 paper# 27)

c:\work\Jor\vol713_28 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2826-2835

Myopic Vitreomacular Traction Syndrome
Tarek A. Almaamon, Safaa S. Mahmoud, Tamer F. Eliwa, Sara S. Hashem
Department of ophthalmology, Ain Shams University, college of medicine, Cairo, Egypt

Background: Myopic traction maculopathy (MTM), also known as myopic foveoschisis typically occurs in
highly myopic eyes often leads to blindness. The pathologic features of foveoschisis may be alone or it may be
associated with foveal detachment or macular hole.
Aim of the work: To assess the role of vitrectomy with internal limiting membrane (ILM) peeling in changing
visual outcomes and optical coherence tomography (OCT) findings of the macula in patients with myopic
vitreo-macular traction syndrome.
Design of the study: prospective Interventional case series.
Methodology: 19 high myopic eyes of 17 patients divided into 3 groups:
Group 1 (Foveoschisis only): (6 eyes)
Group 2 (foveoschisis and foveal detachment): (6 eyes)
Group 3 (foveoschisis, foveal detachment and macular hole): (7 eyes)
Results: In our study, the visual acuity significantly improved in all eyes at 6 months postoperatively. This was
associated with significant reduction of central foveal thickness. There was statistically significant inverse
correlation between changes in best corrected visual acuity (BCVA) and both basal refraction and basal
BCVA. There was statistically significant direct correlation between changes in central foveal thickness (CFT)
and basal refraction. On the other hand, there was significant inverse correlation between changes in CFT and
basal CFT.
Conclusion: Visual improvement was better in foveoschisis with foveal detachment eyes than in foveoschisis
or macular hole eyes.
Keywords: vitreomacular traction, high myopia, myopic foveoschisis, macular hole, BCVA, CFT, OCT, ILM,
peeling, pars plana vitrectomy.


Myopic traction maculopathy, also known as
collected from out-patient Ophthalmic Clinic of Ain
myopic foveoschisis, is a schisis-like thickening of
Shams University Hospital during the period from
the retina in eyes with high myopia and posterior
Janurary, 2017 till September, 2017. The study was
staphyloma. The pathologic features may also
approved by the Ethics Board of Ain Shams
include lamellar or full-thickness macular holes and
University. The cases divided into 3 groups:
shallow foveal detachment [1]. It may be caused by Group 1 (Foveoschisis): (6 eyes) of 6 patients had
premacular traction of vitreous cortex or posterior
foveoschisis only.
ectasia that is associated with posterior staphyloma Group 2 (Foveal detachment): (6 eyes) of 6
in high myopia, resulting in a "stretch retinoschisis".
patients had foveoschisis and foveal detachment.
A degenerative process involving the posterior retina Group 3 (Macular hole): (7 eyes) of 5 patients had
may be another factor associated with myopic
foveoschisis, foveal detachment and macular hole.
foveoschisis [2].

It is better diagnosed by spectral domain optical
Inclusion criteria
coherence tomography (SD-OCT) which is a useful - Highly myopic patients with refractive error > -8.00
noninvasive modality for diagnosing and monitoring
the morphologic recovery of the retina. In turn, for - The vitreomacular traction seen by Optical 445445
predicting the postoperative visual acuity [3]. The
Coherence Tomography (OCT).
current approach in treating vitreoretinal interface is -
to perform a pars plana vitrectomy surgery if the
Exclusion criteria
severity of vision loss justifies the surgical risk [4]. - Eyes with poor visual acuity due to diffuse macular
The internal limiting membrane (ILM) is the
chorioretinal atrophy or large Fuchs spots.
anatomic site of pathology that mediates vitreo-- Other retinal or macular diseases.
macular traction forces to the retina [5].
- Glaucoma.

The corresponding consent form followed the
tenets of the Declaration of Helsinki. Informed
consent was obtained from all participants before
This prospective interventional case series study
enrolment. All applicable institutional regulations
included 19 high myopic eyes of 17 patients. Their
concerning the ethical use of human volunteers were
age ranged from 44­67 years old. These cases were
followed during this research.
Received:12 /3 /2018 DOI: 10.12816/0045849
Accepted:22 / 3 /2018

Full Paper (vol.713 paper# 28)


Ketorolac versus Magnesium Sulphate as an Adjuvant to Lidocaine in
Intravenous Regional Anesthesia for Upper Limb Surgeries
Gihan Seif Elnasr Mohamed*, Amr Ahmed Kasem,
Mayada Ahmed Ibarhim, Ahmed Mohamed Tawfik Elkhateeb
Department of Anesthesia, Faculty of Medicine, Ain Shams University
*Corresponding author: Gihan Seif Elnasr Mohamed, Email: gihanseif@hotmail.com, Phone: 01001832723

intravenous regional anesthesia (IVRA) was first described almost a century ago by August Bier
and has been used for the past 50 years. It is a safe anesthetic technique for upper or lower distal limb surgery.
Purpose: to compare the onset time of sensory blockade when adding ketorolac versus adding magnesium to
the IVRA solution, and to compare the duration of postoperative analgesia.
Material and Methods: this is a randomized controlled trial in two groups. The study was performed in Ain
Shams University Hospitals. Study period range was 1-2 years.
Results: there are 146 patients participated in our study, patients were allocated to two groups 73 patients in
each group, a group of which received magnesium sulphate solution and the other received ketorolac solution.
Conclusion: we evaluated the effects of adding ketorolac and compared it to the effects of adding magnesium
sulphate to the anesthetic solution used in IVRA and we found that magnesium sulphate addition can be of
benefit in faster onset of sensory block in the operative limb. However, magnesium sulphate in the used
concentration (10 ml MgSo4 10% in 40 ml solution) appeared to cause burning pain varying in intensity while
injecting the anesthetic solution.
Keywords: Magnesium Sulphate - Intravenous Regional Anesthesia - Upper Limb Surgeries ­ Ketorolac.

Analgesia and muscle relaxation are
To compare the onset time of sensory
produced by the injection of an adequate local
blockade when adding ketorolac versus adding
anesthetic solution into a distal peripheral vein of the
magnesium to the IVRA solution, and to compare
extremity to be operated upon. The blood flow is
the duration of postoperative analgesia.
prevented by a proximally applied pneumatic

tourniquet. This technique is popular among the
anesthetists around the world (1).
Type of study:
Many studies have suggested that IVRA is a
This is a randomized controlled trial in two
safe and cost-effective technique to provide
analgesia for upper limb surgeries with few side
Study Setting:
effects. However, its limitations are; lack of
The study was performed in Ain Shams
postoperative analgesia, tourniquet pain and time
University Hospitals.
limit to surgical procedure (2).
Study Period: From January 2017 to January 2018.
There are a number of studies in which non-

steroidal analgesics were added to local anesthetics
Study Population
to modify these limitations based on their local
- Inclusion criteria
anesthetic properties. Going through a number of
All patients undergoing upper limb surgeries
studies we could understand that ketorolac is among
distal to the tourniquet level:
the commonest additives to IVRA solution (3).

- Age 18-60 year.
The mechanism of the analgesic effect of - American Society of Anesthesiologists (ASA) I-II.
magnesium is not clear, but interference with
calcium channels and N-methyl-d-aspartate receptors
- Exclusion criteria
seems to play an important role. Magnesium has - Patients with known allergies to the study drugs.
been shown to be successful in decreasing pain - Patients with sickle cell anemia.
associated with injection of propofol and
rocuronium. Previous studies used magnesium for - Patients with Raynaud's disease.
the treatment of chronic limb pain in IVRA and - Patients who received any analgesic drug in the
demonstrated that the addition of magnesium to
previous 24 h.
lidocaine improves the quality of the block, extends
Sampling Method: Randomized controlled trial
the analgesia, and reduces the overall failure rate (4).
in two groups of 73 patients each admitted to Ain Shams
Received:20 /3 /2018 DOI: 10.12816/0045850
Accepted:30 /3 /2018

Full Paper (vol.713 paper# 29)

c:\work\Jor\vol713_30 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (3), Page 2845-2850

Role of Multi-slice CT in Staging of Neuroblastoma
*Tarek Mahmoud Fouad Gad Mohamed1, Walid Hetta2,
Shaimaa Abdelsattar Mohammad2 and Nagat Mansour Khalifa3
Radiology Department, National Cancer Institute, Cairo University 1, Radiology Department , Faculty of
Medicine, Ain shams University2 , Radiology department , National Cancer Institute, Cairo University3.
*Corresponding author: Tarek Mahmoud Fouad Gad Mohamed, Email: tarekmgad@hotmail.com, Mobile: 01003977010

The International Neuroblastoma Risk Group Staging System (INRGSS) is a recent pretreatment
staging system for neuroblastoma (NB), based on imaging by CT before surgery.
Purpose: this study aimed to stage NB cases using CT scan, in relation to available clinicopathologic data.
Patients and Methods: Twenty pathologically proven NB cases were included. All were reviewed for patients'
characteristics, includingage; sex, clinical picture, LN status and metastatic spread. All cases underwent CT scan
for diagnosis. Stagingwas done using IDRFs, LN status and metastatic spread according to the INRGSS and INSS
when available. Results: an abdominal mass was found in 85% of cases and the suprarenal gland was the most
common site of primary tumor (50% of cases). Concerning tumor grade, 85 % of cases were poorly
differentiated. LNs were positive in 70%, and metastatic spread was found in 35% of patients respectively.
Staging according to the INRGSS showed that L2 was the most common stage (45% of cases), followed by M
stage (35%). L1 and MS stages were found in 15% and 5% of cases respectively. Only 7 cases had postsurgical
CT scans, and were staged according to the INSS. Conclusion: it was concluded that the use of the INRGSS
using CT scan, is a recent valuable pretreatment staging system, allowing accurate classification of
Keywords: Neuroblastoma (NB), Computed tomography (CT) scan, Image Defined Risk Factors (IDRFs),
International Neuroblastoma Risk Group Staging System (INRGSS), International Neuroblastoma Staging
System (INSS).

uniformly in different centers, or used for
pretreatment risk classification (3).
Neuroblastoma is the commonest extracranial
The International Neuroblastoma Risk Group
pediatric solid tumor and the most frequent solid
Staging System (INRGSS) is a recent pre treatment
neoplasm in the first year of life (1).It arises from the
staging system for NB, based on the imaging results
precursors of the sympathetic nervous system. The
taken by CT or MRI before surgery. It suggests that
most common primary sites of neuroblastoma are
using a standardized nomenclature can facilitate
the adrenal gland (40%), paraspinal ganglia in the
international collaborative studies all over the world.
retroperitoneum (25%), mediastinum (15%), neck
The INRGSS broadly classifies NB into localized
and metastat
ic cases


The natural history of NB is extremely
Aim: This study aims to stage neuroblastoma cases
heterogeneous, but is usually predictable from
using CT scan according to the INRGSS, in relation
clinical and biologic features(4).Treatment and
to available clinicopathologic data.
outcome of neuroblastoma depend on assessment of

risk status and on stage of the disease (3).

Imaging by Computed Tomography (CT) plays
Patients: This retrospective study included 20
an important role in diagnosis, staging and follow up
pathologically provenneuroblastoma cases. All
of NB. Most protocols include regular CT
patients presented to the Medical or Surgical
assessment, to determine efficacy of therapy and
Oncology outpatient clinics of the National Cancer
thuspredict patient's prognosis (5).
Institute (NCI) -Cairo Universityand underwent CT
scan in the Radiodiagnosis department. Patients' data
Neuroblastoma Staging System (INSS) was used for
were collected from their medical records during the
staging (6). However, this post surgical staging
period from January 2017 to July 2017 and reviewed
system depends on surgical skill; it can't be applied
for clinicopathologic characteristics. Cases with
poor quality CT or with incomplete data were
Received:20 / 3 /2018 DOI: 10.12816/0045851
Accepted:30 / 3 /2018

Full Paper (vol.713 paper# 30)