The effect of orally administered iron-saturated lactoferrin on systemic iron homeostasis in pregnant women suffering from iron deficiency and iron deficiency Anaemia The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2851-2857

The Effect of Orally Administered Iron-Saturated Lactoferrin on Systemic
Iron Homeostasis in Pregnant Women Suffering from Iron Deficiency and
Iron Deficiency Anaemia
Ahmed M Rateb, Ahmed M Mamdouh, Khaled M Balsha
Obstetrics and Gynecology Department - Faculty of Medicine ­ Ain Shams University
Corresponding author: Khaled M Balsha; Mobile: 01114657946; Email:

Anemia is a common medical disorder affecting a lot of women in pregnancy in the
developing countries. Anemia is the second indirect obstetric cause of death after cardiac causes.
Aims: To compare the safety, tolerability, efficacy and hematological response of lactoferrin in treatment of
iron deficiency anemia during pregnancy versus ferrous sulfate capsules. Methodology: Hematological
Response to lactoferrin versus ferrous sulfate in Treatment of Anemia with Pregnancy". Study site: Ain
Shams University hospital. Study design: A double blind clinical trial. Study population: The study was
included Two-hundred pregnant females with iron deficiency anemia attending the outpatient clinics of Ain
shams university maternity hospital for routine antenatal care. For each pregnant woman, age, parity and
gestational history were taken before treatment. All pregnant women took their allocated treatment regularly
for eight weeks after diagnosis of iron deficiency anemia with hemoglobin level and serum ferritin level and
followed up after four and eight weeks. Also, epigastric pain, diarrhea, constipation, nausea, vomiting or
gastric distress reported to assess tolerability of the drugs. Results: The study included 200 pregnant women
in a double blind study: Group I (lactoferrin): 100 cases were received 100mg of bovine lactoferrin (Pravotin
sachets, Hygint, Egypt) twice a day. Group II (ferrous sulfate): 100 cases were received 150mg of dried
ferrous sulphate + folic acid (vitamin B9) 0.50mg (Ferrofol, E.I.P.I.C.O, Egypt) three capsules per day.
Conclusion: lactoferrin is more tolerable than ferrous sulphate. It has lesser GIT side effects and seems to
icrease both hemoglobin and serum ferritin more than iron salts.
Recommendations: Lactoferrin is recommended for patients with iron deficiency anemia.
Keywords: Hematological response, lactoferrin, ferrous sulphate, iron deficiency anemia in pregnancy.

Mediterranean region, 25% in European region
Iron deficiency (ID) and iron deficiency
and 24% in the region of the Americas are anemic
anemia (IDA) are the most common iron disorders
mainly because of iron deficiency (2).
throughout the world. ID and IDA, particularly
Anemia is a common medical disorder
caused by increased iron requirements during
affecting a lot of women in pregnancy in the
pregnancy; represent a high risk for preterm
developing countries (3).
delivery, fetal growth retardation, low birth
Anemia is the second indirect obstetric
weight, and inferior neonatal health. These
cause of death after cardiac causes (4).
pregnancy complications are thought to occur as a
Iron deficiency anemia is 1.8% in the 1st
consequence of an increased iron requirement,
trimester, 8.2% in the 2nd trimester (5), and 27.4%
related to enhanced blood volume and
in the 3rd trimester. Hb levels of < 10g/dL are
development of the fetoplacental unit (1).
observed in up to 30% of women, with more sever
ID and IDA are still a major health problem
anemia (Hb <8g/dL) seen in 10% (6).
in pregnant women. To cure ID and IDA, iron
Anemia may antedate conception, is often
supplements are routinely prescribed. The preferred
aggravated by pregnancy, and the accidents of
treatment of ID/IDA, consisting of oral
labor may perpetuate it (7).
administration of iron as ferrous sulphate, often fails
Anemia during pregnancy and its
to exert significant effects on hypoferremia and may
management remain an important issue in prenatal
also cause adverse effects (1).
medicine. Correct diagnosis and treatment leads to
The World Health Organization (WHO)
effective management of fetal and maternal risk
defines anemia in pregnancy as a hemoglobin
and improved prenatal outcome (8, 9).
(Hb) concentration of < 11 g/dl. Iron deficiency
Diet alone can't supply the 30-40 mg iron
anemia (IDA) is the most common type of anemia
that is required for absorption of 4-6mg iron per
in pregnancy. The iron content of the body is
day needed during the later stage of pregnancy so
normally kept constant by regulating the amount
iron supplementation is strongly recommended for
absorbed to balance the amount lost (2).
all females in developing countries (10).
The WHO estimates that 46% of pregnant
Traditional therapeutic options of iron
women in African region, 38% in Eastern
deficiency anemia during pregnancy were
Received:20 /3 /2018 DOI: 10.12816/0046135
Accepted: 30/ 3 /2018

Full Paper (vol.714 paper# 1)

c:\work\Jor\vol714_2 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2858-2868

Colloid Co-load versus Colloid Pre-load in a Parturient Undergoing Caesarean
Delivery with Spinal Anaesthesia and Its Effects on Maternal Haemodynamics
Mohsen Abdelghany Bassiony, Mona Refaat Hossny, Abd El Aziz Abdallah Abd El Aziz,
Mona Ahmed Mohamed, Noha Mohamed Abd El Aziz
Faculty of Medicine, Ain Shams University, Obstetrics Anesthesia, Intensive Care and
Pain Management department
Corresponding author: Noha Mohamed Abd El Aziz, email:, Tel: +202 0119758252

: cesarean section is the surgical delivery of a baby that involves making an incision in the
mother's abdominal wall and uterus. Spinal anesthesia is considered the "gold standard" technique for cesarean
section. Hypotension is the most common side effect of neuraxial blocks in the obstetric patient with an
incidence rate reported as high as 83%. This has remained a significant concern for the anesthesiologist during
management of this patient.
Aim of the work: This study will be performed to compare the effects of colloid pre-load and colloid co-load
on maternal haemodynamic changes during spinal anaesthesia for cesarean section.
Patient's and Methods: A comparative cross sectional study was conducted at Ain Shams Maternity Hospital.
After obtaining approval of research ethical committee and patients' informed consents at which 105 women
with full term singleton pregnancies were scheduled for elective cesarean section and received spinal
anesthesia. The patient's age were between 18 -42 years, of ASA physical status. In our study 3 groups of
patients were compared; each group is formed of 35 patients Group 1; patients were pre-loaded with 500 ml of
6% HES(hydroxyethyl starch 130/0.4) 20 minutes before induction of anesthesia. Group2; patients were co-
loaded with 500ml of 6% HES (hydroxyethyl starch 130/0.4) during injection of bupivacaine. Group 3; patients
were pre-loaded with 500ml lactated ringer solution 20 minutes before induction of anaesthesia.
Results: There was a decrease in SBP, DBP,MAP and HR in the 3 groups where the lowest values were
recorded in group 3 between 6-15 minutes and there was a high statistical difference p0.0001 while the
intergroup comparison of the groups 1 and 2 showed no statistical significance as regards SBP,DBP,MAP and
. Conclusion: In this study it was found that colloid co-load was somewhat how equal to colloid pre-load in
prevention of hypotension in a parturient undergoing cesarean section under spinal anesthesia in addition it was
found that crystalloid pre-load was inferior to colloid co-load or pre-load in maintaining blood pressure during
spinal anesthesia in parturients .
Keywords: HES: Hydroxyethyl starch, ASA, American Society of Anesthesiologists, SBP, Systolic Blood
Pressure, DBP, Diastolic Blood Pressure, MAP, Mean Arterial Pressure, HR, Heart Rate.

Spinal anesthesia is the popular route of
anesthesia for elective cesarean section. Maternal
administration should take place at the time of
hypotension is a common complication after spinal
induction of anesthesia for cesarean delivery(3).
anesthesia for cesarean delivery. Prevention and

treatment of post spinal hypotension (PSH) in
A comparative cross sectional study was
conducted at Ain Shams Maternity Hospital. After
This hypotension with or without bradycardia
obtaining approval of research ethical committee
have detrimental effects on both the mother (nausea,
and patients' informed consents at which 105
vomiting, dyspnea etc) and fetus (acidosis,
women with full term singleton pregnancies were
neurologic injuries, etc). This complication can be
scheduled for elective cesarean section and received
managed by several approaches like fluid therapy,
spinal anesthesia. The patient's age were between 18
use of vasopressor or simultaneous use of fluid
-42 years, of ASA physical status I-II. In ourstudyall
therapy and vasopressor(2).
patients were assigned randomly to one of three
Fluid infused before or at the time of induction
equal group 35 (thirty five) parturients in each
of anesthesia is referred to as pre-loading and co-
group.Group 1; patients were pre-loaded with 500
loading respectively. Early reports suggested that
ml of 6% HES(hydroxyethyl starch 130/0.4)20
this problem could be prevented by infusing a bolus
minutes before induction of anaesthesia. Group
of fluid before induction of anesthesia, but this
2; patients were co-loaded with 500ml of 6% HES
strategy has met with limited success. Recently,
(hydroxyethyl starch 130/0.4)during injection of
Received: 20/ 3 /2018 DOI: 10.12816/0046136
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 2)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2869-2874

The Value of Using Platelet Rich Plasma after Hysteroscopic Analysis of
Severe Intrauterine Adhesions (A Randomized Controlled Trial)
Mohamed Ibrahim Mohamed Amer, Mortada El-Sayed Ahmed, Reda Mokhtar Kamal,
Ahmed Mohamed Mahmoud Abd Elwahab Torky
Department of Obstetrics and Gynecology, Faculty of Medicine - Ain-Shams University
Corresponding author: Ahmed M.M. Abd Elwahab Torky, Mobile: 01100028287,
Office hysteroscopic examination is now an established step in the diagnostic work up of
cases with abnormal uterine bleeding, infertility, and recurrent miscarriage that can be performed safely and
efficiently without anesthesia in most cases. Objectives: This study aimed at assessment of the efficacy of
the use of platelet rich plasma (PRP) in decreasing occurrence and recurrence of intrauterine adhesions after
operative hysteroscopy. Patient and Methods: This study was conducted in Ain Shams Maternity Hospital
(Early Cancer Detection and Endoscopy Unit) during the period between January 2017 and February 2018.
60 patients seeking for conception with a history of primary or secondary infertility with sever intrauterine
adhesions. 30 patients (case) injected with PRP and 30 patients (control) with IU balloon. All patients had
normal complete blood count, and not taking anticoagulant or NSAID in the 10 days before procedure with
no active cervical or uterine infection. Results: It was found that the mean age in PRP group was 31.8 ± 4
years old and balloon group was 30.5 ± 4.7 range: (20-45 years old). The mean of BMI in PRP group was
24.4 ± 2.2 and balloon group was 25.1 ± 2.4. In this PRP group (13.3%) of patients were nulliparous and
balloon group (10%), (86%) of PRP group are multipara and in balloon group (90%). There was no
significant association between ages, parity with any possible etiology. Our study showed significant
increase of menses duration among the PRP group post-operative (3.0 ±1.2) days and preoperative menses
duration (1.4 ± 1.5) days. Compared to balloon post-operative (1.8 ± 1.3) and preoperative (1.3 ± 1.4) days.
platelet rich plasma had high efficacy and safety in improvement of menses duration, amount
and adhesion score in cases of sever intrauterine adhesions and decreasing postoperative adhesions.
Intrauterine adhesions - Platelet rich plasma


cells) and postoperative assessment by (office
Intrauterine adhesions may occur after
hysteroscopy ­ ultrasound) (2).
intrauterine trauma. The severity of the adhesions
Hysteroscopy is a valuable diagnostic and
varies: some are focal and small bands, some
therapeutic modality in the management of
extensive, some even total occlusion of the uterine
infertility. Hysteroscopy is the gold standard
cavity. Uterine surgery and diagnostic curettage are
procedure for uterine cavity exploration. It is widely
common reasons of adhesions, but serious adhesions
accepted that a complete infertility workup should
usually arise from pregnancy complications such as
include an evaluation of the uterine cavity. Uterine
postpartum hemorrhage, missed or complete
abnormalities, congenital or acquired, are implicated
abortion and placental retention. Multiple curretages
as one of the causes of infertility. In fact, infertility
performed for pregnancy termination is also a risk
related to uterine cavity abnormalities has been
factor and adhesion risk is more than 30% after the
estimated to be the causal factor in as many as 10%
third curretage. Infections, especially uterine
to 15% of couples seeking treatment. Moreover,
tuberculosis cause severe adhesions (1).
abnormal uterine findings have been found in 34%
Intrauterine adhesions may be asymptomatic,
to 62% of infertile women (3).
but generally are related with infertility, menstrual
The role of hysteroscopy in infertility
disorders (hypomenorrhea, amenorrhea), cyclic
investigation is to detect possible intrauterine
pelvic pain or cramping around the time of period,
changes that could interfere with the implantation,
recurrent miscarriage and endometriosis (caused by
growth of the conceptus or both and to evaluate the
backflow of blood from the uterus). Indirect imaging
benefit of different treatment modalities in restoring
methods give useful information in diagnosis as 3D
a normal endometrial environment (3).
ultrasound, but the gold standard diagnostic method
Platelet rich plasma (PRP) is an autologous
is hysteroscopy that has the advantage of concurrent
product derived from whole blood through the
treatment (1). Management and treatment strategy
process of gradient density centrifugation.
include hysteroscopic adhesiolysis; readhesion
Autologous PRP has been shown to be safe and
prevention by intrauterine device, uterine balloon
effective in promoting the natural processes of
stent, Foley's catheter or amnion graft; restoration of
wound healing, soft tissue reconstruction, bone
normal endometrium (hormonal treatment - stem
reconstruction and augmentation (4).
Received:11 /3 /2018 DOI: 10.12816/0046137
Accepted:21 / 3 /2018

Full Paper (vol.714 paper# 3)

c:\work\Jor\vol714_4 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2875-2884

Awareness and Attitude towards Epilepsy among Saudi Arabia
Hanan Abid Alqurashi* , Abdulkader Al Juhani** ,
Bashaer Mahboub Alalwani**, Alhanouf Abdullah Alyahya*** ,
Roula Hadyan Alhadyan*** , Abla Muhammed Alhoshani**** , Rawan Nasser Alhunaki***
Taif University*, Royal Commission Medical Center-Yanbu**,
Almaarefa Colleges***, Qassim University****

Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate
epileptic seizures and by the neurobiological, cognitive, psychological, and social consequences of this
condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure.
Aim of the Study:
To asses and evaluate general population understanding, knowledge and attitude toward
epilepsy and epileptic patients. Methods: It's a cross-sectional randomized study conducted in Kingdome of
Saudi Arabia. An online questionnaire designed to survey public awareness and attitudes toward epilepsy that
posted online & distributed to the public. Estimated about 1000 cases and the statistical package SPSS version 21
was used for data analysis. Result: 20.2% of the participants have a family member with Epilepsy. When asked
if they can define Epilepsy; (39.6%) from the Southern region believe that they can, followed by the rest of the
regions with similar percentages. 40.3% of female participants knew the causes of epilepsy and also 40.3% of
males. The western region was leading with 29% knowing the causes of Epilepsy. (30.4%) of females knew how
to handle a seizing patient while only (22.4%) of males knew how. The Western region had the highest positive
response (31.5%). A high percentage of Males (81.2%) did not think that there're different levels of Epilepsy
while only (4.3%) of females agree on that. Most the responses received from males (43.6%), females (43.6%)
and by regional division; (40%) West, (49%) South, (41.8%) North, (45.5%) Centre, (47.1%) East, agreed that
epilepsy isn't a genetic disorder. (36.5%) of females did not think that epilepsy affects the brain function;
(29.1%) of males, (34.9%) West, (37.8%) Central, (41.4%) East, (34.5%) North and (22.9%) South had the same
opinion. Conclusion: we noticed that the awareness and attitudes of the Saudi public toward epilepsy is less than
expected especially from college students. We plan to target all our community from the different level of
education and regions for more education in order to lower this stigma of epilepsy.
Keyword: Epilepsy, awareness, attitude, causes.


of 6.54 per 1000, no study of epilepsy awareness,
Epilepsy is the 4th most common neurological
knowledge, and attitudes had been reported from
disorder and affects individuals of all ages. Epilepsy
Saudi Arabia (2).
is a disorder of the brain characterized by an
A cross-sectional study was done in the Aseer
enduring predisposition to generate epileptic
region, Saudi Arabia showed that almost all had
seizures and by the neurobiological, cognitive,
heard about epilepsy (96.1%), and the majority knew
psychological, and social consequences of this
someone with epilepsy (60.7%). In spite of that,
condition. The definition of epilepsy requires the
knowledge about the etiology and nature of epilepsy
occurrence of at least one epileptic seizure (1).
was lacking, as 40% of participants thought it was a
Epilepsy can influence one's security, work,
blood disorder, 21.2% believed it was contagious,
connections, driving thus significantly more, Public
and nearly one-third viewed it as due to a mental
perception and treatment of individuals with
disorder and emotional stress (2).
epilepsy are more concerning issues than actual
Another study was conducted to examine
seizures. Epilepsy represents 0.5% of the global
public awareness and attitudes toward epilepsy in
burden of disease, with more than 50 million people
Riyadh, the capital city of Saudi Arabia, revealed
affected worldwide; 80% of them are in developing
that most participants (77.4%) had prior knowledge
regions. People with epilepsy and their families can
of epilepsy, and 52% believed that epilepsy is an
experience the ill effects of disgrace and separation
organic disease. 15% also linked epilepsy to evil
in many parts of the world. Despite the fact that this
spirit possession, and up to 37% preferred spiritual
issue is common in Saudi Arabia, with a prevalence
rituals and religious healing to medical treatments (3).
Received:20 /1 /2018 DOI: 10.12816/0046138
Accepted:30 / 1 /2018

Full Paper (vol.714 paper# 4)

c:\work\Jor\vol714_5 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2885-2891

Rice Bran Oil Ameliorates Hepatic Insulin Resistance in Fructose Fed-Rats
Sohaier A. Abd Elbast1, Mona A. Mohamed2*, Mervat A. Ahmed1, Nehad A. Ali1
1Zoology Department, Faculty of Science, Al-Azhar University, Cairo, 2Biochemistry Division, Chemistry
Department, Faculty of Science, Al-Azhar University, Cairo, Egypt

Insulin resistance is a pathological condition characterized by inadequate peripheral tissue
metabolic response to circulating insulin. High dietary fructose causes insulin resistance syndrome, primarily
due to simultaneous induction of genes involved in glucose, lipid and mitochondrial oxidative metabolism.
Rice bran oil (RBO) is a rich source of antioxidants which contribute to higher oxidative stability and longer
shelf life than other edible oils. Aim of the work: The current study investigated the effects of the daily intake
of RBO on insulin resistant rat liver, as a central organ in carbohydrate metabolism.
Materials and methods: Rats were allocated in 5 groups. Animals in groups 1 and 2 received standard diet
and standard diet containing RBO, respectively. Group 3: animals fed high fructose diet (HFD), which was
categorized into: rats fed HFD either for one month (HFD1) or for 2 months (HFD2). Group 4, rats were fed
HFD containing RBO for one month (HFD1+RBO), while rats in group 5 were fed HFD for 30 days then
RBO was added to the diet for another 30 days (HFD2+RBO). Results and conclusion: addition of RBO to
this model improved insulin sensitivity in liver.
Keywords: insulin resistance, rice bran oil, glycogen.

Insulin resistance is increasing at an alarming rate,
Animals: A total of 60 adult female Albino rats
becoming a major public and clinical problem
weighing 140-220 g were used throughout this
worldwide. Insulin resistance is defined as impaired
study. Animals were purchased from the breeding
ability of insulin to promote glucose uptake and it
unit of the Egyptian Organization for Biological
exerts its metabolic effects in liver, skeletal muscle
Products and Vaccines (Helwan, Egypt) and they
and adipose tissue(1,2). Experimental studies in
were housed in steel mesh cages (4/cage). Rats were
animals documented that the general increase in
maintained for a week (Acclimatization period),
they were fed on a commercial pellet diet. Food and
water were provided ad libitum.

Fructose, a simple sugar found in honey, fruit and
Preparation of diets
high-fructose corn syrup, has a unique metabolism
The standard, high fructose (60g/100g) diets and
that results in oxidative stress and lipogenesis(6,7).
diet containing 10% RBO were prepared as
Fructose intake has increased markedly due to the
previously described by Rajasekar et al. (13) and
increasing intake of beverages sweetened with
Wang et al. (14).
sucrose (50% fructose) and high fructose corn syrup

(55­90% fructose)(8).
Study design
Rice bran oil (RBO) is unique among edible oils
Rats were allocated into 5 groups. Normal control
as a result of its nutritional and functional properties
group (NC): rats were fed on a standard diet. Rice
such as -oryzanol, phytosterols and tocopherols(9).
Bran Oil group (RBO): rats were fed on a standard
These bioactive compounds reduce oxidative stress
diet contained 10% RBO as the sole source of fat.
which causes many diseases such as diabetes,
High Fructose Diet group (HFD): this group was
cancers and neurodegenerative diseases(10). Several
subdivided into 2 sub-groups: rats were fed on HFD
studies have demonstrated that RBO possesses
for only one month (HFD1) and rats which were fed
hypoglycemic activity(5,11) since chronic exposure to
on HFD for 2 months (HFD2) and served as
hyperglycemia may induce dysregulation of gene
reference groups for the corresponding treated
expression that converge on impaired insulin
groups. Rats were fed on HFD which contained
secretion and increased apoptosis(12).
10% RBO for one month (HFD1+ RBO).
This study was designed to monitoring the effects
Rats in this group were fed on HFD for 30 days,
of the daily intake of RBO on insulin resistant rat
and then received HFD with 10% RBO for another
liver, as a central organ in carbohydrate metabolism.
30 days (HFD2+ RBO). Animals were maintained

in their designed groups for 4 weeks except group 5.
Received:20 /3 /2018 DOI: 10.12816/0046139
Accepted:3- / 3 /2018

Full Paper (vol.714 paper# 5)

c:\work\Jor\vol714_6 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2892-2906

Microscopic Evaluation of The Testis in Azoospermic Patients with
Reference to Androgen Receptors in Sertoli Cells
Heba Allah M. Elsherbini, Abdel-Hamid Mohmmed Abdel-Aziz,Fathy E. Mattar,
Abdel-Raouf MohmmedAlmohsen
Departments of Dermatology and Venereology, Faculty of Medicine, Al Azhar University, Egypt
*Corresponding author: Heba Elsherbini, Email:, Mobile:01224121165

The reproductive ability of sexually mature males is dependent on the capacity of the testes
tubules to produce large numbers of highly viable sperms and the interstitial cells to produce adequate levels
of androgens to ensure maturation of the reproductive system.Azoospermia, defined as the complete absence
of spermatozoa in the ejaculate, invariably results in infertility but does not necessarily imply sterility. It is
identified in approximately 1% of all men and in 10 to 15% of infertile males.
Patients and methods: The use of biopsies had been approved by the ethics committee of the Faculty of
Medicine, Al Azhar University. All testicular biopsies were taken after written informed consent at the
Department of Clinical Andrology, International Islamic Center for Population and Research Studies.Eleven
patients with idiopathic infertility, were enrolled in this study and were assessed and diagnosed by a complete
examination and specific investigations.
This study included 11 patients. They were divided into two groups obstructive azoospermia (OA)
and Non-obstructive azoospermia. Non-obstructive azoospermia is subdivided into 4 groups: Early maturation
arrest, late maturation arrest, Sertoli cell only (Sco) and Klienfilter syndrome.
Conclusion: Spermatogenesis and maintenance of reproductive functions are controlled by androgens which
are steroid hormones. Androgens exert most of their effects through genomic actions, which involve their
binding to the androgen receptor (AR).AR plays important roles during later stages of sperm formation and
maturation by influencing the four major cell types: Sertoli, Leydig, peritubularmyoid, and germ cells. Except
for maturation arrest non-obstructive azoospermia, AR positive staining was not detected in germ cells. The
highest number of Sertoli cell androgen receptors was in sections of testis from obstructive azoospermia and
non- obstructive late maturation arrest patients, Testicular sections from patients with Klinefelter syndrome
presented the lowest number of androgen receptor positive cells.It was concluded that the present study
revealed that demonstration of androgen receptors in testicular sections is a good indicator of spermatogenic
activity. Such information is valuable for the decision of obtaining spermatozoa from the testis for ICSI.
Keywords: Infertility, Azoospermia, spermatogenesis, androgen receptors, Sertoli cells.

Androgen receptor of Sertoli cells in azospermic
The AR is a member of a large family of
patients will be studied.
ligand-activated nuclear receptors and is highly

expressed in the testes (1).
Azoospermia, defined as the complete absence
Selection of cases
of spermatozoa in the ejaculate, invariably results
Eleven patients with idiopathic infertility, were
in infertility but does not necessarily imply
enrolled in this study and were assessed and
sterility (2). It is identified in approximately 1% of
diagnosed by a complete examination and specific
all men and in 10 to 15% of infertile males (3).
investigations.The use of biopsies had been
Testicular biopsy remains the key investigation
approved by the ethics committee of the Faculty of
for all testicular causes of infertility. It is not the
Medicine, Al Azhar University. All testicular
only parameter for determining the testicular
biopsies were taken after written informed consent
histopathology pattern but apparently the strongest
at the Department of Clinical Andrology,
indicator to foresee the possibility of finding
International Islamic Center for Population and
sperms in the testis for therapeutic sperm retrieval
Research Studies.
in assisted reproductive techniques (4).

Inclusion criteria
1. Age from 28 to 35 years.
The aim of this study is microscopic
2. Infertility for more than one year.
evaluation of testisinazospermic patients for
3. Willingness to participate and signing of
precise establishment of the disease etiology,
consent after the study had been explained.
Received:20 /3 /2018 DOI: 10.12816/0046140
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 6)

c:\work\Jor\vol714_7 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2907-2912

Prophylactic Oral Nifedipine to Reduce Preterm Delivery: A Randomized
Controlled Trial in Women at High Risk
Emad El-Din A. Soliman1 , Mohammed A. Emara 1 , Haitham A. Hamza1 , Amira H. Al-Sabaawy 2
1- Obestetrics and Gynecology department, Faculty of Medicine, Menofiya university, 2- Obstetrics and
gynecology at Ministry of health, Berket El Saba. H. , Menofiya, Egypt
Corresponding Author: Amira Hefny Al-Sabaawy, Berket El Saba, Menofiya, Mob: +201091234996, e-mail:
Corresponding author: Amira Al-Sabaawy , E-mail:

to evaluate the efficacy of prophylactic nifedipine versus placebo in reducing spontaneous preterm
delivery in asymptomatic women at high risk for preterm delivery.
Background: Preterm birth (before 37 completed weeks of gestation) is a major cause of death and a significant
cause of long-term loss of human potential. Prophylactic nifedipine in reducing spontaneous preterm delivery in
asymptomatic women at high risk for preterm deliver
Patients and methods: A Prospective randomized double-blinded study was carried out on 120 pregnant women
at high risk of preterm labor (5 cases lost in follow-up), (5 discontinued before 28 days because they had preterm
delivery or drug side effects) which attended from the Obstetrics and Gynecology outpatient clinic in Minoufia
University Hospital during the period from March 2016 to August 2017. Detailed history, laboratory
investigations, obstetric and ultrasound follow up study were done.
Results: there was no significant difference (P > 0.5) between nifedipine and placebo groups regarding
maternal age, gestational age, parity, Previous preterm labor and Inter pregnancy interval (years). While, there
was statistically significant difference (P 0.05) regarding mode of delivery, delivery time and medications
side effects, neonatal respiratory distress and neonatal Intensive care unit (NICU) admission in both group.
Additionally, onset of labor between 34-37 week was significantly less frequent in nifedipine group than placebo
Conclusion: we found that the superiority of nifedipine as prophylactic tocolosysis in the mean prolongation of
pregnancy compared to that of placebo in high risk women for preterm labor, it has better effect on neonatal
outcomes, fewer maternal side effects. We would only comment that nifedipine looks like a promising drug in
this regard and further large studies are required to establish this fact.
Keywords: Tocolysis, Nifedipine, Perinatal Outcome, preterm.

terbutaline (4). Betamimetics have a high frequency of
Preterm birth, defined as birth occurring
unpleasant, sometimes severe maternal side-effects
between 26 and 36 completed weeks of gestation is a
including tachycardia, hypotension, tremulousness
major contributor to perinatal morbidity and
and a range of biochemical disturbances.
mortality (1). The rate of preterm birth is increasing
Furthermore, betamimetics have been associated
across low- and middle-income countries, affecting
with at least 25 maternal deaths mainly from
8.6% of births in high-income countries and
pulmonary oedem.There is a need therefore for an
between7.4% to 13.3% in low- and middle- income
effective tocolytic agent with less sideeffects than the
countries (2).There are several possible pathways
betamimetics (5). A meta-analysis reported that
which lead to spontaneous preterm birth, four of
calcium channel blockers decrease the number of
these pathways are supported by a considerable body
preterm births within 7 days of first administration
of clinical and experimental evidence: excessive
and before 34 weeks of gestation in women with
myometrial and fetal membrane over-distention,
preterm labor, with improvement in some neonatal
decidual hemorrhage, precocious fetal endocrine
outcomes. Moreover, they have been associated with
activation, and intrauterine infection or inflammation
fewer adverse drug reactions than have other
(3).These pathways may be initiated weeks to months
tocolytic agents (mainly beta-mimetics), so reducing
before clinically apparent preterm labor.
the need for treatment suspension (6).
The tocolytics which have been most widely
Calcium channel blockers (CCB) are non-specific
tested are the betamimetics ritodrine, salbutamol and
smooth muscle relaxants, predominantly used for the
Received:18 /1 /2018 DOI: 10.12816/0046141
Accepted:28 / 1 /2018

Full Paper (vol.714 paper# 7)

c:\work\Jor\vol714_8 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2913-2915
Public Awareness towards Hypertension among Saudis in AL Riyadh, KSA
Matra Mohammed Fagihi1, Ahmed Mousa Almuhanna2, Abdulmalik Abdulaziz Almughamis3,
Saud Abdulmajeed bin Rakhis3, Eman Aied Alosaimi4,
Muntadar Abduljabar Alsalman5, Hanaa Naif Alharbi6
1Prince Mansour Military Hospital, 2King Saud University, 3Imam Muhammad ibn Saud Islamic
University, 4Umm Al-Qura University, 5King Khalid University, 6Al Qassim University
Corresponding Author: Matra Mohammed Fagihi, E-mail:

Hypertension is a major health problem all over the world, causing high mortality and
morbidity. It is a major risk factor for brain and heart diseases.
Objectives: To assess the level of public awareness and knowledge towards hypertension among Saudis in AL
Riyadh City.
Methods: A cross-sectional self-administrated questionnaire based study distributed among 300 Saudis of AL
Riyadh City.
Results: The age was ranged from 30 to 60 and 55% were females and 45% were males respondents. The majority
of them had bachelor degree and were employed. Most of the respondents had acceptable knowledge about
hypertension, risk factors and management. Also, education was significantly associated with high levels of
knowledge of this disease. Conclusion: Generally, public knowledge was good with high knowledge about risk
factors and managements. No enough campaigns about hypertension to fill the gap. Also, education significantly
impacts the knowledge of population about hypertension.
Keywords: Hypertension, AL Riyadh, KSA.

to early detection and to help in the controlling of this
In all nations, hypertension is a major cause of
fetal disease. Thus, this study aimed to assess the
morbidity and mortality [1].
knowledge of public towards hypertension.
Many complications could happen if the blood

pressure not controlled such as kidney disease,
stroke, coronary artery disease (CAD), infarction and
Cross-sectional, self- administrated questionnaire
atherosclerosis [2] . Moreover, treatment of
was distributed among public in Alriyadh city and their
hypertension is too costly [3]. A study showed that the
age from 30-60 from April. 2017 to May 2017.
prevalence of hypertension in adult population was

about (972 million patients) in 2000 [4].
Compered previous studies revealed that
The surveys was distributed on 300 Saudis in front of
hypertension increase in developing countries and
public mall in Alriyadh city.
lower in developed countries [5]. In KSA, study
Study tool
showed that hypertension is a major risk factor which
The design of the questionnaire was based on
increase the morbidity and mortality [6].
previous studies with some modifications [9]. Self-
Other studies showed the prevalence of
administrated questionnaire that consists of two parts:
hypertension in 1995-2000 was 26 % and in 2005 was
The first part included personal information of
25.5 % among population [7-8]. Hypertension is
participants. The second part consists of multiple
treatable and preventable disease, it is increasing
question such as assessment knowledge about
dramatically over the year and it is significantly
associated with older age and if left untreated it will

result in life-threatening diseases [8]. The public
Statistical analysis
awareness, knowledge and attitude must be clarified
Data were entered and analyzed by (SPSS).

Received:22 /1 /2018 DOI: 10.12816/0046142
Accepted: 2/ 2 /2018

Full Paper (vol.714 paper# 8)

c:\work\Jor\vol714_9 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2916-2925

Study of Structural Changes in Diabetic Macular Edema by Spectral Domain Optical
Coherent Tomography after Intravitreal Injection of Triamcinolone Acetonide
Fatma AbdAlwahab Atwa, Zeinab Saad El-Din Elsanabary*,
Mona Mohamad Aly Farag, Sahar Saad El-Deen Mohamed
Ophthalmology Department, Faculty of Medicine (for Girls), Al-Azhar University, Cairo University*
is to study the morphological changes in Diabetic Macular Edema (DME) before and after intravitreal
injection of triamcinolone acetonide using the spectral domain­optical coherence tomography (SD-OCT)
Patient and methods: The study was held at Al-Zahraa University Hospital. It included 49 eyes of 40 patients
with clinically significant diabetic macular edema (CSDME). A single intravitreal injection of triamcinolone
acetonide (IVTA) at the dose of 4 mg in 0.1 ml was administered. Best corrected visual acuity (BCVA),
intraocular pressure (IOP) and OCT scanning of the macula were done before and 3 months after IVTA. The
OCT study parameters included central foveal thickness (CFT), OCT pattern of DME, vitreomacular interface
(VMI), presence or absence of serous macular detachment (SMD), hard exudates (HEs), hyper-reflective spots
(HRS) and IS/OS junction (Foveal ellipsoid zone) & ELM integrity.
Results: Mean BCVA ± SD were (0.23 ± 0.13) and (0.39 ± 0.22) pre and 3 months after IVTA respectively. The
initial mean CFT ± SD was (424 ± 127.1 um) while 3 months after IVTAit was (283.1 ± 70.2 um). Eighteen eyes
showed SMD which was completely absent 3 months after a single IVTA. There was insignificant statistical
difference of the VMI state before and 3 months after IVTA. Out of thirty-four eyes that showed the presence of
HEs in this study, twenty-seven eyes showed diminution of these HEs size 3 months after injection. Forty-one
eyes and forty-three eyes showed the presence of HRS before and after IVTA respectively. There was
insignificant statistical difference in foveal ellipsoid zone and ELM integrity before and 3 months after IVTA.
Complications were reported in 16 eyes (32.6%). Cataract progression was noted in 6 eyes (12.2 %). Steroid
induced IOP elevation was reported in 10 eyes (20.4%).
Conclusions: The data collected from OCT macular B scan are effective in the prognosis and follow up of
diabetic macular edema. IVTA remains a promising primary therapy for DME at least in short terms. It seems
relatively safe, but not without complications.
Keywords: Spectral Domain Optical Coherence Tomography, Diabetic Macular Edema, Intravitreal
triamcinolone, Central foveal thickness, Hard Exudates, Hyper-reflective spots.


Diabetic macular edema (DME) remains a
The advancement in optical coherence
major cause of vision loss in developed countries
tomography (OCT) technologies including the
despite continued improvements in the care of both
increase in speed of scanning and higher axial
resolution (up to 3 microns for certain OCT
retinopathy.Intravitreal pharmacotherapies have
machines) has made visualization of the retinal
largely replaced photocoagulation or used as
microstructures possible and provided retinal
adjuvant therapy for patients with center-involving
sectional images as in a histology study(3).
DME. Most patients with DME improve with anti-

VEGF treatment and many will also benefit from
treatment with corticosteroids (1).
The study is a single group, randomized,
The visual acuity is not always improved
prospective and interventional. It was performed on
after treatments of the macular edema, which
49 eyes of 40 patients with clinically significant
suggests that macular thickness is only one of the
diabetic macular edema (CSDME) according to the
factors that worsen the visual function. Therefore,
ETDRS classification. It was held at Al Zahraa
quantitative measurements may not explain all
University Hospital between March, 2015 and May,
variations in visual acuity, and other factors
2016. The study was approved by the Ethics
including macular ischemia and retinal cell function
Board of Al-Azhar University.
might be important as well (2).

Received:20 / 3/2018 DOI: 10.12816/0046143
Accepted:30 / 3 /2018

Full Paper (vol.714 paper# 9)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2926-2931

Endovascular versus Open Surgical Reconstruction in Long Segment
Superficial Femoral Artery Occlusive Disease
Ayman Ahmed Talaat, Ramez Mounir Wahba, Ahmed Ashraf Kamel
Department of General Surgery, Faculty of Medicine, Ain Shams University
Corresponding author: Ahmed A. Kamel, Mobile: 01005100357; Email:

The concept of endovascular intervention has been well supported by the continuous advance in
technology in long segment (superficial femoral artery) SFA occlusions. The rapid evolution of stent design,
deployment approaches and adjunctive therapy made the practice of (percutaneous transluminal angioplasty)
PTA safer and more predictable and has reduced superficial femoral artey surgery.
Objectives: To compare the safety and effectiveness of endovascular treatment versus open surgical bypass
in treatment of superficial femoral artery occlusive disease.
Patients and Methods:
This prospective study included 30 patients presenting to the Vascular Department
in Cairo University Hospitals with femoropopliteal occlusive disease for whom percutaneous transluminal
angioplasty with or without stenting was done for 15 cases. Femoropopliteal bypass surgery with saphenous
or synthetic graft was done for 15 cases between March 2017 and January 2018. The procedure, possible
complications, benefits, risks and other alternative interventions were all explained to the patients and an
informed consent was obtained.
Results: In endovascular cases: 1/15(6.66%) cases, developed small haematoma at the site of puncture which
resolved by conservative management. After 6 months follow up,6/15 cases (40%) had intact pedal pulsation,
6/15 cases (40%) had popliteal pulsation with marked improvement of their complaints (disappearance of rest
pain in 3 cases, the other 3 cases which had gangrene, line of demarcation appeared). 1/15 case (6.66%) showed
popliteal pulse at 3 months follow up which disappeared at 6 months but the patient had good circulation with
improvement of rest pain. So, successful cases were 13/15(86.66%) at 6 months follow up. 2 /15 cases(13.33%)
showed occlusion, by Duplex 1 case of them showed occlusion of stent and 1 case showed return to original
occlusion. In open surgical cases: Postoperative wound infection at groin incision developed in 3/15(20%)
cases, 2 cases of them were managed conservatively by IV antibiotic and repeated dressing, and one developed
secondary haemorrhage in which ligation of femoral artery was done and the limb became gangrenous and
Above knee amputation was done. After 6 months follow up, 5/15 cases (33.33%) had intact pedal pulsation,
7/15 cases (46.66%) had popliteal pulsation with marked improvement of their complaints. Disappearance of rest
pain occurred in 3 cases, while 3 cases which had gangrene, line of demarcation appeared and 1 case which had
non healing ulcer, healing of ulcer started to occur. So successful cases 12/15(80%) at 6 months follow up. Thus,
3/15 cases (20%) failed, 1 case developed wound infection at groin incision followed by secondary haemorrhage
in which ligation of the graft was done, the limb was worsen ended in above knee amputation. The other 2 cases
showed occlusion of graft, 1 case ended in above knee amputation, the other below knee amputation was done in
which the stump became gangrenous followed by above knee amputation.
Conclusion: Percutaneous transluminal angioplasty (PTA) has obtained a definite place in the management of
peripheral arterial occlusive disease of the lower limb. It was widely accepted as a first line of treatment for many
patients with SFA occlusive disease. The low complication rate and relatively non-invasive nature of PTA made
it an increasing popular intervention.
Percutaneous transluminal angioplasty, Peripheral vascular disease, SFA lesions, Bypass surgery.


The SFA remains the most difficult
The concept of endovascular intervention
peripheral artery in which to maintain reliable long-
has been well supported by the continuous
term patency despite the rapidly increasing
advance in technology. The rapid evolution of
availability of endovascular therapy tools. This
stent design, deployment approaches and
paradox is most likely a result of its long course
adjunctive therapy made the practice of PTA
within the adductor canal, which exposes it to unique
safer and more predictable and has reduced the
mechanical forces unlike any other vascular territory
incidence of procedure related adverse events in
(1). It is more prone to the development of advanced
long segment SFA lesions, particularly the need
atherosclerotic lesions than other vessels (2).
for emergency surgery.
Received:20 / 3 /2018 DOI: 10.12816/0046144
Accepted:30 / 3 /2018

Full Paper (vol.714 paper# 10)

c:\work\Jor\vol714_11 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2932-2943

Combined Low Dose Aspirin and 17 Hydroxyl Progesterone versus
17 Hydroxyl Progesterone Alone Study in Pregnancy: A Randomized
Clinical Trial for Prevention of Spontaneous Preterm Birth
Hassan Awwad Bayoumy, Amgad Abou-Gamrah, Mostafa Fouad Gomaa,
Asmaa Ahmed Mohamed Alashwah
Obstetrics and Gynecology Department, Faculty of Medicine - Ain Shams University

: Preterm birth: defined as any live birth occurring through the end of the last day of the 37th week
(259th day) following the onset of the last menstrual period. Low-dose aspirin (LDA) has been noted to reduce
the preterm birth (PTB) rate in multiple meta-analyses of the preeclampsia (PreE) prevention trials. It is
unclear if this effect of LDA is entirely due to a reduction in indicated PTB versus reductions in preterm
premature rupture of membranes (PPROM) or spontaneous PTB. In the Maternal-Fetal Medicine Unit
(MFMU) high-risk aspirin (HRA) study, a near significant decrease in PTB was found despite no effect on
preeclampsia. The objective of this study was to assess the impact of LDA on indicated PTB, spontaneous
PTB, and PPROM PTB in the MFMU HRA study population. Aim of the work: This study aim to assess the
efficacy of 17 alpha hydroxyl progesterone and low dose aspirin in reducing the rate of preterm birth in
pregnant women at this risk. Patients and Methods: Study type: A double blinded randomized placebo
controlled clinical trial. Study settings: This study conducted at outpatient clinic of Ain Shams University
Maternity Hospital. Time of the study: The study was held from August 2016 to November 2017.
Data was analyzed according to the intention-to-treat principle. In a total 400 women whom recruited
in the study, 160 were excluded. So we ended in to 240 women whom randomized and allocated in to 2 groups
to intervention. Primary outcome measure was preterm birth. The most important secondary outcome is a
composite of poor neonatal outcome (including bronchopulmonary dysplasia (BPD), periventricular
leucomalacia, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity (ROP), sepsis
and perinatal death).There was no statistically significant difference between both groups as regarding to age,
gravidity, parity, body mass index, mean cervical length, and number of previous preterm labor. There was no
significant difference between two groups as regard preterm premature rupture of membranes
(P.PROM).There was no significant difference between two groups as regard time of delivery there was no
significant difference between both groups in Need for NICU admission, neonatal birth weight, APGAR score,
fetal complications (RDS, jaundice, BPD, HIE, NEC, bleeding, sepsis or even neonatal death).Long term
neurodevelopmental complications was not conducted at this study as it needs more time.In maternal
complications there was no significant difference between both groups.
Conclusion: Further randomized controlled trials with larger sample size should be done to demonstrate the
efficacy of low dose Aspirin in prevention of preterm labor and its complications.
Keywords: IGF-1, IGF-2, Insulin- like growth factors 1 and 2; TVUS: Transvaginal ultrasound.

morbidity. Although most preterm babies survive,
Preterm birth: defined as any live birth
they are at increased risk of neurodevelopmental
occurring through the end of the last day of the 37th
impairments and respiratory and gastrointestinal
week (259th day) following the onset of the last
menstrual period(1).
The obstetric precursors leading to preterm
Preterm deliveries are those that occur at less
birth are: delivery for maternal or fetal indications,
than 37 weeks' gestational age; however, the low-
in which labor is either induced or the infant is
gestational age cutoff, or that used to distinguish
delivered by prelabour caesarean section.
preterm birth from spontaneous abortion, varies by
Spontaneous preterm labor with intact membranes,
location. In the USA, the preterm delivery rate is
preterm premature rupture of the membranes
12­13%; in Europe and other developed countries,
(PPROM), irrespective of whether delivery is
reported rates are generally 5­9%(2).
vaginal or by caesarean section. Preterm labor is
Preterm birth rate has risen in most
now thought to be a syndrome initiated by multiple
industrialized countries, with the USA rate
mechanisms, including: infection or inflammation,
increasing from 9·5% in 1981 to 12·7% in 2005(3).
uteroplacentalischaemia or hemorrhage, uterine
Preterm births account for 75% of perinatal
overdistension, stress and other immunologically
mortality and more than half the long-term
mediated processes(5).
Received:15 /3 /2018 DOI: 10.12816/0046145
Accepted:25 /3 /2018

Full Paper (vol.714 paper# 11)

c:\work\Jor\vol714_12 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2944-2949

Length of Left Anterior Descending (LAD) Coronary Artery in Relation
to Right & Left Dominancy: A Retrospective Computed Tomographic
(CT) Coronary Angiographic Study
Issam Tariq Abdul Wahaab1, Sherif Abou Gamra2, Fatma Magdy Mohamad Salama2, Khaleel A. Hadi3
1Department of Anatomy, Faculty of Medicine, Baghdad University
2Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University
3X-ray Institute, Medical City Directorate, Baghdad, Iraq
*Corresponding author: Issam Tariq Abdul Wahaab, E-mail:

the LAD artery supplies blood to a large part of the myocardium. However, the amount of
myocardium supplied varies depending on the length of LAD artery and as a result; occlusion at different portion
may influence perfusion of different part of myocardial.
Objective: to estimate the length of LAD artery and its possible relationship with the coronary arterial dominance
Patients and Methods: in this study we retrospectively compared 50 coronary CT angiograms of patients with left
coronary dominance with 50 coronary CT angiograms of patients with right coronary dominance
it revealed that there was a significant relationship between the length of LAD artery and the pattern of
dominancy since the P- Value appeared to be < 0.001.
Conclusion: length of LAD artery appeared to be dependent on the dominance pattern and it was taller in left
coronary dominant pattern.
Keywords: Length of LAD, Coronary dominance

Type III: LAD wrap around the apex and supplied
The arterial blood supply to the heart is achieved
the inferoapical segment.
by two coronary arteries and their branches. The

right and left coronary arteries arise from aortic
sinuses of valsalva at the beginning of ascending
To estimate the length of LAD artery and its
aorta and then descend in right and left
possible relationship to the coronary dominance
atrioventricular grooves respectively. The left
anterior descending and circumflex arteries are the

main branches of the left coronary artery whereas the
acute marginal and posterior interventricular arteries
This study was conducted in Ain-Shams hospitals
arise from the right coronary artery (1).
and other private centers in which we retrospectively
The term dominance is used to describe the
compared 50 CT coronary angiograms of patients
anatomical pattern of coronary arteries. Dominant
with left coronary dominance with 50 CT coronary
vessel is the one that supplies the posterior
angiograms of patients with right coronary
diaphragmatic portion of interventricular septum and
dominance in the period between 1st of January 2017
the diaphragmatic portion of left ventricle. So the
to 1st of January 2018.
dominant vessel refers to the coronary artery which
A sample of one hundred young adult male
gives the posterior descending artery(2).
patients, aged 40-60 years, who underwent coronary
The LAD artery supplies blood to a large part of
CT angiograms and found to have normal
the myocardium. However, the amount of
angiograms based on visual assessment of absence of
myocardium supplied varies depending on the length
any luminal irregularities, was chosen. While those
of LAD artery and as a result; occlusion at different
patients with history of renal diseases and
portion may influence perfusion of different part of
cardiomyopathies were excluded. The collected
myocardial (3).
sample was divided into two equal groups with right

and left dominance patterns.
LAD artery was categorized into three types (4):

Type I: LAD terminated before the cardiac apex.
In this study we categorize LAD artery into the
Type II: LAD reached the apex of the heart
Received:20 / 3 /2018 DOI: 10.12816/0046146
Accepted: 30/ 3 /2018

Full Paper (vol.714 paper# 12)

c:\work\Jor\vol714_13 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2950-2955

Clinical Utility of Circulating MicroRNA-21 in Breast Cancer
Hanzada Ibrahim Abdel Fattah, Nermine Helmy Mahmoud, Doaa Mostafa Elzoghby,
Mohammed Mohammed Matar, Iman Mohammed Mohammed El-Shaer
Department of Clinical Pathology, Faculty of Medicine, Ain Shams University
Corresponding author: Iman Mohammed Mohammed El-Shaer, Email:

Breast cancer remains the most frequent type of cancer in females worldwide, with nearly 1.7
million new cases diagnosed in 2012. In Egypt, breast cancer is the most common malignancy among females
accounting for 18.3% of total cancer cases in Egypt. Unfortunately, the traditional imaging techniques as well
as the currently accepted markers such as serum CEA and CA 15.3 cannot adequately identify early stage
patients. MiRNAs are a class of endogenous non-coding RNAs ~22 nucleotides in length, which regulate gene
expression primarily at the post-transcriptional level and thus are involved in many cellular processes, such as
cell proliferation, differentiation, and apoptosis. One of which is miRNA-21 and its alterations have been
shown to play critical roles in breast cancer.
Materials and Methods: This is a pilot retrospective case-control study. We quantified serum microRNA-21
expression levels using qRT-PCR in 30 breast cancer patients and another 10 controls in comparison to CA 15-
3 as a conventional marker of breast cancer used in clinical practice.
MiRNA-21 expression levels in early diagnosis of breast cancer patients with a superior both
sensitivity and specificity of 100% specially in comparison with CA 15.3 that displayed 70% sensitivity and
60% specificity.
MiRNA-21 levels are significantly higher in breast cancer patients compared to healthy subjects.
Furthermore, we found that increased miRNA-21 expression levels correlated with progression of breast
cancer stages.
Breast cancer, miRNA-21, CA15.3


miRNA-21 in serum sample has the advantages of
Breast cancer remains the most frequent type of
simple collection, less invasiveness, and easy
cancer in females worldwide, with nearly 1.7 million
monitoring (5).
new cases diagnosed in 2012. This represents about

12% of all new cancer cases and 25% of all cancers in
women (1).In Egypt, breast cancer is the most common
Study Participants
malignancy among females accounting for 18.3% of
This study was conducted on 30 female
total cancer cases in Egypt(2).
patients attending the Surgery Department and
Unfortunately, the traditional imaging techniques
Out-patient Clinics at El Demerdash Hospitals,
such as mammography and ultrasonography, as well
Ain Shams Universityduring the period from
as, the currently accepted markers such as serum CEA
August 2014 till December 2015. Patients were
and CA 15.3 cannot adequately identify early stage
classified into two groups. Group I (cancer
patients. Therefore, there is an urgent need to search
patients) which was further classified into two
for better markers with higher sensitivity to vastly
subgroups, subgroup (Ia) early stages breast
improve breast cancer diagnosis, staging and treatment
cancer (stage I and II) and subgroup (Ib)
(3).MiRNAs are a class of endogenous non-coding
advanced stages breast cancer (stage III and IV),
RNAs ~22 nucleotides in length, which regulate gene
according to TNM stage classification. While
expression primarily at the post-transcriptional level
group II included 10 apparently healthy female
and thus are involved in many cellular processes, such
subjects served as a healthy control group. All
as cell proliferation, differentiation, and apoptosis.
studied individuals were subjected to full history,
Deregulated expression of specific miRNAs that
clinical examination with special emphasis on
function as tumor suppressors or oncogenes is
breast examination and mammogram. For
associated with the pathogenesis of cancers
patients only, radiological investigations as bone
(4).MiRNA-21 is one of the oncogenic up-regulated
scan, CT scan and/or MRI as well as breastbiopsy
miRNAs and its gene is located on chromosome
were done for histopathological examination and
17q23.1. It has been found differentially expressed in
steroid receptors study.
breast cancer and normal tissues. It is significantly up-
Sample Collection and Processing
regulated in breast cancer tissues up to 10-13folds
Serum samples were collected from all
compared to the normal adjacent tissues, thus serving
participants for the assay of CA15.3.Plasma samples
as a potential marker of breast cancer. Assessment of
were collected from all participants for the assay of
Received:20 /3 /2018 DOI: 10.12816/0046147
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 13)

c:\work\Jor\vol714_14 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2956-2959

Evaluation of Outer Retinal Layers Changes before and after
Intervention in Diabetic Macular Edema
Sherif Zaki Mansour[1] ,Thanaa Mohammed Helmy [1] ,Samah Mahmoud Fawzy[1],
Radwa Reda Mohamed[2]
[1]Ophthalmology Department, Faculty of Medicine, Ain Shams University,[2]Ophthalmology Department,
Faculty of Medicine, Cairo University
Connecting author: Radwa Reda Mohamed Ibrahim, Email:,Mobile: 01007820552

Aim of the work:
this study aimed to evaluate changes in photoreceptors, inner segment/outer segment (IS/OS)
junction and external limiting membrane (ELM) following grid argon laser versus intravitreal injection of
antivgef ( Ranibizumab ) in diabetic type2 patients affected by clinically significant macular edema.
Methods: forty eyes of diabetic type2 patients who were affected by clinically significant macular edema were
randomly categorized into two groups( Group treated by argon grid laser and group treated by intravitreal
injection of antivgef for the first time) both groups were investigated for best corrected visual acuity (BCVA) and
the integrity of the photoreceptors, IS/OS and ELM as being (Continuous(+), interrupted( ±) or Absent (-) ) by
spectral-domain optical coherence tomography (SD-OCT)( CIRRUS HD-OCT) before treatment , 1month,
2months and 3months after treatment . Other variables, included central macular thickness (CMT) and central
macular volume (CMV) were evaluated. Results: significant difference was found between [photoreceptor, is/os]
(+), photorecptor, is/os (+,-) and photoreceptor, is/os (-) groups in BCVA at baseline; it was 0.61,0.73,and 1
and after 6 months it was 0.48,0.73 and 1 . Results were similar for ELM groups. Signiant difference was found
between ELM (+), ELM (+,-) and ELM (-) groups in BCVA at baseline it was 0.59,0.72,and 1 and after 6 months
it was 0.46,0.68 and 1 in lucentis group and signiant difference was found between photoreceptor, is/os (+) and
photorecptor ,is/os (+,-) groups in BCVA at baseline was(0.32and 0.3 and after 6 months it was 0.27and 0.3 .
Results were similar for ELM groups. Signiant difference was found between ELM (+) and ELM (+,-) groups in
BCVA at baseline it was 0.29 and 0.5 and after 6 months it was 0.25 and 0.4 in argon laser group
Conclusion: the more damage of outer retinal layers at the time of DME the lower visual acuity following DME
resolution and the presence of intact of these layers is an important factor in determining final visual acuity.
Keywords: diabetic macular edema, external limiting membrane, inner segment-outer segment junction, integrity
of photoreceptor layer, optical coherence tomography.
Best corrected visual acuity, CMT: Central macular thickness, CMV: Central macular volume, CSME:
Clinically significant macular edema, DR: Diabetic retinopathy, ELM: External limiting membrane, ETDRS:
Early treatment diabetic retinopathy study, IS/OS: Inner segment outer segment, ONL: Outer nuclear layer, SD-
Spectral domain optical coherence tomography, VEGF: Vascular endothelial growth factor.


Diabetic retinopathy (DR) and diabetic macular
external limiting membrane (ELM) and length of
edema(DME) are the major causes of loss of vision
the outer nuclear layer (ONL) [3-5].OCT is a non-
and blindness in diabetic patients. The pathogenesis
invasive imaging modality that produces cross-
of DME has not been fully explained since it is
sectional images with high-resolution of ocular
caused by complex pathological process with many
tissues[6]. Spectral-domain OCT (SD-OCT) yields a
contributing factors [1,2]. Because of the various
higher degree of axial resolution and provides more
clinical presentations of DME, specialized
details of intraretinal structures, the IS/OS junction
techniques such as spectral-domain optical
and ELM in particular [7].Such detailed views are
coherence tomography (SD OCT) have become an
critical, as disturbances of these layers reflect
important tool and an integral part of the diagnosis
and management of this condition with improved
visualization of retinal architecture offered by

OCT[3].Several recent studies of DME had described
new assessment modalities, including optical
coherence tomography (OCT), for microstructural
This study was conducted according to tenets of
visualization of the integrity of the inner segment-
declaration of Helsinki and received the approvals of
outer segment (IS/OS) junction, integrity of the
ethical and scientific committees of the concerned

Received:20 /3 /2018 DOI: 10.12816/0046164
Accepted30: /3 /2018

Full Paper (vol.714 paper# 14)

c:\work\Jor\vol714_15 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2960-2962

Assessment of Attitude and Perception toward Neurology and Neurosurgery
Specialties among Medical Students and Interns Attending College of Medicine at
University of Tabuk in Tabuk City, Saudi Arabia-2017
Mohammed Ahmed Alhejaili1, Mohammed Hamad Alrashedi1, Abdullah Noman Alatawi1, Meshari
Faisal Alenezi1, Khalid Awd Albalawi1, Mohammed Faisal Albalawi2
1 Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk/ KSA
2Medical resident, King Salman Armed Forces Hospital, Tabuk/ KSA
Corresponding Author: Mohammed Ahmed Alhejaili, Medical Intern, Email: ,
Telephone: +966 566669605

Although neurological and psychiatric disorders account for only 1.4% of all deaths, they
account for a remarkable 28% of all years of life lived with a disability. Thus all doctors must be prepared to
meet the needs of patients with such disorders and refer appropriately for specialized care and investigations,
bearing in mind that neurologists often function as consultants for other physicians.
Methods: We have conducted a descriptive cross-sectional study in Tabuk city population, Saudi Arabia. The
study was conducted during the period from October to December 2017. The participants who attended the
clinical years and interns at College of Medicine at University of Tabuk were included in the study. The total
sample obtained was 104. A self-administered questionnaire, about perception and knowledge about
neurological specialties, was filled by participants.
Results: The range of age was 21-26 , with a mean (SD) of 22.72 (1.837), the majority were interns (34.6%).
Nearly (31%) of them reported neurosurgery as the most difficult specialty.
: This study highlights some of the reasons and suggestions to improve and correct perception of
neurological specialties and subjects.
Keywords: neurology, neurosurgery, perceived difficulties.


grind, among other considerations. About 70 years
disorders account for only 1.4% of all deaths, they
ago, Morris B Bender rightly concluded that the
account for a remarkable 28% of all years of life
bottom up pathway in neurological education -from
lived with a disability. Thus all doctors must be
basic science to clinical problems- was becoming
prepared to meet the needs of patients with such
dysfunctional and instituted a top down approach
disorders and refer appropriately for specialized
starting with clinical signs instead, by means of
care and investigations, bearing in mind that
phenomenology seminars.
neurologists often function as consultants for other
In origin, as described by philosopher Edmund
physicians(1). A number of studies in recent years
have highlighted the difficulties medical students
appreciation of phenomena as they are immediately
have in dealing with patients with neurological
perceived, without reference to scientific theory or
prior learning(4).
It concluded that this is due, in part, to
Major problem in medical education today is the
perceptions of neurology particularly in academic
lack of integration of basic science and clinical
subject, that it is merely a diagnostic specialty, and
information into a cohesive whole.
that the teaching of the subject is not particularly
If either of these is taught in a vacuum, the
good. A study done at 2002 that surveyed medical
medical student frequently is unable to reason
students, senior house officers, and general
through clinical problems, and this can result in
practitioners about such matters, and its results
anxiety, dislike, and eventual disinterest in the
merit serious attention(3).
subject material. These negative sentiments are
It compared their knowledge of other organ
applicable to the study of neurology in medical
systems, and their knowledge of disorders of the
nervous system was the poorest. They were asked
Students perceive that the neural sciences and
about the causes of their difficulties in neurological
clinical neurology are overly complex, and many
education, they identified insufficient, poor,
of these students develop a syndrome that is called
irrelevant, or poorly coordinated teaching, and
"neurophobia" (5).
intimidation by neurology's reputation as a tough

Received:20 / 12 /2017 DOI: 10.12816/0046148
Accepted:30 /12 /2017

Full Paper (vol.714 paper# 15)

c:\work\Jor\vol714_16 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2963-2973

Role of Botulinum Toxin Type A in Management of Vocal Fold
Contact Granuloma Meta-Analysis Study
Ahmed A. Mohamed, Amr N. Rabie, Marwa M. ElBegermy, Wael A. Sobih
Department of Otorhinolaryngology,
Faculty of Medicine, Ain-Shams University
Corresponding author: Wael A Sobih; Mobile: 00201010269094; Email:

granulomas of the vocal process of the larynx are benign lesions of the posterior glottis generally
centered over the tips of the cartilaginous vocal processes. Clinically they are associated with odynophagia,
throat clearing, globus, and otalgia.
Aim of the Work: this meta-analysis study aimed to know the role of botulinum toxin type A in management of
vocal fold contact granuloma.
Materials and Methods: this study strictly followed the recommendation of referred reporting items for
systematic reviews and meta-analyses (PRISMA) statement. It was done in the following steps: target
determination, identification the location of articles, screening and evaluation, data collection, data analysis and
finally reporting and interpretation. Results: there was acceptable complete response rate of contact granuloma
to botulinum toxin injection with event rate of 85.422% while rate of improvement among selected cases was
92.962%. Concerning to complications the most common complication was hoarsness of voice with rate of
52.737% while dysphagia was 21.125% among cases. Conclusion: botulinum toxin is a safe and effective
therapy in resolving vocal process granulomas. Complete response and partial response are significant in our
study also decreased Valsalva effort, failure rate and relapse rate are all significant outcomes. While temporary
post injection hoarsness of voice, dysphagia, local pain at injection sites and fluid aspiration considered non
significant outcomes.
Keywords: botulinum toxin type A, vocal fold contact granuloma.


Vocal fold granulomas (VFGs) are areas of
allows for the best possible patient care (4).
chronic inflammation, usually located near the
Botulinum toxin, one of the most poisonous
vocal process of the arytenoids caused by a variety
biological substances known, which is a neurotoxin
of conditions such as intubation, gastroesophageal
bacterium Clostridium
reflux disease, and vocal abuse (1). Management of
botulinum. C.
Botulinum elaborates
VFGs remains a controversial topic for the
antigenically distinguishable exotoxins (A, B, C1,
laryngologist and head& neck surgeon. Their
C2, D, E, F and G).
etiology varies, treatment is difficult, and there is a
All serotypes interfere with neural
high recurrence rate. They were first described as
transmission by blocking the release of
"contact ulcers" in 1928 by Jackson (2) who
acetylcholine, the principal neurotransmitter at the
reported a superficial ulceration along the posterior
neuromuscular junction, causing muscle paralysis.
aspect of the larynx. At that time their etiology was
The weakness induced by injection with botulinum
thought to be voice abuse. Further application of
toxin A usually lasts about three months. Botulinum
endotracheal anesthesia led to a theory that VFGs
toxins now play a very significant role in the
can be a result of trauma secondary to prolonged
management of a wide variety of medical
intubation. Since then, several other factors have
conditions, especially strabismus and focal
been implicated in their etiology including voice
dystonias, hemifacial spasm, and various spastic
abuse and gastroesophageal reflux disease (GERD).
movement disorders, headaches, hypersalivation,
Although these lesions are rare, recurrence rates of
hyperhidrosis, and some chronic conditions that
up to 90% have proven their management to be
respond only partially to medical treatment (5).
challenging (3). The ENT surgeon is often the first
In 1995, Nasri et al. (6) introduced a new
specialist consulted by a patient with a voice
therapy in the treatment of laryngeal granulomas,
disorder. More than half of these patients will have
Botulinum toxin type A was injected into one or
benign vocal fold changes and their treatment is
both vocal folds to induce temporary vocal fold
often a combination of conservative and
paresis allowing resolution of granulomas. The
interventional measures. To this end, ENT surgeons
injectable sites are thyroarytenoid muscle, lateral
with an interest in voice disorders rarely work
cricoarytenoid muscle, interarytenoid Muscle and
alone, and a multidisciplinary team consisting of,
aryepiglottic muscle. The success of this therapy
amongst others, speech and language therapists
was confirmed by Orloff et al. (7) who noted
Received:21/ 3 /2018 DOI: 10.12816/0046149
Accepted: 30/ 3 /2018

Full Paper (vol.714 paper# 16)

c:\work\Jor\vol714_17 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2974-2981
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:

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.
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 is
applied to a wide variety of clinical conditions,
the cornerstone of diagnosis. However, clinical
including Stress urinary incontinence (SUI), pelvic
examination is limited in several ways: (a) it can lead
organ prolapse (POP), defecatory dysfunction,
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 chronic
evacuation disorders; and (c) it cannot detect a
pain syndromes. The first three are the most common
peritoneocele, a finding that indicates the need for
clinical conditions (1).
abdominal rather than vaginal surgery (4).
Whereas exact mechanisms are subject to
Several imaging techniques may be used as adjuncts
debate, risk factors include age, multiparity,
to physical examination. Traditional imaging
complicated vaginal deliveries, obesity, collagen-
procedures (e.g., urodynamic study, voiding
related disorders, hysterectomy, and menopause.
Possible causes include injury to the pelvic floor from
cystocolpodefecography) remain practical and cost-
surgery or childbirth, denervation of the musculature,
effective methods for evaluating uncomplicated
fascial defects, and abnormal synthesis or degradation
anorectal and pelvic dysfunction (5).
of collagen (2).
Magnetic resonance (MR) imaging of the
It has been attributed both to damage to the
pelvic floor is a two-step process that includes
levator ani muscle and to an endopelvic fascial defect,
analysis of anatomic damage on axial fast spin-echo
however, some believe that it is still unclear which of
(FSE) T2-weighted images and functional evaluation
these factors is more responsible. Similarly, SUI has
using sagittal dynamic single-shot T2-weighted
been attributed to urethral hypermobility, to unequal
sequences during straining and defecation (4).
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 anatomic lesion involved (3).
This study is a diagnostic prospective study which
Evaluation of women with pelvic floor failure
was carried out in the Department of Radio-diagnosis
requires a comprehensive approach that includes
at Ain Shams University Hospital from August 2017
clinical assessment, physiologic testing, and
to February 2018. Twenty women with pelvic organ
counseling about conservative versus surgical
prolapse / stress urinary incontinence and/or
Received:5 / 3 /2018 DOI: 10.12816/0046150
Accepted:15 /3 /2018

Full Paper (vol.714 paper# 17)

c:\work\Jor\vol714_18 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2982-2988

Maternal Obesity and Its Effect in Late Pregnancy and Labour
Hossam Aldin H. Kamel, Abdel Sattar M. Ibrahim, Mahmoud M. Abdo*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Mahmoud M. Abdo, E-mail:,
Tel: 00201062762361
In recent years, obesity has become a major public health problem and its prevalence is
increasing at an alarming pace. Moreover, this problem has affected children and adolescents in marked
fashion with a higher prevalence in females than in males.
Objective: To evaluate the effect of maternal obesity on length of gestation and mode of delivery and
subsequent intrapartum and neonatal complications.
Methods: This prospective cohort study involved a total no. of 600 women with singleton pregnancies
delivered in the period between December 2011 and July 2012 and were categorized into three groups
according to their BMI; normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2) and obese (30
kg/m2). The main outcome measures were length of gestation, mode of delivery, risk of delivery and neonatal
complications in overweight and obese women versus normal weight women. Results: Obese women had a
significantly increased risk of post-term pregnancy and higher rate of induction ending in caesarean section
compared with women of normal weight. Again, there was a significantly longer median length of first stage,
increased incidence of second-degree tear and significantly increased risk of low Apgar score. However, the
incidence of postpartum haemorrhage and third-degree tear were similar in all body mass index categories. As
regard shoulder dystocia, there was a trend towards increased incidence with increasing BMI for primiparous
women but just failed to reach significance (P=0.05). There was a trend towards increased incidence of
macrosomia with increasing BMI category (P=0.074) this trend was significantly true for primiparous women
(P=0.047), but no trend was observed for analysis restricted to multiparous women.
Increasing BMI is associated with increased incidence of post-term pregnancy, failed progress of
labour, labour induction, CS delivery, low Apgar score and macrosomic babies.
Keywords: BMI, post-term pregnancy, obesity, complications, macrosomia.


Obesity is a condition in which excess body
that one in five women at antenatal booking are
fat has accumulated to an extent that health may be
obese (5). Many studies have demonstrated that
negatively affected. Obesity is commonly defined
obesity in pregnancy is associated with a wide
as a body mass index (BMI) of 30 kg/m2 or higher.
spectrum of adverse pregnancy outcomes including
Obesity, in absolute terms, is an increase of body
increased caesarean section rates, postpartum
adipose (fat tissue) mass and, in a practical setting,
this is difficult to be determined directly. Therefore,
hypertension, gestational diabetes and fetal death
the common clinical methods used to estimate
(6). Obesity in pregnancy has also been shown to be
obesity are by body mass index (BMI) and in terms
associated with longer gestation (7) and significantly
of its distribution via the waist­hip ratio (1) .
increased risk of post-term delivery (8), which
Obesity has been recognized by WHO as "a
contributes to the greater need for induction of
pandemic nutritional disorder which represents a
labour (IOL) for prolonged pregnancy (9).
rapidly growing threat to the health of populations
As gestation progresses beyond term, perinatal
of an increasing number of countries world- wide"
morbidity and mortality increase as well as
(2). Adults with BMI (calculated as weight in kg.
maternal complications such as pre-eclampsia,
divided by height in meters squared) between 25-
postpartum haemorrhage and caesarean delivery
30kg/m2 are considered overweight and those with
(10). Women with high body mass index (BMI) and
BMI 30 are considered obese (1).
prolonged pregnancy are therefore becoming an
The prevalence of obesity has risen such
that it is now a worldwide epidemic(3).
Management of prolonged pregnancies in obese
As obesity increases, so does the number of
women, however, is difficult because IOL is
women of reproductive age who are overweight and
associated with a high risk of caesarean section and
obese. This is having deleterious effects on female
reproduction in general and a major impact on
haemorrhage and thrombosis whereas conservative
maternity services (4). In UK, it is now estimated
management is associated with an increased risk of

perinatal mortality.
Received:18 /2 /2018 DOI: 10.12816/0046151
Accepted:10 /3 /2018

Full Paper (vol.714 paper# 18)

Background: The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2989-2995

Sildenafil Citrate and Uteroplacental Perfusion in Fetal Growth Restriction
Amr Hasan El-Shalakany, Mohamed Mahmoud Abd El Aleem,
Mohamed Zaifer Ali Bawady
Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University
*Corresponding author: Mohamed Zaifer Ali Bawady. Email: Mobile: 01272794654

Severe early-onset fetal growth restriction can lead to a range of adverse outcomes including
fetal or neonatal death, neurodisability, and lifelong risks to the health of the affected child. Sildenafil, a
phosphodiesterase type 5 inhibitor, potentiates the actions of nitric oxide, which leads to vasodilatation of the
uterine vessels and might improve fetal growth in utero.
Objective: To evaluate effectiveness and safety of Sildenafil citrate for treatment of intrauterine growth
restriction (IUGR). Design: A prospective randomized control study.
Setting: At Ain shams University hospital and Kafr Aldwwar main Hospital in El-Beheria governorate.
Subjects: Eighty pregnant women with gestational age between 24 and 34 weeks having singleton pregnancy
and suffering from IUGR attending an antenatal clinic.
Methods: Eighty pregnant women with FGR and abnormal umbilical artery Doppler between 24and34 weeks
were randomly allocated to sildenafil (n= 40) 25mg tid or placebo (n=40) with a plenty of fluids until delivery.
Main outcome measure: Length of pregnancy, neonatal weight and ICU admission.
Results: Sildenafil treatment was associated with a significant increase in length of pregnancy (P> 0.05) and a
significant increase in estimated fetal weight by ultrasound (P<0.05), and was associated with a significant
decrease in neonatal ICU admission (P=0.218) and neonatal mortality (P=0.290).
Conclusion: Sildenafil citrate can improve utero-placental perfusion and length of pregnancy in pregnancies
complicated by IUGR. It appears to have a significantly positive effect on fetal weight. Sildenafil treatment
may offer a new opportunity to improve perinatal outcomes, for pregnancies complicated by IUGR. However
these observations require further studies on wide scale.
Keywords: Sildenafil Citrate, Uteroplacental Perfusion, Fetal Growth Restriction.


Intrauterine growth restriction (IUGR) is a fetal
small fetuses with a good prognosis [7] Therefore, all
weight that is below the10th percentile for
Doppler indices of the umbilical artery can be used to
gestational age as determined by ultrasound. This
distinguish between the high-risk small fetus that is
can also be called small for gestational age (SGA)
truly growth-restricted and the lower-risk small fetus
or fetal growth Restriction (FGR)[1] , while
Samangaya et al. [2] defined FGR as one or more of
Several new vasodilator drugs have recently been
the following: fetal abdominal circumference <5th
suggested to augment blood flow to tissues, one of
percentile. Amniotic fluid index < 5th percentile or
these drugs is sildenafil citrate (Viagra) [9].
Doppler umbilical artery pulsatility index > 95th
Sildenafil citrate is a selective inhibitor of cyclic
percentile for gestational age. It affects up to 7-8%
guanosine monophosphate (cGMP) formation
of all pregnancies [3, 4]. Fetal growth restriction
through inhibition of type 5phosphodiesterase
(FGR) complicates 7-15% of pregnant women and
(PDE5) [9]. It increases uterine blood flow and
in its early and severs form the risk of perinatal
potentiates estrogen-induced vasodilatation [10].
morbidity and mortality is increased [5].
Several studies postulated that Sildenafil citrate may
Causes of FGR are classified to fetal factor as:
offer a potential therapeutic strategy to improve
chromosomal abnormalities, multiple pregnancies,
utero placental blood flow in FGR pregnancies [11. 12
fetal structural anomalies and fetal infections.
Maternal factors as: hypertension anemia, diabetes

mellitus, chronic lung diseases and heart. Placental
factor as: Chorioangioma, infarction, circumvallate
The aim of this study is to asses the efficacy of
placenta, confined placental mosaicism, obliterative
sildenafil citrate therapy in prolonging pregnancy in
vasculopathy of placental bed [6].
women with fetal growth restriction.
Umbilical artery Doppler has been the mainstay for

diagnosing placental insufficiency for 2 decades.
Research hypothesis
Consequently, fetuses with normal UA Doppler,
Sildenafil citrate may prolong pregnancy in women
normally defined as small for gestational age (SGA),
with fetal growth restriction and abnormal umbilical
have long been considered to be constitutionally
artery Doppler.
Received:20 / 3 /2018 DOI: 10.12816/0046152
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 19)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 2996-3000

Recent Management of Abdominal Aortic Aneurysm
Hossam ElDin Hassan El Azzazy, Haitham Mostafa Elmaleh,
Mohamed Ismail Mohamed, Mahmoud Ahmed Adel El-Said
Department of General Surgery, Faculty of Medicine, Ain Shams University
Corresponding author: Mahmoud A. Adel El-Said, Mobile: 01007848418;
Abdominal Aortic Aneurysms had always been one of the most serious causes of mortality in the
past decades until recently. Thanks to the modern advances in medicine and the technological revolution in
Imaging and endograft Industry, treatment of Abdominal Aortic Aneurysms no longer imposes that high
mortality risk it previously had. Objective: This study aims to review currently available evidence aiming at
designing an approach for the management abdominal aortic aneurysm.
Subjects and Methods:
We are planning to search Medline, Plumbed, Cochrane databases using the keywords:
"management", " abdominal", " aortic", " aneurysm". Any studies published in English with subjects with
surgical and endovascular management of abdominal aortic aneurysm will be included up to 1/3/2017. Results:
The present systematic review confirmed this belief. EVAR patients had a significantly lower 30-day mortality,
shorter hospital and ICU stay, less blood loss or blood transfusion requirement, fewer postoperative cardiac and
respiratory morbidities, less colonic ischaemia, and fewer overall postoperative problems compared to open
repaired aneurysm patients.
Open surgical repair - Abdominal aortic aneurysms - Endovascular aortic aneurysm repair - CT

EVAR (Endovascular Abdominal Aortic
Abdominal Aortic Aneurysms had always
Aneurysm Repair) is now a commonly available
been one of the most serious causes of mortality in
option for a growing population of patients requiring
the past decades until recently.
treatment for AAAs. Some advantages of EVAR
Thanks to the modern advances in medicine
over traditional open surgery include shorter hospital
and the technological revolution in Imaging and
stays, fewer postoperative complications, and greatly
endograft Industry, treatment of Abdominal Aortic
reduced recovery time; the treatment technique may
Aneurysms no longer imposes that high mortality
also result in less operative blood loss (1). New
risk it previously had (1).
devices with fenestrations and branches have
Four randomized controlled trials have now
increased the number of patients who are good
been published comparing EVAR with open surgical
candidates for EVAR, reducing the population of
repair (OSR); the UK EVAR 1 Trial (2), the Dutch
individuals who would otherwise be resigned to
DREAM Trial (3), the US OVER Trial (4) and the
"watchful waiting" for their aneurysms. Recent
French ACE Trial (5).
research now demonstrates that EVAR offers
Patients at greatest risk for Abdominal
reduced mortality rates compared with open repair
Aortic Aneurysm (AAA) are men who are older than
(1). Aneurysms are defined as focal dilatations at
65 years and have peripheral atherosclerotic vascular
least 50% larger than the expected normal arterial
disease. A history of smoking often is elicited.
diameter. A practical working definition of an
Accordingly, in 2005, the US Preventive Services
abdominal aortic aneurysm (AAA) is a transverse
diameter of 3 cm or greater, and for a common iliac
Ultrasonography screening in men aged 65-75 years
aneurysm, a transverse diameter greater than 1.8 cm,
who had ever smoked. As of June 2014, these
based on average values for normal individuals (8).
recommendations were being updated on the basis of
The relationship of atherosclerosis to
evidence from a 2014 study (6).
aneurysm formation is complex, but it is clear that
Not all patients with an AAA are suitable for
both aneurysms and obstructive manifestations are
endovascular repair. The most common reasons to
often found in the same patient, whereas either the
reject a patient based on anatomical configurations
aneurysmal or obstructive manifestation is
include Visceral and renal supply, diameter of the
predominant in others. Specific factors associated
proximal neck, angulation and conical nature of the
with degenerative aneurysms include the presence of
proximal neck as well as calcification and mural
metalloproteinases in the media of aneurysm
thrombosis in it (7).
specimens. In addition, there is evidence for a deficit
Received:7 /3 /2018 DOI: 10.12816/0046153
Accepted:17 /3 /2018

Full Paper (vol.714 paper# 20)

c:\work\Jor\vol714_21 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3001-3006

Role of MRI Diffusion Tensor Imaging in Assessment of Normal Appearing White
Matter in Cases of Multiple Sclerosis
Hanaa Abdel Kader Abdel Hameed, Samer Malak Botros,
Emad Hamid Abdel Dayem, Tarek Hamed Gomaa
Department of Radiodiagnosis, Ain Shams University, Cairo, Egypt
*Corresponding Author: Tarek Hamed Gomaa, Email:, Tel. 01062229712

Multiple sclerosis (MS) is an inflammatory demyelinating condition of the central nervous system
(CNS) that is generally considered to be autoimmune in nature. White matter tracts are affected, including those of
the cerebral hemispheres, infratentorium, and spinal cord. Several methods have been proposed, mainly using
conventional MR modalities like T1, FLAIR or T2 images and enhanced MRI to delineate lesions. Conventional
MR techniques cannot give detailed information about the integrity and location of WM tracts. Diffusion MRI is
one of the non-conventional MRI techniques used for assessment of multiple sclerosis. The emergence of diffusion
tensor imaging (DTI) is of great interest in MS. DTI probe the details of water diffusion within tissues, and could
therefore reveal alterations in normal appearing white matter fibers before being visible in conventional MRI.
Fractional anisotropy (FA), is the measure of the portion of the diffusion tensor that results from anisotropy (i.e, a
measure of the directionality of the molecular motion of water).
Purpose: to evaluate the role of diffusion tensor imaging (DTI) in the examination of the brain white matter that
shows normal appearance on conventional MRI sequences in patients with MS, thus assessing its ability to detect
early abnormalities at diffusion level. Methods: the study included 50 patients; 38 females and 12 males having
MS (between 20 and 40 years of age) referred from Neurologists to Radiodiagnosis Department with 10 ages'
matched healthy control volunteers. Each patient included in the study was subjected to full history taking,
reviewing medical sheet and MR examination including: Conventional MR examination and Diffusion Tensor
imaging. Technique was performed using a standard 3 Tesla unit (Acheiva, Philips).
Results: the study showed that DTI can reveal normal appearing white matter affection in MS cases before visible
sizable plaques can be detected by conventional MRI.
Conclusion: the current application of diffusion MRI to patients with MS shows that it has enhanced our
understanding of the disease pathophysiology. The study reviewed here provides evidence that DTI-derived
measures are more specific to the disease pathological processes and sensitive to the diffuse microscopic injury in
the NAWM.
Keywords: Multiple sclerosis ­ MRI ­ Diffusion tensor imaging.

of WM tracts. Enhanced MRI is reported as the most
Multiple sclerosis (MS) is an inflammatory
sensitive measure of short-term MS activity and is
demyelinating condition of the central nervous
widely used to monitor disease evolution, either
system (CNS) that is generally considered to be
natural or modified by treatment (2).
autoimmune in nature. White matter tracts are
Trials have shown that an early diagnosis
affected, including those of the cerebral hemi-
can make a big difference to the efficacy of MS drug
spheres, infratentorium, and spinal cord. MS lesions,
treatments. Non conventional MR techniques are
known as plaques, may be detected anywhere in the
becoming important in preclinical and clinical trials
white matter with resulting diverse clinical
as companies move forward in developing disease
presentations. Continuing lesion formation in MS
modifying drugs (DMDs) (3).
often leads to physical disability and, sometimes,
Diffusion MRI is one of the non-
cognitive decline (1).
conventional MRI techniques used for assessment of
Several methods have been proposed,
multiple sclerosis. The potential of diffusion MRI is
mainly using conventional MR modalities like T1,
based on the fact that, while diffusing, water
FLAIR or T2 images and enhanced MRI to delineate
molecules probe tissue structures at a microscopic
lesions. Conventional MR techniques cannot give
scale (4).
detailed information about the integrity and location

Received:20 /3 /2018 DOI: 10.12816/0046154
Accepted30: / 3 /2018

Full Paper (vol.714 paper# 21)

Introduction & Aim of the work The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3007-3016

Measurement of Uterine Leiomyomata Volume Pre and Post Uterine Artery
Embolization Aided by MRI
Tamara M. Abdullah, Samer M. Botros, Wafaa R. Aly
Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University
Corresponding author: Tamara M Abdullah, Mobile: 01011569494; Email:

uterine fibroid embolization (UFE) is now evolving to be the first-line treatment for
symptomatic uterine leiomyomata alongside the conventional surgical treatment of hysterectomy and
myomectomy. Cochrane review comprises six RCTs comparing UAE versus hysterectomy or myomectomy for
management of symptomatic leiomyomata where UFE had similar short and midterm outcomes, inclusive of
symptomatic relief, quality of life and patient satisfaction, while benefiting from uterine preservation, shorter
hospital stay and a faster recovery before resuming ordinary life activities. These benefits are in line with the
minimally invasive nature of the embolization procedures. Aim of the Work: t this study aimed to review and
illustrate the role of MR imaging in the pre- and post-procedural assessment for uterine fibroid patients
undergoing uterine artery embolization. Patients and Methods: the current study was carried out in
Radiodiagnosis Department, Faculty of Medicine, Ain shams University and specialized private radiology
centers during the period between April 2017 and December 2017. It included 30 patients that were referred
from gynecology clinic with their ultrasonographic reports to Radiodiagnosis Department, body imaging unit
with a view to carry-out pelvic MRI with contrast. Results: imaging follow-up via pelvic MRI with contrast
was obtained in 30 patients at 3, 6 months after treatment. The mean uterine volume was reduced by 25%
(standard deviation was SD 0.03763) 3 months after treatment and was further reduced by a mean of 30% (SD
0.02638) by six months after treatment. Post-procedural subtraction MRI revealed mean myoma enhancement
to be 5.6 + 0.5 SI in contrast to 133.4 + 18.3 SI prior to UFE. The mean dominant fibroid volume reduced by
34 % (SD 0.09247) after 3 months, 44 % (SD 0.05994) after 6 months. A cumulative reduction in both uterine
and dominant leiomyoma mean volume from baseline to 6 months post ­ UAE was evident with significant
interval changes between 3, 6 months follow up (p 0.000) Conclusion: the MRI findings following UAE vary
with the interval from embolization and success of the procedure. MRI with its multiplanar capabilities was
typically employed to evaluate the uterus following UAE for fibroid infarction, size reduction, location change,
persistent enhancement, fibroid recurrence, changes in adenomyosis, and unexpected complications that may
require surgical intervention or identify women who would benefit from repeated UAE. Recommendations:
further studies on a larger scale of patients are needed to confirm the results obtained by this work.
Keywords: uterine leiomyomata volume, uterine artery embolization, MRI.

potential treatment option in 1995 and has since
been proven to be an efficacious and safe method
leiomyomata traditionally encompasses diverse
with a relatively high success rate in minimizing
treatments ranging from medical treatment up to
pain, bulk symptoms and bleeding linked to uterine
invasive hysterectomy (1). Symptomatic fibroids
fibroids. UAE is increasingly being preferred over
used to be treated with hysterectomy whenever
surgical hysterectomy or myomectomy due to
having unsatisfactory outcome with medical
reduced morbidity, shorter hospitalization, and
treatments. Hysterectomy is an invasive procedure
relative uterine preservation when compared to
that is associated with significant morbidities, 10-
surgical resolution (6).
15% complication rates as well as lengthy hospital
Leiomyomas are hyper vascular benign lesions
stay and prolonged recovery time (2).
with large vessels furnishing higher vascular flow
Patient's desire to preserve their uterus has
relative to the normal myometrial vasculature. This
prompted the development of uterus sparing
permits preferential targeting and occlusion of end
arterial branches that perfuse leiomyomas during
myomectomies (3). Presence of multiple fibroids
the delivery of the particulate embolization agent
with variable sizes, locations, adding to associated
used during UAE. Embolization of these end
pain, high post-operative morbidity as well as
arterial branches ultimately results in infarction,
symptoms recurrence (25% of patients] have made
coagulative necrosis, and eventual shrinkage of the
myomectomy not feasible in all circumstances (4).
targeted leiomyomas (7). Owing to higher accuracy
Uterine artery embolization (UAE) is a minimally
in assessing the size, number and location of
invasive treatment alternative for management of
uterine leiomyomas, Magnetic resonance imaging
symptomatic myomas (5). It was first reported as a
(MRI) is the preferable method over transvaginal
Received:20 /3 /2018 DOI: 10.12816/0046155
Accepted:30 / 3 /2018

Full Paper (vol.714 paper# 22)

INTRODUCTION The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3017-3024

The Effect of Endometrial Injury by Office Hysteroscopy on The
Outcome of Intrauterine Insemination
Abd Almonem M Zakaria, Amro E Abo El-Ezz, Amr M Elbanawany
obstetrics and Gynecologydepartment, Faculty of Medicine-Al Azhar University
Corresponding author: Amr M Elbanawany; Mobile: 01091094000: Email:

Evaluating the uterine cavity is a basic step in investigating infertile women. Both the
condition of the endometrium as well as the uterine cavity are thought to be important factors in determining
receptivity for embryo implantation. Aim of the Work: In our study we conducted a trial to assess the effect
of endometrial injury by hysteroscopy in the outcome of intrauterine insemination (IUI).
Patients and Methods:
This interventional prospective randomized controlled clinical trial was conducted at
ElSayed Galal University Hospital during the period from January 2016 to October 201
7. The study comprised 200 of women diagnosed as unexplained infertility or with mild male factor.
Results: The biochemical and clinical pregnancy rates were higher in women of group I when compared to
women of group II [28 (28%) vs. 8 (8%), p=0.012 and 25 (25%) vs. 4 (4%), p= 0.034, respectively.
Conclusion: Performing endometrial scratch using hysteroscopy in the preceding cycle of intra uterine
insemination is a simple cheap maneuver that improves the chemical and clinical pregnancy outcome.
Keywords: endometrial injury, hysteroscopy, intrauterine insemination.


Intra uterine insemination (IUI), together
rate of IVF-ET which may be effective in IUI
with ovarian stimulation, is a less expensive and
cycles too. First, local injury to the endometrium
invasive treatment in comparison with other
might induce the decidualization of the
assisted reproductive technique (ART) , and has
endometrium and increase its implantation rate.
been widely used for the treatment of infertile
Loeb reported that scratching guinea-pig uteruses
couples with a variety of indications, such as non-
provoked the rapid growth of the endometrial cells
severe male factor infertility, unexplained
which are similar to the decidual cells of
infertility, cervical mucus hostility and ovulatory
pregnancy (5).
disturbances . Ovarian stimulation with exogenous
Second, local injury to the endometrium
gonadotropins, combined with intrauterine
might provoke the wound healing process,
insemination (IUI), is a valid treatment for
involving a massive secretion of different
infertility. Its effectiveness in terms of pregnancy
cytokines and growth factors, including leukemia
rate is 10­14% per cycle reaching cumulative
inhibitory factor, interleukin-11, and heparin-
values of 40­90% after 3­10 treatment cycles (1).
banding endothelial growth factor, which are
An important cause of infertility would
beneficial for embryo implantation (5). The last
be a failure of uterine receptivity and failure of
and the most possible mechanism is COH
implantation. Implantation divided into four steps:
performed during IVF therapy that may negatively
apposition, adhesion, attachment and invasion (2).
affect the embryo implantation (6).
The mid-secretory phase of the menstrual cycle
A recent Cochrane review found that we
(days 19­23), is the most receptive period of the
can improve the endometrial receptivity by
endometrium which is called the window of
scratching the endometrium by any mean such as
implantation (WOI) (3).
curette or biopsy (7).
Endometrial scratching is a simple,

Hysteroscopy is the gold standard
minimally invasive, low-cost procedure that may
procedure for uterine cavity exploration through
boost biochemical and clinical pregnancy rates in
direct visualization in patients with recurrent
women with infertility. The questions regarding
implantation failure. However, the World Health
the underlying mechanism of the procedure action
Organization (WHO) recommends HSG alone for
remain unanswered; however some hypotheses
the management of infertile women. Office
have been made to explain its beneficial effect. It
hysteroscopy (OH) is only recommended by the
was hypothesized that the local injury to the
WHO when clinical or complementary exams
endometrium in a cycle might induce proper
decidualization for implantation competency (4).
abnormality or after in vitro fertilization (IVF)
There are three possible mechanisms by
failure (8).
which endometrial sampling may increase the
Hysteroscopy is known as the most
receptivity and improve the clinical pregnancy
accurate test for diagnosing intrauterine pathology
Received:20 /3 /2018 DOI: 10.12816/0046156
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 23)

Evaluation of Right Ventricle Function after Tetralogy of Fallot Repair (TA Patch technique versus RA-PA approach) The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3025-3031
Topographic Changes in Keratoconic Patients after
Transepithelial (Epi-On) Collagen Cross-Linking
Mohamed Abdel Monem Mahdy, Ahmed Nabil El Sayed Hafiz, Mahmoud Ali Kotb Koritenah
Department of Ophthalmology, Faculty of Medicine Al-Azhar University, Cairo, Egypt
Corresponding author: Mahmoud Ali Kotb Koritenah, E-Mail:, Mobile: 01003922664

To evaluate corneal changes as measured by Pentacam before and after transepithelial corneal
collagen cross-linking in cases of Keratoconus.
Study design: A prospective consecutive case series study carried out at a private lasik centre
Patients and Methods: 74 eyes of 50 patients with progressive keratoconus underwent transepithelial (Epi-on)
CXL using both ParaCelTM and vibeX-Xtra. Baseline examination included: full ocular examination,
uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), corneal topography using PentacamTM to
determine; flat corneal curvature (K1), steep corneal curvature (K2), mean corneal curvature (Km), corneal
astigmatism, corneal thickness at the thinnest location and posterior surface elevation at the highest point in the
central 5 mm. The follow-up visits were scheduled on 3 and 6 months after treatment by checking the BCVA,
Results: Our results showed an improvements in BCVA at the end of the 6th month post operative that showed an
increase from 0.48 to 0.54 and this was statistically significant (P value 0.007) (<0.01), Pentacam topographic
changes were found to be decreased postoperatively and were found to be statistically insignificant.
In this study, with a follow-up for 6 months, we found the transepithelial corneal collagen cross-
linking is beneficial and safe for patients with keratoconus. Transepithelial CXL treatment appeared to halt
keratoconus progression, with a statistically significant improvement in visual acuity by stabilizing or partially
reversing the keratectasia process.
Cornea, KC, CXL, Pantacam

The other method is the "epi-on" or the
Keratoconus is a usually bilateral non
transepithelial technique which involves application
inflammatory progressive corneal thinning that is
of two of riboflavin formulations on the surface of
often of unknown etiology and is characterized by
the cornea followed by exposing the eye to the UV
light for 10 minutes.
biomechanical strength of cornea and stromal
Transepithelial crosslinking in which the
thinning which results in irregular astigmatism and
epithelium is not removed has been proposed to
progressive myopia and this eventually leads to a
offer a number of advantages over traditional
decrease in visual acuity (1).
crosslinking including an increased safety profile
Its incidence in the general population is
by reducing the risk for infection as no epithelial
reported to be approximately one in 2000 (2).
barrier will be broken, faster visual recovery and
Current mainstream therapy is the use of
improved patient comfort in the early postoperative
spectacles and rigid contact lenses, intrastromal
healing period.
corneal rings, with penetrating keratoplasty (PKP)
Recently, evidences had shown that
reserved for advanced cases or contact lens
collagen cross-linking (CXL) with riboflavin drops
intolerance (3). Seeking for a way to halt this
increases the biomechanical strength and stability
progressive disease seems to be of crucial
of the cornea (5).
importance, corneal collagen cross-linking (CXL,
Pentacam imaging is considered among the
X-linking)) is a recently introduced treatment for
most prevalent modalities in the diagnosis, staging,
addressing progressive keratoconus. Cross-linking
and follow-up of keratoconus patients. It is based
is a low-invasive procedure designed to strengthen
on a rotating camera and a monochromatic slit-light
the corneal structure and stop the progression of
source, which rotate together. In addition to
keratoconus (4).
pachymetry and topographic imaging, pentacam
Two methods for the cross-linking are
devices provide elevation maps of the anterior and
used; the "epi-off" technique which involves
the posterior corneal surfaces (6).
removal of the central 7mm diameter area of the
Our aim of this study is to evaluate corneal changes
corneal epithelium followed by application of
as measured by Pentacam before and after
riboflavin 0.1% solution for a total of 30 minutes.
Received:20 / 3 /2018 DOI: 10.12816/0046157
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 24)

c:\work\Jor\vol714_25 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3032-3038

Comparison between Rubber Band and Ethelon Suture as
A Cutting Seton in Perianal Fistula
Ahmed Medhat Ahmed Mokhtar Mehanna
General Surgery, Faculty of Medicine, Ain Shams University
Corresponding author: Ahmed Medhat Ahmed Mokhtar Mehanna E-mail:, Telephone:

fistula-in-ano is a commonly encountered surgical problem. There is a risk of sphincter muscle
damage during fistulectomy. Seton suture is used to decrease this risk. Different types of Setons are used for this
Aim: to compare 2 types of cutting Seton as regard Postoperative pain, duration until Seton cut through, post
operative faecal incontinence and recurrence.
Methods: this study was conducted on 80 patients in 2 groups with high perianal fistula or low perianal fistula
associate with abscess cavity. Patients with inflammatory bowel disease, history of malignancy, and previous recto-
anal operations were excluded from this study. One group with insertion of sterilized rubber band and silk suture
was applied at the anal verge the other with Ethilon sutures. Follow up and tightening of the seton done as
Results: about half (46.25%) had low perianal fistulas with abscess cavity, and 53.75% had high perianal fistulas.
Group (A) patients had 10% wound infection and group (B) had 5%, all responded to conservative management.
The mean VAS score of the patients on the 1st day was (3.7±1.14), and (2.85±0.92) and on the 7th day was
(1.28±0.85) and (0.88±0.88) respectively. Seton fell down after a mean time (26.35 days ± 5.12 days) in group (A)
and (27.65 days ± 6.84 days) in group (B). Complete healing was achieved in 77.5% of group (A) and in 60 % of
group (B) after 1 month and 40 patients (100%) in both groups at 3 months. 7.5% of recurrence in group (A) and
2.5% case of recurrence in group (B).
Conclusion: rubber band Seton is easy and cheap and provide slow and steady cutting of the sphincter maintaining
Keywords: Seton; Cutting Seton; Rubber band Seton

ligation of the intersphincteric fistula tract (LIFT)(8),
Fistula-in-ano is one of the commonly
fistulotomy with reconstruction of the sphincter
encountered surgical problems with prevalence of 1.2
mechanism (9), or fibrin glue (10).
to 2.8/10,000 in some European countries (1).
The oldest and theoretically the simplest
As simple, low anal fistulas can be treated
technique is to use a Seton, the well-known variations
safely only by fistulotomy, the management of
in modern surgical practice being cutting Setons,
complex fistulas needs to balance the outcomes of
drainage Setons, and two stage Seton fistulotomy (11).
cure and continence.
The long-term loose draining Seton, while not placing
There is a risk of sphincter muscle damage
the sphincter at risk, is simply palliative with only
during fistulotomy, and this might lead to an
marginal rates of complete healing (12).
unacceptable risk of anal incontinence (AI) of
The tight or cutting Seton, on the other hand,
varying degrees (2).
has resulted in unacceptable rates of both severity and
The degree of incontinence depends on the
frequency of AI (13).
amount of damaged muscle, preexisting sphincter
Setons have been used to manage anal fistula
damage, and scarring of the anal canal.
from hundreds of years; however, in the literature,
Several alternative treatment strategies have
Setons were commonly used only for high or
been practiced in order to preserve the sphincter
complex anal fistula in order to avoid faecal
mechanism, including draining Setons, cutting
incontinence and recurrence (14).
Setons(3) , rectal mucosal or full-thickness
advancement flaps (4), rerouting (5),two-stage Seton
fistulotomy (6), fistulectomy, anal fistula plug (7),

Received:20 /3 /2018 DOI: 10.12816/0046158
Accepted:30 / 3 /2018

Full Paper (vol.714 paper# 25)

c:\work\Jor\vol714_26 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3039-3048

Comparative Study between Oral Zinc Sulphate, Amino Acids Chelated
Zinc and Placebo in Treatment of Viral Warts
Talal A. Abd El-Raheem1, Shaheera M. El Shafie2, Marwa A. Nassar1,
Marwa H. Sayed1
1Department of Dermatology, STDs, and Andrology, 2Department of Clinical Pathology,
Faculty of Medicine, Fayoum University
Warts are tumors or growths caused by infection with Human Papilloma virus (HPV). More
than 100 HPV subtypes are known. They are a common presenting disease in children and adolescents which
spread by direct contact or autoinoculation. The aim of the Work: The aim of this work was to assess and
compare the efficacy and safety of oral zinc sulphate and amino acids chelated zinc in treatment of viral warts.
Patients and Methods: This cross sectional case control study included 60 patients with multiple viral warts
who were collected from the Dermatology, STDs and Andrology outpatient clinic of Fayoum university
hospital during the period from November 2014 to November 2015. The patients were 29 males and 31
females with ages ranging from 15 to 60 years. Results: There was statistically significant difference in degree
of response in zinc and control groups as no patient in control group showed any response while in both zinc
groups 27.5% of patients showed variable degrees of response. Also, there was no statistically significant
difference in degree of response in both zinc groups. Conclusion: oral zinc in its both forms used in our study
is safe but needs time to act and the response is not high, so it is not fit to be used as a monotherapy, but rather
to be combined with other wart treatment modalities. Recommendations: More studies are needed to assess
the therapeutic effect of zinc and its efficacy in combinations in warts treatment with higher doses and longer
duration of treatment.
Keywords: zinc sulphate, amino acids chelated zinc, treatment, viral warts.

has been tried in viral warts with encouraging
Cutaneous warts are a common
results (6).
presenting complaint in children and adolescents.
In zinc deficiency, the function of the
They are caused by human papilloma virus (HPV).
macrophages and T cells is impaired with fifty
The treatment of warts poses a therapeutic
percent reduction in leucocytes and 40-70%
challenge for physicians. No single treatment has
reduction in antibody-mediated and cell-mediated
been proved effective at achieving complete
immunity (7).
remission in every patient. As a result, many
The aim of this work was to assess and
different approaches to wart therapy exist (1).
compare the efficacy and safety of oral zinc
There are various types of viral warts
sulphate and amino acids chelated zinc in treatment
including common warts, plantar warts, mosaic
of viral warts.
warts, plane or flat warts, periungual warts,

filiform warts, oral warts and genital warts (2).
Common therapeutic modalities for viral
warts include cryotherapy, keratolytics, topical
This study included 60 patients with
immunotherapy with contact sensitizer, oral
multiple viral warts who were collected from the
cimetidine, antimitotic agents, carbon dioxide
Dermatology, STDs and Andrology outpatient
laser, electrosurgery, photodynamic therapy,
clinic of Fayoum University Hospital during the
intralesional injection of antigens and topical
period from November 2014 to November 2015.
immune response modifiers (3).
The patients were 29 males and 31 females with
Zinc is an important element that is found
age ranged from 15 to 60 years. These patients
in every cell in the body. More than 300 enzymes
were divided into 3 groups:
in the body need zinc in order to function properly.
Group 1: Included 20 patients who received oral
It was found that some patients with multiple warts
zinc sulphate.
had low serum zinc levels and that oral zinc
Group 2: Included 20 patients who received oral
supplements may help the body get rid of viral
amino acids chelated zinc.
warts (4).
Group 3: Included 20 patients who received oral
Zinc has been previously used as an
immunomodulator in a number of dermatological

diseases such as erythema nodosum leprosum and
Inclusion Criteria:
dissecting cellulitis of scalp (5). Oral zinc sulfate
· Patients with multiple resistant viral warts.
Received:20 /3 /2018 DOI: 10.12816/0046159
Accepted:30 / 3 /2018

Full Paper (vol.714 paper# 26)

c:\work\Jor\vol714_27 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3049-3055

Effect of Trigonella, Allium Sativum and Their Mixture on Some
Physiological Parameters in Hyperthyroidimic Rats
*Eman G.E Helal, Rasha AA El sayed, Sara Ebrahiem, Mohamed A. Mustafa
Department of Zoology, Faculty of Science (Girls), Al-Azhar University, Cairo, Egypt.
*Corresponding authors: Eman G.E. Helal, E-mail:, mobile: 00201001025364

alterations in the level of hormones including thyroid hormones lead to physiological/ clinical
abnormalities. Aim of work: this study aimed to illustrate the protective effect of Trigonella, Allium sativum or
their mixture against hyperthyroidism induced by L-thyroxin in male albino rats. Materials and methods: thirty
albino rats were divided randomly into five groups. Group A: healthy rats, Group B: normal rats were
subcutaneously injected with 500 µg/kg body weight L-thyroxin once daily for two weeks to induce
hyperthyroidism , Group C: hyperthyroid rats received oral dose of 250 µg/kg body weight/day Trigonella
extract. Group D: hyperthyroid rats received oral dose of 250 µg/kg body weight/day Allium sativum extract.
Group E: hyperthyroid rats received mixture of Trigonella and Allium sativum extract. At the end of the
experiment. Blood samples were collected for biochemical analysis. Results: hyperthyroid rats had significant
increase (P<0.05) in serum levels of triodothyronine (T3), thyroxin (T4), TG, VLDL,AST,ALP,BUN and uric acid
as well as a significant decrease in TSH, LDL, HDL, LDL/HDL and TC, total protein and percentage of body
weight change compared to the normal control group. Oral administration of these extracts ameliorated most of
the tested parameters.
Conclusion: This study concluded that Allium sativum ,Trigonella or their mixture have a protective effect
against hyperthyroidism
: hyperthyroidism, Trigonella, Allium sativum.

recommended for the treatment of hemorrhoids,
Thyroid hormones regulate almost all functional
rheumatism, dermatitis, abdominal pain, cough and
aspects of the body, including metabolic, respiratory,
leprosy(4).Allium sativum (garlic),contains various
cardiovascular, nervous and reproductive functions,
substances including minerals,
either directly or indirectly(1).Alterations in the level
proteins, fats and vitamins. Among many different
of these hormones lead to physiological and clinical
compounds(5) found in garlic, studies suggest that
biological and pharmacological effects of this plant
hyperthyroidism that alters basal metabolic rate and
are mainly due to its sulfur compounds. Some of
causes many health problems. Hyperthyroidism is the
these organo-sulfur compounds are aliin, allicin,
result of excess synthesis and release of thyroid
hormone. Thyrotoxicosis is the hyper metabolic state
associated with elevated levels of free thyroxin
cystein, and others (6). Fenugreek is one of the most
(fT4)or free triiodothyronine (fT3) or both. There has
widely used plants in various indigenous systems of
been a tendency among researchers in attempting to
medicine for the treatment of different ailments.
treat disorders by replacing chemical drugs with some
Trigonella foenum-graecum is used in medicine to
natural plant components (2).Despite the fact that day-
kidneys, disperse cold and alleviate pain. Raw
by-day herbal drugs are gaining much importance for
fenugreek seeds early in the morning with warm
their affordable and safe nature, scientific
water before brushing the teeth has healing effect on
investigations towards the mitigation of thyroid
joint pains, without any side effects(7). Other
disorders by the plant extracts increased(3).Therefore,
medicinal uses of Trigonellafoenum-graecum include
this study is an endeavor to find out a plant extract
its use as antiulcer, wound healing, CNS stimulant,
that can regulate the levels of both of the thyroid
antioxidant , antidiabetic, anti-neoplastic, anti-
hormones. As a member of the Liliaceae family,
inflammatory and anti-pyretic drugs. Fenugreek seed
garlic is one of these plant products, traditionally
used for its cytotoxic, antitumor, antifungal,
mucilaginous fiber (galactomannans); 20-30%
antibacterial, antiviral and anti protozoal properties.
proteins high in lysine and tryptophan; 5-10 % fixed
Furthermore, in the ancient Indian medicine, garlic is
oils (lipids); pyridine-type alkaloids, mainly
Received:20 / 3 /2018 DOI: 10.12816/0046160
Accepted:30 /3 /2018

Full Paper (vol.714 paper# 27)

c:\work\Jor\vol714_28 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3056-3060

Stress Among Medical Students during Simulation Training at King Saud bin
Abdulaziz University for Health Sciences
Alhanouf Alhedaithy1, Rawan Mesmar1, Nouf AlBawardy1, Amal Alomri1, Fadi Munshi2,
Hani Lababidi2 and Evangelos Georgiou3
1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, 2 King Fahad
Medical City, Riyadh, Saudi Arabia,3 Athens University Medical School, Athens, Greece.
Corresponding author: Alhanouf Alhedaithy, Email:
Simulation training is increasingly being used as a safe format to instruct students and trainees
in different skills and procedures in the field of medicine. In this study, we recorded stress levels among
medical students during simulation training for a lumbar puncture (LP) procedure performed on a mannequin
and investigated the association between stress and performance.
Methodology: This study was conducted on 39 fourth year female medical students. Students wore a galvanic
skin response (GSR) sensor on their wrist before being asked to attempt the LP procedure on the mannequin on
two separate occasions. Students' performance was assessed using a validated LP checklist on each attempt.
Data were compared across all simulation attempts and for each student.
Results: Collectively, mean wrist GSR levels increased from the mental rehearsal phase 0.31 mS ± 0.40,
during the first attempt 0.48 mS ± 0.62 and continued to increase significantly (P = 0.007) during the second
attempt 0.60 mS ± 0.80. There were no significant differences (P = 0.32) between the checklist scores of the
first and second attempts.
Conclusion: The results of our study support the previous evidence that linked simulation training with
emotional and physiological stress. Performing highly intense procedures such as LP is considered to be a
potential source of stress. Our findings showed that there was a continuous increase in the level of stress
associated with repeated attempts during the LP simulation that had no significant impact on clinical
performance. As the practice of medicine involves exposure to a remarkable number of stressors and critical
conditions, we emphasize the importance of training medical students in ways to cope more effectively with
these situations.
Keywords: clinical skills, medical education, medical simulation.


Simulation training is increasingly being used as
common serological measure of HPA activity is
a safe format to instruct students and trainees in
cortisol(5, 8), while the most common measures of
different skills and procedures in the field of
SNS activity are the catecholamines, epinephrine
medicine(1). However, undergraduate medical
(EPI) and norepinephrine (NE)(6). Unfortunately,
students have reported experiencing stress during
however, direct measurements of EPI or NE in
high-fidelity trauma simulation(2,3). Furthermore,
saliva seem to provide a poor reflection of SNS
marked cortisol responses to real-life and simulated
activity. Consequently, a surrogate marker of SNS
emergency situations have been detected in army
activity in saliva is being actively sought. Salivary
nurses exposed to a combat casualty simulation(4).
-amylase, an enzyme that is produced by the
Cortisol(5), -amylase (sAA)(6) and chromogranin
salivary gland, has been suggested as a noninvasive
A (CgA)(7) have been proposed as markers of stress
and easily obtained surrogate marker of SNS
that can be measured in saliva. Technical advances
activity(6). Levels of sAA increase in response to
have created new opportunities for the noninvasive
stressful conditions including exercise, written
assessment of stress biomarkers in saliva. The ease
examinations and mental rehearsing. However, the
of use and noninvasive nature of salivary markers is
accuracy of sAA as an accurate indicator of SNS
especially valuable because complex multilevel
activity remains open to debate.
models of individual differences can be studied in

the laboratory or in quasi-naturalistic settings, such
The galvanic skin response (GSR), also known as
as simulation(6). However, it is not clear which one
skin conductance or electro-dermal activity (EDA),
of these salivary components is the best biological
is a sensitive marker of emotional arousal. EDA
marker of stress.
regulates the amount of secretion from sweat
The psychobiology of stress comprises two main
glands. Changes in skin conductance are triggered
systems: the hypothalamic-pituitary-adrenal (HPA)
by environmental conditions or stimuli, with a
stronger stimulus leading to greater skin
(sympathetic) nervous system (SNS). The most
conductance(9, 10). Skin conductance, which is
Received:23 / 1/2018 DOI: 10.12816/0046161
Accepted:3 /2 /2018

Full Paper (vol.714 paper# 28)

c:\work\Jor\vol714_29 The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3061-3065

Review of MRI Wrist Results at KAUH
Fawaz M. AlDhafiri1, Hatem E. Althagafi1, Abdullah H. Gadeer2, Suliman M. Kassar1,
Mohammed Z. Lamfon2, Mohammed G. Alghanemi1, Amre S. Hamdi3
1- King Abdulaziz University, 2- University Of Jeddah, 3-Department Of Orthopedics,
King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Corresponding author: Fawaz AlDhafiri, Email:


Background: Magnetic resonance imaging (MRI) is defined as one of the most important modalities used for
diagnosing lesions of small and complex structures in the body (1). We aimed to investigate the most common
wrist pathologies detected by MRI in KAUH (King Abdulaziz University Hospital) in Jeddah.
Methodology: A retrospective study was done with a total sample size of 127 individuals who underwent wrist
MRI investigation at KAUH in Jeddah (Saudi Arabia), between 2010-2016. The data entry was performed by
using Microsoft Excel 2014, and statistical analysis was performed by SPSS V21.
Results: The results of the analysis showed that the most common wrist pathology was ganglion cysts,
constituting 17.8% of the 157 findings we observed. Other common findings were Tenosynovitis (10.2%), TFCC
(Triangular fibrocartilage complex) tear (10.2%), TFCC degeneration (5.7%) and subchondral cysts (3.8%).
There was also a significant relation between normal/abnormal findings in individuals and their age of
presentation. Age mean was 29.27 (±7.46 SD) for those with normal findings, and 37.33 (±15.62 SD) for those
with abnormal findings, (P value less than 0.001). Regarding X-ray investigation, we found that most of the
Conclusion: It has been found that there is variance between all findings that were discovered by MRI, that there
are differences between our study and those of others, and that due to the different sorts of cases that were
presented to the hospital. We also found that most of the individuals with wrist pathologies did not get X-rays
before MRI, so we recommend a clear policy of ordering MRI, also proper history and examination should be
the essential tool to reach hand and wrist diagnoses. That will help in saving resources.
Keywords: MRI, wrist, hand, disease, carpal tunnel syndrome, tear, ganglion cysts, Tenosynovitis, TFCC, x-ray,
subchondral cysts.


Magnetic resonance imaging (MRI) is regarded as
ligament injuries were the most frequent findings in
one of the most important modalities used in
MRI in patients with wrist pain (6).
medicine for diagnosing lesions of small and
There were no published studies that have been done
complex structures in the body, such as the wrist.
with regards to the common pathologies of the wrist
Because of its high resolution, it can detect a disease
found by MRI in Saudi Arabia. Thus, in this study,
in its early stages (1). Wrist pain is common and when
we aim to identify the most common wrist
the exact lesion is known early, the prognosis will be
pathologies found by MRI at King Abdulaziz
better (2).
University Hospital in Jeddah.
The human wrist is a common site for many

pathologies, including fractures of the carpal bones,
avascular necrosis of scaphoid and lunate bones,
A retrospective study was done at KAUH at Jeddah
carpal tunnel syndrome, ligamentous tears and many
in Saudi Arabia in June 2016 by using paper records
other disorders (3). The application of MRI in the
from the radiology department. Different groups of
wrist can lead to better health care for patients, better
ages from both genders who underwent wrist MRI
management and increasing the accuracy of certain
between 2010-2016 were included in the study, with
diagnosis (3, 4).
a sample size of 127 patients.
A previous study has shown that the most common
The following data were extracted from each
MRI finding was occult bone fracture, including
patient's file: Gender, age, MRI procedure date, X-
scaphoid fracture (5) . Another study found that
ray procedure date if done, and the pathologies that
triangular fibrocartilage (TFC) and scapholunate
were discovered by MRI.

Received:24 / 1 /2018 DOI: 10.12816/0046162
Accepted:4 / 2 /2018

Full Paper (vol.714 paper# 29)

Pediatric airway management The Egyptian Journal of Hospital Medicine (April 2018) Vol. 71 (4), Page 3066-3078

Impact of Laparoscopic Ovarian Drilling (LOD) on Ovarian Reserve and
Ovarian Stromal Blood Flow Using Two-Dimensional (2D) Power Doppler in
Anovulatory Women with Polycystic Ovary Syndrome (PCOS)
Ismael M. Algarhy, Mohamed A. Mohamed, Loay F. El-Desoky,
Ibrahim A. Abdelmotagly
Department of Obstetrics and Gynacology, Faculty of Medicine, Al-Azhar University
Corresponding auhthor: Loay F. El-Desoky; Mobile: 01221750222; Email:

Aim of the Study:
this study aimed to determine the effect of LOD on ovarian reserve and ovarian stromal
blood flow changes, by using Two-Dimensional (2D) Power Doppler Ultrasongraphy in anovulatory women
with Polycystic Ovary Syndrome (PCOS) and whether this could explain the mechanism of action of LOD.
Patients and methods: this study was conducted in the Department of Obstetrics and Gynecology, Faculty of
Medicine, Al-Azhar University, Al-Hussein University Hospital, El-Sayed Galal Hospital and EL-Sheikh
Zayed Especialized Hospital in the period between November 2016 and February 2018. This study included 30
anovulatory polycystic ovary women with clomiphene citrate (CC)-resistant and 30 fertile women as the
control group. Laparoscopic ovarian drilling was done. Serum levels of hormonal profile were measured
(AMH, LH, FSH, LH/FSH ratio and total testosterone), ovarian stromal blood flow Doppler indices (RI and PI)
and occurrence of ovulation or pregnancy. Result: in this study we reported our findings regarding the effects
of LOD on AMH, hormonal profile and ovarian stromal blood flow in women with PCOS with clomiphene
resistance. These results suggested that the measurement of AMH, LH, LH/FSH ratio, total testosterone,
ovarian volume and ovarian stromal blood flow by Doppler were in discrimination of PCOS from potentially
normal women. The data in our study suggested that there were no significant differences as regard AMH,
hormonal profile except total testosterone, ultrasound ovarian findings and ovarian stromal blood flow before
and after LOD, but there were significant differences as regard total testosterone before and after LOD. Also,
there was good predictive value for AMH after LOD for ovulation and clinical pregnancy.
Conclusion: measuring AMH for anovulatory women with PCOS undergoing LOD may be a useful tool in
evaluating the outcome of LOD, but ovarian stromal blood flow 2D Doppler indices did not show significant
changes predicting ovulation or pregnancy rate after LOD.
Keywords: polycystic ovary syndrome, laparoscopic ovarian drilling, ovulation, anti-Mullerian hormone,
ovarian stromal blood flow.

flow velocity and time averaged maximum
Polycystic ovary syndrome (PCOS), one of

the most common endocrine disorders in women of

childbearing age, is characterized by marked
were found to be significantly greater in women
increase in preantral follicle number arranged
with PCOS than in infertile women with healthy
peripherally around a dense core of stroma or
ovaries (6). Power Doppler ultrasound is more
scattered throughout an increased amount of stroma
sensitive than Color Doppler imaging at detecting
(1). This is coupled with menstrual disturbance,
low velocity flow, thus it overcomes the angle
hyperandrogenism, and anovulation (2).
dependence of standard color Doppler and
Ovarian reserve is related to the size,
provides improved visualization of small vessels
number and quality of oocytes within follicles. The
ovarian reserve is the reproductive ability of ovary
Anti-Müllerian hormone (AMH) is a dimeric
that shows number of follicles in it. Aging decreases
glycoprotein, which is a member of the transforming
ovarian reserve and subsequently reproductive
growth factor family ß (TGF-ß). In the female,
ability of women (3).To assess ovarian reserve
AMH is secreted exclusively by granulosa cells of
Gleicher et al. (4) measured serum level of FSH and
primary, pre-antral and small antral follicles (4-
E2 in the follicular phase. One of the best ovarian
6mm) (8). Its secretion gradually diminishes in the
reserve determining factors is antral follicle count
subsequent stages of follicle development and is
which is assessed by transvaginal ultrasound tests
practically undetectable in follicles (8 mm) (8).
during the follicular phase. Within the last years,
Serum AMH concentrations have been correlated
serum AMH measurement has been introduced as
with the number of small follicles and hence
one of the best and easiest markers of ovarian
ovarian reserve. The size of the pool of small
reserve (5).Ovarian stromal peak systolic blood
follicles remains relatively constant during the
menstrual cycle and consequently circulating
Received:20 / 3 /2018 DOI: 10.12816/0046163
Accepted:30 / 3 /2018

Full Paper (vol.714 paper# 30)