c:\work\Jor\vol721_1 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3676-3679

The Effect of Diet and Nutritional Supplements in the Management, Prevention,
and Control of Inflammatory Bowel Disease: A Simple Literature Review
Abdullah Ahmed Aloraini1, Mohammed Atef Syam2, Abdulrazaq Oudah Alzahrani3,
Ghadah Abdulrahman Albalawi4, Sahar Salem Albalawi5, Arwa Farouk Khatib6, Aisha Shadad Aljohani6,
Ahad Ahmad Alkenani6, Waad Mohammed Alluhaibi6, Sajedh Mirza Alkharari7
1- Imam Mohammad bin Saud Islamic University 2- Sulaiman AL-Rajhi Colleges 3- Al-Baha University,
4- Hail University 5- Tabuk University 6- King Abdulaziz University 7- King Khalid University
*Corresponding author: Mohammed Atef Syam, E-Mail: dr.mas93@hotmail.com, Mobile: Mobile: +96655863400

Inflammatory bowel disease (IBD) is known for its episodic relentless course of gastrointestinal
symptoms. There are two major clinically defined forms of inflammatory bowel disease (IBD), Crohn's disease
(CD) and Ulcerative colitis (UC). It's associated with chronic remittent or progressive inflammatory conditions
that may affect the entire gastrointestinal tract and the colonic mucosa, respectively. A lot of literatures have been
done to assess the role of diet in IBD management, prevention, and control, as a result, we will review the articles
that investigated the diet role in IBD, and clarify the new progress that have been done, which will help the
patients and the physicians in managing, and prevention of the acute attacks.
Objectives: In this paper we aimed to present the role of diet and nutritional substances in the management and
prevention of inflammatory bowel disease.
Methods: PubMed database was used for articles selection, and the following keys used in the mesh ("Crohn
Disease"[Mesh]) AND ("Colitis, Ulcerative/diet therapy"[Mesh] OR "Colitis, Ulcerative/prevention and
control"[Mesh] OR "Colitis, Ulcerative/therapy"[Mesh]) AND "Inflammatory Bowel Diseases"[Mesh].
Conclusion: patients with IBD should increase their fiber intake in their diet, and take vitamin D supplement.
Also, introduction of eicosapentaenoic acid (EPA) in a free fatty acid form (EPA-FFA) into their diet is helpful.
However, the overall benefit of diet in this prevalent disease still need more research looking into the variable
dietary regimens that can be given in this special population.
Diet, Nutritional Supplements, Management, Prevention, Control, Inflammatory Bowel Disease.


Inflammatory bowel disease (IBD) is known
consumption has been linked to higher rate of IBD in
for its episodic relentless course of gastrointestinal
Saudi Arabia(5,6). Therefore, a lot of literatures have
been done to assess the link between diet and IBD in
inflammatory condition that may affect the entire
terms of aetiology, management, prevention, and
gastrointestinal tract and/or the colonic mucosa,
control. The objective of this paper is to present the
respectively, and is associated with an increased risk
role of diet and nutritional substances in the
for colon cancer. Crohn's disease (CD) and ulcerative
management and prevention of inflammatory bowel
colitis (UC) are the two major forms of the disease,
and have been associated with systemic clinical

manifestations causing great distress to their
patients(1). IBD aetiology could not be proven with one
PubMed was chosen as the search database
single reason, but it has been appreciated to have a
for the articles selection, because it is one of the
genetic basis and likely involves a response of the
major research databases within the suite of resources
immune system to some environmental agents. The
that have been developed by the National Center for
discordance of IBD among different factors, such as
Biotechnology Information (NCBI). The following
monozygotic twins(2), the development of IBD in
keys used for the Mesh(("Crohn Disease"[Mesh])
immigrants to high-prevalence countries(3), and in
AND ( "Colitis, Ulcerative/diet therapy"[Mesh] OR
countries undergoing rapid westernization also
"Colitis, Ulcerative/prevention and control"[Mesh]
highlights the importance of environmental factors in
OR "Colitis, Ulcerative/therapy"[Mesh] )) AND
this disease pathogenesis. Moreover, a controlled diet
"Inflammatory Bowel Diseases"[Mesh] A total of
would aid in alleviation of the symptoms, sustain
3604 articles were found, with further restriction by
quality of life and people with vitamin D deficiency
PubMed filters, and reviewing the articles titles and
were not associated with development of IBD(4). On
abstracts the final results were 10 articles. In regards to
the other hand, certain food types are common triggers
the inclusion criteria, the articles were selected based
for exacerbation of IBD symptoms, and low fruit
on the relevance to the project which should include
Received:4 / 3 /2018 DOI: 10.12816/0047728
Accepted:13 3
/ /2018

Full Paper (vol.721 paper# 1)

c:\work\Jor\vol721_2 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3680-3687

Evaluation of Coronary Artery Disease among Population with
Fatty Liver Disease Using Multi-Slice Computed Tomography
Wahid H Tantawy, Khaled M Ali, Sarmad F Aziz,
Department of Radio-diagnosis, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Sarmad F Aziz; Mobile: 01096146948; Email: sarmadjaff@ymail.com

Fatty liver disease (FLD) is a common disorder with an increasing prevalence. It is considered to
be an important syndrome associated with several cardiovascular risk factors and to be a component of metabolic
syndrome. Several studies found significant association of fatty liver and coronary artery disease (CAD).
Aim of the Work: was
to evaluate the presence and the severity of coronary artery disease among FLD
population and to evaluate the association of FLD and CAD using Multi-Slice Computed Tomography (MSCT)
and the possibility of considering FLD as a predictor for CAD. Patients and Methods: The study was conducted
in Radiological Department of Ain-Shams Hospital and other private centers. It focused on evaluating 30
patients, who were referred to perform CT coronary angiography. These patients were examined in the period
between 1st of Oct. 2017 and 1st of Apr. 2018. The target sample was patients with fatty liver who underwent CT
coronary angiography for recent chest pain. Fatty liver was diagnosed using non-contrast CT when calculated
attenuation value of the liver is less than spleen by 10 UH. The coronary arteries were assessed using CT
angiography, significant CAD was defined as a stenosis of more than 50% in at least one major coronary artery.
Results: fatty liver developed coronary atherosclerosis were 17 (56.7%) and this was statistically significant
P= 0.017
. Patients with fatty liver developed significant CAD were 9 (30.0%) and this was statistically
insignificant P=0.266. Conclusion: Fatty liver disease may be considered as a predictor for coronary
atherosclerosis and based on this, more individuals from the general population with subclinical CAD could be
detected at earlier stages when fatty liver is identified. Presence of fatty liver may help in cardiovascular risk
stratification and assessment. Recommendations: It will be worthwhile to study whether improving FLD will
ultimately prevent the development of CAD.
Keywords: coronary artery disease; fatty liver disease, multi-slice CT; atherosclerosis.


Coronary artery disease (CAD) is a complex chronic
Moreover, FLD has been included among the
inflammatory disease, characterized by remodeling
components of metabolic syndrome, a clinical
and narrowing of the coronary arteries supplying
condition with a high risk of coronary artery disease
oxygen to the heart. It can have various clinical
(CAD) (5).
manifestations, including stable angina, acute coronary
Recognition of a role for FLD in development of
syndrome, and sudden cardiac death. It has a complex
CAD will allow more individuals from the general
etiopathogenesis and a multifactorial origin related to
population with subclinical CAD to be detected at
environmental factors, such as diet, smoking, and
earlier stages when fatty liver is identified. Presence of
physical activity, and genetic factors II that modulate
fatty liver may help in cardiovascular risk stratification
risk of the disease both individually and through
and assessment (6).
interaction (1).
The standard of reference for diagnosis of CAD is
Fatty liver disease (FLD) is increasingly
still the conventional coronary angiography,
recognized as the most common liver disorder in
however, it is an invasive technique associated with
Western countries. It is the most common cause of
non-negligible complication.
Moreover, this
liver enzyme abnormalities in clinical practice, with
procedure offers little information on coronary
a prevalence of 15%­20% in the general population
artery wall changes associated with the early stage
and increases steadily to 70%­90% in obese or type
of coronary artery disease (7).
2 diabetic patients (2).
Multislice CT coronary angiography has been
Risk factors for atherosclerosis, such as obesity,
proposed as a noninvasive modality to help detect
diabetes, and dyslipidemia, are frequently
coronary plaques and classify coronary artery
associated with FLD (3).
disease (CAD) (8). It has been used successfully to
Fatty liver is blamed to play a role in development
quantify coronary artery calcium, which helps to
of atherosclerosis. However, few clinical studies
predict the presence of coronary artery disease (9).
have examined the association between fatty liver
Coronary CT angiography (CTA) can evaluate
disease and subclinical coronary atherosclerosis in
both calcified plaque and noncalcified plaque.
patients with low to intermediate cardiovascular risk
Coronary CTA is able to show the lumen of the
factors (4).
Received: 20/03/2018 DOI: 10.12816/0047729
Accepted: 30/03/2018

Full Paper (vol.721 paper# 2)

c:\work\Jor\vol721_3 Assessment of Knowledge, Attitude and Practice...

Full Paper (vol.721 paper# 3)

c:\work\Jor\vol721_4 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3692-3696

Refractive Errors among Northern Border University Medical Students
Alruwaili, Amal Muhaysin B1, Turki Dkhallah Turki Alshamdin2, Maram Khalf Ayad Alenzi1,
Deema Faleh M Alanazi1, Afnan Hamdan R Alshammari1, Bashayer Khlaif Alruwaili1
1Faculty of Medicine, Northen Border University, Arar,
2Faculty of Medicine, Al-Jouf University, Al-Jouf, KSA
Corresponding Author: Alruwaili, Amal Muhaysin B, E-Mail: amaa1998@outloook.com, Pone: +966557704711

Uncorrected refractive error is the most common cause of vision impairment worldwide, and the
WHO identified uncorrected refractive error as one of the priorities for the program of Vision 2020. Aim: Aim
of this study was to determine the prevalence of refractive errors (REs) among medical students of Northern
Border University. Subjects and Methods: A cross-sectional study was conducted on 167 students. A
structured close-ended questionnaire was distributed for data collection and checking REs amongst them in the
period between December 2017 and January 2018. All volunteering participants underwent ophthalmic
examination including autorefractometer examination. Results: Our study showed that 67.1% of participants
suffered from REs. 53.9% had myopia, 6.6% hyperopia and 6.6% had astigmatism. 47.9% of cases of refractive
errors have myopia, 5.4% hyperopia, 1.8% astigmatism, 4.2% have both myopia and astigmatism, 0.6% have
both hyperopia and a stigmatism, 0.6% have all myopia, hyperopia and astigmatism. Both eyes were affected in
46.7% of cases, left eye was affected in 6.6% and right eye was affected in 7.2% of cases. Conclusion: the
prevalence of REs among investigated students was 67.1%, which is one of the highest rates reported. There has
to be a concern for a regular checkup starting from early ages as a preventive measure against REs through
increasing knowledge, concerning REs particular for medical students as future health care professionals.
Keywords: Refractive errors, Medical students, myopia, astigmatism, hypermetropia, Northern Border
University, Arar, KSA.

83.1% of participants suffered from REs. 74.129%
Refractive error may be defined as a state
were myopic, while 53.731% were astigmatic, and
in which the optical system of the non-
47.264% had combined astigmatism and myopia (9).
accommodating eye fails to bring parallel rays of
Another study in Nigeria found that sixty-
light to focus on the retina (1). Uncorrected
six (79.5%) of subjects had a form of refractive
refractive error (URE) is the most common cause of
error; 63.6%%, 16.7% and 19.7% were myope,
vision impairment and the secondary cause of
hyperope or simple stigmata, respectively. The
blindness worldwide. It has been estimated that
prevalence of ametropia was 82% in female and
URE accounts for 153million individuals of visual
78% in males. Eight students (12.1%) were wearing
impairment globally, and the WHO identified URE
glasses at the time of the study (10).
as one of the priorities for the program of Vision
The aim of this study is to determine the
2020 (2). According to the WHO report, uncorrected
prevalence of refractive errors in medical students,
refractive error is the second commonest cause of
Northern Border University.
global visual impairment first being the cataract (3).

URE is associated with limitations in vision-related
tasks and decreased quality of life (4,5). Myopia is
Research design: This is a community-based
the most common type of RE, a complex trait
cross-sectional study
including both environmental and genetic
Research environment: Data was collected from
factors (6). Medical students are a group of young
representative sample of undergraduate medical
adults who spend prolonged periods of time on
students, Faculty of Medicine, Northern Border
reading and close-up work. They are a select
University, Arar, Kingdom of Saudi Arabia. The
population with a high level of education as well as
study period was from October 2017 to June 2018.
above average intelligence. With their intensive
A structured close-ended questionnaire was
study regimen that spans many years, medical
distributed to the targeted population to collect
students have been reported to be at high risk for
demographic data and history of REs.
myopia (7). The correlation between myopia and
Inclusion criteria: Willingly participating medical
high education levels was settled long time ago.
students of both genders attending the College of
In European cohort, Mirshahi (8) showed that
Medicine, Northern Border University, Arar,
individuals with higher level of education are more
Kingdom of Saudi Arabia.
likely to bemyopic. A previous study in Al-jouf
Exclusion criteria: Unwilling participants and
University among medical students reported that;
those unavailable for any reason during the study
Received:6 / 3 /2018 DOI: 10.12816/0047731
Accepted:15 /3 /2018

Full Paper (vol.721 paper# 4)

c:\work\Jor\vol721_5 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3497-3702

Spina bifida in Infants and Children in Arar, Northern Saudi Arabia
Anfal Muaddi A Alshalan1, Malik Azhar Hussain2, Nagah Mohamed Abo El-fetoh3, Shoug Zeid T
Alenezi1,Aisha Reja M Alenazi1, Alanazi, MahaMukhlef R1, Alaa Jameel A Ahmed1, Muhammed Ghalib
buqami4, Sukaina Mohammad H Al Haddad5, Asrar Mohammed Alshahrani6, Almaha Ayidh Alshehri6,
Jawaher Mohammed Hassan Al- Ruwaili1, Nawal Ahmed M Alshammari1, Kholoud Abdullah M
Aljohani7, Ahad Massad AlMohammadi7, Nada Kareem S Alruwaili1
1.Faculty of Medicine, Northern Border University,Arar, 2.Assistant Professor, Department of Surgery,
Faculty of medicine, Northern Border University, Arar, KSA,3.Associate Professor, Department of Community
Medicine, Faculty of medicine, Sohag University, Sohag, Egypt,4.Faculty of medicine, Taif University,Taif,
5.Faculty of medicine, King Faisal University, Al Ahsa,6.Faculty of medicine, King Khalid University, Asir,
7.Faculty of medicine, Tabuk University, Tabuk, KSA
Corresponding Author:Nagah Mohamed Abo El-fetoh, E-Mail: elshmaa3332004@yahoo.com, Pone: +966550748692

Neural tube defects (NTDs) are the most common birth defect of the central nervous system.
Spina bifida (SB) is a common birth defect resulting from incomplete closure of the neural tube during the first
month of pregnancy and that is associated with significant clinical complications that can affect survival and the
quality of life for affected individuals. Objective: The study objective was to estimate the prevalence, types,
manifestations, diagnosis, complications as well as treatment outcomes of of Spina bifida in all neonates born in
Maternity and Children hospital in Arar city, Northern Saudi Arabia.
Methods: This is a descriptive study involved all neonates born in Maternity and Children hospital in Arar city,
Northern Saudi Arabia, KSA, during the period from 1 January to 31 December 2017. Data was collected by
retrospective analysis of the recorded data and filling a pre designed questionnaire, which include questions
designed to fulfill the study objectives. Results: The total number of spina bifida cases borne in maternity and
children hospital in Arar city, Northern Saudi Arabia during the year 2017 was 14 cases with a prevalence of
0.51%; 8(57.1%) were females and 6(42.9%) were males. Consanguinity between parents found in 57.1% of
cases, and folic acid deficiency during pregnancy reported in 78.6%. The site of spina bifida was lumbosacral in
57.1% and lumber 42.9%. The type was Spina bifida occulta 57.1%, Myelomeningocele 28.6% and
Myeloschisis 14.3%. Weakness of legs, urinary incontinence 35.7%, hip dislocation, deformity of the body
21.4% and paralysis were the reported complications. Conclusion: The prevalence of spina bifida in Arar,
KSAwas 5.1per 1,000 live births. Majority of the reported cases were females, Spina bifida occulta was the
most common then myelomeningocele and myeloschisis. The site was lumbosacral and lumber.
Keywords: Spina bifida, Arar, Northen KSA, prevalence, types, site, complications, treatment.


Birth defects are one of the leading causes
Prevention Network, Parker (1) reported that the
of infant mortality worldwide1­3 and affect an
prevalence of spina bifida in the United States from
estimated 1% to 3% of all births (1).
2004 to 2006 was 3.5 per 10,000 live births. In
Spina bifida is a type of neural tube defect
contrast, the prevalence of spina bifida was 42.8 per
resulting from an incomplete closure of the spinal
10,000 live births in Algeria during the same
column leading to a herniation or exposure of the
observational period (7-9).
spinal cord or meninges. Spina bifida is the most
A study carrier out on total of 86 patient
common birth defect that can cause disablement for
records with spina bifida were analyzed in Malaysia
a lifetime (2,3). Numerous studies have extensively
found that; prevalence rate in this study ranged
investigated the epidemiological characteristics of
from 1.87 to 8.9 per 1,000 live births depending on
this disease.
weight age. The most common site of the spina
bifida lesion was located at the lumbar region
environmental factors including family history, pre-
(26.74%). In terms of mobility, 32.84% (n=22/67)
gestational diabetes, maternal obesity, insufficient
of patients between the ages 4 and 16years old
intake of folic acid, and use of anticonvulsant
were found to be mobile.
medications have been established as characteristics
As many as 36.07% of patients ranging
of spina bifida (4-6). Recently, the prevalence of
from 5 to 16years of age (n=22/61) received
spina bifida varies by time and region. For instance,
formal education ranging from preschool to
on the basis of the National Birth Defects
secondary school (10).

Received:28 /2 /2018 DOI: 10.12816/0047732
Accepted:9 /3 /2018

Full Paper (vol.721 paper# 5)

c:\work\Jor\vol721_6 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3703-3711
The Pattern of Utilization and Outcome of Complementary and Alternative
Medicine among Primary Health Care Attendees in Tabuk, KSA
Ali Mohammed Alferdos1, Manea Nasser Al-Hablany1, AbdulMajeed Hamm ad Al-Temani2 , Manar
Suliman Manqarah3 , Saad Moryah Al Qahtani1 , Yahya Hassan Alferdos4 , Abdullah H. Altemani5*
1Department of Family Medicine, King Salman Armed Forces Hospital, Northwestern Region,
2Department of Alternative and Complementary Medicine, King Salman Armed Forces Hospital, Northwestern
Region, 3Department of Home Care, King Salman Armed Forces Hospital, Northwestern Region,
4Rijal Almaa General Hospital, Asir Region, 5Department of Family and Community Medicine,
University of Tabuk, Tabuk, Saudi Arabia
*Corresponding Author: Abdullah H. Altemani, Tel No.: +966144562511, E-mail: atemani@ut.edu.sa

Despite all the marvelous advancements in modern medicine, traditional medicine (TM) has
always been practiced.
Aim of the work:
We aimed to assess Patterns of utilization and outcome of complementary and alternative
medicine among primary health care attendees in Tabuk, KSA.
Subjects and Methods:
This cross-sectional study conducted among 345 patients attending the primary health
care centers (PHC) in Tabuk, Saudi Arabia during the period from January 2015 to January 2016. Participants
were selected from 29 centers by a stratified selection method. A structured questionnaire was used to collect
socio-demographic data, going to a non-medical practitioner (TH) for advice about a health problem within the
last year, the reason for that, type of TH provided prescription/advice, outcome, and personal satisfaction. The
Statistical Package for Social Sciences (SPSS) was used for data analysis. The Chi-square and Fischer exact
tests were used to examine the associations and differences between two categorical variables.
Results: Participants (57.1% males), 62.9% had a history of visiting a Traditional Healer, Visiting a traditional
healer was commoner among females (72.3% versus 55.8%, p=0.002)No significant statistical differences were
found regarding other characteristics. Ineffective medical management was the reason in 55.3%, while the firm
belief in TH that it was the reason behind 36.9%. Medical treatment was the most frequent (50.7%) followed by
Zikr (25.8%), 87.6% said the visits were affordable, and 70% of visitors improved.
Conclusion: Traditional medicine practice was prevalent in Tabuk, Saudi Arabia and was most prevalent
among females. No significant differences were found between traditional medicine visitors and their
counterparts regarding other characteristics.
Keywords: Complementary medicine, Pattern, Tabuk, Saudi Arabia.


For centuries, people have been using traditional
proven to be safe and effective are adopted into
means for treating ailments and continued to use
conventional medicine (3).
them alongside modern medicine. Despite all the
More than 80% of the developing world's
marvelous advancements in modern medicine,
population still depends on the complementary and
traditional medicine (TM) has always been
alternative systems of medicine, while about half of
practiced. Traditional medicine refers to health
the people in industrialized countries use CAM (4).
practices, approaches, knowledge, and beliefs
The World Health Organization noted that there
incorporating plant-, animal- and mineral- based
had been an unprecedented increasing interest in
medications, spiritual therapies, manual techniques,
these systems of therapeutics on the global level (5).
and exercises, applied singly or in combination to
Most users of alternative medicine also use
treat, diagnose and prevent illnesses or maintain
conventional medical treatments, since alternative
well-being (1).
medicine is used as a complementary treatment to
This domain has taken the new name
traditional health care rather than as a substitute (6) .
"complementary and alternative medicine" (CAM).
The use of multiple forms of health care (e.g.,
CAM refers to those therapeutic and diagnostic
conventional or complementary medicine beside
disciplines that exist mostly outside the institutions
that of the national health care system) is called
where conventional health care is provided (2.
"Medical pluralism." Most consumers all-over the
TM/CAM constitutes any treatment or therapy that
world practices multiple forms of health care,
is not routinely and universally available to patients
irrespective of whether integration between types of
via the national health care system. These
health care is officially present (7).
definitions are often blurred, and the list of what is
The reasons for medical pluralism were
considered to be CAM changes as therapies that are
explained by Kale(8) , who noted that traditional
Received:7 /3 /2018 DOI: 10.12816/0047733
Accepted:16 /3 /2018

Full Paper (vol.721 paper# 6)

A The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3712-3715

Role of Anterior Segment Optical Coherence Tomography in The Diagnosis of
Subclinical Keratoconus in Comparison with The Pentacam
Fatma Mohammed Elhennawi, Yasser Abdelmaguid Alzankalony,
Mona Kamal Abdellatif, Abeer Mohamed Tawfik Ibrahim
Ophthalmology, Faculty of Medicine, Ain Shams University
The most common ectatic disorder is keratoconus which is characterized by bilateral and progressive
corneal thinning. Role of the pentacam has been well established for screening form fruste keratoconus in
ophthalmology practice. While for anterior segment OCT it can detect the characteristic abnormal corneal thinning in
patients with keratoconus using its pachymetry maps.
Aim of the Work: was to detect how much anterior segment OCT can approach the pentacam's well established
efficacy in diagnosis of early keratoconus among the highly myopic astigmatic patients.
Patients and Methods:
This prospective, non-randomized population study followed the tenets of the Declaration of
Helsinki, and the protocol was reviewed and approved by the Ophthalmology Department of Ain Shams University.
An informed consent was signed by the patients before inclusion. We selected 40 eyes of twenty-three healthy young
volunteers with high myopic astigmatism for the study from patients who attended the outpatient clinic of Maghraby
Eye Hospital at the period of November and December 2017.
This study included 40 eyes of healthy young adults (22 females, 18 males) with high myopic astigmatism
(-4.038 D± 1.194). The mean age ± SD was 24.1 ± 5.702 (range: 16-31 years). Statistically highly significant
differences were observed in all measured cases between Pentacam and Anterior Segment OCT (p <0.01). So the
OCT corneal pachymetry mapping seems promising for evaluating corneas as in cases of early keratoconus.
The OCT corneal pachymetry mapping with its fast acquisition time seems promising for evaluating
highly astigmatic corneas, as in early keratoconus.
Keywords: Anterior Segment Optical Coherence Tomography, Subclinical Keratoconus, Pentacam.


the absolute and relative risk factors of ectasia and
comprehensive analysis of numerous anterior
their cut-off values following LASIK. The most
segment applications which involve, Angle
important risk factors for keratectasia include
evaluation (to diagnose narrow angle glaucoma),
abnormal preoperative corneal topography that is
Anterior chamber biometry (to plan intraocular lens
suspicious for keratoconus 2.
implantation) 1, Corneal flap depth measurement
OCT pachymetry maps can accurately detect the
following LASIK, OCT can also visualize the
characteristic abnormal corneal thinning in patients
LASIK flap early postoperatively to evaluate the
with keratoconus, using four parameters based on
efficacy of microkeratome or femtosecond laser
the central 5-mm diameter of the pachymetry map 4.
being used, It can also assess the potential safety of
This four parameters are, { I­S: the average inferior
lifting the LASIK flap via evaluating the residual
octant thickness (I) minus the average superior
stromal bed and flap 2.
octant thickness (S)}, {IT­SN: the average
The most common ectatic disorder is
inferotemporal octant thickness (IT) minus the
keratoconus which is characterized by bilateral and
average superonasal (SN) octant thickness},
progressive corneal thinning. The cornea becomes
{Minimum: the thinnest corneal thickness},
conical in shape due to non-inflammatory thinning
{Minimum­maximum: the minimum pachymetry
and protrusion. This corneal thinning is focally
minus the maximum pachymetry}.
occurring in the infero-temporal corneal location,
Using these four parameters asymmetry, global
and this characteristic pattern of thinning is the clue
thinning and focal thinning can be detected, and we
to diagnose keratoconus 1.
got diagnostic cut-off points for these parameters.
Keratoconus in the moderete and sever stages is
Keratoconus is diagnosed if, asymmetry that is
easily recognized clinically and topographically,
more than -45 µm for I­S or IT­SN, or Minimum
while subclinical keratoconus is difficult to
thickness of less than 470 µm, or a minimum­
distinguish from normal corneas, because patients
maximum difference more than -100 µm. One
usually have normal visual acuity, stable
abnormal parameter provides reason to suspect
topographic patterns and minimal or no clinical
signs 3. In such suspect cases, OCT plays a major
Two or more abnormal parameters provide a
role in producing highly reliable pachymetry maps
definitive diagnosis. This method is sensitive and
that can detect keratoconus, ectasia and corneal
specific as the topographic KISA (keratometry, I-S,
thinning before LASIK.
astigmatism, and skew percentage) 5.
Post-Lasik ectasia is a relatively rare vision-

threatening complication. It is important to identify

Received:20 / 3 /2018 DOI: 10.12816/0047734
Accepted:30 /3 /2018

Full Paper (vol.721 paper# 7)

c:\work\Jor\vol721_8 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3516-3520

Severe Tracheomalacia Secondary to Double Aortic Arch.
Any Role in Posterior Aortopexy? A Case report
Bayan Almehamadi1, Mansour AlQwaiee2, Ayed Alenazi2, Khaled Baqais2,
AlOtay Abdulmajeed3, Abdullah Al-Shamrani4
1Prince Sultan Medical Military City (PSMMC), 2Pediatric Pulmonologist, PSMMC, 3Pediatric Cardiologist,
Prince Sultan Cardiac Center, PSMMC, 4Pediatric Pulmonologist and Sleep Physician, PSMMC, SA
Corresponding author: Abdullah Al-Shamrani, email: Shamrani999@hotmail.com. Orcid.org/0000-0001-7157-1706,
Mobile: 00966553367555
Tracheomalacia is the abnormal collapse of the tracheal lumen and is common after cardiac compression. In
the severe types, tracheomalacia can lead to significant morbidity, especially if encountered in a critical area,
such as the distal part of the trachea, immediately above the tracheal bifurcation. We report a case that did not
improve after cardiac surgery with persistent airway narrowing of more than 90%, requiring ventilatory
support for a year. The case was difficult to manage, but the patient eventually showed a significant
improvement after a posterior aortopexy that helped a lot in weaning him off the ventilator with a residual
persistent audible wheeze and recurrent chest exacerbation. The diagnostic and therapeutic options for the case
will be discussed.
Keywords: malacia, tracheomalacia, double aortic arch, stridor, wheeze and aortopexy.


Malacia is an abnormal collapse of the airway walls.
finding was a marked narrowing of the airway
There are three main types of malacia:
recommendation to roll out vascular compression
bronchomalacia. The distal third of the trachea is
[Fig. 1]. An upper GI study [Fig. 2] showed
most commonly affected in tracheomalacia.
indentation of the esophagus supporting the
Tracheomalacia appears to be related to a
diagnosis of a vascular ring. Another bronchoscopy
developmental defect in the cartilage of the tracheal
showed severe tracheomalacia with more than a 90%
wall; the lesion typically occurs in infants and young
narrowing of the tracheal lumen with pulsatile airway
children. In most children, the tracheal cartilage
approximately 1 cm above the carina (length 1.5 cm).
normalizes as the airway enlarges, and symptoms
The finding of a complete vascular ring was
may resolve in late childhood. Clinical symptoms
confirmed by CT chest and CT angiogram, which
can range from minor expiratory stridor with typical
showed a dominant posterior right-sided aortic arch
barking cough, recurrent/persistent wheezy chest,
and a smaller anterior left-sided aortic arch [Fig.3
and severe respiratory distress episodes to apnea [1].
and Fig. 4].
Case report:
Therapeutic intervention. The patient was managed
Patient information.
in the PICU, where he was ventilated for 1 year with
An 18-month-old boy, born at term through a
an unusual treatment, during which he had multiple
spontaneous vertex delivery, presented respiratory
failures that prevented extubation or even weaning of
distress, which was diagnosed as transient tachypnea
the ventilatory support. He underwent a vascular ring
of the newborn soon after delivery.
repair ,,resection of the anterior aortic arch".
Clinical finding.
Although he showed good signs of recovery, he
On examination, two days after birth, he had marked
unfortunately failed extubation, despite being on a
ventilator at a low setting. This case was discussed
Additionally, the patient required CPAP followed by
during the Saudi Pediatric Pulmonology Cross
intubation and mechanical ventilation due to a high
Country Round, a multiple case conference with an
PCO2 level.
airway expert in the international medical center
Diagnostic assessment
"Grand Ormond Street Hospital." The recommended
The patient screen was positive for RSV
options were stenting, tracheostomy, and posterior
bronchiolitis during the peak of the winter season.
aortopexy. Each option has its pros and cons, but the
Nonetheless, since the stridor is not a common
majority advised for posterior aortopexy. Repeated
CT angiogram and bronchoscopy showed severe
bronchoscope of 2.8 mm in size was introduced
narrowing of the airway, approximately 80%, with a
under light anesthesia through ETT. In the first time
marginal improvement in the narrowing of the
that the procedure was performed in PICU, the
airway lumen. Posterior aortopexy occurred, and

the patient showed significant improvement and was
Received:2 / 4 /2018 DOI: 10.12816/0047735
Accepted11: /4 /2018

Full Paper (vol.721 paper# 8)

c:\work\Jor\vol721_9 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3521-3525

Potential Risk Factors of Intestinal Parasitic Infection in
AlAhssa, Saudi Arabia
Sara Al-Saad, Jawaher Al-Jadidi, Nouf Al-Sulaiman, Jumanah Al-Qahtani, Dalia Ashour
King Faisal University- medical college - at Alahsa-KSA

Background: Intestinal parasitic infections (IPIs) are endemic worldwide and have been described as
constituting the greatest single worldwide cause of illness and disease. Low income, poor personal hygiene,
environmental sanitation, and limited access to clean water are the factors associated with spread IPIs.
Therefore, the purpose of this study was to determine the community awareness to IPIs and their related risk
factors among people in Al- Ahssa. Subjects and Methods: A cross- section study was conducted in April
2014. A random sample of 120 participants was included. Data collection was gathered through the
questionnaire form which includes inquires about social-demographic data, personal hygiene and habits.
Results: Results showed that 92.7% of the participants were lacking awareness of IPIs. The proportions of
participants who wash fruits and vegetables with only water before eating were 80% and 94% of them used to
eat in restaurants at variable frequencies which was considered as a high risk factor for acquiring IPIs.
However, the percentages of participants practice good hand washing before eating and after toilet were 67.7%
and 90%, respectively which indicates lower risk.
Conclusions: There is a need for campaigns to create awareness regarding the importance of prevention
against the intestinal parasitic infection, and improve delivery of hygiene and health information.
Keywords: Risk factors of intestinal parasites, hygiene, Saudi Arabia


Intestinal parasitic infections (IPIs) are globally
infection. Thus, a light parasitic infection is often
endemic and have been described as constituting the
asymptomatic whereas a mild to heavy infection can
greatest single worldwide cause of illness and
be associated with painful and severe symptoms (3).
disease (1). In 2002, WHO estimated the number of
Intestinal parasitic infections are associated with
people infected by intestinal parasites at 3.5 billion
abdominal discomfort, anorexia, diarrhea and
and the number of people made ill by them at 450
flatus(10).Complications of intestinal parasitic
million (2). Parasites found in the human intestinal
infections include intestinal ulceration, abscesses,
tract can be largely categorized into two groups,
peritonitis, reactive arthritis usually involving lower
protozoa and Helminths. Protozoa can allow serious
extremities and hypersensitivity reactions(11). IPIs
infections to develop, such as, Entameba
rarely cause death but because of the size of the
histolytica­ the most common-, Giardia lamblia and
problem, the global number of related deaths is
substantial (12). In a study that was carried in Al
lumbricoidis, Ancylostoma duodenale (hook worm)
Madinah Al Munawarah, Kingdom of Saudi Arabia
(KSA), a total of 2732 stool samples were screened
and Enterobius vermiculoris .Thus, while still
for intestinal parasites. Positive cases were recorded
found in North America and Europe, their
among 407 stool samples (14.9%). The detected
prevalence is highest in areas of intense poverty in
intestinal parasites were Giardia lamblia (21.9%),
low- and middle-income countries in the tropical
Entamoeba histolytica/Entamoeba coli (17.8%),
and subtropical regions of sub-Saharan Africa, Asia
Trichuris trichiura (16.2%), Ascaris lumbricoides
and Latin America and the Caribbean (4- 6). Amoebic
(15.8%), hookworm (13%), and Enterobius
dysentery from Entamoeba histolyticais is the
vermicularis (0.43%) (13).
second most common cause of death from parasitic
Many factors may contribute to transmission of
(7). It estimates that
parasites. Intestinal parasites are infectious diseases
approximately 50 million people worldwide suffer
of poverty. It is closely associated with low income,
from invasive amoebic infection each year, resulting
poor personal hygiene, environmental sanitation,
in 40-100 thousand deaths annually (8). The soil-
lack of pure water supply, limited access to clean
transmitted helminths (Ascaris lumbricoides and
water, tropical climate, and low altitude (14).
Ancylostoma duodenale) are the most prevalent,
According to the prevalence, the aim of the research
helminths infecting an estimated one- sixth of the
is to determine the community awareness to
global population (9).
intestinal parasitic infections and their related risk
Generally, symptoms signaling the presence of
factors among people in Al-Ahssa.
an intestinal parasite are related to the intensity of
Received:5 /3 /2018 DOI: 10.12816/0047736
Accepted:14 /3 /2018

Full Paper (vol.721 paper# 9)



Full Paper (vol.721 paper# 10)

c:\work\Jor\vol721_11 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3732-3740
Assessment of Cases of Acute Tramadol Toxicity as Regards Clinical, Laboratory
and Management Procedures in Some University Hospitals in Cairo
Magdy A Ismail, Sherif F Mahmoud, Mohammed A Khedr, and Mohammed K Mohammed
Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Mohammed Karim Mohammed, Phone Number: 01005376324,Email: drkemo9.@gmail.com

Tramadol, a widely used opioid in recent years, is a centrally acting analgesic drug that has been used
clinically for the last two decades to treat pain in humans. Tramadol also has antitussive activity. Tramadol is a
centrally acting analgesic which is extensively used in the management of moderate to severe pain. It slightly
affects opioid receptors and inhibits the reuptake of norepinephrine and serotonin in the CNS.
The aim of this study was to e
valuate the clinical manifestations, the laboratory findings, the different lines of
treatment and the outcome of cases presented with acute toxicity by tramadol overdoses. This study was
carried out at Al-Azhar University Emergency Hospitals in Cairo (El-Hussein And Bab El-Shaaria University
Hospitals) and Ain Shams University Hospitals on one hundred subjects in the period from July 2016 to
February 2018. Toxicological screening was done for every patient by rapid lateral flow chromatographic
immunoassay for detection of tramadol and its principal metabolites in human urine by special kits at a cut off
level of 1000 ng/ml. In this study, 95% of studied cases fully recovered and 5% died.
Keywords: Tramadol; substance of abuse; urine screening.


Tramadol hydrochloride is a centrally
Toxicology databases state that the
acting synthetic opioid analgesic used in the
treatment should still be naloxone to antagonize the
treatment of moderate to severe pain. It has a low
opioid effects of tramadol (6).
affinity to opioid receptors and inhibits the
The aim of this study was to evaluate the clinical
reuptake of norepinephrine and serotonin. Its
manifestations, the laboratory findings, the
analgesic effect is partially blocked by Naloxone
different lines of treatment and the outcome of
cases presented with acute toxicity by tramadol
It possesses weak agonist actions at the
microopoid receptor, and inhibits the reuptake of

norepinephrine (2).

Tramadol, a widely used opioid is a
This study included a total of one hundred
centrally acting analgesic drug that has been used
subjects presented with acute toxicity by tramadol
clinically for the last two decades to treat pain in
overdoses, at Al-Azhar University Emergency
humans. Tramadol also has antitussive activity (3).
Hospitals in Cairo (El-Hussein and Bab El-shaaria
Tramadol use is largely considered safe by
University Hospitals) and Ain Shams University
physicians. The most common reported side effects
Hospitals. Approval of the ethical committee and a
are dizziness, nausea, constipation and headache.
written informed consent from all the subjects
were obtained. This study was conducted between
underestimated; several deaths have been reported
July 2016 to February 2018.
when Tramadol was ingested alone in overdose (4).
Patients' Inclusion Criteria: 18 years old or
The most common symptoms of acute
more, male or female having definite history of
tramadol overdose are central nervous system
Tramadol intake given either by the patients
(CNS) depression, nausea, vomiting, tachycardia
themselves or their relatives. They had Positive
and seizures. Higher doses can be associated with
laboratory parameter for qualitative detection of
classic opioid toxicity features of coma, respiratory
Tramadol in urine.
depression and cardiovascular collapse (5).
Patients' Exclusion Criteria: subjects below 18
According to the data of the International
years old, with no definitive history of tramadol
Association of Forensic Toxicologists, therapeutic
intake and negative laboratory parameter for
blood levels in adults range from 0.1­0.8 mg/L,
qualitative detection of tramadol in urine. Patients
toxic level was between 1­2 mg/L and lethal
with history of chronic liver or renal disease were
concentration was higher than 2 mg/L (5).
also excluded.

All patients enrolled in this study were

subjected to history and thorough clinical

examination. From each patient, collection of 3 ml
Received:20 /3 /2018 DOI: 10.12816/0047738
Accepted:30 / 3 /2018

Full Paper (vol.721 paper# 11)

c:\work\Jor\vol721_12 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3741-3748

Comparative Study between Laparoscopic Assisted versus Open
Left Sided Hemicolectomy and Sigmoidectomy for Cancer Colon
Mahmoud A. El-Shafei, Mohamed A. Amer, Ahmed A. Darwish,
Moheb S. Eskandaros, Ahmed A. Hosny
Department of General Surgery, Faculty of Medicine, Ain Shams University
Corresponding author: Ahmed A. Hosny; Mobile: +201229123399; Email: ahmedatef1987@hotmail.com

Traditionally, open procedure through exploratory incisions remains the gold standard approach
for treating colorectal (CRC). Laparoscopic colectomy was proved to be a better alternative to the open approach.
Though in some studies, it was found that the length of the operation tends to be somehow longer. However, in
experienced hands it has comparable oncologic outcomes. Moreover, the laparoscopic approach is associated
with less postoperative pain, faster return of bowel activity, earlier resumption of oral intake and lesser hospital
stay. Aim of the Study: to study and evaluate the effectiveness of laparoscopic left hemicolectomy and
sigmoidectomy compared to the open left sided colectomy and sigmoidectomy for malignancy regarding
operative time, length of hospital stay, return of bowel function, resumption of oral intake, postoperative pain
perception, general postoperative complications, surgical site infections and early recurrence. Patients and
This comparative study has been conducted in El-Demerdash hospital, Ain Shams University - Cairo,
Egypt and has included 60 patients where half of the patients underwent open left hemicolectomy or
sigmoidectomy and the other half underwent laparoscopic left hemicolectomy or simoidectomy. We performed
both procedures during the period between 1st of January 2016 and 1st of January 2017 with 12 months of follow-
up post-operatively. Results: In our study, the laparoscopic operation was associated with less hospital stay,
earlier return of bowel activity, earlier resumption of oral intake without the use of the regular anti-emetics with
better pain control and perception postoperatively. Moreover, it was associated with less surgical site infections
and general complications including the respiratory ones than the open operation. We had similar anastomotic
leak rates and early recurrence rate between both operations. Finally, the laparoscopic operation was associated
with more operative time compared to the open operation. Conclusion: Laparoscopic left hemicolectomy and
sigmoidectomy are oncologically sound when compared to the open left hemicolectomy and sigmoidectomy for
treating left sided and sigmoid cancers. Moreover the laparoscopic approach yielded better outcomes regarding
the postoperative recovery compared to the open approach. Recommendation: A further high volume study is
needed to assess the long term effects of both procedures in our hospital.
Keywords: laparoscopic assisted, open left-sided hemicolectomy, sigmoidectomy, cancer colon.

activity of disease being the primary determinants.
Colorectal cancer (CRC) is a common and
Although there are much fewer data, it appears that
lethal disease. Its incidence and mortality rates vary
pancolitis due to Crohn's disease is associated with a
markedly around the world. Globally, there are 1.4
similar relative risk of colon malignancy as extensive
million new cases and almost 694,000 deaths estimated
ulcerative colitis, although the data are less
to have occurred in 2014 (1). Environmental and
consistent (2). There are a large number of clinical,
genetic factors can increase the likelihood of
environmental and lifestyle factors that are
developing CRC. Although inherited susceptibility
associated with a small and/or uncertain increased
results in the most striking increase in the risk, the
risk of CRC. Obesity is a risk factor for colorectal
majority of CRCs are sporadic rather than familial.
cancer and also appears to increase the likelihood of
Familial adenomatous polyposis (FAP) and
dying from CRC. Although the data are not entirely
consistent, long-term consumption of red meat or
(HNPCC) represent the most common of the familial
processed meat appears to be associated with an
colon cancer syndromes, but together these two
increased risk of CRC, particularly for the left-sided
conditions account for only about 5 percent of CRC
tumors. Cigarette smoking has been associated with
cases. Patients with a personal history of CRC or
increased incidence and mortality from CRC. Other
adenomatous polyps of the colon are at risk for the
factors include; Diabetes, alcoholism, previous
future development of colon cancer. In patients
cholecystectomy and previous abdominal exposure
undergoing resection of a single CRC, meta-
to radiation (3).
synchronous primary cancers develop in 1.5 to 3
CRC is diagnosed after the onset of
percent of patients in the first five years
symptoms or because of occult bleeding in the
postoperatively. Also, there is a well-documented
majority of patients. There are no symptoms in the
association between chronic ulcerative colitis and
majority of patients with early stage colon cancer
colonic neoplasia with the extent, duration, and
and these patients are diagnosed as a result of
Received:20 / 3 /2018 DOI: 10.12816/0047739
Accepted:30 / 3 /2018

Full Paper (vol.721 paper# 12)

c:\work\Jor\vol721_13 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3749-3752

Efficacy and Safety of Colistin for Treatment of Multidrug-Resistant
Acinetobacter Baumannii
Alharthi Khuwilid R1, Alasiri Abdullah K 2*, Alshehri Ibrahim M 3, Almutairi Masaad A4
Departments of Clinical Pharmacy
1- King Abdullah Hospital, Bishah, 2- Medina General Hospital, Medina,3- Rabigh General Hospital, Jeddah,
4- Almahd General Hospital, Medina
*Corresponding author: Alasiri Abdullah K, Mobile No.+966560050083, E-Mail: Abdkasiri@gmail.com

Antibiotic resistance of Acinetobacter baumannii causes various communicable diseases and
increases the risks of admission to intensive care units (ICUs) with high morbidity and mortality rates.
Objectives: Evaluating the efficacy of colistin usage guidelines and recommendations among critically ill patient
infected by a multidrug-resistant Acinetobacter baumannii.
Methods: An observational cross sectional study that was performed during the period from June to August
2017 among 127 critically ill patients who were treated with colistin for multidrug-resistant Acinetobacter
baumannii using bacterial culture and proper identification methods. Evaluations of CRP, bacterial culture, BUN
and serum creatinine level were routinely done pre- and post-treatment.
Results: The method of administrating colistin was through intravenous infusion among all the patients and the
most common indication of colistin usage were pneumonia followed by UTI. All the patients were susceptible to
colistin and shown a negative bacterial cultures among most of the patients. The creatinine level was elevated
(>2 mg/dL) showing nephrotoxicity among 11% of the patient. No allergic, neurological effects or mortality
rates were observed in the study.
Conclusion: The findings of the recent study revealed that colistin is the best therapeutic treatment for A.
baumannii in KSA hospitals due to their broad-spectrum activity that may make them the most important choice
for serious communicable and hospital acquired infections. Proper monitoring of the side-effects of colistin
especially nephrotoxic effects through routine evaluation of creatinine level to detect the renal injury and
adjusting the doses or combination of colistin low dose with other antibiotics.
Keywords: Colistin, Acinetobacter baumannii (A. baumannii), resistance, monitoring, critically Ill, KSA.


Bacterial resistance against antibiotics is a major
that chiefly works on the bacterial cytoplasmic
health problem around the world that impacts the
membrane of bacterial cell (4, 9).
urgent need for development of new medications
Colistin is a polymyxin E that is clinically used for
that may not be available and cost time and money
Acinetobacter (A.) baumannii (10, 11). However,
(1, 2). The resistance of gram negative bacteria
some adverse effects of colistin including renal,
outbreaks including Pseudomonas species and
pulmonary and neurological toxicities after
Acinetobacter species could result in vast
intravenous injection (12). Furthermore, some
worldwide health implications and increase
patients may suffer from gastrointestinal events,
morbidity and mortality rate (3). Acinetobacter
allergic reactions and pulmonary toxicities (13).
baumannii, (A. baumannii is a gram positive

opportunistic pathogen that causes various
communicable diseases and increases the risks of
The present study aimed to evaluate the efficacy of
admission to intensive care units (ICUs) with high
colistin usage guidelines and recommendations
morbidity and mortality rates (4-6).
among critically ill patients infected by a
The treatment of choice for Acinetobacter species is
multidrug-resistant Acinetobacter baumannii.
carbapenems medication but due to the overuse of

these medications has resulted in development of
Metallo beta lactamase (MBL) producing bacteria
Study design:
(7). Although, some antibiotics still active against
An observational cross sectional study that was
this type of bacteria (5, 8).
conducted at King Abdullah Hospital (KAH) -
The Polymyxins are being used for many years for
bishah, Kingdom of Saudi Arabia (KSA), from
treatment of Metallo beta lactamase (MBL)
June to August 2017.
producing bacteria as they consisted of 5 different
Study population:
compounds with polypeptide less toxic antibiotics
All the patients who were treated with colistin for

multidrug-resistant Acinetobacter baumannii using
Received:6 / 4 /2018 DOI: 10.12816/0047740
Accepted:15 / 4 /2018

Full Paper (vol.721 paper# 13)

c:\work\Jor\vol721_14 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3753-3761

Insulin versus Metformin in Treatment of Gestational Diabetes Mellitus
(Randomized Controlled Clinical Trial)
Hatem El Gamal 1, Mohamed Abd Elaleem 1, Sherif Sadek 2, Marwa R. Elhadary
1Department of Obstetrics and Gynecology, Faculty of Medicine, Ain-Shams University
2Department of Internal Medicine, Faculty of Medicine, Ain-Shams University
Corresponding author: Marwa R. Elhadary; Mobile: +201119975534; Email: dr_marwa2050@yahoo.com

the use of anti-diabetic drugs to control gestational diabetes (GDM) was controversial. Some
studies suggested a possible link between the use of oral anti-diabetics and fetal anomalies, fetal macrosomia
and neonatal hypoglycemia whereas others have demonstrated no such relationship. Metformin is a
biguanide hypoglycemic agent that reduces hepatic gluconeogenesis and increases peripheral insulin
sensitivity. Although it crosses placenta, metformin appears to be safe in pregnancy.
Aim of the Work: this study aimed to assess the efficacy of metformin in controlling maternal blood
glucose level compared to insulin in women with GDM.
Patients and Methods: this randomized controlled trial was conducted on 116 patients with GDM recruited
from the outpatient clinic of Ain Shams University Maternity Hospital (ASMH), Cairo, Egypt from
February, 2016 to January, 2017.
Results: macrosomic baby was significantly less frequent among metformin group than among insulin group
(p= 0.047).
Conclusion: metformin has efficacy as that of insulin in glycemic control of GDM and has the following
beneficial effects: reduction the rate of shoulder dystocia, reduction the rate of cesarean section and
reduction the rate of macrosomia more than insulin.
Recommendations: metformin is recommended as an alternative to insulin therapy in control of blood
glucose in patient with GDM when diet therapy and exercise fail to reduce blood glucose values sufficiently.
The time for metformin as an alternative treatment to insulin has come; however, it should be prescribed
after careful consideration of these patient characteristics to minimize the need for supplemental insulin.
Keywords: insulin, metformin, gestational diabetes.


Gestational diabetes mellitus (GDM) is
strongly based on the potential adverse effects of
defined as any degree of glucose intolerance with
hyperglycemia on pregnancy outcomes, and on
onset or first recognition during pregnancy, is
the effectiveness of gestational diabetes mellitus
increasing worldwide and currently complicates
treatment in preventing these outcomes (2).
up to 10% of the pregnancies. GDM is
Treatment of gestational diabetes mellitus using
characterized by insulin resistance or decreased
lifestyle advice ± supplementary insulin has
glucose tolerance, which increases throughout
shown to be effective and to significantly improve
pregnancy outcomes. Lifestyle advice (including
GDM is associated with poorer pregnancy
dietary advice and exercise) is the primary
outcomes and might have long-term implications
intervention offered to women diagnosed with
for both mother and child. Therefore, it must be
gestational diabetes mellitus. However, lifestyle
recognized precociously and appropriately
advice alone does not achieve adequate glycemic
control in up to 20% of women and needs to be
GDM is the most common cause of
supplemented with either oral hypoglycemic or
diabetes during pregnancy, accounting for up to
subcutaneous insulin (3).
90 % of pregnancies complicated by diabetes.
Self-monitoring of blood glucose is the
Women with GDM have a 40­60 % chance of
cornerstone for achieving the set targets of plasma
developing diabetes mellitus over 5­10 years after
glucose in order to reduce perinatal mortality.
pregnancy. Although GDM has been recognized
Recommendations from fourth international
as a disease for time, it remains a controversial
workshop conference on gestational diabetes
entity with conflicting guidelines and treatment
mellitus suggested lowering the capillary whole
protocols (1). Gestational diabetes mellitus is
blood glucose concentration to: pre-prandial< or =
generally asymptomatic, usually being detected
95 mg/dl and either 1h postprandial < or = 140
through systematic screening after the 24th week
mg/dl or 2h values < or = 120 mg/dl (4).
of pregnancy. Evidence to support screening for
Diet is the cornerstone of the management
gestational diabetes mellitus is indirect and
of hyperglycemia in gestational diabetes mellitus
Received:20 / 3 /2018 DOI: 10.12816/0047741
Accepted:30 / 3 /2018

Full Paper (vol.721 paper# 14)

c:\work\Jor\vol721_15 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3762-3765
Magnetic Resonance Imaging of Suspicious Ovarian Lesions
Ayman Mohammed Ibrahim, Amgad Samy Abdel-Rahman, Asmaa Hamdy Ahmed
Radiology Department, Faculty of Medicine, Ain Shams University
*Corresponding author: Name: Asmaa Hamdy Ahmed, e-mail: moazziad14@gmail.com
Characterization of an ovarian lesion represents a diagnostic challenge; the optimal assessment of
an adnexal mass requires a multidisciplinary approach, based on physical examination, laboratory tests and
imaging techniques. Diagnostic imaging plays a crucial role in detection, characterization and staging of adnexal
masses. Magnetic Resonance Imaging (MRI) is an essential problem solving tool to determine the site of origin
of a pelvic mass and then to characterize an adnexal mass, especially in patients with indeterminate lesions.
Aim of the Work:
The aim of the study is to evaluate role of MRI as a powerful and noninvasive technique
which may effectively characterize and differentiate between various suspicious ovarian lesions.
Patients and Methods: The current study is a prospective analysis that evaluated 26 female patients with 36
suspicious ovarian lesions. The study was conducted at Radiology Department of El-Demerdash hospital. The
patients were previously evaluated by ultrasound examination in the period from November 2017 to April 2018.
The patients' age ranged from 12 to 65 years old (mean age 41± 15 SD). 4 patients presented by abdominal
swelling (15%), 8 were complaining of chronic pelvic pain (30.7%), 10 came with menstrual irregularities (38%)
and 4 (15%) cases were accidentally discovered during US examination.
Results: This study included 36 ovarian lesions in 26 patients (8 cases had bilateral masses). The age in cases
with benign lesions ranged from 12 to 65 years (Mean age 37.31 ± 16.214 SD), While the age in cases with
malignant lesions; ranged from 14 to 61 years. (Mean age 44.38±14.015 SD) .
As an advanced technique, dynamic contrast-enhanced MRI (DCE-MRI) plays an important role in
tumor detection and characterization, subtyping, prediction of prognosis, treatment monitoring, and drug
Keywords: Magnetic Resonance Imaging, Suspicious Ovarian Lesions.


Ovarian masses are a common finding in
only exquisite in structural details but can also
daily clinical practice and may be incidentally
provide functional information in tumors (3).
detected or identified in symptomatic patients.

Characterization of an ovarian lesion represents a
MRI provides high spatial resolution, such
diagnostic challenge; it is of great importance in the
that morphology is very well visualized. With the
preoperative setting in order to plan adequate
aid of MRI, adnexal masses with morphologic
therapeutic procedures and may influence patient's
characteristics that are indeterminate on trans-
management. The optimal assessment of an adnexal
vaginal ultrasound can sometimes be better
mass requires a multidisciplinary approach, based
identified as benign or malignant (4).
on physical examination, laboratory tests and

imaging techniques. Preoperative biopsy should not
be performed in ovarian masses, particularly if the
The aim of the study is to evaluate role of
mass appears to be surgically resectable at the
MRI as a powerful and noninvasive technique
moment, as this invasive procedure raises the risk
which may effectively characterize and differentiate
of spreading cancer cells worsening the prognosis
between various suspicious ovarian lesions.
so , diagnostic imaging plays a crucial role in

detection, characterization and staging of adnexal
masses (1).

The current study is a prospective analysis
Magnetic Resonance Imaging (MRI) is an
that evaluated 26 female patients with 36 suspicious
essential problem solving tool to determine the site
ovarian lesions.
of origin of a pelvic mass and then to characterize
The study was conducted at Radiology
an adnexal mass, especially in patients with
Department of El-Demerdash hospital and other
indeterminate lesions (2).
private centers.
The main advantages of MRI are the high

contrast resolution with excellent soft tissue
The patients were previously evaluated by
contrast and lack of ionizing radiation exposure,
ultrasound examination in the period from
which is particularly important in young female
November 2017 to April 2018. The study was
patients (2). MRI can produce images that are not
approved by the ethical Board of Ain Shams

Received:20 / 3 /2018 DOI: 10.12816/0047742
Accepted:30 /3 /2018

Full Paper (vol.721 paper# 15)

10.11648.j.ajcem.20140204.15 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3766-3775

Combined Maternal Serum C3 Activation and Uterine Artery Doppler at 14-20
Weeks as Predictors for Pre-Eclampsia in Primigravida
Ahmed M. Abd Elwahab, Mohamed M. Gebreel, Adel A.El boghdady, Mohamed A. Khedr
Obstetrics and Gynecology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Preeclampsia is a multisystem disorder of pregnancy, which complicates 3%-5% of pregnancies in
the western world. It is a major cause of maternal morbidity and mortality worldwide. The cardinal clinical
features of the condition are hypertension and proteinuria occurring after 20 weeks gestation in women who
were not previously known to be hypertensive.
This study was aimed to assess the efficacy of C3 estimation and measurement of bilateral uterine
artery Doppler before 20 weeks of pregnancy for prediction of preeclampsia in primigravida.
: The study was performed at the Antenatal Care Unit, Obstetrics and Gynecology Department,
Sayed Galal Hospital, Al Azhar University on 131 pregnant women at 14-20 gestational weeks during period
from July 2017 to December 2017 gestation attending.
Results: On follow up the population of the study 131 pregnant women had completed the study that were
classified to 119 (90.8%) with no pre-eclampsia and 12 (9.2%) developed preeclampsia, As regards the
Patients characteristics there was no statistical significant difference between the two groups as regard age,
height, weight, gestational age, SBP and DPB at enrollment (p-value>0.05). There was a significant
difference regarding BMI as (p value < 0.05), with more increasing BMI and decreasing gestational age at
delivery in preeclampsia group in comparison with the no preeclampsia group. As regards the C3, there was
statistically highly significant difference between the two groups regarding serum C3 level as p value <0.05,
with lower levels of C3 serum levels in preeclampsia group. Receiver operator characteristics (ROC) curves
were constructed for estimating the association between pre-eclampsia and serum C3 level. A significant
association was found with serum C3 level being a significant predictor with lower values in cases with
pre-eclampsia than in normal cases [area under the curve (AUC) = 0.935, 95% CI (0.878 to
0.9711.35), best cut off (53.1), sensitivity of 83.3%, specificity of 100% positive predictive value (PPV)
of 100% and negative predictive value (NPV) of 98.3%.
Conclusion: This study demonstrates that lower level of maternal serum C3 in the early second trimester (14-20
weeks gestation) and abnormal increasing in uterine artery indices (PI and RI) are associated with developing
pre-eclampsia several months later in pregnancy.
Keywords: Predictors for Pre-eclampsia in Primigravida, Maternal Serum C3 Activation, Uterine Artery


Preeclampsia is a multisystem disorder of
the pathogenesis of the disease (2).
pregnancy, which complicates 3%-5% of pregnancies
The current theory of the pathogenesis of PE
in the western world. It is a major cause of maternal
as reviewed b y Christopher Redman and Ian
morbidity and mortality worldwide. The cardinal
Sargent is thought to occur as a 2-stage process
clinical features of the condition are hypertension
with poor placentation in the first half of
and proteinuria occurring after 20 weeks gestation
pregnancy resulting in the maternal response in
in women who were not previously known to be
the second half of pregnancy (3) .
hypertensive. Other signs and symptoms include

edema and headache, and in severe cases, the
condition is associated with seizures (eclampsia),
Study Type: Longitudinal, prospective study.
liver, and kidney dysfunction as well as clotting
Study settings: The study was performed at the
abnormalities, Adult Respiratory Distress Syndrome
Antenatal Care Unit, Obstetrics and Gynecology
and fetal growth restriction (FGR) (1).
Department, Sayed Galal Hospital, Al Azhar
Preeclampsia is one the leading causes of
University on 131 pregnant women at 14-20
maternal, as well as perinatal morbidity and
gestational weeks during period from July 2017 to
mortality, even in developed countries. Despite
December 2017 gestation attending.
intensive research efforts, the etiology and
Study population: The Study was held on 140
pathogenesis of preeclampsia are not fully
understood. Increasing evidence suggests that an
The study was approved by the Ethics Board
excessive maternal systemic inflammatory response
of Al-Azhar University.
to pregnancy with activation of both the innate and
Sample size justification:
adaptive arms of the immune system is involved in
Sample size at 140 cases, the "p" for the
Received:20 /3 /2018 DOI: 10.12816/0047743
Accepted:30 / 3 /2018

Full Paper (vol.721 paper# 16)

c:\work\Jor\vol721_17 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3776-3780

Knowledge, Attitude and Practice towards Hepatitis B Virus among
Medical Students in Tabuk City, Saudi Arabia
Saeed Awadh Al Asmari1, Shelian Juweed Alnomsi1, Fasial Dahial Dahash1,
Abdul Wahab Aliasseri1, Abdul Majeed Mohammedal Shehri1, Faisal Hammad Alatawi1,
Wafah Ammad Albalawi1 Hyder Osman Mirghani2
1Medical students, Faculty of Medicine, University of Tabuk, 2Medical Department, Faculty of Medicine,
University of Tabuk, Saudi Arabia
Correspondence: Saeed Awadh Alasmari , e-mail: dr.abdurhman777@outlook.sa


Background: Medical students are at high risk of hepatitis B during their training, and are expected to be future
doctors to acquire proper knowledge and attitude about the virus.
The aim of the work:
The present study aimed at assessing knowledge, attitude, and practice regarding
hepatitis B virus among Saudi medical students.
Materials and Methods: This cross-sectional study conducted among147clinical phase medical students during
the period from may 2017 to April 2017. A self-administered questionnaire (five components and 46 choice
questions with yes/no or yes/no/don't know) was used to assess knowledge (16 queries), attitude (18 items),
symptoms and signs (6 questions), prevention (4 questions), and treatment (two issues) . The Statistical Package
for Social Sciences (IBM, SPSS, version 20, New York) was used for data analysis. The data were presented as
percentages and mean± SD unless otherwise specified. A P-value of <0.05 was considered significant.
Results: Out of 147 medical students (51% males), their age was 22.90±1.2 years, the student's overall
knowledge was 70.54±26.51%, the knowledge regarding symptoms and complications was 83.9±9.11%, while
the prevention, treatment, and attitude scores were 67.17±20.96%, 51.7±32.66%, and 53.52±26.11%
Conclusion: The students in Tabuk had a negative attitude towards hepatitis B virus in spite of the fair
knowledge, their knowledge regarding the virus prevention and treatment were suboptimal.
Keywords: Hepatitis B virus, knowledge, attitude, practice, medical students, Saudi Arabia


Hepatitis is an inflammation of the liver, most
common form of hepatitis in Saudi Arabia with the
commonly caused by a viral infection, There are
genotype HBV/D1 was found to be the most
five main hepatitis viruses, referred to as types A,
prevalent [5]. A study conducted in Jazan[6], Saudi
B, C, D and E.[1]. Hepatitis B is a potentially life-
Arabia reported a prevalence of 1.9% among
threatening liver infection caused by the hepatitis B
premarital clinics with the males more affected than
virus. It is a major global health problem. It can
females. Hepatitis B is a cause of discrimination to
cause chronic infection and puts people at high risk
those who are carriers or infected with the virus,
of death from cirrhosis and liver cancer. The World
people are not accepting a gift, shake hands,
Health Organization (WHO) estimated that about
allowing their kids to play with, and unwilling to
240 million people have been infected with HBV
their children's marrying hepatitis B patients or
world widely [2]. It is found that 1.5 million people
carriers [7].
were killed by hepatitis B globally. Hepatitis B
Medical students are an essential sector of the
infection is common in the Middle East countries
community, they are the doctors of the near future,
compared to the United States and Europe, the
they are at risk of having blood-borne infections
prevalence varies from 0.6 in Iraq to 8% in Sudan
including hepatitis B, they should be provided with
[3].Prevalence of HBV varies greatly from place
the appropriate knowledge, and attitude to prevent
to place, depending on the mode of transmissio
and manage hepatitis B virus in the community.
Thus, this research was conducted to assess the
factors[4]. Factors that increase the risk of infecti
knowledge, attitude, and practice among the
on include unprotected sexual contact with an i
medical students in Tabuk, Saudi, Arabia.
nfected person, sharing needles and drug injecti

on equipment,sharing personal items with an inf
ected person,having direct contact with the bloo
This cross-sectional study was carried out among
the clinical phase medical students during the
touching open wounds or needle sticks, and co
period from May 2017 to April 2018.One hundred
ntact during childbirth [1] . Hepatitis B is the most
and seventeen students from a total of 210 were
Received:7 / 4 /2018 DOI: 10.12816/0047744
Accepted:16 / 4 /2018

Full Paper (vol.721 paper# 17)

Anatomy of the lumbar spine and lumbosacral region The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3781-3789

Evaluation of Left Ventricular Systolic Function by Two-Dimentional
Speckle Tracking Echocardiography in Patients With
Chronic Obstructive Pulmonary Disease (COPD)
Mohey M. Al Abbady, Ahmed M. Fahmy, Ahmed A. Mahdy, Mohamed I. Merekab
Department of Cardiology - Al Azhar University (Cairo)
Corresponding author: Mohamed I. Merekab; Mobile: 01066236782; Email: mohamedmerekab@gmail.com

Chronic obstructive pulmonary disease (COPD) is characterized by chronic airflow limitation. In
addition, COPD presents significant extra-pulmonary effects and is associated with important co-morbidities.
The main causes of morbidity and mortality among COPD patients are cardiovascular disease (CVD), lung
cancer and osteoporosis. Subclinical changes in LV systolic function that cannot be detected by conventional
LV ejection fraction (EF) can be identified by speckle tracking echocardiography for quantification of
myocardial strain and is a superior predictor of outcomes to EF. There are different mechanisms that COPD
affect LV function as physiologcal stress, ventricular interdependence, chronic hypoxia and left ventricular
hypertrophy. Aim of the Work: to evaluate LV systolic function by means of two-dimentional speckle
tracking echocardiography (2D-STE) in patients with COPD and no evidence of CVD. Patients and
This prospective study was carried out on 50 subjects of both sexes, who were presented to El
Hussein University Hospital. Subjects were categorized into two groups; 20 healthy subjects as (control) group
and 30 patients with (COPD) group. Results: The results of the study showed that there were statistically
highly significant correlations of FEV1% with GLS, PAPs and smoking pack years (p < 0.001) and significant
correlations of FEV1% with PO2 and oxygen saturation (p < 0.05). In addition, there were statistically
significant correlations of global longitudinal strain (GLS) with tricuspid annular plane systolic excursion
(TAPSI) and PO2 (p < 0.05) and PAPs and smoking pack years (p < 0.001). According to the comparison
between both COPD subgroups, group (B) COPD subjects showed higher significant correlation with GLS,
FEV1, FEV1/ FVC, PAPs and smoking pack year than group (A) COPD. Therefore, COPD severity is
significantly correlated with GLS. Conclusion: 2D-STE is a novel, fast and non invasive technique so,
clinicians can use 2D-STE to predict risk of cardiovascular morbidity in COPD patients. Recommednations: It
is recommended to perform larger- scaled study in multi-centers to assess role of 2D-STE in diagnosis LV
dysfunction in COPD patients. Other diagnostic modalities as cardiac (MRI) can be helpful for assessment of
LV function.
Keywords: ventricular systolic function, 2D speckl tracking echocardiography, COPD.

century already reporting pathological left
Chronic Obstructive Pulmonary Disease
ventricle (LV) changes found in the autopsied
(COPD), a common preventable and treatable
hearts of COPD patients (3).
disease, is characterized by persistent airflow
Speckle-tracking echocardiography (STE)
limitation that is usually progressive and
is a new non-invasive ultrasound imaging
associated with an enhanced chronic inflammatory
technique that allows for an objective and
response in the airways and the lung to noxious
quantitative evaluation of global and regional
myocardial function independently from the angle
comorbidities contribute to the overall severity in
of insonation and from cardiac translational
individual patients (1).
movements (4).
Cardiovascular events are more common in
Kalaycioglu et al. (5) evaluated LV systolic
patients with chronic obstructive pulmonary
function and its relationship with BODE index, by
disease (COPD) compared to smokers without the
means of 2D-STE in patients with COPD and no
disease. However, whether this is simply due to
evidence of CVD. The study involved 125 COPD
the higher prevalence of traditional cardiovascular
patients and 30 control subjects. All patients
risk factors (CVRF) (hypertension, diabetes
function tests and 6-minute walk tests. The
dyslipidemia) in COPD patients, or whether there
patients were divided into four quartiles according
is a particular pathophysiological connection is
to BODE index score. COPD patients had lower
still widely debated (2).
mitral annulus systolic velocity, average global
The cardiac abnormality related with COPD
longitudinal strain (GLS), average global
has traditionally been right ventricular (RV)
longitudinal strain rate systolic (GLSRs), average
dysfunction, despite publications in the last
GLSR early diastolic (GLSRe), average GLSR
Received:20 /3 /2018 DOI: 10.12816/0047745
Accepted:30 / 3 /2018

Full Paper (vol.721 paper# 18)

Cough The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3790-3793

Pulmonary Alveolar Microlithiasis in Saudi Child: A Case Report
Abdullah Al-Shamrani1, Safa Eltahir2, Gawahir Mukhtar3, Mohammed Al-Belowi4, Wadha Alotaibi5
1Prince Sultan Medical Military City (PSMMC), 2Pediatric Pulmonary Division, King Fahad Medical City
(KFMC), 3 Pediatric Pulmonary Division, KFMC, 4 Pediatric Pulmonary Fellow, KFMC, 5Pediatric Pulmonary
and Sleep Physician, Head of the Pulmonary Unit, KFMC, KSA
Corresponding author: Abdullah Al-Shamrani, Email: Shamrani999@hotmail.com, Orcid.org/0000-0001-7157-1706 ,
Mobile no.: 00966553367555
Background: Pulmonary alveolar microlithiasis (PAM) is a rare but not uncommon disease; it showed
worldwide distribution either familial or sporadic, the most reported cases in Europe, especially in Turkey. The
presence of round shaped little bodies containing concentric calcareous lamellas in pulmonary alveolus is the
hallmark of the disease. With this study, we report a case of PAM in Arabic descent, a Saudi child, who
represented the most characteristics of the disease in dissociation between definite radiological pattern of the
lungs and relatively poor clinical symptoms. Case Presentation: A-9-year-old Arabic female, presented with
occasional nonproductive cough for one year, the patient suspected milliary TB and received antituberculous
therapy. Examination: Revealed well pleasant child with finger clubbing and clear chest. The patient followed
for two years, with marginal deterioration in her general condition. Conclusion: Here, we reported a sporadic
case of PAM in Saudi child that presented with nonspecific clinical picture, which resulted in misdiagnosis and
consequently improper management. The case proves the slowly progression of the disease.
Keywords: Pulmonary alveolar microlithiasis. PAM, Saudi origin, Pediatrics.


Pulmonary Alveolar Microlithiasis (PAM) is a
precipitating or relieving factors for one year. The
rare but not uncommon disease, it showed a
patient suspected to be a case of miliary TB for
worldwide distribution (1), it is caused by mutation
which she received anti-TB therapy for almost 3
of the SLC34A2 gene encoding type IIb sodium
months with no improvement. Family history did
phosphate receptor in the alveolar type II cells,
not show similar or respiratory chronic conditions.
sporadic cases were reported too (2). The presence
On examination, the patient was well
of round shaped little bodies containing concentric
pleasant with positive finger clubbing grade 1, no
calcareous lamellas in pulmonary alveolus is the
lymph adenopathy, positive BCG scar. Vital signs
hallmark of the disease (3). Although it is common
were within normal, with a clear chest on
between 20-30 years of age but pediatric and
auscultation. The chest X-ray (Fig. 1) showed-
neonatal cases were reported (Mariani with Lopez
diffuse micro nodular opacity in both lungs
(4). It affects both genders equally.PAM considered
predominantly in the mid zone, bilateral pleural and
idiopathic in spite of the various etiological theories
fissure calcification, RUL paratracheal cystic
that were reported in the literature. Genetic theory
changes with calcified walls, normal cardiac
was the most accepted one, with autosomal
silhouette, no pleural effusion or pneumothorax.
recessive mode of inheritance. Genetic analysis
CT scan chest (Fig. 2 L &R) showed multi
revealed that there is heterogeneous mutation of
centerilobular nodules predominantly in the mid
SLC34A2 gene, which is responsible for the
and lower zone bilaterally, areas of bullous
familial PAM (5). The most characteristics of the
emphysema in RUL lobe with calcified walls,
disease is disassociation between definite x-ray
Pleural and fissure calcification.
pattern of lungs and relative poor clinical
Her PFT has showed FEV1 80%predicted,
symptoms. PAM showed varies scenarios and
FVC 76% predicted, ratio of FEV1/FVC was
clinical presentations that may make it undiagnosed
normal, overnight pulse oximeter was normal with
for a long time. Moreover, being rare it usually
nocturnal hypoxemia.
comes at the bottom list of differential diagnosis
Diagnosis confirmed by opened right lung
that may further delay early diagnosis. The disease
biopsy and Broncho alveolar lavage, biopsy
is a progressive disease and can lead to serious
showed numerous lamellar (Calculi) ( Fig. 3 ), no
significant fibrosis, no eosinophilia or evidence of
hypertension (6).
vasculities, no fungi, no acid fast bacilli(AFB), no

A 9 years old Arabic female presented with

occasional cough that is dry without any
Received:8 / 4 /2018 DOI: 10.12816/0047746
Accepted:17 /4 /2018

Full Paper (vol.721 paper# 19)

c:\work\Jor\vol721_20 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3794-3805
Using Pregabalin for Prevention of Post Anesthesia Shivering
Mohamed Zein El-Abedin, Hamed Sanad, Usama Ibrahim, Amgad El Khayat
Department of Anesthesia and Intensive care, faculty of medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author Mohamed Zein El-Abedin, E-Mail: mohamedzein482@gmail.com, 00201069352350

: post anesthesia shivering (PAS) is one of the most common complications after surgeries. There
are two methods to reduce the shivering, including pharmacological and non-pharmacological methods.
Aim of the study: the present study compared the efficacy and safety of 150 mg oral pregabalin premedication
on preventing PAS, perioperative core body temperature changes, hemodynamic stability and postoperative
complications. Patients and methods: this prospective, observational study consisted of 200 adult patients
scheduled for general, orthopedic or ENT surgery. The patients were randomized into two groups of 100 patients
each. Group I received 150 mg of oral pregabalin, group II received an oral placebo 60-90 min before operation.
All patients were assessed for perioperative hemodynamic changes, Core body temperature changes, PAS,
amount of pethidine used and postoperative side effects. Results: regarding the efficacy of the preoperative
administration of oral pregabalin, the current study reports valuable preventive effect on shivering for pregabalin
group (8.1%) compared to control group (44.3%), and there was highly significant difference between both
groups according to incidence and scoring of shivering. On the other hand we found no significant difference
between groups according to heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP).
However reduction in SBP and DBP was recorded in both groups after induction which became back up at the
end of surgery. Also tympanic temperature reduction was recorded intraoperatively and came back up during
recovery period with no statistically significant differences between groups. Postoperative nausea and vomiting
were significantly lower with the administration of pregabalin compared with the placebo group. Additionally,
pregabalin increased the incidence of dizziness, blurred vision and drowsiness.
: oral pregabalin premedication adequately prevent PAS but could not affect its timing nor mean dose
of pethidine used. Additionally, oral pregabalin reduced postoperative nausea and vomiting but increased
significantly the incidence of dizziness, blurred vision and drowsiness.
Keywords: Pregabalin, Premedication, Post anesthesia shivering


Postoperative shivering is one of the most
Pregabalin is a GABA analogue; it was
common complications after surgeries, which is seen
introduced and approved by FDA in 2005 for clinical
among 6.3-65% of patients and include involuntary
use. It has analgesic, anticonvulsant, anxiolytic, and
movements of one or more groups of muscles.
sleep-modulating activities. It reduces excitability of
Shivering can cause many side effects such as
dorsal horn neurons after tissue damage. Pregabalin
increased oxygen consumption, carbon dioxide
has been proven to improve various aspects of
production, heart rate, and blood pressure, resulting
recovery after surgery. It has high oral bioavailability
in exacerbation of ischemic heart disease, as well as
(90%), more rapid absorption (peak plasma level: 1
increased intracranial pressure, pain at the surgical
hr.) and linear increase in plasma concentration when
site, and also a sense of discomfort to the patient (1).
its dose is increased. Pregabalin is associated with a
General anesthesia facilitates redistribution of the
significant reduction in pain scores at rest and during
temperature from the central tissues to the peripheral
movement and also reduction in opioid consumption
tissues. Due to anesthesia, core temperature
at 24 h of surgery compared with placebo. Patients
regulation responses like the vasoconstriction
receiving pregabalin have less postoperative nausea
threshold are controlled, and most anesthetic drugs
and vomiting and pruritus compared with placebo (4).
cause peripheral vasodilatation (2).
The use of Pregabalin in the perioperative setting has
Shivering could be the result of hypothermia
been evaluated in many studies. These studies report
readjustment of body core temperature during
promising reductions in postoperative morphine
surgery, or because of fever and shivering, which
consumption but none of these studies have used a
could lead to activation of the inflammatory response
comprehensive scoring system to assess impact on
and cytokine release (3). There are two methods to
postoperative shivering (5-7). Ozgencil et al. (8)
reduce the shivering, including pharmacological and
reported that although postoperative shivering was
non-pharmacological methods. Non-pharmacological
not part of their original study design, it was
methods involve the use of moisturizers, preventing
apparent in the course of the study that incidence of
hypothermia using warm blankets, and warm and
shivering differed among the groups, patients in the
moist oxygen inhalation (1).
placebo group were found to experience more
Received:3 / 4 /2018 DOI: 10.12816/0047747
Accepted:12 /4 /2018

Full Paper (vol.721 paper# 20)


Evaluation of Staging Accuracy of Dynamic MRI in Urinary Bladder Cancer
Hany Mustafa Abdallah, Mohamed Samir Sayed, Ahmed Mohsen Ibrahim Saif
Department of Urology, Faculty of Medicine, Ain Shams University
*Corresponding author: Ahmed Mohsen Ibrahim, E-mail address: Ahmmohsen2000@gmail.com , Mobile no: 01019789296

Urinary Bladder cancer is the second most common neoplasm of the urinary tract worldwide. It
accounts for 6-8 % of malignancy in men and 2-3% in women with the highest incidence rates in North
American and Europe as well as areas with endemic schistosomiasias in Africa and the middle east.
Purpose: To show the staging accuracy of Dynamic MRI in urinary bladder carcinoma.
Patients and Methods:
This is a Prospective randomized clinical study, study setting: Radiology and Urology
Departments, Faculty of Medicine, Ain Shams University, study period: 6 months from August 2017 till
February 2018.
Results: This study conducted on 20 patients (17 male and 3 females) with age ranged from 42 ­ 78 years and
with mean±SD of 55.95±9.01 years. 4/20 patients (20.0%) were presented to TURT procedure while 16/20
patients (80.0%) were presented to radical cystectomy.
Conclusion: In this study, despite small differences between the results of the MRI and pathology, Dynamic
MRI was found to be an accurate modality for assessment of tumor staging, and its routine use in bladder
cancer staging can lead to significant improvement of diagnostic accuracy of the staging and treatment
planning and hence improvement of the prognosis of the patients and their survival rates. Furthermore, the use
of Dynamic MRI systems with higher magnetic field and imaging techniques standardized with higher
resolution could further enhance the accuracy of the method. Further studies with larger sample size may also
help to validate the results of this study.
Keywords: Dynamic MRI - Urinary Bladder Cancer - Conventional Computed Tomography.

- Exclusion Criteria:
Conventional computed tomography (CT)
1. Patients with urinary bladder mass and unfit
and magnetic resonance (MR) imaging are only
for operation.
moderately accurate in the diagnosis and local
2. Patients with metastatic deposits to urinary
staging of bladder cancer, with cystoscopy and
pathologic staging remaining the standards of
3. Patients have contraindications for MRI:
reference. However, the role of newer MR imaging
Patients With:
sequences (e.g, dynamic MRI) in the diagnosis and
a) Implanted electric and electronic devices.
local staging of bladder cancer is still evolving and
b) Heart pacemakers.
has a great participation to optimize treatment (1).
c) Insulin pumps.
Dynamic MRI has the ability to
d) Implanted hearing aids.
differentiate between invasive from non invasive
e) Intracranial metal clips.
urinary bladder cancer, organ confined from non
4. Patients with renal impairment.
organ confined bladder cancer and to identify
5. Patients
lymph node metastasis (2).
revealed to have no bladder cancer were
Staging of urinary bladder cancer using
retrospectively excluded.
MRI has a great outcome in plans of management.
Sampling Method: Randomized clinical study.
It has high efficacy in determination the extent of
Sample Size: 20 patients.
tumor, organ metastasis and lymph node metastasis
Ethical Considerations: approval was obtained
from the ethical committee at Ain Shams
University before starting the research and all
patients were consented to be included in this study
Type of Study:
Prospective randomized clinical study
after explanation of the study procedures and the
follow up course.
Study Setting:
Radiology and Urology Department,
Study Procedures: Patients with urinary bladder
Faculty of Medicine, Ain Shams University
mass in pelviabdominal ultrasound were undergone
Study Period: 6 months from August 2017 till
MRI and results were compared with pathology of
February 2018.
specimens of the patients that had transurethral
resection of the urinary bladder mass and the
Study Population:
- Inclusion Criteria: patients with urinary
patients of cystectomy according to staging of the
bladder mass in pelviabdominal ultrasound.
Received:20 /3 /2018 DOI: 10.12816/0047748
Accepted:30 /3 /2018

Full Paper (vol.721 paper# 21)

c:\work\Jor\vol721_22 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3812-3815

Variation in Morphology of Soft Palate Using Cone-Beam
Computed Tomography in Sakaka Population
Shaliputra Magar, Abdulkarim Owaid Alanazi, Abdulrahman Jaber Alrwuili,
Ahmed Tawireg Al Fuhaiqi, Yunus Kassab Alruwaili
College of Dentistry, Aljouf University, KSA
Corresponding author: Shaliputra Magar, Tel. 00966568522659, Email: shaliomdr@gmail.com


Objective: The aim of the present study was to investigate the variation in morphology of soft palate in age
groups and gender using CBCT in Sakaka population.
Study design: The study sample consisted of 240 CBCT scans aged between 15 and 45 years. The velar
morphology on CBCT was examined and grouped into six types. The results obtained were subjected to
statistical analysis to find out the association between variants of the soft palate with gender and different age
Results: The most frequent type of soft palate was Rat tail shaped. (46.25%) followed by Leaf shape, 18.75%
Butt shape, 13.33% and Handle shape, 10%. S-shape7.5% and Crook shape, was 4.1%. There was no
significant difference between Males and Females.
Conclusions: The knowledge of a varied spectrum of velar morphology and the variants of the soft palate assist
in the better understanding of the velopharyngeal closure and craniofacial anomalies.
Keywords: Soft Palate, Morphology, cone -beam computed tomography.

practical application in today's patient care and
The posterior fibro-muscular part of the palate
dental education environment (5). It has added
which is attached to the hard palate is called soft

palate (1). The palate is formed by the fusion of three
advantages over other radio diagnostic techniques as
components, namely two palatal processes and the
it gives three-dimensional view of an object, correct
primitive palate, which is formed by the front nasal
identification of landmarks as compared to lateral
process. At a later stage, the mesoderm in the palate
cephalogram which gives two-dimensional view of
undergoes intra-membranous ossification to form the
an object (6). The linear measurements that were
hard palate (2). However, the ossification does not
made from CBCT images were not significantly
extend into the most posterior portion, which
different from the actual direct measurements of
remains as the soft palate.
anatomic structures in the dento-maxillofacial area
Soft palate isolates the mouth from oropharynx
during swallowing so that breathing is unaffected,
According to our knowledge, no studies have
the quality of voice can be modified and consonant
been done to determine the varied soft palate
can be correctly pronounced by the closure of the
morphology and configuration using CBCT.
pharyngeal isthmus (2).

There have been various studies carried out
showing variation in morphological patterns of soft
The aim of the present study was to investigate
palate. All the studies were carried out using lateral
the variation in morphology of soft palate in
cephalogram. You et al. observed the image of the
different age and gender groups, and to examine its
velum on lateral cephalograms and classified them
association with, age groups and gender using
into six morphological types (Type 1: leaf shaped;
CBCT in Sakaka population.
Type 2: rat tail; Type 3: butt like; Type 4: straight

line; Type 5: S-shaped and Type 6: crook shaped) (3).

A retrospective study was conducted at
Pepin etal. found that the "hooked or S-shaped"
department of Oral Radiology of our institute. Two
appearance of the soft palate in awake patients
hundred and Forty CBCT scans of healthy
indicated a high risk of the obstructive sleep apnoea
individuals within the age range of 15-45 years were
syndrome (4).
retrospectively selected from the daily outpatients

visited the department from January 2017 to March
Recent advances in radio diagnostic technique
2018. Patients below 15 years and above 45 years of
like CBCT (Cone Beam Computed Tomography)
age and scans of patients showing cleft palate, soft
have allowed its commercial production and
palate syndromes and fractures of the head and neck
were excluded.
Received:3 / 4 /2018 DOI: 10.12816/0047749
Accepted:12 /4 /2018

Full Paper (vol.721 paper# 22)

c:\work\Jor\vol721_23 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3816-3822

Congenital Diaphragmatic Hernia Management and Outcomes:
A Simple Literature Review
Alanazi Waleed Shuwayyikh S1, Abdullah Shafi Almutairi2, Zahra Mohammed Al-Yousef3, Mohammed
Ibrahim Taleb4, Mohammed Saaduddin Sahibzada5, AlaaMutlaq Alshareef5, Sarah khalil Al-Otaibi5,
AsmaMutni Al-Mutairi6,Deem Hatim Al-Fandi7, Sarah Ahmed Al-Dawood8
1- Aljouf University 2- Almajmaah University 3- Alfaisal University 4- Al-Rajhi Colleges 5- IbnSina National
college 6- Qassim University 7- Al-Maarefa Colleges 8- Imam Abdulrahman Bin Faisal university

Congenital diaphragmatic hernia (CDH) is considered as one of the most common congenital
anomalies. As a result, significant literatures have been done to assess the different management procedures and
outcomes of each. Assessment of these literatures will support in providing better outcomes for the patients.
Objective: Aim of the study : Assessment of different management plans of CDH, and the outcomes related. In
addition to providing scientific references for analyzing all the clinical studies in this field. Methods: PubMed
database was used for articles selection. We included all relevant articles to our review with the following topics:
Congenital Diaphragmatic Hernia, Management, Outcomes, Morbidity, and Mortality. We excluded other articles
which are not related to this field. The data were extracted according to specific form to be reviewed by group
members to assess the different procedures, and the outcomes. Conclusion: Congenital Diaphragmatic Hernia has
high complexity regarding its management. Prenatal screening is important because early diagnosis is helpful either
in family education about the condition and its prognosis or in the decision regarding prenatal intervention. Smoking
and alcohol intake are modifiable risk factors of CDH and their complications like prematurity, which is associated
with high incidence of morbidity and mortality. Resolution and improvement of pulmonary hypertension either with
or without treatment in the first 2-3 weeks was a major indicator of good prognosis of the case. Minimally invasive
techniques showed lower rate of complications than open surgeries either prenatally like FETO or postnatally like
thoracoscopic CDH repair. In addition, Hernia repair after decannulation from ECMO showed lower bleeding
complications than repair on ECMO.

spectrum of severity in patients with CDH is
Congenital diaphragmatic hernia (CDH) is considered
dependent on the degree of pulmonary hypoplasia and
as one of the most common congenital anomalies with

a frequency of 1/2200 live births1. CDH can present at
pulmonary hypertension. Presently, delivery of infants
posterior lateral (Bochdalek 95%) and anterior
with CDH is recommended to be close to term
(Morgagni defects). Eighty-six percent of Bochdalek
gestation. The focus of care includes gentle
defects are left-sided, 13% right-sided, and up to 2%
ventilation, hemodynamic monitoring, and treatment
bilateral2. CDH is further classified as either isolated,
of pulmonary hypertension followed by surgery for
syndromic or associated with other anomalies. In its
the defect.
isolated form, CDH leads to two neonatal problems:
Despite advances in neonatal and surgical care, the
(1) the anatomical yet surgically correctable
management of congenital diaphragmatic hernia
diaphragmatic defect; and (2) the coinciding
(CDH) remains challenging with no definitive
pulmonary hypoplasia. The latter is the result of
standard treatment guidelines. In this paper we will
disturbed lung development, which starts in the
be focusing upon reviewing the management, and
embryonic period. As pregnancy continues, viscera
outcome of CDH that have been reached in the last 5
herniate into the chest, and compete for space with the
developing lungs. CDH lungs have fewer airway

branches, smaller cross-sectional area of pulmonary
vasoconstriction with altered vasoreactivity. A patient
PubMed was chosen as the search database for the
with severe CDH is highly sensitive to hypoxemia,
articles selection, because it is one of the major
hypotension, acidosis, and even environmental
research databases within the suite of resources that
stimulation, which can precipitate pulmonary
have been developed by the National Center for
vasospasm and shunting episodes. The broad
Biotechnology Information (NCBI). The following

Received:4 / 4 /2018 DOI: 10.12816/0047750
Accepted:13 / 4 /2018

Full Paper (vol.721 paper# 23)

c:\work\Jor\vol721_24 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3823-3826

Results of Laparoscopic Varicocelectomy
Abdel Salam Amer Emad, Mohammed Hasan Elkaseer, Ahmed Hosam Eldin Hasan Abbas*
El-Sayed Galal University Hospitals, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Name: Ahmed Abbas, E-Mail: ahmedplasticsurgeon@yahoo.com, Mobile no.: 01062545890

varicoceles are one of the most commonly identified scrotal diseases. their prevalence in the
normal adult male population is 15-20% &they are thought to be the most common treatable cause of male factor
infertility. a variety of surgical & non-surgical approaches have been advocated for varicocelectomy. objective: to
make a follow-up for the results of laparoscopic varicocelectomy after 3 & 6 months. Patients and methods: a
total of twenty male patients, presented with history of primary infertility or pain or both and have varicocele
(30% left-sided & 70% bilateral), were included in the study. laparoscopic varicocelectomy was done between
march 2016 and december 2017.we made a follow-up after 3 & 6 months by clinical examination, semen analysis
& colored-doppler ultrasonography. Results: mean operation time was 40 min. (range 22-58 min.). the hospital
stay was one day for all patients. return to normal activities was from 2-3 days. 25% of patients have
postoperative scrotal emphysema. 20% of patients had recurrence & 10% had hydrocele. there was no
postoperative testicular atrophy in any of the patients. during the follow-up period (6 months), there was
improvement in the seminal fluid parameters in 85% of patients. Conclusion: although sooner return to work, less
postoperative pain, more accessibility to both sides from small incisions are achieved by laparoscopic
varicocelectomy, recurrence & hydrocele are more frequent than with the open method.
hydrocele, laparoscopy, male infertility, recurrence, varicocele


Varicocele is an abnormal enlargement or
grade II varicocele while 25% had grade III
dilatation of the internal spermatic vein and the
varicocele. Radiologically, all the patients had grade
pampiniform venous plexus of the testis due to the
III varicocele. Semen analysis was normal in 30% of
inversion of venous blood flow within the spermatic
patients while it showed stress-pattern in 70% of
cord (1). It affects approximately 15-20% of the
patients. Any patient having 2ry varicocele, other
normal adult population. Its prevalence among men
testicular problems as inguinal hernia, hydrocele or
with 1ry male factor infertility is approximately 35%,
testicular tumors or atrophy, previous testicular or
while 70-85% of men with 2ry Infertility present with
inguinal operations or major abdominal surgery was
this condition (2). Although varicocele ­associated
excluded from this study. Investigations for diagnosis
infertility is not fully understood, impaired semen
as colored-Doppler ultrasonography, semen analysis,
analysis in varicocele patients and its improvement
hormonal assay were done. Also CBC, prothrombin
after varicocelectomy are two major evidences that
varicocele has a direct impact on male fertility (3).
ultrasonography were done for preoperative fitness.
With the advent of modern endoscopic surgery,
The indications for varicocelectomy were 1ry,
the technique of laparoscopic varicocelectomy has
2ryinfertility and pain.
progressively improved (4). To establish the

complications and failure rates, we analyzed the
Ethical Issues
laparoscopic results of 20 patients who underwent
Informed consents were taken from all of the
this procedure to repair varicocele after 3&6 months.
patients included in our study. The study was

approved by the Ethics Board of Al-Azhar
A total of 20 male patients with 1ry varicocele were

included in this descriptive study from Al-Azhar
Surgical Technique
University Hospitals and Minia Health Insurance
All the patients included in this study underwent
Hospital. 30% of them had left-sided varicocele &
70% had bilateral varicocele. Their ages ranged
anesthesia. The patient was placed in Supine and
between 18 & 36 years (mean 25). 50% of patients
slight Trendelenburg for laparoscopic entry. Bladder
were complaining of pain, 15% of them were
emptying before abdominal entry was done (have the
complaining of 1ry infertility while 35% were
patient void just before induction to avoid the need
complaining of both. Clinically, 75% of patients had
for urethral catheterization).
Received: 7/ 4 /2018 DOI: 10.12816/0047751
Accepted:16 /4 /2018

Full Paper (vol.721 paper# 24)

Computerized tomographic study of the normal dimensions of the anterior horn of lateral ventricle in adults The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3827-3834

Prophylactic Carbetocin during Elective Caesarean Section in
High Risk group for Atonic Postpartum Hemorrhage
Mohamed Mohamed Gebreel, Mohamed Ali Mohamed, Alaa Shahat Elsayed
Obstetrics and Gynecology Department, Faculty of Medicine, Al-Azhar University
: Postpartum hemorrhage (PPH) is defined as a blood loss more than 500 ml and serious PPH as a
blood loss more than 1,000 ml. PPH is a serious condition remaining the single main cause of maternal
morbidity and mortality. Postpartum hemorrhage (PPH) accounts for nearly one-quarter of all maternal deaths
worldwide and was the second most frequent cause of maternal death in the UK for the 2000­2002 trienniums.
The most frequent cause of PPH is uterine a tony, contributing up to 80 % of the PPH cases. Although
two-thirds of the PPH cases occur in women without predisposing factors, there are several risk factors for
PPH such as previous PPH, preeclampsia, coagulopathy, multiple gestation and antepartum hemorrhage. Also
cesarean section (CS) is a recognized risk factor for PPH and its prevalence is increasing .The administration
of oxytocics after the delivery of the neonate reduces the like hood of PPH and 5 IU oxytocin by slow
intravenous injection is currently recommended in the UK for all cesarean sections. However, the use of
additional oxytocic medication is common to arrest bleeding, or prophylactically if there are risk factors for
PPH. Oxytocin is currently the uterotonic of first choice. It has proven to decrease the incidence of PPH by 40
% and has a rapid onset of action and a good safety profile . A disadvantage of oxytocin is its short half life of
4­10 min, regularly requiring a continuous intravenous infusion or repeated intramuscular injections.
Objectives: was.to evaluate role of carbetocine either i.v or intramyometriam in preventing postpartum
haemorrhge. Patients and methods: this was Randomized controlled double blind study was held at sayed
galal hospital department of obstetrics and gynecology between April 2016 to October 2017 .
Results: We observe fall in rate of atonic postpartum haemorrhage after administration of carbetocin either i.v.
or intramyometriaum . we found diferrance in blood pressure between two group weher increase og blood
pressure in group received carbetocine i.v. .Also we found difference between two group need for additional
dose which increase in goup that received carbetocine intramyometraim.
Conclusion: Adminstration of carbetocine either i.v. or intramyometriaum decrease rate of atonic post partum
haemorrhage in high risk group for atonic postpartum haemorrhage.
Keywords: Prophylactic Carbetocin during, Elective Caesarean, Atonic Postpartum Hemorrhage.

injection is currently recommended in the UK for
all cesarean sections (3) .However, the use of
Postpartum hemorrhage (PPH) is defined as
additional oxytocic medication is common to arrest
a blood loss more than 500 ml and serious PPH as
bleeding, or prophylactically if there are risk
a blood loss more than 1,000 ml. PPH is a serious
factors for PPH (4). Oxytocin is currently the
condition remaining the single main cause of
uterotonic of first choice. It has proven to decrease
maternal morbidity and mortality.
the incidence of PPH by 40 % and has a rapid onset
Postpartum hemorrhage (PPH) accounts for
of action and a good safety profile (5).
nearly one-quarter of all maternal deaths
A disadvantage of oxytocin is its short half life of
worldwide (1) and was the second most frequent
4­10 min, regularly requiring a continuous
cause of maternal death in the UK for the 2000­
intravenous infusion or repeated intramuscular
2002 trienniums(2). The most frequent cause of
injections (6). Carbetocin (Pabal) is a long-acting
PPH is uterine a tony, contributing up to 80 % of
oxytocin analogue indicated for the prevention of
the PPH cases. Although two-thirds of the PPH
uterine atony after child birth by CS under epidural
cases occur in women without predisposing factors,
or spinal anesthesia. Carbetocin has a rapid onset
there are several risk factors for PPH such as
of action (within 1­2 min) and a prolonged
previous PPH, preeclampsia, coagulopathy,
duration of action (approximately 1 h) because of
multiple gestation and antepartum hemorrhage.
sustained uterine response with contractions of
Also cesarean section (CS) is a recognized risk
higher amplitude and frequency. Its safety profile
factor for PPH and its prevalence is increasing .
is comparable to that of oxytocin .
The administration of oxytocics after the
The current pharmacological policy for the
delivery of the neonate reduces the like hood of
prevention of PPH is oxytocin. Most hospitals use
PPH and 5 IU oxytocin by slow intravenous
a bolus of oxytocin 5 or 10 IU; some add an
infusion of oxytocin for a couple of hours.
Received:20 /3 /2018 DOI: 10.12816/0047752
Accepted:30 /3 /2018

Full Paper (vol.721 paper# 25)

c:\work\Jor\vol721_26 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3835-3838
Serum Zinc Level in Children with Acute Lower Respiratory Tract Infection
Mohamed Yosri Shaheen, Hesham Ahmed Mohammed Aly, Nabil Fathy Esmael,
* Wael Taha Ebrahem Hendawy
Departments of Clinical Pathology, Bab Al-Shearia University Hospital,
Al-Azhar Faculty of Medicine
*Corresponding author: * Wael Taha Ebrahem Mohammad Hendawy , E-Mail: waeltaha556@gmail.com, Mobile: 01064383556

: Pediatric respiratory disease remains an important cause of morbidity in both the developing and the
developed world. Pneumonias and inflammatory process develops in alveoli and interstitium as a response to infection-
causing factors such as bacteria and viruses. Since pneumonia in infancy is difficult to discriminate from acute
bronchiolitis, the term acute lower respiratory tract infection (ALRTI) inclusive of these both diseases is used. Zincis a
micronutrient with important roles in growth and in the immune, nervous and reproductive systems. Regular dietary
intake of zinc is necessary because the human body cannot produce zinc and does not have an adequate mechanism for
storing or releasing it.
Objective: was to evaluate serum zinc level in children with ALRTI.
Patients and Methods: Serum zinc level in children with ALRTI. 80 patients (subdivided into 3 groups according to
severity of infection) compared to 20 normal individuals were included in this study.
Results: there was highly statistical significant difference between all patients and control groups as regard serum zinc
level (mean of serum vitamin D level in patients and control groups were 56.413 ±29.474 and 90.135 ± 17.345
respectively, p=<0.0001).
Conclusion: Zinc deficiency occurs in the majority of recurrent respiratory infection in children and therefore a
decreased serum zinc level is considered an additional risk factor for recurrent respiratory infection.
Keywords: Zinc Level, Children, Lower Respiratory Tract Infection.


Acute lower respiratory tract infection
both cell-mediated and humeral immune responses. It
predominantly pneumonia is a substantial cause of
has a fundamental role in cellular metabolism, with
morbidity and mortality(1).
profound effects on the immune system and the
It is the leading cause of mortality and a
intestinal mucosa(5,6).
common cause of morbidity in children below five
In 2009, a systematic review of studies
years of age. In developing countries an estimated 146­
evaluating preventive effects of zinc supplementation
159 million new episodes of pneumonia are observed
on the morbidity burden of ALRI noted an overall
per year(2).
reduction of 15-21% in the incidence of ALRI among
Zinc is an essential antioxidant mineral that is
zinc-supplemented preschool children(7).
involved in numerous aspects of cellular metabolism. A
This study was performed to evaluate the relation
potent antioxidant can act against inflammation and
between zinc deficiency and acute lower respiratory
prevent the resulting tissue injury(3).
tract infections in children.
Zinc deficient children are at increased risk of

restricted growth, developing diarrheal diseases and
respiratory tract infections. It is thought to decrease
susceptibility to ALRTI by regulating various immune
This study was conducted in collaboration between
functions including protecting the health and integrity
the Clinical Pathology and Pediatric departments at Bab
of respiratory cells during lung inflammation and
Al-Shearia University Hospital, Faculty of Medicine,
injury. Supplementation of zinc could reduce the risk of
Al-Azhar University.
pneumonia and the risk and duration of diarrhea,
The study was approved by the Ethics Board of
dysentery and malaria deaths among all infectious
Al-Azhar University.
diseases, and they accounted for 3.9 million deaths
All patients were collected from Pediatric
department at Bab Al-Shearia University Hospital over
Zinc deficiency decreases the ability of the
a period from 8th January 2018 to 5th March 2018, with
body to respond to infection and also adversely affects
appropriate consent to participate in this study after
Received: 4/ 4 /2018 DOI: 10.12816/0047753
Accepted:13 / 4/2018

Full Paper (vol.721 paper# 26)

Clinical Intervention for Maternal Near Miss cases in El Galaa Teaching Hospital The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3839-3845

Clinical Intervention for Maternal Near Miss Cases in
El Galaa Teaching Hospital
Mohamed Taher Ismail, Mohamed Cherine Ramadan,
Ahmad Shaaban Mohamed, Ahmed Moataz Elshishini
Obstetrics and Gynecology Department, Faculty of Medicine, Al Azhar University
Corresponding author: Ahmed Elshishini, email: ahmedshishini88@gmail.com, mobile: 00201275702080

Near miss cases share many characteristics with maternal deaths and can directly inform about
obstacles that had to be overcome after the onset of an acute complication, hence providing valuable
information on obstetric care. This allows for corrective action to be taken on identified problems to reduce
related mortality and long-term morbidity.
Objective: The purpose of this study was to determine the efficacy of possible interventions (in the form of
monthly clinical audit for new near miss cases and feedback strategy) in reducing maternal near miss cases in
El Galaa Teaching Hospital in Egypt and improving WHO indicators of maternal health.
Methods: The study was conducted over 3 stages: Stage I (Formative Stage): Is a retrospective study of
maternal near miss cases over 1 year period, based on WHO criteria from 1/1/2016 to 1/1/2017. Stage II
(Intervention stage): This incorporated a monthly clinical audit for new near-miss cases and feedback
strategy, using WHO case report forms, as well as engagement of opinion leaders for 1 year from 1/1/2017 to
1/1 2018 with 2 to 3 cases discussed monthly. Stage III (Assessment Stage): Evaluating the clinical
performance and frequency of near miss cases after intervention.
Results: In this study, the majority of women with potentially life threatening conditions were referred from
private obstetrician clinic, private hospitals and Ministry of Health to El Galaa hospital. The majority of
Maternal near miss cases (67.9%) gave birth by Caesarean section, this was because of the severity of these
patients' obstetric conditions usually requires urgent action. The main life threatening conditions among
women in this study were hypertensive disorders of pregnancy 41% (24% Pre-eclampsia, 15% Eclampsia, 2%
chronic hypertension).
Conclusion: Our intervention (near miss clinical audit) helped to improve the performance and quality of care
provided to women with complications during pregnancy, as reflected on the maternal health outcome
indicators. Therefore we recommend incorporating clinical audit process in all health facilities. The Maternal
mortality index and Maternal near miss mortality ratio, two of the indicators recommended by WHO, can be
used to monitor and assess the performance and health care level. Health managers and policy makers should
use maternal health outcome indicators for allocation of resources and prioritization of investments.
Keywords: Maternal near miss ­ Maternal mortality ­ Maternal morbidity.


an adjunct to investigation of maternal deaths
The global maternal mortality ratio is
since they represent similar pathological and
210/100,000 births while it is about 240 in
circumstantial factors leading to severe maternal
developing countries as compared to 14/100,000
outcome 2. Near miss cases share many
in developed countries. Most of the deaths and
characteristics with maternal deaths and can
disabilities attributed to childbirth are avoidable,
directly inform about obstacles that had to be
because the medical solutions are well known.
overcome after the onset of an acute
Indeed, 99% of maternal deaths occur in
developing countries that have an inadequate
information on obstetric care. This allows for
transport system, limited access to skilled care-
corrective action to be taken on identified
givers and poor emergency obstetric services 1.
problems to reduce related mortality and long-
A new concept to investigate the cause of
term morbidity 3.
this high variation level in different countries was
Internationally, there is increasing focus
introduced by the World Health Organization as
on maternal near-miss case; Women who
maternal near miss defined as "a woman who
experienced a near miss event can be interviewed
nearly died but survived a complication that
ability to obtain women's perspectives about
occurred during pregnancy, childbirth or within
the care and the obstacles faced. It is a success
42 days of termination of pregnancy.", based on
story A woman herself can be a source of data.
markers of management and organ dysfunction as
Assessing the near miss cases reflects the

quality of care 4.

Received:5 /4 /2018 DOI: 10.12816/0047754
Accepted:14 /4 /2018

Full Paper (vol.721 paper# 27)

The contraceptive implant The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3846-3849
Awareness of Jouf University Medical Students about Brucellosis
Tariq Hadyan Alruwaili, Abdulrahman Abdullah Alruwaili, Fawaz Rawi Al fuhigi,
Ibrahim Mohammed Alshitwee
Medical Intern, Medicine Collage, Jouf University, Sakaka, Al Jouf, Kingdom of Saudi Arabia
Corresponding author: Tariq Hadyan Alruwaili, Email: th00777@gmail.com, Tel. +966533964465

Brucellosis can be well-defined as a bacterial zoonotic infection conveyed to humans by direct
interaction with infected animals or its food products such as meat, cheese, and unpasteurized milk mainly
domesticated ruminants and swine.
Determination of the students' knowledge about Brucellosis.
Methods: Medical students of Jouf University asked to complete a questionnaire capture about their knowledge
on the etiology, clinical feature, complications, prognosis and prevention of brucellosis.
Results: The overall results showed that there is a lack in awareness about brucellosis among the students.
Conclusion: The medical training institutions should give special consideration to brucellosis in their teaching
Keywords: Awareness, Brucellosis, Medical Practitioners.


Brucellosis can be defined as a bacterial zoonotic
medical students were voluntarily and anonymously
infection transmitted to humans by direct contact
surveyed in the current study. A questionnaire was
with infected animals or its food products such as
developed after surveying the literatures, the
unpasteurized milk, meat and cheese, predominantly
questionnaire was tested on a sample of students for
domesticated ruminants and swine (1). The disease is
reliability. Necessary correction was made in the
caused by Brucellae which are aerobic intracellular
questionnaire. The period of the study was from
Gram-negative coccobacilli and have the ability to
February 3, 2016 to April 8, 2016.
Statistical data analysis procedure:
The data were analyzed using SPSS Version-19 for
Furthermore, Brucellosis can be presented as acute or
frequencies in awareness about Brucellosis between
chronic infection characterized by fever, night
groups of the medical students.
sweats, myalgias, fatigue, headache, weight loss and

anorexia(3). Different studies showed that the
incidence of abortion and IUFD in pregnant women
A total of 165 Medical students of al-Jouf University
infected with brucellosis are higher than uninfected
were surveyed in this study, they included 26
pregnant women(4). Other complications could
(15.8%) 1st year students, 57 (34.5%) 2nd year
happen such as spondylitis, neurobrucellosis and
students, 37 (22.4%) 3rd year students, 17 (10.3%) 4th
endocarditis (3).
year students and 28 (17%) 5th year students.
Indeed, Sufficient knowledges are required to
improve patients health conditions to assure
Table 1: Medical students' years
delivering the necessary and proper health care (5).
Lack of knowledge found to be correlated with poor

management of cases (6). In the other hand,
educational interventions are effective strategy for
better diagnosis of diseases (7).
The aim of the study was to measure the level of
awareness among the practitioners. It is considered as

an important issue toward improving the
Table 2 shows the awareness about the etiology of
management and dealing with of Brucellosis,
brucellosis. Out of all surveyed students 4th year
especially in endemic area as in Saudi Arabia (8).
students have the highest proportion of correct

answers (68.24%) and 3rd year students have the
lowest rate of proportion of correct answers
The present study is a cross-sectional study. The
(51.35%). It should be pointed out that there is a false
target population was the medical students of Jouf
belief in the community that camel products are not
University, Saudi Arabia. However, a total of 165
harmful. So, it was included in the questionnaire.

Received:5 / 4 /2018 DOI: 10.12816/0047755
Accepted:14 /4 /2018

Full Paper (vol.721 paper# 28)

c:\work\Jor\vol721_29 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3850-3856

Growth Kinetics and Metronidazole Sensitivity of Blastocystis Sp. Isolated from
Colorectal Carcinoma (CRC) and Non-CRC Patients
Mazloum M. Ahmed, Fayza S.M Habib, Nashwa S. Abdel-Fattah, Ghada A. Saad, Heba M. El Naggar
Parasitology Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Blastocystis sp. is the most common protist detected in human fecal samples in numerous studies globally.
Extreme debate regarding Blastocystis sp. pathogenicity exists. Some studies have speculated a possible
correlation between Blastocystis and CRC. No previous study has investigated the presence of non-genotypic
differences in Blastocystis sp. isolated from CRC and non-CRC patients. The present work aimed to
investigate the growth kinetics (G.K) and metronidazole (MTZ) sensitivity in Blastocystis isolates from CRC
and apparent non-CRC whether symptomatic and asymptomatic Blastocystis carriers. Seven isolates from
CRC patients and 6 from symptomatic and 6 from asymptomatic non-CRC carriers were cultured in Locke's
Egg (LE) medium supplemented with bovine serum and antibiotic mixture and incubated at 37 C. Mean
viable organisms counts of each isolate were counted every 24 hours in medium to follow their GK and after
exposure to different MTZ concentrations to perform drug sensitivity assay. In vitro growth kinetics of CRC
and Non-CRC symptomatic isolates were nearly similar with higher peaks attained at 72 hours incubation than
by the slower growing non-CRC-asymptomatic isolates. MTZ-sensitivity of CRC isolates was nearly similar to
that of non-CRC asymptomatic isolates, both were significantly more sensitive than the symptomatic isolates
especially at high drug concentration of 200 µg/ml of the medium.
Blastocystis sp., Colorectal carcinoma, Symptomatic, Asymptomatic, growth kinetics,
metronidazole sensitivity.


Blastocystis sp. is the most common
significantly increased (53%) in patients with
protists detected in human fecal samples in
colorectal carcinoma (10).
numerous studies globally (1, 2). It is a pleomorphic
In the available literatures, no work was
organism existing in multiple forms: the vacuolar,
carried out to investigate Blastocystis sp. isolates
granular, amoeboid and cystic (3). The extreme
from CRC patients. The existence of extreme
debate regarding Blastocystis sp. pathogenicity had
genotypic diversity among Blastocystis isolates
led many researchers to attempt finding out
from different clinical groups of carriers,
differentiating characters between asymptomatic
necessitates the extrapolation of possible different
and symptomatic human-derived Blastocystis
biological and phenotypic characters between
isolates (4). Different growth profiles characterizing
isolates from different clinical groups were

previously reported (4, 5) demonstrating phenotypic

The aim of the present work was to study the
differences between isolates recruited from
growth kinetics (G.K) and MTZ sensitivity in
different clinical groups.
Blastocystis isolates from CRC and non-CRC
Metronidazole (MTZ) is the first-line
prescribed drug with various rates of efficacy

ranging from 0% to 100% depending on the dose
administered (6). Although MTZ demonstrates
Blastocystis sp. isolates:
effectiveness in some individuals (7), it has also
The present work was done in the period
been shown to exhibit side effects and resistance in
from September 2015 to October 2017. The study
others (8). MTZ induces apoptosis in Blastocystis sp.
was approved by the Ethics Board of Ain Shams
as a defensive mechanism to ensure that some of
the cells survive to propagate the genome (9).
A total of 19 Blastocystis sp. isolates from
CRC, and apparent non-CRC patients attending the
suggests that Blastocystis is associated with various
outpatient clinics of El Demerdash Hospitals of
gastrointestinal conditions including colorectal
Faculty of Medicine, Ain Shams University were
cancer (CRC) (10, 11). Incidence of Blastocystis
studied. Blastocystis sp. isolates were grouped in 3
infection was (36%) in healthy individuals and
groups; 7 isolates from early diagnosed CRC
(34%) in patients with colorectal adenoma.
patients before receiving any chemotherapeutic
However, the incidence was
drugs (GI or CRC group), and 12 isolates from

apparent non-CRC carriers (GII or Non-CRC
Received:20 / 3 /2018 DOI: 10.12816/0047756
Accepted:30 /3 /2018

Full Paper (vol.721 paper# 29)

c:\work\Jor\vol721_30 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (1), Page 3857-3860

Patients' Satisfaction with Health Care Services in Southern Saudi Arabia
Almutairi Omar Owaidh*, Alqarni Abdullrahman Atiah, Alzahrani Saif Abadi, Alzahrani Mohammed Ali,
Alghamdi Mohammed Abdullah, Alzahrani Abdulrahman Abdullah, Alzahrani Mohammed Hassan
Faculty of medicine, Al-Baha university, Saudi Arabia.
Corresponding author: Almutairi Omar Owaidh, mobile no: +966 560217111,email: omar12aa21@hotmail.com

Objective: To evaluate the level of patients' satisfaction in primary health care centers and tertiary hospitals in Al-
Baha, Saudi Arabia.
Methods: A cross sectional study was carried out during March 2018 using a questionnaire that has combined
(outpatient and inpatient) measures to include admitted patients and clinics' attendants. After explaining the study
nature and purpose, an individual consent was obtained from all the participants prior to filling the questionnaire.
The data were analyzed using a computer program (SPSS, version 21.00).
Results: 303 responses were analyzed, of which (50.8%) were males, (93.1%) were aged from 15 to 45 years,
about two thirds (65.3%) were single, (79.9%) were income-satisfied, and the majority (69.6%) has completed or
still studying at the university, which indicates a high educational level among our sample. (82.8%) were satisfied
about nurses' treatment, (90.1%) were satisfied about doctors' treatment, and around (79.6%) were satisfied about
the cleanliness, quietness, and design of the facility.
Conclusion:The satisfaction among our sample is considered high and indicates a good care provided by health
facilities in Al-Baha region, Saudi Arabia. Male gender and higher educational level were associated with higher
levels of satisfaction. The least satisfactory factor was regarding communication; therefore, we recommend
implanting programs concerning communication skills for health care providers.
Keywords: satisfaction, hospital, Al-Baha, Saudi Arabia.


Patient satisfaction is considered as one of the
In PHC centers, the patients were satisfied
most important predictors when measuring health
with the enablement, and the most unsatisfying
outcomes and quality of services provided by any
factor was poor continuity of care by the
health care facility[1]. It is linked to good patient-
In Najran, Saudi Arabia, nurses' services and
compliance.Where satisfied patients were found to
care had the highest score of satisfaction in private
have a better compliance with their plans of
tertiary hospitals. In the same study, the general
satisfaction was found to be high as well (3.91 out of
Patient satisfaction was measured by measuring
5)[6]. Regarding waiting time, a prospective study in
many factors, which are usually reported by the
central Saudi Arabia, waiting time was considered as
patient, and the results would be evaluated by the
the most important factor regarding the care of
researchers to implant new programs and policies
patients attending the emergency department[7].
that hopefully would improve the patients'
High satisfaction levels continued to be present
satisfaction for better outcomes [3-4].
also in the capital of Saudi Arabia tertiary centers.
Those factors include all the services that are
The only factors that have made patients unsatisfied
provided by the employees, nurses, and doctors,
were doctors not introducing themselves or
also, they reflect the patients' thoughts about the
explaining the procedures[8]. Same findings were
general appearance, cleanliness, quietness, and
introduced by a study in Riyadh PHC centers, where
waiting time [5].
physicians didn't explain the patients'medical
Satisfaction can be measured at a clinic base
conditions properly [9].
(outpatient), primary health care (PHC) centers, or
Despite the literature findings of high
even inlarger hospitals, all are directed to identify
satisfaction levels in Saudi Arabia.In Taif, it was
the points of defect in the health care system and
found to be low[10]. While private hospital attendants
thus, aiming to improve them.
had slightly higher levels of satisfaction[11].
Patient satisfaction is an important factor that
In Saudi Arabia, many studies have been done to
should be studied frequently as indicated in a PHC
evaluate the general satisfaction of patients, and
based study that was carried out in Majmaah, Saudi
many of them were done in PHC centers or tertiary
Arabia. The main findings of the study showed a
centers. This study has combined both (PHC and
high level of satisfaction that has reached 82%[2].
tertiary hospitals) by combining the O-PAHC

(outpatient evaluation form) with the I-PAHC
Received:9 / 4 /2018 DOI: 10.12816/0047757
Accepted:18 /4 /2018

Full Paper (vol.721 paper# 30)