ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4045-4047
Prevalence of Multinodular Goiter at Prince Mutaib Hospital in Sakaka Al-jouf
Faisal M. Alarjan, Jarid S. Aljarid, Ahmed M. Alruwaili, Atallah F. Alruwaili, Sultan M. Alshalan
College of medicine, Aljouf University
Corresponding author: Faisal M. Alarjan, E-mail: Faisal_4957@hotmail.com, Tel. +966 53 537 8397
Background: Multinodular Goiter (MNG) is a diffuse multi-nodular enlargement of the thyroid gland in
response to chronic TSH stimulation.
Objective: The aim of this study was to find the prevalence of MNG among patient attending endocrinology
outpatient department.
Methods: This was a hospital-based study that included 324 patients who had visited the OPD in Prince
Mutaib Hospital in Sakaka, Saudi Arabia, in a two months period (Dec 2014 and Jan 2015). Data analysis was
looking for sex, age, marital status and number of children of those who have MNG. Data were analyzed using
SPSS Version-17 and frequencies were obtained.
Results: Files of 324 patients were examined in endocrinology section, 23 of them (age 18-42) were suffering
from Goiter giving a prevalence rate of 10%. 11 of the patients were having Multinodular type of goiter giving
a prevalence of 4.7%, while the rest have solitary type of goiter. Among those 11 patients who are married,
45% of them have MNG type. In addition, male to female ratio regarding MNG was 1.75: 1. Conclusion: In
conclusion, the study showed that there is prevalence of MultiNodular Goiter of 5% among population of
Keywords: Multinodular Goiter, Prevalence, Endocrinology

goiter is sporadic, and there is an estimated incidence
Thyroid gland is one of the endocrine glands
of 5 % in North America (4). While in area with
that is responsible mainly for the production of
previous suffering from iodine deficiency that was
triiodothyronine (T3) and thyroxine (T4) (1). These
corrected later on, elderly people have an incidence
hormones work in regulatory functions of many parts
of 10% of developing MNG due to defiance in their
of the body, also in growth and rate of energy
younger ages (2). In Saudi Arabia, a hospital-based
consumption and making proteins. The normal
study in King Khaled University hospital that has
thyroid gland is anatomically consisted of two lobes;
been concluded in 1994, 614 patients diagnosed with
however, pathological nodules formed within its
goiter over a period of 3 years, the percentage of
structure. These nodules may be only localized
MNG was 44 % (3). Also, king Abdul-Aziz University
colloid-filled follicles, adenomas, or cysts (1). Nodules
hospital has recorded 135 patients in 2005 had MNG
that is larger than 1 cm are easily found in clinical
situation by palpitation, but if nodules is smaller, it
may need further investigations (1). Many terms such
The aim of this study was to find the
as adenomatous goiter, nontoxic nodular goiter, and
prevalence of Multi Nodular Goiter in Aljouf main
colloid nodular goiter are used to describe
hospital Prince Mutaib bin Abdul-Aziz.
Multinodular Goiter. Multinodular Goiter (MNG) is
diffuse multi-nodular enlargement of the thyroid
gland in response to chronic TSH stimulation (2).
Subjects: 324 patients who had visited the
Epidemiological studies showed that goiter is
OPD in Prince Muteb Hospital in Sakaka, Saudi
more common and endemic in population suffering
Arabia, in a two months period (Dec 2014 and Jan
from deficiency in iodine intakes, giving a prevalence
of 15% for mild deficient and 22.6% in moderate
Design: hospital-based design by accessing
iodine deficient area, and the size of the thyroid
to hospital patients records and obtaining
affected is relevant to the increase in the deficient (3).
Globally, around 30% of the world's population lives
Data Collection: sex, age, marital status and
in area with low iodine intakes, such as Latin
number of children of those who have MNG.
America and central Africa, were more than 60
Inclusion/Exclusion: all patients visited the
million of those are known to have goiter (4). On the
endocrinology department during the two months
other hand, sporadic goiter is associated with defect
periods in Prince Mutaib Hospital were included.
in the synthesis of the thyroid hormones (3). Countries
Analysis: Data analysis were carried out using
that has a sufficient intake of iodine, show a
SPSS Version-17 and frequencies were obtained.
prevalence of approximately 5% (3). As in United
States, the most common cause of multi nodular



Full Paper (vol.723 paper# 1)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4048-4053
Primary and Specialized Physicians' Knowledge of and Attitudes Towards the Use
of Complementary and Alternative Medicine in Medical Practice
Sarah Marie1, SebaAlmutairi1, Norah Alsabty2, Maram Al Turki1, Hind Almodaimegh3
King Saud Bin Abdulaziz University for Health Sciences1, King Abdulaziz Medical City, Ministry of National
Guard-Health Affairs, Department of Surgery2, King Abdulaziz Medical City, Ministry of National Guard-Health
Affairs, Pharmaceutical Care Department3
Background: The use of complementary and alternative medicine (CAM) for treatment purposes in Saudi
Arabia is a common practice by the public. Studies have found that using these products is not always a safe
practice. Research has showed that many of CAM products could result in fatal adverse effects either when
used alone or combined with conventional medicine. Health institutions are currently working on increasing
the awareness of these adverse effects and the proper utilization of CAM, however addressing the knowledge
gap among healthcare professionals is still an area of demand. Thus, this study aims to assess the knowledge
and attitude of primary and specialized physicians at King Abdulaziz Medical City KAMC about CAM.
Method: This is a cross sectional study based on an interview structured questionnaire that was validated
through pilot testing and distributed among physicians in the following fields at KAMC; internal medicine,
family medicine, Surgery, pediatrics, and obstetrics and gynecology. We included physicians from both
genders, any nationality, and excluded all physicians who have not been practicing for more than one year.
The minimum sample size required was 231. All the data were entered and analyzed by SPSS software version
21. A confidence interval of 95% was used and a P value less than or equal.05 is significant.
Results: The research team was able to interview 220 physicians from different specialties and occupation
with a response rate of 95.5%. The overall results were that the majority of participants (73.7%) had a poor
knowledge about CAM. Also, it was found that there is no correlation between the level of knowledge and the
specialty (P=0.26). Unlike Saudi physicians who believe in the beneficence of CAM, non-Saudis tend to have
a more negative attitude toward this practice (P= 0.023). Resident and newly practicing medicine physicians
had more positive attitude toward CAM compared to physicians with long history of practice (P=0.037).
Almost 50% of our participants have obtained some knowledge about CAM from websites, books, and EBM
articles. 81.1 % of the physicians insisted on the importance of receiving formal education about CAM.
Conclusion: In conclusion we recommend that education about CAM to be given in the form of seminars,
lectures, or part of the medical school curriculum. We also emphasize that this education should not be given
to a certain medical specialties as our result showed that the knowledge and attitude toward CAM does not
have a correlation with specialty.
Keywords: Physicians' Knowledge, Complementary, Alternative Medicine

disease and cancer, by using CAM(2). In 2005, the
According to the US National Center for
World Health Organization (WHO) reported that
Complementary and Alternative Medicine (NCCAM),
more than 80% of the population of developing
complementary and alternative medicine (CAM) are
countries uses herbal medicine to manage health
defined as a practice that combines the use of health
conditions(3). In 2007, 17.7% of Americans reported
products and healthcare systems that are not currently
using natural, non-vitamin, non-mineral products. By
part of conventional medicine. Although the words
2012 this proportion had increased to 17.9% of the
`alternative' and `complementary' are often used
American population, and had doubled in the north-
interchangeably, `complementary' indicates a practice
central region of the USA(4,5). In 2002, US$2.7 billion
that is used alongside conventional medicine, while
was spent on CAM in the USA, $2.4 billion in
`alternative' medicine is used instead of conventional
Canada, and $2.3 billion in the United Kingdom (6).
medicine(1). CAM includes different therapeutic
In Saudi Arabia, most physicians and
modalities, including manipulative and body-based
members of the public use `TibbuNabawi' (prophetic
treatments such as massage or acupuncture and herbal
medicine) in their practice. More than 70% of the
medicine, which is the main focus of this study(1).
population of the Riyadh region reported using
Recently, the advances in research methods
practices related to prophetic medicine during their
and an explosion of technology in this field
lifetime. Common types of CAM used were Holy
havemade CAM one of the most commonly used
Quran therapy (50.3%), honey (40.1%), black seeds
treatment modalities around the world. Some people
(39.2%), myrrh (35.4%),and alhijama (cupping) (7, 8).
are able to manage various chronic and societally
Insufficient data have been collected regarding the
costly conditions, such as chronic pain and arthritis,
prevalence of the use of CAM in Saudi Arabia.
and more life-threatening diseases such as heart
However, several regional studies have found


Full Paper (vol.723 paper# 2)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4054-4059
Negative Pressure Wound Therapy Versus Conventional Dressing in Treatment of
Diabetic Foot Wound
Atef Bayoumi, Abdullah Al-Sayed, Abdullah Al-Mallah
Vascular Surgery Department ­ Faculty of Medicine ­ Al-Azhar University ­ Cairo ­ Egypt
Corresponding Author: Abdullah Al-Mallah, Email: poet.abdullah2009@gmail.com
Background: Foot wounds in people with diabetes mellitus are a common and serious global health issue.
Negative pressure wound therapy can be used to treat these wounds and a clear and current overview of
current evidence is required to facilitate decision-making regarding its use. Aim of the Work: To compare the
efficacy of negative pressure wound therapy with that of a control group using conventional moist wound
dressings, in healing of diabetic foot ulcers, in terms of 1) Change in size of wound. 2) Rate of granulation
tissue formation as percentage of ulcer surface area. 3) Period of hospital stay. 4) Cost of both modalities of
treatment. And 5) Complications after treatment. Study Design: Prospective Randomized Controlled Trial.
Place: This study was conducted in the vascular surgery department at Al-Azhar university hospitals.
The study included 50 patients randomized into two groups (25 patient for VAC therapy & 25
patient for conventional dressing) suffering from diabetic foot wounds. Results: In our study, 6 of 25 (24%) in
the Conventional treatment group were females whereas 19 of 25 (76%) in the Conventional treatment group
were males. 3 of 25 (12%) in the NPWT group were females and 22 of 25 (88%) were males. In the
Conventional treatment group, 21 of 25 (84%) were above 60 years of age. 20 of 25 (80%) in the NPWT group
were above 60 years of age. Wound bed showed signs of healing by granulation tissue formation in 19 among
25 patients (76%) compared to Conventional treatment, 7 showed granulation among 25 patients (28%) one
week after initiation of treatment. (P=0.001). Granulation of the wounds was > 50% in 20 of the 25 patients
underwent NPWT whereas only 3 of the 25 in the Conventional treatment had shown > 50% granulation.
There was a highly statistically significant difference between average Granulation as % of ulcer area and it is
significantly high in vacuum dressing. It was 51.92 ± 21.03 in Conventional treatment compared with 78.68 ±
18.12 in NPWT group (p- value < 0.05). Wound size was measured at initial presentation and then after
treatment. Before treatment, the mean surface area of wounds in the NPWT group was 40.44 cm2, the
Conventional treatment 38.52cm2. After wound management, mean surface area of the diabetic wounds was
36.08 ± 2.56 cm2 in the NPWT group and 37.63 ± 2.86 cm2 in the Conventional treatment. This represents a
statistically significant difference (P=0.05). At the end of our study the incidence of secondary higher
amputation in NPWT group was 5/25 (20%), the Conventional treatment 6/25 (24%). There was no significant
difference between both groups (P=0.13). There is a statistically significant difference between average graft
take-up and it is higher in vacuum dressing. It was 80.78 ± 14.54 in NPWT and 59.58±19.25 in control group.
(P-value = 0.035). Daily mean cost in conventional dressing group was 67.43 ± 5.3 EP compared to 95.7 ±
10.2 EP in VAC group. A difference which is statistically different. Also, at the end of the study, total mean
cost in conventional dressing group was 1976 ± 123 EP compared to 2275 ± 154 EP in VAC group. There was
a difference in the total cost finally. Period of hospital stay till the wound was fully granulated and ready for
skin grafting was 22.87 ± 7.62 in NPWT compared to 32.53 ± 10.17 in the conventional group. There is a
highly statistically significant difference between average duration of hospital stay and it is reduced
significantly in vacuum dressing. (p-value= 0.02). Conclusion: The rate of granulation tissue formation,
wound surface area, overall graft survival was better in NPWT group as compared to conventional dressing
group. Overall hospital stay and amputation rate were less in the NPWT group. Thus, NPWT can be
considered as a superior option in the management of diabetic foot wounds. Cost of VAC therapy was higher
than conventional dressing.
Key Words: Diabetes - Foot Ulcer - Vacuum Assisted Closure - Negative Pressure Wound Therapy

(VAC) can provide stable and persistent negative
Foot wounds in people with diabetes
pressure, and there are several modes to choose
mellitus (DM) are a common and serious global
from. VAC plays an important role in closing
health issue. Negative pressure wound therapy can
wounds quickly, controlling infection, promoting
be used to treat these wounds and a clear and
angiogenesis, increasing blood flow, and
current overview of current evidence is required to
promoting granulation tissue growth of wounds. It
facilitate decision-making regarding its use (1).
is now widely applied in all kinds of acute,
As a new generation of negative pressure
chronic, and special wounds in clinic with good
drainage technology, vacuum-assisted closure
therapeutic results. However, we need to pay


Full Paper (vol.723 paper# 3)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4060-4063
Assessment of knowledge and Attitude and Practice of Parents towards Epilepsy
among Children in Abha City
Asiri S. Hassan A1, Alshehri S. Yahya M1, Alqutub A.Tariq A2, Alqutub,
Hussamaldin Tariq A2
1King Khalid University, 2King Abdulaziz University
Background: Supporting information and high levels of awareness among parents could support the needs of
the children and help in managing the outcomes of epilepsy.
Objectives: Studying the knowledge, attitude and practice (KAP) of Saudi parents in Abha City regarding
epilepsy, Kingdom of Saudi Arabia (KSA).
Methods: It is a cross sectional study that was conducted during the period from February 2018 to May 2018
at Abha City, Saudi Arabia among 440 parents. The study tool was a questionnaire that consists of 20
questions regarding subject's demographics, knowledge, attitude and practice pattern.
Results: All the included parents rated the word epilepsy as common for them. Most of the subjects knows
that epilepsy can be treated (84.3%), 90.9% knew that epilepsy is associated with hereditary and 52.5%
recognized that epilepsy can be caused by trauma or stroke but only 21.1% only knew that epilepsy could be
treated by surgery. The knowledge of most of the respondents was adequate among 68.2%. The attitude score
was adequate among 76.4% of the parents. The practice score was adequate among 72.5% of the parents.
Conclusion: Most of Saudi parents in Abha showed adequate awareness about epilepsy among children which
showed adequate attitude and practice pattern. This is suggestive to increasing the chances of management of
the disease and decreasing the risk factors and complications of misconceptions.
Keywords: Knowledge, attitude, practice, Epilepsy, parents Abha city, children, 2018.

Epilepsy is a neurological condition with
The present study aimed at studying the
common repeated seizures. In developing countries,
knowledge, attitude and practice (KAP) of Saudi
the prevalence of epilepsy rated from 0.004 to
parents in Abha City regarding epilepsy.
0.008% children suffered from epilepsy (1, 2).
The prevalence of epilepsy in Kingdom of
Saudi Arabia was about 7 cases out of 1000
Study design:
children(2,3). According to the WHO, about 50
It is a cross sectional study that was
million subjects suffer from epilepsy around the
conducted during the period from February 2018 to
world and most of them (85%) are from developing
May 2018 at Abha City, Saudi Arabia.
countries as about 4.7 million epilepsy cases are
Study population and sample size:
located in the Eastern Mediterranean Region(4).
The included sample size was designed
During the last decades, the worldwide
established on the equation (n=Z2PQ/d2) taking the total
awareness regarded epilepsy and its effects on child
size 720022(11) with a margin error (5%) and a confidence
and caregivers (5,6). Also, the attitudes of parents are
level (95%). The sample size was 370 and additional
20% were added then the total sample obtained was
complications among children including the duration
440(12). The subjects were randomly chosen using
and intensity of seizures as the fears from parent's
multiple stratified random sampling technique. The
attitudes could affect the behavioral and
participants were interviewed in 4 different shopping
psychological outcomes of children (7). Supporting
malls in different parts of Abha City. A consent was
information and high levels of awareness among
given by the participants enrolled in the study.
parents could support the needs of the children and
Study tools:

help in managing the outcomes of epilepsy (8,9).
The study tools included a questionnaire and an
However, the level of awareness and
interview with the respondents, the questionnaire consisted
perceptions of population in KSA still requires
of 20 questions that were translated into Arabic after
improvement and the studies regarding the parental
reviewing the available studies found on medical database.
knowledge are limited (6,10).
The questionnaire included questions about subject's
To understand the parental knowledge
demographics, knowledge, attitude and practice pattern.
regarding epilepsy, more surveys and international
Statistical analysis:
care delivery should be done that could influence
The statistical analysis was done using the
the knowledge of the entire family.
Statistical Package for Social Sciences version 20
(SPSS Inc., Chicago, IL, USA).



Full Paper (vol.723 paper# 4)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4064-4066
Systemic Review: Effect Of Weight Reduction On Decreasing Of BP
Abdulrahman F. Alaql1, Waleed T. Alanezi2, Othman M. Albalawi2, Abdullah N.
Alshahrani2, Ali O. Alshargi3
1Imam Muhammad Ibn Saud Islamic University,2Tabuk University, 3Ibn Sina National College For Medical Studies
Background: Lowering the blood pressure could decrease the risks of cardiovascular morbidity and mortality
rates and showed an association between lowering the body weight and management of blood pressure levels
in people with hypertension. This study aimed at reviewing the effects of weight loss on blood pressure and
hypertension. Methods: 29 studies were included in this review. This systemic review showed that significant
reduction in body weight either by dietary or non-dietary intervention could lower the blood pressure among
hypertensive patients undergoing medications. However the extent effects are uncertain and have not been
demonstrated on long term effects.
Keywords: Weight Reduction, Blood Pressure, Prevention, Management, Hypertension.

Hypertension, overweight and obesity are
Information sources and search strategy
major public health hazards affecting the whole
The data were collected after searching all the
population around the world(1). They have a central
electronic database related to the issue of lowering body
role in progression of cardiovascular and a
weight and blood pressure from 2000 up to April 2018.
common risk factor for premature death exceeding
9 million per year. Hypertension is one of the well-
Results of the search and discussion
known complications of obesity as about 30% of
hypertensive patients suffer from obesity (2).
On the initial research more than 9734
During the last decades new non-
studies were yielded from which 2917 were excluded
pharmacological interventions have been used for
for duplicates and the remaining 6817 were excluded
treatment of hypertension including weight loss.
for incomplete data and were not relevant to the
Some studies have shown that lowering the blood
research question. Only 20 studies were included
pressure could decrease the risks of cardiovascular
after reviewing their abstracts.
morbidity and mortality rates and showed an
Participants and interventions:
association between lowering the body weight and
management of blood pressure levels in people
About 2000 hypertensive patients participated
with hypertension (3).
in the included studies with an age ranged from 40-70
The INTERSALT study showed a
years who were diagnosed with hypertension and their
correlation between lowering the systolic and
treatment duration ranged from 6 months to many years.
diastolic blood pressure and the body mass index
Most of the participants received dietary or non-dietary
among more than 10 thousand subjects aged from
interventions for body weight reduction.
20-60 years old (4). Also, obesity is considered as a
Excluded studies:
significant risk factor for induction of
hypertension. In a long term follow up study
Many studies were excluded due to lack of
showed that the long term and medium term weight
complete data, sufficient results and don't answer the
loss are related with decreasing the blood pressure
article question. Some studies also included
among hypertensive patients (5).
hypertensive and non-hypertensive subjects and have
Other studies showed that the central fat
very short duration.
distribution and the waist-hip ratio are associated
Changes in blood pressure
with the blood pressure levels thus decreasing the
amount of visceral adipose tissue was associated
29 studies identified the effect of lowering
with lowering the blood pressure level (6) this
body weight either through diet, non-diet
suggests that lowering the internal fat could reduce
interventions and restricted caloric method. One
the risk of hypertension among obese populations.
study showed that reducing the body weight by 3-5%
However, there is still an argument around
is insufficient to reduce the blood pressure but could
the actual effects of lowering body weight on blood
affect the glycemic state and triglycerides level (7)
pressure thus this review aimed at studying the effects
however another study showed that losing more than
of weight loss on blood pressure and hypertension.
5% of body weight can significantly affect the blood
pressure and normalize it in obese subjects on

antihypertensive drugs (8). Some other studies showed

a strong correlation between lowering blood pressure


Full Paper (vol.723 paper# 5)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4067-4074
Vitamin D Level in Non-Diabetic and Type II Diabetic Patients KFU Health Center:
A Cross Sectional Study
Mohammed A. Al Hewishel, Abdullah H. Al Huwaiyshil, Mustafa A. Alsubie,
Abdullah A. Alhassan a
aStudents Research Committee, Collage of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.
Background: Widespread vitamin D deficiency all over the world has been documented by many previous
studies including recent studies in KSA which revealed incidence reaching up to100%. Also, number of people
with diabetes mellitus is increasing (7% of the world's population in 2011, elevated to 9% in 2014). This
number is expected to exceed 435 million by 2030. Compared to other areas of the world, diabetes prevalence
was highest in Saudi Arabia (20.22%). In 2015, there were 3.4 million cases of diabetes in Saudi Arabia. Many
studies showed high association between vitamin D deficiency and increased incidence of diabetes.
Aim of the work: This study is planned to assess the incidence of vitamin D deficiency in non-diabetic and
type II diabetic patients in KFU health center in Al-Ahsa region.
Methods: Our study is a cross-sectional study done on 860 patients' data including plasma 25-hydroxy vitamin
D3, fasting blood glucose and HbA1c levels.
Results: Our results showed that 89.53% of the patients have vitamin D level below normal. There was higher
incidence of vitamin D deficiency in females (81.67%) than in males (65.27%). The incidence of vitamin D
deficiency was greater in Saudi (82.19%) than non-Saudi (68.40%) and in diabetics (89.68%) than non-
diabetics (76.12%) patients. Within each group, the incidence of vitamin D deficiency was higher in females
than in males. Incidence of vitamin D deficiency was highest in the 21 ­ 40 years group (86.19%) and lowest
in the 1 ­ 20 years group (66.1%). The results showed inverse relationship between vitamin D level and both
fasting blood glucose and HbA1c. The mean fasting glucose was higher in the deficiency group (165.55) as
compared to the insufficiency group (118.67). Also, the mean HbA1c was higher in deficiency group (8.06) as
compared to the insufficiency group (7.23).
Conclusions: There is high incidence of vitamin D deficiency among KFU health center patients. Vitamin D
level was inversely proportional to the level of fasting glucose and HbA1c. This is an evidence of the vitamin
D role on glucose tolerance in diabetic patients.
Keywords: Vitamin D, Diabetes type II, non-diabetic, KFU health center.

animals and can be corrected by vitamin D
Diabetes mellitus (DM) is a syndrome of
supplementation (4­6).
chronic hyperglycemia due to relative insulin
It is well known that obesity and sedentary
deficiency, insulin resistance or both (1). In 2011,
life style predispose to diabetes (7-9).
the International Diabetes Federation estimated the
Meta- analysis of 21 prospective studies
number of people with diabetes worldwide to be
showed an inverse and significant association
nearly 285 million, or 7% of the world's popula-
between circulating 25(OH) D levels and risk of
tion elevated to 9% of the world's population in
type 2 diabetes. Higher 25(OH) D blood levels
2014. This number is expected to exceed 435
were always associated with a lower diabetes risk.
million by 2030 (2).
Each 4 ng/ml increment in 25(OH) D levels was
Vitamin D is a group of steroid hormones
associated with a 4% lower risk of type 2 diabetes
which are mainly formed in the skin under the
Other studies provided prospective evidence that
effect of sun ultraviolet B rays and then modified
low levels of vitamin D also predict
in the liver and kidneys to produce the active form
hyperinsulinemia. It has been suggested that
(1, 25-dihydroxy vitamin D3). It is also present in
vitamin D may act to prevent type 2 diabetes by
food as Vitamin D3 (animal source) and Vitamin
decreasing insulin resistance. Moreover, Dalgård et
D2 (plant source) (3).
al. reported an inverse association between HbA1c
The active form of vitamin D functions by
and 25(OH) D3 in the elderly and concluded that a
binding to intracellular vitamin D receptors (VDR)
high vitamin D status protects against type 2
which modulate gene expression. It is now known
diabetes in younger subjects to subjects older than
that every cell within the body has a VDR. VDRs
70 years (10).
are also present in pancreatic -cells and vitamin D
The National Health and Nutrition
is essential for normal insulin secretion (4). Islet cell
Examination Survey (NHANES) III study between
insulin secretion is reduced in vitamin D-deficient
1988 and 1994 demonstrated a strong inverse
association between low levels of 25(OH) D and


Full Paper (vol.723 paper# 6)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4075-4077
High Tracheal Bifurcation as a Cause of Left Main Bronchus Obstruction in Infant:
A case report from Saudi Arabia
Gawahir M. 1, Khalid A.M. 2, Safa E. 3, Wadha A. 4
1Pediatric Pulmonary division, King Fahad Medical City (KFMC), 2Pediatric Pulmonary Division, King
Khalid Hospital/ King Saud University, 3Pediatric Pulmonary division, King Fahad Medical City(KFMC),
4Pediatric Pulmonary and Sleep Physician, Head of the Pulmonary Unit, KFMC, KSA
Corresponding author: Gawahir M.A. Mukhtar, E-mail: jmukhtar@kfmc.med.sa, Mobile number: 00966543484521
Background: Congenital short trachea (CST) an uncommon abnormality is defined as a reduction in the
number of tracheal rings to 15 or less, compared to the average of 17 rings in normal infants. As a result, the
carina is situated at a higher level than usual that lead the left main bronchus to course abnormally behind the
arch of the aorta, making it prone to compression. CST is associated with a number of syndromes, including
the Di George syndrome, several types of congenital heart disease, some skeletal dysplasias and
meningomyelocoele. Case study: We report a case of one Saudi infant who presented with respiratory distress
since birth and hyperinflation of left side of the lung secondary to extrinsic narrowing of proximal left main
stem bronchus due to compression by arch of the aorta, and he underwent successful aortopexy of the aortic
arch for this condition.
Keywords: High trachea bifurcation, children, Saudi Arabia, case report

and radiology teams confirmed the present of high
An 8-week old infant was referred to us
tracheal bifurcation at a level of second thoracic
with history of respiratory distress since birth. He
vertebra which narrowing the proximal left main
was a product of uneventful pregnancy, full term,
bronchus behind the aortic arch. (Figure 2 &3).
normal spontaneous vaginal delivery (NSVD),

birth weight was 3.2 kg and mother had good
antenatal care. Immediately after birth developed
respiratory distress and cyanosis and kept in NICU
for 10 days, then transferred to other hospital
where he had been admitted till age of 8 weeks,
bronchoscopy was done for him and it was normal
findings but he did not tolerate the procedure and
developed immediately respiratory distress and
transferred to pediatric intensive care unit (PICU),
put on continuous positive airway pressure (CPAP)
, weaned to oxygen via nasal cannula with

persistent tachypnea and wheezes. Then
Figure (2): Axial sections mediastinal window showing the
high bifurcation of the trachea in relation to arch of the aorta.
transferred to our center for further management.

progressive hyperinflation of the left lung
suggestive of air trapping (Figure. 1)

Figure (1): CXR showing Left side lung hyperinflation.

Figure (3): A coronal section mediastinal window showing the
Computed tomography of the chest which
high bifurcation of the trachea in relation to arch of the aorta.
was done in the previous hospital came with a
Echocardiography was done for him and it
report of three distinct areas of ground glass
showed normal heart structures and functions.
infiltrates in lower segment of the right upper lobe,
Naso phayngolaryngeoscopy was done to
the posterior segment of the right lower lobe and
rule out supraglottic stenosis, glottic abnormalities
the posterior segment of the left lower lobe. A
and it was normal. Barium swallow to rule out
second opinion from our pediatric pulmonology
extrinsic esophageal compression was normal.


Full Paper (vol.723 paper# 7)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4078-4084
The Use of Levonorgestrel-Releasing System (Metraplant-E) in the Treatment of
Abnormal Uterine Bleeding
Mohamed Ezz-Eldin A. Azzam, Magd Eldin M. Mohamed, Laila A. Farid, Alshaimaa AA
Mahmoud, Reem Abdelazeem Hussein, Alaa Rashid

Department of Obstetrics and Gynecology and Early Cancer Detection Unit, Ain Shams University, Cairo, Egypt.
Corresponding author: Mohamed Ezz-Eldin A. Azzam, E-mail: prof_m.azzam@outlook.com, Mobile Number: 01003465651
Background: Dysfunctional uterine bleeding (DUB) is one of the commonest condition for which patient
seeks out medical consultation. The prevalence increases with the increase of age peaking before menopause.
Objectives: The aim of this work is to evaluate the effect of this new form of levonorgestrel-releasing IUD on
the treatment of patients with abnormal uterine bleeding.
Patients and Methods: A prospective age-specific comparative analysis of 61 peri-menopausal women
presented with dysfunctional uterine bleeding who constituted the study group. They underwent hysteroscopy
and endometrial sampling during an 18 months period from June 2014 to January 2016 at Ain Shams
University Materity Hospital. Prior to metraplant-E application, all the patients in this study were in the age of
25-58 years old.
Results: The role of Metraplant-E in the treatment of abnormal uterine bleeding (AUB) was evaluated. Sixty-
one women with failed attempt(s) of medical treatment unwilling or unfit for hysterectomy were treated with
Metaplant-E. Menstrual blood loss was assessed by pictoral bleeding assessment chart (PBAC), bleeding index
(B.I) and total bleeding score (T.B.S/month). The bleeding patterns in the form of the mean menstrual blood
loss estimated by bleeding index and the mean menstrual loss estimated by the total bleeding score/month and
PBAC decreased significantly (p = 0.001). The quality of life scale (Likert scale) improved significantly (p =
0.001). All 15 cases who had endometrial sampling demonstrated progestational effect on histo-pathological
Conclusion: Metraplant-E was found to be effective in managing dysfunctional menorrhagia on both clinical
and histopathological levels.
Key Words: Metraplant-E , LNG-IUS, Menorrhagia, Contraceptives

patients had initial abnormal histology report
Dysfunctional uterine bleeding (DUB) is one
which is found more in peri-menopausal age. Peri-
of the commonest condition for which patient seeks
menopausal age, irregular menstruation and
out medical consultation. The prevalence increases
hypertension are risk factors for hyperplasia.
with the increase of age peaking before menopause.
Therefore, it is mandatory to do endometrial
The peri-menopausal women who have anovulatory
sampling in cases of peri-menopausal age with
cycle resulting in DUB. The normal menstrual cycle
is defined as having a mean interval of 28 ±7 days
hypertension [2].
with a men duration of 4 ± 3 days. The upper limit of
Progesterone intra-uterine devices were
normal menstruation is 80 ml per menstruation. Any
originally introduced as contraceptives. However,
deviation from the normal cycle and the amount of
the addition of levonorgestrel, which induces
loss is regarded as abnormal uterine bleeding.
profound remodeling and differentiation of the
Dysfunctional uterine bleeding (DUB) is one of the
oestradiol-primed endometrium, leads to decreased
commonest causes of abnormal uterine bleeding. It is
menstrual bleeding [3]. Its action (levonorgestrel)
defined as heavy and/or irregular menstruation in the
proved to be particularly useful in the treatment of
absence of detectable pelvic pathology, pregnancy or
the following conditions: dysmenorrhea associated
general bleeding disorder. It affects 20 to 30 % of
with endometriosis [4,5,6], idiopathic menorrhagia
women and accounts for 12 % of gynecological
[7,8,9,10,11], adenomyosis and anomalous bleeding
referrals. DUB can be ovulatory or anovulatory.
[12,13,14,15]. Moreover, it has been proposed for use in
Anovulatory DUB occurs at extreme reproductive
the treatment of endometrial carcinoma or as an
age (adolescence and peri-menopausal age) [1].
alternative to surgical treatment in women affected
Hyperplastic endometrium is abnormal
by menorrhagia [16].
histology finding found in DUB. DUB is more
frequent in peri-menopausal age, multiparity and
levonorgestrel-releasing intra-uterine system used
those patients who had undergone tubal ligation.
in this study is developed by Azzam in 2013.
Commonest normal histology of DUB is
Metraplant-E design has a T-shaped frame
proliferative endometrium. One third of the
containing levonorgestrel and ethinyl vinyl acetate


Full Paper (vol.723 paper# 8)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4085-4092
Immediate and Short-term Changes in Left Ventricular Function in Children
Undergoing Percutaneous Closure of Patent Ductus Arteriosus by
Echocardiography and Tissue Doppler
Hebatallah M. Attia, Dina A.E. El Din, Ahmed M. Hassan
Department of Cardiology, Faculty of Medicine, Ain Shams University
Background: Patent ductus arteriosus accounts for 5­10% of all congenital heart diseases. Left-to-right
shunting through the PDA results in pulmonary over-circulation and left heart volume overload. Transcatheter
closure is the method of choice for PDA closure when suitable. Some previous studies have described an
immediate deterioration of left ventricular functions after percutaneous closure of PDA, which is reversible
and improves after few months. Purpose: This study aimed to determine the immediate and short-term
changes in the left ventricular function in children with patent ductus arteriosus after percutaneous closure
using 2D echocardiography and tissue doppler imaging. Patients and Methods: Thirty children with isolated
PDA were treated by trans-catheter closure were studied. The LV dimensions, volumes and systolic function
were assessed by two-dimensional echocardiography and tissue Doppler imaging before the PDA closure, on
day 1 and after one month. Results: The median age of the patients was 4.25 years and mean BSA was 0.73 ±
0.31 m², with the mean PDA diameter of 2.53 ± 0.60 mm. The LVEDD, LVESD, left atrium diameter, ejection
fraction and LVEDV reduced significantly immediately after PDA closure (p < 0.001). After 1 month,
LVEDD, LVESD and LAD continued to decrease, while ejection fraction improved significantly. All tissue
Doppler velocities showed a significant decrease immediately after closure with significant increase of MPI (p
< 0.001) and then were improved within 1 month. Conclusion: percutaneous closure of PDA was associated
with reversible significant decrease in the left ventricular systolic and diastolic functions, which recovered
after one month.
Keywords: Left ventricular function, Echocardiography and tissue Doppler, Patent ductus arteriosus

pulses and symptoms and signs of congestive heart
failure (2).
communication between the descending aorta just
The echocardiogram is the procedure of
distal to the left subclavian artery and the main
choice to confirm the diagnosis and to characterize a
pulmonary artery near its bifurcation. It is a normal
PDA. In addition to evaluating the ductus arteriosus,
and essential component of the fetal circulation as it
the echocardiogram is used to identify and evaluate
allows right-to-left shunting of nutrient-rich,
oxygenated blood from placenta to the fetal systemic
echocardiography is used to measure the cardiac
circulation, thereby bypassing the fetal pulmonary
chamber sizes and quantitate left ventricular systolic
circuit. In the fetus the ductus arteriosus is kept open
function. Two-dimensional imaging demonstrates the
by low arterial oxygen content and placental
geometry of the ductus. Color Doppler is a very
prostaglandin E2 (PGE2). At birth, several changes
sensitive modality in detecting the presence of a PDA
occur to initiate closure of the ductus arteriosus
and is frequently used to estimate the degree of ductal
within the first 15 to 18 hours of life and completely
shunting (3).
closed by 2 to 3 weeks. Spontaneous closure of a
Transcatheter closure is widely considered as
PDA is unlikely to occur in term infants after 3
the treatment of choice for patients diagnosed with
months and in preterm infants after 12 months (1).
PDA since the first experience of the transcatheter
Patent ductus arteriosus is one of the most
occlusion of PDA by Porstmann et al. in 1971(4). It is
common congenital heart defects, accounting for 5-
performed using various devices, such as detachable
10% of all congenital heart diseases in term infants
coils, Nit-Occluders and Amplatzer duct occluder.
with incidence of 1 in 2000 births. Incidence of PDA
Previous studies have reported an immediate change
is greater in preterm infants and more common
in LV performance followed by recovery within a
among females than males with ratio of 2: 1. Several
few months after successful transcatheter closure of
risk factors have been shown to increase the
PDAs in children (5). Hemodynamically significant
incidence of PDA, including high altitude birth,
PDA, once closed, decreases the preload to the LV by
genetic factors and maternal rubella infection.
abolishing the left-to-right shunt and increases the
Clinical signs of ductal patency may include
afterload by isolating the low-resistance pulmonary
continuous murmur, tachycardia, bounding peripheral
circulation from LV outflow circulation. This
simultaneous reduction in the LV preload and


Full Paper (vol.723 paper# 9)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4093-4099
Comparison between B-scan Ultrasonography and Optical Coherence Tomography
in Evaluation of Macular Oedema
Hany M. El-Ibiary, Lamia S. Elewa, Ahmed M. El-Bauomy, Amira S. Abd El Aziz
Department of Ophthalmology, Faculty of Medicine ­ Ain Shams University
Corresponding author: Amira S. Abd El Aziz; Mobile: 01099313482; Email: dr.meeero76@gmail.com
Background: Optical Coherence Tomography is a very sensitive modality for detection of even subclinical
macular edema and provides both qualitative and quantitative results used in monitoring and follow up of patients
before and after treatment of ME. However, B-Scan Ultrasonography is a non-Invasive diagnostic tool that has the
advantage of reliably imaging the posterior segment regardless of the ocular media status and it is less dependent on
patient cooperation. Aim of the Work: To report sensitivity and specificity of B-scan Ultrasonography in detection
of macular edema. Patients and methods: This observational case series was conducted on Forty eyes of 20
patients examined at the ophthalmology clinic of Cairo Fatimic Hospital. They were asked to participate and were
enrolled in this study in the period from December 2017 to March 2018. Results: There was high degree of
agreement between clinical diagnosis and echographic findings of macular thickening. The sensitivity and positive
predictive value (PPV) of B-scan ultrasonography to detect ME were 91.7% (22/24) and 84.6% (22/26)
respectively. The specificity and negative predictive value (NPV) of B-scan ultrasonography to detect ME were
75% (12/16) and 85.7% (12/14), respectively. And consequently, the diagnostic accuracy of B-scan
ultrasonography to diagnose ME was found to be 85% (34/40). Conclusion: Optical Coherence Tomography is the
most sensitive method to diagnose macular edema both qualitatively and quantitatively, but in certain circumstances
when performing OCT would be difficult or even impossible, B-Scan Ultrasonography provides an acceptable
method to qualitatively detect macular edema.
Key words: Macular oedema, B-scan ultrasonography, Optical coherence tomography

may lead to thinning and loss of inner retinal tissue, or
Macular edema is a common phenomenon in
the formation of lamellar hole (2).
various diseases where fluid accumulates in between
Early detection of CME is critical for diagnosis
the retinal cells. The fluid originates from the
and management. Traditional methods of assessing
intravascular compartment. The focal, diffuse, and
macular edema include contact and noncontact slit lamp
cystic forms are all characterized by extracellular
biomicroscopy, indirect ophthalmoscopy, fluorescein
accumulation of fluid, specifically in Henle's layer
angiography (FA), and fundus stereo photography.
and the inner nuclear layer of the retina. The
However the interpretation of their results can be
compartmentalization of the accumulated fluid is
subjective, and subtle changes in retinal thickness in
likely to be due in part to the relative barrier
early CME may not be evident (3).
properties of the inner and outer plexiform layers (1).
Optical coherence tomography (OCT)
The classic pattern of cystoid macular edema
correlates well with retinal histology and can be used
(CME) with the petaloid appearance originating from
to quantitatively and qualitatively monitor retinal
the fluorescein leakage from perifoveal capillaries
thickness over time. Compared to biomicroscopy and
may be seen in cases of advanced edema of various
FA, OCT is more sensitive in detection of macular
origins. This includes postsurgical CME as well as
edema and subretinal fluid, and subclinical macular
CME associated with one of the following
edema is often only detected by OCT (4).
conditions: diabetes, vascular occlusion, hypertensive
Fluorescein angiography and OCT have
retinopathy, epiretinal membranes, intraocular tumors
limitations. Both tests require the ocular media to be of
(e.g., melanoma, choroidal hemangioma), intraocular
sufficient clarity to image the retina. Yet in certain
inflammation (e.g., pars planitis), macroaneurysm,
patients, opacities in the ocular media limit
retinitis pigmentosa, choroidal neovascularization,
biomicroscopy, FA, and OCT. Furthermore, a high
and radiation retinopathy (1).
degree of patient cooperation is required to ensure
Cystoid macular edema may have severe
reliable and accurate testing. However, certain patients,
implications for the function of the retina, including
such as children, often cannot tolerate a FA or follow
decreased visual acuity and contrast sensitivity. Acute or
the specific fixation instructions for OCT testing (5).
chronic edema causes anatomical disruption that may
Ophthalmic ultrasonography is a well-
result in cellular dysfunction and death. Treatment of
CME is important because chronic edema may result in
Ultrasonography has the advantage of reliably
degenerative changes in the macula and permanent loss
imaging the posterior segment regardless of the
of vision. In addition, large cystic changes in the retina
ocular media status. Furthermore, ultrasonography is


Full Paper (vol.723 paper# 10)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4100-4103
Assessment of Corneal Higher Order Aberrations Before and After Corneal
Collagen Cross-Linking in Patients with Keratoconus
Mo'mena A.A., Moamen S., Ahmed A., Tamer E.M., Rafeek E.G.
Ophthalmology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Corresponding author: Mo'mena Awad-Allah, E-mail: m.abd_elrazeik@yahoo.com
Purpose: This study aimed at assessing the shortterm effect of corneal collagen crosslinking on higher order
aberrations of cornea in patients with keratoconus using corneal topography.
Patients and Methods: The study was a prospective cohort study that was conducted in a private specialized eye
hospital on 40 eyes of 28 keratoconus patients. Each patient was fully assessed preoperatively including doing
corneal topography using Pentacam® HR. Transepithelial accelerated CXL was done to all patients. Postoperative
corneal topography was done at six months and data was retrieved and analyzed.
Results: RMS HOA recorded a higher mean value preoperatively, with a high statistically significant difference
(p=0.00). All elements of HOAs showed lower postoperative values except for trefoil 30º. The difference was
statistically significant in comma 0º, comma 90º, spherical aberrations and fifth order comma 90° (p=0.026, p=
0.003, p=0.005, and p=0.001 respectively).
Conclusion: Transepithelial corneal collagen cross-linking improves corneal higher order aberrations. The
maximum effect of the procedure is on comma 0º, comma 90º, spherical aberrations and fifth order comma 90°
Key words: Keratoconus, Corneal collagen cross-linking, Higher order aberrations.

The cornea represents a transparent
The study was conducted on 40 eyes of 28
avascular connective tissue that has a primary
patients. The study was done in accordance with
infection and structural barrier function. With the
the ethical standards of the institutional review
overlying tear film, it forms the anterior refractive
board of the faculty of Medicine, Ain Shams
surface of the eye optical system (1).
The cornea exhibits elastic and viscous
Inclusion criteria: Axial topography
properties, which give it the quality of hysteresis.
consistent with keratoconus according to
Elasticity refers to the ability of a substance to
Rabinowitz criteria. Pachymetry more than 400
deform reversibly under stress. Viscous materials,
microns. BSCVA 6/24 or better. Absence of apical
on the other hand, flow when an external shear
corneal scarring. Absence of systemic collagen
force is applied and do not regain their original
shape when the force is removed. Viscoelastic
Exclusion criteria: History of corneal
materials exhibit characteristics of both viscosity
surgery. Chemical injury.
and elasticity, resulting in energy dissipation when
Preoperative assessment: Full history was
stress is applied. The energy lost in this dissipation
taken with stress on the points related to inclusion
process is called hysteresis (2).
and exclusion criteria. This was followed by
Any disruption of the corneal fiber
performing full ophthalmological examination
network can result in decreased structural integrity
including UCVA, BSCVA, slit lamp biomicroscopy
of the cornea, leading to decreased vision. One of
and fundus examination. Preoperative (base-line)
the diseases that exhibit these pathological changes
corneal topography was done using Pentacam® HR
is keratoconus.
(OCULUS Optikgeräte GmbH) machine.
Keratoconus is a progressive ectatic
Corneal collagen cross linking: Epithelium
disorder. It is usually a bilateral, asymmetric, non-
on accelerated technique was used. Topical
inflammatory degeneration which results in central
anesthesia was administered followed by draping.
and paracentral thinning. The degeneration occurs
ParaCelTM was applied every 1.5 minutes for four
at the level of the chemical composition of the
times followed by Vibex XtraTM drops every 1.5
material of corneal stroma, leading to increased
minutes for four times. Corneal stromal absorption
strain, and redistribution of stress (3).
was verified by slit lamp examination. Exposure to
One of the important modalities in
UVA by the Avedro's KXL® system (Avedro Inc.)
keratoconus treatment that is gaining more and
7.2 joules pulsed (1second on,1 second off) for 5
more importance is corneal collagen cross-linking
minutes and 20 second, achieving total delivery of
(CXL). It is proposed that it slows, stops or even to
120 mWatt.
a limited extent reverses the pathology underlying
keratoconus (4).


Full Paper (vol.723 paper# 11)

a The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4104-4108

Assessment of Endovascular Treatment of Tibial Artery
Occlusion in Diabetic Patients
Mohamed Abdel-Hamid Abdel-Rahman, Ahmed Saeed Daha,
Mohamed Moukhtar Abdel-Fattah Elbanwany
Vascular Surgery Department, Faculty of Medicine, Al-Azhar University

Globally, over 170 million people have diagnosed DM, and by the year 2030, the prevalence is
estimated to raise 2.5-fold. Diabetes mellitus (DM) is one of the strongest predictors of peripheral arterial occlusive
disease and a significant risk factor for progression of asymptomatic disease or claudication into critical limb
ischaemia (CLI). Critical limb ischaemia is the most advanced stage of peripheral arterial occlusive disease. The
prognosis is poor, with amputation rates up to been 30% and mortality up to 25 % after 1 year.
Aim of the Work:
The aim of this work is to evaluate the role of endovascular treatment of tibial artery occlusive
disease in diabetic patients, as regard to efficacy, safety, as well as complications. Patients and Methods: This is
prospective cohort study, diabetic patients with peripheral arterial occlusive disease (affecting tibial arteries), it is the
study of 20 patients, Al-Azhar University Hospitals. Patients with Critical limb ischaemia (CLI) with Computerized
Topographic Angiography (CTA) evidence of significant isolated tibial artery occlusive disease (anterior or posterior
or both). Patients with generally adequate state of cardiac, respiratory and renal conditions that allow the procedure.
The present study was conducted on 20 diabetic patients, 11 males (55%) and 9 females (45%). Their age
ranged between 50 years and 87 years with a mean age of 66.7 12.35. All 20 diabetic patients had tibial disease
which ranges from segmental stenosis to total occlusion. The procedure time was estimated from the time of
infiltration of local anaesthesia to the end of the procedure; It ranged from 45 min to 120 minutes with mean ± SD
(88.920. min).The hospital stay ranged from 1 to 21 days with mean ± SD (5.5 ±6.8). Conclusion: Tibial
angioplasty demonstrated its feasibility, safety and effectiveness in the treatment of diabetic patients with CLI. Limb
salvage should be the main goal in patients with CLI due to infrapopliteal occlusive disease. With a prompt diagnosis,
treatment can be started early and serious consequences may be avoided. Revascularisation that can prevent
amputation is the ultimate treatment strategy.


Globally, over 170 million people have
through the ankle, but not specifically targeted to
diagnosed DM, and by the year 2030, the
the location of ischaemia (5).
prevalence is estimated to raise 2.5-fold (1).
To achieve healing of an ischaemic foot
Diabetes mellitus (DM) is one of the
ulcer and save the leg from amputation,
strongest predictors of peripheral arterial occlusive
revascularization, endovascular or open surgery,
disease and a significant risk factor for progression
with sufficient wound perfusion is necessary. In
of asymptomatic disease or claudication into
recent years, selection of the artery for
critical limb ischaemia (CLI) (2).
revascularization has been the subject of
Critical limb ischaemia is the most
discussion, the angiosome concept has been
advanced stage of peripheral arterial occlusive
introduced (6).
disease. The prognosis is poor, with amputation

rates up to been 30 % and mortality up to 25 %
after 1 year (3).
The aim of this work is to evaluate the role
Diabetic patients who develop CLI are
of endovascular treatment of tibial artery occlusive
more prone to ischaemic events with an impaired
disease in diabetic patients, as regard to efficacy,
functional status. Approximately 80 % of diabetes
safety, as well as complications.
related lower limb amputations are preceded by a

diabetic foot ulcer (4).
Treatment of CLI aims at wound healing,
Study design: this is prospective cohort study.
improvement in quality of life, limb loss
The study was approved by the Ethics
prevention, and prolonged survival. Current
Board of Al-Azhar University.
Study population: diabetic patients with
revascularization of tibial arteries with runoff
peripheral arterial occlusive disease (affecting

tibial arteries).

Full Paper (vol.723 paper# 12)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4109-4112

Loop Knots Versus Harmonic Scalpel in Laparoscopic Appendectomy
Alsayed A. Hamdy, Mohamed F.L. Ayoup, Ashraf A.I. Elsayed
General Surgery Department, Faculty of Medicine, Al Azhar University

Acute appendicitis is the most common indication for intra-abdominal emergency surgery, and
appendectomy is one of the most commonly performed procedures in abdominal surgery. Although
laparoscopic appendectomy (LA) has not yet achieved the status of a "Gold Standard" treatment, it is being
progressively accepted as the treatment of choice for acute appendicitis. Numerous studies have shown many
benefits of LA, including a faster recovery, less postoperative pain, reduced wound infections, shorter hospital
stay and earlier return to work. Aim of the Work: To assess the feasibility of using the ultrasonic-activated
device (harmonic) scalpel in sealing and division of the appendicular stump during laparoscopic
appendectomy. Patients and Methods: This prospective study was carried out at the surgical department of
Al Hussein University hospital during the period from June 2016 to April 2018. 40 patients diagnosed as acute
appendicitis were included And divided into two groups: group 1 containing 20 patients using loop knots and
group 2 containing 20 patients using harmonic scalpel (as a method of appendicular stump sealing. A
comparative analysis was done for both techniques considering the post-operative leakage, the post-operative
pain, hospital stay, surgery time, post-operative bleeding (if), and post-operative infection. Results: A total of
40 patients were included in this study, 20 in the loop knots group and 20 in the harmonic scalpel group. An
analysis of the patients data showed that there was no significant difference between the first group and the
second group with respect to difference in either age or gender. There was no mortality occurred in this study.
There was no significant difference in the overall complication rates (10% in the LOOP group versus 10% in
the harmonic group). Conclusion: Harmonic scalpel and loop knots tying are two promising techniques to
secure the appendix stump in laparoscopic appendectomy with similar complication rates. Harmonic scalpel
costs were higher than loop knots tying but has shorter operative times. Because of the simplicity of
techniques, we highly recommend using of the harmonic scalpel especially by surgeons learning laparoscopic
Keywords: Loop Knots, Harmonic Scalpel, Laparoscopic Appendectomy


Acute appendicitis is the most common
There are several techniques used to close the
indication for intra-abdominal emergency surgery,
appendicular stump during laparoscopic appendectomy.
and appendectomy is one of the most commonly
The most commonly used surgical methods are
performed procedures in abdominal surgery (1).
connected with the use of endo-loop ligature,
Although laparoscopic appendectomy (LA)
laparoscopic staplers, metal or polymer clips or
has not yet achieved the status of a "Gold Standard"
application of purse string suture with the invagination of
treatment, it is being progressively accepted as the
the appendicular base into the cecum, as in the classic
treatment of choice for acute appendicitis.
surgery (4).
Numerous studies have shown many benefits of
These techniques have been compared in
LA, including a faster recovery, less postoperative
many retrospective and prospective studies without
pain, reduced wound infections, shorter hospital
reaching a consensus for prioritizing one particular
stay and earlier return to work (1).
technique over the other (5,6,7).
LA also offers surgeons a better visualization
In this study, there was a comparative study
and identification of another abdominal pathology that
was carried out to clarify the difference between
can mimic acute appendicitis (2).
using harmonic scalpel and loop knots tying in
Although the technique used for LA was first
managing the appendicular stump.
described more than 20 years ago, the technical details
are still not being modified, and improvements can be
To assess the feasibility of using the
measured in terms of complications and costs. There are
ultrasonic-activated device (harmonic) scalpel in
several technical variations that can potentially affect the
sealing and division of the appendicular stump during
outcome of LA, including the techniques used for
laparoscopic appendectomy. To assess efficiency,
skeletonization of the appendix, the use of single-port
safety, ease, and flexibility of the technique. To assess
versus multiple-port instrumentation and the technique
possible complications. To compare the loop knots
used for closure of the appendiceal stump (3).
with harmonic scalpel in sealing appendicular stump


Full Paper (vol.723 paper# 13)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4113-4119
Role of Recent MR Imaging Modalities in Diagnosis of Problematic Breast Lesions
Maged M.A. Ghanem, Mohamed S.T. El-Feshawy, Ahmed M.S. Abdelmaksoud
Department of Radiodiagnosis, Faculty of Medicine-Al-Azhar University
Corresponding author: Ahmed M.S. Abdelmaksoud, Mobile: 01091530382; Email: ahhhmed488@gmail.com
Background: Breast imaging reporting and data system (BIRADS) III and IV lesions are considered
indeterminate breast lesions and an imaging dilemma. Contrast enhanced MRI shows high sensitivity in
detecting these lesions but with low specificity leading to unnecessary biopsy in some of them and high false
positive rate. So there was a need for new imaging techniques to raise the specificity of MRI. One of these new
imaging techniques is MRS which can improve breast cancer diagnosis especially in indeterminate breast
lesions. IT is a noninvasive method that can be added to the DCE­MRI of the breast increasing only the time
of examination but allow better characterization of lesions depending on their chemical composition.
Objective: To assess the diagnostic value of recent MR imaging modalities in diagnosis of problematic breast
lesions categorized by mammography or sonomammography as (BIRADS III and IV) and correlation of these
findings with available histopathological findings, clinical data or follow up.
Patients and Methods: Study was carried out in the Radiology Department of Al-Azhar University Hospitals.
The work took place during the period between May 2017 and June 2018. A total of 35 patients, presented
with breast lesions for characterization, were included in the study.
Results: We found that MRS measurement increased the specificity of the breast MRI in characterizing
different breast lesions especially when it is combined with conventional dynamic MRI.
Conclusion: MRS is a noninvasive scan that can be added easily to standard breast MRI protocols as an
adjuvant tool. Detection of choline peak using choline SNR can accurately differentiate benign from malignant
breast lesions especially indeterminate breast lesions with high sensitivity and specificity especially by adding
its results with the results of the standard DCE- MRI scan.
Keywords: Breast Imaging Reporting and Data System - Computed tomography - Dynamic contrast
enhancement - Magnetic resonance

characterized by being noninvasive, more specific
Breast cancer is the most common cancer
in lesion localization, superior contrast resolution,
among women in Arab countries with a young age
of around 50 years or even younger at presentation.
physiological processes such as blood flow,
Locally advanced disease is very common and total
perfusion, diffusion and metabolite concentrations
mastectomy is the most commonly performed
which have provided an entire new world of insight
surgery. Traditional approaches to assess breast
into breast imaging (3).
lesions are routine screening methods, such as
The use of magnetic contrast agent is
helpful in the evaluation of the breast lesions
Mammography provides a widely available,
depending on the analysis of the uptake, and
reliable and cost-effective screening tool, however
pattern of enhancement (4).
contraindicated in pregnancy and lactation, has
H-MRS allows noninvasive molecular
decreased efficacy in patients with dense breasts,
analysis of biologic tissues and has been suggested
patients with silicone implant and patients that
as an adjunct to MR examination to improve the
have previous surgery (1).
specificity of distinguishing benign from malignant
Breast US is routinely used as an adjunct
breast masses classified according to BIRADS
to mammography to help differentiating benign
category. The diagnostic value of H-MRS is
from malignant lesions. The accuracy of US
typically based on the elevation of choline
diagnostic methods is controversial because there
compounds which are the markers of active tumor
is a considerable overlap of benign and malignant
and aid in the discrimination between benign and
characteristics on US images and interpretation is
malignant breast lesions mainly the BIRADS 3-5
subjective, dependant on the operator (2).
masses (1).
MRI is a helpful imaging modality in
diagnosis of breast neoplasms and suspicious
characterized by their cellular chemistry obtained
lesions (not for follow benign or malignant criteria,
from proton MR spectroscopy (MRS). Proton MRS
after lumpectomy to differentiate scarring from
analyses of the breast have shown high levels of
recurrence, female with positive family history of
total choline-containing compounds at 3.2 ppm in
breast cancer, diffuse edema pattern). It is
malignant lesions but low levels in normal breast


Full Paper (vol.723 paper# 14)


Comparative Study between Laparoscopic Sleeve Gastrectomy and Laparoscopic
Mini Gastric Bypass in Control of Type 2 Diabetes Mellitus in Obese Patients
Ashraf Abd-Elhamid Abd-Elmonem1, Kamel Suliman Hamad2, Mohamed Noshi El-Alfi3,
Abd El-Hafez Abd-El Aziz Selim1, Fouad Ebrahim Fouad Agwa*
1General Surgery Department, 2Clinical Pathology Department, 3Internal Medicine Department
Faculty of Medicine, Al-Azhar University
*Corresponding author: Fouad Agwa , E-Mail: foadagwa@gmail.com

Among morbidly obese adult patients (body mass index (BMI) <40 kg/m2) those who are
super obese (BMI < 60 kg/m2) present particular challenges for bariatric surgeons. Management of super
obese (SO) patient has been associated with higher morbidity and mortality and increase surgical risk. The
optimal surgical management of these patients is controversial. Aim: This work aimed to focus light on super
obese patient. Considering the advantages, the disadvantages and determine long-term outcome of different
plans of management regarding the recent guidelines for this group of patients. Patients and Methods: This
study included 60 obese patients with type 2 diabetes mellitus (DM) and randomly divided using closed
envelopment method into two groups: Group (1): (30 patients) treated by laparoscopic Sleeve gastrectomy
(LSG), Group (2): (30 patients) treated by laparoscopic Mini-Gastric Bypass (MGB). Results: This study
included 60 obese patients with type 2 D.M. As regard all sample patients (60 obese patients with type 2 D.M), the
group age ranged between 22 -55 years with a mean ± SD of 37.88 ± 9.52 years. The group BMI ranged between
37 ­ 72 kg/m2 with a mean ± SD of 52.42 ± 9.45 kg/m2. Of the 60 patients, 38 patients (63.3%) were women and
22 patients (36.7%) were men. Conclusion: Bariatric surgery (LSG and MGB) is not only weight reducing surgery
but a metabolic surgery which can cure most of the metabolic syndrome and they are considered the most effective
long term treatment modality for type 2 diabetes in obese patients and with comparing between LSG and MGB, our
study suggests that MGB has better and earlier effect than LSG in diabetes remission.
Keywords: Laparoscopic Sleeve Gastrectomy, Laparoscopic Mini Gastric Bypass, Type2 Diabetes Mellitus,
Obese Patients.

obese patients is that surgical navigation is more
Among morbidly obese adult patients
complex (1).
(BMI < 40 kg/m2), those who are super obese
Moreover, thicker layers of abdominal
(BMI < 60 kg/m2) present particular challenges
wall and intraabdominal fat, longer distance
for bariatric surgeons. Management of super
between the xiphoid and the esophagus), and
obese (SO) patient has been associated with higher
massive hepatomegaly are some of the surgical
morbidity and mortality and increased surgical
hindrances associated with this patient population.
risk. The optimal surgical management of these
Surgical treatment of super­super obese patient
patients is controversial. Obesity is a multifactorial
has also been associated with higher surgical
condition that arises as a result of genetic, cultural,
morbidity and mortality and increased surgical risk
social, and dietary factors (1).
(3). In addition, higher BMI at the time of surgery
In the USA, the obesity epidemic has
has been linked with higher incidence of major
reached record numbers, with greater than 30 % of
surgical complications for certain bariatric
the adult population being obese, and twice that
procedures, as well as longer length of
number experiencing overweight or obesity (2).
hospitalization, increasing rates of 30-day
With these alarming percentages, the
readmission, and rising treatment costs (1).
management of obesity has become a public health
Initial surgical management options for
priority and many options for weight loss are
these patients include the well-established and
available for this population. Surgical intervention
widely accepted Roux-en-Y gastric bypass
has been shown to be the most reliable and popular
(RYGB) surgery as well as sleeve gastrectomy
way to treat morbidly obese patients struggling
(LSG), a procedure that has gained recent
with conservative treatments such as diet and
popularity due to its simplicity and favorable
exercise (2).
complication profile (1).
Among the population of morbidly obese
When deciding which type of bariatric
adult patients (BMI >40 kg/m2), super obese (BMI
surgical procedure the most appropriate is for
> 60 kg/m2) patients present particular challenges
super obese patients, cost, operative time, pre-
for bariatric surgeons. Among the common
surgical comorbidities, and experience of the
technical difficulties related to the size of super
surgeon have to be considered. The rate of post-

Full Paper (vol.723 paper# 15)

Introduction The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4126-4133

Role of CT Enterography in the Diagnosis of Crohn's Disease
Sherine K. Amine (1), Merhan A. Nasr (1), Ahmed M. Moustafa (2), Rania M. Abd El Rasool (1)
(1) Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University
(2) Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University
Corresponding author: Rania M. Abd El Rasool; Mobile: 01067841674; Email: rania.abdelrasol55@yahoo.com

Crohn's disease is a multifactorial chronic inflammatory disease characterized by non-caseating
granuloma formation with a tendency toward remission and relapse, it affects any part of the GIT from mouth
to anus with 80% small bowel involvement, most commonly the terminal ileum, with characteristic multiple
discontinuous sites involvement (skip lesions) and transmural inflammation. Aim of the Work: The purpose of
this study is to highlight the value of CT in diagnosis of (CD) and its ability to assess the degree of activity and
its complications. Patients and Methods: This prospective study was conducted on 87 patients with GIT
symptoms where CTE was performed to evaluate its possible impact on accurate diagnosis, detection of
complications and consequent guidance for management planning. It was performed in radiological department
of Ain ­Shams University hospital: CT Unit in the period from "July 2017 to April 2018. The patients' age
ranged between (24 ­ 72 years) with a mean of 48 years. Results: Of the 87 patients with GIT symptoms that
were highly suggestive of inflammatory bowel disease evaluated, 32 were UC, 21 were CD, 9 were other types
of IBD and 25 were normal. Of the 21 CD patients evaluated, 7 were male and 14 were female. Conclusion:
The role of MDCT in the diagnosis of Crohn's disease and its complications is undeniable, with a proven
efficacy in identifying the enteric and extra-enteric manifestations of the disease. However, advancements in
CT E protocol design have allowed increasing accuracy in diagnosis, and the acquisition of studies at a much
lower radiation dose. Recommendations: Further studies on a larger scale of patients are needed to confirm the
results obtained by this study.
Keywords: CT enterography, small bowel, Crohn's disease (CD).


Crohn's disease (CD) is an idiopathic chronic
detects early mucosal disease (sens. 69.6%, spec.
inflammatory disease of the gastrointestinal tract that
95.8%) as well as complications such as strictures,
has varying levels of severity, diverse manifestations,
fistulae, and abscesses (diagnostic accuracy 80.3%)
and an unpredictable course. It may affect any part of
(5). Computed tomography enterography (CTE) is
the gastrointestinal tract from mouth to anus. Signs
undoubtedly a superior imaging test compared with
and symptoms often include abdominal pain, diarrhea
SBFT. It is more sensitive and reproducible, can
(which may be bloody if inflammation is severe),
detect extraluminal complications, and is faster and
fever, and weight loss (1).
better tolerated. A potential downside of CTE is that
The etiology of Crohn's disease is complex
the radiation doses are higher than SBFT. The
and likely multifactorial, with genetic, immunologic,
radiation dose from a single CTE is not particularly
infectious, microvascular, and possibly environmental
concerning, and newer CT techniques have shown a
and lifestyle factors contributing (2).
significant decrease in radiation dose using modified
Enteric involvement tends to be segmental,
protocols and reconstruction algorithms (6).
and inflammation often is transmural. Superficial
CT Enterography plays an invaluable role in the
mucosal (aphthous) and deep linear ulcers may be
evaluation of acutely ill patients with Crohn's disease,
present, separated by segments of uninvolved
particularly when there is concern for high-grade
mucosa, depending on the severity and chronicity of
obstruction, perforation, or abscess. The combination of
Crohn's disease (3).
a short examination time, single-breath-hold scanning,
Barium small bowel follow-through (SBFT)
and widespread availability ensures that CT will
studies and enteroclysis have been the traditional
continue to play an important role in the care of these
radiologic standards of reference for assessment of
individuals. However, CT enterography has a high
the small bowel. However, both techniques may fail
radiation burden, especially in young patients, who may
to clearly depict extraluminal complications such as
require multiple examinations over several years (4).
fistula and abscess formation, and both have limited
MR imaging of the small bowel combines a
sensitivity, particularly when there are overlapping
high-tissue-contrast examination with multiplanar
pelvic loops. In addition, there is a radiation burden
interrogation of the abdomen and pelvis. There is no
with both techniques (4).
ionizing radiation burden, a major advantage in young
Conventional Enteroclysis (CE): Crohn's
patients. Furthermore, like CT enterography, MR
disease has been traditionally investigated with the
imaging allows excellent depiction of the
use of small bowel barium enteroclysis, which
complications of inflammatory bowel disease (5).


Full Paper (vol.723 paper# 16)

c:\work\Jor\vol723_17 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4134-4142

Assessment of Early Left Ventricular Diastolic Dysfunction in Patients with
Metabolic Syndrome by 2D Speckle Tracking Echocardiography
Mohammed Hesham Hassan, Mohammed Saad El-Gammal,
Ahmed AL-HABBAA, Eslam Mubarak Ali*
Department of Cardiology -Al Azhar University, Cairo, Egypt
*Corresponding author: Eslam Mubarak Ali; Mobile: 01140421032; Email: islam.mobarak@yahoo.com


Background: Metabolic syndrome predisposes to left ventricular dysfunction and heart failure, early
detection of associated subclinical cardiac changes has important diagnostic and prognostic values. 2D
strain and strain rate allow detection of subtle abnormalities of global and regional left ventricular systolic
and diastolic functions.
Objectives: To detect early diastolic dysfunction in the left ventricle in patients with metabolic syndrome by
2D speckle tracking echocardiography based on global longitudinal isovolumic relaxation strain rate.
Subjects and Methods: This prospective study included a total of 100 subjects divided in to 75 metabolic
syndrome (MS) patients referred to Al-Azhar university hospital outpatient clinic for evaluation and
treatment of hypertension and/or diabetes mellitus and 25 age and sex matched healthy volunteers as a
control group. All subjects underwent conventional echocardiographic examination and assessment of
diastolic dysfunction by speckle tracking.
Results: There were no statistically significant differences between MS and controls in all traditional
parameters of LV systolic function. On the other hand, significant differences were observed between MS
and the control group in most of the parameters of GLS and SR IVR.
Conclusion: Impairment of diastolic function detected by speckle tracking based on global longitudinal
isovolumic relaxation strain rate in metabolic syndrome patients.
Keywords: Metabolic syndrome, Left ventricular diastole, Speckle tracking, Echocardiography.


Metabolic syndrome (MS) is a condition
pulmonary congestion from occurring. This
characterized by the accumulation of multiple risk
process is referred to as, diastolic function (3).
factors (insulin resistance, hyperglycemia,
Metabolic syndrome is common and it is
dyslipidemia, hypertension, visceral obesity) for
cardiovascular disease in an individual with a
morbidity and mortality as well as with increased
background of obesity and/or lack of exercise (1).
risk of heart failure through multiple complex

metabolic reactions most prominent among which
Even more with the change of the modern
are altered insulin signaling, glycotoxcity,
lifestyle and diet structure, incidence of MS
lipotoxicty, increase cytokine activity and
increased year by year, it is greatly endangering
intramyocyte and/or interstitial deposition of
people's health. However, it is not known
triacylglycerol plus effect of endothelial
whether MS is also associated with abnormal
dysfunction (4) (Figure1).
cardiac function. If MS indicates persons who
A 2D strain echocardiographic method has
have already developed abnormal left ventricular
been introduced that measures myocardial
(LV) function, early recognition of MS would be
deformation by tracking localized acoustic
important (2).
markers frame by frame (speckle tracking). This

method has been used for noninvasive assessment
Left ventricle diastole occurs in order for
of global and regional myocardial strain in the left
the left ventricle (LV) to fill adequately with
and the right ventricle, avoiding the angular
enough blood, at a low enough pressure, to
sensitivity of tissue Doppler echocardiography


Full Paper (vol.723 paper# 17)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4143-4147

Evaluation of Prophylaxis and Management of Venous
Thromboembolism in Surgical Cancer Patients
Omar Mokhtar Elhayeg, Abdelaziz Ahmed Abdelhafez, Mohamed Alaa Eldin Beshta
Department of Vascular Surgery, Faculty of Medicine - Alazhar University
Corresponding author: Mohamed A.E. Beshta, Mobile: 01063232395; Email: mohamedalaa26111988@gmail.com

Deep venous thrombosis is considered to be one other challenges in medical practice because of
silent nature in most of the cases and the complications that may end with death. It's very difficult to study its
incidence. There is strong relation between malignancy and thrombosis. The incidence of deep venous thrombosis
in malignancy differs according to the type of the tumor. There are many risk factors of deep venous thrombosis
other than malignancy like surgery, history of previous attack, immobility, obesity, pregnancy, and
contraceptives, and others. The incidence differs from one risk factor to another and also according to presence of
other co-morbidities. Venous thrombosis occurs as a result of one or more three factors postulated by Virchow
either abnormalities of blood flow, abnormalities of blood or vascular injury. Deep venous thrombosis in
malignancy may be due to other causes like surgery, chemotherapy or central venous catheters.
Objective: The aim of this work was to evaluate the efficacy of prophylactic measures before, during and after
surgery in reducing the risk of developing venous thromboembolism in cancer patients undergoing surgery and
how to mange the thromboembolic events if occurred after surgery in surgical cancer patients.
Patients and Methods: This is a prospective study conducted on 20 patients presented to the Oncology surgery
unit and Vascular surgery outpatient clinic of AL-Hussein University Hospital and Ahmed Maher Teaching
Hospital between December, 2017 and June, 2018. Patients with operable tumors were included in this study
while cancer patients with comorbidities interfering with surgical procedures were excluded. Data were recorded
in predesigned sheet including age, sex, special habits, obesity, history of previous DVT and history of chronic
illness. Duplex study was done pre and post operative to diagnose DVT .Time of operations were assessed. All
included patients were assessed for the appropriate regimen of prophylaxis either mechanical or pharmacological
or combination of both. Diagnosed patients with DVT after surgery were treated with heparin and oral
anticoagulants. Results: Of the 20 patients, 9 (45%) were females and 11(55%) were males. The age of the
patients ranged between 33 and 82 years with a mean age at presentation was 59.85 years.
With the 20 patients who used preoperative prophylaxis regimens, the incidence of postoperative deep vein
thrombosis was 10%; with average time of DVT development of (1.25 ± 0.35) months. In addition, the rate of
bleeding was 5%; developed at 1-month duration.
Conclusion: patients with cancer particularly those undergoing surgery are at risk of developing venous
thromboembolic complications. Low molecular weight heparin (LMWH) and Unfractionated heparin (UFH)
prophylaxis in patients undergoing cancer related surgery has proved to be effective and safe in reducing the risk
of an acute event. Thromboprophylaxis with LMWH, UFH and mechanical methods should be considered for all
patients with a malignancy who undergo surgery.
Recommendation: Both pharmacological and mechanical thromoboprophylaxis measures are required to
minimize the risk of developing deep vein thrombosis and its complications in surgical cancer patients (SCP).
Keywords: Venous thromboembolism - deep vein thrombosis - Low-molecular-weight heparin - unfractionated

Among its many direct and indirect complications
The association between cancer and thrombosis has
is its role as a major risk factor for venous
been known since at least the 19th century. Cancer-
thromboembolism (VTE), discovered in a fifth of all
associated venous thromboembolism (VTE) has
cancer patients and as many as half on postmortem
significant clinical consequences for patients.
examination (3). It is well established that cancer
Thromboembolism is a leading cause of death in
patients are at an increased risk of venous
cancer patients and cancer patients who develop VTE
thromboembolism (VTE). In fact, the presence of
have a significantly worse survival (1).
malignancy increases the risk of (VTE) by a factor of
4 to 6, and large population-based studies showed
thrombosis include deep vein thrombosis (DVT) and
that the incidence of VTE is on the rise (4).
pulmonary embolism (PE), as well as visceral or
Understanding underlying pathophysiology and natural
splanchnic vein thrombosis, together described as
history in deep venous thrombosis is essential in guiding
VTE (2). Cancer continues to pose a costly and
appropriate prophylaxis, diagnosis and treatment. Deep
growing international threat toward modern day
venous thrombosis is usually silent in nature in most of
hospitalized patients and usually presented by non-

specific symptoms and signs (5).

Full Paper (vol.723 paper# 18)

c:\work\Jor\vol723_19 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4148-4153

Evaluation of The Diagnostic Role of Non-Coding RNA and
Exosomal Related Gene Association in Lung Cancer
Fawzia Khalil1, Hanan H. Shehata1, Nehad Osman2, Omar Abdel-Rahman3,
Marwa Ali1 and Ghada Mohamed1
1 Medical Biochemistry and Molecular Biology Department, 2 Pulmonary Medicine Department, Clinical
Oncology and Nuclear Medicine Department, Faculty of Medicine ­Ain Shams University

Exosomes are microvesicles that are recently discovered in intercellular communication
especially between tumor cells as lung cancer that are important for tumor development and progression.
Objectives: Examine the diagnostic role of serum exosomal LncRNA in lung cancer among Egyptian
Methods: Lung cancer characteristic exosomal RNA-based biomarker Lnc-RNA-RP11-510M2.10 was
selected based on bioinformatic methods, followed by RT-qPCR validation of their expression in serum of 20
patients with lung cancer and 10 healthy volunteers.
Results: serum exosomal Lnc-RNA-RP11-510M2.10 showed a significant negative association with lung
cancer patients in comparison to patients with healthy persons (p<0.001).
Conclusion: Lnc-RNA-RP11-510M2.10 could be used as diagnostic and prognostic biomarker tools for lung
Keywords: Lung cancer, Exosomal RNA extraction, Lnc-RNA-RP11-510M2.10.


Lung cancer is the most common cause of cancer
decrease the risk of lung as well as other cancers.
death worldwide, nearly 85% of patients have a
There are no associations between intakes of
group of histological subtypes collectively known
different types of fat and lung cancer risk.
as NSCLC, of which lung adenocarcinoma
Conversely, cured meat (e.g., pressed duck, cured
(LUAD) and lung squamous cell carcinoma
pork and sausage), deep-fried cooking, and chili
(LUSC) are the most common subtypes (1).
increase risk for lung cancer (6).

Risk Factors:
Alcohol Intake:
Tobacco smoking:
Is associated with greater risk for lung cancer
Causes 80% - 90% of all lung cancers. Risk
particularly among people who consume at least 30
factors are typically dose- and duration-dependent,
g/d of alcohol than those who refined from alcohol
and many carcinogens act synergistically when
combined with tobacco smoke. For example,

arsenic in drinking water has been associated with
Exercise and Physical Activity:
lung cancer when combined with exposure to
Data shows that physical activity is associated
tobacco smoke. Radon, a naturally occurring
with lower risk of lung cancer, moderate to high
radioactive gas found in some homes, is estimated
levels of physical activity are associated with a
to cause 21,000 cases of lung cancer per year (2).
reduction of 13% to 30% in lung cancer risk. As a

whole, physical activity can aid in reduction of
Chronic Obstructive Pulmonary Disease:
lung cancer risk and mortality among heavy
COPD is known as a systemic inflammatory
smokers (8).
disorder with many pulmonary and extra-

pulmonary manifestations, as an increased risk for
Air Pollution:
primary lung cancers development (3).
The long-term of surrounding air pollution as
Secondhand or Passive Smoking:
A significant risk factor and causes 1.6% of
hydrocarbon compounds is associated with the risk
lung cancers (4). Recent study reported that
of lung cancer, most probably by inflammation,
exposure during childhood increase risk by 3.6 fold
oxidative stress, stimulation of a procoagulatory
for lung cancer in adulthood (5).
state and disturbance of the autonomic nervous

system (9).
Diet and Food Supplements:
It is estimated that 11% of lung cancers are
Antioxidant vitamins and other micronutrients,
attributed to urban air pollution among Europeans
as carotenoids, present in fruits and vegetables,

Full Paper (vol.723 paper# 19)


Prevalence of Glaucoma among High Myopia
Osama Abd El Kader Salem *, Amr Ismail El Awamry*,
Yasser Abd El Maguid El Zanklony *, Omnia Mohammed Abd El-Fatah **
* Department of Ophthalmology, Faculty of Medicine, Ain Shams University
** Department of Ophthalmology, Faculty of Medicine, Cairo University
Corresponding author: Omnia Mohammed Abd El-Fatah, Email: ghaderelmaa13355@yahoo.com,
Phone No.: +201066922162
Glaucoma is an optic neuropathy that is characterized by the selective loss of retinal ganglion cells
and their axons, which manifests as the loss of the retinal nerve fiber layer (RNFL). Numerous studies have
shown that the extent of RNFL damage correlates with the severity of functional deficit in the visual field (VF),
and that RNFL measurement by optical coherence tomography (OCT) has good sensitivity for the detection of
glaucoma. Purpose: To assess the prevalence of glaucoma among high myopic patients and the association
between them using standard automated perimetry (SAP) and optical coherence tomography (OCT).
Patients and Methods: A prospective observational randomized cross sectional study included a total of 80 eyes
with high myopia, in the period from November 2017 to April 2018.
Results: This cross sectional study included 44 subjects with 80 eyes regarding high myopia using the outpatient
services of the Qlawoon Hospital, Cairo, who satisfied the inclusion and exclusion criteria between November
2017 and April 2018 aiming to determine the prevalence of glaucoma in high myopic patients.
Conclusion: RNFL thickness mean is; for average thickness is 86.37, for superior thickness is 90.06 and for
inferior thickness is 82.68 a highly significant P-value.
Keywords: Glaucoma - high myopia - intraocular pressure - myopic macular degenerations.


more frequently in a generalized or diffuse pattern
Glaucoma is an optic neuropathy that is
rather than in a localized pattern. These
characterized by the selective loss of retinal ganglion
characteristics of highly myopic eyes make it
cells and their axons, which manifests as the loss of
difficult to accurately determine the cup-to-disc ratio
the retinal nerve fiber layer (RNFL). Numerous
and the extent of RNFL damage in susceptible
studies have shown that the extent of RNFL damage
patients (5).An early detection and follow up of
correlates with the severity of functional deficit in
glaucoma require functional testing using standard
the visual field (VF), and that RNFL measurement
automated perimetry (SAP) as gold standard,
by optical coherence tomography (OCT) has good
particularly the 24­2 Swedish Interactive Threshold
sensitivity for the detection of glaucoma (1).
Algorithm (SITA) strategy, as well as structural
High myopia (6 D or more) is a known risk
testing which can be based on ophthalmic findings.
factor for open angle glaucoma (2).
But, one of the most reliable methods for objective
population-based investigations have shown that
glaucomatous damage is the optical coherence
myopia, in particular high axial myopia, can be a
tomography (OCT) which provides both quantitative
risk factor for glaucomatous optic neuropathy (3).
and qualitative measurements of the RNFL
It has remained unclear, which factors
thickness. OCT in diagnostics of the ONH structural
associated with myopia were responsible for the
changes became a part of standard procedure for
increased susceptibility for glaucomatous optic
diagnosis and monitoring of patients with retinal
nerve damage in myopic eyes. Histological studies
pathology. OCT is also highly sensitive in
reported on morphological particularities in eyes
with axial high myopia. These features included a
glaucomatous ONH changes (6).
thinning and stretching of the lamina cribrosa in the

highly myopic secondary macrodiscs (also called
megalodiscs), and an elongation and thinning of the
A prospective observational randomized
peripapillary scleral flange in the parapapillary
cross sectional study included a total of 80 eyes with
region of highly myopic optic nerve heads (4).
high myopia, in the period from November 2017 to
Clinical diagnosis of glaucoma in this group
April 2018. The study was approved by the
of patients is often difficult because of the variation
Ethics Board of Ain Shams University.
in the sizes, shapes, tilt of the optic nerve head, and

the presence of large peripapillary atrophy (PPA) in
Inclusion criteria:
these eyes. In high myopia, RNFL loss also occurs 1. Spherical equivalent refraction 6.0 D or more.

Full Paper (vol.723 paper# 20)

The Role Of Diffusion Weighted Magnetic Resonance Imaging And Subtraction Magnetic Resonaceimaging In Assessing Treatment Response Of Hepatocellular Carcinoma After Transarterial Chemoembolization The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4165-4174
The Role of Diffusion Weighted Magnetic Resonance Imaging and Subtraction
Magnetic Resonance imaging in Assessing Treatment Response of
Hepatocellular Carcinoma After Transarterial Chemoembolization
Mohammed S. Hassan, Mohammed G. Abdel-Mutaleb, Elhadi I. Ahmed
Department of Radiology, Faculty of Medicine -Ain Shams University
Corresponding author: Elhadi I Ahmed; Mobile: 01027667141; Email: hadiizaldeen@hotmail.com

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, and has a poor
prognosis unless treated. Ablative therapies are promising treatment options for patients who are not eligible for
surgery. Monitoring tumor response after transarterial chemoemolization (TACE) procedure is an important task in
oncologic imaging. Early favorable response indicates effectiveness of therapy, while early treatment failure
identification is also critical in patient management. In such cases further re-treatment will be mandatory. Aim of
The aim of this study is to evaluate the efficiency of both diffusion weighted images and subtracted dynamic
MRI technique in the detection of residual/ recurrent disease after TACE ablation of non resectable hepatocellular
carcinoma (HCC) lesions. Accurate judgment of tumor viability will help diagnose the need for further treatment
sessions. Patients and Methods: This study included 32 patients having 54 HCC lesions that underwent
transarterial chemoembolization procedure over a period of 6 months (2017- 2018) were followed up 1-1.5 months
by dynamic MRI. 12 patients of which underwent a second follow up within 3-4 months. Patients' ages ranged
between 59 to 73 years (mean age 53.1); 26 patients were males and 6 were females. All patients had liver cirrhosis
related to chronic viral hepatitis. Results: In 1ry response and follow up findings post TACE, where good response
was defied as disappearance of any intra tumoral arterial enhancement in treated lesions, residual disease was
defined as at least 30% reduction in the sum of diameters of the viable enhancing lesion in the arterial phase, no
response was less than 30% reduction in the enhancing lesion diameters. Progressive disease was defined as 20%
increase in the sum of diameters of the enhancing lesions in comparison to the target lesion diameter at the start of
treatment. Conclusion: MRI is a powerful tool in detection of residual tumor viability, quantifying tumor necrosis
and detecting complications after TACE. Imaging protocol should include dynamic study combined with post
processing subtraction images for better tissue characterization.
Keywords: DW MRI, subtraction MRI, hepatocellular carcinoma, transarterial chemoembolization.


Hepatocellular carcinoma is the fifth most
of the tumor with the chemotherapeutic agents.
common cancer worldwide, and its incidence is
Lipiodol is used as a carrier for the
rising in many countries, including the United
chemotherapeutic agents. It slowly reaches the
States. In 2008 it was estimated that 748,300 new
sinusoids, and gets trapped within the tumor that
cases were diagnosed (1). The major risk factor for
lack Kupffer cells (4).
development of hepatocellular carcinoma is
The assessment of the treatment efficacy is
cirrhosis, particularly cirrhosis related to chronic
viral hepatitis, alcoholic cirrhosis, cirrhosis caused
chemoembolization has been successful or not and
by hemochromatosis, and primary biliary cirrhosis
hence aids in guiding future therapy (3).
Histological evaluation of locoregional treatment
The main curative treatment for HCC is
efficiency is neither easy nor reasonable for
considered to be surgical resection. However, non-
patients. Using tissue biopsy can only be
surgically fit patients can benefit from locoregional
conclusive when it shows viable malignancy.
ablative therapy (2). Ablative techniques can be
Therefore, repeated negative biopsies do not
classified to either chemical or thermal. Chemical
exclude the presence of residual tumor. Thus
ablation refers to the use of ethanol and acetic acid,
monitoring treatment response is indispensable to
whereas thermal ablation is achieved by using heat
radiological imaging to evaluate any viable
(radiofrequency ablation, microwave ablation, laser
residual tumor (3).
ablation); or cold (cryoablation) (3). All these
therapeutic measures end in tumor coagulative
(MDCT) and magnetic resonance imaging (MRI)
necrosis (4).
are widely used for post treatment monitoring.
TACE affects the tumor by selective or
Triphasic CT is used as the standard imaging
super-selective embolization of tumor vessels with
technique to evaluate the therapeutic response. It is
chemotherapeutic agents reducing the tumoral
done immediately post TACE to ensure the
blood flow. Embolizing particles prolonged contact
retention of lipiodol by the tumor and repeated 1

Full Paper (vol.723 paper# 21)

c:\work\Jor\vol723_22 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4175-4178
Role of Computed Tomography Perfusion Compared to Computed
Tomography Triphasic Study in Assessment of Hepatic Focal Lesions
Sherif Abou Gamra , Mohamed Amin Nassef , Merhan Ahmed Nasr
Department of Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Abeer Muneer Ali Farag,E mail: abeer_muneer@hotmail.com

of this study is: to evaluate the role of computed tomography perfusion and computed tomography
triphasic in assessment of hepatic focal lesions.
Methods: The study included 43 patients (between 30 to 60 years old) referred from radiodiagnosis
department. Each patient included in the study was subjected to full history taking and availability of the
previous studies. Results: The study showed that CT perfusion revealed more accurate results than CT
triphasic. Conclusion: The current application of CT perfusion to patient with hepatic focal lesions showed
that it enhanced our understanding of the disease diagnosis staging, prognostic evaluation and monitoring
therapeutic response.
Keywords: ct perfusion ­ hepatic focal lesions.


Early diagnosis is important to improve
parameters of blood flow (BF), blood volume
survival rates in the affected individuals. The liver
(BV), arterial perfusion (AP), portal perfusion
has a dual blood supply and most liver diseases
(PP), and hepatic perfusion index (HPI) were
cause changes in blood flow (BF). Hence it is
calculated in the normal liver parenchyma and
important to evaluate the hemodynamic changes to
hepatic focal lesion samples.
discover lesions early and assess therapeutic
Study place: Police Authority Hospital-
response 1.
Radiodiagnosis Department.
Sample size: 43 patients
techniques with multi-slice computed tomography
Equipment used: 320-dual energy detector row
(CT) allow quantification of the perfusion
parameters of tissues 2.
Inclusion Criteria:
Conventional cross-sectional imaging
1. Patients over 30 years old.
methods such as CT and magnetic resonance, as
2. Both sexes are included.
well as imaging with ultrasonography, may not be
3. Known
adequate for detection of tumor-associated
carcinoma, primary malignancy with metastases
vascularity. CT perfusion imaging is a recently
and hepatic hemangiomatas.
developed noninvasive imaging technique that
4. Average kidney function tests.
allows both qualitative and quantitative evaluation
Exclusion Criteria:
of tumor vascularity 3.
1. Children.
One goal of perfusion CT is to improve
2. Lactating and pregnant females.
detection and characterization of liver lesions
3. Patients known to have end stage liver disease.
compared to standard triphasic imaging 4.
4. Known patients with allergy.

All cases had been subjected to the following:
-Full clinical assessment.
The aim of the work is to show the role of
-Revision of the patient's investigations
CT perfusion and triphasic imaging in the
including renal function tests (urea and
assessment of hepatic focal lesions.

-Revision of the previous radiological
investigations done for the patients.
This study was be done with pathologically
-Written consent was taken from all patients.
proven hepatocellular carcinoma patients, primary
The liver perfusion protocol:
malignancy with liver metastases and hepatic
All cases were performed using Toshiba
hemangiomas who will were referred by the
Aquilion One 320-DE MDCT scanner.
Hepatology Departments of different hospitals.
A. Liver perfusion scan protocol:
The study was approved by the Ethics Board of
1. Select the liver perfusion protocol.
Ain Shams University. During routine abdominal
2. Acquire AP and lateral scanograms.
CT examination using multi-detector CT and with
3. Position the dynamic volume sequence to cover
IV contrast media injection, CT Perfusion
the liver.

Full Paper (vol.723 paper# 22)

c:\work\Jor\vol723_23 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4179-4184
Comparative Study between Ultra-Sound Guided Femoral Nerve Block and
Adductor Canal Block in Postoperative Analgesia after Knee Arthroscopy
El-Feky, A A, Abdel Karim, U I, Ismael, A M
Anesthesiology and Intensive care department, Faculty of Medicine, Al-Azhar University

Background :
Analgesia after knee operations can be achieved by integrated multimodal analgesic
protocols using two or more analgesic modalities that work by different mechanisms that will optimize the
analgesia and minimize the potential risks and side effects.
Objective: of this study was to evaluate the reliability of the postoperative pain control using adductor canal
block (ACB) compared with that using the femoral nerve block (FNB) in patients undergoing knee
Patients and Methods: Eighty patients who had been scheduled to knee arthroscopy were included in this
prospective, blinded study, and were randomly allocated into two groups (40 each); A group, had received
ACB and F group, had received FNB. After 15 minutes; sensation, motor power and vital signs are assessed,
then patients transferred to operating room where all patients had received general anesthesia. Total
intraoperative fentanyl and vital signs are assessed. The postoperative pain (numeric rating scale [NRS]) and
quadriceps power were assessed in the postoperative care at (1, 2, 4, 6, 8, 10, 12, 18 and 24) hours. The time
to 1st pethidine and total pethidine requirements were also recorded.
Results: Patients in group FNB had significantly less quadriceps power (at 6-8 h) postoperatively than those
in groupACB. There were no significant differences between the two studied groups as regard NRS, time to
1st pethidine and total pethidine requirements in the 1st 24 h.
Conclusion: In patients undergoing knee arthroscopy, the ACB can maintain a higher quadriceps power
compared with the FNB and is efficient as FNB in control of postoperative pain.
Keywords: Anesthetic techniques, adductor canal block, femoral nerve block, regional, bupivacaine, knee


Postoperative pain is an important
preserving the muscle power to expedite the
consequence of knee surgeries that can affect
recovery (4). The adductor canal block (ACB),
early ambulation, range of motion and duration of
which is relatively new block with high success
stay in hospital. Advance surgical techniques like
rate. In contrast to FNB, ACB is predominantly a
arthroscopies and early mobilization after
sensory block that preserves the quadriceps muscle
surgery have made knee surgeries more
strength with the favorable earlier mobilization
patients friendly (1). Analgesia after knee
than the FNB (5). Ultrasound guidance has renewed
operations can be achieved by integrated
multimodal analgesic protocols using two or more
anesthesiologists to reliably place local anesthetic
analgesic modalities that work by different
in the desired location and to avoid inadvertent
mechanisms that will optimize the analgesia and
needle trauma to surrounding structures (6).
minimize the potential risks and side effects (2).
The aim of the study was to compare the
Numerous analgesic techniques were introduced
efficacy and safety of adductor canal block versus
aiming to minimize systemic narcotic usage which
femoral nerve block in post-operative course for
could reduce the incidence of known adverse
knee arthroscopy. The primary outcome was the
reactions including tiredness, nausea, respiratory
time to first analgesic requirement. The secondary
depression, decrease intestinal motility and urinary
outcomes were pain score, motor affection, total
retention (3).
Femoral nerve block (FNB) is commonly used
in knee surgeries to control postoperative pain.

The FNB is invariably associated with reduced
quadriceps muscle strength and increased risk for
fall. Consequently, with the FNB, the goal ofpain
comparative study included a total of 80 patients
relief will compromise the goal of preserving the
scheduled for knee arthroscopy attending at AL-
muscle strength. The ideal nerve block for knee
Azhar University Hospitals. Approval of the
surgeries should provide effective analgesia while
ethical committee and a written informed consent

Full Paper (vol.723 paper# 23)

A The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4185-4188

Feasibility and Safety of Catheter Directed Foam Sclerotherapy Combined with
Tumescent Local Anesthesia for Treatment of Axial Varicose Vein
Mohamed Atef Bayoumi, Mohamed Yahia Zakaria,
Foad Mohamed Ahmed
Vascular Surgery Department, Faculty of Medicine, Al-Azhar University

Varicose veins is a common health problem, with an estimated prevalence of greater than 20%
(range 21.8% to 29.4%). Approximately 5% (range 3.6% to 8.6%) have venous oedema, skin changes or
ulceration. Chronic venous disease (CVD) is the most common venous disorder. It is caused by venous
hypertension due to either reflux, outflow obstruction or both. Aim of the Work: The aim of the work was to
review the feasibility and efficacy of catheter-directed foam sclerotherapy in treatment of saphenous vein
incompetence. Patients and Methods: This clinical trial was conducted at vascular surgery department at Al
Azhar University Hospital. The study included 25 patients suffering from primary varicose vein. All patients
were belonging to class C2 to C4 Ep as Pr according to CEAP classification. This mean: C2 to C4 clinically
stage to stage venous disease in which there were uncomplicated, moderate to severe varicosities. Ep
etiologically the disease was primary with well functioning deep system. Anatomically, the varicosities
affected the superficial system mainly the great saphenous vein. Results: Between March 2017 and March
2018, 25 patients (25 limbs) were treated with CDFS at vascular department ­ Al-Azhar University hospitals.
Demographic data and severity of venous disease are shown in Table below. Conclusion: The use of this
catheter based technique facilitated foam sclerotherapy with a high primary and acceptable short-term
occlusion rates, and low numbers of complications. Further studies are required to evaluate how the migration
of foam into the common femoral vein can be diminished and whether the techniques used in this study of leg
elevation and manual compression provide any advantage.
Catheter Directed Foam Sclerotherapy, Tumescent Local Anesthesia, Axial Varicose Vein.

The treatment of primary varicose veins
Varicose veins are a common health
included conservative measures through leg
problem, with an estimated prevalence of greater
elevation to reduce edema, venotonic drugs and
than 20% (range 21.8% to 29.4%). Approximately
elastic stocking. The Sclerotherapy was either
5% (range 3.6% to 8.6%) have venous oedema,
traditional injection or foam sclerotherapy.
skin changes or ulceration (1).
Operative measures included stripping
Chronic venous disease (CVD) is the most
with early and late complications. Endovenous
common venous disorder. It is caused by venous
measures included radiofrequency and laser
hypertension due to either reflux, outflow
ablation (5).
obstruction or both (2).
The use of ultrasound guided foam
The clinical stages of varicose veins have
sclerotherapy to treat varicose veins has rapidly
been classified using the Clinical, Etiological,
increased during the last decade. Foam
anatomical and Pathophysiological (CEAP)
sclerotherapy is cheap, does not require
anaesthesia, is effective and has an acceptable
classification C1 ­ C3) are more prevalent in
safety profile. The treatment rationale is that
women, with no significant gender differences
sclerosant agents damage the endothelium
being reported in the prevalence of severe varicose
irreversibly by disrupting cell membranes resulting
veins (C4 ­ C6) (3).
in sustained vasospasm and vessel obliteration.
Diagnosis of primary varicose veins was
The direct instillation of sclerosant agents
carried out depending on patient history, physical
as "microfoam" with air made became an attractive
examination and duplex scanning was considered
treatment for axial reflux in the great or small
the method of choice for the investigation of venous
saphenous vein (GSV and SSV) (6).
reflux. It combines the assessment of anatomic
A large number of reports have
structure and the function evaluation of blood flow
documented the potential advantages of this
to enable quantification of reflux duration in
technique for treating incompetent axial veins (7).
specific superficial and deep vein segments. In

addition, the choice of this method was as a non-
invasive and repeatable method of measurement (4).
The aim of the work was to review the

feasibility and efficacy of catheter-directed foam

Full Paper (vol.723 paper# 24)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4189-4193

Low Dose Ketamine in Prevention of Propofol Injection Pain
Naglaa Mohammad Aly, Manal Mohamed Kamal, Dalia Ahmed Ibrahim, Alaa Ahmed Whied Mohamed
Department of Anesthesia, Intensive Care &Pain Management, Faculty of Medicine - Ain Shams University
Corresponding author: Alaa A.W. Mohamed, Mobile: 01277893945; Email: alaawhied@gmail.com

Propofol is the most widely used intravenous anesthetic agent for induction and maintenance of
anesthesia as well as for sedation inside and outside operation theatre. Propofol is almost an ideal intravenous
(IV) anesthetic agent, but pain on its injection still remain a problem. Pain may not be a serious complication,
but most patients remember it as one of the unpleasant encounters with anesthetists. In one survey pain on
propofol injection stands seventh most important problem in the current practice of clinical anesthesia.
Ketamine is (NMDA) receptor antagonist agent and a dissociative anesthetic with neurostimulatory side effect,
multiple research trials suggest ketamine as a strong analgesic agent in sub anesthetic IV doses.
Objective: The aim of the current study was to prove the effectiveness of low dose ketamine in preventing
propofol injection pain.
Two groups each included 60 patients (middle age females who performed ovum pick up surgery:
Ketamine group 60 patient received ketamine 0.2 mg/kg with propofol. Saline group 60 patient received normal
saline 10 ml with propofol. Results: In the current study pain and hemodynamic changes (BP, pulse) were
observed. Regarding pain: The incidence of propofol injection pain in the current study was reduced from
93.2% in saline group to 55% in ketamine group, the incidence of severe pain was completely abolished with
ketamine. Regarding hemodynamics: There was no statistical significance between both groups regarding heart
rate, regarding BP the degree of drop in BP in ketamine group was to less extent than in saline group that
proves the role of ketamine in hemodynamic stability.
Conclusion: Finally ketamine in low dose was effective in reduction of propofol injection pain.
Propofol - Intravenous ­ Blood pressure - N-methyl-D asparate.


Propofol is considered the most common
intravenous (IV) anesthetic agent used for
This comparative observational study was
induction and maintenance of general anesthesia
conducted at Ain Shams University, Obstetrics and
with rapid onset and short duration of action.
Gynecology Hospital on patients undergoing ovum
However, the incidence of pain following propofol
pick up surgery after obtaining approval of
injection varies between 28 and 90% in adults if
research ethical committee. A written informed
vein on dorsum of hand is used (1).The quality of
consent was obtained from each patient. This study
pain was described as extremely sharp.
was a prospective, randomized, and double-blinded
Aching, or burning. It has been arranged as
the seventh most important problem in current
According to a sample: 60 cases per each
practice of clinical anesthesia by American
group were needed: Group K: 60 patients received
ketamine 0.2 mg/kg with propofol. Group S: 60
Strategies to reduce the incidence of pain on
patients received normal saline 10 ml with
propofol injection include adding lidocaine to
propofol. Inclusion criteria: ASA I and II adult
propofol, cooling or warming propofol, diluting
patients with age between 18-40 years old
propofol solution, injection to large vein and
scheduled for ovum pick up surgery under general
pretreatment with IV injection of lidocaine,
anesthesia were included in the study. Intensity of
ondansetron, metoclopramide, an opioid, magnesium
injection pain was assessed using a four point
or thiopental with or without tourniquet; all have
verbal response scale. Exclusion criteria: Patients
been tried with variable results (2).
who refused to participate, ASA physical status III,

IV, patients younger than 18 years or > 40 years
old, BMI > 30, history of epilepsy. Patients having
The aim of this study is to try to prove the
a history of parenteral or oral analgesics within the
effectiveness of low dose of ketamine in reduction
last 24 hours before initiation of operation or those
of propofol injection pain.
having allergy to study agents will be excluded.

The aim of the present study is to ensure
On arrival to operating theatre, the
the effect of low-dose ketamine in reduction of
standard monitors were applied to the patients
propofol injection pain.
including electrocardiogram, pulse oximetry and

Full Paper (vol.723 paper# 25)

c:\work\Jor\vol723_26 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4194-4199
Intracytoplasmic Sperm Injection Outcome in Patient at Risk of
Poor Responder Using Mild Ovarian Stimulation Protocol versus
Short Gonadotropin Releasing Hormone Agonist Protocol
Mohamed S. Hasanien, Shoukry A. Elawdy, Amr M. Elerasy
Department of Obstetrics and Gynecology, Faculty of Medicine ­ Al-Azhar University
Corresponding author: Amr M. Elerasy; Mobile:01000141386; Email: amroerasy@yahoo.com

Poor ovarian response to stimulation in IVF cycles is a challenging and frustrating condition for
both clinician and patient, due to its poor prognosis in terms of pregnancies and live births. Although in the
literature a large number of papers have been published in which many stimulation protocols suggested should
be considered as the best for these women, however, no conclusive results have been reached. Aim of the
To evaluate ICSI outcome in patient at risk of poor responder using mild ovarian stimulation protocol
versus short gonadotropins releasing hormone agonist protocol. Patients and Methods: This randomized
controlled study was conducted on one hundred patients, complaining of infertility at risk of poor responders,
patients with at least two of the criteria specific for poor responders at assisted reproductive technology unit,
international Islamic center for population studies and research, Alazhar University, Cairo, Egypt, between august
2016 and august 2017. Results: Statistically significant differences were found in the Endometrial thickness, E2
at day of HCG, No. of dominant follicles at day of HCG, Number of retrieved oocyte, fertilization rate, Embryo
number, Number of transferred embryos, Pregnancy rate and cost p-value 0.029, 0.036, 0.007, 0.027, 0.048,
0.019, 0.046, 0.044 ,0.001 respectively. Conclusion: ICSI outcome was evaluated in patients at risk of poor
responders using short Gonadotropin releasing hormone agonist versus mild ovarian stimulation protocol
(clomiphene citrate); showing that short Gonadotropin releasing hormone agonist should be preferred in these
Keywords: Sperm Injection Outcome, Poor Responder, Mild Ovarian Stimulation, Short Gonadotropin
Releasing Hormone.


slightly increased. The limitation in quantifying the
In the field of assisted reproductive
incidence of these patients among the infertile
technologies great steps forward have been made in
population is due to the difficulty of a clear
recent years in terms of clinical knowledge and
definition in literature(2).
technological development especially in IVF
Predicting ovarian response before starting
laboratories. One of the fundamental steps to reach
hormonal stimulation is the only way to administer
the success is still related to the number of eggs
an efficient and safe treatment.The most important
predictors of the ovarian response to hormonal
gonadotropins in combination with GnRH
stimulation are age, biochemical parameters (basal
FSH levels in the early follicular phase,serum
The Bologna ESHREcriteria represent the
antimullerian hormone (AMH), and morphological
first real attempt by the scientific community to
characteristics (antral follicular count {AFC} and
unify the many definitions proposed to identify
ovarian volume)(2).
poor responder patients by establishing a definite
Although ovarian reserve declines with age
point from which to begin and how to find
it doesn't represent an optimal predictor of ovarian
therapeutic strategies. It was concluded that "poor
response (3).
ovarian responders " should be considered patients
Although many protocols with different
having at least two of the following criteria:
doses and types of gonadotropins have been
(1)previous episode of poor ovarian response (<3
proposed in the literatures over the past 20 years
oocyte)with astandard dose of medication, (2)an
for the management of poor responder patient, yet,
abnormal ovarian reserve with AFC <5-7 follicles
there is no really efficient treatment that could
or AMH <0.5-1.1 ng/ml, (3)women above 40 years
solve the problem of poor ovarian response and the
of age or presenting other risk factors for poor
current question is still about the ideal protocol for
response such as aprevious ovarian surgery,genetic
patients defined as 'poor responders'?
Aim of the Study
autoimmune disorders(1).
To evaluate ICSI outcome in patient at risk
The incidence of poor ovarian responders
of poor responder using mild ovarian stimulation
among infertile women has been estimated at 9-24
protocol versus short gonadotropins releasing
% but according to recent reviews, it seems to be
hormone agonist protocol.

Full Paper (vol.723 paper# 26)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4200-4206

Management of Liver Metastasis of Colorectal Cancer
Magdy Salah El- Din Hussain, Mahmmoud Abd El Hady Abd El Aziz,
Mohammed Rabie Mohammed Bassyoni
Department of General Surgery, Faculty of Medicine- AlAzhar University
Corresponding author: Mohammed R.M. Bassyoni; Mobile: 01026650170; Email: drmah.rabie2010@gmail.com

Globally, colorectal cancer is the third most common cancer among men and the second most
common among women. Colorectal cancer is the fourth most frequently diagnosed cancer, but the second-leading
cause of cancer deaths. Incidence of colorectal cancer has decreased significantly in recent decades, mortality rates
have fallen as well. Those declining rates are largely attributed to earlier diagnosis through screening and more
sophisticated and effective methods of treatment.
Objective: That work represents colorectal cancer metastasis management, early detection and screening of
colorectal cancer.
Subjects and Methods:
This observational study was conducted on 10 patients with liver metastasis admitted
to GIT Surgery Unit, Cancer National Institute and postoperative follow up and observation at El-Haram
Hospital and Cancer National Institute between April 2017 and December 2017.
This work is observational study. The patients in this study were divided into two (2) groups: group
1 and group 2. The included patients were prepared through studying the patient's condition, preoperative &
intraoperative assessment. Choice of operation and how to manage synchronous metastases. The type of
resection does not seem to influence the prognosis if a clear margin is obtained. The carcinoembrionic antigen
(CEA) level is strongly correlated with recurrence-free survival. A free margin of at least 1 cm offers the best
chance of avoiding recurrence.
In this work observational study results preoperative, operative and postoperative results were
recorded. Operative results (type of surgery, surgical technique), postoperative results (liver related
complications, general complications, and postoperative morbidity and mortality of liver resection of
colorectal cancer. Prognosis and follow up of patients of study and postoperative recurrence.
Carcinoembryonic antigen - Colorectal carcinoma - Metastatic colorectal cancer - Colorectal liver


Colorectal cancer is the third most
through the targeted therapy and double or triple
commonly diagnosed cancer in males and the
combination protocols [3].
second in females. It is the second most deathly
The three active agents for metastatic
cancer worldwide. The mortality rates have been
colorectal cancer known as conventional
decreasing dramatically in western countries
chemotherapy are fluoropyrimidines, irinotecan
largely resulting from improved treatment and
and oxaliplatin the associations FOLFOX /
increased awareness and early detection [1].
XELOX and FOLFIRI are commonly used in the
Liver is the most common site of
Lebanese hospitals [4].
metastasis from colorectal cancers 50-60% of the
Metastatic colorectal cancer patients are
cases. Close to one third of patients have liver
subdivided into four clinically defined groups
metastases either at the time of diagnosis
[group 0]: Primarily technically R0-resectable
synchronous in 1/3 of the cases or during the
liver or lung metastases and no biological relative
disease course metachronous in 2/3 of the cases.
The prognosis of colorectal liver metastases has
resectable metastatic disease with curative
improved in the last few years. Surgical resection
intention. The goal of a disease free status after
of liver metastases is considered the only curative
downsizing by chemotherapy enabling secondary
treatment option for patients with resectable liver
surgery may give the potential of longterm
metastases and no extrahepatic disease [2].
survival or cure. [Group 2]: disseminated disease
Chemotherapy is backbone in treating
technically never unlikely resectable intermediate
metastatic colorectal cancer recent advances in
intensive treatment. The treatment intention is
chemotherapy regimens have increased the median
rather palliative in patients with symptoms or
overall survival from 6 months to over 30 months
extensive disease very active first line treatment

with a high likelihood to induce metastases

Full Paper (vol.723 paper# 27)

c:\work\Jor\vol723_28 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4207-4217

Antibiotic Practicing Habits, Knowledge and Attitude toward Education about
Antibiotics among Dentists in Jazan City
Nasser Ibrahim Zakri1, Nasser Mohammed Alshehri1, Abdulrahman Nasser Shebli1
1Dentist General Practitioner, Faculty of medicine, Jazan university, Jazan
Inappropriate use of antibiotics not only drives antibiotic resistance and misuses resources but also
increases the risk of potentially fatal reactions and exposes people to unnecessary side effects and unfavorable
outcomes ranging from gastrointestinal disturbances to fatal anaphylactic shock. In developed countries, surveys
about general dental practitioners' prescribing habits have raised awareness of the quality of prescriptions of
antibiotics. Whilst some surveys have emphasized that dental prescriptions do not follow clinical guidelines, other
authors have concluded that there is a lack of scientific information about appropriate and efficient prescription of
proper antibiotic. Moreover, changes in the dental pharmacotherapeutic field have been so rapid in recent years that
necessitate the constant updating of dental practitioners' knowledge about new drugs, drug interactions, and useful
therapeutic trends is necessary.
Methods: We have conducted a descriptive cross-sectional study among dentists and dental trainee in Jazan city. The
questionnaire required information about antibiotic prescription habits, knowledge about preventive majors of dental
infection, and followed approaches in dental emergencies. Data collected through distribution of online filled
questionnaire. The participants filled the questionnaire online then resent it again to the researcher. The distributed
questionnaire was in Arabic language to overcome the language barrier. Collected data verified and coded before its
entry to Statistical Package for the Social Science (SPSS).
Participants were classified into four categories by age: from 20 to 24 years (30.9%), from 25 to 30 years
(53.9%), from 31 to 35 years (8.6%) and above 35 years (6.6%). More than half of participants were Dental
graduates (56.4%%), (37%) were students and Interns, (6.2%) were with Master/ Diploma and only one of them with
PhD (.4%).The majority of participants prescribed antibiotic for acute apical abscess (72.8%), on the other hand, less
than half of participants (45.7%) prescribed antibiotics for acute apical abscess without systemic involvement, and
nearly two thirds (65.4%) of participants prescribed antibiotic for medically compromised patient after tooth
It is alarming that most dentists do not perform a proper microbial diagnosis before selecting an
antibiotic as adjunct periodontal therapy. As a result, they tend to prescribe broad spectrum antibiotics depending on
the probability and most likely diagnosis. Also, the misconception of indications for antibiotic prescription and low
knowledge about antibiotics assist in the misuse and in proper use of antibiotics.Educational initiatives and
continuous refreshment of knowledge may prevent unnecessary prescription in endodontic emergency treatments.
Keywords: Dental, Awareness, Antibiotic, Prescription, Abscess, Communication, Education


reason, antibiotics contribute to the vast majority of
Dentists commonly prescribe medications for
medications prescribed by dentists (4). The use of
common oral conditions, mainly infections (1), they

prescribe between (7%) and (11%) of all common
antibiotics as an adjunct in the management of
antibiotics (2), and their prescription for antibiotics has
orofacial infections is an important treatment option
become an important aspect of dental practice. In
dentistry, antibiotic prescription is empirical because
clinically indicated. However, systemic antibiotic
the dentist does not know what microorganisms are
prescription may be associated with unfavorable side
responsible for the infection, as samples from the root
effects (5). Inappropriate use of antibiotics not only
canal or periapical region are not commonly taken and
drives antibiotic resistance and misuses resources but
examined for culture and sensitivity. Thus, based on
also increases the risk of potentially fatal reactions and
clinical and bacterial epidemiological data, the
exposes people to unnecessary side effects and
microorganisms responsible for the infections can only
unfavorable outcomes ranging from gastrointestinal
be suspected according to local facilities, and
disturbances to fatal anaphylactic shock (6). In addition,
treatment is decided on a presumptive basis with broad
antibiotic prescription for common medical problems
spectrum antibiotics often being prescribed (3). For this
increases patient expectations for antibiotics, leading
to a vicious cycle of increased prescribing in order to

Full Paper (vol.723 paper# 28)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4218-4223
Evaluation of Fixation of Mastectomy Flaps in Reduction of Seroma Formation in
Breast Cancer Patients
Ahmed M., Nabil E.S., Samy R., Samy G.
Department of General surgery, Ain Shams University
Corresponded author: Ahmed M. Omar, Tel: 01223401697, Email: viamatter@gmail.com
Background: Seroma is the most common complication following modified radical mastectomy (MRM), as
post mastectomy dead space left between skin and anterior chest wall where seroma is formed causing
multiple health issues.
Aim of the Work: Is to evaluate the feasibility and efficacy of fixation of skin flaps to anterior chest wall for
closing postoperative space with drainage as an alternative to the classic form of mastectomy closure with
closed suction drain for MRM for female patients with breast cancer.
Patients and Methods: A total of 60 patients, admitted to the following hospitals: Sydnawy Insurance
Hospital, and Ain Shames University Hospitals with a diagnosis of breast cancer and were treated by modified
radical mastectomy. Patients were divided into 2 groups group A (n=30) were flap fixing group and group B
(n=30) were non flap fixing group all patient were presented with breast cancer with age range of 32 to 75,
postoperative patients were followed and their data were collected and compared.
Results: All 60 patients were evaluated as we had no patients who were lost in follow up. Patients'
demographics were not different in the two groups. We reported less overall complication in group A than
group B, also reduced total seroma volume in group A and reduced number of drain days in group A than B.
Conclusions: Fixation of skin flaps to chest wall and closure of dead space post modified radical mastectomy
actually reduce incidence of seroma formation
Keywords: Modified Radical mastectomy, Seroma, Reducing seroma, Fixation of skin flaps

planning treatment and all available options are
Breast cancer is a major global problem
considered in order to optimize cancer control (6).
with nearly one million cases occurring each year
This may include treatment options as
over the past several decades, the incidence of the
surgery, endocrine
therapy, chemotherapy, and
disease has rising worldwide, increasing in
radiotherapy. Adjuvant therapies are usually
developing and developed countries. It comprises
offered after surgery but can sometimes be given
17% of all cancers (1).
beforehand when it is termed neoadjuvant (6).
Female breast cancer is the most commonly
Surgery remains the mainstay of treatment
diagnosed malignancy amongst women worldwide
for breast cancer despite recent and continuing
(23% of all new cancer cases), with an incidence
advances in medical treatment (6).
rate > twice that of colorectal cancer and cervical
The most frequent early complication of
cancer, and about three times that of lung cancer. It
breast cancer surgery is seroma formation, with
is the second leading cause of cancer deaths in
reported rates of 3% to 92%. A seroma is a serous
women today secondary to lung cancer (2).
fluid collection which may develop in the space
In Egypt, breast cancer represents the most
between the chest wall and skin flaps following
common cancer among Egyptian females and
mastectomy or axillary lymph node dissection for
constitutes 37% of all female cancers (3).
breast cancer. Exact pathophysiology of seroma is
The age standardized rate (ASR) for breast
still debatable. Reasons that may account for the
cancer incidence in Egypt is 37.3 compared to 76
occurrence of seroma include a large operative field,
in the United States. Although incidence remains
division of lymphatic channels, the loose axillary skin
significantly lower than in highly developed
hollow that follows surgical resection and the highly
countries, rates are steadily increasing (4).
mobile, dependent nature of the area (7).
The diagnostic process of breast cancer is
Seroma is often encountered for no obvious
made by a combination of clinical assessment,
reason and without prodromal warning. Due to its
radiological imaging and a tissue sample taken by
commonality some authors consider seroma a
either cytological or histological analysis that is
"necessary evil;" which will occur unpredictably in a
called triple assessment (5).
predictable number of patients (7).
Once a diagnosis is made, a treatment plan is
Although seroma is not life threatening and
formulated for each individual patient. The
usually painless, it can lead to significant morbidity
multidisciplinary approach for breast cancer is used in
including flap necrosis, wound dehiscence,
predisposes to sepsis, prolonged recovery period,


Full Paper (vol.723 paper# 29)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (3), Page 4224-4229
Effect of Intraperitoneal Ketamine as Postoperative Analgesia in Laparoscopic
Ahmed M. Shawky, Ali A.A.A. Essa, Ahmed A.E.A. Emam
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed A.E.A. Emam, Email: emam34678@gmail.com, Mobile: 01027221833

Background: Laparoscopic surgery is gaining popularity so different modalities of pain management should
be used as patients experience postoperative pain of different sources especially from the abdomen, back and
shoulder region which is severe especially in first postoperative hours.
Objective: We aimed to evaluate effect of intraperitoneal instillation of ketamine and normal saline on post-
operative pain and analgesic requirements after laparoscopic cholecystectomy.
Patients and Methods: Forty patients undergoing laparoscopic cholecystectomy were randomly allocated and
divided into two groups, The ketamine intraperitoneal (KIP) group (n=20 patients), in which 0.5 mg/kg
ketamine diluted in 30 ml normal saline was instilled intraperitoneally,The saline intraperitoneal (SIP) group
(n=20 patients), in which 30 ml of normal saline was instilled intraperitoneally. Patients receive these drugs as
follow, 16 ml in gall bladder fossa while other 14 ml under copula of diaphragm on both sides while patients
were placed in 15-20-degree trendelenburg position. This was done before patients recovered from anesthesia,
then patients extubated and transferred to ward. Patients were evaluated according to VAS, time to first
analgesic and total analgesic requirements during 24 hours post-operative.
Results: Our results showed that usage of ketamine decreases postoperative pain and analgesic consumption in
the first 24 hours after surgery along with longer pain free period compared to patients who were given
bupivacaine after laparoscopic cholecystectomy. In our study ketamine 0.5mg/kg was safely used as we did
not observe any sign of toxicity.
Conclusion: Intraperitoneal instillation of local anesthetic is an easy, cheap and safe method which provides
good analgesia in the immediate postoperative period after laparoscopic surgery. Ketamine is highly effective
in postoperative pain control in laparoscopic cholecystectomy without any hazards on patients.
Keywords: Adverse Drug Reactions, Visual Analogue Scale, N-methyl­D-aspartate, Anesthesiologist

N-methyl­D-aspartate (NMDA) receptor
Laparoscopic cholecystectomy is presumed
activation is considered one of the mechanisms of
to be the method of choice for gall bladder surgery.
postoperative pain and hypersensitivity through
While laparoscopic cholecystectomy is concerned to
both peripheral and central effects (4).
induce less pain than open surgery, pain is the
Ketamine is a non-competitive NMDA
principal cause of delayed hospital discharge after
receptor antagonist with hypnotic and analgesic
laparoscopic cholecystectomy (1).
activity, which can be administrated in many ways (5).
Patients undergoing laparoscopic procedures
It simply crosses from most tissue
experience postoperative pain especially in the
membranes that lead to easy absorption. It also has
abdomen, back and shoulder region which require
early onset and short duration of action and
more attention. Pain intensity usually peaks during
because of peripheral action at both opioid and
first postoperative hours.
NMDA receptor, its peripheral application has
There are three components of pain after
been recently evaluated in many studies (6).
laparoscopic surgeries: Visceral pain which results
It seems that intra-peritoneal administration
from the stretching of the intra-abdominal cavity.
of ketamine could be an acceptable alternative to
Shoulder pain which results from phrenic nerve
local anesthetics such as Bupivacaine for
irritation caused by residual carbon dioxide in the
postoperative analgesia in laparoscopic surgery (7).
peritoneal cavity. Somatic pain due to small surgical
incision, which has much less pain intensity (2).
The aim of this study is to evaluate the
Various multimodal approaches have,
effect of intra-peritoneal instillation of ketamine
therefore, been tried to improve postoperative pain.
0.5mg/kg in patients undergoing laparoscopic
These include parenteral analgesics, local
cholecystectomy on post-operative analgesia as a
infiltration with local anesthetics, epidural and
primary outcome. The secondary outcome is the
intrathecal opioids and local anesthetics,
total analgesic consumption in the first 24 hours
interpleural and intercostal nerve blocks as well as
intraperitoneal routes that in turn has been explored
with local anesthetics and opioids (3).



Full Paper (vol.723 paper# 30)