ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4413-4419
Effect of Direct Acting Anti-viral Agents on Insulin Resistance in Chronic HCV
Patients
Amgad Ali Abd El-Hadi Alzahaby1, Mohamed Mahmoud Abdel-Halim1, Ahmed Ali El-sayed
Hussien2
1Tropical Medicine and Gastroenterology Department- AlAzhar University,
2Ain Shams University
Corresponding author: Amgad Ali Abd El-Hadi Alzahaby, Email: amgad_elzahaby@hotmail.com, Mobile: +201114992485
ABSTRACT
Background: HCV infection is a major cause of chronic liver disease worldwide, ultimately leading to
cirrhosis and hepatocellular carcinoma. Globally, it is estimated that up to 185 million people have been
infected with HCV, and among these, according to the World Health Organization, ~ 130150 millions are
chronically infected. Recent estimates place to ~ 700,000 the yearly death toll of liver-related, long-term
sequelae of HCV. In many regions of the world, where access to therapy is available, the number of deaths due
to HCV has even surpassed.
Aim of the work: The goals of our study is to evaluate the effect of direct antiviral agents (DAAs) on insulin
resistance in chronic HCV patients receiving (daclatasvir + sofosbuvir +\- ribavirin) for 12 weeks and 12
weeks post treatment.
Methodology: The study was conducted at, Gastroenterology and Hepatology Unit, Police Authority
Hospitals. It included 80 patients with chronic HCV infection (treatment naive patients). Patients were
classified in to 4 groups: Group 1: 20 non diabetic, non-obese patients; Group 2: 20 diabetic, non-obese
patients; Group 3: 20 obese, non-diabetic patients and Group 4: 20 diabetic, obese patients.
Results: The current study showed highly significant decrease in HOMA-IR in all groups at end of treatment
and 12 weeks post treatment.
Conclusion: Antiviral therapy (DAAs) improves insulin resistance during HCV treatment. These findings
suggest that HCV plays an etiological role in the pathogenesis of impaired glucose homeostasis. Moreover, the
decrease of insulin resistance through viral eradication implicates clinical benefits by readily available
regimens.
Recommendations: Confirmation of the current results by conduction of larger scale studies.
Keywords: Direct acting anti-viral agents, HCV.

INTRODUCTION
Since the introduction of direct acting anti-
HCV infection is a major cause of chronic
viral agents (DAAs) e.g: sofosbuvir (SOF), and
liver disease worldwide, ultimately leading to
daclatasvir (DCV), the duration of treatment has been
cirrhosis and hepatocellular carcinoma. Globally, it is
significantly shortened and response rates have
estimated that up to 185 million people have been
increased with substantial improve- ments in the side
infected with HCV (1), and among these, according to
effect profiles (8).
the World Health Organization, ~ 130150 millions
Hepatitis C virus infection has been shown to
are chronically infected (2). Recent estimates place to
be linked to a higher prevalence of type 2 diabetes.
~ 700,000 the yearly death toll of liver-related, long-
This association is due to B-cell dysfunction in the
term sequelae of HCV (3). In many regions of the
stage of chronic hepatitis, which becomes more
world, where access to therapy is available, the
advanced with the development of liver cirrhosis
number of deaths due to HCV has even surpassed (4).
together with insulin resistance (IR) that occurs early
Egypt has the highest prevalence rate of HCV
in the course of the disease even in patients with or
in the world (5), making it the most challenging public
without minimal fibrosis. The mechanisms for HCV-
health problem facing the country. Studies showed that
induced IR are only partially understood and include
14.7% of the Egyptian population carries HCV-
a direct inhibitory effect of HCV on insulin signaling
antibodies and 10% have an active infection with
pathway. Insulin resistance in chronic HCV results in
predominance of genotype 4 (about 93.1 % of cases) (6).
an increased rate of progression of hepatic fibrosis,
Optimal therapy for patients with hepatitis C
cirrhosis and hepatocellular carcinoma (9).
virus genotype 4 (HCV-4) infection is changing
AIM OF THE WORK
rapidly; the standard of care for a long time has been
a combination of pegylated interferon (PEG-IFN) and
The goals of our study is to evaluate the
ribavirin (RBV), with modest response rates and
effect of direct antiviral agents (DAAs) on insulin
considerable adverse events (7).
resistance in chronic HCV patients receiving
4413
Received:9/4/2018



Accepted:18/4/2018

Full Paper (vol.725 paper# 1)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4420-4423
Pruritus Vulva in Adolescent Females in Arar City, KSA
Aisha Reja M Alenazi1, Nawal Ahmed M Alshammari1, Batool Abdullah Albahrani2, Abdulaziz
Saad M ALShamrani3, Noof Saad M Alruwaili1, Alaa Jameel A Ahmed1, Hajar Moosa
Alkhadhabah2, Wafa Hammad Albalawi4, Nour Hamoud Abdullah Alanazi1
1 Faculty of Medicine, Northern Border University, 2 Faculty of Medicine, Emam Abdulrahman Bin Faisal
University, 3Faculty of Medicine, AlBaha University, 4 Faculty of Medicine, Tabuk University
ABSTRACT
Background: Pruritus vulvae or vulvar itch is an unpleasant vulvar sensation that provokes the urge to scratch
to obtain relief. It is a common complaint in females of all ages. A pruritus vulva is not a condition. It is the
symptom of various -most often benign, sometimes malignant disorders. The study aimed at investigating
the prevalence in valval itching and its manifestations and causes among young females in Arar city, KSA.
Methods: This is across sectional study conducted among 300 of the studied women, Arar, KSA. Data were
collected by using pre designed online questionnaire which include questions designed to fulfill the study
objectives. Results: Pruritus vulvae were found in 30.7% of the studied sample. Most (60.7) of the examined
girls age was between 15- 20 years old. 79.3% of the sample was single (unmarried). Manifestations of pruritus
vulvae were 43.5% redness, 21.7% edema, 67.4% reported association of pruritus with increased vaginal
discharge. 56.5% reported increased pruritus before menses and 37% after. Only 37% of the pruritus cases
asked for medical help but only 23.9% got better after treatment. There was a significant correlation between
pruritus vulvae and both age group and marital status (P= 0.001). Conclusion: Pruritus vulvae were found in
30.7% of the studied sample. Prevention of genitourinary infection among adolescents regarding personal
hygiene is mandatory. Recommendations include counseling during periodic medical examination about
personal hygiene, especially during menstruation.
Keywords: Adolescents, Female genitourinary tract, Pruritus Vulva, Genitourinary infection, Hygiene,
Personal hygiene. Arar City, KSA

INTRODUCTION
This study aimed at investigating the
Itch is the most frequent symptom in
prevalence in vuval itching and it's manifestations
dermatology and has been intensively studied in
and causes among young females in Arar city, KSA.
recent years. Nevertheless, there are few true
PATIENTS AND METHODS
epidemiological studies on itch (1). Pruritus vulvae
Study design and setting: A cross-
simply mean itching of the vulva. Most women
sectional study was carried out on female
experience a slight vulval itch occasionally.
population of Arar, Northern Province of Saudi
However, pruritus vulvae means the itch is
Arabia, KSA.
persistent and causes distress. About 1 woman in
10 visits a doctor about a persistent itchy vulva at
Sampling: The sample size was
some stage in her life. Vulval itching can affect
calculated using the sample size equation: n=z2p
any woman, at any age. It can lead to scratching
(1-p)/e2. Data were collected from Arar general
and rubbing which can break the skin and can lead
female population. Systematic random sampling
to soreness, bleeding and skin infections (2).
technique was followed.
Vulvo-vaginal pH is high in childhood, but in
Data collection: Data was collected by
puberty the pH starts to decrease from an average
using pre designed online questionnaire which
of 7 to an average of 4 in adult women. An
include questions designed to fulfill the study
increase of pH may activate the proteinase-
objectives. Socio-demographic characteristics
activated receptor-2 (PAR-2) which is a well-
including age, educational level, marital status
known itch mediator (3). Unlike other areas of the
and occupational status. Questions about itching,
skin, the vulva is difficult for the patient to
its timing, duration and recurrence. If the case was
examine herself. Additionally, genital skin
diagnosed and how it was diagnosed.
symptoms often trigger concerns of poor hygiene,
Statistical Analysis: All the data were
sexually transmitted infections, or undiagnosed
analyzed using statistical package for social
cancer, all of which canelicit embarrassment, fear,
sciences (SPSS Inc.) version 20. Descriptive
and anxiety (4). Clinical experience indicates that
statistics were done for the prevalence and
patients frequently do not consult a doctor for
quantitative variables. Risk factors were
acute itch, but more often do for chronic itch (1).
determined using logistic regression. A 2-sided p-
value of less than 0.05 was considered statistically
significant.
4420
Received:29/4/2018



Accepted:8/5/2018

Full Paper (vol.725 paper# 2)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4424-4427
Role of Ultrasound Guided foam Sclerotherapy in Treatment of Lower Limb
Varicose Vein
Alaa Hamdy Mohamed, Ahmed Hassan Soliman, Mohamed El Gharib Abo El Maaty
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Alaa Hamdy Mohamed, Mobile: +201025578677, E-mail: dr.3laahamdy@gmail.com
ABSTRACT
Background: Veins have one-way valves which prevent blood from backing up into the legs when we stand or
sit. When the valves become incompetent (or begin to have reflux), blood pools and causes an increase in
pressure in the leg veins becoming enlarged and twisted.
Objective: It was to evaluate the safety and efficacy of foam sclerotherapy in the treatment of primary varicose
veins.
Methodology: This study was carried out in Radiology Department of Ain Shams University Hospitals. 20
patients with sonographically proven primary varicose veins for which they had foam sclerotherapy injection.
Result: The 20 patients enrolled in this study were ranging from 24 to 52 years with mean age of 36.4 years.
Conclusion: Foam Slcerotherapy is effective & safe in treatment of primary varicose veins.
Keywords: Varicose veins (VV), Phlebograph (PHL), foam sclerosant (SCL)

INTRODUCTION
Its advantages include: relatively low
Veins have one-way valves which prevent
price, can be administered in an outpatient setting
blood from backing up into the legs when we
and an excellent method for treating recurrent
stand or sit. When the valves become incompetent
varicose veins (5).
(or begin to have reflux), blood pools and causes
an increase in pressure in the leg veins becoming
AIM OF THE WORK
enlarged and twisted (1).
The objective of this study is to evaluate
This may contribute to varicose veins and
the safety and efficacy of foam sclerotherapy in the
causes symptoms of fatigue, heaviness, aching, burning,
treatment of primary varicose veins.
throbbing, itching, cramping, swelling and restlessness
of the legs. Severe varicose veins can compromise the
PATIENTS AND METHODS
nutrition of the skin, leading to eczema, inflammation or
Patients:
even ulceration of the lower leg (2).
This is a descriptive study. During a period
In general, age and gender were the most
of 6 months duration from August 2017, twenty
relevant risk factors for varicose veins. Male: 3.4
patients were enrolled in the study. All patients
female 6.5. In addition in females the most
with primary varicose veins, the diagnosis was
frequent risk factors were oral contraception and
confirmed by Doppler U/S.
in both gender a predominately sitting posture at
Inclusion criteria: Patient diagnosed by
work. Regarding the family history, varicose
varicose veins unilateral or bilateral by U/S duplex
veins by the mother was most frequent compared
study. No age predilection.
to varicose veins by the father or both (3).
Exclusion criteria: Past history of DVT.
Sclerotherapy is the chemical ablation of
Signs of superficial thrombophlebitis. Bleeding
abnormal veins. The modern goal of therapy is
tendency. Systemic cases of varicose veins as
irreversible fibrotic occlusion, followed by
hyperhomocysteinemia.
reabsorption of the target vessel (4).
Ethical Considerations: Obtaining an
Sclerotherapy is an old technique that has
informed consent from the patient concerning the
been revolutionized by recent technological
complications of the procedure, the complication of
advances. Foaming detergent sclerosants offered
the sclerosing material & the acceptance of the
increased potency and could be visualized by means
involvement in the study. The study was approved
of ultrasonography. Ultrasound guidance allowed
by the Ethics Board of Ain Shams University.
better anatomic visualization, greater hemodynamic
understanding, more precise foam targeting and
Study procedures: Patient preparation:
delivery, and monitoring for unwanted foam passage
stop antiplatelets drugs before the procedure by 8
into deep veins. With these advances, sclerotherapy
hs. Patent position: Slight Trendlenberg position.
has now become a competitive treatment for any
Procedure duration: 30 mins. Machine used:
type or size of vein (5).
Ultrasound device LOGIG P5 with a superficial
probe of 7.5 MHZ.
4424
Received:17/4/2018



Accepted:26/4/2018

Full Paper (vol.725 paper# 3)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4428-4433
Growth Kinetics of Egyptian isolates of Trichomonas vaginalis: Possible Correlation
to Clinical Presentation
Basant O. Mohammed, Khalifa E. Khalifa, Noha A. Elleboudy, Hesham M. Hussein,
Magda E. Azab
Parasitology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Khalifa E. Khalifa, Email: drkhalifa_khalifa@med.asu.edu.eg
ABSTRACT
Background: Trichomonas vaginalis is the most common non-viral sexually transmitted infection (STI) in the
world. Trichomoniasis is an important risk factor for herpes simplex type II infections, human
immunodeficiency virus (HIV) acquisition and transmission, pelvic inflammatory disease and cervical
neoplasia. Studying the variation in growth patterns of the parasite can be used for biological characterization
of the parasites and might be related to the severity of clinical presentation.
Aim of the Work: Study the growth kinetics of Egyptian Trichomonas vaginalis isolates in term of log phase,
growth peaks reached, division rate and generation time of each isolate and correlation of such parameters with
the clinical presentation of the patients, if any.
Material and Method: The study was carried on 300 vaginal washouts collected from Egyptian women
patients aged 20-45 years suspected for trichomoniasis. Positive samples for Trichomonas vaginalis were
cultured and sub cultured on modified Diamond's medium. Growth kinetics for each isolate was done by
inoculated 104 trophozoites/ml into 2 tubes containing 10 ml of sterile culture medium followed by counting
the trophozoites every 24 hours over seven days using a hemocytometer. Growth curves were done for each
isolate by plotting the parasites numbers against the time. Division rates and generation times were calculated
for each isolate.
Results: Out of the 300 collected samples, twelve were found positive for Trichomonas vaginalis trophozoite
by wet mount examination and culture technique. Comparison of the growth kinetics of the twelve
Trichomonas vaginalis isolates revealed a salient difference among all isolates after 48 to 96 hours. Isolates 1,
2, 6, 8 and 10 had a log phase of 48 hours. Isolates 4, 5, 7, 11 and 12 had a log phase of 72 hours. Isolates 3
and 9 had a log phase of 96 hours. The fast growing isolates of Trichomonas vaginalis reached maximum
growth after 48 hours and the highest yield was observed in isolate 10 (150.253.13). Slowly growing isolates
reached a maximum after 96 hours with the lowest yield in isolate 3 (40.521). Regarding the clinical
presentation, isolates 1, 2, 3, 4, 5 and 11 showed mild discharge and congested cervix. Isolates 6, 7, 8, 9, 10,
and 12 showed profuse discharge with varying clinical findings on gynecological examination. Isolate 10 had
the most severe pathology with cervical erosion. Isolate 9, 12 showed bleeding during examination, isolate 8
showed vaginal ulcer while isolate 6 showed just erythema of the vagina.
Conclusion: Comparison of the growth kinetics of the twelve Trichomonas vaginalis isolates revealed a salient
difference among all isolates after 48 to 96 hours. Regarding the clinical presentation, no clear correlation was
found between the growth kinetics and clinical presentation of the patients. Methods other than growth kinetics
such as genotyping and determination of genetic variability are needed to verify the relation between isolates
of Trichomonas vaginalis and clinical presentation.
Keywords: Trichomonas vaginalis, growth kinetics, growth curves.

INTRODUCTION
are mostly asymptomatic in men, women usually
Trichomoniasis is the most prevalent non-
present with vaginal discharge, pruritus and
viral sexually transmitted infection worldwide. It
dysuria. Trichomoniasis is an important risk factor
has been estimated that 276.4 million new
for herpes simplex type II infections, human
infections occurred in 2008 with 11.5% increase
immunodeficiency virus (HIV) acquisition and
over the 2005 incidence rate (1). Worldwide, the
transmission, pelvic inflammatory disease and
estimated prevalence rates vary with geographic
cervical neoplasia. Data from studies in Africa
location, age, race, community and the method
suggest a 1.5 to 3-fold increase in HIV
used for diagnosis. Accordingly, prevalence rates
transmission
associated
with
Trichomonas
varying from 2% to almost 50% were recorded (2).
vaginalis infection. Studies done in Egypt have
In Egypt, a prevalence rate of 8.7% among married
linked trichomoniasis to acquisition of herpes
women from Upper Egypt was recorded (3). In
simplex type II, cancer cervix and infertility (5,6).
another study a prevalence rate of 36% was
Variation in phenotypic behavior of
encountered among symptomatic women in the
Trichomonas vaginalis such as pathogenicity,
child bearing age; 20-45 years (4). While infections
metronidazole sensitivity, clinical manifestations
4428
Received:24/5/2018



Accepted:3/6/2018

Full Paper (vol.725 paper# 4)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4434-4438
Assessment of Vitamin D Status In Patients With Essential Hypertension
Youssef Khalel Ahmad1, Esam Mohamed El-Ghamry1, Salwa Tawfik2, Wael Mohamed Atia3,
Mohammad Mohammad Keder4, Sameh Ahmad Abd-El Kader1
1Internal Medicine Department, 2 Internal Medicine, National Research Center, 3Cardiology Department,
4Clinical Pathology Department, Faculty of Medicine, Al-Azhar University,
Corresponding author: Sameh Ahmed Abdelkader, E-Mail: samehahmed806@yahoo.com, Mobile: 01099815248
ABSTRACT
Background: There is close relationship between Vit D deficiency and hypertension. It was found that Vit D
is potent inhibitor of Renin Aldosterone Angiotensin System (RAAS) which is the main mechanism
responsible for development of hypertension. Aim of The Work: To assess the role of vitamin D deficiency in
the development of essential hypertension and aggravation of its vascular complications. Subjects and
Methods:
This study was conducted on 80 individuals. Individuals were divided into two groups: Group 1:
comprising 60 patients with essential hypertension. Group 2: comprising 20 healthy individuals. All
individuals included in the study were submitted to: Complete history and physical examinations to evaluate
exclusion criteria. Liver and renal function tests, fasting and PP blood glucose, CBC, lipid profile, serum
vitamin D (25hydroxycholecalciferol), serum Ca & Ph. Doppler study on carotid artery to assess vascular
complications and Echocardiography to assess ventricular mass was done. Results: There was statistically
significant decrease (p value <0.05) in vitamin D in patients group in comparison to control group. There was
highly statistically significant increase (p value <0.001) in intimal thickness and left ventricular mass in
patients with low vitamin D level in comparison to patients with normal vitamin D level. In the patient group,
6 patients (10%) were suffering from vitamin D deficiency while 30 (50%) were suffered from vitamin D
insufficiency while 24 (35%) show normal levels of vitamin D. Interestingly, intimal thickness and ventricular
mass were significantly higher in patients with essential hypertension with low vitamin D than those with
normal vitamin D levels. Conclusions: Vitamin D deficiency occurs in the majority of essential hypertension
patients and therefore decreased serum vitamin D levels is considered an additional risk factor for
cardiovascular morbidity and mortality.
Keywords: Vitamin D Status, Essential Hypertension

INTRODUCTION
10% of cases are categorized as secondary
Vitamin D is a molecule displaying an
hypertension, defined as hypertension due to an
important physiological impact. Average human
identifiable cause, such as chronic kidney disease,
diet is neither rich in vitamin D2 (of plant origin)
narrowing of the aorta or kidney arteries, or an
nor in vitamin D3 (of animal origin). Therefore,
endocrine disorder such as excess aldosterone,
humans have to rely on the endogenous production
cortisol or catecholamines(8).
of vitamin D3 in Ultraviolet (UV) exposed skin
Accumulating evidence has indicated that the
(1). Exposure of skin to sunlight is the major source
concentration of 25- hydroxyvitamin D in the blood is
of vitamin D for human, which provides
inversely associated with blood pressure (9).
approximately 95% of daily requirement (2).
The central function of Vitamin D is
AIM OF THE WORK
elevation of plasma calcium and phosphate levels
The study was performed to clarify the role
for bone health (3). In addition, there has been an
of vitamin D in essential hypertension and
increasing interest over the last few years in the
aggravation of its vascular complication.
relationship of vitamin D with extra-skeletal
diseases (4). Vitamin D deficiency has been found
SUBJECTS AND METHODS
to contribute to various cardiac conditions, such as
This study was conducted on 80 subjects of both
hypertension, coronary artery disease, stroke and
sexes. This study was conducted at Al-Hussein
atherosclerosis (5).
University Hospital. All subjects were selected from the
Hypertension is one of the most important
outpatient clinic and Cardiology Department, Al-Hussein
risk factors for cardiovascular disease, which is the
University Hospital over a period from January, 2017 to
major cause of morbidity and mortality worldwide
April, 2018. The patients and subjects were divided into
(6). Hypertension is classified as either primary
two groups: Group 1 (patients group): comprising 60
(essential) or secondary hypertension. About 90
individuals have essential hypertension, Group 2 (control
95% of cases are categorized as primary
group): comprising 20 apparently healthy individuals
hypertension, defined as high blood pressure with
with age and sex matched. The study was approved by
no obvious underlying cause (7). The remaining 5
the Ethics Board of Al-Azhar University.
4434
Received:3/4/2018



Accepted:12/4/2018

Full Paper (vol.725 paper# 5)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4439-4442
The role of transobturaor vaginal tape (TOT) in the management of female stress
urinary incontinence - 2 year follow up, Minia University experience
Ahmed M. Abdelghany
Department of Obstetric and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
Corresponding author: Ahmad M. Abdel ghany, Email: ahmedabdelghany28@yahoo.com
ABSTRACT
Objective: The aim of this study was to evaluate the effectiveness and safety of minimally invasive surgical
procedure trans-obturator vaginal tape (TOT) in the treatment of female stress urinary incontinence and follow
up these cases for 24 months regarding effectiveness, safety and possibility of complications.
PATIENTS: 30 women with genuine stress urinary incontinence (SUI) demonstrated by history, clinical
examination and urodynamic study.
METHODS: 30 patients diagnosed with SUI underwent transobturator sling (inside-out technique) (TVT-O
Gynecare , Johnson& Johnson, USA.) The patients were followed up for 24 - months regarding subjective
and objective cure rates.
RESULTS: The mean operative time (min.) was 19.67 (8.06). The mean intraoperative blood loss (ml) was
8030.52. There was no case complicated by intraoperative bleeding (mild or severe), bladder, urethral,
vascular injuries and anesthetic complications. Subjective and objective cure rates of these patients were (95%)
both.
Conclusion: The results of this study concluded that management of genuine stress urinary incontinence by
transobturator vaginal tape (TVT-O) is an easy and safe method with low complications and high success rate.
Keywords: Stress urinary incontinence - Transobturator vaginal tape.

INTRODUCTION
of Medicine, El-Minya University, from September
Urinary incontinence is a significant health
2007 to February 2010.
problem in the developed and the developing
The study included 30 patients diagnosed
countries. Population studies have shown that about
to have genuine stress urinary incontinence (SUI)
1035% of all women have urinary incontinence (1).
demonstrated by history, clinical examination and
Stress urinary incontinence (SUI) is the most
urodynamic study.
common type of incontinence. A lot of different
Ethical issue:
techniques are used for the treatment of SUI; slings
are the most effective and durable form of treatment
Following ethical guidelines of the research,
(2). Various tissues and synthetic materials are used
an approval was taken from the Department Ethical
for that purpose. The new synthetic materials,
Committee before the start of research. Also written
replacing the torn fascia, are the basis of the recent
informed consent was taken from each patient.The
development of a multitude of surgical techniques of
objectives of the study were explained for each
SUI and other pelvic floor lesions. The tension-free
patient, also the details of the used procedure.
vaginal tape (TVT) procedure has revolutionized the
Sample size calculation:
surgery of female SUI, and it is now considered by
The study consisted of 30 patients, this
many surgeons to be the gold-standard surgery for
sample size was calculated by a specific program
female SUI with excellent long-term efficacy (3). The
called EPI-INFO and for calculation of the sample by
TVT procedure, which uses a retropubic route, has
this method the following data are needed:
been associated with a number of complications
Prevalence of the female urinary stress incontinence
resulting from penetrations of the surgical device into
from previous researches. Total number of population
pelvic vessels, nerves, and organs (4). The
under the study. The sample size required can be
transobturator vaginal tape (TOT) approach was
calculated according to the following formula.
developed for female SUI with the aim of avoiding
the risk of urethral and bladder injuries with minimal
Formula:
vaginal dissection within a short period of time (5).
n= t x p(1-p)
The procedure is now the most popular technique in

m
many worldwide centers with good results.
Description:
n = required sample size
PATIENTS AND METHODS
t = confidence level at 95% (standard value of 1.96)
p = estimated prevalence of in the project area
This study was carried out at the
m = margin of error at 5% (standard value of 0.05)
department of Obstetrics and Gynecology, Faculty

4439
Received:2/5/2018



Accepted:11/5/2018

Full Paper (vol.725 paper# 6)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4443-4447
Role of Chest Ultrasound in Detecting Successful Pleurodesis in Patients with
Malignant Pleural Effusion
Nabil Farouk Awad1, Abd-Allah Mohammad ElBalsha 1, Wafik Ebrahim Aly 2,
Emad Khamis Ahmed Seddik 1
1Department of Chest Diseases, 2Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University
(Cairo), Egypt
Corresponding author: Emad Khamis Ahmed Seddik, Email: dr_emad_2020@yahoo.com
ABSTRACT
Background: One of the easiest sign to identify during chest sonography is the movement of the visceral
pleura compared to immobility of the parietal pleura. This sign of `pleural sliding', firstly described in
veterinary medicine and was used to exclude the presence of pneumothorax when present and to suspect
atelectasis, fibrosis or pleural adhesions (pleurodesis) when absent.
Aim of the Work: This study aims to detect successful pleurodesis with povidone-iodine in patients with
malignant pleural effusion by using the chest ultrasonography.
Subjects and Methods: This study was carried out on 30 patients with malignant pleural effusion attended to
AL-Hussein University hospital, Al-Azhar University in the period between October 2017 and May 2018.All
patients underwent full history taking, complete clinical examination, plain chest X-ray, routine lab
investigations, CT scan of the chest, pleural fluid analysis including physical, chemical, Bacteriological and
cytological examination for malignant cells, medical thoracoscopy, transthoracic ultrasonography before and
after pleurodesis to assess the presence or absence of sliding sign.
Results: The results of this study revealed that the transthoracic ultrasound can easily detect sliding sign and
assess the success of pleurodesis. Iodopovidone was effective in inducing pleurodesis in patients with
malignant pleural effusion.
Conclusion: Transthoracic ultrasound for the evaluation of pleurodesis is feasible and simple. Iodopovidone
was effective in inducing pleurodesis in patients with malignant pleural effusion.
Keywords: Transthoracic ultrasound, Sliding sign, Pleurodesis.

INTRODUCTION
nodules, pleural thickening 1 cm or more and hepatic
Most of the malignant pleural effusions are
metastasis.
the result of metastases to the pleura from other sites.
Thoracic ultrasonography easily detects the
The primary tumors were, in the decreasing order of
sign of `pleural sliding', due to the movement of the
frequency: lung (37%), breast (17%), unknown site
visceral pleura on the parietal pleura. This sign is
(10%), lymphoma (9%), gastrointestinal (8%), ovary
absent when pleurodesis is successful (5).
(7%) and mesothelioma (3%) (1).
Management of malignant effusions depends
AIM OF THE WORK
on palliation of dyspnea and prevention of the
This study aims to detect successful
reaccumulation of pleural fluid to provide the highest
pleurodesis with povidone-iodine in patients with
possible quality of life, regardless of the need for
malignant pleural effusion by using the chest
other treatment modalities (2).
ultrasonography.
Pleurodesis is defined as the symphysis
between the visceral and parietal pleural surfaces; its
SUBJECTS AND METHODS
function is to prevent accumulation of either air or fluid
This study was carried out on 30 patients with
into the pleural space. Effusions of malignant origin are
malignant pleural effusion attended to AL-Hussein
the most common indication for pleurodesis (3).
University hospital, Al-Azhar University in the period
Unfortunately, pleurodesis fails in 1040%
between October 2017 and May 2018. They were
of patients with recurrence of pleural fluid and
diagnosed by pleural fluid cytology or tissue biopsy (CT-
dyspnea. Because pleurodesis is associated with
guided, Abrams or thoracoscopic biopsy).Informed
considerable cost and morbidity, the identification of
consent was obtained from all patients enrolled in the study.
patients who will experience an unsuccessful
All patients underwent full history taking, complete clinical
pleurodesis would be desirable (4).
examination, plain chest X-ray, routine lab investigations,
CT scan of the chest, pleural fluid analysis including
The chest ultrasound can easily visualize
physical, chemical, Bacteriological and cytological
pleural effusions and help in identifying malignant
examination for malignant cells, medical thoracoscopy and
effusion. Sonographic criteria of malignant effusions
multiple pleural biopsies, histopathological examination,
include diaphragmatic and parietal pleura nodule or
transthoracic ultrasonography before the injection of
4443
Received:16/5/2018



Accepted:25/5/2018

Full Paper (vol.725 paper# 7)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4448-4453
Evaluation of the Use of Short Acting Insulin in the Management of Mild to
Moderate Diabetic Ketoacidosis: A Simple Literature Review
Ali Abdullah Alnajrani 1, Suhaib Abdulrahman Al-Khilaifi 2, Sultan Salman Aldhafeeri 3, Nasser
Falah Alqahtani 4, Reem Ahmed B. Alanazi 4, Rawan Adel Shafaay 4, Sufana Mohamedwageeh
Saadi 5, Aishah Abdulrahman Al-Hamoud 6, Hadeel Salem Alwagdani 7, Naseem Ahmad Matari 8
1Najran University, 2Umm Al-Qura University, 3Qassim University, 4Almaarefa College, 5Ibn Sina
National College, 6King Faisal University, 7Taif University, 8King Khalid University
ABSTRACT
Background: Diabetes mellitus (DM) is one of the most common chronic diseases. It can cause a lot of
complications such as retinopathy, nephropathy, and neuropathy. Patients with DM are at risk of having acute
attacks of hyperglycemia and ketoacidosis as well as hypoglycemia. Diabetic ketoacidosis management is
accomplished by the administration of intravenous infusion of regular insulin. Intravenous insulin infusion
requires ICU admission in most of institutions, which will increase the hospitals cost (infusion pumps, IV
access, nurses). Accordingly, we have done a literature study to determine whether intermittent subcutaneous
use of these rapid-acting analogs might be as effective as intravenous insulin infusions in treating
uncomplicated diabetic ketoacidosis.
Objective: In this study, we aimed at evaluating the effect of using short acting insulin in the management of
mild to moderate DKA.
Methods: PubMed database was used for articles selection, and the following keys were used in the mesh
("Insulin
Lispro"[Mesh])
AND
("Diabetic
Ketoacidosis/drug
therapy"[Mesh]
OR
"Diabetic
Ketoacidosis/therapy"[Mesh]) A total of 13 articles were found, with further restriction by PubMed filters, and
reviewing the articles titles and abstracts the final results were 5 articles.
Conclusion: Subcutaneous (S/C) Aspart insulin every 2 hours can be as safe and effective as SC Lispro insulin
every one hour and as continuous IV insulin infusion in the treatment of mild to moderate uncomplicated cases of
DKA. There was no significant statistical difference among the 3 approaches regarding the efficacy, and the mean
duration of the treatment period. SC aspart insulin every 2 hours is more economical and fairer type intervention.
Keywords: Short acting insulin, diabetic ketoacidosis, evaluation, subcutaneous aspart insulin.

INTRODUCTION
regular insulin that is initiated in the ED and
Diabetes mellitus is a complex metabolic
continued in an ICU 7 setting for frequent insulin/
disorder whose main clinical and diagnostic feature
fluid adjustments, glucose monitoring, and electrolyte
is hyperglycemia (1). Diabetes has reached epidemic
assessment. Although insulin administration by any
proportions, affecting around 387 million people
route is effective for treating diabetic ketoacidosis,
worldwide. Over the next 20 years, its prevalence
intravenous insulin is preferred over subcutaneous
is predicted to double, and more than half-a billion
and intramuscular insulin because it provides rapid,
people will be affected (2). Estimated regional
titratable glycemic control (7,8).
diabetes prevalence ranges from 5.1% in Africa to
Intravenous insulin infusion requires ICU
11.4% in North America and the Caribbean, with
admission in most of institutions, which will increase
more than 75% of subjects living in low and
the hospitals cost (infusion pumps, IV access, nurses)
middle-income countries (2). Moreover, the increase
Therefore, in the present study, it was aimed at
in prevalence is estimated to be greater in
determining whether intermittent subcutaneous use of
developing areas (3), as many countries adopt
these rapid-acting analogs might be as effective as
Western life style habits (sedentary behavior, lack
intravenous
insulin
infusions
in
treating
of physical activity and energy-dense diet) which
uncomplicated diabetic ketoacidosis.
are well recognized risk factors for type 2 diabetes
mellitus (T2DM) (4).
METHODOLOGY
Diabetes
mellitus,
second
only
to
Sample
hypertension as the most common chronic condition
PubMed was chosen as the search database
of emergency department (ED) patients, can cause
for the articles selection, because it is one of the
acute hyperglycemia and ketoacidosis, responsible for
major research databases within the suite of
more than 1 million ED visits in 2005 (5).
resources that have been developed by the National
Traditionally (and more recently endorsed by the
Center for Biotechnology Information (NCBI). The
American Diabetes Association) (6), the treatment of
following keys were used for the Mesh ("Insulin
diabetic ketoacidosis is accomplished by the
Lispro"[Mesh]) AND ("Diabetic Ketoacidosis/drug
administration of a low dose intravenous infusion of
therapy"[Mesh] OR "Diabetic Ketoacidosis/
4448
Received:30/4/2018



Accepted:9/5/2018

Full Paper (vol.725 paper# 8)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4454-4462
Pediatric Intestinal Obstruction, Management and Outcomes:
A Simple Literature Review
Alaa Mutlaq Alshareef 1, Shahd Saeed Alghaseb 2, Lamia Saeed Alghaseb 2, Shahad Ahmed
Alqahtani 2, Norah Fahad Alshahrani 2, Norah Abdullah Hasoosah 2, Alia Musfer Alqahtani2,
Marwah Nasser E Alabdrabalameer 3, Abdullah Salem Al-Rayshan 4, Tareq Hamad Alotaibi 5
1Ibn Sina National College, 2King Khalid University, 3Maastricht University, 4Najran University,
5Shaqra University
ABSTRACT
Background: Acute intestinal obstruction occurs when there is an interruption in the forward flow of intestinal
contents. This interruption can occur at any point along the length of the gastrointestinal tract, and clinical
symptoms often vary based on the level of obstruction. Intestinal obstruction in children can occur as a result
of various causes such as, intussusception, adhesive small bowel obstruction, malrotation, and Hirschsprung's
disease. In this review paper we will go through the literatures that have been investigated to assess the various
management measures and its outcomes.
Objective: In this review we aimed at assessing of different management plans of gastrointestinal obstruction
in different conditions like Intussusception, Congenital Duodenal Obstruction and Adhesive Small Bowel
Obstruction (ASBO), and the outcomes related. Moreover, providing a reference paper analyzing all the
clinical studies in this field.
Methods: PubMed database was used for articles selection, and the following keys used in the Mesh
("Intestinal Obstruction/diet therapy"[Mesh] OR "Intestinal Obstruction/drug effects"[Mesh] OR "Intestinal
Obstruction/ drug therapy"[Mesh] OR "Intestinal Obstruction/surgery"[Mesh] OR "Intestinal Obstruction/
therapy"[Mesh]).
Results: Intussusception should be treated with hydrostatic reduction (HR) even with more than one try
because this method was associated with high success rate. After successful HR, patient can be discharged
from ED if there were no suspected complications. Surgical treatment is indicated mostly in cases of
complications. Manual reduction was associated with significantly better post-operative outcomes and lesser
time to recovery. It is advised not to maintain high threshold for resection in order to avoid post-operative
recurrence or perforation. The use of Gastrografin in treating children with adhesive small bowel obstruction
when the conservative management fails is safe. However, half of the patients will need surgical management
after all.
Conclusion: The laparoscopic approach in the management of congenital duodenal obstruction can be
performed in neonates safely. It showed similar outcomes to the open approach despite the presence of high
conversion rate.

Keywords:
Pediatric intestinal obstruction, congenital duodenal obstruction, gastrografin, laparoscopic
approach.

INTRODUCTION
Despite advances in neonatal and surgical
Gastrointestinal obstruction occurs when
care, the management of gastrointestinal obstruction
the intestinal content flow is interrupted. The
is challenging. A surgeon should decide wither to
interruption can occur at any point throughout the
take the patient for open or laparoscopic surgery or
gastrointestinal tract. The obstruction presentation
follow a non-operative treatment. In this paper we
depends on the level of obstruction. Intestinal
focused upon reviewing the management, and
obstruction can occur as a result of various cause,
outcome of gastrointestinal obstruction in children.
and most of the time present as a medical
Pathophysiology
emergency(1). As a result physicians should early
The most important concerns in relation to
recognize such cases and provide the appropriate
intestinal obstruction are their effect on whole body
management. Acute intestinal obstruction is
fluid/electrolyte balances and the mechanical effect
associated with nausea, vomiting, dysphagia,
that increased pressure has on intestinal perfusion.
abdominal pain and failure to pass bowel
Proximal to the point of obstruction, there will be a
movements(2). To approach the diagnosis certain
dilatation of the intestinal tract as a result of intestinal
tests can be done such as radiography,
secretions and swallowed air(3). As a result of the
ultrasonography, and contrast fluoroscopy and
obstruction the intestinal content will fail to pass which
computer tomography in less certain cases(2).
will lead to cessation of flatus and bowel movements.
4454
Received:1/5/2018



Accepted:10/5/2018

Full Paper (vol.725 paper# 9)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4463-4468
Clomiphene Citrate and Metformin" Stair Step" Protocol Vs. Traditional Protocol
in Patients with Polycystic Ovary Syndrome "PCOS"
Ahmed Abdel Hay Ali, Samir Fouad Khalaf, Mohamed Mohamed Farahat
Department of Obs. & Gyn., Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmed Abdel Hay Ali, E-Mail: ahmed.a.hay@gmail.com, Mobile: +201002689994
ABSTRACT
Background: Clomiphene citrate is the most popular drug for ovulation induction mainly in cases of PCOS,
used alone or with combination of other drugs e.g. metformin.
Aim: To evaluate the efficacy of stair step protocol versus traditional protocol using clomiphene citrate alone
or combined with metformin and to assess the uterine and systemic side effects of cumulative doses in single
cycle.
Patient and Methods: Sixty (60) patients in two groups diagnosed as PCOS, based on the revised Rotterdam
criteria (2003), *Group 1: In the stair-step protocol (n = 30), Clomiphene Citrate was administered at 50 mg
daily for 5 days following the onset of a spontaneous or progestin- induced menses. The follicular response
monitored by TVS starting on day 8. When the mean diameter of the follicle size is below 11mm on cycle day
14, the dosage increases to 100 mg/day for 5days.Then on cycle day 19 re-evaluation by TVS was restarted.
Metformin with initial dose 500mg/day (and gradually increased to 1,500 mg /day during 6 weeks).**Group 2:
In the traditional protocol (n = 30), Clomiphene citrate was administered 100 mg daily for 5 days after the
onset of spontaneous or progestin-induced menstruation. The following variables were measured: ovulation
rate (The number of follicles that mature and ovulate during given menstrual cycle), Side effects on uterine
artery & systemic side effects e.g. Hot flushes.
Results: The findings of this study indicated no significant difference between the 2 groups in using
clomiphene citrate by stair step protocol or traditional protocol (P>0.05).
Conclusion: Clomiphene citrate in the stair step protocol combined with metformin has a higher efficacy
compared to CC in the traditional protocol in patients with PCOS in terms of ovulation and clinical pregnancy
rates without any detrimental side effects on endometrial thickness or Doppler of uterine arteries, stair step
protocol suitable for use in clinical practice.
Keywords: Clomiphene citrate- Stair step- Metformin- Ovulation induction.

INTRODUCTION
initiated in days 2-5 of menstruation; it may be
Polycystic ovary syndrome (PCOS) is a
initiated at any time in patients with oligo-
common endocrine system disorder among women
/amenorrhea. However, clinicians usually prefer to
of reproductive age. Women with PCOS may have
begin CC treatment following spontaneous or
enlarged ovaries that contain small collections of
progesterone-induced menstruation in these patients.
fluid called follicles located in each ovary as seen
Generally 50 mg CC for 5 days is used in the first
during an ultrasound exam. Infrequent or
cycle. In cases of anovulation, CC dose is increased
prolonged menstrual periods, excess hair growth,
by 50 mg in the in the subsequent cycle (4).
acne, and obesity can all occur in women with
A new protocol is the stair-step protocol in
polycystic ovary syndrome. In adolescents,
which the increasing daily clomiphene citrate dose
infrequent or absent menstruation may raise
is administered without intervening menses
suspicion for the condition (1).
between the dosages. The important point is that
Polycystic ovary syndrome (PCOS) is the
U\S monitoring is required during the stimulation.
most common cause of female infertility and
The potential advantage of stair-step protocol is the
affects 5-10% of women of reproductive age (2).
lack of a waiting period until the next
menstruation. Potentially adverse effects of the
Infertility affects 40% of women with PCOS.
cumulative doses in the same cycle on the
PCOS is the most common cause of anovulatory
endometrium and on systemic side effects may be
infertility. Approximately 90%95% of anovulatory
disadvantages of stair-step protocol (5).
women presenting to infertility clinics have PCOS.
Women with PCOS have a normal number of
Metformin is an oral biguanides and firstly
primordial follicles and primary and secondary
used to treat type 2 diabetes mellitus. It acts primarily
follicles are significantly increased (3).
in the liver by inhibiting gluconeogenesis and also by
increasing peripheral insulin sensitivity (6).
Clomiphene citrate (CC) is the first drug of
choice for ovulation induction in the management of
Obesity may reduce the beneficial effects of
infertility in PCOS, Although CC treatment is usually
Metformin as the response to Metformin in PCOS
4463
Received:20/5/2018



Accepted:29/5/2018

Full Paper (vol.725 paper# 10)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4469-4472
In Vitro Antimicrobial Combinations for Pan-Drug Resistant Acinetobacter Species
Samia Abdou Girgis, Sherif Wadie Nashed, Sally Mohamed Saber, Rania Mohamed Abdel Halim,

Nashwa Mohamed Naguib Mahmoud Omar
Clinical Pathology Department, Ain Shams University
Corresponding author: Nashwa M.N. Mahmoud Omar, Mobile: 01090229797; Email: nousha_22@hotmail.com
ABSTRACT
Background: Pandrug resistant Gram-negative organisms (PDRGNs) have emerged, as a major threat to
hospitalized patients. They have been associated with mortality rates ranging from 30 to 70%. Because of the
high morbidity and mortality rates of severe pandrug resistant acinetobacter spp infections, combination
therapies, as opposed to monotherapy, are suggested. A synergistic effect may be developed when antibiotics
are used in combination. Through this synergistic effect, treatment efficacy can be improved and resistance can
be prevented.
Aim of the work: To investigate the use of in vitro antibiotic synergy test (checkerboard) for pandrug resistant
acinetobacter species with a clinical feedback on the most synergistic antimicrobial combination.
Materials and Methods: During this study, one hundred isolate of drug resistant acinetobacter species
identified by routine culture and sensitivity using disc diffusion susceptibility test, were collected from
critically ill patients admitted to Ain Shams University Internal Medicine Intensive Care Units. The isolates
were subjected to: (i) Determination of MIC using Vitek 2 automated system to confirm resistance of
acinetobacter species to all commercially available antibiotics, (ii) Broth micro-dilution method (BMD) for
determination of tigecycline susceptibility, and (iii) Determination of antimicrobial synergy by broth
micodilution (Checkerboard method).
Results: Vitek 2 system results showed that, all of the 100 isolates were resistant to all antibiotics included in
the study. On the other hand, 100% of the isolates were sensitive (S) to Colistin. As regards the results by
Broth microdilution antibiotic susceptibility method, all 100 isolates (100%) were resistant to
ampicillin/sulbactam, meropenem and ciprofloxacin, whereas 95 isolates (95%) were resistant to amikacin,
whereas all 100 isolates (100%) tested were sensitive to tigecycline. The results of the antibiotic combinations
were as follows; the activity of ampicillin/sulbactam in combination with amikacin showed synergy in (48%),
addition in (42%) and indifference in (10%). The activity of ampicillin/sulbactam in combination with
ciprofloxacin showed, synergy in (36%), addition in (52%) and indifference in (12%). The activity of
meropenem in combination with amikacin showed, synergy in (26%), addition in (53%) and indifference in
(21%). No antagonistic activity was detected between any of the antibiotic combinations used.
Conclusion: The prevalence of XDR/PDR resistant Acinetobacter spp. was highest in blood samples (43%)
followed by sputum samples (35%) recovered from critically ill patients admitted to Ain Shams University
Internal Medicine Intensive Care Units. Vitek 2 system showed that, all of the 100 isolates were resistant to all
antibiotics included in the study. On the other hand, 100% of the isolates were sensitive (S) to colistin. Broth
microdilution antibiotic susceptibility method showed that, all 100 isolates (100%) were resistant to
ampicillin/sulbactam, meropenem and ciprofloxacin, whereas 95 isolates (95%) were resistant to amikacin,
whereas all 100 isolates (100%) tested were sensitive to tigecycline, indicating that acinetobacter spp. did not
attain resistance to tigecycline yet. The broth microdilution antibiotic synergy test (Checkerboard method),
being the reference method for assessing antimicrobial synergy, showed that the highest synergic activity
belongs to ampicillin/sulbactam and amkacin (48%), and the lowest synergic activity belongs to meropenem
and amikacin (26%).
Keywords: PDRGNs, Antimicrobial combinations, Checkerboard broth microdilution method.

INTRODUCTION
monotherapy, are suggested. A synergistic effect
Acinetobacter spp. have emerged as one of
may be developed when antibiotics are used in
the most important pathogens involved in health
combination. Through this synergistic effect,
care associated infections in recent decades,
treatment efficacy can be improved and resistance
characterized by their ability to accumulate
can be prevented (2).
different mechanisms of antimicrobial resistance,
Pandrug resistant bacteria employ several
often showing a multidrug-resistant phenotype (1).
mechanisms in attaining resistance that include; enzymatic
Due to the high morbidity and mortality
deactivation of antibiotics, decreased cell wall permeability
rates of severe drug resistant acinetobacter spp
to antibiotics, altered target sites of antibiotic,
infections, combination therapies, as opposed to
efflux mechanisms and increased mutation rate (3).
4469
Received:20/3/2018



Accepted:30/3/2018

Full Paper (vol.725 paper# 11)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4473-4477
Discussion of the Causes, Effect and Potential Methods of Alleviating Patient
Anxiety When Undergoing Magnetic Resonance Imaging (MRI)
Zyad Mansour Almutlaq
King Saud bin Abdulaziz University for Health Sciences, College of Applied Medical Sciences, Radiology
Department
Corresponding Author: Zyad Mansour Mohammed Almutlaq, Email: zy.almutlaq@gmail.com, Telephone number: +966550280067.
ABSTRACT
Background: In performing an MRI examination the patient may feel anxious due to the nature of the MRI
scan as the patient would be inserted into the narrow bore of the MRI scanner and would be asked to be
immobile during the examination period for approximately 20 to 90 minutes depending on the scan type.
Patient feeling anxious may also be evoked by several causes and consequently may develop into anxiety
reactions by the patient either before, during, or after the scan. Aim: This paper aim to study the issues
surrounding the anxiety in patients undergoing MRI examinations by identifying the prominent causes,
outlining the possible effects of anxiety, discussing the main potential methods for alleviating patient's anxiety.
Materials and methods: This review is conducted by using a comprehensive search of PubMed, Google
Scholar, and Elsevier, August 1993, through March 2018. The following search terms were used: causes of
anxiety in MRI, claustrophobia and MRI, effects of anxiety in MRI, alleviation of anxiety in MRI patient.
Conclusion:
Patient's anxiety can pose problems that may impede the process of the MRI examination.
Patient's anxiety may have adverse effects on both patient and the healthcare institution as it can cause
financial losses for the healthcare institutions. However, sedation techniques, acoustic noise reduction, and
adequate patient preparation for the MRI scan are possible methods that can alleviate patient's anxiety.

Key words:
MRI, Medical Imaging, Patient Anxiety, Claustrophobia.

INTRODUCTION
into anxiety reactions by the patient either before,
Magnetic resonance imaging (MRI) is one of
during, or after the examination.
the main medical imaging modalities along with
Computed Tomography (CT), Ultrasound (US), X-
AIM AND METHOD
Rays, Single-Photon Emission Computed Tomography
Taking into account the above-mentioned
(SPECT), and Interventional radiography (IVR). The
points, this paper aimed at discussing the issues of
prominence of MRI has increased since 1980 until it
anxiety in patients undergoing MRI examinations
has become a common diagnostic procedure these
by identifying the prominent causes of anxiety and
days, where MRI is an advanced imaging technique
then outlining the possible effects of anxiety. This
capable of imaging the human body internal organs
will be followed by a brief discussion of the main
and detecting various abnormalities, with high-
potential methods for alleviating patient's anxiety.
resolution details (1-2). MRI is distinguished from other

medical imaging modalities using a high magnetic
field with radio waves for obtaining a diagnostic image
Causes of patients' anxiety:
instead of exposing a patient to an ionizing radiation (3).
Claustrophobia
Therefore, it is considered biologically safe. Moreover,
Claustrophobia, a severe form of anxiety, is
MRI is the best imaging tool that has the ability to
one of the most common causes of apprehension
provide a clear contrast between the soft tissues in the
amongst patients undergoing MRI examinations.
image (4). Thus, it helps diagnosing in an accurate way
McIsaac et al. (1) recognised that approximately 37%
various types of disorders within body organs that not
of patients who are booked for MRI scans have
functioning in a normal orderly healthy manner.
different levels of claustrophobia. Also, Dewey et al.
In performing an MRI scan, the patient will
(5) declared that from 1% to 15% of MRI participants
be inserted into the bore of the MRI machine.
express claustrophobia. Although there is a distinct
Subsequently, the patient will be asked to be
variation between the proportions mentioned in the
immobile
during
the
examination
for
above sources, these percentages indeed represent a
approximately 20 to 90 minutes depending on the
large number if they are converted to real numbers,
scan type. However, due to the nature of the MRI
particularly as there are thousands of patients during
scan, the patient may feel anxious. This feeling
the year who are referred to the medical imaging to
which is evoked by several causes may develop
be scanned by MRI (2).
4473
Received:3/5/2018



Accepted:12/5/2018

Full Paper (vol.725 paper# 12)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4478-4485
Role Of Pet/Ct Scan In The Assessment Of Primary And Loco Regional Recurrent
Breast Cancer
Maha Mourad El-Saeed, Ahmed Mohamed Basiouny, Yasser Ibrahim Abd ElKhalek
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Maha Mourad El-Saeed, Mobile: +01221967699, E-mail: mahamourad00@gmail.com
ABSTRACT
Objective: Study the accuracy of 18F-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission
tomography/computed tomography (PET/CT) scan in diagnosis of primary and loco regional recurrent breast
masses compared with histopathological results and to correlate the results of 18F-fluoro-2-deoxy-D-
glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) with histopathological
findings in breast carcinoma patients.
Methodology: This study is a prospective study conducted on 24 female patients presented to Ain Shams
University Hospitals (oncology,surgery and obstetrics and gynecology departments) with pathologically
proven breast cancer underwent PET/CT.
Result: SUVmax of the tumor is directly related to the histopathological grade and to the size of the tumor.
Invasive ductal carcinoma has predominantly higher SUVmax than invasive lobular carcinomas. Also
SUVmax tumor/ SUVaverage liver is more accurate that SUVmax tumor alone. However, no relation between
SUVmax and the presence of distant metastasis. 18F-FDG uptake may serve as a prognostic indicator for
biological behavior in breast tumors
Keywords: Breast cancer, 18F-fluorodeoxyglucose, positron emission tomography/ computed tomography,
Simple Uptake Value (SUV), prognostic factors.

INTRODUCTION
Other non-radiographic methods included
Breast cancer is the most common type of
clinical and physical examination, Laboratory
cancer and the second leading cause of cancer-
investigation of tumor markers and confirmatory
related death among women. It affects more than 1
pathological examination (4).
million women worldwide. The number of cases
Several studies and systematic reviews
worldwide has significantly increased which is
were carried out to evaluate and compare the
attributed to modern lifestyle (1).
accuracy of the different radiographic methods in
Outcomes for breast cancer vary depending
detection of primary and recurrent breast cancer.
on the cancer type, extent of disease, and patient's
In
1990,s; 18F-fluoro-2-deoxy-d-glucose
age. However it is still with poorer prognosis in
positron emission tomography (FDG PET) was
developing countries when compared to developed
introduced in clinical oncology. It has been shown to
countries, Of course its diagnosis plays a role in
be an effective and accurate imaging technique for a
improving the survival rate of patients.
variety of diagnostic oncology tasks in breast cancer,
Approximately 30% of patients relapses within 15
lymph node staging, staging and restaging of
years after initial treatment (2).
recurrent and metastatic disease, and treatment
Early diagnosis and accurate follow-up of
monitoring (5). FDG PET is an effective whole-body
these patients are important for efficient patient
imaging technique, its diagnostic value is based on
management. In addition; early diagnosis of
the detection of metabolic changes preceding
recurrent breast cancer is important for planning
structural findings. However, FDG PET is of limited
future therapeutic strategies which, if initiated
value in the characterization of primary breast lesions
without delay, aim either to cure or to prolong
owing to its moderate sensitivity compared to that of
disease-free survival and to improve the quality of
MRI. On the other hand, the number of involved
life of patients with cancer (3).
lymph nodes and the presence, or absence of micro
Standard imaging techniques include
metastatic disease was claimed to be not sufficiently
radiological
examinations,
such
as
X-ray
determined with FDG PET alone (6).
mammography, ultrasonography (US), computed
A new promising modality for the early yet
tomography (CT) and magnetic resonance imaging
accurate detection of relapsing cancer breast is the
(MRI). Nuclear medicine techniques are also playing
PET/CT scan. CT, is considered the primary method of
an increasing role in diagnosing and staging breast
investigation because of its low cost and widespread
cancer. In the past only bone scintigraphy was used
availability, provides high-resolution anatomic details
for follow-up of women with breast cancer to detect
but may underestimate the actual tumor burden by
bone metastases at an early stage.
overlooking small tumor clusters in areas of distorted
4478
Received:15/4/2018



Accepted:24/4/2018

Full Paper (vol.725 paper# 13)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4486-4489
Evaluation of the Internal Nasal Valve using Computed Tomography Pre and Post
Rhinoplasty and Its Correlation to Symptomatic Improvement
1Amr Gouda Shafik, 2Ahmed Mostafa Mohamed, 1Tahany Mohamed Rabie, 1Hussam Adel
Alkady
1Department of Otorhinolaryngology, 2Department of Diagnostic Radiology ,Faculty of medicine, Ain-
Shams University
Corresponding author: Hussam A. Alkady, Mobile: 01111390530; Email: hussamadel@hotmail.com
ABSTRACT
Background: The INV area is the narrowest area of a nasal cavity, which is formed by the nasal septum, the
caudal border of the upper lateral cartilage ULC, the head of the inferior turbinate, and the pyriform aperture
and the tissues that surround it. Accurate evaluation of the INV is important to the workup for repair of
problems that involve this area. The initial evaluation of the nasal valve occurs with the clinical examination,
anterior rhinoscopy, the Cottle maneuver, and endoscopy, which all are used clinically to assess nasal airflow.
Objective: This study aims to evaluate the internal nasal valve by using reformatted (CT) scans of the nasal
airway pre and post rhinoplasty and its correlation to symptomatic improvement according to (NOSE) scale.
Patients and Methods: This prospective study of twenty patients who were subjected to rhinoplasty at ENT
departments of Ain-shams university hospitals.
Results: This study included 20 cases of age's ranges from 20 to 30 years. The mean age among study cases
was 23.8 3.22. There were 14 males and 6 females. So, the majority of cases (70%) were males. In our study,
we detected that there is no significant correlation between CT scans analysis of the INV pre and post-
rhinoplasty and there is no significant correlation between CT scans analysis of the INV and the NOSE score
pre and post-rhinoplasty. On the other hand, there is high significant correlation between NOSE score pre and
post-rhinoplasty.
Conclusion: In our study, we detected that there is no significant correlation between CT scans analysis of the
INV pre and post-rhinoplasty and there is no significant correlation between CT scans analysis of the INV and
the NOSE score pre and post-rhinoplasty.
Keywords: External nasal valve - internal nasal valve - nose obstruction symptomatic evaluation

INTRODUCTION
Correction of internal valve collapse must be
The airflow resistance provided by the
done during both functional rhinoplasty, which may
airways during breathing is essential for good
include inferior turbinectomy, septoplasty, and
pulmonary function. Nasal airway resistance accounts
placement of spreader grafts which is one of the most
for more than 50% of total airway resistance, most of
effective means of correcting internal valve collapse (4).
this resistance occurs in the anterior part of the nose
Accurate preoperative evaluation of the
which called the nasal valve (1).
internal nasal valve is critical to the workup for
In 1903, the nasal valve was originally
reconstruction or repair of problems that involve
described by Mink. It is divided into external and
this area. A CT scan of the internal nasal valve can
internal portions. The external nasal valve is
provide the surgeon with improved anatomical
formed by the columella, the nasal floor, and the
information to assess that region (5).
nasal rim (or caudal border of the lower lateral
Computed Tomography (CT) has been
cartilage LLC). The internal nasal valve INV area
proposed as an objective tool to measure internal nasal
is the narrowest area of a nasal cavity, which is
valve anatomy preoperatively and postoperatively. The
formed by the nasal septum, the caudal border of
acquired CT scans must be reformatted to obtain
the upper lateral cartilage ULC, the head of the
sections through the internal nasal valve at a more
inferior turbinate, and the pyriform aperture and the
appropriate orientation by using reformatted coronal
tissues that surround it (2).
and sagittal CT scans, so the valve cross-sectional area
Collapse of the internal nasal valve is a
and valve angle can be measured (6).
common finding in patients who present with nasal
airway obstruction. Although this can be a
AIM OF THE WORK
congenital condition, weakness of the internal nasal
This study aims to evaluate the internal
valve can also occur with nasal aging, following
nasal valve by using reformatted (CT) scans of the
traumatic injury, and even more commonly
nasal airway pre and post rhinoplasty and its
because of prior nasal surgery secondary to
correlation to symptomatic improvement according
rhinologic surgery (3).
to (NOSE) scale.
4486
Received:23/5/2018



Accepted:2/6/2018

Full Paper (vol.725 paper# 14)


c:\work\Jor\vol725_15 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4490-4495
Association of Scavenger Receptor Gene with Premature Coronary Artery Disease
Manal Abd Al Aziz, Wessam El Sayed Saad, Hoda Ahmad Abdelsattar, Adham Ahmad Abd El
Tawab, Marium El Sayed Ahmad Fathi
Clinical Pathology Department, Faculty of Medicine, Ain Shams University
Corresponding author: Marium El Sayed Ahmad Fathi, E-mail: cutemar2@hotmail.com
ABSTRACT
Background: Coronary artery disease (CAD) is one of the greatest causes of morbidity and mortality
worldwide. It is the principal threat to health in countries in Africa and the Middle East and one of the leading
causes of disease burden in developing countries. Scavenger receptor class B type1 (SCARB1) is a multi-
ligand cell surface receptor. This membrane protein facilitates the uptake of cholesterol esters from high-
density lipoprotein cholesterol (HDL-C) and drives cholesterol from tissues to the liver in the various stages of
reverse cholesterol transport pathway.
Aim: The aim of this work is to study the association of rs5888 polymorphism of SCARB1 gene and
premature coronary artery disease.
Patients and Methods: PCAD group included 20 patients newly diagnosed angiographically with premature
coronary artery disease, and non-PCAD group that included 20 age and sex matched non-CAD individuals
who showed no luminal stenosis in coronary angiographic results.
Results: The frequency of the wild type (CC) was higher in the control group (60%) than patients' group
(25%) and it can be considered as a negative risk factor for PCAD (OR: 0.71, 95% CI [0.60-0.82], p < 0.01).
The homozygous and heterozygous mutations (TT & CT) were statistically more frequently distributed in
PCAD patients compared to control subjects (30 % and 45 % respectively), however only the CT genotype was
considered as positive risk factor for PCAD (OR: 4.02, 95% CI[1.96-10.54], p= 0.01).
Conclusion: Allele frequencies of studied SCARB 1 SNP revealed a higher frequency of distribution of T
alleles in patients' group when compared with control group; on the other hand it shows the higher frequency
of distribution of C alleles in control group when compared to patients' group.
Keywords: PCAD, SCARB 1

INTRODUCTION
In PCAD patients, where the disease
Coronary artery disease (CAD) is a leading
progresses at an earlier age than usual; studying the
cause of morbidity and mortality all over the world,
genetic predisposition to this vulnerable plaque
affecting millions of people in both developed and
production showed that progression may be
developing countries (1). In Egypt, cardiovascular
avoided by following established preventive
diseases accounted for 46% of all-causes of
measures and altering patients' lifestyles (6).
mortality with 107.2 thousand deaths in 2012,
Scavenger receptor
class
B
type1
where nearly half of these deaths occur at an age
(SCARB1) is a multi-ligand cell surface receptor
less than seventy years (2).
expressed both on macrophages and on liver cells,
Premature coronary artery disease (PCAD)
indicating a major role for clearance of excess
is defined as CAD which manifests for the first
cholesterol from the body(7). This membrane
time under the age of 55 years for males and under
protein facilitates the uptake of cholesterol esters
65 years for females(3). Risk factors for CAD are
from high-density lipoprotein cholesterol (HDL-C)
both environmental and genetic; environmental
and drives cholesterol from tissues to the liver in
factors contributing to the development of CAD
the various stages of reverse cholesterol transport
includes obesity, hypercholesterolemia, alcohol
pathway and this makes SCARB1 gene an
intake, smoking, diabetes and hypertension.
attractive marker for CAD(8).
Hypercholesterolemia arising from abnormal lipid
SCARB1 receptor is encoded on SCARB1
metabolism has been considered to be one of the
gene which is located on 12q24.31. Various
most key risk factors for CAD pathogenesis (4).
SCARB1 polymorphisms in humans have been
Moreover, apart from these modifiable
shown to be associated with altered serum lipid
factors, accumulating evidences have shown close
profile (9). One exonic single nucleotide
associations of genetic polymorphisms in candidate
polymorphism (SNP) (rs5888) within SCARB1
genes with the risk of CAD, especially the early-
gene has been linked to lower the receptor
onset CAD. In patients with PCAD, the role of
expression and function. This SNP is a "C" to "T"
genetic risk factors is expected to be more
substitution at cDNA position 1050 base position
important than that of environmental factors(5).
on exon 8 (10).
4490
Received:18/5/2018



Accepted:27/6/2018

Full Paper (vol.725 paper# 15)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4496-4504
Fixation of Unstable Femoral Neck Fractures in Adults, Review Article
Ahmed H. Yousrya, Shady S. El-Beshrya, Gergis Nabil Benyameenb,#
aDepartment of Orthopedics, b Faculty Of Medicine, Ain Shams University, Egypt
Corresponding author: Gergis Nabil Benyameen; Address Rod El Farag, Cairo. Tel. 022458239;
Mob. 01201330211; Email dr.gergisnabil@yahoo.com
ABSTRACT
Background Femoral neck fracture is a common problem especially in young adults. There are different
methods of fixation of unstable femoral neck fractures in adults, some of which are accompanied by
complications.
Aim of Study: A systematic review on the different methods of fixation of unstable femoral neck fractures in
adults with clarifying the incidence of nonunion, avascular necrosis, displacement and other complications in
each type of fixation.
Methods A systematic review of literature was conducted on twelve studies (556 patients) published in
literature using different methods of fixation with inclusion criteria including English literature, human studies
on adults aged 18-70 years with unstable neck of femur fractures Pauwel grade 3. Exclusion criteria including
in vitro studies, pathological and nonunited fractures in people aged below 18 or above 70 years with stable
neck femur fractures Pauwel grade 1,2.
Results: Targon femoral neck device had been provided to achieve highest rate of union with less
complications than other methods of fixation but further evaluation of this device should be done within
multiple studies in the future. Primary valgus osteotomy achieved a high union rate but still carries some
complications especially delayed osteotomy site healing,coxa vara if improper reduction or fixation in addition
to that its technically demanding and needs special surgical skills.Medial buttress plate augmentation should
be studied more and more in further studies with longer follow up periods and larger number of patients
Conclusion: Targon femoral neck device had been provided to achieve highest rate of union with less
complications than other methods of fixation but further evaluation of this device should be done within
multiple studies in the future.
Key Words Unstable femoral neck fractures, Pauwels III, young adults,primary valgus osteotomy.

INTRODUCTION
Radiographic evaluation of femoral neck
Femoral neck fracture is a common problem
fracture depends on:
especially in young adults to the extent that more than
X ray imaging:(3) AP view of the pelvis. AP
250000 hip fractures occur in united states each year
view and cross lateral view of affected proximal
(50 % involve the femoral neck). The number is
femur. A physician assisted internal rotation view of
projected to double by the year 2050(1).
the injured hip is helpful in diagnosis. Frog lateral
Risk factors include female sex, white race,
view of the hip is contraindicated.
increasing age, poor health, tobacco and alcohol use,
CT imaging:(4) Is of value in trauma
previous fracture, fall history, and low estrogen level (1).
patient. Is of choice in non displaced fractures
Vertical shear (Pauwel type 3) femoral neck
when MRI imaging is contraindicated.
fractures result in young adult from high energy trauma
Pauwel classification of femoral neck fracture(5)
extending to medial calcar and lesser trochanter and
This is based on the angle of fracture from
apparently evident in AP view of plain x ray(2).
horizontal (fig 1): Type 1: < 30 . Type 2: 31-70.
A common clinical picture of femoral neck
Type 3: > 70 (vertical fracture pattern).
fracture patients in displaced types is non
There is also garden classification of femoral
ambulatory patient on presentation with shortening
neck fracture (figure 2)(4). Type 1: Incomplete / valgus
and external rotation in the lower limb. Patient with
impacted. Type 2: Complete and non displaced on AP
non displaced or stress fracture typically lacks the
and lateral views. Type 3: Complete with partial
deformity pattern and may be able to weight bear
displacement. Trabecular pattern of femoral head does
but the main complain becomes groin pain(3).
not line up with that of acetabulum.
An accurate history is important in patients with
Type 4: Completely displaced. Trabecular
femoral neck fracture especially in older individuals
pattern of the head assumes a parallel orientation
giving history of loss of consciousness, prior syncopal
with that of the acetabulum.
episodes, medical history, chest pain, prior hip pain
Aim of treatment: To minimize patient discomfort.
(pathological fracture) and pre injury ambulatory status is
To restore hip function. To al ow rapid mobilization by early
very important in detection the method of treatment(3).
anatomic reduction and internal fixation.
4496
Received:1/6/2018



Accepted:10/6/2018

Full Paper (vol.725 paper# 16)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4505-4508
Management of Complications of Arteriovenous Grafts in Patients with Chronic
Renal Failure
Mohamed Abd El Hamid Abd El Rahman, Islam Taha Ghalwash,
Mohammed Abou Al-azayem El-Kenany
Vascular Surgery Department, Faculty of Medicine, Al-Azhar University
Corresponding author: Mohammed Abou Al-azayem El-Kenany, E-Mail: dr.m.elkenany@gmail.com, Phone: +0201144277879
ABSTRACT
Background: With increasing number of patients sustained on chronic Haemodialysis, access related surgery
forms a significant proportion of vascular surgical practice today. A cursory review of patients with
Arteriovenous graft access reveals a considerable variety in short and long term complications that could
happen and in the management of those complications.
Aim: The aim of this work is to assess the outcomes of different modalities of management of complications
of Arteriovenous grafts in chronic renal failure patient on regular hemodialysis from arteriovenous graft.
Patients and Methods: Thirty chronic renal failure patients with complicated Arterio-venous grafts performed
before for regular hemodialysis were enrolled into this study. The patients were recruited from the Vascular
Surgery outpatient clinic of El-Hussein University Hospital. Patients were followed up at intervals of:
immediately after fistula creation, first day after creation, 1 month, 3 months, 6 months and 9 months after
creation for detecting any complications. Follow up of all patients was based on clinical examination and also
by duplex ultrasound and CT venography if needed.
Results: Arteriovenous graft complications incidence were higher in male than females, those results were
explained by male cases being associated with more co-morbidities and smoking. Venous outflow stenosis and
venous hypertension were the most encountered complication, while surgical management in form of ligation
and excision was the commonest management modality used. We also noticed a correlation between the
duration from creation of AV synthetic graft and interval between primary and secondary intervention. The
older the AV graft the longer was the interval between primary and secondary intervention. This can be
correlated to years of education those group of patients had, as those patients tended to pay more attention to
early manifestations and used better dialysis centers.
Conclusion: Surgical management in form of graft ligation and excision or surgical revision seems to be the
simplest yet most effective management modality facing the majority of the complications not neglecting the
role of endovascular intervention in venous hypertension.
Keywords: ESRD, Hemodialysis, complications, management, surgical, endovascular.

INTRODUCTION
lesions are common, occurring in the majority of
Arteriovenous Grafts have a relatively short
patients with dialysis access making intimal
life span if compared with native A-V fistulas and are
hyperplasia the greatest unsolved problem in
prone usually to many complications, requiring
Haemodialysis causing Venous Outflow Stenosis
multiple salvage procedures to maintain their patency.
or Arterial Inflow Stenosis which will eventually
Arteriovenous graft complications are categorized as
lead to Recirculation and Arteriovenous graft
Thrombotic Complications of A-V access include
failure or failure to mature representing the
(Venous Outflow Stenosis and Arterial Inflow
thrombotic complication of arteriovenous grafts (2).
Stenosis) and Non-Thrombotic Complications of A-V
Interventions
for
such
Thrombotic
access include (Bleeding, Pseudoaneurysms, seroma,
complications include either open Surgical Techniques,
Arterial steal, Venous hypertension, Neuropathy and
Percutaneous Techniques, Hybrid Approach or
Cardiopulmonary complications) (1).
Thrombolysis. Arteriovenous graft accesses tend to
Inherently, dialysis access initiates intimal
thrombose more frequently than autogenous accesses,
hyperplasia in the venous outflow. Intimal
but because of the presence of IH at the venous
hyperplasia occurs primarily at the outflow
end, they can often be treated repeatedly and
anastomosis of a prosthetic access. It can also
provide long-term access without a significant
involve distant central veins, even in the absence of
interruption in dialysis. Grafts tolerate balloon
previous indwelling catheters. Some patients
catheter thrombectomy better than autogenous
develop intractable intimal hyperplasia; others
accesses because they do not have viable endothelium
develop an equilibrium that stabilizes over time.
subject to injury. Segments of the graft can also be
The mechanisms behind arteriovenous (AV) access
replaced as necessary to deal with graft degeneration
intimal hyperplasia are ill-defined, but the resulting
or even localized soft tissue infections, maintaining
access through the residual unaffected graft (3).
4505
Received:29/5/2018



Accepted:8/6/2018

Full Paper (vol.725 paper# 17)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4509-4514
A Two-Week Nitazoxanide-Based Quadruple Treatment as a Rescue Therapy for
Helicobacter Pylori Eradication
Ali A. Waheeb1, Ahmed O. Dorrah1, Waleed M. Mousa1,
Alaa M. Ebrahim2
1Tropical Medicine and Gastroenterology Department- Al Azhar University,
2Tanta University
Corresponding author: Ali Ahmed Waheeb, Email: aliwahib@hotmail.com, mobile: +201223442516
ABSTRACT
Introduction: Helicobacter pylori is the most common prevalent chronic human bacterial infection estimated
in 50% of the global population but only induces clinical diseases in 10-20% of infected individuals. These
include peptic ulcers, acute and atrophic gastritis, intestinal metaplasia, gastric adeno-carcinoma and gastric B-
cell lymphoma. H. pylori infection has become highly resistant to traditional first-line treatment regimens
because of antibiotic resistance coupled with poor patient compliance with completing the treatment course.
Many clinical studies proved that nitazoxanide (NTZ) was found to be well tolerated by humans, with an
encouraging rate of eradication when it was administered with omeprazole.
Aims: The aim of the work is to compare between the efficacy of traditional triple therapy and nitazoxanide-
based quadruple therapy in treatment of H. pylori and to evaluate the efficacy of nitazoxanide-based regimens
as a rescue regimen for H. pylori eradication in resistant patients.
Methodology: This study was carried out on 85 Helicobacter pylori (H. pylori) infected patients; Patients were
classified in to 3 groups: Group 1: 60 patients with positive H. pylori Ag taking 14 days triple therapy
composed of amoxicillin (1 gm twice daily), clarithromycin (500 mg twice daily) and omeprazole (40 mg once
daily).; Group 2: 25 patients with positive H. pylori Ag (nave: not having previously taken or received a
particular treatment for H. pylori) taking 14 days quadruple therapy composed of nitazoxanide (500 mg twice
daily), in addition to triple therapy.; Group 3: 22 patients with positive H. pylori Ag after treatment (resistant
for triple therapy from group 1) taking 14 days nitazoxanide-based quadruple therapy.
Results: This work recorded the best results for H. pylori eradication (92%) in group II who received
nitazoxanide based quadruple therapy compared with group I eradication rate (63.3%), who received
traditional triple therapy regimen and better results (77.3%) in group III (resistant patients from group I).
Conclusion: This study could state that, using nitazoxanide can overcome traditional triple therapy resistance;
in addition to its efficacy in treating nave patients who didn't take any medical treatment for H. pylori.
Recommendations: Nitazoxanide (NTZ) based regimen namely NTZ/ clarithromycin / PPIs and amoxicillin is
a recommended H. pylori therapeutic regimen in our community.
Keywords: Helicobacter-Pylori, Nitazoxanide.

INTRODUCTION
However, a study based on the Maastricht
Helicobacter pylori (H. pylori) is a small,
EQ guidelines, indicated that treatment with a PPI-
Gram-negative spirochete inhabiting the mucous
based triple regimen as first-line therapy will fail in
layer overlying the gastric epithelial cells in humans.
~30% of patients on an intention-to-treat (ITT) basis,
It is the most common prevalent chronic human
and will fail in ~ 50 % of patients who are treated
bacterial infection estimated in 50% of the global
with PPI-based triple regimen with Metronidazole (5).
population (1).
H. pylori infection has become highly
H. pylori only induces clinical diseases in 10-
resistant to traditional first-line treatment regimens
20% of infected individuals. These include peptic ulcers,
because of emerging antibiotic resistance coupled
acute and atrophic gastritis, intestinal metaplasia, gastric
with poor patient compliance with completing the
adeno-carcinoma and gastric B-cell lymphoma (2).
treatment course that decrease H. pylori eradication
Furthermore, according to the World Health
rates. So there is a considerable interest in evaluating
Organization, H. pylori is classified as a type 1
new antibiotic combinations and regimens (6).
carcinogen and is the primary cause of peptic ulcer
Nitazoxanide (NTZ) is an antibiotic with
disease, gastric carcinoma, and mucosa-associated
microbiological characteristics similar to those of
lymphoid tissue lymphomas (MALT) (3).
metronidazole with nearby cost. It was settled as a
Current H. pylori infection preferred
therapy having a broad spectrum of activity against
treatment involves; proton pump inhibitor (PPI)-
micro-aerobic and anaerobic bacteria, anaerobic
based triple or quadruple regimens (4).
protozoa, and helminthes (7).
4509
Received:29/5/2018



Accepted:8/6/2018

Full Paper (vol.725 paper# 18)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4515-4522
Study of Efficacy of the Use of Peri-Operative Pregabalin and Dexamethasone on
Post-Operative Pain in Patients undergoing Lumbar Laminectomy
Mohammed Ahmed El-Feky, Wael Mohammed El-Mahdi and
Bahaa Mohamed Abd El-Raouf
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University
Corresponding author: Bahaa Mohamed Abd El-Raouf, dr.bahaa007@gmail.com
ABSTRACT
Objective: This study aimed at studying the efficacy of the peri-operative use of pregabalin and
dexamethasone for post-operative pain relief in patients undergoing lumbar laminectomy.
Methods: It is a prospective randomized controlled study. The patients on whom the study had been carried
out fulfilled the following criteria: Age: above 20 years till 60 years, Gender: both females and males, ASA I
and II, Patients scheduled to undergo elective lumbar laminectomy without fusion, patients had been randomly
categorized into 2 equal groups by closed envelope technique, 30 in each group. Group P: Pregabalin +
Placebo: Patients had been orally given single dose of 150 mg of pregabalin dissolved in 10 ml distilled water
one hour before the initiation of anesthesia and until the second post-operative day, the doses had been given
every 12 hours for a total of 4 doses. Group PD: Pregabalin + Dexamethasone: Patients had been orally given
single dose of 150 mg of pregabalin dissolved in 10 ml distilled water one hour before the initiation of
anesthesia and until the second post-operative day, the doses had been given every 12 hours for a total of 4
doses. Patients received 16 mg dexamethasone intravenously with induction of anesthesia.
Results: There was a significant difference about the heart rate intra operative and the mean arterial blood
pressure intraoperative and postoperatively at different intervals. As regarding the ETCO2 group P had a
higher average at baseline. Group PD had a significant lower consumption of pethidine in comparison with
group P. However, there was no significant difference observed in the consumption of ketorolac between the
two groups. In comparison between the two studied groups, the overall mean satisfaction score was
significantly higher among group PD than among group P.
Keywords: Dexamethasone, Pregabaline, Pain Management, Lumbar Laminectomy, Anesthesia

INTRODUCTION
dexamethasone for post-operative pain relief in
One of the primary reasons for development
patients undergoing lumbar laminectomy.
of health care is the relief of pain. It is well
documented that inadequately relieved pain can lead to
PATIENTS AND METHODS
complications in the postoperative period. Therefore,
After approval of the local ethical committee
the pain of surgery must be relieved totally (1).
and having an informed consent from every patient,
No single therapy can achieve this goal. Multimodal
this study was carried out at Al-Azhar hospital on 60
strategy refers to the simultaneous use of multiple analgesic
patients. The study was approved by the Ethics
methods or drugs. A multimodal approach typical y deploys
Board of Al-Azhar University. The patients on
interventions such as local anesthesia; a non-steroidal anti-
whom the study had been carried out fulfilled the
inflammatory (NSAID) drug, or an opioid to achieve a
following criteria: Age: above 20 years till 60 years.
combination of analgesic chemotherapy (2).
Gender: both females and males. ASA I and II.
Patients scheduled to undergo elective lumbar
Pain is defined as "an unpleasant sensory and
laminectomy without fusion.
emotional experience associated with actual or potential
Exclusion criteria: Body mass index is
tissue damage. The concept of preemptive analgesia (or
more than 35 kg/m2. Impaired renal or hepatic
treating postoperative pain by preventing the establishment
function. Pre-operative use of antidepressant or
of central sensitization) seems very logical (3).
anticonvulsants. Patients who have allergy or
It has been suggested that performing neural
contraindication to pregabalin or dexamethasone.
blockade with local anesthetics before the surgical
Patients who received steroids within 24 hours
incision may prevent the nociceptive input from altering
before surgery or during 72 hours after surgery.
the excitability of the central nervous system (4).
Patients had been randomly categorized into 2
AIM OF THE WORK
equal groups by closed envelope technique, 30 in
This study aimed at studying the efficacy
each group, as recommended by the Biostatistics
of the peri-operative use of pregabalin and
Department in Public Health, Al-Azhar University.
Group P: Pregabalin + Placebo: Patients
had been orally given single dose of 150 mg of
4515
Received:20/5/2018



Accepted:29/5/2018

Full Paper (vol.725 paper# 19)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4523-4526
Role of Ultrasound in Assessment of Joint Pain among Hemodialysis Patients
Ahmed Alaa Eldin Ahmed Saad, Ahmad Mohammad Abdulfattah Al-Ashkar, Ahmad
Mahmoud Ahmed Mohamed Fahmy, Nabil Fathy Ismael Hassan, Mohammad Sobhy
Abdulhameed Abdulkhaliq
Al-Hussein University Hospital, Internal Medicine & Nephrology Department, Faculty of Medicine, Al-Azhar
University, Cairo, Egypt
Corresponding author: Mohammad Sobhy Abdulhameed, E-mail: dr_mhsobhey@yahoo.com, Tel: 01008965573
ABSTRACT
Background: Few studies including limited number of patients assessed the rheumatologic effects of
hemodialysis (HD) on joints using ultrasonography. Joint ultrasound has been emerged as a cheap non-
invasive tool for assessment of joint pain among HD patients. This was the aim of our study to make use of
such tool in such life quality threatening complaint. Objective: to determine the role of ultrasound in
evaluation of joint pain and its causes among patients on regular HD. Patients and Methods: One hundred
and four patients with end stage renal disease (ESRD) who were regular on HD three sessions per week four
hours per session were subjected to history taking, complete physical examination stressing on musculoskeletal
examination and ultrasonography of painful joints by a an ultrasonography expert. Results: Dialysis related
arthropathy (DRA) was not the only cause of joint pain among HD patients but there were diverse causes in
different joints. As regard affected joints, knee was the most affected one then came wrist, shoulder, ankle and
elbow respectively. As regard causes of joint pain, DRA was the commonest one then came osteoarthritis, non-
specific ultrasonographic findings and few cases showed normal ultrasonographic studies. Conclusion: This
study confirmed that joint pain in HD patients has diverse causes not DRA by necessity but other causes must
be considered as well as multifactorial etiologies.
Key words: Joint ultrasound, Dialysis related arthropathy, Joint pain.

INTRODUCTION
physical examination stressing on musculoskeletal
End-stage renal disease (ESRD) is a significant
examination and ultrasonography of the painful joint
problem in nearly all countries, and the prevalence has
by an expert sonographer. Their ages ranged between
increased dramatical y in developing countries and is
30 & 70 years (mean 50). Patients who were 18 years
expected to continue increasing (1). Patients with ESRD may
old or younger at time of examination were excluded
undergo hemodialysis (HD) as a choice of renal replacement
as well as patients known to have collagen diseases.
therapy (RRT) as a life saving measure and may develop
All patients underwent musculoskeletal
many complications associated with high risk of
ultrasonography of the painful joints (Knee, wrist,
comorbidities and mortality (2). ESRD patients of al ages
shoulder, ankle and elbow). Ultrasonograms were
have poor quality of life that's why health care professionals
obtained and interpreted by one researcher (A.F.,
caring for HD should target not only patients' life span but
rheumatologist) using conventional grey-scale
improving their quality of life as wel (3).
ultrasound machine with a 7.5-12 MHz linear
One of the most important qualitative
transducer. All joints were examined for tendons
parameters for evaluating patient's quality of life is
defects, echogenicity, fluid around and enthesitis,
joint pain (4) which is very common in HD patients (5)
joint effusion and synovial thickness. Knee joint
and a major cause of depression, disturbed sleep
was examined also lemnesci, femoral cartilage
rhythm,
impaired
dialysis
adequacy
and
sharpness and clarity in addition. Wrist joint was
noncompliance for HD (6). Causes of pain among HD
subjected to the same items plus median nerve
patients are diverse and not only of renal origin but
compression features suggestive of carpal tunnel
even may be due to more than a single cause (5).Our
syndrome (CTS). Shoulder joint was also examined
aim was to evaluate joint pain and its causes among
for muscles tears (supraspinatus, subscapularis and
HD patients on regular HD whether it was of renal
infraspinatus) in addition to examination of the
origin or not by the aid of ultrasound.
acromio-clavicular joint. For ankle joint, it was
examined also for tibio-talar joint as well.
PATIENTS AND METHODS
As regard laboratory investigations, serum
A total number of 104 ESRD patients who
calcium, phosphorus and parathyroid hormones were
were regular on hemodialysis and having joint pain in
measured for correlation with joint pain and
Al-Hussein university hospital and nephrology
ultrasonographic
features.
Serum
parathyroid
specialized hospital at Galaa military medical
hormone (PTH) was assayed in all patients by the
complex were subjected to history taking, complete
4523
Received:26/5/2018



Accepted:5/6/2018

Full Paper (vol.725 paper# 20)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4527-4532
Retrospective study to evaluate the results of medical thoracoscopy in diagnosis of
exudative pleural effusion at chest department El-Hussein university hospital in the
period from July 2013 to July 2018
Ibrahim Abd El-Fattah Mohsen, Salim Mohammed Mohammed Abo-Sabe, Mahmoud Al-
Saeed Ahmed, Ahmed Adel Ibrahim Eaid
Department of Chest Diseases, Faculty of Medicine, Al-Azhar University (Cairo), Egypt
Corresponding author: Ahmed Adel Ibrahim Eaid, Email: ahmed.rona2@yahoo.com
ABSTRACT
Background: Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space
and intrathoracic structures. It enables taking pleural biopsies under direct vision, therapeutic drainage of
effusions, and pleurodesis in one sitting. Persistent and recurrent exudative pleural effusions become common
and thoracocentesis and blind pleural biopsy procedures do not give a definitive diagnosis in many patients.
Therefore, thoracoscopy today remains the gold standard for these cases. In tuberculous pleuritis, the combined
yield of histology and culture for rigid thoracoscopy was nearly 100%.
Objective: This study was carried out to analyze our five years experience of medical thoracoscopy in the
management of undiagnosed exudative pleural effusion at chest department El-Hussein University Hospital.
Materials and Methods: All patients with undiagnosed exudative pleural effusion who underwent
thoracoscopy during the period between July 2013 to July 2018 at Al Hussein University Hospital were
included in the study. All patients were subjected to thorough history taking, clinical examination, routine
laboratory investigations, pleural fluid analysis and medical thoracoscopy with multiple pleural biopsies. All
patients data, thoracoscopy results and complications were recorded.
Results: Thoracoscopy was successful for giving final diagnosis in 122 patients (84.13%) from total 145
patients. Malignancies reported in 113 patients (77.9%) of patients and TB reported in 6.2% of patients.
Mesothelioma was the most common diagnosis in 67 patients(46.2%) Minor complications occurred only in 14
out of 145 patients (9.65%), 4 patients (2.8%) developed cellulitis, 8 patients (5.5%) developed surgical
emphysema, and 2 patient (1.4%) developed bleeding.
Conclusion: Medical thoracoscopy is an easy, safe procedure with high diagnostic sensitivity for pleural
effusion of uncertain etiology.
Keywords: Exudative pleural effusion, medical thoracoscopy, tuberculosis.

INTRODUCTION
The aim of this study was to analyze our
Pleural effusion, pneumothorax, and pleural
five years experience of medical thoracoscopy in the
thickening are frequently encountered in pulmonary
management of undiagnosed exudative pleural
practice. Although the radiographic detection of
effusion at chest department El-Hussein University
pleural abnormalities may be obvious, determination
Hospital.
of a specific diagnosis can present a challenge.
Computed axial tomographic (CT) and ultrasound
MATERIALS AND METHODS
scans of the thorax and bronchoscopy with
transbronchial biopsies may be helpful in selected
This study was started in July 2013 and
circumstances, but the diagnostic yield for pleural
terminated at July 2018 at chest department, Al
disease is disappointingly low (1,2). Percutaneous access
Hussein University Hospital. All patients who
to the pleural space is diagnostically useful and
underwent thoracoscopy during this period were
relatively simple; however, approximately 25 percent
included in the study. Thoracoscopy was
of pleural abnormalities remain undiagnosed after
performed for diagnosis of exudative pleural
thoracentesis and/or closed pleural biopsies (3-6). CT-
effusions, which could not be detected by pleural
guided Abrams needle biopsy is a reasonable initial
fluid analyses using the routine biochemical,
diagnostic procedure if pleural thickening is the main
cytological, microbiological investigations and
abnormality (7). Thoracoscopy (or pleuroscopy)
closed pleural biopsy. All patients underwent
involves passage of an endoscope through the chest
detailed clinical evaluation with history, clinical
wall and offers the clinician a "window" for direct
examination and radiological examination (CXR,
visualization and collection of samples from the
CT). All the patients underwent the routine
pleura. It is a valuable diagnostic procedure and, in
investigations including complete blood count and
some cases, can also provide an opportunity for
renal
function
tests.
Prothrombin
time,
treatment (8).
international normalized ratio, and platelet counts
were done to rule out any bleeding tendency.
4527
Received:27/5/2018



Accepted:6/6/2018

Full Paper (vol.725 paper# 21)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4533-4538
Plasma Factor VII and Histidine-Rich Glycoprotein as A Potential
Markers in Pre Eclampsia
Sanaa Mohamed Abdel Aty, Buthyna Ahmed El Sharawy, Sahar Abdel Maksoud, Entsar
Raafat and Mahmoud Ahmed Ghareeb
Clinical Pathology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt And Obstetrics And
Gynecology Department, Zagazig Faculty Of Medicine, Zagazig, Egypt
Corresponding author: Sanaa Mohamed Abdel Aty, E-Mail: sana84215@gmail.com, Mobile: 01119979367
ABSTRACT
Background: Preeclampsia (PE) is a complex and serious multi-system disorder of pregnancy with a
worldwide incidence of 5-7% and contributes significantly to maternal and perinatal morbidity and mortality.
Normal pregnancy is associated with a local hypercoagulable state that becomes more profound in PE.
Histidine-rich glycoprotein (HRG) is a protein interacting with angiogenesis, coagulation, and inflammatory
responses, processes known to be altered in preeclamptic pregnancies.
Aim of the work: Is to analyze changes in the circulating levels of plasma factor VII (Plasma F VII) and HRG
in women developing PE and to evaluate them as markers for early diagnosis of PE.
Subjects and Methods: This study was carried out on 80 pregnant women after 20 weeks of gestation. The
subjects were divided into: Group I (G1): 40 cases with preeclampsia; Group II (G2): 40 normal pregnant
women who were matched for age and gestational period. Plasma FVII and HRG were measured by ELISA
Results: Plasma FVII levels were significantly higher in G1 (206.22 46.25 ng/ml) as compared to G2 (97.46
21.95 ng/ml) (p<0.001). Significant positive correlation of plasma FVII with fibrinogen and significant
negative correlation with platelet count and HRG were detected. At cut off 125.75 ng/ml plasma FVII levels
shows high sensitivity and specificity (95%). HRG levels were significantly lower in G1 (37.1 7.52 pg/ml) as
compared with G2 (79.8724.15 pg/ml) (p<0.001). HRG shows significant positive correlation with platelet
count and significant negative correlation with each of fibrinogen and plasma FVII. At cut off 46.45 pg/ml.
HRG shows high sensitivity (92.5%) and specificity (87.5%).
Conclusion: Plasma FVII and HRG can be used as early marker for detection of PE.
Key words: PE: preeclampsia-HRG: histidine rich glycoprotein-plasma factor VII

INTRODUCTION
in which endothelial cell dysfunction is of major
Preeclampsia (PE) affects 5% to 7% of
relevance (3).
pregnant women each year all over the world,
A number of circulating factors which
responsible for up to 18% of maternal deaths in the
contributes to maternal endothelial cell dysfunction have
United States each year, and is the number one
been
known,
including
syncytiotrophoblast
cause of premature births (1).
microparticles, cytokines, apoptotic factors, and
In normal pregnancy, it is well established
antiangiogenic as well as proangiogenic factors.
that, a local hypercoagulable state is essential for
Moreover, endothelial cell dysfunction causes increased
placental
homeostasis.
These
physiological
coagulability in the placental microvasculature and in
compensatory mechanisms thought to be important
the vasculature in general, which leads to disturbances
in preventing severe bleeding during pregnancy
of the coagulation and the fibrinolytic system (4).
and delivery. However, small placental thrombi are
Blood coagulation begins when tissue
frequently observed in women with pre-eclampsia
factor (TF) is exposed to blood, binds plasma
(PE), which may compromise placental perfusion
factor (F) VII, and change it to active form (FVIIa).
and fetal growth development and possible
In the presence of Ca2+ and lipid, this bimolecular
progression to intrauterine death. It could also
complex (TF:FVII:FVIIa) activates FIX and FX,
account for many of the features' of PE, whose
thus triggering coagulation pathways, leading to
etiology is complex (2).
thrombin generation (2).
The pathogenesis of preeclampsia is not fully
Histidine-rich glycoprotein (HRG) is a
understood, it occurs on a two-step model. The first
multidomain protein involved in hemostasis as well
one is an inappropriate trophoblast invasion of the
as in the angiogenic pathway, and has both
maternal spiral arteries in early pregnancy, leading to
proangiogenic and antiangiogenic characteristics (5).
inadequate implantation and placentation, thus
HRG is a potent inhibitor of FXIIa
causing relative hypoxia in the placenta. The second
procoagulant activity, and its plasma levels are
step involves general systemic inflammatory response
relatively high and do not fluctuate widely, except
4533
Received:13/5/2018



Accepted:22/5/2018

Full Paper (vol.725 paper# 22)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4539-4542
Surgical Management of the Infected Femoral Pseudoaneurysms In Intravenous
Drug Addicts
Ashraf Mohammed Ewida, Yasser Hussin Hassan Metwally, Mohammed Abdessalam
Abdallah Hemdan
Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Corresponding author: Mohammed Abdessalam Abdallah Hemdan,email: abdessalam101n@gmail.com
ABSTRACT
Background: Vascular system complications are an ongoing hazard of intravenous drug abuse.
Patients and Method: This is a prospective study. The study was conducted on twenty patients who were
presented at AL Hussein University Hospital in Cairo with infected femoral artery pseudoaneurysm over a
period of eight months from Nov 2017 to July 2018. The inpatient medical charts were reviewed. Data were
obtained on their demographic, clinical, management and outcome parameters.
Result: Among the twenty intravenous drug users presenting with infected femoral artery pseudoaneurysms,
(16) of the patients (80%) were seropositive for HCV. All were operated, with (5%) mortality. Primary ligation
and debridement was the technique used almost exclusively (75%). One patient was managed by primary
reconstruction by direct in-situ repair. Four patients were managed by primary revascularization through exta-
anatomical bypass. Mean follow up period was three months.
Conclusion: Ligation and debridement appears to be a simple, safe and effective procedure in infected
pseudoaneurysms in IV drug users.
Keywords: IV drug users, infected pseudoaneurysms, revascularization, ligation.

INTRODUCTION
rupture arteries; secondly, to excise and drain the
IV drug abuse is an international socio-
local septic tissue. Controversy exists as to which
medical problem. The number of drug users was
is the appropriate way to manage infected femoral
increasing in recent years. It was estimated that about
pseudoaneurysm ligation or revascularization (2,8).
14 million people worldwide injected illicit drugs in
Trans-obturator bypass is a valuable option of
2011(1). Femoral triangle is a common site for illegal
revascularization so, vascular surgeons may need
substances injection with accidental puncturing of the
to become more familiar with this procedure and
common
femoral
artery.
Vascular
system
consider performing it in appropriate cases (9).
complications are an ongoing hazard of intravenous
drug abuse. Repeated failed attempts to inject
preparations as heroin and cocaine into a major lower
limb deep vein are likely to cause arterial or venous
injury. Pseudoaneurysm is a pulsating, encapsulated
hematoma in communication with the lumen of a
ruptured artery (1,2).
These patients are usually presented with
painful groin swelling with bleeding puncture site.
Pulsating and tender swelling is commonly seen in
examination. If left untreated, the infected
pseudoaneurysm may be accompanied by systemic
sepsis, life-threatening hemorrhage, loss of limb or

even death. Various other vascular complications,
Fig. (1): Right infected femoral artery pseudoaneurysm
such as deep venous thrombosis (DVT) and arterial
with ongoing bleeding.
embolization can occur (2). Different diagnostic
modalities are used for primary diagnosis and
PATIENTS AND METHODS
intraoperative
assessment.
In
addition,
This study was conducted on twenty
postoperative and long term follow-up such as
patients who were presented at AL Hussein
imaging options as duplex US (3,4), CT, CT
University Hospital in Cairo with infected femoral
angiography, MRA in selected cases and bedside
artery pseudoaneurysm over a period of eight
tests as Doppler signals detection, digital PO2 by
months from Nov 2017 to July 2018. Upon clinical
pulse oximeter and ABI evaluation (2,5,6,7).. The
suspicion, all underwent duplex US of the
treatment aims are firstly to control actual or
concerned limb except a patient who was
potential hemorrhage by oversewing or ligating
massively bleeding at presentation and had to be
4539
Received:18/5/2018



Accepted:27/5/2018

Full Paper (vol.725 paper# 23)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4543-4550
Transverse Comparisons Between Ultrasound and Radionuclide Parameters in
Children with Pelvi-Ureteric Junction Obstruction
Samer Malak Botros, Ali Hagag Ali, Norhan Osama shawky
Radiology Department -Faculty of Medicine- Ain Shams University
Corresponding author: Norhan Osama shawky, Email: norhanmedecine@gmail.com
ABSTRACT
Pelvi-ureteric junction (PUJ) obstruction is one of the causes of an obstructive uropathy which may be
congenital or acquired. Ureteropelvic junction (UPJ) obstruction is a blockage at the point where ureters
attaches to the bladder. This blocks the flow of urine out of the kidney, Urine can build up and damage the
kidney, so radiologic imaging is crucial in diagnosing UPJ obstruction. It seemed therefore interesting to
determine if some US parameters could predict the radionuclide parameters and which ultrasound parameter
most influencing the kidney function. The initial step was to grade the severity of hydronephrosis, calyceal
dilatation and cortical thinning, although it was easy for us to classify the importance of hydronephrosis in
three groups according to anteroposterior diameter (APD). AP diameter of renal pelvis and differential renal
function were the most effective parameters for surgical decision. These parameters can be used for
appropriate management of antenatal hydronephrosis.
Key words: UPJ: Uereteropelvic junction, US: Ultrasonography, APD: anteroposterior diameter

INTRODUCTION
Not uncommonly, asymptomatic UPJ
Pelvi-ureteric junction (PUJ) obstruction/
obstruction is discovered in older children or adults
stenosis is one of the causes of an obstructive
when radiologic studies, such as ultrasonography,
uropathy which may be congenital or acquired with a
intravenous
pyelography
(IVP),
computed
congenital PUJ obstruction being one of the
tomography (CT) scanning, or magnetic resonance
commonest causes of antenatal hydronephrosis(1).
imaging (MRI), are performed for other reasons. The
use of intravenous contrast material with nephrogenic
Several methods are used in diagnosing
and delayed excretion phases during CT scanning
upper urinary tract obstruction as: ultrasonography,
may provide qualitative information regarding
intravenous pyelogram, un-enhanced CT,diuretic
obstruction, but in general, CT should be avoided
renography, magnetic resonance urography and
because of the inherent high radiation dose. When
antegrade or retrograde pyelography (2).
hydronephrosis is seen when UPJ obstruction is
It may present in both paediatric and adult
suspected, diuretic renography is more accurate than
populations although they tend to have differing
CT (4).
aetiology. The estimated incidence in paediatric
Intravenous pyelography (IVP) has historically
populations is ~1 per 1000-2000 new-borns(1).
been the primary study used to diagnose UPJ
PUJ obstruction is most commonly
obstruction in adults, because it also provides anatomic
unilateral but is reported to be bilateral in ~30%
and functional information. However, ultrasonography
(range 10-49%) of cases (3).
is preferred as the initial study in children because of its
Radiologic imaging is crucial in diagnosing
nonionizing and non-invasive nature (5).
UPJ obstruction. The diagnosis of UPJ obstruction
CT may depict ureteropelvic junction (UPJ)
signifies functionally impaired transport of urine from
obstruction when it is used as a primary study for
the renal pelvis into the ureter. Because the increased
evaluating common presenting symptoms. In older
renal pelvic pressure from obstruction may lead to
children, the modality is useful for assessing causes
progressive renal injury and embarrassment, correct
of acquired UPJ and ureteral obstruction (e.g., stones,
diagnosis is clinically important (3).
tumors,
retroperitoneal
processes).
Often,
Current
radiologic
standards
define
hydronephrosis is found incidentally on CT scans,
hydronephrotic kidneys as those with an anteroposterior
and further studies are needed to distinguish UPJ
(AP) diameter at the renal pelvis of greater than 4 mm at
obstruction from nonobstructive hydronephrosis(6).
a gestational age of less than 33 weeks and an AP
Cortical thinning in a hydronephrotic
diameter of greater than 7 mm at a gestational age of 33
kidney may be seen on CT scans and may be
weeks or older. An abnormal initial ultrasonogram
predictive of ipsilateral renal function. The use of
should be followed up with another ultrasonogram after
intravenous contrast material with nephrogenic and
4 weeks in severe cases or after 33-34 weeks in mild to
delayed excretory-phase images also may be
moderate cases(4).
helpful in determining whether renal function and
excretion are impaired (6).
4543
Received:30/4/2018



Accepted:9/5/2018

Full Paper (vol.725 paper# 24)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4551-4555
Retrospective Study of The Corticosteroids Administration in
Glioblastoma Patients as A Prognostic Factor in The Disease
Khaled Abdel Karim Mohamed, Mohamed Reda Kelany, Omar Mohamed Abdelrahman,
Abdelrahman Mostafa El-Sayed El-Adawy
Clinical Oncology and Nuclear Medicine Department, Faculty of Medicine, Ain Shams University
Corresponding author: Abdelrahman Mostafa El-Sayed El-Adawy, email: abdelrahmanadaway@gmail.com
ABSTRACT
Background: Glioblastoma multiforme (GBM) is the most common and most malignant of the glial tumors.
Optimum management consists of maximal safe surgical resection, followed by concurrent chemo-
radiotherapy treatment then adjuvant chemotherapy with temozolomide. A considerable part from the care of
patients with GBM involves general medical management, containing corticosteroids. Despite steroids
common use, there is experimental and clinical evidence that corticosteroids have direct effects on tumor cell
proliferation and apoptosis.
Aim of the Work: was to discuss the clinical relation between corticosteroids usage in Glioblastoma
Multiforme (GBM) patients and quality of life as well as the disease progression free survival according to the
recorded data from the joined hospitals.
Patients and Methods: Retrospective analysis of 66 adult patients diagnosed with GBM by surgery or
imaging criteria. In order to assess the relation between corticosteroid dependence and the survival, patients
were recruited into two groups (arms) according to dependency. Arm (A) was steroid dependent(34 patients)
and arm (B) was steroid non-dependent (32 patients).
Results: Corticosteroids dependency was statistically significant correlated to both Overall Survival
(OS)(median 2.5 in arm (A) vs. 13.1 months in the arm (B), p < 0.001), and Progression-free survival ratio
(PFS)(median 2.3 in arm (A) vs. 9.4 months in arm (B), p = 0.035). Also, steroid dependency was independent
prognostic factor by doing the COX regression analysis.
Conclusion: Dependence on corticosteroids during course of treatment is identified as a poor prognostic factor.
Keywords: Corticosteroids, GBM, Glioblastoma multiforme, Dexamethasone, Prognostic Factor.

INTRODUCTION
Treatment is complex and initially consists
According to Globocan web site, incidence
of maximal-safe surgical resection followed by
of CNS tumors in Egypt was estimated by
radiation
therapy
(RT)
with
concurrent
6.6/100000. In a study that included 1618 cases of
temozolomide (TMZ) chemotherapy followed by
CNS tumors among Egyptians in delta region,
six cycles of maintenance TMZ(6).
Gliomas were of the highest frequency 35.2 %.
Steroids were introduced into the care of
Glioblastoma represented 38.3% of gliomas(1).In
brain cancer patients nearly 60 years ago based on
another study performed in Ain Shams University
their powerful effects on tumor-induced edema.
Hospitals, a total number of registered newly
Ingraham pioneered the use of cortisone to treat
diagnosed patients received during the study period
postoperative cerebral edema in neurosurgical
were 943 cases. CNS tumors accounted for 53 newly
patients in 1952, and Kofman first used prednisone
diagnosed cases (5.6%) and it was ranked as the
for peritumoral edema from brain metastases in
fourth common cancer in both sexes. Glioblastoma
1957. More than 50 years ago, it was demonstrated
Multiforme was the most common pathology
that dexamethasone effectively alleviated cerebral
occurring in about 43.3% of the presented cases(2).
edema due to brain tumors (7).
Exposure to ionising irradiation has been
Edema results from the flow of fluid into
associated with increased risk of development of
the extracellular space of the brain parenchyma
glioma, while association with the use of cell phones
through an incompetent bloodbrain barrier (BBB)
could not be confirmed in epidemiological studies.
(8).Dexamethasone is most commonly used by
Rare hereditary syndromes carry an increased risk for
neuro-oncologists owing to its comparably minimal
glioma: Cowden-, Turcot-, Lynch-, Li-Fraumeni
mineralocorticoid activity, possible lower risk of
syndrome and neurofibromatosis type 1(3).
infection and occurrence of cognitive impairment.
GBM is the most aggressive diffuse glioma
It has been suggested that corticosteroids produce
of astrocytic cell line and classified as grade IV in
their anti-edema effect by reducing the
WHO Classification(4). GBM remains an incurable
permeability of tumor capillaries(9).
disease with a median survival of 15 months (5).
4551
Received:1/6/2018



Accepted:10/6/2018

Full Paper (vol.725 paper# 25)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4556-4560
Management of Pseudo Tumor Cerebri by Frequent Tapping VS
lumboperitoneal Shunt
Ali K. Ali, Maamoun M. Abo Shousha, Mohammed R. Metwally
Department of Neurosurgery, Faculty of Medicine, AL-Azhar University
Corresponding author: Mohammed R. Metwally, Mobile: 01124242660; Email: ahmadmohamad705@gmail.com
ABSTRACT
Background: The syndrome known as pseudotumor cerebri (PTC) is generally thought of as a condition
characterized by increased intracranial pressure (ICP) without evidence of dilated ventricles or a mass lesion
by imaging, normal cerebrospinal fluid (CSF) content, and papilledema occurring in most cases in young,
obese women without any clear explanation. Aim of the Work: to highlight the early diagnosis, causes of
visual deterioration of idiopathic intracranial hypertension, its pathophysiology will be discussed. Special
emphasis will be given for trends in management of this disease especially frequent tapping and
lumboperitoneal shunt and comparing results of both techniques. Patients and Methods: This prospective and
retrospective study was conducted on 20 patients of special criteria confirmed to have pseudotumor cerebri by
clinical presentation, radiological findings, fundus and visual field examination. Results: The papilledema of
PTC was identical with that in patients with other causes of increased ICP. In most of cases it was bilateral
symmetrical, however it was asymmetric in 1% of cases. In the frequent tapping patients group, results showed
improvement of all symptoms in about 80% of patients. And in 20% of patients there were persistent
complaints especially headache and blurred vision. In the lumboperitoneal shunt group, 65% of Cases showed
improvement of all symptoms while 35% of cases showed shunt failure and complications.
Conclusion: Concerning the category of patients participated in this study, and particularly with whom
medical measures were failing, consideration should be given to investigation of the cranial venous outflow
tract with a view to some therapeutic intervention if appropriate.
Key words: Intracranial pressure, Lumboperitoneal shunt, Papilledema

INTRODUCTION
and should not be made without neuro imaging, a
Idiopathic intracranial hypertension was
lumbar puncture (LP(& fundus examination (4).
known as benign intracranial hypertension as its
Medical therapy is most appropriate when
name implies, a disease of raised intracranial
the primary problem is headache in the setting of
pressure which usually runs a self-limiting course
good visual function and when it is the opinion of
without evidence of hydrocephalus or intracranial
the physician and the patient that weight loss alone
masses. Although termed `benign', this condition
will take too long to render an effect (5).
can cause blindness due to severe papilloedema (1).
LP is sometimes useful to relieve increased
The etiology is generally poorly understood
ICP in patients with IIH. The rationale behind the
and the exact mechanisms of the raised pressure are
procedure is uncertain. Repeated LPs are traumatic
not known. The condition is found typically in young,
for the patient and often technically difficult to
obese women, often with menstrual irregularities or
perform, but they are useful in selected individuals
taking an oral contraceptive pill, and an endocrine
with intermittent exacerbation of symptoms (6).
disturbance has been suggested. However, careful
Surgery is performed when patients
endocrine studies have failed to show significant
initially have severe optic neuropathy or when
endocrine abnormalities (2).
other forms of treatment have failed to prevent
Occasionally, the condition is asymptomatic
visual loss, known surgery of this condition is
and discovered during a routine ophthalmic
lumboperitoneal shunt (7).
examination when papilloedema was found.
However, the most common symptom, as well as
AIM OF THE WORK
most often the initial symptom, is headache, which
This work aimed at giving highlights about
occurs in approximately 90% of cases. The character
the early diagnosis, causes of visual deterioration
of the headache is not specific, but it is generally
of idiopathic intracranial hypertension, its
different from previous headaches and is severe (3).
pathophysiology was discussed. Special emphasis
The diagnosis of IIH requires that there be
was given for trends in management of this disease
no intracranial or spinal mass, no evidence of
especially frequent tapping and lumboperitoneal
hydrocephalus, documented increased ICP, and
shunt and comparing results of both techniques.
normal CSF contents. Thus, the diagnosis cannot
4556
Received:1/6/2018



Accepted:10/6/2018

Full Paper (vol.725 paper# 26)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4561-4564
Correlation Between Visual Acuity And Optical Coherence Tomography Macular
Parameters In Controlled Type II Diabetic Patients
Mariana Nashaat William Yacob, Tamer Mohamed Fathi El-Mekkawi, Mouamen Mohamed
Mostafa, Rania Serag El-Kitkat
Department of Ophthalmology Faculty of Medicine - Ain Shams University
Corresponding author: Mariana Nashaat William Yacob: Mobile: 01200299069, Email: menonashat123@gmail.com
ABSTRACT
Background: Diabetes Mellitus (DM) is a chronic metabolic disease with considerable morbidity and
mortality. Diabetic retinopathy (DR) and diabetic macular edema (DME) are major complications of DM and
are the principal cause of vision loss among the working age group in developed countries. Optical coherence
tomography (OCT) uses low-coherence interferometry to provide noncontact and noninvasive optical biopsy of
the tissue morphology of the retina, making it a useful tool for detecting and managing DME.
Aim of the Work: To study the effect of controlled type II DM on visual acuity (VA) and macular changes by
OCT. In addition, to correlate VA to macular parameters detected on OCT retinal examination.
Patients and Methods: This is a retrospective case control study that included 30 eyes of 22 controlled type II
diabetic patients (group1) and 30 eyes of 19, age and sex matched healthy subjects (group 2). All diabetic
patients were diagnosed as DME using OCT parameters. Correlation between central foveal thickness (CFT)
and VA was done.
Results: There were statistically significant differences in UCVA & BCVA between the 2 groups. The
difference in the central foveal thickness (CFT) from ETDRS map of OCT between the 2 groups was
statistically significant. There were statistically significant differences between CFT from ETDRS map and
both UCVA & BCVA. Statistically significant differences were detected between CFT and both FBS and
2HPP levels. Furthermore, statistically significant differences were detected between BCVA and both FBS and
RBS levels.
Conclusion: Based on the data in our study, results pose a recommendation of regular follow up of three blood
sugar-assessing parameters (FBS, 2HPP and RBS) and referring patients to ophthalmologists if abnormal
values were detected.
Recommendations: Using large sample size will give more valid results. In our study, we evaluated the
structure of the fovea, further studies can evaluate structure using OCT and function by electrophysiology.
OCT angiography also could be useful in scanning retinal vasculature.
Keywords: Diabetic macular edema (DME), visual acuity(VA), optical coherence tomography(OCT).

INTRODUCTION
retinal thickening. c. Thickening of the retina at
DM is a chronic metabolic disease with
least 1 disc area in size that extends to within 1 DD
considerable morbidity and mortality(1).
of the fovea(4,5).
DR and cataract represent the leading
Optical coherence tomography is used to
cause of visual impairment and vision loss in adults
diagnose DME, enabling better understanding of
younger than 75 years(2).
the mechanisms of disease and managing it(6).
Visual impairment due to DR and DME
AIM OF THE WORK
has an impact on patients' quality of life(3).
To study the effect of controlled type II
The Diabetic Retinopathy Study (DRS) and
DM on visual acuity (VA) and macular changes by
the Early Treatment Diabetic Retinopathy Study
OCT and to correlate VA to macular parameters
(ETDRS) classified DR into: non-proliferative
detected on OCT retinal examination.
diabetic retinopathy (NPDR) {mild, moderate,
severe and very severe} and proliferative diabetic
PATIENTS AND METHODS
retinopathy (PDR) {low risk, high risk and
advanced PDR}. DME may be developed with
This was a retrospective case control study
both types of DR (4).
that included 34 eyes of 22 controlled type II
diabetic patients (group1) and 31 eyes of 19, age
Clinically significant macular edema
and sex matched healthy subjects (group 2),all
(CSME) was first used in the ETDRS and is
diabetic patients were diagnosed as DME using
defined as any of the following: a. Thickening of
OCT parameters. The study was approved by the
the retina within 500 m of the fovea. b. Hard
Ethics Board of Ain Shams University.
exudates within 500 m of the fovea with adjacent
4561
Received:30/5/2018



Accepted:9/6/2018

Full Paper (vol.725 paper# 27)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4565-4571
Three-Dimensional Ultrasound versus Hysteroscopy in Uterine Cavity
Assessment after Failed Intracytoplasmic Sperm Injection: a study for

accuracy of a diagnostic test
Faten Mosbah Ibrahim Al-Zinaty1, Mohammed Sayed Ali2, Mohammed Mahmoud Al
Sherbeeny2, Tarek Aly Raafat-
1Obstetrics and Gynecology Clinics, Al-Tayseer Clinics, 2Department of Obstetrics and Gynecology, Faculty of
Medicine, Ain-Shams University
Corresponding author: Faten Mosbah Ibrahim Al-Zinaty, Email: fatenmosbah@hotmail.co.uk, Phone: +201222117730.
ABSTRACT
Background: Implantation failure after intracytoplasmic sperm injection (ICSI) is related to either maternal
factors or embryonic causes. The maternal factors include uterine anatomic abnormalities either congenital or
acquired. Three-dimensional transvaginal ultrasound allows detailed evaluation of pelvic organs. Office
hysteroscopy is the gold standard tool for visualization of intracavitary lesions and the cervical canal in an
office-based environment.
Aim of The Work: It was to compare between three-dimensional ultrasound (3D USS) and hysteroscopy for
evaluation of the intrauterine cavity after trial of ICSI and to study the accuracy of diagnostic test in a tertiary
care facility.
Patients and Methods: It was a prospective; blinded; controlled clinical trial comparative study. Both
hysteroscopy and 3D USS procedures were done for uterine cavity assessment after failed attempt of ICSI
treatment for fifty two asymptomatic infertile women.
Results: Seventeen cases of our studied patients were without intracavitary or cervical lesions. From all
studied cases, lesions (n=66) were seen either by hysteroscopy or by 3D USS where lesions (n=24) were seen
by hysteroscopy and seen by ultrasound. Lesions (n=34) were seen by hysteroscopy. Lesions (n=36) were seen
by ultrasound. Measure of agreement of Kappa was 0.273. Overall sensitivity of 3D USS was 70.59% and
specificity 62.50% with positive predictive value (PPV) 66.67% and negative predictive value (NPV) 66.67%,
accuracy was 66.67%, positive likehood ratio (LR+ve) 1.88% and negative likehood (LR-ve) 0.47%. The p-
value was 0.026, which is statistically significant.
Conclusion: It is important to investigate the uterine cavity in infertile women with history of unsuccessful
ICSI. 3D USS has a good sensitivity and specificity for diagnosis of uterine cavity abnormalities and it could
be used before hysteroscopy as a first line of investigation of intrauterine lesions.
Key Words: Intracytoplasmic Sperm Injection (ICSI), Repeated implantation failure (RIF), Hysteroscopy,
Three-Dimensional Ultrasound (3D USS), Gold Standard, Sensitivity, Specificity.

INTRODUCTION
expression of adhesive molecules and immunological
Intracytoplasmic sperm injection (ICSI) is
factors like Anti Sperm (ASA), Anticardiolipin (aCL),
an assisted reproductive technology (ART) used to
Lupus anticoagulant (LA), Anti-Phosphatidylserine
treat sperm-related infertility problems (1).
(aPS), Anti-Phosphatidylethanolamine (aPE), and Anti-
ICSI was introduced in 1992 to improve
nuclear antibody (ANA), Anti-DNA, Anti-Zona and
fertilization in couples with or without detectable
Anti-ovarian (AOA) antibodies, Thrombophilia, decrease
abnormalities of semen parameters (2). ICSI has
expression of endometrial integrins, increase of natural
become the premier treatment modality for severe
killer cells activities and imbalance of cytokine networks
male factor infertility, yielding excellent pregnancy
(balance between IL-12 and IL-18), may decrease
and implantation rates (3).
endometrial receptivity, whereas chromosomal and
genetic abnormalities of the male sperm or female
However, even after ICSI, complete failure
ovarian defects, embryonic aneuploidia or zona hardening
of fertilization occurs in 1-3% of cycles. Most
are embryonic reasons for the failure of implantation.
cases occur due to low number of mature oocytes,
Among the various etiologies that where, endometrial
failure of oocyte activation or non-availability of
regularity due to anatomical malformations of the uterus,
appropriate spermatozoa for injection (4).
either congenital (septate uterus and bicornuate uterus) or
The probable causes of repeated in vitro
acquired (uterine fibroids, especially submucous type,
fertilization (IVF) failures are classified as: reduced
endometrial polyps, intrauterine adhesions and
endometrial receptivity, embryonic defects or
hydrosalpinx), play an important role in infertility and
multifactorial causes. Intrauterine and endometrial
success of IVF programs (5).
integrity abnormalities such as thin endometrium, altered
4565
Received:3/6/2018



Accepted:12/6/2018

Full Paper (vol.725 paper# 28)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4572-4575
Juvenile Nasopharyngeal Angiofibroma in a Woman: A rare case report
Mohammad S. Al-Ahmari and Kholood S Assiri
The Department of ORL-HNS, Khamis Mushayt General Hospital, Aseer, Kingdom of Saudi Arabia
Correspondence author: Mohammad S. Al-Ahmari, Email: malahmari@hotmail.com
ABSTRACT
Background: Juvenile nasopharyngeal angiofibroma (JNA) is rare otolaryngology disorder worldwide and in
Saudi Arabia. It is a benign tumor that tends to bleed and occurs in the nasopharynx which most commonly
occurs in men more than women.
Methods: A view of rare case report following a 27-year-old woman presented with recurrent attack of epistaxis for
six months which was associated with nasal obstruction and snoring who was radiologically and surgically managed
in Otolaryngology-Head and Neck Surgery (ORL-HNS) Clinic of Khamis Mushayt General Hospital and follow up
for one year who was completely asymptomatic. Conclusion: Juvenile nasopharyngeal angiofibroma in a female is
very rare, and if confirmed sex chromosome studies must be performed. Surgery is the mainstay of treatment of
JNA. Preoperative embolization result in less blood loss and complete resection.
Keywords: Juvenile nasopharyngeal angiofibroma, rare, female, otolaryngology disorder

INTRODUCTION
complaining of recurrent epistaxis for six months.
Juvenile nasopharyngeal angiofibroma
Khamis Mushayt General Hospital is a tertiary care
(JNA) is a highly vascular, aggressive and locally
hospital in Khamis Mushayt City, Aseer Region,
invasive tumor. This tumor has a high potential to
South western area of the Kingdom of Saudi Arabia.
cause serious illness from severe epistaxis,
The patient complaint was mainly from right side
involvement of intracranial structures and high-rate
with small amount. Symptom was progressive with
of recurrence. The age of presentation varies
no aggravating or relieving factors. It is associated
between 7 and 19 years (1),with isolated patients
with right nasal obstruction, snoring and headache.
presenting earlier or later. It is characterized
No history of visual loss, or diplopia.
morphologically by irregular, proliferating vascular
On examination, the patient was generally
channels within a fibrous stroma, which consists of
stable, but she had right reddish nasal mass with
plump, spindle or stellate cells. It has a peculiar
nasal discharge Fig (1). No external affection,
propensity for local extension into the adjacent
normal vision, and normal extraocular movement.
tissues that often precludes complete surgical
Basic laboratory investigations were normal.
resection and likely is responsible for tumor
CT scan revealed expansile enhancing right nasal
persistence and recurrences in 21 to 34% of the
mass filling and ipsilateral maxillary and projecting
affected patients (2).
posteriorly onto nasopharynx. Associated thinning
Topographically, this tumor frequently
out of the medial wall of the right maxillary sinus and
originates in the posterolateral wall of the nasal
medial wall of the right orbit Fig (2).
cavity, close to the superior margin of the
The decision was made to treat the patient
sphenopalatine foramen. Subsequently, JNA may
operatively with preoperative embolization. Patient
cause bone erosion and displacement of adjacent
prepared for embolization by 48 hours, intervention
structures, thus involving the nasopharynx, paranasal,
radiologist detect the main blood supply of the
ethmoidal and maxillary sinuses, and orbit and skull
lesion, which is right sphenopalatine artery, he did
base, with possible intracranial extension (2).
embolization of distal right maxillary artery with
A review of the literature reveals rare cases
its branches. Fig(3A) shows conventionaldigital
of female and older male patients with JNA (3, 4, 5, 6).
subtracting angiography with iv contrast that shows
Malignant transformation of the tumor is also a rare
right nasal enhancing lesion, while Fig (3B) shows
finding and reported to be associated with recurrent
the lesion post embolization of distal right
radiotherapy (7).
maxillary artery and its branches (nasopharyngeal
This article aims to report an uncommon
angiofibroma) showing normal flow in right ICA
case of Juvenile nasopharyngeal angiofibroma.
andtheirbranches, no flow through right external
carotid artery mainly in the maxillary artery with
CASE DESCRIPTION
no mass blush, and non-opacifying left common
carotid artery appropriate with occlusion.
A 27-year-old woman presented to the
Endoscopic sinus surgery was performed, there is
Otolaryngology-Head and Neck Surgery (ORL-
right friable nasal mass, bleed on touch, all the
HNS) Clinic of Khamis Mushayt General Hospital,
lesion removed Fig (4) and sent for histopathology,
4572
Received:8/5/2018



Accepted:17/5/2018

Full Paper (vol.725 paper# 29)


ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (5), Page 4576-4581
Assessment of Corneal Thickness in Healthy and Diseased Corneas by
Different Imaging Techniques
Doaa Maamoun Ashour, Ahmed Taha Ismail, Maged Maher Salib Roshdy, Khaled Abd
Elwahab El Tagoury
Ophthalmology Department, Ain Shams University, Cairo, Egypt
ABSTRACT
Background: Accurate measurement of corneal thickness (CT) is highly important in decision making and
planning for refractive surgery. It is also important in diagnosis of keratoconus, measuring intraocular pressure
and monitoring corneal edema. Different methods are available for CT measurement including optical and
ultrasound based techniques.
Aim of the Study: was to assess the diagnostic accuracy of optical (AS OCT and Pentacam) and ultrasound
imaging systems (USP) in measuring corneal thickness in healthy and diseased corneas.
Materials and Methodology: Three groups were included: 20 healthy corneas, 20 eyes with keratoconus (KC)
and 20 eyes with corneal scars. In all cases central corneal thickness (CCT) was measured using ultrasound
pachymetry, Pentacam and anterior segment optical coherence tomography (AS OCT).
Results: In normal corneas the mean difference (MD) between US and Pentacam, US and OCT & Pentacam
and OCT (-1.39.4, 0.410.4 &1.710.7m) to be statistically insignificant between the 3 pairs with
coefficient of determination 1 between the 3 pairs. In KC group the mean difference (MD) between US and
Pentacam (-7.715.1 m) was statistically significant while the MD between US and OCT & Pentacam and
OCT (4.715.7 and 12.314.1 m) was not statistically significant. In scar group the MD between the 3 pairs
(-1.179.1, -13.620.8 &-12.573.0) with statistically significant difference between USP and OCT.
Coefficient of determination was found 0.9.
Conclusion: USP, AS OCT and Pentacam have high agreement regarding CCT measurement in normal
corneas. However, when we studied KC and scarred corneas we found that OCT measurements are higher than
those of Pentacam in most of the cases regarding CCT.
Keywords: CCT, Pentacam, AS OCT.

INTRODUCTION
can be used for CCT measurements (5). Ultrasound
Anterior segment (AS) imaging became a
Anterior Segment imaging technologies are:
rapidly advancing field. New modalities such as
Simple one-dimensional ultrasound system (USP)
rotating Scheimpflug imaging and AS OCT are
and Ultrasound biomicroscopy (UBM)(4).
now used to replace or supplement the previously
The aim of the current study was to assess
established methods such as Orbscan scanning slit
the diagnostic accuracy of optical (AS OCT and
tomography (Bausch & Lomb, Inc., Rochester,
Pentacam) and ultrasound imaging systems (USP)
NY) and ultrasound biomicroscopy (UBM) (1,2).
in measuring corneal thickness in healthy and
These methods are used with the traditional
diseased corneas.
methods for measuring CT such as USP which was
considered as the standard method due to its
SUBJECTS AND METHODS
reliability, ease of use and low cost in comparison
This
observational
cross
sectional
to recent modalities. However recent modalities
prospective study was conducted on a consecutive
offer pachymetric mapping systems which were not
series of subjects attending outpatient clinic of
available with USP and is of a great importance in
Ophthalmology
Department,
Ain
Shams
refractive surgery and corneal ectasia (3). Various
University. Approval of the ethical committee and
methods are used for CCT measurement. Both
a written informed consent from all the subjects
optically based AS imaging technologies and US
were obtained. This study was conducted between
AS imaging technologies are available. Optical
March 2015, and January 2018).
Anterior Segment imaging technologies Generally,
have excellent resolution rapid acquisition and easy
The subjects were divided into three
alignment (4).The three major optical systems for
groups: Group (A): 20 eyes with healthy non-
Anterior Segment imaging are Scanning slit
operated corneas. Group (B): 20 eyes with KC.
combined with topography (Orbscan), AS-OCT
Group (C): 20 eyes with corneal scar.
and Rotating Scheimpflug camera systems (4).
Inclusion criteria: Group (A): eyes of adults
Conofocal microscopy and specular microscopy
(20-40 years old) with no corneal pathology and no
are also optically based imaging technologies that
history of corneal surgery. Group (B): eyes with KC,
4576
Received:26/5/2018



Accepted:5/6/2018

Full Paper (vol.725 paper# 30)