The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5137-5143
Study of Behavioral Deficits Elicited by Exposure to Lipopolysacaride /Chronic
Mild Stress in Male Wistar Rats
Mai Ahmed Ebeid1, Sawsan Aboul-Fotouh1,2, Ahmed Mohyeldin Abdel-tawab1,2,
Omnyah Aly El-Kharashi1, Hadwa Ali Abd Al-khalek3
1Department of Pharmacology, 2Clinical Pharmacology Unit, 3Department of Histology
Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding Author: Mai Ahmed Ebeid, E-mail: Mai_ebeid@med.asu.edu.eg, Tel: +20 12 00520090
Background: depression may be considered "the disease of the modern era". With a high prevalence
worldwide causing significant morbidity and mortality and constituting a heavy burden on social and economic
welfare. Despite decades-long research the exact pathogenesis of depression is still not fully understood.
Aims: to investigate the behvioral deficits elicited by exposure to the combined model of lipopolysaccharide
(LPS) then chronic mild stress (CMS) in male Wistar rats and to investigate the putative role of inflammatory
cytokine production induced lipopolysaccharide exposure together with chronic stress in the pathogenesis of
depressive like behaviour. Materials and Methods: Sixty five Male Wistar rats were divided into two groups;
Control group (n=29): naïve rats left undisturbed, not exposed to stress and LPS/CMS exposed group (n=27).
Results: exposure to LPS/CMS model induced a depressive-like behavior manifested by a decline in body
weight gain, alongside an increase in immobility time in FST and a decrease in time of active interaction in
SIT. Conclusion: this work highlights the depressive like behaviour induced by exposure to the combined
model of lipopolysaccharide and chronic mild stress. This work also underscores the putative role of
lipopolysaccharide exposure in modulating the stress-induced neuroinflammation which is thought to be
crucial, not only for the pathogenesis of depression, but also for a wide array of neurological diseases.
Key words: depression; chronic mild stress; lipopolysaccharide; forced swimming test; open field test; social
disturbances, bear a strong similarity with those of
Depression is a common mental disorder
that presents with depressed mood, loss of interest
Systematic validation of the endotoxin- or
or pleasure, feelings of guilt and poor
cytokine-induced anhedonia as an animal model of
concentration. According to WHO it is the 4th
depression is not consistent. The striking
leading contributor to the global burden of disease
similarities between symptoms of MDD in humans
in 2000. By the year 2020, depression is projected
and the behavioral and physiological alterations
to reach 2nd place calculated for all ages, both
induced by endotoxin or cytokine exposure in
sexes. This makes depression a major concern to
rodents offer a convincing `face validity' for this
the personal and economic welfare (1). However,
model (6). So that, we proposed in the present work
despite extensive biological research, the
that combined model of LPS then CMS could be a
pathophysiology of depression is still elusive and
plausible model of depression that reflect some
treatments that target the causal factors of
depressive disorders in human.
depression are not available (2).
Over the last two decades, there has been
MATERIALS AND METHODS
growing evidence that inflammatory processes and
neural-immune interactions are involved in the
Sixty five Male Wistar rats weighed from
pathogenesis of major depression and may underlie
200-300 g were purchased from the National
some of serotonergic and adrenocortical correlates.
research center, El-Giza, Egypt. Rats were allowed
This hypothesis was termed the monocyte-T-
at least 1 week to acclimatize to the lab conditions.
lymphocyte or cytokine hypothesis of depression(3).
Rats' chow was purchased from Meladco for
It is well-known that LPS (either peripheral
Animal Food, El-Obour, Egypt. Pellets and tap
or central), brain neuroinflammation and the
water were provided ad libitum unless otherwise
recommended by the study protocol. The
cytokines, such as IL-1, IL-6 and TNF-, may
temperature was maintained at 24°C. A 12/12 h
induce specific symptoms, labeled as the sickness
light/dark cycle was maintained with lights on at 5
behavior syndrome (4). Symptoms of sickness
am. Animals were housed, each in one cage in the
behavior, such as anorexia, reduction of locomotor
above conditions, unless otherwise recommended
activity and exploration, anhedonia and cognitive
by the study protocol. All procedures were done
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5144-5152
Adjunctive Intravitreal Bevacizumab with Vitrectomy for Diabetic Vitreous
Sayed A. Mahfouz, Mahmoud M. Khalil, Mohammed A. Elbahr
Department of ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Background: Postoperative vitreous hemorrhage (VH) following pars plana vitrectomy (PPV) for
proliferative diabetic retinopathy (PDR) is a common event, with a reported incidence of 29% to 75%.This
complication delays visual rehabilitation, interferes with fundus examination, and may necessitate additional
surgical procedures. Vascular endothelial growth factor (VEGF) is an angiogenic mitogen, and the
involvement of VEGF in PDR has been suggested by studies that have demonstrated that VEGF
concentrations were markedly elevated in both vitreous and aqueous fluids of patients with active PDR
compared with samples from patients without diabetes, with NPDR, or with quiescent PDR. Bevacizumab
(Avastin®, Genentech, Inc., South San Francisco, CA) is a full-length recombinant humanized monoclonal
antibody that binds to all isoforms of VEGF.
Aim of the Work: to evaluate the safety and efficacy of intravitreal bevacizumab (IVB) at the end of
vitrectomy operation for prevention of postoperative rebleeding in patients with diabetic vitreous hemorrhage.
Patients and Methods: The study included 20 eyes of 20 patients undergoing PPV for severe non-clearing
vitreous hemorrhage for more than 1 month. Eligible eyes were randomly assigned to one of two groups:
Group A (10 eyes) did not receive any intravitreal injection and Group B (10 eyes) received 1.25 mg IVB
injection at the end of surgery. All patients were subjected to complete history taking and full ophthalmic
examination including best-corrected visual acuity, anterior segment examination, fundus examination and B-
scan ultrasonography was performed. All patients underwent three-port pars plana vitrectomy using 23-gauge
instrumentation under local anesthesia. At the end of surgery, fluid-air exchange was performed and the
intraocular air is left as tamponade in selected cases. The follow up period occurred over 1 week, 1 month and
3 months. The main outcome measures were occurrence of vitreous hemorrhage and BCVA.
Results: At 1 month after surgery, the incidence of early postoperative VH was 30% and 20% in Group A and
B, respectively (p = 0.641). Mild vitreous hemorrhage (grade 1) was the major component of early VH at 1
month (20% of 30% and 10% of 20%, in Group A and B, respectively). Analysis of changes in the mean
BCVA at 1 month after surgery showed significant improvement from the preoperative BCVA in all study
groups, the mean differences between pre-BCVA (Log MAR) and post BCVA (Log MAR) among the studied
groups was 0.865 ± 0.351 with statistically significant difference between the two groups (p = 0.000).the mean
differences between pre-BCVA (Log MAR) and post BCVA (Log MAR) among the studied groups was 0.865
± 0.351 with statistically significant difference between the two groups (p = 0.000). At 3 months after surgery,
the incidence of late postoperative VH was 20.0% and 0.00% in Group A and B, respectively, with no
significant difference between the two groups(P=0. 237). Again, analysis of changes in the mean BCVA at 3
months after surgery showed significant improvement to 1.080 ± 0.2098 and 0.870 ± 0.17767 in Group A and
B, respectively, with statistically significant difference between the two groups (p >0.027).
Conclusion: The incidence of late postoperative vitreous hemorrhage is lower than that of early postoperative
vitreous hemorrhage and is not affected by intraoperative intravitreal bevacizumab injection and Adjunctive
use of intravitreal bevacizumab with pars plana vitrectomy for complications of PDR is safe and well-tolerated
with no serious ocular or systemic adverse events.
Keywords: Diabetic Vitreous Hemorrhage, Intravitreal Bevacizumab, pars plana vitrectomy.
Postoperative vitreous hemorrhage (VH)
Diabetic retinopathy (DR) is a leading
following pars plana vitrectomy (PPV) for
cause of blindness among persons aged 20-64 years
proliferative diabetic retinopathy (PDR) is a common
in the United States (US) and is the most common
event, with a reported incidence of 29% to 75% (3).
complication of diabetes, after a duration of 10
years, about 7% of persons with diabetes have
rehabilitation, interferes with fundus examination,
retinopathy, rising to 90% after 25 years, in persons
and may necessitate additional surgical procedures.
diagnosed with diabetes before the age of 30 years,
Although the source is often not identifiable,
the prevalence of proliferative diabetic retinopathy
etiologies of early postoperative VH include
(PDR) is around 25% after 15 years and 55% after
dispersion of residual blood from the peripheral
20 years (1). In 2002, WHO reported that DR
vitreous skirt or retinal surface into the vitreous
caused 4.8% of blindness globally (2).
cavity, remnants of fibrovascular tissues, and
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5153-5160
Role of Interventional Radiology in the Management of Postoperative Biliary
1Hana Hamdy Nasif, 1Mennatallah Hatem Shalaby, 2Mohamed Hosni Kamel Abdelmaksoud, 1Ahmed
Salama Hussein Mohamed Elsakka
1Departemnt of Radiology, Faculty of Medicine, Ain Shams University
2 Department of Interventional Radiology, Theodore Bilharz research institute, Visiting Scholar, Interventional Radiology,
Stanford University, CA, USA
Corresponding author: Ahmed S.H.M. Elsakka, Mobile: 01098451004; Email: email@example.com
Background: Biliary postoperative complications include biliary stenoses, biliary leaks, fistulas and collection
or abscess formation. These complications usually occur due to injury after laparoscopic cholecystectomy,
gastric or hepatic resection, bilio-enteric anastomosis and after liver transplantation. In most of the cases a new
surgical intervention is not possible. Endoscopic intervention is usually the optimal initial management of
these complications; however, in patients with altered enteric passage, tight low biliary stricture, high up
obstruction or leakage endoscopic approach becomes impossible. Therefore, the percutaneous trans-hepatic
approach is of extreme importance in the diagnosis and treatment of the problem especially in complex cases
Objective: This study aimed to highlight the spectrum of percutaneous cholangiographic findings and methods
of treatment of postoperative benign biliary stenoses, biliary leaks and to detect its significance in management
of these problems.
Patients and Methods: This study was conducted in Theodor bilharz research institute (TBRI), Egypt from
February 2013 to June 2018. 17 patients with benign postoperative biliary complications (stricture and leak)
were treated with a percutaneous transhepatic procedure. Only adult patients (age >18 years) were included in
Results: All patients had cholestasis and/or bile leak according to clinical and biologic findings (i.e., jaundice
or an episode of cholangitis). Biliary obstruction and/or leak was confirmed by abdominal ultrasonography
(US), multidetector computed tomography, and/or magnetic resonance (MR) cholangiography when US results
were not conclusive and confirmation of the site & extension of the stricture and/or leak was needed. The
results of the present study demonstrated that treatment of post-operative biliary complications (stricture
and/or leak) by percutaneous transhepatic procedures was an effective option with acceptable rate of
Conclusion: We concluded that the percutaneous treatment of post- operative biliary complications is an
effective alternative to surgery. This method should certainly be preferred when the local conditions were not
favorable to a surgical repair, failure of endoscopic approach or when a recurrence was observed after an
unsuccessful previous repair. Its advantages compared with surgery were its minimally invasive nature,
reduced risk of complications, and the fact that all options remain open in case of failure.
Keywords: Ultrasonography - Magnetic resonance - Percutaneous transhepatic biliary drainage
availability of experienced hepatobiliary surgeons.
Bile duct injuries are an infrequent but
Radiologists play a key role in diagnosis and
potentially devastating complication of biliary tract
treatment. Imaging is vital for initial diagnosis,
surgery, with cholecystectomy accounting for the
assessment of the extent of injury, and
largest proportion of such injuries. The annual
preprocedural planning. Depending on the type of
incidence of bile duct injuries increased from
injury, appropriate management methods may
approximately 0.2% in the era of open
include endoscopic, percutaneous, and surgical
cholecystectomy to approximately 0.5% after
laparoscopic cholecystectomy became widely
Interventional radiology (IR) has an
available. Biliary injuries are associated with high
established role in the diagnosis and management
morbidity and mortality, impaired quality of life,
and substantial financial burdens to patients and
stenoses and/or biliary leaks and fistulas may be
Optimal management of biliary injuries is
effectively treated with dilatation of the narrowed
achieved with a multidisciplinary approach.
anastomotic tract or bile diversion away from the
Successful management depends on the type of
site of defect in the bile wall. Drain collection and
injury, timing of injury recognition, presence of
tract embolization are the other options for bile
complications, condition of the patient, and
leak percutaneous treatment. A large variety of
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5161-5165
Evaluation of Calcaneal Fractures by Multi Detector CT and Its Significant
Effect on the Surgical Management Planning
Alia Abd Allah El Fiky, Remon Zaher Elia, Amir Louis Louka, Doaa Sobhy Aneis
Department of radiodiagnosis, Faculty of Medicine, Ain Shams University
Background: Familiarity with the normal calcaneal anatomy is important for understanding fracture
mechanisms and classification schemes. Clinical presentation at the time of evaluation generally includes (a) a
history of a fall from a height, and (b) certain signs that aid the physician in identifying possible calcaneal
Purpose: To look at the role played by the multi detector computed tomography (MDCT) in assessing
calcaneus fractures and delineate the fracture fragment which help in decision making in the management of
extra and intra articular fractures of the calcaneum and pre-operative planning.
Patients and Methods: This study will be conducted on patients with calcaneal fractures suspected clinically
or by x ray diagnosis. The patient will be referred from orthopaedic department at Ain Shams University
Hospitals; the patient will be investigated using MDCT.
Results: This study included 44 feet of 41 patients (three bilateral); 35 males and 6 females, representing
85.4% and 14.6% of all patients respectively, their mean age was 34.22 years, we observed that calcaneal
fractures commonly occur in male than female.
Conclusion: Multi detector CT is the best method of assessing calcaneus fracture in order to decide
management. It delineates the fracture fragments and help in making the pre-operative planning of the fracture.
Keywords: Computed tomography, calcaneal fracture, Sanders classification, musculoskeletal
Familiarity with calcaneal anatomy and
The calcaneus is the largest and most
fracture patterns is essential for radiologists to
commonly fractured of the tarsal bones.
guide the treating physicians (2).
Calcaneal fractures represent only about 2% of
PATIENTS AND METHODS
all fractures but 60% of fractures involving the
tarsal bones (1).
This study was conducted on patients
with calcaneal fractures suspected clinically or
Familiarity with the normal calcaneal
anatomy is important for understanding fracture
by x ray diagnosis. The patients were referred
mechanisms and classification schemes. Clinical
from orthopaedic department at Ain Shams
presentation at the time of evaluation generally
University Hospitals; the patients were
includes (a) a history of a fall from a height, and
investigated using MDCT.
(b) certain signs that aid the physician in
identifying possible calcaneal fractures (2).
Ain Shams University Hospitals. The
Modern calcaneal fracture classification
study was approved by the Ethics Board of
systems rely heavily on computed tomography
Ain Shams University and an informed
(CT) because of its three-dimensional approach,
written consent was taken from each
rather than on two-dimensional conventional
radiography as was used in the past. Use of
participant in the study.
multidetector CT has allowed the development of
Sample size: 41 patients
classification systems that correlate with
Equipment used: MDCT, 80 slice
The Sanders classification system is the
Inclusion criteria: Age group: any age.
most commonly used system for describing intra
Both sexes are included. Trauma patients
articular fractures of the calcaneus, which
account for the majority of calcaneal fractures.
suspected to have calcaneal fracture by history
Extra articular fractures are classified according
and clinical examination or by x ray examination.
to a tripartite anatomic division of the calcaneal
Exclusion criteria: Previous calcaneal
surface. Treatment can be either surgical or
surgery that might have altered the normal
conservative depending on the radiologic
anatomy, pregnant women.
classification of the fracture (2).
All patients will be clinically assessed
by: Clinical history. Physical examination.
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5166-5172
Comparison between volume-controlled and pressure-controlled ventilation in
COPD patients undergoing laparoscopic cholecystectomy
Mohamed A. Zaghloul , Samir A. El-Sebaie , Azza A. Abd Al-Alim, Abdel Rahman M. El-Sotouhy
Anesthesiology, Intensive Care and Pain Management Department, Faculty of Medicine, Ain Shams University
Background: Chronic obstructive pulmonary disease (COPD) is a well-known independent risk factor for the
development of postoperative pulmonary complications. Managing ventilation and oxygenation during
laparoscopic cholecystectomy (with creation of pneumoperitoneum) in these patients presents many
Aim of this study: was to compare between volume-controlled and pressure-controlled ventilation in COPD
patients undergoing laparoscopic cholecystectomy.
Methods: A case control study was conducted on 60 participants aged between 18 and 60 years, diagnosed
with COPD and scheduled for laparoscopic cholecystectomy. To start with, all patients received volume-
controlled ventilation (VCV). Fifteen minutes after creation of pneumoperitoneum, they were randomized to
receive either VCV (Group A) or pressure-controlled ventilation; PCV (Group B). Hemodynamics, ventilatory
parameters, arterial blood gas analyses were noted. All data were analyzed statistically.
Results: There was no significant difference between study groups as regards hemodynamic variables. Peak
airway pressure was significantly lower in PCV group compared with VCV group. Mean airway pressure was
significantly higher in PCV group compared with VCV group. As regards arterial blood gas analyses, there
was no significant difference between study groups as regards PaO2 and SpO2. Patients in PCV group had
higher PaCO2 (yet not clinically significant) at 35 min, compared with patients in VCV group.
Conclusion: PCV and VCV were generally effective in maintaining adequate ventilation, oxygenation and
hemodynamic stability. Peak airway pressure was significantly lower in PCV group compared with VCV
group, thus decreasing the risk of barotrauma. PCV may be a better choice than VCV in COPD patients
undergoing laparoscopic cholecystectomy.
Key words: Laparoscopic cholecystectomy, chronic obstructive pulmonary disease, pressure-controlled
ventilation, volume-controlled ventilation.
the whole concept of safe ranges of pressure and
Chronic obstructive pulmonary disease
volume in mechanical ventilation 5. Ventilatory
(COPD) is a well-known independent risk factor
parameters must be adjusted to overcome the
for the development of postoperative pulmonary
respiratory consequences of pneumoperitoneum
and cardiac complications after thoracic or non-
such as elevated peak and plateau airway pressure
thoracic surgery 1.
and decreased dynamic compliance of the
respiratory system 6.
considered to be the gold standard for laparoscopic
Several ventilatory strategies have been
surgical procedures 2. During laparoscopy, the
proposed to prevent intraoperative atelectasis and
peritoneal space is insufflated with gas and this
improve arterial oxygenation in laparoscopic
pneumoperitoneum may result in intraoperative
surgeries but they remain controversial. Pressure-
atelectasis, which impairs normal gas exchange 3.
controlled ventilation (PCV) can be used in the
In patients with concomitant pulmonary diseases,
management of patients with elevated peak airway
creation of pneumoperitoneum and patient's
pressures, which occurs with pneumoperitoneum 7.
position during surgery exert additional negative
During PCV, pressure limits and uniform
effects on intraoperative pulmonary function,
distribution of forces within the lung reduce the risk
which makes a higher challenge for the
of volutrauma and barotrauma. Characteristics of
anesthesiologist than for the surgeon 2.
PCV tend to compensate for any potential reduction
The use of volume-controlled ventilation
in ventilation caused by pressure limitation 5 .
(VCV) is common, as this has been the only
Moreover, PCV better maintains stability regarding
available mode on ventilators for a long time. This
intraoperative ventilatory parameters in patients with
mode ensures satisfactory minute ventilation, but
can lead to higher pressure levels 4.
laparoscopic cholecystectomy 2.
Developments in our understanding of
pressure-volume curves and the demonstration of
microscopic shear stress lung injury have changed
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5173-5177
Prevalence and Determinant Factors of Osteoarthritis of the Knee Joint among
Elderly in Arar, KSA
Khalid Waleed AlKuwaity1, Tasneem Noor Mohammad2, Malik Azhar Hussain3,
Annas Jamal Alkhanani4, Abdulla Mohamed Bakr Ali5
1College of Medicine, King Faisal University, Al Ahsa, 2Microbiology department, Faculty of Applied Medical sciences,
Northern Border University, Arar, 3Surgery department, College of Medicine, Northern Border University, Arar, Saudi Arabia,
4College of Medicine, 6 October University, Cairo, 5Faculty of Medicine, Sohag University, Egypt.
Background: Osteoarthritis of the knee, the disease of knee joint dysfunction and pain caused by joint
degeneration, it is the commonest joint disease. In most cases of joint degeneration there is no clear
identifiable cause, but increasing age, excessive joint loading, and joint abnormalities and trauma increase the
risk of OA. It has significant effects on human health and quality of life (QoL). Objective: This study was
carried out aimed to determine the prevalence and determinant factors of osteoarthritis of the knee among
elderly population in Arar, KSA. Methods: The present cross sectional community based study was conducted
in Arar city, the capital of Northern Borders Governorate on 238 elderly people of age 60 years and more. Data
was collected through personal interviews with the sampled population and filling a predesigned questionnaire.
It included questions regarding the already previously diagnosed osteoarthritis of the knee joint and its
determinants. Results: the mean age (± SD) was 70.4 (±9.3) years, male to female ratio was 48.3 to 51.7. The
overall prevalence rate of osteoarthritis of the knee joint was 24.5%.Osteoarthritis was almost equal in females
and males (26.8% and 26.1%, respectively), it was insignificantly associated with increasing age, female sex,
hypertension and diabetes (P>0.05), while significantly associated with the BMI. Conclusion: Osteoarthritis of
the knee joint is common among elderly population in Arar, KSA. It was almost equal in females and males.
Keywords: Osteoarthritis, knee joint, elderly, Arar, KSA, determinants, prevalence.
United Kingdom (UK) 20% to 30% of elders over
Musculoskeletal diseases are major public
60 years have symptomatic osteoarthritis 6.
health problems, they cause more functional
In the Middle East, more than one million
limitations in the adult and geriatric population in
people suffer from OA in Iraq, Yemen, Saudi
most welfare states than any other group of
Arabia, and Syria 7.
disorders. They are a major cause of years lived
Approximately 85% of individuals over the
with disability in all continents and economies, but
age of 75 years of age experience some symptoms
figures for the prevalence of most musculoskeletal
of osteoarthritis. 40% of individuals with the
disease are scarce 1.
disorder experience significant difficulties with
Osteoarthritis (OA) is the most common
daily activities to the point of interfering with
arthritic condition worldwide. It has considerable
work-related or social roles 8.
social and economic impact with an estimated annual
In Al-Modeer et al. 9, arthritis ranked as
cost in medical care and lost work running into
the fourth (29.5%) most prevalent diseases among
billions of dollars 2. It is characterized by altered joint
elderly females. This might be due to the post-
anatomy, especially the loss of articular cartilage.
menopausal osteoporotic changes among females.
Pathologically OA may be defined as a condition of
A study by Moharana et al. 10 found that, 37.0%
synovial joints characterized by focal loss of articular
of females were having osteoarthritis. The Vishnoi
cartilage and simultaneous proliferation of new bone
et al. 11, found that, the prevalence of osteoarthritis
(osteophytes) with the remodeling of joint contour 3.
was 12.6%, more in females than males (13.71 %
The precise mechanism of cartilage
vs. 11.93 %). Ubaidula et al. 12 reported that, the
degradation in osteoarthritis is still unclear, but a
prevalence of osteoarthritis was 28.0 %. 32.6% in
complex interplay of genetic, environmental,
females and 24.2% in males.
metabolic and biochemical factors is proposed 4.
In Arar city, Northern Saudi Arabia, up to
The prevalence varies in different regions
our knowledge, no previous community based
of the world with prevalence rates ranging from
studies described the pattern of osteoarthritis of the
3.8-70% depending on the methodology of studies,
knee joint was available.
whether clinical, radiographic, patient self-
This study was carried out aimed to
reporting or physician diagnosis 5. As the incidence
determine the prevalence and determinant factors
and prevalence of osteoarthritis rise with increasing
of osteoarthritis of the knee among elderly
age, extended life expectancy will result in a
population in Arar, KSA
greater number of people with the condition. In the
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5178-5182
Knowledge, Attitude and Practice of the Parents Regarding Child Vaccinations
in Arar, Northern Saudi Arabia
Ashwaq Arar S Alruwaili, Nagah Mohamed Abo El-fetoh2, Thmer Arar S Alruwaili, Waad Alazri S
Alanazi, Hala Hamdan R Alhazmi, Noor Awad B Alanazi,Hibah Abtan B Alshammari, Arwa Ahmed A
Alshammari, Ahlam Hussein Alrwaili
Faculty of Medicine, Northern Border University, Arar, KSA, 2. Department of Community Medicine, Faculty of Medicine, Sohag
University, Sohag, Egypt
Background: Parental decisions regarding vaccination are very vital for increasing the vaccination rate and
parent compliance to the immunization schedule. Worldwide studies show that besides other factors, parental
knowledge and beliefs have major influence on starting and continuing of child vaccination. Objective: The
study aim to assess knowledge, attitude and practice of the parents regarding child vaccinations in Arar,
Northern Saudi Arabia. Methods: A cross-sectional community based study carried out during the period from
1st January to 30th July 2018. A systematic random sampling technique was used; 367 participants was
included. Data collected using a pre-designed online questionnaire distributed among parents of children and
adolescents to be self-administered. Results: the majority (40.1%) of children aged less than 6 years old,
58.9% were males, fathers' education was university or more in 47.7% of participants and mothers' education
was secondary school 75.5%. Most (88.3%) of parents were sure that the vaccinations are important for their
children, 68.4% think vaccination reduces the probability of death or illness of a child, 85.6% think that
vaccinations reduces the number of infectious diseases, 89.6% think that the vaccinations have a role in the
child health, 6.8% were aware that some vaccinations are accompanied with side effects such as fever and
83.1% were aware that even healthy child needs vaccination. 70.1% of parents gave their child all mandatory
vaccines, 77.9% follow the child's compulsory immunization, 76.6% of parents feel secure after vaccination of
their children. Conclusion: knowledge and acceptance of childhood vaccinations, perceptions of vaccine-
related health benefits is good among parents in Arar, Northern Saudi Arabia.
Keywords: children; cross sectional; immunization; parents; Arar, Northern Saudi Arabia; vaccine
children, their knowledge and practices regarding
Immunization is the most cost-effective
immunization in general have a great impact on the
and the highest impact health intervention which
immunization status of their children [6, 7].
reduces hospitalization, treatment expenditure, and
To improve parents' awareness, good
mortality . There are many barriers against
knowledge regarding vaccination is required.
immunization, including misinformation about
Therefore, physicians, pharmacists, nurses, and
vaccines, adverse effects of vaccines, vaccine-
others health care providers should provide parents
preventable diseases, and disease development
with correct information about the risks and
after the administration of vaccines . Although in
benefits of vaccines . The most important factor
the past few decades; developed countries have
affecting parental practice is communication
seen sufficient improvement in vaccination
between parents and the sources of information or
coverage, low rates of complete vaccination still
pose a problem in the developing countries.
communication will improve parents' perceptions
Surveys have shown that almost one third of the
of the benefits and risks of vaccines [9, 10].
deaths among the children under the age of five can
The aim of this study was to assess
be prevented by vaccine .
knowledge, attitude and practice of the parents
Parents' decisions regarding immunization
regarding child vaccinations.
are very important for increasing the immunization
rate and compliance and for decreasing any
possible immunization errors. Parents' knowledge
A cross-sectional community based study
and practices regarding immunization are the major
conducted in Arar, Northern Saudi Arabia. The
factors that contribute to their vaccination decisions
study included 367 participants. The study period
. Studies have shown that improving parents'
was from 1st January to 30th July 2018. A
systematic random sampling technique was used;
immunization status and affects the success of
we included parents of every 10th family. Data
immunization programs . This is because parents
collection: using pre-designed online questionnaire
are the primary health decision-makers for their
distributed among parents of children and
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5183-5188
Swabbing of Subcutaneous Tissues with Betadine for Prevention of Surgical
Site Infection after Caesarian Section
Sherif Abd AlKhalek Akl, Sherif Fathi ElMekkawi, Ahmed M. El-Kotb, Adel Sayed Okily
Obstetrics & Gynecology Department, Faculty of Medicine, Ain Shams University
Background: The progressive increase in the incidence of caesarean birth has been a notable feature of
contemporary obstetric practice and caesarean delivery is now the most frequent major surgical procedure
performed in obstetrics and gynecology. In Egypt the rate of cesarean delivery is 51, 8 % of all deliveries.
Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return
to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics,
postoperative infectious morbidity still complicates cesarean deliveries. Aim of the Work: To assess the
efficacy of subcutaneous swabbing of cesarean section wounds with povidone iodine to prevent postoperative
wound infection. Patients and Methods: The study population was randomized into 2 groups: Povidone-
Iodine Group: Included 275 women who underwent elective caesarian section with subcutaneous tissue
irrigation with Povidone iodine 1% solution and control Group: Included 275 women who underwent elective
caesarian section without subcutaneous tissue irrigation. Results: Incidence of SSI didn't differ significantly
between the Povidone-Iodine group and the Control group (6.11% vs 8.54%, p = 0.37). No significant
differences were found between both groups regarding the severity of SSI based on required treatment or
incidence of postoperative pyrexia. Conclusion: There was no benefit of subcutaneous tissue swabbing with
povidone iodine in decreasing wound infection following cesarean section.
Keywords: Subcutaneous Tissues, Betadine, Surgical Site Infection, Caesarian Section
If prophylactic antimicrobials are given,
Cesarean delivery defines the birth via the
the incidence of abdominal wound infection
abdominal route (1). The World Health Organization
following cesarean delivery ranges from 2 to 10
(WHO) recommends that the rate of caesarean
percent depending on risk factors (7).
sections should not exceed 15% in any country.
Numerous good quality trials have proved
However, in recent years the rate has risen to a record
that a single dose of an antimicrobial agent given at
level of 46% in china and to levels of 25% and above
the time of cesarean delivery significantly
in many Asian countries, Latin America and the USA
decreases infection morbidity (8).
(2). From 1970 to 2010, the cesarean delivery rate in
Wound irrigation with povidone-iodine, an
the United States rose from 4.5 percent of all
antiseptic solution, may be useful for reducing
deliveries to 32.8 percent (3). The progressive increase
infection, but it is of uncertain efficacy and risk.
in the incidence of caesarean birth has been a notable
Povidone-iodine irrigation is a simple and
feature of contemporary obstetric practice and
inexpensive solution with the potential to prevent
caesarean delivery is now the most frequent major
surgical site infection (9).
surgical procedure performed in obstetrics and
gynecology. In Egypt the rate of cesarean delivery is
Multiple studies investigated the use of
51, 8 % of all deliveries (4).
povidone-iodine irrigation in multiple types of
surgery. The infection rate was 2.9% in the
Cesarean delivery is one of the most
treatment group and 15.1% in the control group (p<
common surgical procedures performed by
0.001). The treatment group did not experience any
obstetricians. Infectious morbidity after cesarean
interference with wound healing or adverse
delivery can have a tremendous impact on the
postpartum woman's return to normal function and
her ability to care for her baby. Despite the
Povidone-iodine (Betadine) is an antiseptic
widespread use of prophylactic antibiotics,
solution consisting of polyvinylpyrrolidone with
postoperative infectious morbidity still complicates
water, iodide and 1% available iodine; it has
cesarean deliveries (5).
bactericidal ability against a large array of
pathogens (10). Although a vast amount of literature
Wound infection is an infrequent but
exists regarding its use as a topical antibacterial
serious complication of surgery. Postoperative
agent in surgery, its use as a prophylactic irrigation
infection often requires repeat surgery and
solution against surgical site infection has been
prolonged hospitalization, and it may compromise
examined to a lesser degree (9).
ultimate surgical outcomes (6).
AIM OF THE WORK
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5189-5194
Revisional Laparoscopic Mini-Gastric Bypass for Weight Loss Failure after
Hossam El-Din Hassan Hussein, Ahmed Elnabil Mortada, Haitham Mostafa Elmaleh,
Ahmed Adel Abbas, Amir Nagui Abdalla Iskandar
General Surgery Department, Faculty of Medicine, Ain Shams University
Corresponding Author: Amir Nagui Abdalla Iskandar, E-mail: firstname.lastname@example.org
Background: bariatric surgery has proven its effectiveness in achieving and maintaining weight loss and
improving obesity-related co-morbidities, quality of life, and survival. As demand for bariatric surgery
increases, so too will the need for revisional surgeries. The revision rate following primary bariatric surgery is
reported to be between 10% and 25%. To facilitate weight loss surgically, many different types of bariatric
procedures have been developed and established.
Objectives: to assess the effectiveness of revisional laparoscopic mini-gastric bypass for management of
inadequate weight loss after different restrictive procedures.
Patients and Methods: the present study is a prospective study that was conducted at Ain Shams University
Hospitals in Egypt, between July 2016 and July 2018. It included Forty (40) patients who underwent a
restrictive bariatric procedure 2 years ago or more with inadequate weight loss. Operative time, intraoperative
complications, rate of conversion. Postoperative pain, consumption of analgesics, length of hospital stay, start
of oral feeding.
Results: the patients series involved 40 patients, 12 of which were male patients (40%) whereas, 24 were
female patients (60%). The patients' age at the time of revisional surgery ranged from 23 to 57 years old with a
mean ± SD of 38.50 ± 8.42 years. The preoperative BMI ranged from 31.25 to 52.62 kg/m2 with a mean ± SD
of 41.59 ± 4.99 kg/m2 with an excess weight ranging from 19.79 to 86 kg with a mean ± SD of 46.51 ± 14.27
kg. The mean time interval between the initial restrictive surgery and the revisional LMGB was 41.63 ± 16.92
months. 18 patients (45%) had a VBG as their primary restrictive surgery, 10 patients (25%) had LAGB, 8
patients (20%) had LSG and 4 patients (10%) had LGCP. 28 patients (70%) underwent LMGB for IWL
compared to 12 patients (30%) for WR.
Conclusion: the revisional Laparoscopic Mini-Gastric Bypass (r-LMGB) appears to be a feasible and safe
option after failed restrictive bariatric surgery. However, additional studies with larger population and longer
follow up period are required to evaluate longer-term success.
Keywords: Revisional Laparoscopic Mini-Gastric, Weight Loss Failure, Restrictive Procedures
procedures are the Vertical Banded Gastroplasty
(VBG) which is no longer performed nowadays,
effectiveness in achieving and maintaining weight
the Laparoscopic Adjustable Gastric Banding
loss and improving obesity-related co-morbidities,
(LAGB), the Laparoscopic Greater Curvature
quality of life, and survival. As demand for
Gastric Plication (LGCP) and the Laparoscopic
bariatric surgery increases, so too will the need for
Sleeve Gastrectomy (LSG) (3). The Vertical Banded
revisional surgeries. The revision rate following
primary bariatric surgery is reported to be between
partitioning the stomach at the angle of His through
10% and 25% (1). To facilitate weight loss
a window created near to the lesser curvature at the
surgically, many different types of bariatric
base of the pouch. A silastic ring was then placed
procedures have been developed and established.
around this window to secure the narrow,
They fall into three main categories: A) Restrictive
tabularized stomach reservoir. However, another
procedures that lead to fixed or adjustable physical
technique has been adapted by some surgeons by
reduction in the size of the upper gastrointestinal
using polypropylene mesh instead of the ring
tract. B) Malabsorptive procedures that bypass a
which increased the incidence of dense adhesions
proportion of the intestine with less physical
and subsequently adding to the technical challenge
restriction of food intake. C) A combination of the
of revisional surgery. The VBG eventually was
restrictive and malabsorptive, which combines
abandoned in favor of other operations such as the
restriction of the upper food pathway with
Adjustable Gastric Banding (4).
intestinal bypass (2).
The Adjustable Gastric Banding is placed
There are four major restrictive surgical
around the upper stomach to create a small
procedures that were used over the last years after
proximal pouch. This produces a moderate
patient selection, assessment, and evaluation. These
restriction in the volume and type of foods the
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5195-5202
Evaluation of GERD Diagnosis, Management, and Outcomes
Mada Bejad G. Almutairi1, Salem Muaedh Alsulaimi2, Rayan Ali I Alghamdi2, Khalid Abdullah
Alrehaili2, Sohaib Aziz Habhab2, Abdulrahman Mohsen Althagafi2, Faisal Ali Alghamdi3, Naif
Abdulaziz Meighrbl3, Waleed Mohammed Alsuhaymi3, Mohammed Saeed Al_Yahya4
1Almaarefa College, 2Umm Al-Qura University, 3University of Jeddah, 4King Khalid University
Background: Gastroesophageal Reflux Disease (GERD) is a condition which develops when the reflux of
gastric content causes troublesome symptoms or complications. GERD is arguably the most common disease
encountered by the gastroenterologist. It is equally likely that the primary care providers will find that
complaints related to reflux disease constitute a large proportion of their practice.(1) GERD condition can
present with different presentations and the response to the intervention significantly differs from patient to
patient. As a result reviewing the new literatures done in this field will help in providing a better outcomes for
Objective: Treating patients with GERD is difficult and needs different approaches. In this paper, we
reviewed the major and the latest studies regarding GERD symptomatology, risk factors, diagnosis and
Method: A comprehensive search was done using biomedical databases; Medline, and PubMed, for studies
concerned with assessment of GERD. Keywords used in our search through the databases were as; "GERD
Pathophysiology", "GERD Classification", and "GERD Management".
Conclusion: GERD is a condition which develops when the reflux of gastric content causes troublesome
symptoms such as heartburn, regurgitation, and sleep disturbance. GERD can be diagnosed by various
measures such as GERD Questionnaire, PH Monitoring, and Upper Endoscopy. Initially GERD can be
managed by simple life modification measures, then physicians can add Protons Pump Inhibitors (PPIs), and
Histamine 2 Receptor Blocker (H2RBs). In case of PPIs and H2RBs failure in reliving GERD symptoms
physicians may go for anti-reflux surgical interventions.
Keywords: GERD, Diagnosis, Management, Outcomes.
"GERD Classification", and "GERD Management".
GERD is defined as heartburn, acid
More relevant articles were recruited from references
regurgitation, or both, at least once a week. These
lists scanning of each included study.
troublesome symptoms are caused by the
movement of gastric contents into the esophagus.
No software was used, the data were
GERD represents a common disorder,
extracted based on specific form that contain
particularly in the Western world (about 10%-20% in
title of the study, name of the author, objective,
Western countries and under 5% in Asia) and its
summary, results, and outcomes. Double revision
prevalence appears to be increasing. The incidence rate,
of each member's outcomes was applied to ensure
reported by two longitudinal studies was 4.5 and
the validity and minimize the errors.
5.4/1000 people per year, respectively. In Saudi Arabia,
Alsuwat et al. 2 found that the prevalence of GERD is
Normal gastric acid has a pH of 1.5 to 3.5
suspected to be around 25% of the population, which
(similar to lemon juice) secreted by the stomach's
means it is slightly higher than Western countries and
parietal cells in response to histamine,
much higher than countries of East Asia.
acetylcholine, and gastrin. All three of these
substances coordinate hydrogen ion generation;
In this review our aims are: 1) Discussing the
however, histamine represents the dominant route
pathogenesis that stands behind GERD development.
and plays an important role in current GERD
2) Discussing the various methods of GERD
diagnosis, and management 3) Providing a paper that
Lower esophageal sphincter (LES) is located
analyzed the recent literatures done in this field.
at the juncture of the stomach and the esophagus.
When LES pressure is lower than intragastric
pressure, LES become lax. Subsequently, acid
We performed comprehensive search using
contents can easily reflux into the esophagus. This
biomedical databases; Medline, and PubMed, for studies
will be leading to the mentioned troublesome
concerned with evaluation of GERD published in
symptoms (esophageal and extra esophageal)
English language. Keywords used in our search through
depending on the severity. Transient LES relaxation
the databases were as; "GERD Pathophysiology",
(TLESR) occurs largely in the postprandial period,
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5203-5209
Bacteriological study of Acne Vulgaris in Cairo Egypt
Taimor Mohammed Khalifa El-Tonsy1, Mamdouh Attia Mohammed2, Yasser Abou El-Ela Hamed1,
Samah Hamdy Tawfik1
Department of 1Dermatology, Venereology and Andrology, 2Clinical Pathology, Faculty of Medicine, Al Azhar University
Corresponding author: Samah Hamdy Tawfik, Mobile: 01224202010; Email: semsemakenzy@ gmail.com
Background: acne vulgaris is chronic inflammatory dermatosis of the pilosebaceous units which is
characterized by open and/or closed comedones (blackheads and whiteheads) and inflammatory lesions
including papules, pustules, or nodules, in some cases, is accompanied by scarring. Acne is multifactorial
disease including increased sebum production, hypercornification of pilosebaceous duct, an abnormality of
microbial flora especially colonization of the duct with propionibacterium acne and the production of
inflammation. P.acne has been implicated in the pathogenesis of acne for more than 100 years.
Objective: the present work was done to determine bacteria involved in acne vulgaris among Egyptian acne
Patients and Methods: this study was conducted on one hundred patients with inflammatory acne vulgaris
recruited from the Dermatology outpatient clinic of Al-Hussien hospital.
Results: in this study, S.epidermidis was higher in normal skin than in acne lesion. But P.acne was higher in
acne lesion than in normal skin with significant statistical difference. There was a significant relation between
type of organisms isolated and severity of acne lesions in both aerobic and anaerobic state. There was a
significant relation between positive acne family history and liability for post acne scar. Even though there was
no significant relation between hermonal therapy and severity of acne lesions. We noticed that the majority of
female patients with POP history had moderate acne lesions. In this study, the high percentage of
S.epidermidis was observed in moderate acne lesion and in normal skin in aeorobic state but high percentage
of P.acne was found in moderate acne lesions in anaerobic state. However, P.acne can not be solely held
responsible for the initiation of inflammation in inflamed acne lesions or for the variation in its severity.
Conclusion: the high percentage of no growth result in this study directs us that the antibiotic treatments are
not the most useful treatment for acne and there are other effective methods for treatment whether topical as
retenoids or ablative as Lasers. Patient with family history of acne lesion especially first relative (mother) we
must keep in mind that they are more susceptible for post acne scar so we should start with the perfect
treatment as early as possible to prevent the post acne sequels.
Keywords: 1,25 dihydroxy vitamin D3, Dihydrotestosterone, Propionibacterium acnes, Pilosebaceous units
variety of cytokines and are implicated in inflammatory
Acne vulgaris is a chronic inflammatory
and immune responses. The pathogenesis of acne
dermatosis of the pilosebaceous units which is
includes hormonal, inflammatory, and immunologic
characterized by open and/or closed comedones
mechanisms. Several major pathophysiologic factors
(blackheads and whiteheads) and inflammatory
(mainly endogenous) influence the development of
lesions including papules, pustules, or nodules, in
acne lesions (2): Hyperplasia of sebaceous glands with
some cases, is accompanied by scarring (1).
increased sebum production (seborrhea) as a reaction
to androgenic hormone stimuli, modification of the
Reports vary, but incidence rates suggest
quality of sebum lipids, regulation of skin
that acne is more frequent and severe during
adolescence (70% to 87% of the adolescent
differentiation of sebaceous follicles with ductal
population), although onset may be delayed until the
hypercornification and formation of plugs of cornified
age of 30 or 40. The frequency of acne in the
adolescent population increases with age and
frequently, but not always, resolves in adulthood (2).
Propionibacterium acnes (p.acne). Rupture of the
The etiology of acne appears to be
obstructed pilosebaceous duct leading to inflammation.
complicated and is not completely understood. The
Acne treatment options are vast and
pilosebaceous unit is the target organ in acne. This
include a number of non-hormonal and hormonal
explains the distribution of acne in regions such as
therapies. When deciding on the acne treatment
face, neck, and the upper parts of the chest and
regimen, one should take into account individual
back, specific areas that have a high density of
patient factors including disease state, predominant
sebaceous glands (2).
lesion type and severity, pre-existing medical
The pilosebaceous unit possesses sebocytes
conditions, desired treatment mode topical vs. oral,
that synthesize and accumulate lipids and express a
and endocrine treatment (3).
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5210-5214
The Utility of Fibrinogen/C-reactive protein Ratio versus D-dimer and Fibrin
Degradation Product in Diagnosis of Overt Disseminated Intravascular
Coagulation in Intensive Care Unit patients
Sherif W. Nashed, Ahmed A. Elshebieny, Mohammed M. Maarouf, Nancy R. Nawar
Department of Anesthesiology, Faculty of Medicine Ain Shams University
Corresponding author: Nancy R. Nawar; Mobile: 01001023246; Email: email@example.com
Background: Coagulopathies in ICU are one of the most common complications in ICU. DIC is one of the
most threatening coagulopathies in ICU.It is accompanied with high mortality rates in ICU.Early diagnosis of
DIC is very important for early intervention for better prognosis.DIC is caused by several pathologies like
sepsis, trauma, obstetric causes and malignancies. Aim of the Work: to compare between the sensitivity
between fibrinogen/CRP ratio and FDP and D-dimer. Patients and Methods: After obtaining approval from
the medical ethical committee at Ain Shams University, this observational prospective study was conducted at
Ain Shams University Intensive Care Units. The study included 70 patients in Demerdash ICU after including
patients with ISTH score 5. 2 samples were collected from each patient. Results: The results were in favor to
the classical parameters of diagnosis of overt DIC in comparison with the new parameter of DIC. It showed
that D-dimer and FDPs together were more sensitive than fibrinogen/CRP ratio. Conclusion: The D-dimer and
FDP tests offered the best test panel in the diagnosis of DIC especially in overt DIC due to their high
Key words: fibrinogen, C-reactive protein, D-dimer, fibrin degradation product, overt disseminated
intravascular coagulation, ICU
Type of Study: Observational Prospective study.
Disseminated intravascular coagulation
Study Period: 3 months.
(DIC) is a serious, life-threatening condition in
which the proteins in the blood involved in blood
clotting become overactive (1).
Inclusion Criteria: Adult patients aging
between 20-70 years in both sexes. General surgery
The subcommittee on DIC of the International
and obstetric patients. American society of
Society on Thrombosis and Haemostasis has suggested
anesthesiologists ASA III and ASA IV.
the following definition for DIC: "An acquired
syndrome characterized by the intravascular activation
Exclusion Criteria: ASA V. Patients
of coagulation with loss of localization arising from
whom were presented with isolated thrombosis. 3)
different causes. It can originate from and cause
Hepatic patients with thrombocytopenia. Patients
damage to the microvasculature, which if sufficiently
below and above the desired age group. Patients
severe, can produce organ dysfunction" (2).
presented with chronic DIC.
DIC is most commonly observed in severe
Sampling Method: An observational
sepsis and septic shock. Indeed, the development
prospective study was found to be the most suitable
and severity of DIC correlate with mortality in
design in order to achieve the study objectives.
severe sepsis (3).
Sample Size: Using PASS program, setting
alpha error at 5% and power at 80%. Result from
The symptoms of DIC are often those of
previous study Kimet al.(5) showed that the sensitivity
the underlying inciting condition. In addition,
of Fibrinogen/CRP ratio for detecting DIC cases was
symptoms of thrombosis, embolism, organ
67% compared to 91% as reported by Yu et al. (6) for
dysfunction, or bleeding may be present(4).
D-dimer and FDPs. Based on this conclusion, , the
AIM OF THE WORK
needed sample was 70 DIC cases.
The aim of this work was to compare
Study Procedures: The International
between the sensitivity of fibrinogen/CRP ratio and
Society for Thrombosis and Haemostasis (ISTH)
FDP and D-dimer.
has adopted a score that assists in the diagnosis and
the identification of patients at risk for the
PATIENTS AND METHODS
development of DIC. The score is based on readily
Study setting:After obtaining approval
available coagulation assays including Prothrombin
from the medical ethical committee at Ain Shams
time PT, Platelets count, fibrinogen and D-
University, this study was conducted at Ain Shams
dimer(7).Patients who fulfilled terms of ISTH score
University Intensive Care Units.
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5215-5220
A Comparison Between Pulled and Pushed Monocanalicular Silicone
Intubation In Management of Congenital Nasolacrimal Duct Obstruction
El-Sayed M Elewah, Abd-Elmoez H Ahmed, Abdel-Mongy El Ali, Anas M Ebrahim
The Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Background: Congenital nasolacrimal duct obstruction (CNLDO) is usually caused by a membranous block at
the valve of Hasner. Symptoms of CNLOD include epiphora, mucous discharge, or mucopurulent discharge.
Many CNLDOs can resolve spontaneously by the first year of life. Children who ultimately have unsuccessful
responses to canalization will undergo invasive procedures for CNLDO, including probing, silicone intubation,
balloon dacryocystoplasty and dacryocystorhinostomy. There are two types of lacrimal intubation,
monocanalicular and bicanalicular. Pushed monocanalicular stent is characterized by the probe guide actually
placed inside the silicone tube, rather than attached at the end as in conventional ``pulled'' intubations stents.
Aim of the work: was to compare the success rate of pulled monocanalicular (MCI) versus pushed
monocanalicular silicone intubation (PMCI) of the nasolacrimal duct for congenital nasolacrimal duct
Patients and methods: In a prospective randomized clinical trial 67 eyes of 67 patients with CNLDO
underwent either pulled monocanalicular silicone intubation (MCI) (=32 eyes) or PMCI ( =35 eyes). Cases
were considered successful if reached grade 0 or 1 in fluorescein dye disappearance test -complete or partial
resolution of symptoms - after two months after tube removal.
Results: This study included only patients with simple obstruction at the level of the Hasner valve and
diagnosed intraoperative during the initial probing thus, the surgical outcome was assessed in 30 eyes of 30
patients in the MCI groups. 15 eyes received MCI in the upper punctum and 15 eyes received MCI in the
lower punctum. The other 30 eyes 30 patients did PMCI with Masterka tube. 15 eyes received PMCI in the
upper punctum and 15 eyes received PMCI in the lower punctum. 33 females (55%) & 27 males (45%) with
age ranged from 12 to 46 months with mean of 26 ± 11 months. Follow-up of the patients was done at 1 week,
1 month, 2 and 3 months post-operative. Tube removal was done 3 months post operatively in both types of
tube. The overall success rate in the MCI intubation groups was 86.7%, whereas in the PMCI intubation
groups was 80%. However, the difference in the success rates between the two groups was statistically
insignificant (P= 0.4884) using Chi-square test.
Conclusion: Results indicate that MCI has higher success rate in CNLDO treatment compared with PMCI in
this small series of patients.
Keywords: lacrimal drainage system; congenital nasolacrimal duct obstruction; silicone intubation.
The etiology of congenital nasolacrimal
surrounding the management-both conservative
duct obstruction (CNLDO) is most commonly a
and surgical- of childhood epiphora. The treatment
membranous obstruction at the valve of Hasner at
of CNLDO includes conservation , topical
the distal end of nasolacrimal duct. General
antibiotics with tear duct massage till age of 10
stenosis of the duct is the second most common
months , and surgical intervention ranging from
cause of duct obstruction (1).
simple probing to more invasive procedures, such
as stent intubation around one year and
dacryocystorhinostomy at age of 4 years (6).
congenital lacrimal obstruction is watering
Nasolacrimal silicone intubation is a treatment for
(epiphora) and mucopurulent discharge observed
CNLDO after failed probing and irrigation (7).
from the first month of life. This usually affects
Intubation was more successful than probing in
only one eye, although both eyes may be affected
patients with Down syndrome (8).
in up to 20% of cases (2).
Many studies have indicated excellent
CNLDO is a common condition in early
results with monocanalicular silicone intubation for
childhood, which is reported to occur in 3-5% of
the initial correction of congenital nasolacrimal
mature children (3).
duct obstruction (9).
Most cases resolve spontaneously or after
Most intubation stents are composed of a
lacrimal sac massage (4). For those children whose
silicone tube attached at each end by stainless steel
obstruction does not spontaneously resolve,
probe guide or flexible Polyethylene-ether-ketone
probing is an initial procedure (5).
(PEEK) thread. Because the probe guide must
reach to the inferior turbinate and then drawn out
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5221-5226
Assessment of Different Methods of Ovulation Induction on Endometrial and Ovarian
Blood Flow by Three Dimension Transvaginal Ultrasound & Doppler Indices
Abd El Moneim Mohamed Zakaria, Abd El Monsef Abd El Hamid Sedek, Ahmed Sayed Saleh Soliman
Obstetrics and Gynecology Department, Faculty of Medicine, Al Azhar University
Corresponding Author: Ahmed Sayed Saleh Soliman, E-mail: firstname.lastname@example.org
Background: the study was performed in a prospective randomized fashion in order to compare the value of
tansvaginal ultrasound, and the value of combined colour Doppler imaging of uterine, ovarian blood flow and
transvaginal folliculometry in assessment of ovulation induction of infertile women.
Objectives: Ovulation rate was taken as the gold standard for assessment of ovulation induction result.
Patients and Methods: Analysis of the results provided the following information: A) Better sensitivity &
specificity of colour Doppler indices in detection of ovulation. B) Better timing of human chorionic
gonadotrophin administration & better ovulation rate when colour Doppler was used in cycle monitoring.
Results: It can be concluded from the results of this study that combined use of transvaginal sonography & colour
Doppler imaging is more reliable in assessment of ovulation & is more useful in monitoring of follicular growth and
vascularity in clomiphene citrate induced cycles than the use of transvaginal ultrasound alone.
Conclusion: combined use of transvaginal sonography & colour Doppler imaging is more reliable in
assessment of ovulation & is more useful in monitoring of follicular growth and vascularity in clomiphene
citrate induced cycles than the use of transvaginal ultrasound alone. The study opens a new field of ongoing
research on the valuable application of colour Doppler studies in the management of gynecologic infertility
due to ovarian cause.
Keywords: Transvaginal Ultrasound, Colour Doppler, Ovulation Induction Clomiphene Citrate
A good blood supply towards the
The standard definition of infertility is
endometrium is usually considered to be an essential
considered as failure to conceive after 12 months of
requirement for normal implantation. Endometrial
unprotected regular intercourse. Statistically, it
microvascular blood flow determined by an
affects almost 10% of the couples, with 40% of the
intrauterine Doppler technique has been shown to be
cases related to female pathology, disorders of
predictive of pregnancy and superior to other
ovulation account for about 30% to 40% of all
conventional parameters predicting endometrial
cases of female infertility. These disorders are
generally among the most easily diagnosed and
It has been proved that 3-D ultrasound is a
most treatable causes of infertility (1).
very highly reproducible technique. With 3-D
Ovulation induction is the most common
ultrasound, a volume of a region of interest can be
method of infertility treatment in which the ovaries
acquired and stored. 3-D ultrasound, allows for a
are stimulated to produce multiple follicles. The
whole assessment of relevant vessels and
most commonly used oral agent for induction of
quantitative assessment of vessel density and
ovulation is Clomiphene Citrate which is a
perfusion within a specified area. A whole
nonsteroidal triphenylethylene derivative that
evaluation is then possible for endometrial and
exhibits both estrogen agonist and antagonist
subendometrial vascularization and also for ovarian
properties, i.e. selective estrogen receptor
stromal vascularity (5).
modulating activity (2).
Colour Doppler mapping and sampling of
FSH is available mixed with LH activity in
flow velocity waveforms proved that the peak
various gonadotropins including more purified
systolic velocity appeared to follow the mean rise
forms of urinary gonadotropins, as well as without
in circulating LH by approximately 12 hours (6).
LH activity recombinant FSH. It is used commonly
Transvaginal ultrasonography with colour
in infertility therapy to stimulate follicular
Doppler imaging and pulsed Doppler spectral
development, notably in IVF therapy, as well as
analysis have been used to measure follicular
with intrauterine insemination (IUI). Gonadotropin
volume and derive indices of blood flow. The end
preparations as HMG (Human Menopausal
points for each follicle include: the volume, peak
Gonadotrophins), FSH and LH prepared from
systolic velocity and pulsatility index. The value
human urine collected from postmenopausal
for peak systolic velocity, before the administration
women that was extracted in 1953 and injected
of human chorionic gonadotropin (HCG), can be
intra-muscularly (IM) or subcutaneously (SC) (3).
used to identify follicles with a high probability of
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5227-5232
Comparative Study between Femoral Arterial Doppler and Echocardiography in
fluid responsiveness assessment in Septic Shock Patients
Hany Mohamed Mohamed EL Zahaby, Ahmed Mohamed El Sayed El Henawy, Ahmed Monier Ahmed
Youssef, Eslam Kandil Abd El Moaty Ghallab
Department of Anesthesiology, ICU and Pain Management- Ain Shams University
Corresponding author: Eslam Kandil Abd El Moaty Ghallab, E-Mail: Es_kg88@yahoo.com, Mobile: 0201007731217
Background: Fluid replacement is considered the cornerstone of resuscitation in critically ill patients
especially in patients with septic shock. However, only about 50% of critically ill hemodynamically unstable
patients are responsive to fluids. Furthermore, both under resuscitation and overzealous fluid administration
adversely affect the outcome. Consequently, the resuscitation of critically ill patients requires an accurate
assessment of the patients' intravascular volume status and their volume responsiveness.
Aim of the Study: The aim of this study is to compare between the femoral arterial doppler and
Echocardiography in fluid responsiveness assessment in septic shock patients.
Methodology: The study was conducted on 30 adult male and female patients admitted to Critical Care
Department in Ain shams University Hospitals with the diagnosis septic shock. All patients in this study have
the Criteria of Septic shock. Echocardiographic examination and femoral Doppler were done for all included
patients. Velocity time integral on left ventricle outflow tract and Velocity time integral on femoral artery were
measured before and after fluid resuscitation, after infusion of 30 ml/kg over 3 hours,
Results: These results show that there were 23 patients were responded clinically to fluid resuscitation from all
total number of 30 patients. From all total number of patients whom clinically responded, 22 patients responded to
fluid resuscitation by transthoracic echocardiography and 23 patients responded by femoral Doppler.
Conclusion: These results showed that femoral Doppler parameters were a reliable predictor to fluid
responsiveness in patients with severe sepsis and septic shock as well as transthoracic echocardiography in
dynamic monitoring of the change in stroke volume after a maneuver that increases or decreases venous return
(preload). However femoral Doppler seems to be easier and rapid tools to be used by junior staff.
Keywords: Femoral Arterial Doppler, Echocardiography, Septic Shock Patients
preload responsive heart may not be recognized
Fluid replacement is considered the
cornerstone of resuscitation in critically ill patients
Dynamic parameters of volume status
especially in patients with septic shock. However,
outperform the static ones in predicting preload
only about 50% of critically ill hemodynamically
responsiveness and should be used to optimize
unstable patients are responsive to fluids.
preload in septic shock patients (4).
Furthermore, both under resuscitation and
overzealous fluid administration adversely affect
AIM OF THE WORK
the outcome. Consequently, the resuscitation of
The aim of this study is to compare
critically ill patients requires an accurate
between the femoral arterial doppler and
assessment of the patients' intravascular volume
status and their volume responsiveness (1).
assessment in septic shock patients.
Traditional methods of determining the
PATIENTS AND METHODS
adequacy of volume resuscitation have relied on
preload measures, there are central venous pressure
This study was conducted in the Intensive
(CVP), pulmonary artery wedge pressure (PAWP),
care unit of Ain Shams University Hospitals at
right ventricular end-diastolic volume index
2017, to compare between femoral arterial Doppler
(RVEDVI), left ventricular end-diastolic area index
and Echocardiography in fluid responsiveness in
(LVEDVAI), and global end-diastolic volume
septic shock patients.
(GEDV) also known as static parameters of volume
After the Medical Ethical Committee in
status. However, none of these is accurate in
Ain Shams University approval and informed
predicting preload responsiveness (2).
consent was taken from thirty patients' relatives
It is important to realize that stroke volume
(1st degree) were included in the study.
(SV) or cardiac output (CO), or its surrogate, for
Inclusion criteria: Age: 18 - 60 years. Sex:
example, pulse pressure (PP) or arterial blood flow
both sexes. Sepsis as life-threatening organ
velocity, is the preferred end-point because a
dysfunction caused by a dysregulated host response
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5233-5240
Surgical Management of Lobar Intracerebral Hemorrhage
Ahmed Khamis Abd El-Hady, Mohamad Mobarak Alsakka, Ahmed Mahmoud El-Sherif, Ashraf Abd
El-Monem Sayed, Abd El-Kafy Sharaf El-Din Ibrahim
Department of 1Neurosurgery, Faculty of Medicine, Al-Azhar University and 2Damanhur Medical National Institute
Corresponding author: Ahmed khamis Abd El-Hady, E-Mail: email@example.com, Mobile: 01006962527
Aim of work: We conducted a case study to evaluate the surgical management of lobar intracerebral
hemorrhage. Patients and Methods: This study included 20 patients who were diagnosed with Lobar ICH
between January 2017 and December 2017, All cases were managed surgically. ICH is a neurological
emergency and medical care should starts rapidly with stabilization of airway, breathing functions, circulation
and other associated pathologies as fits and elevated blood pressure. CT scan was the standard diagnostic tool
in the 1ry management of the cases. A routine preoperative investigation as CBC, PT was done. Cases
admitted to a postoperative ICU for at least 48 hours and a follow up CT scan was done. Results: We observed
all survivors for at least 2 months and asses our outcome using Glasgow Outcome Scale. Conclusion: Care of
such cases and rehabilitation plays an important role to have a good prognosis.
Keywords: Lobar intracerebral haemorrhage, Traumatic, Spontaneous, Results, Discussion
the presence of hemorrhage, CT angiogram is a
Intracerebral hemorrhage (ICH) is a
very sensitive for identifying associated vascular
devastating disease with high rates of mortality and
morbidity. Approximately 10% to 23% of strokes
Repeat imaging study should be considered
are caused by rupture of cerebral blood vessels and
for evaluation of any acute deterioration in the
the overall Intracerebral hemorrhage incidence
neurological examination or for follow-up of any
worldwide is 24.6 per 10000 person-years (1).
underlying lesion or vascular anomaly (6).
Lobar Intracerebral hemorrhage is the
The beneficial effects of surgical
bleeding in the largest part of the brain called the
management of supratentorial ICH remain
cerebrum. It may be traumatic or spontaneous (2).
It is evidenced that vascular malformation,
The surgical trial in Lobar Intracerebral
aneurysms and drug abuse are causative factors for
Hemorrhage (STICH) aims to establish whether a
spontaneous ICH among young adults while
policy of earlier surgical evacuation of the
hypertension (most important and prevalent risk
hematoma in selected patients with spontaneous
factor) (2), tumors, vasculopathy, coagulopathy and
lobar intracerebral hemorrhage will improve
cerebral amyloid angiopathy are causes among
outcome compared to a policy of initial
older adults. Other risk factors include low
cholesterol levels, heavy alcohol intake and
The aim of early surgical Traumatic
cigarette smoking. Among children, leukemia is
Intracerebral Hemorrhage (TICH) treatment is to
found to be a significant cause (3).
prevent secondary brain injury, which is thought to
The acute presentation of ICH can be
be caused by number of mechanisms. Extravasated
difficult to distinguish from ischemic stroke.
blood is believed to be neurotoxic leading to
Symptoms may include headache, nausea, seizures
secondary injury that may be avoided by early
and focal or generalized neurological symptoms.
surgical removal. Larger TICHs may be associated
Finding such as coma, headache, vomiting,
with an ischemic penumbra of brain tissue that
seizures, neck stiffness and raised diastolic blood
could be salvaged and some TICHs expand to the
pressure increase the likelihood of ICH compared
point where they cause mass effect, resulting in
to ischemic stroke, but only neuroimaging can
secondary brain injury (8).
provide a definitive diagnosis (3).
AIM OF THE WORK
In addition to a prompt clinical history and
neurological examination, rapid neuroimaging with
To evaluate the surgical management of
a non-contrast CT is highly sensitive and specific
Lobar Intracerebral Hemorrhage.
for ICH and is the key of early diagnosis (4).CT
PATIENTS AND METHODS
scan will reveal not only the location and size of
the ICH but also intraventricular extension, mass
This study is a descriptive analytical
effect, hydrocephalus and early signs of herniation
clinical trial study for evaluating the clinical and
(5). MRI can be as sensitive as CT in determining
functional outcomes of the surgical cases with
lobar intracerebral hemorrhage.
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5241-5250
Clinical Profile of patients with Ascitic Fluid Infection at Ain Shams University
Sanaa Moharam Kamal, Sara Mahmoud Abdelhakam, Yasmine Mahmoud Massoud, Kareem Abd El
Aziz Abd El Hafeez, Hazem Ahmed Kamal
Department of Tropical Medicine, Ain Shams University
Corresponding author: Hazem Ahmed Kamal, E-Mail: firstname.lastname@example.org, Mobile: 0106 15 474 15
Background: Ascites is a common problem in patients with chronic liver disease. About 60% of patients with
cirrhosis will develop ascites. Patients with chronic liver disease and cirrhosis frequently develop infections of
the ascitic fluid.
Aim: The aim of this study is to assess the clinical profile of patients with ascetic fluid infection admitted to
Tropical Medicine department at Ain Shams University hospitals.
Patients and Methods: The current Cross-sectional study was conducted at The Tropical Medicine
Department, Ain Shams University on 87 Egyptian patients with chronic liver disease and ascites during the
12-months period from June 2017 to May 2018 by collecting their clinical, laboratory and radiological data.
Results: The frequency of infected ascites among the studied patients with chronic liver disease and ascites
was 31%. The main presenting symptom of infected ascites was abdominal pain (37%) and the most common
clinical sign was lower limb edema (81%). The most frequently isolated micro-organism was E.coli that was
detected in 7% of patients with infected ascites. Among the 27 patients with infected ascites, 12 patients
responded to the third generation cephalosporins, nine patients responded to Meropenem.
Conclusion: Infection of the ascitic fluid is frequent among patients with chronic liver disease and cirrhosis
admitted to Ain Shams University Hospitals. Almost one third of the ascitic patients developed at least one
attack of spontaneous bacterial peritonitis or bacterascites. Monomicrobialbacterascites is more frequent than
polymicrobialbacterascites and E coli is the most common isolated organism. Third-generation, broad-
spectrum cephalosporins remain a good initial therapy for patients who do not have allergy to cephalosporins.
Alternative antibiotics such as Meropenem and pipercillin-tazobactam should be considered for patients for
patients who fail to improve on traditional antibiotic regimens.
Keywords: Ascites, Spontaneous bacterial peritonitis, Ascitic fluid infection.
associated with hospital mortality of 20% to 40%
Ascites is a common problem in patients
. Patients who recover an attack of SBP have an
with chronic liver disease. About 60% of patients
increased risk of recurrence of 40% to 70% in one
with cirrhosis will develop ascites (1). The main
year and poorer survival on follow-up (4).
pathophysiology of ascites is progressive increase
Other variants of ascitic fluid infections
in portal venous pressure as a result of increased
include culture-negative neutrocytic ascites,
intrahepatic resistance caused by cirrhosis (2). Portal
monomicrobial non-neutrocyticbacterascites and
hypertension increases the hydrostatic pressure at
polymicrobialbacterascites. These variants of
the sinusoidal level and causes some hemodynamic
infected ascites are distinguished from classic SBP
changes including the splanchnic vasodilation,
largely by ascitic fluid analysis. It is important to
reduced systemic resistance, increased plasma
recognize these variants in at-risk patients who do
volume and cardiac output. These alterations
not fulfil classical definitions of SBP (6).
stimulate the renin-angiotensin-aldosterone system
The bacterial isolates in SBP may differ
leading to renal sodium and water retention that
from the isolates detected in neutrocytic ascites,
result in ascites (3).
monomicrobial non-neutrocyticbacterascites and
Patients with chronic liver disease and
cirrhosis frequently develop infections of the
organisms are the most common organisms in SBP (7).
ascitic fluid. Spontaneous bacterial peritonitis
Third generation cephalosporins are
(SBP) is defined as an ascitic fluid infection
commonly used as emperical treatment of infected
without an evident intraabdominal surgically
ascites with cirrhosis as they cover both
treatable source, it primarily occurs in patients with
enterobactericae and non-enterococcal streptococci
advanced cirrhosis (4). The diagnosis is established
(8). The development of multidrug resistant strains
by positive ascitic fluid bacterial culture and
raise the need to investigate other antibiotic
elevated ascitic fluid absolute polymorphonuclear
regimen based on the prevalence and the
leukocyte (PMN) count (250 cells/mm3). SBP
antimicrobial resistance pattern of the infection (9).
occurs in one third of patients with cirrhosis and is
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (10), Page 5251-5258
Diffusion weighted Image MRI in Assessment of Patients with Multiple Myeloma
Reem H. Basiouny, Arwa A. Hendy, Rasha T. Khattab
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Arwa A. Hendy, Mobile: +201002345833, E-mail: email@example.com
Background: Recent developments in diagnostic imaging techniques have magnified the role and potential of
MRI in patients with multiple myeloma. Quantitative diffusion-weighted imaging of the bone marrow is
adjunct tool for the diagnosis of a diffuse MR imaging pattern in patients with multiple myeloma.
Aim of the Work: This study aimed to evaluate the apparent diffusion coefficients (ADCs) of magnetic
resonance (MR) imaging patterns in the bone marrow of patients with multiple myeloma (MM) and to
determine a threshold ADC that may help distinguish a diffuse from a normal pattern with high accuracy
Patients and Methods: This study was carried out in Radiology Department of Ain Shams University
Hospitals. This study included 30 patients newly diagnosed, untreated MM and 16 healthy control subjects
underwent spinal MR imaging including diffusion-weighted imaging, and bone marrow ADCs were
calculated. Pattern assignment was based on visual assessment of conventional MR images.
Results: Mean ADCs 6 standard deviation in patients with MM for the normal, focal, and diffuse MR imaging
patterns were 0.360 x 10-3 mm2/sec +/- 0.110, 1.046 x 10-3 mm2/sec +/- 0.232, and 0.770 x 10-3 mm2/sec +/-
0.135, respectively. There were significant differences in ADCs between diffuse and normal (P .001), diffuse
and focal (P.001), and focal and normal (P.001) patterns. Patients with a diffuse pattern had more features of
advanced disease, higher international staging system score, increased incidence of high-risk cytogenetics, and
higher revised international staging system score. ADCs greater than 0.548 x 10-3 mm2/sec showed 100%
sensitivity (9 of 9) and 98% specificity (10 of 11) for the diagnosis of a diffuse (vs normal) MR imaging
pattern, whereas an ADC greater than 0.597 x 10-3 mm2/sec showed 100% sensitivity (9 of 9) and 100%
Conclusion: ADCs of MR imaging patterns in patients with MM differ significantly. A diffuse MR imaging pattern
can be distinguished more objectively from a normal MR imaging pattern by adding quantitative diffusion-weighted
imaging to standard MR imaging protocols.
Keywords: Multiple Myeloma, DW MRI.
definition of symptomatic disease(1,7). Diffusion-
Multiple myeloma (MM) is a hematologic
weighted imaging (DWI) with calculation of apparent
malignancy characterized by abnormal plasma cells
diffusion coefficients (ADCs) may be used as an
in the bone marrow and/or in extramedullary sites,
adjunct method to increase diagnostic confidence and
urinary and/or serum monoclonal immunoglobulin,
to better distinguish a diffuse MR imaging pattern
and osteolytic lesions in most patients (1). The
from a normal MR imaging pattern. So far, this
Durie and Salmon staging system for MM, which
technique has been applied to a relatively small
was introduced in 1975, is still used to assess tumor
number of patients with myeloma, with promising
burden and prognosis. The plain radiographic
results for initial assessment and prognosis (8; 9).
skeletal survey is an important part of this system,
AIM OF THE WORK
since multiple osteolytic lesions define stage III
To evaluate the apparent diffusion
disease (1,2). The prognostic implications of
coefficients (ADCs) of magnetic resonance (MR)
magnetic resonance (MR) imaging of the bone
imaging patterns in the bone marrow of patients
marrow for MM have already been established for
with multiple myeloma (MM) and to determine a
abnormal versus normal MR imaging results and
threshold ADC that may help distinguish a diffuse
for individual MR imaging patterns of
from a normal pattern with high accuracy.
involvement(3,4). For example, abnormal spinal MR
imaging results have been shown to help identify
PATIENTS AND METHODS
patients with asymptomatic (smoldering) myeloma
Patients: The study was conducted in the
who are likely to benefit from early treatment(3).
period between October 2016 and May 2018 in
More recently, it was shown that patients with
Radiology Department at Ain Shams University
smoldering myeloma and more than one
Hospitals. The patients underwent MR examination
unequivocal focal lesion on whole-body MR
using a 1.5 T machine (Philips Healthcare, Best,
images have an increased risk of developing
Netherlands) using phased array coil. Inclusion
myeloma-related symptoms and should receive
Criteria: Any age group and sex. Patients with newly
treatment(5,6). Accordingly, the most recent
diagnosed, untreated MM and healthy control subjects
International Myeloma Working Group criteria for
underwent spinal MR imaging including diffusion-
MM incorporate MR imaging findings in the
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5259-5269
Role of Neuroendoscopy in Management of Intraventricular Lesions
Shehab Mohamed El Khadrawy, Mohamed Ahmed Ellabbad, Ahmed Mohamed Alzebak
Department Neurosurgery, Elhussin University Hospital, Cairo, Egypt.
Objective: Intraventricular (IV) lesions are easily being approached with the endoscope through the
ventricular system, because intraventricular tumors often cause cerebrospinal fluid (CSF) pathway obstruction
and hydrocephalus. The aims of endoscopy in intraventricular tumors are usually the restoration of CSF
pathway obstruction, clarification of the histology, and if possible, a complete tumor removal.
Methods: Twenty five consecutive cases with IV lesions were removed or biopsied with or without ETV and
septum pellucidostomy. Patient information was retrospective entered into a database. Outcomes were
evaluated by life table analysis.
Results: Twenty five patients had completed with ETV in 16 cases; six cases by cyst fenestration, seven cases
tumor biopsy 10 cases cyst removal, two cases hematoma were evacuated. 16 cases improved post-operative
(clinical and radiological), three cases needed VP shunt, Three cases with same clinical as pre-operative, One
case presented with paresis, Two cases operated microscopically after one year.
Conclusions: The advantages of the endoscopic approach are minimal dissection and brain retraction. Reach
to the target is rapid. The method of choice for removal of colloid cysts, arachnoid cysts and restore CSF pass
way obstructed by lesions at the same operation.
Keywords: Arteriovenous malformation, Cerebrospinal fluid, Endoscopic third ventriculostomy, External
ventricular drain, Intra cranial pressure, Intraventricular hemorrhage, Ventriculoperitoneal, Aqueduct of
Hydrocephalus should be treated beside tumor.
One of treatment options is ventriculoperitoneal
approached with the endoscope through the
shunting (VP shunting). But it contributes to
dissemination of some tumors such as
intraventricular tumors often cause cerebrospinal
pineoblastoma and germ cell tumors into peritoneal
fluid (CSF) pathway obstruction, resulting in
maneuvering with the endoscopes is available.
AIM OF THE WORK
However, even in patients with narrow ventricles,
The aim of this study was retrospectively
the lesions may be approached accurately and
evaluating of the role and outcome of use of
safely with the aid of neuronavigation (1, 2). The
endoscope in intraventricular lesions in term of:
aims of endoscopy in intraventricular tumors are
Diagnostic of the deep lesions. Management of
usually the restoration of CSF pathway obstruction,
increased ICP. Excision of lesions as much as
clarification of the histology, and if possible, a
complete tumor removal (3).
PATIENTS AND METHODS
Advantages of the endoscopic approach are
an improved visualization and illumination in the
This retrospective study was carried on 25
depth of the ventricles as well as less brain tissue
successive patients who sought medical advice in
dissection and retraction.
2016, 2018 in Alhussien University Hospital and
Alexandria University Hospital. The inclusion
The endoscopic tumor surgery was limited
criteria were patients with Intraventricular lesions
to tumor biopsy, mostly performed after an
(tumors, colloid cyst, arachnoid cyst and hge) with
endoscopic third ventriculostomy (ETV) in patients
or without hydrocephalus. The study was
hydrocephalus (4, 5).
approved by the Ethics Board of Al-Azhar
Lesions were removed or biopsied with or
management of ventricular tumors is stereotactic
without ETV and septum pellucidostomy.
biopsy procedure. But it has a high risk of sampling
error because of migration of tumor from target
Then Clinical and radiological assessment
after puncture of ventricle and (CSF) drainage. It
of the patients were performed pre operation and
never contributes to treat of obstructed
immediate after surgery, one month, two months
and four months after surgery for assessment of
patient clinical, lesions recurrence for total
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5270-5277
An Egyptian study for standardization of myocardial T1 mapping values on a 3
Tesla MRI machine
Ahmed Samir Ibrahim, Emad Hamid Abdel-Dayem, Hossam Mohsen Hassan
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Hossam Mohsen Hassan,email: firstname.lastname@example.org,Mobile: 01110636022
Objective: of this study is to set standard values for the native T1 values in both normal and diseased
myocardium on a 3 tesla MRI machine.
Methodology: this study was carried out in Misr Radiology Center. 31 patients were divided into normal
group (control) including 10 patients and diseased group including 21 patients.
Result: The native T1 values on the healthy myocardium ranged from 1110 to 1300 msec, with ECV values
ranging from 25 to 33 % with variable elevations of the native T1 and ECV values according to the pathology
affecting the myocardium. We concluded that the above values are the reference values for the 3 T MRI
Keywords: Cardiovascular Magnetic Resonance (CMR), Extra-cellular Volume (ECV), Late Gadolinium
normal myocardium, but not as high as in acute MI
In the heart, diffuse interstitial fibrosis plays
an essential role in the development of a variety of
Native T1-mapping can display the typical
cardiomyopathies and is associated with increased
non-ischemic patterns in acute myocarditis, similar
mortality. Previously, endomyocardial biopsy was the
to LGE imaging without the need for contrast
principle method used to diagnose myocardial
agents. T1-mapping also detected additional areas
fibrosis. Currently, T1 mapping is a novel and
of myocardial involvement and identified extra
expanding application of cardiac MR imaging and
cases beyond T2W and LGE imaging (5).
has the potential to depict diffuse interstitial fibrosis
A relatively higher pre-contrast T1 value
in a variety of cardiac diseases (1).
and ECV, and lower post-contrast T1 value were
Rapid innovations in CMR now permit the
found with T1 mapping in the myocardium of
routine acquisition of quantitative measures of
HCM patients, which suggested T1 mapping is
myocardial and blood T1 which are key tissue
better in the evaluation of myocardial fibrosis (6).
characteristics. T1 quantification requires the
acquisition of multiple images to derive the T1
recovery curve which is governed by the exponential
time constant for MR longitudinal relaxation, T1.
This parameter can be displayed as a pixelwise "T1
map" whereby an estimate of T1 is encoded in the
intensity of each pixel. Its quantitative nature permits
establishing normal T1 ranges, and T1 values can be
assigned colors to simplify visual interpretation (2).
Native T1-mapping as well as ECV
mapping is currently being explored as a diagnostic
tool for a wide range of cardiomyopathies. Native
T1 changes are detectable in both acute and chronic
MI. Elevated native T1 has been reported in a
number of diseases with cardiac involvement:
Figure (1): Tissue characterization using native T1 and
extracellular volume fraction (ECV). Absolute values
myocarditis, amyloidosis, lupus and decrease in
for native T1 depend greatly on field strength (1.5 T or 3
native T1 have been associated with Anderson
T), pulse sequence (MOLLI or ShMOLLI), scanner
Fabry disease, and high iron content (3).
manufacturer and rules of measurements (7).
In chronic MI, there is replacement of
T1 mapping is hypothesized to contribute
myocardial cells by scarring or fibrosis with an
to the characterization of cardiac masses based on
increase in extracellular collagen. Importantly, there
the spectrum of T1 relaxation times in tissue
is no edema, as this has resolved in the initial weeks
consisting of fat, calcium, melanin, blood and
after MI. Therefore, T1 values are higher than in
simple fluid. Thrombi and myxomas showed
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5278-5283
Epidemiology outcomes of proximal humerus fractures in Saudi Arabia
Nibras Khaled Aljabri1, Ashaq Mubarak Al-Qahtani2, Ali Mohammed Alahmari3, Feras Ali Alyamani1,
Mohammed Ahmed Almutawah4, Malak Abdulaziz Alsaif5, Bashir Adel Almaghrabi1, Elaf Fahad
1Umm Al-Qura University, Makkah, 2 Najran University, Najran, ,3 King Khaled University, Abha, 4Imam Abdulrahman Bin Faisal
University, Khubar, 5King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Corresponding Author: Nibras Khaled Aljabri, E-mail: Mr_nibras@hotmail.com
Background: Proximal humerus fractures (PHF) are osteoporotic fractures that affect women over 70 years of
age. Like fractures of the femoral neck they have become a public health concern. As the population ages there
is an increase in the number of people in poor general condition with an increased risk of falls on fragile bones.
The incidence of these fractures has increased by 15% per year.
Methods: All patients managed for PHF in Saudi Arabia in the past year were included in this prospective
study (prospective cohort study; level 2). Three hundred and twenty-five patients were included with 329
Results: There was a ratio of two women to one man. At the final follow-up 50 patients had died (15%) and 25
patients were lost to follow-up. The mean age was 70 years old. There were two types of risk factors. The first
was fragile bones, and the second was patient specific risk of falls. The severity of the fracture increased with
the age of the population. Hospitalization was necessary in 43% of the cases in our study. Surgical
management was necessary in 21%. This lack of relationship between the percentage of displaced fractures
(58%) and the percentage of surgically treated fractures is a sign of the difficulties of managing this
population, which is usually in poor general condition.
Conclusion: Proximal humerus fractures (PHF) is frequent and its prevalence is increasing. The ageing
population is the cause, resulting in a population that is in poor general condition with an increased risk of
falling on increasingly fragile bone. Measures must be taken in this growing population to prevent the risk
factors of PHF because management of these fractures may become another source of dependency in the
Keywords: Epidemiology; Fracture; Proximal humerus; Prevalence; Osteoporosis
250% in men. These fractures will probably
Proximal humerus fractures (PHF) are the
become more difficult to treat due to delayed
seventh most frequent fracture in adults and the
union, an increase in the number of complications
third in patients over 65 following wrist and
and in the rate of pseudarthrosis. Palaven et al. (3)
femoral neck fractures. They represent 5.7% of
estimated that the number of shoulder fractures
diagnosed fractures. This is mainly an
would increase three fold in the next 30 years.
osteoporotic fracture and its prevalence increases
Court-Brown and Caesar (4) talk about a
as one moves north in Europe. There is a linear
revolution in the management of fractures because
increase in the incidence of this entity after the
trauma centers were created in the developed
age of 40. Like fractures of the femoral neck, PHF
countries between 1970-1980 to manage trauma
have become a public health. The ageing
secondary to high-energy traumas, which mainly
population means there is an increase in the
affect young men. At present, the prevalence of
number of people poor general condition with a
that type of trauma is decreasing while traumas on
greater risk of falling on weak bones. This regular
osteoporotic bone are increasing. The latter are
increase in the prevalence of osteoporotic
managed differently because the short and long-
fractures results in higher medical costs
term aims are different. Lind T et al. (5) noted that
(hospitalization, treatment, convalescence. . .) and
in 730 fractures, 29% of the patients needed to be
can result in loss of autonomy. The management
hospitalized; 75% of these were over 60 and only
of these fractures will be a real challenge for
21% underwent surgery, which represents 583
future healthcare policies in the upcoming years.
hospital days per year for a Danish city of
Kannus et al. (1,2) studied PHF between 1970 and
250,000 inhabitants. The aims of the present study
1998 in patients over the age of 60 admitted to
were to define the epidemiology of this population
hospitals in Finland. The number of patients went
presenting a PHF and evaluate the severity of the
from 208 fractures in 1970 to 1105 in 1998 or
fracture and its therapeutic management in
increased by 15% per year. In 28 years and if the
relation to different subgroups in this population.
ageing of the population is taken into account, this
fracture has increased by 166% in women and
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5284-5289
Complications Following Inhaled Anesthetics Administration: A Systematic
Review of Current Literature
Haitham Alnahedh 1, Nasser Saleh Alalhareth 2, Daniel Coric 3, Khadija Abdullah AlBahrani 4,
Mohammad Ibrahim Aljumah 5, Saud Ahmed Alshehri 1, Ziyad Aljohani 6, Dalia Saleh Alsharidah 7,
Abdulrhman Mansour Altamimi 8, Wala Mohammed AlBin Saleh 4
1- King Saud bin Abdulaziz University for Health Sciences, 2- King Abdulaziz University Rabigh Branch,
3- Nepean Hospital, NSW, Australia, 4- Maternity and Children Hospital-AlHassa,
5- Western Sydney University, 6- Ibn Sina National College for Medical studies,
7- Princess Noura University, 8- Umm Al Qura University
*Corresponding Author: Wala Mohammed AlBin Saleh, E-mail:
Background: anesthesia and sedation are an essential part of surgical operations and treatment in the intensive
care unit. Sedation in the ICU is essential to keep patients well while they are intubated, mechanically
ventilated, or agitated. It is also a cornerstone when they undergo any kind of invasive procedures. Most
patients who require anesthesia are in generally bad health condition, such as failed kidney or liver, putting
them at a greater danger of the complication of anesthesia itself. Newer agents, however, are trying to
overcome these challenges.
Aim of the Work: our aim in this study is to understand the mechanism of action of inhaled anesthesia, study
their common adverse effects and complication and explore how to prevent them.
Material and Methods: we conducted this review using a comprehensive search of MEDLINE, PubMed, and
EMBASE, January 1987, through March 2017. The following search terms were used: anesthesia,
complication of anesthesia, inhaled anesthesia, overcoming challenges in surgery
Conclusion: inhaled anesthetics are a basis in both surgical operations and sedation within the intensive care unit
and are used for sedation or anesthesia. Most patients who require the use of anesthetics are critically ill, and may
have renal dysfunction, hepatic dysfunction, or both. Therefore, the administration of safe anesthetic agent is
essential to prevent the occurrence of severe adverse events. Newer agents have been reported to be safer.
Keywords: Anesthesia, Complication of Anesthesia, Inhaled Anesthesia, Overcoming Challenges in Surgery
intravenously or through inhalation. The most
Anesthesia and sedation are an essential
common intravenous anesthetic agents are
part of surgical operations and treatment in the
propofol and midazolam, which need highly
intensive care unit (ICU). It was previously
functioning kidney and liver to be well excreted
estimated that more than ninety percent of patients
. Moreover, midazolam, propofol, along with
admitted to the intensive care unit will require to
be under sedation. Sedation in the ICU is essential
previously associated with high incidence of
to keep patients well while they are intubated,
delirium, especially in the elderly, or critically ill
mechanically ventilated, or agitated. It is also a
patients (2). On the other hand, inhaled anesthetic
cornerstone when they undergo any kind of
or sedative agents include sevoflurane, isoflurane,
invasive procedures (1). Generally used anesthetics
desflurane, along with other agents that have
for either anesthesia or sedation, are intravenous
similar mechanisms. The use of inhaled anesthetic
or inhaled (1). Most patients in the intensive care
agents has been common for a long time during
unit or who require anesthesia are critically ill,
surgical operations, and any other procedure that
and many of them have either hepatic dysfunction,
requires general anesthesia induction. The use of
or renal dysfunction, or both. This will often lead
to a significant delay in the excretion of these
universally essential in almost all patients who
drugs, leading eventually to over-sedation. A prior
undergo surgery or need general anesthesia for
report has suggested that the incidence of over-
any other reason. However, they have not been
sedation in patients admitted to the intensive care
used commonly in intensive care units, unless
unit can be as high as 60% (2). Moreover, this
patients had special circumstances like status
delay in systemic clearance of the anesthetic agent
epilepticus, and status asthmaticus (4). Lately,
will cause a phenomenon called drug hangover`.
there has been a growing trend that encouraged
drug hangover` is defined as the delay of patient
the use of inhaled sedative agents in patients
awakening, delay of functioning reflexes in the
admitted to the intensive care unit. This started
airway, and delay in time to extubation, in a
primarily from a trial published by Kong et al.
patient who was on an anesthetic agent. (1) As we
that reported improved post-sedation outcomes
mentioned, anesthetic and agents are either given
regarding extubation times and awakening (5).
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5290-5297
Retropupillary Fixation of Iris-Claw Intraocular Lens versus Trans-Scleral
Suturing Fixation for Aphakic Eyes without Capsular Support
Elaraby A Nassar, Adel A Othman, Mohamed K Mohamed, Ahmed M Sakr*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding Author: Ahmed M. Sakr; Email: email@example.com
Background: many reasons can lead to an aphakia without sufficient capsular support for a posterior chamber
intraocular lens, such as intraoperative complications during phacoemulsification, intracapsular cataract
extraction, ocular trauma and lens dislocation caused by various reasons.
Aim of the Work: was to compare retropupillary fixation of an iris-claw IOL (artisan aphakia lens) with
transscleral suturing fixation of aposterior chamber IOL for aphakic eyes without sufficient capsular support as
regards safety, visual recovery and complications of the procedure.
Material and Methods: this a prospective interventional case series study included a total of 45 eyes of 42
patients of the age group 13-60 years, selected from those attending the Ophthalmology Department at Al-
Azhar University Hospitals according to the inclusion and exclusion criteria.
Results: in group A, the duration ranged from 15 to 45 min with a mean of 30.30±6.06min, in group B, the
duration ranged from 35 to 85 min with a mean 60.60±12.41min. The P-Value was< 0. 001. The IOP showed
at day 1 postoperative was higher in group B 20.06±4 than group A A16.40±3.9 p value was 0.012, however
IOP was nearly at the same level at the end of the follow up period 15.23±3.63 in group A and 15.23±3.63 in
group B with p value 0.713.
Conclusion: the results of our study indicated that IC-IOL and SF-PCIOL implantations are both satisfactory in
correcting aphakia without sufficient capsular support to hold an IOL in the posterior capsule.
Keywords: Aphakia, Iris Claw Intraocular Lenses
aphakic eyes without adequate capsular support.
Several surgical methods of intraocular
However, IC IOL implantation in the anterior
lens (IOL) implantation for eyes without
chamber may cause damage to the corneal
sufficient capsular support have been developed.
endothelial cells(2). In contrast, there have been
Angle-fixated anterior chamber IOL implantation
various reports regarding the complications
is one therapeutic option and has technical
associated with trans scleral suturing fixation,
advantages such as ease and minimal invasion
such as ciliary choroidal body hemorrhage,
vitreous prolapse into the anterior chamber, retinal
complications such as progressive damage of
detachment, IOL dislocation, uveitis, cystoid
corneal endothelial cells, decompensation, chronic
macular edema, and conjunctival erosion.
inflammation in the anterior chamber, secondary
Although the technique of trans scleral suturing
glaucoma, and cystoid macular edema have been
fixation has been improved to reduce those risks
reported (1). Implantation of an iris-clawfixated
associated with the surgery, most of these
anterior chamber (ICIOL)is another method. Early
techniques are still complex and invasive and
generations of iris-claw anterior chamber IOLs
require extensive experience to be performed
lacked adequate space between the IOL andiris or
safely and in a short time period (3). Retropupillary
corneal endothelial cells, which can lead to
fixation of Artisan IOL in the posterior chamber is
damage to the iris or corneal endothelial cells.
expected to be a less invasive and safer method of
Later generations of iris-clawfixated anterior
posterior chamber IOL implantation for aphakic
chamber IOLs were developed with avaulted optic
eyes without sufficient capsular support(4). The
design, which can provide enough space for
aim of this work is to compare retropupillary
aqueous flow between the IOL and iris to avoid
fixation of an iris-claw intraocular lens (IOL)
iris chafing. Because the lens was originally
(artisan aphakia lens) with trans scleral suturing
designed for surgical correction of phakic myopic
fixation of a posterior chamber IOL for aphakic
eyes and the haptics are enclavated to the mid-
eyes without sufficient capsular support as regards
peripheral iris stroma, it barely interferes with
safety, visual recovery and complications of the
physiological movement of the pupil. This new
design can reduce dispersion of iris pigment
AIM OF THE WORK
epithelium that can cause chronic ocular
The aim of the work was to compare
inflammation (2). Previous studies have reported
retropupillary fixation of an iris-claw IOL (artisan
the efficacy of ICIOL implantation in the anterior
aphakia lens) with transscleral suturing fixation of
chamber for correction of refractive error in
aposterior chamber IOL for aphakic eyes without
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5298-5303
Prognostic Value of Platelet to Lymphocyte Ratio in Patients with Non-Small Cell
Mohammad Sabry Elkady, Ghada Refaat and Zeinab Elsayed, Kyrillus Farag*
Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding Author: Kyrillus Farag, Email: firstname.lastname@example.org
Background: The prognostic value of Platelet-to-lymphocyte ratio (PLR) in patients with non-small-cell lung
cancer (NSCLC) is still indistinct. We conducted this study to assess the prognostic significance of
pretreatment PLR in patients with unresectable NSCLC.
Aim of the Work: to assess the prognostic significance of pre-treatment PLR in patients with NSCLC.
Material and Methods: we retrospectively reviewed 130 patients treated for NSCLC with definitive/palliative
chemotherapy and/or radiotherapy in Ain-Shams University hospital, Clinical Oncology department between
January 2014 and December 2016. Pre-treatment CBC was available for the 130 patients to calculate PLR by
dividing the absolute platelet count by the absolute lymphocytic count.
Results: Out of 130 patients with available pre-treatment complete blood picture, population age ranged from
23 to 87 years. Male to female ratio was 4.8:1. Adenocarcinoma presents 51% of cases. Unresectable stage II
and stage III present 2% and 27% respectively, while Stage IV presents 69%. Using a cut-off value of 150,
high PLR>150 was significantly associated with poor overall survival (OS) (median OS: 10.33 months; 95%
CI: 6.23-14.42), compared to patients with PLR<150; (median OS: 24.63 months, 95% CI: 11.5-37.76,
p=0.008), but not PFS. In multivariate analysis, PLR>150 was an independent poor prognostic factor for OS;
(HR=1.9, 95% CI; 1.092-3.3, p=0.023).
Conclusion: High PLR is associated with poor OS in patients with unresectable NSCLC.
Keywords: Platelet to Lymphocyte ratio, Non-small cell lung cancer, prognostic factor.
including upregulation of cytokines, chemokines
Lung cancer remains the most common
and inflammatory mediators, promotion of
cancer in the world, both in term of new cases
angiogenesis, local immunosuppression, inhibition
(1.8million cases, 12.9% of total) and deaths (1.6
of apoptosis, and DNA damage are involved in this
million deaths, 19.4% of total cancer cases).
response and are associated with an increased risk
Although lung cancer is the most common cancer
of metastasis. There is increasing evidence that
worldwide among men, it ranks second in more
measures of the systemic inflammatory response,
developed regions (490,000 cases) after prostate
such as neutrophil, lymphocyte, C-reactive protein
cancer (759,000 cases) in 2012 worldwide statistics
(CRP), and the Glasgow Prognostic Score (GPS),
(1). In Egypt, lung cancer comes forth in ranking
have prognostic value in a variety of cancers (5).
with crude incidence rate 8.2% of all cases among
The plateletlymphocyte ratio (PLR), defined as
males. The age standardized rate and crude
the absolute platelet count divided by the absolute
incidence rate for lung cancer per 100,000 were
lymphocyte count, has gained a lot of interest in
10.1 and 7.6 in lower Egypt, 10.8 and 6.3 in middle
recent years. Published data suggested that elevated
Egypt, 6.7 and 6 in upper Egypt Respectively(2). To
PLR was an important prognostic factor in
date, disease stage based on tumor-node-metastases
esophageal cancer, gastric cancer, renal cell cancer,
(TNM) classification is the best prognostic factor
and malignant pleural mesothelioma (6). In a
(3). In an attempt to better estimate the prognosis,
prospective study done by Sanchez-Lara and
colleagues (7) in Mexico from 2009 to 2011, on 119
investigated, such as performance status, weight
patients with stage III-IV NSCLC, treated with
loss, biomarkers and other factors. EGFR
chemotherapy, evaluating prognostic significance
mutations may be a positive prognostic factor for
of baseline PLR on overall survival, using cut-off
survival in advanced NSCLC patients treated with
value: 150. Results were statistically significant
chemotherapy with or without erlotinib, and may
with HR:1.16, 95%CI: (0.52-2.50). Another study
predict greater likelihood of response. Patients with
done by Liu et al (8) in China, retrospectively
KRAS-mutant NSCLC showed poorer clinical
reviewed data of 210 patients with stage III-IV
outcomes when treated with erlotinib and
NSCLC treated with chemotherapy from 2001 to
chemotherapy (4). Recently, it is widely recognized
2012, also evaluating prognostic significance of
that systemic inflammatory response plays an
baseline PLR on overall survival, using cut-off
important role in the initiation and progression of
value:150. HR was 2.025, 95% CI:(1.4-2.9).
cancer. Molecular factors and biological pathways
However, the prognostic value of PLR in NSCLC
remains uncertain. Therefore, in this study, we
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5304-5312
Comparative study between Ultrasound guided Pectoral nerves block and
Thoracic epidural as analgesia in breast surgeries
Magdy Ahmed Abdel-Mo`men, Saad Eldein Mahmoud Elkhateeb, Hesham Said Abdel-Ra`oof,
Mohamed Ahmed Elbadawy Mohamed*
Department of Anesthesiology and Intensive Care, Faculty of Medicine - Al-Azhar University
*Corresponding Author: Mohamed Ahmed Elbadawy Mohamed, Mobile: 01005032374; Email: email@example.com
Background: Breast surgery is an exceedingly common procedure and associated with an increased incidence
of acute and chronic pain. These procedures cause significant acute pain and may progress to chronic pain
states in 2560% of cases. Regional anesthesia techniques may improve postoperative analgesia for patients
undergoing breast surgery. Acute postoperative pain due to insufficient or ineffective pain control is a major
risk factor for the development of chronic pain after breast surgery. This condition includes paresthesia,
intercostobrachial neuralgia and phantom breast pain.
Aim of the Work: we aimed at comparing the analgesic effectiveness and safety of pectoral (Pecs) block
versus thoracic epidural in breast surgeries.
Material and Methods: The present study was conducted to compare the efficacy and safety of the Pecs II
block with thoracic epidural (TE) on sixty female patients ASA I-II, their ages ranged from 18- 65 years old
scheduled for unilateral breast surgery. The patients were allocated randomly into two groups (n=30)
according to type of regional anesthesia administrated. (Pecs block or TE).
Results: The results of the present study demonstrated that, Pecs block caused hemodynamic stability,
decreased the intensity of post-operative pain, reduced post-operative analgesic requirement, prolonged the
time needed for first request of analgesia, decreased PONV. Therefore it can be considered as quite safe
procedure and effective as well for intraoperative and postoperative pain control in breast surgeries.
Conclusion: Whether it is more superior to thoracic epidural depends on the type and extent of surgery. For
surgeries involving the axilla, Pecs block is required as part of axillary compartment block but for medial breast
incisions, thoracic epidural offers denervation of anterior branches of the intercostal nerves, which Pecs block does
Keywords: Pecs, thoracic epidural, breast surgeries
muscles is dissected to reach the lateral pectoral
Breast Surgery is becoming more and more
and the medial pectoral nerves. The main
common. Patients are often middle-aged women
indications are breast expanders and subpectoral
and with high public awareness around issues of
prosthesis where the distension of these muscles is
breast cancer. The numbers are increasing. Breast
extremely painful3. A second version of the Pecs
surgery is an exceedingly common procedure and
block is called ``modified Pecs block'' or Pecs
associated with an increased incidence of acute and
block type II. This novel approach aims to block at
chronic pain. Regional anesthesia techniques may
least the pectoral nerves, the intercostobrachial,
improve post-operative analgesia for patients
intercostals III-IV-V-VI and the long thoracic
undergoing breast surgery 1. Postoperative pain for
nerve. These nerves need to be blocked to provide
surgeries involving chest wall is mostly managed
complete analgesia during breast surgery3. Epidural
using multimodal analgesia i.e. by using
anesthesia represents one of the central neuroaxial
combination of non-steroidal anti-inflammatory
block techniques. Improvements in equipment,
drugs (NSAIDS), paracetamol, opioids and local
drugs and technique made its popularity and
anesthetic infiltration. In extensive surgeries like
introduced it as a versatile anesthetic technique
radical mastectomy and latissimus dorsi flaps,
with many applications in surgery and pain control.
some anesthetists may employ the use of
Satisfactory post-operative analgesia prevents
paravertebral blocks or thoracic epidural analgesia
unnecessary patient discomfort. It may play a role
or pectoral nerves block. Every year, thousands of
in decreasing morbidity, postoperative hospital stay
patients undergo surgery in the region of the breast
and thus the cost4 . Inadequate postoperative
and axilla. These procedures cause significant
acute pain and may progress to chronic pain states
in 2560% of cases2. The pectoral nerves block
morbidity and mortality which subsequently delay
(Pecs block) is an easy and reliable superficial
recovery and the return to daily living5.
block. Once the pectoralis muscles are located
AIM OF THE WORK
under the clavicle the space between the two
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5313-5320
Impact of Using Contact Lenses with Hygiene Rules in Saudi Arabia
Rakan Awadh Alhumaidi, Khaled Hamdi Bin Yousef *
Medical intern, Taif University, Taif, Saudi Arabia.
Corresponding Author; Khaled Hamdi Bin Yousef, E-mail: firstname.lastname@example.org
Background and Objectives: this study aimed at assessing the level of compliance among contact lens
wearers with hygiene rules, the prevalence of associated eye complaints, to determine the demographic factors
of compliance and eye complications.
Material and Methods: this is cross-sectional study on 500 subjects' contact lens wearers at three
ophthalmology clinics in Saudi Arabia (King Abdul-Aziz University Hospital in Jeddah, King Khalid
University Hospital in Riyadh and King Fahad University Hospital in Khobar) during the period between July
2017 and March 2018. A semi-structured questionnaire was administered to investigate 10 items with a
compliance score (0-10) was calculated as the number of rules to which the participant is fully compliant.
Socio-demographic data were analyzed as factors for compliance and correlation of compliance scores with the
presence and number of ocular complaints.
Results: contact lenses were used for cosmetic purpose (47.8%), and for refractive errors (38.6%); and most
frequent lens type was monthly (42.6%). Results showed that 22.6% of participants changed sterile solution
daily; 15.8% changed the lens box monthly, 81.2% washed their hands before, 89.6% washed lens before and
33.2% after wearing the lenses, and 37.2% followed the correct washing method. The mean (SD) compliance
score was 4.67 (1.60) and females had a moderately higher score than men. The majority of participants
(93.0%) reported eye complaints and 73.6% had two or more concomitant symptoms.
Conclusion: contact lens wearers have poor compliance with several hygiene rules resulting in the high prevalence
of eye complaints. Therefore, it is important to teach contact lens wearers the specific hygienic rules of the target
population to prevent serious eye complications.
Keywords: Compliance; Hygiene Rules; Contact Lenses Wearers
and practitioners (1). These modalities include
In 2005, the numbers of contact lens users
general hygiene rules such hand cleaning before
worldwide were reported to be 140 million and
wearing lenses, as well as specific rules like lens
the trend is increasing since last two decades (1). In
Saudi Arabia, a survey among Saudi women
frequency, etc. Compliance with these rules was
estimated that 70.2% of women were using
demonstrated to improve contact lens-related eye
contact lenses, majorly (approximately 2 out 3)
symptoms and associated complications (10).
for cosmetic purpose (2). According to the data
However, majority of studies have reported poor
from the U.S. reports, approximately 41 million
compliance with these rules among 40% to almost
adult contact lens wearers were reported in 2015,
100% of users, which constitutes a supplemental
representing 16.7% of U.S adults in the same year
challenge for the prevention against these eye
(3). Although the use of contact lenses is a
complications (11-14). A high proportion of contact
practical and aesthetic solution due to its ability to
lens users do not consult an eye specialist prior to
provide an effective vision correction and
begin its use (2), which might be limiting
comfort, users are exposed to increased risk of
awareness about the related hygienic rules thereby
complications because of inadequate related-
increasing the risk of further complications.
hygiene (3). Wearing contact lenses represents an
Therefore, it is crucial to assess the level of
important risk factor for developing microbial
awareness and compliance with hygienic rules
keratitis (4). It is incriminated in several eye
among contact lens users and the associated eye
infection outbreaks, with a rise of atypical
outcomes and to investigate the factors of poor
infections such as Acanthamoeba keratitis and
compliance. Studying these factors may help
Fusarium keratitis that were reported in several
define the relevant preventive measures and
countries (5-7). These eye complications are known
targeted awareness rising campaigns within a
to affect 2 out of 1,000 contact lens users; leading
particular population, to reduce the rate of related
severe outcomes like blindness, in addition to
consequent care expenditures (4, 8,9). Studying
AIM OF THE WORK
contact lens-related eye complications and their
This study aimed at assessing the level of
associated risk factors have enabled determining
compliance among contact lens users with related
safe lens wear modalities and hygiene rules,
hygienic rules in Saudi Arabia; and to determine
which are generally well known by eye specialists
the prevalence of associated eye complaints, as
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5321-5325
Etiologies and In-Hospital Outcomes of Nonhemolytic Jaundice among Infants at
King Abdulaziz University Hospital (KAUH)
Ahmed Saleh Hejazi, Abdullah Alzahrani, AbdulelahAli Alshehri,
Fahd M. Aldhafiri, Hasan Aljefri, Fawaz M. Aldhafiri*
King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia
*Corresponding Author: Fawaz M. Aldhafiri, E-mail: email@example.com
Background: most of articles addressed the underlying causes and management of Neonatal Nonhemolytic
Jaundice, however only a few have investigated nonhemolytic jaundice among infancy which can turn fatal in
severe case, however can be prevented by early diagnosis.
Aim of the Work: was to investigate the most common etiologies of nonhemolytic jaundice among infants
presented to at King Abdulaziz University Hospital (KAUH) which may help pediatricians to rearrange their
differential diagnosis about nonhemolytic jaundice in infants.
Material and Methods: this is a retrospective observational study of all infants aged between 1-12 months,
conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia from January 2016 to
November 2017. Data collection was done using Microsoft Excel while data analysis was done using SPSS
version 21. Chi -square test was used to test if associations would be appropriate.
Results: out of total 105 patients enrolled in this study, complete data set was available for 88 only patients
during 2012. The mean age at presentation in months was 2.73 (± SD 2.21) range from 1 to 12 months. Among
the sample, the final outcome was as follows ; 59 (67%) jaundice-free, 14 (15.9%) still diseased and 15 (17%)
dead. Sepsis was the most common cause of jaundice with 33 cases (37.5%), followed by biliary atresia 10
cases (11.4%) and congenital hypertrophic pyloric stenosis 7 cases (8%). On the other hand, the least common
causes were rare diseases like wolman syndrome, crigler-najjar syndrome and autoimmune hepatitis and each
of them represents 1 case. The overall number of deaths in our study was 15 (17%). Seven of them were due to
sepsis and 2 were due to biliary atresia.
Conclusion: we hope to help the local physicians in Jeddah to arrange their differential diagnosis of nonhemolytic
jaundice among infants and deal with it seriously, due to the high incidence of critical illness and death.
Keywords: Nonhemolytic Jaundice, hyperbilirubinemia, Infant jaundice, KAUH.
syndrome and byler disease.Other causes include
Jaundice is defined as a yellowish
discoloration of the skin and sclerae that indicates
thrombocytopenia, hepatic infarction and acute
increasing in the bilirubin concentration in the
liver failure . According to several studies, the
blood due to an abnormality of bilirubin
most common causes of nonhemolytic jaundice
metabolism or excretion. After the neonatal
are Cytomegalovirus infection, sepsis, breast milk
period, the normal serum total bilirubin
jaundice, biliary atresia, neonatal hepatitis and
concentration is below 1 mg/dL . Jaundice
total parenteral nutrition. According to a study
usually becomes clinically apparent when the
conducted in China the main causes of
serum bilirubin concentration is more than 2
mg/dL which is double the maximum limit of
Cytomegalovirus infection, then sepsis and finally
normal . In our study we will focus on
breast milk jaundice . Another study found that
nonhemolytic jaundice in infancy, since there are
the incidence of neonatal sepsis ranges from one
few studies regarding nonhemolytic jaundice in
to five cases per 1000 live births. While,
this age group.There are several etiologies of
cholestatic jaundice affects approximately 1 in
nonhemolytic jaundice, including breast milk
every 2,500 infants [4,5]. It is estimated that
jaundice that present early in the infant lifetime.
approximately 40% of cholestasis in infants is due
Also infections may cause jaundice in infants such
to neonatal hepatitis . Human cytomegalovirus
as urinary tract infection, Cytomegalovirus
(CMV) is the commonest etiological agent
responsible for causing neonatal hepatitis .
(TORCH), neonatal hepatitis and sepsis.
Breastfeeding jaundice appears after the first three
Additionally, genetic syndromes or diseases
to five days, peaking within two weeks after birth,
associated with jaundice of infant as Crigler-
and progressively declined to normal levels over 3
Najjar syndrome, Inborn error of metabolism
to 12 weeks . The incidence is about 1:200 in
(galactosemia, tyrosinemia), cystic fibrosis,
babies and in rare cases may lead to kernicterus
Biliary atresia, biliary cysts, Alpha1-Antitrypsin
. In April 2017 a study conducted in Korea
deficiency, Neonatal iron storage disease, alagille
found that the overall incidence of biliary
atresia(BA) was 1.06 cases per 10,000 live births.
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5326-5333
Comparison between Different Lines of Antiviral Combination Therapies against
Hepatitis C Virus Genotype 4 in Egyptian Patients
Mahmoud Abd El Megid Osman, Kadrey Mohamed Elsaeid, Neveen Ibrahim Mosa, Shereen Abou
Bakr Saleh, Khaled Amro Zaky Mansouer, Mohammed Fathy Sayed Mohammed Zaky*
Internal Medicine Department, Faculty of Medicine, Ain Shams University
*Corresponding Author: Mohammed Fathy Sayed Mohammed Zaky, E-mail: firstname.lastname@example.org
Background: hepatitis C virus (HCV) infection in one of worldwide chief causes chronic liver illness. The
extended effect of it is highly inconstant, ranging from least histological changes to broad fibrosis and cirrhosis
with possibility of hepatocellular carcinoma (HCC). The morbidity and mortality of this global infection are
growing. The estimated worldwide prevalence of HCV is a by the World Health Organization (WHO)
affecting >170 million people worldwide. There is a varied distribution of HCV infection with about 23
million people likely to have it in the countries of Eastern Mediterranean Region. This is nearly number of
infected people in both Americas and Europe. Egypt is considered to have highest prevalence worldwide with
an expected 14.7% of total population seropositive for HCV.
Aim of the Work: to compare the different new lines of antiviral combination therapies against hepatitis C
virus genotype 4 in Egyptian patients as regards efficacy and safety.
Material and Methods: an open label, single-center, parallel-groups, randomized controlled clinical study,
comparing the different lines of antiviral combination therapies against hepatitis C virus in Egyptian patients as
regards efficacy reflected by the sustained virological response and safety through reporting adverse effects occur
with each drug combination. This study was conducted on confirmed HCV chronically infected patients with
diagnosis based on HCV-RNA PCR. The cases were collected from viral hepatitis treatment unit in Electricity
hospital, one of the centers of National Committee for Control of Viral Hepatitis (NCCVH). All cases in this study
were assessed and managed according to updated guidelines by NCCVH in parallel with the European Association
for Study of Liver (EASL) and the American European Association for Study of Liver (AASLD).
Results: this study was conducted on 1000 patients with confirmed diagnosis of chronic HCV with positive
serum HCV RNA by PCR technique. The cases were collected for this study had chronic hepatitis either
without cirrhosis or with compensated cirrhosis differentiated by using the FIB-4 score. They could be INF-
naïve or INF-experienced. The antiviral regimens used were SOF/SIM, SOF/LDV±RBV, SOF/DCV±RBV,
PAR/OMB/RBV, and IFN/SOF/RBV. Out of 1737 patients who underwent initial evaluation, 531 patients
were not eligible for therapy due to the presence of one or more exclusion criteria. The main causes for
treatment exclusion were advanced liver decompensation, inadequately controlled diabetes and HBV co-
infection. The total number of patients enrolled and eligible for antiviral treatment was 1206, 1000 of them
started the treatment course, while 206 patients did not start it due to receiving treatment in other centres or
died before starting the treatment.
Conclusion: 1000 patients started antiviral therapy for HCV, they showed good adherence to treatment and high
SVR rates compared to other recently published real-life studies. We used seven different treatment regimens, all of
which proved to be efficacious and safe with no clear preference for each over others.
Keywords: Antiviral Combination Therapies, Hepatitis C Virus Genotype 4
14.7% of total population seropositive for HCV (2).
Hepatitis C virus (HCV) infection in one of
HCV has 6 most important genotypes (GTs) and the
worldwide chief causes chronic liver illness. The
genetic multiplicity of HCV has been clearly related
extended effect of it is highly inconstant, ranging
to the topographical spreading of it in different
from least histological changes to broad fibrosis and
populations. HCV GT4 appears in about 8% of
cirrhosis with possibility of hepatocellular
chronic HCV infections worldwide; it is
carcinoma (HCC). The morbidity and mortality of
predominant HCV genotype in Middle East &
this global infection are growing (1). The estimated
Africa, especially Egypt (90%) (3). The main aim of
worldwide prevalence of HCV is a by the World
hepatitis C treatment is to therapy the infection. An
Health Organization (WHO) affecting >170 million
additional objective of it is to prevent their
people worldwide. There is a varied distribution of
complications, as necro-inflammatory process,
HCV infection with about 23 million people likely
stiffness, cirrhosis with or without decompensation,
to have it in the countries of Eastern Mediterranean
HCC, serious extra-hepatic signs and death (4). The
Region. This is nearly number of infected people in
definition of sustained virological response (SVR) is
both Americas and Europe. Egypt is considered to
nonappearance of HCV RNA after treatment
have highest prevalence worldwide with an expected
accomplishment. The infection is cured in more than
ninety nine percent of patients who reach a SVR
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5338-5344
The Impact of Antithyroid Antibodies on Pregnancy Outcome following
Intracytoplasmic Sperm Injection (ICSI) cycle
Abdel Fattah Mohamed Al Sayed AlSinety 1, Asem Anwar Abdo Mousa 1, Ahmed Samy Soliman Amer 1,
Ahmed Mohamed Kamal Fata 2, Hagagy AbdAlatif Ahmed Abozeid 1
1Obstetrics and Gynecology Department, 2International Islamic Center of Population Studies and Researches, Faculty of Medicine, Al-
* Corresponding author: Hagagy AbdAlatif Ahmed Abozeid, E-Mail: email@example.com
Background: the presence of antithyroid antibodies (ATA) are frequently encountered in general population
and approximately 1/5 of childbearing age women are positive for the antithyroid peroxidase antibody (TPO-
Ab) or antithyroglobulin antibody (TG-Ab). Autoimmune thyroid diseases are rather frequent in women in the
childbearing age, affecting 5-20% of them. They are characterized by the presence of antithyroglobulin and
antithyroperoxidase antibodies, grouped under the definition of ATA. ATA are often detected in subjects
complaining of hypo- or hyperthyroidism, but are no rarely found in patients without any sign of thyroid
Aim of the Work: to investigate the impact of antithyroid antibodies on pregnancy outcome in cases of one or
two failure of Intracytoplasmic Sperm Injection (ICSI) cycle.
Patients and Methods: the present study is a prospective study. This study was conducted at Ahmed Oraby
IVF center (private center), and was approved by the Medical Ethical Committee of Al-Azhar University.
Informed consent was obtained from every patient according to Hospital Ethics Committee. Age of patients,
diseases status and previous treatments were recorded. This study was done on 50 patients complaining of
infertility with history of one or two failure of ICSI cycle and patients divided into two groups, in the ATA
positive group, 25 women were positive for TG-Ab and/or TPO-Ab, 25 women negative for TG-Ab and/or
TPO-Ab served as controls. All patients did not receive any adjuvant treatment, such as glucocorticoids,
anticoagulants, or other adjuvants. Patients with other autoimmune diseases, or positive for anticardiolipin
antibody, antinuclear antibody, lupus anticoagulant, or rheumatoid factor were excluded from this study.
Results: there were no significant differences in age, BMI, basal LH, FSH levels, cause of infertility and
duration of infertility between two main groups. No significant differences in terms of the days of ovarian
stimulation, estradiol level, total gonadotropins dose, number of oocytes retrieved, available embryos and
blactocysts number neither of embryos transferred nor in rates of fertilization, implantation and clinical
pregnancy between two main groups were found. The only statistically significant among the ATA positive
group increase the abortion rate was found p value 0.02.
Conclusion: patients with anti-TPO antibodies showed no significant differences in fertilization, implantation,
pregnancy rates, live birth rates but higher risk for miscarriage following intracytoplasmatic sperm injection-ICSI
and embryo transfer when compared with those negative for anti-thyroid antibodies.
Keywords: Antithyroid Antibodies, Intracytoplasmic Sperm Injection, Antithyroglobulin, Antithyroid Peroxidase
Women with no signs of thyroid dysfunction who
The presence of antithyroid antibodies
were ATA positive, the risk of spontaneous
(ATA) are frequently encountered in general
miscarriage increased three to five folds more than
population and approximately 1/5 of childbearing
ATA negative women (3). Some authors even
age women are positive for the antithyroid
reported an unexpectedly high ATA prevalence in
peroxidase antibody (TPO-Ab) or antithyroglobulin
euthyroid women with a history of three or more
antibody (TG-Ab) (1). Autoimmune thyroid
unsuccessful IVF cycles, and ATA-positivity was
diseases are rather frequent in women in the
found to be associated with a low pregnancy rate in
childbearing age, affecting 5-20% of them. They
IVF. On the contrary, other studies failed to detect
any difference in IVF success rate between ATA
positive and ATA negative women (4). Previous
antibodies, grouped under the definition of
researches showed there were 10.5% of infertility
antithyroid antibodies (ATA). ATA are often
women who were positive for ATA (5). It has been
detected in subjects complaining of hypo- or
shown that the TPO-Ab level was associated with
hyperthyroidism, but are no rarely found in patients
the thyroid stimulating hormone (TSH) level: 1)
without any sign of thyroid dysfunction (2). Some
TPO-Ab positive women had significantly increase
evidence suggests that ATA could exert a negative
TSH level. 2) Some women with normal TSH level
influence on the female reproductive potential.
were found to be positive for TPO-Ab (6). The
presence of ATA in euthyroid women may be
The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (9), Page 5345-5350
Role of Layer by Layer Irrigation by Povidone Iodine during Closure of
Potentially Contaminated Wounds in Reduction of Surgical Site Infection
Abd Alla Abd Alhamid Sallam, Mostafa Mahmoud Salama, Hamada Mohamed Fahmy Alshaer*
Department of General Surgery, Faculty of Medicine, Al-Azhar University
* Corresponding author: Hamada Mohamed Alshaer, E-Mail: firstname.lastname@example.org
Background: surgical site infection (SSI) is the infections occurring up to 30 days after surgery that affect the
incision, deep tissue at the operation site or involve the organs or body space. Infection at the surgical site
remains the second most common adverse event occurring to hospitalized patients and a major source of
morbidity following surgical procedures.
Aim of the Work: this study was done to assess the role of irrigation of partially contaminated wounds by
povidone iodine in reduction of surgical site infection.
Patients and Methods: this descriptive prospective study was carried out on 100 patients of potentially
contaminated wounds at El-Hussein University Hospital and others, Patients divided into two groups A&B
each group consisted of fifty patients, Group A: their wounds irrigated layer by layer with povidone iodine
during closure, Group B: their wounds closed without irrigation with povidone iodine.
Results: total number of cases with SSI in our study is twenty cases 20% of the total count. In group A there
was nine cases two of them showed pus formation. While, in group B there was eleven cases eight of them
undergo pus formation.
Conclusion: from our study we concluded that The irrigation of the subcutaneous tissue during closure of
potentially (clean) contaminated wounds layer by layer by povidone-iodine 10% solution did not significantly
reduces the surgical site infection percentage but significantly reduced the formation of pus within the infected
wound cavity and thus reducing the severity of surgical site infection.
Keywords: Surgical site infection (SSI), Potentially (clean) contaminated wound, Povidone-iodine (PVI), Irrigation.
contaminated wound is an operative wound in
Surgical site infection (SSI) is the
which the respiratory, alimentary, genital, or
infections occurring up to 30 days after surgery
uninfected urinary tract is entered under
that affect the incision, deep tissue at the
controlled conditions, including controlled
operation site or involve the organs or body
contamination by the contents of the relevant
space(1). Despite considerable research on best
tract(s), is rated clean contaminated or Class II.
practices and strides in refining surgical
Specifically, operations involving the biliary tract,
appendix, vagina, and oropharynx are included in
environmental improvements in the operating
this category, provided there is neither evidence
room (OR), and the use of prophylactic
of infection nor major break in technique. SSI
preoperative antibiotics, infection at the surgical
rates in this class of procedures ranges from 4% to
site remains the second most common adverse
10 % (1). Most SSIs are caused by gram-positive
event occurring to hospitalized patients and a
cocci, including Staphylococcus aureus (S aureus)
major source of morbidity following surgical
procedures (2, 3). All surgical wounds are
colonizing a patient's skin. Meanwhile, there is an
contaminated by bacteria, but only a minority
increased likelihood of infection caused by gram-
actually demonstrates clinical infection. In most
negative bacilli after surgery on the GI tract;
patients, infection does not develop because
Enterococcus faecalis and Escherichia coli are
innate host defenses are quite efficient in the
common pathogens after clean contaminated
elimination of contaminants at the surgical site.
surgery (5, 6). Intraoperative wound irrigation is the
The Centre for disease control and prevention
flow of a solution across the surface of an open
(CDC) (1) has established four wound classes
wound to achieve wound hydration and it is
based on the degree of contamination with
widely practiced to help prevent SSI (7, 8). It is
intended to act as a physical cleaner by removing
Contaminated and Dirty-infected wounds. The
cellular debris, surface bacteria and body fluids,
evidence reveals that the risk of SSI increases if
to have a diluting effect on possible
the surgical wound is contaminated with more
contamination, and to function as a local
than 105 microorganisms per gram of tissue.
antibacterial agent when an antiseptic or antibiotic
However, this threshold is reduced when foreign
agent is used. Up to 97% of surgeons state that
bodies, such as detritus, sutures, and drains, are
they use intraoperative irrigation (7). Evidence
present in the surgical wound (4). Clean-
shows that the irrigation of the incisional wound
with an aqueous povidone iodine (PVP-I) solution