ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5709-5714

The Evaluation of Routine Central Nodal Dissection in Radiologically Node
Negative Differentiated Thyroid Carcinoma
Ayman AbdAllah AbdRabo, Mohamed Fayek Mahfouz, Ahmed Adel Darwish, Ahmed Yosry
AbdulAleem Ammar
Department of General Surgery, Faculty of Medicine-Ain Shams University
Corresponding author: Ahmed Yosry AbdulAleem Ammar, Mobile: 01007384576; Email: ahmed.yosry@med.asu.edu.eg
thyroid cancer is the most common malignant disease in endocrine system and is rapidly
increasing in incidence. The use of routine prophylactic central neck dissection for the treatment of
differentiated thyroid cancer has been an area of debate over the past few decades. Aim of the Work: the
primary aim of surgery was to resect disease, minimize the chance of recurrence and achieve this with minimal
morbidity. Selecting the appropriate procedure is critical as not only does surgery provide initial therapy, but
also optimizes the patient for adjuvant radioactive iodine (RAI) therapy when required. Patients and
this study was conducted to evaluate the efficacy of prophylactic central lymph nodal dissection in
patients diagnosed with differentiated thyroid carcinoma from several points of view including operative time,
hospital stay, postoperative complications and most importantly the recurrence. Our patients were operated
upon between August 2016 and August 2017 with minimal follow up of 6 months and follow up extended to 2
years after surgery. Results: Operative time was significantly higher in group B with a mean time of 141.68 ±
12.72 as compared to group A. The most outstanding difference in terms of complications was detected in
transient hypoparathyroidism that occurred in 16% of group B patients. A single case of recurrence was
detected at 12 month in group A that was confirmed by fine needle aspiration cytology which required
reoperation. Conclusion: there was no convincing evidence that pCND leads to an improvement in recurrence rate,
overall survival, or any clinically significant variable when applied indiscriminately to DTC patients.
Keywords: Differentiated thyroid cancer, papillary thyroid carcinoma, radioactive iodine

and pretracheal nodes and at least one paratracheal
Thyroid cancer is the most common
lymph node basin (1). The inability to diagnose
endocrine malignancy, and its incidence is
lymph node metastases accurately by preoperative
increasing at the highest rate among cancers
ultrasonography (low sensitivity) or intraoperative
worldwide (1). Differentiated thyroid cancer (DTC),
inspection, the high incidence of lymph node
which derives from follicular epithelial cells,
metastases, the decreased risk of local recurrence
includes papillary and follicular cancer; DTC
and need for reoperation and its morbidity, the
accounts for more than 90% of all thyroid cancers
improved ability to justify radioactive iodine (RAI)
(2). Lymph node metastases are a common finding
in papillary thyroid carcinoma (PTC), occurring in
surveillance, and the failure of I131 ablation in
20­50 % of patients in the central compartment of
approximately 30% of cases are considered factors
the neck (level VI) and in 10­30 % in the lateral
that favor routine (or prophylactic) central lymph
compartment of the neck (levels II ­V) (3).
node dissection (5). Given the excellent overall
However, despite good prognosis, loco- regional
survival rates associated with PTC and the
recurrence is relatively common after curative
potential morbidity associated with reoperative
surgery. With recognition of the step-wise
cervical surgery, prophylactic CND may seem to
progression of metastasis from central (level VI) to
be appropriate, as it may decrease the disease
lateral (levels II­V) compartments, routine
recurrence rate by extirpating level VI lymph nodes
prophylactic central neck dissection (pCND) has
been advocated at the time of total thyroidectomy
to minimize loco- regional recurrence (4). The
This work aimed at prospectively
central compartment is bounded by the hyoid bone
comparing between total thyroidectomy alone and
(superior), carotid artery (lateral), and sternal notch
total thyroidectomy combined with central node
or innominate artery (inferior). The American
dissection in clinically and radiologically negative
Thyroid Association (ATA) defines central
lymph nodes in cases of differentiated thyroid
compartment neck dissection as "comprehensive,
compartment-oriented removal of the prelaryngeal

Full Paper (vol.731 paper# 1)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5715-5724

Clinicopathologic Study of Endometrial and Hormonal Changes after Metformin
Therapy in Patients with Polycystic Ovary Syndrome
Salah-el-din Sayed Semary 1, Al-Sayed A. Abd-Elrahman 2, Ahmad Taha 3, Mahmoud F.Midan4,
Rashed M. Rashed4, Tarek M. Emran5
1. Department of Pathology, Faculty of Medicine, Al-Azhar University, Damietta.
2. Department of Anatomy and Embryology, Faculty of Medicine, Port Said University, Egypt.
3. Department of Physiology, Faculty of Medicine, Port Said University, Egypt.
4. Department of Obstetrics and Gynecology, Al-Azhar Faculty of Medicine, Damietta
5. Department of Clinical Pathology, Al-Azhar Faculty of Medicine, Damietta
*Corresponding Author: Salah-el-din Sayed Semary , E-mail: drsalahsemary@yahoo.com
Polycystic ovary syndrome (PCOS) is a common complex genetic condition of women in the
reproductive age. PCOS is a heterogeneous syndrome characterized by clinical/biochemical androgen excess,
ovulatory dysfunction and polycystic ovaries. Metformin therapy has been proved to improve fertility in
patients with PCOS, inducing not only high ovulation and pregnancy rates, but also reducing the incidence of
miscarriages. Aim of the Work: This study was aimed to evaluate the effects of metformin therapy on
hormonal profile and endometrial tissue, including pattern of immunohistochemical expression of androgen
receptors (AR), in patients with PCOS. Patients and Methods: 100 patients with PCOS were included in this
study. Each investigated case was submitted to detailed medical history, clinical examination that included
body hair distribution, body weight, height and body mass index (BMI), transvaginal ultrasound, laboratory
investigations ( included fasting insulin, free testosterone, LH and FSH levels). Endometrial pipelle samples
were taken for histopathological evaluation and assessment of androgen receptor expression. These
investigations were done before and after three months of metformin treatment. Results: A significant
decrease of BMI of the investigated cases after metformin therapy was observed (P value <0.003). There was a
significant decrease of LH level after metformin therapy from 9.17±2.84 Miu/ml to 6.18±3.6 Miu/ml and of
fasting insulin level from 14.3±4.3 to 8.2±5.9. Insignificant increase of FSH level from 3.87±1.8 to 4.85±2.6 and
also insignificant decrease of free testosterone level from 1.58±o.83 to 1.38±1.4 were also observed.
Histopathological results of the endometrial specimens before metformin therapy revealed histologic features
of early proliferative endometrium in 64 cases, 20 cases with a late proliferative endometrium and examination
of the remaining 16 cases revealed features of simple endometrial hyperplasia. Among the 64 cases diagnosed
as early proliferative endometrium before the therapy, 60 cases showed features of a late proliferative
endometrium after treatment and the remaining 4 cases showed no histomorphologic changes. Among the 20
cases diagnosed as a late proliferative endometrium before therapy, 6 cases showed features of early secretory
phase after therapy, 6 cases showed features of mid-secretory endometrium while the remaining 8 cases
showed a late secretory endometrium that indicate successful ovulation after therapy. Regression of
hyperplasia after therapy was noted in 6 of the 16 cases diagnosed as simple endometrial hyperplasia.
Immunohistochemical (IHC) results revealed marked increase in endometrial AR expression in patients with
PCOS compared to the normal fertile controls (p<0.004). Also, a significant decrease of AR expression in
endometrial epithelial and stromal cells after metformin administration in patients with PCOS was noted
(p<0.003). Conclusion: Metformin therapy restores normal menstrual cyclicity in patients with PCOS, induces
ovulation and showing significant decrease in endometrial AR expression.
Keywords: PCOS, Metformin, AR immunoexpression.
via stimulation of ovarian androgen secretion and
Polycystic ovary syndrome (PCOS) is a
inhibition of hepatic sex hormone-binding globulin
common disorder of women in the reproductive age
production (2). Patients with PCOS usually need
medical treatment for management of menstrual-
manifestations and its main symptoms may appear
related disorders and infertility and also have
from adolescence (1). Various diagnostic criteria
various long-term complications which have been
have been proposed, generally centered on the
frequently underestimated (3). Gestational diabetes
features of hyperandrogenemia, oligo-ovulation and
and hypertensive disorders are more likely to occur
polycystic ovarian morphology (1). Insulin resistance
in women with PCOS during pregnancy, and as they
is present in a majority of cases, with compensatory
get older, metabolic diseases such as glucose
hyperinsulinemia contributing to hyperandrogenism
intolerance, type II diabetes and hyperlipidemia are
frequently occurred (3). Therefore, lifelong follow-up

Full Paper (vol.731 paper# 2)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5725-5735

The Utility of P53, P63, P57 and Ki67 Immunohistochemistry in the
Differentiation between Hydropic Abortion and Molar Pregnancy
(Immunohistochemical Study)
Salah-el-din Sayed Semary 1, Al-Sayed A. Abd-Elrahman 2, Mhammed Hafez Mohammed 3
1. Department of Pathology, Faculty of Medicine, Al-Azhar University, Damietta.
2. Department of Anatomy and Embryology, Faculty of Medicine, Port Said University, Egypt.
3. Department of Obstetrics and Gynecology, Faculty of Medicine, Port Said University, Egypt.
*Corresponding Author: Salah-el-din Sayed Semary , E-mail:drsalahsemary@yahoo.com
The classification of molar pregnancies into a complete and a partial hydatidiform mole and the
differentiation from hydropic abortions are usually accomplished by histomorphologic features alone, but
sometimes may be inaccurate or inconclusive. Immunohistochemical staining techniques have been reported as
a good diagnostic method complementary to the histologic diagnosis. One of the advantages of this technique
is the ability to apply it retrospectively to sections of formalin fixed/paraffin embedded tissue and therefore,
there is no need for expensive or sophisticated techniques. Aim of the Work: This study aimed to determine if
immunohistochemical expression of p53, p63, p57 and Ki67 could aid in differentiating molar from non molar
pregnancies on one hand and complete mole from partial mole on the other hand. Materials and Methods: A
total of 180 placental specimens were enrolled in this study including 60 non molar placental specimens with
hydropic changes (HA) and 120 molar specimens (60 complete hydatidiform moles (CHMs) and 60 partial
hydatidiform moles (PHMs). The studied cases were examined histologically and immunohistochemically for
expression of p53, p63, p57 and Ki67. Results: There was a significant difference in p57 expression between
HA and PHM (P value < 0.05), HA and CHM (P value < 0.0001) and also between PHM and CHM (P value <
0.003). There was a significant difference in Ki67 expression between HA and PHM (P value < 0.03), PHM
and CHM (P value < 0.01) and between HA and CHM (P value < 0.009). There was no significant difference
in P63 expression between HA and PHM (P value 0.8), PHM and CHM (P value 0.5), and also between HA
and CHM (P value 0.2). A significant difference in p53 expression between HA and CHM (P value < 0.007)
was noted, also between PHM and CHM (P value <0.005), while no significant difference between HA and
PHM in expression of p53 (P value 0.8).
Keywords: Molar pregnancy and hydropic abortion, immunohistochemistry.
these conceptuses could be confused with PHM (5).
Although morphologic features are often
About 8% to 30% of patients with complete
adequate to differentiate hydropic abortions from
hydatidiform mole need chemotherapy after
molar gestations, early hydropic abortions may
evacuation for persistent trophoblastic disease and
exhibit atypical trophoblastic proliferation and
0.6% - 1.5% of patients will have a recurrent molar
pronounced hydropic swelling that can be
pregnancy (6). With partial molar pregnancy, the risk
occasionally confusing, leading to an erroneous
of persistent trophoblastic disease is much lower
diagnosis of hydatidiform mole (HM) (1).
than in cases of a complete mole and only about 5%
Furthermore, the most reliable feature of molar
of patients with partial mole require chemotherapy
gestation, the presence of macroscopically
after evacuation (7). The risk of choriocacinoma in
identifiable large hydropic vesicles, is only seen in
complete hydatidiform mole is about 10%-30% and
the second trimester of gestation (2). The recent trend
in partial hydatidiform mole is 0.5%-5% (8). Several
toward ultrasound study in early pregnancy has
immunohistochemical markers have been studied
resulted in evacuation of hydatidiform moles at
for this differential diagnosis and one of these
earlier stages before the development of the usually
markers is p57 gene, which is a cyclin-dependent
recognized diagnostic criteria; i.e., trophoblastic
kinase inhibitor located on chromosome 11p15.5 (9).
hyperplasia and cistern formation (3). Even very
It is strongly paternally imprinted and expressed
experienced pathologists have problems in
predominantly from maternal allele in most tissues
differentiating some PHM from CHM because the
. P57expression is markedly reduced or absent in
degree of trophoblastic proliferation and the
CHM compared to strong expression in both PHM
proportion of hydropic villi vary in both conditions
and HA, so, it is diagnostic of CHM but helpless in
(4). Because hydropic degeneration occurs in 15% to
differentiation between PHM and HA (11). Ki-67
40% of nonmolar spontaneous abortion, some of
labeling index in cytotrophoblastic cells could be
helpful in differentiation between abortion and

Full Paper (vol.731 paper# 3)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5736-5742

Supraclavicular Brachial Plexus Nerve Block versus Patient Controlled Analgesia
for Post-Operative Pain Management in Forearm Surgery
Mohamed Mohamed Nabil El Shafei, Mahmoud Hasan Mohamed Hasan,
Ahmed Abd Eldayem Abd Elhak, Mai Mohamed Zakaria Abdelhamid
Anesthesiology and Intensive Care Department, Faculty of Medicine, Ain Shams University
Corresponding author: Mai Mohamed Zakaria Abdelhamid, Mobile: 01112071838, E-mail: mai_zakaria256@yahoo.com
supraclavicular Brachial plexus block is an excellent method for attaining optimal operating
conditions for upper limb surgeries by producing complete muscular relaxation, maintaining haemodynamic
stability and the associated sympathetic block. Aim of the Work: the purpose of this study was to compare
Supraclavicular Brachial plexus nerve block to patient controlled analgesia for postoperative pain management
in forearm surgeries. Therefore, we performed a randomized study to compare the efficacy of Supraclavicular
Brachial plexus nerve block with that of patient controlled analgesia. Patients and Methods: sixty-four
patients presenting to Ain Shams University hospitals for forearm surgeries were enrolled in this prospective
randomized study after providing written consents. Participants were instructed about the study protocol and
visual analogue scale (VAS). Approval was obtained from the research ethics committee of anesthesia and
intensive care department, at Ain Shams University. Results: the results of the study revealed that there is
significant difference between supraclvicular brachial plexus block and patient controlled analgesia regarding
the postoperative analgesia after forearm surgery. Conclusion: there is significant difference between
supraclvicular brachial plexus block and patient controlled analgesia regarding the postoperative analgesia
after forearm surgery. Significantly better pain control was observed in the supraclvicular brachial plexus
block group. Patient satisfaction was greater in the supraclvicular brachial plexus block group. Nausea and
vomiting were observed more frequently in patient controlled analgesia group.
Keywords: Patient controlled analgesia, peripheral nerve stimulation, subclavian artery, systolic blood

Inadequate postoperative pain management
(sympathectomy), better postoperative analgesia,
has been correlated with poor functional recovery
earlier discharge for outpatients, and fewer side
in some patients (1), and can activate a variety of
effects. The classical approaches (interscalene,
biologic cascade systems, resulting in ileus, nausea,
supraclavicular, infra-clavicular, and axillary) have
delayed mobilization and feeding, delayed hospital
been described for many years (7). Supraclavicular
discharge, and unanticipated hospital readmission
Brachial plexus block is an excellent method for
(2). Opioids are considered the cornerstone for
attaining optimal operating conditions for upper
limb surgeries by producing complete muscular
postoperative pain, and PCA is the most frequent
relaxation, maintaining haemodynamic stability
mode of postoperative opioid administration
and the associated sympathetic block. They also
(3). However, potent opioids result in potential side
provide extended postoperative analgesia with
minimal side effects. In addition, it offers a better
drowsiness, sedation, nausea, vomiting, pruritus,
preservation of mental functions in elderly;
urinary retention, ileus, and constipation are
decreased risk of aspiration due to intact
frequently observed during opioid PCA(4). Because
pharyngeal and laryngeal reflexes; avoids difficult
of these unwanted adverse effects, PCA is often
intubation; decreases postoperative complications
associated with intubation and provides better
management(5). Patients consider nausea and
postoperative analgesia without undue sedation
vomiting to be the most undesirable postoperative
facilitating early mobilization and discharge (8).
complications (6). Postoperative analgesia with
fewer side effects is not only important for the
The aim of this study was to compare
patient but is also important for the surgeon.
Supraclavicular Brachial plexus nerve block to
Brachial plexus block offers many advantages over
patient controlled analgesia for postoperative pain
general anesthesia for upper extremity surgery,
management in forearm surgeries. Therefore, we
including reduced surgical stress response,
performed a randomized study to compare the

Full Paper (vol.731 paper# 4)

Full Paper (vol.731 paper# 5)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5748-5752

A Comparative Study between the Performing Spinal Anesthesia in
Sitting versus Lateral Position on Patient Hemodynamics
Galal Adel El Kadi, Randa Ali Shokry Mohamed, Andrew Mehany Fares*
Anesthesia, Intensive Care and Pain Management Department, Faculty of Medicine,
Ain Shams University
* Corresponding Author: Andrew Mehany Fares, E-mail: Androomehanyy@yahoo.com

spinal anesthesia is frequently accompanied by hypotension, which may be defined in absolute
terms as a systolic blood pressure of 90 or 100 mmHg or in relative terms as a percentage (20% fall from
baseline). The severity of hypotension depends on the height of the block, the position of the patient and the
volume status. Aim of the Work: to compare the effect of performing spinal anesthesia in sitting versus lateral
position on patient hemodynamics (blood pressure and heart rate).
Patients and Methods: after approval from departmental ethics committee and written informed consent from
the patient, a randomized study was conducted on eighty patients with American society of anesthesiologists
physical status I and II aged from 21 to 50 years of both genders. The study conducted from January 2018 to May
2018. Preoperative investigations were done according to the local protocol designed to evaluate the patients.
Results: The onset of sensory block of spinal anesthesia (the time needed to reach the sensory level between T8
& T10) was relatively faster in lateral group (3.93 ± 1.05) than in sitting group (4.40 ± 1.26) but, these differences
were statistically not significant.
Conclusion: because we have used hyperbaric bupivacaine, it is more likely that the drug settled down more
quickly in the sitting position than in the lateral position.
Keywords: Performing Spinal Anesthesia, Lateral Position, Patient Hemodynamics.


Spinal anesthesia can be initiated with the
patient in either the sitting or the lateral position,
To compare the effect of performing spinal
and each position has its advantages and
anesthesia in sitting versus lateral position on patient
disadvantages. The sitting position appears to be
hemodynamics (blood pressure and heart rate).
optimal for the placement of spinal anesthesia as

identification of landmark, particularly midline, is
much easier. However, maintaining the sitting
After approval from departmental ethics
position is often difficult for patients. On the other
committee and written informed consent from the
hand, the lateral position is generally considered
patient, a randomized study was conducted on
easy to maintain for patients. However, the
eighty patients with American society of
identification of anatomical landmark is difficult (1).
anesthesiologists (ASA) physical status I and II aged
Spinal anesthesia is frequently accompanied
from 21 to 50 years of both genders, the study
by hypotension, which may be defined in absolute
conducted from January 2018 to May 2018.
terms as a systolic blood pressure of 90 or 100
Study design and sampling:
mmHg or in relative terms as a percentage (20% fall
The study was a randomized, prospective,
from baseline). The severity of hypotension depends
comparative, clinical and single-blinded study.
on the height of the block, the position of the patient
Inclusion Criteria:
and the volume status (2).
The study was conducted on patients ASA I
Spinal anesthesia induced hypotension is
to II, aging 21-50 years of both genders who were
caused by an increase in venous capacitance because
allocated for lower abdominal, urological, pelvic,
of sympathectomy causing venodilation in the lower
gynacological or lower limb surgeries under spinal
part of the body. Hypotension caused by a reducion
in systemic vascular resistence is physiologically
Exclusion Criteria:
compensated by an increase in cardiac output.
Patients who were ASA III or IV, liver or
However, a high level of spinal block can inhibit the
kidney dysfunction, heart failure or myocardial
cardioaccelerator fibers leading to a fall in the heart
rate and hence, instead of a compensatory increase,
hemodynamics instability, morbid obese (BMI 30)
cardiac output usually decreases. The combined
and any contraindication for spinal anesthesia.
effect of reduced cardiac output and decreased
Preoperative preparation:
systemic vascular resistence accounts for the high
Routine preoperative assessment was done
incidence of hypotension after spinal anesthesia (3).
to all patients on the day before operation; including


Full Paper (vol.731 paper# 6)

Introduction and Aim of the work The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5753-5769

Comparison between Cabergoline and Coasting in Prevention of Ovarian
Hyperstimulation Syndrome and their effect on Intracytoplasmic Sperm
Injection Outcome
Ismaeil M. El-Garhy , Ahmed O. Abdel Motaal , Mohamed G. Omr
Department of Obstetrics and Gynecology
Faculty of Medicine, Al Azhar University
Corresponding author: Mohamed Gamal ,email:mohamedgamalomer90@gmail.com,Mobile : 01091133258

Aim of the work:
ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, serious and potentially fatal
complication of ovarian stimulation, affecting1­14% of all IVF/ICSI cycles. This study aimed to compare
cabergoline after hCG administration with delayed hCG administration (coasting) in high risk patients to
prevent OHSS in ART cycles. Patients and methods: this prospective comparative randomized study
included 100 patients at risk of OHSS performed in the Assisted Reproductive Technologies Center, Al-
Azhar University and in Private IVF Centers during the period from November, 2015 to October, 2016.
Results: comparison between the two groups showed no significant difference regarding age, BMI, presence
of risk factors of OHSS, but there was a significant difference regarding FSH, LH and the mean diameter of
follicles on day of hCG administration. Conclusion: PCOS affects 5 to 10% of women of childbearing age
and is the most common cause of anovulatory infertility in developed countries. Recommendations: further
studies including large number of cases and for longer duration will further confirm the efficacy of
cabergoline and coasting on prevention of OHSS.
Keywords: Cabergoline, Coasting, Ovarian Hyperstimulation Syndrome, Intracytoplasmic Sperm Injection

with chronic an ovulation in women without
WHO defines infertility as follows:
specific adrenal and pituitary gland disease. A
infertility is the inability to conceive a child. A
family history of polycystic ovary syndrome may
couple may be considered infertile if, after two
be present in a subset of patients, however, the
years of regular sexual intercourse, without
genetic basis of the syndrome remains unclear.
contraception, the woman has not become
Most often, the age of onset is perimenarchal and
pregnant (and there is no other reason, such as
it is characterized by the appearance of menstrual
breastfeeding or postpartum amenorrhoea).
disturbances, hirsutism, acne, and more rarely and
Primary infertility: is infertility in a couple
male pattern of alopecia. Polycystic ovary
who have never had a child.
syndrome is also associated with metabolic
Secondary infertility: is failure to conceive
disturbances, such as obesity and insulin
following a previous pregnancy. Infertility may be
resistance with hyperinsulinemia (2).
caused by infection in the man or woman.
ICSI is a laboratory procedure in which one
Causes of Infertility:
or more eggs (oocytes) are retrieved. Fertilization is
Male factors 30%.
achieved by the injection of individual sperm into
Female factors 30%.
each egg (3).
Combined 10%
Implantation is the final and the most
Unexplained 25%.
crucial step in intra cytoplasm sperm injection
Others 5%
(ICSI) and in vitro fertilization (IVF), however it
Polycystic ovary syndrome is a clinical
is the least successful, as a few embryos replaced
diagnosis characterized by the presence of two or
in the uterine cavity will result in clinical
more of the following features: chronic oligo-
pregnancy. The majority of women undergoing
ovulation or anovulation, androgen excess and
IVF will reach the embryo transfer (ET) stage,
polycystic ovaries. It affects 5 to 10% of women
with good quality embryos available for transfer,
of childbearing age and is the most common cause
but only a small proportion of them will ever
of anovulatory infertility in developed countries.
achieve a clinical pregnancy or live birth. Up to
85% of the embryos replaced into the uterine
menstrual irregularities and signs of androgen
cavity will fail to implant this makes the ET
excess (such as hirsutism, acne, and alopecia (1).
procedure a highly vital, but an inefficient step in
IVF (4).
heterogeneous clinical syndrome, which has been
In 1989, a study carried out by Englert et
defined as the association of hyper androgenism
al. (5) reported a 33.3% pregnancy rate with

Full Paper (vol.731 paper# 7)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5770-5776

Comparative Study between Flexible Ureteroscopy and Semirigid Ureteroscopy in
Management of Upper Ureteric Stones using Laser Lithotripsy
Youssef Mahmoud Kotb, Ahmed Farouk Mahmoud, Kerollous Nashaat Harras Soliman
Department of Urology, Faculty of Medicine ­ Ain Shams University
Corresponding author: Kerollous Nashaat Harras Soliman, Mobile: 01220162592; Email:
There are various options in the management of proximal ureteral stones, which includes medical
expulsive therapy, extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS; retrograde),
percutaneous nephrolithotomy (PCNL), laparoscopy (LAP), and open surgery.
Objective: The aim of this study was to evaluate the efficacy and safety of both semirigid and flexible
ureteroscopy in management of upper ureteric stones using laser lithotripsy.
Patients and Methods: To achieve this goal, this prospective study was done at the urology department, Ain
Shams University Hospitals on 60 patients with upper ureteric stones less than 2 cm in size. They were divided
into groups of 30 patients in each group. Patients in group A were treated by semirigid ureteroscopy. While
patients in group B were treated by flexible ureteroscopy using laser lithotripsy in both procedures.
Results: Stone free rate was 90.0% in group A while it was 93.3% in group B. Mean operative time was 55.07
± 13.24 min in Group A while it was 64.63 ± 17.33 min in Group B. Success rate was 76.7% in group A, while
it was 90.0% in group B. 20% of patients in group A had intra or postoperative complications in the form of:
6.7% of cases had failure to access to the stone, in 3.3% of cases there was upward migration of stone toward
kidneys, 3.3% of cases had ureteral submucosal injury, 3.3% of patients had postoperative fever and 3.3% of
patients developed haematuria.
Conclusion: Flexible ureteroscopy is a favorable option for patients having proximal ureteral stones with
higher stone free rate and success rate. On the other hand, semirigid ureteroscopy is an acceptable alternative
for treatment of proximal ureteral stones. Flexible ureteroscopy costs is much higher compared to semirigid
Keywords: Flexible Ureteroscopy; Semirigid Ureteroscopy; Upper Ureteric Stones.


Urinary calculi is the third most common
affliction of the urinary tract, exceeded only by
ureterolithotomy was being performed widely,
urinary tract infections and the pathological
nowadays in the management of ureteral stones
conditions of the prostate. The prevalence of
ESWL (Extracorporeal Shock Wave Lithotripsy)
urinary tract stone disease is estimated to be 2-3%
and endoscopic interventions are preferred (5).
Open ureterolithotomy is no longer considered as
Patients with urolithiasis constitute an
a valid option in a well equipped endourological
important part of everyday urological practice.
center (6).
The optimal clinical management of this disease
Nowadays, extracorporeal shock wave
requires knowledge of the diagnostic procedures,
lithotripsy (ESWL) and ureteroscopy (URS) are
the rational treatment of acute stone colic, stone
the most commonly performed treatment options
expulsive treatment and the modern principles of
in the management of proximal ureteral stones.
stone removal (2).
Although the European Association of Urology
The primary goal of complete stone
(EAU) urolithiasis guidelines showed that both
clearance for the management of proximal
URS and ESWL should be considered as a first-
ureteral stones is to preserve renal function,
line therapy for proximal ureteral stones, the
prevent further stone growth, cure infection, and
optimal treatment of these stones still remains
relieve obstruction (3).
debatable (4).
There are various options in the
In proximal ureteral stones smaller than
management of proximal ureteral stones, which
1cm, ESWL constitutes the first treatment
alternative. However, difficulties encountered
extracorporeal shock wave lithotripsy (ESWL),
during visualisation of the stone, presence of
ureteroscopy (URS; retrograde), percutaneous
impacted and/or calcium oxalate monohydrate and
nephrolithotomy (PCNL), laparoscopy (LAP), and
cystine stones, actual health state of the patient
open surgery (4).
lower the success rates of ESWL and lead to

preference of URS in such cases (7).


Full Paper (vol.731 paper# 8)

c:\work\Jor\vol731_9 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5777-5782
The Prevalence of Musculoskeletal Disorders among EMS Personnel in
Saudi Arabia, Riyadh
1Nawfal Aljerian,2 Saud Alshehri,2 Emad Masudi,3
Abdulaziz Mohammad Albawardi,1 Fiasal Alzahrani,2 Radhi Alanazi
1King Abdulaziz Medical City- Riyadh, 2King Saud Bin Abdulaziz University,3 King Saud Bin Abdulaziz University

Musculoskeletal disorders (MSDs) are common among EMS personnel throughout the world.
Objective: The aim of the study was to determine how common the (MSD) among the EMS personnel and its
associated factors such as smoking, BMI and place of work (field-workers and hospital-workers) in Saudi Arabia,
Methods: Cross-sectional study to measure the prevalence of (MSD) among the EMS personnel. The Nordic
Musculoskeletal Disorders Questionnaires were distributed to collect the data from SRCA and tertiary hospitals. The
required sample size was 180 from each group. Chi-square test was used to assess the association between the MSDs
and categorical date.
Results: Questionnaires of 360 participants were completed and analyzed. The most prevalent site affected was the
lower back (60.3%) followed by knees (41.4%), neck (40.3%) and upper back (40%); the least frequent disorder was
that of hip/thigh (10.3%). Hence, (37.2%) of the paramedics suffer low back pain during their duty. Also, BMI results
have shown a prevalence of obesity (19.2%), overweight (41.4%) and only (36.1%) fall within the normal range of
BMI and increased BMI is highly associated to lower back (p=0.009). Furthermore, smokers number were very high
(65%) and it was associated with MSD with (P<0.05) in the lower back and knees. The result showed that there was
no significant difference between work places.
Conclusion: The very high prevalence of MSDs was found among paramedics. It is suggested that paramedics have
to be engaged in programs at their work place. Such as, exercise, improve the manual handling techniques and
encourage smoke cessation.
Keywords: EMS Personnel, Musculoskeletal Disorders; Prevalence; Back Pain; Paramedics; Occupational Disorders;
Work-Related Injuries.

medical impairment and early retirement on medical
grounds than the general worker and worker in
Musculoskeletal disorders (MSDs) comprise a
medical occupations, and the study revealed that they
wide range of conditions that affect muscles, tendons,
have higher "somatic health problems" (e.g. MSDs)
ligaments, joints, bones, peripheral nerves and blood
than general workers (6). A study reported that EMS
vessels leading to pain, discomfort and impaired
personnel have a high body mass index (BMI), which
mobility (1). MSDs incur a significant economic burden
showed that over 75% of them where overweight or
on governments and ministries of health, particularly
obese due to busy work schedule and lack of exercise
in terms of costs, reduced productivity, increased
(7). Obesity is highly associated with MSDs such as
disability and absenteeism in both developed and
(low back pain, carpal tunnel syndrome, and plantar
developing countries (2-3). A study done in Baskent
fasciitis) (8). Smoking cigarettes also has a negative
University, Turkey, found that the MSDs are common
influence on musculoskeletal system such as
in hospital workers and the most common group was
intervertebral disc degeneration, muscle pain, tendon
the nurses (4).
rupture, delays fracture healing, and it is highly related
Emergency Medical Services (EMS) personnel are
to back pain (9). A recent study found the prevalence of
a group of health care professional which the job
MSDs among the EMS personnel have not changed
requires to intervene and rescue emergency ill patients
since 1990s and more than 50% of them complain of
as efficiently and quickly as possible, and they work
musculoskeletal pain and discomfort at least one day
day/night shifts with 12 hours per shift. Work-related
in a year (10); it seems to be the main reason behind the
musculoskeletal disorders (WRMSDs) are defined as
early retirement among the EMS personnel (11). EMS
any musculoskeletal disorders that occur during work
personnel (EMT or Paramedics) are at higher risk of
or resulted from work-related events (5)

. A systemic
back pain due to nature of the emergency duty, they
review measured the health status among the
are manual handling (lifting, moving and extricating
emergency medical services (EMS) personnel, the
from vehicles) the patients and equipment, facing
study found that EMS personnel are at higher risk of
stressful environments and long- time standing,

Full Paper (vol.731 paper# 9)

Syntactic profile in children with autism spectrum disorders (ASD) The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5783-5787

Syntactic Profile in Children with Autism Spectrum Disorders (ASD)
Omnya M. Lotfy, Azza A. Azzam, Ahmed N. Khattab and Safaa R. El-Sady
ENT Department, Phoniatric Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Omnya M. lofty, Tel: +201097806667, E-mail: omnya-mohamed87@ hotmail.com

in autism spectrum disorder the range of language abilities varies between total muteness to an
apparent grammatically complex language. There is a debate on the effect of autism on syntax development if it
is normal, delayed or deviant.
Aim of the Work:
it was to assess the syntactic profile of ASD children.
Patients and Methods:
a cross sectional descriptive research design. The subjects of this study comprised a
convenient sample of 20 children diagnosed as ASD and other 20 normal children as control group with age
range between 3 years 8 months and 11 years 8 months. Modified Arabic preschool language scale (PLS-4) Test
and Stanford Binet intelligence scales, fifth edition were done for all children and Child autism rating scale
(CARS) was done for children with ASD.
Results: syntax in ASD is significantly delayed compared to the syntax of normal subjects. Significant
impairments in certain items of syntax as (Making grammatical judgments or repairing grammatical errors,
understanding pronouns or expressing them, retelling sentences or stories, answering logically using negation,
expressing jobs in speech, using irregular plurals, using dualization, question formulation, using past tense forms
and using words that describe physical state) was found.
Conclusion: syntax in ASD was found to be affected and is found to be below the total language level of the
study subjects and this was confirmed by sustained repeated impairments in certain items of syntax.
Keywords: Autism spectrum disorder, syntax, language delay, and Arabic PLS-4.


People with Autism Spectrum Disorder
Children with autism produce less question and
(ASD) tend to have communication deficits,
negation utterances (9).
dependence on routines, high sensitivity to changes

in their environment, and intensely focusing on
inappropriate items (1).
To assess the syntactic profile of ASD
Syntax is the set of rules, principles, and
processes that govern the structure of sentences in a

given language, specifically word order. The term
syntax is also used to refer to the study of such
Type of study: descriptive cross sectional
principles and processes (2).
There is a debate on the effect of autism on
Patients: This study was applied on 20
syntax development, while some studies (3) suggest
children diagnosed as ASD in Phoniatric or
that the syntactic levels of autistic individuals with
Psychiatry clinics and other 20 normal children as
spoken language do not appear to be delayed relative
control group.
to other language domains, or relative to non-autistic

peers with developmental delays, some other studies
Inclusion criteria: Total language age above 2.5
(4) suggest that the mastery of syntax in autistic
children lags behind that of both normal and
Exclusion criteria:
mentally retarded children who have attained the Children having any other psychological
same level of nonlinguistic mental functioning.
A variety of specific features have been Children having any neuromotor disorder
described in the language of individuals with autism,
interfering with assessment.
for example:
Children having any known genetic or
The reversal of pronouns (saying ``you'' for ``me,''
chromosomal abnormality.
and vice versa (5).
Children having visual or hearing impairment.
Impaired comprehension of words referring to
emotions (6).
Procedures and clinical tools
Reduced sensitivity to grammatical errors (7).
For assessment of children, the following
Errors of verb tense marking (8).
selected assessment steps; extracted from the
Impaired use of articles and conjunctions (8).
language assessment protocol that is structured

and used at the Unit of Phoniatrics Ain Shams

University was used:

Full Paper (vol.731 paper# 10)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5788-5794

Role of MRI in Diagnosis of Medulloblastoma
Sameh M. Abdelwahab, Amgad S. Abdel-Rahman, Basma Gamal Abdelrhman
Department of Radiology, Faculty of Medicine - Ain Shams University
Corresponding author: Basma Gamal Abdelrhman, Mobile: 01019692010; Email: basmagamal860@gmail.com

Brain tumors represent the most common solid neoplasm in children and second most common
pediatric malignancy overall. The majority of primary childhood brain tumors occurs in the infratentorial
compartment and includes: medulloblastoma, juvenile pilocytic astrocytoma (JPA), ependymoma,
brainstem/pontine glioma, and atypical teratoid rhabdoid tumor (ATRT) which is an additional rare but
important primary brain tumor of early childhood.
This study aims to provide an overview of the imaging features and appearances of the most
common primary posterior fossa brain tumors in children and the diagnosis of medulloblastoma.
Patients and Methods:
The pool of our study was 25 patients (12 males and 13 females) who presented to
diagnostic radiology departments at EL Demerdash Teaching Hospital and National Cancer Institute. They had
been diagnosed to have posterior fossa lesions. Patients' age ranged from 1 to 17 year with mean age of 4.73
years.Results: statistically significant difference between medulloblastoma and other posterior fossa tumors
according to location and diffusion. Medulloblastoma is 4th ventricular in location and shows restriction in
diffusion weighted images. Conclusion: Medulloblastoma is predominately 4th ventricular in location,
Medulloblastoma is restricted in diffusion weighted images.
Keywords: Magnetic resonance imaging, diffusion weighted images, medulloblastoma, posterior fossa tumors.


medulloblastoma have a high likelihood of long-
Posterior fossa tumors are more common in
term survival, with a 5-year survival rate of 80%.
children than adults. Central nervous system tumors
Intensified therapy has been shown to increase
are the most common solid tumors in children;
survival in children with disseminated disease.
between 54% and 70% of all childhood brain tumors
However, the quality of life in long-term survivors
originate in the posterior fossa (1).
remains an important issue, because most survivors
Certain types of posterior fossa tumors, such
have neurologic and cognitive deficits (4).
astrocytomas of the cerebellum and brain stem,
medulloblastoma tumor formation have been
occur more frequently in children. Some glial
discovered. Advances in the molecular biology of
tumors, such as mixed gliomas, are unique to
medulloblastoma indicate that better understanding
children; they are located more frequently in the
cerebellum (67%) and are usually benign (2).
medulloblastoma may lead to the development of
Hydrocephalus is common in children with
new therapies for the disease (5).
posterior fossa tumors, occurring in 71% to 90% of
Although medulloblastoma has a highly
pediatric patients; approximately 10% to 40%
characteristic appearance on computed tomography
demonstrate persistent hydrocephalus after posterior
(CT) scanning, magnetic resonance imaging (MRI)
fossa tumor resection (2).Medulloblastomas are
is the preferred tool. The multiplanar capability of
highly malignant tumors; they are the most common
MRI provides better 3-dimensional visualization of
malignant posterior fossa tumor in the pediatric
the extent of the tumor, as well as better
population. They are characterized by their tendency
visualization of edema and herniation, when present.
to seed along the neuraxis, following cerebrospinal
MRI also is better for evaluating the remainder of
fluid (CSF) pathways, and they represent one of the
the neuraxis for metastasis. In addition, MRI
few brain tumors, including ependymoma,
spectroscopy may help better delineate the tumor's
pinealoblastoma, and lymphoma, to metastasize to
boundaries (6).With CT scanning, only axial images
extraneural tissues. Originally classified as a glioma,
can be obtained; by contrast, with MRI, any plane
medulloblastoma is now referred to as a primitive
can be used for imaging. On CT scans, posterior
neuroectodermal tumor (PNET) (3).
fossa images often are degraded by beam-hardening
Of medulloblastoma patients, 10-30%
artifacts (7).
demonstrate CSF dissemination at diagnosis,
mandating evaluation of the entire neuraxis with
To describe findings of different posterior
contrast-enhanced studies. Extra-axial metastases
fossa lesions and the diagnosis of medulloblastoma.
account for 5% of cases; most metastases are to the

bone; less frequently, metastases are to the liver and
lymph nodes (4). Children with non-disseminated

Full Paper (vol.731 paper# 11)

c:\work\Jor\vol731_12 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5795-5806
Comparison between Cyanoacrylate, Sutureless and Polypropylene Sutures in
Mesh Fixation on Lichtenstein Tension free in repair of Open Inguinal Hernia

Ahmed Abd El Aal Sultan, Mahmoud Saad Kamal Ismail,
Mohamed Ibrahem ELAnany
Department of General Surgery, Faculty of Medicine, Al -Azhar University
Corresponding authors: Ahmed Abd El Aal Sultan, e-mail: dr.ahmedsultan@azhar.edu.eg

inguinal hernia repair is one of the most common operations in general surgery. The Lichtenstein
tension-free operation has become gold standard in open inguinal hernia repair. Despite the low recurrence rates;
postoperative pain and discomfort remain a problem for a large number of patients.
Aim of the work: the aim of this study is to compare between cyanoacrylate, sutureless and polypropylene sutures
in mesh fixation on lichtenstein tension free in repair of open inguinal hernia regard as postoperative pain,
infection, recurrence,& cost benefit.
Methods: a total of thirty patients with primary unilateral uncomplicated inguinal hernia were randomized to
undergo lichtenstein tension free hernioplasty, and were randomized using close envelope into three groups: Group
A: Inguinal hernioplasty with mesh fixation using polypropylene sutures (10 patients), Group B: Inguinal
hernioplasty with mesh fixation using cyanoacrylate glue (10 patients) and Group C: Inguinal hernioplasty with
mesh placement without sutures (10 patients). Primary outcome was early and late postoperative pain. Secondary
endpoints were use of painkillers after 24 hours, morbidity rate and recurrence rate. Follow-up time was 6 months.
Results: significantly, less postoperative pain was reported in group B compared to the other two groups (A&C).
Additionally, trends toward a higher postoperative quality of life, a faster surgical procedure, and a shorter hospital
stay and earlier return to daily activities were seen in patients within group(B).Clinical recurrence was reported in
only one patient in Group C after a period of four months follow up postoperatively.
Conclusion: cyanoacrylate glue seemed to be a simple, original, reasonable, feasible, reproducible technique and
competitive alternative to the standard tissue-penetrating meshfixation devices in open inguinal hernioplasty. It is
accompanied by a reduction in chronic inguinal pain, with no increase in the early recurrence rate.
Keywords: Inguinal Hernia, Lichtenstein Inguinal Hernioplasty, Cyanoacrylate Glue, Mesh Fixation,
Postoperative Pain.


Inguinal hernia repair is one of the most

common general surgical operations performed
efficacy of mesh fixation with glue, and indicated the
worldwide. More than a million inguinal hernia
viability of a sutureless Lichtenstein procedure. We
repairs are performed annuallyin the United States and
report our experience of glue mesh fixation compared
Europe alone [1]. Since the introduction of the Bassini
to sutureless and polypropylene sutures in mesh
method in 1887, more than 70 types of pure tissue
fixation on Lichtenstein tension free in repair of open
repair have been reported in the surgical literature. An
inguinal hernia [4].
unacceptable recurrence rate, prolonged postoperative

pain and recovery time after tissue repair along with
our understanding of the metabolic origin of inguinal
The aim of this study is to compare between
hernias led to the concept of tension-free hernioplasty
cyanoacrylate, sutureless and polypropylene sutures in
with mesh. The main categories of inguinal hernia
mesh fixation on lichtenstein tension free in repair of
repair are the open repairs and the laparoscopic
open inguinal hernia regard as postoperative pain,
repairs. In the open category, repair of the hernia is
infection, recurrence,& cost benefit.
mainly achieved by tension-free mesh repair [2].

described for the first time in 1989, became a widely
This was a prospective study which was done
accepted method due to its safety, easiness of learning
in Department of Surgery, EL-Hussein Hospital, AL-
and low recurrence rate, lichtenstein open tension-free
Azhar University (Cairo) in the period from
mesh augmented repair postoperative pain and
November 2017 to July 2018. It included 30 patients,
chronic postoperative pain syndromes still remain a
10 cases underwent inguinal hernioplasty with mesh
problem [3]. The reports concerning application of
fixation using polypropylene sutures (Group A), 10
glues in inguinal hernia repair are growing in number.
cases underwent inguinal hernioplasty with mesh
In the first preliminary report, Canonico showed the
fixation using cyanoacrylate glue (Group B) and 10

cases underwent inguinal hernioplasty with mesh

Full Paper (vol.731 paper# 12)

Role of percutaneous transcatheter embolization of gonadal vein using N-butyl cyanoacrylate in treatment of varicocele The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5807-5812

Role of Percutaneous Transcatheter Embolization of Gonadal Vein
Using N-Butyl Cyanoacrylate in Treatment of Varicocele
Lobna Abdelmonem Habib, Nermeen Nasry Keriakos, Khaled Essam Basiouny
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Khaled Essam Basiouny, Mobile: +201141682108, E-mail: khaledbasiouny19@gmail.com

Percutaneous embolization of the internal spermatic vein to treat varicoceles is a minimally invasive
outpatient procedure that, when performed by experienced interventional radiologists, has high technical success
rates, low recurrence rates, very low morbidity and minimal radiation. It has been demonstrated to be equal to
surgical ligation in clinical results and as or more cost effective. Its minimally invasive nature allows it be well
tolerated with shorter recovery times and less discomfort relative to surgery. When skilled and experienced vascular
and interventional radiology services are available, embolization is an effective alternative to surgery and should be
offered as such or as primary therapy for varicocele treatment.
Objective: The aim of this study is to discuss the role of N-buty cyanoacrylate for gonadal vein embolization in
treatment varicocele causing testicular pain or infertility.
Methodology: this study was carried out in Radiology Department of Ain Shams University Hospitals.
This ross setiona desriptive study inuded 20 patients with varioee presented y pain, infertility or
recurrence after surgery and dianosis was confirmed y utrasound.
Result: varicocele embolization has significant role in improving scrotal pain and infertility.
Varicocele, gonadal vein, butyl cyanoacrylate, primary infertility, percutaneous embolization


Varicoceles, a dilation of veins within the
visualization of the internal spermatic vein and
pampiniform plexus, are present in 15% of the
possible collaterals (4).
general male population. It is also one of the most
Percutaneous embolization of varicocele
frequent causes of male-factor infertility, with a
requires selective catheterization of the internal
prevalence of 30%­40% among men presenting for
spermatic vein(s) followed by its occlusion with N-
primary infertility evaluation and up to 85% in
butyl cyanoacrylate: lipidol mixture(5).
secondary infertility (1).
Between 3-5 months after the procedure,
Color Doppler ultrasound detects a
patients attend another appointment. For patients
varicocele either by measuring augmented scrotal
referred because of testicular pain, complete absence
vein size or by demonstrating blood refluxing
of symptoms was considered as clinical success.
through the pampiniform plexus during the Valsalva
Regarding patients treated for infertility, sperm
maneuver. The measurement of retrograde peak flow
analysis immediately before and at least 3 months
creates a possibility to detect further subclinical
after the procedure was performed. Sperm
concentration, motility and morphology after the
The indiations of non media intervention
procedure were compared to those before the
for iniay sinifiant varioee inude infertiity
procedure. Values of 15 million sperm/mL, 40% of
or sufertiity speiay with impaired semen
motile sperm and 4% of morphological normal forms
parameters, hypoonadism, srota pain, and
were used for considering normalization and clinical
testiuar atrophy. Treatment options for varioee
success (6).
an e divided into two major ateories: (1)
perutaneous ousion, y intravenous injetion of
The aim of this study is to discuss the role of
various materias to oude the varioees and (2)
N-buty cyanoacrylate for gonadal vein embolization
suria iation or ippin of the varioees to
in treatment varicocele causing testicular pain or
prevent venous refux (3).
embolization of the internal spermatic vein are the
Patients: During a period of 6 months
main therapeutic options for men with varicocele. By
duration from December 2017, twenty patients were
comparison with surgical ligation, percutaneous
enrolled in the study. All patients with varicocele,
embolization is a cheaper and less invasive method,
diagnosed by ultrasound and scrotal Doppler, 10
requiring only local anesthesia and allows
patients presented with infertility (50 %), 9 patients


Full Paper (vol.731 paper# 13)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5813-5817

Comparative Study between The Addition of Pethidine Vs Fentanyl to
Hyperbaric Bupivacaine for Spinal Anesthesia in Caesarean Section
Gihan Seif Elnasr Mohamed, Noha Sayed Hussien Ahmed,
Gamal Eldin Adel Abdel Hameed, Aisha Abd Rahman El Sabaa*
Anesthesia, Intensive Care and Pain Management Department, Faculty of Medicine,
Ain Shams University
*Corresponding Author: Aisha Abd Rahman El Sabaa, E-mail: aishaabdelrahman5@gmail.com

cesarean section is the most common obstetric surgery in the world. Spinal anesthesia is a preferred
technique for cesarean delivery for its distinct advantages over general anesthesia as the simplicity of the
technique, reliability, minimal fetal exposure to drugs, patients' awareness and minimization of the hazards of
Aim of the Work: to define first time require analgesia in postoperative among two groups.
Patients and Methods: this prospective comparative study was carried on fifty patients, ASA physical status II,
aged from 18 to 45 years. These patients were scheduled for elective caesarean delivery under spinal anesthesia
and divided to two groups. This protocol was approved by Research Ethical Committee of Ain Shams University.
Written informed and verbal consent was obtained from each patient before being included in this procedure.
Results: the addition intrathecal 25mg pethidine make the total duration of analgesia 169.20 ± 7.59 minute but
adding 25g fentanyl intrathecal extended the period of effective analgesia up to 178.40 ± 6.25 min with high
significant P-value (0.000). The rapid onset of sensory and motor blocks in (F) group than (P) group with P
value=0.000, also increased duration of sensory and motor blocks in (F) group than (P) group with P value 0.000.
Conclusion: intrathecal opioid is a good technique of labor analgesia, although pethidine was the most widely
used opioid for obstetric analgesia, it has character of local anesthetics so adding pethidine intrathecal in dose
25mg enhanced effect of local anesthetics but associated with more complications as nausea, vomiting and
Keywords: Pethidine, Fentanyl, Hyperbaric Bupivacaine, Spinal Anesthesia, Caesarean Section.


Intrathecal opioids are quite commonly used
pharmacological features include sedation, mild
as adjunct to local anesthetics in regional anesthesia
reductions in body temperature, and dose-dependent
with multiple advantages. The most common causes
reduction in food intake (3).
of mortality in regional anesthesia are high spinal and
As for Pethidine, it is a lipophilic opioid
local anesthetic toxicity. Hence, reduction in the doses
analgesic with local anesthetic effects when
of local anesthetics and better management of local
administered intrathecally. It can be used as a sole
anesthetic toxicity is possible in this way. Opioids
agent for spinal anesthesia. However, it is not as
intrathecally decrease nociceptive inputs form A delta
widely used as bupivacaine for this purpose (4).
and C fibers without affecting dorsal root axons or
Although pethidine continues to be the most
somatosensory evoked potentials (1).
commonly administered opioid in obstetrics, it is no
Fentanyl is a potent synthetic mu receptor-
longer the preferred option for most care settings.
stimulating opioid, was first synthesized by Dr. Paul
Newer opioid derivatives such as fentanyl are favored,
Janssen in December 1960. The drug was first used as
because of the short onset time for pain relief and
an intravenous analgesic clinically in Europe in 1963
clearance. In particular, fentanyl has been shown to
and in the United States in 1968 and since then has
have a similar safety profile for children and adults in
become one of the most important and frequently used
both the pre-hospital and hospital settings (5).
opioid analgesics in the world (2).
Pethidine is the only member of the opioid
Fentanyl was discovered to identify an
family that has clinically important local anesthetic
improvement in human health analgesic over
activity in the dose range which is normally used for
morphine, an opioid frequently associated with
analgesia. Pethidine is unique as the only opioid in
histamine-release, bradycardia, hyper- or hypotension,
current use, which is effective as the sole agent for
and prolonged postoperative respiratory depression.
spinal anesthesia. In lower doses, intrathecal pethidine
Historically, the pharmacological features of
is also an effective analgesic for treating pain during
fentanyl have been described primarily through the
labor (6). Apart from axonal block its prolonged
study of the human approved fentanyl citrate
postoperative analgesic actions were because of its
formulation. Fentanyl has a wide margin of safety,
action on nociceptive synaptic junctions in spinal
minimum effects on the cardiovascular and respiratory
cord, Pethidine, a -receptor and -receptor agonist,
systems, and is readily reversible. Other
has a more prominent effect in the prevention and
Received:21 /6 /2018
Accepted:30 /6 /2018

Full Paper (vol.731 paper# 14)

c:\work\Jor\vol731_15 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5818-5827
The Predictors of Obstructive Sleep Apnea at A High Altitude: Results of a
Population-based Study in the Western region of Saudi Arabia
Fahad Rajallah Alharthi1, Ibrahim Masoodi1, Naif Alomairi1, Abdullah Hassan,
Almuntashiri1, Abdulaziz Alfaifi2
1.Dept of Internal Medicine College of Medicine, Taif University ,2.Dept of Internal Medicine King Abdul Aziz
Specialist hospital, Taif ,KSA
Corresponding author: Ibrahim Masoodi, Email: ibrahimmasoodi@yahoo.co.in , Phone number : +966531507399

The sleep disturbances are common at high altitudes. This study aimed to determine the prevalence and
predictors of obstructive sleep apnea at high altitudes.
This cross-sectional observational study was conducted from March 2018 to June 2018 to assess the
predictors of obstructive sleep apnea based on Berlin, Stop-Bang and Epworth sleepiness scale questionnaire from
adult population of Taif City at an altitude of 1879 m from sea level in Saudi Arabia.
Of 1002 participants, the majority (614 participants, 61.3%) were males and the mean± SD age of
participants was 30.6± 10.3 years (Range 11 - 67 years). In this study 24.9% participants were found to be at a high
risk of having sleep apnea. Male gender, older age and smoking were found to be significantly associated with higher
risk of sleep apnea according to Berlin, Stop-Bang and Epworth sleepiness scale questionnaire. Diseases found to be
associated with a high risk of developing sleep apnea included hypertension (p<0.001), hyperlipidemia (p<0.001),
diabetes (p<0.001), psychological disorders (p<0.001) and asthma (p<0.001) .On the other hand, cardiac disorders
were found to have an insignificant effect on sleep apnea (p=0.076) in this study. Almost one-third of the participants
(34.9%; 95% CI= 32.0% to 37.9%) were found to have an abnormal level of daytime sleepiness according to Epworth
Sleepiness Scale (ESS). These results were comparable to the previous studies at low altitude.
Our study demonstrated that the predictors of OSA at high altitudes are comparable to those at low
Daytime sleepiness, Obstructive sleep apnea, prevalence, Diabetes, Hypertension, Asthma.


enough data to suggest that there is an association
Obstructive sleep apnea (OSA) is a common sleep
between OSA and certain medical conditions like type
disorder characterized by recurrent upper airway
2 diabetes mellitus, coronary heart disease, and
collapse during sleep with frequent awakening and
sleep dissolution. When left untreated it significantly
Polysomnography (PSG) is considered to be the gold
increases the risk of cardiovascular diseases, stroke,
standard for diagnosis of OSA in adults but owing to
and death. Consequent to this daytime sleepiness,
its high cost and limited accessibility, it does not
reduced cognitive performance, OSA increases the risk
appear to be the universal tool in the detection of Study
of motor vehicle accidents and work accidents. It is
participants at risk for OSA. Hence screening of Study
evident that the early screening to identify the at-risk
participants with OSA symptoms, such as snoring,
population of OSA will positively affect the individual
nocturnal gasping, witnessed apnea, etc. and those who
in particular and society at large. The prevalence of
have co-morbid conditions related to a high risk of
OSA varies according to the measurement methods,
OSA, such as elevated body mass index, smoking,
diagnostic criteria, and apnea-hypopnea index (AHI)1.
hypertension etc. becomes a plausible tool to screen
While it is prevalent more often in old people, there
and for further evaluation in a given population for
seems some gender difference as the prevalence in
OSA5 .
males is 24% and 9% in females .However, with an
Of various questionnaires available the Berlin
epidemic of obesity, the prevalence of OSA has
questionnaire is the most widely used questionnaire for
increased in the last two decades both in developing
screening people at high risk of OSA in clinical
and developed countries2. Possibly due to the
practice, and its screening properties have been
craniofacial features among Asians population the data
validated in several population-based studies6. The
related to OSA is similar in Asian and western
diagnostic performance of the Berlin questionnaire was
countries3. Apart from obesity various other factors
shown to have a pooled sensitivity of 0.76 and a pooled
contributing directly or indirectly are Study
specificity of 0.45 when predicting OSA with an AHI
participants with resistant hypertension and Study
cutoff of 5 7.
participants with cardiovascular diseases4. There is
Received: / /2018
Accepted: / /2018

Full Paper (vol.731 paper# 15)

c:\work\Jor\vol731_16 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5828-5838
The predictors of Gastroesophageal Reflux Disease among University
students: A cross sectional study in the western region of Saudi Arabia.
Gamal Mohamed Hasan Elnemr1,2, Abdullah Hassan Almuntashiri1, Saud Abdulaziz
Alghamdi1, Fahad Rajallah Alharthi1, Ibrahim Masoodi1

1. Department of Internal Medicine, Faculty of Medicine, Taif University, KSA, 2. Department of
Medical and Radiological Researches, Nuclear Materials Authority, Egypt.
Corresponding author: Ibrahim Masoodi, Email: ibrahimmasoodi@yahoo.co.in, Phone number: +966531507399
Gastroesophageal reflux disease (GERD) is one of the most common health problems that
cause a financial burden on healthcare systems worldwide. The prevalence of GERD in Saudi Arabia is
steadily increasing. There is a paucity of data regarding GERD among University students.
Material and Methods: This cross-sectional observational study was conducted to assess the prevalence of
GERD among male students of Taif University in the western region of Saudi Arabia in addition to
determining the risk factors associated with the occurrence of GERD. Data were collected through a self-
administration questionnaire. In addition, weight and height were measured to calculate the body mass index
(BMI) of participating students.
Results: Of 464 students who participated from different colleges of the University; More than half of the
male students in Taif University (53.2%, 95% CI= 48.7% to 57.8%) suffer from GERD. There was higher
prevalence among smokers, overweight and obese students, those who drink plenty of soft drinks. Students
with hypertension, psychiatric diseases, diabetes mellitus, asthma or irritable bowel syndrome had higher
prevalence of reflux. GERD was significantly present among students with history of psychological stress.
Conclusion: Special consideration should be given to raising the awareness of about gastro esophageal
reflux disease among the public and its controllable risk factors. The psychological stress among University
Keywords: Gastroesophageal reflux disease, Stress, Smoking, obesity, NSAIDs.


Gastroesophageal reflux disease (GERD) is
material or a dysfunctional LES allowing reflux
of large amounts of gastric juice and delayed
gastric emptying which is known to increase the
outpatients. Its prevalence is steadily rising
volume and pressure in the reservoir until the
throughout the world1,2. The disease is associated
valve mechanism is defeated, leading to GERD.
with restricted activity and missed working days
Usually a combination of these mechanisms is the
which imposes a significant financial burden for
cause of GERD in a given person. The transient
healthcare systems in addition to the costs of
relaxation of the lower esophageal sphincter
management of symptoms3. The symptom
being the most common mechanism , permanent
complex in GERD is either typical which
LES relaxation, and transient increase of intra-
includes heartburn, regurgitation, and dysphagia
abdominal pressure that overcomes the LES
or atypical mostly extra-esophageal symptoms,
pressure have been described to be other
such as coughing, chest pain, and wheezing in
mechanism of LES dysfunction leading to
most of the patients. The esophagus functions as
an ante grade pump, the lower esophageal
sphincter (LES) as a valve, and the stomach as a
The most serious complication of long-
reservoir. Various mechanisms postulated in the
standing or severe GERD is the development of
pathogenesis of GERD are poor esophageal
Barrett esophagus present in 8-15% of patients
motility decreasing the clearance of acidic
with GERD4. Barrett esophagus is thought to be
Received: / /2018
Accepted: / /2018

Full Paper (vol.731 paper# 16)

c:\work\Jor\vol731_17 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5839-5848
Incidence and Prognosis of Acute Renal Failure in Patients
with Severe Sepsis and Septic Shock
Madiha M Zidan, Ahmed A El-Shebiny, Rafeek Y Atalla, Mohamed A Mohamed
Department of Anesthesia, Intensive Care and Pain Management
Faculty of Medicine, Ain Shams University
Corresponding author: Mohamed A Mohamed; Mobile: 01002963468; Email: malek.hikal@gmail.com

Background: Sepsis is a life-threatening condition that arises when the body's response to infection causes
injury to its own tissues and organs. Acute kidney injury (AKI), previously called acute renal failure (ARF)
is an abrupt loss of kidney function, Generally it occurs because of damage to the kidney tissue caused by
decreased kidney blood flow (Kidney ischemia) from any cause. AKI may lead to a number of
complications, including metabolic acidosis, high potassium levels, uremia, changes in body fluid balance,
and effects on other organ systems, including death. Aim: The aim of the study is to show the incidence and
prognosis of acute renal failure in patients with sepsis and septic shock. Patients and methods: This
prospective randomized study was conducted on patients who were admitted to ICU in Ain Shams
University Hospitals. Forty patients were included in this study and an informed written consent was
obtained from patients and/or relatives. All patients were adult, more than 18 years old, admitted to ICU
suffering from severe sepsis or had septic shock for monitoring, management and follow up to their
condition in period of six months. All patients were more than 18 years old that were critically ill either in
severe sepsis or had septic shock. We excluded patients less than 18 years old, patient or relatives who
refused to be included in this study, and if he/she has a history of previous kidney troubles or dysfunction.
All patients were subjected to assessment of the demographic data of the patient, causes and site of infection,
pathogenic bacteria as declared by different cultures, APACHE 2 score on admission, all patients were
managed as declared by ICU, protocol for septic patients, hemodynamic monitoring was done daily, routine
lab investigation daily, coagulation profile had to be done on days 0, 3, 7 of admission, SOFA score on days
0, 3, 7 of admission, renal functions include blood urea and creatinine clearance test had to be done daily,
any deterioration of renal function was reported, and if the patient was in need for renal replacement therapy
or dialysis, this would be reported. Results: Forty patients were included in this study, their ages with a
mean of 58.37 ± 15.66 years. 23 patients (57.5%) were males and 17 patients (42.5%) were females. The
most frequent risk factors were hypertension (62.5%) followed by diabetes (52.5%). The incidence of AKI
was 60% of patients and the need for renal replacement therapy (RRT) was 9 (22.5%). Outcome of admitted
patients in ICU was 23 (57.5%) survived patients and 17 (42.5%) non-survived patients. The study showed
that there were no statistical significant differences between AKI and Non-AKI patients except for; gender
(male), BMI, gram ­ve bacterial infection, creatinine, BUN, creatinine clearance, history of ACE
administration, use of vasopressors, APACHE II score at admission and mortality were statistically
significant (p < 0.05). Conclusion: The incidence of AKI was 60% of patients in our study. The development of
septic AKI adversely affected clinical outcomes. Moreover, the severity of AKI was associated with increased short-
term mortality as observed in ICU patients. The study showed that there were no statistical significant differences
between AKI and Non-AKI patients except for; gender (male), BMI, gram ­ve bacterial infection, creatinine, BUN,
creatinine clearance, history of ACE administration, use of vasopressors, APACHE II score at admission and mortality
were statistically significant (p < 0.05).
Key words: acute renal failure, severe sepsis, septic shock reported AKI in up to half of the septic
patients (3).

Both sepsis and acute kidney injury

Sepsis is a life-threatening condition
(AKI) are diseases of major concern in
that arises when the body's response to
critically ill patients. Severe sepsis is often
infection causes injury to its own tissues and
complicated by AKI (1). The overall incidence
organs. Common signs and symptoms include
of septic AKI (SAKI) among all intensive
fever, increased heart rate, increased
care unit (ICU) admissions ranges between 15
breathing rate, and confusion. There also may
and 20 % (1).
be symptoms related to a specific infection,

Large studies in critically ill patients
such as a cough with pneumonia, or painful
convincingly demonstrated the "intimate"
urination with a kidney infection. In the very
bond between AKI and sepsis. For instance,
young, old, and immuno-compromised
the BEST Kidney and FINNAKI studies,
people, there may be no symptoms of a
which covered different time periods, both
specific infection and the body temperature
may be low or normal, rather than high (2).
Received 14/3/2018
Accepted 24/3/2018

Full Paper (vol.731 paper# 17)

c:\work\Jor\vol731_18 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5849-5855

Manual Placental Removal versus Cord Traction for Placental Delivery at
Caesarean Section in Correlation to Blood Loss
Esmael Mohamed Talaat El Garhy, Ashraf Hamdy Mohamed, Hazem Sayed Shaaban,
Ahmed Mohamed Mostafa Salem*
Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Mohamed Mostafa Salem, Mobile: 01002833608, Email:
Delivery by cesarean section is one of the most commonly performed obstetrical operations
all over the world, but it exposes women to the inherent risks of major abdominal surgery, e.g., injury to
the pelvic structures, infection, and the need for blood transfusion etc. Antepartum physiological
adaptation in preparation for blood loss at delivery includes a 42% increase in plasma volume and a 24%
increase in red blood cell volume by the third trimester. Objective: The aim of this work was to compare
the manual removal of placenta and spontaneous placental delivery combined with cord traction at
caesarean section. Patients and Methods: We compare between both groups using computer programs
to evaluate the safety and efficacy of each method. Results: There was a significantly higher estimated
intraoperative blood loss in women who had their placentae manually separated when compared to women
who had spontaneous placental separation. Conclusion: There was a statistically significant drop of
hematocrit level in both groups with no statistically significant drop of hemoglobin. In addition, there was
increased incidence of endometritis.
Caesarean Section, placental delivery, blood Loss.
spontaneous delivery, cord traction with
spontaneous placental separation and manual
Caesarean section is the most common major
removal (6).
operation performed on women. Some of the
In placental drainage, the end of the umbilical
short term morbidities of caesarean section
cord is left unclamped, placental blood drained
include hemorrhage (1), need for blood
and placenta delivers spontaneously through
uterine incision, this method is not widely used
endometritis (2). Long term morbidities include
placenta preavia, placenta accreta and ectopic
The two methods most frequently used are cord
pregnancy. Some of complications mentioned
traction combined with external uterine massage
increased by different ways of performing
or expression of the uterus, and manual removal.
caesarean section operation and variation in
Cord traction involves gentle traction on the
techniques (3).
umbilical cord with external uterine massage
The method of removing the placenta is one such
after delivery of the baby and oxytocic has been
procedure that may increase or decrease in the
given this method takes about three to five
morbidity of caesarean section (4).
minutes. Manual removal of the placenta done
The process of placental separation starts
by the use of gloved hand with gentle sawing
immediately after delivery of the baby by
action to separate the placenta from its placental
contraction and retraction of uterine muscle
bed; this method takes about two minutes to be
which result in reduction in the size of the uterus
done. Some obstetricians practice manual
consequently the placental bed to which the
removal as they consider it quicker to deliver
placenta is attached become smaller than the
than cord traction. The process of manual
incompressible placenta, the placenta sheared off
removal of the placenta cause more bleeding and
and blood vessels supplying the denuded
may increase the risk of infection, so there is
placental bed are compressed by continued
some studies, have found manual removal of
contraction and retraction of uterine muscle to
placenta to increase postoperative morbidity,
reduce the bleeding and oxytocin is given after
while other studies have not. So the primary
delivery of the baby to minimize blood loss (5).
objective is to compare the risk of significant
blood loss associated with spontaneous and
Placental delivery types at caesarean section
manual removal of the placenta during caesarean
have been described as, placental drainage with
Received: 20/6/2018

Full Paper (vol.731 paper# 18)

c:\work\Jor\vol731_19 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5856-5864
Assessment of the Relation between Fetal Hemodynamic Indices in Late
Pregnancy and Birth Weight in Gestational Diabetic Mellitus Mothers: A
correlational study
Magdy Mohamed Mahmoud Abd el Gawad 1, Mohamed Hussain Moustafa 1, Laila Aly Farid 1,
Noha Emad El Din Abd El Aziz 2

1. Obstetrics and Gynaecology Faculty of Medicine ­ Ain Shams University.
2. Obstetrics and Gynecology at Manshyet El Bakry General Hospital.


Background: The offspring of women with gestational diabetes mellitus (GDM) are prone to
macrosomia. However, birth weight is difficult to be correctly estimated by ultrasound because of
fetal asymmetric growth characteristics. This study aimed at investigating the correlations between
fetal hemodynamics, fetal growth indices in late pregnancy and birth weight in GDM. Methods: A
total of 180 women with GDM and 180 normal controls (NC) with singleton gestation and presented
between 38-40 weeks gestation were enrolled in this study. Fetal hemodynamic indices, including the
systolic/diastolic ratio (S/D), resistance index (RI), pulsatility index (PI) of umbilical artery (UA),
middle cerebral artery (MCA), and renal artery (RA), were collected. Fetal growth indices, including
biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur
length (FL), were also measured by ultrasound. Birth weight, mode of delivery and need for Neonatal
ICU admission data were collected. Results: The independent samples t-test showed that BPD, HC,
AC and FL were larger in GDM than in NC (P < 0.05). Birth weight was higher in GDM than in NC
(P < 0.001). Among all included women, there was a highly statistically insignificant difference
between GDM and NC groups as regard all ultrasound indices including UA_S/D, UA_RI, UA_PI,
MCA_S/D, MCA_RI, MCA_PI, RA_S/D, RA_RI and RA_PI (P>0.05). Pearson's correlation
analysis showed in GDM group that there was a highly statistically significant negative correlation
between birth weight and the following ultrasound indices: (UA_RI, UA_S/D, UA_PI, MCA_RI and
MCA_PI) and that there was a statistically significant positive correlation between birth weight &
RA_RI (P<0.01) (r = -0.273, -0.453, -0.537, -0.237, -0.265 and 0.169 respectively, P < 0.05), but
As regard NC group there was a highly statistically significant negative correlation between birth
weight and the following ultrasound indices: (UA_S/D, UA_RI, UA_PI and MCA_PI) (r = 0.148, -
0.360, -0.252 and -0.184 respectively, P < 0.05) but no correlation was found with any of renal artery
indices (P > 0.05). Conclusions: Fetal hemodynamic indices in late pregnancy might be helpful for
estimating newborn birth weight in women with GDM.
Keywords: Fetus; Gestational Diabetes Mellitus; Infant; Middle Cerebral Artery; Renal Artery;
Ultrasound; Umbilical Artery.
The most common and significant
GDM is diabetes diagnosed during
neonatal complication associated with GDM is
pregnancy that is not clearly type 1 or 2
macrosomia, which is defined as a birth weight
diabetes (1).
greater than 4,000 to 4.500 grams, as well as
hyperglycemia cases during pregnancy are due
larger for gestational age, with the birth weight
to GDM. The estimated incidence of GDM in
above to 90th percentile for population-specific
Europe is 3% to 5% or 150,000 to 250,000
and set-specific growth curves (4). The increase
pregnant women out of the five million who
in fetal body fat occurs in the insulin
give birth each year (2). In Egypt, Impaired
dependent tissues, such as the thighs, intra-
Glucose Tolerance which occurs during
hepatic and abdominal adipose tissues. Fat
pregnancy affects 7.2% of all pregnancies and
accumulation tends to be truncal with larger
is considered a major cause of maternal and
shoulder circumference which leads to an
fetal morbidity (3).
increased risk for cephalopelvic disproportion
shoulder dystocia, and birth trauma (5) .

Full Paper (vol.731 paper# 19)

c:\work\Jor\vol731_20 retracted


Full Paper (vol.731 paper# 20)

c:\work\Jor\vol731_21 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5875-5885

Comparison between the role of contrast enhanced mammography and
dynamic contrast enhanced MRI in assessment of breast cancer recurrence

Saher Mohamed Elfiky, Noha Abdelshafy Elsaid, Enas ahmed Azeb, Marwa Elsayed
Elmor, Nehal Abdelshafy Abdelaleem
Radiology department, Faculty of medicine, Ain Shams University
Corresponding Author: Tarek Hamed Gomaa Hassan,
Email:Tarekhamed11@hotmail.com. Tel.01062229712

Purpose: To elucidate the diagnostic value of contrast enhanced mammography in comparison
with dynamic MRI in cases of breast cancer recurrence and to correlate with available clinical
data, histopathology findings and/or follow up. Methods: 30 patients were enrolled in this study.
The age ranged between31-68 years old. Patients were referred from the General Surgery or
Oncology Departments in the period from August-2015 until April-2018. The patients underwent
full history taking and clinical examination and CESM and breast magnetic resonance image
(BMRI) examination. Finally US guided biopsy was performed. Results: Contrast enhanced
spectral mammography (CESM) showed slightly lower sensitivity (88.89%) and overall accuracy
(86.67%) than BMRI (96.30% and 90% respectively). However specificity was higher in CESM
(66.67%) than that of BMRI (33.33%). Conclusion: In spite of the lower sensitivity of the CESM
compared to MRI, the CESM appeared to be a suitable, easy, more comfortable, low cost and fast
alternative to MRI in early detection of breast cancer recurrence specially for patients with
contraindications to MRI.

Keywords: Recurrent breast cancer ­ BMRI ­ CESM.


limited by low specificity, high cost, long
Breast cancer is not only a leading
duration of examination time (patient must
cause of death among women but also
lie still in the prone position for a half-hour
carries a high risk of recurrence, the earlier
or longer during image acquisition), and
the diagnosis of recurrence, the better the
limited availability3.
CESM is a relatively new imaging
Up-to-date, mammography appears
modality that can be used as complementary
to be the most consistentmethod for the
test to standard mammogram using the same
early detection of breast cancer; yet, it has
MG equipment, on the same examination
bothlimited sensitivity and specificity in the
day. Only renal function test is needed
detection and diagnosis of breast lesions,
before contrast injection, than in less than 10
especially in dense breasts. Moreover thefull
minutes with slightly higher exposure
extent of the disease may not be clearly
radiation dose, we can solve many
depicted. In reference to this, mammography
mammographic problems with high quality
image, easy to interpret by same radiologists
breastcancers.Therefore, management of
and provides both anatomic and functional
these women should include testing that
information of the lesions similar to MRI 4.
improves the early diagnosis of recurrence,
as contrast enhanced mammography and
Patients and Methods

Thirty patients were enrolled in this study,
BMRI is currently the gold standard
the age ranged between31-68 years old.
for breast cancer detection and staging but is
Patients were referred from the General

Full Paper (vol.731 paper# 21)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5886-5895
Laparoscopic repair of inguinal hernia transabdominal preperitoneal
(TAPP) versus total extraperitoneal (TEP) Techniques
Hazem Abd El-Salam Mohammad, Ahmed Adel Abbas,
Sameh Khaled Ahmed Ali
Department of general surgery, Faculty of Medicine, Ain Shams University
Corresponding author: Sameh Khaled Ahmed Ali, Mobile: 01005263472; Email: same7khaled@gmail.com
The fundamental mechanism of abdominal wall hernia formation is the loss of
structural integrity at the musculotendinous layer. The exact cause of inguinal hernia is still
unknown but the factors contributing in its occurrence include; preformed congenital sac,
chronic passive rise in the intra-abdominal pressure and weak abdominal wall. Objective:
The aim of this study is to compare the results of laparoscopic hernioplasty with
Transabdominal pre-peritoneal (TAPP) versus Totally Extraperitoneal (TEP) as techniques
for repair of inguinal hernia. Patients and Methods: In our study, 30 patients were included
divided on two groups, 15 for each. Group A; underwent laparoscopic Transabdominal pre-
peritoneal (TAPP) repair with mesh, Group B; underwent laparoscopic Totally
Extraperitoneal (TEP) repair with mesh. Follow up of patients was done in the out-patient
clinic at ain shams hospitals, 7 days after discharge then at 3, and 6 months postoperatively at
the period between March 2018 and August 2018. Results: Both groups were compared in
terms of operative technique, operative time, intra & post operative complications, early post
operative pain within one week, hospital stay, restriction of physical activity and incidence of
recurrence and chronic pain. Conclusion: Interpretation of results revealed that the TEP repair
appeared technically more difficult as evidenced by increased operative time and more post
operative pain in first hours. It needs a long learning curve and a dedicated team for technique
excellence. However, it is preferred because it is associated with less wound-related
complications, shorter hospital stay and rapid return to normal activity.
Keywords: Transabdominal pre-peritoneal, totally extraperitoneal.
Repair of an inguinal hernia via
surgery is the only treatment for inguinal
Over 1 million abdominal wall
hernias and can prevent incarceration and
hernia repairs are performed each year in
strangulation. Health care providers
the United States, with inguinal hernia
recommend surgery for most people with
repairs constituting nearly 770,000 of
inguinal hernias and especially for people
these cases; approximately 90% of all
with hernias that cause symptoms.
inguinal hernia repairs are performed on
Research suggests that men with hernias
males (1).
that cause few or no symptoms may be
able to safely delay surgery until their
Hernia repair went through several
symptoms increase. Men who delay
stages dating back to ancient Egypt
surgery should watch for symptoms and
through the conventional repair with tissue
see a health care provider regularly. Health
approximation that was associated with a
care providers usually recommend surgery
recurrence rate of 60% till Francic C.
for infants and children to prevent
Usher introduced a polypropylene based
incarceration (2).
prosthesis to bridge the hernia defect and
to reinforce the abdominal wall without
Conventional surgery was based
tension. With the implantation of
on Bassini's operation; this consisted of
prosthesis the recurrence rate in hernia
apposition of the transversus abdominis
repair was downsized (1).

Full Paper (vol.731 paper# 22)

c:\work\Jor\vol731_23 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5896-5906
Internal Limiting Membrane Peeling for Diffuse Tractional Diabetic Macular Oedema
Mohamed I. EL-Kasaby
Department of Ophthalmology, Faculty of Medicine for girls, Al-Azhar University, Cairo- Egypt.
Corresponding author: Mohamed EL-Kasaby, email: Ammarelkasaby@yahoo.com., Mobile: +2 01001241403 -
010423513- Fax:+202:22731988.
Aim: To determine the efficacy of internal limiting membrane (ILM) peeling vitrectomy for diffuse
tractional diabetic macular oedema. Patients and methods: A prospective non ­randomized interventional
study was carried out at Nour- EL­Hayaha Eye Center (Cairo) between March, 2015 and March, 2017. 40
eyes of 31 patients with symptomatic marked diminution of vision and tractional diabetic macular oedema
were enrolled in this study. Ocular examinations included measurements of best corrected visual acuity
(BCVA) at a distance using a logarithm of the minimum angle of resolution (logMAR) scale, refractive
status using an autorefractometer (KR-8100; Topcon corporation, Tokyo, Japan), IOP was measured by
Goldman applanation tonometry (CT-80; Topcon corporation, Tokyo, Japan), and fundus evaluation using an
indirect ophthalmoscope were obtained. 23-gauge vitrectomy with internal limiting membrane peeling
assisted by staining by brilliant blue G stain(BBG) were performed for all patients with a follow ­up period
at least 6 months. Spectral domain optical coherent tomography (SD OCT) images were obtained at the
follow ­up visits to determine the presence of an epiretinal membrane (ERM). Results: At 6 months there
was a median 200µ decrease from baseline in the central subfield thickness (P<0.005).Mean change in the
central subfield macular thickness was -150µ (SD± 130.56).There was 7 (17.5%) cases developed iatrogenic
retinal break during removal of posterior vitreous and treated by endodiathermy, of greatest importance,
3(7.5%) eyes developed a vitreous hemorrhage treated by conservative treatment after B scan evaluation, and
1(2.5%) eye developed a retinal detachment. All complications were successfully managed. 23 out of 40 eyes
(57.5%) underwent cataract surgery with IOL implantation within 6 months of pars plana vitrectomy.
Transient elevation of IOP was developed in 7(17.5%) eyes and managed carefully with antiglucomatous
drugs. One eye developed persistent elevation of IOP that required maintenance anti glaucomatous drug.
Also macular hole developed in one eye and epiretinal membrane developed in one eye. Conclusion: ILM
peeling achieved higher anatomic success with a reduced need for additional surgical interventions and or
event postoperative ERM formation that might result in subsequent visual loss.
Keywords: Internal limiting membrane. tractional diffuse macular oedema .brilliant blue G.
includes breakdown of the blood-retinal barrier
(BRB) secondary to weakened capillary
The internal limiting membrane (ILM) is a very
intercellular tight junctions, loss of pericytes, and
thin and transparent acellular membrane on the
leukostasis in the retinal vessels and vasoactive
surface of the retina. It is adjacent to Muller cell
factors such as vascular endothelial growth factor-
foot plates (lamina rara externa (0.03-0.06 µ) .The
A (VEGF-A), various growth factors, and matrix
lamina densa is thinnest at the fovea and thicker in
the posterior pole than at the equator or vitreous
vitreoretinal interface (the posterior vitreous
base; it plays an important role in the early stages
cortex and ILM) have also been found to promote
of retinal development; however, its function in
DME. Specifically, the hyaloid becomes taut and
adults is not yet understood. (1),(2) Because the ILM
thickened with induced cellular proliferation and
rests on the retinal nerve fiber layer (RNF)-
production of cytokines. The fovea and the
ganglion cell layer (GCL)complex ,it can
vitreous base are the points at which the posterior
theoretically damage these layers during the
vitreous cortex and the ILM have the strongest
process of peeling with subsequent significant
attachment. Advanced Glycation End-Products
bearing on postoperative visual acuity(3). Diabetic
(AGEs), accumulated in the posterior vitreous
macular oedema (DME), caused by intraretinal
cortex, increase cross-linking of collagen fibrils
fluid accumulation in the macula, is the most
and induce structural changes in the posterior
common cause of visual impairment in diabetic
hyaloid that strengthen vitreomacular adhesions
patients. The pathogenesis is multifactorial and
Received:21/6/2018 Accepted:30/6/2018

Full Paper (vol.731 paper# 23)

c:\work\Jor\vol731_24 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5907-5917

Myoring Femtosecond-Assisted Intracorneal in Management of Keratoconus
Mohamed I. EL-Kasaby
Department of Ophthalmology, Faculty of Medicine for girl, Al-Azhar University, Cairo- Egypt.
Corresponding author: Mohamed EL-Kasaby ,email: Ammarelkasaby@yahoo.com., Mobile : +2 01001241403 - 010423513-
: To evaluate long term follow up data on implantation of a full ring intra corneal implant
(Myoring) for management of keratoconus with no cross linking postoperatively done. Patients and
A prospective non ­randomized interventional clinical study was carried out at Nour- EL­Hayaha
Eye Center (Cairo) between July, 2015 and July, 2017.40 eyes of 20 patients with symptomatic marked
diminution of vision and keratoconus grade 2 to 4 were enrolled in this study. For all patients, a MyoRing
(Dioptex, GmbH, Austria) was implanted using a femtosecond laser (Victus Femto Second Laser SW version
3.2 Technolas Perfect Vision GmbH .Munich, Germany). Inclusion criteria; age was between 18 and 35
years, maximum K reading less than 60D (based on pentacam examination), and a central corneal thickness
(CCT) was at least 380 m. Patients who had corneal scarring, any concomitant ocular disease or any history
of ocular surgery were excluded from the study. Patients who failed to complete follow-up examinations one
month after the surgery were also excluded. Results: 40 eyes of 20 patients 5 males (25%) and 15 females
(75%) with keratoconus grade 2 to 4 enrolled in this study with a mean age of 24.6 ± 7.92 years.
Preoperatively, mean central corneal thickness (CCT) was 440.25±44.49 m in the right eye and mean CCT
441.35±43.02 in the left eye, while mean keratometry (K) readings, 52.57±5.24diopters (D) in the right eyes
and 50.16±3.59 D in the left eyes. Postoperatively, there was a statistically significant improvement in the
uncorrected distance visual acuity(UDVA), corrected distance visual acuity(CDVA), K readings, manifest
spherical and cylindrical refractive errors, and spherical equivalent (P<0.05). Mean K reading decreased by
6.8 D, from52.57±5.24D to 45.77±2.16D. No serious intraoperative complications were occurred.
Conclusion: Myoring had the capability in halting the progression of the disease, Insert it whatever the site
of lesion and it was noticed that no need for cross linking done postoperatively.
Keywords: Keratoconus, Femtosecond laser, MyoRing, Cross linking.

potential advantage of the MyoRing over ring
Keratoconus is a rare (prevalence of 1 in
segments is its effectiveness on advanced
2000) chronic corneal disease affecting a young
keratoconus and also its ability to reduce
population. The cornea assumes a conical shape as
keratometric power of the cornea much more(1).
a result of progressive, non-inflammatory
Satisfactory 6-month results of vision, refraction,
thinning. Nonsurgical therapeutic options for
keratoconus are spectacles and contact lenses. In
more advanced cases and in cases of deformed or
MyoRing implantation in a pilot study(2).
opaque cornea, corneal grafts, either lamellar or
Patients and methods:
penetrating keratoplasty are the main treatment
options. Although keratoplasty has acceptable
In this prospective, randomized, interventional
results, ongoing research seeks less invasive
clinical study, 40 eyes of 20 patients with post
methods including corneal collagen cross-linking
lasik ectasia and keratoconus grade 2 to 4 entered
and intrastromal corneal rings to treat
the study. The study protocol was adhered to the
keratoconus. Intrastromal corneal ring segment
tenets of declaration of Helisinki and was
implantation has been proved to be safe approach
approved by the ethics board of AL- Azhar
to reinforce corneal structure in mild to moderate
university .An informed written consent was taken
keratoconus and other ectatic disorders. However,
from each participant in the study after a detailed
they are not as effective in more advanced cases.
explanation of the procedure and possible benefits
Recently proposed MyoRing (Dioptex GmbH,
and risks. Patients with a history of previous
Linz, Austria) is a complete intrastromal ring
ocular surgery and coexisting ocular diseases
designed to be placed into a corneal pocket. A
other than keratoconus were excluded. Patients
Received: 20/6/2018

Full Paper (vol.731 paper# 24)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5918-5926
Pain Assessment after Short Course versus Long Course Palliative
Radiation of Painful Bony Metastasis
Khaled Abdelkarim Mohamed; Dalia Abd El-Ghany El-Khodary; Ahmed Mostafa
Mohamed; Abdelfattah Rashad Abdelfattah Elmasry
Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University
*Corresponding author: Abdelfattah Rashad Abdelfattah Elmasry, Mobile: 01021415712, Email:
the most common cause of pain in cancer patients is bone metastases. Objective: to
evaluate the different fractionation schedules. Patients and Methods: this is a prospective cross
sectional study conducted at Ain-Shams University Hospitals and Nasser Institute Cancer Centre, to
assess the equivalence of two fractionation regimens (20 Gy over 5 fractions versus 30 Gy over 10
fractions) as regard pain relief in painful bony metastases. Over 6 months fifty patients were assigned
to either fraction arms using consecutive sampling. Results: both fractionation regimens were
effective at palliating pain from bone metastases. Pain score was consistently going down from week 0
to week 12, although maximum benefit was reached earlier in the shorter arm (at week 8), both
comparison groups leveled a favourable response at week 12. At 3 months, the observed overall
response rate was 88% versus 84% and complete response rate was achieved in 44% versus 36% in
both short- and long fractionation course respectively, with no statistical difference was found in terms
of pain relief. With the median time to pain progression was 79.0 days for the short arm versus 77.0
days for the protracted arm. Conclusion: lower dose of radiotherapy may provide equivalent outcomes
to higher ones in palliating bone pain. So, the the surrounding normal tissue role in pain process
caused by bone metastases as well as the effect of radiation in this environment has to be furtherly
investigated, which may lead to pain control augmentation.
Keywords: Pain Assessment; Palliative Radiation; Painful Bony Metastasis
that is localized to the primary site, and
widespread metastases (4). the definition of
The most common cause of pain in
oligometastases varies means five or fewer
cancer patients is bone metastases (1). Among
metastatic lesions. skeletal-related events
solid cancers, prostate, breast, thyroid, lung,
typically encompass pathologic fracture, spinal
and renal cell carcinoma account for 80
cord compression, surgical intervention or use
percent of all skeletal metastases (1).
of palliative radiotherapy (RT) (5).
The primary disease site determines
The treatment of an asymptomatic
the prognosis for patients with bone
bone metastasis may be deferred unless the
metastases; patients with breast and prostate
patient develops pain or is at risk for a skeletal-
cancer have a longer median survival when it's
related event. The treatment of bone
compared with lung cancer (2).
metastases may involve several types of
Bone metastases can be categorized as
bisphosphonates, or radioisotopes, in addition
uncomplicated generally refers to the absence
to local interventions such as external beam
of: impending or established pathological
radiotherapy (EBRT), stereotactic body
fracture, previous surgical fixation, impending
radiotherapy (SBRT) hemi-body irradiation
or established spinal cord compression,
(HBI), radioisotopes, surgery, or percutaneous
impending or established cauda equina or
vertebral augmentation depending on the site
nerve root compression (including cranial
and extent of disease, histology and biomarker
nerves), neuropathic pain, previous radiation,
profile of the metastasis (2).
or associated soft tissue mass. Approximately
one-third of bone metastases are considered to
be `complicated' (3). oligometastatic disease
describes an intermediate state between disease
Received:21/6/2018 Accepted:30/6/2018

Full Paper (vol.731 paper# 25)

Prophylactic use of Parenteral Ketamine versus Ondansetron for Prevention
of Shivering during Spinal Anesthesia in Hernia Surgeries
Nabila Mohammed Abdel Aziz Fahmy, Ayman Ibraheem Tharwat Sayed, Amr Hosny
Hamza Ali, Aya-tullah Hosny Kamal El-Deen Abd El-Aleem
Department of Anesthesiology, Intensive Care Medicine & Pain Management, Faculty of Medicine, Ain Shams
Corresponding Author: Aya-tullah Hosny Kamal El-Deen Abd El-Aleem; Phone No.: (+2) 01127610348; E-mail: ayottoo@hotmail.com
Background: Perioperative shivering is a common complication in modern anesthesia. It's usually
defined as readily detectable fasciculation or tremors of the face, jaw, head, trunk or extremities
lasting longer than 15 seconds.
Aim of the work: Compare the anti-shivering effect of parentral low dose ketamine and ondansetron
after spinal anesthesia during hernia surgery, as well as the anticipated side effects and complications.
Patients and Methods: This study presents a prospective randomized single blinded study. After
obtaining approval from the medical ethical committee of Ain Shams University, this study was
conducted in Ain Shams University hospitals operating rooms. Study period was from January 2018
to May 2018.
Results: Our results indicated that low dose ketamine and ondansetron were effective, with more
extent to ketamine, in prevention of post spinal shivering in patients undergoing hernia surgery and
these results agreed with other results of studies done before.
Conclusion: Our results indicated that Prophylactic low dose ketamine (0.25mg/kg) and Ondansetron
(4mg) significantly decreased shivering in patients undergoing spinal anesthesia without significant
side effects. Ketamine found to be more effective in controlling post spinal shivering.
Keywords: Hernia Surgeries ­ Anesthesia ­ Ondansetron ­ Prophylactic
Shivering is uncomfortable for the
cytokines by the surgical procedure. The core
patient and may interfere with monitoring of
temperature usually decreases by 0.5-1.5 c in
electrocardiogram, blood pressure (BP), and
the first hour after induction of anesthesia. All
oxygen saturation. It increases oxygen
general anesthetics markedly impair normal
consumption, lactic acidosis and carbon
thermoregulatory control. However, non-
dioxide production. Those effects are
thermoregulatory shivering may also occur in
particularly bothersome in the surgical
normothermic patients in response to certain
population (1).
anesthetics or postoperative pain (3).
Regional anesthesia may impair
The treatment of shivering includes
thermoregulatory control and up to a 57%
incidence of shivering during regional
anesthesia has been reported. Regional
pharmacological management is by external
anesthesia produces vasodilatation, which
heating like the use of forced air warming,
facilitates core-to-peripheral redistribution of
warming blankets, warmed fluids etc.,
heat (2).
according to the results of a meta-analysis, the
most frequently reported pharmacological
Postoperative shivering occurs in 5-
interventions include clonidine, pethidine,
65% of patients recovering from general
tramadol, nefopam and ketamine (4).
thermoregulatory shivering in response to core
Unfortunately, no gold standard
hypothermia or may result from the release of
treatment is known for shivering as the
Received: 20/6/2018

Full Paper (vol.731 paper# 26)

c:\work\Jor\vol731_27 The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73(1), Page 5935-5939

Attitudes and Perceptions of Medical Students toward Neurosurgery as a
Career, Riyadh, Saudi Arabia

Nayef Ghasham AlQahtani1, Turki Alhumaid1, Khalid Almazyad1, Ibrahim Almesned 1,
Abdulaziz Almusalam1, Sajida Agha2

1King Saud Bin Abdulaziz University for Health Sciences, College of Medicine, Riyadh, Saudi
Arabia. 2King Saud Bin Abdulaziz University for Health Sciences, Medical Education, Riyadh, Saudi
Corresponding Author: Nayef Ghasham AlQahtani, Phone: 00966541900031, Email: naif50501@hotmail.com
Introduction: Medical students usually show a preference toward a specific specialty. They could
have the preference before entering the medical school but their preference could change. There has
been a decline in surgical specialty as a career choice by medical students more recently. The
of the study is to evaluate the attitude and perception of medical students toward
neurosurgery. Methods and Materials: This is a cross-sectional study that was conducted in King
Saud Bin Abdulaziz University for health sciences in RIYADH, SAUDI ARABIA on 218 medical
students from the fifth and sixth year, using a validated questionnaire comprising of 15 questions with
a scoring based on Linkert ranking scale (1, disagree; 2, agree somewhat; 3, agree moderately; 4,
agree Strongly). Results: The distribution response was 85%, only 186 (102 males vs. 84 females)
medical students completed the questionnaire. The data shows that the majority of students think that
their neurosurgery teaching is inadequate, neurosurgical history is difficult to obtain, neurosurgical
signs are difficult to elicit and that most of them 86% aren't considering neurosurgery as a future
career because it can impede family life. Conclusion: This study point out some areas that can be
targeted and improved to enhance the student's perception of neurosurgery as a specialty and to
facilitate learning of neurosurgery knowledge during medical school. Also, a study on a larger sample
might be required to generalize the results.
Keywords: Neurosurgery, Career choice, Medical Students attitude, Working time, Surgical training,
Linkert scale

There are many factors which may
Medical students usually show a preference
contribute to medical students' deviation away
toward a specific specialty. They could have
from surgical specialties like surgeons' life
the preference before entering the medical
style, long working hours, family pressure and
school but their preference could change.
financial income compared to the working
During or near the end of clinical years,
hour requirements. Another factor is that the
students have tried most of the major
number of female medical students has greatly
specialties like internal medicine, General
increased recently which have also contributed
surgery, Pediatric, obstetrics and gynecology
to this trend. In one study they found out that
etc. And have acquainted the nature and
females are less likely than males to join a
working environment of each specialty, so
surgical training program2. In the same study
now they have better visualization and more
students have designated working hour
transparent idea of what they want. Recently
limitations a higher priority than Future
there has been a propensity toward non-
income, however, 86% of students said that
surgical specialties as a career choice by
the most important factor in choosing a
medical students, which is a concern1.
residency program is intellectual interest2.

Surgical training is not only a science
Received: 7/7/2018

Full Paper (vol.731 paper# 27)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2018) Vol. 73 (1), Page 5940- 5943

Assessment of Oral Metronidazole in Pain Management Post Haemorrhoidectomy
Essam Fakhry Ebied, Ahmed Adel Darweesh, Ahmed Aly Khalil, Sahar Mahmoud Shahban Nmr
General Surgery - Faculty of Medicine- Ain Shams University
Corresponding Author: Sahar Mahmoud Shahban Nmr, phone: 01062901156, E-mail: sahar_elnmr@yahoo.com
Haemorrhoids are a very popular disease. Approximately 50% to 66% of people have problems
with haemorrhoids at some point in their lives. The pathophysiology of haemorrhoids is not exactly well
known. Theories were developed trying to understand the pathophysiology of haemorrhoids e.g., varicose vein
theory, anal lining sliding theory, hyperactivity of internal sphincter theory and vascular hyperplasia theory.
Diagnosis is made by integration of available clinical data (symptoms), clinical examination and
investigations. Although, we are using the term to refer to the disease resulting from their congestion and
swelling, it is hard to evaluate the exact prevalence of haemorrhoids in a certain community as a lot of people
suffering from the condition don't seek for medical advice
Objectives: This thesis study was done to assess the efficacy of oral metronidazole administration in
management of post haemorrhoidectomy pain.
Patients and Method: This study was conducted at El Demerdash Hospital and Damanhour National Institute
in 1/1/2018 to 30/6/2018. 80 patients presented to the General Surgery Clinic and met the inclusion criteria in
six month duration. The participants were divided into two groups 40 in each group.
Results: When the results of both groups were put in a comparison, it showed that group A had a significant
lower pain values in day 1 and 3 than group B but both groups(p=0.043*,p= 0.004)results were equivocal in
day seven with no significant difference(p=0.268). Also results showed that group B needed more analgesics
than group A and that confirms that metronidazole do decrease pain experienced by the patients after the
operation and decreased their need for analgesics(p=0.043). Otherwise, both groups show no significant
differences according to the time of first bowel movement(p=0.967).
Conclusion: Oral Metronidazole administration post haemorrhoidectomy significantly decrease the post-
operative pain and decrease the need for more analgesics with no significant effect on the time of the first
bowel movement.
Key words: Haemorrhoidectomy, postoperative pain, metronidazole, analgesics

straining during defecation, which interferes with
Haemorrhoids are a very common medical
venous return causing congestion of the
problem. Approximately 50% to 66% of people
haemorrhoids. In addition, prolonged sitting on a
have problems with haemorrhoids at some point in
toilet is thought to cause some sort of decrease in
their lives (1).
the venous return in the perianal area (a tourniquet
Haemorrhoids are normally findings of
effect), causing congestion of haemorrhoids (3).
vascular structures in the anal canal although, we
In about 40% of patients suffering from
used to use the term to refer to the disease resulting
pathological haemorrhoids, there are no significant
from their congestion and swelling. It is hard to
symptoms. Patients may suffer from only internal
evaluate the exact prevalence of haemorrhoids in a
or external haemorrhoids but a combination of both
certain community as a lot of people suffering from
also is reported (4).
the condition don't seek medical advice. At least
Haemorrhoids are usually diagnosed by
50% of US population suffer from haemorrhoids at
physical examination, inspection of the anus and
some times during their life span and around 5% of
the surrounding area can verify presence of
the population are affected at any given time(1).
external haemorrhoids and prolapsed internal ones,
Haemorrhoids are classified into internal
which may be or may be not thrombosed. Full
haemorrhoids and external haemorrhoids according
examination by doing PR to detect any polyps,
to their presence to the dentate line. External
tumours, enlarged prostate or abscess may be not
haemorrhoids are derived from ectoderm, while
possible without proper sedation because of pain.
internal haemorrhoids are developed from
Differentiation between external and internal
endoderm (2).
haemorrhoids is according to their relation to
A number of factors are thought to be a
dentate line (5).
cause for example, Low-fiber diets, straining and
Conservative treatment usually consider
constipation. As a result of low-fiber diets intake,
advice of having high dietary fiber diet, plenty
small-caliber stools are formed, which result in
intake of water and oral fluids to keep good
hydration, nonsteroidal anti-inflammatory drugs,
Received: 1/7/2018


Full Paper (vol.731 paper# 28)

Assessment of the Use of Ultrasound in Local Anesthesia for Ophthalmic Surgery The Egyptian Journal of Hospital Medicine (July 2018) Vol. 73 (1), Page 5944- 5953
Assessment of the Use of Ultrasound in Local Anesthesia for
Ophthalmic Surgery
Ibrahim Hassan El-Banna, Ibrahim Abdel-Ghany, Amr Mohmoud Montaser,
Hadeel Magdy Abdel-Hameed
Anesthesiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Correspondence: Ibrahim H. Khalil, E-mail: Ibrahimhassan2002@hotmail.com,
Eye surgery is the most common surgery in the elderly. Many ophthalmic procedures, such as
cataract extraction can be performed safely in an outpatient setting, using regional anesthesia
and mild sedation. The number of outpatient ophthalmic procedures will increase as the
population continues to age. dvantages of regional anesthesia over general anesthesia are
numerous; it is generally safer with less incidence of complications and less bleeding.
Aim: The purpose of this thesis is to evaluate the use of ultrasonography in the performance
of local anesthesia for ophthalmic surgery. This assessment includes whether ultrasound will
add to the safety of the technique and its success rate.
Patients and methods: After approval of our institutional ethics committee and obtaining a
written informed consent, 100 adult patients having routine cataract extraction were divided
randomly into: Group A (peribulbar anesthesia) and Group B (retrobulbar anesthesia), with 50
patients in each group. Each group was subdivided into two subgroups: In one the anesthesia
was administered blindly, in the second using B-scan ultasonography, with 25 patients in each
one. Patients randomly allocated to one of these four subgroups until the required number is
reached in each group.
Results: Results of the current study demonstrated comparable degree of globe akinesia after
10 minutes (p = 0.342). The majority of cases showed no globe movement after 10 minutes.
Similarly, lid akinesia showed no significant difference between 4 groups (p = 0.082). This
was accompanied by partial satisfaction of the majority of surgeons with the procedure;
comparable in the 4 subgroups (p = 0.270).
Conclusion: Peribulbar and retrobulbar regional anesthesia of the orbit during cataract
surgery are safe procedures if blindly applied. Ultrasonography-guided needle injection
doesn't add to the safety and/or efficacy of the procedure. Therefore, ultrasound guidance is
not an advantage in orbital regional anesthesia; whether administered by the peribulbar or
retrobulbar technique.
Keywords: Eye surgery, cataract surgeries, extraocular muscles, ophthalmic artery, orbit.
Peribulbar, retrobulbar and sub-
Eye surgery is the most common
Tenon's techniques are widely used
surgery in the elderly. Many ophthalmic
methods of regional anesthesia in ocular
procedures, such as cataract extraction,
surgery. Recently, using of high resolution
corneal transplants, trabeculectomy, lid
ultrasound B scanning which can identify
surgery, and even viterectomy or repair of
the needles and cannulas is used in
a detached retina can be performed safely
regional anesthesia. It can be also used in
in an outpatient setting, using regional
ophthalmic block to demonstrate the
anesthesia and mild sedation. The number
distribution of the local anesthetic
of outpatient ophthalmic procedures will
solution. Its use showed that using
increase as health-care costs are contained
retrobulbar and sub-Tenon's injection, the
and the population continues to age.
anesthetic solution accumulated almost
Advantages of regional anesthesia over
directly into the muscle cone and, in
general anesthesia are numerous; it is
contrast, after peribulbar injection, the
generally safer with less incidence of
anesthetic fluid spread from the orbital fat
postoperative nausea and vomiting, post-
into the muscle cone(2).
operative restlessness, post-operative lung,
Aim: Evaluate the use of ultrasonography
in the performance of local anesthesia for
complications and less bleeding(1).
ophthalmic surgery.
Received: 1/7/2018


Full Paper (vol.731 paper# 29)

c:\work\Jor\vol731_30 The Egyptian Journal of Hospital Medicine (July 2018) Vol. 73 (1), Page 5954- 5960
Role of MDCT in diagnosis of lower limb peripheral arteries diseases
Ali Basyoni Amin, Haytham Mohamed Nasser, Mohamed Shaker Ghazy
Radiology departments, Ain Shams Hospitals.
Corresponding author: Ali Basyoni Amin, Email: Aliamin521@gmail.com.
Lower limb peripheral arterial disease (PAD) is a common disease that affects about two
hundred million peoples per year. It is the third leading cause of cardiovascular morbidity. We plan to
evaluate the diagnostic performance of 64-section computed tomographic (CT) angiography in the
assessment of steno-occlusive disease in patients with PAD, with conventional digital subtraction
angiography (DSA) as the reference standard.
Aim of study: is to compare the diagnostic accuracy of multidetector computed tomographic (MDCT)
angiography in diagnosis of PAD compared to the DSA as pre-operative evaluation of lower limb
peripheral arterial diseases.
Patients and methods: The study included 20 patients clinically presented with symptomatic PAD from
February 2018 to July 2018. The study protocol was approved, and written informed consent was
obtained from all patients. The patients underwent CT angiography and subsequent DSA. For stenosis
analysis (70% stenosis), the arterial bed was divided into 35 segments and evaluated by three readers.
Inter observer agreement was determined with generalized statistics. Accuracy, sensitivity, specificity,
was calculated. Mc Nemar test was used to prove significant differences between CT angiographic and
DSA findings.
Results: A total of 700 arterial segments were evaluated, with excellent agreement between readers (
0.928). On a segmental basis, both sensitivity and specificity for stenosis of 70% or more were at least
96% (386 of 400 segments and 290 of 300 segments, respectively), with an accuracy of 98% (686 of 7oo
segments).There was no significant difference between CT angiographic and DSA findings (P = .62­.87).
Conclusion: The diagnostic performance of 64-section CT angiography is excellent in patients with
clinical symptoms of PAD.
Keywords: MDCT, DSA, PAD


procedures The advent of alternative minimally
invasive procedures, such as multidetector
peripheral arterial disease (PAD) is a relatively
computed tomographic (MDCT) angiography
common disorder, particularly in the elderly
has markedly reduced the need for diagnostic
population, that is caused and exacerbated by
catheter angiography, effectively limiting its use
cardiovascular risk factors, such as a history of
to patients undergoing interventional treatment.
smoking, an elevated cholesterol level, or the
Whereas CT angiography is clinically more
presence of hypertension or diabetes mellitus .
useful than duplex ultrasonography (DUS) in the
diagnostic work-up of patients with PAD
In patients suspected of having PAD, it
Further potential benefits of CT angiography
is important to not only establish the diagnosis
include widespread availability, ease of use and
but also accurately define the extent and severity
rapid examination times over large volumes and
of disease when planning subsequent treatment.
considerable cost savings when this modality is
Traditionally, pretreatment assessment of PAD
used as a first-line diagnostic procedure (2).
has been performed with conventional catheter
Recently, a meta-analysis studies that
angiography is an invasive procedure that can
were performed to evaluate the diagnostic
have a complication rate (puncture site
performance of peripheral CT angiography with
complication and catheter-related complications)
predominantly 16-section CT scanners showed
as high as 10%. Currently, complications of
overall sensitivity and specificity of 95% and
digital subtraction angiography (DSA) are
96%, respectively, in the detection of stenosis of
substantially reduced, most of all in diagnostic
more than 50% or occlusion Improved
performance (sensitivity, 97%­99%; specificity,
Received: 1/7/2018


Full Paper (vol.731 paper# 30)