The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7850-7859
The Role of Uterine Artery Doppler Sonography in Predicting Pre-eclampsia at
14-20 Weeks of Gestation
Maysaa A. Chyad, Enas A. Azab, Mennatallah H.Shalaby, Ahmad A. Aly
Department of Radiodiagnosis
Faculty of Medicine - Ain Shams University
Corresponding author; Mobile: 01016262353; Email: firstname.lastname@example.org
Background: the introduction of Doppler technology has proved the first opportunity for repetitive,
noninvasive hemodynamic monitoring in human pregnancy compared to other methods of maternal and fetal
monitoring. Aim of the Work: this study aimed to predict usefulness of uterine artery Doppler in predicting
pre-eclampsia and to study uterine artery Doppler waveforms at 14-20 weeks of gestation. Patients and
Methods: this prospective study was carried out in the Radiodiagnosis Department Ain Shams University.
This study included 33 pregnant women (between 14 to 20 weeks of pregnancy); they were chosen randomly
from patients referred from maternal clinics, all were primigravida, single pregnancy during the period from
June 2017 to December 2017. Results: regarding our results when RI index was used, sensitivity, specificity
were 90.0%, 87.0% and when PI index was used sensitivity, specificity were 60.0%, 87.0%. Conclusion: we
can conclude that uterine artery Doppler between 14- 20 weeks of gestation is a simple rapid non-invasive
procedure and it can be used as a reliable indicator for prediction of preeclampsia to use it as a screening test.
Recommendations: we recommend other studies with a wide scale of population (large number) in more than
one center; this will lead to increased surveillance and delivery in a well-equipped setup in high risk detected
patient which is necessary to reduce the maternal and fetal complications.
Key words: uterine, artery, Doppler, solography, pre-eclampsia, gestation
resulting from the failure of second wave of
disorder with variable maternal and fetal
trophoblastic invasion into spiral arterioles, this
manifestations (1). Pre-eclampsia complicates
will result in increased resistance to flow within
3%-8% of pregnancies worldwide, overall 10-
the uterine arteries and decreased plancental
15% of maternal deaths are associated with
perfusion as well as due to imbalance between
preeclampsia and eclampsia (2).
the prostacycline and thrombaxane A2
Even in the era of modern obstetrics,
production (5). The crucial issue to understand is
pre-eclampsia remains as a major complication
that the prime mover of pre-eclampsia is
of pregnancy which can lead to significant
abnormal placentation. Two common theories
incidences of maternal and neonatal mortality
appear to be interlinked, ie, a genetic theory and
and morbidity. Despite advances in medical
an immunological theory (6). Pre-eclampsia can
research, reliable screening test for prediction
be perceived as an impairment of the maternal
of these adverse complications still lacking (1).
immune system that prevents it from
In the mother, pre-eclampsia may cause
recognizing the feto-placental unit (7). This
premature cardiovascular disease, such as
concept has led to the idea of using Doppler
chronic hypertension, ischemic heart disease
assessment of uterine artery flow velocity
and stroke later in life, while children born after
waveform as a screening test for predicting
preeclamptic pregnancies and who are
preeclampsia (8).Doppler examination of uterine
relatively small at birth, have an increased risk
arteries is a noninvasive tool that can be used to
of stroke, coronary heart disease and metabolic
indirectly assess trophoblast development and
syndrome in adult life (1).Pre-eclampsia is
uteroplacental perfusion (9).Uterine artery
defined as the development of hypertension,
Doppler sonography which is done during the
proteinuria, or both, after 20 weeks in women
second trimester can accurately predict pre-
with previously normal blood pressure (3). It
eclampsia, Resistance Index (RI), pulsatility
may be associated with many other signs and
index (PI) which are considered indirect
symptoms such as edema, visual disturbances,
measures of uteroplacental circulation (10).
Aim of the Work: this study aimed to predict
fundamental cause of pre-eclampsia is thought
usefulness of uterine artery Doppler in
to be the abnormal uteroplacental circulation
predicting pre-eclampsia and to study uterine
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7860-7868
Clinical and Lab-Assessed Antibiotic Resistance Pattern of Uropathogens
among Women with Acute Uncomplicated Cystitis
Ahmed M. Abdelkhalik1, Mohamed M. Agha1, Ahmed M. Zaki1, Ahmed Tahoun2
1Urology and 2Clinical Pathology Departments, Faculty of Medicine, Al-Azhar University, Cairo,
Corresponding author: Mohamed M. Agha, Mobile: 01091224033;
Background: acute uncomplicated cystitis (AUC) in females is among the most frequent infections in
community. Treatment of AUC in Egypt usually based on empirical therapy.
Objectives: To determine the most common uropathogens and their pattern of resistance to commonly
used antimicrobials aiming at finding a proper antibiotic which can be used as effective empirical
therapy in AUC.
Patients and Methods: Observational, hospital based, cross sectional study was performed. Three
hundred and twelve female patients were recruited for the study with positive urine culture and clinical
symptoms correlate with AUC during the period from December 2017 to August 2018.
Results: Eight organisms were isolated. E. coli was the most common uropathogen and was isolated
from 231 cases (74%). The next most common was Pseudomonas which was detected in 41 cases
(13.1%). Other organisms include MRSA (6.1%), Klebsiella (2.2%), Enterococcus spp. (1.9%), proteus
(1.3%), Acinetobacter and Staph. aureus (0.6%) each. Isolated uropathogens in this study were least
resistant to Nitrofurantoin (47.1%). The highest resistance rate was to TMP/SMZ (87.8%). Resistance
pattern to quinolones were 64.1%, 67% and 60.6% to Ciprofloxacin, Norfloxacinand and Levofloxacin
Conclusion: The most common cause of community acquired AUC was E. coli. Nitrofurantoin can be
used as a first line empirical therapy for AUC as it showed the least resistance pattern (47.1%).
Antimicrobial resistance is a crucial issue which evolves continuously and thus more studies must be
carried out in different regions and constanttime intervals.
Key words: Urinary tract infection, Acute uncomplicated cystitis, Antibiotic Resistance Pattern.
Urinary tract infections are one of the
characteristic clinical presentation. New onset
most common infections in women (1). Acute
frequency, dysuria, and urgency, together with
uncomplicated cystitis refers to a bladder
the absence of vaginal discharge or pain, has a
infection that occurs in women who have
positive predictive value of 90% for acute
normal structure and function of the
cystitis(7). Diagnosis may be confirmed by urine
genitourinary tract(2). 10% of women
analysis, urine culture and sensitivity test and
experience at least one episode of acute
may be pelvi-abdominal ultrasonography to
uncomplicated urinary infection in a year, and
60% have at least one episode during their
bacteriuria refers to bacterial colonization
lifetime (3). The peak incidence of infection
105cfu/ml(8). The World Health Organization
occurs in young, sexually active women aged
has named antibiotic resistance as one of the
18 to 24 years (4). E. coli accounts for 85% of
three most important public health threats of the
community acquired and 50% of hospital
21st century(9). It was estimated that at least
acquired urinary tract infections. Gram-positive
23,000 people die annually in the USA as a
Enterococcus faecalis and Staphylococcus
result of an infection with an antibiotic-resistant
saprophyticus are causative agents for the
organism(10). Antibiotic resistance is estimated
remainder of community acquired infections (5).
to cause around 300 million premature deaths
Development of acute uncomplicated urinary
by 2050(11). Knowledge of the antimicrobial
infection follows colonization of the vagina and
resistance patterns of common uropathogens is
the periurethral area by uropathogenic E. coli(6).
essential to provide an effective empirical
Acute uncomplicated urinary infection has a
therapy for AUC.
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7869-7882
Role of Recent Imaging Modalities in Diagnosis of Diabetic Foot
Mohamed Kamal Hamed Elsharkawy, Mokhtar Ragab Ramadan, Mostafa Mahrose Abd Elhamed
Department of Radiodiagnosis, Faculty of Medicine, Alazhar University
Corresponding author: Mostafa Mahrose Abd Elhamed, Mobile: 002001023136936, E-Mail: email@example.com
Background: osteomyelitis and septic arthritis complicate up to one third of diabetic foot infections that
require hospitalization and often result from contaminated soft tissues. Early diagnosis is difficult to achieve
through noninvasive imaging studies. Nuclear medicine and radiologic imaging techniques, although
commonly used, may lack accuracy. CT is used routinely because it is widely available, but it is of limited
diagnostic value in early stages of acute osteomyelitis of the foot and in patients with diabetic
osteoarthropathy. MRI, because of its high sensitivity and specificity, is considered the modality of choice
for diagnosing osteomyelitis of the foot and for identifying associated soft-tissue abnormalities such as
cellulitis, phlegmon, abscess, sinus tracts and ulcers. Aim of the work: this study aimed to assess the role of
recent imaging modalities such as high resolution ultrasound, CTA, MRI, MRA and PET/CT in the early
detection and /or improving the prognosis of diabetic foot.
Conclusion: the major complication facing patients with diabetic foot is amputation that is why tight
glycemic control is mandatory. In addition to routine screening for early detection of diabetic foot
complications can be helpful. With advancement of radiological techniques, the prognosis of diabetic foot
Keywords- CTA, MRI, MRA, PET/CT, diabetic foot
Diabetes Mellitus is a complex metabolic disorder
contra-lateral side (5). By the Doppler without
characterized by hyperglycemia, micro vascular
resorting to intravenous contrast injection we can
disease and peripheral sensory neuropathy
be assessed The internal vascularity of the
rendering skin susceptible to injury. Furthermore,
pathology--e.g., synovitis. Magnetic Resonance
it blunts healing and predisposes the extremity to
Imaging (MRI) also has many inherent advantages
increase occurrence of infections (1). Associated
such as the imaging of deeper soft tissue structures,
complications in the lower limb include Charcot's
bones, and joints, and it is fewer operators
joint (progressive destructive arthropathy caused
dependent. However, MRI and ultrasonography
by neuropathy), ulceration, infection, gangrene
are, complementary imaging techniques and the
and amputation (2). Clinical assessment of the
choice of modality will often depend upon local
swollen, red and hot foot for the presence of
expertise, accessibility and cost(5). In comparison
osteomyelitis is poor, even in the presence of soft-
with imaging modalities such as CT, MRI and
tissue ulcer. Therefore, the radiologist is often
ultrasound, FDG-PET is advantageous because it
asked to participate in the evaluation (3).
offers full body coverage, high sensitivity, an
Assessment of the lower limb vessels to detect the
absence of artifacts from metallic hardware.
degree of vascular affection is crucial for
Fluorine-18 (F18) Fluoro-Deoxy Glucose-Positron
determining the prognosis and surgical decision of
Emission Tomography (FDG-PET) represents a
any intervention. The vessels of the lower limbs
promising imaging technique and has shown many
can be examined in order to identify segments of
advantages compared to conventional radionuclide
stenosis, or occlusion with Doppler ultrasound,
imaging methods. FDG-PET has the highest
conventional angiography, CT, MR angiography
diagnostic accuracy for confirming or excluding
chronic osteomyelitis (6).
The foot is mostly superficial structures and thus is
Aim of the work
particularly suitable for high-resolution ultrasound
evaluation. Direct patient contact allows accurate
This study aimed to assess the role of recent
identification of the site of symptoms and allows a
imaging modalities such as high resolution
pertinent history to be obtained. Moreover,
ultrasound, CTA, MRI, MRA and PET/CT in the
Ultrasound offers real-time comparison with the
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7883-7891
Impact of Usage of Different Coping Strategies on Academic Performance
of Female Students in College of Medicine, Al-Ahsa
Manal Ali Saleh Baaleis1, Sayed Ibrahim Ali*2
1. Medical Intern, College of Medicine, King Faisal University, Saudi Arabia
2. College of Medicine, King Faisal University, Saudi Arabia, College of Education, Helwan
*corresponding author: Sayed Ibrahim Ali, Email: firstname.lastname@example.org
Background: academic stress can be prescribed as mental distress with respect to some anticipated
frustration associated with academic failure or even awareness of the possibility of such failure.
Medicine in specific is one of the most stressful fields of education because of its highly demanding
professional and academic requirements, highly extensive medical curricula, repeated difficult exams
and fear of failure all are causes of persistent stress and anxiety for medical students. Student's ability
to handle these increasing demands of medical school can affect their academic success and emotional
health. Experiencing stress and anxiety is beneficial to some extent as it can enhance the academic
performance. In the other hand, increasing levels of stress that students exposed may have a negative
effect on their cognitive functioning and learning abilities in the medical school. Coping is an important
key point of dealing with stress and preventing psychological problems.
Aim of the work: this study explored the impact of usage of different coping strategies on academic
performance of students of College of Medicine in Al-Ahsa, 2018 and which type they use more than
the other and which of these different strategies comprise more satisfaction than the others do.
Methods: this was a cross sectional study was carried out among female students in college of medicine
in king Feisal University in the academic year 2017-2018. Data had been collected by electronic and
paper survey, which contained demographics, educational level, family income, GPA, studying hours
and the Lazarus's ways of coping framework, which was a widely accepted model containing 66 points
that distinguishes between distinct active and emotion based coping methods. Results: 73 students were
completed the survey, 58.9% of them reported being upset\sad for significant amount in 2 weeks period,
and 49.3% of students report that they feel they need psychiatric consultation. No significant association
was noticed between GPA and each of coping strategies addressed in this study. Positive reappraisal
was the most used strategy by 76.86%, while confrontive coping was the least to use by 55.83%.
Conclusion: medical students were more vulnerable to academic stress due to highly demanding
professional and academic requirements. To overcome this, students used different coping strategies.
According to our study, there was no significant impact on the GPA or difference between these
Keywords: Coping Strategies, Academic Performance, Female Students, College of Medicine, Al-
Academic stress is described as mental
assignments, extensive medical curricula, long
distress with respect to some anticipated
studying hours, lack of support from health
frustration associated with academic failure or
experts or family, poor quality of the
even awareness of the possibility of such failure
educational process at the college, irregular
(1). Medicine in specific is one of the most
busy schedules, huge number of exams, tough
stressful fields of education because of its
competition with peers and fear of
highly demanding professional and academic
failure(2,3). Non-academic stressors have two
requirements. Several factors were responsible
sub categories: psychosocial stressors which
for this; we can classify them into two
include: high family expectations, home
categories: academic stressors and non-
sickness, new living circumstances, financial
academic stressors. Academic stressors like
problems, fear of future failure in medical
facing difficulties in learning new medical
career. Socio-demographic stressors include:
words, difficulties in reading long textbooks
gender, smoking, substance use, marital status,
especially if there is no preparatory year to
working during the study, parents' level of
prepare students for these new terminologies,
education, cultural background and the family
income (2,3). Several studies carried out among
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7892-7901
Comparative Study of Anti-Mullerian Hormone, inhibin-B, and Three-
Dimensional Ultrasound Determinants of Ovarian Reserve in Patients
Farid I. Hassan, Walid A. El Sheikh, Wael R. Hablas, Doaa E. Abou Shama
Obstetrics and Gynecology Department, Faculty of Medicine, Al-Azher University- Cairo Egypt
Corresponding auther: Doaa elsayed Abou Shama, E mail: doaaaboushama @ gmail .com
Background: Intracytoplasmic sperm injection (ICSI) is an in vitro fertilization procedure in which
a single sperm is injected into an oocyte. Objective: Aim of the Work: Comparing three-
dimensional ultrasound parameters, with anti-Mullerian hormone (AMH) and other conventional
endocrine markers for the prediction of ovarian response in patients undergoing intracytoplasmic
sperm injection cycles. Methods: This observational prospective study was conducted at Alexandria
Armed Military Hospital, on a sample of 100 women aged between 25 and 35 years, enrolled for
intracytoplasmic sperm injection (ICSI). Results: a good correlation between inhibin B and other
numerical variables. There was strong positive correlation between inhibin B and AMH, strong
negative correlation between inhibin B and both FSH and LH. Inhibin B correlated moderately
negatively with age and moderately positively with AFC, number of collected oocytes. Inhibin B
correlated positively with the number of oocytes and number of grade 1 embryos. As regard
pregnancy rate, the good-response group had significantly higher chemical and clinical pregnancy
rates, as there was no chemical or clinical pregnancy occurred in poor responders. Conclusion: AFC,
AMH and Inhibin B are effective in predicting the ovarian reserve as well as the response to
induction, and both AFC and AMH are the most significant predictors of response to ovarian
stimulation during ICSI. Recommendations: Larger scale studies including higher number of
patients are needed to verify the validity of this parameter as a marker of ovarian reserve in patients
Key words: anti-Mullerian hormone, inhibin B, three dimensional ultrasound, ovarian reserve, ICSI.
as the clomiphene citrate challenge test(4).
Infertility is a disease of the reproductive system
Other predictors of ovarian reserve include
defined as the failure to achieve a clinical
ultrasound measures, such as pre-treatment
pregnancy after 12 months or more of regular
ovarian volume and AFC, which is the total
unprotected intercourse (1). Since the stabilization
of small antral follicles in both ovaries.
of in vitro fertilization, it became obvious that
Generality of these measures, however, have
almost half of the couples failed to realize
restricted predictive value, oftentimes
fertilization and that phenomenon was assign to
because in fact predictors of ovarian reserve
a male gamete dysfunction. The adoption of
not ovarian response, e.g. AMH, or have
assisted fertilization techniques especially ICSI
fundamental inter-patient variability, e.g. age,
has been able to mitigate male factor infertility
or intra-cycle fluctuation, e.g. basal FSH (5).
by giving the consistent ability of a viable
Patients with very low ovarian reserve may
spermatozoon to activate an oocyte (2).
still become pregnant, and those with high
Intracytoplasmic sperm injection (ICSI) is an in
ovarian reserve might not attain ongoing
vitro fertilization procedure in which a single
pregnancy. Nevertheless, previous studies has
sperm is injected directly into an oocyte. This
been tailored established on markers of
procedure is most ordinarily used to cope male
ovarian response offers that outcomes are
infertility problems, though it may also be used
amended and the incidence of low and high
where eggs cannot easily be permeated by
response reduced compared with standard
sperm and sometimes sperm donation (3).
ICSI treatment (6).
A number of predictors intracytoplasmic
Since serum AMH levels be inverted the
sperm Injection (ICSI) have been identified,
ovarian follicular pool, any lowering in serum
including patient age; concentration of
AMH level denotes reduction in the number
hormonal markers, such as basal FSH, LH,
of small growing follicles. So AMH is a
estradiol, inhibin B, and of ovarian response to,
preferable marker and is superior to other
more recently, AMH; and dynamic tests, such
Anti-mullerian hormone is generated by
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7902-7907
Assessment of normal values of Area Strain by using
Three-dimensional speckle-tracking Echocardiography
Ali Mohammed Al Amin, Mohammed Hisham Hassan, Yehia El Maadawy Mohammed,
Ashraf Al-Amir Abd Elfattah, Mostafa Tarek Mostafa*
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mostafa Tarek Mostafa, Email address: email@example.com
Background: area strain (AS) has become a parameter of increasing concern. AS is a parameter that combines both
the longitudinal and the circumferential deformations and it is acquired using three dimensional speckle tracking
echocardiography (3D STE). This parameter should be used to detect pathological changes as it is more sensitive than
the conventional parameters in evaluating left ventricular (LV) systolic function. Aim: the present study aimed to
estimate the maximum normal systolic reference value of Area Strain in a sample of healthy subjects. Subjects and
Methods: the study conducted 180 healthy subjects (33.4±9.7yrs, 94.4% males, 5.6% females). The subjects were
volunteers without heart-related diseases or other diseases .They were classified into three different age groups :
Group I is between the ages of 20-30, Group II is between the ages of 30-40 and Group III is between the ages of 40-
50. Results: the study showed that the mean global area strain at group I , group II and group III were -28.40 ± 2.48%
, -28.57 ± 2.73% and -28.53 ± 2.81% respectively. The mean maximum systolic global area strain of all the studied
subjects was -28.50 ± 2.66%. The difference between the three groups was statistically insignificant. Conclusion: the
study concluded that global area strain obtained from 3D STE may be used clinically as an additional diagnostic
method since Area Strain can provide a more global and comprehensive assessment of LV systolic function than
Keywords: Area Strain (AS), three dimensional (3D), speckle tracking echocardiography (STE)
Strain echocardiography has become an established wall of the ventricle, and is the first endocardium area to be
and important clinical evaluation technique for cardiac
affected by various cardiopathies. In other words, 3D tracking
function. Myocardial strain has been shown toadd information
of myocardial displacement can be broken down into the three
on global and regional function and the timing spatial axes: longitudinal, circumferential and radial, in the
of myocardial contraction beyond such conventional markers
case of left ventricular myocardium. Comparing the
as LV ejection fraction (1). The area strain (AS) is a
displacement of two different points, information on
measurement of the relative percentage change in myocardial deformation or strain can be obtained in each of
the area of a particular myocardial segment, representing the
these three different directions. You can see a surface by
percentage change in the myocardial surface from its original combining 2 of these directions. By consolidating longitudinal
dimensions (2). The three-dimensional speckle-tracking
and circumferential deformation in a given myocardium
echocardiography (3D-STE) is a promising instrument to
segment, the deformation of subendocardial surface, which in
precisely quantify LV strain using complete 3D pyramidal data
this case is inversely proportional to the deformation of the
sets. Preliminary studies showed that 3D-STE may overcome
myocardium in the third dimension, the radial one, can be
the constraints of Doppler-based strain or 2D-based speckle-
acquired (8). The study aim is to estimate the maximum normal
tracking strain images (3-5). In addition, 3D strain analysis is
systolic reference value of Area Strain in a sample of healthy
angle independent and keeps away from strain estimation
mistakes due to out-of-plane movement. At last, it gives new
indices such as Area Strain and may enable more Patients and Methods
exact estimations of LV twist and shear strain (6).
This prospective study was carried out on 180 consecutive
Area tracking, known as Area Strain (AS), is a novel concept
subjects (mean age=33.4±9.7yrs, 94.4% males, 5.6% females)
in the Islamic Cardiac Center in Al-Azhar University during
which is quantified by the percentage of deformation in the LV
the period from January 2017 to September 2018. The subjects
endocardial surface area using 3D-STE. Area Strain
of this study were volunteers without heart-related diseases or
other related diseases. They were classified into three different
deformations (7). This gives an estimate of the subendocardial
age groups: Group I is between the ages of 20-30, Group II is
surface deformation that is inversely proportional to the radial
between the ages of 30-40 and Group III is between the ages of
deformation (systolic thickening and diastolic thinning) of the
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7908-7916
Evaluation of choroidal thickness in different stages of diabetic
Horaya A. Saad Allah1, A.Tarek H. ElEmary2, Jihan A. Mohammed1, Asmaa M. Gamal1
Department of Ophthalmology, Al-Azhar University, Faculty of medicine for Girls, Cairo,2
Department of Ophthalmology, Research Institute of Ophthalmology, Giza - Egypt
Corresponding author: Asmaa M. Gamal, email: firstname.lastname@example.org
Purpose: to assess changes of choroidal thickness (CT) in diabetic patients in different stages of
diabetic retinopathy and diabetic macular edema using spectral domain optical coherence
Patients and methods: One hundred and sixty three subjects were enrolled: 113 diabetic patients
(186 eyes) and 50 normal individuals as controls. Eyes were divided into two groups according to
age; group A from 35 to 50 years and group B from 51 to 65 years. Both groups classified according
to retinopathy grade: DR1 (no DR), DR2 (mild- moderate nonproliferative diabetic retinopathy
(NPDR)), DR3 (severe NPDR), DR4 (untreated proliferative diabetic retinopathy (PDR)) and DR5
(previously treated PDR).
All participants underwent full ophthalmic examination, stereoscopic color fundus photography,
and spectral domain optical coherence tomography (RS-3000; Nidek). Spectral domain optical
coherence tomography examination consisted of linear scans, 6 mm in length, centered onto the
fovea, and macula multi scans. Choroidal thickness was measured manually at the fovea and at
500, 1000, and 1500 um distance along all scans in the macula.
Results: Mean age was not significantly different between patients with diabetes and controls. In
the macular area, CT was significantly lower in the nasal quadrant versus all other quadrants (P,
0.0001), in both groups. No significant CT difference was found between controls and diabetic eyes
without detectable DR. Diabetic macular edema did not influence CT. In early NPDR (mild and
moderate) and treated PDR the mean choroidal thickness was significantly decreased than control.
In severe NPDR and treated PDR, the mean subfoveal choroidal thickness was not different than
control. There was a statistically significant increase in choroidal thickness in PDR when compared
with the mild NPDR group (P=0.027). DME was associated with a non-statistically significant
increase in choroidal thickness compared with eyes without DME (P=0.13).
Conclusion: Choroidal thickness is reduced in diabetic eyes. Subfoveal choroidal thickness
increased with the severity of diabetic retinopathy but showed no statistically significant
association with the presence of DME. Spectral domain optical coherence tomography clearly
confirms in vivo previously reported histopathologic observations. The role of choroid in the
pathophysiology of DR needs to be adequately investigated.
Key words: diabetic retinopathy, choroid, choroidal thickness, OCT.
Diabetic retinopathy (DR) is the leading
Clinical and histopathologic findings suggest
cause of blindness among working age
that vascular changes may also affect the
adults.1 Retinal vascular and neural
choroid in patients with diabetes (4). These
alterations are considered the main
findings include obstruction of the
pathologic phenomena of DR1. Increased
retinal vascular permeability because of
alterations of the blood retina barriers
neovascularization (58). Because the choroid
caused by tight junction disassembly and
provides oxygen and nutrients to the outer
endothelial cell mediated leukostasis are
retina, and it maintains the highly
considered as major mechanisms for retinal
metabolically active photoreceptor cells,
edema and ischemia (2,3).
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7917-7924
Clinical Comparative study between subcutaneous Continuous Analgesia
versus continuous transversus abdominis plane block post caesarian section
Abdulhafez M. Alhosainy, Ahmed G. El-Sawy, Islam S. Abd-Elhamed*
Department of Anesthesia and Intensive Care
Faculty of Medicine, Al-Azhar University
*Corresponding author: Islam S. Abd-Elhamed; Mobile: 01001994830 Email: email@example.com
Background: post cesarean section pain is associated with a variety of unfavorable post-operative
consequences; affect both mother and the newborn, especially the first 48 h after delivery. The pain can
be improbable, disrupting mother/child bonding and also affects mental, chest, heart problems, and
prolong the hospital stays. Aim of the Work: to compare the efficacy and safety of bilateral continuous
transversus abdominis plane (TAP) block versus continuous wound infiltration for pain relief after
surgery. Patients and Methods: this study was conducted on forty patients of American Society of
Anesthesiologists (ASA) physical status I or II, scheduled for elective CS were enrolled in this
controlled study. Information about the study was explained comprehensively both orally and in written
form to the patients. All patients gave written informed consents prior to their inclusion in the study.
Results: there was no difference between TAP block & CWI as regarding pain during rest but TAP
block was more effective during movement than CWI, opioid consumption was much less in TAP group
than in CWI group and the time of first analgesia request was earlier in CWI group than in TAP group.
Conclusion: both TAP block & CWI provided post-operative analgesia but USG TAP block increased
the time to first analgesic request, reduces the total pethidine consumption with hemodynamic stability
and decreases the incidence of adverse effects in patient undergoing caesarian section compared to
continuous wound infiltration.
Keywords: subcutaneous Continuous Analgesia, continuous transversus abdominis plane block,
Caesarean section (CS) is one of the
Previously, local anesthetic wound
most common surgical procedures in the world.
infiltration through subcutaneous or subfascial
Post-operative pain affects both mother and
catheters was used to treat postoperative pain in
newborn, especially the first 48 h after delivery.
many types of surgery including CS (5).
The pain can be Improbable, disrupting
Local anesthetic wound infiltration is
mother/child bonding (1).
now widely recognized as a useful, easy and
The well-known side effects of the
safe adjunct in a multimodal approach to
opioids such as nausea, vomiting, itching and
postoperative pain management in different
sedation, may disturb the interaction between
surgeries. This relatively simple technique as
mother and child, breastfeeding and post-
the surgeon directly places a multiorifice
partum experience in a dose-dependent manner.
subcutaneous or subfascial catheter to infuse
But a number of alternative strategies have been
local anesthetic or NSAID into wounds at the
described to reduce opioids consumption post-
end of the procedure, it is technically efficient
and safe, offers the potential to provide
One of the alternative strategies is the
complete analgesia or to substantially reduce
transversus abdominis plane (TAP) block, a
the need for opioids and their related side
regional anesthetic technique which can
effects, can be used for several days, and can be
provide sensory and motor block of anterior
used with portable pumps, which may be used
abdominal wall from T10 to L1 although
in an ambulatory setting (6).
lacking any visceral effect. It is used for lower
Continuous wound infiltration with
abdominal surgery such as CS (3).
local anesthetic through a multiorifice
The Interest in TAP block increased
subcutaneous or subfascial catheter increases
in the last few years after introduction of
the duration of action and efficacy of local
ultrasound in anesthetic practice (4).
anesthetic compared with a one-time wound
injection of local anesthetic (7).
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7925-7931
Non operative conservative management of blunt trauma to the spleen in
Children: A Single Tertiary Hospital Experience
Mabrouk Akl1, Ayman Albaghdady2, Ahmed Elshazly3, Hala Fouad C, Hany Embaby4, Mary KeriakosN,
Mahmoud Elshahawy4, Diaa EldeebN, Mohamed ElshafeyN, Abdelrahman Elsabaa 4.
1 Alazhar University (Pediatric surgery department), 2 Ain Shams University, 3 Banha University, C: Cairo University, 4
Nasser institute for research and treatment
Background: Splenic injury is the leading cause of major bleeding in the patients of blunt abdominal trauma.
In earlier medical practice, the blunt splenic injury was managed surgically in most cases, but the increased
understanding of the splenic function in the immunological process and the identification of post-splenectomy
complications have led physicians to prefer the non-operative management .
Material and methods: A retrospective study of the patients with blunt trauma to the spleen in the pediatric
age group between the year 2015 and 2018. The study was conducted in (Nasser Institute Hospital for research
and treatment). Management of the patients was done using hypovolemic resuscitation and serial follow up.
Abdominal ultrasound, complete blood picture and Abdominal CT were done. Data was tabled and analyzed.
Results: A total of 123 blunt splenic trauma patients were identified. Traffic-related accident and falling from
height were the main mechanisms of injury. Splenic contusion and hematoma were the most frequent finding
on initial computerized tomography (CT) scans, followed by shattered spleen, blush, and devascularization.
Non-operative management failed in 6 patients who underwent splenectomy. (95.12%) of the patients
managed successfully using hypovolemic resuscitation without need for surgical interference.
Discussion: Non-operative management is considered for patients with low-grade splenic injuries, unless
operated upon for other associated injuries. In fact, higher-grade injuries could also be managed non-
operatively. Splenic angioembolization of bleeding vessels increased the success rate of non-operative
management in hemodynamically stable patients. In our study, although we didn`t use splenic
angioembolization we were able to reach high rates of success. In comparison with the operative management
of blunt splenic trauma, the non-operative management has the added benefit of preserving the splenic
Conclusions: Most blunt splenic trauma patients were successfully treated non-operatively, with a low failure
rate. The severity of injury and presence of associated lesions should be carefully considered in developing the
Key Words: Spleen, Pediatric, Injury, Non-operative management, NOM.
spleen is one of the most commonly injured
Blunt trauma is one of the most common
organ in blunt abdominal trauma patients, its
causes of morbidity and mortality in children,
management was a point of controversy.
In spite of the great prevention efforts, blunt
The risk of laparotomy, the discovery
abdominal trauma (BAT) still remains a
of the immunological role of the spleen and
leading cause of morbidity and mortality
the recognition of the risk of the
especially in children. The mode of trauma is
variable but the most common cause is traffic
(OPSI), all these factors, made the non-
accident, which represents about 75-80%.
operative management of blunt splenic injuries
Other causes include falling from a height,
is the treatment of choice in hemodynamically
bicycle handlebar injuries, injuries in contact
stable patients (2). The Advantages of the non-
sports or child abuse. The organs most
operative management include a decreased
commonly injured are the spleen and the liver
lifetime risk of developing overwhelming
followed by the kidney, the pancreas, the
postsplenectomy infection, a shorter hospital
urinary bladder and hollow viscera (1). As the
stay, fewer blood transfusions, and a
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7932-7938
Two-dimensional speckle tracking echocardiography for assessment of both
atria functions in patients with atrial septal defect
Mansour M. Mostafa, Mohammad I. Al-Deftar, Mohamed S. Mohamed*
Department of cardiovascular medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohamed S. Mohamed; Mobile: 01000904618; Email: Se0101731@gmail.com
Background: of all the types of congenital heart disease, ASDs represent the second most common and
account for 7% to 10% of all congenital heart defects. The most common type of atrial septal communication
is an ostium secundum defect, representing 80% of all ASDs. In unaffected individuals, the chambers of the
left side of the heart are under higher pressure than the chambers of the right side. In the case of ASD, which
may result in a clinically remarkable left-to-right shunt, blood shunts from the left atrium to the right atrium.
This extra blood from the left atrium may cause a volume overload of the right side.
Aim of the Work: The aim of this work was to assess feasibility of using 2-dimensional speckle-
tracking echocardiography (2D-STE) for evaluation of left and right atrial function in patients with
unrepaired atrial septal defect, to compare both LA & RA function in patients with unrepaired atrial
septal defect with those apparently healthy individuals, and to correlate both LA & RA function with
the size of inter-atrial shunting.
Patients and Methods: The ethical approval was obtained from the hospital Ethical Research Committee
and each patient entering the study signed an informed consent. Thirty patients included in this study with
secundum atrial septal defect. All were under the age of sixteen at time of diagnosis. They were recruited
from cardiovascular department at Sayed Galal University Hospitals during the period from December 2016
to November 2018.
Results: Speckle tracking echo of both atria showed a significant correlation with QP/QS, ASD
maximal size, ASD minimal size, RA to LA area ratio and pulmonary pressure. Patients with PH were
older (33.4+/-14.6 vs. 23.8 +/- 12.2 years; p<0.06) and had larger defects (17.8+/4.6 mm vs. 14.5.1+/-
5.0 mm; p<0.08). The proportion of women was nearly similar in both groups (55% in patients with PH
vs. 63% in those without; p=NS). Most patients with PH had ASDs with more complex shapes on
echocardiography. However, some patients with simpler and smaller defects, such as central ASD with
a diameter of <5 mm, also developed PH.
Conclusion: The new echocardiographically-derived myocardial deformation indexes, which reflect
structural changes assessed by transthoracic echocardiography, can be used to detect abnormalities in atrial
function before clinical deterioration.
Keywords: echocardiography, atrial septal defect, right atrium, left atrium, speckle and pulmonary
Of all the types of congenital heart
remarkable left-to-right shunt, blood shunts from
disease, ASDs represent the second most
the left atrium to the right atrium. This extra
common and account for 7% to 10% of all
blood from the left atrium may cause a volume
congenital heart defects (1). Worldwide, ASDs
overload of both the right atrium and the right
are noted to be 1.64 per 1000 live births with a
ventricle. If untreated, this condition can result in
female-to-male ratio of 2:1 )2(.
enlargement of the right side of the heart and
The most common type of atrial septal
ultimately heart failure(4).
communication is an ostium secundum defect,
Echocardiography is the most common
representing 80% of all ASDs. Ostium primum
diagnostic method for assessing atrial function
but the technique has some limitations.
approximately 10%. The rarest type of ASD is an
Traditionally, assessment of left atrial function
unroofed coronary sinus (3).
has been performed by measuring volumes with
In unaffected individuals, the chambers
2D echocardiography. Additionally, it can be
of the left side of the heart are under higher
assessed with trans mitral Doppler and
pressure than the chambers of the right side. In
pulmonary vein Doppler (5 ).
the case of ASD, which may result in a clinically
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7939-7950
Role of CD11a and CD18 in Diagnosis of Acute Promyelocytic Leukemia
Mona H. Alrayes*, Reham H.M. Hammad*, Enas M. Radwan** and Samar M. Abd El-Hamid*
*Department of Clinical Pathology, Faculty of Medicine for Girls, Al-Azhar University and **Department
of Clinical Pathology National Cancer Institute (NCI), Cairo University.
Corresponding author: Samar M. Abd El-Hamid, email: firstname.lastname@example.org
Background: Acute promyelocytic leukemia (APL) is an aggressive subtype of acute myeloid leukemia
(AML) that requires rapid diagnosis and early intervention. Previous studies spotted light on APL being
negative for members of 2 integrin family CD11a and CD18.
The aim of this work: was to study the value of absence of CD11a and CD18 molecules in screening and
its relation to prognosis of APL cases.
Patients and methods: This cross sectional study was conducted on seventy adult (>18 years) patients with
de novo AML, recruited from National Cancer Institute, Cairo University. They were divided in to 2 groups;
group 1 of APL cases (n= 35) and group 2 of AML-Non APL cases (n= 35) as a comparative group. Both
groups were investigated by flow cytometry for the expression of CD11a and CD18 molecules on leukemic
Results: Comparison between group 1 and group 2 illustrated significant reduction in % of cells expressing
CD11a (p= 0.014), CD18 (p=0.008) and % of cells co-expressing CD11a /CD18 (p=0.007) in group 1
compared to group 2. There was significant positive correlation between % of cells expressing CD18 and
TLC (r=0.411, p=0.014). There was significant positive correlation between CD11a MFI and hepatomegaly
(r=0.390, p=0.021) in AML-Non APL group. Regarding the output data of ROC curve for discriminative
percentage of leukemic cells expressing CD11a and CD18 between APL and Non-APL groups, at cut off
78.95% and 23.5% respectively, the specificity for both was 60% and 68.6%, respectively. While sensitivity
was 77.1% and 68.6%, respectively, with Area Under Curve (AUC) of 0.671 and 0.686 and p value of
0.014, and 0.008 for leukemic cells expressing CD11a and CD18, respectively.
Conclusion:  There is significant reduction in % of cells expressing CD11a and CD18 in APL patients,
but they were neither sensitive nor specific to be used as single markers in diagnosis of APL patients. 
Positive correlation seen between the most important prognostic factor, TLC and both CD18 MFI and
percentage of cells expressing CD18 could throw light on the potentiality of CD18 as a prognostic factor.
 Significant positive correlation between CD11a MFI and hepatomegaly in Non-APL cases might
suggest a role of CD11a in migration of leukemic cells.
Keywords: APL, AML, CD11a, CD18.
Acute promyelocytic leukemia (APL) is
The APL is characterized by a highly
an aggressive hematological neoplasm that
specific immunophenotyping, which is (CD34-
requires rapid diagnosis and early intervention.
CD117+ HLA-DR-) . Some of the studies have
APL is characterized by the defining
thrown light on APL being negative for both
translocation t (15; 17), resulting in the PML:
CD11a and CD18 .
RAR-alpha rearrangement . The confirmatory
Both CD11a and CD18 molecules are
cytogenetic and molecular studies are relatively
members of 2 integrin family, and their
time-consuming. According to the National
significance is derived from their exclusive
Comprehensive Cancer Network (NCCN)
presence in leukocytes . CD11a contributes to
Guidelines, ATRA should be started before
the strong adhesion and initiation of trans-
genetic confirmation in patients with clinical and
endothelial migration. CD18 is involved in many
pathological features of APL, because early
inflammatory and immunological reactions.
initiation of ATRA may prevent the lethal
Mutations of the CD18 result in a profound
complication of bleeding .
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7951-7962
Surgical Treatment of Ingrown Toenail by Nail Fold Resection
Ahmed Mohammad Ahmed Mohammad*, Mohammad Elsayed Radwan, Mohammad
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Mohammad Ahmed Mohammad, E-mail: email@example.com, Tel:
Background: ingrown toenail is a common condition. Although many methods for treatment
are available, there is no consensus on the optimal treatment.
Aim of the study: to evaluate surgical correction of ingrown toenails via soft-tissue excision
of the nail folds with preservation of the nail and its matrix.
Patients and Methods: This study includes one hundred (100) patients suffering from
ingrowing toenail; these patients were enrolled in a combined prospective study and had a
retrospectively gathered outcome analysis at the department of surgery, AL-Azhar University
Hospital from October 2017 to October 2018.
Results: significantly short operative time was recorded. Postoperative wound complications
occurred in 15.7%% of patients. All cases presented in grade I (33 cases), only one case,
symptoms and signs of grade I recurred 1 months after operation (recurrence rate 0.9%). The
27 cases presented in grade II ingrown toenails, symptoms and signs recurred in 7 cases
(recurrence rate 6.5%). The 48 cases presented in grade III, symptoms and signs recurred in 10
cases (recurrence rate 9.2%). The recurrence rate in all cases was 18 cases (16.66%).
Conclusion: nail fold excision of ingrowing toenail without matrisectomy is considered as an
effective and safe method for ingrown nail treatment.
Keywords: matrisectomy, ingrowing toenail.
Ingrown toenails are frequently
fitting shoes and using warm water baths and
encountered in clinical practice, with an
estimated 10 000 new cases per year in the
Surgical intervention is ultimately required
United Kingdom. Young men are most
in refractory cases. Many approaches have
frequently affected, and the associated
been described, with most targeting the nail
morbidities have significant economic
as the causative agent. Partial nail avulsion
impact, secondary to decreased mobility and
coupled with chemical destruction of the
work absenteeism. Currently, a wide variety
nail matrix (matricectomy) with phenol
of treatment options exist; however, they are
remains the most preferred surgical
associated with poor cosmetic results, low
rates of patient satisfaction and high rates of
Vandenbos and Bowers (3) suggested
that pressure necrosis of the soft tissue
Initial treatment of an ingrown
surrounding the nail contributes to the
toenail, or onychocryptosis, is conservative
pathogenesis of ingrown toenails. Indeed,
management, including avoiding tight-
increased nail-fold skin width in patients
with ingrown toenails, greater weight-
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7963-7967
Early Versus Late Fixation of Mandibular Fractures in Adults
Osama A. Alshahhat, Mahmoud A. Amin, and Ahmed M. Safwat
Department of Plastic Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Osama Abd Elraheem Alshahhat, E-Mail: firstname.lastname@example.org, Mobile: 01223311901
Background: facial fractures occur most commonly in males in the third decade of life. The most
frequent causes of facial fractures are road traffic accident, interpersonal violence, falls, and sports-
related accidents. Mandible fractures are one of the common facial fractures in the adult population.
However, the timing of treatment of mandible fractures remains a source of debate.
Aim of the work: the aim of the study was to evaluate the effectiveness of early versus late treatment
of isolated mandibular fractures in adults upon healing and postoperative complications.
Patients and Methods: the present study included 20 patients who were presented by isolated
mandibular fractures. They were divided into two groups according to the time utilized from injury to
operative intervention: Group 1: included 11 patients who were treated within 72 hours. Group 2:
included 9 patients who were treated after 72 hours up to 14 days. All included patients were underwent
full history taking, examinations (general and local) done in a systematic manner, laboratory and
radiological examination. Outcome was documented for all patients.
Results: both groups were comparable as regard to age and sex (no females). The most common cause
of trauma in studied patients was road traffic accident. Operative time extended from 110 to 192 minutes
with no significant difference between absorbable and non-absorbable groups (150.07±23.99 vs
160.06±20.54 minutes respectively). There were a total of 20 males and no females in the study group
with a mean age of 23.3±6.3 (range 18to 38 years) in the immediate group and 26.6±8.1 (range 18 to
39 years) in the delayed group. The most common fracture types in both groups were parasymphyseal
and angle fractures with RTA as the most common etiology. In the immediate group, there were one
patient with temporomandibular joint pain after surgery, five patients with numbness, and one patient
with malocclusion. In the delayed group, no patients with TMJ pain, seven patients with numbness, and
two patients with malocclusion.
Conclusion: our study did not reveal a statistically significant difference in the development of
postoperative complications after mandible fracture repair between the early and late treatment groups.
Keywords: Complications, delayed treatment, mandibular fracture
Facial fractures occur most commonly
immediate care, others prefer to delay
in males in the third decade of life. The most
treatment, especially if faced with difficult
frequent causes of facial fractures are road
logistics in obtaining operating room time (2).
traffic accidents, interpersonal violence, falls,
Airway compromise and hemorrhage
and sports-related accidents. Their prevalence
are indications for acute reduction. In
is geographically dependent. Road traffic
mandibular fractures, delaying repair may
accidents are the most common cause of facial
increase bacterial count and osseous
fractures all over the world. Nasal fractures are
devascularization, so early immobilization is
the most common, followed by dentoalveolar
and mandibular fractures, mid face and orbital
Fractures can be classified as favorable
floor fractures, and then frontal sinus (1).
or unfavorable based on the stability afforded
Mandibular fractures are one of the
by the pull of muscles on the fractured segments
common facial fractures in the adult population.
of bone. The temporalis and masseter muscles
However, the timing of treatment of mandible
exert the primary upward force while the
fractures remains a source of debate. All
downward force is exerted by the suprahyoid
mandibular fractures through the dentoalveolar
musculature and gravity. If these forces act to
areas are open fractures because of the potential
bring the fracture line together, the fracture is
for communication through the periodontal
favorable; if they act to pull the fracture line
ligament space. Although some clinicians
apart, the fracture is unfavorable. Following
propose that mandibular fractures benefit from
callus formation of non-reduced mandibular
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7968-7974
Effect of three Intravitreal Injections of Aflibercept on the CNV Guided by
Optical Coherence Tomography Angiography in Wet Age Related Macular
Ahmad El-Sayed Hudieb
Ophthalmology department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmed El-Sayed Hudieb, Email: email@example.com, Phone Number: 002-01015488588
Background: age-related Macular Degeneration (AMD) is a progressive, degenerative disease that affects the
macula and it isone of the most common leading causes of irreversible vision loss in old patients with age more
thanfifty. Optical coherence tomography angiography (OCTA) can detect the presence of choroidal
neovascularization (CNV), structural changes in AMD; moreover, changes in choroidal blood vessel flow.
Aim: to assess and compare structural retinal changes in patients with neovascular age-related macular degeneration
(AMD) treated with 2mg/0.1ml intravitreal aflibercept three times with an interval of one month each.
Patients and methods: twenty eyes of non-diabetic non-hypertensive ARMD patients were included. They received
2mg/0.1ml intravitreal aflibercept three times with an interval of one month each. OCTA was done before the first
injection and was repeated one month after the third injection.
Results: the area size and the GLD of the CNV had highly statistically significantly improved after 2mg/0.1ml three
intravitreal aflibercept injections.
Conclusion: aflibercept is an effective treatment in AMD; it can decrease the area size, GLD and thickness of the
CNV. OCTA is an effective tool that can provide a noninvasive method in the diagnosis and follow up of the activity
and anatomical changes in AMD.
Keywords: optical Coherence Tomography Angiography; Aflibercept; Wet Age Related Macular Degeneration;
CNV; Macular thickness.
Age-related Macular Degeneration (AMD) is the
Since VEGF plays an important role in the
leading cause of irreversible vision loss among
pathogenesis of the choroidal neovascular
individuals aged 50 or older in developed
membrane (CNVM), the treatment for exudative
countries. It can be classified into two types: dry
AMD has been revolutionized with intravitreal
(atrophic) AMD and wet (exudative) AMD (1).
anti-VEGF therapy: Ranibizumab, Bevacizumab
Advanced wet AMD is characterized by
and Aflibercept (5).
choroidal neovascularization (CNV), the leakage
Aflibercept is a fusion protein with
ofnew blood vessels can cause edema and
bindingdomains from native VEGF receptors,
disorders in retinal architecture eventually
binds VEGF-A,VEGF-B, and placental growth
causing blurred and distorted vision. If left
factors 1 and 2 withhigh affinity. Ophthalmologic
untreated, the area of neovascularization can
studies demonstrated that aflibercept suppresses
expand rapidly leading to the development of
choroidal neovascularization in patients with
fibrous scarring. Recent studies show that within
exudative age related macular degeneration with
3 years of onset of neovascularization, about 75%
excellent visual outcomes (6).
of untreated patients will present a visualacuity of
20/200 or worse (2).
The introduction of intravitreal anti-
vascular endothelial Growth factor (VEGF)
blockade for neovascular age-related macular
geneticpredisposition, and history of cataract
degeneration (AMD) in the last decade has had a
surgery, smoking history and diabetes (3).
significant beneficialimpact on patients with
Vascular Endothelial growth factor-A (VEGF-A)
neovascular AMD (7).
has been implicated to play a major role in the
Published studies hint at the optical
pathogenesis of the wet AMD (4).
coherence tomography angiography (OCTA)
VEGF-A and placental growth factor (PGF) are
potential efficacy in the evaluation of common
members of the VEGF family of angiogenic
ophthalmologic diseases such age related macular
factors which may act as potent mitotic factors,
degeneration (AMD), diabetic retinopathy, artery
vascular permeability and chemotactic for
and vein occlusions, and glaucoma (8).
endothelial cells (5).
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7975-7981
Comparison Between Temporal Versus Nasal Anterior Transposition of
the Inferior Oblique Muscle for Management of Dissociated Vertical
Deviation with Inferior Oblique over Action: Two Years Follow Up
Mahmoud M Saleh and Nour Elden A Abdelhalim
Department of Ophthalmology, Al-Azhar University, Cairo, Egypt
* Corresponding author: Mahmoud Saleh, e-mail:Shahdmsaleh@hotmail.com.
Background: anterior nasal transposition (ANT) is a relatively new procedure which can be used to
eliminate inferior oblique over action. An advantage of this procedure over temporal anterior
transposition is that it avoids ante-elevation syndrome.
Objective: to compare anterior temporal transposition (ATIO) of the inferior oblique muscles versus
anterior nasal transposition (ANT) in management dissociated vertical deviation (DVD) with inferior
oblique muscle over action (IOOA).
Patients and Methods: The study included 50 eyes of 28 patients with DVD of at least 10 prism
dioptres in the eye involved. The patients were divided into two groups. Group A (25 eyes of 15
patients) managed by temporal anterior transposition (ATIO) of the inferior oblique muscles and Group
B (25 eyes of 13 patients) managed by nasal anterior transposition (ANT) of the inferior oblique
muscles. All patients were followed for at least 24 months postoperatively. The size of preoperative and
postoperative angle of DVD, grade of IOOA preoperative and postoperative, need for repeated surgeries
and complications were recorded and evaluated.
Results: In group A the mean DVD angle was decreased in primary positions from 21.11±4.32 to 9.5
±4.7 (P<0.001) and from 19.5±4.6 to 5.51 ±2.65 (P<0.001) in group B mean IOOA grade was
decreased from +2.0 ±0.7 to +0.18±0.4 in group A (P<0.001) and from +2.5 ±0.7 to +0.1±0.5 (P<0.001)
in group B. In group B, two patients developed hypotropia of 5 and 6 PD. Persistent IOOA (+1) was
observed postoperatively in two eyes in each group. Limited elevations in abduction developed in 3
patients in group A, the incidence of recurrence rate after 24 months was 2 eyes 10% in group A and
one eye 5% in group B.
Conclusion: Anterior transpositions either temporal or nasal of the inferior oblique muscles are safe
and effective in management of DVD with inferior oblique muscle over action. Anterior nasal
transposition (ANT) is more effective in correction of DVD with less incidence of antielevation
syndrome and recurrence of DVD, however may induce persistent hypotropia.
Keyword: DVD, IOOA, ATIO and ANT.
Dissociated vertical deviation (DVD)
has been abandoned by many surgeons (3,4).
is characterized by elevation, abduction and
Currently, two methods have been preferred,
excyclotorsion of the nonfixing eye without
particularly when both DVD and IOOA are
corresponding hypotropia in the other eye. It is
present, and these are anterior transposition of
demonstrated by upward drifting and outward
the inferior oblique muscle (ATIO) and
movement of the occluded eye on cover testing
myectomy of the inferior oblique muscle (MIO)
(1). DVD is usually, but not always, bilateral but
asymmetrical. In addition to DVD, inferior
Anterior nasal transposition (ANT) is a
oblique over action (IOOA) is also responsible
relatively new procedure (8,9), in which the
for excessive elevation of one or both eyes but
insertion is transposed to a location over the
only in adduction (2).
nasal half of the inferior rectus muscle typically
Several different procedures have been
2 mm nasal to the nasal border of the inferior
used with varying success to surgically manage
rectus muscle and 2 mm posterior to the inferior
DVD. In the past, bilateral large (symmetrical
rectus insertion). The inferior oblique is thus
or asymmetrical) inferior rectus resections were
transformed from an extorter into an intorter
advocated but, in recent years, this procedure
and from an elevator to a depressor. The ANT
A STUDY OF THE FUNCTIONAL AND STRUCTURAL CHANGES IN SKELETAL MUSCLES IN RESPONSE TO ANEMIC HYPOXIA IN MALE ALBINO RATS
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7982-7987
Assessment of uterine cavity after hystroscopic removal of sub- mucous
fibroids by morcellation
Waleed A. Ayad
Department of Obstetrics and Gynecology, Al-Azhar Faculty of Medicine, New-Damietta- Egypt
Study Objective: sub- mucous fibroid can be removed hystroscopically by different techniques ,
hystoscopic shaver represent one of the most recent treatment of intra cavitary fibroids, althought
its usage is simple and has a good result for removal of fibroid, it may be complicated by formation
of intra uterine adhesions.
Study Objective: to determine the incidence and types of uterine syechia following
hystroscopic myomectomy by morcellation. Design: prospective observational study. Patients
and methods: Setting: Al- Azhar University hospital (New Damietta) during the period from
August 2016 to March 2018. Patients: fifty women who had hystroscopic myomectomy by intra
uterine Bigatti shaver (IBS).for different reasons (abnormal uterine bleeding, infertility, recurrent
pregnancy loss). Interventions: office hysteroscopy after 2 months from hystroscopic
myomectomy by Bigatti shaver. Measurements and Main Results: Evaluation of uterine cavity
especially formation of adhesions is observed. The incidence of adhesions was 8%. The
development of adhesion was usually associated with multiple myomas present in posterior
position who need long resection time and usually the resection is incomplete. The adhesions were
usually mild (75%) and there was no complications were reported after hysteroscopic
myomectomy. Conclusion: the IBS proves to be an effective and safe new instrument for the
removal of submucous fibroids, however such procedure may be followed by formation of intra
uterine adhesions however most adhesions are filmy and its incidence is less than conventional
hystroscopic methods as reviewed in literature.
Keywords: hysteroscopy; myomectomy; uterine adhesions; synechiae; integrated Bigatti Shaver.
are common complaints of IUA, and the
Intra uterine morcellator or shaver
accompanying retrograde menstruation may
represents a new alternative technique for
lead to endometriosis. Adhesions are a
removal of uterine fibroids without usage of
significant source of impaired organ
The 1st hystroscopic morcellator was
Truclear which was approved by food and
possibly, pain with consequent financial
drug administration (FDA) in 2005, followed
by Myosure tissue removal system in 2009 2.
Intrauterine Bigatti shaver follows the team of
PATIENTS AND METHODS
hysreoscopic morcellation and has shown to
The present study is a prospective follow up
be better than conventional methods 3.
study. The study included 50 women
Formation of Intra Uterine Adhesions
indicated for hystroscopic myomectomy using
(IUA) after hystroscopic surgery found to be
intrauterine Bigatti shaver (IBS). They were
2.4 % of patients undergoing hysteroscopic
selected from Obstetrics and Gynecology
Department, (Al-Azhar Faculty of Medicine,
demonstrated a frequent occurrence of IUA
New Damietta), during the period from
which could be as high as 31.345.5 % 4.
August 2016 to March 2018.
Intra uterine adhesions are the most
After full explanation of the study protocol for
common drawbacks after hystroscopic
each patient, an informed consent was signed
surgery, and its prevalence is correlated to
by each participant.
intra uterine lesions (fibroids, polyps or
In addition, the study protocol was approved
by the Research and Local Ethics Committee
In addition to abnormal menses,
of Al-Azhar Faculty of Medicine.
infertility and recurrent spontaneous abortion
Inclusion criteria: Patients underwent
Evaluation of The Accuracy of Trigger Finger Injection Using Ultrasound
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7988-7996
Evaluation of the Accuracy of Trigger Finger Injection Using
Abd Elhakim Abd Allah Massoud1, Amro Ahmed Fouaad1, Mohamed M Abdelkareem2,
Ahmed Mohamed Ali El Baqary1
1Department of Orthopedic Surgery, 2Department of Rheumatology, Physical Medicine,
Rehabilitation, Faculty of Medicine, Al-Azhar university, Cairo
Corresponding author: Ahmed Mohamed Ali El Baqary, Mobile: 01064262658; Email:
Background: Trigger finger is a common cause of disability and pain in the hand and The lines of
management of this disease start by conservative treatment as rest, NSAID, local corticosteroid
injection under the tendon sheath either blind or by musculoskeletal ultrasound guidance and
surgery may indicated in recurrent cases.
Aim of the study: The aim of the present study was to evaluate the musculoskeletal ultrasound
accuracy to guide the injection of corticosteroid in trigger finger management.
Material and methods: 50 cases that complaint from symptoms of trigger digit in this randomized,
prospective control study were recorded. All the cases were injected by 1 ml corticosteroid 1ml of
2% lidocaine at the level of the A1 pulley under the tendon sheath. The injection done under control
of musculoskeletal ultrasound after a blinded needle insertion. Comorbidities and associated
diseases were recorded. Follow up examinations at the 2 week and 6 months, no complications
were recorded. The results were assessed according to the green's grading. The pain was assessed
according to visual analogue scale.
Results: The cases in the present study were assessed according to age, associated diseases and
hand dominance. The female patients were more than male patients in the present study. The
injection under control of musculoskeletal ultrasound accurate more than a blinded injection even
when an expert physician who did it. And It showed the same efficacy according to green's grading
at the period of follow up examinations when compared with the pre-injection status. No
complications were seen during the period of the follow up.
Conclusion: A different technique of injection using musculoskeletal ultrasound guidance all of
which gave excellent accuracy superior to a blinded injection even when it is done by expert
physician. However, the post injection result was similar to that of a blinded injection. Level one
of evidence (randomized prospective study).
Keywords: Ultrasound -Trigger finger- Corticosteroid injection
Trigger digit is a common hand
hypoechoic of the A1 pulley and tendon
problem (1). The pathology in the A1 pulley
in the form of thickening, which lead to
The tendon loses its normal smooth
clicking with movement, painful triggering
gliding surface at the pulley system. The A1
pulley is the most commonly level affected.
It is more in females than in males (4,5,6) with
Ultrasound findings of trigger digit
the highest involvement in the thumb (4,6,7) .
may include synovial sheath effusion with
The incidence of lifetime risk in normal
changes in the shape during movement,
population to develop trigger digit is between
diffuse thickening which appear as
2.5 to 3.5 % and 10% with diabetics (8,9) .
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 7997-8006
Diagnostic Value of Plasma M2-Pyruvate Kinase in Egyptian Patients with
Ali Ahmed Wahib1, Mohamed Safwat Seif El-Nasr1, Mahmoud Bastawy Ismail2, Diaa
Mohammad Eltiby1*, Sayed Abd-Elrehim Sayed3, Moataz Yousry Soliman1
Departments of 1Tropical Medicine, 2Clinical Pathology and 3Pathology
Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Diaa Mohammad Eltiby, E-mail: firstname.lastname@example.org
Background: M2-pyruvate kinase (M2-PK) is a tumor growth key regulator and plays a crucial role in
tumor metabolism and can dynamically regulate aerobic glycolsis. Notwithstanding, the colonoscopy
is the gold standard for early detection of colorectal cancer (CRC), the acceptance of this invasive
technique is low. Aim of the work: to assess the diagnostic value of plasma M2-PK in Egyptian patients
with CRC. Methods: we measured the plasma M2-PK using Enzyme-linked immunosorbent assay in
CRC patients and comparing these levels with those obtained from patients with functional bowel
disorders (FBD), inflammatory bowel disease (IBD),colorectal polyp and apparently healthy
individuals and to detect its sensitivity and specificity. Results: the value of plasma M2-PK level was
higher in CRC patients, 15.22 U/ml than other groups. Average plasma M2-PK was 6.78, 5.28, 2.25
and 2.1 U/ml among colorectal polyp, IBD, FBD patients and normal individuals respectively. The
plasma M2-PK can be used in differentiating between CRC and normal individual with 83.33%
sensitivity, 100% specificity at area under the curve (AUC) 0.949 with cut-off >6U/ml. Also, it can be
used to discriminate between colorectal polyp and CRC patients at cut-off level of >10.6 U/mL with
75.5% sensitivity and 87.5% specificity and to differentiate between FBD and organic colonic lesions
at cut-off level >3 U/ml with 81.94% sensitivity and 83.3% specificity. Conclusion: plasma M2-PK
was considerably elevated in CRC patients and may be used as non-invasive biomarker for CRC.
Recommendation: future researches including a large and long-term follow-up studies are
Keywords: Colorectal cancer; M2-Pyruvate kinase; Functional bowel disorders; IBD; colorectal Polyp.
Colorectal cancer (CRC) is a major public
In spite of the fact that, the gold standard
health problem, being the third most commonly
for the early detection of CRC is colonoscopy;
diagnosed cancer and the fourth reason of
the acceptance of this invasive and expensive
cancer death worldwide (1).Most cases of CRC
method is low even in more developed
are preventable at early stage, and several
countries (8,9). The selection of patients who
randomized, controlled trials have shown lower
should undergo colonoscopy and/or imaging
mortality among patients who undergo
procedures is one of the key points of the
screening than among those who do not (2,3).
diagnostic process, which should avoid the
Survival is markedly affected by the stage of the
abuse of invasive and costly tests as well as the
disease at the time of diagnosis (4).
Regardless of considerable progress that
diseases. The investigation and procedures to
has been made over the past years in diagnosis
differentiate organic from functional bowel
and management strategies of CRC, still many
disorders represents a considerable burden both
of the CRC patients are diagnosed in late stages
for patients and community health service (10).
and do not respond to treatment (5), therefore
Premalignant conditions of CRC as chronic
studies should be done to improve our
inflammatory bowel disease (IBD) and
understanding of pathological process in the
colorectal polyp are preventable. In all such
CRC for identifying the best diagnostic,
cases, recognition of the disease at an early
stage is essential to devise suitable preventive
supporting its role in prevention, early detection
cancer strategies (11). Therefore, to develop an
and treatment (6, 7).
alternative modality based on blood biomarkers
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8015-8021
Immunohistochemical Study of CDK5 and Ki-67 in Cervical Precancerous Lesion
Amira Nasr Elsokary*, Samah Mohamed Attiah, Bahaa Bedair Ghannam
Department of Pathology, Faculty of Medicine, Al-Azhar University, Egypt
*Corresponding author: Amira Nasr Elsokary, Tel: 002-01003997007, Email: email@example.com
Background: cervical carcinoma is one of the commonest female tumors worldwide arises from
cervical intraepithelial neoplasia. Cervical cancer is a multifactorial process and infection with some
types of human papilloma virus (HPV) has been suggested as the most important risk factor. The genesis
of cancer was correlated with abnormal regulation of DNA damage and repair. A research proved that
CDK5 was mandatory for the DNA damage response in cancer cells. Ki-67 is a nuclear protein that is
associated with RNA transcription and cell cycle progression. Aim of the work: the purpose of this
study was to evaluate the expression of CDK5 in cervical precancerous lesions and carcinoma to clarify
its role in carcinogenesis and progression of cervical cancer, as well as the expression of Ki-67.
Material and Method: specimens included (55 cases) consisted of precancerous lesions (15), SCC
(30), adenocarcinoma (10). All specimens were formalin-fixed and embedded in paraffin blocks.
Multiple serial 5-microne thick sections were cut from the paraffin blocks of the specimens; one was
stained by Hematoxylin and Eosin for histopathological examination, Other Sections were
immunostained with antibodies to CDK5 and K-i67. Results: high tumor grade and high FIGO stage
were positively correlated with CDK5 IHC expression (P-value=0.012 and 0.042) and with Ki67 IHC
expression (p-value= 0.01 7and 0.044) respectively. Conclusion: there is a direct positive correlation
of both CDK5 and Ki-67 expression with high tumor grade and high FIGO stage of cervical carcinoma.
Keywords: precancerous, SCC, adenocarcinoma, CDK5, Ki-67
Cervical cancer is usually associated with
tumors of the cervix is International
human papilloma virus (HPV) (1). Cervical
intraepithelial neoplasia (CIN) is the precursor
Obstetricians (FIGO) (7).
lesions of cervical squamous cell carcinoma (2).
The genesis of cancer was related to
CIN 1 Known as mild dysplasia; CIN 2
abnormal mechanism of DNA damage and
Known as moderate dysplasia and CIN 3
repair. Cyclin dependant kinase 5 (CDK5) is
known as severe dysplasia. The grading of
important for the DNA damage response in
CIN depends upon the proportion of the
tumor cells (8). Ki-67 is a prognostic factor for
epithelium occupied by basaloid atypical cells
the assessment of biopsies from precancerous
reflecting a progressive loss of maturation and
and cervical cancer. Clinically; Ki-67 has been
increasing lesion severity (3).
shown to correlate with the stage of tumors (9).
The World Health Organization (WHO)
Aim of the work
(4) recognizes three basic types of invasive
The purpose of this study is to evaluate the
carcinoma of the cervix: squamous cell
expression of CDK5 in cervical precancerous
lesions and carcinoma to clarify its role in
carcinogenesis and progression of cervical
Histological grading divides Squamous
cancer, as well as the expression of Ki-67.
cell carcinoma (SCC) into three subtypes,
CDK5 reactivity and proliferation rate as
depends upon the proportion of the tumor
assessed by Ki-67 was correlated with the
keratinization with the formation of keratin
pearls and mitoses, Well differentiated (grade
Materials & Methods
1), Moderately differentiated (grade 2), Poorly
This study included total 55 cervical
differentiated (grade 3)(5).
specimens (32 punch biopsy and 23 total
Grading of cervical adenocarcinoma
abdominal hysterectomy cases) of formalin
depends upon gland architecture (glandular and
fixed paraffin embedded blocks. The blocks
papillary architecture versus solid areas) and its
collected from the archival files of the
nuclear features (6). The staging system for
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8022-8030
Phytochemical screening and insecticidal activity of different extracts of
Acacia modesta Wall. on adult Culex pipiens mosquito.
Eman Mohamed Salah1, Reham R. Ibrahim2, Ahmed Hussien3, Khadega Salem4, Mariam H.
Gonaid1, Hesham S. M. Soliman2
1Faculty of Pharmaceutical sciences and Pharmaceutical Industries, Future University in
Egypt.2Helwan University, Faculty of Pharmacy, Pharmacognosy Department, Cairo, 3Institute of
Medical Entomology, Ministry of Health, Giza, 4Research Institute of Ophthalmology.
Corresponding author: Eman Mohamed Salah, Mobile phone: +01128266142,
E-mail: firstname.lastname@example.org, email@example.com
Background: Insect-transmitted diseases remain a major source of illness and death worldwide.
Mosquitoes alone transmit diseases in more than 700 million people annually. The aim of the work: is
to perform phytochemical screening tests and to investigate the insecticidal effects of different extracts
of the aerial parts of Acacia modesta (A. modesta) Wall. on adult Culex pipiens (Cx. pipiens) mosquito.
Materials and methods: Different A. modesta Wall. extracts were bioassayed against adult Cx. Pipiens
mosquito to estimate their insecticidal effects. Three different extracts of A. modesta Wall. aerial parts
were prepared (distilled water, ethanol and acetone extracts). Different concentration for each prepared
extract were tested for their insecticidal activity as well as different duration of exposure e.g. one hour,
24 hours, 48 hours and 72 hours were also performed. Results: The efficacy of these extracts varies
according to type of solvent used, concentration of extract and duration of exposure. With continuous
exposure for 24 hrs; efficacy of A. modesta Wall. extract was elevated from 6291% in the same
manner. Expanding the exposure for 48 hrs; show continuous elevation up to 90100 %. Meanwhile,
the highest concentration of the tested plant extracted in acetone is one third (100 mg/ml) compared to
other solvents (300 mg/ml), results showed that using acetone as a solvent is better than either distilled
water or ethanol for its insecticidal activity. Conclusion: It was evident from the results that the plant
is a potential source of botanical insecticides against adult Cx. pipiens mosquitoes and their toxic effects
are time and concentration dependent. Moreover, phytochemical screening for the aerial parts of A.
modesta Wall. resulted in the identification of carbohydrates and/or glycosides, tannins, flavonoids ,
unsaturated sterols and/or triterpens as well as saponins.
Keywords: Acacia modesta Wall., Culex pipiens, insecticides and phytochemical screening.
Insect-transmitted diseases remain a major
antifeedent, antioviposition, repellent and
source of illness and death worldwide.
growth regulating activity2.
Mosquitoes alone transmit diseases in more
A. modesta, commonly known as Phulai, is a
than 700 million people annually1.
member of the family Fabaceae (also called
Control of such diseases is becoming
Leguminosae) and sub-family Mimosaceae. It
increasingly difficult because the over
is a deciduous, slow-growing small tree with
production of detoxifying mechanisms of
thorny youngshoots and dark brown and black
resistance of chemical insecticides has reported
wood, reaching 7 meters height and 20 cm
for most mosquito species. On the other hand,
majority of mosquito species have also
Reports on A. modesta aerial parts exposed the
developed high levels of resistance to microbial
presence of flavonoids, alkaloids, terpenoids
control agents. One alternative control
and tannins and long chain alcohols4. The aim
approach is the use of natural insecticides from
of the current study is to perform
phytochemical screening tests and to
The botanical insecticides are generally pest
investigate the insecticidal effects of different
specific and are relatively harmless to the non-
extracts of the aerial parts of A. modesta Wall.
target organisms including man2. They are also
on adult Cx. pipiens mosquito
biodegradable and harmless to environment.
One plant species may possess chemical
substances with a wide range of activities, like
Materials and methods
extracts from Azadriachta indica which showed
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8031-8038
Effect of Maternal Body Mass Index in Relation to Embryo Quality and
Clinical Outcomes in Couples underlying ICSI.
Ahmed S. Soliman (1), Shokry A. El Awady (2), Haitham M. Wahab (1)
(1) Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University
(2) Department of Obstetrics & Gynecology, the International Islamic Center for Population Studies
Corresponding author: Haitham M. Wahab; Mobile: 01019595567; Email: firstname.lastname@example.org
Background: The rising incidence of obesity coupled with its detrimental effects on fertility led to
greater numbers of overweight and obese women utilizing assisted reproduction technologies (ART),
such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).
Aim of the Work: To evaluate the impact of body mass index on embryo quality and clinical outcomes
in couples underlying ICSI.
Patients and methods: a retrospective observational comparative study was conducted on 400 Women
at ART Unit, International Islamic Centre for Population Studies and Research (IICPSR), Al-Azhar
University. Data were recruited from the patient`s files who did ICSI trial in IICPSR from December
2015 to December 2017, after exclusion of cycles in which the body mass index (BMI) was not
recorded. After approval of the local ethics committee, all pregnant women were briefed about the
nature of the study and informed consent was obtained from them before inclusion in the study.
Results: The duration of infertility was progressively higher as BMI increased. Basal luteinizing
hormone, follicle-stimulating hormone, and estradiol levels were higher in group 2 than in group 1.
Higher total doses of gonadotropin were required in group 2 to obtain equivalent ovarian response than
in group 1. No significant difference was observed on ovarian response and embryonic parameters.
Serum estradiol level on ovulation triggering day was significantly higher in group 2. Ovarian
hyperstimulation and cycle outcome were not significantly different between both groups. Conclusion:
Overweight and obesity appear to have independent adverse effects on ovarian response to stimulation
and outcomes in women undergoing ICSI.
Keywords: Body Mass Index, Embryo Quality, Clinical Outcomes Couples underlying ICSI
Obesity has become a worldwide
are of reproductive age, and about 17% of
epidemic, with approximately 1.6 billion adults
their children are aged 219 years (5).
being overweight and 400 million obese (1, 2).
A raised BMI is also related with a
The effects of obesity and overweight were
high risk of reproductive complications in
studied in various diseases. It was known that
women such as menstrual dysfunction,
obesity might cause diabetes, osteoarthritis,
anovulation, and infertility (6, 7). The women
cardiovascular diseases, sleep apnea, breast and
with a higher BMI also show a lower
uterine cancers and other reproductive
conception rate and higher abortion rate (AR),
disorders in women (3). Body mass index (BMI)
and they usually experience other reproductive
has been widely used to assess the degree of
obesity and overweight objectively and used as
Infertility affects one in seven couples
an indicator in many studies.
and a significant proportion of these cases are
Women with a raised BMI are known
thought to be either directly or indirectly related
to have a threefold greater risk of infertility due
to obesity. Obese women in the general
to disturbances in the hypothalamic-pituitary
population have a lower chance of conception
within one year of stopping contraception
,psychological and social factors (4).
compared with normal-weight women. The
In the United States, about 66.7% of
combination of infertility and obesity confers
women and 75% of men are overweight or
obese; out of which, nearly 50% of the women
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8039-8046
Comparative Study between Intrathecal and Caudal Epidural Anesthesia
in Children for Lower Abdominal Surgery
Mostafa Mohammed Mahdy, Maamon Mohammed Ismail, Amr Soliman Hamrosh, Ahmed
Elsayed Kamel Elfiky
Department of Anaesthesia and Intensive Care, Faculty of Medicine Al Azhar University
*Corresponding author: Ahmed Elsayed Kamel Elfiky, Mobile: 01007085123, E-Mail: magdi. email@example.com
Background: regional anaesthesia techniques are now established in the practice of pediatric
anaesthesia. It is one of the most common techniques used for post-operative pain management in
pediatric patients especially for urogenital, rectal, inguinal and lower extremity surgeries.
Objective: to compare caudal and spinal anaesthesia in paediatrics regarding haemodynamics, efficacy
(sensory block characteristics, motor block characteristics) post-operative analgesia, surgeon's
satisfaction, parents' satisfaction and complications incidence.
Material and Methods: the present study was carried on100 patients, with age ranging from (6-12)
and of ASA(american society of anaesthesia.) I, II classes undergoing infraubmliclal pediatric surgeries,
patients in each group were randomly assigned to receive spinal or caudal epidural anaesthesia.
Results: the demographic data of patients as regard age, sex and ASA classification showed no
statistical significant difference between the two groups, where the study was designed to compare
between the effectiveness of spinal anaesthesia with bupivacaine 0.3mg/kg and caudal anaesthesia with
bupivacaine 2mg/kg(1ml/kg vol.) as a sole anaesthetic technique adequate for infraumblical pediatric
surgeries below T10 as regard the sensory and motor block characteristics, perioperative haemodynamic
effects, pain assessment, analgesic requirements, and both the surgeon ad parents satisfaction was
assessed.the results showed the superiority of subarachnoid on achieving rapid onset of sensory
blockade, intense motor blockade, on the other hand the caudal epidural had the advantage of longer
post-operative analgesic effect and lower post-operative analgesic consumption, furthermore both
techniques gained good degree of parent and surgeon satisfaction.
Conclusion: if both techniques are correctly used and the anatomy of the patient is normal there is
minimal risk of complications.
Key words: intrathecal, caudal epidural, infraumblical, pediatric surgeries.
The appearance of neuromuscular
management is to achieve safety and reliability
blocking agents and the development of volatile
anesthetics in the forties shifted the techniques
The common advantages of spinal
toward general anesthesia. However, regional
anaesthesia are adequate anaesthesia without
pediatric anesthesia did not disappear (1).
polypharmacy, endotracheal intubation and
Both spinal and caudal anaesthetic
respiratory support, minimal biochemical and
blocks can be given easily in combination with
G.A(general anesthesia) or as the sole to
analgesia, absence of post-operative nausea and
provide anaesthesia and additional post-
vomiting, rapid return of feeding, minimal
operative analgesia especially for infraumlical
postoperative apnoeic spells, low cost, reduction
lower abdominal pediatric surgeries (block
in post-operative hospital admissions in an
below T10), furthermore both technique can
outpatients population (3).
replace G.A in circumstances where is shortage
Spinal anesthesia though gaining
of anaesthetic drugs, supplies and monitoring
popularity in children, the misconceptions
equipment which are not available especially in
regarding its safety and feasibility can be better
the developing countries (2).
known with greater use and experience (4).
There are advantages to use regional
Caudal anesthesia was first described at
anaesthesia that are evident and continue to
the turn of last century by two French
increase the popularity of its practice. One of
physicians, Fernand Cathelin and Jean-
the valuable goals during anaesthetic
Anthanase Sicard (4). Today pediatric caudal
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8047-8053
Ficolin-2 a newmarker for severity of liver inflammation in patients with
chronic hepatitis C
Abd El Monem M. Barrak*, Hesham E. Lashin*, Mahmoud M. Metwally** and Nabil I. Abd
Internal Medicine* and Clinical Pathology**Departments, Faculty of Medicine, Al Azhar University
Corresponding author: Nabil I. Abd El-Rahman,email: firstname.lastname@example.org
Background: ficolin-2 is a kind of human serum complement lectin with a structure similar to
mannan-binding lectin (MBL) and it has been implicated in innate immunity. Recent studies have
shown that complement pathway activation may contribute to hepatitis. However, the relationship
between ficolin-2 and viral hepatitis remains largely elusive. Aim of the work:this study aimed to
determine the dynamics of ficolin-2 in patients with chronic hepatitis C. Patients and Methods: thirty
patients who had not yet received therapy and twenty normal control subjects were included in this
study. A sandwich enzyme-linked immunosorbent assay (ELISA) was used to measure the ficolin-2
concentrations in all serum samples of patients and 20 healthy donors. Results: we found that the
concentrations of ficolin-2 were significantly higher in chronic hepatitis C patients with abnormal
ALT values than in chronic hepatitis C patients with normal ALT values and healthy controls. Ficolin-
2 concentrations in chronic hepatitis C patients with abnormal ALT values were positively correlated
with ALT levels (*P <0.05). Then, we found ficolin-2 concentrations in rapid viral response (RVR)
group decreased significantly (*P <0.05), while in non-RVR group, ficolin-2 decreased slightly (P
>0.05). Conclusion:our findings suggested that early increased ficolin-2 is highly correlated with
hepatic inflammation and rapid viral response.
Keywords: ficolin-2, Liver inflammation, Chronic H CV.
Hepatitis C virus (HCV)infects 170 million
approximately 80% identity in amino acid
people worldwide and approximately 80% of
sequence; H-ficolin has only about 50%
identity with the other two .M-ficolin,
hepatitis with a risk of progression to cirrhosis
predominantly found in monocytes and
and hepatocellular carcinoma .Humoral
granulocytes, is the homologue of murine
innate immune proteins that play a role in anti-
ficolin-Band porcine ficolin-; L-ficolin is the
infection include pentraxins and defense
homologue of murine ficolin-A and porcine
collagens such as C-type lectins and
ficolin-.The third human ficolin, the Hakata
ficolins.Ficolin-2 (which has a molecular
antigen originally identified and defined by
weight of 35 kDa of a single chain) was first
autoantibodies present in a small minority of
cloned and described as a type of lectin
lupus patients, is synthesized in both liver
(secreted into bile as well as blood) and lung
structure and function similar to C1q, MBL and
(and secretedinto the bronchi). It is the most
lung surfactant proteins A and D (SP-A and SP-
abundant plasma ficolin and the most potent at
D). Both MBLand ficolin-2 are produced
activating complement in vitro .All the three
mainly by the liver and M-ficolin is produced
have the ability to activate the lectin pathway of
by cells in the bone marrow and cells derived
complement, an activity known to be shared
from the bone marrow. They are able to
with just two collectins, mannan-binding
recognize conserved pathogen associated
lectin(MBL) and CL-L1 [7,8].L-ficolin (like
molecular patterns on the surface of invading
MBL) appeared to be a major pattern
pathogens and initiate the innate immune
recognition molecule in human plasma.It has
a uniquely complex set of binding sites,
Humans have three types of ficolins; they are
potentially conferring the ability to recognize
present in the bloodstream: M-ficolin
and interact with a wide range of
(monocyte ficolin or ficolin-1); L-ficolin (liver
pathogen.Recently, it was found that ficolin-
ficolin or ficolin-2) andH-ficolin (Hakata
2 had specificity for the HCV envelope
antigen or ficolin-3).M- andL-ficolin have
glycoproteins E1 and E2, resulting in activation
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8054-8060
Management of Infected Mesh Following Ventral Hernia Repair
Osama Abbas El Kattan, Ahmed Abd El Mawgod Abd El Salam, Ahmed El Sayed Fathy
Department of General Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed El Sayed Fathy Mohamed, Mobile: 01142434949, email: email@example.com
Background: abdominal hernia represents a major health care burden. With over 350,000 repairs
performed annually in the United States, millions of dollars are consumed with results that are often far
from ideal. The use of the prosthesis in the abdominal wall hernia repair (AWHR) has introduced new
problems. Although mesh has reduced hernia recurrence rates, it has its own set of complications. So,
mesh infection is one of the most devastating complications after the implantation of any mesh.
Objective: this work aimed to focus on management of infected mesh after ventral hernia repair.
Patients and Methods: this study was conducted in the Department of Surgery, Faculty of Medicine,
Al-Azhar University Hospitals from September 2016 until March 2018. The study included 40 patients
with surgical mesh infections after the repair of the ventral hernia. Results: cases with laparoscopic
hernia repair, minor infections and a patient unfit for surgery were excluded for any medical reason.
And after taking the history of the disease and clinical examination and the necessary investigations
and the most important is to take a sample of infected fluid over the mesh to determine the type of
infection caused by this or doing fistulogram if the fistula connected to the intestine small or large.
Conclusion: research of best practices in surgical technique, preoperative care and mesh materials is
ongoing, and much remains to be learned on prevention and management of this complex and
potentially devastating complication.
Keywords: abdominal wall hernia repair, partial removal of mesh, Complete mesh removal
Abdominal hernia represents a major
might reduce the incidence of mesh infection (5).
health care burden. With over 350,000 repairs
Numerous types of prosthesis have been
performed annually in the United States,
developed to provide greater strength and lower
millions of dollars are consumed with results
recurrence rates, and at the same time, the risk
that are often far from ideal (1). The use of the
of infection and other complications have been
prosthesis in the abdominal wall hernia repair
decreased (6). Some known risk factors for mesh
(AWHR) has introduced new problems.
infection have been reported prolonged
Although mesh has reduced hernia recurrence
operative time or types of mesh are predictive
rates, it has its own set of complications. So,
factors in heterogeneous series of groin hernia
mesh infection is one of the most devastating
repairs or AWHR (7). On the other hand,
complications after the implantation of any
postoperative surgical site infections or
mesh (2). The risk of infection in AWHR
concomitant intra-abdominal procedures have
appeared to be higher than other clean cases,
been related to mesh hernia repair (8). Complete
but there is a wide range reported from 1% to
removal of the infected mesh (CMR) has been
10% depending on the type of mesh, technique,
recommended if the infection cannot be
and patient population (3). Infection of
resolved by conservative measures and/or
abdominal wall prostheses can have grave and
antibiotic therapy or partial removal of mesh (9).
costly consequences and severe impact on the
However, this fact generally induces a hernia
patient's life due to prolonged hospitalizations
recurrence and needs subsequent surgical
and multiple re interventions, as well as very
procedures such as autologous flap reconstruction
elevated social costs (4). So, these are an
or another mesh implantation after the infection
incentive to explore any and all means that
has been resolved (10). CMR also can lead to a high
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8061-8073
Study the role of serum cartilage oligomericmatrix protein (COMP) in the
diagnosis of rheumatoid arthritis patients
Mohammad A. Sweilam1, Mohammad A. Attia1, Hanan M. El-Saadany2,
Asmaa S. Ibrahim1*
Departments of 1Clinical Pathology and 2Physical Medicine, Rheumatology & Rehabilitation
Faculty of Medicine - Tanta University
*Corresponding author:Asmaa S. Ibrahim; Mobile: 01002558308; Email:firstname.lastname@example.org
Background: rheumatoid arthritis (RA) is a systemic autoimmune disease of unknown etiology.
Cartilage oligomeric matrix protein (COMP) is one of markers used for early predicting joint
destruction and disease activity in RA disease. Objective: in the present study we evaluated the role of
COMP as diagnostic marker in RA patients in comparison with other traditional markers and its
correlation with disease activity parameters. Patients and Methods: blood samples were collected from
50 patients newly diagnosed with rheumatoid arthritis (Group I) and also from 30 healthy subjectsas a
control group (Group II).Serum level of COMP was measured by enzyme-linked immunosorbent assay
(ELISA). Results: there was a high significant difference between the RA patients group and the control
group regardingserum COMP level.Also, there was a significant correlation between serum COMP
level with clinical and laboratory data of active RA patients.Conclusions: serum COMP could be useful
for early diagnosis of rheumatoid arthritis and also could be used as a marker of disease activity and
Keywords: serum cartilage oligomeric matrix protein, rheumatoid arthritis
Rheumatoid arthritis (RA) is a
cartilage and bone that may cause joint
chronic inflammatory disease that influence
distortion and disability (4).
from 0.5% to 1% of population, so it
It is very important to start
believed to be the most common chronic
diagnosis and treatment in the early stages
inflammatory autoimmune disease. It often
of RA, because this may help in slowing
occurs at 50 years of age, women are
down progression of thedisease. The
influenced from three to four times more
diagnosis and staging of patients with RA is
than men (1).
mainly depends on the clinical symptoms,
imaging results and some classic laboratory
characterized by pain in several joints and
tests such as citrullinated peptides (Anti-
destruction of bone and cartilage in joints.
CCP), ESR, CRP and RF(5).
Also, it can result in disability and loss of
joint function (2).
specificity have been discovered each day
Rheumatoid arthritis is also
to aid in diagnosis and prognosis of
characterized by multiple extra articular
rheumatoid arthritis in the early stage.
manifestations such as: nodules, muscle
Cartilage oligomeric matrix protein
weakness, nervous system, vasculitis,
(COMP) is a novel marker of cartilage
hematological abnormalities, skin disease
degradation which was detected in the
e.g. neutrophil dermatitis, ocular, lung,
synovial fluid and serum of patients with
cardiac and other organs could be involved,
rheumatoid arthritis (6).
which influencing a small percentage of the
COMP is a non-collagenous matrix
adult persons all over the world (3).
protein and it is a member of the
The most important characteristic of
rheumatoid arthritis is proliferative and
mainly expressed in cartilage and also in
inflammatory synovitis of the peripheral
tendon and biological fluids including
joints which is accompanied by progressed
synovial fluid and serum in patients with
and severe destruction to the articular
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8074-8076
Treatment of Fracture Head Radius in Children with Closed Reduction and
Salama F.1, Elshoura S.1, Mandour I.1
Orthopedic surgery Department, Faculty of medicine, Al-Azhar University
Corresponding author: Ibrahim Mandor, email: email@example.com
Background: radial head fractures represent 5-10% of traumatic injuries of the elbow in children and
1% of all pediatric fractures. They result from a fall on the outstretched arm, with the elbow extended
and the forearm supinated.
Objective: this study aimed to assess the results of treatment of fracture head radius in children with
closed reduction and fixation with elastic nail. The results were assessed clinically and radiologically.
Methods: this study included 20 patients with fracture head radius in children who were treated with
closed reduction and elastic nail in the Department of Orthopedic at New Damietta Al-Azhar University
Hospital from Jan 2018 to September 2018.
Results: this study was carried out on twenty patients with epiphyseal fractures of head radius treated
with elastic nail from Jan 2018 to Oct 2018 and follow up for (1-10) months, 16 case excellent, 2 cases
good, one case fair and one case bad. Conclusion: we were convinced by the versatility of the Titanium
Nancy nailing as it provides a solution to fracture head radius that would have been exposed to open
reduction, with no wasting time during operation, less infection rate, less blood loss and improved
Keywords: fracture head radius in children with closed reduction and elastic nail.
Displaced radial head and neck fractures are
technique in 1993 by the same surgeon, allowed
rare injuries in children, with an incidence of 1-
extracapsular but, intramedullary reduction and
5% of all elbow fractures in children. The most
fixation without any need for pin removal
incidence is between 5 and 15 ages and fall on
surgery besides (8-9).
the outstretched arm with the elbow extended,
which causes valgus compression on the radial
Aim of work
head, that defined as the injury mechanism (1-2).
This study aimed to assess results of
The best choice of the treatment depends on the
treatment of fracture head radius in children
degree of the radial head angulation, which are
with closed reduction and fixation with elastic
mostly affects the long-term results. Then a lot
nail. The results were assessed clinically and
of classification systems based on the degree of
displacement, degree of angulation and the
presence of the associated injuries or no
Patients and methods
association, were introduced (3-4). A related-
In this study, 20 patients (12 males, 8
literature showed that for severe or moderate
females) that had fractures of head radius, aged
angulated fractures, reduction of the displaced
5 to 15 years old were operated by closed
head must be performed either conservative or
reduction and fixation with intramedullary
surgical before casting (5). However, reduction
elastic nail in Al-Azhar University Hospital in
with hand manipulation is acceptable if only the
Damietta from Jan. 2018 to september 2018
stable construct is persistent. But surgical
Outcome after head radius fractures has
techniques vary as percutaneous reduction with
traditionally been measured by invest
K-wires, Nancy nail fixation and open
parameters and objective physical variables.
reduction with or without internal fixation (6-7).
We evaluated the association between
Open reduction is used only in communited
radiological position, objective physical result
fractures and cases where closed reduction has
(range of movement), and the patient-perceived
outcome, measured with the Disabilities of the
Intramedullary technique which was the only
arm, shoulder and elbow.
one who described by Metaizeau (5) in 1980
further developed to Nancy nail fixation
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8077-8083
Laparoscopic varicocelectomy initial experience at Al_Azhar Hospital
Ali Mohamed Farag, Ahmed Youssef Abo-Elsaad, Yasser Ali Ahmed, Ahmed Saber Mohamed
Department of Urology, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Saber Mohamed Azzam, Mobile: 01023265742, E-mail: firstname.lastname@example.org
Background: Varicocele is a collection of dilated veins in the pampiniform plexus that drain the testicle
and may contribute to male infertility. A variety of surgical & non-surgical approaches have been
advocated for varicocele treatment.
Objective: Evaluate laparoscopic varicocelectomy with regard to intra and post-operative parameters.
Patients and Methods: At Departments of urology of Al_azhar University Hospitals (Damietta).
Prospective randomized study was performed about laparoscopic varicocelectomy during the period
from June 2016 to December 2017 after obtaining informed consent. The group included patients with
clinically palpable varicocele confirmed by U/S complaining of infertility (primary, secondary) or
chronic testicular pain.
Results: The range operative bilateral Laparoscopic Varicocelectomy time was 60-90 minutes. There
were no intra operative complications in the study group. The average hospital stay was 24-36 hours.
Post-operative analgesics (2-3) doses, daily activities initiation usually started after 4-5days. Hydrocele
formation was seen in (11.1%) patients recurrence was seen in (5.6%) patient. None of the patient has
developed an atrophic testis as a result of the laparoscopic procedure. Patients had improvement of the
seminal fluid parameters during follow up period and pregnancy rate was (25%).
CONCLUSION: Laparoscopic varicocele ligation is a simple and safe technique causing minimal
morbidity and enabling rapid return to normal activity.
Keywords: varicocele, laparoscopy, infertility.
Varicocele is one of the most common
Techniques include open surgical ligation of the
causes of male infertility (1). Varicocele is found
spermatic vein, retrograde or anterograde
in 25% of men with abnormal semen parameters,
sclerotherapy, microsurgery, and laparoscopy.
compared with 12% of men with normal semen
Each technique has its own advantages and
parameters, suggesting that it is associated with
impaired testicular function and male infertility.
Surgery is currently the most popular
Nevertheless, only 20% of men suffer from
treatment of varicocele patients with sign of abnormal
infertility problems among adults with
semen, testicular hypertrophy or pain. The recurrence
documented varicocele (2).
rates following varicocele repair range from 5% to
The causes of varicocele largely remain
20% depending upon the technique used. The main
unknown, as does the pathophysiology of
causes of high recurrence varicocelectomy are
developed collateral within the interrupted venous
Typically, men with varicocele are
drainage system and persistence or progression of
asymptomatic; Physical examination is the
uninterrupted pathological venous drainage routes (6).
mainstay of varicocele diagnosis. Both adult
Currently, the best approach for the
and adolescent varicocele are graded as
treatment of adolescent varicocele has not been
follows: grade I, palpable impulse in the
established. There are three options for a
spermatic cord veins during Valsalva maneuver
surgical varicocele repair: retroperitoneal
without enlargement of the veins at rest; grade
II, palpable engorged veins with the patients
standing without Valsalva maneuver, but not
visible; grade III, veins easily visible through
successfully via laparoscopy (7).
the scrotal skin while the patient is standing (4).
Laparoscopic varicocelectomy was
first introduced as an efficient treatment for
varicocelectomy is still a matter of controversy.
male infertility in 1992. Aaberg et al. reported
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (11), Page 8084-8090
Study of the Effect of Repetitive Transcranial Magnetic Stimulation on a
Sample of Children with Attention-Deficit/Hyperactivity Disorder
Abdullah Ahmed Abdullah Mekky, Amgad Ahmed Moshref Gabr, Mohamed Ahmed Lotfy
Kamal, Mohamed Mahmoud Hamouda and Ahmed Said Abd El Khalik Khalil*
Department of Psychiatry, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmed Said Abd El Khalik Khalil,email: email@example.com, mobile:01062915246.
Background: attention Deficit Hyperactivity Disorder (ADHD) is one of the most common
neuropsychiatric disorder that affects children and young adults and cause significant functional
impairment. Although there are effective medications and psychobehavioural therapies that help with
management of ADHD, the medications can have significant side effects, which limit their use. There
is need to explore other treatment options. transcranial magnetic stimulation (TMS) and repetitive
transcranial magnetic stimulation (rTMS) are recent safe and non-invasive investigative and therapeutic
tools. Aim of the work: to study the effect of repetitive transcranial magnetic stimulation on a sample
of children with Attention-Deficit/Hyperactivity Disorder. Methods: the sample was consisted of (35)
child; their ages were ranged from 6 to 12 years old after diagnosed clinically according to DSM-5
through a designed semi structured interview and through application of Conner's teacher-28 and
parent-48 rating scales as ADHD combined type. Females were (11) children with percentage 31.4%,
while males were (24) children with percentage 68.6%. All patients on the sample were not receiving
any medical or behavioral therapy for ADHD. Results: means scores of inattention, hyperactivity and
impulsivity were reduced significantly in the post 5 days and 2 weeks follow up (P-values > 0.001(,
started to rise again in its evaluation after 4 weeks but not reaching its values before rTMS sessions. the
percentage of severe cases in each scale category was dramatically decreased immediately and 2 weeks
after rTMS sessions and started to rise again in its evaluation after 4 weeks but to lower percent than
before rTMS sessions (70%, 100% and 60% had severe inattention, hyperactivity and impulsivity
respectively before rTMS, reduced to 0%, 0%, 10% immediately and 2 weeks after rTMS but increased
to (20%, 40% and 40%) after 4 weeks. no patient experienced any significant adverse effects during the
study, except 3 children reported mild headache that resolved spontaneously within an hour without
medication. Conclusion: this study concluded that r TMS over left dorso-lateral prefrontal cortex may be safe
and effective way of providing relatively lasting relief of ADHD symptoms especially in children with severe
Key words: ADHD neurobiology TMS rTMS.
ADHD is a multifactorial disorder
Disorder (ADHD) is the most common
associated with environmental and genetic
neurobehavioral disorder during childhood that
factors (4). Dopamine alteration is believed to be
affects 5-12% in school age children. Male to
the main neurochemical underlying its patho-
female ratio is around 3:1 in children &
physiology (5) and deficient inhibitory control is
adolescents. Approximately 8-10% of males &
the characteristic of children with this disorder.
3-4 % of females under the age of 18 suffer
Based on these facts, brain stimulants are, to
from ADHD (1). Prospective study show ADHD
date, the most successful as well as the most
symptoms continue in 60% of the children who
controversial therapy employed. Despite the
has this disorder even after their puberty (2).
enormous amount of research done, clinicians
According to the Fifth Edition of American
and parents are eagerly waiting for additional
Psychiatric Association's Diagnostic Statistical
and better therapeutic options.
Manual of mental disorders (DSM 5), ADHD is
Studies show that other psychiatric
defined as developmentally inappropriate
disorders are more common in ADHD patients
levels of inattention, hyperactivity, and/or
such as anxiety disorders, mood disorders,
impulsivity which result in functional
impulse control disorder, substance abuse,
impairments in multiple settings, thus affects
personality disorders especially antisocial
family, academic and social aspects (3).
personality and learning disabilities. And some