c:\work\Jor\vol742_1 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 219-225
Assessment of Renal Functions in Infants and Children with Congenital Heart

Mohamed Seif Mohamed*, Moftah Mohammed Rabeea *, Hassan Saad Abu Saif * and Kamel
Soliman Hammad**

*Pediatric Department, **Clinical Pathology Department, Faculty of Medicine, Al-Azhar University

Corresponding author: Doctor Mohammad Seif Taha, email:dr.seifpediatrics@gmail.com


Background: children with congenital heart diseases have a number of risk factors for potential
development of chronic kidney diseases later in life such as : including pathophysiological changes related
to a structurally abnormal heart, polycythemia, cyanosis and chronic hypoxia change in renal blood flow
and intraglomerular hemodynamics with derangements in neurohormonal activation. Objectives: this study
aimed to assess renal functions in infants and children with congenital heart diseases and to compare renal
functions between children with congenital cyanotic and acyanotic heart diseases.
Patients and Methods: this across sectional case control study was carried out on 05 infants and children with
congenital heart diseases (20 patients with congenital acyanotic heart diseases (Group A) and 20 with congenital
cyanotic heart diseases (Group B) who were attended at the Pediatric Cardiology Units at Al-Azhar University
Hospitals (El-Hussein and Bab El-Sheryia Hospitals) and apparently 20 healthy children age and sex matched
included as a control group (Group C). Their age ranged from one month to 5 years old. Patients were subjected
to full history taking, full medical examination which included the heart and abdomen and laboratory
investigations which included complete blood picture, urine analysis, estimation of glomerular filtration rate,
urinary albumin creatinine ratio. Data were collected, tabulated and statistically analyzed. Results: comparing
both groups A and B by group C as regards renal functions results; group B had higher values in all parameters
(Estimated glomerular filtration rate (EGFR) and urinary albumin and creatinine ratio.
Conclusion: risk of renal dysfunctions increase by time especially in children with cyanotic CHD which may
be due to effect of chronic hypoxia and other conditions such as polycythemia.
Key words: congenital heart diseases, with congenital acyanotic heart diseases, congenital cyanotic heart
diseases, glomerular filtration rate (eGFR), urinary albumin creatinine ratio.

Children with congenital heart disease have
uncommon complication and renal biopsy has
a number of risk factors for potential
been seldom performed. Adverse effects of
development of chronic kidney later in life,
chronic hypoxia on renal tubular function have
including pathophysiological changes related to a
been less frequently documented. Secondary
structurally abnormal heart and circulation.
renal tubular acidosis seemed to be an acquired
These include polycythemia, cyanosis and
complication in patients with chronic cyanosis (3).
chronic hypoxia changes in renal blood flow and

Aim of the work:
derangements in neurohormonal activation (1).
This study aimed to assess renal functions
Several studies have revealed that
in infants and children with congenital heart
nephropathy is a prominent feature and a
diseases and to compare renal functions between
potential complication of congenital cyanotic
children with congenital cyanotic and acyanotic
heart diseases (2).
heart diseases.
It has been documented that chronic cyanosis
Patients and Methods:
affects renal glomerular structure and function in

the kidney. The structural hallmark of glomerular
This was a cross sectional study and it was carried
injury in patients with congenital cyanotic heart
out on fifty infants and children with CHD from
disease had been described as glomerulomegaly,
those attending the Pediatric Cardiology Units at
capillary dilatation, thickening of the capillary
Al-Azhar University Hospitals (El-Hussein and
walls, focal or diffused proliferation of mesangial
Bab El-Sheryia Hospitals). They were enrolled in
cells and segmental or global glomerulosclerosis.
this case control study to evaluate renal functions
Although proteinuria is the major urinary
in both cyanotic and acyanotic congenital heart
abnormality in patients with cyanotic congenital
heart disease, nephrotic syndrome is an
Received:15/9/2018 Accepted:30/9/2018

Full Paper (vol.742 paper# 1)

c:\work\Jor\vol742_2 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 226-236

Assessment of Heart Rate Variability in Young Patients with Primary
Mansour M. Moustafa, and Mohamed Samy, Mohamed Omar

Cardiology Department, Faculty of Medicine, Al-Azhar University (Cairo)
Corresponding author: Mohamed Omar, Mob: 01149972692. Email: m.omercardio@gmail.com

Objective: this study aimed to determine the association between HRV and hypertension young adult
patients, the effect of antihypertensive medications on HRV parameters was also studied. Subjects
and Methods:
70 subjects under age of 40 years were classified into two groups: A- Patients' group,
It included 50 subjected they were classified according to type of antihypertensive medications into 3
subgroups; 1): 20 patients on ACE-I, (2): 15 patients on BB, 3): 15 patients on CCB. B)- Control group
included 20 healthy subjects. Pulse rate, BP, ECG and 24h Holter monitor were used to measure heart
rate variability (HRV). Results: high statistical significant difference was found between patients and
control according to SDNN rMSSD, pNN50 and LF/HF ratio ( P < 0.001). HRV parameters showed
improvement in patient treated by BB and ACE-I, whereas no improvement was seen in patients
treated by CCB. Conclusion: disturbed cardiac autonomic function was found in young hypertensive
patients, treating such patients with either BB or ACE-I was associated with improvement of such
autonomic imbalance.
Keywords: Primary hypertension, autonomic nervous system, ambulatory blood pressure, dipping,
heart rate variability.


This study included 70 young adult
The autonomic sensory system assumes
subjects (<40 years of age) attendings
a job in the pathogenesis of hypertension.
Expanded thoughtful action or diminished
University Hospital for assessment and follow-
parasympathetic movement adds to the
up of blood pressure. They were classified into
advancement and support of hypertension (1).
two main groups:
Estimation of pulse inconstancy (HRV) in the
The patients' group: constituted 50
recurrence area gives data on how the self-
primary hypertensive patients, they were
further sub classified into 3 subgroups
cardiovascular framework (2). In reality, the
according to the treatment drug; (Subgroup1)
high-and low-recurrence parts of HRV
included 20 patients on angiotensin-converting
separately mirror the action of the
enzyme inhibitor (ACEI), (subgroup 2)
parasympathetic and thoughtful sensory
included 15 patients on beta blockers (BB) and
system. The low-to high-recurrence proportion
(subgroup3) included 15 patients on calcium
is a proportion of sympatho-vagal equalization
channel blocker (CCB).
The control group: 20 normal subjects
In subjects in danger of hypertension and
matched in age and sex with the patients group.
in hypertensive patients, the high-recurrence
Inclusion criteria:
segment of HRV is commonly lessened.
Patients diagnosed as HTN with BP
Decreased HRV predicts all-cause mortality
140/90 or taking antihypertensive medication
and heart occasions (1). Changes in thoughtful
according to the latest ESC guidelines (5).
adjustment of the cardiovascular framework
Exclusion criteria:
may consequently be a hazard factor for
Patients with secondary HTN patients,
cardiovascular intricacies (4), which may be
age > 40 years, Diabetic patients, chronic
reversible by circulatory strain bringing down
kidney disease, heart failure, atrial fibrillation,
treatment (1). The present article gives an
arrhythmia (atrial and ventricular), ischemic
account of changes in HRV on youthful
heart disease and obese patients.
hypertensive grown-ups and impact of
treatment by antihypertensive medications.
Informed consent was obtained from all

participants then thorough history taking which
Subjects and Methods
focused on personal history (age, sex, smoking,
occupation and special habit of medical
Received: 04/10/2018
Accepted: 23/10/2018

Full Paper (vol.742 paper# 2)

c:\work\Jor\vol742_3 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 237-243
Evaluation of Intravitreal Aflibercept Injection for Macular Edema
Secondary to Retinal Vein Occlusion

Emad Abdel Aal Saliem

Lecturer of Ophthalmology, Ophthalmology Department, Al-Azher Faculty of Medicine, Assuit

E-mail: emadophtha@yahoo.com.

To evaluate the efficacy of intravitreal aflibercept injection in eyes with macular edema
due to retinal vein occlusion (RVO). Patients and Methods: prospective, non-randomized clinical
study included 60 eyes of 60 patients with macular edema due to RVO. Thirty patients had branch RVO
(BRVO) and 30 had central RVO (CRVO). Each patient had received intravitreal injection
of aflibercept once followed by re-evaluation of BCVA and CMT monthly during the follow up period
up to 6 months after injection. Results: One month after IV aflibercept injection in patients with RVO
3 months, the main best-corrected visual acuity improved from 1.05±0.004 µm at baseline to
0.75±0.07 logMAR at 1 month, to 0.58±0.10 logMAR at 3rd month and at the 6th month improved to
0.45±0.14 logMAR (p0.05). On the other hand, the mean BCVA improved from 1.40±0.03 µm at
baseline to 1.13±0.07 logMAR at 1 month, to 0.98±0.06 logMAR at 3rd month and to 0.92±0.08
logMAR at 6th month (P 0.05) in patients with RVO > 3 months. The mean central macular thickness
reduced from 485.57±71.51 µm at baseline to 316.78±58.38µm (P0.05) after 1 month, to
259.45±50.84µm (P0.05) at the 3rd month and to 225.85±34.44µm (P0.05) at 6th month in patients
with RVO 3 months. Meanwhile, in those with RVO > 3 months the main CMT reduced from baseline
625.91±167.56µm to 395.07±98.89µm (P0.05), to 319.53±53.28µm (P0.05) and at the 6th month
reduced to 276.50±38.89 µm (p0.05). No intra-operative or post-operative complications as retinal
detachment, vitreous hemorrhage, or elevated intraocular pressure. Subconjunctival hemorrhage or
local hyperemia at the injection site may be observed in some cases. Long term duration without
treatment is associated with less improvement in the visual acuity. Conclusion: Intravitreal injection of
aflibercept is more clinically effective and generally well tolerated for treatment of macular edema due
to RVO.
Key words: Aflibercept, RVO, ME.


Retinal vein occlusion (RVO) is a
ischemia, which may in turn increase the levels
common sight-threatening vascular disorder of
of VEGF, hence exacerbating ME and
the retina, in which macular edema is the main
hemorrhages leading to visual impairment [5,6].
cause of visual impairment [1]. It may involve
Not all people with CRVO will require
the central (CRVO) or a branch (BRVO) retinal
treatment and macular edema will resolve in
vein, which may be caused by a compression by
about a third of those with non-ischaemic
adjacent atherosclerotic retinal arteries [2].
CRVO. However, most will need treatment and
Retinal ischemia following vascular occlusion
the number of options has increased in recent
can cause both vitreous and aqueous vascular
endothelial growth factor (VEGF) elevation [3].
photocoagulation has been the standard therapy
Thrombosis of the retinal veins causes an
for patients with macular edema secondary to
increase in retinal capillary pressure resulting in
branch retinal vein obstruction (BRVO) [8].
increased capillary permeability and leakage of
However, laser treatment was not found to be
fluid and blood into the retina. Increased
beneficial to those with macular edema
production of vascular endothelial growth
secondary to CRVO, for these patients, no
factor (VEGF) occurring early in RVO is a
therapeutic modalities could be offered [9].
major contributor to the evolution and
persistence of ME and hemorrhages [4]. In
demonstrated the benefit of anti-vascular
addition, the high levels of VEGF promote the
endothelial growth factor (VEGF) therapies and
progression of retinal non perfusion and
steroids for the management of patients with
Received: 04/10/2018
Accepted: 23/10/2018

Full Paper (vol.742 paper# 3)

c:\work\Jor\vol742_4 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 244-253
Comparative Study between the Use of Room Temperature and Cold
Intra-Thecal Heavy Bupivacaine and Its Effect on Intraoperative Shivering
in Lower Limb Orthopedic Surgery
Hassanein Abd- Elkareem Hamzawy, Alsayed Mostafa Stohy, Wael Mohamed El-Mahdi,
Ayman Baligh Hassan Gamal*
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ayman Baligh Hassan Gamal, E-Mail: hossamesmail31@gmail.com

the mechanisms responsible for shivering in patients undergoing surgery are intra-
operative temperature loss increased sympathetic tone, pain, and systemic release of pyrogens, and the
direct effect of local anesthetic temperature on temperature-sensitive neurons in the spinal cord.
Objective: to compare the effects of warm intrathecal bupivacaine versus cold intra-thecal bupivacaine
on shivering and haemodynamic stability in parturient candidate for elective lower limb orthopedic
surgery under spinal anesthesia.
Patients and Methods: the current study was carried out in in Alexandria Police hospital, on 80
parturient, aged 20-60 years old, ASA I-II, scheduled for elective lower limb orthopedic surgery under
spinal anesthesia, after the approval from the Local Ethical Committee and informed written consents
from all the patients of the study. Patients were randomly allocated into two equal groups (40 patients
each); group R (Warm group), group C (Cold group).
Results: Comparison between the two studied groups showed no significant statistical differences at all
the measured times.
Shivering continues to be a common problem after spinal anesthesia. The etiology of this
symptom is unknown, and there is no definite treatment.
Cerebral spinal fluid, General anaesthesia, Intravenous
Shivering associated with spinal
Several factors affect the dissemination
anesthesia is an extremely frequently
of the local anesthetic agents (LA) used in
complication that occurs in up to 55% of the
spinal anaesthesia within cerebral spinal fluid
patients (1). In addition to disrupting the comfort
(CSF). The density of the local anaesthetic used
of the patient, shivering has various
plays a significant role in the dissemination
hemodynamic effects, including increased
within the CSF and the level and duration of the
oxygen consumption, increased carbon dioxide
effect of spinal anaesthesia(6).
production and increased cardiac effort (2). Also
Although many studies have been
shivering may interfere with the monitoring of
undertaken to treat shivering after spinal
ECG, blood pressure and oxygen saturation (3).
anesthesia by combined of warm parenteral
The mechanisms responsible for
fluids and warm local anesthetics significantly
shivering in patients undergoing surgery are
reduced the incidence of shivering, Some
intra-operative temperature loss increased
researchers have studied the effects of local
sympathetic tone, pain, and systemic release of
anesthetic temperature after injection intra-
pyrogens, and the direct effect of local
thecally on shivering(4). The result of another
anesthetic temperature on temperature-
study suggested the existence of thermo-
sensitive neurons in the spinal cord(4).
sensory mechanisms in the human spinal canal
The central nervous system (CNS),
and the effect of warming anesthetic solutions
including the spinal cord, receives thermal
prior to injection to reduce the incidence of
signals from the body and plays an essential
shivering (5).
role in the regulation and maintenance of body
Orthopedic Surgery is a common
temperature (3).
surgical procedure concerned with injuries and
conditions that affect the musculoskeletal
Received: 05/10/2018
Accepted: 24/10/2018

Full Paper (vol.742 paper# 4)

c:\work\Jor\vol742_5 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 254-261
Effect of successive cyclic oral contraceptive pills on pregnancy outcome
pretreatment of PCOS patient in ICSI

Hana Abd El Moneim Younes*, Yousef El Said Abo Shady*, Fayza A. Abdel Hakam*, Asmaa
Mohamed Awad Gomaa*

*Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University

*Corresponding author: Asmaa Mohamed Awad Gomaa, Mobile: 00201129923985, E-Mail: z.yasmena@yahoo.com

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that primarily
affects women of reproductive age, with prevalence rates ranging from 5% to 10%.
To evaluate the role of oral contraceptive pills (OCP) pretreatment in the improvement of
intra cytoplasmic sperm injection (ICSI) pregnancy outcome, in patient with PCOS.
Methodology: Started with 200 proved PCOS and after exclude of any patient with criteria rather than
including criteria, so 60 proved PCOS women undergo ICSI were elected and divided into tow groups
30 patients for each. The 1st group treated with COC (3-6monthes) before ICSI and the 2nd group was a
control group.
Results: Clinical pregnancy rate as a main outcome was significantly more frequent in the study group
than in the control group. The LH mean as a secondary outcome was significantly more decreased in
the study group than in the control group and the FSH/LH ratio before and after COC increasing ratio
towards normalization.
Successive cyclic oral contraceptive pills for patients with PCOS as a pretreatment in ICSI
can increase clinical pregnancy rates as a main outcome, improve the synchronism of follicular
development, decrease the LH mean as a secondary outcome. And increase FSH/LH ratio before and
after COC towards normalization.
Keywords: ICSI, Cyclic oral contraceptive pills, PCOS, Pregnancy outcome


Polycystic ovarian syndrome (PCOS)
have metabolic disorders, such as abnormality
is a common endocrine disorder that primarily
of glucose and lipid metabolisms that are
affects women of reproductive age, with
inevitably involved in diabetes mellitus and
prevalence rates ranging from 5% to 1o% (1).
coronary artery diseases, respectively(4).
One of the most common reproductive

Given these endocrine abnormalities,
endocrine diseases that impact many young
infertility is a common complication of PCOS.
women worldwide is PCOS. This hormonal
Studies have reported PCOS as the major cause
problem affects 4 ­ 18% of women of
of infertility in up to 2o% of couples(5).
reproductive age exhibiting various symptoms,
Nearly eight decades following its
such as irregular menstruation, hirshutism,
original description, polycystic ovary syndrome
infertility and metabolic disorders (2).
(PCOS) remains a poorly understood entity.
In 2013, a consensus panel established
Various pathophysiologic mechanisms have
a controversial definition (the Rotterdam
been proposed; including intrinsic ovarian,
criteria) for PCOS, to include at least 2 of the
adrenal, and hypothalamic- pituitary pathways,
following criteria: oligo- or anovulation
but none was shown to provide a complete
(menses less than once every 35 days),
explanation for the development of this
Hyperandrogenism (laboratory-confirmed or
condition. Much interest has occurred lately
clinical symptoms), or Polycystic ovaries on
over the metabolic aspects of the syndrome,
ultrasound. With exclusion of other conditions
rendering insulin resistance with compensatory
with similar signs such as androgen-secreting
hyperinsulinemia the mechanism most widely
studied today (6).
dysfunction and hyperprolactinemia (3).
Polycystic ovary syndrome remains to
These symptoms in PCOS women are
be a challenge to endocrinologists and
strongly correlated with overweight and
gynecologists. As much as the pathogenesis is
obesity. Also, women with PCOS are likely to
still not clear, so is the perfect way of treating
Received: 06/10/2018
Accepted: 25/10/2018

Full Paper (vol.742 paper# 5)

c:\work\Jor\vol742_6 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 262-269

The Role of Visceral Fat, IL-6, Adiponectin and Leptin Levels on Reflux
Esophagitis in Obese Patients

Salem Soliman Ahmed Salama, Abd El-Monem Mohamed Barrak, Amin Mahmoud Hejazi Kamel
Soliman Hammad, Ahmed Farag Abd-Alkader*

Internal Medicine Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

*Corresponding author: Ahmed Farag Abd-Alkader, E-mail: dr.ahmed.farag2018@gmail.com

Gastroesophageal reflux disease (GERD) is one of the most common problems encountered
in clinical practice today. The pathophysiology of GERD is complex, involving diverse factors.
Aim of the work: was to assess the role of visceral fat and IL-6, adiponectin and leptin levels on reflux
esophagitis in obese patients.
Patients and Methods: This prospective observational case-control study included a total of 90
participants; 60 patients with reflux esophagitis and 30 age and sex-matched healthy controls. Evaluation
of the Role of Visceral Fat, IL-6, Adiponectin and Leptin Levels on Reflux Esophagitis in Obese Patients
was done.
Results: An overall 90 patients were enrolled in this study, 50 males and 40 females, were assorted into
three groups, obese and had GERD group, non-obese and had GERD, included 30 patients (33.3%),17
males (56.7%) and 13 females (43.3%), and control group, included 30 patients (33.3%),18 males (60%)
and 12 females (40%). The mean levels of body mass index, weight circumference, fasting-plasma
glaucous, two hours post-prandial plasma glucose, Creatinine, liver enzymes, and lipid parameters were
elevated in obese group when compared with non-obese and control groups. Consequently, the mean levels
of leptin and interleukin-6 were high in obese group in comparison with other groups. Interestingly, the
mean level of adiponectin was high in non-obese group in comparison with obese and control groups.
Conclusion: Inflammatory cytokines, adipokines, and visceral fat referring abdominal obesity had an
association with reflux esophagitis.
Keywords: reflux esophagitis, obesity, adiponectin, leptin, visceral fat

Gastroesophageal reflux disease (GERD) is one

of the most common problems encountered in
Obesity is strongly associated with inflammation,
clinical practice today(1). The pathophysiology of
presumably because of an increase in visceral fat
GERD is complex, involving diverse factors such
and other tissues such as the liver secreting
as gastric acid secretion, dysfunction of the anti-
proinflammatory cytokines (e.g., interleukin [IL-
reflux barrier, gastric emptying disturbances, and
6)(4). Subsequently, abdominal visceral adipose
tissue seem to have a major rule in the
mechanisms. These different factors of GERD
pathophysiology of GERD not only the metabolic
are incompletely understood, however they all
effects but also its mechanical effect as a part of
share one common initiating event: increased
increasing the intraabdominal pressure that leads
exposure of the esophageal epithelium to gastric
to disturbances of the sphincter, and esophageal
contents, mainly acid, pepsin, trypsin, and bile
motility functions(5). Furthermore, it was
acids(2). Mucosal injury, characterized by a
established that abdominal visceral adipose tissue
nonspecific inflammatory reaction surrounding
may be an optimal predictor of GERD among
the acid damaged epithelial cells, may occur in
obese patients even better than body mass index,
the setting of pathological reflux. This leads to the
and weight circumference(6). Visceral fat is an
endoscopic findings of mucosal breaks,
important endocrine organ that secretes different
strictures, columnar metaplasia (Barrett's
bioactive substances such as adipocytokines.
esophagus), and adenocarcinoma(3).
Thus, obesity may affect the pathogenesis of
Received: 03/10/2018
Accepted: 22/10/2018

Full Paper (vol.742 paper# 6)

c:\work\Jor\vol742_7 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 270-276

Immunohistochemical Study of CDK5 and Ki-67 in Cervical Precancerous
Lesion and Carcinoma

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: ameranasr.medg@azhar.edu.eg


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.
precancerous, SCC, adenocarcinoma, CDK5, Ki-67


Cervical cancer is usually associated with
Grading of cervical adenocarcinoma
human papilloma virus (HPV) (1). Cervical
depends upon gland architecture (glandular and
intraepithelial neoplasia (CIN) is the precursor
papillary architecture versus solid areas) and its
lesions of cervical squamous cell carcinoma (2).
nuclear features (6). The staging system for
CIN 1 Known as mild dysplasia; CIN 2 Known
tumors of the cervix is International
as moderate dysplasia and CIN 3 known as
severe dysplasia. The grading of CIN depends
Obstetricians (FIGO) (7).
upon the proportion of the epithelium occupied

by basaloid atypical cells reflecting a
The genesis of cancer was related to
progressive loss of maturation and increasing
abnormal mechanism of DNA damage and
lesion severity (3).
repair. Cyclin dependant kinase 5 (CDK5) is
The World Health Organization (WHO)
important for the DNA damage response in
(4) recognizes three basic types of invasive
tumor cells (8). Ki-67 is a prognostic factor for
carcinoma of the cervix: squamous cell
the assessment of biopsies from precancerous
and cervical cancer. Clinically; Ki-67 has been
epithelial tumors.
shown to correlate with the stage of tumors (9).
Histological grading divides Squamous

cell carcinoma (SCC) into three subtypes,
Aim of the work
depends upon the proportion of the tumor
The purpose of this study is to evaluate the
keratinization with the formation of keratin
expression of CDK5 in cervical precancerous
pearls and mitoses, Well differentiated (grade
lesions and carcinoma to clarify its role in
1), Moderately differentiated (grade 2), Poorly
carcinogenesis and progression of cervical
differentiated (grade 3)(5).
cancer, as well as the expression of Ki-67.
CDK5 reactivity and proliferation rate as
Received: 14/09/2018
Accepted: 30/09/2018

Full Paper (vol.742 paper# 7)

c:\work\Jor\vol742_8 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 277-283

Prediction of Ipsilateral and Contralateral Cervical Lymph Node
Metastasis in Unilateral Papillary Thyroid Carcinoma

El Sayed R. Ahmed*, Said H. Bendary, Mohamed Esmat, Ibrahim M. Hasan, Mohamed F. Abd
Elmoaty, Mohamed R. Abd Elhamid
Department of General Surgery, Faculty of Medicine, Al Azhar University

*Corresponding author: El Sayed R. Ahmed, Email: gogoseka1@gmail.com

Surgical therapy is the cornerstone of treatment in patients with papillary thyroid
cancer (PTC). Surgical therapy in PTC includes hemithyroidectomy or total thyroidectomy (TT) and,
in cases of lymph node metastases, cervical lymph node dissection (CLND). The inclusion of
prophylactic central compartment neck dissection (pCCND) as a new approach in the management of
patients with PTC with clinically negative cervical lymph nodes raised controversies among the
endocrine surgeons and predictive factors for central lymph node (CLN) metastasis in unilateral PTC
cases not well defined.
To investigate the risk factors associated with CLNM in clinical lateral cervical lymph
node-negative (cN0) and analyze the rate of ipsilateral and contralateral CLN metastasis in unilateral
PTC cases in Al Azhar University Hospitals in the period from May 2016 till June 2018.
Patients and Methods:
A prospective case-control descriptive study was performed to investigate the
research questions during the period from the 1st of May 2016 till the end of June 2018 in Al-Azhar
University Hospitals. A total of 04 selected patients suffering from papillary thyroid with clinically
negative cervical lymph nodes who have received total thyroidectomy with bilateral CLND. The
clinicopathological features of PTC patients with respect to sex, age, observation, tumor diameter,
multifocality, extrathyroidal invasion, lymphovascular invasion and capsular invasion.The risk factors
of CLNM were analyzed by Chi-squared test and multivariate logistic regression model.
Ipsilateral CLN metastasis were present in 47.5% (19/40).Results analysis showed that males
patients with tumor size (>1 cm) (P=0.027; OR, 2.153), age <45 years old (P=0.017; OR, 2.009) and
capsular invasion (P= 0.018; OR= 0.730) were the predictors of ipsilateral CLN metastasis.Contralateral
CLN metastasis were present in 17.5% (7/40) and prelaryngeal lymph node (LN) metastasis (P=0.008;
OR, 13.333) and ipsilateral CLN metastasis (P=0.051; OR, 9.231), pretracheal lymph nodes (P=0.051;
OR, 9.231), lymphovascular invasion (P=0.043; OR, 5.113) and ETE (P=0.05; OR, 4.901)
independently predicted contralateral CLN metastasis.
Conclusion: For the high-risk PTC patients with CLNM, prophylactic CLND may be beneficial.
Nevertheless, the present data was a single center prospective analysis, and the long-term prognostic
factors including recurrence rate and mortality rate were lacking. Therefore, the results of this research
may only serve as a tool in predicting CLNM.
Keywords: central lymph node, central lymph node metastasis, thyroid papillary carcinoma

Papillary thyroid cancer (PTC) accounted for
first-line diagnostic procedure for detecting
>90% of all the new thyroid cancers (1). PTC
thyroid nodule. Surgery is the gold slandered
appears as an irregular solid or cystic mass or
treatment of papillary thyroid cancer.
nodule in a normal thyroid parenchyma.
Approximately 4-6 weeks after surgical thyroid
Although its differentiated characteristics,
removal, patients may have radioiodine therapy
papillary carcinoma may be overtly or
to detect and destroy any metastasis and
minimally invasive. Papillary tumors have a
residual tissue in the thyroid (4). The lymphatic
propensity to lymphatic spread but are less
drainage of the thyroid and its pattern is
likely to invade blood vessels (2). The most
relatively consistent, and the spread of lymph
common presentation of PTC is an
node metastasis in PTC takes place in a
asymptomatic thyroid nodule or a palpable
stepwise fashion. Generally, cervical lymph
cervical lymph node (3). The biopsy using fine-
node metastasis in PTC involves the central
needle aspiration (FNAB) can be considered the
compartment first, followed by the ipsilateral
Received: 21/06/2018
Accepted: 30/06/2018

Full Paper (vol.742 paper# 8)

c:\work\Jor\vol742_9 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 284-293

Relationship between Estradiol Level, Transvaginal Ultrasound
Endometrial Thickness, Body Mass Index and Endometrial Pathology in
Women with Postmenopausal Bleeding

1Mohammed Samir Fouad Khalaf, 1Mahmoud Samy Zaki, 2Mohamed Saied Elshourbgy,
1Ahmed Magdy Lotfy Abdelmageed

1Department of Obstetrics and Gynecology, 2Department of Clinical Pathology, Faculty of Medicine,
Al-Azhar University

Corresponding author: Ahmed Magdy Lotfy Abdelmageed


Background: menopause is derived from the Greek words; men (month) and pauses (Cessation). A
woman is considered menopausal after cessation of menstruation for 1 year after an average age of 46.
Postmenopausal bleeding (PMB) is defined as bleeding recurring in a menopausal woman at least 1
year after cessation of cycles. It must always be investigated because many causes are premalignant or
malignant. The most common premalignant and malignant causes are complex hyperplasia with atypia
and carcinoma of the endometrium. These disorders are present in as many as 1/3 of the patients
evaluated for PMB in many series. Objective: this study aimed to explore the relationship between
estradiol level, transvaginal ultrasound, endometrial thickness and body mass index and their correlation
to endometrial pathology in women with postmenopausal bleeding. Patients and Methods: in the
present study, 80 patients with postmenopausal bleeding were examined regarding BMI,
ultrasonographic assessment of endometrial thickness and pathological findings of the endometrium.
D&C was performed for all patients under general anesthesia using a sharp ended curette starting first
with the fundus, posterior wall, anterior wall, right and left lateral wall. The patients' age ranged from
46-69 years, with a mean of 53.53 ± 4.1 years. Results: in the present study, there was a highly
statistically significant difference between benign and malignant groups as the endometrium was
markedly thicker in the malignant group. Our study displayed that there was a statistically high
significant difference between benign and malignant groups as regard the presence of fibroid uterus
(due to presence of excess unopposed estrogen in those obese women) and the presence of adenomyotic
or normal uterus inbetween both groups. Conclusion: transvaginal ultrasonography is an excellent first-
step diagnostic method of excluding the endometrial abnormalities in women with postmenopausal
bleeding. Ideally, a non-invasive investigation is preferred over an invasive one and also an economical
investigation preferred over an expensive one; this applies equally to affluent countries and third world.
Endometrial biopsy is the ``gold standard'' for diagnosing abnormalities in the endometrial tissue of
patients with PMB.
postmenopausal bleeding, transvaginal ultrasound, relative risk.


Postmenopausal bleeding (PMB) is the
with PMB (1). The association between obesity
occurrence of vaginal bleeding following a
and endometrial cancer was greater in
woman's last menstrual cycle. Accounts for
postmenopausal women compared to women of
five per cent of office gynaecology
reproductive age, and also in non users of COCs
presentations were detected. Generally, four to
had a higher risk, obesity increases the relative
11 per cent of postmenopausal women will
risk (RR) of developing endometrial cancer
experience bleeding. The chance of this
two- to threefold (2).
occurring reduces as time since menopause
An endometrial biopsy is considered
increases (1).The majority of women referred to
the gold standard for evaluation of PMB.
outpatient gynaecological services had pelvic
Endometrial biopsy can be obtained with an
ultrasound in order to evaluate the endometrial
endometrial pipelle in the outpatient setting, or
thickness and assess for pelvic pathology.
by hysteroscopy and curettage (with or without
Transvaginal ultrasound (TVUS) is considered
dilatation) in either the outpatient or inpatient
an acceptable initial investigation in women
setting (3).
Received: 05/10/2018
Accepted: 24/10/2018

Full Paper (vol.742 paper# 9)

c:\work\Jor\vol742_10 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 294-298

Use of Toric Intraocular Lens in Correcting Regular Astigmatism during Cataract

Mahmoud M. Ismail, Ahmad E.Hudeib, Mohamed F. Khattab*

Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

*Corresponding author: Mohamad F. Khattzb E-mail: dr.mfawzy88@gmail.com,Telephone No.: +2001002952128

to date Toric intraocular lenses (IOLs) have reported to be an effective method to reducepre
existing refractive corneal astigmatism and so spectacle independence following cataract surgery.
Aim of the Work: wasto evaluate the visual and refractive outcomes and the rotational stability of the
EnvistaToric Intraocular Lens after cataract surgery in patients with pre-existing corneal astigmatism.
Patients and Methods: this study included 20 Eyes of 20 patients submitted to cataract surgery with pre-
existing corneal astigmatism of 1.50 D. or moreat Al-Hussein University Hospital and Nour Al-Hayah Eye
Hospital between July 2017 and August 2018 that were implanted with EnvistaToric Intraocular Lens after
phacoemulsification surgery

Results:Using toric IOL to correct corneal astigmatism is a relatively new surgical choice in patients with a
cataract and previous corneal astigmatism. After three months post operative, UCVA(Decimal),
BCVA(Decimal) and Rotation(degrees) were: 0.5_1 (0.81±0.14), 0.9_1 (0.97±0.05) and 0_7 (2.75±1.65)

Conclusion: It could be concluded that Toric IOL implantation was a successful surgical forcorrection of
astigmatism and cataractwithout affecting corneal integrity.

Keywords: Toric intraocular lenses,Cataract, Astigmatism

This prospective non-comparative clinical study

included a total of 20 Eyes of 20 patients
Astigmatism is considered one of the
submitted to cataract surgery and were
most common refractive error which increases
implanted with EnvistaToric Intraocular Lens
with age
after phacoemulsification surgery. Patients
(1).Both astigmatism and cataract are impairing
attended at Al-Hussein University Hospital and
vision and life, so in single operation by
Nour Al-Hayah Eye Hospital. Approval of the
implantation of toric IOL we can improve
ethical committee and a written informed
quality of life and get rid of spectacles(2).
consent from all the subjects were obtained. This
Specific toric intraocular lenses were designed
study was conducted between July 2017 and
firstly by shimizu in 1992, These types of
August 2018.
lenses have been used to correct Astigmatism
Preoperatively, all patients underwent certain
during phacoemulsification surgery(3).
examinations that included medical history and
Today, cataract surgery is considered to be
specific ophthalmic examination that included
refractive surgery that gives us dual benefit by
uncorrected distance visual acuity (UCVA) and
one operation, getting rid of spectacles and
Bestcorrected distance visual acuity (BCVA)
remove cataract as well(4).
using, slit lamp evaluation, and cycloplegic

refraction, intraocular pressure and fundus
examination. An Optical biometry (IOL Master,
The aim of this study was to evaluate
Carl Zeiss Meditec AG) was used to measure
the visual and refractive outcomes and the
axial length, keratometry, and anterior chamber
rotational stability of the Toric IOL after
depth. Inclusion criteria of this study enrolled
cataract surgery in patients with regular
the eyes that had visually significant cataract,
corneal astigmatism
age over 40 years and preexisting regular corneal

astigmatism of (-1.50 D to -6).
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 10)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 299-302

Dystrophic Epidermolysis Bullosa Pruriginosa Presenting with Flagellate
Scarring Pattern Before and After Treatment
Safia T. Metwaly, Zizette A. Moussa, Nivin Y. K. Shenouda, Mounira Waked, Mariam Alfons, Ghada
M. Raslan, Ahmed Sadek, Fady W. Georgy

*Al-Haud AL-Marsoud Hospital for Dermatology, Venereology and Andrology, Cairo, Egypt
*Corresponding Author: Fady Waheed Shawkey Georgy, E-mail: fadywaheed.fw@gmail.com
Dystrophic Epidermolysis Bullosa Pruriginosa (DEB-Pr) is a rare subtype of DEB which is
characterized by intense pruritus and leading to skin blistering and nodular or lichenoid lesions most prominent
on the extremities, especially shins of tibia. Toenail dystrophy is also frequently observed, but not necessary
for diagnosis. Although many cases of DEB-Pr are caused by mutations of type VII collagen due to reported
variants in COL7A1 gene, the clinical pictures vary. We report a patient with DEB-Pr who presented with
striking flagellate hypertrophic scarring lesions. Histopathological and electron microscopic findings are
essential for diagnosis, given the considerable overlap with clinically similar presentations such as
hypertrophic lichen planus, prurigo nodularis, lichen simplex chronicus and dermatitis artefacta. Case
Herein, we report a case with a history of blistering since childhood followed by intensely
pruritic papulonodules, predominantly on the shins of tibia and dorsum of feet with distinct flagellate scarring
pattern and toenail dystrophy. Our case was monitored before and after treatment with topical Tacrolimus
0.03% ointment and systemic Cyclosporine. Conclusion: Our case had an excellent response to topical
Tacrolimus 0.03% ointment and systemic Cyclosporine treatment.
Keywords: Dystrophic Epidermolysis Bullosa Pruriginosa, Pretibial Epidermolysis Bullosa, Histopathology,
Genodermatoses, Mechanobullous.

gave a history of having mild to moderate trauma-
induced skin blistering during childhood and teenage
mechanobullous genodermatosis characterized by
years. 5 years ago, he reported his conditioned
skin fragility and trauma-induced blisters.
worsened with severe pruritus leading to the
Dystrophic Epidermolysis Bullosa (DEB) is a
aforementioned lesions. There was no history of drug
clinically heterogeneous subgroup of EB caused by
intake or seasonal variation or exacerbation before the
mutations in COL7A1 (OMIM 120120), which
onset of his lesions. The patient was not diabetic nor
encoded type VII collagen, gave rise to defective
hypertensive nor on any form of medication. He had
anchoring fibrils at the dermoepidermal junction, as
no known allergies to drugs or food.
well as sublamina densa blistering as a consequence
There was no history of consanguinity. He
[1]. DEB-Pr is an unusual clinical subtype of DEB
gave a positive family history; his late mother was
characterized by severe pruritus, resulting in
suffered from the same dermatologic condition, as
scratching-induced secondary linear pruriginous or
he was 18 years old son. His late mother was
lichenified plaques and marked scarring, especially
suffered from toenail dystrophy. The son also had
on the shins of tibia [2]. Most cases were sporadic [3].
toenail dystrophy; however, he was just starting to
However, a few showed autosomal dominant or
demonstrate mild to moderate trauma-induced skin
autosomal recessive pattern of inheritance [2, 4].
blisters leaving post-inflammatory scars and hyper-
Common clinical differential diagnoses included
pigmentation like his father used to in his childhood
hypertrophic lichen planus, prurigo nodularis, lichen
and teenage years [Figure 2].
simplex chronicus, lichen amyloidosis, keratosis
By examination, our patient had multiple,
lichenoides chronica (Nekam's Disease) and
excoriated, hypertrophic, violaceous, linear papules,
dermatitis artefacta [2, 5,6].
plaques, nodules as well as bullae forming distinct
flagellate patterns on shins of tibia and the dorsum
A 48-year-old male carpenter was presented
of his feet. His lesions were also found on forearms,
with flagellate scars and bullae on shins of tibia and
back, buttocks and thighs. [Figures 1a]
papulo-nodules on thighs, forearms, back, buttocks and
Histopathology revealed a sub epidermal
thighs with toenail dystrophy [Figure 1a & 1b]. He
blister with hyperkeratosis [Figure 3]. Transmission
Received: 9/10/2018
Accepted: 28/10/2018

Full Paper (vol.742 paper# 11)

c:\work\Jor\vol742_12 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 303-309

MRI Versus Ultrasound In Diagnosis Of Meniscal Tear In Knee Joint

* Hossam Adel Mohamed Mostafa1, Ahmed Mohamad Abou Elfotuh 1, Mohamad Mobarak
Alsakka 1

Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University

*Corresponding author: Hossam Adel Mohamed,e-mail:hosamadelmohammed@gmail.com, mobile: -01014200044

Background: the menisci of the knee are complex structures with various important functions within
the knee. Loss of the menisci leads to a significantly increased risk of developing degenerative changes
in the long term.
this study aimed to investigate the role of Ultrasound (US) in diagnosis of meniscus tears as
compared to Magnetic Resonance Imaging (MRI)
Patients and Methods: this study included 50 patients, presented by pain, swelling, stiffness/limitation
of movement or a history of acute/chronic knee trauma, in the duration between November 2017 and
July 2018. The research was carried on the Radiology Department, Al Azhar General Hospital, Zagazig,
Sharkia Governorate, Ministry of Health. All patients underwent musculoskeletal ultrasound in
different position then underwent magnetic resonance imaging included different pulse sequences and
scanning planes.
Results: this study included 50 patients, 31 (62%) males and 19 (38%) females. The patient's age
ranged between 10 and 67 years with a mean of 37.65 ± 10.24 SD. Male patient's age ranged between
10 and 67 years with a mean of 36.35 ± 11.03 SD, while female patient's age ranged between 29 and
55 years with a mean of 40 ± 8.34 SD.
Conclusion: high resolution ultrasonography had high accuracy in detecting presence of tears in both
the medial and lateral menisci. MRI is more sensitive in detection and determines types of tears than
Keywords: MRI Knee, ultrasound, menisci

Meniscal tears are the most widely recognized
ordinarily are even tears, increments with age.
pathology of the knee with a mean yearly
The consolidation of clinical data and the
occurrence of 66 for every 100000. Verifiably
rejection of an elective reason can permit
it was trusted that the menisci filled no
certain conclusion of a symptomatic meniscal
utilitarian need (1). Menisci are critical for load
tear (4). Precise finding of meniscal tear relies on
transmission, stun ingestion, and joint
imaging. Knee arthrography has been to a great
adjustment (2). Knee wounds are normal,
extent supplanted by Magnetic reverberation
particularly when participating in games
imaging (MRI). MRI is presently the analytic
people. Wounds to delicate tissues, for
strategy for decision in assessment of menisci.
example, tendons, ligament and ligaments are
The precision of MRI in diagnosing meniscal
normally experienced. Harm deep down
tears has been accounted for to be higher than
additionally can happen. The knee joint is a
90 %. In any case, the utilization of MRI isn't
compound sort of synovial joint and because of
just costly, yet additionally has a few
the absence of hard help, solidness of the joint
confinements including metallic inserts,
is very reliant on its supporting ligamentous
claustrophobia, tolerant movement curios, and
structures, and in this manner wounds of
tendons and menisci are amazingly normal (3).
reverberation imaging (MRI) isn't in every case
Exact and convenient determination of a
promptly open. It has been proposed to utilize
meniscal tear is basic for diminishing dreariness
ultrasonography for the investigation of the
and arranging treatment. It is entrenched that
menisci of the knee and especially to analyze
meniscal harm inclines the nearby articular
tears since 1989. Ultrasonography is a less
ligament to expanded hub and sheer pressure,
expensive, quicker and more accessible
bringing about early degenerative osteoarthritis
technique than MRI. The affectability and
the pervasiveness of asymptomatic tears, which
particularity of a few investigations on the
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 12)

c:\work\Jor\vol742_13 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 310-317

Assessment of serum vitamin D level before and after narrowband therapy
in vitiligo
Hassan Abou Khodair, Ahmed Wahhed-Allah Amer, Hesham Samir Abd Al Samee, Naglaa
Fathy Arafat Gad
Department of Dermatology, Venereology and Andrology Department, Faculty of Medicine
(Damietta), Al-Azhar University
Corresponding author: Naglaa Fathy Arafat Gad, Mobile: 01062547887, email: ihussein@olemiss.edu

Vitiligo is an acquired, progressive, multifactorial, depigmenting disorder characterized
by the appearance of circumscribed white macules in the skin due to chronic progressive loss of
functional melanocytes in the epidermis. The etiology of vitiligo is not clear, although various
hypotheses have been proposed.
To evaluate the serum levels and the possible role of 25 OH vit D in vitiligo and to detect
whether its level is modulated by Narrowband ultraviolet (B NB-UVB) therapy.
Patients and Methods: The current study included 30 patients with vitiligo. In addition, 30 healthy
subjects who were age and gender matched, served as a control group. All persons were recruited from
the outpatient clinic of Al-Azhar University hospital (Damitta) and from Dermatology, Leprosy and
Venereology Mansoura Hospital, from March 2018 to June 2018.
Results: Vitamin D levels were lower in patients with vitiligo as compared to the control subjects.
Levels of vitamin D increased significantly after NB-UVB therapy. Also, VASI scores showed
improvement after NB-UVB therapy. The mean VASI score in both groups showed highly significant
decrease after treatment by NB-UVB. Comparison and correlation between VASI before NB- UVB
therapy and 25(OH) D showed good negative correlation.
Decreased vitamin D serum level was found in vitiligo patients, indicating its possible
involvement in the pathogenesis of the disease. This level was increased significantly after NB-UVB
therapy. In addition, vitamin D serum level correlated negatively with the severity of the disease.
Narrowband ultraviolet B, vitiligo, melanocyte stimulating hormones


Vitiligo is a chronic depigmenting
Narrowband ultraviolet B (NB-UVB)
disorder characterized by the absence of
phototherapy is a widely used and effective
functional melanocytes in the skin. The
modality in the treatment of vitiligo. The
etiology and pathogenesis are still not
mechanism of action of NB-UVB in patients
completely understood (1).
with vitiligo has not been completely
elucidated. Beneficial effects of phototherapy
autoimmune cause, together with an underlying
have been demonstrated in a variety of skin
genetic predisposition (2).
disorders. Such therapy results in increased
Vitiligo is frequently associated with
cutaneous vitamin D synthesis, which could be
systemic autoimmune disorders, including
one of its mechanisms of action (5).
thyroid disease, diabetes, and pernicious
Previous studies showed that full-body
anemia (3). A link was reported between low
NB-UVB is more effective compared with daily
vitamin D levels and some autoimmune
oral intake of vitamin D in the treatment of
disorders, such as type I diabetes, rheumatoid
vitamin D deficiency. The mechanism of action
arthritis, and multiple sclerosis. Vitiligo could
of NB-UVB in vitiligo is through induction of
be another example of a relationship between
immuno suppression and stimulation of the
vitamin D deficiency and autoimmunity.
proliferation of melanocytes in the skin and the
Vitiligo has been found to be associated with
outer root sheath of hair follicles (6).
low levels of 25-hydroxyvitamin D [25(OH)
There is a stimulatory effect on
D]. In addition, vitiligo patients who had
melanogenesis and on the production of
comorbid autoimmune diseases were found to
melanocyte stimulating hormones (MSH).
be more likely to have very low 25 (OH) D
Moreover, several data demonstrate that the
levels (4).
UVB portion of the sunlight (29o ­ 32o nm)
brings about the photochemical conversion of
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 13)

c:\work\Jor\vol742_14 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 318-324

Assessment of right ventricular outflow tract fractional shortening as a
measure of right ventricular function in chronic heart failure patients

*Nura Ibrahim Maiyadi ¹,², Ibraheem Faragallah ¹, Ahmad Abdelhameed Rozza ¹

¹Department of Cardiology, Faculty of Medicine, Al-Azhar University, Egypt,²Specialist Hospital
Sokoto, Sokoto State, Nigeria

*Corresponding author: Nura Ibrahim Maiyadi; Mobile: 01147793760; Email: nimdee030@gmail.com

: assessment of RV function is a major component of the management and prognostication
of heart failure (HF) patients. Its complexity makes this task difficult and therefore not appropriately
considered. Right ventricular outflow tract fraction (RVOT FS) can serve that purpose if done. The
functional capacity of a HF patient must always be assessed and decision made on that basis.
Aim of the study: this study aimed to investigate the applicability of RVOT FS in assessment of RV
function and also its relation to functional capacity.
Patients and methods: seventy-one (71) patients with heart failure with reduce ejection fraction
(HFrEF) were studied prospectively and nineteen (19) control healthy individuals (normal ECG, normal
left and right ventricular function and no cardiac risk factors). A 2D guided M-mode was taken in the
parasternal short axis view to determine RVOT FS and a six-minute walk test (6MWT) was done to
determine their functional capacity.
Results: there was a reduced RVOT FS reduced in the HFrEF group (p value =0.005), 6MWT D was
reduced in the HFrEF group (p value <0.001), there was a positive correlation of RVOT FS with
RVFAC (r=0.839, p value<0.001) TAPSE (r=0.830, p value<0.001), S'(r=0.830, p value<0.001)
6MWT D (r=0.953, p value<0.001) and a negative correlation with RIMP(r=-0.867, p value<0.001),
RV FLS(r=-0.878, p value<0.001), SPAP(r=-0.633, p value<0.001). 6MWTD with RVFAC (r=0.851,
p value<0.001) TAPSE (r=0.825, p value<0.001), S' (r=0.837, p value<0.001), RVOT FS (r=0.953, p
value<0.001) and a negative correlation with RIMP (r=-0.827, p value<0.001), RV FLS (r=-0.902, p
value<0.001), SPAP (r=-0.621, p value<0.001). RVOT FS between HF subgroups significant (p
Conclusion: RVOT FS is a simple and reliable parameter that can be used in assessment of RV function
and has very positive correlation with functional capacity assessed by 6MWT.
Keywords: right ventricular outflow tract, chronic heart failure, right ventricular function

Chronic heart failure has recently been defined
The aim of this study was to investigate the
as Heart Failure (HF) diagnosed 3month
applicability of RV outflow tract fractional
duration(1). Recently heart failure has been
shortening (RVOT-FS) in the evaluation of RV
classified into heart failure with reduce ejection
function in patients with chronic HFrEF.
fraction (HFrEF), with mid-range (HFmEF)
Secondly to investigate the correlation between
and preserved ejection fraction (HFpEP)(2). It
RVOT-FS and exercise capacity in patients
has long been established that clinical
with chronic HFrEF.
presentation and prognosis of heart failure

patients is highly dependent on the RV
Patients and methods:
function(3­5) The complexity of RV geometry
Study design:
has for long hindered the adequate assessment
The study was performed in Al Hussain
of RV function(6­9). Right ventricular outflow
University Teaching Hospital of Al Azhar
tract fractional shortening is a new parameter
University, Cairo-Egypt for 1year period from
November 2017 to October 2018. This study
distress(10,11).Functional capacity is a major
was conducted prospectively on ninety
determinant and a prognostic factor in the life
individuals categorized into two groups. These
of a HF patient and this ought to be determined
groups were control group (19 individuals)
healthy individuals (Normal ECG, normal left
Aim of the work:
and right ventricular function(15) and no cardiac
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 14)

c:\work\Jor\vol742_15 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 325-334
Doppler and 3D ultrasound in prediction of the nature
of adnexal swelling

Yahia A. Wafa (1), Ismail M. Al-Garhy (1), Prof. Dr. Nabeil M. Fekry (2),
Ahmed S. Abdelhamid

(1) Deprtment of Obstetrics and Gynecology, (2) Al-Agouza Police Hospital

Corresponding author: Ahmed S. Abdelhamid; Mobile: 01100002523; Email: dr.ahmedsabryallam@icloud.com

An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a
common gynecologic problem. Early diagnosis and intervention is essential especially in younger women to
conserve the ovarian function. Aim of the Work: to evaluate the usefulness and value of Doppler and 3D
Ultrasound as a method to enhance differentiation between benign and malignant pathologies before surgical
intervention in women having adnexal swellings. Patients and Methods: This study was carried out in
Obstetric and Gynecology Departments in Al-Azhar University Hospitals on 30 patients who had a preliminary
diagnosis of an adnexal mass. After history taking and clinical examination, all patients underwent abdominal
sonographically, Doppler examination and 3D ultrasound scan from April 2017 to September 2018. Results:
Women with malignant masses were older than those with benign masses (46.00±9.76 vs 44.50±7.62 years)
respectively. BMI in benign cases was lower than recorded in malignant cases (30.13±3.21 vs 38.57±0.81)
with statistical significant difference between two them (P <0.01). Malignant cases were higher in
postmenopausal 4(67 %) while Benign masses were higher in premenopausal 19 (79.2%) while, five cases
(83%) of malignant cases were nulliparous. Regarding the diagnostic accuracy for the prediction of adnexal
malignancy with 3DPD histogram analysis have been satisfied. Resistance index (RI) in benign cases ranged
from 0.50-1.90 with mean value 1.18±0.41 and in malignant cases ranged from 0.30-1.50 with mean value
0.77±0.50. Sensitivity, specificity, PPV, NPV of RI was 78.8%, 75.0%, 77.2% and 76.1% respectively.
Pulsatility index (PI) in benign cases ranged from 0.61-2.50 with mean value 1.80±0.52 and in malignant cases
ranged from 0.80-1.37 with mean value 1.09±0.24. Sensitivity, specificity, PPV, NPV of PI was 90.9%, 88.0%,
91.0% and 86.5% respectively Peak systolic velocity (PSV) in benign cases ranged from 2.00-11.00 with mean
value 6.88±2.71 and in malignant cases ranged from 14.00-35.00 with mean value 22.83±7.31. Sensitivity,
specificity, PPV, NPV of PSV was 100%, 100%, 100% and 100% respectively. There was statistical significant
difference between two studied groups regarding to resistance index, pulsatility index and peak systolic
velocity (P < 0.05). The high risk was higher in malignant cases with 5 (83.3%) and lower in benign cases (1;
4.2%). There was statistical significant difference between two studied groups regarding to 3D ultrsound
examination (P < 0.05). Conclusion: 3D ultrasound with color Doppler scan characteristics are found to be
very important for discriminating benign from malignant tumors.
Key words:
Doppler, 3D ultrasound, benign/malignant pathologies, nature of adnexal swelling


Although ovarian cancer is the 17th most common
Adnexal swellings or masses represent a
cancer in women, it is the fifth most common cause
spectrum of conditions from gynecological and non-
of cancer death in woman, accounting for 5% of
gynecologic sources. Gynecological sources include
cancer deaths--more than any other gynecologic
the ovaries, fallopian tubes, ectopic pregnancy,
cancer (3).
tuboovarian abscess, paratubal or paraovarian cyst,
Non neoplastic conditions of the ovary that may
hydrosalpinx and broad ligament leiomyoma (1). Non-
present as adnexal masses include the following:
gynecologic sources of adnexal swellings include
pregnancy luteoma, hyperplasia of ovarian stroma,
hyperthecosis, massive edema, solitary follicle cysts
diverticulum, nerve sheath tumor, pelvic kidney,
and corpus luteal cysts, multiple follicle cysts
peritoneal cyst, and gastrointestinal carcinoma (2).
(polycystic ovaries), multiple luteinizing follicle cysts
Adnexal masses are considered a group of the
and/or corpora lutea, endometriosis, surface epithelial
most common diseases in gynecology, ovarian
inclusion cysts (germinal inclusion cysts), simple cysts,
tumors, alone, represent two thirds of these cases.
inflammatory lesions, and paraovarian cysts (4).
The American Cancer Society estimates that 22,280
The differential diagnosis of adnexal masses
new cases of ovarian cancer will be diagnosed in
remains a clinical challenge, but an accurate
2016 and 14,240 women will die from the disease.
diagnosis is essential for adequate management.
Received: 06/10/2018
Accepted: 25/10/2018

Full Paper (vol.742 paper# 15)

c:\work\Jor\vol742_16 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 335-340

Comparative study between sub-coronal and peno-scrotal approach of
semi-rigid penile prosthesis implantation

Basiony Abd Alhady, Mohamed Abdelshafy, Osama Al Shahat, Mourad Mahmoud, Ahmed
Taha, Abdel Rahman Awadeen

Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Al-Azhar University

Aim of the work:
study was done to compare the benefits and risks for patients doing insertion of
penile prostheses for treatment of erectile dysfunction by two different approaches (sub-coronal and
penoscrotal) and to try discover the most suitable one. Patients and Methods: a total of 24 patients
were included in this study that had all complaining from sever erectile dysfunction. All patients were
subjected to pre as well as post-operative fixed assessment. International Index of Erectile Function
(IIEF), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS). Patients were classified into
two groups according to the approach of implantation. Procedure was done for every individual patient.
Analysis of the final results was done to compare the different procedures and evaluate them
individually and comparatively in an effort to categorize the overall benefit of each procedure. Results:
each of the two test groups showed a significant improvement and satisfaction of complaining, as well
as a significant difference between the two groups as regard(EDITS) (p-value <0.005). Conclusion: In
general, management of erectile dysfunction had a strong impact on the quality of life of the patients
especially who underwent the penile prostheses implantation, most significantly affecting their
"selfesteem", the penoscrotal approach was more suitable for semi-rigid penile prostheses than
subcoronal one.

Erectile dysfunction (ED) is defined as the
The aim of this study was to compare the
consistent inability to achieve and maintain a
benefits and risks for patients doing insertion of
penile erection adequate for satisfactory sexual
penile prostheses for treatment of erectile
intercourse. ED may substantially decrease the
dysfunction by two different approaches (sub-
quality of life for both the man and his partner
coronal and penoscrotal) and to discover the
(1). ED may be related to vascular disease,
most suitable one.
neurological disease, hormonal defects,

cavernosal fibrosis from Peyronie's disease,
ischaemic priapism or diabetes mellitus (2).The
A total of 24 patients were included in this
first-line treatment for ED was the oral
study that had all complaining from sever
administration of a phosphodiesterase type V
erectile dysfunction, they had been suffered for
inhibitor. The phosphodiesterase type V
more than 1 year at least.The study was
inhibitor had revolutionized ED management
executed in the period from January 2016 to
due to the inhibitor's high rates of efficacy and
January 2018 in Al-Azhar University Hospital
favourable adverse-effects profile (3). In patients
(Plastic Surgery and Urology Surgery
who did not respond to the medical
Department). The study was approved by the
management of ED, penile prosthesis
Ethics Board of Al-Azhar University.
implantation (PPI) was a definitive option for
The mean age of the patients was 46 years.
ED management. Modern penile prostheses
There were 9 cases heavy smokers, 15 patients
have been available since the early 197os (4).
had controlled diabetes and 9 patients had hyper
With regard to the surgical technique, various
lipidemia. All patients were within normal
approaches had been described for implanting
range of hormonal profile. All patients and their
penile prostheses: the dorsal subcoronal, penile
partners were subjected to pre as well as post-
proximal, longitudinal penoscrotal, transverse
penoscrotal perineal and combined incisions (5).
AIM of the WORK
Function(IIEF),Erectile Dysfunction Inventory
of Treatment Satisfaction (EDITS).They were
Received: 08/10/2018
Accepted: 27/10/2018

Full Paper (vol.742 paper# 16)

c:\work\Jor\vol742_17 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 341-351
Myocardial bridge analysis by multidetector computed tomography and its
association with coronary atherosclerosis

Islam Shwaky Abd Elaziz 1, Mansour Mohamed Sallam 1,
Mohamed Abo mandour Mousa 1, Ahmed Raouf Nawar 2

1- Department of Cardiology, Faculty of Medicine, Al-Azhar University, Egypt,2-Department of Cardiology,
Denshal Teaching Hospital, Egypt

Corresponding Author: Ahmed Raouf Nawar, Phone: 01099922821, email: ahmedraouf788n@gmail.com

myocardial bridge is still a major public health problem despite the impressive stride in
diagnosis and management. Furthermore, the early and accurate diagnosis with the proper management
is an important challenge. The determination of the prevalence of myocardial bridges and their location
and morphology is extremely important for the prediction of potential complications which are likely to
cause greater myocardial damage. Aim of the work: this study aimed to assess noninvasively by using
MDCT the presence of atherosclerotic plaques in relation to myocardial bridge coronary segments and
to determine the prevalence of myocardial bridges and their morphology (length, depthand diameter)
and location. Methods: this was a prospective observation study that was done from June 2017 to April
2018 and included 52 patients presented to the Coronary Care Unit at Al-Azhar University Hospital with
stable angina. All patients were subjected to: thorough history taking, full clinical examination, surface
ECG, treadmill stresses ECG and do MDCT scan to detect of the presence of myocardial bridge: as
regard site, length, depth and degree of systolic obstruction, coronary plaque assessment. Results:
among the 52 patients we found that 23 patients had MB and coronary plaque included in group A, 29
patients had MB without coronary plaque included in groupB, In group A, MB was in Mid LAD in
18(78.3%) patients, Distal LAD in 5(21.7%) patients, the mean depth of MB was 3.89 ± 1.75 mm, the
mean length of MB was 22.16 ± 9.44 mm, the mean degree of systolic obstruction of MB was 61.65 ±
19.47 %. While, in group B mid LAD in 20 (69.0%) patients, distal LAD in 7 (24.1%) patients and
proximal LAD in 1 (3.4%) patients, distal RCA in 1(3.4%) patient, the mean depth was 2.83 ± 1.54 mm
(p = 0.017), the mean length was22.22 ± 13.55 mm, the mean degree of systolic obstruction was is
41.72 ± 24.94 % (P < 0.004).
Conclusion: some anatomic characteristics of myocardial bridge, such as degree of systolic
obstruction and depth, may help the development of coronary plaque.
Myocardial Bridge, Multidetector Computed Tomography, Coronary Atherosclerosis.

Myocardial bridging an inborn coronary
The incidence of MB was reported between 15
abnormality is defined as an intramural segment
to 85% in autopsy studies (5). The frequency had
of a coronary artery that normally courses
been reported in angiographic studies varies
epicardially for a varying segment of length
from 0.5 to 16% (6). The incidence reached 4o%
(1).Myocardial bridging was first described by
with the provocation test occurred within
Geiringer (2) who reported dissection method
coronary angiography (7). This difference
on autopsy samples and reported an incidence
between angiography and autopsy series
of 23% with predominance of myocardial
referred to multiple factors including the depth
bridges on anterior interventricular artery.
and length of the tunneled artery, with only
According to text (Gray's Anatomy) the
deeply located coronary artery segments within
anatomical distribution of muscle bridges were
the ventricular myocardium appearing to be
classified into two as types: superficial (75% of
compressed enough during systole to be
cases) (3) or deep (25% of cases), depending on
diagnosied on angiography. Also, the
the thickness of the covering muscle layer (4).
occurrence of atherosclerotic plaques proximal
Additionally, the superficial type can be further
to MB may lead to underdiagnoses (8).
classified as complete or incomplete.

Incidence of Myocardial Bridge
Received: 08/10/2018
Accepted: 27/10/2018

Full Paper (vol.742 paper# 17)

c:\work\Jor\vol742_18 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 352-363
Assessment the Role of Bisphenol A on Chemotherapeutic Efficacy of
Cisplatin against Hepatocellular Carcinoma in Male Rats

Hanaa M. Serag, Magda M. El Komy and Hend S. Ahmed*

Zoology Department, Faculty of Science, Mansoura University, Mansoura, Egypt

*Corresponding author: Hend Shafiq Ahmed, E-mail: hsh.mit.sci@gmail.com
Aim: the objective of this study was to investigate the effect of bisphenol A (BPA) in DENA and CCl4
induced hepatocellular carcinoma male rats. Materials and Methods: DENA was given as a single
intraperitoneal injection of freshly prepared (200 mg/kg.bw)for initiation the carcinoma and CCl4 once
every week (3ml/kg.bw) for 10 weeks to promote the carcinogenic effect of DENA in male rats. In addition,
the study aimed to elucidate the chemo-resistant role of bisphenol A (322 mg/kg.bw) against cisplatin
chemotherapeutic effect, as a potent antineoplastic agent in the treatment of hepatocellular carcinoma male
rats induced by DENA and CCl4. Results: obtained result showed that the group of rats which was orally
administrated by BPA , as well as hepatocellular carcinoma treated rats group significantly have increased
relative liver/body weight ratio, serum ALT, AST, ALP, serum total bilirubin, serum total protein and serum
AFP and TNF-, serum TL, TC,TG,LDL,V-LDL levels while a decrease in HDL level .Additionally there
was an elevation in hepatic MDA, H2O2 and a significantly depression in SOD, CAT, GST activities and
GSH level, as well as an increases in hepatic p53, caspase-3 while a decrease in Bcl-2 level .on the other
hand an intraperitoneal injection of cisplatin (1.5mg/kg /bw) repeated two times a week for 3 weeks to the
hepatocellular carcinoma induced rats group showed amelioration in the above parameters significantly
more than that of hepatocellular carcinoma group treated also with BPA. Conclusion: the consumption of
BPA might resist the cisplatin chemotherapy treatment of hepatocellular carcinoma in male rats.
Keywords: Hepatocellular carcinoma, Bisphenol A, Cisplatin.


compounds which lack direct genotoxic capacity,
In a strategic situation in human body the
but enhance tumor formation after initiation by a
liver is found , it is mainly responsible for
hepatotoxic compound, e.x. carbon tetrachloride,
CCl4 [1].Oxidative stress and liver cell injury
manufacturing energy and molecules used by
resulting from reactive oxygen species which
other cells in nearby or very distant tissues.
involved in DENA/CCl4 pathogenesis that induce
Liver is an interesting organ with the unique
hepatocarcinogenesis [2]. Furthermore, DENA is
capacity to regenerate upon injury .This self-
a genotoxic compound which forms alkyl DNA
repairing ability works as a double-edged
sword if the inflicting agent continue or becomes
abnormalities in rat liver which finally lead to the
chronic, resulting in cirrhosis, liver failure,
development of HCC. Cisplatin (CIS) is an
and/or development of liver neoplasia .
effective chemotherapeutic agent that is used in
Hepatocellular carcinoma (HCC) is a major
nearly 50% of all cancer patients. Cisplatin binds
health problem worldwide, and represents the
with DNA to form intrastrand crosslinks and
fifth most prevalence cause of cancer and the
adducts, then inhibit DNA replication and/or
third cause of cancer-related deaths worldwide.
transcription and activate several signal
For cancer research, animal models of chemically
transduction pathways, culminating in the
induced carcinogenesis, particularly HCC, have
activation of apoptosis. The development of CIS
been conducted in rats. Two types of
chemoresistance is a major problem with CIS
carcinogenic compound are known: genotoxic
treatment of HCC. Bisphenol A [2, 2-bis (4-
compounds which are recognized by their
hydroxyphenyl) propane] (BPA) is one of the
capability to induce structural DNA changes, e.x.
highest volume chemicals produced worldwide,
diethylnitrosamine (DENA) and promoting
and human exposure to BPA is thought to be
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 18)

Introduction The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 364-374

Comparative Study between the Effect of Nifedipine, Ritodrine and Magnesium
Sulphate Therapy on Doppler Indices of Fetal Umbilical and Middle Cerebral
Arteries in Patients with Preterm Labour

Hosam Eldin Hussein Kamel*, Noha Mohamed Sabri HosamEldin*, Mohamed Ahmed Attia Soltan *

*Department of Obstetrics and Gynecology Department, Faculty of Medicine, Al Azhar University

Corresponding author: Mohamed Ahmed Attia Soltan, Mobile: 00201021543881, E-Mail: mhmd.soltan2917@gmail.com

Spontaneous preterm labor (SPTL) and preterm birth (PTB), is the single most important cause
of perinatal mortality and morbidity in high-income countries despite the enormous efforts over the past several
decades. Preterm labor is defined as regular, painful, frequent uterine contractions causing a progressive
effacement and dilatation of the cervix occurring before 37 completed weeks of gestation. Many drug therapies
were used as tocolytics in cases of preterm labor, however none of them proved to be the best. The present
study was performed to compare three of the used drugs for tocolysis to assess their efficacy and side effects
on the mother and fetus.
Aim: The aim of this study is to compare the effect of oral nifedipine, intravenous ritodrine infusion and
magnesium sulfate infusion used as tocolytics in cases of preterm labour on Doppler parameters of fetal
umbilical and middle cerebral artery and to evaluate their effects on the mother and the fetus in order to choose
the safest and the most effective drug.
Methodology: This study was held in the period from December 2014 to october 2015 on 90 patients attended
and admitted from the Casualty Unit of the Obstetric Department In Elsayed Glal University Hospital with
preterm labor pains , intact membranes, singleton pregnancy between 28 and completed 34 weeks gestation.
All patients had been dated accurately with a gestational age based on the last menstrual period and if available
a corresponding second trimester ultrasound report performed before 20 weeks gestation.
Treatment continued until contractions stopped for 24 hours, maximum doses were attained without response;
unacceptable side effects occurred or labor proceeded. Successful treatment was defined as cessation of
contractions observed for 24 hours and no further cervical changes. Patients with successful treatment were
put under observation for another 24 hours without additional treatment then discharged on no maintenance
Results: Maternal tachycardia, palpitation and dyspnea were more common in the ritodrine group with (p-
value = 0.000). The present study showed increase in umbilical artery PI after treatment in the magnesium
sulfate group only which was statistically significant (P value = 0.016). The study showed statistically
significant increase in middle cerebral artery PI after treatment in magnesium sulfate group
with a P
value=0.000 and statistically significant decrease in middle cerebral artery with nifedipine group with P
value=0.027. When comparing the cerebroplacental ratio before and after treatment in the three groups; the
study showed significant increase in cerebroplacental ratio after treatment in the magnesium sulfate group with
P value = 0.000, which is statistically significant. This suggests that nifedipine could be used as a safer
alternative to ritodrine and magnesium sulfate.
Conclusion: In our study, nifedipine therapy was not associated with a significant change in maternal systolic
and diastolic blood pressure after 24h, with minor insignificant effect on maternal heart rate. Fetal heart rate
was not affected after therapy. Fetal Doppler study found no clinically significant effect on the pulsatility index
(PI) of umbilical and middle cerebral artery, while with magnesium sulfate therapy there was increase in
cerebro- placental ratio 24hr after treatment, these findings ensure safety of the drugs on the maternal and fetal
Keywords: Nifedipine, Ritodrine, Magnesium Sulphate, Fetal Umbilical, Preterm Labour

Preterm labor is defined as the presence of
(between 20 and 37 wk). Preterm labor precedes
uterine contractions of sufficient frequency and
almost half of preterm births and preterm birth
intensity to affect progressive effacement and
neonatal mortality in the United States. In addition,
dilation of the cervix prior to term gestation
preterm birth accounts for 70% of neonatal
Received: 15/09/2018
Accepted: 30/09/2018

Full Paper (vol.742 paper# 19)

c:\work\Jor\vol742_20 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 375-381

Role of susceptibility weighted imaging in acute ischemic stroke

1Tarek Ibrahiem Menecie, 2 Sherif Abd-El-fattah Khedr, 1Mohammad Ali Saeed Hassan,
1Mahmoud Hassan Mohammad Zaghloul

1Department of Neuorology, Faculty of Medicine- Al-Azhar University, 2Department of
Radiology, Faculty of Medicine, Cairo University

Corresponding author: Mahmoud Hassan Mohammad Zaghloul, Mobile: 01013904246; Email: mahhas290@gmail.com

stroke is a clinical syndrome of rapidly developing symptoms and signs of focal loss of
cerebral function without apparent cause other than vascular origin, lasting 24 hours at least, or may
lead to death before this. Hemorrhagic transformation (HT) is defined as hemorrhagic change in
ischemic brain and includes a wide range of radiologic phenomena, from petechial hemorrhage to frank
hematoma with mass effect. Objective: in our study, we aimed to determine the diagnostic value of
susceptibility weighted image in detection of cerebral micro bleeds and prediction of hemorrhagic
transformation in patients with acute ischemic stroke and their impact on choosing the most appropriate
therapeutic protocol. Patients and Methods: this study included 28 patients with acute ischemic stroke.
Patients admitted in Neurology Department of Nasser Institute Hospital within 72 h after the onset of
the neurological symptoms, during the study period from 1/1/2018 to 30/8/2018, their age ranged
between 23-85 years. Results: SWI image was a highly sensitive MRI sequence for detection and
evaluation of cerebral micro bleeds especially on 3T magnet. Microbleeds were traditionally
categorized according to their presumed underlying etiology into lobar (CAA related pathology) and
deep (arteriosclerosis) microbleeds. There was a highly significant positive correlation between both
age and hypertention with number of both cortical and basal ganglionic microbleeds. While, the age
was obviously more correlated with cotical microbleeds, hypertention, in contrast, was more correlated
with basal ganglionic microbleeds. Conclusion: presence of microbleeds in cerebral infarct lesions
requires a comprehensive assessment for the therapeutic option, especially when using thrombolytic
therapy or anticoagulants, but a relatively small number of microbleeds would not affect safety when
using antiplatelet therapy.
Keywords: hemorrhagic transformation, diffusion-weighted imaging, susceptibility-weighted


Stroke is a clinical syndrome of rapidly
understand how ischemia occurs. Ischemia is a
developing symptoms and signs of focal loss of
reduction in blood flow sufficient to interfere
cerebral function without apparent cause other
with normal cellular function. Brain tissue is
than vascular origin, lasting 24 hours at least, or
highly sensitive to ischemia, so even brief
may lead to death before this (1).Worldwide,
ischemic periods to neurons can lead to a
stroke is the second leading cause of mortality,
complex sequence of events that may culminate
resulting around 6,000,000 deaths per year
in cellular death (2).SWI is a highly sensitive in
(2).Strokes can be classified into two major
detecting hemorrhage so allows good
types: ischemic and hemorrhagic. Ischemic
visualization of the hemorrhagic lesion.
strokes are due to interrupted brain tissue blood
supply while hemorrhagic strokes are caused by
susceptibility by decreasing arterial blood flow,
extravasation of blood out of a blood vessel or
thus increasing deoxyhemoglobin levels, and
an abnormal vascular structure. About 85% of
may also increase pooling of deoxygenated
strokes are ischemic and the rest are
blood (7).
hemorrhagic. Some hemorrhages develop
Several important tissues have unique
inside areas of ischemia (Hemorrhagic
magnetic susceptibility differences relative to
transformation). Actually, it is unknown how
surrounding tissues. Signals from these
many hemorrhagic strokes start as ischemic
substances are out of phase with background
stroke (3).Understanding of the pathogenesis of
tissues at sufficiently long echo times. Thus
brain damage following ischemia is to
phase imaging is a good means for enhancing
Received: 15/09/2018
Accepted: 30/09/2018

Full Paper (vol.742 paper# 20)

Introduciton The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 382-387

Topography-guided photo-refractive keratectomy followed by corneal collagen
cross-linking for keratoconus

Magdy Ezzat Khallaf, Mohamed Ahmed El-Mallah, Rasha Hassan Ismail

Department of Ophthalmology, Faculty of Medicine, Al-Azhar University

*Corresponding Author: Rasha Hassan Ismail, Phone No.: (+2)01200665575, E-mail: rashaesmail@yahoo.com


Background: KC is a bilateral, progressive, non-inflammatory corneal degeneration. Corneal deformation and
thinning causes irregular astigmatism and leads to visual impairment. Aim of the work: this study aimed to
evaluate simultaneous topography-guided partial PRK and CXL as a therapeutic intervention in patients with
KC. Methodology: the present study was designed to evaluate simultaneous topography-guided partial PRK
and CXL as a therapeutic intervention in patients with KC. It included 25 keratoconic eyes of 17 patients; 8
cases were bilateral and 9 cases were unilateral. All included cases underwent full history taking and
ophthalmologic examinations for preoperative evaluation and postoperative assessment. Follow up was carried
out at first postoperative day and at 1, 3 and 6 months post-operatively. Results: when comparing K1, K2,
thinnest location and BCVA at 1, 3 and 6 months postoperatively to the corresponding values at first
postoperative day, there was non-significant difference at any point of time. Conclusion: simultaneous
topography-guided partial PRK and CXL as a therapeutic intervention in patients with keratoconus is an
effective without significant complications; thus, it had a good efficacy, stability over time and safety.
Keywords: KC, ICRS, CXL


Keratoconus (KC) is a progressive corneal
customized topography-guided surface ablation
disorder that can lead to severe vision deterioration
treatment (T.CAT) has been reported in patients
through the development of irregular astigmatism
with stable or subclinical KC with promising visual
and corneal scarring. Thus far, techniques that have
outcomes (4). The disadvantage of ablative
been employed to improve vision in patients with
procedures is that tissue removal might lead to
KC include the use of spectacles, rigid gas
further destabilization of corneal biomechanics and
permeable contact lens, intracorneal ring segment
progression of the ectatic disorder. Until recently,
(ICRS) implantation, and in the most severe cases,
simultaneous topography-guided Photo-refractive
lamellar or penetrating keratoplasty (1). It has been
Keratectomy (PRK) followed by CXL seems to be
shown that the progression of the disorder can be
the most effective approach for optimum results in
impeded by riboflavin-ultraviolet A (UVA) corneal
the treatment of KC patients, as it is capable of
collagen cross-linking (CXL) (2). The application of
offering functional vision with stabilization of the
CXL is capable of stabilizing the cornea in KC and
ectatic disorders (1).
in postoperative refractive ectasia for up to 5 years

after the procedure, but topography and visual
Aim of the work
outcomes of treated patients show only minimal
The aim of this work was to evaluate
improvement (3).The irregular astigmatism in KC
simultaneous topography-guided partial PRK and
can be confronted with the use of customized laser
CXL as a therapeutic intervention in patients with
ablations that restore the refractive properties of the
anterior corneal surface. The application of

the period from January 2014 till June 2018. The
Patients and methods
study was approved by the Ethics Board of Al-
Azhar University.
The present study included 25 keratoconic
Before inclusion in the study, all patients
eyes. They were from 17 patients; 8 cases were
were offered explanation and all information
bilateral and 9 cases were unilateral. This study
needed about the procedure, indication, technique,
was conducted at Ophthalmology Department; Al-
post-operative expectations and possibility of
Azhar Faculty of Medicine and International
complications. Then, an informed consent was
Ophthalmology Hospital (New Damietta) during
obtained from the patient. KC was diagnosed using
Received: 08/10/2018
Accepted: 27/10/2018

Full Paper (vol.742 paper# 21)

c:\work\Jor\vol742_22 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 388-395
Assessment of Procalcitonin Level in Chronic Hemodialysis Patients with

Mustafa Abd-Elfattah El-Ballat (1), El-Sayed Mohammed Rashid (1), Abd-Elraouf Abd-Elraouf Abo
Nar (2), Salah Fathi Ali Radwan (3).

(1) Internal Medicine and Nephrology Department, (2) Clinical Pathology Department, Faculty of
Medicine, Al-Azhar University, Cairo, (3) Nephrology Department, El-Sahel Teaching Hospital, Cairo,

Corresponding author: Salah Fathi Ali Radwan, email: dr.sradwan@yahoo.com

Circulating procalcitonin (PCT) is an inflammatory marker produced by several cell types
including adipose tissue following cytokine stimulation. In contrast to its role in the general population,
obesity has been associated with improved survival in chronic renal failure patients undergoing
haemodialysis. The aim of our study was to evaluate the link between plasma PCT concentration and
metabolic parameters of obesity in chronic hemodialysis patients.
Patients and methods: We determined PCT in 80 subjects; they were divided into: 30 obese, body mass
index(BMI)>28Kg /m2, chronic renal failure patients' undergoing haemodialysis, 30 non obese, body mass
index(BMI)<28 Kg/m2, chronic renal failure patients' undergoing haemodialysis,20 obese, body mass
index(BMI) >28Kg/m2,normal healthy subjects as control. Complete clinical examination and laboratory
investigations were done.
Results: Elevated plasma procalcitonin (PCT) levels, within the normal range, of the 80 subjects included
was not dependent on anthropometric measures including body weight, height, body mass index and waist
circumference. It was found to be correlated to age (0.020, P<0.05) and urea (0.024, P<0.05) in obese
haemodialysis patients'.
Conclusion: Our findings based on community-based data showed that higher plasma procalcitonin levels
in the normal range are associated with increased measures of obesity in chronic renal failure patients'
undergoing haemodialysis. Because associations were not dependent on BMI, plasma procalcitonin may
serve as a new marker for adipocyte dysfunction, chronic low-grade inflammation, or both.
Keywords: Procalcitonin, hemodialysis, obesity.

Procalcitonin (PCT) was first described in 1993
discriminating bacterial from viral infections(4)
as a diagnostic marker of infection. It is a
and true bacteremia from contaminated blood
polypeptide of 116 amino acids and has a
cultures(5). It is known that Gram-positive or
molecular weight of 13 kDa. It is the precursor
Gram-negative bacteria or fungi activate different
for the calcium homeostasis hormone, calcitonin.
Toll-like receptor (TLR) signaling pathways,
resulting in production of different pro-
concentrations in normal serum and is thought to
inflammatory cytokines that ultimately stimulate
be produced in physiological conditions by the
PCT release(6).
neuroendocrine cells in the thyroid gland and

The reference value of procalcitonin in adults and

children older than 72 hours is 0.15ng/mL or less.
Procalcitonin (PCT) high levels are strongly
Reference values have not been established in
associated with systemic bacterial infections(1, 2).
infants younger than 72 hours. In healthy adults,
and with the severity of illness(3). It is produced
the reference range of procalcitonin is below the
in response to bacterial endotoxin and
level of detection(7). The half-life of procalcitonin
inflammatory host cytokines and may help in
Received: 08/10/2018
Accepted: 27/10/2018

Full Paper (vol.742 paper# 22)

c:\work\Jor\vol742_23 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 396-402
Efficiency of Lepidium sativum Seeds in Modulation the Alterations in
Hematological Parameters Induced by Sodium Nitrite in Rats

Enas S. Abdel-Baky

Department of Biological and Geological Sciences, Faculty of Education, Ain Shams University,
Cairo, Egypt

Sodium nitrite is an inorganic compound with the chemical formula NaNO2. It is
probably best known as a food additive to prevent botulism.
Aim of the work:
The current study was designed to investigate the possible protective effect of
aqueous extract of Lipidium sativum seeds on hematotoxicity induced by sodium nitrite (NaNO2) in
male albino rats.
Materials and Methods: The experimental animals were divided into four groups. The first group
without any treatment and served as control. The second group was given an intraperitoneal injection
(IP) of a single dose of sodium nitrite (50 mg/kg body weight) 24 h prior to decapitation. The third
group was received orally 300 mg/kg body weight of Lipidium sativum seeds extract for four weeks.
The fourth group were treated orally with Lipidium sativum seeds extract (300 mg/kg body weight)
for four weeks, prior to IP injection with a single dose of sodium nitrite (50 mg/kg body weight).
Finally, blood samples were collected for hematological parameters estimation including red blood
cell count (RBCs), hemoglobin (Hb), packed cell volume (PCV), mean corpuscular volume (MCV),
mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), platelet
count (PLTs) and total and differential white blood cells (WBCs).
Results: The obtained data revealed that NaNO2 induced a significant decrease in the percentages of
RBCs count, Hb content, PCV, MCH, MCHC, platelets, WBCs, neutrophils, monocytes, eosinophils
and basophils count. On the other hand, a noticeable increase in the percentage of lymphocytes was
recorded in NaNO2 treated rats. Whereas, the treatment with Lipidium sativum seeds extract alone to
rats did not cause a significant alterations in the hematological indices comparing to control group.
There was a significant increase in total WBCs and neutrophils counts and a significant decrease in
lymphocyts, monocyts, eosinophils and basophils counts. The treatment with Lipidium sativum seeds
extract before injection with sodium nitrite were significantly ameliorated the changes induced in
hematological parameters which caused by sodium nitrite comparing with the control group. Whereas,
there were a significant increase in total WBCs count, neutrophils and eosinophils and a significant
decrease in lymphocytes, monocytes and basophils.
Conclusion: It could be concluded that the treatment with Lipidium sativum seeds extract
significantly improved the changes in hematological parameters that caused by sodium nitrite and
induced a significant increase of WBCs count may stimulate the animal's immune system activation.
Key words: Hematological parameters, Lepidium sativum seeds, Sodium nitrite.

Food additives are substances intentionally
and it is one of the principal preservatives.
added to food and used for various purposes,
Previous researchers reported that nitrites are
including preservation, coloring and enhance
environmental pollutants present in food and
food (1).They are products of oxidation of
water and it is responsible for most of the toxic
nitrogen by microorganisms in plants, soils
effects observed with excess nitrate ingestion
and water. Nitrites are used as food additives
(3). Sodium nitrite is a white to slightly
mainly for production of specific flavor and
yellowish inorganic salt, with the chemical
for preservation of meat products. Several
formula NaNO2. It may interact in the
organic nitrites and nitrates have been used
stomach with amines of the foods, producing
clinically but the only inorganic nitrite of
nitrosamines or free radicals (4). These
therapeutic using is sodium nitrite (2). The
products may induce lipid peroxidation that
nitrites used in the form of salts or free acids
may increase the harmful hazards to the
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 23)

c:\work\Jor\vol742_24 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 403-410

Vestibular Evoked Myogenic Potentials (VEMP) in patients with Multiple

1Gehan Abdel-Rahman El- Zarea, 1Ahmed Ismail Abbas, 2Mohamed Hamed Rashad, 1Ahmed
Mohamed Almeciry

1Department of Audio Vestibular Medicine ENT Department, 2Department of Neurology, Faculty of
Medicine Al-Azhar University

Corresponding author: Ahmed Mohamed Almeciry, Mobile: 01091249347; email: meciry_a@yahoo.com

multiple sclerosis (MS) is a chronic demyelinating disease in which the insulating covers
of nerve cells in the brain and spinal cord are damaged and this damage disrupts the ability of parts of
the nervous system to communicate, resulting in a range of signs and symptoms. Objective: this study
aimed to assess cervical vestibular evoked myogenic potentials (cVEMP) in patient with multiple
sclerosis and to demonstrate the value of cVEMP as a good method for the assessment of vestibulospinal
tract in patients with MS. Patients and Methods: to achieve this target, we enrolled 50 subject: 30
patients diagnosed as MS in addition to 20 healthy control. The cVEMP response was evaluated for the
presence of positive (p1) and negative (n1) peaks of the first biphasic wave complex; latency (p1 and
n1 latency) and peak to peak amplitude. The bilateral otoscopy was normal in cases and controls, with
no middle or outer ear disease that could bias the study results being found. The pure tone audiometry
showed levels of hearing compatible with normal hearing in the 20 healthy subjects, with hearing
thresholds that did not exceed 25 dB for any individual. Results: the present results showed that 60 %
of MS patients had VEMP abnormalities (absent responses and/or prolonged latencies). In the present
study, patients with absent VEMP wave were found to have significantly higher disease duration. In the
present study, the absence of P13­N23 waves were more frequent in patients with greater EDSS score,
and also absence of P13­N23 waves were more frequent in patients with MS with vestibular symptoms
and greater disability.
we can say that in patients with MS in which demyelination has extended to the
vestibulospinal tract, there is going to be a prolongation of the p13 and n23 wave. In fact, this increase
in the p13 and n23 latencies is clear in the patients with MS in comparison to the control group.
multiple sclerosis, vestibular evoked myogenic potentials, pure tone audiometry, EDSS.


Multiple sclerosis (MS) is a chronic
meta-analysis in different referral centers of
demyelinating disease in which the insulating
Egypt has found 648 patients with definite MS.
covers of nerve cells in the brain and spinal cord
Vestibular Evoked Myogenic Potentials
are damaged and this damage disrupts the
(VEMP) was a myogenic potential generated by
ability of parts of the nervous system to
a sound stimulus that allows noninvasive
communicate, resulting in a range of signs and
exploration of the vestibular sense organ
symptoms. These symptoms include sensory
(saccule and inferior vestibular nerve). VEMP
and motor impairment, ataxia, spasticity,
acoustic stimulus can be evoked by presenting
fatigue, and cognitive impairment and leads to
clicks through headsets. The macula was
significant disability (1).
activated by sound stimulus, generating an
MS was the most frequently seen
electrical potential which goes through the
demyelinating disease, with a prevalence that
pathway of the inferior vestibular nerve, lateral
varies considerably, from high levels in North
vestibular nerve, vestibulospinal tract, and
finally, ipsilateral motor neuron of neck muscle
(> 100/100,000 inhabitants) to low rates in
(3). Although initially used in peripheral
Eastern Asia and sub-Saharan Africa
vestibular disorders, recent findings suggested
(2/100,000 population) (2). A community-based
that VEMP reflected functions of the central
survey in Al Quseir, Egypt, has found an MS
otolithic pathways as well, indicating that they
prevalence of 13.74/100,000. A retrospective
could also be applied to disorders of the central
Received: 09/10/2018
Accepted: 28/10/2018

Full Paper (vol.742 paper# 24)

The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 411-419

Diagnostic Accuracy of chest Ultrasonography versus Other Diagnostic
Imaging Tools for Identification of Lower Respiratory Diseases in Children

Sherif Mostafa Kamal Reda(1), Hatem Refaat Hablas(1), Mohamed Ali Abboud(2), Moustafa
Abdelhafez Zedan(3), Mahmoud Mohamed Abd Elnaby Ghallab(1)
1Department of Pediatrics,2 Department of Radiology, 3Department of chest disease ,Faculty of Medicine,
Al-Azhar University
Corresponding author: Mahmoud Mohamed Abd Elnaby Ghallab, Mobile: 00201002017487, E-Mail:

respiratory distress is the primary diagnosis in nearly 50% of children admitted to the pediatric
emergency room and is a common cause of cardiopulmonary arrest in children. There is substantial
variability in the etiology and severity of illness. The presenting clinical findings usually help to determine
the type of problem. The causes include pneumonia, bronchial asthma, pneumothorax, acute bronchiolitis
and pleural effusion. Objective: the present study was designed to compare chest ultrasound, as a diagnostic
tool in the diagnosis of children with acute conditions of RD with the diagnosis of other radiological tools
(Chest X-ray and CT chest. Methodology: this study included 200 infants and children, attending the
Paediatric Department in Sayed Galal and Al- Hussein, AL-Azhar University Hospitals and they were
suffering from respiratory distress. Their ages ranged from 12 month to 60months with mean age 32.52
months ± 13.91 months. Males were 134/200 (67%) while, females were 66/200 (33%) with male to female
ratio 2.03:1. Results: as regard distribution of patients according to clinical or radiological diagnosis, the
study showed that uncomplicated pneumonia n84 (42.0%), pneumonia with effusion n32 (16.0%), non
pneumonic effusion n8 (4.0%), lung abscess n4 (2.0%), pneumothorax n14 (7.0%), lung collapse n16
(8.0%), mediastinal mass n4 (2.0%) and acute bronchiolitis n38 (19.0%). Conclusion: from our study, we
can conclude the following: in view of our study it can be concluded that, chest US offers an important
contribution to the diagnostic procedures of pleuro-pulmonary disorders in children, as pneumonia,
pneumothorax, pleural effusion, lung abscess, lung collapse, mediastinal mass and acute bronchiolitis.
Keywords- RD, Chest X ray, CT chest


Traditionally, air has been considered the
years transthoracic ultrasound was limited
enemy of ultrasound and the lung has been
exclusively to the examination of pleural
effusions. However, over the past few years
ultrasonography examination. Chest diagnostic
ultrasonography of the pleural space and lung
imaging is essential when dealing with a critically
parenchyma is gaining a wide consensus in
ill patient. At present, direct visualization of the
lung parenchyma is performed with a chest X-ray
particularly in emergency conditions (3).The
(CXR) and computed tomography (1).While, the
limitations of computed tomography along with
computed tomographies scan of the chest is
the risk of ionizing radiations mandate the search
considered the gold standard for the imaging
for a safe diagnostic tool for patients with
diagnosis of all the chest conditions, it is neither
suspected pneumonia, with the advent of portable
inexpensive nor available within the intensive care
bedside ultrasound (4). Lung ultrasound may be
unit, necessitating potentially dangerous transport
used to distinguish viral from bacterial pneumonia
to the radiology department. In addition, it
(5). The relative ease of bedside chest
exposes the patient to high doses of ionizing
ultrasonography (chest ultrasonography) as an
radiation. Ultrasound compares favorably with
computed tomography scan in the diagnostic
respiratory situations, because it offers accurate
ability for some disease conditions, most
information that is of diagnostic and therapeutic
prominently pneumothorax, where it has a
relevance. This is why it is often used by
sensitivity of92% compared to computed
intensivists who ask radiologists for a second
tomography. In addition it is relatively cheap and
opinion in difficult or complicated case studies.
is readily available at the bedside making it easier
Experienced radiologists can integrate chest
and faster than chest X-ray or CT (2). For many
ultrasound findings with better radiological
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 25)

c:\work\Jor\vol742_26 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 420-427

Comparative Study between Betamethasone and Dexamethasone as a
Prophylactic Corticosteroids Therapy on Neonatal Outcome in Elective
Cesarean Section at 37 Weeks

Abdalla Khalil Issa 1, Wael Soliman Taha 1, Abdelsattar Abdullah Elsayeh2, Hany Khayri Elhadad1

1-Obstetrics and Gynecology Department, 2- Pediatrics Department, Faculty of Medicine, Al Azhar

*Corresponding Author: Hany Khayri Elhadad, Phone No.: (+2) 01025017934, E-mail: hanykh123@yahoo.com

preterm birth is the most costly complication of pregnancy and the leading cause of
neonatal morbidity and mortality. There are multiple strategies to minimize the risk and the impact of
prematurity, such as administration of antenatal corticosteroids (ACS), in association with tocolysis,
neuroprotection with magnesium sulphate, and neonatal life-saving therapies. Aim of the Work: this
study aimed to assess the comparison between betamethasone and dexamethasone before elective cesarean
section at (37-37+6) weeks, in reducing neonatal respiratory morbidity and admission to neonatal intensive
care unit (NICU) with respiratory complications. Patients and Methods: this clinical observational
prospective study had been conducted at El Hussein University Hospitals Obstetrics and Gynecology
Department from December 2017 to July 2018 to assess the comparison between betamethasone and
dexamethasone as a prophylactic corticosteriodes before elective cesarean section at (37-37+6) weeks.
Five hundred pregnant women attended to out-patient clinic, the patient were at risk of preterm labour
before 37 weeks. Results: the rate of neonatal admission to primary care baby unit (PCBU) and TTN
was significantly lower in group I [Betamethasone Group] when compared to group II [Dexamethasone
Group]. There was a statistically significant difference between both groups regarding need for
mechanical ventilation (1 to 9) respectively with p value of 0.011.Conclusion: antenatal corticosteroids
(ecpecially betamethasone) were effective in prevention of respiratory complications after elective
caesarean section at term.
Keywords- Betamethasone, Dexamethasone, Cesarean Section

Antenatal corticosteroid treatment of
with prematurity as the cause premature
women at risk of very preterm birth before 34
liberation of surfactant from the alveoli perhaps
weeks gestation is one of the most effective
by induction of an enzyme concerned with the
treatment for the prevention of RDS, reducing
biosynthesis of surfactant. The steroids used are
neonatal mortality and morbidity (1).This is of
fluorinated steroids, with identical biological
importance for developing countries where
activity and readily cross the placenta in their
resources are scarce and it is often difficult to
biological active forms (3).Betamethasone has a
provide expensive treatment such as neonatal
longer half-life than dexamethasone and the
care. Based on high grade evidence, antenatal
interval from treatment to delivery may have
steroid therapy is very effective in preventing
impacted efficacy of steroids. Betamethasone
neonatal mortality and morbidity, yet remains
administration for pregnant women who are at
at low coverage in low/middle-income
risk of premature delivery results in more
countries. If scaled up, this intervention could
substantial reduction in the risk of respiratory
save up to 500000 neonatal lives annually
distress syndrome (RDS), intraventricular
(2).Pulmonary surfactant is produced by type II
hemorrhage (IVH) and retinopathy of
alveolar cells. It spreads in the lung tissue
prematurity (4). Synthetic glucocorticoids have
preventing alveolar collapse during expiration
been successfully employed for more than 20
and the alveoli to open easily at the next
years to enhance fetal lung maturation in
inspiration (1). Antenatal corticosteroids
situations where preterm delivery is anticipated.
administration to promote fetal lung maturity is
The most extensively studied regimens of
the one of the most effective interventions to
corticosteroid treatment are two doses of
prevent the morbidity and mortality associated
betamethasone 12 mg given intramuscularly 24
Received: 09/10/2018
Accepted: 28/10/2018

Full Paper (vol.742 paper# 26)

c:\work\Jor\vol742_27 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 428-435
Assessment of validity of the `Culprit Score' for predicting the culprit
artery in patients with acute inferior wall myocardial infarction

Karim Adel Ellakany (1), Ibrahim Abdelfattah Yasin (2),
Moustafa Ibrahim Mokarrab (2), Mansour Mohamed Sallam (2)
1- Department of Cardiology, Damanhour Teaching Hospital, 2-Department of Cardiology, Faculty of
Medicine, Al-Azhar University

Corresponding Author: Karim Adel Ellakany, Phone: 01002839070, email: karimellakany@gmail.com

Acute myocardial infarction is still a major health problem inspite of the impressive
stride in diagnosis and treatment. Therefore, the early diagnosis and proper management is an important
challenge. The identification of infarct related artery and site of occlusion in inferior wall myocardial
infarction is extremely important to predict complications.
Aim of the work: evaluating the use of `culprit score' for prediction of the culprit artery in inferior wall
Methods: This was a prospective observation study that was done from June 2017 to July 2018 and
included 100 patients presented to the coronary care unit at Al-Azhar University Hospitals and National
Heart Institute with inferior wall myocardial infarction. All patients were subjected to: history taking,
clinical examination, ECG, cardiac enzymes, echocardiography and coronary angiography. Culprit
Score is defined as: [(II -V2) / (III + V1 ­ aVL)] by measuring ST elevation in leads (II, III) and ST
displacement in leads (V1, V2, AVL).
Results: Mean age of patients involved in the study was 56.42+10.78 years with 80% of patients being
male. The sensitivity and specificity, positive predictive value (PPV) and negative predictive value
(NPV) of Culprit Score 0.5 to predict proximal RCA occlusions were 79.49 %, 86.89 %, 79.49 %,
and 86.89 %, respectively and 0.5 to 1.5 to predict distal RCA occlusions were 78.13 %, 86.76 %,
73.53 %, and 89.39 %, respectively; and score >1.5 to predict LCX occlusions were 79.5 % and 86.9
%; 78.1 % and 86.7 %; and 75.8 % and 92.9 %, respectively.
Conclusion: Culprit score could reliably predict the site of occlusion in inferior wall myocardial
Keywords: Culprit Score, predicting, culprit artery, acute inferior wall myocardial infarction.


Worldwide, coronary artery disease is the
The culprit artery of ST-segment
single most common cause of death and its
elevation myocardial infarction (STEMI) is
frequency is increasing. However, in Europe,
usually the left anterior descending artery
there has been a trend to reduce coronary artery
(LAD) in anterior STEMI. But inferior STEMI,
disease mortality over the past 30 years (1).
the culprit artery is either the right coronary
Myocardial infarction could be caused by
artery (RCA) or left circumflex (LCx) artery.
an occlusive coronary thrombus at the site of a
Various ECG criteria were suggested to predict
pre-existing atherosclerotic plaque. In rare
the culprit artery based on analysis of ST-
cases, infarction may result from prolonged
segment elevation and depression in different
coronary vasospasm, inadequate myocardial
ECG leads (2).
blood flow or increased myocardial demand (15).
The aim of this study is evaluating the use
The electrocardiogram (ECG) is being
of Culprit Score to predict the culprit artery and
used for decades to diagnose acute myocardial
site of occlusion in patients with inferior wall
infarction in the patients with chest pain
myocardial infarction.
because it is reliable and inexpensive tool. More
Patients and Methods
recently, an emphasis has been made on ECG
This prospective observational study
features that allow better determination of the
involved 100 patients from the patients
site of occlusion and thereby better estimation
admitted to Al-Azhar University Hospital and
of the size of the area at risk and prediction of
National Heart Institute with the diagnosis of
complications (11).
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.742 paper# 27)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 436-450

Study of Cognitive Impairment in Euthymic Bipolar Disorder Patients
Mohammed Hashem Kamal Bahary, Ali Ismail Abd El-Rahman Ismail, Ismail Sayed Muhammad
Sadek, Mahmoud Ahmad Ahmad El-Gendy
Psychiatry Department, Faculty of Medicine, Al-Azhar University
Corresponding author: Mahmoud Ahmad Ahmad El-Gendy, Phone number: +0201066059025,
E-mail: rd.division.amsa@gmail.com
researchers came to agreement on that bipolar disorder is commonly linked to impairment in
cognitive functions by a remarkable degree. More and more evidence continue to support that the cognitive
impairment remains persistent even within euthymic periods which in turn points to cognitive impairment as a
possible characteristic of the disorder.
Aim of the Work: objective assessment of bipolar patients' cognitive deficits present during remission and
holding a Comparison of these deficits with control subjects who are completely healthy.
Patients and Methods: assessing cognitive functions including executive functions, attention and memory in
euthymic bipolar patients by using relevant scales, then using SPSS for comparing the results with those of a
control group.
Results: when compared to healthy control subjects, euthymic bipolar patients were found to exhibit a
markedly noticeable impairment in attention, executive functions and total memory score. It was also
noteworthy that the association between the duration of illness demonstrated through the number of episodes
and the extent of impairment in cognitive functions.
Conclusion: there is an apparent association of bipolar disorder with cognitive impairment even when patients
are in euthymic state and consequently, the number of episodes increases the impairment degree.
Keywords: Bipolar, Euthymic, Cognitive

dysfunction in patients with bipolar disorder. That
Major characteristics of bipolar disorder are
growth is in consistence with the recent focus of
episodic pathological mood alterations which in turn
NIMH together with the Research Domain Criteria
can be manic, depressive or a mix of the two types
(RDoC) initiative on implementing a dimensional
(1) with an onset that is relatively early (in patient's
approach towards neuropsychiatric illnesses. One of
twenties) and a chronic course (2). There has been a
the fundamental RDoC constructs that crosses
consistent association of Bipolar disorder with
boundaries of DSM-5 and it might bring significant
outstanding comorbidity both medical and
enhancement in our grasping the knowledge of the
psychiatric, untimely death, high degrees of
different brain-based illnesses, including bipolar
impairment of functional capacity and worsen
disorder and the pathophysiology behind them. (35).
quality of life (3). There has also been a remarkable
Recently, the most popular area of research
link between bipolar disorder and elevated risk of
in bipolar disorders is directed towards studying
suicidal attempts and eventually going through with
neurocognitive impairment, factors causing it and its
it (4) and eliciting a magnificent burden on
consequences, also the production and evolving of
new strategies of treatment to control or maybe
Both type I and II of bipolar disorder affect
prevent these deficits (6).
a portion of 2­3% of the worldwide population, this
Reasons suggesting the importance of
makes bipolar disorder even more prevalent than
establishing cognitive impairment prevalence among
other fully addressed conditions as type 1 diabetes,
people with bipolar disorder are numerous.
rheumatoid arthritis, or HIV infection. To many
Clinically, cognitive impairment is a huge element
people's shock, bipolar disorder is ranked the sixth
participating to the entire load of disability in mood
leading cause of disability around the world. It is
disorders, it is also a core aim in therapeutic
also known to be causing significant rates of both
intervention. Understandable information regarding
morbidity and mortality; to give an example, cases
characteristics and numbers of those in need for a
of death by suicide formulates a percentage of
closer and more intense attention to clinical care and
people living with bipolar disorder up to 15%. (5)
social involvement to face the hazardous and
There has been a noticeable growth of
disabling effects of cognitive impairment, all of that
studies directed towards monitoring cognitive
would be of great help to service planning.

Full Paper (vol.742 paper# 28)

INTRODUCTION The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 451-459
Management of Acute Appendicitis during Pregnancy

Mohamed Sobhy Teamma, Hamada Rashad Abdel-Kader, Wael Soliman Taha and Mohamed Atef
Radi Ahmed

Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Corresponding author: Mohamed Atef Radi Ahmed, Mobile: 00201118443529, E-Mail: mohammedatefradiahmed@yahoo.com

Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal
pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical
symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner
lining of the abdominal wall and sepsis. Appendectomy is the most common abdominal operation performed as
an emergency basis.
Objective: The aim of the study was to evaluate the management of acute appendicitis during different stages of
pregnancy as regard the diagnosis, operation time, operative and post-operative complications and pregnancy
Subjects and Methods: This prospective study included a total of 20 pregnant women who had signs and
symptoms of acute appendicitis which admitted at Al-Azher University Hospitals and Elmenia General Hospital
from March 2018 till November 2018. All patients were subjected to open appendectomy under spinal anesthesia.
Results: Abdominal pain, nausea, vomiting, leucocyte count, CRP and body temperature were not helpful in
establishing the correct diagnosis. There was no maternal morbidity related to the appendectomy. We found no
increase in pregnancy complications in cases with appendicitis.
. Conclusion: Accurate and prompt diagnosis of acute appendicitis should be done to avoid un-necessary
exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.

Appendicitis, Pregnancy


Acute abdomen is generally described as a
procedure performed by a surgeon in training.
sudden onset of severe abdominal pain with
Advances in modern radiographic imaging have
associated findings of tenderness, guarding, and
improved diagnostic accuracy, however the
abdominal muscle rigidity on physical examination.
diagnosis of appendicitis remains essentially clinical,
The pathology of the acute abdomen encompasses
requiring a mixture of observation, clinical acumen
inflammatory, infectious, vascular, mechanical,
and surgical science and as such it remains an
traumatic, and neoplastic etiologies. The reason we,
enigmatic challenge and a reminder of the art of
as medical providers are so concerned with the acute
surgical diagnosis (2).
abdomen is that there is classically several etiologies
Acute appendicitis can occur at any time
that require emergent surgical intervention(1).
during pregnancy, although it occurs most often
The vermiform appendix is considered by
during the second trimester (45%) and (30%) during
most to be a vestigial organ; its importance in surgery
the first trimester and the remaining (25%) in the
results only from its propensity for inflammation,
third trimester. The overall incidence being 0.15 to
which results in the clinical syndrome known as
2.10 per 1000 pregnancies .it is the most common
`acute appendicitis'. Acute appendicitis is the most
reason for acute abdominal surgery seen in the 15­
common cause of an `acute abdomen' in young
40 age groups in all communities and sexes; if it
adults and, as such, the associated symptoms and
occurs during pregnancy, non-obstetrical surgery is
signs have become a paradigm for clinical teaching.
require. It is easier to diagnose patients with a history
of typical acute appendicitis. Furthermore, 20­33%
appendectomy (termed `appendectomy' in North
of patients have atypical clinical and laboratory
America) is the most frequently performed urgent
findings. The clinical findings of acute appendicitis
abdominal operation and is often the first major
seen during pregnancy are generally atypical, and

Full Paper (vol.742 paper# 29)

c:\work\Jor\vol742_30 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (2), Page 460-466
Evaluation of Diagnostic Laparoscopy with laparoscopic Appendectomy in
Females with Acute Right Lower Quadrant Pain, a Multicenter Study

Nesreen Aref 1, Mohamed Al Saeed 2, Bilal O Al-Jiffry 2, Majed Al-Mourgi 2, Alaa Younes 2, Tamer
Abdel-Rahman 2, 3, Samir Badr 2,4, Abdullah Al-Sawat 2

1Department of Obstetrics and Gynecology, Taif University, Saudi Arabia,2 Department of Surgery, Taif
University, Saudi Arabia ,3General Organization of Teaching Hospitals and Institutes (Benha),4General
Organization of Teaching Hospitals and Institutes (Damanhur)

Background and aim of the study:
Diagnostic laparoscopy is the gold standard for diagnosis of acute
right lower abdominal pain (ARLQP) in females especially in child bearing age and its value to perform
laparoscopic appendectomy in such complex conditions is gaining acceptance amongst surgeons. The aim
of this multicenter study was to evaluate the values of diagnostic laparoscopy with laparoscopic
appendectomy in female patients with acute right lower quadrant abdominal pain.
Material and method: This multicenter prospective study enrolled 253 female patients who presented
with acute right lower quadrant pain to Taif tertiary hospitals (Saudi Arabia) and performed laparoscopic
appendectomy during diagnostic laparoscopy from May 2012 to April 2017.
The study included 253females with mean age of 31.1±6.8 years. Diagnostic laparoscopy with
laparoscopic appendectomy was done for all of them. Acute appendicitis was the most common cause of
ARLQP (22.1%). 10.5% of macroscopically normal appendices had acute appendicitis. Mean total
operating time was 65.6±14.7 and for the appendectomy portion of the operation it was 14.3±2.8 minutes
when the appendix was grossly inflamed and it was 11.8±2.3 minutes when the appendix was apparently
normal (incidental appendectomy).The mean hospital stay for grossly inflamed appendix was 24.8±5.5
hours, of incidental appendectomy without associated pelvic pathology was 22.3±5.2 hours increased to
72.4±16.5 hours if other pelvic pathology was managed. Post operative complications occurred in 4%. No
operative or early postoperative mortality was recorded.
This study supports the value of diagnostic laparoscopy in diagnosis and management of
females with ARLQP and verified that acute appendicitis is the most common cause in such females. The
study proved also that laparoscopic appendectomy is safe, effective, quick in addition; the study verified
the role of incidental appendectomy in prevention of reoperation for future appendicitis.
Keywords: Females, Lower abdominal pain, diagnostic laparoscopy, laparoscopic appendectomy,
incidental appendectomy

Appendicitis is the most common cause of cute
such condition [4].Diagnostic laparoscopy may
right lower quadrant abdominal pain (ARLQP);
reduce the need for unnecessary open
however, a broad spectrum of common and
appendectomy; however, it does not prevent
uncommon conditions may mimic acute
missed acute appendicitis as some studies found
appendicitis especially in women of childbearing
that about one third of normally appearing
age which may carry a diagnostic dilemma [1-
appendices was inflamed on pathological review
3]. Accurate diagnosis is the cornerstone in
even in presence of other pelvic pathology [5, 6].
avoiding inappropriate treatment and despite
Most of the studies found that laparoscopic
improvements in imaging; it may still be difficult
appendectomy has less postoperative pain, a
to differentiate between gynecologic and non-
shorter hospital stay, and fewer complications
gynecologic causes of abdominal pain which
than conventional approach [7-14].Incidental
makes diagnostic laparoscopy to be the gold
appendectomy which is the removal of a
standard for proper diagnosis and treatment in
macroscopically normal appendix has been

Full Paper (vol.742 paper# 30)