c:\work\Jor\vol743_1 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 467-474
Popliteal Vascular Injuries

Mohammed Al Saeed

Department of Surgery, College of Medicine and Medical Sciences

Corresponding author: Mohammed Salem Al Saeed, Telephone: 00966505370360, email: dr.alsaeed@mail.com

Injury of the popliteal vessels is one of the most limb-threatening peripheral vascular
injuries. The high morbidity after popliteal vascular injury can be explained by the fact that the popliteal
artery is an end artery with an insufficient collateral supply; in addition, the popliteal vein provides the
bulk of lower leg and foot drainage. Delays in diagnosis and interference in addition to associated complex
tissue injuries would be associated with high amputation rate. However, high level of suspicion with early
recognition and management by multidisciplinary team are necessary to optimize limb salvage. The aim
of this review is to discuss the different factors that may affect the morbidity, incidence, presentation and
diagnostic tools, various management options, and outcome of popliteal vascular injury.
Keywords: popliteal trauma, vascular injury, outcome

The incidence of popliteal vascular injury is low
Anatomical considerations:
and the vein is commonly injured with the artery
The popliteal artery is the continuation of the
[1-3]. The collateral flow around the knee is not
superficial femoral artery as it emerges from the
sufficient to sustain viability after popliteal
adductor hiatus [10, 11]. It courses posteriorly with
arterial injury with high amputation risk
the vein and the tibial nerve in the popliteal fossa
especially in blunt trauma [2]. Optimal
between the medial and lateral heads of the
management strategies of popliteal vascular
gastrocnemius and popliteus muscles and only
injuries are still under investigation [3-5].
ceiled by subcutaneous tissue [1-3, 10]. This
However, the advancement of imaging
relatively superficial position and the lack of
modalities, improved diagnostic accuracy, and
protection of the artery by any overlying
the evolution of endovascular techniques offer
structures makes the blunt trauma produces
alternative modalities to traditional surgical
injury of greater magnitude than would occur to
management [1-4, 6-9]. Outcome can be improved
a more protected arteries subjected to the same
if the lesion is early recognized and managed by
force [2, 3, 10, 11]. The popliteal vessels are tethered
multidisciplinary team [1, 3]. The standards of care
to the distal femoral shaft at the adductor hiatus
for patients with suspected popliteal vascular
and to the proximal tibia by the tendinous arch
injury is urgent operative exploration in unstable
of the soleus muscle making the artery anchored
patients or/and those with hard signs and
at either end [1,3, 11]. This double fixity increases
arteriography is only indicated in stable patients
susceptibility of the artery to stretching injuries
with non occlusive lesions and in patients with
following dislocations of the knee or fracture
soft signs only [1-4, 9, 12-14]. Primary repair is done
dislocations involving the upper tibia [1, 3]. Such
if the damaged segment is less than 2 cm
injury may damage long segments of the vessel,
otherwise a graft is required. Veins must be
though thrombosis may only occur at one point
repaired when possible with early fasciotomy
leading to underestimation of the extent of the
especially in prolonged ischemia, presence of
injury at operation [1, 3, 7-9 ].
marked edema, and combined arterio-venous
The popliteal artery rarely trifurcates and the
injury [1-3]. Dead limb must be amputated,
artery commonly divides to the anterior tibial
however, amputation is considered in life
artery and the tibioperoneal trunk and the latter
threatening conditions as
courses for about one inch and further divides to
bleeding and in complex injuries [7],The aim of
the peroneal and posterior tibial arteries [10, 11].
this review is to discuss the different factors that
The anastomosis between the sural, geniculate,
may affect the morbidity, incidence, presentation
and muscular branches of the popliteal artery
and diagnostic tools, various management
behind the knee and the branches of the deep
options, and outcome of popliteal vascular
femoral artery proximally and tibial arteries
distally are abundant [7-10]. However, this

Full Paper (vol.743 paper# 1)

c:\work\Jor\vol743_2 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 475-481
Early and Mid-Term Results of Treatment of Superficial Venous
Insufficiency of the Lower Extremity Using Endovenous Laser

Mohamed Al-Saeed1 and Hossam M Saleh2, 3

1Department of Surgery and Vascular Surgery, Taif University, Saudi Arabia,2Al-Hada Armed
Force Hospital, Taif, Department of Vascular Surgery, Saudi Arabia,3Ain Shams University,
Department of Vascular Surgery

Background and aim of the study:
Endovenous laser ablation (ELA) has become an important
procedure to treat saphenous vein reflux. In this study the early and mid-term results of
endovenous laser ablation of the long or/and short saphenous veins (ELAS) will be evaluated.
Patients and methods: This prospective study was conducted from March 2010 to December
2016. The study enrolled 35 symptomatic patients with unilateral or bilateral superficial venous
insufficiency (CEAP; 2-6) with documented reflux in long saphenous, short saphenous, or both
veins by duplex ultrasound.
Results: Thirty five patients were enrolled in this study, 30 women with mean age 35.5± 8.2 years
and 5 men with mean age of 32.2± 7.8 years. ELAS was performed in 52 limbs 9 of them had
ulcers. Early postoperative clinical and ultrasound examination revealed complete ablation of the
targeted veins (100%) with no reflux. Great saphenous alone was ablated in 76.9% of limbs, short
saphenous in 13.5%, and both 9.6%. Postoperative complications were minimal, well tolerated,
and completely resolved within 3-27weeks with treatment. In 88.9% of limbs with active
ulceration, healing occurred after a mean of 6.6±1.6 months. Only 61.5% of legs (including all
ulcer patients) were followed up for 49.5±11.3 months; recorded recanalization by duplex ultra
sound was 0%, 10.3%, and 20.8% after 1, 3, and 5 years respectively. Recanalization was
insignificantly higher in long than short saphenous veins. The recorded recurrence of ulcers after
1, 3, and 5 years of follow up was 0%, 12.5%, and 40% respectively. Conclusion: endovenous
laser ablation of the saphenous veins is safe and has excellent early and mid-term outcomes for
treatment of superficial venous insufficiency with or without ulceration of the lower extremities.
Keywords: Endovenous laser ablation, saphenous veins, venous insufficiency, varicose veins, ,
venous ulcer.

Chronic venous insufficiency (CVI) of the
luminal obliteration [5]. The procedure can
lower limbs is usually the result of
be performed on an ambulatory basis with
incompetent valves in one or more of the
the use of tumescent local anesthesia, even
saphenous veins and their primary
though, the results of this minimally
tributaries [1]. Symptoms of CVI can be
invasive techniques have been shown to be
ameliorated by compression therapy but it
at least equal to that of high ligation and
does not cure it [2]. For long time high
stripping with minimal complications and
ligation and stripping of the saphenous
shorter recovery [7-9]. In this study the early
vein(s) was the main curative procedure to
and long term results of endovenous laser
eliminate incompetence and reflux [3].The
ablation of the long or/and short saphenous
first report about the use of endovenous laser
veins (ELAS) will be evaluated.
to ablate varicose veins was introduced by

Boné which is followed by the approval of
Patients and methods: This prospective
US Food and Drug Administration in
study was conducted in Taif tertiary hospital
January 2002 to allow endoluminal delivery
and enrolled 35 patients from March 2010 to
of laser energy directly into the blood
December 2016. The study was conducted
vessels [4-6]. The thermal effect on the venous
after approval from the Ethics Committee of
wall leads to collagen contraction with
the Hospitals and written informed consents
eventual fibrosis, thickening of its wall and
were obtained from all participants. All

Full Paper (vol.743 paper# 2)

c:\work\Jor\vol743_3 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 482-490

Optical Coherence Tomography Angiography Study for Evaluation of
Microvascular Changes in the Subclinical Diabetic Retinopathy

Hisham Fawzy Khalil, Ahmed Elsayed Hodaib, Ahmed Younis Elsaeid

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

Corresponding author:Ahmed YounisElsaeid, Mobile: 00201110531368, 01005025004 E-Mail:ahmedyounes143@yahoo.com,

diabetic retinopathy is the specific microvascular complication of diabetes mellitus and
affects 1 of 3 with DM. DR remains a leading cause of vision loss in working adult population. Patients
with severe levels of DR were reported to have poor quality of life and reduced physical, emotional and
social well-being, and they utilize more health care resources. Objective: this study aimed to evaluate the
vascular density, perfusion density and foveal avascular parameters changes in subjects with diabetes
mellitus showing no manifestations of diabetic retinopathy using optical coherence tomography
angiography. Methods: 40 subjects were categorized into two groups, group A for healthy subjects and
group B for the diabetic subjects. HbA1c, renal functions, liver functions and lipid profile were obtained
from each individual. Best corrected visual acuity were obtained from each individual and each were
subjected to full ophthalmic examination, IOP measurement, fundus fluorescein angiography FFA, Optical
Coherence Tomography OCT and Optical Coherence Tomography Angiography OCTA. Results:
statisticallysignificantdifferenceswerefoundbetweenthehealthygroupand the diabeticgroupin OCTA
parameters. Full vascular density VD significantly decreases in the diabetic patients even in those showed
BCVA 0.7 and totally intact FFA and OCT (P>0.001). Perfusion density PD also was significantly
decreased in the diabetic patients (P>0.001). Foveal avascular zone showed significant changes in area
value and perimeter, however the circularity changes were statisticallyinsignificant.Conclusion: using
OCTA was proven to be clinically significant in differentiating healthy eyes from diabetic eyes that showed
no clinically acceptable hallmarks. So, that the term "Subclinical diabetic retinopathy" was suggestible to
refer to a clinical state where the FAZ metrics, vascular density and perfusion density showed a particular
deviation from the normal healthy parameters.
Keywords -OpticalCoherence Tomography Angiography, Diabetic Retinopathy


Diabetic retinopathy is the specific
vascular caliber have greatly increased our
microvascular complication of diabetes mellitus
knowledge of early microcirculation alterations
and affects 1 of 3 with DM. DR remains a leading
in prediabetes, diabetes and diabetic macro and
cause of vision loss in working adult population.
microcirculation complication[6].Clinically, DR
Patients with severe levels of DR are reported to
has two principal stages.The first phase,
have poor quality of life and reduced physical,
nonproliferative DR (NPDR), is characterized by
emotional and social well-being, and they utilize
retinal microvascular changes such as pericyte
more health care resources[1]. Recent studies[2-
loss, basement membrane thickening, formation
5]supported the concept that the retinal
of microaneurysms and intraretinalmicrovascular
vasculature may provide a summary measure of
abnormalities. The more serious proliferative DR
lifetime exposure to the effects of hyperglycemia.
(PDR) stage is characterized by the development
Advances in retinal photographic techniques and
of new blood vessels (neovascularisation) NV's
in image analysis allowed objective and precise
on the surface of the retina. This in turn leads to
in vivo measurement of retinal vascular changes.
fibrovascular changes and tractional retinal
In particular quantitative assessment of
detachment resulting in blindness[6]. Fluorescein
retinopathy signs and measurement of retinal
angiography or color fundus photographs have

Full Paper (vol.743 paper# 3)

c:\work\Jor\vol743_4 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 491-496
Effect of perinatal risk factors on coagulation system in premature infants

Karima Abd-elhalim Mahfouz, Hatem Refaat Hablas, Mahmoud Abdellatif Hashish,
Mohammed Hosney Youssef Mohammed Sokkar*

Departments of Clinical Pathology, Faculty of Medicine, Al-Azhr University

*Corresponding author: Mohammed Hosney Youssef Mohammed Sokkar, E-Mail: sokkar2016@gmail.com, Mobile: 01004554436

: neonates have different blood clotting and fibrinolytic activities from the adults. Compared with full-term
infants, premature infants are more prone to bleeding diathesis after birth, such as intracranial hemorrhage and
pulmonary hemorrhage. The defective coagulation factors in premature infants contribute to predisposition of bleeding
in premature infants.
Objective: it was to assess the hemostatic profile by screening tests in preterm infants with perinatal risk factors.
Patients and Methods: the study was conducted on 90 subjects, 30 preterm with risk factors, 20 preterm without risk
factors, 30 full term and 10 adults. All of them were subjected to full clinical history, examination and routine
investigation including CBC, prothrombin time, activated partial thromboplastin time, thrombin time and fibrinogen
Results: the results of this study revealed a prolongation in the PT, APTT and TT together with a lower fibrinogen
concentration in the group of preterm without risk factors in comparison with the group of full term and adult and
revealed that there is more prolongation in the PT, APTT and TT together with more decrease in fibrinogen
concentration in the group of preterm with risk factors in comparison with the group of preterm without risk factors, full
term and adult but there is no significant difference between full term and adult as regard PT, APTT, TT and fibrinogen
Conclusion: preterm infants without perinatal risk factors show a lower hemostatic profile when compared with
healthy full term and adult. Preterm infants with perinatal risk factors show more decrease in hemostatic profile when
compared with healthy full term and adult. Perinatal risk factors (preeclampsia, diabetes and urinary tract infection)
seem to interfere with coagulation protein synthesis.
Keywords: Perinatal risk factors, preterm infants, fibrinogen concentration, thrombin time, coagulation system

both lead to the same fundamental reactions that
Hemostasis is a process which keeps blood
produce fibrin (3).
flowing freely within blood vessel (1). Hemostasis is the
The coagulation factors are generally serine
first stage of wound healing. This involves three major
proteases (enzymes), which act by itself or in
component:1) vasoconstriction, 2) temporary blockage
combination with other factors cleaving downstream
of a break by a platelet plug, and 3) blood coagulation
proteins. The coagulation factors circulate as inactive
(blood changing from a liquid to a gel), and formation
zymogens (4).
of a fibrin clot. Hemostasis involves as well arrest on
Developmental haemostasis represents the
going thrombosis and repair (2).
maturation of the haemostatic system from birth to
Coagulation is the process by which blood
adulthood. There are differences in the concentration,
changes from liquid to gel, forming a blood clot. It
structure and activity of many proteins involved in
begins almost after an injury to the blood vessel has
blood clotting (5). These changes are necessary for
damaged the endothelium lining the vessel. Leaking the
physiological development and providing appropriate
blood through the endothelium initiates two processes:
diagnosis and treatment of bleeding and clotting
(1) changes in platelets, (2) exposure of subendothelial
disorders (e.g. thrombosis) (6).
tissue factor to plasma factor VII and factor XII which
Fibrinogen (factor I) is a glycoprotein that is
ultimately leads to fibrin formation (3).
converted enzymatically by thrombin to fibrin and
There are the contact activation pathway (also
subsequently to a fibrin-based blood clot during tissue
known as the intrinsic pathway), and the tissue factor
and vascular injury (7).
pathway (also known as the extrinsic pathway) which
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.743 paper# 4)

Introduction The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 497-503
Relation between Lactate in Vaginal Fluid and Time to Spontaneous Onset of
Labour for Women with Suspected Prelabour Rupture of the Membranes

Abd-Elmonem M. Zakaria, Mofeed F. Mohammed, Abdelhakeem O. Shehab

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

Corresponding author: Abdelhakeem O. Shehab; Mobile: 01064049181; Email: drshehabshehab@yahoo.com

investigation of the relationship between lactate level in vaginal fluid and the latent phase of
labour in pregnancies is complicated by preterm premature rupture of membranes (PPROM). To assess
whether lactate determination in vaginal fluid can predict, onset of labour for women with suspected prelabour
upture of the membranes (PROM). Patient and Methods: 110 pregnant women with history of PPROM
recruited from the outpatient clinic and emergency room in EL Hussein Hospitals and Om El Masreen Hospital
during the period from February 2018 till August 2018. All women underwent sterile speculum examination;
then 5 ml of sterile saline solution was injected in the posterior vaginal fornix using a sterile speculum and 2ml
of the injected saline was withdrawn with the same syringe for lactate Measurement. Results: the best cutoff
point of vaginal fluid lactate concentration as a predictor of onset of labor within 48 hours after PPROM was
4.7 mmol/L above which the onset of labor within 48 hours was likely with a sensitivity of 95.4%, specificity
of 91.3%, a positive predictive value of 97.7%, a negative predictive value of 84%, an overall accuracy
of94.6%, a positive LR of 10.97 and a negative LR of 0.05. Conclusion: lactate determination in vaginal fluid
seems promising as a tool to predict onset of labor within 48hours in women with PPROM. The best
cutoff point of vaginal fluid lactate concentration as a predictor of onset of labor within 48 hours after PPROM
was 4.7 mmol/L.
Keywords: amniotic fluid, lactate, PROM, spontaneous onset of labour.


Premature rupture of membranes (PROM) is
importance because failure of diagnosis can lead to
defined as leakage of amniotic fluid beginning at
least 1 hour prior to the onset of labor at any
chorioamnionitis and preterm birth, on the other
gestational age. Preterm premature rupture of
hand over diagnosis can lead to unnecessary
membranes is defined as PROM that occurs before
interventions like hospitalization or induction of
37 weeks gestation (1). PROM is an important
labor (4).Traditionally the diagnosis of membranes
obstetric problem, it occurs in 10% of all gestation
was rupture clinical in over 90% of cases, being
and about 2-4% of preterm pregnancies, which is
confirmed based on the presence of suspicious
responsible for 30% of all preterm birth.
history, or ultra-sonographic finding followed by
Management of patients with PROM, regardless
documentation of fluid passing from the cervix
the gestational age, remains controversial (2).The
(5).These traditional diagnostic methods have some
interval between PROM and time to onset of labor
limitation and cannot be applied to all patients with
is referred to as latency period, as this period tends
100% accuracy (1). The absence of non invasive
to increase the risk of maternal and fetal infection
gold standard test for diagnosis of membranes
rupture leads to search for an alternative
chorioamnionitis which occurs in 3-5% of cases of
biochemical markers which have high amniotic
PROM. While fetal infection occurs in about 5% of
concentration but low vaginal fluid concentration
all cases of PROM and about 15- 20% in those with
e.g. prolactin, alpha fetoprotein, insulin like growth
chorioamnionitis. Fetal infection may occur as
factor binding protein-1, fetal fibronectin, diamine
septicemia, pneumonia, urinary tract infection,
oxidase and B-HCG (6).Lactate was the end product
local infection such as omphalitis (infection of the
of anaerobic metabolism, usually its production
umbilical cord) or conjunctivitis (3). Other
takes place in hypoxic tissue, but can be produced
complications that may be associated with PROM
under aerobic conditions (7). Lactate was produced
include umbilical cord prolapse in about 1.5% of
in the myometrium and chorio-decidua and
cases of PROM. Placental abruption, caesarean
transferred to AF across the membranes, but the
delivery, postpartum hemorrhage and postpartum
main source of lactate was the fetus mainly through
infection (2).Correct diagnosis of PROM had great
urine and lung excretion (8). Lactate concentration
Received: 10/10/2018
Accepted: 29/10/2018

Full Paper (vol.743 paper# 5)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 504-510

Comparative Study between the Complications of Sleeve Gastrectomy versus the
Complications of Gastric Bypass
Mohamed Fathy Sharaf, Eslam Taha Ghalwash, Mohammed Ali Abdelaty Awad Elkelany
Departments of General Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Mohammed Ali Abdelaty Awad Elkelany, E-mail: Mohammedkelany1985@gmail.com
Background: obesity means having too much body fat. Causes of obesity includes: diet, sugar overload, genetics,
insufficient sleep, social determinants, environment, and stress. Complications of obesity includes: type II diabetes
mellitus, heart diseases, metabolic syndrome, hyperlipidemia, respiratory diseases, male sexual dysfunction,
neurological diseases, gastrointestinal diseases, rheumatic diseases, urological diseases, psychological
abnormalities, trauma, pancreatic diseases, gall bladder diseases, diverticulitis and hernia. Sleeve gastrectomy is an
excellent procedure for management of morbid obesity. Complications of Sleeve gastrectomy includes:
Hemorrhage, leakage, nutritional deficiencies, ineffective EWL and weight regain, cholelithiasis, stenosis,
gastroesophageal reflux disease GERD and hiatus hernia, gastric torsion, gastro-bronchial fistula and venous
thrombosis. Complications with Roux-en-Y Gastric Bypass includes: Hemorrhage, leakage, nutritional deficiencies,
ineffective excess weight loss EWL and weight regain, trocar site hernia, cholelithiasis, dumping syndrome, Internal
hernia, obstruction of the biliopancreatic limb, intussusceptions volvulous, gastrogastric fistula, marginal ulceration
and gastrojejunostomy anastomotic stricture.
Aim: To compare complications associated with Sleeve Gastrectomy versus complications associated with
open or laparoscopic Gastric Bypass and its effects on patients' life and to know which procedure is better.
Patients and Methods: group (A): includes 15 cases underwent sleeve gastrectomy. With inclusion criteria of
obese patients with body mass index (BMI) 40 kg/m2 or BMI 35 kg/m2with associated co morbidity
(hypertension, Diabetes mellitus, hyperlipidemia, arthritis, cardiac diseases, etc.) and exclusion criteria of
patients with previous bariatric surgery, previous upper gastrointestinal surgery, hiatus hernias, heavy sweet
eaters, drug and/or alcohol addiction, psychiatric disorders and patients >60 years old or <18 years old were
excluded and group (B): includes 15 cases underwent gastric bypass with inclusion criteria of obese patients
with body mass index (BMI) >40 kg/m2 or BMI > 35 kg/m2 with associated comorbidity (hypertension,
Diabetes mellitus, hyperlipidemia, arthritis, cardiac diseases, etc.) and heavy sweet eaters and exclusion
criteria of patients with previous bariatric surgery, previous upper gastrointestinal surgery apart from
laparoscopic cholecystectomy. Patients with hiatus hernias, drug and/or alcohol addiction, psychiatric
disorders and patients >60 years old or <18 years old were excluded.
Results: three complications developed with sleeve gastrectomy 20% as follows 1 case of hemorrhage 6.6% ,
1 case of leakage 66% and one case of gall bladder stones while gastric bypass complications resembles 2
cases 13.3% as follows:1case of deep venous thrombosis 6.6% and one case of gall bladder stones 6.6%.
Conclusion: obesity is a common disease affecting more than 300 million adults worldwide. It is defined as a
body mass index greater than 30 kg/m2. The laparoscopic sleeve gastrectomy was adopted as a primary
procedure and over time it has become the most popular bariatric operation worldwide and it is effective for
weight loss and results in improvement and even resolution of co-morbidities like type 2 diabetes.
Laparoscopic gastric bypass surgery is another safe and simple surgical intervention for treating morbid
obesity and diabetes mellitus and is now being performed more frequently
Recommendations: both sleeve gastrectomy SG and roux-en-y gastric bypass RYGB are safe, short, simple
and effective bariatric operations. Our study showed Roux-en-y gastric bypass has less complication than
Sleeve gastrectomy. Further prospective studies have to be applied to a larger number of patients for longer
periods of follow up are needed.
Keywords: Obesity- Sleeve Gastrectomy- Roux-En-Y Gastric Bypass.

mean that a person's weight is greater than what's
Obesity means having too much body fat. It
considered healthy for his or her height (1).
is different from being overweight, which means
Being obese increases risk of diabetes, heart
weighing too much. The weight may come from
disease, stroke, arthritis, and some cancers. If you
muscle, bone, fat, and/or body water. Both terms
are obese, losing even 5 to 10 percent of your weight
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.743 paper# 6)

c:\work\Jor\vol743_7 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 511-516
Dosimetric Study Comparing Three-Dimensional Conformal Radiotherapy to
Intensity Modulated Radiotherapy in Management of Rectal Carcinoma.
Retrospective study

Mahmoud M. Shaban, Mohamed ElSayed Mansy, Khaled M. El Shahat

Clinical Oncology Departmentt, Faculty of Medicine,Al Azhar University,Cairo-Egypt

Corresponding author: Khaled M. El Shahat, email:khelshahat@yahoo.com


Background: the External radiotherapy (EBRT) is the common treatment selection in patients
with locally advanced rectum carcinoma. Three-dimensional conformal radiotherapy (3DCRT) and
intensity modulated radiotherapy (IMRT) are most techniques used in radiotherapy. However, which one
is superior is all controversial. Patients and Methods: thirty-two patients of RC treated with IMRT were
selected for current retrospective study. 3DCRT plans were also plan for all the patients. 3DCRT plans in
compared to IMRT plans were on the basis of planning target volume (PTV) coverage, dose to normal
organs, homogeneity index (HI) and conformity index (CI). Results and Discussions: in both the planning
techniques 98% of PTV was covered with more than 96% of prescribed dose. D 95% 15, D 35 and D (Dose
to 15%, 35% and 50% volume respectively) for bladder was reduced by 2.09%, 14.623% and 32.57% in
IMRT compared to 3DCRT. V (Volume received 45 Gy also volume received 50.4Gy) and in case of bowel
doses were found to be better in IMRT than to 3DCRT. There is significant difference found between doses
to both femoral heads in IMRT and 3DCRT. The CI 95% 45 in IMRT plans was found much better than
that in 3DCRT whereas HI in both the techniques were found almost same. Conclusion: IMRT in better
significantly in reduction the irradiated of OAR and improved dose conformity in the PTV compared to
that by 3DCRT. So, it can be concluded that IMRT should be chosen as best technique for the radiotherapy
of Rectum carcinoma
Keywords: IMR, rectal Carcinoma, treatment planning, dosimetric comparison, 3DCRT


For many years surgery has been
availability of Machines equipment by advance
regarded as the main treatment for rectal
techniques like IMRT in many center in Egypt
carcinoma. Total meso-rectal excision (TME) is
and staff have good training for new advances of
best selection over Abdominoperineal excision
radiotherapy(4). In addition, the good results for
(APR) due to its better overall good survival rate
treatment approaches, for advance techniques
and a lower of tumor recurrence (1).Colorectal
using in radiotherapy for reduction dose to organs
carcinoma has been considered the second most
at risk like for tumor site head and neck, prostate
common cause of cancer in women (9.2% of
and etc. there are very small number of studies
diagnoses) and the third most common in men
that aim to evaluate the advance techniques start
(10.0%) in the year 2012, worldwide more than
from 3 DCRT and IMRT in consider to target
one million people are diagnosed annually of
volume coverage by prescribed dose and dose to
colorectal carcinoma resulting in about 715,000
organs at risk (OAR)(5,6) . The current study for
deaths as of 2010 up from 490,000 in 1990
compare the dosimetric tools of 3 DCRT Varus
(2,3).The development in the treatment planning,
IMRT in terms of target coverage and doses to
the procedure of radiotherapy by a Three-
OAR in the control of rectal carcinoma (7-8).
Patients and Methods
technique for treating rectal cancer and advance
This retrospective observational dosimetric study
techniques like IMRT as advance modalities for
had been carried out at the clinical oncology
of radiotherapy delivery continues to be utilized
department at Al-Hussein university hospital.
by various cancer centers in many countries, such
Thirty patients with pathological evidence
as Egypt due to upgrading in the infrastructure of
confirmed rectum cancer and radiological
Received: 07/10/2018
Accepted: 26/10/2018

Full Paper (vol.743 paper# 7)

c:\work\Jor\vol743_8 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 517-523

Pattern and Outcome of Acute Disseminated Encephalomyelitis (ADEM)

1Mohsen Taha Elke'iy, 2Kamel Suliman Hamad, 1Al Hassan Mustafa Zahran, 3Haytham
Muhammad Nafady, 1No'man Al Basiouny Gouda

1Department of Pediatric Neurology, 2Department of Clinical Pathology, 3Department of Radiology,
Faculty of Medicine ­ Al-Azhar University

Corresponding author: No'man Al Basiouny Gouda, Mobile: 01015994703;
Email: noaman_goda@yahoo.com

Acute disseminated encephalomyelitis (ADEM) is an immune disease marked by
widespread of inflammation in the brain and spinal cord. ADEM typically damages myelin, causing
destruction of white matter. It often occurs following a viral infection or vaccination. Its symptoms are
similar to multiple sclerosis (MS) and are considered part of the multiple sclerosis borderline diseases.
Patients and Methods:
This is an observational prospective study done in Bab Al-Shariah University
Hospital in period between 31th of December 2017 to 30th of December 2018 on children from birth to
18 years old who were having definite ADEM by neuroradiological study of the brain (MRI brain)
presented to the Neuropediatric outpatients clinic or inpatients of Pediatric Department during the
period of the study. Those with history suggestive of definite perinatal asphyxia or with other congenital
malformation of neurological system were not involved in our study.
Results: We found that the most common clinical features of ADEM in our community are fever,
disturbed conscious level (DCL), motor system weakness and convulsions, and the most valuable tool
in diagnosis is brain MRI. These findings are very important in the diagnosis, management and
counseling of patients with ADEM.
ADEM is an area of active research especially in the field of imaging where there is a
rapid development. In future we may have better diagnostic and therapeutic options for ADEM.
Multiple sclerosis, acute disseminated encephalomyelitis, multiphasic disseminated


Acute disseminated encephalomyelitis
cortical gray-white junction of both cerebral
(ADEM) is an immune mediated disease of the
hemispheres, cerebellum, brainstem, and spinal
brain. It usually occurs following a viral
cord, but periventricular white matter and gray
infection but may occur following vaccination,
matter of the cortex, thalami and basal ganglia
bacterial or parasitic infection, or even appear
may also be involved. When there is recurrence of
spontaneously. As it involves autoimmune
more than one demyelinating episode, it is called
demyelination, it is similar to multiple sclerosis,
recurrent disseminated encephalomyelitis or
and is considered part of the multiple sclerosis
multiphasic disseminated encephalomyelitis
borderline diseases (1).
(MDEM) (3).
The incidence rate is about 8 per
Neurologic deficits develop 3­6 weeks
1,000,000 people per year. Although it can
following an antecedent event. The onset can be
occur in all ages, most reported cases are in
abrupt or may happen over a period of several
children and adolescents, with the average age
days. Prodromal illness may precede the
around 5 to 8 years old. The mortality rate may
neurologic symptoms. ADEM can affect any
be as high as 5%, however full recovery is seen
part of the neuraxis and thus the clinical
in 50 to 75% of cases with increase in survival
rates up to 70 to 90% with figures including
polysymptomatic: altered mental status,
minor residual disability as well. The average
pyramidal dysfunction, cerebellar ataxia,
time to recover is one to six months (2).
brainstem syndromes, optic neuritis, myelitis,
ADEM produces multiple inflammatory
lesions in the brain and spinal cord, particularly in
extrapyramidal syndromes. Seizures are
the white matter. Usually the lesions are found in
common, may be focal or generalized.
the subcortical and central white matter and
Encephalitic illness is more common in
Received: 08/10/2018
Accepted: 27/10/2018

Full Paper (vol.743 paper# 8)

c:\work\Jor\vol743_9 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 524-533
Multifocal electroretinogram changes in Egyptians with axial high myopia

Abdullah A. El-Gamal*, Omar H. Salama, Adel A. Hassouna

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

*Corresponding author: Abdullah A. El-Gamal, email: drabdullahelgamal@azhar.edu.eg,mobile: +201092793658

high myopia is a global burden that attracted researchers to its consequences. Although,
there is few data regarding what high myopia causes to the normally appearing eyes. Effect of high
myopia on retinal function can be detected by the multifocal electroretinography, which is capable of
measuring and mapping retinal functions. Purpose: to measure changes in retinal functions in response to
elongation of the axial length (AL). Patients and Methods: this is a descriptive study in which 15
patients aging 18-40 years with spherical equivalent (SE) of -5 were included. A thorough ocular
examination, including but not limited to visual acuity; best corrected visual acuity; anterior segment
examination and fundus examination, was done and standard multifocal electroretinogram (mfERG) was
performed. The measurements were taken in concentric rings and in quadrants, and then analyzed and
statistically compared to normal readings of the matching age group. Results: a total of 30 eyes those
were completely normal except for long AL with normal or tessellated fundi. The mfERG showed
varying reductions in amplitudes (amp.) as well as elongations of implicit times (Imp.T), of both P1 and
N1 components, at almost all rings and quadrants. Conclusion: retinal functions at different layers were
significantly affected by extension of the AL, and that increases as the axial length increases.
Recommendations: future studies should consider high myopia in normally appearing eye as well as in
Egyptians to detect any special pattern of retinal function affection for that ethnicity.
Keywords: Multifocal electroretinogram, axial length, high myopia, retinal function, Egypt.

Researchers argued the definition of high
There is consensus between studies that the
myopia, with a spherical equivalent of -5.00
mfERG response is negatively affected in
diopter (D) or less as the most agreed definition.
myopia. Almost all studies reported decreased
High myopia is a great challenge because, it
amplitudes and elongated implicit times, and
exposes the eye towards pathological changes
that these changes intensify as the degree of
and complications such as, but not limited to,
myopia increases (4). In addition, myopia is
glaucoma; retinal detachment (RD); macular
mainly due to the axial component, with the
degeneration; and cataract (1). The pathological
refractive part playing a minor role (5).
consequences rise in 30-50% of highly myopic
Studies showed no doubt that retinal function,
patients, and those pathologies have taken
mfERG response, reduces with elongation of the
attention of lots of studies. However, studies
axial length. However, there were different
lack enough information about high myopia in
results regarding the most affected location
otherwise normal eyes (2).
and/or interpretation of the analysis of the cause

The multifocal electroretinogram (mfERG) is a

new recoding technique for retinal function,
As mfERG is influenced by ethnicity (9) and
which is capable of measuring functions of
there is scanty of data about effect of axial high
multiple retinal locations, within the central 40-
myopia on the mfERG response in Egyptians.
50%, simultaneously. Its ability to make a
Therefore, this study provides additional data
topography of retinal functions and/or lesions
regarding that issue.
has lent it a privilege over the other retinography

techniques (3).

Received: 09/10/2018
Accepted: 28/10/2018

Full Paper (vol.743 paper# 9)

c:\work\Jor\vol743_10 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 534-542
The role of immune metabolic mediators (IL-1, visceral adiposity index and
Apo- lipoproteins) in the pathogenesis of pre-diabetic state in obese persons

Ahmed Abdel-Monem Khoreba1 ; El-Sayed El-Meghawry El-Sayed 2; Sabry Mohamed Al-Azhary 2;
Saad El-Deen Mohamed El-shreef 2; Tarek Mustafa Emran3 and Magdy Ahmed Mohamed2

1Department of Internal Medicine; Faculty of Medicine, Al-Azhar University (Cairo)
2Department of Internal Medicine; 3Department of clinical pathology; Damietta Faculty of Medicine, Al-
Azhar University

Corresponding author: Magdy Ahmed Mohamed, E-Mail: magdy7555@gmail.com, Mobile: 01069244870

Pre-diabetes is the stage before Diabetes mellitus (DM) there are two forms of prediabetes
Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Many inflammatory markers have been
found to be related to Pre-diabetes, such as interleukin-1 (IL-1), visceral adiposity index, insulin resistance,
and insulin secretory states and serum levels of Apo- lipoproteins in the pathogenesis of pre-diabetic state in
obese persons.
AIM OF THE WORK: To assess the role of Interleukin-1, visceral adiposity index, insulin resistance, and
insulin secretory states and serum levels of Apo- lipoproteins in the pathogenesis of pre-diabetic state in
obese persons.
Patients and Methods: This study is a prospective one that was carried out on one hundred and twenty (120)
patients attending to internal medicine outpatient clinic and inpatient department of internal medicine, Al-
Azhar university hospital, Damietta. The populations of the study were classified into (60) obese persons and
(60) non obese persons. All were subjected to full history and Clinical examination, Laboratory tests include
HbA1c, Fasting blood sugar, post prandial glucose level, Liver Function Test (ALT, AST, serum albumin,
bilirubin, and GGT), Renal Function Test (Creatinine, Urea, Uric Acid), Lipid Profile (Cholesterol,
Triglycerides, HDL Cholesterol, and LDL Cholesterol) and High sensitive C-reactive proteins, OGTT,
Visceral adiposity index based on (WC, BMI,TG, and HDL-C, it estimates the visceral adiposity functionality,
VAI=(WC/{36.58+(1.89×BMI)})×(TG/0.81)×(1.52/HDL-C), serum Interleukin-1 levels and Apo -
Results: Our study showed that there was statistically significant increase in VAI, IL-1, Apo- lipoproteins,
ALT, AST, Cholesterol, TG, LDL, HDL, S. insulin, HOMA and HbA1c in group I in comparison to group
III, on the other hand there was statistically significant increase in VAI, IL-1, Apo- lipoproteins, ALT, AST,
Cholesterol, TG, LDL, HDL, S. insulin and HOMA in group II in comparison to group IV and there was
statistically significant increase in IGT in group I subjects in comparison to group III subjects.
Conclusion: IL-1 and Apo- lipoproteins consider as a risk factor in the pathogenesis of pre-diabetes in
obese persons, which may progress to Diabetes So Therapy targeting IL-1 may ameliorate the condition
and VAI is associated with insulin resistance.
Keywords: Pre-diabetes, Immune metabolic mediators, IL-1, Apo- lipoproteins, VAI.

Pre-diabetes is the precursor stage before DM in
The pro- inflammatory markers are positively
which not all of the symptoms required
correlated with (IR) and features of metabolic
to diagnose diabetes are present, but blood sugar is
syndrome (4).
abnormally high. This stage is often referred to as

the grey area (1). T2DM is the most prevalent
Esser et al. (5) showed that Visceral adipose tissue
metabolic disease in the world and is characterized
has more macrophage, T-lymphocytes and
by defects in insulin secretion and insulin resistance
inflammatory molecules than SC adipose tissue,
in the skeletal muscle, adipose tissue and the liver
moreover a low number of anti-inflammatory
(2). Obesity in particular excess visceral adiposity is
regulatory T- lymphocytes were recently found in
the visceral adipose tissue, and this less favorable
hyperglycemia, dyslipidemia and hypertension
inflammatory role of visceral adipose tissue is in
which increase the risk of developing T2DM (3).
line with the belief that this tissue has an important
Received: 09/10/2018
Accepted: 28/10/2018

Full Paper (vol.743 paper# 10)

c:\work\Jor\vol743_11 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 543-549

Comparative study between usage of topical azithromycin versus
conventional therapy in treatment of posterior blepharitis causing dry eye

Abdullah Hussein Hamed, Hassan Metwally Bayoumi, Maged Muhammad
Mokhtar Morad*

Ophthalmology Department, Faculty of Medicine, Al-Azhar University

* Corresponding Author: Maged Muhammad Mokhtar Morad, E-mail: quiet_fighter@yahoo.com

blepharitis is an inflammatory condition of the eyelid that is usually associated with
bacterial infection or some skin conditions (such as dandruff on the scalp, or acne rosacea). Aim of the
this study aimed to compare the outcome of using topical azithromycin and conventional therapy
in improving signs and symptoms of posterior blepharitis causing dry eye.Patients and Methods: this
comparative study was done between usage of conventional therapy and topical azithromycin in
treatment of posterior blepharitis causing dry eye. One hundred and twenty eyes of sixty patients of
both sexes above age of 18 diagnosed with posterior blepharitis causing dry eye disease are recruited
from the ophthalmological clinic of Al-Azhar university Hospitals. Results: the azithromycin group
showed a significant improvement of sign, symptoms and investigations over the conventional group
in the 2nd visit (after 1 week) while, there was a non significance regarding the 3rd visit after one month
of treatment and 3rd after one month of stoppage of treatment. Conclusion: conventional therapy and
topical azithromycin are effective on posterior blepharitis causing dry eye disease, azithromycin has
more compliance and better tolerability to the patients with sustained effect on the ocular tissue that
give it a preference over the conventional therapy.
Keywords: topical azithromycin, conventional therapy, posterior blepharitis causing dry eye


epithelium lining the MG ducts, while another
condition of the eyelid that is usually associated
theory suggested that the changes were
with bacterial infection or some skin conditions
occurring in the MG secretions or the meibum.
(such as dandruff on the scalp, or acne rosacea)
Once obstruction occurs, the lipid composition
(1). Blepharitis can be classified in several
of the meibum becomes altered. Alterations
different ways: first one based on the length of
included thickening of the secretions, increased
disease process: acute or chronic blepharitis.
melting point of the secretions, ductal
Second classification was based on the
stagnation and pouting of the MG orifices.
anatomical location of the disease: Anterior
Bacterial colonisation and inflammatory
blepharitis affects the eyelid skin, base of the
mediators are released when the meibomian
eyelashes and the eyelash follicles and included
glands become obstructed. The inflammatory
the traditional classifications of staphylococcal
mediators are formed when lipolytic enzymes
blepharitisand posterior
that are produced from bacteria, such as
blepharitis that affects the Meibomian glands
Staphylococcus epidermidis, Staphylococcus
and gland orifices (2). Meibomian glands are a
modified, holocrine, sebaceous glands that are
Cornebacterium. The lipolytic enzymes
embedded in the tarsal plate of the both the
released by the bacteria result in highly
upper and lower eyelid and excrete lipid onto
irritating free fatty acids that compromise the
the surface of the eye to form the lipid layer of
tear film integrity. Both the structural changes
the tear film to reduce aqueous tear evaporation.
to the MG and the secretions contribute to
Dysfunction of the Meibomian gland (MGD) is
increased evaporation of the tear film, increased
a common eyelid condition which is
tear osmolarity and increased inflammatory
responsible for developing evaporative dry eye
cytokines that ultimately damage the ocular
(3).There are several proposed theories on the
surface, resulting in patient symptoms and
etiology of this obstruction. One theory
development of that condition (4, 3). Clinical
suggested that Meibomian gland dysfunction is
symptoms include burning, grittiness, dryness,
the result of hyperkeratinisation of the
foreign body sensation, redness, crusty and
Received: 10/10/2018
Accepted: 29/10/2018

Full Paper (vol.743 paper# 11)

c:\work\Jor\vol743_12 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 550-557

Role of Magnetic Resonance Cholangiopancreatography in Evaluation
of Biliary Obstruction

Mohamed Farouk Aggag, Mohamed Said AbduAziz Shehata , Ziad El Sayed El Sayed Badawy
Department of Radiology, Faculty of Medicine, Al-Azhar University

Corresponding author: Ziad El Sayed El Sayed Badawy, Mobile: +201005307423,
E-Mail: ziadelsayed@hotmail.com

Background: obstructive jaundice which is caused by bile duct obstruction can be clinically and
biochemically indistinguishable from cholestatic jaundice caused by hepatocellular disease. The
management of both these conditions being radically different, the principle task of the radiologist is to
differentiate between hepatocellular and obstructive jaundice, by using available imaging modality and
help in further management. With the availability of non-invasive modality like magnetic resonance
imaging (MRI), it is possible to diagnose obstructive jaundice early and accurately without any patient
discomfort. The purpose of this article is to describe the protocol for evaluation of obstructive jaundice
with use of magnetic resonance cholangio pancreatography sequence of MRI and to describe the
imaging features of the most common causes of obstructive jaundice like biliary calculi, bile duct
primary sclerosing cholangitis, and pancreatic head carcinoma. Aim of work: this work aimed to study
and evaluate the role of MRCP in patients with biliary obstruction. Patients and Methods: this study
included 30 patients with biliary obstruction during the period from December 2017 to October
2018. MRCP was performed on a 1.5 T MRI system, using a phased-array body coil. Fasting for 4 hours
prior to the examination is required to reduce gastro-duodenal secretions, reduce motility to eliminate
motion artifacts and to promote distension of gall bladder.For optimum visualization of ducts, acquired
images were reformatted in different planes using multiplanar reconstruction (MPR) and maximum
intensity projection (MIP). Results: in all cases, MRCP displayed the different parts of the biliary tract
and localized the exact site of obstruction in all of the obstructed cases. According to the morphology
encountered at the site of obstruction, MRCP was found highly specific in differentiating the calcular,
malignant and benign causes of obstruction. The quality of images were degraded by the presence of
massive ascites, marked patient obesity in our study by the instability to hold breath in a reproducible
manner. Lack of the therapeutic role and the inability to perform functional studies mainly at
the papilla remain the main limitation of the technique. Conclusion: MRCP should be the next step
following depiction of biliary obstruction by U/S. Consequently in the near future there will be no place
for the diagnostic use of the ERCP which shall be then restricted to a therapeutic role.

Keywords: MRCP, obstructive jaundice, biliary stricture, cholangiocarcinoma, choledocholithiasis

MRCP is now commonly used as a
retrograde cholangiopancreatography (ERCP) (3).
noninvasive diagnostic tool in visualization of

the pancreaticobiliary tree without injection of
MRCP is based on heavily T2 weighted
contrast media, exposure to ionizing radiation or
sequence that presents static or slowly moving
the injurious puncture of PTC (1). It can be used to
fluids including bile as bright (hyperintense)
establish the presence and severity of biliary and
structures against a dark (hypointense) back
pancreatic ductal dilatation, detect the length of
ground of surrounding organs. The initial MRCP
the stricture as well as the exact cause and
location of the obstructing lesion (2). MRCP was
gradient ECHO sequences by using 2D or 3D
first used in the 1990s. Since then it has
steady state free prescession sequence, however a
undergone considerable technical evolution and
limitation to such sequences was their inability to
maturation and has reached the stage at which
display non dilated bile ducts, recent
MRCP has become an alternative to diagnostic
developments include fast high- spatial-
resolution MRCP sequences such as heavily T2
Received: 09/10/2018
Accepted: 28/10/2018

Full Paper (vol.743 paper# 12)

Corneal Topographic and Biomechanical Changes after Small Incision Lenticule Extraction (SMILE) In Myopic Eyes The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 558-563
Corneal Topographic and Biomechanical Changes after Small Incision Lenticule
Extraction (SMILE) In Myopic Eyes

Nour Elden A Abdelhalim

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

Small incision lenticule extraction (SMILE) offers laser vision correction by using a less
invasive technique that creates a lenticule inside the intact cornea. This procedure limits the biomechanical
strength of the cornea and reduces flap-induced complications.
To evaluate outcome, post-operative corneal topographic and biomechanical changes in myopic
patients who had undergone SMILE.
Methods: The study included 40 eyes of 20 patients treated by SMILE for myopia and myopic astigmatism.
Data included uncorrected and best corrected visual acuity (UCVA and BCVA), spherical equivalent (SE),
central pachymetry Pentacam (oculus) topography to evaluate changes in keratometric readings (K1 and K2)
and asphericity (Q). Corneal hysteresis (CH) and corneal resistance factor (CRF) were measured with ocular
response analyzer. Patients were treated and followed for 12 months.
Results: SMILE procedure for the correction of myopia and myopic astigmatism was performed on 40 eyes
of 20 patients. There was highly significant difference between pre and postoperative keratometric regarding
K1 and K2 was change from 42.9 ± 0.82 and 39.8 ± 1.14 to 43.9 ± 1.21 and 40.5 ± 1.18 respectively (P value
<0.001).Corneal resistance factor and hysteresis were also change from 11.55 ± 1.29 mm Hg and 11.68±1.40
mm Hg to 9.47 ± 1.29 mm Hg and 8.49 ± 1.54 mm Hg, respectively) (P < .0001). At the end of follow up
UDVA was 20/20 or better in 86 % of eyes.
Conclusions: Biomechanical stability with small-incision lenticule extraction has been demonstrated with
establishment of myopic and astigmatic corrective ability, so SMILE represents a safe and effective
refractive option. The incidence of intraoperative and or postoperative complications remains minimal.
Although visual recovery may be slower than LASIK in most cases.

Key words:
SMILE, LASIK, Myopia and Topography


Laser in-situ keratomileusis (LASIK) is
the creation of a flap thus avoiding flap-related
currently the most common laser refractive
early or late complications. The absence of flap
procedure for the treatment of myopia. Its
creation with minimal disruption of the anterior
stromal architecture as the corneal lenticule is
improvement in visual acuity and minimal
extracted from the mid stroma allows for much
postoperative patient discomfort. Although
greater preservation of biomechanical integrity
LASIK patients report 95 % satisfaction, a
and stability of the cornea. Minimal disruption of
spectrum of complicated side effects can
negatively impact results (1). The femtosecond
Bowman's layer and anterior stroma may be
laser has been used to cut LASIK corneal flaps
associated with less risk of dry eye (4).
with high precision for over a decade. The ability
Small incision lenticule extraction
to perform these highly accurate cuts to the
(SMILE) offers a paradigm shift in laser vision
corneal tissue has sparked new enquiry into a
correction by using a less invasive technique that
method of lamellar refractive surgery that may be
creates a lenticule inside the intact cornea and
less invasive (2,3).
subsequently removing it through an incision,
In 2009, small incision lenticule
typically less than 4 mm in size (5). The
extraction (SMILE) was approved in Europe.
development of a procedure that limits the
SMILE potentially offers more advantages than
damage to corneal nerve fibers and preserves the
femtosecond assisted LASIK as it does not require
biomechanical strength of the cornea reduces the
Received: 04/10/2018
Accepted: 23/10/2018

Full Paper (vol.743 paper# 13)

c:\work\Jor\vol743_14 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 564-574

Compartment and Sciatic Nerve Block for Knee Arthroplasty

Samir Mohamed Yassin El-Habashy, Mostafa Abd-Elhamid Hassan Abo-El Enin, Amgad
Zakaria El Khiat, Ayman Mahmoud Mohamed

Department of Anesthesiology and Intensive Care, Faculty of Medicine - Al-Azhar University

Corresponding author: Ayman Mahmoud Mohamed, email: hossamesmail31@gmail.com

Ambulatory knee procedures have become increasingly common due to the effectiveness
of the anesthetic techniques that facilitate rapid and safe discharge.
To compare between spinal anesthesia versus ultrasound guided combined fascia iliaca
compartment and sciatic nerve block for knee arthroplasty.
Patients and Methods: This study enrolled 40 patients (ASA) physical status (1, 2, 3), 20 patients in
each group scheduled to undergo elective unilateral knee arthroplasty procedures. All patients of block
group (group B) received premedication with 0.05 mg/kg midazolam intravenous injection. Group (S)
(20) patients received spinal anesthesia attained by 20 mg/4ml of 0.5% heavy bupivacaine together with
fentanyl 25 µg injected aseptically using a 22-G needle in subarachnoid space at the L4-5 level then the
patients were required to wait in the lateral decubitus position on operated side for 5 minutes. Group
(B) (20) patients received ultrasound guided combined fascia iliaca compartment and sciatic nerve
block using a 22-G needle.
In the present study, sufficient block could not be obtained in two patients in block group, they
shifted to general anesthesia and excluded from the evaluation, and we replaced them by two other
The preferential selection and successful use of anesthesia techniques are based on not
only having a short preparation time and rapid onset of action, but also on providing lower rate of
complications and adverse events, a longer duration of analgesia, good patient satisfaction and optimal
condition for patient discharge compared with other available agents.
Visual analogue scale, surgical anesthesia time, Total-knee joint arthroplasty


Ambulatory orthopaedic procedures
have become increasingly common due to the
aforementioned patients also reduce the success
effectiveness of the anesthetic techniques that
of regional anesthesia (5).
facilitate rapid and safe discharge (1).
Sudden hemodynamic changes during
Regional anesthesia techniques are
spinal anesthesia pose an additional risk due to
used as an alternative to general anesthesia in
the presence of accompanying diseases and
these procedures. It is generally accepted that
previous neurological disorders (4).
both peripheral nerve blocks and spinal
Spinal anesthesia is widely used for
anesthesia provide sufficient anesthesia, better
lower limb surgery in the elderly for efficacy,
postoperative analgesia and satisfaction than
rapidity, minimal effect on mental status,
general anesthesia, in addition to being
reduction of blood loss, and protection against
minimally invasive and using less resources (2).
thrombo-embolic complications. But risk of
Spinal anesthesia is particularly
severe and prolonged hypotension is associated
preferred by patients undergoing unilateral
with spinal anesthesia. This is due to the rapid
lower limb surgery due to the fact that only the
extension of the sympathetic block, hindering
desired region undergoes nerve blockade,
which results in early mobilization and good
significant morbidity and mortality (6).
patient satisfaction (3).
As quadruple nerve blocks of the lower
These patients are also poor candidates
extremities require high-dose local anesthetics,
for general anesthesia because they have
the risk of systemic side effects is increased.
diseases such as diabetes and hypertension and
Nevertheless, these blocks are preferred for
a decreased systemic functional reserve (4).
analgesia. The use of ultrasonography (USG)
Received: 14/10/2018
Accepted: 23/10/2018

Full Paper (vol.743 paper# 14)

c:\work\Jor\vol743_15 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 575-583
Visual Acuity, Rafraction, And K Reading Changes After Five Versus Six
Millimeters Optical Diameter Intracorneal Ring Segments For Treatment Of

*Adel M. Abdul Wahab, *Mohammed I. El-kasaby, *Mohammed T. Elnaggar, *Shaimaa M.

*Faculty of medicine for girls, Al Azhar University** Cario- Egypt­ Research institute of

Corresponding author:Shaimaa Mamdouh Mostafa,email: sh_mesallam3@yahoo.com,Mobil :+01094142798

To evaluate changes in visual acuity, refraction, and keratometric (K) readings after implantation
of five millimeters versus six millimeters optical diameter of intracorneal ring segments (ICR) for treatment
of keratoconus grade (2-4).
Patients and methods:
A prospective nonrandomized clinical comparative study. Thirty four eyes were
included in this study. They were classified into two groups:
Group I: Seventeen eyes of patients with Keratoconus grades (2-4) were subjected to 5 mm optical diameter
intracorneal ring implantation.
Group II: Seventeen eyes of patient with keratoconus grade (2-4)were subjected to 6 mm optical diameter
intracorneal ring implantation.
Results: Thirty four eyes of 22 patients (9 males and 13 females) with keratoconus grade (2-4) were
enrolled in this study. The mean age + SD of the patients in group I was 26.36 ± 7.06 years and in group II
was 23.09 ± 6.92 years.
The mean keratometric (K) reading decreased from 50.05 ± 3.64D. to 46.96 ± 4.42D in group I and
from50.48 ± 5.18D to 46.91 ± 5.44D in group II. There was a statistically significant improvement in the
postoperative uncorrected distance visual acuity, corrected distance visual acuity, K readings, manifest
spherical and cylindrical refractive errors, and spherical equivalent in both groups. No serious intraoperative
complications were reported.
Conclusion: Both 5mm and 6mm ICR improve significantly UCVA, BCVA, decreased the corneal power
and corneal astigmatism but 6 mm showed significant improvement in cylindrical errors and BCVA
compared to 5 mm ICR.
Corneal topography, Pentacam, femtosecond laser, keraring segment, keratoconus.


Keratoconus (Kc) is a progressive, non-
anterior corneal surface, leading to improved
inflammatory, bilateral, ectatic disease of the
refraction and visual acuity (2).
cornea that is characterized by corneal steepening
Tunnel creation can be done either by a
which progresses to irregular conical shape, with
manual technique or using a femtosecond laser
subsequent irregular astigmatism and decreased
under topical anesthesia. The advent of the
visual acuity (1).
femtosecond laser has made the procedure safer,
Intrastromal corneal ring segments (ICRS) were
more accurate, and easier. Other advantages of
introduced as an alternative option for the
femtosecond laser include less discomfort to the
refractive rehabilitation of patients with
patient and better patient cooperation, precise
keratoconus, especially those with poor visual
control of tunnel depth, width, and centration (3).
acuity not correctable with glasses and those with
The aim of this study was to evaluate
contact lens intolerance. One or two circular rings
visual acuity, refraction, and topographic corneal
of (polymethyl methacrylate) were inserted in the
changes after implantation of five millimeters
mid peripheral corneal stroma. The net result was
versus six millimeters optical diameter of
a flattening effect and regularization of the
Received:15/6/2018 Accepted:1/7/2018

Full Paper (vol.743 paper# 15)

c:\work\Jor\vol743_16 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 584-592

Sleep Disorders in Children with Chronic Kidney Disease and its Impact
on General Health

1Mohsen Taha Elke'iy, 1Moftaah Mohammed Rabeea, 2Kamel Soliman Hammad, 1Mohammad
Abd-Elnaby Abd-Elqawy Bakr

1Department of Pediatrics and Pediatric Neurology, 2Department of Clinical Pathology, Faculty of
Medicine, Al-Azhar University

Corresponding author: Mohammad Abd-Elnaby Abd-Elqawy Bakr, Mobile: 01275390887;
Email: bakr88mohamed@gmail.com

sleep disorders are important, but often overlooked health problem in children with
chronic kidney disease (CKD). Sleep disorders included: sleep apnea, change of sleep architecture,
restless leg syndrome, insomnia and excessive day time somnolence. Sleep apnea is a chronic sleep
disorder which causes repeated cessation of breath while a person is sleeping. Characteristics of sleep
apnea included loud snoring, breathlessness, waking up from sleep and daytime sleepiness.
Objective: this study aimed to detect the prevalence of sleep disorders among cases with chronic kidney
disease, to detect pattern of different forms of sleep disorders among cases with chronic kidney disease,
to assess impact of sleep disorders on general health and its relation to dialysis and to assess effect of
new treatment strategies on these disorders. Patients and Methods: we studied 30 chronic HD patients
with ESRD on hemodialysis for at least 5 months in a cross sectional study from Pediatric Hemodialysis
Unit, El-Sayed Galal Hospital, Abou El Rish Children's Hospital, Cairo university Egypt. Results:
Sleep efficiency correlated negatively with higher levels of creatinine. EDS, present in 15% of our
patients, was strongly related to iron status. Sleep apnea, present in 15% of our patients was more
common in males, more common in patients who dialyzed during the afternoon shift. AHI is
significantly related to anemia, and malnutrition (serum albumin). The most frequent sleep related
disorder observed in our study group was RLS/PLM (30%).
Keywords: arteriovenous fistula, chronic kidney disease


An adequate amount and quality of
Restless leg syndrome (RLS), also
sleep are essential for normal growth,
known as Willis-Ekbom syndrome, is a
development, and overall health of children.
Disturbed sleep can adversely affect a child's
unpleasant nocturnal sensations in the lower
daytime function, resulting in behavioral and
limbs that are relieved by movement. These
emotional problems as well as decrements in
sensations generally occur deep within the
daytime alertness and cognitive performance
muscle of the leg, but patients occasionally
(1).Sleep disorders are important, but often
report feeling them on the skin. Two-thirds of
overlooked health problem in children with
patients experience the sensation bilaterally;
chronic kidney disease (CKD) (2).Sleep
one-third of patients have unilateral symptoms.
disorders included: sleep apnea, change of sleep
The most common site of symptoms is the
architecture, restless leg syndrome, insomnia,
upper calf, with 75% of patients reporting
excessive day time somnolence. Sleep apnea is
sensations there. About 80%-90% of RLS
a chronic sleep disorder which causes repeated
patients present with periodic limb movements
cessation of breath while a person is sleeping.
of sleep (PLMS) (5).Patients with renal
Characteristics of sleep apnea include loud
impairment had short, fragmented sleep with
snoring, breathlessness, waking up from sleep,
total sleep times between 260-360 min. Sleep
and daytime sleepiness (3). Insomnia is the
efficiencies ranged between 66%-85% and time
inability to fall asleep or stay asleep and is
spent awake ranged from 77-135 min
characterized by poor sleep quality and poor
(6).Excessive daytime somnolence (EDS) is
quality of life (4).
defined as the inability to stay awake or alert
throughout the course of the day, resulting in
Received: 11/10/2018
Accepted: 30/10/2018

Full Paper (vol.743 paper# 16)

REVIEW The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 593-601

Evaluation of Double Face Preputial Flap for Management of Hypospadias in

Mohammed El-Sayed Radwan, Mohammed Abdel Razek Desoky, Ahmed Abdel Raouf
Abdel Monem Shabaan
Department of General Surgery and Pediatric Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Abdel Raouf Abdel Monem Shabaan, Mobile:
(020)01026432982, E-Mail: ahmedra2of1982@gmail.com
hypospadias is a congenital anomaly in which meatal orifice opens in the vental
aspect of penis instead of the glans tip. The meatal orifice may be located anywhere between the tip
of the penis and the perineum. Objective: the aim of this study was to evaluate double face
preputial flap for management of hypospadias in children about success rate, cosmetic result and
appearance of complications such as fistula, strictures or disruption. Methodology: this study was
conducted on 30 patients who were suffered from mid penile, proximal penile and peno scrotal
hypospadias. The age of our cases at the time of repair were ranged between 4-12.5 years. Results:
after finishing results of our study we noticed that was no statistically significant difference between
results after double face preputial flap technique and ordinary transverse preputial island flap
technique (Duckett's procedure) regarding fistula formation or skin infection. Conclusion: although
the incidence of fistula formation was lower than that was reported in the classic Duckett repair,
however, there was no statistically significant difference between results of double face preputial
flap technique and current Duckett's procedure regard skin disruption and fistula formation.
Keywords: double face preputial flap, incidence of fistula

mobilization and dorsal plication had been
used to correct the penile curvature of
hypospadias with chordee (3).
Hypospadias is one of the most
The surgical repair of primary
humans. Its incidence varies between
hypospadias in childhood may result in
1:1000 and 1:100 births. The etiology was
late postoperative complications involved
not fully understood, but there were
the external urinary meatus (Stenosis and
theories involving testosterone deficiency,
retrusive meatus), the urethra (stricture,
fistula and diverticulum), the corpora
predisposition, tissue remodeling and
cavernosa (penile curvature, torsion or
others(1). Hypospadias repair is a
deformity), the preputial skin or the
genitalia. The main causes of these late
reconstructive surgery and many different
surgical complications were poorly
techniques are currently being used (2).
infection, wound dehiscence, urine
extravasation, hematoma or ischemia or
identified in 20% of cases, had a higher
necrosis of transplanted tissues (4).
incidence of complications. Various
surgical techniques had been used to
The term "crippled hypospadias" had
repair proximal hypospadias, including
been coined for individuals with
tubularized incised plate and onlay island
remaining functional complications after
multiple attempts at hypospadias repair.

Full Paper (vol.743 paper# 17)

c:\work\Jor\vol743_18 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 602-607
Pseudotumor cerebri controlled with ventriculo-peritoneal shunt as a rare
complication of ROHHAD syndrome: a case report

Abdullah Al Shamrani1, Ashwaq Al Tawil2, Afaf A Bin-Khathlan 3, Ali H. Alwadei4

1Prince Sultan Medical Military City (PSMMC), 2Pediatric Endocrine Division, King Fahad Medical City
(KFMC), 3Ophthalmology Department, (KFMC),
4National Neuroscience Institute, (KFMC), Riyadh, Saudi Arabia, KSA

Corresponding author: Abdullah Al-Shamrani, Email: Shamrani999@hotmail.com, Orcid.org/0000-0001-7157-1706, Mobile no.

rapid-onset obesity with hypoventilation, hypothalamic dysfunction and autonomic
dysregulation (ROHHAD) is a rare yet possibly fatal condition. It is similar to common obesity
syndromes (whether exogenous or genetic) sideways with other endocrinopathy in early childhood.
Objective of the study: this study aimed to present the clinical manifestations, laboratory and imaging
results as well as complications and treatment particularly for ventriculo-peritoneal shunt for a
ROHHAD patient with pseudotumor cerebri. Patient and methods: in this case report, a 10-year-old
girl was presented to the emergency department with recurrent episodes of dyspnea, hypernatremia
and cyanosis. Results: her obesity was controlled with sleeve surgery and hormonal evaluation
showed high prolactin level and hypothyroidism. She continued to have symptomatic hypoventilation
and severe Pseudo-Tumor Cerebri (PTC), idiopathic intracranial hypertension (IIH), in addition to
significant reduction in her visual acuity. She was diagnosed with ROHHAD syndrome based on the
clinical, laboratory and radiological findings. Brain and abdominal magnetic resonance imaging were
performed to demonstrate a possible accompanying neural crest tumor, which was normal, but follow-
up images were recommended. Conclusion: ROHHAD syndrome should be suspected in all cases of
rapid onset obesity associated with hypothalamic-pituitary endocrine dysfunction. Also provided the
high prevalence of cardiorespiratory arrest and potentially associated neural crest tumors, early
recognition of ROHHAD syndrome is quite crucial to avert mortality and morbidity. Moreover, Early
ventriculoperitoneal shunt insertion might be a lifesaving procedure to avoid visual impairment and
subsequent blindness in severe pseudotumor cerebri.

: obesity, hypoventilation, hypothalamus, papilledema, hypernatremia, shunt, pseudotumor
cerebri, idiopathic intracranial hypertension.

In 1965, the first case of rapid-onset obesity
and the reason behind the high morbidity and
mortality rate was the high incidence of
hypoventilation, and autonomic dysregulation
cardiorespiratory arrest which could be
(ROHHAD) was reported [1]. ROHHAD is
prevented by the early recognition of the
defined as a sporadic disorder with
breathing disorder as well as early ventilatory
abnormalities including significant weight
support [4-6]. The criteria for diagnosis of
gain, breathing problem (hypoventilation) and
ROHHAD can be summarized as follows: 1)
other disorders in both endocrine and
rapid-onset obesity 2) alveolar hypoventilation
autonomic nervous system [2]. Ize-Ludlow et
starting after the age of 1.5 years, 3) evidence
al. reported fifteen patients with the condition
of hypothalamic dysfunction, as defined by 1 or
[3]. ROHHAD syndrome is potentially lethal
Received: 12/10/2018
Accepted: 1/11/2018

Full Paper (vol.743 paper# 18)

c:\work\Jor\vol743_19 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 608-616
Anatomy, Biomechanics and Complications of Arthroscopic Anterior Cruciate
Ligament Reconstruction

Kamal Abdel Rahman AbdelHafez, Mohammed AbdelAziz Hassan, Wael Said Altaher Mohammed

Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Wael Said Altaher Mohammed, Mobile: 00201149452945, email: dr.wael86@yahoo.com
With increasing road traffic accidents and athletic participation, traumatic lesions of the ligaments
about the knee are becoming increasingly more common. Those injuries can be isolated or combined with other
components of the knee. No procedure is ever completely free of risks. However, Anterior Cruciate Ligament (ACL)
reconstruction is a safe procedure that is performed thousands of times each year. ACL reconstruction surgery uses
a graft to replace the ligament. The most common grafts are autografts using part of body, such as patellar tendon or
one of the hamstring tendons. Results of arthroscopic ACL reconstruction have been excellent; the success rate has
been reported to be more than 95% in term of patient satisfaction. Aim of the work: was to discuss anatomy and
biomechanics of anterior cruciate ligament and the complications of arthroscopic anterior cruciate ligament
reconstruction. Conclusion: It could be concluded that the challenge is to perform the reconstructive procedure with
high success and minimal complications and morbidity. To accomplish this, it requires a combination of a skilled
surgeon, appropriate graft selection and careful attention to the details of rehabilitation.
Arthroscopic, Anterior cruciate ligament
Arthroscopy of the knee was first performed
frequently. Secure graft fixation is an important factor,
in 1918 when Kenji Takagi used a cystoscope to
especially in the early postoperative period (5).
examine the intra-articular structures of the knee (1).
Complications associated with this surgery
Burman, at the Hospital for Joint Diseases in New
occur in 1.8% to 24% of the procedures, which include
York, reported on his arthroscopic study of cadaveric
joint stiffness, patellar fracture, infection, hardware
joints, including the knee, in 1931 (2). He concluded
failure, graft failure, wound complications, deep vein
that arthroscopy should be used for purposes of
thrombosis and periarticular fractures. A rare and
diagnosis rather than traditional open exploratory
surgery. His report was met with little enthusiasm by
reconstruction and revision reconstruction is femoral
his medical colleagues.
fracture (5).
Arthroscopic surgery of the knee evolved slowly over
Patella fracture after anterior cruciate
the years. The first arthroscopic knee surgery was
ligament reconstruction of the knee can be a serious
performed by Masaki Watanabe in 1955. The
problem in the total rehabilitation of the patient, and
procedure involved a partial excision of pigmented
that possibility should be considered during anterior
villonodular synovitis. Watanabe performed the first
cruciate ligament reconstruction. These complications
arthroscopic meniscectomy (3). Arthroscopic
can be prevented by avoiding taking too much bone
techniques were pioneered by Bradley (4). Over the past
graft, by using the most precise tools for cutting, while
25 years, the arthroscope has revolutionized the
rehabilitation must be carefully planned (6).
diagnosis and surgical treatment of disorders of the
Aim of the work was to discuss anatomy and
knee. The future holds nothing but promise for further
biomechanics of anterior cruciate ligament and discuss
advancements in treatment of the knee, as well as other
the complications of arthroscopic anterior cruciate
ligament reconstruction.
ACL reconstruction has become a great
challenge and many techniques has been evolved and
created according to way of graft fixation such as
The knee joint starts its formation from
metal and biodegradable interference screws, staples,
vascular mesenchyme between femur and tibia in the
buttons, press-fit. The success of the surgery depends
fourth week of gestation between the blastoma of
on several factors including the timing of the surgery,
femur and tibia. A distinct amount of ACL fibers
graft choice, tunnel placement, graft tensioning, graft
appear in approximately the 8th week after gestation.
fixation methods, and postoperative rehabilitation
At this time, the fibroblasts within the ligament are
protocol. Orthopedic surgeons use bone­patellar
already aligned to the axis of strain of the ACL (7, 8).
tendon­bone or hamstring tendon grafts most
By 9 weeks, the cruciate ligaments are
composed of numerous immature fibroblasts having
Received: 10/10/2018
Accepted: 29/10/2018

Full Paper (vol.743 paper# 19)

c:\work\Jor\vol743_20 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 617-626
Phacoemulsification with Posterior Sub-Tenon Triamcinolone Acetonide
Injection for Prevention of Progression of Diabetic Macular Edema after

Cataract Surgery

Hassan Mohamed Hegazy, Mahmoud Mohammed Ahmed Ali, Mohamed Abd elmoneim
Mohamed Sedik Ghoneimy*

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

*Corresponding author: Mohamed Abd elmoneim Mohamed Sedik Ghoneimy, Mobile: +201288999633,
E-Mail: dr.mohamedsedik@live.co.uk
diabetic macular edema (DME) is the most common cause of visual loss in diabetic
patients. The pathogenesis of DME is multifactorial. It results from multiple biochemical and cellular
changes that eventually cause leakage and exudation. A number of patient characteristics such as
increasing age, females, duration of DM, poor glycemic control and moderate to severe retinopathy
have been found associated with poor prognosis after cataract surgery in diabetic patients.
Objective: the aim of this study was to evaluate the efficacy of phacoemulsification with posterior
sub-Tenon's triamcinolone acetonide injection for prevention of progression of diabetic macular edema
following uneventful cataract surgery by phacoemulsification.
Patients and Methodology: this interventional study included 20 eyes of 20 diabetic patients with
visually significant cataract and coexisting DME during the period from December 2017 to October
2018. Preoperative and postoperative best corrected visual acuity (BCVA) using LogMAR and
intraocular pressure (IOP) were recorded.
Results: statistically significant improvement in BCVA was detected when comparing postoperative
values at one week, one month and three months to corresponding preoperative values. In addition,
values at one month and three months were significantly improved when compared to values at one
week post-operative. On other hand, values at three months revealed non-significant difference when
compared to values at one month.
Conclusion: this study suggests that posterior sub-Tenon's triamcinolone acetonide injection can be
given safely and easily at the time of phacoemulsification surgery in patients with visually significant
cataract and DME.
Keywords: Sub-Tenon's, Triamcinolone acetonide, Diabetic retinopathy, DME, OCT
better with visual acuity (VA) in DME than
Diabetic maculopathy is the most common
axial retinal thickening, although the degree to
cause of visual impairment in diabetic
which retinal thickening corresponds to VA
retinopathy (DR) and is manifested most
depends on the pattern of DME seen (4).
frequently as diabetic macular edema (DME)
Additionally, OCT is the best modality for
visualizing and evaluating pathology of the
vitreomacular interface, including epiretinal
ophthalmologists in the evaluation of DME are
membranes (ERM) and vitreomacular traction
slit-lamp biomicroscopy, fluorescein fundus
(VMT), which may contribute to the
angiography (FFA), and macular optical
persistence of DME after focal laser
coherence tomography (OCT) (2).
FFA has been in use for over half a century and
can identify vascular abnormalities including
endothelial growth factor (VEGF), and it can
microaneurysms, neovascularization (NV),
also identify patients who may benefit from
intra-retinal microvascular abnormalities
pars plana vitrectomy (PPV) and membrane
(IRMA), capillary non-perfusion and leakage.
peeling (MP) (5).
However, leakage detected by FFA does not
It has been demonstrated that DR progresses
necessarily correspond to macular edema
in approximately 10­30% of patients after
(ME) (3).
cataract surgery, although some authors have
Only OCT can measure central macular
hypothesized that the progression of DR after
thickness (CMT) objectively. This is
cataract surgery is due simply to the natural
important because no observation correlates
Received: 11/10/2018
Accepted: 30/10/2018

Full Paper (vol.743 paper# 20)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 627-631
Electroencephalogram study in non-convulsing children with delayed language
Hassan Ali Hassan*, Gehan Abdel Rahman Al-Zaree**, Mahmoud Abdel Moety Monzer***,
Sameh Abdel Aziz Ahmad*, Mahmoud Atef Abdel Qader Al-Tantawy*.
* Pediatrics Department ­ Faculty of Medicine ­ Al-Azhar University ­ Cairo ­ Egypt.
** Audiology Unit ­ ENT Department - Faculty of Medicine ­ Al-Azhar University.
*** Neurology Department - Faculty of Medicine ­ Al-Azhar University
Corresponding author: Mahmoud Atef Abdel Qader Al-Tantawy, E-Mail: dralttanttawy@gmail.com, Phone: 01017422588
Background: Speech is the motor act of communicating by articulating verbal expression, whereas language
is the data of an emblem system used for social communication. Aim of the work: This study aims to find a
relationship between childhood speech, language disorders and epileptiform discharges without seizures and to
evaluate the cognitive function in those children, which may help in early diagnosis and management of such
cases. Study Design: Case control study Place: Pediatrics Department at Al-Azhar University Hospitals.
The study was conducted on fifty patients with speech/language disorder without epilepsy, their
age ranged from 2-5 years, who were selected from Outpatient Clinic of Pediatric Neurology, Al-Azhar
University Hospitals through the period from March 2018 to October 2018. The study also included fifty
normal language developed children who were matched both in age and gender as control group. Results: The
control group matched the study group in age and gender with no statistical difference between them. Delayed
language development (DLD) affected males (64%) more than females (36%) with ratio of 1.78: 1. Caesarean
section (C.S.) represented 44% of cases 56% of the cases were delivered through the normal vaginal delivery
(p value > 0.05). In our study we were unable to find any influence of epileptogenic activity on IQ levels.
Electrocardiogram must be performed for the child who suffers from delayed development of the
language even if he does not complain of clinical convulsions. Diagnosis and treatment should be carried out
by a multi-disciplinary team and not a single specialty.
EEG. Language. Development. Interictal epileptiform activity.

There is currently sizable proof that
Speech is the motor act of communication
interictal spikes will contribute to psychological
by articulating verbal expression, whereas language
feature impairment. Interictal spikes in both
is that the data of a logo system used for social
rodents and humans result in transient impairment
communication (1).
of memory retrieval, whereas in immature animals,
Language could be expressed through writing,
interictal spikes can result in long-term adverse
signing, or perhaps gestures within the case of people
effects on brain development (5).
who have medical disorders and will rely upon eye
The effect of epileptiform activity is greater
blinks or mouth movements to speak. The most
with more frequent activity, repeated and bilateral and
intensive period of speech and language development
symmetrical discharges. Subclinical discharges alone,
for humans is the 1st 3 years of life, a period when the
without seizures, are usually not treated medically,
brain is developing and maturing. Delayed language
but this issue has been the subject of debate (5).
development (DLD) children may show abnormal
It is not known how epileptiform
findings on functional and structural neuro-radiological
discharges contribute to speech and language
and neuro-physiological investigations (2).
disorders. Research in the area of speech and
Not every electrical EEG epileptiform
language dysfunctions in children with epilepsy is
discharge should necessarily be accompanied by a
scarce and the need for speech and language
clinical seizure. Many epileptiform discharges can
intervention has not received much attention (6).
occur without external visible clinical manifestations.
Such EEG transients were described as "subclinical"
intervention could mitigate the emotional, social and
or "interictal" or "larval" discharges (3).
cognitive feature deficits of this incapacity and should
An association between EEG abnormalities
improve the end result (7).
and language disorders such as Land au-Kleffner
However, it is difficult to envisage recurring
syndrome (LKS), continuous spike-wave throughout
interictal epileptiform discharges as being not associated
slow wave sleep (CSWSS) and atypical benign partial
with any effects on normal cerebral functions, on the
brain disease is well documented (4).
grounds that they do not cause external clinical
manifestations so, this work was designed.
Received: 11/10/2018

Accepted: 30/10/2018

Full Paper (vol.743 paper# 21)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 632-638
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. 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
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 imaging
Stroke is a clinical syndrome of rapidly
highly sensitive to ischemia, so even brief
developing symptoms and signs of focal loss of
ischemic periods to neurons can lead to a
cerebral function without apparent cause other
complex sequence of events that may culminate
than vascular origin, lasting 24 hours at least, or
in cellular death (2).SWI is a highly sensitive in
may lead to death before this (1).Worldwide,
stroke is the second leading cause of mortality,
visualization of the hemorrhagic lesion.
resulting around 6,000,000 deaths per year
Thromboembolism can also change susceptibility
(2).Strokes can be classified into two major types:
by decreasing arterial blood flow, thus increasing
ischemic and hemorrhagic. Ischemic strokes are
deoxyhemoglobin levels, and may also increase
due to interrupted brain tissue blood supply while
pooling of deoxygenated blood (4).
hemorrhagic strokes are caused by extravasation
Several important tissues have unique magnetic
of blood out of a blood vessel or an abnormal
susceptibility differences relative to surrounding
vascular structure. About 85% of strokes are
tissues. Signals from these substances are out of
ischemic and the rest are hemorrhagic. Some
phase with background tissues at sufficiently
hemorrhages develop inside areas of ischemia
long echo times. Thus phase imaging is a good
(Hemorrhagic transformation). Actually, it is
means for enhancing contrast in magnetic
unknown how many hemorrhagic strokes start as
resonance (MR) imaging. In 1997, it was
ischemic stroke (3).Understanding of the
possible to remove most of the unwanted phase
pathogenesis of brain damage following ischemia
artifacts and keep the local phase of interest (5).
is to understand how ischemia occurs. Ischemia
Combination of the phase and the magnitude
is a reduction in blood flow sufficient to interfere
information made a new susceptibility weighted
with normal cellular function. Brain tissue is
magnitude image, which is called nowadays as
Received: 15/09/2018

Accepted: 30/09/2018

Full Paper (vol.743 paper# 22)

c:\work\Jor\vol743_23 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 639-647

Vertebrobasilar Occlusive Diseases in a Group of Egyptian Patients with
Posterior Circulation Ischemiaat Interventional Neurology Unit Al-Hussein
University Hospital
Tarek Mohamed Awny 1, Wael Osman Mohamed 1, Ahmed Hamed Ali 2, Ahmed
Khairy Elsayed Fahmy Ahmed Kaoud 1
1 Neurology, 2 Radiology Departments, Faculty of Medicine, Al-Azhar University, Cairo
* Corresponding author: Ahmed Khairy Elsayed Fahmy Ahmed Kaoud, E-mail: dr.ahmedkhairy123@gmail.com
Background: stroke is the third leading cause of long-term disability and a major cause of mortality
worldwide. Eighty percent of strokes are ischemic. Twenty percent of ischemic events involve tissue
supplied by the posterior (Vertebrobasilar) circulation. Aim of the Work: the aim of the study was to
assess clinical, risk factors, etiology and vascular lesions of vertebrobasilar occlusive diseases in a
sample of Egyptian patients with posterior cerebral circulation ischemia at Al-Hussein Neuro-
intervention Unit. Patients and Methods: this study was carried out on patients presented with
posterior cerebral circulation ischemia undergoing diagnostic cerebral angiography at the Neuro-
interventional Unit in Neurology Department of Al -Hussein University Hospital and Bab-Alshaeria
University Hospital. We studied risk factors, vascular lesions, symptoms and signs in patients with
vertebrobasilar disease. Results: in the present study, DM was the most frequent risk factor, present in
20 patients (66.67%), followed by hypertension (19 patients [63.33%]), hyperlipidemia (14 patients
[46.67%]), smoking (13 patients [43.33%]) and IHD (12 patients [40%]). Conclusion: early detection
of stenotic lesions is highly valuable for preventing patients from recurrent TIAs and strokes. Recent
improvements in imaging with application the arrival of vertebral artery angioplasty and stenting,
however, have opened up new opportunities for intervention in this disease. Digital subtraction
angiography is the gold standard method for diagnosis of vertebrobasilar diseases and the most sensitive
for detecting intracranial and extracranial stenotic lesions.
Keywords: vertebrobasilar occlusive diseases, posterior circulation ischemiaat interventional
Stroke is the third leading cause of
is stenosis and the main cause of bilateral ICVA
long-term disability and a major cause of
disease is atherothrombosis. The most common
mortality worldwide (1). Eighty percent of
risk factors of vertebrobasilar disease are
strokes are ischemic. Twenty percent of
ischemic events involve tissue supplied by the
mellitus, smoking, coronary artery disease,
posterior (vertebrobasilar) circulation.The
obesity and previous stroke (2). Atherosclerosis
paralysis of vertebrobasilar stroke can be
most commonly affects the origin and proximal
devastating and some forms have high rates of
portion of the vertebral artery and is frequently
death. VertebroBasilar ischemia has a variety of
associated with similar disease in the internal
different vascular pathologic features at various
carotid artery (6).
locations and has multiple clinical courses and
The most common mechanism of
outcomes (2). Vertebral Artery stenosis may
stroke in patients with vertebral artery stenosis
occur either extra- or intra-cranially, but it is
is intra-arterial embolism, rather than
often localized at the origin of the vessel as it
hemodynamic failure (7). Hemodynamic stroke,
arises from the subclavian artery. Proximal
however, is less commonly caused by vertebral
vertebral (V1 segment) lesions account for
artery stenosis, because both vertebral arteries
approximately 9% of all posterior circulation
feed into one basilar artery (8). Also, in contrast
strokes (3). Vertebral artery is the second most
to the internal carotid artery, the vertebral artery
common location of stenosis after internal
gives off numerous branches at the neck region,
carotid artery stenosis at the carotid bifurcation
therefore facilitating a considerable collateral
(4, 5). The most common lesion of ICVA
blood supply, which often reconstitutes the dis-
(Intracranial vertebral artery) occlusive lesions
tal artery after occlusion at the origin (9). The
Received: 12/10/2018

Accepted: 01/11/2018

Full Paper (vol.743 paper# 23)

c:\work\Jor\vol743_24 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 648-659

Effect of Selective Serotonin Reuptake Inhibitors and Serotonin
Norepinephrine Reuptake Inhibitors on Trabecular Bone Score and Bone
Mineral Density in Primary Fibromyalgia
Hesham S. Hamoud, Mohamed M. Ghait, Yasser A. Hussein, Muhammad M. Harb
Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Al-Azhar University,
Cairo, Egypt
Corresponding author: Muhammad M. Harb; Mobile: 01009952990; Email: Dr_2MH@Yahoo.com
fibromyalgia is characterized by chronic widespread pain classified as primary and
concomitant. Aim of the Work: this work aimed to determine the correlation between selective
serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
usage and bone mineral density (BMD) and trabecular bone score (TBS) changes in primary
fibromyalgia patients.
Patients and Methods: The present study was conducted on study on 100 Egyptian patients
diagnosed as primary fibromyalgia categorized according to drug medication into two 2 groups,
50 patients on SSRIs and 50 patients on SNRIs, recruited from Rheumatology, Physical Medicine
and Rehabilitation Departments at Al-Hussein and Sayed Galal, Al-Azhar University Hospitals.
In addition to another 50 age matched the control group subdivided into 25 primary fibromyalgia
patients not on those drugs and 25 healthy individuals selected by nurses and medical staff, after
an informed consent from all subjects from June 2018 to December 2018.Results: DXA and TBS
revealed that usage of SSRIs and SNRI was significantly associated with low BMD (Osteopenia
and osteoporosis) specially spine BMD reduction with low TBS (partially degraded and
degraded) particularly for old people. Conclusion: the present study provided evidence that usage
of SSRIs or SNRI was significantly associated with low BMD (Osteopenia and osteoporosis)
specially spine BMD reduction with low TBS (Partially degraded and degraded) particularly for
old people and despite low BMD was found in the SRI users; it also found in 1ry fibromyalgia not
on SRIs so 1ry fibromyalgia should also be considered as a contributing factor for low BMD.
Keywords: SSRI, SNRI, FMS, fibromyalgia, osteoporosis, TBS, BMD, bone mineral density,
trabecular bone score.

reuptake of 5-hydroxytryptamine (5-HT) (Serotonin)
Fibromyalgia is characterized by chronic
through the inhibition of the 5-HT transporter (5-HTT)
widespread musculoskeletal pain that often co-exists
which is located on the presynaptic neuron, thereby
with sleep disturbances, fatigue, cognitive dysfunction,
increasing levels of 5-HT within the synaptic cleft and
stiffness and tenderness to palpation at specific tender
modulating neurochemical signaling [3]. Usage of
points. It has been classified as primary and
SSRIs was significantly associated with lumbar spine
concomitant. Primary fibromyalgia indicates that there
BMD reduction, particularly for old people [4]. Two
is no underlying or concomitant medical condition that
SNRI's have gained FDA approval for the
might have contributed to a patient's pain.
management of fibromyalgia Duloxetine and
Fibromyalgia is considered concomitant if another
Milnacipran [5], CaMoS study found an elevated
condition such as osteoarthritis, rheumatoid arthritis,
danger of fractures in individuals who used SSRI or
systemic lupus erythematosus, or hypothyroidism is
SNRI, even after controlling other multiple risk factors
present and in turn contributes to a patient's pain or
for osteoporosis [6]. Currently, DXA (Dual-energy X-
fatigue [1]. Fibromyalgia is associated with low level of
ray absorptiometry) scan was used to assess BMD and
physical activity and exercise, which may lead to an
FRAX assessment tool to predict 10-year probability
increased risk of osteoporosis resulting in a substantial
of hip fracture, the diagnosis of osteoporosis rests on a
impact on quality of life [2]. Selective serotonin
real bone mineral density (BMD) measurement using
reuptake inhibitors represent a class of commonly
DXA. Microarchitecture of cancellous bone was a
used antidepressants. They act by preventing the
determinant for bone strength which can't be measured
Received: 10/10/2018

Accepted: 29/10/2018

Full Paper (vol.743 paper# 24)

ABSTRACT The Egyptian Journal of Hospital Medicine (Jaunrary 2019) Vol. 74 (3), Page 660-668
Laparoscopic Appendectomy versus Glove Single Port Laparoscopic
Appendectomy in Pediatrics under Spinal versus General Anesthesia.
A controlled Randomized Study
1Rafik Yousef Shalaby, 2Magdy Mahmoud Mostafa, 3Ahmed Said Abd El-Rahman,
1Mabrouk Maowed Akl, 1Islam Mohamed Abd Al-Monem
1Department of Pediatric Surgery, 2Department of General Surgery, 3Department Anesthesia and Intensive Care,
Faculty of Medicin, Al-Azhar University
Corresponding author: Islam Mohamed Abd Al-Monem, Mobile: 01014661490; Email: drislammakhlouf@gmail.com
Background: The glove single-port laparoscopic appendectomy it is a novel SILS technique which is
extremely cheaper than the other commercial devices. Objective: this study aimed to compare between
conventional laparoscopic appendectomy (CLAP) and glove single port laparoscopic appendectomy (GSPLAP)
under tow different anesthetic technique. Patients and Methods: this study of laparoscopic appendectomy was
conducted over thirty six children (n=36). All patients were randomized into 4 groups by a random-number
table sequence after giving informed parental consent. The allocations will be contained in opaque sequentially
numbered closed envelopes and every patient drew an envelope. Results: Two cases of GSPLAP were
converted to multi-port due to difficult accessibility of the appendix and adhesions (suppurative appendicitis).
The Mean operative time for CLAP was significantly lower than GSPLAP procedure. For CLAP was
38.39±10.12 min (ranged from 26 to 75 min) and was 49.11±11.98 min (ranged from 38 to 86 min) for
GSPLAP. We observed that GSPLA was less painful significantly than CLAP for the first postoperative hours
(3hrs) the time of postoperative needs of analgesia in pt. underwent LA under SA is delayed. Conclusion:
Using a combination of 0.5% hyperbaric bupivacaine and a fentanyl provided effective anesthesia for
laparoscopic appendectomy with low-pressure Co2 Pneumoperitoneum. It offers better pain management for
the patients, earlier recovery and less operating room costs. We recommend an increasing use of spinal
anesthesia for laparoscopic appendectomy especially in patients with risks for general anesthesia.
Keywords: acute appendicitis, general anesthesia, post- operative nausea and vomiting, spinal anesthesia

organs in abdomen, as well as fast recovery in the
Acute appendicitis (AA) is a common
post- operative period [6, 7].
cause of acute abdominal pain with a life- time
Single incision laparoscopic surgery
incidence and it was ranged between 7­
(SILS) attempts to evolve laparoscopy with the aim
9%.Approximately 20­30% of children with acute
of quicker recovery, less pain and better patient
abdominal pain referred to pediatric surgical
satisfaction. By reducing trauma to the abdominal
services have AA. Another 50% have benign, self-
wall, it is potentially offer better outcomes than
limiting, non- specific abdominal pain. The
even conventional laparoscopic appendectomy.
incidence of AA varies per age group ranging from
The glove single-port laparoscopic appendectomy
one to six per 10,000 children annually under 4
it is a novel SILS technique modified by the
years of age to 19 to 28 per 10,000 children under
introduction of a single port made with a surgical
the age of 14 years [1, 2].
glove.The device allows simultaneous passage of
The treatment of AA remained essentially
several laparoscopic instruments through one small
unchanged since its first description by Charles
incision. General anesthesia (GA) being the only
McBurney in 1889. Appendectomy by McBurney`s
suitable technique for laparoscopic surgeries needs
incision remained the procedure of choice for
a relook. Some complications as pressor response
nearly a century until 1983 when Kurt Semm
to endotracheal intubation, increased release of
offered an alternative, laparoscopic appendectomy
stress hormones, sore throat, post-operative pain,
(LA) [3- 5].
post- operative nausea and vomiting (PONV) are
Since its first description in the early 1980s
from the disadvantages of using GA [8-14].
LA has advanced to be the treatment of choice for
Spinal anesthesia (SA) has the advantage
both complicated and uncomplicated appendicitis,
of providing analgesia and total muscle relaxation
with increasing numbers of procedures performed
in a conscious and compliant patient and an
per year. Many advantages of laparoscopic surgery
uneventful postoperative recovery. At the same
have been documented over to open appendectomy
time, it also protects against the potential
(OA). It requires small incisions and gives good
complications of (GA). Despite these advantages,
visualization, it also gives better access to reach the
regional anesthesia is still preferred only for
Received: 13/10/2018

Accepted: 2/11/2018

Full Paper (vol.743 paper# 25)

c:\work\Jor\vol743_26 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 669-678

Comparative Study Between Lightweight Meshes Versus Traditional
Heavyweight Meshes for the Repair of Inguinal Hernia

Muhammad Ramadan Ismael Khalil, Mohammad Hassan El-Shafey, Adel Mohammad Abdul-
Haleem Lasheen
Surgery department,faculty of medicine,Al-Azhar university
Correspondence author: Muhammad Ramadan Ismael Khalil,Tel: +201116693385, +201024594466 , E-mail:
Background and aim: the ideal outcome of inguinal hernia surgery is to provide a repair that is free from
recurrence, pain and infection with minimal scarring and with improvement in patient's quality of life. Aim of the
: this study aimed to compare light weight poliglecaprone (Ultrapropolypropylene/Monocryl), UltraProTM
mesh with the standard heavy weight polypropylene mesh in tension free Lichtenstein inguinal hernia repair.
Patients and methods: the current study included 40 patients complained of uncomplicated inguinal hernia and
they were randomized into two groups according to the type of mesh used in tension free Lichtenstein inguinal
hernia repair. Group I, 20 patients received the standard polypropylene mesh. Group II, 20 patients received light
weight UltraProTM mesh, using sutures for their fixation. Results: the UltraProTM (LWM) mesh proved to be as safe
and effective as the standard (HWM) prolene mesh in repair of uncomplicated inguinal hernia. There was no
difference between the two groups as regard to the technical difficulties, operative complications and surgeons
were equally satisfied. There was more incidence of chronic pain with prolene mesh (25%) compared to (zero%)
with UltraProTM mesh. The mesh fixation time and the overall operative time were shorter with UltraProTM mesh.
Conclusion: the shorter operative time and the no-need to use analgesics could partially compensate the higher
cost of UltraProTM mesh in the absence of other economic factors such as the duration of patient improvement
and return to work.
Keywords: hernia, inguinal, Lichtenstein, mesh, UltraProTM, polypropylene.


Inguinal hernia repair is one of the most common
mesh awareness and less chronic pain with
operative procedures performed in general surgery.
improved quality of life [7- 9]. UltraProTM [Ethicon, Inc,
Almost 14% of the population develop an inguinal
Somerville, NJ] is a recently introduced mesh that is
hernia with around 80,000 repairs performed each
composed of two weaves of light weight
year in the UK and 800,000 repairs each year in the
polypropylene and poliglecaprone, which is a
US [1, 2].Lichtenstein hernioplasty is now described as
monofilament, gives the mesh additional stiffness
a ``gold standard'' for open inguinal hernia repair in
for handling and dissolves in approximately 90 days
the European Guidelines on inguinal hernia [3]. Many
trials have been published proving the superiority of
The aim of the present work was to compare light
mesh repair over non-mesh techniques [4].Despite
reducing the incidence of recurrence compared with
/Monocryl), UltraProTM mesh with the standard
sutured tissue repair, the use of prosthetic mesh has
heavy weight polypropylene mesh in tension free
been linked with chronic pain and foreign body
Lichtenstein inguinal hernia repair.
sensation [5]. The incidence of foreign body sensation
Patients and methods:
is reported to occur in around 40% [5] and chronic
The present study included forty patients,
pain in around 30% of patients [5, 6]. There is growing
presented to Al-Azhar University Hospitals, for
interest in the use of lighter weight meshes (LWM)
elective repair of uncomplicated inguinal hernia,
for all types of hernia repair based upon predicted
during the period from March 2018 till September
benefits when compared with heavyweight meshes
2018. The study was approved by the Ethics Board
(HWM). These include accelerated recovery with
of Al-Azhar University.
less postoperative pain and earlier return to normal
The study was randomized using close-envelope
activity, increased patient comfort with reduced
into two groups:
Received: 11/10/2018

Accepted: 30/10/2018

Full Paper (vol.743 paper# 26)

c:\work\Jor\vol743_27 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 679-683

Comparative study between transanal endorectal pull-through and
modified Duhamel's procedure in management of Hirshsprung's disease

Mohammed Abd El Baky Fahmy1, Sameh Abd El Hay Abd El Hamid2, Omar Mohammed
Elsamahy1, Hanan Mahmoud Mohammed1
1Pediatric Surgery, Faculty of Medicine, Al Azhar University for Girls, 2 Pediatric Surgery, Faculty of
Medicine, Ain Shams University

Corresponding author: Hanan Mahmoud Mohammed, E-Mail: Hananm1882@gmail.com, Mobile: 01065084549

Background- Hirschsprung's disease (HD) is a congenital disorder characterized by an absence of
neuronal cell bodies in both myenteric and submucous plexuses in the intestinal wall. The aganglionosis
always starts distally and is limited to the rectum and the sigmoid colon in 80­85% of the cases.HD
occurs in about 1/5000 live born babies and is more common in boys than girls (4:1). Patients with HD
are most often diagnosed in the neonatal period. The clinical presentation is distended abdomen,
delayed passage of meconium and vomiting, older children more often present with chronic
constipation, approximately 10% of patients with HD present with enterocolitis. Surgical management
for HD aims at removing the aganglionic bowel and reconstructing the intestinal tract. There has been
a continuous development over the years of operative techniques used for HD from multi-staged
procedures (a preliminary colostomy) to one stage pull-through.Aim of the work: comparative study
between transanal endorectal pull-through and modified Duhamel's procedure in management of
Hirshsprung's disease. Patients and Methods: this randomized prospective study was done on 20
patients with Hirschsprung's disease during the period from January 2016 to January 2018, group A
included 10 patients underwent modified Duhamel's procedure compared to group B 10 patients
underwent trans-anal endorectal pull-through procedure. Results: the two techniques were nearly
equivalent in the post-operative outcomes. Conclusion: currently, as there was no evidence suggesting
that one technique has significant superiority over another, so it is up to surgeon's choice to select the
technique that was easy and feasible in his hands, but TEPT was preferable for neonates, with no past
history of enterocolitis and using modified Duhamel's if the two staplers were available is safe and with
less complications
Keywords: Hirschsprung's disease, transanal endorectal pull through, modified Duhamel's procedure.

Hirschsprung's disease (HD) is a
more common in males than females (4:1) (3).
congenital gastro-intestinal motility disorder
The patients with HD were mostly diagnosed in
characterized by an absence of neuronal cell
the neonatal period (4). The clinical presentation
bodies in both auerbach's and miessner's
was distended abdomen, delayed passage of
plexuses in the intestinal wall (1). The
meconium and vomiting, older children often
aganglionosis, pathognomonic for HD, always
present with chronic constipation, and
starts distally and was restricted to the rectum
Approximately 10% of patients with HD
and the sigmoid colon in 80­85% of the cases,
present with enterocolitis(1).
less frequently, the aganglionosis involves the
Contrast enema was the first diagnostic
whole colon with or without a part of the small
procedure and showed a transition zone
intestine. Functionally, this results in a
between the normal (often dilated) and the
sustained contraction of the aganglionic
narrow aganglionic bowel in about 70­90% of
segment causing obstructive symptoms (2). HD
the cases (5). For definite diagnosis a rectal
occurs in about 1/5000 live born babies and is
biopsy was needed for histological evaluation
Received: 12/10/2018

Accepted: 01/11/2018

Full Paper (vol.743 paper# 27)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 684-693
Comparative study between corneal biomechanical parameters in diabetic
patients and normal individuals using ocular response analyzer (ORA)
Adel Abd El-Rahman Osman, Ehab Abd-Elsamea El-Sheikh,
Ayman Shawky Abd El-Haleim El-Sanhoury
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
Corresponding author: Ayman Shawky Abd El-Haleim El-Sanhoury, Mobile: 01121479735;
Email: aymanshawkysanhoury@gmail.com
Background: the cornea exhibits viscoelastic properties, which give it the quality of hysteresis. Corneal
hysteresis is an important indicator of the biomechanical properties of the cornea. Objective: this study aimed
to show the impact of diabetes on corneal biomechanics and to compare corneal biomechanics in diabetic to
that in healthy non diabetic individuals using ocular response analyzer (ORA). Patients and Methods: we
conducted our study on the diabetic patients and healthy non diabetic individuals to detect the relation between
diabetes mellitus and the corneal biomechanics. Our study was performed on 120 eyes of 60 individuals as we
categorized them into three groups. Group A involved 40 eyes from 20 controlled diabetic patients, group B
involved 40 eyes from 20 non-controlled diabetic patients and 40 eyes from 20 healthy non diabetic individuals
(Group C). Results: our study reported that diabetes mellitus led to an increase in corneal biomechanics as
CH and CRF were elevated in patients with diabetes mellitus (Groups A & B). Conclusion: the corneal
biomechanics in the diabetic groups were significantly higher compared to those of the control group, as the
mean CH was 9.23 ± 0.98 mmHg in the controlled diabetic group (Group A), 10.11 ± 0.44 mmHg in the non-
controlled diabetic group (Group B) and is 8.03 ± 0.94 mmHg in the healthy non-diabetic individuals (Group
The difference in CH between the three groups was statistically highly significant (P = 0.00). Meanwhile,
the mean CRF was 9.26 ± 1.35 mmHg in the controlled diabetic group (Group A), 10.03 ± 0.99 mmHg in the
non-controlled diabetic group (Group B) and 8.37 ± 0.56 mmHg in the healthy non-diabetic individuals
(Group C). The difference in CRF between the three groups was statistically highly significant (P=0.00).

cornea, ocular response analyzer, corneal hysteresis, corneal resistance factor, intra-ocular pressure,
diabetes mellitus, corneal compensated intra-ocular pressure, Goldman correlated intra-ocular pressure.

of bonds, which is expected to be accelerated in
Diabetes mellitus (DM) is a common
diabetes, leads possibly to a gradual stiffening of
systemic disease, its prevalence ranges between
corneal tissue (6) and that is consistent with the
8.3% and 11.6% of the general population in
observation that diabetic corneas are less
different ethnic groups (1).DM is characterized by
susceptible to the development and progression of
chronic hyperglycemia and an altered cellular
keratoconus (7).
homeostasis which may lead to multi-organ
The effect of diabetes mellitus on the
dysfunction. 70% of DM patients suffer a number
human cornea may have a clinical significance.
of debilitating complications affecting the
Corneal changes induced by chronic abnormal
physiology, morphology and clinical appearance of
glucose metabolism had been reported in the
the cornea. These complications caused diabetic
epithelial, stromal and endothelial layers. Stromal
keratopathy in the form of structural and functional
changes included structural alterations produced by
abnormalities resulting in impaired epithelial and
collagen cross-linking. In vitro studies showed that
endothelial function, punctate keratitis, decreased
collagen cross-linking causes increased stiffness of
corneal sensitivity, recurrent corneal erosions and
the cornea, which in turn may affect the
delayed wound healing (2).The hyperglycemia
measurement of intraocular pressure (IOP) and
caused by DM
induced formation
causing overestimation of the true IOP (8).The ORA
accumulation of advanced glycosylation end
is a further development of a non-contact
products (AGEs), which in turn was strongly
applanation tonometer, that measures the corneal
associated with a number of pathological
hysteresis (CH) and the corneal resistance factor
complications of DM (3).Studies had shown an
(CRF). CH is believed to reflect the damping
increased levels of AGEs in the cornea of DM
properties of the cornea comparable with a shock
patients that led to an increase in collagen cross-
absorber. The CRF provides the total resistance to
linking bonds (4,5). As biomechanical behavior is
deformation of the cornea. It also contains portions
dependent on the regulation and organization of
of the viscous damping (9).
structural components of the cornea, the formation
Received: 13/10/2018

Accepted: 2/11/2018

Full Paper (vol.743 paper# 28)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 694-701

High Resolution Ultrasonic Imaging in the Evaluation of the Posterior Segment
Magdy E. Khallaf, Fatma A Atwa, Abd Allah El Husiny, Ahmad M Salah Eldein
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmad Mohammad Salah Eldein, E-mail: dr_ahmad_aa@yahoo.com, Phone no.: 01005422240
Purpose: to evaluate the role of high resolution 20 MHz ultra sound in assessment of posterior segment
Patients and Methods: a prospective, case series study was conducted on 40 patients who attended the
ophthalmology outpatient clinic of Al-Azhar university hospitals (2014-2018). All should have a posterior
segment disorder either retinal, vascular, vitreo-macular, optic nerve head or choroidal disorder. They should
be with clear media, therefor we can reach a diagnosis based on clinical examination and augmented by optical
coherence tomography (OCT) and fundus fluorescein angiography (FFA) whenever indicated, the patients
were evaluated using both high resolution 20 MHz ultrasound(US) and conventional 12.5 MHz US and
compare their results to the gold standard clinical diagnosis to assess their sensitivity to reach the diagnosis.
Results & Conclusion: we have two main characters for well diagnosis by any US tool, resolution and
sensitivity, and neither the 20 MHz nor 12.5 MHz could combine both of them. Therefore, we recommended
tocombine the examination by both of them as they are complementary to each other.
Keywords: High Resolution US, OCT, FFA, 20MHz US

posterior segment in comparison to the conventional
Ultrasonography is one of the most valuable
frequencies in clear media, keeping the clinical
diagnostic tool in ophthalmology. It is a safe, reliable,
diagnosis augmented by OCT & FFA as the gold
non-invasive diagnostic tool that accepted as an
standard, therefore we can assess the high frequency
integral tool in diagnosis and management of a wide
US reliability and dependability in opaque media.
spectrum of intra ocular and orbital pathologies even
in opaque media as corneal and anterior chamber
opacities, cataract and vitreous hemorrhage (1).
The study protocol adhered to the tenets
of Helsinki and was approved by ethical board
Developments in transducer, pulser/receiver,
of Al-Azhar uniVersity and informed written
and digital signal-processing technologies particularly
consent was taken from each patient in the
development of sensitive, broadband 20-MHz
study, A prospective case series study was
transducers have allowed higher frequencies to be
conducted on forty eyes of thirty-three patients
valuable for evaluation of the posterior segment (2).
who attended the ophthalmology outpatient clinic
OCT had filled the gap in high-resolution
of Al-Azhar university hospitals (2014-2018) with
imaging of the posterior segment of the eye, which is
different posterior segment disorders.
more valuable than resolution provided by 10-MHz
Inclusion criteria, All patients should
US, it can provides an axial resolution of 10 µm and a
have: 1- Cornea, anterior segment, crystalline lens
lateral resolution of 20 µm, however OCT can be used
and vitreous gel all are clear enough for fundus
only when all optical media (cornea, lens, vitreous) are
examination and OCT, FFA imaging. 2- Posterior
mostly clear and is limited to the central fundus (i.e.,
segment pathology, that could be either posterior
images are acquired through the pupil) (3).
vitreal, retinal, optic nerve head or choroidal
Recently, the availability of higher
pathology. Uncooperative patients and patients
frequency probes such as the 20-MHz has made the
who had unclear media (like central corneal
evaluation of the posterior segment structures much
better with higher resolution in comparison to the
hemorrhage, etc.) that prevent fundus viewing and
previous 10-MHz probe (4).
(or) FFA or OCT. to be taken when been indicated
for diagnosis were excluded from this study.
To evaluate the use of higher frequency
Each patient subjected to the following: 1-
ultrasound to provide improved resolution of the
Complete ophthalmological examination including

Full Paper (vol.743 paper# 29)

c:\work\Jor\vol743_30 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (3), Page 702-704

Predictive Factors for Failed Endoscopic Retrograde Cholangiopancreatography
Hassan Abd El-Hafiez, Mohamed Abdel Rasheed, Mohamed Ismail Fadel*
Tropical Medicine Department, Faculty of medicine, Al Azhar University
*Corresponding author: Mohamed Ismail Fadel, E-mail: isia992018@yahoo.com

Background: failure during cannulation renders the endoscopic retrograde cholangiopancreatography (ERCP)
unsuccessful and gives rise to various consequences, including cholangitis and pancreatitis, which may require
interventions, such as percutaneous transhepatic cholangiography (PTC) and surgery, with higher morbidities.
Aim of the Work: we aimed to establish predictive factors for ERCP failure.
Patients and Methods: a total of 103 ERCP procedures were done from October 2016 to October 2017 in the
endoscopy unit at AL Hussein university hospital. Patients were divided according to ERCP results into 2 groups;
group I consists of 93 cases of successful ERCP procedure (90.2%) and group II consists of 10 cases of failed
ERCP procedure (9.7%). After clear written consent, full clinical, sonographic and laboratory evaluation were
done for all patients.
Results: patients with history of previous abdominal surgery and\or CBD stricture had a significant higher rate
of ERCP failure. Duodenal diverticula, papillary mass and gastric outlet obstruction were significantly higher in
failed ERCP group.
Conclusion: any patient with history of previous abdominal surgery, CBD stricture and benign or malignant
tumors should be investigated before ERCP with non-invasive image as magnetic resonant
cholangiopancreatography (MRCP) or Endoscopic ultrasound (EUS).
Keyword: Endoscopic Retrograde Cholangiopancreatography, Magnetic Resonant Cholangiopancreatography
and Endoscopic Ultrasound
Since its introduction in 1968, endoscopic
retrograde cholangiopancreatography (ERCP) has
This prospective study was carried out at AL
become a commonly performed endoscopic
Hussein University Hospital Endoscopy unit from
procedure. The diagnostic and therapeutic utility of
October 2016 to October 2017. The examined
ERCP has been well demonstrated for a variety of
patients were divided according to ERCP results into
disorders, including the management of biliary
2 groups; group I successful ERCP cases; and group
malignancies, and the evaluation and treatment of
II of failed ERCP cases.
benign and malignant disease of the pancreas (1).
All patients signed an informed written
consent before the procedures, after receiving an
endoscopic retrograde cholangio-pancreatography
explanation on the risks, benefits and alternatives of
(ERCP) requires selective cannulation of the bile
ERCP and associated therapeutic procedures.
duct. Despite advances and new developments in
study was approved by the Ethics Board of Al-
endoscopic accessories such as catheters, guide-
Azhar University.
wires and sphincterotomes, selective biliary
cannulation fails in 5%-15% of cases, even in expert
All patients were subjected to full history
high-volume centers (2).
taking, full laboratory evaluation included; complete
blood picture, prothrombin time and partial
Difficult biliary cannulation was defined as
thromboplastin time, liver functions, renal functions
failure to achieve selective biliary access by wire-
and serum amylase, as well as abdominal ultrasound
guided cannulation despite 5 min of attempted
and\or abdominal CT or MRCP when needed.
cannulation (cannultion time > 5 min), papillary
contacts > 5 times, attempted unintentional
ERCP was performed under general
pancreatic duct cannulation > 3 times, or hook-nose-
anesthesia with the patient in the left-lateral or semi
shaped papilla (difficult type of cannulation) (2).
prone position. All procedures were performed by
standard videoduo-denoscopes (Fujinon ED-250

Received: 12/10/2018

Accepted: 01/11/2018

Full Paper (vol.743 paper# 30)