The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 957-968

Effect of Intravenous Immunoglobulin in Reducing Bilirubin Levels in
Hemolytic Disease of Newborn

Shaimaa Waheed Ibrahim El Fekey*, Hamed Mohammed El-Sharkawy1, Aisha Abd-Ellatif
Elsaied Ahmed2, Mohammed Abd-Ellatif Nassar1 and Marwa Mohamed Elgendy1
Departments of 1Pediatric Medicine and 2Clinical Pathology, Faculty of Medicine, Tanta
University, Egypt
*Corresponding author: Shaimaa Waheed Ibrahim El Fekey, Mobile: 01000994337; Email:

hemolytic disease of the newborn is an autoimmune haemolytic disease and
caused by antibodies produced due to Rh and ABO incompatibilities. Neonatal jaundice is a
common clinical problem encountered during the neonatal period. To avoid the associated
neurological complications; exchange transfusion and phototherapy have been traditionally used.
Aim of the work: was to assess the efficacy of intravenous immunoglobulins in neonates with
Rh and/or ABO incompatibility in reducing the duration of phototherapy and the need for
exchange transfusion and hospital stay. Subjects and Methods: in this clinical intervention
study 40 patients diagnosed with hemolytic disease of newborn were grouped into group A and
B. All neonates were treated with standard protocol for phototherapy and exchange transfusion.
Group A patients received only phototherapy. Group B patients received intravenous
immunoglobulins in a dose of 0.5 gm/kg of body weight single dose and phototherapy. Exchange
transfusion was given to the patients of both groups if the bilirubin rose by 0.5 mg/dl per hour.
Results: there was significant decrease of bilirubin level in group B [that received phototherapy
plus Intravenous Immunoglobulin (IVIG)] than group A [that received phototherapy only].
Hospital stay and duration of phototherapy decreased in group B than group A. Number of cases
exchanged blood in group A was higher than cases of group B. Conclusion: addition of
intravenous immunoglobulins for treatment of hemolytic disease of newborn significantly
reduces bilirubin levels, duration of phototherapy, need for exchange transfusion and hospital

Key words: Hemolytic Disease of Newborn, Bilirubin, Intravenous Immunoglobulin.


Hemolytic disease of the newborn is
an autoimmune haemolytic disease and
Because of the risks and burdens of
occurs as a result of hemolysis and
shortening of the life span of the newborn's
immunoglobulin (IVIG) has been suggested
erythrocytes because of antibodies crossing
as an alternative therapy for alloimmune
from the mother by the placenta. Hemolysis
hemolytic disease of the newborn (HDN) to
of erythrocytes in the fetus and newborn is
reduce the need for exchange transfusion .
most frequently caused by antibodies
Immunoglobulins seem to block Fc
receptors on macrophages, which reduces
. Exchange transfusion
the breakdown of antibody coated
and phototherapy have traditionally been
erythrocytes and lowers the circulating
used to treat jaundice and avoid the
Received: 15/10/2018
Accepted: 05/11/2018

Document Outline

Full Paper (vol.745 paper# 1)

Introduction The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 969-977

The Sacroiliac Joint Injection
Hesham M. Farhoud1, Ashraf M. Enite2, Abd Elkhalek AlZalabany1,
Tarek M. Elatar1*
Departments of 1Orthopedic Surgery and 2Radiology
Faculty of Medicine (for girls), Al-Azhar University, Egypt
*Corresponding author: Tarek M. Elatar, Mobile: 01010283986, E-mail:
Background: the sacroiliac joint (SIJ) is the largest axial joint in the body, with an average surface area
of 17.5 cm2, it is an accepted source of low back and/or buttock pain with or without lower extremity
pain. Based upon history and physical examination findings, the prevalence of sacroiliac joint pain in
chronic low back pain population has been shown to range from 22.5% to 62.8%. Aim of this work:
to evaluate the therapeutic benefit of intra articular corticoid injections into the sacroiliac joints in a
standardized fashion. Patients and Methods: This study included 20 adults with SIJ pain due to
different reasons and who were scheduled to undergo SIJ injection of corticosteroids and local
anesthetic. Demographic data to consider includes sex, age, weight, occupation, affected side, co
morbidity and suggested pathology of the examined SIJ. Results: there is significant decrease of the
inflammatory back pain in 85% of patients; on mean post 2.001.86 compared to pre 7.501.24
according to VAS of patients after 6 months follow up (p-value <0.001 HS). Its minimally invasive
procedure & good result by single injection to all patients during 6 months follow up. Conclusion: CT
guided sacroiliac joint minimally invasive, short time, very accurate and good results obtained. Intra
articular SIJ injection is an effective method for alleviating pain in patients suffers from SIJ pain at least
in short term.
Key words: Sacroiliac Joint, intra articular injection
Sacroiliac joint (SIJ) pathology is a
joint cannot function independently because all
common cause of low back pain (LBP),
of these muscles are shared with the hip joint.
accounting for 1027% of cases of mechanical
The ligamentous structures and the muscles that
LBP below L5 level (1,2). If there is no definite
they support influence the stability of the SI
clinical or radiological diagnostic criteria for
joint. The SI joint is innervated mainly by the
SIJ pain, intra articular injection of SIJ have
sacral rami dorsales(5). The anatomical
become the choice assessment method for
structure, innervations, presence of sinusoids
making the diagnosis of SIJ pain. There is good
around the joint, and inter-individual variations
results for diagnostic SIJ injections by using
in structure make SIJ injections difficult to
local anesthetic or placebo blocks and 75
accomplish without any guidance (e.g.,
100% pain relief as the diagnostic for
fluoroscopy, computerized tomography (CT),
sacroiliitis(3). SI joint pain definition is a pain
ultrasound). Clinically-guided SIJ injections
localized in the region of the SI joint, stimulated
without radiographic guidance have been
by special tests of the SI joint, and improved by
reported to result in low rates of intra-articular
selective infiltration of the SI joint by a local
injections, spread into sacral foramina,
anesthetic. Depending on the diagnostic criteria
extension into the epidural space, and vascular
For diagnosis of SIJ pain (clinical examination,
uptake (6).Sacroiliitis is an inflammatory
process of the sacroiliac (SI) joints involving
investigateion), the reported prevalence of SI
one or both sides. It is one of the major clinical
pain through thepatients with axial LBP
accounting for 16% and 30%(24). The SI joint
is a diarthrodial synovial joint. The anterior part
nonsteroidal anti-inflammatory drugs and the
is a true synovial joint. The posterior part is a
application of physical modalities.However, in
syndesmosis consisting of the sacroiliac
severe painful cases, local treatment of the SI
Ligaments, the gluteus muscle (medius and
joint through intraarticular corticosteroid
minimus), and the piriformis Muscle. The SI
Received: 16/10/2018
Accepted: 05/11/2018

Full Paper (vol.745 paper# 2)

c:\work\Jor\vol745_3 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 978-987
Alkaline phosphatase and haptoglobin as predictor of neonatal jaundice
Hannan Mohamed Abd Elmonem *, Ahmed Ragab Fakhr El-Din*, Emad Farah Kholeef & Shahenda
Nasr Eldin*
*Department of Pediatrics, Faculty of Medicine, Aswan University
Corresponding author: Shahenda Nasr Eldin, Mobile: (020)01118301197, E-Mail:
The term kernicterus refers to the clinical features of bilirubin encephalopathy. Its risk is
increased in term babies with very high bilirubin levels. Kernicterus is also known to occur at lower levels of
bilirubin in term babies who have risk factors and in preterm babies.
Objective: The aim of the present study was to investigate whether serum alkaline phosphatse & haptoglobin
(Hp) level could be used for the early diagnosis and prediction of hyperbilirubinemia in newborns.
Methodology: The study is a prospective clinical study design, which was carried out in Pediatric Department,
Faculty of Medicine, Aswan University Hospital. The study included 100 newborns with gestational age more
than 35wk delivered in obstetric department.
Results: Our study showed no statistically significant difference between jaundiced and non- jaundiced cases
regarding the mode of delivery, maternal gravidity and parity. As regards previous sibiling affected, we found
a significant relation between clinically appearing jaundice and previous sibling affected with neonatal
hyperbillirubinemia, which may reflect genetic susceptibility for hyperbillirubinemia. No significant
relationship between gestational age and clinically appearing jaundice. When assessing the relationship
between clinically appearing jaundice and birth weight, our results revealed no significant relationship.
Conclusion: The cord blood alkaline phosphatase level is not only a useful predictor for severe neonatal
jaundice but also can predict the early onset of neonatal hyperbilirubinemia and expected methods of treatment
in healthy newborns more than 35 weeks gestational age.
Keywords: Alkaline phosphatase, Haptoglobin, Neonatal jaundice

Elevation of the serum bilirubin level is a
population have a black nubian skin colour which
common, if not universal, finding during the first
mask jaundice and delay its diagnosis, raising the
week of life. This can be a transient phenomenon
idea of prediction in accessible applicable ways .
that will resolve spontaneously or can signify a
Umbilical cord blood is an important but
serious or even potentially life-threatening
underutilized resource that can be used in the care
condition. Independent of the cause, elevated
of premature neonates. Use of umbilical cord blood
serum bilirubin levels can be potentially toxic to
results in many improved outcomes and its use for
the newborn infant (1).
laboratory testing of neonates is an increasingly
Bilirubin is one of the biologically active end
common practice that has demonstrated benefits (1).
products of heme catabolism. Its clinical
Alkaline phosphatase is found in almost all
significance in the neonate relates to its propensity
for deposition in the skin and mucous membranes,
liver, bile ducts and bone. It is a hydrolase enzyme
producing easily identifiable jaundice (2). As many
responsible for removing phosphate from many
as 60% of otherwise healthy, term newborns
types of molecules (2). It is found in many forms
develop some degree of elevated TB levels.
depending on its origin within the body. It plays an
Imbalance between bilirubin production and its
integral role in metabolism within the liver and
elimination may result in increasing jaundice or
development within the skeleton. Due to its
hyperbilirubinemia (3).
widespread prevalence in these areas, its
At present, for essentially economic reasons,
concentration in the bloodstream is used as a
maternal discharges have to be scheduled early
biomarker helping in diagnosis such as in cases of
within 48 hr of childbirth, so most cases of neonatal
hepatitis or osteomalacia (4). Abnormal levels of
jaundice cannot be detected. Therefore, early
alkaline phosphatase in the blood could indicate
diagnosis of jaundice and timely actions are
issues relating to the liver, gall bladder or bones.
necessary. Moreover, In Aswan a major portion of
Kidney tumors, infections as well as malnutrition
Received: 16/10/2018
Accepted: 05/11/2018

Full Paper (vol.745 paper# 3)

c:\work\Jor\vol745_4 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 988-993
Comparison between self-gripping mesh and sutured mesh in open inguinal
hernia repair
Mahmoud Mohamed Abou El-Yazid, Mahmoud Mohammed Mahran and Alaa Abdel Aty
Department of General Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Alaa Abdel Aty Mahmoud, Phone: (020) 01273999797 E-Mail:

A b s t r a c t
Background: Inguinal hernias are one of the most common problems encountered by the surgeon,
accounting for about 10-12% of all operations. Operations for the inguinal hernia are one of the most
common procedures. Currently herniorrhaphy is the most performed surgical procedure in the world.
Aim: The aim of this study is to compare tissue adhesives and how it can reduce postoperative
complications, especially chronic pain as well as recurrence rate in self-gripping mesh compared with
sutured mesh in open inguinal hernia repair.
Methods: This study conducted on 30 cases of fresh inguinal hernia submitted to inguinal hernioplasty
"mesh repair" 15 of them submitted to sutureless mesh "Group I" while the other 15 cases submitted to
sutured mesh "Group II".
Results: Our results revealed that there was no statistical difference between both groups regarding the
age. Also, there was no significant difference between both groups regarding gender. Our study revealed
that the operative time was longer and blood loss was more during operation in sutured group than in
sutureless group. In spite of increase incidence of complications sutured group than in sutureless in our
study but there was no difference between both groups regarding complications.
Conclusion: From our study we can conclude that the use of self-grip (sutureless) meshes and sutured
meshes in the management of groin hernias have nearly the same results in experienced hands.
Self-gripping mesh, Sutured mesh, Inguinal hernia


in inguinal hernia repair and post-operative
Inguinal hernias are one of the most common
morbidity is now often attributed to other
problems encountered by the surgeon,
outcome measures, especially chronic pain and
accounting for about 10-12% of all operations.
surgical site infection (SSI) (3).
An inguinal hernia can be defined as protrusion
of a part or whole abdominal viscous into the

The current surgical options for mesh
inguinal canal either through the deep ring or
fixation include, but are not limited to, sutures,
through Hasselbach's triangle. Approximately
tacks or staples, self-fixing meshes and fibrin or
75% of all hernias occur in the groin with a
other glues. However, there is no consensus
lifetime risk of 27% in men and 3% in women.
among doctors on the best surgical technique.
About 2/3 of these hernias are indirect and one
The choice of options often depends on
third is direct (1).
surgeons' personal preference (4).

Operation for the inguinal hernia is one
Heavy weight polypropylene meshes have been
of the most common procedure that a general
found to elicit inflammatory reactions
surgeon undertakes and various surgeons have
responsible for mesh shrinkage when scar tissue
given their valuable contribution to different
evolves. Thus, it has been recommended to use
techniques of inguinal hernia repair for better
low-weight meshes and to limit the extent of
outcome in relation to various complications
fixation. More recently, self-gripping meshes
like groin pain, infection, testicular atrophy and
have been developed, avoiding the need for
recurrence etc. related to older techniques (2).
additional fixation. The Parietex ProGri self-
fixating mesh is composed of monofilament

Nowadays mesh hernia repair has
polyester and polylactic acid (PLA) grips, and
become gold standard and increasing mesh
is indicated for use in inguinal and incisional
procedure in hernia surgery led to substantial
hernia repairs (5).
decrease in hernia recurrence rate (1). The use of
mesh has reduced recurrence rates to below 5%
Received: 15/10/2018
Accepted: 04/11/2018

Full Paper (vol.745 paper# 4)

c:\work\Jor\vol745_5 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 994-1002
Assessment of complement (C2&C4) in patients with recurrent candidal
Rabie Bedir Atallah1, Osama Abd-Alazeem Hashem*1, Hesham Samir Abd El-Samea2,
Hagar Ali Mokhtar Abouzayed3
1Dermatology, Venereology &Andrology Department,2 Clinical pathology, Faculty of Medicine, Al-Azhar
University, Damietta, Egypt, 3 M.B.B.Ch
*Corresponding author: Osama Abd-Alazeem Hashem, Tel: 01062227676; Email:
Over the past few decades, candidiasis is a disease of growing incidence that
parallels the increasing number of immunocompromised people. The entity of recurrent
candidal infections has been defined as at least four symptomatic episodes at the last year.
Candida albicans pathogen acts as activating surface for complement deposition i.e., covalent
binding of C3b. Opsonization is the process of deposition of complement fragments on the
surface of pathogen that allows their recognition, ingestion, and destruction by macrophages,
phagocytic cells, neutrophils, and monocytes. IgG antibodies and C3 fragments are the classical
opsonins. Phagocytes express specific receptors for C3 fragments. Complement opsonization
resulting from the direct activation of the alternative pathway on pathogen surface allows their
elimination by phagocytes before the mounting of an adaptive immune response and the
appearance of antibodies.
Aim of the work: The aim of the present work is to clarify the relation between serum
complement (C2&C4) and recurrent candidal infections.
Patients and Methods: A case control study. Sera were obtained from 50 recurrent candidal
infection patients and 30 healthy volunteers. C2 levels were measured using ELISA with
standard kits from EIAab R&D Systems. C4 levels were measured using Automated
Chemistry ELISA with standard kits from EIAab R&D Systems.
Results: Serum complement C2 was significantly lower among the cases with recurrent
candidal infection (65.6348.35pg/ml) than in healthy volunteers 200.29 358.43) with p-
value= 0.01.
Conclusion: Recurrent candidal infection can be caused by low (C2) level in patient's serum.
There is significant alteration in complement (C2) level (P 0.01). There is no significant
alteration in complement (C4) level (P 0.05). Serum complement (C2) level can be used as a
laboratory investigation for patients with recurrent candidal infections especially those with
associated systemic disease.
Keywords: Recurrent candidal infections, candida albicans, complementC2, complement C4.
Conflict of interest: No financial and personal relationships between authors and others that
might be perceived by others as biasing their work. Potential conflicts do not exist.
Candidiasis is a disease of growing
Candida albicans is the most
incidence. The number of cases increases
immunosuppressed patients endogenous
immunocompromised people over the past
infections emanating from colonization
few decades (1). The entity of recurrent
sites can occur with cutaneous infections,
candidal infections has been defined as at
oroesophageal candidiasis and candidal
least four symptomatic episodes at the last
vaginitis (3).
year (2).
The mucosal lesions are milk curd-
like loosely adherent white patches on the
Received: 03/10/2018
Accepted: 22/10/2018

Full Paper (vol.745 paper# 5)

c:\work\Jor\vol745_6 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1003-1007
Role of Pattern Electroretinogram in Early Detection of Glaucoma

Mohamed Abdel-Monem Mahdy, Mohamed Mohamed-Aly Ibrahim, Mohamed Gamal Mostafa

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

Corresponding author: Mohamed Gamal Mostafa Nasar, Mobile: 00201099080936, E-Mail:
Background: glaucoma is the most common cause of irreversible blindness. Primary open angle glaucoma
(POAG) is the most commonly diagnosed form. Pattern electroretinogram emerged as a promising tool for
diagnosing of early glaucoma. Aim of the work: the present study aimed to assess the role of pattern
electroretinogram in differentiating between patients with early glaucoma and normal controls. Methodology:
this study included 25 early glaucoma patients and 25 normal controls. They were undergone into careful
history taking, complete ophthalmic examination and investigations by using PERG, SD- OCT and perimetry.
Results: regarding the comparison we found reduction in amplitude of P50 and N95 between early glaucoma
patients and normal controls.
Keywords- PERG, POAG, SAP
Glaucoma is a group of optic neuropathies
especially those evoked by pattern stimulation
characterized by progressive degeneration of
(6).Improved strategies for achieving earlier and
retinal ganglion cells. These are central nervous
more accurate diagnosis of glaucoma will facilitate
system neurons that have their cell bodies in the
the prompt implementation of effective treatment
inner retina and axons in the optic nerve.
options, and subsequently will minimize the
Degeneration of these nerves results in cupping, a
anticipated rising burden of the disease in the near
characteristic appearance of the optic disc and
future (7).
visual loss (1). Glaucoma affects more than 70
million people worldwide with approximately 10%
Aim of the work
being bilaterally blind (2) making it the leading
cause of irreversible blindness in the world.
This study aimed to assess the ability of
Glaucoma can remain asymptomatic until it is
Pattern Electroretinogram (PERG) to differentiate
severe; resulting in a high likelihood that the
between patient with early primary open angle
number of affected individuals is much higher than
glaucoma (POAG) and normal control patient.
the number known to have it(3). Primary open angle
Patients and methods
glaucoma is the most common type of glaucoma
which is considered chronic optic progressive
This study was carried out on patients
neuropathy accompanied by characterstic cupping,
attending the outpatient clinic of Damnhour
atrophy of optic disc, visual field loss, open angle
Opthalmology Hospital during the period from
and no obvious systemic or ocular disease(4).
January 2018 to September 2018. The study was
Various population-based epidemiological studies
approved by the Ethics Board of Al-Azhar
have reported that more than 50% of glaucoma
cases remain undiagnosed, even in the developed
countries(6). Detection of glaucoma at its earliest
A total of 50 patients (100 eyes) were
stage is a major goal for clinician and researcher.
included in this study: 25 early glaucoma patients
Standard achromatic perimetry (SAP) is integral
(15 men and 10 women; mean SD age 43,8 4
tool for early recognition of visual field loss.
years) and 25 age matched normal controls (16
Among several limitations of standard achromatic
men and 9 women; mean SD age 44,9 3,6 years).
perimetry (SAP), is the subjective nature of the
All patients underwent full opthalmic examination
test. This provoked the interest of researcher to
included visual acuity testing, slit lamp
look for alternatives, objective information
biomicroscopy, gonioscopy, IOP measurement,
provided by electrophysiological responses,
Oct, perimetry and perg.
Received: 08/10/2018
Accepted: 27/10/2018

Full Paper (vol.745 paper# 6)


Prognostic Significance of Systematic Lymphadenectomy as Part of
Primary Debulking Surgery in Patients with Ovarian Cancer
Saied Hosny Bendary 1, Mohamed Esmat Abd Elghany 1,
Salama Saad Abd Al Latif 2, & Mohamed Ahmed Abd Elrauf Attia1*
1 Surgical Oncology Department, 2 Clinical Pathology Department, Faculty of Medicine, Al Azhar
*Corresponding Author: Mohamed Ahmed Abd Elrauf Attia, Phone No.: (+2) 01008382152, E-mail:

worldwide, ovarian cancer is diagnosed in more than 200,000 women yearly and
accounts for over 125,000 deaths. Unfortunately, about 70% of cases are diagnosed in an advanced-
stage with evidence of upper abdominal spread in approximately half of these.
Aim of the Work: was to review the surgical management of female patients with ovarian cancer
including intraperitoneal complete cytoreduction and systematic lymphadenectomy to show
prognosis, post operative morbidities, recurrence and follow up.
Patients and Methods: this study was conducted at Al-Azhar university hospitals and El Agousa
police hospital Ministry of interior - on 20 female patients who suffered from different stages of
epithelial ovarian cancer with stage II, none bulky stage III, and only One patient with bilateral
ovarian cancer stage Ic.
Results: This is study conducted on female patients with ovarian cancer the mean age of the studied
patients was 51.35 years ranging from 37-64 years. 55% of patients represented with abdominal
distension, 50% had abdominal pain, 40% abdominal discomfort,15% had abnormal bleeding ,65%
had nonspecific GIT manifestation ,20% had urinary symptoms and 10% had back pain.
Conclusion: Although the relationship between the retroperitoneal spread of lymph nodes and patient
prognosis has been demonstrated in several studies. lymphadenectomy, as a routine treatment
procedure in ovarian cancer, remains controversial. Moreover, systematic lymphadenectomy often
prolongs operation times, which may result in additional surgical complications such as lymphocele,
lymphatic obstruction, lymphocysts and lymphedema, however these complications may be
alleviated, and better outcome occurred by proper intra operative and post operative management by
expert gynecological oncologist involvement and leveraging adequate instruments, which can
eventually improve survival.
Keywords: Systematic Lymphadenectomy - Ovarian Cancer - Primary Debulking Surgery.


Ovarian cancer is the second most
number of studies have demonstrated the
lethal gynecologic malignancy worldwide, and
importance of maximal cytoreductive surgical
the majority of women present with an
effort minimizing residual disease (2).
advanced stage of the disease. Primary
cytoreductive surgery followed by platinum
lymphadenectomy as part of maximal
and taxane combination chemotherapy is the
debulking surgery is still controversial. Some
standard treatment of this disease (1).
investigators have reported that systematic
Peritoneal implantation by exfoliation
(complete) lymphadenectomy removes bulky
of tumor cells and lymphatic dissemination are
or microscopic nodal diseases and might result
common routes of spread in ovarian cancer, so
in the improvement of survival in patients with
cytoreductive surgery should include both
advanced ovarian cancer (3).
intraperitoneal and retroperitoneal surgical
A meta-analysis from nine studies
procedures. In recent years, there has been
concluded that systematic lymphadenectomy
growing recognition that radical pelvic and
might improve overall survival in advanced
abdominal cytoreductive procedures are
ovarian cancer (4).
associated with a favorable prognosis in
patients with advanced ovarian cancer, and a
analyzing data from previous randomized
Received: 17/10/2018
Accepted: 06/11/2018

Full Paper (vol.745 paper# 7)

c:\work\Jor\vol745_8 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1016-1022

Evaluating the role of OCT in optic disc analysis in glaucoma patients

AbdElmongy E. Ali, Abdullah M. EL-Amin, TagEldin M. Othman, Ahmed F. Gabr, Nesma O.

Department of Ophthalmology, Faculty of Medicine, Aswan University, Aswan, Egypt

Corresponding author: Nesma O. Mohamed, Mobile: (+20)01061199305, E-mail:

thirty patients underwent full ophthalmic examination, including a review of medical history,
best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, gonioscopy, dilated
fundoscopic examination, automated perimetry, and OCT at 1 month and after 6 months.
Objectives: the aim of the study was to assess RNFL thickness, ONH clinically and by OCT and
correlate RNFL thickness by OCT with visual fields by standard automated perimetry in glaucoma
patients, highlighting the usefulness of OCT in glaucoma patients where diagnosis by standard
means were not confirmatory.
Patients and methods: All patients were scanned using SD-OCT (RS-3000; Nidek) after dilation with 1%
tropicamide eye drop and the images were acquired by a single operator. Also, standard automated perimetry
was conducted using the SITA 24-2 of the Humphrey Field Analyzer program (Carl Zeiss Meditec) with a
Goldmann size III stimulus on a 31.5-apostilb background.
Results: There was a statistically significant difference between patients at 1 month and after 6 months as regards
OCT (RNFL), on comparison between the four quadrants at 1 month the mean of the inferior quadrant was >
superior > temporal > nasal respectively. After 6 months the mean of the four quadrants as well as the total
RNFL thickness decreased but only the decrease in the temporal quadrant and total RNFL thickness was
statistically significant (P=0.003, P=0.044 respectively).
Conclusion: An OCT would be significantly informative early in the disease course to diagnose a preperimetric
glaucoma, to confirm on a visual field, and to follow up glaucoma progression.
Keywords: Glaucoma, OCT

Glaucoma is a leading cause
circulation of ONH and axoplasmic transport.
irreversible blindness throughout the world. A
POAG is a major worldwide health concern,
1996 study estimated the prevalence of
because it has an insidious onset and leads to
glaucoma in the world by the year 2000 to be
irreversible blindness(2).
66.8 million, with 6.7 million suffering from
bilateral blindness (1).
In glaucoma there is a relatively slow
loss of retinal ganglion-cell axons. Early loss
Glaucoma is currently defined as a
is usually in the mid-peripheral visual field.
disturbance of the structural or functional
The disease becomes symptomatic at a
integrity of the optic nerve that causes
relatively late stage when central vision is
affected and the visual acuity declines or
may also lead to visual field defects over
extensive loss of peripheral vision occur.
Blindness due to glaucoma is largely can be
minimized by adequate lowering of IOP and
minimized by early glaucoma discovery.
enhancement of optic nerve head (ONH)
While the visual damage is irreversible, it can
usually be arrested, and to achieve this, early
diagnosis have to be attempted(3).
multifactorial chronic and progressive optic
neuropathy with a characteristic acquired loss
A number of ocular imaging devices
of optic nerve fibers. Such loss develops in
the presence of open anterior chamber angle,
reproducible quantification of the retinal
Characteristic visual field abnormalities, and
nerve fiber layer (RNFL) and optic nerve
elevated IOP that affects haemodynamic
head (ONH). The commercially available
Received: 16/10/2018
Accepted: 05/11/2018

Full Paper (vol.745 paper# 8)

c:\work\Jor\vol745_9 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 1023-1030
Esthetic evaluation of early rhinoplasty with complete unilateral cleft lip repair
after nasoalveolar molding
Mohammed Ellithya, Osama Alshahatb, Refaat Ibrahima, Wael Elmohandesc, Sadek Abdelrahmand
a Pediatric surgery department, Al-Azhar university. b Plastic surgery department Al-Azhar university. c Dental
surgery, Al-Azhar university. d General surgery department, Al-Azhar university.

Corresponding author; dr. Refaat Ibrahim. Email:, Mobile: 01001567863
Background: The aesthetic outcome of primary rhinoplasty with complete unilateral cleft lip repair is a
challenging due to nasal deformities, tissue deficiencies and alveolar ridge displacement. The aim of this study
is aesthetic evaluation of primary rhinoplasty with complete unilateral cleft lip repair after nasoalveolar
molding (NAM). Patient and methods: The study was applied on 30 patients with complete unilateral cleft
lip, mean age at presentation was 89.17 73.02 days (range 15-260 days). Presurgical nasoalveolar molding
(PNAM) was done for all patients with mean duration of molding 78.48 5.635 days (range 66-87 days).
Measurements of nose and alveolar defect were taken by caliper before application of the device and after
application of the device and after one month of operation and compared with each other's. All patients were
subjected to lip repair with Millard technique with primary closed rhinoplasty. Primary rhinoplasty with cleft
lip repair becomes easier since NAM diminishes the tension over the soft tissues and reduces severity of
deformity in the lower lateral alar cartilages. Postoperative nasal stent has a great role in improve the esthetic
outcome of primary rhinoplasty. Results: There were significant improvement of nasal symmetry and
reduction of alveolar gap width (AGW) after use of NAM. Conclusion: This study suggests that PNAM within
15 days post-delivery is effective at reducing alveolar gap width, alignment of cleft alveolar segments and
improvement of nasal symmetry as long as the parents cooperate in placing and maintaining the NAM device
in the newborn's mouth and nose.
Nasoalveolar molding, Unilateral cleft lip, Esthetic evaluation, Early rhinoplasty, Primary closed

Cleft lip with or without cleft palate is the
and exposure to teratogenic agents(4). The cleft lip
most common congenital malformation of the head
is typically repaired at 3 to 5 months of age, but
and neck. The impact on quality of life for the child
may be later if Presurgical nasoalveolar molding
and the family can be severe, particularly in
(PNAM) is chosen. PNAM involves the
repositioning of the alveolar segments and
psychological needs must be recognized and
deformed lower lateral cartilages by active
addressed, in for all those involved with the
molding in the neonatal period prior to the primary
patient(1). It is reported that the cleft lip and palate
cheiloplasty. The alveolar segments, premaxilla,
has significant variation depending upon
and surrounding soft tissue gradually shift to their
normal anatomical positions.
background and socio economic status (2). They
may vary from minor notching of lip or bifid uvula
to complete unilateral or bilateral cleft of the lip
and palate(3). The overall prevalence of orofacial
cleft OFC is estimated to be approximately 1 in 700
live births, accounting for nearly one half of all
craniofacial anomalies. As reported by the World
Health Organization (WHO), the prevalence at
birth of OFC varies worldwide, ranging 3.422.9

per 10,000 births for cleft lip, with or without cleft
Figure 1: Device for presurgical nasoalveolar
palate (CL/P), and 1.325.3 per 10,000 births for
cleft palate alone (CPO). The risk factors for CL/P
and CP include family history, maternal nutrition,
Received: 17/10/2018
Accepted: 06/11/2018

Full Paper (vol.745 paper# 9)

Observational study for critically ill patients with respiratory disease on mechanical ventilation for patient ventilator dyssynchrony causes and effect on weaning in respiratoy intensive care unite in Sayed galal hospital The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 1031-1035
Study of Patient Ventilator Dyssynchrony, Causes and Effect on Weaning in
Mechanically Ventilated Patient in Respiratory Intensive Care Unit,
Observational Study
Moustafa Abd El Hafez Zedan, Abdalla Soliman Ayoub, Ameen A Hegazy*
Department of Chest disease and * Department of Internal Medicine, Faculty of Medicine, Al Azhar
University, Cairo, Egypt
Corresponding author M

oustafa Abd El hafez Zedan, Ph

one: (020) 010 3
0 096479, M

Background: Obtaining the comfort in intensive care unit to patients is important. Patient-ventilator
dyssynchrony is a big problem in respiratory ICU and when a chest physician facing it in ICU must be
aware about causes and deleterious effects on the patients, so study of causes and its impact on weaning
outcomes is very important.
Aim of the work:
was to study patient ventilator dyssynchrony, causes and effect on weaning in
mechanically ventilated patients in respiratory ICU.
Patients and Methods: Fifty patients were included in the study admitted at Sayed Galal, Al-Azhar
University Hospital during period from May 2014 - December 2017 in RICU, all patients underwent
the following ,Full history taking , Genral ,Local examinations, Monitoring for occurance of agitation,
patient ventilator dyssynchrony, and duration of weaning, and observation for the cause of the problem.
Exclusion criteria, shock patient with haemodynamic instability.
Results:The diagnosis of cases 18 COPD, 9 pneumonia, 8 bronchectasis, 4 Ild (interstitial lung
disease), 6 OHS(obesity hypoventilation syndrome) and 5 pulmonary edema. Patients with dyssncrony
have more duration of weaning 5.5455+ .90453 days than patients without dyssnchrony have duration
of weaning 3.8125+.83417 days with significant difference. And the dyssnchrony group have more
duration of ICU stay time (days) with 9.8485+1.03444 days than the patients without dyssnchrony
have duration of weaning 8.0625+.85391 days with significant difference .
Conclusion: Patient ventilator asynchrony occurs frequently, it is sensitive to ventilator settings and
artificial airway problem, increased secretions, bronchospasm, alteration in body posture and seems to
be associated with prolongation of weaning time.
Key words: Patient ventilator dyssnchrony, weaning

Patient ventilator asynchrony (PVA) is a
weaning in mechanically ventilated patients in
mismatch between patient and ventilator
respiratory ICU.
assisted breaths and the ventilator's ability to

meet the patient's flow demand (1). The Patient-
Patients and Methods:
ventilator interaction occur two respiratory
This study included a total of fifty patients with
pumps firstly patient's pulmonary system
respiratory diseases attending at Respiratory
controlled by the neuromuscular system and
Intensive Care Unit, Sayed Galal, Al-Azhar
affected by the mechanical characteristics of
University Hospital. Approval of the ethical
the lungs and thorax, and secondly the
committee and a written informed consent from
ventilator controlled by the ventilator settings
all the subjects were obtained. This study was
and the function of the flow valve. Anything
conducted in period from May 2014- December
that affects the harmony between the 2 pumps
results in asynchrony (2). PVA is common in

the intensive care unit (ICU) with up to 25%
Patients' age ranged from 34-63 years and
ventilated patients exhibiting asynchronous
includes 33 males and 17 females. All patients
ventilator interaction (3).
were subjected to the following; full history
The aim of the work was to study patient
taking, general and local examination,
ventilator dyssynchrony, causes and effect on
monitoring for occurrence of agitation and /or
Received:13/10/1018 Acepted:2/11/2018

Full Paper (vol.745 paper# 10)

c:\work\Jor\vol745_11 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 1036-1046
Evaluation of Serum Iron and Transferrin in Idiopathic Nephrotic Syndrome
Patients Attending Al-Hussein Pediatric Nephrology Clinic
Moftah Mohamed Rabeea*, Nayera Mahmoud Al-Akkad*, Gamal Zakariya El-Morsi**, Ahmed Elsayed
Pediatric* and Clinical Pathology** Departments, Al-Azhar Faculty of Medicine.
Nephrotic syndrome is characterized by excessive urinary excretion of albumin and other intermediated-
size plasma proteins such as transferrin.. Excessive urinary losses of transferrin can produce low serum transferrin level
that may lead to low plasma iron concentration and consequently the development of iron resistant microcytic hypochromic
anemia. The aim of the work to evaluate changes in serum iron and transferrin and the relationship between the serum
and urinary transferrin in the active and remission state of nephrotic syndrome
Patients and methods: The present work included fifty children with idiopathic nephrotic syndrome (INS), divided
into 2 groups: group A (25 cases in activity) and group B (25 cases in remission). These two groups were age and sex
matched with a mean age of (7.74 2.45). All patients in this work were clinically evaluated together with routine
laboratory investigations. Serum albumin and urinary alb. /creatinine were assessed. Levels of serum iron, serum ferritin,
serum transferrin and urinary transferrin were measured.
Results: This work shows that the level of hemoglobin, MCV, HCT were statistically significantly lower in the cases
in active state than cases in remission. The mean serum iron, serum ferritin and serum transferrin were significantly lower
in the cases in active state than in the cases in remission .The mean urinary transferrin was statistically significantly higher
in the cases in active state than in the cases with remission.
Conclusion: Urinary transferrin can be considered a reliable parameter for early prediction of iron deficiency
anemia in children with active nephrotic syndrome.
Key Words: Hemoglobin (HG), Mean corpuscular volume (MCV) Albumin/creatinine ratio (alb. /creat) iron deficiency
anemia ,serum iron ,transferrin
Introduction and aim of the work
Iron is essential for most living organisms. It is a
component of hemoglobin, myoglobin as well as a
number of enzymes such as cytochrome oxidase,
This study is a cross-sectional included fifty children
xanthine oxidase, peroxidase and catalase (1). Iron is
with idiopathic nephrotic syndrome; from those
derived from dietary ingestion and it is present in red
attending the pediatric nephrology clinic, Al-Hussein
meat, liver, eggs, green leafy vegetables and fortified
University Hospital; and who were under regular follow
cereal products (2). Transportation of iron is through the
up. During the period from July 2017 to Augustl 2018.
mucosal cells of the upper small intestine by the plasma
Diagnostic criteria for INS were based on the
protein transferrin. Transferrin synthesis occurs
International Study of Kidney Disease in Children.They
primarily in the liver and appears to be related to the level
were 22 males and 28 females. Their ages ranged from 4
of iron storage (3). Childhood nephrotic syndrome
14 years.
characterized by heavy proteinuria results in low plasma

albumin and odema (4). The most common age for
Inclusion criteria: included children with well-
nephrotic syndrome is between 1.5 and 8 years (5). It is
established INS with preserved renal function, and under
characterized by marked urinary excretion of albumin
regular followed-up at Al-Hussein pediatric nephrology
and other intermediated-size plasma proteins such as
transferrin (6). Transferrin is important glycoprotein for
Exclusion criteria: Patients with renal impairment
iron transport between sites of absorption and storage
and use in the body. In nephrotic syndrome, excessive
patients with any manifestations of systemic disease or
urinary losses can produce low serum transferrin level
patients with secondary nephrotic syndrome.
that may lead to decrease serum iron level (7), patients
The patients were classified into 2 groups:
with nephrotic syndrome commonly have microcytic
Group A: This group included 25 nephrotic patients in
hypochromic anemia (6).
activity either 1st time or relapser (recurrence of severe
The aim of the work is to evaluate changes in serum
proteinuria > 40 mg/m2/h or urine albumin dipstick > 2+
iron and transferrin and the relationship between the
on 3 successive days, often with a recurrence of edema
serum and urinary transferrin in the active and remission
after withdrawal of steroid therapy. It included 11 males
state of nephrotic syndrome.
Received: 15/10/2018
Accepted: 04/11/2018

Full Paper (vol.745 paper# 11)

c:\work\Jor\vol745_12 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 1047-1052
Clinicalcharacteristics of children with chronic rheumatic valvular heart
disease in Cardiology Unit, Assiut University Children Hospital

Lamiaa E. Ali*, Farouk E. Hassanein, Faisal Alkhateeb A. Abdullah
Pediatrics Department, Faculty of Medicine, Assiut University, Assiut, Egypt
*Corresponding author: Lamiaa E. Ali, E-mail:

chronic rheumatic heart disease (RHD) is still common in developing countries and
associated with major complications and high mortality. Aim: to describe clinical characteristics of children
with chronic rheumatic valvular heart disease. Patients and Methods: the study included fifty patients with
chronic rheumatic valvular heart disease attending Assiut University Children Hospital over six months.
Full through history and clinical examinations were done to all cases. All cases have been subjected to chest
X-ray, standard 12-lead ECG, and echocardiography. Results: female patients were slightly commoner
than malepatients.Mitral valve was the commonest valve affected followed by aortic valve. Regarding
ECG, left atrial hypertrophy was the commonest finding and mitral regurge was the commonest valve
lesion. While, left atrial hypertrophy was the commonest finding in chest X-ray. Respecting
echocardiography, there was slightly increased in left ventricular end diastolic diameter and left
atrium.Heart failure was the most commoncomplication that occurs in RHD patients. Patients' compliant
with long acting penicillin (LAP) were more than non-compliant. Conclusion: echo-cardiography is the
most important tool for evaluation of valvular heart disease. Left atrial hypertrophy is the commonest
finding by ECG. There is increase in left ventricular end diastolic diameter and left atrium by
echocardiography. Left atrial hypertrophy is the commonest finding in chest X-ray. Mitral valve is the
commonest valve affected followed by aortic valve. Patients' compliant with LAP are more than non-
compliant patients. Recommendation: echocardiography must be used as a screening tool for early
detection of subtle cases of RHD. Application of control programs with special emphasis on the regular use
of secondary prophylaxis.
Rheumatic heart disease, Rheumatic fever, Long acting penicillin, secondary prevention.


Chronic rheumatic heart disease (RHD)
It is very important to distinguish
is characterized by recurrent inflammation with
fibrinous repair. The main anatomic changes of
physiologicalincompetence. Pulmonary stenosis
the valve include leaflet thickening, commissural
is rarely found in patientswith chronic rheumatic
adhesion, and shortening of tendinious cords. It is
heart disease, usually present at birth.
caused by an autoimmune reaction to group A
Echocardiography was shown to be more
hemolytic streptococci that lead to valvular
effective in detecting carditis than clinical
damage (1).
examination (4).
Recurrent attacks of rheumatic fever
Where facilities for echocardiography
(RF) lead to valvular heart disease, heart
are available, regular follow up (at least once per
complications are long-term and severe, if valves
year) should be undertaken.If echocardiography
are involved. Recurrence of RF is common in
is not available; diagnosis of valvular disease
absence of maintenance of low dose of
must depend on careful clinical examination
antibiotics, especially during first few years after
supported by an electrocardiogram (ECG) and
first episode (2).
chest X-ray (5).
About 80-90% of children younger than
The necessity of surgery for chronic
fifteen years live in areas where RHD is endemic.
rheumatic valve disease is determined by the
Mitral incompetence (MI) is the commonest
severity of the patient's symptoms and/or
lesion found in patients with chronic RHD (3).
evidence that cardiac function is significantly
impaired (6).
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 12)

c:\work\Jor\vol745_13 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1053-1063
Early Complete Response after Chemotherapy as A Prognostic Indicator for
Final Outcome in High Grade Non-Hodgkin's Lymphoma Patients

Ahmed Yousery EL Agamawy 1, Mohsen Salah El Din Zekry 1, Hala Abd El Badie Nayel 2and Eslam
Mohamed Mohamed 1*
1Clinical Oncology And Nuclear Medicine Department, Faculty Of Medicine, Al-Azhar University, 2Kasr
Al-Ainy Center of Clinical Oncology and Nuclear Medicine, Faculty Of Medicine, Cairo University,
Cairo, Egypt
*Corresponding Author: Eslam Mohamed Mohamed,

In spite of progress in management of high-grade Non-Hodgkin's Lymphoma (NHL), more
than 30% will ultimately relapse after standard treatment. Aim of study: was to estimate early complete
response (CR) as a prognostic factor for final outcome and benefit of early switching to second line
chemotherapy for slow responders. Patients and Method: Newly diagnosed patients with high-grade
NHL were randomized to either Group A or Group B. All patients received 3 cycles of CHOP/RCHOP
while, only patients in the group B who didn't achieve early CR were shifted to second line
chemotherapy. Results: The clinicopathological characteristics of patients included in the two groups
were comparable. Assessment of treatment results after the 6th cycle showed that 10 patients achieved late
CR, 4 patients in group A (40%-4/10) and 6 patients in group B (6/785.7%). This difference was
statistically significant (p-value 0.04). Out of the early CR group (24 patients), one patient died and
another developed CNS relapse thus, both mortality (1/24) and relapse rate (1/23) of early CR group is
4%. Two patients of late CR group relapse (2/10-20%). The difference between the relapse rates of early
CR (4%) and late CR (20%) wasn't statistically significant. The remaining 22 patients (22/23-95.7%)
achieved early CR and 8 achieved late CR (8/10-80%) were in maintained remission. Regarding toxicity
profile, there was no significant difference between both groups.
: Early shifting to second-line chemotherapy is tolerable and promising. However, studies
with larger number of patients are mandatory to identify who may need this approach.
Keywords: NHLs, early complete response and shifting to second line in NHLs.

Although major advances have been
Although RCHOP regimen is the
made over the last decades in the management
standard treatment for patients with aggressive
of aggressive non-Hodgkin`s lymphoma, not all
NHL about 30% to 50% of patients are not cured
patients achieving a response go-on to achieve a
by this treatment, 20% suffer from primary
cure. Relapses are observed in a significant
refractory disease, whereas 30% relapse after
proportion of patients. Consequently, the aim
achieving CR depending on disease stage or
remains to identify patients who are at risk for
prognostic index (3).
relapse and may benefit from intensification of
initial therapy (1).
Patients with relapsed DLBCL treated
with either R-ICE or R-DHAP followed by
The development and utilization of
autologous stem cell transplant had a 3-year OS
Rituximab had obviously improved the
of 49% in the Collaborative Trial in Relapsed
prognosis of NHL patients and had been the
Aggressive Lymphoma (CORAL) study and
standard of care in first-line treatment regimens.
there was no statistically difference between the
Standard first-line chemotherapy included
two regimens as second line treatment (4).
Rituximab with CHOP (R-CHOP), with
expected 5-year and 10-year overall survival
The aim of the current study was to
(OS) rates of 58% and 43.5%, respectively (2).
estimate early complete response (CR) as a
Received: 17/10/2018
Accepted: 06/11/2018

Full Paper (vol.745 paper# 13)

c:\work\Jor\vol745_14 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1064-1068

Functional Outcome of Humeral External Rotation Osteotomy in ERB's
Ahmed Shamma, Galal Mansour, Mostafa Salah Mohamed*

Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
* Corresponding author: Mostafa Salah Mohamed, E-mail:
: Shoulder internal rotation contracture is the most common deformity affecting the
shoulder in patients with Erb's palsy. With progression of the deformity, the glenohumeral joint become
more dysplastic which may lead to severe functional impairment of the affected limb.
Aim of the Work: was to evaluate the functional outcome of external humeral rotational osteotomy.
Patients and Methods: This is a prospective study on 10 patients with Erb's palsy who underwent external
humeral rotational osteotomy. In this study the patients were evaluated for improvement of abduction and
external rotation of shoulder after at least 6 months of operation.
Results: The mean preoperative external rotation improved from -40 to 41 and the mean preoperative
abduction improved from 135 to 150. The mean mallet score for preoperative external rotation
improved from 2.20 to 4 and the mean mallet score for preoperative abduction show no difference as
all patients could raise their arms above 90 degree pre and postoperatively.
Conclusion: External humeral rotational osteotomy improves shoulder function in patients with
brachial plexus birth palsy suffering from internal rotation contracture associated with advanced
glenohumeral joint deformity.
Keywords: Humeral External Rotation, Osteotomy in ERB's Palsy, Obstetric Brachial Plexus Palsy

Obstetric brachial plexus palsy (OBPP)
humeral rotational osteotomy in children with
occurs due to injury of the nerve roots of the
Erb's palsy.
upper extremity in the neck which may occur in
case of difficult delivery. Erb's palsy (C5, 6) is
a very common type of OBPP. Most of the
This prospective study included a total
infants with Erb's palsy will show spontaneous
of 10 patients with Erb's palsy who underwent
recovery (1, 2). However, some of them show
external humeral rotational osteotomy attending
internal rotation contracture of the shoulder
at Al-|Azhar University Hospitals. Approval of
joint due to lack of opposition to muscle forces
the ethical committee and a written informed
generated by latissmus dorsi, pectoralis major,
consent from all the subject's parents were
subscapularis and teres major muscles.If this
obtained. This study was conducted between
internal rotation deformity is not repaired, it
January 2017 and June 2018.
may progress to posterior dislocation of the
Inclusion criteria:
shoulder joint with bony deformity of the
Older Children with limited active and

passive external rotation and associated with
Surgical treatment of the internal
advanced glenohumeral deformity.
rotation contracture is either by soft tissue
Exclusion criteria:
release or by bony osteotomy. Traditionally, the
osteotomy is done for older children with
Other paralytic conditions.
advanced glenohumeral deformity. The
All patients are subjected to carful
direction of the osteotomy is external rotation
history taking and open communication with
osteotomy aiming to improve the function of
their parents and the functional deficits. Careful
the upper extremity. This osteotomy ignores the
examination is also done.
glenohumeral deformity as it may lead to
posterior dislocation of the humeral head in
The patient should be properly exposed
relation to the glenoid. 4).
to permit complete inspection of both
shoulders. Swelling, asymmetry, muscle
The aim of the current work was to
evaluate the functional outcome of external
dyskinesia, infection and any venous distention
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 14)

c:\work\Jor\vol745_15 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1069-1074

Comparative Study for Serum Zinc and Copper Levels in Cases with Normal
Pregnancy Versus Preeclampsia
Ahmed Saied Sayed Mohamed1 , Fahd Abdelaal El-Omda1 ,Ahmed Taha Abdelfatah1 ,Mahmoud
Abdellatif Hashish2
1Department of Gynecology and Obstetrics, 2Clinical Pathology, Faculty of Medicine, Al-Azhar
University, Cairo, Egypt
Correspondence author: AHMED SAIED SAYED MOHAMED, Phone: 01278601420 - Email:
Preeclampsia is a leading cause of both maternal and prenatal morbidity and mortality
worldwide. Preeclampsia is more common in developing countries due to women's low dietary intake of
essential minerals and vitamins, micronutrients such as copper, zinc, magnesium, manganese and
Aim of work: was to investigate the levels of serum zinc and copper in preeclamptic women versus
normal pregnant women.
Patients and Methods: This case-control prospective study included a total of 50 pregnant women
attending the Antenatal Clinic, Department of Obstetrics and Gynecology, Al-Azhar University Hospital.
Subjects were categorized into 2 groups. Group I: 25 women with preeclampsia and Group II: 25
normal pregnant women without preeclampsia who served as controls. Studied group women were
subjected to the following investigations: Urine analysis for detection of albumin and measurement of the
degree of proteinuria, CBC, liver function tests, renal function tests, coagulation profiles and serum zinc
and copper estimation were done. Results: have showed that preeclamptic pregnant women have low
serum concentration of zinc (Zn) and copper (Cu) comparing to the healthy pregnant women. Zinc levels
in control group was 95.7 mg/dL and in preeclamptic group 60.8 mg/dL with highly significance
statistical difference (p<0.001). Copper levels in control group was 96.7mg/dL and in preeclamptic group
62.9 mg/dL with highly significance statistical difference (p<0.001).
Concusion: It could be concluded that there are certain circumstances where preeclamptic pregnant
women have low serum concentration of zinc (Zn) and copper (Cu) than the healthy pregnant women.
This suggests the possible involvement of depleted serum trace element in the pathogenesis of
preeclampsia, but we could not tell if this decrease in serum levels of Zn and Cu was a cause or a result of

Key words:
Zinc, Copper, Normal pregnancy nutrition, Preeclampsia.
stands next to hemorrhage and embolism among
Preeclampsia is one of the most important
pregnancy related cause of death (1).
diseases of pregnancy. It complicates 7%-10%
of all pregnancies and is a leading cause of both
The greatest impact is in developing countries,
maternal and prenatal morbidity and mortality
where it accounts for 20- 80% of the strikingly
worldwide. Preeclampsia is defined as a
increased maternal mortality. Preeclampsia is
more common in developing countries due to
(hypertension), swelling (edema) and protein in
women's low dietary intake of essential minerals
the urine (proteinuria) developing after the 20th
and vitamins. Pregnant women in developing
week of pregnancy. The etiology of this
countries have been reported to consume diets
relatively common medical complication of
that are low in minerals and vitamins.
pregnancy still unknown. Hypertensive disorders
Inadequate dietary intake might be harmful not
account for 40000 maternal deaths annually. It
only for the mother but also for the growing
Received: 14/10/2018
Accepted: 03/11/2018

Full Paper (vol.745 paper# 15)

c:\work\Jor\vol745_16 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1075-1078

Management of Lumbo-Peritoneal Shunt Complications in Patients with
Idiopathic Intracranial Hypertension
Ibrahim Ewaiss1, Mohamed Rashid2, Al-Sayed Roshdy1, Samer Magdy1*
Departments of 1Neurosurgery and 2Clinical Pathology, Faculty of Medicine, Al-Azhar University
* Corresponding Author: Samer Magdy Sharaf El-Din, E-mail:
Background: lumboperitoneal (LP) shunt is one of the best surgical management in treatment of
Idiopathic intracranial hypertension (IIH).
Objective: to review the LP shunt complications and their management in IIH.
Patients and Methods: a total of 20 patients who got complications after LP shunt and needed shunt
revision were included. There were 18 females and 2 males treated at Al-Hussein university hospital
and Al-Mataria teaching hospital during the period from December 2015 and June 2018.
Results: there were 18 (90%) females and 2 (10%) males with age ranged from 18 to 48 years.
Obstruction was the most common complication happened in 8 (40%) patients. Migration was the
second common complication happened in 6 (30%) patients. Shunt infection is the one of the most
dangerous complication and needs early intervention. There was one (5%) case of infection which
required removal of the LP shunt. Tow (10%) patients had CSF leakage. One (5%) patient had
symptoms of over drainage. One (5%) patient had radiculopathy. One (5%) patient had intestinal
Conclusion: LP shunts for the treatment of IIH seems to be a safe procedure. Serious complications
were rare. Only one case was deteriorated. Some patients need more than one shunt revision.
Keywords: Lunboperitoneal shunt, Idiopathic intracranial hypertension, complications.
Idiopathic intracranial hypertension
repeated lumbar punctures to shunt operation
(IIH) is a disorder characterized by increased
and optic nerve sheath decompression(4).
intracranial pressure with normal cerebrospinal
Lumboperitoneal (LP) shunt has many
fluid composition, and no other cause of
advantages over ventriculoperitoneal (VP)
shunt includes: lack of cerebral cannulation, the
neuroimaging. Main symptoms are headache,
possibility of using regional anesthesia with
vomiting, diplopia and visual disturbances(1).
percutaneous insertion in adults, freedom from
Main signs are papilledema, visual field loss
proximal obstruction by choroid plexus and
and sixth nerve palsy(2).
brain parenchyma, a low rate of infection and
The incidence of IIH is 0.9/100,000
the ability of insertion in the presence of
individuals. It increases to 3.5/100,000 in
small/slit ventricles(5).
women ages 1544, and to 19.3/100,000 in
women aged 2044 years who are 20 % or more
above their ideal weight(3).
It is to evaluate the LP shunt
complications and their management in IIH.
The treatment of IIH has two major
goals: the alleviation of symptoms (usually
headache) and the preservation of vision.
In this retrospective and prospective
Medical therapy and weight reduction are
study, 20 patients with IIH got complications
successful treatments in most patients. Visual
after LP shunt insertion (age ranged from 18
fields should be monitored. In rare cases, visual
48 years with average of 31 years). There were
defects or acuity may worsen despite medical
18 females and 2 males treated at Al-Hussein
treatment, and surgical treatment may be
university hospital and Al-Mataria teaching
necessary. Surgical management ranges from
hospital during the period from December 2015
and June 2018. Written consent was obtained
Received: 18/10/2018
Accepted: 07/11/2018

Full Paper (vol.745 paper# 16)

c:\work\Jor\vol745_17 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1079-1087
A Case Control Study on the Effect of Vitamin D on Childhood Cancer
Salma B. Galal (1), Somaya M. Lashin (1), Hanaa AbouElyazid (1), Sahar A. Khalil (2) and
Doaa S. Ahmed (1)*
1- Department of Community and Occupational Medicine, Faculty of Medicine for Girls, Al-Azhar University.
2-Pediatric Oncology Department, National Cancer Institute, Cairo, Egypt
* Corresponding author: Doaa Sadek Ahmed,

Background: Childhood cancer in Egypt is a growing concern for the society. The role of vitamin D
as promising anticancer agent is evident. A limited number of studies have examined vitamin D status
among pediatric oncology patients.
Aim of the Work: was to detect some risk factors of childhood cancer, to assess level of vitamin D and
identify factors influencing its level in newly diagnosed cancer children and controls.
Subjects and Methods: A case control study was designed including 160 children, aged 1 to 15 years.
80 children were randomly chosen from newly attendants of the National Cancer Institute in Cairo,
while controls were recruited from healthy children accompanying parents in a polyclinic in Cairo. The
questionnaire included, beside characteristics of parents, risk factors of childhood cancer. A subsample
(40 cases, 40 controls) was investigated for serum vitamin D. SPSS 17 was used for statistical analysis.
Results: 63.8% of the diagnosed cancer children were males compared to 55% of controls.
Hematological tumor was the most predominant type. Significantly more cases than controls were of
higher birth order , had older fathers, less educated mothers, positive family history of cancer, no folic
acid supplementation of mothers during pregnancy, and low vitamin D level (p=0.000). In addition,
they mentioned less frequent sun exposure days, incorrect timing of exposure, and lack of sport
Conclusion: It is concluded that deficiency of vitamin D, family history of cancer and lack of maternal
folic acid were detected as significant risk factors of childhood cancer.
Keywords: Childhood Cancer, Vitamin D.
Childhood cancers describe cancers
per million children. The rates were 146.6 and
that occur between birth and 15 years of age.
116.0 for males and females respectively. These
They differ from adult cancers in the way they
cancers represented 2.7% of total cancer for all
grow and spread, how they are treated, and how
ages (4).
they respond to treatment. Globally, 215,000
The development of cancer is a
cancers are approximately diagnosed per year
multistep process which is characterized by
in that age group with an estimated 80,000
uncontrolled cell growth and division.
cancer-related annual deaths among them (1).It
Malignant transformation is a complex process
was documented that cancer incidence rates
starts by initiation of cellular genetic mutation
increased in children by 0.6% per year from
followed by promotion of initiated cells to
1975 to 2012 (2).
become cancerous through environmental
More than 80% of all childhood cancer
substances or even radiation and chemicals
cases occurs in low- and middle-income
(epigenetic changes). Finally cancer can spread
countries. In Egypt, it is of concern as its
to surrounding or distant tissues or organs (5).
incidence is increasing rapidly. There is a large
Through previous studies which
uncertainty accompanies statistics for cancer
mentioned risk factors of cancer, optimal level
incidence and survival. Children's Cancer
of vitamin D has been acknowledged as
Hospital estimated 8500 children diagnosed
promising anticancer agent through its anti-
with cancer in Egypt every year (3). Results of
carcinogenic properties in the form of
the national population-based cancer registry
decreasing cell proliferation, increasing cell
showed a crude incidence rate equal to 128.6
differentiation, decreasing angiogenesis, and its
Received: 10/10/2018
Accepted: 29/10/2018

Full Paper (vol.745 paper# 17)

Study the Relationship between Chronic Inflammation and DNA Changes Children on Regular Hemodialysis The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1088-1093
Study the Relationship between Chronic Inflammation and DNA Changes in
Children on Regular Hemodialysis
Maha Zein El-Abden 1, Manal Abdel Salam1, Soheir Saad Korraa2,
Heba Allah Moawad 1
1Department of Pediatrics, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2Department of Molecular Biology, National Center for Radiation Research and Technology- Atomic
Energy Authority, Cairo, Egypt
Corresponding author: Manal Abdel Salam, Tel.: 01006337676,Email:
Background and Aim of the Work: Inflammation is a common feature in chronic kidney disease (CKD),
especially enhanced in end stage renal disease patients on hemodialysis (HD). Under inflammatory
conditions, reactive oxygen species (ROS) and reactive nitrogen species (RNS) are generated from
inflammatory and epithelial cells and result in DNA damage. In this study we assess DNA fragmentation in
children with chronic kidney disease on regular hemodialysis sand detect its relation with some of the
inflammatory markers.
Material and Methods: The study included 40 children with CKD on regular hemodialysis (HD), and they
were selected from the hemodialysis unit of Al-Zahraa hospital, Al-Azhar University, during the period from
April 2016 to January 2018. Another group of 40 apparently healthy children, matches age and sex with
patients group as a controls. Serum level of C-reactive protein (CRP), tumor necrosis factor (TNF-) and
DNA fragmentation assay in the same line with routine investigations were assessed for both groups
Results: Children on regular hemodialysis have significantly higher CRP and TNF- serum levels compared
to their controls, it was (27.254.64 mg/L),(10.041.90 ng/ml) and (1.860.59 mg/L) (2.750.56 ng/ml)
respectively, (P<0.001). There was a significant increase in DNA fragmentation in patients group
(1.510.31) compared to the controls (0.540.21) with (P<0.001). DNA damage was present in (92%) of the
study patients. There were significant positive correlations between DNA fragmentation and serum level of
CRP, TNF-, body mass index and dialysis duration.
Conclusion: Almost children on hemodialysis are exposed to DNA damage with significant association with
inflammatory markers, duration of hemodialysis and BMI.
Keywords: CKD, DNA damage, hemodialysis, TNF-

Chronic kidney disease (CKD)
HD). This chronic inflammatory state seems to
is a progressive condition marked by deteriorating
contribute to aggravate kidney dysfunction and favor
kidney function over time. The early stages of CKD
the occurrence of comorbidities and the risk of mortality
are manifested by kidney damage and are generally
asymptomatic, whereas more advanced stages of
Chronic inflammation can itself lead to
CKD require treatment of uraemia and its
increased oxidative stress in advances renal
complications and ultimately renal replacement
disease, with malnutrition, chronic volume
therapy when end-stage renal disease (ESRD) is
overload and autonomic dysfunction as some
reached (1).
factors implicated in the increased inflammatory
Patients with chronic kidney disease
state seen in renal impairment. Studies have
(CKD) have high incidence rates of cardiovascular
observed association between many mediators of
disease and cancer. Several factors contribute to
inflammation such as CRP, IL-6, TNF- and renal
these conditions, uraemia, micro-inflammation and
dysfunction, in chronic kidney disease patients, the
oxidative stress [free radicals, reactive oxygen
polymorphnuclear neutrophils are activated and
species (ROS), etc] are the main mechanisms
myeloperoxidase is generated, triggering reactive
underlying this phenomenon (2).
oxygen species activation(4).
Inflammation is a common feature in CKD,
Extensive genetic damage in patients with
especially enhanced in ESRD patients on hemodialysis
CKD, possibly due to accumulation of uremic
Received: 27/10/2018
Accepted: 21/11/2018

Full Paper (vol.745 paper# 18)

c:\work\Jor\vol745_19 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1094-1097
Compliance to short term antibiotics in rural and urban areas in Al-Ahsa-KSA
Abdulrahman Abdulwahab Alhulaybi, Abdullah Saud Almutairi, Salem Ali Almarri, Amro khalid
College of Medicine, king Faisal University, Alahsa, Saudi Arabia
Background: non-adherence to medication is considered as one of the largest drug related issues in the medical
field. It results in development of drug resistance besides other harmful effects on the health of individuals. Aim
of the work:
there is very little data about compliance in Saudi Arabia. So, we conducted this study to see the
adherence to the antibiotics by the patients in Al-Ahsa comparing the urban and rural population.
Methods: this was a cross sectional observational study in which 215 people were asked questions about the
adherence to the antibiotics prescribed by physicians. A convenient sample of 215 people was selected due to the
constraint of resources (Finance and time). A questionnaire was designed to include the questions about the
adherence to the antibiotics prescribed besides demographic characteristics. Data were entered in SPSS statistic20
which was also used for analysis by using crosstab for the numeric data and chi-square was used to see if there was
a relationship between variables. Results: the present results showed that 70.69% of
the population was not adhering and 29.30% were adhering to the antibiotic course. In urban population, 38% of
the people were adhering to the short term antibiotics compared to 22% in rural areas.
Conclusion: there is a need for increasing the awareness about completing the antibiotic course among the people
in general and in rural areas in particular.
Compliance to the drugs can be described as taking
Method and procedures:
the drugs according to the prescription by the
physician (1).However, non-adherence to medication
This was a cross sectional observational study in
is considered as one of the largest drug related issues
which 215 people were asked questions about the
(2).It is believed that it is big problem in many
adherence to the antibiotics prescribed by physicians.
societies of the world (2). Not taking the antibiotics
A convenient sample of 215 people was selected due
according to doctor prescription may lead to drug
to the constraint of resources (Finance and time). The
resistance (3-7). There are many kinds of drug
questionnaire was designed to include the questions
compliance, but this research focused on the
about the adherence to the antibiotics prescribed
adherence to short term antibiotics. In 2013 a study
besides demographic characteristics. The target
conducted in Riyadh found that non-compliance
population in this research was adults in the rural and
resulted in several undesired consequences.
urban society groups. This was a cross sectional
Admissions due to non-compliance had been
observational study in which 215 people were asked
estimated to account for up to 10.5% of all admissions
questions about the adherence to the antibiotics
to hospital (7). In 2012 there was a study in Germany
prescribed by physicians. A convenient sample of 215
about medication adherence and it showed that 33%
people was selected due to the constraint of resources
of Germans repeatedly fail to follow their doctor's
(Finance and time). A questionnaire was designed to
recommendations regarding the pharmacological
include the questions about the adherence to the
treatments and only 25% of Germans describe
themselves as fully adherent(5).There was little data
characteristics. Procedure for data collection included
about compliance in Saudi Arabia. So, we conducted
visits to public places in urban areas ( Malls,
this study to see the adherence to the antibiotics by
university, public street ) and to different rural areas (
the patients in Al-Ahsa comparing the urban and rural
Villages, farms, desserts ). Data were entered in SPSS
population. The question was "are we taking our
statistic 20 which was also used for analysis by using
antibiotics in the right way?" This was what our
crosstab for the numeric data and chi-square was used
research based on. The aim of this research was to
to see if there was a relationship between variables.
determine how many people were adhering to their
medications and what were the reasons of non-
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 19)

c:\work\Jor\vol745_20 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1098-1110
Direct Cost Estimation of Infection Control Strategy in Pediatric Intensive
Care Unit at Tanta University Hospital

Mohammed Nagy Hammad Elganiny1, Ahmed Abd Elbasset Abo Elezz1, Enas Arafa Elzimmrany2
and Dina Hassan Abd Elhady3

Department of Pediatric Medicine1 and Department of Clinical Pathology 2, Faculty of Medicine,
Department of Applied Statistics Faculty of Commerce3 - Tanta University, Egypt
Corresponding author: Mohammed Nagy Hammad Elganiny; Mobile: 01066802698;


Background: Hospital-acquired infections (HAIs) are a major complication of hospital care in adult and
children. Estimating the cost of infection control is important because HAIs cost a lot by extending patient
length of stay this is a major risk factor for HAI.
Estimation of the direct cost of medical infection control measures and the direct cost of
hospitalization among patients with and without hospital-acquired infections in the Pediatric Intensive Care
Unit at Tanta University Hospital.
Subjects and Methods: fifty infants and children (with and without HAI) who were admitted to PICU
were subjected to clinical examination and investigation to diagnose infection. The direct cost included
feeding requirements, investigations, procedures, medications and infection control measures. Prices used
according to the period from October 2016 to September 2017 for calculating patients cost.
Results: The average total direct cost of hospitalization, for cases with HAI was 8940.45 EP, which was
significantly higher than that for patients without HAI (2935.63 EP). There was a significant difference in
the average cost per day between patients with and without HAI. The average total direct cost of
management for cases with HAI was 7068.77 E.P, which was significantly higher than that for patients
without HAI (2191.66 E.P). The average total infection control cost for cases with HAI was 1871.69 E.P,
which was significantly higher than that for cases without HAI (743.96 E.P). The mean length of stay
(LOS) in PICU was significantly longer for patients with HAI (19.08 days), while in patients without HAI
was 7.44 days (range 4-11).
Conclusion: The cost of infection control is much lower than the cost of hospital-acquired infections
management that prolongs hospital stay causing financial losses to the health system.

Key words: Cost Estimation; Infection Control Strategy; Pediatric Intensive Care Unit.

morbidity and mortality (2).

Healthcare-associated infections (HAIs) in
The level of risk relates to the type of
the Pediatric Intensive Care Units (PICUs) are a
clinical contact healthcare workers who are
major problem resulting in a prolonged length of
dealing with potentially infected or colonized
hospital stay, increased medical costs, and
patient groups, instruments or environments, and
the health status of the healthcare worker (e.g.
increased morbidity and mortality (1).
Blood stream infection (BSI), urinary tract
immunized or immuno-compromized) (3).
infection (UTI) and pneumonia are the most
Vascular access is crucial in the critical care
common NI reported from an Intensive Care Unit
setting. Central venous catheters (CVCs),
(ICU) set-up, and associated with increased
peripherally inserted central catheters (PICCs),
length of hospital stay, health-care expenditure,
and arterial catheters, are common place in
Received: 15/10/2018
Accepted: 04/11/2018

Full Paper (vol.745 paper# 20)

c:\work\Jor\vol745_21 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1111-1122

The study of oxidative status in children with end stage renal disease on regular

Ahmed Mohamed Mahmoud Odima1, Nagy Mohamed Abo Elhana1, Wesam Salah Mohamed2 and
Mohamed Abd Elaziz Elgamsy1.

Department of Pediatric Medicine1 and Department of Clinical Pathology 2, Faculty of Medicine, Tanta
University, Egypt.
Corresponding author: Ahmed Mohamed Mahmoud Odima; Mobile: 01008869083; Email:


Oxidative stress has long been demonstrated in haemodialysis patients. However, the factors
influencing their oxidative status have not been characterized extensively in these patients. Despite
heterogeneity in the oxidative stress levels in the CKD population, there has been little effort to measure patient
oxidative stress levels before the use of any anti-oxidant therapies to optimize outcome.
Objectives: Assessment of oxidative stress and the effects of using antioxidant medications on oxidative status
in children with end stage renal disease under regular hemodialysis.
Subjects and Methods: 70 children were included in this study and were categorized into 2 groups: Group
(1): 35 children with ESRD on regular haemodialysis. Their ages ranged from 8 to 15 years old. They were 14
males and 21 females. All patients were undergoing haemodialysis three times per week, with each dialysis
session lasting for three to four hours. Group (2): 35 healthy children with matched age and sex that were
serving as control group. All patients were receiving antioxidant drugs regularly for 3 months. These
antioxidant drugs were vitamin E in a dose of 5 mg/kg/day, vitamin C in a dose of 100-200 mg /day, N-Acetyl
Cysteine in a dose of one sachet (200 mg) twice daily with meal. All children in both groups were subjected
to: (a) complete history taking. (b) Full clinical examination. (c) Laboratory Investigations [Routine
Investigations: CBC, blood urea, serum creatinine and BUN, PTH and PT, PTT and Bleeding Time. Specific
: Measuring levels of 1-Interleukin-1, tumor necrosis factor alpha, thiobarbituric acid reactive
substances and malondialdehyde].
Results: There was an increase in markers of oxidative stress in children with end-stage renal disease on
regular haemodialysis in the form of: 1) Increase serum level of interleukin 1 (IL-1). 2) Increase serum level
of tumor necrosis factor alpha (TNF-). 3) Increase serum level of thiobarbituric acid reactive substances
(TBARS). 4) Increase serum level of malondialdehyde (MDA). These levels were decreased with antioxidant
drugs used in this study.
Conclusion: The high levels of oxidative stress markers were decreased after regular therapy by antioxidant
medications for 3 months in the form of vitamin E (5 mg/kg/day), vitamin C (100-200 mg /day) and N-Acetyl
Cysteine (one sachet (200 mg) twice daily with meal).
Key words: Oxidative status: End stage renal disease; Hemodialysis.


ESRD represent the state in which a
million in 2003 (2).
patient's renal dysfunction has progressed to the
The etiology of CKD in Egyptian children
point at which homeostasis and survival can no
less than 5 years of age was comprised of
longer be sustained with native kidney function and
parenchymatous disease in 73% of cases and
maximal medical management. At this point renal
obstructive etiology in 27% of cases, while after 5
years of age parenchymatous disease was 67% and
transplantation) become necessary (1). Data from
obstructive etiology accounted for 33% of cases,
the United States Renal Data System (USRDS)
this was explained by the possible abuse of
revealed that in patients younger than 20 years old
nephrotoxic antibiotic in young infants and
of age, the annual incidence of ESRD increased
children (3).
marginally from 13 per million in 1988 to 15 per
A compound becomes a free radical by
Received: 15/10/2018
Accepted: 04/11/2018

Full Paper (vol.745 paper# 21)

c:\work\Jor\vol745_22 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1123-1127
Incidence, Prevention and Management of Post Tonsillectomy Hemorrhage
Ali Abdallah Abdel Rahman, Mohammad Amin Al-Morsy, Mohamed Said Hussein
Department of Otolaryngology, Faculty of medicine, Al-Azhar University
Corresponding author: Mohamed Said Hussein, email:
Background: Tonsillectomy is one of the most frequently performed operations in otolaryngology,
especially in children. Basically, bleeding within 24 h has been classified as primary bleeding whereas
bleeding occurring from the next day after surgery has been classified as secondary bleeding.
Aim of the Work: Was to review the possibility of decreasing the incidence of post- tonsillectomy
hemorrhage along with the associated complications.

Methods: This is a prospective study enrolling one thousand and two hundred patients undergoing
tonsillectomy (with or without adenoidectomy in Al- Azhar University Hospitals (El-Hussien Sayed Jalal
- AL Zahraa) from April 2018 till December 2018. We restricted the study to full time participants and
resident staff so that complete records would be available.
Results: The mean age of patients was 13.53 years, 47.62% of patients were male while 52.38% of patients
were female. Primary bleeding occurred in 16 cases while secondary bleeding occurred in 32 cases. There
are significant differences among studied groups as regard to control methods of post-tonsillectomy bleeding
which could be conservative or operative.
Conclusion: We concluded that patients with post-tonsillectomy bleeding should return for clinical
evaluation as they may need conservative management or possible operation interference either for ligation
or cautery of bloody tonsil, that trigger a need for external carotid artery ligation.
Keywords: Bleeding, Cautery, Tonsillectomy, Sutures
primary bleeding whereas bleeding occurring
Tonsillectomy is one of the most frequently
from the next day after surgery has been classified
as secondary bleeding. The clinical symptoms of
especially in children(1).
primary bleeding are more severe than those of
secondary bleeding because of the possible risk of
Since bleeding after tonsillectomy may lead to
aspiration or laryngospasm and invisible
reoperation, the need for transfusion, and even
swallowing of blood with a consequent
death, it is particularly important to give it special
circulatory failure(5).
attention. The incidence of bleeding after
tonsillectomy is approximately 0.510%, with
Aim of the Work
deaths occurring in 1 in 20,000 patients(2).
In this study we aimed to review the possibility
of decreasing the incidence of post-

Primary bleeding is likely caused by inappropriate
tonsillectomy hemorrhage along with the
surgical techniques, insufficient hemostasis and
associated complications.
the exposure of small blood vessels(3).
Patients and Methods
Secondary post-tonsillectomy bleeding (PTB),
defined as any bleeding that occurs 24 hours or
This is a prospective study enrolling 1200
longer after surgery, is estimated to occur in
patients undergoing tonsillectomy (with or
approximately 25% of patients undergoing
without adenoidectomy) and admitted to Al-
tonsillectomy. The incidence increases with age
Azhar University Hospitals (El-Hussien Sayed
as well as being more common if the indication
Jalal Al-Zahraa) regardless to their age. Out of
for surgery was recurrent tonsillitis(4).
which, 48 patients had post-tonsillectomy
bleeding. Approval of the ethical committee and a
Bleeding within 24 h has been classified as
Received: 17/10/2018
Accepted: 06/11/2018

Full Paper (vol.745 paper# 22)

INTRODUCTION The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1128-1136

Day 3 embryo Transfer versus Day 5 Embryo Transferversus Day 6 Embryo
Transfer in Cases of Intracytoplasmic Sperm Injection
Hossam Eldin H. Salem (1), Assem A. Mosa (1), Emad Eldin R. Matar (2),
Ahmed A. Elsamanoudy (1)
(1) Department of Obstetrics and Gynecology, (2) Department of Pathology
Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed A. Elsamanoudy; Mobile: 0127392007; Email: ahmed_
IVF is becoming now the gold standard for solving the problem of infertility, nearly million
IVF babies were born. The time of embryo transfer still rises a big question and is still a field of great debate
whether to transfer it early as day 3 or wait till day 5 or day 6 to give a good chance for embryo selection.
Aim of the work: to determine whether embryo transfer on day 3 versus day 5 versus day 6 shows a
significant difference in implantation, clinical pregnancy, live birth, miscarriage and multiple pregnancy
rates among women undergoing intracytoplasmic sperm injection. Results: Concerning multiple pregnancy
rates day 3 embryo transfer was 7 (14%) in compared to 31 (31%) in day 5 embryo transfer in compared to
13 (26%) in day 6 embryo transfer which still shows significant difference between three groups. There was
only slight difference between live birth in three groups, for day 3 we had (14%) 19 (5 twins and 9 single)
living babies while for day 5 we had (44%) 70 (26 twins and 18 single) while for day 6 we had (20%) 31 (11
twins and 9 single). Using Pearson Chi-Square there was significant difference between the three groups
regarding live birth. There was great difference in success rates and outcome of embryo transfer between
three groups. Conclusion: From this study we can conclude that there is significant difference in either
pregnancy or delivery rates between day 3 and day 5 and day 6 when patients are appropriately randomized.
Delaying embryo transfer to day 5 or day 6 offers advantage to patients undergoing ICSI. Embryos that
develop to the expanded blastocyst stage and are transferred on day 5 after retrieval are approximately as
likely to implant compared to those for which expansion and transfer are delayed until day 6.
Key words: IVF, Intracytoplasmic Sperm Injection

There was a transient biochemical
The ability to freeze and subsequently
pregnancy reported by Australian Foxton School
thaw and transfer embryos has significantly
researchers in 2000 (1).
improved the feasibility of IVF use (5).
In 1991, Cohenet al. at the Worcester
The other very significant milestone in
Foundation, proved fertilization in vitro was
IVF was the development of the intracytoplasmic
capable of proceeding to a birth of a live rabbit.
sperm injection (ICSI) of single sperms by
Chang's discovery was seminal, as it clearly
Palermo et Brussels (6).
demonstrated that oocytes fertilised in vitro were
capable of developing, if transferred into the
This has enabled men with minimal
uterus and thereby produce live young (2).
sperm production to achieve pregnancies. ICSI is
sometimes used in conjunction with sperm
Although it lasted only a few days and
recovery, using a testicular fine needle or open
would today be called a biochemical pregnancy.
testicular biopsy. Using this method, some men
Shettles attempted to perform an IVF in 2013, but
with Klinefelter's syndrome, and so would be
his departmental chairman interdicted the
otherwise infertile, have occasionally been able to
procedure at the last moment (3).
achieve pregnancy. Thus, IVF has become the
There was also an ectopic pregnancy
final solution for most fertility problems, moving
reported by Schulman in 2010. In 2010, Schulman
from tubal disease to male factor, idiopathic
successfully carried out a world's first baby to be
subfertility,endometriosis, advanced maternal age,
conceived in Oldham General Hospital, Greater
and anovulation not responding to ovulation
Manchester, UK (4).
induction (7).
Received: 18/10/2018
Accepted: 07/11/2018

Full Paper (vol.745 paper# 23)

c:\work\Jor\vol745_24 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1137-1150
Study of Serum Leptin in Polytransfused Children with Beta Thalassemia
Ahmed Mohamed Abd EL-Gawad Asfour*, Ali Abd El-Latif Afia*, Mohamed Saeed El-
Shorbgy** and Mohamed Abd El-kareim Mohamed*

Pediatric Department* and Clinical pathology Department**, Faculty of Medicine Al-Azhar

Corresponding author: Ahmed Mohamed Abd EL-Gawad Asfour, email:
thalassemic patients with frequent blood transfusion can result in iron overload and
increase serum ferritine level. Leptin is a polypeptide hormone that is mainly expressed in bone marrow
and adipocytes and previous studies consumed that it is lower in thalassemic patients compared to
healthy children as a result of hemsedrosis.
The aim of this study was to evaluate leptin serum levels in patients with - thalassemia
Patients and methods: This case-control study was conducted on 50 children from 13 to 17 years old,
at Al-Azhar university Hospitals (Sayed Galal & Al-Hussien hospitals). They were subdivided in two
groups 30 patients (- thalassemia major) and 20 as control that were matched in age and sex.
All Children were examined to be free from heart disease , iron deficiency anemia, kidney disease,
diabetes, fever and systemic diseases were enrolled after taking informed consent of their parents.
After collecting the samples, leptin and ferritin levels of the serum were measured in two groups by
ELISA method .Then, the data were analyzed by the related statistical tests and SPSS 20 software.
Results: The mean of the serum levels of leptin and ferritin showed a significant difference in
the case and control groups (P-value < 0.05). Levels of leptin in the case group showed no significant
gender difference (P-value < 0.05).
Conclusion: Based on the results of this study, thalassemia major reduces serum levels of leptin
regardless of age and body mass .
Beta-Thalassemia; Child, Ferritin, Leptin.
Every year 100,000 neonates are born with
complex, which includes glucocorticoids,
thyroid and insulin (3).
Bone marrow contains active obesity
heterogeneous disease of the human being.
genes as well as fat cells. The fat content of
Recently, the quantity and quality of the life of
bone marrow in human regulates his/ her
these patients have been significantly improved
hematopoiesis activity (4). The structural
by regular transfusion and iron chelating
similarity between the leptin receptor and the
therapy (1).
cytokines signaling molecules of the
Leptin, a polypeptide of 146 amino acids,
hematopoiesis system improves the growth
is an obesity gene product, which is widely
potential of the active hormones in form of
produced in different tissues, including bone
blood cells (5). In addition, leptin binds to the
marrow and adipocyte ( also known as lipocytes
hematopoietic complementary DNA receptor
and fat cells, are the cells that primarily
of humans and the destruction of leptin receptor
compose adipose tissue, specialized in storing
stimulates the defected production of
energy as fat) and has a direct correlation with
erythrocyte products (4). Consequently, due to
body mass index (2). This hormone is multi-
mutations in the major beta-thalassemia,
functional that leads to increase energy levels,
several breaks occur in process of red blood
and affects angiogenesis, inflammation, and
cells maturation and antagonized with some
hematopoiesis. It is regulated by an intricate
hepatosplenomegaly, hypothyroidism and
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 24)

c:\work\Jor\vol745_25 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1151-1155

Bacteremia Predictive Factors among Inpatients of Internal Medicine Department.
A Prospective Cross- Sectional Survey in Aswan University Hospital
Mohammed Zain Eldeen Hafez 1, Soumaia Ahmed Kassem 1,
Wafaa Salah Eldin Mohamed 2, Ahmed Yehia Araby Youssif 1*

Departments of 1 Internal Medicine and 2 Clinical Pathology, Faculty of Medicine, Aswan University,
Aswan, Egypt
* Corresponding author: Ahmed Yehia Araby Youssif, E-mail:, Mobile: (020) 01001266016

bacteremia is the presence of bacteria in the blood stream that are alive and capable of reproducing.
It is a type of blood stream infection
Aim of the Work: was to identify bacteremia predictive factors among inpatients at Internal Medicine Department
in Aswan University Hospital and to improve the management and decrease mortality among inpatients through
clinical parameters.
Patients and Methods: we estimated blood cultures of one hundred patients at our department from April 2017 to
April 2018.
Results: The final diagnosis and univariate analysis have shown use of central venous line (p<0.001), high axillary
body temperature (p<0.001), greater pulse rate (p<0.001), leucocytosis (p<0.001), neutrophilia (p<0.0001), and
creatinine (p<0.002) were associated with bacteremia. Positive blood cultures patients have shown in our study that
temp >38OC, leucocytosis, neutrophillia >85%, tachycardia>90 and serum creatinine >1.3% were independent risk
factors of bacteremia.
Conclusion: The presence of bacteremia can be highly predicted by fundamental clinical information such as high
pulse rate, leucocytosis, high grade temperature and neutrophilia.
Keywords: Bacteremia Predictive Factors

Bacteremia is the presence of bacteria in the
or dental procedures, or instrumentation of the
blood stream that are alive and capable of
bladder or colon (3).
reproducing. It is a type of blood stream infection (1).
Intermittent bacteremia is characterized by
Bacteremia is defined as either a primary or
periodic seeding of the same bacteria into the
secondary process. In primary bacteremia, bacteria
bloodstream by an existing infection elsewhere in the
have been directly introduced into the bloodstream
body, such as an abscess, pneumonia, or bone
(2). Injection drug use may lead to primary bacteremia
infection, followed by clearing of that bacteria from
(2). In the hospital setting, use of blood
the blood stream. This cycle will often repeat until the
vessel catheters contaminated with bacteria may also
existing infection is successfully treated. Persistent
lead to primary bacteremia. Secondary bacteremia
bacteremia is characterized by the continuous
occurs when bacteria have entered the body at another
presence of bacteria in the bloodstream (1).
site, such as the cuts in the skin, or the mucous
It is usually the result of an infected heart
membranes of the lungs (respiratory tract), mouth or
valve, a central line-associated bloodstream infection
intestines (gastrointestinal tract), bladder (urinary
(CLABSI), an infected blood clot (suppurative
tract), or genitals. Bacteria that have infected the body
thrombophlebitis), or an infected blood vessel graft
at these sites may then spread into the lymphatic
system and gain access to the bloodstream, where
Persistent bacteremia can also occur as part of the
further spread can occur (3).
infection process of typhoid fever, brucellosis, and
Bacteremia may also be defined by the timing of
bacterial meningitis. Left untreated, conditions
bacteria presence in the bloodstream: transient,
causing persistent bacteremia can be potentially fatal
intermittent, or persistent. In transient bacteremia,
bacteria are present in the bloodstream for minutes to
Bacteremia is clinically distinct from sepsis,
a few hours before being cleared from the body and
which is a condition where the blood stream infection
the result is typically harmless in healthy people. This
is associated with an inflammatory response from the
can occur after manipulation of parts of the body
body, often causing abnormalities in body
normally colonized by bacteria, such as the mucosal
temperature, heart rate, breathing rate, blood
surfaces of the mouth during teeth brushing, flossing,
pressure, and white blood cell count (4).
Received: 20/10/2018
Accepted: 09/11/2018

Full Paper (vol.745 paper# 25)

c:\work\Jor\vol745_26 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1156-1164
Influence of Sleeve Gastrectomy on Gastro-Esophageal Reflux Disease
Ashraf Abd El-Hameed Abd El-Moneim, Abd El-Fattah Morsi, Tamer Abdu Mohammed
Department of General surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Tamer Abdu Mohammed Megahed, Mobile: +201000862100, E-Mail:
Background: bariatric operations can induce reflux by affecting organs motor functions depending on
the type of procedure performed. Laparoscopic sleeve gastrectomy (LSG) relatively new option of
morbid obesity treatment, simpler to perform, short learning curve, and shorter duration (procedure time
and hospital stay).
Objectives: The aim of this work was to evaluate upper gastrointestinal symptoms before and after
sleeve gastrectomy on short term follow up period of 6 months post-operatively and to assess the
relation between Gastro-Esophageal Reflux Disease and sleeve gastrectomy.
Patients and Methods: This follow up study included 50 morbidly obese patients treated with
laparoscopic sleeve gastrectomy during the period from May 2018 to October 2018. Rome III Criteria
and upper GI Endoscopy evaluation was done preoperatively then 6 months postoperatively concerning
upper GI symptoms.
Results: Before LSG 60% asymptomatic, 40 % GERD, 6.7 % dyspepsia (PDS predominance). UGI
endoscopy showed 40% no significant findings, 60% gastritis, 20% esophagitis, 13.3% duodenitis, DU
6.7%. 40% H-pylori positive and 60% negative. After 6 months follow-up, 93.3% complained of upper
GI symptoms, 66.7 % prevalence of dyspepsia (p<0.001). GERD symptoms disappear in 83.3%. 20%
increased Vomiting of all patients associated with GERD (p =0.030). 13.3% increased Dysphagia (p
=0.125) associated with dyspepsia. 100% correlation between GERD and hiatus hernia (p<0.001) and
66.7% between vomiting and incompetent cardia (p=0.029).
Conclusion: Improvement of Gastro-Esophageal Reflux Disease after Sleeve Gastrectomy in patients
complaining of GERD pre-operatively, although there is incidence of post-operative hiatus hernia and
develop of gastrointestinal symptoms .
Recommendation: further studies have to be applied.
Keywords: Obesity, laparoscopic sleeve gastrectomy, upper gastrointestinal symptoms, GERD,
GERD superiorly according to databases
(GERD) may present with half the obese
suggestion (4). Few studies have clams that
patients need surgical intervention with high
Sleeve Gastrectomy may predispose GERD "de
incidence between obesity and (GERD) (1).
novo" (5).
GERD incidence range among the obese
The golden standard operation that
population is 22-70%. Range among non-obese
widely used for weight loss, control of co-
population is 15-20% and Barrett's esophagus
morbidities and improve Gastro-Esophageal
is 1-2% (2). So obesity is reflux pathogenesis
Reflux symptoms become Roux-en-Y Gastric
risk factor. Bariatric operations can induce
bypass (6).
reflux alone away from body mass index (BMI)
Sleeve Gastrectomy originally was the
factors according to procedure performed(1).
first step in duodenal switch, then for its good
Sleeve Gastrectomy and Gastric Roux-
results established a definitive procedure (7).
en-Y bypass show great results in weight loss
Sleeve Gastrectomy effect on GERD is
but differ in the impact on co-morbidities (3).
unknown as some studies suggests that it may
Gastric bypass improve the symptoms of
exacerbate or induce symptoms when done to
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 26)

c:\work\Jor\vol745_27 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1165-1173

Electrocardiography versus Echocardiography for assessment of left
ventricular hypertrophy in ischemic heart disease patients with and
without cardiovascular risk factors
Mansour Mohammed Moustafa, Abdel Aziz Rezk Shredah, Kamal Ahmed Marghany, Ahmed
Yahya Sayed Zakaria*
Department of Cardiology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Yahya Sayed Zakaria, Mobile: 01122459207; Email:
it is well documented that left ventricular hypertrophy (LVH) detected by 12-lead
electrocardiography or echocardiography is a major risk factor for cardiovascular morbidity and mortality
in cohorts ranging from the general population to those with established cardiovascular disease, including
coronary artery disease (CAD).
aims of this study were to detect prevalence of LVH in CAD patients by standard
echocardiography by measuring LVM indexed to body surface area and to test the sensitivity and
specificity of new ECG criteria, Peugero-Lo Prosti criteria, for detection of left ventricular hypertrophy
and comparing it with other ECG criteria to diagnose LVH.
Patients and Methods: This observational cross sectional study was conducted at El-Hussein University
Hospital and Minia Health Insurance Hospital during the period from July 2016 to June 2017, the study involved
230 patients of either sex, and referred for Echocardiography department to perform 2D transthoracic
Results: In our study, we founded that firstly, the echo-LVH is prevalent in CAD patient (41.5%) regardless
the presence of other cardiovascular risk factors. Moreover, our results showed that, the prevalence of echo-
LVH is significantly higher in patients with CAD and hypertension, than in patients with CAD only (54%
Vs. 32%). Secondly, the Peguero-Lo Prosti criteria has a higher sensitivity (61.4%) for detecting LVH
among the patients with CAD than Sokolow-Lyon criteria (26.5%), Cornell voltage criteria (32.5%) and
Romhilt Estes point score (41%) considering LVMI by echocardiography as reference standard.
Conclusion: the prevalence of echocardiographic LVH in CAD patient is high regardless the presence
of other cardiovascular risk factors. Overall the present study shows that, Peguero-Lo Presti criteria has
higher sensitivity and specificity in the ECG diagnosis of LVH compared to Sokolow-Lyon criteria,
Cornell voltage criteria and Romhilt-Estes point score system considering LV mass index by 2D
Echocardiography as reference standard.
Keywords: Left ventricular hypertrophy, Coronary artery disease, ECG, ECHO
It is well documented that left ventricular
The importance of detecting LVH in
hypertrophy (LVH) detected by 12-lead
CAD patients is based on several reasons.
electrocardiography or echocardiography is a major
Firstly, in CAD patients that the relative risk of
risk factor for cardiovascular morbidity and
cardiac death conferred by LVH was 2.14, 2.4
mortality in cohorts ranging from the general
and 2.1 after adjustment for other factors
population to those with established cardiovascular
including hypertension and the number of
disease, including coronary artery disease (CAD) (1).
coronary vessels affected. Secondly, there is
Coronary artery disease can play a role
now strong evidence to suggest that regression
in the pathogenesis of LVH, as the normal
of LVM is associated with improved prognosis
myocardium attempts to compensate for the
in hypertensive patients. Thirdly, a hypothetical
ischemic or infarcted tissue (2).
analysis suggests that identifying and
Recent evidence suggests that left
regressing LVH in normotensive patients with
ventricular hypertrophy (LVH) is an important
angina should be worthwhile and cost-effective
cause of cardiac death in patients with CAD.
However, there is limited data about detection and
Several electrocardiographic (ECG)
significant of LVH in such population (3).
criteria have previously been proposed to
diagnose LVH, with modest differences in the
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 27)

c:\work\Jor\vol745_28 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1174-1179

Pericardiectomy for Managing Constrictive Pericarditis. A Case Report of A
30-Years-Old Saudi Female.
Nora Alsomali1, Afrah Alsomali2, AftabTuri3, Atli Eyjolfsson4
1 College of Medicine, Alfaisal University, 2 College of Medicine, Alfaisal University, 3 King Faisal
Specialist Hospital and Research center, 4 King Faisal Specialist Hospital and Research center

constrictive pericarditis (CP)is the final stage of a chronic inflammatory process that leads
to the thickening and calcification of the heart's pericardium, restricting its natural elasticity and diastolic
filling. CP has nonspecific symptoms; hence, requires a high index of suspicion and complete
investigations. Aim of the work: this is a case of a young Saudi female presented with a 3 years history of
shortness of breath associated with abdominal distention. Patient and Methods: multimodal imaging, lab
workup and cardiac catheterization were done to confirm the diagnosis of CP. Results: the patient was
managed by total pericardiectomy; during which her calcification was found to be encasing the heart at its
length dimension and invading deeply into the myocardium. The patient experienced complicated
postoperative course; however, now is doing fine. Conclusion: to our knowledge there are no similar cases
reported in the literature from Saudi Arabia. Therefore, the aim of this case was to highlight the importance
of early diagnosis and management of CP for better prognosis.
Key words:
constrictive, pericarditis, pericardiectomy, calcification, Saudi Arabia


Constrictive pericarditis (CP) is a product of an
option for patients with definitive constrictive
ongoing chronic inflammatory process that result
pericarditis (1). The CP etiology and management
in the thickening and calcification of the heart's
has been well documented in the Western
pericardium; impairing its diastolic filling (1,2).
literature, however, we lack adequate information
The etiology of CP can differ (Idiopathic, post
and recent updates regarding CP management in
viral, tuberculous, post-surgical, radiation-
Saudi Arabia (6). The case report aimed to
induced, etc.); however, they all have the same
highlight the importance of early diagnosis and
end results (1,3). Tuberculous pericarditis remains
management of CP for better prognosis and
to be the most common etiology in both
developing and underdeveloped countries, while

idiopathic pericarditis, previous cardiac surgery
and chest radiotherapy are the common etiologies
This is a case of a 30-year-old Saudi female with
in the developed countries.
a 3 years history of shortness of breath (SOB) that
Although the true prevalence of CP remains
got worse on January 2018. In addition, it was
unknown, it is known to occur in 0.2-0.4% of
associated with abdominal distention, for which
patients who had undergone cardiac surgery,
she was admitted at a local hospital. During her
where idiopathic pericarditis occurs in less than
1% of the patients (3-5). Early diagnosis is
essential, since CP is considered a potentially
suggestive of calcific constrictive pericarditis and
reversible cause of diastolic heart failure, but
was managed with diuretics.
continues to be a challenging clinical diagnosis;
The patient afterwards referred to our hospital for
due to its nonspecific symptoms, thus, often
further intervention and investigation. History
was also positive for intermittent palpitation and
(4).Echocardiography is proven to be a useful
weight loss for 5 years. There was no history of
initial imaging method, but cardiac CT and MRI
cough, chest pain, fever, loss of consciousness,
has higher accuracy in detecting pericardial
night sweats, joint pain or urinary tract infection
thickening and calcification. The gold standard
symptoms. No contact with TB patients, previous
for diagnosis is cardiac catheterization and
surgeries or radiations. On physical examination,
pericardiectomy is the only definitive treatment
she had irregular pulse. Chest showed bilateral
Received: 21/10/2018
Accepted: 10/11/2018

Full Paper (vol.745 paper# 28)

c:\work\Jor\vol745_29 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1180-1185
Pedicled thoracodorsal artery perforator flap for reconstruction of post
burn contracted neck

Osama Alshahhat, *Mohamed Autifi, Mohamed Hosny, Mohamed Osama, Mohamed Farid
and Moaaz Moaty

Departments of Plastic Surgery and *Anatomy and Emberyology, Faculty of Medicine, Al-Azhar

Corresponding author: Moaaz Mahmoud Abd Almoaaty, E-Mail:, Mobile: 01126223879

The thin and pliable skin of the neck is a region with multidirectional activity, and
postburn contractures forms there easily. Different methods of reconstruction were described. In our
study the thoracodorsal artery perforator flap (TDAP) is used to reconstruct the post burn contracted
(PBC) neck. Its main vascular supply is the thoracodorsal artery, and can be harvested as an island flap.
Aim of the work: to evaluate the aesthetic and function outcome of TDAP flap as a new technique for
reconstruction of PBC neck.
Patients and Methods:
this study included a total of 10 TDAP flaps. Were studied prospectively for
their efficacy in reconstruction of PBC neck in 10 patients. Also donor site morbidity, patient
satisfaction, and complications were evaluated. Between November of 2017 and January of 2019, this
study was preceded by preserved cadaveric dissection. All were island flaps. The range of flap size was
18 5 cm in length, and 9 2 cm in width. Primary closure of donor site was performed in all cases.
Results: 8 of the 10 flaps survived completely, two cases of distal necrosis not exceeding 2 cm (20%),
and no total flap necrosis. Most of the patients were satisfied with both the functional and aesthetic
Conclusion: PBC neck affects function, and appearance. In our view, the island TDAP flap is a good
option for neck resurfacing regarding a wide arc of rotation, a relatively larger flap dimensions, a
reliable pedicle length, and acceptable donor site morbidity.
Keywords:Thoracodorsal artery perforator flap, post-burn neck contracture, island flap,
fasciocutaneous flap.
Post-burn neck contractures are a challenging
techniques, including skin grafts, pre-expanded
problem for plastic surgeons. Post burn
flaps(3), and perforator flaps(4).
contracted neck is characterized by restrictions
Based upon the use of TDAP flap for
in range of neck motion, especially extension.
Functional and cosmetic abnormalities
reachability to the neck(5) we used it in neck re-
resulting from this type of distortion can cause
extreme depression (1).
The purpose of this article is to report
In 2005 Onah classified the burn
our clinical experience with the use of island
contractures of the neck based on the numeric
TDAP flap as a new reconstructive modality for
categories of 1 to 4 (type 1-type 4), which
neck re-surfacing. We aim to emphasize the
include position, severity, and likely problems.
Subgroups within each numeric category are
complications, and the functional outcome.
used to designate the width of the contracture,

which affect the options available for
Aim of the study
reconstruction. The numeric category depends
The aim of the study is to evaluate the
on the extent of flexion or extension by the
contracted neck and the anatomical position of
thoracodorsal artery perforator flap as a new
the neck (2).
technique for reconstruction of post burn

contracted neck.
The post burn contracted neck can be

reconstructed with a wide range of surgical
Patients and Methods
Received: 19/10/2018
Accepted: 08/11/2018

Full Paper (vol.745 paper# 29)

c:\work\Jor\vol745_30 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (5), Page 1186-1196

Breast-Conserving Surgery after Neoadjuvant Chemotherapy for Locally
Advanced Breast Cancer: Single Institute Experience
Mohamed Esmat1* and Wael El-Sheshtawy2
Department of 1General Surgery (Surgery Oncology Unit) and 2Clinical Oncology
Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohamed Esmat, E-Mail:

from clinical and pathologic aspects, locally advanced breast cancer (LABC) can be considered a
relatively heterogeneous group of tumors.
Objective: we aimed to evaluate local control after breast-conserving surgery in patients with locally advanced
breast cancer who received neoadjuvant chemotherapy for down staging.
Patients and Methods: a retrospective study was performed to include patients with locally advanced breast cancer
who underwent breast-conserving surgery after neoadjuvant chemotherapy (anthracylcine based regimen followed
by taxans). The clinical, pathologic, and surgical factors that could contribute to locoregional recurrence were
Results: after neoadjuvant chemotherapy, 94 patients underwent breast-conserving surgery. The average tumor
diameter was 5.3 cm, and 87.8% of patients achieved a size of up to 3 cm. Furthermore, 85.7% were at clinical
stage III, 75.5% had T3-T4 tumors, 81.6% had N1-N2 axilla, and 89.8% had invasive ductal carcinoma. A
pathologic optimal response was achieved in 26.5% of the tumors, and all the samples had free margins. The 5-
year overall survival rate was 81.6%, and the mean follow-up duration was 94.1 months. The rate of ipsilateral
breast tumor recurrence was 10.2%, while the rate of locoregional recurrence was 16.3%. The regression analysis
showed that multifocal morphology response was the only factor associated with ipsilateral breast tumor recurrence
(p=0.04). The pathologic response evaluation criteria in solid tumors (RECIST) breast cutoff was the only factor
associated with locoregional recurrence (p=0.01).
Conclusion: breast-conserving surgery is a safe and effective therapeutic option for selected locally advanced
breast tumors after receiving neoadjuvant chemotherapy.
Keywords: Breast Neoplasms; Neoadjuvant Therapy; Drug Therapy Combination; Breast-Conserving Surgery;
Recurrence; Disease-Free Survival.

Breast cancer is the most prevalent cancer
(NC) does not increase the survival rates, it is
among women. Worldwide, 1.7 million new
used to improve the outcome of tumor
cases are estimated to occur each year and
resection, increase the breast-conservative
mortality rate is increasing in developing
surgery (BCS) rates (3,4), and determine patients
countries. This may be owed to the delay in the
with better prognoses, those who showed a
diagnosis until the disease is in an advanced
pathologic complete response (pCR) (5).
stage (1). During the past decade, advanced
The conservative surgery rate after NC
stage III and IV carcinomas represented 8.5%
varies from 37% to 82% (6, 7); however, only
of all tumors in United States and 44.7% of all
1.7% to 28% of these patients are classified as
tumors in Brazil, making advanced breast
LABC (7, 8). The role of conservative surgery in
carcinoma a public health problem in Brazil (2).
the management of breast cancer is well known
From clinical and pathologic aspects,
if the surgery is combined with radiotherapy (5,
locally advanced breast cancer (LABC) can be
9). There is a limited number of studies of large
considered a relatively heterogeneous group of
cohorts of patients with LABC who underwent
tumors. Despite neoadjuvant chemotherapy
NC and conservative surgery (10). The safety of
Received: 21/10/2018
Accepted: 10/11/2018

Full Paper (vol.745 paper# 30)