The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1197-1204
The Value of Late Mid-Trimester Ultrasound Cervical Assessment after
Cerclage for the Prediction of Preterm Birth
Yehia Abdul-Rahman El Wasat, Walid Mamdouh Atallah, Ahmed Tawfeek Suliman, Mostafa
Zain Al Abideen Mostafa
Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, Egypt
Corresponding author: Yehia Abdul-Rahman El Wasat, email: firstname.lastname@example.org
Background: Spontaneous preterm birth constitutes a significant obstetric dilemma as prematurity is a
major risk factor of neonatal death or a lifelong morbidity. Despite extensive efforts to reduce preterm
birth, the means to identify and prevent it remains limited. Sonographic surveillance of CL can identify
the increased risk of spontaneous preterm birth.
Objective: To determine the predictive value of ultrasonographic assessment of the cervix after
cerclage insertion for the outcome of preterm birth before 34 weeks of gestation.
Patients and Methods: A prospective study included fifty women with singleton pregnancies were
followed-up with monthly transvaginal ultrasonographic examinations before and after cerclage
insertion. Ultrasonographic parameters of the cervix included the closed endocervical canal length and
funneling depth measured from the internal cervical os.
Results: The change in cervical length was predictive; as with stable cervical length an association with
a later gestational age at delivery was evident. Patients with cerclage who delivered after 34 weeks had
a slower rate of cervical shortening compared to those who delivered prior to that date (median = 4mm
versus 7mm per 4 weeks). The overall cervical length at 28 weeks was statistically different between
patients who delivered before 34 weeks and those who delivered later (24.00±2.92 versus 33.19±5.5
Conclusions: Transvaginal ultrasound for cervical assessment can be a helpful tool in the prediction of
preterm birth after cerclage insertion. A late second-trimester cervical transvaginal ultrasound scan can
guide the addition of interventions such, progesterone and antenatal corticosteroids for fetal lung
Keywords: Cerclage, Transvaginal Ultrasound, Preterm birth
Spontaneous preterm birth constitutes a
Cervical insufficiency describes the
significant obstetric dilemma as prematurity is
inability of the cervix to retain a pregnancy as a
a major risk factor of neonatal death or a
result of painless cervical dilatation leading to
lifelong morbidity. Despite extensive efforts to
subsequent expulsion of the fetus out of the
reduce preterm birth, the means to identify and
uterus. Cervical insufficiency accounts for 10
prevent it remains limited (1). Premature
25% of second trimester pregnancy losses (6).
remodeling of the cervix and cervical
Cervical cerclage is a common procedure that
insufficiency are found to contribute to the
showed to be effective in prevention of mid-
etiologies of SPTB (2). Sonographic surveillance
trimester losses in women at high-risk of
of cervical length (CL) can identify the
cervical insufficiency. Cervical cerclage
increased risk of spontaneous preterm birth. An
restores cervical length and the mechanical role
inverse relationship exists between cervical
of the cervix (6-9). A patient-level meta-analysis
length as measured by ultrasound and the risk
of five randomized trials on the effect of
of SPTB. Moreover, diagnosis of a shortened
cerclage placement in singleton pregnancies
cervix at before 24 weeks of gestation increases
with a prior history of preterm delivery
demonstrated a significant reduction in
ultrasonographic evaluation of the cervix is a
recurrent SPTB at<35 weeks of 30%, and a 36%
safe and well-accepted technique (4, 5).
decrease in mortality and morbidity (10).
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1205-1214
Reconstructive Option Selection for Lower Third Leg Defects
Ahmed Mohamed Soliman, Wael Mohamed Ayad, Ahmed Taha Sayed, Yasser Helmy Ismail
Plastic and Reconstructive Surgery Department, Al Azhar University
Background: patients with the lower 3rd leg defects are increasing in number especially among victims of road
accidents .Due to anatomical features of this area nearly most cases required flap coverage. Aim of the work: the
aim of this study was to help in selection of the appropriate option for coverage among available local perforator
flaps and free microvascular flaps. Patients and methods: 30 patients with lower 3rd leg defect were included in
this study and they were categorized into 2 groups. 15 patients underwent reconstruction by using local flaps (A)
and 15 patients under went reconstruction using free micro-vascular flaps (B). Results: free flaps were more
versatile than local flaps, but consumed more operative time and had higher morbidity Conclusion: small and
moderately-sized lower 3rd leg soft tissue defects can be covered easily and safely by using locally available
perforator flaps. Local flaps do not scarify any of the main arteries, consume less operative time, there was a
specific like to like soft tissue replacement leading to a better cosmetic and reconstructive outcome. Free flaps
have proven its versatility and reliability in coverage of significantly large and complex defects.
Keywords: lower third leg, lower limb
vascular anatomy, angiosome and perforasome
Lower limb traumas are common among victims of
concepts, as well as innovations in flaps design(6).
road accidents. The relatively unprotected antero
The propeller flap, a pedicle based perforator flap, is
medial portion of the tibia is at risk of bone exposure
well documented as an option for the majority of
following trauma. Because of complexity of the
coverage in the lower limb, particularly below the
defect, soft tissue coverage remains a challenge to
knee, with the peroneal and posterior tibial artery
plastic surgeons (1). The goal of lower extremity
perforators being commonly used(7).The reverse
reconstruction is the coverage of defects with good
sural fasciocutaneous flap is also a viable option for
aesthetic and functional outcome and salvages the
the soft tissue coverage of distal third leg. It was,
limb (2) leg defect may result from trauma, tumor
firstly described by Masquelet et al. as skin island
resection and chronic diseases such as peripheral
flap supplied by arteries accompanying the
vascular disease or post contracture release (3).The
superficial sensory nerve of leg. Hence, described as
reconstructive ladder offers a list of options in terms
neurocutaneous Island flap (8). The advancement of
in surgical closure of the wound. However, the
microscopy, micro-instruments and sutures had
simplest option is not always the best option. A
allowed the development of free flap surgery.
failed technique in lower limb reconstruction can
Microsurgery has allowed the direct transfer of large
have a devastating effect on the patient resulting in
tissue units from distant donor sites, allowing
further tissue and bone loss, deterioration of co-
wounds to be covered and reconstructed based on
morbidities and functional deficit with an end point
flap suitability rather than wound proximity (9).
involving amputation. For this reason, the best
Microsurgical free flaps have featured early on
reconstructive option is often not the easiest choice
reconstructive algorithms. As it offers versatile and
and should consider all options including free flap
sufficient coverage without the limitations of the
reconstruction (4). The local flap has the disadvantage
pedicle, and elevation and anastomosis can occur
of limited mobility. The cross-leg flap has
well beyond the zone of injury, but unfortunately
disadvantages, too, not only in that it causes
qualified micro surgeons not available in all centers
discomfort to patients because it restricts the
and not all patient can withstands long operative time
movement of the legs, but also in that it requires a
of the surgery (9).
secondary operation to isolate the pedicle(5).
Perforator flaps, gained a high popularity due to their
Aim of the Work
main advantages: decreasing donor-site morbidity
The aim of this study was to help in selection of the
and improving aesthetic outcome. The use as local
appropriate option for coverage among available
perforator flaps in lower leg was possible due to a
local perforator flaps and free microvascular flaps.
better understanding of the cutaneous circulation, leg
Patient and Methods
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1215-1225
Yields of Bronchoscopy and Bronchoalveolar Lavage in Diagnosis of Undefined Persistent
Wheezy Chest Among Children
Hussein Mohamed Ibrahim El-Assal1, Hatem Refaat Hablas1, Mohamed Sami El-Hakim2, Mohamed
Ibrahim Mohamed Abo Sekkeen1
Departments of 1Pediatrics and 2Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Ibrahim Mohamed Abo Sekkeen, Mobile: 00201001547870, E-Mail: email@example.com
Background: Wheezing in infants and children is a common problem presented to primary care offices.
Approximately 25 to 30 percent of infants will have at least one episode of wheezing. By three years of age,
an episode of wheezing will have occurred in 40 percent of children, and by six years of age, almost one half
of children will have at least one episode of wheezing. Most infants and children with recurrent wheezing have
asthma, but other causes should be considered in the differential diagnosis. The most common diagnoses in
children with persistent wheezing are asthma, allergies, gastroesophageal reflux, infections, foreign body
aspiration and bronchopulmonary dysplasia. Objective: the present study was designed to evaluate the clinical
role of different types of bronchoscope and bronchoalveolar lavage in diagnosis of undefined persistent wheezy
chest among the age group from 6 months to 14 years, at Al-Azhar University Hospitals in Cairo. Patients
and Methods: This a prospective study was conducted on 50 children complaining from different respiratory
problems who had enrolled consecutively from the Outpatient Clinic and the Inpatient Pediatric Department
of Al-Azhar Faculty of Medicine University Hospitals (AL-Hussein and Bab-Elshareya), from January 2017
to December 2018. Patients ages ranged between 6 months and 14 years. Results: as regard distribution of
patients according to post bronchoscopy diagnosis, the study showed that foreign body inhalation n16 (32%),
Chronic aspiration n9 (18%), tracheobronchomalacia n2 (4%), bronchial mass n1 (2%), streptococcus
pneumonia n7 (14%), hemophilus influenza n2 (4%), staphylococcus aureus n3 (6%) and pseudomonas
aeuroginosa n2 (4%), candida albicans n1 (2%), Mycobacterium TB n1 (2%). Conclusion: It could be
concluded that if radiography is normal and the child continues to wheeze, bronchoscopy should be the next
step, the bronchoscope is a valuable tool in the diagnosis and treatment of airway disorders in children. It has
a good safety profile with rarely reported life threatening or long-standing complications.
Keywords- Persistent wheezy chest, Bronchoscopy, Bronchoalveolar lavage.
Wheezing in infants and children is a common
and cardiac abnormalities, If radiography is normal
problem presented to primary care offices.
and the child continues to wheeze, bronchoscopy
Approximately 25 to 30 percent of infants will have
should be the next step (2). Bronchoscopy is a
at least one episode of wheezing. By three years of
diagnostic and therapeutic procedure that permits
age, an episode of wheezing will have occurred in
direct visualization of normal and pathological
40 percent of children, and by six years of age,
alterations of the upper and lower airways. Expert
almost one half of children will have at least one
knowledge of airway anatomy is a prerequisite for
episode of wheezing. Most infants and children
successful performance of the procedure. The
with recurrent wheezing have asthma, but other
major advantages of the flexible bronchoscope
causes should be considered in the differential
include the ability to insert it nasally, orally or
diagnosis, Children with continuous wheezing for
through a tracheostomy to visualize apical
at least 1 month or minimum three episodes of
segments of upper lobes as well as segmental and
wheezing in 2 months are defined as persistent
subsegmental bronchi in all lobes (3). The use of the
wheezy children (1). Chest radiographs is indicated
flexible bronchoscope has progressively increased
in children who present with unexplained wheezing
to cover the visual diagnosis of the upper and lower
that is unresponsive to bronchodilators or with
airways lesions as well as interventional,
recurrent wheezing. Plain- film radiography can
therapeutic and supportive work such as:
identify congenital anomalies of the lung,
Bronchoalveolar lavage (BAL) for cytological,
parenchymal lung disease, and some foreign bodies
virological, bacteriological and immunological
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1226-1232
Muscle Invasive Bladder Cancer: comparison between Radical Cystectomy
and Bladder Sparing Therapy
Mohamed Esmat*1, Sabri Moussa2, Wael El-Sheshtawy3
Departments of 1Surgery, 2Urology and 3Clinical Oncology, Faculty of Medicine, Al-Azhar University,
* Corresponding Author: Prof. Mohamed Esmat, E-Mail: Prof.firstname.lastname@example.org
Background: bladder cancer (BC) is a life menacing disease that harvested a considerable number of deaths
anniversary. Noteworthy, BC is the most predominant cancer among Egyptian men with a prevalence rate
of more than 15% resulting in 8,000 deaths yearly. Aim of the work: this study was implemented to retrieve
which modality (Radical cystectomy (RC) vs bladder-sparing therapy (BST)) had the superiority in the
management of patients with muscle-invasive bladder cancer (MIBC). Methods: we performed a
retrospective, case-control study from the archived files at the Urology Department in coordination with
the Surgical Oncology Unit and Clinical Oncology Department at Bab-Elsharya and Al-Hussein University
Hospitals, Faculty of Medicine, Al-Azhar University, Cairo between January 2007 and October 2013.
Patients with MIBC, Stage II (T2a-T2b, N0, M0) or Stage III (T3a-T4a, N0, M0), and suitable for chemo-
radiation and surgery were enrolled in this study. Results: this study comprehended an overall 148
candidates diagnosed with MIBC. Of them, 95 participants were submitted to RC, whilst 53 patients were
subordinated to BST. The overall 5-year survival rate was 58.9% and 39.6 % in RC and BST groups,
respectively (log-rank test, P= 0.273). Additionally, disease-free survival rates were 86.8% in patients
subjected to BST and 91.6% in patients subjected to RC (log-rank test, p= 0.6). Conclusion: despite no
differences were established between RC and BST regarding overall survival rate and disease-free survival
rate, BST is an emerging procedure with considerable low complications relative to RC.
Keywords: bladder-sparing therapy, muscle-invasive bladder cancer, radical-cystectomy.
Bladder cancer (BC) is a life menacing disease
and the oncological outcomes, the current
that harvested a considerable number of deaths
tendency in the management of tumors focused
anniversary. Noteworthy, BC is the most
on preserving the affected organs with
predominant cancer among Egyptian men with a
subsequent therapy based on chemotherapy and
prevalence rate of more than 15% resulting in
8,000 deaths yearly(1, 2). Transitional cell
therapy (BST), based on trans-urethral resection
carcinoma (TCC), which is related mainly to
of bladder tumor (TURBT) followed by
tobacco smoking, is the main type of BC with an
radiotherapy and chemotherapy, is a promising
incidence rate of more than 90%(3). Of note,
approach in the management of patients with BC
with comparatively concise advantages in the
constituted about 25% among patients with BC(4).
terms of maintaining bladder function, achieving
Herein, a high concern should be given to MIBC
oncological outcomes, and considerably lower
patients particularly with the obscurity of the
rats of morbidities and mortalities(8, 9). The
adequate treatment. Throughout the past decade,
optimal management of patients with MIBC is
radical cystectomy (RC) approach was the
still a doubtful question in the literature
standard treatment of patients with MIBC(5).
especially with the diversity in the surgical
However, this approach was associated with
techniques, treatment modalities and patient's
conceivable morbidities that ameliorate the
demographic characteristics. Thereafter, this
patient's quality of life and leads to a high
study was implemented to retrieve which
mortality rate principally in old age patients(6).
modality (RC vs BST) had the superiority in the
Thereafter, to ensure the patients quality of life
management of patients with MIBC apart from
COMPARATIVE STUDY BETWEEN SYSTEMICALLY AND PERINEURALLY ADMINISTERED TRAMADOL AS AN ADJUNCT IN ULTRASOUND GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1233-1241
Comparative Study Between Systemically and Perineurally Administered
Tramadol as an Adjunct in Ultrasound Guided Supraclavicular Brachial Plexus
Ahmed Alsaied Abd Elrahman 1, Huda Fahmy Mahmoud 2, Nagwa Mohamed Gamal Eldin 2, Eman
Mohamed Sobhy Abd Elshakoor 2*
1 Anesthesia, Surgical Intensive Care and Pain Medicine Deparmtent, Suhag University.
2 Anesthesia and Surgical Intensive Care Department, Aswan University
* Corrosponding Author: Eman Mohamed Sobhy Abd Elshakoor, E-mail: Nubiankandake@gmail.com
Background: brachial plexus block remains the only practical alternative to general anesthesia for significant surgery
on the upper limb. It can be extremely useful in patients with significant co-morbidities such as severe respiratory and
cardiovascular disease, morbid obesity and in those with potential airway difficulties.
Aim of the Work: comparing the efficacy of systemically administered tramadol and perineurally administered
tramadol as an adjunct to bupivacaine in supraclavicular brachial plexus blocks on onset of sensory, motor
blockade and postoperative analgesia along with demand for rescue analgesic in the postoperative period.
Patients and Methods:
Group A: bupivacaine 0.5%-20 ml + lidocaine 2% -5 ml for block.
Group B: bupivacaine 0.5%-20 ml + lidocaine 2% -5 ml mixture for block and tramadol (100 mg) diluted
to 10 ml intravenously.
Group C: bupivacaine 0.5%-20 ml+ lidocaine 2% -5 ml+ tramadol (100 mg).
Results: In motor onset block there was a highly significant difference between the three study groups. Also, it
was highly significant faster in group C where tramadol given perineurally compared with those of placebo and
systemic tramadol administrations. Duration of sensory block there was a highly significant difference between the
three study groups. It was highly significant longer in group C where tramadol given perineurally compared with
those of placebo and systemic tramadol administrations. Regarding First request of rescue analgesia there was a
highly significant difference between the three study groups.
Conclusion: the mixture of tramadol, bupivacaine and lidocaine injected perineurally for supraclavicular
brachial plexus block hastens the onset of sensory block, motor block and provides a longer duration of motor
blockade and postoperative analgesia as compared to other two groups in which tramadol was either injected
intravenously (systemic group) or was not given at all (control group).
Keywords: Systemically and Perineurally Administered Tramadol, Supraclavicular Brachial Plexus Block
Brachial plexus block remains the only
perioperative fasting can be minimized, diet more
practical alternative to general anesthesia for
significant surgery on the upper limb. It provides a
continuously monitored. These blocks are therefore
superior quality of analgesia and avoids the
particularly useful in the ambulatory surgical
common side-effects associated with general
setting for a wide variety of patients and
anesthesia such as postoperative nausea and
procedures. For more complex major procedures,
vomiting. It can be extremely useful in patients with
continuous catheter techniques allow prolongation
significant comorbidities such as severe respiratory
of analgesic block with earlier mobilization,
and cardiovascular disease, morbid obesity and in
improved rehabilitation, and the potential to reduce
those with potential airway difficulties. In addition,
hospital stay and improve functional outcome (1).
it simplifies the management of other disease
Local anesthetics alone for supraclavicular
conditions such as diabetes mellitus, where
brachial plexus block provide good operative
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1242-1250
Students' approaches to learning and perception of learning environment: A
comparison between traditional and problem based learning medical curricula
Abdulrahman Alquliti, Ehab abd elmoneim , Nisreen albouq, Motausm aboonq , kafaf jalali, Sahal arabi,
Taibah University, Medina, Saudi Arabia
Background: Teaching and learning are fundamentally different between conventional and problem based
learning (PBL) curricula. There is a transformation in the College of Medicine, Taibah University, Saudi Arabia
(CMTU) from the conventional to a PBL curriculum. Aim: To compare students' approaches to learning and
their perception of learning environment between conventional and PBL curricula at CMTU. Method: A cross
sectional study was conducted through a self-administered questionnaire on a convenience sample from the third
year undergraduate male and female medical students enrolled in both PBL and conventional curricula during the
academic year 2015- 2016. Students' approaches to learning and perception of learning environment were
measured using the "Approaches and Study Skills Inventory for Students (ASSIST)" and the "Dundee Ready
Education Environment Measure (DREEM)" instruments, respectively. Results: A total of 101 questionnaires
(49 (48.5%) and 52 (51.5%) from traditional and PBL curricula, respectively) were analyzed. When compared to
conventional curriculum students, PBL curriculum students showed a significantly higher overall DREEM
(136.98 ±21.45 vs. 111.59 ±27.93; p <0.001) as well as all its subscales. Significantly higher ratings for strategic
approach towards learning (60.77 ±9.12 vs. 56.35 ±9.93; p=0.02) and net learning orientation (deep approach +
strategic approach - surface apathetic approach; 85.60 ±17.32 vs. 77.76 ±20.63; p=0.04) were seen in PBL
curriculum students. Conclusion: The transformation to a PBL curriculum at CMTU was accompanied by a tilt in
the learning style towards a desired deep and strategic learning styles and a definite improvement in the perception
of learning environment among students.
Keywords: problem based learning (PBL),College of Medicine, Taibah University(CMTU),Approaches and
Study Skills Inventory for Students (ASSIST),Dundee Ready Education Environment Measure (DREEM).
Medical curricula are designed to ensure students
brainstorming to come up with the most relevant
gain of the appropriate clinical and scientific skills.
issues essential to fully understand the subject (5);
The most often practiced medical teaching method
concomitantly it helps the development of generic
is referred to as conventional system which
skills, such as problem solving, thinking ability,
emphasizes the broad coverage of content areas
communication among peers, teamwork within the
using lecture as the starting point. Another more
group, and time and information management (6).
recent method that has gained much attention in
Since its inauguration 16 years ago, College of
medical education is the problem based learning
Medicine, Taibah University (CMTU) has adapted
(PBL), which is a constructivist model of education
conventional medical curricula. In a critical analysis
in which the starting point for learning is a problem
of the conventional curriculum at CMTU, Khoshhal
or query that the learner systematically explores. In
and Guraya, 2013 reported a non-uniform,
PBL, learning is viewed as a process of active
unharmonized, and unstandardized curriculum that
knowledge building rather than passive knowledge
is far teacher centered and information oriented (7)
reception (1). Criticism directed to conventional
and recommended program ratifications based on
medical curricula included overcrowding of the
modern teaching strategies. Furthermore, analyses
curriculum, over-presentation of the same subjects,
of the learning styles of undergraduate students at
the presence of non-relevant subjects (2, 3), and the
CMTU showed a predominance of reflectors
lack of students participation in finalizing the
superficial style that illustrated the need to promote
curriculum; which impedes the personal growth of
self-directed learning through modifying the
students (4). On the other hand, in PBL the start by a
instructional strategies of the existing curriculum, in
sample clinical problem or scenario encourages
order to influence the learning styles of the students
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1251-1259
Association of Albumin to Creatinine Ratio with Severity of Coronary Artery
Mostafa Atyia ELsawasany1, Abd Alaleem Aly ELgendy2, Ahmed Mohamed Salah Eldeen1, Haysam
Sabry Abd Elhameed3, ELsayed Antar Mohamed Aly1*
Departments of 1Cardiology, 2Clinical Pathology, and 3Internal Medicine,
Faculty of Medicine, Al-Azhar University
*Corresponding author: ELsayed Antar Elshehawy, Mobile: 01122646938; Email: email@example.com
Background: Coronary artery disease (CAD) is a major cause of mortality and morbidity in many countries.
Atherosclerosis of coronary arteries is responsible for almost all cases of CAD. Pathology of endothelium is the
main cause of atherosclerosis of coronary arteries. Coronary artery disease is affected by many factors and several
different risk factors. Objective: To investigate the association between the level of microalbuminuria and
the severity of coronary artery disease angiographically. Patients and Methods: The study was conducted on
100 patients who underwent coronary angiography in Cardiology department of Al-Azhar faculty and 6 October
Cardiology Hospital on selective basis. The population study was divided into 2 groups according to
microalbuminuria. Group (I): included 66 patients with angiographic evidence of coronary heart disease and
without microalbuminuria. Group (II): included 34 patients with angiographic evidence of coronary heart disease
and having microalbuminuria. Results: In the present study it was found that increased severity of coronary
artery disease was more prevalent among patients with microalbuminuria compared to those with normo-
albuminuria and the difference was statistically significant. Conclusion: Microalbuminuria is predictive for
CAD independently with other risk factors. Microalbuminuria increase severity and number of CAD lesions
and aggressive treatment of microalbuminuria may be beneficial in CAD patients.
Keywords: Coronary artery disease, Microalbuminuria, B-type natriuretic peptide
Coronary artery disease (CAD) is a major cause of
An increasing number of studies in different
death and disability in many countries.
patient populations have reported that MA is
Atherosclerosis of coronary artery due to
associated, independently of traditional risk
endothelial pathology is the main factor for the
factors, with all causes of cardiovascular
majority of all cases of CAD. Coronary artery
morbidity and mortality in patients with diabetes,
disease has many factors and several different risk
hypertension and in the general population (4).
factors; old age, male sex, hypertension, diabetes
Although a 24-hours urine collection is the gold
mellitus, cigarette smoking and dyslipidemia are
standard for the detection of microalbuminuria,
the major and independent well known risk factors
several studies have found that a urinary albumin
or CAD (1).
to creatinine ratio is equally sensitive and specific
CAD risk factors do not entirely explain the
variation in cardiovascular disease incidence and
Urinary albumin to creatinine ratio does not require
mortality between individuals and among
early morning or timed collections, it gives a
populations. Other risk factors have been
quantitative result that correlates with the 24-hour
proposed to better identify patients who are
urine values over a wide range of protein excretion,
potentially at risk of CAD. Many individual
it is cheap to perform, and repeat values can be easily
biomarkers have been related to cardiovascular
obtained to ascertain that microalbuminuria, if
risk, including levels of high sensitivity CRP (C-
present, is persistent (6).
reactive protein), B-type natriuretic peptide (BNP)
AIMS OF THE WORK
fibrinogen, D-dimer and homocysteine (2).
Aims of this work are to observe the relationship
between the albumin/creatinine ratio and the
microalbuminuria (MA), which is gaining
presence and extent of coronary artery disease,
recognition as a good marker of an atherogenesis
and to add microaluminuria as a simple marker to
of coronary artery, owing to its association with
coronary artery atherosclerosis and compare it
several atherosclerotic risk factors and early
with other risk factors.
systemic vascular endothelial damage (3).
PATIENTS AND METHODS
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1260-1265
Rapid onset obesity with hypothalamic dysfunction, hypoventilation and
autonomic dysregulation in children: a case series from Saudi Arabia
Gawahir Mukhtar 1, Wadha Alotaibi2, Khalid Al-mobaireek3, Safa Eltahir1, Suhail Al-Saleh 4
1 -Pediatric Pulmonary Division, King Fahad Medical City (KFMC), 2 -Pediatric Pulmonary and Sleep
Physician, Head of the Pulmonary Unit, KFMC, KSA 3-Pediatric Pulmonary Division, King Khalid
Hospital/ King Saud University , 4 -Division of Respiratory Medicine, Hospital for Sick Children,
University of Toronto, Toronto, Ontario, Canada
Corresponding author: Gawahir Mohamed Ahmed Mukhtar, E mail: firstname.lastname@example.org, Mobile number
Background: rapid onset of obesity with hypothalamic dysfunction, hypoventilation and autonomic
dysregulation (ROHHAD), which was previously known as late-onset central hypoventilation with
hypothalamic dysfunction, is a rare and complex syndrome that has been described in several case reports
and series worldwide. Patients with ROHHAD are usually reported to be healthy prior to a characteristic
rapid weight gain associated with autonomic and hypothalamic dysfunction and fatal central
hypoventilation in the absence of mutations in the paired-like homeobox 2B (PHOX2B) gene. Case study:
despite increased advancing knowledge of the disease course, the variable onset often results in delaying
or missed diagnosis of ROHHAD syndrome which resulted in fatal cardiopulmonary arrest, central
hypoventilation or impaired neurocognitive function. Here, we reported the first case series of ROHAAD
syndrome from Saudi Arabia comprising four patients with different clinical manifestations. In this article
we reported 4 cases of ROHHAD as a first serial cases from Arab area according to our Knowledge, with
variable manifestations, but all sharing the rapid onset of obesity and hypoventilation, but case 1 her main
striking feature was altered pain sensation and thirsty as autonomic dysregulation, while the second patient
was twin 2 had pseudotumor cerebri and behavioral changes and her second twin was healthy, the third
case also had behavioral changes and case 4 had obstructive sleep apnea. Conclusion: due to the overlap
in symptoms and signs between ROHHAD and other well-characterized disease entities, multidisciplinary
care with input from a center with expertise in ROHHAD was crucial to the successful management of
patients with suspected ROHHAD syndrome. Furthermore, mortality associated with the high incidence of
cardiopulmonary arrest may be prevented by early ventilatory support.
Key words: ROHHAD, children, Saudi Arabia, case series, PHOX2B gene,
The patient in case 1 was a young girl who first
She also had unstable blood pressure and
presented at age of 7 years with a history of rapid
impaired pain sensitivity, which was typical of
weight gain over the previous 4 months combined
autonomic dysregulation. The patient was seen
with a cough and shortness of breath for the
by a member of the nephrology team regarding
previous 2 months. At admission, she was found
her symptoms of hypernatremia and unstable
to suffer from nocturnal hypoxia, morning
blood pressure and by the endocrinology team,
hypercapnia (Reached SpCO2 68 mmHg),
for hypernatremia as well as obesity and
hypernatremia (Serum sodium >160 mmol/L) as
well as central precocious puberty with
luteinizing hormone releasing hormone levels in
Extended investigations, included serum and
the normal range and a normal cortisol stress
urine osmolality, as well as brain and abdominal
response. Furthermore, the patient did not report
computerized tomography (CT) scans were
polydipsia and only drank water upon request.
performed. The patient received intravenous
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1266-1278
Laparoscopic Ureterolithotomy Versus Ureteroscopy In Management Of
Upper Ureteral Stone Larger Than 15 Mm In Adults
Mohamed Zaki Ali, Ahmed Mohammed Saafan, Magdy Mostafa Saleh, Mostafa Ahmed
Departments of Urology, Faculty of Medicine, Aswan University
*Corresponding author: Mostafa Ahmed Mostafa ElBakry, Mobile: 01003706454, Email: email@example.com
Background: There are multiple approaches for treatment of patients with upper ureteral stones.
Extracorporeal shockwave lithotripsy (SWL), ureterorenoscopy (URS), percutaneous nephrolithotomy
(PCNL), laparoscopic ureterolithotomy (LU) and open ureterolithotomy each has advantages and
disadvantages. Although SWL is minimally invasive and can be performed as an outpatient
procedure, disadvantages include a high retreatment rate, long treatment time, and inability to dissect
a large or impacted stone. Objective: The aim of this study was to compare between laparoscopic
ureterolithotomy and retrograde ureteroscopy for treatment of large upper ureteric stones as regard
operative time, blood loss, hospital stay, post-operative pain, use of analgesia, intraoperative &
postoperative complications and success rate. Conclusion: LU provides a higher stone-free rate than
URS in the management of large proximal ureteral stones. There are no differences regarding overall
post-operative complications or major postoperative complications between the procedures. Semi-
rigid URS is associated with a short operative time and length of hospital stay; however it leads to a
higher need for auxiliary procedures. When counseling a patient with a large proximal ureteral stone,
LU should be advised as the procedure with the higher chance of stone removal, although it is also
more invasive, leading to longer operative time and length of hospital stay. Utilization of flexible
ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves
further systematic evaluation.
Keywords: Laparoscopic Ureterolithotomy, Ureteroscopy Management, Ureteral Stone
mainly for patients with a large stone burden
There are multiple approaches for
and proximal ureteral stones (2).
treatment of patients with upper ureteral
stones. Extracorporeal shockwave lithotripsy
Laparoscopic ureterolithotomy can be
used after first-line treatment has failed or is
expected to fail. This approach may be a
laparoscopic ureterolithotomy (LU) and open
worthwhile alternative to open surgery (3),
ureterolithotomy each has advantages and
because the role of open ureterolithotomy
disadvantages. Although SWL is minimally
declined rapidly after advancements of
invasive and can be performed as an outpatient
minimally invasive surgery (4).
procedure, disadvantages include a high
retreatment rate, long treatment time, and
Laparoscopic surgery has been used for
inability to dissect a large or impacted stone
many types of urologic surgery involving
URS is recommended as first-line
established in laparoscopy since Geau
treatment for upper ureteral stones. Flexible
developed a balloon dissection technique for
ureteroscopy with laser lithotripsy has a high
the retroperitoneal space. Retroperitoneal
surgical success rate, but this procedure
laparoscopic ureterolithotomy is a new option
necessitates special devices that are not
minimally invasive technique to treat large,
available in all hospitals. PCNL is considered
hard, long standing, and impacted upper ureter
calculi in selected patients. However, large
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1279-1286
Assessment of Ventricular Outflow Tract in Macrosomic Neonates
Ahmed Fetouh Abd Elrahman Elhass*, Ahmed Mohamed Ismail, Mohamed Mahmoud
Abd Elmohsen, Ibrahim Mohamed Abofarag
Department of Pediatrics and Neonatology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Fetouh Abd Elrahman, Mobile: (+20)01091577711, Email: firstname.lastname@example.org
Introduction: Fetal macrosomia is encountered in up to 10% of all deliveries. It occurs in 15-45% of
diabetic pregnancies. Factors associated with fetal macrosomia include genetics; duration of gestation;
presence of gestational diabetes; high pre-pregnancy body mass index (BMI); excessive gestational
weight gain and diabetes mellitus. Macrosomia is reportedly associated with neonatal morbidity,
neonatal injury, maternal injury, and cesarean delivery. Moreover, shoulder dystocia, brachial plexus
injury, skeletal injuries, meconium aspiration, prenatal asphyxia, hypoglycemia, and fetal death. All
types of maternal diabetes are risk factors for macrosomia and can affect the foetal cardiac development
in the form of Hypertrophic cardiomyopathy and congenital cardiac malformation.
Aim of work: To evaluate the cardiac changes and ventricular outflow tracts in macrosomic neonates
clinically and by 2D transthoracic echocardiography.
Patients and Methods: This prospective study was carried out in NICU of Sayed Galal University
Hospital on fifty macrosomic neonates' thorough detailed history, clinical examination, Chest X-ray,
important laboratory investigation, two dimensional M-mode and Doppler echocardiographic
Results: The fifty macrosomic neonates consisted of 29 males (58%) and 21 females (42%) with mean
age ± SD of 2.16±0.84 days (range, 1-5 days). Statistically, significant relation between inter ventricular
septum diastole (IVSD) (mm) according to HbA1c level, increase IVSD with increase HbA1c level,
and show statistically significant relation between inter ventricular septum diastole (mm) and
LTVOTO. When IVSD increase the incidence of LVOTO increase While TABSE decrease with the
increase in IVSD. It also showed significant negative correlation between IVSD and MPI and PAP.
Conclusion: Elevated maternal HbA1c level can lead hypertrophic cardiomyopathy mainly septal
hypertrophy, which increased incidence of ventricular outflow tract obstruction. These
echocardiographic findings (TAPSE and MPI) seem to be a better index of the cardiac outcome of
macrosomic neonates than other clinical, laboratory or radiological parameters.
Recommendations: Early echocardiographic examination for early detection of myocardial
dysfunction or cardiac defect is essential in all macrosomic neonates andIDM even those without
audible murmur, especially so if not improving with proper intervention. Echocardiographic indices
especially TAPSE and Tei index for all macrosomic neonates to detect early cardiac changes in
particular left ventricular dysfunction.
Keywords: Macrosomia, infant of diabetic mother (IDM), echocardiogram, inter ventricular septum
diastole (IVSD), ventricular outflow tract obstruction, Tricuspid Annular Plane Systolic Excursion
(TAPSE) and Tei index.
The American College of Obstetricians
observed as a consequence of maternal
macrosomia as birth-weight over 4,000g
irrespective of gestational age or greater than
the 90th percentile for gestational age after
macrosomia include genetics; duration of
correcting for neonatal sex and ethnicity (1).
gestation; presence of gestational diabetes; high
pre-pregnancy body mass index (BMI);
Fetal macrosomia occurs in 15-45% of
excessive gestational weight gain and diabetes
diabetic pregnancies. It is most commonly
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1287-1297
Study of Atrial Fibrillation and Venous Thromboembolism in Critically Ill
Patients in Intensive Care Unit
Yasser Elsayed Mohammed
Cardiology Department, Faculty of Medicine, Al-Azhar University
Bachground: atrial fibrillation (AF) is the most common arrhythmia in patient hospitalized in ICU
and is associated with increased morbidity and mortality. Venous Thromboembolism (VTE), including
deep venous thrombosis (DVT) and pulmonary Embolism (PE), is recognized as a common
complication in critically ill patients. Risk factors including critical illness, mechanical ventilation,
sedative medications and central venous catheter insertion are major contributing factors to the high
risk of VTE. Objective: it was to evaluate the causes and outcomes of AF and VTE in patients admitted
to intensive care unit due to non-cardiac causes. We studied 143 consecutive patients admitted to ICU
for non-cardiac emergencies. Results: only 48 (33.5 %) patients were complicated. AF is the most
common complication happened in 27 patients (56 %) of complicated cases; pulmonary embolism
comes next with 13 patients (27.1%) of complicated cases, DVT in the third place with 8 patients (16.6
%) of complicated cases. The age of patients admitted to ICU was directly related to complication
happened in ICU, the older the patient is the more he is vulnerable to complications, the increased body
mass index and increased weight was directly related to complications, the hemoglobin level is strongly
related to cardiac complications . There was increased risk of DVT and pulmonary embolism due to
prolonged bed ridden state.
Conclusion: patients of ICU who have a higher risk than other for adverse cardiac complications, the
most common cardiac complications are AF, DVT and pulmonary embolism and finally cardiac
complications leads to increased rate of mortality and morbidity.
Keywords: Atrial Fibrillation, Venous Thromboembolism, Intensive Care Unit.
Atrial fibrillation (AF) is the most
and central venous catheter insertion are major
common arrhythmia in patients hospitalized in
contributing factors to the high risk of VTE (1).
intensive care units (ICUs) and is associated
VTE is a common lethal disease that
with increased morbidity and mortality. Most
affects hospitalized patients, recurs frequently,
frequently, the diagnosis of the underlying
is often overlooked, and can result in long term
arrhythmia is possible from the physical
examination, the response to maneuvers or
thromboembolic pulmonary hypertension and
post thrombotic syndrome. Although it is the
3rd most common cause of hospital-related
Twelve leads electrocardiogram is the
deaths, less than half of all hospitalized patients
corner stone to identify the rhythm of
at risk for VTE, received adequate prophylactic
tachyarrhythmia, presence of pre-excitation,
treatment. Most of hospitalized patients have at
Brady arrhythmias and heart blocks.(2).
least one or more risk factors for VTE, and
Cardiac arrhythmias are a common
without prophylaxis, the incidence of hospital
problem encountered in the intensive care unit
acquired DVT is 10% to 20% among medical
(ICU) and represent a major source of
patients and even higher among surgical
morbidity. The inciting factor for an arrhythmia
patients (15% to 40%) (4)
in a given patient may be an insult such as
Patients and Methods:
The study included 143 consecutive
patients who admitted to ICU for non cardiac
exogenous), or an electrolyte abnormality (3).
emergencies . The study was approved by the
Venous thromboembolism (VTE),
Ethics Board of Al-Azhar University.
including deep venous thrombosis (DVT) and
All patients admitted to ICU, from
pulmonary embolism (PE), is recognized as a
November 2015 to november 2016 were
common complication in critically ill patients.
included in the study, 319 patients were
Risk factors including critical illness,
admitted to ICU during this time with medical
mechanical ventilation, sedative medications,
emergency, surgical emergency or for post-
operative observation, 167 patients were
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1306-1313
The Use of Trans Abdominal Ultrasound in Assessment of the Lower Uterine
Segment Thickness in Patients with Previous Cesarean Section
Ismael M. Mira, Abdel-Monsef A. Sedek, Ahmed T. Ahmed
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University,Cairo, Egypt
Corresponding author: Ahmed T. Ahmed; Mobile: 01125768883; Email: email@example.com
Introduction: There is a steady increase in the rate of cesarean delivery. In Egypt, Cesarean sections
were performed in 38.84% of deliveries in 2008, 37.88% in 2009, 39.08% in 2010, 37.72% in 2011 and
41.17% in 2012, repeated cesarean sections (RCS) was the main indication. In making plans for delivery,
physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of
complications from a trial of labor. Approximately 60-80% of appropriate candidates who attempt vaginal
birth after cesarean (VBAC) will be successful. Aim of the Work: was to determine a cut-off value that can
be clinically used to allow a safe vaginal delivery by using abdominal ultrasound to evaluate the thickness of
the lower uterine segment in patients with history of previous cesarean section. Patients and Methods: The
lower uterine segment thickness was measured by both transabdominal ultrasound in 200 cases, gravidas (37
week 40 week),100 cases with previous CS (study group) undergoing repeated CS, and the other 100 cases
without any scar in the uterus (control group), then the grade of the scar was assessed intraoperatively.
Results: By TAS the best cut- off value was 2.5 mm and this yielded a sensitivity of 77.3% and a specificity
of 73.5%. At this cut-off value, the positive predictive value was 85% while the negative predictive was
62.5% and the accuracy was 76%. Conclusion: Ultrasonographic evaluation permits good assessment of the
risk of scar complications intra partum. The lower uterine segment thickness is related to the grade of the
scar. The best timing to perform the scan is at late third trimester. A cut-off value of 2.5 mm by TAS can be
safely used with high degree of sensitivity and specificity.
Key words: Ultrasound, lower uterine segment, previous cesarean section, VBAC.
There is a steady increase in the rate of
an incidence of about 43.5% in the past 5 years.
cesarean delivery with the exception of the years
So, there is an increase in CS rate in Cairo
between 1989 and 1996 when the annual rate of
University Hospital and the increase was mainly
cesarean delivery actually decreased. This decrease
due to increase in the primary CS rate (3).
was largely due to a significantly increased rate of
Vaginal Birth After Caesarean (VBAC) and to a
In making plans for delivery, physicians
closely mirrored decrease in the primary rate. These
and patients should consider a woman's chance of
trends were short lived, and in 2007, the primary
a successful VBAC as well as the risk of
cesarean delivery rate was above 30 percent,
whereas VBAC rates dropped to 8.5 percent (1).
Approximately 60-80% of appropriate candidates
who attempt VBAC will be successful (4).
In Egypt, a significant rise in cesarean
section rate has occurred from 4.6%in 1992 to
VBAC avoids major abdominal surgery,
10.3% in 2000. However, hospital based
lowers a woman's risk of hemorrhage and
cesarean deliveries were much higher in1998
infection, and shortens postpartum recovery. It
(13.9%) and increased to 22.0% in 2000.
may also help women avoid the possible future
Although the cesarean section rate was slightly
risks of having multiple cesareans such as
higher in private hospitals, the rate has also
hysterectomy, bowel and bladder injury,
increased consistently in public hospitals (2).
transfusion and abnormal placenta conditions
(placenta previa and placenta accreta) (4).
Cesarean sections were performed in
38.84% of deliveries in 2008, 37.88% in 2009,
Among factors that should be considered
39.08% in 2010, 37.72% in 2011 and 41.17% in
in selection of candidates for vaginal birth after
2012, repeated cesarean sections (RCS) was the
cesarean delivery (VBAC): one previous prior
main indication and a large proportion of patients
low-transverse cesarean delivery, clinically
were having previous one cesarean section with
adequate pelvis, no other uterine scars or previous
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1314-1321
Effect of Tranexamic Acid on Blood Loss in Elective Cesarean Delivery
Esmail Talaat Al-Garhy, Ashraf Hamdy Mohamed, and Islam Abdullatif Barakat*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Islam Abdullatif Barakat, Mobile: (+20)01229702442, Email: firstname.lastname@example.org
Background: tranexamic acid as an agent given before surgical procedures reduces the blood
transfusion risk, mean volume lost, and the requirement for reintervention due to bleeding issues,
without raising thrombotic risks.
Aim: to evaluate Tranexamic acid agent infusion as regards its efficacy in blood volume loss reduction
in practice of elective lower segment cesarean section delivery.
Patients and Methods: A double blinded, randomized, controlled research clinical trial. All study
subjects have been recruited from the cases scheduled for elective cesarean delivery in the labor ward
of Mokattam Insurance Hospital. The study subjects were totally 200 cases allocated in by
randomization into 2 research groups. The study research group have been composed of 100 cases
that were administered a mixture of tranexamic acid 25mg/kg in 200 ml of normal saline by intravenous
drip for 20 minutes before incision, while the control research group contained 100 cases administered
a volume of normal saline in accordance to patient's weight (25 mg/kg) by intravenous drip for 20
minutes before time of incision.
Results: Blood loss volume was statistically significantly lower among Tranexamic research group than
among placebo research group (p value <0.001). Postoperative hematocrit was statistically significantly
higher among Tranexamic research group than among placebo research group (p value =0.020).
Hematocrit reduction was statistically significantly lower among Tranexamic research group than
among placebo research group (p value <0.001). PPH and blood transfusion were statistically
significantly less frequent among Tranexamic research group (p values=0.010, 0.005 consecutively).
Conclusions and Recommendation: The administration of tranexamic acid before starting a cesarean
section is valuable as a prophylaxis against intra-operative and post-partum bleeding issues.
Future research studies are required to consider various variables such as racial and ethnic differences and
consider various clinical case scenarios e.g. previous cesarean delivery and categorization of more possible
critical indications of cesarean such as second stage cesarean, emergency cesarean section and time interval
of decision to incision as those variables could influence blood volume loss indices.
amino acid lysine that has an antifibrinolytic
Postpartum hemorrhage is defined
pharmacological impactvia the reversible
clinically as blood loss of 500 cc or more within
blockage of the lysine binding sites on
24 hours after delivery. Statistical estimates of
its incidence in the research studies differ
administration of Tranexamic acid have been
widely, from 3 % to 15 % of deliveries (1). About
routinely implemented for management and
one in five of these hemorrhages progress to
prevention of bleeding with satisfactory results
severe form that could jeopardize maternal life
research findings from previous research trials
or future fertility and causes hazardous risks
have displayed that Tranexamic acid in
exposure to issues transfusion, surgical
elective surgical procedure decreases the blood
intervention, and intensive care admission(2).
transfusion risk, mean volume transformed , and
Post partum hemorrhage is considered a leading
the requirement for re-operation due to active
cause for maternal mortality and accounting for
bleeding, without raising thrombotic events(6-
mortalitiesglobally(3). Its clinically expected risk
factors involve prior history of post partum
hemorrhage, multi parity, obesity, prolonged or
The current research main goal is to
augmented course of labor, multifetal gestation,
asses and evaluates Tranexamic Acid infusion
as regards the efficiency in blood loss reduction
during elective lower segment cesarean section
Tranexamic acid is a synthetic derivative of the
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1322-1329
Comparative Study between Adenoidectomy with Myringotomy and Adenoidectomy with
Ventilation Tube Insertion in Management of Secretory Otitis Media
Wael Hassan Aboulwafa, Hatem Salah Eldin El Habashy, Marwan Ahmed Ibrahim,
Mohamed Sobhy Ali
Otorhinolaryngology Department, Faculty of Medicine, AL-Azhar University, Egypt
Corresponding author: Mohamed Sobhy Ali, Mobile: 01092149427; Email: email@example.com
Background: Otitis media with effusion is one of the most common chronic otological conditions and the
most common cause of conductive hearing loss in the pediatric population. Ventilation tubes insertion with or
without adenoidectomy is considered as a standard surgical procedure. Objective: this study aimed to compare
the efficacy and the complications of adenoidectomy with myringotomy in comparison with adenoidectomy
and ventilation tube insertion in management of otitis media with effusion. Patients and Methods: this was a
prospective study carried out between October 2017 to October 2018 (One year). The study included 60 cases
diagnosed with persistent otitis media with effusion due to adenoid enlargement and they were categorized
randomly into two groups (30 cases per each). Group I underwent myringotomy alone with adenoidectomy
and group II underwent myringotomy with ventilation tube insertion with adenoidectomy. All patients were
subjected to full ENT examination, tympanometry and hearing evaluation. Patients were followed up (After
myringotomy healing, at one month and 3 months after healing) for 3 months after tube extrusion or
myringotomy closure. Postoperative evaluation was done for all patients and complications were assessed.
Results: the mean healing time was significantly longer in children who underwent adenoidectomy with
ventilation tube (Group II) compared to patients of group I, (p<0.001) (28.5 vs. 2.2 weeks). The number of
cases with OME recurrence after 3 months of healed myringotomy were significantly higher in group I (18
ears, 30.0%) compared to group II (6 ears, 10.0%), (p<0.006). Postoperative tympanogram was improved in
both groups but, it was significantly improved in the group who underwent adenoidectomy with ventilation
tube (Group II) compared to the group who underwent adenoidectomy with myringotomy only at all follow
up intervals (p=0.015, 0.002, 0.022), respectively. The incidence of some postoperative complications such as
otorrhea and tympanic sclerosis was significantly higher in group II (p=0.024 for otorrhea and p<0.001 for
tympanic sclerosis). Conclusion: both used procedures were effective in the treatment of OME in children, but
adenoidectomy with ventilation tube insertion was significantly better in improving tympanogram and
reducing OME recurrence, while, it may increase incidence of some complications. Further studies are
warranted with larger number of cases and longer follow-up period to confirm these results.
Keywords: Adenoidectomy, myringotomy, ventilation tube, otitis media
middle ear effusion) (6). When chronic adenoid
Otitis Media with Effusion (OME) is defined
infection is suspected, adenoidectomy is being
as the presence of a middle ear effusion in absence of
increasingly used for the treatment of OME; a recent
infection; its synonyms include `glue ear' and serous
study had confirmed its effectiveness (7). Also,
otitis media (1). Fluid in the middle ear is associated
adenoidectomy was beneficial in treating otitis media
most commonly with a conductive hearing loss and an
in children who were older than 4 years of age and had
increased risk of acute middle ear infection (2).
previously undergone ventilation tube insertion (8).
Management of OME consisted of many choices, auto
Ventilation tubes of the ear were tiny cylinders placed
inflation and medical treatment included antibiotic,
through the ear drum to allow air into the middle ear (3).
mucolytics and corticosteroids (3). Surgery was
Myringotomy with ventilation tube placement remains
indicated in cases where the effusion does not resolve
the most common surgical procedure in treatment of
spontaneously or failed medical treatment for 3 months
OME, common indication for tube insertion include
and the main purpose of surgery was to restore middle
recurrent acute otitis media, chronic Eustachian tube
ear ventilation by eliminating negative intratympanic
dysfunction and OME (9). There were some
pressure thus, the mucosa was normalized, hair cells
complications associated with tube insertion which
increased and the secretion potential was reduced (4).
were more frequent than anticipated, reaching 80% of
The adenoids may play an important role in the
operated ears under specific circumstances and in
pathogenesis of OME, adenoid hypertrophy can cause
certain subgroups of children (10). The main associated
mechanical obstruction of the Eustachian tube (5). The
complications were purulent otorrhea (1026%),
adenoids may be the source of bacteria infection which
myringosclerosis (3965%), segmental atrophy (16
can induce inflammation of the middle ear and may
75%), atrophic scars and pars flaccida retraction
provide a microenvironment for the generation of T
pockets (2128%), tympanic membrane perforation
lymphocytes (A lymphocyte phenotype found in the
(3%, but as high as 24% with Ttubes), cholesteatoma
Versatility of Medial Hemisoleus muscle flap techniques in Reconstruction of soft tissue defects of lower leg
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1330-1336
Medial Hemisoleus Muscle Flap in Reconstruction of Soft Tissue
Defects of Lower Leg
Mohamed Makboul, Ahmed Mousa, Mohamed Elotiefy and Mohamed Hamdy Mohamed Ahmed
Plastic Surgery Department, Faculty of Medicine - Aswan University
Corresponding author: Mohamed Hamdy Mohamed Ahmed; Mobile: (+20)01099050142, Email: firstname.lastname@example.org
Background: Reconstruction of lower leg represents a challenge task for plastic surgeons. Although microsurgical
flaps have been the golden choice for this reconstruction, many hospitals do not have equipment or microsurgical
staff trained for this type of procedure.
Aim: The objective of the current study is to evaluate of clinic applicability and functional outcome results of
medial hemisoleus muscle as a reconstructive flap modality in lower third leg soft tissue defect. This includes
clinical study comparison between two surgical modalities of hemisoleus muscle Hap elevation.
Methodology: This study was conducted in Plastic Surgery Department, Aswan University Hospital from May
2017 to August 2018. It was a descriptive study including 30 patients (23 males and 7 females with the age ranging
between 29 and 51 years). Results: Our study confirmed this fact as preservation of lateral portion is suitable for
planter flexion with gastrocnemius muscle and medial hemisoleus muscle flap showing long arc of rotation
especially distally based posterior tibial artery medial hemisoleus muscle flap has long arc of rotation cover up to
heal defect. Conclusion: Medial hemisoleus muscle flap is a reliable option for the reconstruction of soft tissue
defects of lower leg based on minor pedicle or reversed flow based on posterior tibial artery. Careful flap
dissection with preservation of as many perforators as possible is the key to success.
Keywords: Lower leg, soft tissue defects, medial hemisoleus muscle flap, reversed flow medial hemisoleus muscle
flap, distally based perforator medial hemisoleus muscle flap.
Reconstruction of the lower leg represents a
the leg as an alternative to the use of microsurgical
challenge for many plastic surgeons. Although the
microsurgical flap has been the method of choice for
An advantage of using the hemisoleus flap rather
this reconstruction (1-4), many hospitals do not have
than the whole soleus muscle flap is the preservation
equipment or microsurgical staff. of plantar flexion of the foot performed by the lateral
In other cases, the patients are not candidates for
portion of the muscle, which is left in its original
microsurgical reconstruction because of their medical
location. Moreover, the medial flap has a greater arc
conditions, and the surgeon is therefore required to
of rotation than that of a conventional soleus muscle
use alternative methods of reconstruction. Often,
flap (1-3). The medial part of the muscle is supplied in
defects in the lower leg quickly result in the exposure
its whole length by perforators of the posterior tibial
of relevant structures such as bone and tendon, the
artery. Because of this constant arterial supply, the
coverage of which requires the performance of a safe
medial part of the soleus muscle is viable as a muscle
reconstruction method with a well-vascularized
flap distally based or a reversed flow manner (1-3).
tissue (2, 3).
This study reports thirty cases of reconstruction of
The soleus muscle is located in the posterior
defects of the lower leg with the use of the medial
compartment of the leg anterior to the gastrocnemius
hemisoleus muscle flap.
muscles, and is classified as type II muscle according
to the classification of Mathes and Nahai. Medial
THE AIM OF THE STUDY
head of soleus dominant pedicle arises from posterior
The objective of the current study is to evaluate of
tibial artery and peroneal artery and minor pedicle
clinic applicability and functional outcome results of
arises from posterior tibial artery (2, 3).
medial hemisoleus muscle as a reconstructive flap
The soleus muscle is frequently used for the
modality in lower third leg soft tissue defect. This
reconstruction of defects of the middle third of the
includes clinical study comparison between two
leg, based on its major pedicle. However, the viable
surgical modalities of hemisoleus muscle Hap
use of the soleus muscle in a reverse manner based
on posterior tibial artery (dominant and minor
pedicles) or distally dased manner on its minor
PATIENTS AND METHODS
pedicle only, has been described by several authors
for the reconstruction of defects of the lower third of
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1337-1347
Measurement of Epicardial Adipose Tissue Thickness and Vitamin D Status in Obese Egyptian
Adolescents and their Relationship with Cardiovascular Dysfunction
Abd Allah Hussein El-Sadek 1, Mohammed Noshy El-Alfy 1, Mansour Mohammed Mustafa 2, Abd Allah
Mohammed El-Khshen 3, Kamel Soliman Hammad 4, Ahmed Ali Hassan Ali *1
Departments of 1 Internal Medicine, 2 Cardiology, 3 Diagnostic Radiology, 4 Clinical Pathology,
Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Ali Hassan Ali, E-mail: email@example.com, phone:
Background: Epicardial Adipose Tissue (EAT) is the cardiac visceral adipose tissue, influencing its
structure and function, and easily assessed by trans-thoracic echocardiography. Vitamin D deficiency is
prevalent among obese adolescents and is thought to affect the cardiovascular system.
Objective: This study was aimed to assess the EAT thickness (EATT) and Vitamin D status in obese
adolescents to clarify their relationship with cardiovascular dysfunctions.
Patients and Methods: This was a case-control study done at the Internal Medicine Outpatient Clinics of
Al-Azhar University Hospitals during the period from February 2016 to February 2018. It included 90 ado
lescents divided into two equal groups; obese group (45 obese) and healthy non-obese group (45 ones). Hi
story taking, clinical examination, laboratory investigations, and echocardiographic assessment were done
to retrieve all relevant data.
Results: Obese adolescents were substantially different from non-obese regarding their anthropometrics w
ith worse glucose homeostasis, insulin resistance and lipid profile, with a high prevalence of Metabolic Sy
ndrome (MetS) (57.8%). Echocardiographically, they had a significantly increased carotid intima-media th
ickness (cIMT) and EATT, higher incidence of hypertrophic cardiac remodeling, impaired systolic and dia
stolic LV and RV functions. 25-Hydroxy Vitamin D (25[OH]VD) levels was lower in obese group vs. non
-obese (10.2 ± 3.8 vs. 19.09 ± 7.8) respectively. EATT, cIMT, and s. Adiponectin showed the highest diag
nostic capability in identification of Adolescence obesity and MetS.
Conclusion: EATT is an easily obtainable marker of cardiovascular structural and functional derangements.
Vitamin D deficiency significantly worsen the cardio-metabolic risk profile and the cardiovascular function
among Egyptians obese adolescents.
Keywords: Epicardial Adipose Tissue, Vitamin D, Adolescence Obesity, Cardiovascular Dysfunction.
Throughout the past decades, the incidence of
emerging of metabolic syndrome (MetS( (6).
adolescent obesity has significantly increased in
Hereafter, it is a strong risk factor in the
both developed and developing countries(1, 2).
developing of cardiovascular dysfunction(7). Of
Obesity in adolescence usually associated with
note, carotid intimamedia thickness (cIMT) is a
considerable morbidities that hinder the quality of
strongest predictive parameter in the detection of
life(3). These complications not only restricted to
heart attack and stroke in adulthood and is
adolescence period but also extended to the
established to be increased among adolescent
adulthood which can lead to premature death(4).
obese patients (8).
Additionally, these sequels enhance the incidence
The epicardial adipose tissue thickness (EATT)
of obesity in the next generations(5). The most
reflects the cardiac and visceral adiposity, and it
terrible complications associated with adolescent
has been suggested as a new cardiometabolic risk
obesity are elevated blood pressure (BP),
factor owed by its close association with the
diabetes, dyslipidemia that constitutes in the
myocardium status(9). EATT contributed
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1348-1352
Impact of Extracorporeal Blood Flow on Blood Pressure, Pulse Rate and
Cardiac Output in Hemodialysis Patients
Mohammed Zein Eldeen Hafez, Hala Abdellah Mahmoud, Ramadan Ghaleb Mohammed,
Omar Abdelrahman Ahmed AbdAllah
Internal Medicine Department, Faculty of Medicine - Aswan University
Corresponding author: Omar Abdelrahman Ahmed AbdAllah; Mobile: 01144287127; Email:firstname.lastname@example.org
Background: If blood pressure (BP) falls during hemodialysis (HD) (intradialytic hypotension (IDH)) a
common clinical practice is to reduce the extracorporeal blood flow rate (EBFR). Consequently, the efficacy
of the HD (Kt/V) is reduced.
Aim of the Work: The aim of the present study is to investigate the impact of changes in extracorporeal blood
flow rate (EBFR) on blood pressure (BP), pulse rate (PR) and cardiac output (COP) in hemodynamically stable
patients during hemodialysis.
Patients and Methods: The population of this study consisted of 40 patients that on renal dialysis (RD) three
sessions weekly. Patients were investigated prior to and after one conventional hemodialysis session. Prior to
the hemodialysis session, an echocardiograph was performed to evaluate left ventricular ejection fraction
(LVEF) and establish the degree of potential heart failure.
Result: In the present study regarding measure of BP, PR and COP in EBFR 200 ml/min, 300 ml/min and 400
ml/min, there was significant increase in systolic BP at an EBFR 200 ml/min as compared with EBFR 300
ml/min and EBFR 400 ml/min. but there was no significant change in systolic BP at an EBFR 300 ml/min as
compared with an EBFR 400 ml/min.
Conclusion: IDH has been associated with many adverse clinical events including myocardial stunning,
cerebral atrophy and increased mortality. Change of BFR from 400 ml/min or from 300 ml/min to EBFR 200
ml/min can increase in BP so help in decrease occurrence of complications of IDH beside other methods of
increasing BP during hemodialysis.
Keywords: Blood flow rate, Blood Pressure, Intradialytic hypotension, Renal dialysis
of endotoxins (18), adenosine (19) and increased
hemodialysis )HD) (intradialytic hypotension
synthesis of endogenous vasodilators have been
(IDH)) occurs in 1530% of hemodialysis sessions
(1) and it is an independent predictor of
Intradialytic hypotension is usually treated by
cardiovascular morbidity(2) and mortality(3).
discontinuation of fluid removal and volume
Intradialytic hypotensive events are a common
replacement (3). Reduction in extracorporeal blood
complication of maintenance hemodialysis,
flow rate (EBFR) during hemodialysis has been
affecting up to one third of chronic dialysis
suggested as a supplementary treatment modality
treatment sessions (4). Intradialytic hypotension
(21). However, data on the impact of changes in
(IDH) can be defined as an abrupt decline in blood
EBFR on blood pressure (BP) during HD are
pressure that causes symptoms and/or requires an
conflicting and very limited. Interestingly, data
intervention (5). Intradialytic hypotension has been
from (22) demonstrated that the SBP, DBP, and
associated with many adverse clinical events,
mean BPs were significantly higher during the
including myocardial stunning (6), cerebral atrophy
BFR of 400 mL/min as compared with the blood
(7) and increased mortality (8).
flow of 200 mL/min, although data from (23)
Predisposing factors include intrinsic patient-
demonstrated a systolic BP was significantly
related factors such as the presence of autonomic
higher at an EBFR of 200 mL/min as compared
neuropathy (9), abnormal cardiac reserve (10) and
with 300 mL/min, but not as compared with 400
reduced venous compliance (11) as well as
mL/min. At EBFR of 200, 300 and 400 mL/min
potentially modifiable treatment related parameters
diastolic BP, mean arterial pressure, PR and COP
such as ultrafiltration (UF) profiling (12) and
remained unchanged (23).
changes in serum calcium concentration (13).
AIM OF THE STUDY
The aim of the present study is to investigate the
multifactorial. Factors such as inadequate plasma
impact of changes in extracorporeal blood flow rate
volume during fluid removal (1), rapid reduction in
(EBFR) on blood pressure (BP), pulse rate (PR)
plasma osmolality (14), autonomic dysfunction (15),
and cardiac output (COP) in hemodynamically
heart disease (16), impaired baroreflexes (17), release
stable patients during hemodialysis.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1353-1358
Efficacy of Intravenous Tranexamic Acid in Reducing
Blood Loss after Elective Cesarean Section
Samir Abd Allah Ali, Tamer Fares Oof, Mohamed Fouad Elmolla
Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Fouad Elmolla, Mobile: 01279837613,email: email@example.com
Background: Primary post-partum hemorrhage (PPH) is defined as blood loss greater than or equal to 500 ml within
24 hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml within 24 hours.
Objective: was to determine the efficacy and safety of tranexamic acid in reduction of blood loss after the elective
Patients and Methods: We performed a randomized, controlled study of 200 pregnant females who underwent
elective CS. The patients had attended the Labor Ward in Al-Azhar University Maternity Hospital. 100 of them
received tranexamic acid 20 minutes before beginning of anesthesia in addition to oxytocin after delivery of the baby;
the other 100 patients received oxytocin only.
Results: In the 1st two hours post-partum vaginal bleeding was significantly less severe in study group than control
group (p<0.019). There was nonsignificant difference between study and control groups as regards preoperative
hemoglobin concentration (p=0.195), Postoperative hemoglobin concentration was significantly greater in study
group than control group (p<0.001), Reduction in hemoglobin levels ware significantly less in study group than
control group (p<0.001). There was nonsignificant difference between study and control groups as regards to
preoperative hematocrite (p=0.967), Postoperative hematocrite levels were significantly higher in study group than
control group (p0.015), Reduction in hematocrite levels ware significantly less in study group than control group
Keywords: Cesarean section, lower segment cesarean section
Cesarean section is defined as the delivery of a
approximately 25% of worldwide maternal deaths
baby through a surgical abdominal incision. Cesarean
(WHO Recommendations 2006) and also causes 12%
section (CS) rates are increasing to as high as 25 to 30
severe anemia of survivors. In order to reduce
% in many areas of the world (1).
maternal mortality and morbidity rates caused by
Delivery by CS causes more complications
bleeding, it is important to reduce the amount of
than normal vaginal delivery. Infection can occur at
bleeding during and after cesarean sections (3).
the incision site, in the uterus and in other pelvic
In severe cases, CS may cause obstetric
organs such as the bladder. blood loss in a cesarean
hemorrhage, hysterectomy, admission to an intensive
delivery is greater than with vaginal deliveries. This
care unit, or maternal death. Medications, such as
can increase levels of anemia or a blood transfusion (1
oxytocin, misoprostol, prostaglandin F2, and
to 6 women delivered by CS per 100 require a blood
tranexamic acid, have been used to control bleeding
transfusion), increase the possibility of injury to
during and after CS (4).
organs such as the bladder or bowel. Scar tissue may
Tranexamic acid is a synthetic derivative of
travel inside the pelvic region causing blockage and
the amino acid lysine that has an antifibrinolytic effect
pain. Adhesions also increases levels of future
through the reversible blockade of the lysine binding
pregnancy complications such as placenta previa or
sites on plasminogen molecules. The intravenous
placental abruption. Extended hospital stays and
administration of tranexamic acid has been routinely
recovery time. There may be a negative reaction to the
used for many years to reduce hemorrhage during and
anesthesia given during a cesarean or negative reaction
after surgical procedures like coronary artery bypass,
to pain medication given after the operation.
oral surgery, orthotopic liver transplantation, total hip
The increase of the Risk of additional
or knee arthroplasty, and urinary tract surgery (5).
surgeries: Includes possibility of hysterectomy,
Tranexamic acid is very useful in reducing
bladder repair or another cesarean. Risks and
blood loss and incidence of blood transfusion in the
complications may occur to the baby e.g.; premature
surgeries. Tranexamic acid treatment is inexpensive
birth breathing problems, low APGAR scores and fetal
and would be considered highly cost effective in high,
injuries may occur (2).
middle- and low-income countries (6).
One of these common complications is
primary or secondary postpartum hemorrhage (20%).
AIM OF THE WORK
It leads to the increase of maternal mortality and
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1359-1364
Assessment of the Causes and Outcomes of Upper Gastrointestinal
Tract Bleeding Patients in Aswan University Hospital
Mohammed Zein Eldeen Hafez, Soumaia Ahmed Kassem,
Mohammed Ahmed Hamed Abd-Allah
Internal Medicine Department, Faculty of Medicine - Aswan University
* Corresponding author: Mohammed Ahmed Hamed Abd-Allah, E-mail: firstname.lastname@example.org, Mobile: (+20) 01007792762
Background: Gastrointestinal (GI) bleeding is a potentially life threatening abdominal emergency that remains a
common cause of hospitalization. Bleeding from the upper gastrointestinal tract is approximately five times more
common than from the lower gastrointestinal tract bleeding and seems to be more common in men and the elderly.
Aim: Identify various cause and outcomes of upper gastrointestinal tract bleeding patients in Aswan University
Hospital by follow-up the patients and their different fates on the numerous lines of treatment.
Methodology: This study included 100 patients who were complaining of upper gastrointestinal tract bleeding and
selected from patients in Aswan University Hospitals.
Results: The results of the current study showed that the most common causes of upper GIT bleeding are the
variceal causes representing 57% of causes of GIT bleeding, followed by non-variceal causes representing 43% of
causes of GIT bleeding. The most common cause of the variceal bleeding is the esophageal varices alone
representing (40%) of the causes of variceal bleeding followed by combined esophageal and gastric varices
representing (12%) and the gastric varices alone representing (5%) of the causes of upper GIT bleeding.
Conclusion: The endoscopic therapy was successful in most cases. The recurrence rate of bleeding was
significantly high among patients with variceal bleeding. The patients with variceal bleeding have fewer treatment-
related complications and better survival rates when they are treated by band ligation,
Keywords: Upper Gastrointestinal, Tract Bleeding
Acute gastrointestinal (GI) bleeding is a
Various clinical features can be helpful in
potentially life threatening abdominal emergency that
predicting outcomes for patients with upper
remains a common cause of hospitalization (1). Upper
gastrointestinal tract bleeding. End points, other than
gastrointestinal tract (GIT) bleeding is defined as
mortality, include recurrent bleeding during the same
bleeding derived from a source proximal to the
hospitalization, prolonged hospital stay, and surgery
ligament of Treitz (2). Bleeding from the upper
for bleeding. Repeated bleeding within 72 hours of the
gastrointestinal tract is approximately five times more
initial bleeding episode is a marker for increased
common than from the lower gastrointestinal tract
morbidity and mortality.
bleeding and seems to be more common in men and
Other independent risk factors for poor outcome
the elderly (3).
include age older than 60 years, ongoing bleeding, and
Gastrointestinal tract bleeding can be acute or
hypotension on presentation. A number of these risk
chronic bleeding. Acute bleeding can be manifested by
factors have been grouped together in order to
symptoms as hematemesis, melena, and hematochezia.
improve predictive ability. The criteria using the
Blood may be bright red or it may be old and take on
mnemonic BLEED is helpful (Ongoing Bleeding, Low
the appearance of coffee grounds. The signals
systolic blood pressure, Elevated prothrombin time,
indicating chronic gastrointestinal tract bleeding
Erratic mental status (change in mental status), and
include overall weakness, dyspnea, and syncope.
Comorbid Disease (other than bleeding) requiring
These mentioned symptoms, in particular, lead to the
admission to intensive care unit (ICU) as acute
suspicion of hypochromic anemia developing in
myocardial infarction (MI)).
consequence of chronic bleeding (4).
Evidence of any one of the BLEED criteria places
Causes of upper gastrointestinal bleeding (UGIB)
the patient in a poor outcome category. This outcome
include: Peptic ulcer disease, esophageal and gastric
predictor applies to both lower and upper
varices, hemorrhagic gastritis, esophagitis, duodenitis,
gastrointestinal bleeding. Other risk or provocative
factors for upper gastrointestinal bleeding include
gastrointestinal malignancy, portal hypertensive
anticoagulation therapy and coagulopathy with
gastropathy, gastric polyps. Gastric varices occur in
elevated prothrombin time or thrombocytopenia.
around 20% of patients with portal hypertension (PH)
Aspirin and other non-steroidal anti-inflammatory
(5). They are normally identified at a time of bleeding
drugs are associated with gastrointestinal ulceration
and are associated with a more severe hemorrhage,
and bleeding (7).
require more transfusion and have a higher mortality
A major goal of treatment of upper gastrointestinal
than esophageal bleeding (6).
tract bleeding is to stop active bleeding and prevent
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1365-1370
The Predictive Value of the Integrated Weaning Indices in
Mechanically Ventilated COPD Patients
Suzan Salama Sayed, Khalid Hussein Ahmed, Sayed Abdelsabour Kinawy, Islam Galal Sayed
Department of Chest Diseases and TB, Faculty of Medicine, Aswan University, Egypt
Background: COPD exacerbations necessitating mechanical ventilation representing important aspect of disease
management. Attempts to search for better weaning index is a continuous process.
Aim of the work: was to study the accuracy of the integrated weaning indices including, CROP index and CORE
index as predictors of weaning success in COPD exacerbation under mechanical ventilation.
Patients and Methods: 102 COPD patients necessitating mechanical ventilation >24 h underwent daily screen of
subjective and objective indices for weaning readiness, and patients were classified according to weaning outcome
into successful group (Group S) (60 patients) and failure group (Group F) (42 patients).
Results: There were no significant observed difference regarding the demographic data between the successful
and the failure groups. There was highly significant difference between both weaning groups regarding dynamic
compliance, NIF, P0.1, CROP index and CORE index (P value < 0.05). AUC of CROP index (0.80) was moderately
precise compared with that of CORE index (0.63).
Conclusion: CROP index is superior to CORE index as a predictor of weaning success in mechanically ventilated
Keywords: Weaning, COPD, mechanical ventilation, weaning predictor, CROP index, CROP index.
Chronic obstructive pulmonary disease
(COPD) considered a major epidemiological health
successful weaning or liberation from mechanical
problem worldwide. The prevalence and burden of
ventilation in COPD exacerbation . CROP index
COPD are projected to extend over the approaching
represents an integrative index first described by
decades because of aging of the world's population
Yang and Tobin in 1991 (compliance, respiratory
and continued exposure to COPD risk factors .
rate, oxygenation and pressure) . Delisle and co-
COPD exacerbation represents an acute
workers proposed CORE index (an integrated index
deterioration of respiratory symptoms that demands
of compliance, oxygenation, respiration and patient
additional therapy . COPD exacerbations had
effort) which was developed by adding airway
deleterious effect on health status, rates of
occlusion pressure (P0.1) to the CROP index,
hospitalization and readmission and it can induce
suggesting that it would improve its power to expect
respiratory failure . Severe COPD exacerbations
spontaneous breathing trial (SBT) outcome .
The aim of the current study was to define the
represent significant percentage of ICU admissions
accuracy of the integrated weaning indices including,
. Once mechanical ventilation initiated; planning for
CROP index and CORE index as predictors of
weaning should starts .
weaning success in COPD exacerbation under
Traditionally, decision to start weaning
process was taken by attending physician after
improvement of patient's clinical condition, arterial
PATIENTS AND METHODS
blood gas parameters and largely depends on clinical
This prospective observational study included a
experience . The rate of failure of the first trial of
total of 102 COPD patients who had achieved the
weaning reach about 20% in mechanically ventilated
weaning criteria and start weaning, attending at a
RICU, Department of Chest Diseases and TB,
In patients of chronic obstructive pulmonary
Faculty of Medicine, Aswan University.
disease (COPD), the weaning failure percentage rise
Approval of the ethical committee and a written
to 59% .
informed consent was given by surrogate decision
A topic of constant investigation for over
maker. This study was conducted between September
many years is the searching for ideal predictors of
2017 to March 2018.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1371-1376
Galectin-3 and Severity of The Coronary Artery Disease in Ischemic
Patients Guided by Coronary Angiography
Reda Biomy Bastawesy1, Mohamed Kamal Salama2,
Hossam Eldin Mohamed Mansour2, Ahmed Barakat Ahmed2,
Faculty of Medicine, Department of cardiology 1Kafr El Sheikh University, 2 Aswan University
Corresponding author: Ahmed Barakat Ahmed, MSC, E-mail: email@example.com.
Background: The inflammatory process is actively involved in atherosclerosis and underlies all stages of
atherosclerotic plaque development: the beginning, the progression and the plaque rupture. It has been reported
that during the inflammatory process the expression of Gal-3 is increased in human atherosclerotic lesions,
suggesting its involvement in atherogenesis. Aim: In the present study, we tried to evaluate the levels of Gal-3 in
patients with chronic stable angina and its relation to the severity of coronary artery disease (CAD) and the CAD
risk factors such as Aging, Diabetes, Hypertension, Smoking and Dyslipidemia. Patients and Methods: Our
study population consisted of 95 chronic stable angina patients who were planned for coronary angiography. All
patients had clinical and/or electrocardiographic evidence of significant stable ischemic heart disease.
Results: We found a significant positive correlation between CAD and Gal-3 levels (r = 0.207), (p value= 0.045).
Patients with multi-vessel (MVD) had significantly higher plasma Gal-3 levels and syntax score than 3 vessel
disease (TVD) and single vessel disease (SVD) (P value <0.001)., while Patients with TVD had significantly
higher plasma Gal-3 levels and syntax score than SVD, but still lower than MVD Patients (P value <0.001.
Conclusion: Gal-3 plasma levels were significantly correlated with the severity of CAD in chronic stable angina
and can be used as a prognostic marker of chronic stable angina patients.
Recommendation: We recommend that the Gal-3 might be useful for risk stratification and outcome prediction
of coronary heart diseases.
Keywords: Coronary artery disease, syntax score, chronic stable angina.
risk factors such as Aging, Diabetes, Hypertension,
The inflammatory process is actively
Smoking and Dyslipidemia.
involved in atherosclerosis and all stages of
AIM OF THE STUDY
atherosclerotic plaque development: the beginning,
we tried to evaluate the levels of Gal-3 in
the progression and the plaque rupture1. In recent
patients with chronic stable angina and its relation to
years, several studies have been done define the
the severity of CAD and the coronary artery disease
mechanism that leads to acute clinical events, and
risk factors such as Aging, Diabetes, Hypertension,
systemic approaches are pursued to discover serum
Smoking and Dyslipidemia.
biomarkers useful to identify patients with plaque at
risk of future vascular events2,3. Galectin-3 (Gal-3) is
PATIENTS AND METHODS
a galactosidase-binding protein and a member of the
Our study was conducted from January 2018
Galectin family which contains more than 10
to July 2018 at Aswan university hospital. Our study
members. It is expressed in the epithelia of several
population included 95 chronic stable angina patients
organs and inflammatory cells such as macrophages,
who were planned for coronary angiography. All
dendritic cells and Kupffer cells4. The extracellular
patients had clinical and/or electrocardiographic
Gal-3 has been demonstrated to activate different
evidence of significant stable ischemic heart disease.
Patients with Prior heart failure, Severe valvular heart
monocytes/macrophages, mast cells, neutrophils, and
diseases, Connective tissue diseases, Coexisting
lymphocytes, and it has been shown to facilitate cell-
cancers and chemotherapy and radiotherapy,
cell and cell-matrix interaction5. It is known that Gal-
Pericardial disease, Cirrhosis and Atrial fibrillation
3 is able to form dimers through the amino-terminal
were excluded from the study.
non-lectin domain that allows cross-linking
All the patients were subjected to
appropriate glycoproteins on the cell surface6.During
A) Clinical assessment including (CV risk factors,
the inflammatory process this lectin is up regulated
general and local examination).
and it has been reported that the expression of Gal-3
B) Electrocardiography twelve leads resting ECG
is increased in human atherosclerotic plaques,
done for all patients to exclude non-sinus rhythm
suggesting its involvement in atherogenesis7. In the
and to detect any ischemic changes or arrhythmias.
present study, we will try to evaluate the levels of Gal-
C) Echocardiography done in the left lateral position
3 in patients with chronic stable angina and its relation
using Philips IE 33 X51 MHz transducer on outpatient
to the severity of CAD and the coronary artery disease
basis, m-mode and 2 D was acquired to evaluate
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1377-1386
Evaluation of Silodosin in Comparison to Tamuslosin in Treatment of Benign
Prostatic Hyperplasia with lower Urinary Tract Symptoms: A Prospective Study
Mohammed H. M Mousa, El Sayed M. Salih, El Sayed M. Mousa.
Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohammed H. M Mousa, E-mail: mohammedhassan8181@Gmail.com
Background: benign prostatic hyperplasia represents one of the main fields of urology.
objective: aim of the study to verify the efficacy and safety of the alfa one adrenoreceptor blocker silodosin
compared with tamsulosin in patients with lower urinary tract symptoms associated with bph.
patients and methods: outcomes were assessed by change from baseline in ipss, quality of life (qol), qmax, pvr.
responders to the treatments on the basis of ipss decrease 25% and qmax increase 30% were calculated.
results: silodosin and tamsulosin significantly improved ipss total score in (p=0.625). both no statistically
significant difference. improved qol (p<0.505) both no statistically significantly difference between both
improved qmax (p<0.633). silodosin and tamsulosin no statistically significantly. improved pvr; there no
statistically significantly difference between both (p<0.0001). in silodosin group, a retrograde ejaculation was
reported in 25 patients from 40 patients were sexually active (62.5%). while in tamsulosin group, a retrograde
ejaculation was reported in 1 patient from 41 patients sexually active (2.4%).
conclusions: silodosin is not only comparable to tamsulosin in treatment of luts/bph, with safety. however,
retrograde ejaculation troublesome for sexually active patients.
keywords: silodosin, tamsulosin, benign prostatic hyperplasia, lower urinary tract symptoms, quality of life, -
1a adrenergic receptors.
Lower urinary tract symptoms (LUTS) are a
surgery to relieve the obstruction imposed by the
common problem of aging males. Benign prostatic
enlarged portion of the prostate. However, apart from
hyperplasia (BPH) is the most common cause of LUTS
invasiveness, there are potential complications of
in elderly men over 70 years of age. BPH, usually,
surgery, including the unfortunate development of
starts in men in their 50s; by the age of 60 years, 50%
permanent urinary incontinence (2).
of men have histological evidence of BPH and 80% of
men in their 70s suffer from BPH-related LUTS (1).
AIM OF THE STUDY
Symptomatic BPH is characterized by a mix
of obstructive and irritative symptoms, collectively
The aim of the study is to verify the efficacy and safety
known as prostatism. The former include difficulty in
of the Alfa one adrenoreceptor selective antagonist
initiation of micturition (hesitancy), poor or
silodosin compared with tamsulosin in patients with
interrupted flow, post-void dribbling, and sensation of
lower urinary tract symptoms associated with Benign
incomplete voiding that can manifest (urge to revisit
prostatic hyperplasia (BPH).
the toilet immediately after voiding). The latter
includes frequency of micturition, nocturia, dysuria
PATIENT AND METHODS
and urgency or even urge incontinence (1).
The former category is expected to provide
Prospective Randomized Study.
relatively rapid symptom relief starting within 2-6
Study population patient's selection: patient
weeks, while the latter acts more slowly restricting the
with lower urinary tract symptoms (LUTS) associated
hyperplasia, and taking 6 months or longer to produce
with BPH attending to our urological department at Al-
symptom relief (1).
Hussin University hospital and Al Harm hospital with
Alfa-blockers are now considered as first-line
type patients Men 50 with BPH
drugs in the medical management of BPH. Silodosin;
Target sample is 100 patients
Patients included in this study were introduced
1A-adrenoceptor blocker is said to be highly
selective for this receptor subtype. Our objective is to
into two group :
compare the effectiveness and safety of silodosin in
Group A: patients were treaetd by silodosin 8 mg for
elderly men with BPH, in comparison to the older
Group B: patients were treated by tamsulosin 0.4 mg
The definitive management of symptomatic BPH is
for 3 months.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1387-1395
Supine versus Prone Position Percutaneous Nephrolithotomy
Amir Elmetwally Ibrahim Abd Elgawad*, Farouk Ismail Elguoshy, Yasser Ali Ahmed
Department of Urology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Amir Elmetwally Ibrahim Abd Elgawad, Mobile: 01001992278,
Background: percutaneous nephrolihotomy (PCNL) is the first choice for treatment of single more than 2cm
and multiple renal stones. The prone position is the classical position preferred by most surgeons. Then the
supine position was developed for percutaneous nephrolithotomy.
Objective: to compare between supine and prone PCNL in the management of renal stones regarding number
of puncture, stone free rate, operative time, intraoperative and postoperative complications.
Patients and Methods: the patients were selected, all having multiple stones, or stone size 2 cm or more.
They were 30 patients divided into two groups, group (A) prone 15 patients and group (B) supine 15 patients.
The study excluded patients with renal anomalies, uncontrolled coagulopathy, pregnancy, immunosuppression,
and ages less than 10 years.
Results: the study demonstrated a significant difference only in operation time which was (89.00±30.37) in
prone group & (64.67±24.75) in supine group with p-value (0.023) between the prone and supine position,
with shorter operation time in the supine than the prone. The study has also demonstrated that there is no
statistically significant difference between the two groups as regarding to stone free rates, hospital stay,
intraoperative, and postoperative complications.
Conclusion: in patients with multiple renal stones, or stone size 2 cm or more, supine PCNL has proved to be
superior to prone PCNL as regarding operative time. However, Urologists should be familiar with the
differences in the positions and be able to use the method appropriate for each patient.
Keywords: Percutaneous nephrolithotomy, intra venous urogram, extracorporeal shockwave lithotripsy
patients, those with skeletal deformities or
After many years, PCNL is the treatment
compromised cardiopulmonary status) and the
of choice for large and/or complex urolithiasis.
difficulty of obtaining a combined retrograde and
Instead of becoming obsolete over the decades,
antegrade accesses to the renal cavities, when needed
PCNL underwent considerable evolution since its
are issues that have been overlooked for years (5).
introduction in 1976, progressively acquiring a
The supine positions for PCNL are not the
new configuration to improve its efficacy and
unique alternatives to the prone position as
safety in expert hands (1).
demonstrated by many of recent literature,
The old static procedure become a
proposing flank, lateral, flank prone, split-leg
technically updated to mini-invasive approach a
modified lateral, prone flexed, supine oblique,
continuous advances regarding imaging techniques,
semisupine positions, and many others. The
anesthetic skills, patient positioning, renal access
relevant aspect is that all these authors made their
puncture, retrograde and antegrade use flexible
proposals in a common effort to improve their
endoscopes with better technology and vision, a
surgical percutaneous practice. Of course,
variety of accessories, intracorporeal lithotripsy
efficacy, feasibility, and safety of PCNL
devices, and postoperative renal drainage (2).
performed in any alternative position have been
In 1976 the prone position was the one
compared to those of the prone PCNL, by now
used by Fernstrom and Johansson (3) when they
with substantially equivalent urological outcomes
described the percutaneous nephrolithotomy
(in terms of operative time, stone-free rates,
technique. Then it became the traditional
hospital stay, and complication rates) (2).
technique. The prone position provided a wide
Among the advantages of PCNL
surgical field for renal puncture and easy
performed in the supine position there are numbers
nephroscopic manipulation, easier upper pole
of urological and anesthesiological advantages
puncture with a lower risk of pleura, lung, and
which have been widely reported. The ventilatory,
spleen/ liver injury, a good distension of the
cardiovascular, and pharmacokinetic problems of
collecting system (4).
the prone position are overcomed in the supine
On the other hand, the anesthetic concerns
positions, with better access to the airways and the
of the prone position (especially in morbidly obese
cardiovascular system (6).
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1396-1405
The Role of Diffusion Weighted MRI in Assessment of Rectal Cancer
Ahmed Abdel Fattah Abu Rashed, Mohamed Ismail Hammad, Mahmoud Sabry Qutb Sallam*
Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mahmoud S. Q. Sallam, Mobile: 01003882827, Email: firstname.lastname@example.org
Background: Magnetic resonance imaging has become the most accurate technique in local staging of rectal cancer.
The identification and staging of rectal cancers at MR imaging is largely based on differences in T2 signal intensity
between the tumor, the mucosa and submucosal layers, the muscular layer, the perirectal fat, and the mesorectal fascia.
Objective: Was to assess the role of Diffusion Weighted MRI in assessment of rectal cancer and correlation of
these findings with available histopathological findings.
Patients and Methods: A total of 30 patients, proved by colonoscopy to have rectal carcinoma, were included in
this retrospective study wich was carried out in the Radiology Department of Al-Azhar University Hospitals. The
work took place during the period between June 2018 and Januray 2019.written consent was taken from each
patient. The study was carried out after approval of the ethical committee of scientific research, faculty of medicine,
Results: we found that DW MRI measurement increased the specificity of the rectal MRI in characterizing different
rectal cancers especially when it is combined with conventional MRI.Also the use of additional DW MR imaging
yields better diagnostic accuracy than does use of conventional MR imaging alone in the evaluation of complete
response (CR) to neoadjuvant chemoradiation treatment (CRT) in patients with locally advanced rectal cancer.
Conclusion: DW MRI has a growing role in rectal cancer staging either primary staging or evaluating the post
chemo radiotherapy state.
Keywords: diffusion weighted , Magnetic resonance imaging, Rectal Cancer.
them referred from surgical department and others are
Rectal cancer is one of the most common
from outpatient clinic. All cases were examined on
tumors in industrialized countries and one of the most
GENERAL ELERTRIC 1.5 Tesla Machine at MRI
common malignant tumors of the gastrointestinal tract.
unit, Al-Hussein University Hospital. They proved by
MRI is the modality of choice for staging rectal cancer
colonoscopy to have rectal cancer. This study was
to assist surgeons in obtaining negative surgical
composed of full history and clinical data. They
margins. MRI facilitates the accurate assessment of
underwent MR examination prior to which written
MRF and the sphincter complex for surgical planning
consent was taken from each patient.
(1). Diffusion weighted imaging (DWI) has an increasing
In our study we classified our patients into 2
clinical role in the imaging of patients with rectal
groups: Group I: The group included 11 patients who
cancer, especially in the restaging phase after
were treated surgically without chemo or radio therapy,
chemoradiation treatment (CRT). Diffusion imaging is
suggested by MRI examination to be at T1-T2-T3, N0-
gaining increasing attention for rectal cancer imaging
N1, and M0 stage, who underwent MR examination
not only qualitatively but also quantitatively (2)
before surgery. Group II: The group included 19
The challenge for preoperative imaging in
patients who were treated surgically after neoadjuvant
rectal cancer is to determine subgroups of patients with
therapy, suggested by MRI examination to be at Tx N2
different risks for recurrence; those with superficial
M0 and T3-T4 Nx M0 stage, who underwent
tumors who can be treated with surgery alone, those
preoperative MR before neoadjuvant chemoradiation
with operable tumors and a wide circumferential
therapy and again 6-8 wks after the end of the treatment
resection margin who can be treated with a short course
for the re-staging of disease.
of radiation therapy followed by total mesorectal
A- Preparation: The patient should avoid large
excision, and those with advanced cancer and a close or
movements. Each patient was subjected to rectal
involved resection margin who require a long course of
luminal distension by sterile gel.
radiation therapy with or without chemotherapy and
B- Patient position: The patient asked to lie supine on
extensive surgery (3).
the examination couch with the body-array coil was
AIM OF THE WORK
placed on the pelvis .
The aim of this work is to assess the role of
C- MRI Sequence: The routine protocol used for
magnetic resonance with diffusion in staging of rectal
rectal imaging that includes: Localizer images in three
carcinoma in relation to histopathological findings.
orthogonal planes were taken first.Sagittal,T2-weighted,
fast (turbo) spin-echo sequence from one pelvic
PATIENTS AND METHODS
sidewall to the other. Axial sections of the pelvis with
The present study started on June 2018 till
large field of view T1 and T2 weighted images, T2-
January 2019. The study included 30 patients; some of
weighted high resolution axial oblique images through
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1406-1415
Evaluation of Laparoscopic Splenectomy in Idiopathic
Al Sayed Ahmed Hamdy, Mohamed Fathi Labib, Ahmed Talaat Gomaa*
Departments of General Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Talaat Gomaa, Mobile: (+20)01271820424; Email: email@example.com
Background: primary ITP was defined according to the American Society of Hematology 2011 evidence-based
practice guideline as a platelet count less than 100 × 109/L without other causes or disorders that may be
associated with thrombocytopenia. The main first-line therapy for ITP is oral corticosteroids. Splenectomy is
generally considered a second-line therapy in patients who are refractory to steroids and in those who relapse
after an initial response to medical therapy. Objective: the aim of this study was to evaluate the feasibility,
safety and efficacy of LS in ITP patients. Patients and Methods: this study was carried out on 20 patients
diagnose as having ITP and indicated for splenectomy, 60% were females and 40% were males. Their age
ranged from 17-33 years with a mean of 24.3± 5.39 years. Results: the platelet count raised from (30000 to
140000/L) pre-operative to (90000 to 190000/ L) post-operative. There was statistically significance difference
between pre and post-operative platelet count (p <0.001). From the assessment of platelet count according to
American Society of Hematology 2011 evidence-based practice guidelines for ITP. Nineteen patients (95%)
achieved complete response, while only one patient (5%) achieved partial response. Conclusion: it was
concluded that LS produces an adequate postoperative rise in platelet count and it is associated with less
operating time, post-operative hospital stay, blood loss and postoperative complications.
Keywords: Laparoscopic Splenectomy, ITP
Primary immune thrombocytopenia (ITP),
splenic macrophages which enhance the uptake of
formerly known as idiopathic thrombocytopenic
antibody-coated platelets resulting in phagocytosis
purpura or primary immune thrombocytopenic
(5). Also, the spleen serves as a critical niche for
immune cells that promote anti-platelet antibody
characterized by low platelet counts (< 100 x 109/L)
formation (6). In addition, the spleen serves as a
as a result of immune mediated destruction of
reservoir for long-lived anti-platelet antibody-
circulating platelets and suppression of platelets
producing plasma cells (7).
production in absence of any obvious initiating
and/or underlying cause of thrombocytopenia such
corticosteroids are considered the first-line therapy
as infection, drugs and autoimmune diseases (1).
for ITP, but only 20%-40% of cases achieve a
Clinical picture of ITP varies from patient to
stable response. Splenectomy is the main therapy
patient. Nearly one-quarter of patients are
for patients failing to respond to corticosteroids for
asymptomatic and diagnosed as having ITP through
decades, and about two-thirds of patients achieve a
incidental routine blood tests (2). Some patients
long-lasting response. Although some new drugs
present with mild mucocutanaeous or subcutaneous
are developed to treat ITP as second-line therapies
haemorrhages while others present with major
in recent years, splenectomy is still the better
bleeding requiring immediate intervention (3).
choice with less cost and more efficiency (8).
Severity of bleeding depends upon platelets count
as patients with platelet counts less than 10 x 109/L
AIM OF THE WORK
are at increased risk of serious or life-threatening
The aim of this study is to evaluate the
internal bleeding (e.g. intracranial haemorrhage,
feasibility, safety and efficacy of LS in ITP
mucocutaneous bleeding, lower gastrointestinal
bleeding, other internal bleeding and menorrhagia).
Platelet counts between 30-50,000 mm3 increase
PATIENTS AND METHODS
the risk of dangerous bleeding from minor trauma,
This study was carried out on twenty patients
30,000/mm3 increase the risk of spontaneous
diagnosed as having primary ITP according to the
guidelines of the ASH (9). They were referred by the
The spleen plays a critical role in the
Hematology department to our surgical department
pathogenesis of ITP. For most patients, the spleen
in Faculty of Medicine, Al-Azhar University for
is the primary site of platelet clearance through
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1416-1422
Trichoscopic Clues for Diagnosis of Patchy Scalp Alopecia in the Egyptian Patients
Abd Elrauof Mohamed AL Mohsen, Mohamed Saeed Mohamed Hasan, Abd Elrhman Ali Rizk
Department of Dermatology, Venereology and Andrology,
Faculty of Medicine, Al Azhar University
Corresponding author: Abd Elrhman Ali Rizk, Mobile: 01113690038; Email: firstname.lastname@example.org
Background: trichoscopy is a non-invasive office technique used for differentiating cicatricial from non-
cicatricial alopecia. Trichoscopy helps the dermatologist for diagnosis of alopecia with rarely need of
histopathology. Hair loss is distressing problem and associated with psychological complications. Common
causes of hair loss include Alopecia areata, Tinea capitis, Traction alopecia and trichotillomania.
Objective: this study aimed to assess the trichoscopic features in the Egyptian patients with patchy hair loss and
to find sensitive and/or specific trichoscopic findings that can help in their diagnosis and follow up.
Methodology: our study included 500 patients categorized into two groups cicatricial (176 cases) and non-
cicatricial (324 cases). Cicatricial included four types 2ry alopecia 139, DLE 24. FD 5 &LPP 8 and non-cicatricial
included five types AA 148, localized androgenetic 21, CTA 15, TC 117 and TTM 23.
Results: in our study, the sensitivity and specificity of trichoscopic patterns were evaluated in diagnosis of PCAs
and NCAs. We found some trichoscopic patterns that were sensitive and specific for making diagnosis of PCAs.
The perifollicular scale had 90% sensitivity and 99.5% specificity for a diagnosis of PCAs. Hair tufting was only
observed in LPP and FD. This study showed 100% specificity for the presence of each blood vessel pattern that
was seen in PCA. The specificity of tortuous branching vessels was 100% for a diagnosis of DLE.
Conclusion: dermoscopy was very useful to identify signs of early clinical response, adverse effects and markers
of disease activity even if that couldn't be detected by unaided naked eyes.
Keywords: dermoscopy, trichoscopic, hair loss, patchy scalp alopecia.
Hair loss is daily complaint in dermatologic
trichoscopic findings that can be helpful in their
clinics, true diagnosis and evaluation of hair loss is
diagnosis and follow up.
very important, many patients with hair loss especially
in female consider their hair loss to be a serious
PATIENTS AND METHODS
problem leading to distress and negatively affecting
their activities (1).Hair loss may be diffuse or localized
Five hundred patients with patchy hair loss
diffuse as androgenic alopecia and telogen effluvium
were included in this study. The examined patients
localized as Alopecia areata, also they may be
were collected from dermatology, venereology and
classified as cicatricial or non-cicatricial (2).The
andrology outpatient clinics in Al Azhar University
dermoscopic examination of the hair and scalp known
Hospitals. Duration from September 2017 to January
as trichoscopy (3). Trichoscopy (Dermoscpe of hair
and scalp) is a noninvasive diagnostic technique used
in evaluation of hair loss beside other diagnostic
A verbal consent was taken from all the
techniques as pull test and trichogram that allows the
patients about the aim of this study.
recognition of morphologic structures not visible by
The study was approved by the Ethics
the naked eye (4). Trichoscopy is useful for the
Board of Al-Azhar University.
diagnosis and follow-up of hair and scalp disorders.
Dermoscopy help dermatologists to make true
diagnosis of different type of hair loss (5). Trichoscopy
Patients with patchy alopecia either:
allows for magnified observation of the following: 1- 1. Child or adult.
hair shafts, 2- hair follicle openings, 3- the 2. Cicatracial or noncicatracial.
perifollicular and 4- blood vessels. Abnormalities in 3.
the appearance of these four structural components of
the scalp aid in the differential diagnosis of hair loss
All patients of the study were subjected to the
AIM OF THE WORK
The aim of this study was to assess the Associated symptoms Itching, Pain and Burning.
trichoscopic features in the Egyptian patients with Drug history.
patchy hair loss and to find sensitive and/or specific Psychosocial history.
History of hair care practices/use of hair cosmetics.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1423-1427
Coproantigen Versus Classical Microscopy as a Diagnostic Tool for Entamoeba
histolytica Infection in the Egyptian Patients
Ahmed M.S. Bayoumy¹, Mohsen T.I. Elkeiy ², Tarek K.I .Zaalok¹, Hesham M. Gad³,
Wael A.M. Abd Elhamid¹
¹ Department of Parasitology, ² Department of Pediatrics, Faculty of Medicine, ³ Department of Biochemistry,
Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmed M.S. Bayoumy, e-mail: email@example.com
Background: Entamoeba histolytica, an amoebic protozoan, is considered as one of the most common causes of
nonviral (Parasitic) diarrheal illness in humans. Laboratory diagnosis consists primarily of direct microscopic
examination of stool specimen for both trophozoites and cysts. However, because of the intermittent fecal excretion
of the parasite, the case may be mis-diagnosed and the patient may continue excreting the parasite and infecting
others. That is why other methods of diagnosis should be looked for that can help overcome the defects and
drawbacks of microscopy when used alone for diagnosis. Aim of the work: the current study aimed to evaluate the
efficacy of coproantigen detection by ELISA test in comparison with direct microscopy in diagnosis of E.
histolytica/dispar in stool specimens from patients with diarrhea and other gastrointestinal symptoms.
Material and Methods: stool samples were collected form 250 children included in the present study (150
symptomatic and 100 asymptomatic groups) between the ages of 1 and 10 years and subjected to direct microscopic
examination and ELISA test for coproantigen detection.
Results: out of 250 stool samples, 64 specimens (25.6%) were positive for E. histolytica/dispar by direct microscopy,
while 79 specimens (31.6%) were positive by ELISA test. The sensitivity and specificity of ELISA test compared to
direct microscopy were found to be 96.9% and 90.9%, respectively. Conclusion: ELISA test for coproantigen
detection in stool samples is a rapid and effective method with high sensitivity and specificity for diagnosis of
amoebiasis in stool specimens even when the parasitic count is low, thus reducing the chances of missing positive
cases even in the asymptomatic cases.
Keywords: Entamoeba histolytica, microscopic stool examination, coproantigen.
Amoebiasis is a human infection, which is caused
threatening abscess in liver, brain or lungs (10). Water-
by Entamoeba histolytica, a protozoan of cosmopolitan
associated outbreaks of E. histolytica disease had been
distribution, with or without clinical manifestations (1).
reported (11) and sexual transmission was also recorded
It affects more than 50 million people worldwide and is
(12). Clinical features of amoebiasis range from
considered as the most common parasitic infection
asymptomatic colonization to amoebic colitis
specifically in the tropics and subtropics (2).
(Dysentery or diarrhea) and the invasive extraintestinal
It is an important cause of morbidity and mortality
infection, which manifests most commonly in the form
worldwide (3) mainly in developing countries, where
of liver abscess (12).
sanitation infrastructure and health services are often
The traditional method of diagnosing intestinal
insufficient (4). Although the distribution of the parasite
infection by microscopic examination of fresh stool
is worldwide, the preponderance of morbidity and
samples was only 50-60% sensitive and can give false
mortality is experienced in the Central and South
positive results. This is because E. histolytica is
America, Africa, and India (5).
Children and young adults are the most affected
morphologically identical nonpathogenic species,
group, specifically in regions with limited resources and
Entamoeba dispar and Entamoeba moshkovskii (13).
in areas with low hygienic measures (6). Humans are the
A correct diagnosis of infection is, however,
main host of E. histolytica and there are no other known
necessary to avoid undue treatment for amoebiasis of
animal reservoirs of this parasite (7) and most of the
patients infected with the nonpathogenic species, so
infected persons are carriers (8). The infection is
WHO stressed on the urgent need to develop improved
responsible for a considerable number of cases of
methods for specific diagnosis of E. histolytica
prolonged diarrhea in travelers (9). In addition, infection
infection in the developing countries (1).
with E. histolytica may lead to the development of life-
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1428-1432
Macrophage Migration Inhibitory Factor in the Early Diagnosis of
Endometriosis and Relationship to the Stage of the Disease
Abdel Monem M. Zakaria (1), Sameh S. Sayed (1), Mekky A. Aly (2), Wael M. Abou Hedeba (1)
(1) Department of Obstetrics and Gynecology, (2) Department of Clinical Pathology
Faculty of Medicine - Al Azhar University
Corresponding author: Wael M. Abou Hedeba, Mobile: 01062717150; Email: firstname.lastname@example.org
Background: Endometriosis is a chronic disease affecting women of reproductive age. Adolescent onset of
symptoms is common. Macrophage migration inhibitory factor (MIF) is one of non-invasive blood biomarker that
was found in endometriosis. Aim of the work: to evaluate the value of macrophage MIF in peripheral blood of
women with and without endometriosis as a non-invasive early diagnostic method and correlate its level to the
stage of the disease. Patient and methods: This observational case-control study was conducted in El-Hussein
Hospital, Al-Azhar University, Cairo and private clinics. The study was approved by the local research ethics
committee. During the period from May 2016 till July 2018. Results: Both groups were comparable as regard the
incidence of infertility and the presence of chronic pelvic pain. The infertility was equal in both groups; it affected
96% of patients and control groups. The chronic pelvic pain was symmetrically present in both groups; it affected
70% of endometriosis and the control group. The level of MIF was 10.03±1.78 pg/ml in patients with endometriosis
and 4.82±1.78 pg/ml in control group with significant P value (P <0.001). In our study, the level of MIF differed
according to the stage of endometriosis, in stage I, it was 8.6±0.2 pg/ml, in stage II, it was 10.1±0.1 pg/ml, in stage
III, it was 11.3±0.2 pg/ml and in stage IV, it was 14+0.0 pg/ml. Conclusion: MIF factor is a promising marker not
only for noninvasive diagnosis of endometriosis but as a target for therapy also.
Keywords: Macrophage Migration Inhibitory Factor, Endometriosis and Stage of the Disease.
oxidative stress markers, microRNAs (miRNA),
Endometriosis is a complex and mysterious
tumor markers and other proteins (7).
disease. It is unknown why and when it begins,
Macrophage migration inhibitory factor
whether different disease types share a common origin
(MIF) is one of non-invasive blood biomarker that was
and what caused the wide individual variation in pain
found in endometriosis. MIF might have a great
symptoms, disease severity and tendency to progress.
relationship with the neovascularization of ectopic
Even the nature of endometriosis as being a chronic
endometrial implants. In 2005, Cao et al. using ELISA
and progressive disease is being debated (1).
to measure peripheral blood MIF of women suffering
Endometriosis is defined histologically by
from endometriosis, the result showed that the level of
the presence of endometrium glands and stroma
MIF in peripheral blood of women with endometriosis
outside the uterine cavity. By time, it forms a cyst that
increased by 364% than normal controls. It rose
can vary in size from a few millimeters to over 20 cm,
significantly in the earlier stage and reached its peak
and it contains old blood, giving it the nickname
level in the advanced stages (IIIIV); those findings
elucidated a plausible link between MIF and the
macroscopically detectable lesions of three types:
disease progress. On the other hand, MIF can also
stimulate endometriotic stromal cells to produce
endometriotic cysts i.e. endometrioma (OMA) and
potent angiogenic factors (8).
deep lesions i.e. deep infiltrating endometriosis (DIE)
(3).The prevalence of endometriosis among the general
AIM OF THE WORK
female population is unknown because presently the
The aim of this study is to evaluate the value
only reliable method to confirm the diagnosis is
of macrophage migration inhibitory factor in
peripheral blood of women with and without
It is well documented that there is a long
endometriosis as a non-invasive early diagnostic
diagnostic delay worldwide between the onset of
method and correlate its level to the stage of the
symptoms and the diagnosis (5,6).
A Cochrane Review of blood biomarkers
PATIENT AND METHODS
for endometriosis included 141 studies that evaluated
This study was an observational study of case-
122 biomarkers. These included angiogenesis factors,
control type performed in El-Hussein hospital, Al-
growth factors, apoptosis markers, cell adhesion
Azhar University, Cairo and private clinics. The study
molecules, high-throughput markers (biomarkers
was approved by the local research ethics committee.
searched from the proteome of metabolome),
During the period between May 2016 and July 2018,
hormones, immune system or inflammatory markers,
100 patients candidate for diagnostic laparoscopy
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (6), Page 1433-1447
Assessment of Retinal Vascular Plexuses and Choriocapillaris in
Adult High Myopia Using Enhanced Depth Imaging Optical
Coherence Tomography Angiography
Mohamed Anwar El-Massry, Hassan Metwaly Bayoumy, Atef Hassan Sayed Abdellatif*
Ophthalmology Department, Faculty of Medicine, Al-Azhar University
*Corresponding author: Atef Hassan Sayed Abdellatif, E-mail: email@example.com, Mobile: (+20) 01272229060
Background: High myopia is a common eye health problem due to its sight threatening complications. Using
the newly introduced noninvasive devices, it's easier now to assess the morphological, anatomical and
pathological changes accompanied with high myopia.
Objectives: The aim of this study was to assess retinal vascular plexuses and choriocapillaris density and
measuring the FAZ in the SCP & DCP with also assessment of central macular and subfoveal choroidal
thickness in high myopia in adults using enhanced depth imaging optical coherence tomography angiography.
Patients and Methods: This prospective observational study was carried out from June 2018 to November
2018 on 75 eyes of patients attending outpatient clinic of Ophthalmology department of Research Institute of
Ophthalmology in Giza.
Results: The best corrective visual acuity in the normal group was statistically significantly higher than the
Myope group. The Macular thickness in the normal group was statistically significantly higher than the Myope
group. The choroidal thickness in the normal group was statistically significantly higher than the Myope group.
The FAZ DCP in the Myope group was statistically significantly higher than the normal group.
Conclusion: The OCTA is certainly able to take over other invasive imaging techniques and new researches
using this device might be able to study different pathologies affecting the posterior segment.
Keywords: High myopia, OCTA, DCP
intravenous dye to obtain images which make them
High myopia is associated with a refractive
time consuming and annoying for the patients
error of at least 6 D and/or axial length greater than
undergoing this procedure for follow up (4,5).
25.5 mm. The latter leads to mechanical stretching
Moreover, nausea and allergic reactions may
and rarefaction of the retina and choroid resulting in
develop due to repetitive usage of the dye while
various complications such as peripheral retinal
indocynine green is contraindicated in pregnancy
degeneration, retinal tears, posterior staphyloma,
and patients with kidneys disease (6).
lacquer cracks and choroidal neovascularisation (1).
The recently introduced OCTA incorporated
In addition to the previously mentioned
in EDI-OCT provided many implements that
complications, affection of retinal and choroidal
revolutionized retinal imaging. OCTA is based on
circulation due to decreased vessels density and flow
will lead to defective nourishment of the posterior
angiography (SSADA) algorithm and Segmentation
Fundus Fluorescein Angiography and
The former is based on detecting the
Indocynine Green have long been regarded the
reflectance amplitude variation of blood flow over
benchmark imaging modalities for evaluation of
time to distinguish vessels from static tissue while
high myopic eyes. They provide two dimensional
the latter produces transversal slices of the retinal
image sets that allow for dynamic visualisation of
and choroidal layer at any depth(11).
blood flow with a wide field of view. However, some
Acquired images are then projected as
major drawbacks for these 2 types of investigations
separate en-face image for each layer for evaluation.
will limit their usage in studying retinal and
Compared to the above mentioned techniques, it's a
choroidal vascular changes in high myopic
non invasive procedure using motion contrast
instead of IV dye, making it more reliable and
Firstly, achieving a detailed image of the
hazard-free for follow up patients with no fears of
deep retinal capillary plexus (DCP) and the
adverse effects or contraindications. Also it is less
choriocapillaris with these imaging techniques is not
time consuming as, beside the fact that it is non
possible due to scattering of light by nerve fibre layer
invasive, it takes few seconds to obtain images for
and in case of FFA; leakage of fluorescein dye that
the vascular plexuses (12).
obscures detailed visualisation of deeper layers.
The superficial vascular network is
Secondly, these are invasive techniques, using
composed of long, horizontal arterioles and venules,