c:\work\Jor\vol747_1 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1448-1456
Multidetector Computerized Tomography Versus Magnetic Resonance
Imaging in Diagnosis of Basal Ganglia Signal Intensity Alteration
Mostafa Ali Motawie, Mostafa Mohammad Shakweer,
Mohammed Ashraf Abd El Moniem Aly Ahmed*
Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohammed Ashraf Abd El Moniem Aly Ahmed, Mobile: (+20) 01000086560,
E-Mail: m.ashrf88@yahoo.com

the basal ganglia are part of the extrapyramidal motor system, participating in the production of
movement, but they are also involved in memory, emotion, and other cognitive functions.
Objective: This work aimed to study the role of multidetector computerized tomography versus magnetic
resonance imaging in diagnosis of basal ganglia signal intensity alteration with highlight on accuracy, sensitivity,
specificity of each tool in reaching the proper diagnosis.
Patients and Methods: this study was designed to examine the effectiveness of both computed tomography and
magnetic resonance imaging in diagnosis of different basal ganglia lesions. It included 50 patients, selected from
Al-Azhar University hospital.
Results: sensitivity of CT in diagnosis of basal ganglia lesion was 86.0%, and failed to elicit diagnosis in 14.0%
of patients. There was no significant difference between males and females. MRI sensitivity in diagnosis of basal
ganglia lesions was 92%, while it was unable to diagnose 4.0%. There was no significant difference between males
and females (the sensitivity in males was 94.7% and in females, it was 83.3%).
Conclusion: MRI is superior to CT for diagnosis of different basal ganglia lesions, except for senile calcification,
where CT was superior to MRI. However, CT presents a considerable sensitivity. Thus, it is advisable to start with
CT examination to avoid high cost of MRI, otherwise start with MRI when the cost is not a matter or the condition
is not in an emergency situation. In such emergent situations, MRI must be used as a first choice.
Keywords: CT, MRI, Basal Ganglia.

nuclei are not as clearly depicted on CT. On MR
The basal ganglia consist of a group of related
imaging, the caudate and putamen generally follow
subcortical nuclei, which, together, are responsible
cortical gray matter signal intensity. In the healthy
for multiple brain functions. Primarily, the function
adult, the globus pallidus, subthalamic nucleus, and
of the basal ganglia is to control and regulate
substantia nigra often appear relatively hypointense
volitional movement to ensure smooth performance.
to cortical gray matter on T2WI, due to higher iron
However, there are multiple other functions of the
concentration. In a young patient, the substantia nigra
basal ganglia, including procedural learning, routine
is hyperintense on T2WI. With increasing age and
behaviors, and contributions to cognition and
higher iron content, there is increasing susceptibility
emotion. Anatomically, the basal ganglia are
of the substantia nigra on gradient called echo T2 (2).
composed of several nuclei: the striatum (consisting
CT and MR imaging are complementary
of the caudate nucleus, putamen, and nucleus
studies, each with unique advantages. CT is the most
accumbens), the globus pallidus, the substantia nigra,
and the subthalamic nucleus. Functionally, the basal
demonstrates calcification, acute hemorrhage, prior
ganglia have considerable connections to the cerebral
ischemic injury, and volume loss. CT is useful in
cortex, thalamus, and brain stem; in fact, anatomists
consider portions of the thalamus as components of
implantable devices, including subthalamic and brain
the basal ganglia (1).
stem stimulators in patients with movement
Most of the basal ganglia are well-
disorders. MR imaging is advantageous in
demonstrated on cross sectional imaging. Non-
delineating anatomy and demonstrating signal-
contrast CT shows the caudate, putamen, and globus
intensity alteration(3).
pallidus as having relatively high attenuation
Systemic and metabolic abnormalities often
compared with white matter. The substantia nigra
involve the basal ganglia or thalamus on both sides
Most of the basal ganglia are well-demonstrated on
and careful assessment of brain abnormalities
cross sectional imaging. Non-contrast CT shows the
occurring simultaneously outside these structures is
caudate, putamen, and globus pallidus as having
important (4). In many cases, MRI alone does not
relatively high attenuation compared with white
usually allow to establish diagnosis, even with its
matter. The substantia nigra and the subthalamic
high capability of tissue characterization, but

Full Paper (vol.747 paper# 1)

c:\work\Jor\vol747_2 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1457-1461
Double Silicone Intubation for Management of Recurrent Acquired
Nasolacrimal Duct Obstruction
Mahmoud Abd El-Halim Soliman Rabea, Mohamed Al Taher Abd El Wahab,
Ehab El Sayed Abd El Salam*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ehab El Sayed Abd El Salam, E-mail: dr.ehab_salam@yahoo.com, Mobile: (020) 01033025334

the obstruction of the nasolacrimal excretory system may occur in the proximal puncta, canaliculi,
common canaliculus, or more distally within the lacrimal sac or nasolacrimal duct. Nasolacrimal duct obstruction
occurs as a congenital or acquired disease. Acquired causes can be numerous.
Aim of the Work: to evaluate Dacryocystorhinostomy (DCR) with double silicone tube in the management of
recurrent epiphora after failed conventional DCR.
Patients and Methods:
This is a prospective study which was done on 30 patients with recurrent or persistent
acquired epiphora who gave positive past history of previous DCR.
Results: Epiphora improved significantly in 27 out of 30 patients (90%) after six month postoperatively.
Conclusions: DCR is the gold treatment intervention for acquired nasolacrimal duct obstruction (NLDO) in adults,
Silicone intubation (SI) increases success rates and double SI further increases the success rates of DCR for recurrent
cases and is considered safe and effective technique.
Keywords: DCR, epiphora, NLDO.

Watering of the eye is an annoying problem
It is to evaluate Dacryocystorhinostomy (DCR)
embarrassing the patient both socially and functionally.
with double silicone tube in the management of
Epiphora, which is defined as watering of the eye due to
recurrent epiphora after failed conventional DCR.
insufficient drainage of tears through lacrimal passages

represent the vast majority of cases with watery eye (1).
The commonest cause of epiphora is nasolacrimal
This is a prospective study which was done on 30
duct obstruction (NLDO), which may be congenital or
acquired. Acquired NLDO may be primary or secondary(2).
Ophthalmology department (Al-Azhar University,
The primary causes of lacrimal pathway
Damietta). The work was done at the period from
obstruction include acute or chronic inflammation, trauma
March 2016 to April 2017 after an informed consent.
or congenital malformations. Patients generally present
The study was approved by the Ethics Board of Al-
with epiphora and lacrimal sac swelling, purulent
Azhar University.
secretion, blurred vision and facial pain. Dacryocystitis
The following inclusion and exclusion criteria
and recurrent conjunctivitis are typical (3).
were used:
Primary or idiopathic acquired nasolacrimal duct
Inclusion Criteria: (1) Patient with recurrent or
obstruction (PANDO) is the commonest cause of NLDO
persistent acquired epiphora who give positive past
and is defined as a clinical syndrome of complete
history of previous DCR. (2) Stable position of both
nasolacrimal duct obstruction without other lacrimal
tubes during postoperative follow up period.
excretory system pathology (4(.
Exclusion Criteria: Patients with primary
The standard surgical procedure for nasolacrimal
acquired epiphora with negative past history of lacrimal
duct obstruction is dacryo-cysto-rhinostomy (DCR) in
surgery, congenital epiphora, involutional Ectropion,
which the lacrimal sac is connected directly to the nasal
Epiphora secondary to ENT cause (Polyp, Deviated
cavity to allow drainage of tears (5(.
septum and Hypertrophied inferior turbinate) and one
Although Caldwell was the first to propose an
or both tube extrusion during follow up period.
endonasal approach in 1893, it was limited by the
The following items were considered:
technology available at that time. Toti is considered the
1- History of watering eyes which may be related
father of DCR which is external procedure described for
to blepharitis or dry eyes, allergies, eye drops, drugs and
the first time, in 1904.
With the advent of rigid nasal endoscopes which
2- History of nasal problems may be an
facilitated intranasal access to the lacrimal sac, an
important factor for exclusions.
endoscopic approach became feasible and was first used
3- Past history of medical disorder (diabetes
clinically in the late 1980(6).
mellitus, hypertension, IHD and allergic rhinitis) and

their medications and use of blood thinner as well.

Full Paper (vol.747 paper# 2)

c:\work\Jor\vol747_3 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1462-1472
Sonographic Assessment of Myometrial Thickness as A Predictor for the Latency
Interval in Women with Preterm Premature Rupture of Membranes
Abdalmonem Mohamed Zakaria, Waleed Alsayed Alsayed Alnagar, Khaled Mahmoud Ahmed Ahmed
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Khaled Mahmoud Ahmed Ahmed, Mobile: (+20)01007665054, E-Mail: dr.khaled.m.a.a@gmail.com

Spontaneous rupture of membranes is a normal component of labor and delivery. Rupture of
membranes before the onset of labor is considered premature (PROM), and induction of labor is common if the
patient is at or close to term. Patient management becomes more challenging when rupture of membranes occurs
preterm (PPROM), and in the absence of labor.
Objective: The aim of this work was to measure the myometrial wall thickness (MT) by ultrasound scanning in
women with PPROM as predictors for the latency interval, and see other impacts that predict the latency interval.
Patients and Methods: This study included a total of 100 pregnant women attending at Labor and Delivery
Ward in Al Hussein Hospital, Al-Azhar University. This study was conducted between May 2018 to December
2018. Pregnant women were divided into three groups: preterm premature rupture of membranes (PPROM,
n=50), and term nonlabor control (T-CTR, n =25) and preterm nonlabor control (P-CTR, n=25).
Results: revealed that women with PPROM were slightly older compared with those in P-CTR group and T-
CTR group but with no statistical significant difference. There was no significant difference among groups in
number of previous pregnancies. There was also no significant difference in maternal body weight among
groups. Regression analysis suggested that there was a direct correlation between latency interval and fundal
MT with a very strong positive Pearson correlation and a highly significant p value.
Conclusion: It could be concluded that there was a significant thickening of the fundal walls of the uterus follow
PPROM. A thick myometrium in no laboring PPROM women is associated with long latency interval.
Keywords: PPROM, Myometrium, Oligohydramnios Ultrasound preterm birth, latency interval

14 days), and early (less than 25 weeks at onset)
Spontaneous rupture of membranes is a
oligohydramnios has been associated with a
normal component of labor and delivery. Rupture of
neonatal mortality rate greater than 90% (5).
membranes before the onset of labor is considered
Similar to myocardium, the force of labor is
premature (PROM), and induction of labor is
uterine wall tension opposed to the resistance of the
common if the patient is at or close to term. Patient
cervix, perineum and pelvis. Mathematical
management always becomes more challenging
modeling reveals that uterine wall stress (defined as
when rupture of membranes occurs preterm
applied force per unit cross- sectional area of
(PPROM), and in the absence of labor. The natural
material) is directly proportional to both the
history of PROM progresses in such a way that 90%
intracavitary pressure and the radius of the
of term patients and 50% of preterm patients enter
curvature, but inversely proportional to the
spontaneous labor within 24 hours. The major
thickness of the myometrium. Thus, the thicker the
question regarding management of these patients is
myometrium, the lower the uterine wall stresses (6).
whether to allow them to enter labor spontaneously
Sonographic observation that the myometrium
or to induce labor. In large part, the management of
thins symmetrically during active labor with the
these patients depends on their desires (1).
least amount of thinning at the uterine fundus
Many cases of PPROM are caused by
stimulate scientists to rethink the mechanisms
idiopathic weakening of the membranes (2). Other
responsible for the uniform dispersion of the
causes include incompetent cervix, abruption
contractile forces that insure efficient fetal
placenta, and amniocentesis. The incidence of
expulsion. Sudden decompression with the uterine
PPROM ranges from 2% to 20% and is associated
sac, which has been filled with a minimally
with 18% to 20% of perinatal deaths (3).
compressible fluid that normally opposed
Perinatal risks with PPROM are primarily
thickening, is the most likely physiologic
explanation (7).
respiratory distress syndrome, intraventricular
A direct correlation was found between fundal
Hemorrhage, patent ductus arteriosus, and
myometrial thickness (MT) and the latency interval
necrotizing enterocolitis(4).
(LI). Showing that the thicker the fundal
Pulmonary hypoplasia is the most serious
myometrium, the longer the latency interval (8).
complications, and can be lethal, the presence of
The latency interval is defined as the time
severe (AFI less than 2 cm), prolonged (more than
period (days or hours) from the time of rupture of

membranes reported by the patients to delivery. Our

Full Paper (vol.747 paper# 3)

c:\work\Jor\vol747_4 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1473-1480
Arthroscopic Bankart Repair with Subscapularis Augmentation in
The Treatment of Recurrent Anterior Shoulder Instability with Bone Loss
Ibrahem A. Hussein, Mohamed Abdel-Aziz Hassan, Samir A. Nematallah
Orthopedic Department, Faculty of Medicine, Al-Azhar University, Cairo
Corresponding author: Samir Ahmed Nematallah. Mobile: 01004649490, Email: drsamirortho@azhar.edu.eg
Background: In this study, we focused on the analysis of new published surgical technique in the management of
recurrent anterior shoulder dislocation in presence of glenoid bone defect using traditional Bankart repair augmented
with subscapularis tendon. Method: This prospective study was performed on 30 patients having recurrent anterior
shoulder dislocation; these patients were managed between January 2016 and December 2018, Thirty-one shoulders
in thirty-one patients had arthroscopic Bankart repair and subscapularis augmentation. One patient was lost to follow
up; thirty patients with thirty shoulders were evaluated using American shoulder and elbow surgeons score, the
percentage of glenoid bone defect was evaluated using PICO method. Results: 30 patients were followed for 22.03
Months range 16 ­ 24 Months. Only one patient had recurrent dislocation after significant trauma. The American
Shoulder and Elbow Surgeon Score (ASES) shows significant improvement in score from Mean ± SD 13.27 ± 3.24
to 23.47 ± 3.14 after, function Mean ± SD from 6.23 ± 2.01 to 8.83 ± 0.75 and pain decrease from Mean ± SD 6.17 ±
1.53 to1.33 ± 0.80, with no significant functional changes in ROM even ER at 90 abduction Mean ± SD changes from
79.00 ± 9.95 to 77.33 ± 7.85 or ER at side Mean ± SD changes from 68.67 ± 18.14to 66.33 ± 15.31.
Conclusion: The procedure of Bankart repair with Arthroscopic Subscapularis Augmentation (ASA) is an effective
procedure in the management of recurrent anterior shoulder dislocation associated with GBD 25% with good results.
Keywords: Bankart repair, Subscapularis augmentation, recurrent anterior shoulder dislocation, and glenoid bone


subscapularis tendon are the main problems related to
Recurrent anterior shoulder dislocation is a common
(5). Recently,
injury in young and active patients (1) with an incidence
biomechanical studies have reported that the sling
rate of about 1.7%. Without surgical treatment, the
effect of the subscapularis is the main effect of
recurrence rate in young patients is unacceptably high
stabilization after the Latarjet procedure (14-16).
about 70.3% (2). However, after arthroscopic Bankart
Therefore, Johnson reported an arthroscopic technique
repair the recurrence rate of 13.1% was still reported
using the subscapularis tendon to address the
(2).Different pathologies are involved in the problem of
capsulolabral deficiency (17); this procedure has been
instability; glenoid bone loss, potentially engaging
developed using the effect of the subscapularis tendon
Hill-Sachs defect (3), capsular insufficiency (4) and
to stabilize the shoulder, thus avoiding a high
subscapularis tendon elongation (5).
complication rate, especially the major complication of
Putti and Platt inaugurated an open shoulder soft
nerve palsy. However, this procedure was abandoned
tissue stabilization procedure, using the subscapularis
due to complications related to the metal implant used
tendon. This procedure is performed as follows: the
for fixation of tendon to the glenoid edge.
release of the subscapularis tendon at 2.5 cm medial of
Recently, four techniques have been described in
the insertion at the lesser tuberosity, open the capsule
which the subscapularis tendon was used to treat
and suture the medial border of the lateral stump to the
anterior capsulolabral deficiency.
capsule tissue, and at least suture the lateral border of
The first technique, described by Denard et al.
the medial subscapularis tendon laterally. Osmond-
(18)consisted of a subscapularis flap used to augment the
Clark (4) was the first who described the procedure. But
Bankart repair, whereas the second technique,
osteoarthritis and the limitation of external rotation
described by Chaudhury et al. (19)consisted of tenodesis
were reported as late complications (6). Different
of the tendon and its advancement and fixation to the
modifications of the Putti-Platt procedure were
medial border of the glenoid neck using multiple
described in the following years (7). Bristow(8)and
anchors. The third technique described by Blasiak et al.
Latarjet(9) both described a non-anatomical procedure
(20) used a split of the subscapularis tendon which was
using the conjoined tendon with the attached coracoid,
detached from the distal part and fixed at the anterior
passed the conjoined tendon through the subscapularis
glenoid rim. The fourth technique was presented by
tendon, and fixed the bone block at the glenoid (9,10).
Klungsoyr et al. (21), the sling effect was used to
This procedure helps to solve the problem of the
stabilize the shoulder using a hamstring tendon graft
GBD, capsular insufficiency, and subscapularis tendon
and enhancing the anterior rim of the glenoid with the
elongation. However, although high complication rates
same graft. Maiotti et al. (22) Based on the procedure of
after the early Bristow procedures as well as after the
Johnson (17) a new arthroscopic technique consisting of
arthroscopic Bristow-Latarjet procedure were reported,
an upper third subscapularis tenodesis at the anterior
their popularity increased (10, 13). The pathological
border of the glenoid rim combined with the traditional
problems of a stretched capsule and elongation of the
Bankart repair was developed. This technique was

Full Paper (vol.747 paper# 4)

c:\work\Jor\vol747_5 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1481-1490

Results of Coronary Artery Bypass Graft Surgery in
Sharq Elmadina Hospital, Alexandria
El Husseiny E. Gamil1, Ali R. Mahmoud2, Mohamed E. Mahmoud1, Mohamed A. Mohamed
Departments of 1Cardiothoracic Surgery and 2General Surgery
Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed A. Abd El Badie; Mobile: 01012972837, E-Mail: badi388@gmail.com

coronary artery bypass graft (CABG) surgery has been shown to be an effective method for
treating angina pectoris and prolonging life in patients with severe coronary artery disease.
Aim of the Work: to assess postoperative short-term results of coronary artery bypass graft surgery in Shark
Elmedina hospital, Alexandria. Patients and Methods: This retrospective study was conducted on 170
patients with isolated ischemic heart disease admitted to Shark Elmadina hospital from January 2016 to January
2017. In the current study, pre-operative data were collected to identify the risk factors that may affect the
outcome of surgery and intraoperative data and post-operative complications. Results: The most common risk
factors were dyslipidemia (64.7%), hypertension (57.1%), diabetes mellitus which represents 50%, smoking
which represents 37,6%, peripheral vascular disease which represents 31,7%. Other risk factors which had a
low percent were history of chronic hepatic disease, previous stroke or myocardial infarction or lung disease
or renal disease. What is worth to mention that echo preoperative affects the outcome of surgery as in our study
EF of patients' ranges from 40% to 75%. Intraoperative data also affects the outcome of surgery as number of
grafts as there was one patient had done 5 grafts and 34 patients have done 4 grafts. Another important event
was LLIMA dissection as there were 9 patients have dissected LIMA during harvesting. Another event was
endartrectomy as there were 11 patients have LAD endartrectomy, 6 patients have RCA endartrectomy. Long
bypass time and clamp time affects the results of surgery maximum bypass time 200 minute and maximum
clamp time 120 minute. Post-operative ICU and ward stay affects the results as maximum ICU or ward stay
was 9 days. The most common complication was wound infection which had an incidence 7% and the second
complication was renal impairment which had an incidence 5.2%, reopening (2.9%), elevated liver enzymes
which represents 2,3% and other complications which had low incidence as pleural effusion, lung atelectasis
and stoke. Finally, mortality was 1.1%. Conclusion: CABG surgery is safe and the risk of major complications
is low. Although major complications occur rarely they pose a great challenge to the patient and the surgeon.
Early recognition and management of major complications are paramount to long term outcome.
Keywords: coronary artery bypass graft surgery, postoperative short-term outcome.


Coronary artery disease (CAD) is the
CABG is a surgical procedure to use the own
leading cause of death globally, and is expected to
patient conduit to bypass the atherosclerotic
account for 14.2% of all death by 2030 (1).
narrowing and improve blood supply to the
According to the statistics from the American
Heart Association (AHA), mortality data show that
myocardium (4).
cardiovascular disease, as the underlying or
Myocardial revascularization has been an
accounted for 34.3% of all (1 of every 2.9)
established mainstay in the treatment of coronary
artery disease for almost half a century, used in
Several alternative treatments exist for
clinical practice since 1960s. It is the most
(CAD), including medical therapy, percutaneous
intensively studied surgical procedure ever
coronary intervention (PCI) or balloon angioplasty,
undertaken (5).
and coronary artery bypass graft surgery (CABG).
Despite the novel other alternatives for
Depending on the severity, number and position of
coronary artery revascularization, CABG is still
atherosclerotic lesions and the clinical history of
one of the most durable and effective means of
the patient, any of the abovementioned treatment
revascularization for patients with coronary heart
may be chosen. For high- risk patients, such as
disease either on pump or Off pump coronary
those with left main coronary artery disease, severe
artery bypass (OPCAB), using left internal
three- coronary vessel disease, severe ventricular
mammary artery, right internal mammary artery,
dysfunction (low ejection fraction EF), and
radial artery and saphenous venous grafts in
diabetes mellitus(DM), CABG is preferred
addition to other grafts options (6). Each year,
600,000 patients in USA undergo myocardial

Full Paper (vol.747 paper# 5)

c:\work\Jor\vol747_6 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1491-1513

Limb Lengthening for Achondroplasia: Systematic Review and Meta-analysis
Yasser Ali Elbatrawy, Ashraf Mohammed Abdelaziz, Mohamed Ahmed Abdel-Meged Zidan
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Mohamed Ahmed Abdel-Meged Zidan, Mobile: (+20) 01220427437,
E-Mail: drmohamedzidan@gmail.com
Achondroplasia is the most common genetic skeletal dysplasia. It is characterized by a rhizomelic form
of dwarfism, exaggerated lumbar lordosis, a prominent forehead and a low nasal bridge. The trunk is generally of
near normal length. The incidence of achondroplasia is approximately 1 in 25000 people.
: In the present systematic review, we have aimed to synthesize evidence from the published literature
about the safety and efficacy of limb lengthening in patients with achondroplasia. Also, we have aimed to assess
which age is preferred to start the lengthening and effect of early management on natural growth and psychiatric
Methods: An electronic search was conducted from the inception till September 2018 in Medline via PubMed. Data
entry and processing were carried out using a standardized Excel sheet and reviewers extracted the data from the
included studies. We performed all statistical analyses using Review Manager (RevMan) 5.3 for windows.
Results: In the present study, 17 studies were included in the present systematic review and meta-analysis. In terms
of gained length of femur, the overall effect estimate showed that limb lengthening procedure achieved a mean
increase in femur length by 11.9 (95% CI 9.39 ­ 14.43) cm. In addition, the overall effect estimate showed that limb
lengthening procedure achieved a healing index of femur 30.46 (95% CI 24.326 ­ 36.59) days/cm. Similarly, the
overall effect estimate showed that limb lengthening procedure achieved a mean increase in tibia length by 9.5 (95%
CI 8.169 ­ 10.927) cm. The overall effect estimate showed that limb lengthening procedure achieved a healing index
of tibia of 32.09 (95% CI 18.65 ­ 25.52) days/cm
Conclusion: It could be concluded that limb lengthening is a reliable procedure with a relatively low complication
rate in increasing the length of femur and tibia in patients with achondroplasia.
Keywords: Achondroplasia, Meta-analysis.

conducted by Ilizarov led to a method allowing bilateral
Skeletal dysplasias are a group of genetic
lengthening with acceptable risks (6).
disorders that affect the size and shape of the limbs,
Lengthening of the arms and legs of individuals
trunk and skull, typically resulting in short stature (1). On
with achondroplasia can potentially result in height
the basis of data from seven population-based birth
gains of up to 30 cm and may improve limb function (7).
defect-monitoring programs in the United States, the
On the other hand, limb lengthening was reported to be
estimated prevalence of achondroplasia ranges from
associated with high incidence of serious complications.
0.36 to 0.60 per 10,000 live birth (2). Achondroplasia
There is a growing body of evidence that lengthening is
creates an external appearance of disproportionate short
commonly associated with infection, pain, swelling of
stature in which extremities are too short relative to the
the limb, neurovascular complications, contractures of
trunk and head, due to inadequate enchondral
the soft tissues, subluxation and dislocation of adjacent
ossification in the long bones, with an adult height that
joint, bone-related problems at the lengthened site and
is below the third percentile (3). In addition to the
psychological problems (8).
discomforting cosmetic appearance, achondroplasia
Previous study by Donaldson et al. (9), on ten
often results in lumbar (lordosis) and spinal stenosis
achondroplastic children underwent limb lengthening,
later in life, which may require surgery to correct (1).
reported an average total length gain of 20.5 cm, with a
Less commonly, achondroplasia may lead to
high rate of complications. Another report by Kim et al.
neurological complications, craniofacial abnormalities,
(10) assessed whether patients were satisfied with leg
sleep-disordered breathing, thoracolumbar kyphosis,
lengthening using the AAOS lower limb, SF-36, and
angular deformities of the knee and leg, otitis media,
Rosenberg self-esteem scores. The minimum follow up
deafness, speech delay, weight gain and obesity (4).
was 4.5 years. They concluded that even with numerous
Among the various surgical options that can be
complications, serial limb lengthening is a good option
offered to those affected from achondroplasia, limb
in terms of improvement in quality of life scores.
lengthening was proposed in order to increase height at

maturity and restore normal body proportions in
The aim of the current study was to synthesize evidence
affected individuals (5). The fundamental research
from the published literature about the safety and
efficacy of limb lengthening in patients with

Full Paper (vol.747 paper# 6)

c:\work\Jor\vol747_7 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1514-1515
Levetiracetam Induced Cutaneous Side Effects: Case Report
Saud Alnaaim
Clinical Neurosciences department, College of Medicine, King Faisal University

Many drugs have been successfully used for the treatment of epilepsy. However, medications related
complications are usually inevitable. The aim of the work was to report the limited rare cutaneous manifestations
associated with Levetiracetam (LEV); a commonly used anti-epileptic drug (AED). Two cases were reported with
literature review. Method: This is a retrospective case report enrolling two patients with primary generalized epilepsy
who developed different cutaneous manifestations that were previously reported in the literature on minimal
occasions. Conclusion: LEV is not known to induce cutaneous manifestations, and if occurred, it would be dose-
related. Therefore, utmost care should be taken when prescribing LEV dosage to avoid such complication.


Epilepsy is one of the commonly encountered
Her history and medications were reviewed and were
neurological diseases in medical practice. The
not remarkable for any obvious causes. The suspension
prevalence of the disease in Saudi Arabia is about 6.5
of LEV induced skin rash is raised and considered.
per 1000 [1]. Different types of epilepsy do exist,
Consequently, topiramate was started, and LEV was
including generalized onset, focal onset, combined or
discontinued. We admitted in the ward was under
unknown [2].
observation and for symptomatic management. Her
Generalized onset epilepsy is having many tools for
rashes resolved after 24 hours.
treatment including pharmacological treatment. LEV is

one of the widely used medication for the treatment of
epilepsy [3]. Its complications are limited and mostly rare
An 18-year-old female patient has been diagnosed
[4]. Recently, some literature reported cutaneous
with primary generalized epilepsy for 16 months.
complications as a rare side effect of this drug.
She was treated with sodium valproate (VAD) in
In the present case study, we are reporting two cases
another hospital. Then, we shifted to LEV when
of LEV related cutaneous complications in the form of
presented to our clinic because of VAD side effects.
hyperpigmentation of the skin and maculopapular rashes
Initial Levetiracetam dose was 500mg TWICE daily
that have been discussed based on the literature data.
then she was kept on 750mg TWICE daily for about six

Due to breakthrough seizures, we increased her
A 25-year-old female patient was diagnosed with
dose to be 1000mg TWICE daily. After seven days from
primary generalized epilepsy seven years ago. She has
the new dose initiation, she started to notice skin
been on topiramate since the beginning of her treatment
changes over her hand bilaterally. She did not stop AED,
regimen until she was presented at the clinic
and she was presented to the emergency department and
complaining from paresthesia and psychomotor slowing
a very near appointment with neurology clinic was set
symptoms and asking for other AED choices if possible.
up. She presented to the clinic with hyperpigmentation
Discussion about the risk of breakthrough attacks and
skin changes over dorsal surfaces of her hands
risk of status epilepticus was initiated. However, her
bilaterally at day 12 after new dose initiation. There
preference was to switch to alternatives considering her
were noticeable early similar skin changes over her feet
preference and her marital status as she is married. For
bilaterally which were not noticed by the patient. The
which, slow taper down plan of topiramate was
skin changes involved about 10% of body surface area.
discussed with her and LEV was selected to be initiated.
Her rash was managed accordingly. LEV has been
LEV was prescribed in a dose of 500mg BID for one
replaced by topiramate successfully without seizure
week along topiramate slow taper down plan. After two
recurrence or rash. Her condition improved gradually.
weeks, her LEV was reached 1000mg BID. She

continued using the same dose for two days till she
noticed skin changes over her upper limbs bilaterally.
Hyperpigmentation is darkening of the skin, mucous
Therefore, she was presented to outpatient clinics to
membranes, or nails that may result from a variety of
seek a medical opinion. She was referred immediately
causes like sun exposure injuries, infections,
by a family physician to our clinic. She was on LEV
1000mg BID and end of taper-down of topiramate with
photosensitivity, or allergic reactions [5]. It has
a dose of 25mg BID at that time. Her skin lesion
been reported that medications are the cause in 10 to
manifested as a maculopapular rash over her forearms
20% of patients with acquired hyperpigmentation [6].
and abdomen mainly.
The level of evidence supporting a causal relationship

Full Paper (vol.747 paper# 7)

c:\work\Jor\vol747_8 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1516-1524

The Value of Middle Cerebral Artery and Umbilical Artery Doppler Indices in
Assessment of Fetal Wellbeing and Prediction of Neonatal Outcome in Preeclampsia
Yehia A. Wafa1, Fahd A. Mohammed2, Osama M. Deif 1, Mohammed A. Shosha1*
1Department of Obstetrics and Gynecology, Faculty of Medicine-Al-Azhar University
2Department of Obstetrics and Gynecology, Police Hospitals
*Corresponding author: Mohammed A. Shosha; Mobile: 01276005633; Email: dr.mshosha.ms@gmail.com.

Aim of The Study:
To evaluate the value of middle cerebral artery and umbilical artery Doppler indices in
assessment of fetal wellbeing and prediction of neonatal outcome in pregnant women with preeclampsia.
Patients and Methods: This study included 100 pregnant women with preeclampsia, 50 women with uneventful
pregnancies, Ultrasound and Doppler studies were carried out to estimate fetal weight, fetal biophysical profile and
resistance indices of the middle cerebral and umbilical arteries. C/U RI <1.0 was considered abnormal. Adverse
neonatal outcome was diagnosed when Apgar score <6 at 5 minutes, C.S for fetal distress, stained meconium,
abnormal BPP, perinatal death and/or neonatal admission to neonatal intensive care unit.
Results: adverse neonatal outcome in groups A, B and C was significantly correlated to UA-RI and UA-PI. Between
the normal and adverse neonatal outcome, in group A, there was a significant difference in UA-RI (P-value = 0.021);
in group B, there was a significant difference in UA-RI and UA-PI (P-value <0.001 and P-value <0.001 respectively);
and in group C, there was a significant difference in UA-RI and UA-PI (P-value <0.001 and P-value =0.004
respectively). In our study, both absent and reversed diastolic flows were significantly correlated with bad neonatal
outcome in the study group (P value <0.001, r-value = 0.428). Conclusions: MCA and UA Doppler indices are good
utilities for the assessment of fetal wellbeing and prediction of neonatal outcome in pregnant women with
Keywords: Doppler indices, preeclampsia, neonatal outcome.

restriction (IUGR), oligohydramnios, placental
Preeclampsia is a major contributor to
abruption, and non-reassuring fetal status found on
maternal mortality worldwide and remains a leading
ante-partum surveillance by Doppler ultrasound (6).
cause of perinatal mortality and morbidity,
On the other hand, IUGR fetuses represent a subgroup
complicating 2­8% of pregnancies (1). Although the
of fetuses that have failed to reach their growth
precise mechanism through which preeclampsia
potential for various reasons, such as genetic
develops is uncertain, research in the field continues
disorders, infection and uteroplacental insufficiency
to advance understanding of the underlying
to a degree that may affect the health of the fetus. In
pathophysiology. Endothelial cell dysfunction
other words, IUGR is the pathological counterpart of
following placentation appears to play a central role
SGA (7). High flow resistance in the capillaries of
in the pathogenesis of the disease (2).
terminal villi leads to a low end-diastolic velocity in
An inadequate invasion of trophoblasts with
the umbilical artery and a subsequent hypoxia (8).
consequential placental ischemia as a result of
During chronic fetal hypoxia there is continuous
insufficiently dilated uterine spiral arteries is thought
reduction of cerebral vascular resistance resulting in
to be an initial cause in the pathogenesis of pre-
decrease middle cerebral artery resistance index
eclampsia (3). The current routine prenatal surveillance
values gradually (9).
tests such as the non-stress test and fetal biophysical
The use of Doppler umbilical wave forms as a fetal
profile (BPP) may not be sensitive or specific enough
surveillance test had gained a wide popularity,
to detect fetuses with an early compromise (4). Doppler
especially in high risk cases (10). Considering that CPR
flow velocimetry of the umbilical and fetal cerebral
RI reflects not only the circulatory insufficiency of the
circulation serves as another modality for the
placenta by alteration in the umbilical resistance index,
assessment of fetal status. This technique can be
but also the adaptive changes resulting in modification
helpful in identifying the compromised fetus and
of the middle cerebral artery resistance index. It
could be of clinical value in the differential diagnosis
seemed to be a potentially useful tool in predicting
between drug-induced changes in fetal biophysical
adverse perinatal outcome in high risk cases (11).
behavior and those due to fetal compromise (5). As a

result of impaired utero-placental blood flow,
manifestations of preeclampsia may be seen in fetal
To evaluate the value of middle cerebral artery and
placental unit. These include intrauterine growth
umbilical artery Doppler indices in assessment of fetal

Full Paper (vol.747 paper# 8)

c:\work\Jor\vol747_9 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1525-1533
Procoagulant Activity of Platelets and Tissue Factor
Microparticles in Behçets Disease
EL Desouki EL Desouki Fouda*, EL-Sayed AL Maghawri EL-Sayed**,
Mona Hilmy Alrayes***, Mohammed Abdel Maboud El Shennawy*
*Department of Internal medicine, Faculty of Medicine, Al-Azhar University(Cairo), ** Internal medicine Al-
Azhar Faculty of Medicine (Damietta), and *** Department of Clinical Pathology,
Faculty of Medicine for Girls, Al-Azhar University
Corresponding author: Mohamed Abdel Maboud El Shennawy, e.mail: Mohamedmina936@gmail.com

Microparticles are found in all body fluids including peripheral blood. They play an important role in
blood clot formation and increased cell aggregation.
Aim of this work: Was to evaluate the level of circulating platelet microparticles (PMP) and tissue factor
microparticles (TFMP) in Behcet`s disease and to assess the relation of these procoagulant markers and Behçet's
disease activity.
Patients and methods: This study included 100 persons divided to three groups; Behçet's disease (BD) group (40)
patients, systemic lupus (SLE) group (40) patients as a comparative and control group (20) persons. Platelet-free
plasma was ultra-centrifuged. PMPs and TFMPs were identified and enumerated with flow cytometry using anti
CD61PE and CD142Percp antibodies. D-dimer was measured by ELISA.
Results: There was statistically significant increase of PMP (CD61), tissue factor MP (CD142), CD61-MFI and
CD142-MFI in Behcet`s group in comparison to Control group (p0.001). There was statistically significant increase
of PMP and tissue factor MP in Behcet`s when compared to Lupus group (p0.001), while CD61/CD142, CD61-
MFI and CD142-MFI revealed no significant difference. D-dimer was significantly increased during Behcet`s and
SLE disease activity (p=0.036 & p=0.021 respectively). Active Behcet`s disease had significant increase of both
CD61 and tissue factor expressing PMP (CD61/CD142) when compared to patients with inactive state (p0.001 &
p=0.004 respectively), while CD142 showed no significant difference (p=0.38). In Behcet`s group, there was
significant positive correlation between CD61 and each of CD61/CD142 and D-dimer (p=0.001).
Conclusion: PMP and TF MP are significantly elevated in BD in comparison to SLE. PMP, PMP expressing TF
and D-dimer are markers of disease activity in both BD and SLE, while ESR and CRP are not. PMP is positively
correlated to TF expressing PMP and D-dimer in BD denoting enhanced prothrombotic state. PMP, PMP expressing
TF and D-dimer are characters of ANCA positive BD.
Keywords: Platelet microparticles, Tissue factor microparticles, Behçets` disease and Systemic lupus erythematosus

to allow assembly of tenase and prothrombinase
Microparticles have received increased attention as
complexes, and (ii) exhibit a `thromboplastin-like'
universal markers of activation in eukaryotic cells (1).
activity, i.e. a tissue factor activity (4).Later studies
MPs carry markers of the parent cell, including those
confirmed both hypotheses. Thus, TF does not only
induced by activation, apoptosis, cell Lysis or
have an extravascular distribution, but can also be
oxidative stress. Blood contains microparticles (MPs)
present within the blood where TF is associated with
derived from different cell types, including mainly
cell-derived vesicles (5).
platelets, red blood cells, granulocytes, monocytes,
Circulating MPs blood levels result from the
lymphocytes and endothelial cells. Overproduction of
balance between their rates of release from cells and
MPs has been related to various physiological and
their clearance from the circulation. Changes in MP
pathophysiological conditions such as cell adhesion,
levels in circulating blood may be due to some
apoptosis, immune response, vascular function,
pathological conditions .PMPs are the most abundant,
vascular remodeling and angiogenesis, hemostasis
representing about 70­90% of all circulating MPs (6).
and thrombosis, cardiovascular diseases, cancer and
A consensus protocol to measure MPs do not yet
infections (2).
exist, flow cytometry-based detection of MPs have
The clinical relevance of these procoagulant MP
been shown to be a reliable and reproducible method
properties has been demonstrated in various
thromboembolic diseases (3).
Behçet's disease (BD) is a multisystemic
Dvorak and co-workers showed that several
vasculitis, characterized by cutaneous lesions such as
cancer cell lines release a coagulant activity that is
aphthous stomatitis, genital ulcers, erythema
associated with membrane vesicles. They postulated
nodosum-like lesions and papulopustular lesions, as
that these vesicles (i) provide a phospholipid surface
well as uveitis, epididymitis, neurological symptoms,

Full Paper (vol.747 paper# 9)

c:\work\Jor\vol747_10 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1534-1543
Comparative Study between Mesotherapy and Conventional Systemic
NSAIDs in the Treatment of Chronic Low Back Pain with Sciatica
Eman Ahmed Saad1, Fatma H. El Nouby1, Ghada El Fayomi2, Amal Fehr3*, Nehal Ahmed Fathy4
Department of Rheumatology, Physical Medicine and Rehabilitation, Faculty of Medicine,
Aswan1, Mansoura2, Helwan3, Assiut4 Universities, Egypt
*Corresponding author: Dr.Amal Fehr, Faculty of Medicine, Helwan University, Egypt.
Email; amal.fehr@med.helwan.edu.eg https://orcid.org/0000-0002-3110-5126

Chronic low back pain is a common painful medical problem which has significant
socioeconomic impact. Conventional pharmacological therapy usually associated with adverse effects.
Mesotherapy is the injection of active substances into the surface layer of the skin. This method allows a slower
spread, higher levels, and longer lasting effects of drugs in the tissues underlying the site of injection compared
with those following intramuscular injection. This technique is useful when a local pharmacological effect is
required and relatively high doses of drug in the systemic circulation are not.
Objective: The aim of this study was to compare mesotherapy versus conventional systemic administration of
NSAIDs in chronic low back pain with sciatica (radicular pain).
Patients and Methods: Fifty patients were randomized to receive anti-inflammatory therapy according to the
following protocols: group I had received ketoprofen 100mg (2ml) + 2% lidocaine (1ml) + saline (2 ml) for
4 injections. Group II had received: 100 mg ketoprofen orally twice daily.
Results: After receiving treatment (After one and three months; As regarding VAS, repeated measure of the
mean VAS score for each group separately showed statistically significant reduction (P < 0.01), and
statistically highly significant higher percentage regarding sever grade of disability in group II (57.1% and
72.7%; respectively) compared with group I (42.9% and 27.3%; respectively) (P < 0.05).
Conclusion: It could be concluded that the administration of NSAIDs via mesotherapy technique provides
better therapeutic benefit than that induced by oral drug administration. That beside the lower drug amounts
administered to patients undergoing mesotherapy and the low frequency of administration.
Keywords: Mesotherapy and Conventional Systemic NSAIDs, Chronic Low Back Pain, Sciatica

through dermal multi-punctures, where the
Low back pain (LBP) is the most frequent type
injection site corresponds to the area of the
of musculoskeletal pain. It is often recurrent and
pathological condition (7).
has important socio-economic consequences (1).
Mesotherapy has been suggested as a treatment
Chronic low back pain (CLBP) treatment is usually
for pain relief in musculoskeletal diseases; it is
multimodal and might include medications,
considered as a therapeutic discipline that cannot
rehabilitation, spinal injections, or surgery. The
be ignored as it is widely used in several different
choice of medication depends on the severity,
specialties and has been the subject of numerous
duration, comorbidities and type of pain (2). Non-
international congresses (8). The objective of this
steroidal anti-inflammatory drugs (NSAIDs) are
type of administration is to modulate the
the most frequently prescribed medications
pharmacokinetics of the injected substance and to
worldwide and are widely used for patients with
prolong the pharmacological effects at a local level.
low back pain based on their analgesic potential
One of the main advantages of mesotherapy is that
and their anti-inflammatory action (3).
a local pharmacological effect can be obtained
The high frequency of adverse events with
without the need for high systemic concentrations
(8, 9). In this regard, mesotherapy is recommended
dysfunction, cardiovascular complications, and the
to reduce the required dose (and the frequency of
risk of drug­drug interactions, particularly in older
administration) of certain analgesics, and at the
patients with comorbidities) explains the
same time can synergize with other therapies in the
increasingly widespread use of "alternative"
management of pain (10).
treatments (4). Local pharmacological therapy; such
The aim of this study was to compare
as local injectable therapies are effective, well
mesotherapy versus conventional systemic
tolerated and represent acceptable alternative to
administration of NSAIDs in chronic low back pain
systemic NSAIDs (5, 6). Mesotherapy is a minimally
with sciatica (radicular pain).
invasive technique that consists of Local
Intradermal Therapy (LIT) with pharmaceuticals or
This prospective comparative study
other bioactive substances given in small quantities
included a total of 50 patients with chronic low

Full Paper (vol.747 paper# 10)

INTRODUCTION The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1544-1551

Potency of Dexamethasone in Labor Induction
Abd Elazeem Mohamed Ahmed, Osama Mohamed Deif and Mohamed Aly El-Saftawy*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed Aly El-Saftawy; Mobile: (+20)01064420247,
Email: mohamedsofyomar@hotmail.com

Induction of labor is one of the most common interventions practiced in modern obstetrics.
In the developed world, the ability to induce labor has contributed to the reduction in maternal and perinatal
mortality and morbidity.
Objective: The aim of this study is to establish whether dexamethasone plays a role in shortening the duration
interval between initiation of labor induction and beginning of the active phase of labor in post-term pregnancy,
so shortening the duration of labor.
Methodology: This case-controlled trial study was conducted in the labor ward of El Hussein University
Hospital and El-Shiekh Zaid Specialized Hospital to evaluate the effect of dexamethasone infusion
administration on the duration of induction of labor. This study comprised 100 pregnant women with full term
pregnancy, who admitted to the labor ward for induction of labor because of full-term pregnancy (gestational age
40 weeks).
Results: There was a high significant statistical difference between the two studied groups as regards duration
between labor induction and active phase of labor being shorter in case group. Active phase and second stage
of labor were shorter in duration in cases of study than control. No significant statistical difference between
the two studied groups as regards mode of delivery, neonatal outcome (birth weight, Apgar score at 1 minute,
Apgar score at 5 minutes and fetal complications (meconium stained liquor and admission to NICU).
Conclusion: Intravenous infusion of two ml (8 mg) of dexamethasone appears to shorten labor duration.
Keywords: Dexamethasone, Labor induction

Although administrating corticosteroids is
The process of childbirth starts from the axis of the
a suggested method to shorten labor duration,
hypothalamus, the pituitary gland, and the adrenal
pCRH concentrations predicted the likelihood of
glands. Steroid substances produced in the adrenal
delivering within one week of corticosteroid
glands of the human fetus affect the placenta and
treatment. Current findings suggest that pCRH may
the membranes and transform the myometrium
be a diagnostic indicator of impending preterm
from the static to the contractile state(1). The
delivery. Increasing the precision in predicting
placenta may play a role in this process because it
time to delivery could inform when to administer
produces a lot of CRH (Corticotrophin releasing
antenatal corticosteroids, thus maximizing benefits
hormone). The adrenal glands of the fetus do not
and reducing the likelihood of exposing fetuses
produce a considerable amount of cortisol until the
who will be delivered at term (5).
third trimester. During the last weeks of pregnancy,
Several animal studies have shown the
importance of corticosteroid secretion by the fetal
(Dehydroepiandrosterone sulfate) contents of the
adrenal glands on the beginning of labor (6), and
fetus rise and this leads to an increase in maternal
infusing glucocorticoids in the lamb fetus was also
estrogens; particularly sterol(2).
shown to induce preterm labor (1).
Placental CRH is not under the influence
These findings have led to the hypothesis
of negative feedback from cortisol. The
that corticosteroids also has an effect on the labor
concentration of CRH in the fetus rises during the
of women (3).
last 12 weeks of pregnancy. This results in
Kalantaridou et al. (7) have suggested that
modification of the contractility of the uterus (2),
the corticotrophin-releasing hormone (CRH),
stimulation of the membranes to produce more
which has been identified in various organ systems,
prostaglandins, stimulation to produce C steroids
including the female reproductive system, is the
from placental adrenaline (3), and increase in the
principal regulator of the hypothalamic­pituitary­
estrogen content (4).
adrenal axis. Circulating placental CRH is
This will disturb the ratio of estrogen to
responsible for the physiologic hypercortisolism of
progesterone and will cause expression of
the latter half of pregnancy and plays a role in the
contractile proteins. In fact, the increase in CRH
onset of labor. O'Sullivan et al. (8) reported that a
near the end of pregnancy confirms the presence of
prolonged gestation is more likely to occur when
a placental-fetal clock (2).
the fetus has congenital adrenal hyperplasia caused

Full Paper (vol.747 paper# 11)

c:\work\Jor\vol747_12 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1552-1558
Comparison between The Effect of Sucralose and Sodium Saccharin on
Some Physiological Parameters in Male Albino Rats
Eman G.E. Helal1, Abdullah Al-Shamrani2, Mohamed A. Abdelaziz3, Mariam S. El-Gamal1
1Department of Zoology, Faculty of Science (Girls), Al-Azhar University, 2Pediatric Pulmonology and Sleep
Medicine, Prince Sultan Medical Military City, King Saud bin Abdulaziz University and Health
Science,3Medical Physiology, Faculty of Medicine, Al-Azhar University
* Corresponding author: Eman Helal, email: emanhelal@hotmail.com, mobile:00201001025364 ,

Non-nutritive sweeteners (NNSs) are becoming popular as sugar substitutes for diabetic patients
or to decrease body weight. Aim of the work: This study was aimed to determine the effects of sucralose and
sodium saccharin on some physiological parameters in male albino rats. Materials and methods: We used
thirty male albino rats weighing from 100 to120 gm. The period of the experiment was 30 days. The animals
were divided into three groups; Group 1: control, Group 2: rats received sucralose and group 3: rats received
sodium saccharin. The following parameters were processed: serum glucose, ASAT, ALAT, serum creatinine,
serum urea, protein and lipid profiles and hormonal levels (insulin, testosterone, serum T3 and T4). Results:
There was an increase in ASAT and ALAT activities, serum creatinine and serum urea levels in group 2 and
group 3, lipid profile in the group received sucralose (TC and HDL) and T3&T4 in the group received
saccharin as compared to the control group. Meanwhile, a drop in serum glucose, insulin, total protein,
albumin, albumin/globulin ratio and triglycerides in group 2 and group 3, lipid profile in the group received
saccharin (TC and HDL) and T3&T4 in the group received sucralose was observed when compared to the
control group. Conclusion: it could be concluded that sucralose and sodium saccharin must be carefully used
because they have very dangerous effects-especially sodium saccharin- and we have to replace them with
natural sugar.
sucralose, sodium saccharin, ASAT, ALAT, T3,T4, testosterone, insulin.


adverse effects on the central nervous system,
Artificial sweeteners are used as sugar
substitutes called "zero" or "light"- beverages,

foodstuffs, pharmaceuticals and personnel care
system, reproductive performance, and red blood
products. They have been used by consumers to
cells constituents and morphology. On the
acquire a sweet taste, for reasons of economics,
contrary, some reports suggest sucralose is a
blood glucose control, or energy control. The
possible trigger for some migraine patients(4).
health risks of artificial sweeteners consumption is
Saccharin is a non-nutritive, non-caloric
still a highly controversial topic(1). Artificial
intense artificial sweetener. In the European
sweeteners have allegedly been related to some
Union, Saccharin is known under the E number
effects such as cancer, weight gain, metabolic
E954. It has 300-500 times the sweetness of
disorders, migraines, type-2 diabetes, vascular
sucrose, with a slight bitter aftertaste. It is widely
events, preterm delivery, kidney function
used sweetener as it is heat-stable, so, it is used in
disorders, liver antioxidant system, hepatotoxicity,
hot beverages, canned vegetables, bakery products
immune system disruptions and alteration of gut
and reduced sugar jams. It has a long shelf life and
microbiota activity. Human studies failed to show
it is inexpensive. Saccharin goes directly through
a direct connection to cancer risk. However, other
the human digestive system without being
studies, , have shown association with kidney
digested; and can trigger the release of insulin in
function decline and vascular risk factors(2).
rats(5). Although 66%­84% of saccharin was
Sucralose, one of the newest artificial
excreted in the urine and 10%­ 40% of the dose
sweeteners has been approved by the Food and
was recovered from the feces after dosing for 24 h,
Drug Administration in 1998. Sucralose itself
traces of saccharin radioactivity remained in many
contains no calories but due to its very sweet taste
tissues after 72 h, including liver, heart, adrenals,
(approximately 600 times as sweet as sugar),
pancreas, thymus, and testes. These data promote
sucralose in the granulated format is often mixed
the possibility that saccharin may have specific
with other sweetening ingredients such as
biological functions when entering into these
maltodextrin. This dilutes its intense sweetness
tissues(6). This chemical is one of the most
and provides volume and texture(3). It has no
sweeteners that has been extensively studied and

Full Paper (vol.747 paper# 12)

Retrospective study of facial fractures fixation outcome in Al-Azhar University Hospitals (El- Hussein and Bab- Elsharia) The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1559-1565

Retrospective Study of Facial Fractures Fixation Outcome in Al-Azhar
University Hospitals (El-Hussein and Bab-Elsharia)
Abdelmonim Hussein Houta, Abdelrahman Awadeen Abdelrahman and Mahmoud Metwally Mahmoud*
Department of Plastic, Reconstructive& Burn Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mahmoud Metwally Mahmoud, E-Mail: mahmoudmetwally@azhar.edu.eg, Mobile: 01009781218

maxillofacial fractures incidence varies between different nations, mandibular fractures are the most
common, multidisciplinary approach is often required, and early consultation with other specialties is
recommended also understanding of common posttraumatic complications will guide surgical management.
Aim of the work:
to analyze the outcome of maxillofacial fractures fixation helping optimization of surgical
practice and medical service appraisal.
Patients and Methods:
the data were retrospectively collected from the medical records of 76 cases treated at
Plastic Surgery Department, Al-Azhar University, from 2014 to 2017 and patients were examined as full
maxillofacial examination.
the total number of patients with maxillofacial trauma presenting to Plastic Surgery Department, during
the period from 2014 to 2017 was 76 patients. Males were more frequently affected than females, where males
accounted for 92.1% (70 patients) and females accounted for 7.9% (6 patients) of the study population. The ages of
the patients ranged from 4 to 61 years, with a mean of 24.84 ± 10.57 years. Road traffic accident (RTA) was the
most common cause of trauma, 42.1% of cases. A total of 43 (56.5%) cases had mandibular fractures. Most of the
fractures were treated by means of open reduction and internal fixation using plates (67 cases; 88.2%), whereas 6
(7.9%) cases were treated by means of closed reduction and maxillo- mandibular fixation and 3(3.9%) were treated
by splinting.
the main etiological factor in maxillofacial injuries is RTA with males between 11 and 30 years of
age being affected predominantly.
Keywords: retrospective study, maxillofacial fractures, maxillofacial trauma.


Maxillofacial fractures are resulting from
site of injury due to their prominent position within
different types of trauma to the face, and may occur
the facial skeleton(4).
in isolation or combined with other injuries (1).
Maxillofacial fractures incidence varies
required, and early consultation with other
widely between different nations depending on,
specialties is recommended also understanding of
local demographic and socioeconomic status,
common posttraumatic complications will guide
generally, the incidence is higher in males than in
surgical management (5).
females with peak incidence between 20 and 30
The management of maxillofacial fractures
remains a challenge, demanding both skill and
Facial fractures have many causes; however,
experience, the main aims of fracture management
traffic accidents, assaults, falls, and sport injuries, road
are; to anatomically reduce the fractures, adequately
traffic accidents have always been the most frequent
stabilize them to allow healing, restore pre injury
cause of facial fractures worldwide(3).
function and to avoid complications(6).
The main cause of injury in Egypt is due to

road traffic accidents followed by gunshot and fall
from height (4).
To analyze the outcome of maxillofacial
Mandibular fractures are the most common
fractures fixation helping optimization of surgical
practice and medical service appraisal.
zygomaticomaxillary fractures and nasal fractures,

however, this is not corresponding with other
studies that found that nasal bones and
This study has been carried out as a
zygomaticomaxillary complex the most common
retrospective study of maxillofacial fractures, and

was done at Al-Azhar University hospitals (El-

Full Paper (vol.747 paper# 13)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1566-1576
Management of Postcholecystectomy Obstructive Jaundice
Mohammad Mohsen Salem, Yasser Hussein Hassan, Abdou Ibrahim Zeyada
Department of General Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Abdou Ibrahim Zeyada, Mobile: 01060011419, email: abdozyada42@gmail.com

Although laparoscopic cholecystectomy (LC) has many unquestionable advantages, this type of
surgery has a higher incidence of complications than those of open cholecystectomy including biliary tract
injury or stricture causing hyperbillirubinaemia and jaundice and subsequently a lot of complications as acute
peritonitis or acute cholangitis as well as complications of jaundice that may be so severe causing hepatorenal
To find the proper method of management of postcholecystectomy obstructive jaundice.
Patients and Methods:
A retrospective study of 20 patients who were presented with postcholecystectomy
obstructive jaundice within 2 years from the date of surgery were selected for this study. Patients were
subclassified according to the cause of postcholecystectomy jaundice into 4 groups:
Group A: patients presented with jaundice due to missed common bile duct (CBD) stones.
Group B: patients presented with jaundice due to biliary injury.
Group C: patients presented with jaundice due to biliary stricture.
Group D: patients presented with jaundice due to medical causes.
ERCP should only be attempted when there is biliary contiuity evident by MRCP. Roux en Y
hepaticojejunostomy is the most used modality in management. The best treatment of post-cholecystectomy
obstructive jaundice is undoubtedly prevention of bile duct injury during cholecystectomy.
Conclusion: The classic pattern of laparoscopic injury appears to be misidentification of the common duct for
the cystic duct, resection of a portion of the common and hepatic ducts, and an associated right hepatic arterial
Cholecystectomy, obstructive jaundice, bismuth classification.


Obstructive jaundice which occurs for the
The best treatment of postcholecystectomy
first time in the postoperative period may be due
obstructive jaundice is undoubtedly prevention. As
to a variety of causes and always requires detailed
the incidence of postcholecystectomy obstructive
investigations to establish the diagnosis, cause and
jaundice is still high, so in this research we will
outline the necessary course of action (1).
high-light the different methods of diagnosis,

prevention and treatment of this complication (3).

iatrogenic biliary passage injury and/or missed
pathology remain a challenging problems.
The aim of this work is a trial to find the
Despite the use of modern technology
before, during and after operation, a proportion of
postcholecystectomy obstructive jaundice.
patients who after an interval of time following

initial surgery for biliary lithiasis or injury of the
bile duct, comes for reoperation because of
A brief summary about the patients'
residual, or recurrent common bile duct calculi, or
groups including age, sex, history, investigations,
traumatic or ischemic stricture of the bile duct (2).
intervention, outcome is shown in the following

tables (tables 1-4):


Full Paper (vol.747 paper# 14)

c:\work\Jor\vol747_15 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1577-1579

The Outcome and Safety of a Long Course of Inhaled Tissue Plasminogen
Activator in The Management of Plastic Bronchitis: A Case Report
Ayed M. Alenazi*, Khaled Baqais, Abdullah AL-Shamrani, Mohammed Alzaid
pediatric pulmonologist at Prince Sultan Military Medical City/Riyadh/KSA
Corresponding author: Ayed Alenazi Tel: 00966505219401; email: ammalonazi@psmmc.med.sa

Plastic bronchitis (PB) is a rare disease that is characterized by formation of rubber-like
tracheobronchial casts that occlude the airway, occurring secondary to several conditions, most commonly as a
complication of single-ventricle palliative cardiac surgery. Inhaled tissue plasminogen activator (t-PA) was reported
to be effective in treating PB. Aim of the work: To show the outcome and safety of a long course of inhaled tissue
plasminogen activator in the management of plastic bronchitis. Methodology: this was a case report, we report the
case of a teen with PB treated with a prolonged course of t-PA with no adverse effects. Results: we reported the
case of an 11-year-old boy with trisomy 21 who had a Fontan procedure for his complex congenital heart disease,
complicated by PB that was treated with a prolonged course of t-PA. Our patient was an 11-year-old boy with
trisomy 21 who was diagnosed with an unbalanced AV canal defect with a small right ventricle and bilateral superior
vena cava. His surgical cardiac course consisted of a pulmonary artery banding at 2 months of age and bilateral
bidirectional Glenn with tightening of the pulmonary artery banding at 24 months of age. He had pulmonary artery
debanding and ligation of both right and left Glenn shunts at the age of 6 years. Since the age of 3 years, he was
admitted many times to the hospital with various diagnoses, including bronchial asthma, bronchopneumonia and
pulmonary hypertension, all of which were treated accordingly. He was admitted at the age of 9 years with a history
of fever and cough productive of plastic-like material that took the form of the bronchial tree. The diagnosis of PB
was confirmed. Subsequently, he was admitted frequently with the diagnosis of PB and was treated with aggressive
airway clearance including hypertonic saline, dornase alpha and t-PA. The longest t-PA duration was 82 days, which
clinically proved to be effective and safe. Conclusion: PB is a rare and serious disease. The long-term use of inhaled
t-PA was effective and safe.
Keywords: plastic bronchitis, t-PA, Fontan surgery.


Plastic bronchitis (PB), previously known as fibrinous
eosinophilic inflammatory cells and casts composed
bronchitis, pseudo membranous bronchitis, mucoid
mainly of fibrin and acellular (Type 2) with little or
impaction, Hoffman bronchitis or cast bronchitis, is a
a cellular infiltrates composed mainly of mucin,
rare and fatal disease characterized by the formation of
occurring predominantly in patients with congenital
rubber-like tracheobronchial casts that occlude the
cyanotic heart disease. Plastic bronchitis was
airway (1).
diagnosed by the expectoration of branching
Although the exact pathogenesis of cast formation
bronchial casts, atelectasis seen on chest X-ray and
remains poorly understood, many investigators have
performance of rigid bronchoscopy (5).
tried to explain the cast formation as defects in
Management of PB includes various strategies,
lymphatic drainage into the bronchial tree; to date, this
including removal of casts by rigid bronchoscopy,
remains the accepted explanation (2).
controlling the underlying disease, use of anti-
Plastic bronchitis can occur secondary to pulmonary
inflammatory drugs such as steroids or nonsteroidal
disease (Asthma and chronic suppurative lung
drugs (ibuprofen, corticosteroid), azithromycin or
disease), cardiac disease (post-cardiac surgery
inhaled lytic agents (acetylcysteine, DNAse,
secondary to congenital cyanotic heart disease; post-
heparin, and tissue-plasminogen activator) and
Fontan connecting systemic venous return to
surgical management (6).
pulmonary circulation); hematological disorders
The use of inhaled tissue-plasminogen activator (t-
(Sickle cell anemia, thalassemia alpha and lymphoma),
PA) is theoretically associated with bleeding
immunodeficiency (infectious causes such as TB, viral
tendency (7).
infection and bronchopulmonary aspergillosis) and the

use of pegylated interferon (3).
Systemic lymphatic disease or conditions such as
Here, we report the case of a teen with PB treated
Turner's and Noonan's syndrome are also associated
with a prolonged course of t-PA with no adverse
with plastic bronchitis, even though the predisposing
factors have not yet been determined (4).
The report of the case:
Plastic bronchitis is classified into 2 main types:
Our patient was an 11-year-old boy with trisomy 21
inflammatory (Type 1), with high infiltration of
who was diagnosed with an unbalanced AV canal

Full Paper (vol.747 paper# 15)

c:\work\Jor\vol747_16 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1580-1586

Ultrasound Guided Percutaneous Nephrostomy, Feasibility in Lateral Position
Ayman F. Alham , Mohamed A. Hindawy , Sayed M.El-Eweedey
Urology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ayman F. Alham, Mobile: 01014070524, email: aymankandel90@gmail.com

Background: ultrasound guided percutaneous nephrostomy was reported in various positions to different
indications. Objectives: this study was conducted to determine the feasibility of Percutaneous Nephrostomy (PCN)
in lateral position.
Patients and methods: this study was conducted during the period from March 2018 to November 2018. Fifty patients with
urinary tract obstruction who were candidate for percutaneous nephrostomy at El-Hussein and Bab El-sharia hospitals were
enrolled in the present study. Results: out of 50 patients who underwent percutaneous nephrostomy in lateral position
(56%) were males, 44% were females. Success rate for fixation of PCN was 90%. Total number of patients with marked
hydro nephrosis before the procedure represented 58% of total patients and 42% with moderate hydro nephrosis.
Complication of technique : no complication represented 80% ,minor complications were 20%,9% showed transient
hematuria, single patient with pain 2.2%, 4.4% showed catheter related complications, 4.4% showed Inflammation of
skin at the side of the wound. Cause of obstruction, pregnant females were 10%, PUJ causes were 18%, ureteric causes
were 46%, urinary bladder mass was 14%, single case was emphysematous pyelonephritis, others were10%.
Conclusion: ultrasound guided percutaneous nephrostomy in lateral position is feasible and equal to standard
technique but recommend PCN in lateral position in, pregnant female, obese patients, ascetic patients and patient
with special difficulties in breathing.
Keywords: ultrasound, percutaneous nephrostomy, lateral position.

well and may suffer from ventilator and cardiovascular
(PCN) Percutaneous nephrostomy is a
compromise as a result of increased intra-abdominal
passageway that is introduced percutaneously into the
pressure. Patients with severe kyphosis cannot be placed in
renal pelvicalyces that can later be maintained by a tube,
the prone position.
stent or catheter [1].Following its introduction by
We present patients suffering from either morbid obesity,
Wickbom in 1954 who described percutaneous puncture
ascites and pregnant female who underwent PCN
of the renal pelvis as a diagnostic procedure, Goodwin
successfully in the lateral decubitus position [5].
and Casey first described its therapeutic use for relief of

urinary tract obstruction the following year in 1955 [2].
Mahmood et al. stated that its good safety profile,
This study was performed in Urology
percutaneous nephrostomy is the preferred technique
Outpatient Clinics of Al-Azhar University Hospitals at
for treatment of various urological conditions and its
El-Hussein and Bab El-sharia Hospitals who were
pioneering role for relief of urinary tract obstruction
candidate for percutaneous urinary diversion in cases of
remains in good use until today [3].
urinary tract obstruction, which may be secondary to
They added that PCN has traditionally been
intrinsic or extrinsic ureteral obstruction during the
performed with the patient in the prone position,
period from March 2018 to November 2018.This was a
probably to reduce the risk of injury to adjacent
prospective interventional non control study.
visceral organs, particularly the colon. The prone
The study was approved by the Ethics
position, however, is associated with disadvantages such
Board of Al-Azhar University.
as patient discomfort and circulatory and ventilatory

difficulties, particularly in obese patients [4].
Gofrit et al. described a technique of
uncorrectable bleeding disorders and patients with
percutaneous nephrostomy with the patient in the lateral
known renal vascular malformations or arterial
position using local anesthesia and ultrasound-guided
aneurysm uncooperative patient.
puncture is usually performed with the patient in the prone
position. Morbid obese patients do not tolerate this position
Pre procedure assessment: after
detailed medical, surgical history and complete

Full Paper (vol.747 paper# 16)

c:\work\Jor\vol747_17 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1587-1598

Role of Nonsteroidal Anti-Inflammatory Drugs in Prevention of Macular Edema
after Uneventful Phacoemulsification in Diabetic and Non-Diabetic Patients
Marwa M. Al Fassih, Hanan S. Hegazy, Abd El Magid M. TagEldin, Naglaa A. Elkoussy
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Corresponding author: Marwa M. Al Fassih, Tel: 01013578866; E-mail: janamohamed1978@yahoo.com

Pseudophakic cystoid macular edema is one of the most important complications after cataract
surgery. This can result in decreased visual acuity.
Purpose: The study aimed to assess the efficacy of using NSAIDs as a prophylaxis, to prevent macular edema and
improvement of visual acuity.
Patients and methods: The study included 100 eyes with cataract and accepted phacoemulsification, classified
into: Group 1: Non-diabetic patients were subdivided into: (1A didn't receive NSAIDs, 1B received NSAIDs).
Group 2: Type 2 diabetic patients were subdivided into: (2A didn't receive NSAIDs, 2B received NSAIDs).
One drop of nepafenac 0.1% was administrated four times daily for 2 days before surgery, 30-120 minutes prior
to surgery. Postoperatively nepafenac was given four times daily for four weeks. SD-OCT was performed to
measure CFT before phacoemulsification, repeated 1 week and 1 month postoperatively.
Results: In subgroup 1A; CMT increased through one month, while subgroup 1B, CMT decreased through the
same time. There was significant difference in CMT change between preoperative and 1week postoperative as well
as between preoperative and 1 month postoperative (p=0.025, 0.037 respectively).
For subgroup 2A; CMT increased through one month. There was significant difference in CMT change (p<0.001)
between preoperative and 1week postoperative as well as between preoperative and 1 month postoperative
(p<0.008) between subgroup 2B and subgroup2A
Conclusion: The prophylactic use of topical NSAIDs appears to be effective for preventing CMT change after
phacoemulsification. It reduces the incidence of PCME in normal and diabetic patients ensures a favorable
Keywords: Pseudophakic cystoid macular edema, phacoemulsification, nepafenac.


associated with cataract surgery. Nepafenac is a
Cystoid macular edema (CME) is one of the most
prodrug that rapidly penetrates the cornea and is
important complications after cataract surgery. It is the
deaminated into the active metabolite, amfenac, by
main cause of decreased visual acuity, even in patients
intraocular hydrolases within ocular tissues, including
without risk factors or an uneventful cataract surgery
the ciliary body epithelium, retina, and choroid (6).
This bioconversion is targeted to the retina and
The incidence of clinical CME varies from 0.1% to
choroid (7). Macular changes are likely to occur after
2% in patients without risk factors. However, some
cataract surgery in diabetic patients, especially those
clinical trials have reported up to 9% angiographic
with pre-existing retinopathies, compared with
CME which means increased central macular
nondiabetic patients, ranging from 31% to 81% (7).
thickness measured by optical coherence tomography
Assessing and managing ME after cataract surgery
(2). The most accepted pathogenesis of Pseudophakic
in diabetic patients arises from the fact that two clinical
cystoid macular edema (PCME) involves intraocular
forms of edema can be present, either diabetic macular
inflammation with prostaglandin (PG) release and
edema (DME) alone or in combination with Irvine-
disruption of the blood aqueous and blood retinal
Gass CME. Retinal capillary hyperpermeability from
barrier (3).It can occur in uncomplicated eyes. There are
intraocular inflammation consider the major pathway
risk factors like PCME in the contralateral eye,
in the development of this edema. OCT can provide
diabetes mellitus, uveitis, epiretinal membranes, PG
both qualitative and quantitative data to explore the
analog use, and aging. That is why, NSAIDs are
relationship of ME and cataract surgery in patients
routinely used in the postoperative period. They inhibit
with diabetic retinopathy (8).
cyclooxygenase (COX-1 and COX-2) enzymes, they
Deciding usage of nonsteroidal anti-inflammatory
agent to as standard in patients undergoing cataract
inflammation(4).NSAIDs decrease the incidence,
surgery is important to ensure a favorable outcome (9).
severity and duration of macular edema. They provide

a very good anti-inflammatory effect apart from
maintaining intraoperative mydriasis and decrease
100 eyes of 88 patients with cataract were enrolled
postoperative pain (5). Nepafenac is a topical NSAID
in a prospective non-randomized interventional study.
used for the treatment of pain and inflammation
This study was conducted in outpatient ophthalmology

Full Paper (vol.747 paper# 17)

c:\work\Jor\vol747_18 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1599-1603

Revision for Aseptic Loosening of Primary Total Knee Arthroplasty
Elsherbiny Ali Elsherbiny*, Ismail Ahmed Yaseen*, and Hisham Mohamed Safwat *
Department of Orthopedic surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Elsherbiny Ali Elsherbiny, email: elsherbinyortho@gmail.com, mobile: 00201226220972

the modes of failure of total knee replacement(TKR) can be classified as intra-articular or extra-
articular, as biological or mechanical, as early or late. Aseptic loosening is one of leading cause of failure of total
knee replacement. Purpose: it was to spot light on different surgical strategies; to assess the results of 20 cases
of revision total knee arthroplasty after aseptic loosening of primary total knee arthroplasty.
Materials and Methods: this is a prospective interventional study which was conducted during the period from
June 2016 to April 2019 with mean follow up two years. It included 20 patients (20 knees) which were
undergone for revision TKR due to aseptic loosening of knee prosthesis. These cases were operated at Al-Azhar
University hospitals (Al Hussein & Bab El Shaeria).
Results: the average knee society score (KSS) was 79 (range from 55 to 94) compared with an average
preoperative KSS of 38 (range from 28 to 48). The mean knee function score at the last follow up was 72 (range
from 35 to 95) compared with the mean preoperative knee function score of 31 (range from 10 to 55).
Conclusions: results of revision TKA due to polyethelene (PE) wear and its resultant osteolysis were mostly
satisfactory to the patients,
Keywords: Aseptic loosening, total knee, revision.


Total knee arthroplasty (TKA), which is
It included 20 patients with 20 knees who
primarily used to manage pain and increase
underwent revision TKR due to aseptic loosening
function in patients with symptomatic severe knee
of knee prosthesis due to PE wear and osteolysis.
osteoarthritis, is now the most commonly
The patients were operated at Al-Azhar University
performed joint arthroplasty procedure in the
Hospital. The mean age of studied patients was
United States. In 2012, >670,000 knee arthroplasty
64,8. 6 patients were males and 14 were females.
operations were performed in the United States
The mean body mass index (BMI) was26,2.
with an increase of 86% since 2003 (1).

Factors help to the increase in number of
Ethical statement:
TKAs include population growth, aging and increased
The patients received an explanation about
longevity of the population, expanded demands for
the nature, purpose and potential risks of the study.
performing TKA, especially in persons <65 years of
An informed written consent was taken prior to
age, obesity, decrease in post operative complications,
surgery. The study was approved by the Ethics
and increased patient demand (2).
Board of Al-Azhar University.
About 1.5 million of patients with primary

knee arthroplasty are 50 to 69 years old,
Statistical analysis
underscoring a large population at risk for revision
Data were analyzed using Statistical
operations and long-term complications (3).
Program for Social Science (SPSS) version 15.0.
Aseptic loosening is one of the most
Quantitative data were expressed as mean±
common causes for revision after total knee
standard deviation (SD). Qualitative data were
arthroplasty. However, the diagnosis may remain
expressed as frequency and percentage.
difficult until the prostheses are migrated (4).
The following tests were done:
Finding the etiology of a painful TKA before
Independent-samples t-test of significance:
surgery is extremely important because "in cases of
was used when comparing between two means.
undiagnosed pain, revision is bad and usually
Probability (P-value):
associated with bad results" (5).
­ P-value < 0.05 was considered significant.
Aim: the aim of this study was to spot light on
­ P-value < 0.001 was considered as highly
different surgical strategies and to assess the results
of 20 cases of revision total knee arthroplasty after
­ P-value > 0.05 was considered insignificant.
aseptic loosening of primary total knee arthroplasty.

In this study we used constrained condylar knee
This is a prospective interventional study
prosthesis in(14) patients, posterior stabilizer in (4)
which was conducted during the period from June
patients and rotatory hinged knee in(2) patients.18
2016 to April 2019 with mean follow up two years.
patients were primary osteoarthritis and 2 patients

Full Paper (vol.747 paper# 18)

c:\work\Jor\vol747_19 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1604-1606

Case Report: Arthroscopic Fixation of Type V Acromioclavicular Joint Dislocation
Omer Alrasheed
Orthopedic Surgery Department, King Faisal University, KSA
Email: omar-2614@live.com

Acromioclavicular Joint (ACJ) dislocation is a common injury. It is common among athletes involved in contact
sports and victims of motor vehicle accidents. High-grade (ACJ) dislocation (Type IV-VI) is managed surgically
through different procedures. These range from a simple plate and screw fixation to more complex procedures
involving ligament repair, transfer and reconstruction. The rationale for an arthroscopic approach to treat a
dislocated AC joint is to minimize the soft tissue injury through preserving as much blood supply as possible to
support post-operative healing. Also, to decrease the risk of surgical site infections and better postoperative
outcomes. On the other hand, the arthroscopic technique needs an experienced surgeon. In this case, report our aim
to encourage fixing (ACJ) with this technique.


One of the oldest traumatic pathologies
standard, from a clinical and radiological point
recorded in the literature is acromioclavicular (ACJ)
of view (7, 8). On the other hand, it has been reported
dislocation (1). With an incidence 1.8 per 10,000 per
that most open surgeries are associated with
year (2, 3), with a significant increase in military
complications such as infection, correction loss or
populations of up to 92 per 10,000 person-years (3) and
implant migration (2).
contact sports, as one study showed 40% of 226

collegiate football players with shoulder injuries had
AC dislocation (4). In a recent study, AC dislocation
A 44-year-old man presented to the Emergency
reports for about 12% of all shoulder injuries, almost
Room complaining of severe right shoulder pain for
half of which (43.5%) are associated with sports in
the past four days. He mentioned that the pain started
young people (5). Moreover, AC dislocation is 10 times
after he fell directly on it. He stated that the pain
more common in males from 20 to 39 years of age and
increased with shoulder movement and noticed
predominant in young people since it is associated
deformity in the right shoulder.
with high-impact sports and high-speed vehicle
On examination, there was obvious deformity
accidents (1). Coracoclavicular ligaments are the link
on inspection, tenderness over the acromioclavicular
between the clavicle and the coracoid in the moment
joint on palpation, and a limited range of motion. The
of abduction. In AC dislocation these ligaments are
neurovascular bundle was intact. Shoulder X-ray
ripped. Under the effect of gravity, the arm gets pulled
(Figure 1) was done which revealed markedly
downwards, while the clavicle is lifted upwards under
dislocated right acromioclavicular joint with the
the action of trapezius muscle (6) giving rise to a step-
clavicle pointing upwards from its lateral end. For
off deformity. Clinically, there is a sharp pain in the
more accurate assessment for management, we
upper portion of the shoulder, limitation, swelling,
ordered a shoulder CT.
bruising, deformity, and piano key sign (1). AC
CT showed a high-grade acromioclavicular
dislocations are classified in six types after Rockwood
dislocation with noticeable incongruence of the
based on morphology on plain radiographs recently
articular sides, the superior clavicular displacement
updated with magnetic resonance imaging (MRI) (2, 6).
was approximately 100% of clavicular width relative
As a rule of the thumb, Rockwood type I and II are
to the acromion. Indicating rupture of the main
generally treated conservatively, Rockwood types IV,
acromioclavicular ligaments. Meaning that, this
V, and VI are treated surgically and Rockwood type
patient had a Rockwood type V acromioclavicular
III is quite controversial as some surgeons prefer
dislocation. As per the clinical findings, our patient
conservative treatment, while other option for surgical
was undergoing surgical intervention arthroscopic AC
treatment (4, 6). There are 60 surgical techniques to treat
joint reconstruction with dog-bone. The patient was
AC dislocation, with more than 150 variations (3,7).
positioned in a beach chair attitude. First, a posterior
However, none of them has been recognized as a gold
portal for viewing and an anterolateral portal for

Full Paper (vol.747 paper# 19)

Introduction The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1607-1615

The Value of Target Therapy in Metastatic Cancer Colon
Ahmed Yousery Al Agamawy1, Sohier Sayed Ismail2, Shaymaa Mamdouh Anwar Ibrahim 1*
Clinical Oncology & Nuclear Medicine Department, 1Al-Azhar University,
2Ain Shams University, Cairo, Egypt
*Corresponding author: Shaymaa Mamdouh Anwar Ibrahim, E-mail: rshaltout80@gmail com

Colorectal cancer is the third leading cause of cancer-related deaths in the United States when men
and women are considered separately, and the second leading cause when both sexes are combined It is expected
to cause about 49,700 deaths during 2015.
Aim of the Work: The present work was aimed to study the efficacy of treatment of metastatic cancer colon
(KRAS wild type) with chemotherapy plus anti-EGFR (Erbitux) and chemotherapy alone.
Patients and Methods: This phase II prospective study included a total of 37 patients of metastatic cancer colon
(KRAS wild type) treated with chemotherapy plus anti-EGFR (Erbitux) and chemotherapy alone for (KRAS
wild type) attending at Police Hospital. This study was conducted between September 2016 and August 2018.
Results: We have studied the value of adding target therapy in the metastatic colon cancer patients. Some of them
received chemotherapy with cetuximab as target therapy versus patients received chemotherapy alone. In the
current study, median progression-free survival (PFS) of the whole studied sample (n =37) was 10.0 months
(range.3.0.-.21.0). Median survival was significantly higher in the chemotherapy and cetuxumab group (P: less
than 0.001). Using cox regression analysis group with cetuximab associated with better survival (P=0.047) with
protective hazard ratio of 0.974. The cumulative PFS proportion is presented at 12 months. Median overall survival
of whole studied samples (n=37) was 21.0 months (range 18-23 months) and there were 25 cases dead and all cases
progressed. Median OS was higher in chemotherapy with cetuximab group and was of a significant difference
(P=0.001). There were others factors studied their relation to OS like age but no significant difference bit older
patient had better OS by (34.8 % vs 28.6 %), also PS no significant difference but patient with PS =0 had better
OS by (41.7% vs 28%) according to RT and LT colon there was LCC with better OS than RCC but no significant
difference but LT site of colon had better survival by (42.9 %vs 18.8%).
Conclusion: Cetuximab was beneficial in down-staging programs and significantly improve progression-free
survival and response rates and overall survival for patients with metastatic colorectal cancer
Keywords: Target Therapy, Metastatic Cancer Colon

Excluding skin cancers, colorectal cancer is the
chemotherapy, approximately 30-35% of the patients
third most common cancer diagnosed in both men and
with stage III CRC eventually relapse (5). Although
women in the United States. The American Cancer
some patients may have either an isolated metastases
Society's estimates for the number of colorectal cancer
or a local recurrence that is curable via surgery, most
cases in the United States for 2015 are: 93,090 new
patients with metastatic CRC (mCRC) are incurable
cases of colon cancer and 39,610 new cases of rectal
The treatment in this setting generally consists of
cancer. Colorectal cancer is the third leading cause of
palliative chemotherapy with the goal of prolonging
cancer-related deaths in the United States when men
overall survival (OS) and maintaining quality of life
and women are considered separately, and the second
The median OS for patients with unresectable mCRC
leading cause when both sexes are combined It is
who receive best supportive care alone is
expected to cause about 49,700 deaths during 2015 (1).
approximately five to six months while patients on
Prognosis is dependent on stage at
chemotherapy in the modern era routinely live longer
presentation with five-year survival rates varying from
than two years (6).
93% in stage I (T1-2 N0) to only 44% in stage IIIC
In Egypt colorectal cancer has no age
disease (N2) (2).
predilection and more than one - third of tumors affect
Although patients with early stage CRC
a young population The high prevalence in young
commonly undergo potentially curative resection,
people can neither be explained on hereditary basis nor
disease recurrence may occur and is thought to arise
can it be attributed to bilharziasis The disease usually
from occult micrometastases that are present at the
presents at an advanced stage and predisposing
time of surgery (3).
adenomas are rare Similarity of the data from different
This is the premise to offer adjuvant
centers suggests that this is the picture of colorectal
chemotherapy for those who present with stage III or
cancer typical of Egypt (7).
II with high-risk features as it could potentially
Alcohol, Diabetes, diets high in fat and
eradicate micrometastatic disease (4).
cholesterol, Ethnicity, Race, and Social Status, family
medical history, genetics e.g. mutations leading to

Full Paper (vol.747 paper# 20)

c:\work\Jor\vol747_21 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1616-1620

Effect of Phytoestrogen (Fennel) on Some Sex Hormones and Other
Physiological Parameters in Male Albino Rats
Eman G.E. Helal1, Nora Abdul-Aziz AL Jalaud2, Mohamed A. El-Aleem3,
Shaimaa S. Ahmed1
Zoology Department, Faculty of Science, Al A
- zhar U
niversity (Girls), a
, Egypt
mam Abdulrahman B
F sal U
niversity , Physiology Department, Faculty of Medicine, Al A
- zhar University (Boys), Cairo, Egypt
*Corresponding Author: Eman G.E. Helal, E-mail: emanhelal@hotmail.com, mobile: 00201001025364,

: Phytoesrogenis plant derived compounds which have an estrogenic effect.
Objectives: The present study was carried out to investigate some pharmacological and biochemical effects of
fennel oil on male albino rats.
Materials and methods: Twelve animals were divided randomly into two groups. Group A: Control.
Group B: Treated rats. The rats were given an oral dose of 1 ml/kg body weight/day fennel oil once daily for one
month. At the end of the experiment, blood samples were collected for biochemical analysis.
Results: The fennel oil induced highly significant decrease (p<0.01) in total cholesterol(TC), triglycerides (TG),
low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), LDL/high-density lipoprotein (HDL),
while significant increased (p<0.05) HDL. In addition, it showed highly significant decrease (p<0.02) in FSH,
testosterone and sperm count compared to normal control group.
Conclusion: Fennel herb has several therapeutic benefits, but it also has negative effect on male sex hormone
and sperm count. So men must reduce their usage of it.
Fennel, Lipid profile, Albino rats, Physiological parameters.


Fennel (Foeniculumvulgare) is a well-known
In the present study, we aim to clarify the effect
Mediterranean aromatic plant. It is a herb consumed
of fennel as phytoestrogen on some sexual hormone
orally and having several therapeutic applications.
and some physiological parameters in male albino
Besides,it is used in traditional medicine and as a
spice. It has diuretic, analgesic, antipyretic, and

antioxidant activity (1).
Its therapeutic properties are due to volatile
Fennel oil was purchased from Cap Pharm for
compounds; phenols, and flavonoids in the plant
Extracting Natural Oils & Herbs, Cairo, Egypt. The
extract. According to phytochemical studies, over 30
oil of fennel contains 50% of trans-anethole and 25%
various terpenes and terpenoids have been identified
of fenchone.
in fennel (2).

Moreover, other compounds such as estragole
Experimental animals
(methyl chavicol), fenchone, trans-anethole, and -
The experiment was carried out on 12 male
phellandrene are the main constituents of the fennel
albino rats of the Rattus rattus strain weighting (130-
seed (3).
140gm) obtained from animal farm of El-Nile
The presence of flavonoids, cumarin, and
Company for Pharmaceutical Product (El-Nile, Cairo,
anethole has been also identified. Anethole and
Egypt). Animals were housed in metallic cages and
fenchone are the main components (4,5). Cumarin has
maintained under standard condition of temperature,
anti-aromatase, estrogenic, reductase inhibiting, and
humidity and natural light/dark cycle along the
anti-androgen activities. Moreover, flavonoids and
experimental period.
anethole are also estrogenic compounds that could
Food and water were available throughout the
depress serum levels of testosterone, and as a result,
experiment ad libitum.
reduce sperm production (6).
Rats were left to acclimatize for one week before

starting the experiment.


Full Paper (vol.747 paper# 21)

INTRODUCTION The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1621-1630

Evaluation of Ultrasonographic and Anti-Müllerian Hormone (AMH)
Changes as Predictors for Ovarian Reserve after Laparoscopic Ovarian Drilling
Versus Conservative Treatment for Women with Polycystic Ovarian Syndrome
Yahia A. Wafa (1), Ibrahim R. Al sawi (1), Salah A. El beltagy (2), Ebtsam G. Hussien (1)
(1) Department of Obstetrics and Gynecology, (2) Department of Clinical Pathology
Faculty of Medicine, Al-Azhar University
Corresponding author: Ebtsam G. Hussien; Email: dr_ebtsam.2010@yahoo.com

Until recently, there was no international consensus either on the definition of polycystic
ovarian syndrome (PCOS) or on what constitutes a polycystic ovary. At a recent consensus of The European
Society of Human Reproductive and Embryology/American Society of Reproductive Medicine
(ESHRE/ASRM), a refined definition of the PCOS was agreed: namely two out of the following three
criteria; Oligo- and/or anovulation, Hyperandrogenism (clinical and/or biochemical) and Ultrasonographic
features of PCOS.
Aim of the Work: evaluation of ovarian volume, antral follicles count and anti mullerian hormones as
predictors of ovarian reserve after conservative treatment versus laparoscopic ovarian drilling in women with
polycystic ovarian syndrome.
Patients and Methods: This prospective controlled study was conducted on 20 women attending Outpatient
Clinics of Al Hussein University Hospital & Aswan University Hospital for infertility treatment. It was
conducted between January 2016 and February 2018.
Results: No significant difference was found between clomiphene citrate (CC) and laparoscopic ovarian
diathermy (LOD) groups regarding to AFC and summed ovarian volume in follow up periods, (P=
0.645,P=0.401//P=0.238, P=0.301) respectively. There was a highly significant difference between CC,
LOD and control groups regarding to AMH (P < 0.001) after 6 months of treatment. The study revealed that
there was no statistically significant difference between groups according to clinical & reproductive
Conclusion: The relative contribution of each individual measure of the ovarian reserve is clearer and most
authors agree that antral follicle counts and serum anti-müllerian hormone levels had the most
discriminative. Antral follicle counts are easy to perform and cheap in comparison as all units had access to
ultrasound facilities. Follicle counts, as a quantitative measure of the ovarian reserve, are also subject to
`assay' variation due to intra- and inter-observer differences and require additional time and manpower to
Keywords: ultrasonography, anti-müllerian hormone, ovarian reserve, laparoscopic ovarian drilling,
conservative tremens, PCOS


restores the ovulatory cycle or increases
According to the revised 2004 consensus on
responsiveness to gonadotropins stimulation.
diagnostic criteria of polycystic ovarian syndrome
The term "ovarian reserve" (OR) refers to
(PCOS) of Rotterdam European Society of Human
the size of the non-growing or resting primordial
Reproduction and Embryology/ American society
follicle population, which presumably determines
the numbers of growing follicles and the quality or
sponsored PCOS 2003 consensus workshop group,
reproductive potential of their oocytes [2].
the PCOS was defined as two out of the following
The tests of ovarian reserve are of two
three criteria (after exclusion of specific underlying
types either stimulatory tests or non-stimulatory
diseases of the adrenal or pituitary glands): Oligo-
tests. The stimulatory tests are also termed "the
or Anovulation, Hyperandrogenism, and the
ovarian challenge tests" or dynamic ovarian reserve
presence of 12 or more follicles per each ovary
tests. They may be performed by administrating
ranging from 2 to 9 mm in diameter or ovarian
clomiphene citrate or a GnRH agonist. The non-
volume of more than 10 cm3 [1].
stimulatory tests include measuring basal follicular
Laparoscopic ovarian diathermy (LOD) is a
stimulating hormone (FSH) level, Antral follicles
treatment method for PCOS, which has replaced a
count (AFC), ovarian volume assessment, Inhibin-B
more invasive and damaging technique of ovarian
level, and Anti-Müllerian Hormon(AMH) level [3].
wedge resection. The mechanism of action of LOD
The basal FSH level in the serum is the
is still uncertain. A hypothesis suggests that a
most commonly used test, in routine practice, to
minimal injury to an unresponsive ovary either
assess the ovarian function and its disorders;

Full Paper (vol.747 paper# 22)

c:\work\Jor\vol747_23 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1631-1635

Study of The Outcome of Staged Cutting Seton in
Treatment of High Perianal Fistula
Abd El Fattah Morsi
Department of General Surgery, Faculty of Medicine, Al-Azhar University
Correspondence: Abd El Fattah Morsi, E-Mail: doc_amsmk82@yahoo.com

an inexpensive and effective method of treatment of high complex perianal fistulae is seton suture.
Most difficult point in seton is maintaining tension and pressure on suture to produce muscle cutting in anal
Objective: the aim of this study was to assess the consequence, which fail to be noticed in seton suture to diminish
the recurrence rate and incontinence after the treatment of fistulae.
Patients and Methods:
this study was conducted on 53 patients who underwent treatment for an anal fistula with
staged seton suture. Clinical examination and MRI fistulogram was done to all patients. Prolene 1 was used as
drainage then cutting. Follow up in outpatients was recorded.
Results: there was no pain or mild pain in all cases. The recurrence rate in two cases (3.7%). Incontinence to flatus
in three cases (5.6%) and one case to soft stool (1.8%).
Conclusion: there were many factors affecting outcome of high perianal fistula surgery by seton suture to decrease
recurrence and incontinence such as proper examination of the patient, magnetic resonance image (MRI) fistulogram,
meticuolous surgery and good identification of internal opening.
Keywords: perianal fistula, prolene, seton, extracorporeal knotting.


Perianal fistula is a familiar proctologic illness
fistulas have been usually managed by either
with incidence that reaches 2.8/10,000 in some
fistulotomy, or fistulectomy, which have been
countries (1). Fistula-in-ano is a chronic form of
confirmed their effectiveness (6). Seton has been
perianal abscess that is spontaneously or surgically
applied for curing of perianal fistula for many years;
drained. If the abscess cavity does not heal
however, it was generally used for complex anal
completely, it will become an inflammatory track with
fistula with the intention of fecal incontinence
a primary internal opening at the dentate line of anal
avoidance (7).
crypt and a secondary external opening in the perianal
The principle of seton fistulotomy is that a
skin (2). There are main forms of fistula-in-ano, based
striated muscle superficially to the fistula track is
on thesphincter muscles involved in the fistula:
surrounded by a section of soft rubber tubing. The
tubing is fixed firmly and left in situ, after one or two
suprasphincteric, or extrasphincteric form (3).
weeks, the striated muscle is slowly separated by a
Complex fistula suspected when the fistula tract
progression of ischemic necrosis. Conversely, since
crosses more than 30% of the external sphincter or
the slowly process, the muscle does not spiral apart,
with multiple tracts and has an anterior location in
leaving a defect, but repairs behind the process of
females. Usually the cure of complex fistula pretenses
division, so that fibrous tissue is formed in the couch
a high risk for impairment of continence and high rate
of the fistula. This procedure keep away from the
of recurrence (4).
occurrence of gutter deformity and it's associated with
Surgical curing of perianal fistula is uttered by
soiling and impaired continence. The difficulty with
the area of sphincter muscles involved, therefore there
this technique is that recurrent fistulae appear to be
is no single suitable method for the healing of fistulas,
relatively common (8). Setons possibly of the cutting
and the cure must be in a sense of balance between the
type or a loose seton which setted to encourage
extent of sphincter division, rate of postoperative
drainage and prevent the recurrence of perineal sepsis,
healing, and functionless of this area (4). Type and the
and may be left in place long-term or removed with
degree of fistula are the main beliefs during anal
eventual cure (9).
fistula surgery for eradicating the fistulous tract,
Different categories of setons are used for this
conserve sphincter function, and avoid recurrence. So,
purpose like silastic tube, silk, braided silk, rubber
the ethics of surgery include uprooting the fistula; get
band, braided polyester, vascular loop, nylon, cable
riding of the infective source in the internal opening,
tie, prolene suture and so forth (10). The accounted
and creating a sufficient drainage (5).
incontinence varies from 0% to 62% and recurrence
There are numerous options for fistula treatment,
rate varies from 0% to 16%, with dissimilar seton
but most of the superficial or least sphincter involved
materials used (10,11).

Full Paper (vol.747 paper# 23)

c:\work\Jor\vol747_24 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1636-1642

Effect of Collateral Circulation on Left Ventricular Systolic Function in
Patients with Totally Occluded Artery Undergoing PCI
Moustafa Ibrahim Mokarrab, Mansour. M. Mostafa, Attia Morsy Khamis,
Sameh Mosaad Abdul-Wahab and Mahmoud Gamal Yousef *
Department of Cardiovascular Medicine, Faculty of Medicine- Al-Azhar University
*Corresponding author: Mahmoud Gamal Yousef; Mobile: (+20)1111831719; Email: mahmoudwork17@hotmail.com

Over the past three decades, accumulating evidence has documented that pre-existing well-
developed CCC at the onset of acute myocardial infarction plays an important role in preserving left ventricular
function, reducing infarct size, preventing left ventricular aneurysm formation, and survival.
The aim of this study is to evaluate the effect of collateral circulation as measured by Rentrop score on
left ventricular regional and global systolic function in patients with totally occluded vessel pre and post PCI and
the ensuing impact of successful PCI. Methodology: Sixty patients have single vessel coronary chronic total
occlusion with viable myocardium of CTO related territories, successful revascularization at ERMED and ICS,
between June 2017 and December 2018, were considered to participate in this prospective study, The study
subjects were divided into three groups according to Rentrop score , each group contain 20 patients : Group (I)
Rentrop score 0 , Group (II) Rentrop score 1 and Group (III) Rentrop score 2. Results: There was no statistically
significant difference between the three groups regarding the incidence of diabetes, smoking and hypertension.
There was high statistically significant difference in EF between each group after revascularization, EF was higher
in group (III) than group (I) and group (II). There was statistically significant difference in WMSI comparison
between each group after revascularization WMSI was lower in group (III) than group (I) and group (II).
In general increase Rentrop score before revascularization lead to more improvement in WMSI and
EF after successful revascularization with improvement of quality of life.
Keywords: Coronary collateral circulation, CTO, PCI.
Abbreviation and acronyms : ATCP =Atypical chest pain, CABG = Coronary artery bypass graft, CAD = Coronary
artery disease, CCC = Coronary collateral circulation, CCs = Collateral channels, CMR = Cardiovascular magnetic resonance,
CTO = Chronic total occlusion, EF = Ejection fraction, ERMED = Egyptian Railway Medical Center, HTN = Hypertension,
ICS = International cardio scan, LAD = Left anterior descending artery, LCX = Left circumflex artery, LV = Left ventricle,
MACE = Major adverse cardiac events, OMT = Optimum medical therapy, PCI = Percutaneous coronary intervention, RCA
= Right coronary artery, SD = Standard deviation, SOB = Shortness of breath, TIMI = Thrombolysis in Myocardial Infarction,
WMSI = Wall motion score index, TCP = Typical chest pain .


infarction plays an important role in preserving left
Coronary collaterals are potentially present
ventricular function, reducing infarct size, preventing
vascular channels, which dilate and supply alternative
left ventricular aneurysm formation, and survival (4).
perfusion to the coronary arteries in case of severe
But there is dispute whether the extent of collaterals is
stenosis. Coronary collateral circulation (CCC) usually
directly related to viability and functional recovery (5).
supplies basal level of perfusion to the ischemic

myocardium and maintains the tissue viability (1).
Despite shortcomings of the data concerning the
The aim of this study is to evaluate the effect of
relationship between CCC and myocardial viability,
collateral circulation as measured by Rentrop score
CCC does not generally appear to perfuse the
on left ventricular regional and global systolic
nonviable myocardial tissue (2).
function in patients with totally occluded vessel pre
Despite decades of study, the functional role of
and post PCI and the ensuing impact of successful
coronary collateral circulation remains controversial.
A beneficial effect of coronary collaterals on infarct

size has been suggested by many clinical investigators
but not by others. Although stenotic lesions of between
75% and 90% can produce myocardial ischemia, they
Sixty patients have single vessel coronary
are never accompanied by angiographically visible
chronic total occlusion with viable myocardium of
collateral circulation. More severe narrowing or
CTO related territories, successful revascularization
complete obstruction is necessary to stimulate
at ERMED and ICS between June 2017 and
development of angiographically visible collaterals (3).
December 2018 were considered to participate in this
Over the past three decades, accumulating
prospective study.
evidence has documented that pre-existing well-
The study subjects were divided into three groups
developed CCC at the onset of acute myocardial
according to Rentrop score:


Full Paper (vol.747 paper# 24)

Introduction The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1643-1648

Effect of Intensive Phototherapy on Bilirubin Induced Neurological
Defect (BIND) Score in Neonates with Severe Hyperbilirubinemia
Yasser Abdelrahman Ahmed, Yasser Tolba Kassem, Samar Abdel Nafae Ismail
Pediatrics and Neonatology Department, Faculty of Medicine, Al-Azhar University, Assuit
Corresponding author: Samar Abdel Nafae Ismail, Mobile: (+20)01000962976, Email: dr7oodasamar@gmail.com

neonatal hyperbilirubinemia is a leading cause of morbidity and mortality in developing countries.
Adverse consequences include neonatal mortality, classic manifestations of choreoathetoid cerebral palsy, isolated
auditory impairment, and a diverse manifestation of subtle processing disorders because of BIND.
Aim of the Work: the aim of the current study was to evaluate the effectiveness of intensive phototherapy on
BIND score in neonates with severe hyperbilirubinemia. Patients and Methods: the current study is a
prospective study conducted on 100 neonates with severe hyperbilirubinemia admitted to NICU at university
Hospital, Faculty of Medicine, Al-Azhar University, Assuit, Egypt in the period between November 2017 and
May 2018. The study group was divided into 2 groups, hemolytic and non-hemolytic hyperbilirubinemia groups.
Results: regarding TSB and direct bilirubin at admission no significant difference was detected between both
groups (p=0.543 and 0.632). Regarding TSB and direct bilirubin at discharge no significant difference was
detected between both groups (p=0.712 and 0.213). Results show no significant change between hemolytic and
nonhemolytic jaundice regarding rate of decline per hour of total bilirubin and direct bilirubin after 8 hs. No
significant difference between study groups regarding BIND score at admission. At discharge, 95 (95%)
neonates had BIND score 0 and 4 (4%) had BIND score 1-3. One neonate (1%) died before scoring.
Conclusion: care must be taken not to delay the decision of exchange transfusion to the degree that endangers
baby's life. BIND score can be used to assess the efficacy of intensive phototherapy in newborn with
Keywords: Intensive Phototherapy, Bilirubin, Neurological Defect, Neonates, Severe Hyperbilirubinemia.

hours) as elicited by history and physical
Neonatal jaundice is defined as yellow
examination (4). Intensive phototherapy in neonatal
discoloration of the skin, sclera from the eyeball,
hyperbilirubinemia rapidly decreases total serum
and mucous membranes caused by bilirubin
bilirubin (TSB) below the threshold for treatment
deposition in these tissues. Jaundice may be
(5). Bilisphere is a novel neonatal phototherapy
present at birth or at any time during the neonatal
device designed to provide blue light illumination
period. Jaundice should be taken seriously because
to the whole of a baby's skin surface. Neonatal
of indirect (non-associated) or direct bilirubin
phototherapy is most effective at high irradiance
(conjugated) during the first 24 hours of life (1).
and high treatment area coverage; the bilisphere
In a recent study performed in the NICU of
360 is designed to maximise both factors. This
Azhar Assuit, University hospital in year 2018,
standalone device is mounted on a mobile stand
cases of neonatal hyperbilirubinemia represented
with four wheels each with a brake. The therapy
45.3% of total admission, with total serum
chamber is a horizontal cylinder containing 16 blue
bilirubin level ranging from 8.6 -58.5 mg/dL,
TL 20W/52 fluorescent tubes (6).
where total serum bilirubin between 20-25 mg/dL

was 26.5%, total serum bilirubin between 25-30
mg/dL was 20.8% and above 30 mg/dL was
The aim of the current study is to evaluate
19.1%. So hyperbilirubinemia remains a serious
of the effectiveness of intensive phototherapy on
problem in our country that needs further studying
bilirubin induced neurological dysfunction (BIND)
(2). Bilirubin toxicity remains a significant problem
score in neonates with severe hyperbilirubinemia.
despite recent advances in the care of jaundiced

(hyperbilirubinemic) neonates. There is a recent
increase in reported cases of classical kernicterus,
This study was conducted as a prospective
partly due to earlier hospital discharge and
study on 100 neonates with severe hyper-
bilirubinemia admitted to NICU at University
hyperbilirubinemia (3).
Hospital, Faculty of Medicine, Al-Azhar
Acute kernicterus remains a clinical
University, Assuit, Egypt, in the period between
November 2017 and May 2018. The study was
neurological dysfunction" BIND is the score of
approved by the Ethics Board of Al-Azhar
onset, severity and progression of acute bilirubin
encephalopathy in infants with hyperbilirubinemia
The study group was divided into 2 groups,
(total serum bilirubin >95th percentile for age in
hemolytic and non-hemolytic.

Full Paper (vol.747 paper# 25)

c:\work\Jor\vol747_26 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1649-1654

Serum Dickkopf-1 as A Biomarker for The Diagnosis and
Prognosis of Hepatocellular Carcinoma
Khalid Mahmoud Abd El-Hafeez 1, Mahmoud Bastawy Ismael 2,
Ahmed Abd-Elaleem Abuo-Elhasan 1, Amir Abd El-Aziz Mohammed Al-Damaty 1
Departments of 1Tropical Medicine and 2Clinical Pathology, Faculty of Medicine,
Al-Azhar University-Cairo, Egypt
Corresponding author: Amir Abd El-Aziz Mohammed Al-Damaty, Email: mero4u2012@yahoo.com

Hepatocellular carcinoma is one of the commonest cancers in world. It is one of the major health
problems and its incidence is increasing. The main routinely used parameter for diagnosis of HCC is AFP, also it
can be elevated in the liver cirrhosis. It represents a liver cell specific, not a tumor specific marker, for these
reasons, we suggest use AFP as a supplementary marker for HCC diagnosis. So, identification of a sensitive
biomarker to improve early diagnosis of HCC is in need.
Aim of the work: this study was aimed to evaluate the clinical significance of serum Dickkopf-1 (DKK1) as a
diagnostic and prognostic marker in hepatocellular carcinoma. Patients and Methods: in this study 100 subjects
were included and divided into 3 groups, Group I: included 50 patients with HCC, and divided into 2 subgroups
according to Barcelona Clinic Liver Cancer (BCLC) into early HCC (24 patients) and late HCC (18 patients).
Group II: included 25 patients with liver cirrhosis. Group III: included 25 healthy subjects (control). Clinical
assessment, routine laboratory evaluation, CT scan and measurements of serum alpha-fetoprotein (AFP) and DKK1
were performed to all patients and repeated to group I patients 1 month after treatment.
Results: the current study showed that Serum DKK1 was significantly elevated in HCC group compared to liver
cirrhosis and healthy control groups, with increased level in late than early stage. The optimum cut off values of
DKK1 for diagnosis of HCC was 1.92 ng/mL (AUC 0.926, sensitivity 88% and specificity 83%). While the
optimum cut off value for AFP was 102 ng/mL (AUC 0.904, 71% sensitivity and 84% specificity). Testing of both
serum DKK1 and AFP increased the diagnostic accuracy for HCC (AUC 0.964, sensitivity 91%, and specificity
90%). Serum DKK1 level significantly decreases after HCC treatment with radio-frequency ablation.
Conclusion: It could be concluded that Testing of both serum DKK1 and AFP significantly increased the
diagnostic accuracy for HCC. Meanwhile, DKK1 can be used alone for diagnosis of HCC even in HCC with
inconclusive AFP. Serum DKK1 might be a potential diagnostic and prognostic marker for HCC.
Keywords: HCC patients, DKK1, AFP.

screening method for liver cancer are ultrasound
Hepatocellular carcinoma is the sixth most
examination (US) of the liver and determination of
common malignant disease, and the third leading

cause of cancer related death worldwide. HCC is
serum AFP levels [7]. Abdominal ultrasound is better,
prevalent in Asia and Africa, but it raises recently in
simple and easy method for the detection of HCC but
the Western world due to an increase in hepatitis C
it is an operator dependent and many focal lesions
virus infection [1]. In Egypt, Cancer liver forms
could be missed [8].
11.75% of the malignancies of all GIT organs and
AFP has approximately 60% specificity and
1.6% of the total malignancies [2].
40% sensitivity for diagnosis of HCC, since minor
Risk factors for HCC includes chronic
elevations are common in the patients with chronic
hepatitis B virus and chronic hepatitis C infections,
liver diseases, cirrhosis, germ cell tumor and in
cirrhosis, chronic alcohol abuse, aflatoxin ingestion,
pregnancies [9].
non-alcoholic steatohepatitis (NASH) and metabolic
So, it is necessary to find specific and
liver diseases [3].
sensitive marker for early diagnosis of HCC, and for
Both HCV and HBV infections are most
monitoring of the treatment response.
common risk factors for HCC among the Egyptian
Dickkopf-1 (DKK1) is secretory protein which was
patients. 10%-20% of the general Egyptian population
first identified in 1998. DKK1 is an inhibitor of
are HCV infected [4].
Wnt/-catenin signaling pathway and a downstream
80% - 90% of patients with HCC have
target for -catenin [10].
underlying cirrhosis and the remaining 10% - 20% of
The Wnt/-catenin signaling pathway plays the main
the cases develop HCC without cirrhosis [5].
role in the development of both normal liver and
HCC is disease with fast infiltrating growth
hepato-carcinogenesis [11].
and very poor prognosis [6]. The commonly used
It is hardly expressed in the normal human adult
tissue except in placenta and embryonic tissue [12].

Full Paper (vol.747 paper# 26)

Introduction The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1655-1662

Effect of Adding Ketamine as An Adjuvant to Lidocaine in
Ultrasound Guided Supraclavicular Brachial Plexus Block
Mohamed M. Shamlol, Saad EL-Din M. EL-Khateeb, Khaled M. Alaa Saleh
Department of Anesthesia & Intensive Care, Faculty of Medicine, AL Azhar University
Corresponding author: Khaled M. Alaa Saleh; Mobile: 01113234579 Email: khaled.alaasaleh@gmail.com

Brachial plexus block is one of the most commonly used regional anesthetic techniques for
postoperative analgesia. Its popularity originates in part from easily palpable landmarks and relative ease of
placement. A number of adjuvants, such as ketamine, dexmedetomidine, and others have been studied to
prolong the effect of supraclavicular brachial plexus block.
Aim of the Work: Evaluation of the effect of adding Ketamine as an adjuvant to lidocaine in ultrasoung
guided supraclavicular brachial plexus block.
Patients and Methods: This randomized controlled study was conducted at the Department of Anesthesia,
EL-Hussein Hospital, AL-Azhar university on 60 patients of ASA physical status I-II of either sex aged 18-
60 years. They were randomized into two equal groups 30 patients in each. Group A (Ketamine group):
received 5 mg/kg lidocaine 2% and 2 mg/kg ketamine in a total volume 30 cc. Group B (Control group):
received 5 mg/kg lidocaine 2% and saline in a total 30 cc.
Results: the study showed a significant increase in mean control group compared to ketamine group
according to postoperative VAS.
Conclusion: Using of ultrasound led to decreasing the complications of supraclavicular brachial plexus
block and adding ketamine as an adjuvant to lidocaine decreased the postoperative pain and the need for
analgesics, without significant adverse effects. Therefore, it could be considered as an option to enhance the
analgesic effects of the brachial plexus block.
Keywords: Ketamine, adjuvant, Lidocaine, US-guided supraclavicular brachial plexus block.

appreciated during injection, and it allows the
Regional anaesthesia has many of the
operator to distribute LA uniformly around the
advantages reported when compared to general
target nerve. This may reduce the amount of LA
anesthesia for patients undergoing upper limb
required to successfully block the nerves so reduce
surgery, including improvement of peri-operative
the risk of systemic LA toxicity and other
sedation, improved patient satisfaction, accelerated
complications (9). Increasing the duration of local
post-operative recovery (1), reduced housing
anesthetic action is often desirable because it
consumption (2), reduced post-operative nausea and
prolongs surgical anesthesia and analgesia.
vomiting (PONV), short-term anesthesia unit (3)
Different additives have been used to prolong
and early hospital discharge (4, 5). The
regional blockade. Vasoconstrictors, opioids,
supraclavicular nerve mass is ideal for upper limb
clonidine, verapamil etc. were added to local
procedures from the mid-humerus to the hand
anesthetics, but the results were either inconclusive
level. The brachial plexus is more complex at the
or associated with side effects (10).
level of its stem, formed from nerve roots C5-T1,
Ketamine is a noncompetitive antagonist of
so the blockade here has the greatest potential to
the N-methyl-D aspartate receptor (NMDAR). It is
block all branches of brachial plexus. This leads to
used for premedication, sedation, induction, and
rapid onset and ultimately high success rates for
maintenance of general anesthesia. Central,
anesthesia, elbow clamping, forearm and hand
regional, and local anesthetic and analgesic
surgery (6). The success of the clavicle nerve
properties have been reported for ketamine.
depends on the appropriate techniques for nerve
Intravenous (IV) administration of low-dose
ketamine decreases postoperative opioid use and
concentration and size of local anesthesia used (7).
improves analgesia. The addition of ketamine to
Recent studies showed that ultrasound guided
epidural lidocaine or bupivacaine increases the
masses have a faster onset and improved cluster
duration of regional anesthesia and post-operative
quality with fewer complications than non-
analgesia. It has been seen that peri-incisional use
ultrasound techniques, which rely on anatomical
of 0.3-0.5% ketamine combined with local
features to guide the needle (8).
anesthetic in surgical wounds enhances analgesia
One of the most important benefits of real-
by a peripheral mechanism (11, 12).
time ultrasound imaging during peripheral nerve
There have been many advocated
blockade is that deposition of LA can be readily
modifications of the original techniques. These

Full Paper (vol.747 paper# 27)

ABSTRACT The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1663-1669

Comparative study between Ondansetron, Alizapride and Dexamethasone in
Prevention of Postoperative Nausea and Vomiting in Laparoscopic Surgery
Ismail A. Shabaik, Hamed A. Sanad, Mohamed A. Abdel-Halim, Amr M. Zaki
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Al-Azhar University
Corresponding author: Amr Mohamed Zaki Mohamed, Mobile: 01099649136;
Email: amrzaki2001189@gmail.com
Post-operative nausea and vomiting (PONV) is a common cause of post-operative discomfort
with incidence ranges from (50%-70%) after laparoscopic surgery.
Objective: To compare the effectiveness of dexamethasone, ondansetron and alizapride as monotherapy
administered intravenously in postoperative nausea and vomiting prophylaxis for patients with moderate to high risk
for nausea and vomiting undergoing laparoscopic surgery under general anesthesia.
Patients and Methods: The study population was 120 Egyptian patients from both sexes undergoing
laparoscopic surgery under general anesthesia with endotracheal intubation at Al-Azhar University Hospitals
(El Hussein Hospital and Bab Al-Sharya Hospital). Approval of the study was taken from the Ethics Committee
of Al-Azhar University. Prior to initiation of the study, written informed consent of the patient was obtained
after full explanation of elements contained in the research protocol. There were 4 study groups; Control group,
ondansetron group, alizapride group and dexamethasone group.
Results: Age, sex, smoking history, related history, duration of surgery, type of surgery,
vital signs and postoperative pain severity did not have any significant value in our study. Comparing the 4 studied
groups according to postoperative nausea and vomiting presence, time of incidence and number of episodes had a
significant value.
Conclusion: Intravenous 0.1 mg/kg of ondansetron is very safe and highly significant in control of
postoperative nausea and vomiting (PONV), it is even more effective than using 50 mg of intravenous
alizapride or 8 mg of intravenous dexamethasone as prophylaxis. Dexamethasone is slightly better than
alizapride in control of postoperative nausea and vomiting.
Keywords: Dexamethasone, Ondansetron, Alizapride, laparoscopic surgery, post-anesthetic care unit.


Postoperative nausea and vomiting (PONV) is
part of the fresh gas has not been shown to increase
a common cause of postoperative discomfort and its
the risk (10).
incidence rate ranges from (50%-70%) after
The relative risk of nausea and vomiting is four
laparoscopic surgery (1). Risk factors include opioid
times higher during menses; days one to eight of
analgesic drugs, postoperative pain, the anesthetic
the menstrual cycle (11). Female gender is associated
agent or anesthesia technique, sudden movement or
to more PONV than men (12). Non-smoking and
positional changes of the patient, a history of motion
younger age are well-known high risk factors for
sickness, hypotension, the site of surgical operation,
PONV (13).
day of menstrual cycle and estrogen level(2).
Ondansetron is a selective 5-hydroxytryptamine
The best scoring system for PONV has been
receptor antagonist with potent antiemetic
argued. The Apfel score; age<50 years, female, non-
activities. Its clearance half-time is 3.2-3.9 hours
smoking, and history of PONV, and opioid
and a single dose of ondansetron provides long
administration has become highly accepted (3).
antiemetic effects. Ondansetron is effective in
The Sinclair score includes duration and type
preventing post-operative nausea and vomiting
of surgery as well. The risk factors for PONV also
been assessed by Apfel group. These include female
gynecologic, thyroid, and ophthalmic surgeries.
patients, younger than 50 years, history of nausea
The best dose for PONV prophylaxis is a single 4
and/or vomiting after anesthesia and opioid intake (4).
mg bolus of I.V. ondansetron(14).
Hypotension and bradycardia may trigger
The D2-receptor antagonist alizapride is a
emesis (5). A liberal crystalloid regime reduces PONV
risk (6). Fasting 6 hours for food and 2 hours for clear
related to metoclopramide (15). Alizapride is a well-
liquor exhibits explicit benefits, e.g. reduced PONV(7).
established antiemetic which is widely used in
Complete opioid free anesthesia has a
oncology and perioperative medicine (16).
reducing effect of PONV (8). A long surgical period
Since the mid 1980s, studies have stated
may have a great impact on PONV in women who
that dexamethasone can decreases vomiting in
undergo laparoscopic surgery (9).
patients after chemotherapy (17). Subsequent studies
The duration of nitrous oxide exposure
have also found that dexamethasone effectively
seems to have an impact; less than 1 hour use as

Full Paper (vol.747 paper# 28)

c:\work\Jor\vol747_29 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1670-1674

Prospective Analysis of Pressure Injuries Patients in Relation to
Deep Venous Thrombosis
Fawzy Ahmed Hamza, Abd Elnaser Mohammad Abdelrahman, Mahmoud Zidan Abdelaziz
Department of Plastic and Burn Surgery, Faculty of Medicine - Al Azhar University
Corresponding author: Mahmoud Zidan Abdelaziz, Mobile: (+20)18889341110, E-Mail: drmahmoud59@yahoo.com

Pressure injuries are a serious complication of multimorbidity and immobility. They are defined as a
wound that develops in the upper layers of the skin as the result of sustained, externally applied pressure and then
enlarges both radially and into the deeper tissue layers. Objective: It is prospective analysis of the possibilities of
occurrence of deep venous thrombosis in pressure injures patients. Patients and methods: This study was conducted
to analyze the possibilities of incidence of DVT in pressure injuries patients at AlAzhar University Hospitals;
ElHussein and Sayed Galal Hospitals. This study was performed on 30 patients complaining of pressure injuries.
The age of the patients ranged from 19 to 59 years and there were 20 males and 10 females. Results: The results of
the study revealed that there was no incidence of deep venous thrombosis in 29 patients with pressure injuries during
the follow up period. The incidence of DVT of this present research was not statistically significant with only one
case of DVT with 0.03% (p = 0.08). Conclusion: From all the above-mentioned data, we might conclude that all
patients with pressure injuries had less incidence of deep venous thrombosis. Therefore, we encourage further
research and exploration in this promising field that may help in discovering a solution for deep venous thrombosis.
Keywords: Pressure Injuries Patients, Deep Venous Thrombosis.


Pressure injuries are a serious complication of
their severity is classified according to the depth of
multimorbidity and immobility. They are defined as a
extension (6).
wound that develops in the upper layers of the skin as
The damage can be reversed by removing the
the result of sustained, externally applied pressure and
excessive pressure that caused it, as long as there is no
then enlarges both radially and into the deeper tissue
open wound. As soon as a grade 1 decubitus injury
layers (1). Injuries are not always preventable or
(L89.0) is found, pressure-reducing measures such as
curable. Impaired perfusion, among other factors,
pressure-free positioning, frequent changes of
increases the risk of decubitus injuries, and cognitive
position, and frequent inspections should be ordered
disturbances can make prophylactic measures more
and carried out (7).
difficult (2).
A deep vein thrombosis (DVT) is a blood clot
The prevalence of high-grade decubitus
in a vein, deep in the body. Veins are blood vessels
injuries (grades 3 and 4) is as high as 3% and may
with valves that help blood flow in one direction.
reach 4% among elderly persons receiving nursing
When your muscles contract the blood is pushed
care in institutions. There has been no significant
through the veins in your legs and arms. Blood clots
decline in the prevalence of decubitus injuries over the
can block the flow of blood through the body. This can
last 10 years, as a study from Hamburg has shown (3).
cause swelling and other problems in the body.
Risk factors should be assessed at the first
Another concern is that the clot may break lose, travel
contact of an immobile patient with a health-care
through the bloodstream and block blood flow in the
professional. The appropriate measures to be taken can
lungs, heart, or brain (8).
then be determined based on the patient's individual

risk profile (4). With an emphasis on two cardinal
principles; active promotion of movement and passive
It is prospective analysis of the possibilities of
pressure reduction through frequent changes of
occurrence of deep venous thrombosis in pressure
injures patients.
perfusion, and any underlying diseases that restrict

mobility should be addressed with specific therapy,
and accompanying symptoms, such as pain and should
Study design
be treated symptomatically (5).
Type: Prospective cohort study.
A decubitus injury is usually accompanied by
Site: This study was conducted on 30 pressure injuries
an inflammatory reaction, and often by local bacterial
patients at the Plastic and Burn Surgery Department of
colonization or systemic infection. Exudation from
Al-Azhar University Hospitals (Alhussien and Sayed
large areas of damaged skin leads to fluid and protein
Galal University Hospitals).
loss. Since decubitus injuries first arise in the upper
Period: from December 2017 to October 2018.
layers of the skin, then extend outward and downward,

Full Paper (vol.747 paper# 29)

c:\work\Jor\vol747_30 The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (7), Page 1675-1679

Predictive Value of First Trimester Uric Acid in
Development of Gestational Diabetes
Osama Al Saeed Ali, Ibrahim Ramadan Al Sawy, Medhat Ali Salah, Mohammad Kamel Kattaria*
Departments of Obstetrics and Gynecology, Clinical Pathology,
Faculty of Medicine, Al Azhar University, Cairo, Egypt
*Corresponding author: Mohammad Kamel Kattaria email: Qattaria@yahoo.com

Gestational diabetes mellitus (GDM) is considered a common complication in pregnancy, affecting greater
than 10% pregnancies worldwide. However, the definitive underlying causes still not fully explained.
Objectives: This study aimed to detect the predictive value of uric acid level at first trimester in development of GDM.
Patients and Methods: The study was conducted on 300 first trimester pregnant females attending the Outpatient Clinic
of Al-Azhar University Hospital. All cases underwent measurement of first trimester serum uric acid level. Between 24
and 28 weeks of gestation glucose challenge test was done. Positive cases underwent confirmation by 3 h glucose tolerance
test. Results: The Pearson's test showed that there was a highly significant correlation between serum uric acid at first
trimester and plasma glucose levels at 24-28 weeks.
Conclusion: There is increased risk in development of GDM with the increase in uric acid level at the first trimester.
Keywords: GDM, Uric acid, First trimester.


Pregnancy is associated with insulin resistance,
As pregnancy proceeds, the level of uric acid
caused primarily by diabetogenic hormones secreted
increases may be due to increased fetal production,
from placenta mainly progesterone, corticotropin-
reduced albumin binding and a reduction in clearance of
releasing hormone, placental lactogen and growth
uric acid until near the pregnancy end when it
hormone. GDM develops during pregnancy in women
approaches non-pregnant value (6).
whose pancreatic function is not sufficient to cope with

the insulin resistance associated with the pregnant state
(1). Prediction and diagnosis of GDM is important for
This study was conducted at Bab Al Shaarya
ongoing pregnancy and has important implications for
University Hospital from January 2018 to December
subsequent health of the mother. GDM is considered a
2018. It is a prospective observational study which
significant risk factor for subsequent development of
included 300 pregnant women in their first trimester who
type II diabetes and is associated with a poorer
regularly attended the Outpatient Clinic for routine
cardiovascular risk profile compared to women without
antenatal care. Measurement of serum uric acid was done
GDM (2).Uric acid is formed from xanthine by the effect
for all women between 9-13 weeks. They underwent a
of xanthine oxidase. It is considered the main product of
screening test for GDM at 24-28 weeks. The aim was to
purine metabolism. Normal serum uric acid levels are
detect if serum uric acid had a predictive value in
generally 3.5 ­ 7.2 mg/100 ml for men and 2.6 ­ 6.0
development of gestational diabetes.
mg/100 ml for women. The reason is that uric acid
Inclusion criteria
excretion is enhanced by estrogen during the productive

- Pregnant not exceeding 13weeks gestation.
period. In extracellular fluids, the limit of uric acid
Exclusion criteria
solubility is 7.0 mg/dL and patients with greater serum
- Gestational age >13 week.
concentrations are considered hyperuricemic (3).
- Pregestational DM.
Recent studies have showed that increased
- Gout or other endocrine disorders.
serum uric acid level is accompanied by
- Chronic renal diseases.
hyperinsulinemia, hypertension, dyslipidemia and
- Drugs known to increase uric acid level in the blood
obesity, supporting that it could be a member of the
such as aspirin, caffeine, diuretics and phenothiazines
group of factors of the metabolic syndrome (4).
All patients were fully counselled for their
Early in pregnancy, the level of serum uric acid
approval to be included in this study and they all signed
falls 25-35% due to an enhancement of renal clearance
written informed consent.
secondary to increased glomerular filtration rate or
reduced proximal tubular reabsorption and due to
1. Taking approval consents of patients.
changes in its production rate (5).

Full Paper (vol.747 paper# 30)