The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1680-1686
Left Ventricular Torsion before and after Percutaneous
Mitral Balloon Valvuloplasty
Shady Mohamed Akl El-Sayed Akl(1) , Mohammad Ismail Al-Deftar(2),
AbdelMohsen Mostafa Aboualia (2) , Mohamed Salem Elbaz(2)
(1) Ministry of Health, Sherbeen General Hospital, (2) Cardiology Department,
(2) Faculty of Medicine, Al-Azhar University
Corresponding Author: Shady Mohamed Akl El-Sayed Akl, email: firstname.lastname@example.org
Background: The valve disease is frequently caused by the rheumatic mitral stenosis in developing and developed
countries alike and it is still a key issue. Although there is a significant decrease in rheumatic fever diffusion, its
percentage is still about 12% of the native valvular heart disease.
Aim of Work: The key objective of this work was to assess the impact of percutaneous mitral balloon valvuloplasty
(PMBV) on the LV torsion and this objective was achieved by using the two-dimensional speckle-tracking
Patients and Methods: The study used the prospective observational method and had been carried out in the
Department of Cardiology, Al-Azhar University Hospitals. The treatment group consisted of 35 patients who were
candidates for PMBV and the control group consisted of 20 matching patients in terms of gender and age but they
were healthy. All the participants of study had been assessed using the conventional echocardiography and speckle-
tracking echocardiography on the previous day and 3 months after the procedure.
Results: Using the parameters of the conventional echocardiography, we found that there were no significant
differences between the treatment group and the control group in the LV ejection fraction (EF) and RV systolic
function (TAPSE) before the PMBV. After applying the Speckle-tracking echocardiography, the results indicated
that LV torsion decreased in the treatment group compared to the control group before the PMBV. After 24 hours
and 3 months after the PMBV, the patients of treatment group had shown a statistically significant improvement in
Conclusion: The LV torsion in MS patients significantly improved immediately and in the short-run follow-up after
Keywords: Rheumatic mitral stenosis, Echocardiography, Management.
INTRODUCTION AND RATIONALE
transesophageal echocardiography (3DTEE) has
The valve disease is frequently caused by the
achieved a higher degree of accuracy and feasibility as
rheumatic mitral stenosis in developing and developed
a method used to calculate the MVA in patients who
countries alike and it is still a key issue. Although
are assessed for PBMV (5). But the planimetry is
there was a significant decrease in rheumatic fever
required to be accurately conducted at leaflet tips in a
diffusion, its percentage is still about 12% of the native
well-oriented plane. Consequently, it is necessary to
valvular heart disease (1).
be conducted by expert operators. As a result, the key
One of the most important objectives of
challenge of using this method is the hardness of
echocardiography is to evaluate the RHMS acuteness
obtaining such a plane (6).
and such evaluation is conducted by measuring the
In 1923, the Surgical Commissurotomy(7) was
mitral valve area (MVA) and choosing the right
first introduced and in the 1940s, it was considered the
patients for the percutaneous mitral balloon
typical treatment for patients with MS (8). However,
valvuloplasty (PMBV) (2). In addition, the MS
when the Inoue balloon catheter was introduced in
management was dependent on the accuracy of
1984 (9), the percutaneous mitral balloon valvuloplasty
(PMBV) had become the safest and most effective
evaluation of the echocardiography of the mitral value
treatment for MS.(10) Then, it has been developed as
area (MVA) (3).
the most favorite treatment method for patients who
The method that achieved the highest level of
were symptomatically selected with rheumatic MS (11).
reliability in the mitral valve area calculated compared
Then, when the preferred mitral valve anatomy
to the Golin's Formula, which is invasively derived
became available, the balloon valvuloplasty has been
and considered by some as the golden standard for
chosen as the favorable procedure (12). The mitral
calculating the MVA, is the planimetry 2-dimensional
valve is considered suitable for the PBMV based on
MVA(MVA2D) (4). However, the advancement of
the results of echocardiography and the criteria which
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1687-1697
The Effect of Dual Trigger of Oocyte Maturation with Gonadotropin-Releasing
Hormone Agonist and Low-Dose Human Chorionic Gonadotropin on Pregnancy
Rate in Women at Risk of Ovarian Hyperstimulation Syndrome
Marwa Salah Elsayed Abdel-Aal1*, Yehia Abdel Salam Wafa1, Shokry Abdel Azeim El Shershaby2
1Obstetrics and Gynecology Departments, Faculty of Medicine
2International Islamic Center for Population Studies and Research (Assisted Reproduction Unit)
*Corresponding author: Marwa Salah Elsayed Abdel-Aal, Registrar OB/GYN, MOH, Egypt,
Phone: 020/01065117808; E-mail: email@example.com
Background: the purpose of this study was to compare rates of ovarian hyperstimulation syndrome (OHSS) and
the pregnancy outcome after using gonadotropin-releasing hormone agonists (GnRHa) alone and GnRHa in
combination with low-dose human chorionic gonadotropin (hCG, dual trigger) for final oocyte maturation in
women undergoing controlled ovarian hyperstimulation (COH).
Patients and Methods: the study included 150 female patients with high risk of OHSS occurrence who were
allocated by the Computer-based randomization method into two groups with 75 patients in each arm, Group I
received GnRHa trigger and Group II received dual trigger (GnRHa + low-dose (1500 IU) hCG trigger).
Results: Our study showed that the incidence of OHSS was higher after dual trigger than GnRHa trigger but
with no statistically significant difference (8.0 vs 1.33 %, p >0.05). There were 6 cases of OHSS developed with
dual trigger group (Group II) (3 were mild early OHSS, 2 were moderate early and one case was severe late
OHSS). In contrast, there was only one case of severe late OHSS seen in Group I.
Conclusion: Dual trigger for final oocyte maturation using GnRHa and low-dose hCG is associated with
increased the incidence of early OHSS compared to GnRH alone. However, dual trigger appears to be a safe
approach with a satisfactory pregnancy outcome. Also, the dual trigger improves the oocyte maturation, the
number of yield embryos and the quality of embryos.
Keywords: Dual trigger, gonadotropin-releasing hormone agonist, human chorionic gonadotropin, ovarian
hyperstimulation syndrome, luteal phase support, oocyte maturation, quality of embryos.
Ovarian hyperstimulation syndrome (OHSS)
generally conservative, and potentially life-
is an iatrogenic complication of supra-physiologic
threatening complications of OHSS, which require
ovarian stimulation. The syndrome is almost
exclusively associated with exogenous gonadotropin
prophylactic measures a must (4).
stimulation and is only rarely observed after
Many strategies have been tried to prevent
clomiphene citrate treatment or spontaneous
OHSS, including cycle cancellation, coasting (5),
intravenous albumin administration around the time
OHSS characterized by cystic enlargement of
of oocyte retrieval (6), and Gonadotropin-releasing
the ovaries and acute fluid shift from the
hormone agonist (GnRHa) as an oocyte trigger in
intravascular space to the third space caused by an
GnRH antagonist cycles (7), natural-cycle In Vitro
Fertilization (IVF) or in vitro oocyte maturation
neoangiogenesis. The clinical manifestations of
OHSS reflect the extent of the shift of fluid into the
Unfortunately, none of the strategies currently
third space and the resulting hemoconcentration due
employed completely prevents OHSS after hCG
to intravascular volume depletion. Symptoms range
from mild abdominal distention due to enlarged
The risk of OHSS can be reduced by using a
ovaries alone or with an accompanying fluid shift
GnRHa trigger, instead of hCG trigger, in patients
into the abdomen, to renal failure and death as a
undergoing controlled ovarian stimulation (COS)
result of hemoconcentration and reduced perfusion
with a GnRH-antagonist protocol. Since the
of organs such as the kidneys, heart and brain (2).
technique was first suggested in 1988 (9), a number of
The exact cause of OHSS has not been
studies have investigated the efficacy and safety of a
completely elucidated, but it seems likely that the
GnRHa trigger (9).
release of vasoactive substances secreted by the
An analysis by Humaidan et al. (10)
ovaries under human Chorionic Gonadotrophin
demonstrated similar results in patients receiving a
(hCG) stimulation may play a key role in triggering
GnRHa trigger and those receiving an hCG trigger in
this syndrome (3). Standard treatments for OHSS are
terms of number of oocytes retrieved, fertilization
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1698-1701
Histopathological Study of the Chronic Toxic Effects of Dapoxetine
Administration on Testes of Male Albino Rats
Mohammed Fathy Assasa, Esam Said Mohammed, Osama Moustafa Moustafa,
Ahmed Mohammed Albuomy Abo Alfotoh
Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine,
Al-Azhar University, Cairo, Egypt
*Corresponding Author: Ahmed Mohammed Albuomy, Phone Number: 01023548550, Email: firstname.lastname@example.org.
Background: Dapoxetine is a short acting oral SSRI, purely created for the on-demand treatment of premature
ejaculation. The present study was carried out to see the histopathological effects of Dapoxetine on the
testis of adult albino rats. Materials and methods: Dapoxetine was administered orally by gavage to rats for
consecutive 70 days, Eighty apparently healthy male albino rats weighing 125150 g were used throughout the
experiments .The rats were divided randomly into four groups (n=6). Each group 20 rats: Group (1) Control
group, Group (2) receiving 1 mg of dapoxetine /70 days, Group (3) receiving 5 mg of dapoxetine /70 days and
Group (4) receiving 10 mg of dapoxetine /70 days. Histological slides were prepared and stained with H and E
stain. On examination, distortion of seminiferous tubules, decreased thickness of germinal epithelium,
decreased diameter of seminiferous tubules and decreased counts of germinal cell lineage were found in
Keywords: dapoxtine; histopathological effects; ssri.
Eighty apparently healthy male albino rats
Dapoxetine, a selective serotonin reuptake
weighing 125150 g were used throughout the
inhibitor, can be considered as an antidepressant
experiments. The animals were housed in metal
drug and has been used for the treatment of
cages in a conditioned room and were provided
premature ejaculation, in males. Dapoxetine
with a standard laboratory diet and water ad
hydrochloride is a rapidly absorbed short-acting
SSRI being investigated specifically for on-demand
hydrochloride orally by gavage for 70 consecutive
treatment of premature ejaculation, in males. Side
effects include the following: allergy, G.I.T
The rats were divided randomly into four groups
disturbances in the form of nausea, vomiting,
(n=6). Each group 20 rats:
withdrawal of the drug leads to premature
Group (1) Control group on water freely and
ejaculation, headache and infertility (1).
normal ordinary diet.
Mechanism of action of chronic dapoxetine
Group (2) receiving 1 mg of dapoxetine /70
effects on the Reproductive system. Its action
occurred by decrease of testosterone production,
Maximal therapeutically equivalent dose
due to deficits in neuroendocrine cells of
hypothalamic pituitary axis, decrease of both FSH
Group (3) receiving 5 mg of dapoxetine /70
and LH secretion and increased prolactin secretion
(2). Spermatogenesis at all levels is affected. It
5 times maximal therapeutically equivalent
includes increase percentage of teratozoospermia,
dose (5 times Max.T.E.D).
decrease normal formed sperms, sperm motility
Group (4) receiving 10 mg of dapoxetine /70
affected, decrease of percentage of viable sperms
and daily sperm production is decreased (3). The
10 times maximal therapeutically equivalent
chronic dapoxetine treatment has a detrimental
dose (10 times Max.T.E.D). At the end of the
effects on the spermatogenesis, impairs sperms (4).
experiment (at end of 70 days) the animals were
sacrificed and male sex organs (testes) were
AIM OF THE WORK
dissected and preserved in suitable fixative and
The aim of the current study is to see the
prepared for histopathological examination.
Chronic Toxic Effects of dapoxetine administration
1. The testes were dissected out from the rats
on testes of male albino rats.
under ether anesthesia. The tissues were fixed
in 10% formalin, processed and blocks were
MATERIALS AND METHODS
made in paraffin wax. 4-5 µm thick sections
This study was carried out at Animal House,
were cut and stained with hematoxylin and
Faculty of Pharmacy, Al-Azhar University.
eosin. The sections were examined in the light
Approval of the ethical committee was obtained.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1702-1709
Effect of Maternal Obesity on Labor Induction in Postdate Pregnancies
Farid I. Hassan, Mofeed F. Mohamed, Salah Eldin M. Ali
Obstetrics and Gynecology Department,Faculty of Medicine,Al -Azhar University
Corresponding author: Salah Eldin M. Ali; Mobile: 01111194669; Email: email@example.com
Background: Obesity has been recognized by WHO as "a pandemic nutritional disorder which represents a
rapidly growing threat to the health of populations of countries world wide". As obesity increases, so does
the number of women of reproductive age who are overweight and obese. The problems related to the
management of obesity in pregnancy are many. There are both short-and long-term complications and
implications for both mother and fetus.
Aim of the Work: Evaluation of the effect of maternal obesity on labor induction in post-date pregnancies.
Patients and Methods: This prospective case-control study was conducted on two hundred (200) pregnant
women who were divided into 2 groups: 100 non-obese pregnant women with BMI < 30 kg/m2 and 100
obese pregnant women with BMI 30 kg/m2. These women were investigated for success of induction of
labor. All women participants were recruited from Al Hussein and Military Hospitals Departments in the
period from 12 2017 till 11 2018.
Results: As regards success of induction, our study revealed that a greater number of obese women had
failed induction ending in CS delivery ( no dilatation of cervix after 24 hours of vaginal prostaglandin )
compared to their normal weight counterparts.
Conclusion: Obesity is associated with increased incidence of failure of induction of labor ending in CS
delivery, increased duration of induction of labor till vaginal deliveries, low Apgar score and increased fetal
Keywords: maternal obesity, labor induction, post-date pregnancies.
600 million were obese. These metabolic
Obesity represents a state of excess body
disorders are dramatically increasing among
fat. Normal, healthy men have a body fat
adults in the Eastern Mediterranean Region. Data
percentage of 15-20%, while normal, healthy
for adults aged 15 years and older from 16
women have a percentage of approximately 25-
countries in the Region showed the highest levels
30% (1). Although body weight is easily obtained,
of overweight and obesity in Egypt, Bahrain,
it is a limited index of obesity because the
Jordan, Kuwait, Saudi Arabia and United Arab
differences in weight among individuals are only
Emirates. The prevalence of overweight and
partly the result of variations in body fat (2).
obesity in these countries ranges from 74% to
The body mass index (BMI), also known
86% in women and 69% to 77% in men (4).
as the quetelet index, is used more commonly than
As obesity increases, so does the number
body fat percentage to define obesity. In general,
of women of reproductive age who are overweight
BMI correlates closely with the degree of body fat
and obese. Obese women have reproductive
in most settings; however, this correlation is
disadvantages. This translates into difficulty in
weaker at low BMIs (3). An individual's BMI is
achieving pregnancy, early and recurrent
calculated as weight (kg)/ height (meter2).
pregnancy loss, preterm delivery, and a myriad of
Although several classifications and
increased obstetrical, medical and surgical
definitions for degrees of obesity are accepted, the
complications with pregnancy, labor, delivery,
most widely accepted classifications are those
and the puerperium (5). Obesity in pregnancy has
from the WHO (4), based on BMI. The WHO
shown to be associated with significantly
designations included the following:
increased risk of post-term pregnancy (2). Late-
Grade 1 overweight (commonly called
term and post-term pregnancies are associated
overweight): BMI of 25-29.9 kg/m2.
with an increased risk of perinatal morbidity and
Grade 2 overweight (commonly called
mortality (6). Women with high body mass index
obesity): BMI of 30-39.9 kg/m2.
(BMI) and prolonged pregnancy had an
Grade 3 overweight (commonly called severe
increasingly prevalent clinical problem (2).
or morbid obesity): BMI greater than or equal
Management of prolonged pregnancies
to 40 kg/m2.
in obese women, however, is difficult because
Obesity became a worldwide epidemic.
IOL is associated with a high risk of caesarean
Worldwide obesity has more than doubled since
section and its attendant complications of
1980. In 2014, more than 1.9 billion adults, 18
infection, haemorrhage and thrombosis whereas
years and older, were overweight. Of these over
conservative management is associated with an
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1710-1718
Anterior Segment Optical Coherence Tomography
Changes after Phacoemulsification
*Heba Allah A Said, *Heba M. Abdelrahman and *Ahmed Sh. Abdullah
*Department of Ophthalmology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo-Egypt
*Corresponding author: Heba M. Abdelrahman, Email: firstname.lastname@example.org, Phone No: 01062352663
Background: phacoemulsification can cause changes in the anterior segment parameters that could be detected by
anterior segment optical coherence tomography.
Purpose: To determine the changes in the anterior segment parameters and intraocular pressure after
Subjects and methods: A prospective, non-randomized study included twenty eyes with visually significant cataract
that underwent phacoemulsification with foldable intraocular lens implantation (IOL). Complete ophthalmological
examination and anterior segment optical coherence tomography (ASOCT) were performed before surgery and one
Results: There were statistically significant differences in the anterior segment parameters after cataract surgery. The
anterior chamber angle (ACA) at the temporal side before and one month after surgery were 22.58º ± 6.4º , 33.14 º ±
6.48º respectively (p < 0.001). The ACA at the nasal side before and one month after surgery were 23.33º ± 6.93º,
34.16º ± 6.99º respectively (P< 0.001).
Conclusion: Phacoemulsification with IOL implantation results in significant widening of the ACA proved by
quantitative assessment of ASOCT imaging. At the same time it caused small but significant reduction in IOP.
Keywords: Phacoemulsification, anterior chamber angle, anterior segment optical coherence tomography.
Cataract and glaucoma are considered the major
A total of twenty eyes with visually significant
causes of visual impairment in the world (1).
cataract, as the only cause of visual impairment, were
Phacoemulsification is one of the most frequent
selected from the outpatient clinic.
surgical techniques used for cataract removal (2). In
Exclusion criteria included:
addition to restore vision, phacoemulsification has
Eyes with prior penetrating ocular surgery
been shown to decrease intraocular pressure (IOP) in
Complications related to cataract removal, such as
patients without glaucoma and in patients with
posterior capsular rupture and vitreous loss.
glaucoma (3). Because elevated IOP is the main risk
Eyes with corneal abnormalities such as edema,
factor in the development and progression of
abrasion or dystrophy, pterygium and other
glaucoma, phacoemulsification cataract extraction
with foldable intraocular lens implantation (IOL) has
Eyes with peripheral anterior synechiae
been implicated to treat both the first and the second
Complete ophthalmic examination was
leading causes of blindness in the world (4).
postoperatively included the following; uncorrected
AIM OF THE WORK
visual acuity (UCVA), best corrected visual acuity
To determine the changes in the anterior segment
(BCVA), IOP measurement by Goldmann applanation
parameters and IOP following phacoemulsification
tonometry, slit-lamp examination (Haag-Streit, USA),
biomicroscopic fundus examination with 90D lens if
possible. Images of the anterior segment were obtained
SUBJECTS AND METHODS
using a commercially available OCT device (Nidek
A prospective, non-randomized comparative study
3000). Standard resolution scans captured the temporal
was carried out at Al-Zahraa university hospital from
and nasal quadrants (nasal-temporal 0°-180°) with
5/2016 to 12/2016.
participants looking straight ahead. All the images
An informed written consent was taken from each
were taken with the patients in a sitting position. After
participant in the study. The study protocol adhered to
several scans were acquired, we selected the best
the tenets of the Declaration of Helsinki and was
approved by the Ethics Board of Al-Azhar University.
For analysis, the scleral spur (SS) insertion
landmark is located where the less reflective ciliary
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1719-1724
Management of Keratoconus Using Myoring
Ahmed Rabie Mohammed*, Mahmoud Mohamed Ismail,
Mohammed Ahmed Wahdan, Ahmed Hassan Barada
Department of Ophthalmology, Faculty of Medicine, Al Azhar University
*Corresponding author: Ahmed Rabie Mohammed, E-Mail: email@example.com,
Background: keratoconus (KC) is an ectatic condition of the cornea which is usually progressive and non-
inflammatory, affecting both eyes asymmetrically. It is characterized by stromal thinning that leads to corneal surface
irregularity. Vision affection is due to irregular astigmatism and corneal scarring.
Aim of the Work: assessment of the effectiveness of Myoring intreating patients with keratoconus.
Patients and Methods: prospective non-randomized non-comparative clinically controlled study, Myoring was
implanted for (20) eyes of 20 patients with progressive keratoconus.
Results: visual acuity and corneal parameters improved significantly in all patients after one year postoperatively.
Conclusion: Myoring when used in suitable patients has the potential to produce excellent long-term vision results
in mild, moderate and advanced keratoconus cases, regardless of cone position and disease progression.
Keywords: keratoconus, intracorneal rings, Myoring.
PATIENTS AND METHODS
Keratoconus (KC) is an ectatic condition of
In this prospective non-randomized non-
the cornea which is usually progressive and non-
comparative clinically controlled study, Myoring was
inflammatory, affecting both eyes asymmetrically. It is
implanted for (20) eyes of 20 patients (11 males & 9
characterized by stromal thinning that leads to corneal
females) with progressive keratoconus. All cases were
surface irregularity. Vision affection is due to irregular
performed and followed up in Al-Azhar University
astigmatism and corneal scarring(1).
hospitals at the period from October 2015 to
All layers of the cornea are affected by KC,
especially thinning of the corneal stroma and rupture
in Bowman's layer. Descemet's membranebreaks and
Ethical consideration: A signed informed consent
folds lead to acute hydrops and striae(2).
was obtained from all participants and the study was
Intracorneal ring segments were designed to
approved by the Ethics Board of Al-Azhar University.
achieve refractive adjustment by flattening the cornea.
The following inclusion and exclusion criteria were
Intracorneal rings have several distinct and important
advantages. New thicknesses and different ring sizes
Inclusion criteria: All patients were between 16-40
and the use of femtosecond lasers to dissect channels
years with thinnest corneal pachymetry higher than
inside the cornea will likely improve the surgical
390 microns, corneal curvature more than 48D,
scotopic pupil less than 6mm and no central scarring.
The Myoring (DIOPTEX) is a complete,
Exclusion criteria: Age: <16 or > 40 years, thinnest
flexible, continuous, PMMAringdesigned to correct
corneal pachymetry less than 390 microns, corneal
moderate and high myopia. The diameter ranges from
curvature less than 48D, scotopic pupil more than
5.0 to 8.0 mm, the thicknesses from 150 to 350 m and
6mm or central scarring.
the width of the ring is 0.5mm. The anterior surface is
convex and the posterior surface concave, with aradius
All patients were undergone slit-lamp
of curvature of 6.0 mm. It can be considered a
examination of anterior segment, assessment of
permanent contact lens, which is squeezed underneath
uncorrected visual acuity (UCVA) and best spectacle
the corneal surface(3).
corrected visual acuity (BSCVA), pachymetry and
corneal topography with anterior and posterior
AIM OF THE WORK
Assessment of the effectiveness of Myoring in
treating patients with keratoconus as regard changes in
The procedure for placement of Myoring
visual acuity, error of refraction and corneal
can be performed with topical or local anesthesia. The
operative field is prepared, and the patient is prepared
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1725-1731
Measurement of Helicobacter Pylori in Patients with Bronchial Asthma
Abaas Saeed Al-maragy1, Mohammed Abdallah Rakha1, Ahmed Abdel-Hameed abou-Zeed2,
Mohanad Mohammed Ahmed1
Departments of 1Chest Diseases and 2clinical pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohanad Mohammed Ahmed, Email: firstname.lastname@example.org
Background: Current evidence indicates an inverse association between Helicobacter pylori and asthma and
allergy. H. pylori is a Gram-negative bacterium which represents the major cause of peptic ulcer and gastric cancer,
and preferentially elicits a T helper (Th)-1 response. Many H. pylori factors, such as the neutrophil-activating
factor of H. pylori (HP-NAP), are able to drive Th-1 polarization and to display a powerful inhibition of allergic
Th-2 response. Special attention has been drawn to HP-NAP as a potential novel strategy for the prevention and
treatment of asthma and atopy.
Aim of the Work: This study was aimed to measure helicobacter pylori in patient with bronchial asthma.
Subjects and Methods: This study included a total of 50 patients with bronchial asthma and 20 age-matched
control individuals attending at AL-Hussein, Al-Azhar University Hospitals in the period between April 2018 and
December 2018. All patients underwent full history taking, complete clinical examination, plain chest X-ray,
routine lab investigations, spirometry before and after bronchodilators and H. pylori antigen in stool by ELISA.
Results: The results of this study revealed that there is a relation between bronchial asthma and helicobacter pylori.
Conclusion: There were improvement in pulmonary function tests in asthmatic patients with H. pylori positive
more than asthmatic patients with H. pylori negative.
Keywords: Helicobacter pylori neutrophil-activating factor, protein, Th-1/Th-2, Treg, asthma.
observations that microbial exposure per se could not
The prevalence of airway allergic disease
such as asthma has over the years increased in
be considered in generic terms as "pro-atopic". For
developed countries. The causes of this increase
example, other microbial-derived agents exemplified
remain largely unknown. Proposed associations
by the components of Freund's adjuvant displayed
include changes in smoking habits(1) exposure to
atopy-antagonistic activity(11), and stimuli derived
food-borne and orofecal infections(2), types of
from normal gut flora were demonstrated to be
dwellings,(3) ownership of furry animals,(4) number of
necessary to facilitate the expression of oral tolerance
siblings, family income/education level,(5)and the
to fed allergens(12), and also inhalation tolerance to
presence of particulates in diesel exhaust.(6)
aeroallergens (13). These observations suggested that
The inverse association between family size
microbial-derived stimuli had potential to modulate
and manifestations of allergy has been consistently
the etiology and pathogenesis of atopic diseases in
found,(7) and there is also a much-published potential
dichotomous ways, their ultimate effects perhaps
link between allergy and childhood infection,
especially with Helicobacter pylori(8). Until the late
The current study was aimed to measure
1980s, interest in the role of infections in allergic
helicobacter pylori in patient with bronchial asthma.
diseases focused principally upon the process of
primary allergic sensitization.
SUBJECTS AND METHODS
The literature of the time contained several
This study included a total of 50 patients with
observations which argued for a role for infections,
bronchial asthma and 20 age-matched control
including the ability of bacterial-derived immune-
individuals attending at AL-Hussein, Al-Azhar
stimulants such as pertussigen to selectively improve
University Hospitals. This study was conducted
priming for immunoglobulin (Ig)E antibody
between April 2018 and December 2018.
production(8), and the potential of lipopolysaccharide
All patients underwent full history taking,
to bypass tolerance to mucosally applied allergens.
complete clinical examination, plain chest X-ray,
Also, other studies reported that respiratory viral
routine lab investigations, spirometry before and
infections such as influenza could subvert the
after bronchodilators and H. pylori antigen in stool
generation of protective "inhalation tolerance" to
aeroallergens(9). Signals such as enterotoxins from
skin-dwelling bacteria have been invoked as
Exclusion criteria include: Patients
important contributors to the pathogenesis of atopic
with respiratory failure, acute severe asthma , patients on
mechanical ventilation, Patients unable to do pulmonary
However, it was also clear from other
function tests, Patients on proton pump inhibitors ,
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1732-1736
Role of Platelet Indices and Antiplatelet Antibody in Differentiating Immune
Thrombocytopenic Purpura from Other Causes of Thrombocytopenia
Nagwa Mohammed Mowafy, Mohsen Taha Elkeiy, Mohammed Abdel-Hameed Khedr,
Mohamed Haseeb Gouda Masselihy
Departments of Clinical Pathology, Faculty of Medicine, Al-Azhr University
*Corresponding author: Mohamed Haseeb Gouda Masselihy, EMail:email@example.com,
Background: thrombocytopenia may be defined as a decrease in number of platelets in the circulating blood. Bone
marrow examination may be required to discriminate causes of thrombocytopenia as hypoproductive or
hyperdestructive. However, this procedure is invasive and time consuming. Objective: this study aims to assess
the diagnostic value of mean platelet volume (MPV), platelet distribution width (PDW) and platelet large cell-ratio
(P-LCR) and anti-platelet antibody in discriminating causes of thrombocytopenia as hypoproductive or
hyperdestructive immune thrombocytopenia purpura (ITP).
Patients and Methods: the study was conducted on 45 subjects15 patients suffering from ITP, 15 patients suffering
from other causes of thrombocytopenia, and 15 healthy controls. All of them were subjected to full clinical history,
examination and routine investigation including CBC, routine chemical analysis (liver function, renal function, etc.),
BM aspirate and detection of antiplatelet antibody. Results: the results of this study revealed that in ITP patient
group, we found that the MPV, PDW and P-LCR were significantly higher in comparison to non-ITP group. As
regard anti-platelet antibody detection by ELISA method was positive (60%) in ITP group, positive (26.7) in non-
ITP group and negative in all patients in control group. It revealed no significant difference between ITP group and
non-ITP group to diagnose ITP. Conclusion: from this study, we could conclude that, measuring of platelet indices
(MPV, PDW and LCR) provides useful diagnostic test in differentiating ITP from hypoproductive
thrombocytopenia, thus may avoid the need for bone marrow examination. Measurement of anti-platelet antibody is
not a reliable test in diagnosis of ITP.
Keywords: Immune thrombocytopenia purpura (hyperdestructive thrombocytopenia), Hypoproductive
thrombocytopenia, Platelet indices (Mean Platelet Volume (MPV), Platelet Distribution Width (PDW) and Platelet
Large Cell-Ratio (P-LCR) and anti-platelet antibody.
thrombocytopenic purpura (ITP), disseminated
Platelets (thrombocytes) are colorless blood cell
decreased platelet productions (hypo-production
that play an important role in processes such as
thrombocytopenia) are associated with a number of
bone marrow diseases (4).
inflammation, and innate immunity. Platelets are
Platelet indices (PI), mean platelet volume (MPV)
formed from the cytoplasm of megakaryocytes (MKs),
and platelet distribution width (PDW), platelet large
their precursor cells, which reside in the bone marrow
cell ratio (P-LCR) are a group of derived platelet
(1) . Platelet disorders can be either quantitative or
parameters obtained as a part of the automatic
qualitative. Qualitative disorders are due to defective
complete blood count. Emerging evidence suggests
platelet functions (thrombasthenia). Quantitative
that PIs may have diagnostic and prognostic value in
disorders are either due to decreased platelet count
certain diseases (5). The combined interpretation of
(thrombocytopenia) or increased platelet count
highly useful in differential diagnosis of platelet
Thrombocytopenia may be defined as a subnormal
related disorders (6).
number of platelets in the circulating blood. Normal
Platelet antibodies can be autoimmune (directed
platelet counts in adult (150410 x 109/L) while in
against endogenous, i.e., the patient's own platelet
children (7-12 years old) is (170-450 x 109/L) (3).
antigens) or alloimmune (directed against antigens on
The two main causes of thrombocytopenia
exogenous platelets encountered through pregnancy or
excluding pseudothrombocytopenia are increase
transfusion). Platelet antibodies may be directed to a
number of antigenic "targets" carried on platelet
(hyperdestructive thrombocytopenia), such as immune
cytoplasmic membranes (7). This platelet antibody
The Egyptian Journal of Hospi t Ab
al u E
ci a N
a . et
2019) Vol. 74 (8), Page 1737-1747
Teratogenicity of monosodium glutamate on the pregnant rats
and their fetuses
Abu Elnaga N.A. 1, Sarhan M. 2, Mansour H. 1
1- Zoology Department, Faculty of Science, Al-Azhar University, Cairo (Girls branch)
2- Zoology Department, Faculty of Science, Al-Azhar University, Assuit
Background: 2% to 3% of all living newborns showed at least one recognizable congenital
malformation. Monosodium glutamate (MSG) is widely used as flavor enhancer. But, it induces
embryonic and fetal toxicity in rats during the gestational periods. Aim of the work: this study
aimed to detect the effects of MSG on placenta and fetal developmental stages at 15th and 19th days
of gestation. Material and Methods: fifty mature pregnant Albino rats (Weight 200 ± 20 g) were
categorized into two groups according to the time of dissection at 15thor 19th days of gestation.
From each group, half of the pregnant mothers (G15 and G19)were daily administrated MSG ( 7
g/10mL/kg b. w. by oral)from the 9th to 14th days of gestation). The control groups (C15 and C 19)
were received water only. Results: in G15 and G19 groups, the uterine and fetal shape, number of
implantation sites, number of living fetuses, body length, fetal and placental weights and the
placental co-efficient were negatively changed when compared to the control groups(C15 and C
19). Also, the placental tissue showed congested blood sinuses and large hemorrhagic areas which
contained hemolysed blood cells. Some atrophied decidual cells and pyknotic nuclei were observed
with highly distorted maternal and fetal placental layers. Conclusions: this study showed that short-
term MSG exposure caused several maternal and fetal changes. Therefore, MSG is considered as
embryotoxic agent and the mothers must avoid administration of this substance during the gestation
may cause severe intrauterine growth
The most critical period in embryonic
development is when cell differentiation and
morphogenesis are at their peak. At this time,
histopathological changes in the fetal period.
the embryos are more susceptible to any
Monosodium glutamate (MSG) was shown to
teratogen (1). Monosodium Glutamate (MSG)
penetrate placental barrier and distribute
is one of the world's most extensively used
almost evenly among embryonic tissues using
food additives which are ingested as part of
3H-Glu as a tracer. When a lower (1.0 mg/g)
commercially processed foods. As a flavor
and a higher (2.5 mg/g) doses of MSG were
enhancer, MSG increases the sapidity of food
alternatively injected to Kunming maternal
(2). A previous study showed that oral
mice in every other days from mating to
administration of MSG to pregnant rats
deliveries, obvious injury occurred in the
influenced the body weight and hypothalamus
ability of memory retention characteristic
of their offspring. Abnormalities of fetuses
cytopathological changes induced by MSG
found in the limbs ranged from absence to
showed swollen cytoplasm, dark pyknotic
various degrees of digits fusion on both
nuclei and loss of neurons. These experimental
anterior and posterior limbs (3). The body and
findings indicated that MSG performed its
transplacental neurotoxicity in a dose-
implantations, growth rate of the viable
offspring were affected after MSG treatment.
2 -Material and methods
MSG also induced some abnormal changes in
Animals: the present work was carried
gestation such as abortion and\ or resorption of
out on fifty mature pregnant Albino rats
fetuses (4). Miko et al.(5) and Hegazy et al. (6)
(Weight 200 ± 20 g). They were obtained from
reported that monosodium glutamate exposure
El -Rammed Medical Hospital, Cairo and
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1748-1758
Immunohistochemical Study of Cancer Stem Cells and Angiogenic
Markers in Renal Cell Carcinoma, Clinicopathologic Correlation
Walaa Ibrahim Mohamed Ghonaim, Bahaa Bedeir Ghannam,
Abeer Said Farg, Eman Mohamed Ahmed
Department of Pathology, Faculty of Medicine, Al- Azhar University, Cairo, Egypt
Corresponding author: Walaa Ibrahim Mohamed Ghonaim,email: firstname.lastname@example.org
Background: Despite advanced therapy of renal cell carcinoma (RCC), up to 40% RCC develop recurrence
with high metastatic rate and continues to be one of the fatal forms of cancer. Therefore, detecting new
biomolecular markers for prognosis of RCC is important and a major need. Relevant markers of CSCs and
angiogenic may serve as prognostic biomarkers of RCC. However, their actual prognostic significance remains
inconclusive. Aim of the work: we planned this study to evaluate CD133 and VEGF immunohistochemical
expression in renal cell carcinoma cases and its correlation with clinicopathologic data to evaluate their clinical
significance and prognostic value.
Methods: this study was carried out on 50 cases of radical nephrectomy specimens. Hematoxylin and
eosin-stained sections from all cases were re-evaluated and further stained immunohistochemically stained
sections were done by using antibodies against CD133 and VEGF.
Results: expression of CD133 was down -regulated with the level of malignancy of the RCC and was tightly
correlated with tumor grade (p=<0.001), capsular invasion (p=<0.001) and grade of lymphocytic infiltrate
(p=<0.001), while, there were no significant associations between CD133 expression and tumor stage, the
type, size, TNM stage grouping and tumor laterality. Expression of VEGF was associated with high grade
(p<0.001) and clinical stage (p=0.026), large size (p=0.008), capsular invasion (p=<0.001), nodal invasion
(p=0.011) and grade of lymphocytic infiltrate (p=0.002) of RCC. There was a statistically significant
correlation between CD133 and VEGF with adverse relation between the two markers.
Conclusions: our study demonstrated that the expression of CD133 was down -regulated with the level of
malignancy of the RCC and was tightly correlated with tumor grade, capsular invasion and grade of
lymphocytic infiltrate. These facts demonstrated that CD133 play an important role in the development and
progression of RCC. Elevated expression of VEGF is a characteristic feature of high grade and stage, large
size and capsular invasion of RCC. There was a statistically significant correlation between CD133 and VEGF
with adverse relation between the two markers.
Keywords: Renal cell carcinoma, CD133, VEGF.
strategies for treatment of tumors. CD133 has been
Renal cell carcinoma (RCC) is a
investigated as a marker for identification of CSCs
significant health problem with a wide variation in
in renal carcinomas and it is a possible marker
prognosis usually associated with a high metastatic
related to tumor progression and invasion that has
index at the diagnosis. Up to 40% of patients
been extensively studied in different tumors in the
experience recurrence following surgery for
clinically localized disease because of the
Some research results reported that
resistance to radiations and chemotherapies (1).
over-expression of CD133 CSC marker in cancer
Finding better prognostic markers are the goal in
patients including gastric cancer (5), ovarian cancer
order to optimize patient selection for specific
(6) and hepatic cancer (7) correlates with a poor
therapeutic approaches. Accumulated evidence
prognosis. However, its prognostic significance in
showed that cancer can be considered as a stem
RCC is not yet clear. The function of VEGF is not
cell disease (2). The concept of contribution of
limited to angiogenesis and vascular permeability.
Autocrine and paracrine VEGF signaling occurs in
multi-differentiation, as well as tumor initiation,
some tumor cells, contributing to induction of
progression, metastasis and resistance to
CSCs, independent of any role that VEGF may
treatments was widely accepted (3), so it is better
have in angiogenesis. Recently, VEGF-targeted
to understand the characteristic and prognostic
therapies have been identified as a promising
role of CSCs in RCC to create therapeutic
therapeutic approach in treatment of RCC (8). In
Comparative Study between Three Different Doses of Magnesium Sulfate as a Technique of Hypotensive Anesthesia during Functional Endoscopic Sinus Surgery
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1759-1768
Comparative study between three Different Doses of Magnesium
Sulfate as a Technique of Hypotensive Anesthesia during Functional
Endoscopic Sinus Surgery
Hamed A. Sanad, Amgad Z. Mohamed, Ahmed A. Abd-elraouf
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed A. Abd-elraouf; Mobile: 010044707637; Email: email@example.com
Background: Hypotensive anesthesia represents a great challenge for the anesthetists. Although, there is great
benefit from inducing hypotensive anesthesia, there is a great risk of major morbidity and mortality.
Aim of this work: Evaluation of the optimal dose of MgSo4 to create hypotension during functional
endoscopic sinus surgery.
Materials and methods: This prospective, control, randomized, clinical study was conducted on 60 patient
divided into three groups. Patients were recruited from the Department of Anesthesia and Intensive Care, AL-
Azhar University Hospitals. Each group received different dose of MgSo4 5-10-15 mg/kg/h. Then, we took
measures of Bp, Spo2, HR and cortisol. Our observations then were statically analyzed.
Results: There was more stability in hemodynamic parameter in group II and III. There was significant
decrease in blood pressure in group III. In addition, there was a decrease in heart rate in group II and III but
this decrease wasn't significant. Magnesium sulphate decreased release of stress hormone especially in group
Conclusion: Deliberated hypotension is very useful during surgery to decrease time and blood loss.
Magnesium sulphate is one of the most useful techniques to induce hypotension during surgical operation. We
suggest that using magnesium sulphate in 40 mg\kg as loading dose then continuous infusion at 15 mg\kg\h is
the most effective and safest technique. Magnesium sulphate is very useful agent to abolish stress response.
Key words: Magnesium Sulfate, Technique, Hypotensive Anesthesiam, Endoscopic Sinus Surgery.
ATP-ase and Na-K ATP-ase involved in
hypotension) is an anesthetic technique that
permits the clinician to lower arterial blood
depolarization and repolarization phases. Thus, it
pressure electively in order to decrease blood loss
acts as a stabilizer of cell membrane and
during surgery and to provide a dry surgical field
intracytoplasmic organelles. Magnesium also
for the surgeon (1). Deliberate hypotension is an
exerts its effects on L-type calcium channels in
acceptable intraoperative technique for improving
membranes and the sarcoplasmic reticulum by
surgical condition when a bloodless operative filed
inhibiting the calcium activation depending on the
is needed together with reduction of blood loss and
sarcoplasmic channel. Magnesium limits the
the need for blood transfusion with its concomitant
outflow of calcium from the sarcoplamic reticulum
hazards. In addition, it helps in improving
(6). In addition, magnesium sulphate acts as a
myocardial performance by reducing the preload
vasodilator agent by increasing the synthesis of
and after load (2).
prostacyclin as well as inhibiting angiotensin
Nevertheless, one should avoid the
converting enzyme activity. Also, magnesium
temptation to select any particular blood pressure
sulphate has small dose-dependent myocardial
as the endpoint of hypotensive anesthesia. The
depressant effect (2).
minimum acceptable blood pressure must be
Recently, the antagonistic effect of
individualized to each particular patient's
magnesium at N-methyl-D- aspartate (NMDA)
intercurrent illness (3).
receptors has led to studies of its adjuvant effect in
perioperative analgesia (6).
produced by either a reduction in cardiac output or
The contraindications of hypotensive
a decrease in systemic vascular resistance (SVR)
anesthesia have relaxed over the years because of
(4). Drugs with different modes of action have been
better drugs, monitoring, and more experience with
used alone or in combination to induce
the techniques. However, several contraindications
hypotension. These drugs may be classified
must be considered, cerebrovascular disease, liver
depending on their mode of action (5). Intravenous
dysfunction, renal dysfunction, or severe
magnesium sulphate may be one of the agents used
peripheral claudication, which suggest that the
for deliberate hypotension because magnesium
patient is less likely to have organ perfusion.
intervenes in the activation of membrane calcium
Patients with severe anemia and hypovolemia are
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1769-1784
Arthroscopic Posterior Cruciate Ligament Reconstruction
Ahmed Shamma, Mohammed El Nahas, Eslam Ahmed Hosny
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
corresponding authoer: Eslam Ahmed Hosny,email:firstname.lastname@example.org
Background: The Posterior Cruciate Ligament (PCL) injuries constitute 3-20% of knee injuries. The rate may be
higher because acute tears often go undiagnosed. More than one half of PCL injuries occur through traffic and
industrial accidents; less than one half occur through sports-related injuries. PCL injuries are rare in children.
Combined injuries to the PCL and other structures of the knee are much more common (97%) than isolated PCL
injuries (3%). Complete tears occur in approximately 40% of cases; partial tears in approximately 55%; and avulsion
tears in 7%.
Aim of the work: was to evaluate the arthroscopic reconstruction of the posterior cruciate ligament by the single
bundle technique, the results and the outcomes
Patient and Methods: This a case series non-controlled prospective clinical study included a total of ten patients
with posterior knee instability attending at El Hussein, Al-Azhar University Hospitals. This study was conducted
between August 2016 to May 2018. All patients underwent PCL arthroscopic reconstruction.
Results: showed a satisfactory highly statistically significant difference between pre and post-operative according
Lysholm score (P-value <0.001).
Conclusion: Arthroscopic single bundle reconstruction for complete posterior cruciate ligament (PCL) tear produce
satisfactory clinical results in medium term follow-up.
Keywords: Posterior Cruciate Ligament, Reconstruction.
The PCL injuries constitute 3-20% of knee injuries.
The posterior cruciate ligament (PCL) is one of the
The rate may be higher because acute tears often go
four major ligaments of the knee. It connects
the tibia to
undiagnosed. More than one half of PCL injuries occur
the medial condyle of the femur. This configuration
through traffic and industrial accidents; less than one
allows the PCL to resist forces pushing the tibia
half occur through sports-related injuries. PCL injuries
posteriorly relative to the femur. The PCL is an
are rare in children. Combined injuries to the PCL and
intracapsular ligament along with the anterior cruciate
other structures of the knee are much more common
ligament (ACL) because it lies deep within the knee
(97%) than isolated PCL injuries (3%). Complete tears
joint. They are both isolated from the fluid-filled
occur in approximately 40% of cases; partial tears in
synovial cavity, with the synovial membrane wrapped
approximately 55%; and avulsion tears in 7% (4).
around them. The PCL gets its name by attaching to
The PCL ruptures are uncommon apparently due to
the posterior portion of the tibia (1).
its strong fiber structure. The most frequent injury
The fibers of the PCL may be split into two
mechanism in isolated PCL tears is a direct blow on
functional bundles; the anterolateral bundle (ALB) and
the anterior tibia with the knee flexed thus driving the
the posteromedial bundle (PMB), relating to their
tibia posteriorly. Automobile accidents (in which the
femoral attachments. The tibial attachment is
knee hits the dashboard) and soccer injuries (in which
relatively compact, with the ALB anterior to the PMB.
an athlete receives a blow to the anterior surface of the
These bundles are not isometric: the ALB is tightest in
tibia during knee flexion) characteristically produce
the mid-arc of knee flexion; the PMB is tight at both
this type of injury. In other PCL injury mechanisms
extension and deep flexion (2).
(hyperextension, hyperflexion or rotational injuries
The posterior cruciate ligament (PCL) is the
with associated valgum/varum stress), other knee
strongest ligament about the knee and is approximately
structures are also often damaged (3).
twice as strong as the anterior cruciate ligament. Its
The severity is divided in three degrees and an
main function is to prevent the posterior dislocation of
acute injury is distinguished from a chronic injury.
the tibia in relation to the femur, providing 95% of the
Clinical presentation will depend on the degree, the
strength to resist the tibial posterior displacement.
condition of the injury and the symptoms if are
Along with the anterior cruciate ligament (ACL) the
observable, which include swelling, pain, feeling of
PCL controls the passive 'screw home' mechanism of
instability, limited range of motion and difficulty in
the knee in terminal knee extension. It also provides
mechanical support for the collateral ligaments during
Studies on the natural history of PCL injury show
valgus or varus stress of the knee (3).
that isolated grade I and II ligament injuries have good
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1785-1790
The Influence of Fetal Head Circumference and Fetal Weight Assessed by
Intrapartum Ultrasound on Labor Outcome
Isameel Talaat Elgarhy, Noha Mohamed Sabry, Hossam Mohamed Mohamed Abdelkader
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Hossam Mohamed Mohamed Abdelkader, Mobile: (+20)01003377224; Email:
Background: birth represents one of the most important of all the experiences of the human race. Despite the
complexity and sophistication of modern obstetrics, it is important to remember the simple objective of every
pregnancy, namely the delivery of healthy baby to healthy mother. During the last decade, assessment of
prolonged second stage has been incorporated into the standard routine antepartum and intrapartum evaluation of
labor. Objective: The aim of the present study was to determine if fetal head circumference and fetal weight could
predict the rate of caesarian section and vaginal deliveries in primigravidas women in labor.
Patients and methods: The study is a prospective cohort study that was conducted at Alexandria Police Hospital
maternity labor ward from April 2018 to December 2018. One hundred pregnant parturient admitted to the labor
ward of Alexandria Police Hospital for delivery were participated in this study according to specific inclusion criteria.
Results: The present study assessed ultrasonographically the head circumference and fetal weight as predictive
values on labor outcome. The receiver operator curve (ROC) showed that these were good predictors of mode of
delivery (sensitivity of 85 % and specificity of 92.6 %).
Conclusion: The numerical data have a significant relation between intra partum head circumference and fetal
weight relative to maternal pelvic diameter and the incidence of primary caesarian section, maternal and fetal
complications. So measurement of intrapartum head circumference and fetal weight are good predictors of labor
Keywords: Fetal Head Circumference, Fetal Weight, Intrapartum Ultrasound
ultrasonographic methods (6). Increasing attention is
Birth represents one of the most important of
being paid to the accuracy of using various
all the experiences of the human kind. Despite the
ultrasound measurements in estimating fetal head
complexity and sophistication of modern obstetrics it
circumference and fetal weight. Ultrasound could be
is important to remember the simple objective of
useful for decreasing the number of C-sections
every pregnancy, namely the delivery of a healthy
performed defensively by obstetricians who wish to
baby to a healthy mother. The fullest possible
avoid the possibility of a complicated delivery (7).
understanding of the birth process, its perturbations
and appropriate management policies is central to
AIM OF THE WORK
that objective (1).
The aim of the present study is to determine if
One of these complexities is prolonged labour,
fetal head circumference and fetal weight could
operative delivery procedures arising from prolonged
predict the rate of caesarian section and operative
labor increase maternal morbidity, fetal morbidity,
vaginal deliveries in nulliparous women in labor.
and the cost of care. Cephalopelvic disproportion
(CPD), due to narrow maternal pelvic diameter
PATIENTS AND METHODS
relative to fetal head circumference (FHC) or large
Design and Settings: The study is a prospective
FHC relative to maternal pelvic diameter, is the main
cohort study that was conducted at Alexandria Police
cause of prolonged labor (2).
Hospital maternity labor ward from April 2018 to
Maternal risks include birth canal and pelvic
December 2018. The study was approved by the
floor injuries, increased rate of operative vaginal and
Ethics Board of Al-Azhar University.
caesarean deliveries, and postpartum hemorrhage (3).
Birth weight of an infant is the single most important
Methods: One hundred pregnant parturient admitted to
determinant of newborn survival (4). Limiting the
the labor ward of Alexandria police Hospital for
potential complications associated with the birth of
delivery were subjected to the following inclusion
excessively large fetuses requires that accurate
criteria of the study.
estimation of fetal weight occurs before decision to
deliver is made (5).
Maternal age between 20 to 30 years old.
The two main methods for predicting birth All parturients were primigravidas.
weight in current obstetrics are clinical and Normal singleton pregnancies.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1791-1798
Comparative Study between Metformin and Insulin in
Controlling Gestational Diabetes Mellitus
Ehab Hassanin Mohamad1, Abdel Monsef Abdel Hamed Sedek1,
Ahmed Fathy Abdel Aziz2, Hisham Adel Abo Elez1*
1Departments of Obstetrics & Gynecology and 2Clinical Pathology,
Faculty of Medicine, Al-Azhar University
*Corresponding author: Hisham Adel Abo Elez, Mobile: 01026596980, Email: email@example.com
Background: the use of antidiabetic drugs to control gestational diabetes was controversial. Some studies
suggest a possible link between the use of oral antidiadetics and fetal anomalies, fetal macrosomia and neonatal
hypoglycemia whereas others have demonstrated no such relationship.
Objective: This study aims to assess the efficacy of metformin in controlling maternal blood glucose level
compared to insulin in women with GDM.
Patients and Methods: The present study included 116 pregnant women who have been diagnosed as
gestational diabetics before 34 weeks gestation with singleton pregnancy. They had FBG level ranging from 90-
169 mg/ dl or 2-hour postprandial blood glucose level ranging from 110-176 mg/dl. The exclusion criteria
include pregnant women with preexisting DM and underlying diseases known to affect fetal growth,
preeclampsia, unbalanced chronic disease, twin pregnancy, or refused to participate.
Results: Comparison of the baseline characteristics was performed between 2 groups and there were no
significant differences between the two groups regarding maternal age, gravidity, parity, GA at time of
diagnosis, GA at beginning of treatment, and BMI at time of diagnosis. Analysis of the results revealed that
metformin was an effective medication for control of blood glucose in women with GDM who failed to achieve
euglycemic with diet only.
Keywords: Gestational diabetes mellitus, metformin, metformin in gestational diabetes.
suggest lowering the capillary whole blood glucose
Gestational diabetes (GDM) is defined as
concentration to: pre-prandial< or = 95 mg/dl and
any degree of glucose intolerance with onset or first
either 1h postprandial < or = 140 mg/dl or 2h values <
recognition during pregnancy, is increasing
or ~ 120 mg/dl (2).
worldwide and currently holds up to 10% of
2. Medical nutrition therapy (MNT) and exercise:
pregnancies. GDM is characterized by insulin
Diet is the cornerstone of the management of
resistance or low glucose tolerance, which increases
hyperglycemia in gestational diabetes mellitus
throughout pregnancy. GDM is associated with lower
irrespective of the pharmacological therapy. The
pregnancy outcomes and may have long-term effects
targets to be achieved by medical nutrition therapy
on both mother and child. Therefore, it must be
are to provide sufficient nutrition to the mother and
understood that it is managed early and
fetus, provide adequate calories for maternal weight
appropriately. GDM is the most common cause of
gain, to achieve normoglycemic state and lastly to
diabetes during pregnancy, accounting for up to
prevent ketosis. Addition of 300 kcal /day is usually
90% of complex pregnancies due to diabetes.
required in 2nd and 3rd trimester in normal weight
Women with diabetes (GDM) have a 40-60%
women. A minimum of 175g carbohydrate per day
chance of developing diabetes within 5-10 years
should be provided. A moderate exercise program
after pregnancy. Although GDM is recognized as a
might improve fasting and postprandial glucose
disease of time, it is remains, a controversial entity
level and insulin sensitivity (3).
with conflicting guidelines and treatment protocols
3. Insulin therapy: Insulin therapy is the most
validated treatment option when medical nutrition
Treatment of gestational diabetes mellitus
therapy fails to achieve the target glycemic control.
can be classified into:
Despite emerging evidence supporting the use of
1. Glucose monitoring: Self-monitoring of blood
glyburide or metformin in the management of
glucose is the cornerstone for achieving the set targets
GDM, many guidelines continue to recommend
of plasma glucose in order to reduce perinatal
insulin as the first-line therapy. This is primarily the
mortality. Recommendations from fourth international
result of two factors: pregnancy category B for all
workshop conference on gestational diabetes mellitus
insulins except glulisine and glargine, and safety
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1799-1803
Effect of Upper Versus Lower Limbs Resisted Exercise on
Nitric Oxide Levels in Diabetic Patients; Type 2
Samir Elgazzar, Omar Elsaadany, Hany Obaya, Mohamed Helmy
Department of Physical Therapy for Cardiovascular, Respiratory Disorders and Geriatrics,
Faculty of Physical Therapy, Cairo University
Corresponding author: Mohamed Helmy, Mobile: (+20)01008434889, E-Mail: firstname.lastname@example.org
Background: There were 8.2 million cases of diabetes in Egypt in 2017 with prevalence in adults about 15.1%.
As the number of people diagnosed with type 2 diabetes continues to increase it has become imperative that health
care providers understand the importance that exercise plays in the treatment of this disease and preventing its
complications including nephropathy, retinopathy and cardiovascular disease.
Objective: this study aimed to investigate the effect of upper resisted exercise versus lower resisted exercise on
glycosylated hemoglobin and nitric oxide (NO) in diabetic patients type 2.
Methods: this study included 60 diabetic patients who were selected from the outpatient clinic of Internal
Medicine Department in Agouza Police Hospital from July 2018 to December 2018. They were assigned into two
groups equal in number. Group (A) received a program of upper limbs resisted exercise and Group (B) received a
program of lower limbs resisted exercise for 3 months.
Results: The results of this study revealed a significant increase in six-minute walk test and nitric oxide and a
significant decrease in glycated hemoglobin in both groups. Group (A) is superior to Group (B) in modulating
glycated hemoglobin and nitric oxide levels. Group (B) is superior than Group (A) in increasing six-minute walk
Conclusion: upper limbs resisted exercise is beneficial than lower limbs resisted exercise in modulating glycated
hemoglobin and nitric oxide in type 2 diabetic patients. Lower limbs resisted exercise is beneficial than upper limbs
resisted exercise in improving six-minute walk test.
Keywords: Diabetes type 2, upper limbs resisted exercise, lower limbs resisted exercise, nitric oxide.
Diabetes is a global health problem and the most
show the greatest benefits (8). Resistance exercise
common chronic disease affecting almost all
provides other mechanisms to reduce risk factors for
countries in the world. A pandemic has become
CVD compared to aerobic exercise (9,10). Other
widespread and continues to increase at an alarming
improvements in involuntary and blanket function
rate in recent decades(1). Specific long-term effects of
have been observed.
diabetes include the development of retinopathy,
Endothelin-1 reduction is important because it is
nephropathy and neuropathy. People with diabetes
a potent vasodilator and also has atherosclerotic
also have a risk of other diseases, including
effects, which means that reduction with chronic
peripheral cardiovascular disease and vascular brain
exercise may have beneficial effects on the
Cumulative evidence suggests that NO is
important in regulating glucose uptake during
AIM OF WORK
exercise (3), especially with people with type 2
This study aimed to compare between the effect of
diabetes (4). It became increasingly clear that
upper resisted exercise versus lower resisted exercise
oxidative stress has contributed to the development
on glycosylated hemoglobin and nitric oxide in
of large vascular complications (5).
diabetic patients type 2.
In fact, recent studies have shown that the
mechanism of ventricular dysfunction is largely due
PATIENTS AND METHODS
to the bioavailability of NO of endothelial cells
Sixty patients of both genders were selected from
derived from oxidative stress (6). Nitric oxide (NO)
outpatient clinic of Internal Medicine Department at
has an angiogenesis, anti-platelet, anti-proliferative,
Agouza Police Hospital, represented by the sample
decreased permeability, and anti-oxidant properties
of this study and all patients were diagnosed as type
2 diabetes (more than 5 years). Their age ranged from
Resistance exercise also showed reductions in
(50-60) years and they were on oral hypoglycemic
the risk of type 2 diabetes in both men and women,
treatment. The study was performed from July 2018
regardless of moderate physical activity, with
to December 2018. The study was approved by the
resistance in combination with aerobic exercises that
Ethics Board of Al-Azhar University.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1804-1808
Effects of Laparoscopic Sleeve Gastrectomy on
Hypertensive Morbidly Obese Patients
Hazem A. Megahed1*, Masoud Kh. El-Syed1 and Reihan M. Saad2
Departments of 1General Surgery and 2Cardiology,
Faculty of Medicine for Boys, Al-Azhar Univerisity, Damietta, Egypt
*Corresponding auther: Hazem A. Megahed, E-Mail: email@example.com , mobile: 00201068687477
Background: bariatric surgery is the standard way for obtaining a sustainable weight reduction in morbidly obese
patients and it is a beneficial in lowering hypertension (both on the short and long terms)and improving other
metabolic parameters. LSG is a relatively safe, simple and effective procedure which gained more popularity and
became the most commonly performed bariatric operation.
Aim: this prospective, randomized study designed to evaluate the outcomes of laparoscopic sleeve gastrectomy
(LSG) on hypertensive morbidly obese patients.
Patients and Methods: this prospective, randomized study was performed between January 2015 and December
2018 on 50 morbidly obese patients for whom a laparoscopic sleeve gastrectomy for treating morbid obesity was
done in the department of general surgery, Al-Azhar University Hospital, Damietta.
Results: the comorbidities among the 50 patients included hypertension (40), dyslipidemia (20), sleep apnea (18)
and diabetes mellitus (15). These preoperative comorbidities significantly improved within 6 months after LSG and
at the end of follow-up period which was one year after operation, nearly all comorbidities were resolved or
improved.There was also a significant short-term effect on obesity and hypertension following surgical treatment
and the decrease of blood pressure occured prior to significant reduction of weight.
Conclusions: laparoscopic sleeve gastrectomy can improve and resolve elevated blood pressure in morbidly obese
patients not only on the long term but also on the short term. It is a relatively safe and effective method not only for
reduction of excessive body weight but also for improving and resolving many other comorbidities of morbid obesity.
Keywords: bariatric surgery; hypertension; laparoscopic sleeve gastrectomy; weight loss; obesity.
Obesity is a critical health problem that is
Some articles suggested that hypertension in
increasing all over the world. It is defined as body mass
morbidly obese patients is related to sympathetic
index (BMI)30kg/m2 (1).
nervous system activation and enhancement of sodium
Morbid obesity is accompanied by increasing
reabsorption by stimulation of renin-angiotensin
risks of cardiovascular disease, dyslipidemia,
mechanism besides increased arterial stiffness on the
obstructive sleep apnea, stroke ,diabetes type 2,
long run (7-10). Some studies proposed that up to 70%
musculoskeletal disorders, some cancers (endometrial,
of hypertension in adults may be directly linked with
breast, and colonic carcinoma),osteoarthritis and many
adiposity and can be corrected by treatment of
other diseases(2,3). Bariatric surgery is the standard way
obesity(11). LSG was firstly performed as the first phase
for obtaining a sustainable weight reduction in
of bariatric operation biliopancreatic diversion with
morbidly obese patients improving their quality of life
duodenal switch which was done in two stages(12). By
and reducing long term mortality by diminishing the
the year 2000, LSG operation started to gain popularity
risk to previously mentioned comorbidities(4). LSG
and become a stand-alone procedure(13,14). Such
becomes a relatively safe, simple effective procedure,
profound results with regards to weight loss were
and a widely popular bariatric surgery(5).
noted following the first portion of the procedure and
Hypertension is one of obesity associated
both the patients and the surgeons preferred to forego
comorbidities which show improvement in its control
the second stage and by the year 2012, LSG gained
and may be reduced or even cured after correction of
more popularity and become the most commonly
obesity as reported by some studies and in the same
performed bariatric operation(15).
way it is easy to measure and to make a comparison
LSG is a restrictive procedure which limit
between pre and post operative results what led us to
food intake mechanically. Furthermore, it suggested
do this study(6)
that LSG may decrease appetite stimulation by
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1809-1816
Study of Serum Betatrophin Level in The Patients of Type 2 Diabetes Mellitus
Aliaa H. El-Ghandour, Aml S. El-Bendary (1), Abeer A. Shahba (2), Ghada A. Soliman (1),
(1) Department of Clinical Pathology, (2) Department of Internal Medicine
Faculty of Medicine, Tanta University
Corresponding author: Aliaa H. El-Ghandour; Mobile: 01221933647; Email: firstname.lastname@example.org
Background: Type 2 DM is due primarily to lifestyle and genetic factors. A number of lifestyle factors are
known to be important to the development of type 2 DM. Betatrophin, also known as angiopoietin-like protein
(ANGPTL8), is a circulating protein predominantly produced in the liver and adipose tissue. Betatrophin is
induced as a result of insulin resistance. It is reported to modulate pancreatic -cell mass and glucose
homeostasis reflectable on lipid metabolism.
Aim of the Study: Evaluation of the role of betatrophin in patients with type 2 diabetes mellitus.
Patients and Methods: This clinical study was carried out at Clinical Pathology Department, Tanta University
Hospital and included 80 subjects who were divided into two groups: Group 1:40 Patients diagnosed with type
2 diabetes mellitus. Group 2: 40 normal subjects with matched age and sex as a control group.
Results: In type 2 diabetes mellitus patients group, serum betatrophin ranged from 25.83 to 860.65 ng/l with
a median value of 54.815 ng/l while in control group, betatrophin ranged from 7.5-53.2 ng/l with a madian
value of 11.250 ng/l. There was significant statistical difference in betatrophin between the two groups. (P <
0.001). Betatrophin was significantly higher in type 2 diabtes mellitus patients as compared to control group.
Conclusion: Circulating betatrophine concentrations were significantly increased in patients with T2 DM and
associated with glucose homeostasis and insulin sensitivity. Thus, the level of serum betatrophin has a potential
role in detection and pathogenesis of T2DM.
Keywords: betatrophine, type 2 diabetes mellitus.
1. Insulin resistance in peripheral tissue, (defined
Diabetes mellitus is a group of metabolic
as decreased biological response to normal
diseases characterized by hyperglycemia resulting
concentrations of circulating insulin), especially
from defects in insulin action, insulin secretion, or
fat, muscle, and liver.
both. The chronic hyperglycemia of diabetes leads to
2. Impaired insulin secretion.
long-term damage, dysfunction, and failure of
3. Excess glucose production by liver.
various organs, especially the kidneys, eyes, heart,
A combination of multiple genetic and
nerves, and blood vessels (1).
Symptoms of marked hyperglycemia include
pathogenesis of type 2 diabetes (T2DM) (4).
polydipsia, polyuria, weight loss, sometimes with
Betatrophin Protein belongs to angptl family
polyphagia, and blurred vision. Acute life
which consists of eight members (angpt l to angptl
threatening complications of uncontrolled diabetes
8). This protein is an atypical ANGPTL protein as it
are hyperglycemia with ketoacidosis or the non
lacks the fibrinogen-like domain and only possesses
ketotic hyperosmolar syndrome.
the N-terminal coiled-coil domains (5).
Long-term consequences of diabetes include
nephropathy causing renal failure, peripheral
(ANGPTL-8) or lipasin secreted from the liver and
neuropathy with a risk of foot ulcers, amputations,
adipose tissue controversially was reported to
retinopathy with potential loss of vision.
modulate pancreatic -cell mass and glucose
Also, autonomic neuropathy leading to
homeostasis reflectable on lipid metabolism (6).
gastrointestinal, genitourinary, and cardiovascular
Lipoprotein lipase (LPL) is determining in the
symptoms and sexual dysfunction.
disposal of plasma TAGs where its dysregulation
Patients of diabetes have an increased
increased incidents of cardiovascular disease and
T2DM. One of the key regulators of LPL is
peripheral arterial and cerebrovascular disease.
Hypertension and abnormalities of lipoprotein
Betatrophin may be responsible for the
metabolism are often found in people with diabetes
increased plasma TAGs levels in obese and T2DM
Type 2 DM previously known as non-insulin
Betatrophin protein, also known as
dependent diabetes, or adult-onset diabetes, accounts
hepatocellular carcinoma-associated protein TD26. It
for about 85% of diabetic cases (3).
has been identified as a specific hormone that
The pathophysiology of type 2 DM is
promotes pancreatic cell proliferation and lipid
complex. It depends on three major abnormalities:
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1817-1825
Estimation of Serum Hepcidin and Ferritin in
Patients with Chronic Liver Disease
Safia Mahmoud Mohamed1, Amal Abd el-Aleem Morsy2,
Nessren Mohamed Bahaa El-Deen Mohamed1*, Aya Ragab Mohamed1
Departments of 1Tropical Medicine and 2Clinical Pathology,
Faculty of Medicine for Girls, Al-Azhar University
*Corresponding author: Nessren Mohamed Bahaa-El-Deen, E-Mail: email@example.com, Phone: 01003703546
Background: Hepatitis C virus affect iron metabolism leading to iron overload which associated with liver
Aim: estimation of the level of serum hepcidin and ferritin in chronic hepatitis C, cirrhosis and hepatocellular
carcinoma on top of hepatitis C.
Methods: this study was conducted on 60 Egyptian patients (study group); Group I comprise 20 patients with
chronic HCV infection, Group II comprise 20 patients with HCV cirrhosis, Group III comprise 20 patients with
HCC due to HCV infection, and also, control group comprise 20 apparently healthy individuals. All patients
and control were subjected to history taking, clinical examination, abdominal ultrasound, computed tomography
on abdomen. Laboratory investigations include complete blood picture, renal function tests, liver function tests,
and viral hepatitis marker. Antinuclear antibody, Alpha-fetoprotein, serum iron, serum ferritin and serum
Results: There was highly significant decreased in S. iron level in group I, II and III in comparison to control
group (p=0.000). There was highly significant increase in S. Ferritin level in group II and group III in
comparison to control group and in group III in comparison to group I. Also, there was significant increase in
S. Ferritin level in group II in comparison to group I. There was highly significant decrease in S. hepcidin level
in group II and group III in comparison to control group, in group II and group III in comparison to group I and
in group III in comparison to group II. S. Hepcidin has highly significant negative correlation with S. ferritin in
group I, II and III.
Conclusion: Low levels of serum iron, ferritin and hepcidine were observed in HCV cirrhotic and HCC
compared to control group.
Keywords: HCV, cirrhosis, serum iron, serum ferritin, serum hepcidin.
Hepatitis C virus infection is a major global
cause a release of iron by macrophages and
health challenge, it is estimated that more than 80
million people are chronically infected worldwide,
Hepcidin controls plasma iron concentration
with 3-4 million new infection and 350,000 death
and tissue distribution of iron. It inhibits intestinal
occurring each year because of HCV related
iron absorption by enterocytes in the duodenum
through its binding to ferroportin and inducing its
The Egypt Demographic and Health
internalization and degradation (10). Theses
Surveys (EDHS) measured antibody prevalence
mechanisms result in decrease of serum iron
among the adult populations aged 15-59 years at
concentration and increased intracellular iron
14.7% in 2009 (2) and 10.0 % in 2015(3).
content (11). The liver is the main iron storage organ
Hepatitis C virus remains the leading cause
a third of the body's total iron is deposited in
of chronic liver disease, accounting for 50% to 70%
hepatocyte, in the portal tracts, sinusoidal
of primary liver cancers (4). The incidence of chronic
mesenchymal cells and reticuloendothelial cells (12).
liver disease is increasing (5).
It also plays a fundamental role in iron metabolism,
Hepatocellular carcinoma (HCC), the most
as both transferrin (the main transporting protein)
common primary liver represents cancer, the sixth
and ferritin (the major storage protein) are
most common cancer worldwide, which results in
synthesized here (13).
the third cause of death from cancer per year (6).
Egypt has rising rates of HCC (7).
AIM OF THE WORK
Hepcidin is acysteine rich circulating
Estimation of the level of serum hepcidin and
bioactive peptide that is predominantly secreted
ferritin in chronic hepatitis C, cirrhosis and
from the liver and excreted in the urine (8). It also
hepatocellular carcinoma on top of hepatitis C.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1826-1831
Vitrectomy with Inverted Internal Limiting Membrane Flap
Technique for Treatment of a Traumatic Macular Hole
Emad Abdel Aal Saliem
Ophthalmology Department, Al-Azhar Faculty of Medicine, Assiut, Egypt
Corresponding author: Emad Saliem, Email: firstname.lastname@example.org
Background: Macular hole is a round full-thickness opening in foveal center which is an important cause of
central vision loss. In most cases it is idiopathic, i.e., due to abnormal vitreo-foveal traction without any apparent
predisposing conditions. Other causes include 1) High myopia. 2) Blunt ocular trauma.
Aim: to evaluate the anatomical closure rates and visual outcomes in patients with traumatic macular holes
treated by vitrectomy with inverted internal limiting membrane (ILM) flap technique.
Patients and Methods: a prospective interventional study was conducted on 10 eyes of 10 patients with
traumatic macular holes not spontaneously closed for more than 3 months after trauma and treated by vitrectomy
with inverted internal limiting membrane flap technique at I-vision private center, Cairo and Alforsan eye private
center, Assiut between September 2015 and December 2018. After surgery, both closure rate and visual outcome
were re-evaluated monthly during the follow up period up to 6 months.
Results: the main best-corrected visual acuity improved after PPV with inverted ILM flap technique from 0.87
± 0.09 logMAR at baseline to 0.73 ± 0.11 logMAR at 1st month, to 0.49 ± 0.13 logMAR at 3rd month and reached
to the maximum improvement 0.29 ± 0.10 logMAR by the end of 6th month (P < 0.001). The macular holes were
successfully closed in all cases (100%). Conclusion: vitrectomy with inverted internal limiting membrane flap
technique is associated with complete closure of the macular hole with restoration of the normal architecture and
also a significant improvement of vision.
Keywords: Vitrectomy, Inverted Internal Limiting Membrane Flap Technique, Traumatic Macular Hole.
Full-thickness macular hole is a relatively
Recently, Michalewska et al.(9) have reported the
common cause of loss of central vision. The
efficacy of the inverted ILM flap technique for large
pathogenesis in blunt trauma is not definitely known;
macular holes. Kuriyama(11) and Michalewska et al.
some authors theorized that the macular rupture as a
(12) also found that the inverted ILM flap technique
result of ocular trauma could result in rupture of the
contributed to a high macular hole closure rate in
fovea(1). Another hypothesis is that sudden separation
highly myopic eyes. The present study is the first
of vitreous might be the cause of TMH, although many
one that designed to evaluate the surgical and visual
cases actually have an attached posterior vitreous(2).
outcomes of the vitrectomy with inverted ILM flap
Optical coherence tomography (OCT)
technique as a line of treatment of non-spontaneously
allowed the detection of changes in the subclinical
closed TMHs for more than 3 months.
inner retinal layers that could play a role in the
Aim: to evaluate the anatomical closure rates and
pathogenesis of TMH formation (3).
visual outcomes in patients with traumatic macular
The standard treatment of MH is vitrectomy
holes treated by vitrectomy with inverted internal
with internal limiting membrane (ILM) peeling, gas
limiting membrane flap technique.
tamponade, and postoperative face-down positioning,
aiming to completely eliminating the macular
PATIENTS and METHODS
tractions and thus allowing the hole edges to come
together(4,5). In addition to elimination of tangential
included 10 eyes of 10 patients (7 males and 3
traction on the fovea, ILM peeling is believed to
females), with traumatic macular holes documented
increase the extensibility of the retina and enhancing
by FFA and OCT who had underwent pars plana
Müller cell gliosis which is associated with bridging
vitrectomy with inverted internal limiting membrane
the gap between the retinal hole edges(6,7).
flap technique at I-vision private center, Cairo and
The MH is closed by this standard procedure in
Alforsan eye private center, Assiut, between
approximately 90% of cases(8). However, in some
September 2015 and December 2018. The patients'
cases the standard procedure does not successfully
ages ranged from 21ys to 45ys with the main of
close the MH, such as MHs with large diameters,
33.8±7.91ys. The main of duration of symptoms was
those have existed for a long time, and secondary MHs
15.5±2.07ys. An informed written consent was taken
resulting from uveitis, ocular trauma, high myopia,
from each participant in the study. The study was
and proliferative vitreoretinopathies (9,10). Up to that
approved by the Ethics Board of Al-Azhar
time, there was no effective treatment for these MHs.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1832-1835
New Concepts for Surgical Management of Spontaneous
Abd El-Halim Abd-Elrazek Mousa, Mohamed Ahmed El-labbad,
Mustafa Mahmoud Mohamed Tolba *
Department of neurosurgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mustafa Mahmoud Mohamed Tolba; Mobile: (+20)01019459503; Email: email@example.com
Background: Spontaneous intracerebral hemorrhage (ICH) represents cerebral parenchymal bleeding that may also extend
into ventricular, and rarely, subarachnoid space. ICH, as a stroke subtype, is associated with poor neurological outcome as
well as high mortality (about 40% per month). ICH can be classified as either primary or secondary, depending on the
underlying cause of bleeding. Objective: This study was aimed to represent criteria for surgical management for
spontaneous intracerebral hematomas. Patients and Methods: This study included a total of 30 subjects, both sexes, aged
19-80 years with variable sizes and sites of spontaneous intracerebral hematomas. Conscious level and functional
disabilities were measured by the neurological examination, Radiological evaluation was done pre, early post-operative
and a month later to evaluate: the evacuation of the hematoma, monitoring the hemostatic measures done intraoperative to
prevent re-collection of the hematoma in presence of different co- morbidities like HTN, coagulopathy, ... etc. Results:
Statistics revealed significant improvement in subjects operated with GCS 8, with motor power deficit G 0 , clear chest
, age below 60 years old (P>0.001).
Conclusion: Patients with spontaneous intracerebral hematomas showing good prognosis in patients below 60 years old,
with clear chest complaining of motor power deficit G 0, with GCS 8.
Keywords: Surgical Management, Spontaneous Intra-Cerebral Hematomas.
Spontaneous intracerebral hemorrhage (ICH)
its origin from chronic hypertension or amyloid
represents cerebral parenchymal bleeding that may also
angiopathy (3).Secondary ICH is less common, and it is
extend into ventricular, and rarely, subarachnoid space.
associated with vascular abnormalities (e.g. arterio-
ICH, as a stroke subtype, is associated with poor
venous-malformations and aneurysms), impaired
neurological outcome as well as high mortality (about
coagulation or tumors. Even though hypertensive ICH is
40% per month)(1).ICH represents around 1015% of all
the most frequent type of ICH, vascular abnormalities
strokes in Europe, USA and Australia, while in Asia it
should always be considered in these circumstances
accounts for about 2030%. It has been reported that
because of high risk of recurrent hemorrhage and also
every year 2 million people worldwide have ICH (1). ICH
regarding the choice of the right therapy. Also, it should
can be classified as either primary or secondary,
always be kept in mind that nowadays ICH as a
depending on the underlying cause of bleeding (2).
consequence of the use of anticoagulant therapy is
Primary ICH is more common (7888% of cases) and has
becoming increasingly frequent, and it occurs in almost
20% of cases in the USA (4).
Fig. (1): CT brain showing lt intracerebral hematoma (4).
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1836-1843
Assessment of Liver Fibrosis Using Real Time Elastography and FIB 4
Score in Comparison to Liver Biopsy in Chronic HCV Egyptian Patients
Hassan Abd El Hafiez Rashed, Diaa Mohamed Eltibi, Ahmed
Hany Eissa²*, Mohamed Mahmoud El Kassas²
Department of Tropical Medicine, Faculty of Medicine, Al-Azhar University and ²National
Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
*Corresponding author: Ahmed Eissa, E-Mail: firstname.lastname@example.org
Background: HCV is one of the etiologies causing liver fibrosis through direct deposition of extracellular matrix in
the liver as a response to wound healing to compensate for the injury
Aim of this study: assessment of liver fibrosis using sonography-based real time elastography (RTE) and FIB 4
score in comparison to liver biopsy for assessment of the stage of liver fibrosis in chronic Egyptian HCV patients.
Patients and Methods: one hundred sixteen (116) patients with HCV were enrolled in the study from 2014-2015 in
the National Hepatology and Tropical Medicine Research Institute Outpatient Clinics, Cairo, Egypt.
Results: the mean RTELFI of the studied group was 2.68 ± 0.74. The correlation between different fibrosis stages,
FIB-4 and RTELFI showed significant relations between the degree of hepatic fibrosis and FIB-4 with p = 0.001 &
RTELFI with p <0.001. Positive correlation was detected between fibrosis stage, FIB-4 and RTELFI. At a cutoff
value of 3.26 for RTELFI, the test had a sensitivity of 72% and a specificity of 90% in detecting advanced fibrosis
with AUC = 0.791 (95% confidence interval 0.649-0.933).At a cutoff value of 2.26 for FIB-4 index, the test had a
sensitivity of 50% and a specificity of 87% in detecting advanced fibrosis with AUC =0.797 (95% confidence
Conclusion: RTE has excellent accuracy for F4 and F3 and is superior to FIB-4.
Keywords: RTE, FIB4, HCV.
the validation set, the negative predictive value to
HCV is one of the etiologies causing liver fibrosis
exclude advanced fibrosis (stage 4-6) was 90% with a
through direct deposition of extracellular matrix in the
sensitivity of 70%. A cutoff of>3.25 had a positive
liver as a response to wound healing to compensate for
predictive value of 65% and a specificity of 97%(4).
the injury. Liver fibrosis, whatever the degree of it,
The problem with FIB-4is that it carries the risk of
may be associated with worse outcomes in the context
overestimating the degree of fibrosis due to the effect
of HCV infection(1).
of necroinflammatory activity on transaminases(5).
Liver biopsy has been always considered as the
Transient hepatic elastography (TE) is a simple
gold standard method of detecting degree of fibrosis.
non-invasive method that is used to evaluate liver
But, because of the associated risk of bleeding, there
stiffness, depending on uni-dimensional transient
was refusal by many patients. Also, the sampling bias,
elastography, a technique that uses elastic waves and
and the variability in reading between pathologists(2).
low frequency ultrasounds (50 Hz). TE was validated
Other non-invasive methods were introduced into the
in many chronic liver diseases that are not due to viral
research field in a trial to find an easier way to judge
infection(6). In both adults and children, it was, initially
the degree of fibrosis and in the same way avoid the
projected and then validated in patients with chronic
previous disadvantages of liver biopsy(3).
FIB-4 and real time elastography were introduced
Several studies have emphasized the presence of a
in the last decade among many other diagnostic tools
significant correlation between TE and fibrosis stage,
as APRI score, fibro-test, MRI elastography to help as
as assessed by the METAVIR scoring system(7).
non-invasive methods to detect the degree of liver
The old RTE module depended on compression
fibrosis. The FIB-4 is a used equation for evaluating
by the operator to transmit a strain within the liver
liver fibrosis, based on age, AST, ALT and platelet
parenchyma then a strain profile is to be calculated
count. It was initially invented in the APRICOT study
along the compressed area. Nowadays, an automatic
(AIDS Pegasys Ribavirin International Coinfection
strain is generated by the heartbeat. In order to interpret
Trial) to evaluate the presence of liver fibrosis in
the results to fibrosis indexes, a new interpretation
HIV/HCV co-infected patients. At a cut-off of <1.45 in
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1844-1848
Assessment of Serum Level of Chitinase-3-Like-Protein 1 among
Emad Eldin Abdelmoneim El-Gamal1, Hany Othman Abo Al-Wafa1,
Hesham Samir Abd-Alsamee2, Marwa Eslam Bazied1
Departments of 1Dermatology, Venerology and Andrology and
2Clinical Pathology, Faculty of Medicine, Al-Azhar University
Corresponding author: Marwa Eslam Bazied, Mobile: 01065011344
Background: psoriasis is a chronic inflammatory autoimmune skin disorder, with a high relapse rate. The
etiology and pathogenesis of psoriasis are still unclear. Many cytokines produced by inflammatory cells give
rise to the induction and maintenance of psoriatic plaques. YKL-40 or chitinase 3-like protein1(CHI3L1) may
be involved in angiogenesis in psoriasis which has an important role in the pathogenesis of the disease.
Objectives: The aim of this study was to study the serum level of YKL-40 in patient with psoriasis in order to
assess its possible role in pathogenesis and severity of the disease.
Patients and method: this study included 60 psoriatic patients and 30 healthy subjects of matched age and
sex, served as a control group. Blood samples were taken from all patients and controls for estimation of serum
level of YKL-40 by ELISA.
Results: A statistically significant increase in median serum YKL-40 level in psoriatic patients compared with
control group. A positive correlation between serum YKL-40 and severity of psoriasis according to PASI
Conclusion: serum YKL-40 can be used as a new marker for evaluation of disease severity, progression and
therapeutic decision in psoriasis.
Keywords: Arachidonic acid, Endothelial dysfunction, Epidermal growth factor receptor
Psoriasis is a chronic inflammatory skin
articular chondrocytes, synovial cells, endothelial
disease that affects 2-3% of the world's population
cells and macrophages (7).
(1, 2). Classical psoriasis is also known as chronic
The exact biological functions of YKL-40
psoriasis or psoriasis is the most common type. It
are unknown. However, it is suggested that it
can be diagnosed fairly easily as distinct red
participate in the physiological and pathological
plaques with well-defined borders and silver-
processes such as angiogenesis, mitogenesis and
white dry scales, found in the elbows, knees and
remodeling (8). It is expressed and secreted by
scalp, although they can be more comprehensive.
cancer cells of different origins along with avariety
Other less common types of psoriasis also occur,
of non-malignant cells including inflammatory
such as raster, Pimples, rheumatic psoriasis and
and structural cells. Thus, it is implicated in
arthritis (3, 4).
cancers, cardiovascular diseases, infections and
other disorders (9).
The cause of psoriasis is unknown,
Serum levels of YKL-40 are increased
although it is generally thought to be a complex
during tissue remodeling and in a variety of
inflammatory disease with a genetic and immune
inflammatory conditions, such as rheumatoid
basis that can be altered by many environmental
arthritis, chron's disease and cancers. According to
factors such as stress, weather, physical trauma,
the role of YKL-40 in inflammatory diseases, we
medication and infection (5).
will study serum YKL-40 in psoriasis (10).
The aim of this work was to study the
Psoriasis is characterized by excessive
serum level of chitinase -3-like- protein 1 (YKL-
40) in patient with psoriasis in order to assess its
inflammatory cell accumulation and excessive
possible role in pathogenesis, severity and
dermal angiogenesis (6).
therapeutic approach of psoriasis.
protein1(CHI3L1) is a member of 18 glycosyl
PATIENTS AND METHODS
hydrolases (mammalian chitinase) family.YKL-40
This study included a total of 60 psoriatic
is one of the major secreted proteins from human
patients and 30 normal healthy individuals with
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1849-1856
Management of Women with Severe Preeclampsia by
Different Regimens of Magnesium Sulfate
Abd EL Samea Hassan Khalifa, Mohamed Mohamed Farahat and Khaled Mustafa Alsaudi
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
Corresponding author: Khaled Mustafa Alsaudi, Mobile: (+20)01153350100, E-Mail: email@example.com
Background: Preeclampsia is serious syndrome that can affect human pregnancy causing serious complications.
Preeclampsia is pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial
activation. Objective: The aim of our study was to assess the comparative effects of three regimens for the
administration of the magnesium sulfate when used for the care of women with severe preeclampsia to determine the
effective dose of magnesium sulfate in controlling cases with severe preeclampsia and prevention of eclampsia and to
determine whether only loading dose of magnesium sulfate is effective in prevention of eclampsia or not.
Patients and methods: The study included 240 pregnant women presenting to the casualty unit diagnosed as cases of
severe preeclampsia in the Obstetrics and Gynecology Department, Al-Azhar University Hospital and EL Mahalla
General Hospital. A randomized controlled study that compared three regimens for administration of MgSO4 used for
these cases. Results: There was no significant difference between occurrence of eclampsia in the three groups after
either administration of loading dose of MgSO4 only or administration of loading dose with maintenance dose for 12
hours or maintenance dose for 24 hours in the studied patients.
Conclusion: Magnesium sulfate proved to cause many hemodynamic changes as it has vasodilator effect on maternal
and fetal blood vessels. Magnesium sulfate should be given to all patients with severe preeclampsia.
Keywords: Preeclampsia, Magnesium Sulfate
Preeclampsia is a common complication of
drug have evolved over the years, but have not yet been
pregnancy and occur in about 5-10% of all pregnancies
formally evaluated (7).
(1). Preeclampsia is defined as a development of
In past, MgSO4 was given according to Pritchard
hypertension (140/90 mm Hg) and new onset of one or
regime in which 5 grams of magnesium sulfate was
more of the, proteinuria (> 300 mg of urinary protein in
administered four-hourly for 24 hours after loading
24 h), end organ dysfunction after 20 weeks of
with 14 grams. It was observed that many patients did
gestations and unfortunately is a major cause of
not receive maintenance therapy due to fear of toxicity
maternal and fetal morbidity and mortality worldwide
but they did not convulse any further (8). On the basis
of this observation, many studies were planned to
In view of recent studies that indicate a minimal
compare the efficacy of loading dose of magnesium
relation between quantity of urinary protein and
sulfate versus the standard regime in the management
pregnancy outcome in preeclampsia, massive
of preeclampsia to prevent fits (9).
proteinuria (greater than 5 g) has been eliminated from
Ehrenberg and Mercer(9) studied abbreviated
consideration of preeclampsia as severe. Also, because
postpartum magnesium administration in 200 women
fetal growth restrictions is managed similarly in
with mild preeclampsia. None of these women and
pregnant women with or without preeclampsia, it was
none of the other cohort given the 24 hour magnesium
removed as a finding indicating severe preeclampsia(3).
infusion developed eclampsia.
In normal pregnancy, adequate uteroplacental
Implementation of magnesium sulfate would be
perfusion depends on normal physiologic development
strengthened if guidelines and recommendations for
of the placental vascular system through trophoblast
practice could be based on reliable evidence about the
invasion of the uterine spiral arteries. The placental
comparative effects of alternative regimens.
vasculature is subsequently converted into a dilated,
low-resistance system, through a process termed
AIM OF THE WORK
The aim of our study was to assess the
Preeclampsia is thought to be the consequence of
comparative effects of three regimens for the
impaired trophoblastic invasion of the maternal spiral
administration of the magnesium sulfate when used for
the care of women with severe preeclampsia to
Magnesium sulfate is a drug of choice in
determine the effective dose of magnesium sulfate in
preeclampsia as an anticonvulsant rather than an anti-
controlling cases with severe preeclampsia and
hypertensive (6). Regimens for administration of this
prevention of eclampsia and to determine whether only
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1857-1864
Adverse Effects of Mono Sodium Glutamate, Sodium Benzoate and
Chlorophyllins on some Physiological Parameters in Male Albino Rats
Eman G.E. Helal*1, Abrar W. Barayan2, Mohamed A. Abdelaziz3, Nahla S.A. EL-Shenawe1
1Department of Zoology, Faculty of Science (Girls), Al-Azhar University, Egypt,
2Ministry of Health, Maternity and Children Hospital, Saudi Arabia, Makkah,
3Physiology Department, Faculty of Medicine, (Boys), Al Azhar University, Egypt
*Corresponding Author: Eman Helal, Email: firstname.lastname@example.org, Mobile: 00201001025364, orcid.org/0000-
Background: Chlorophyllin is known as natural green. Chlorophyll derivative is used as a food additive (foodcoloring
agent). Mono sodium glutamate (MSG), the sodium salt of amino acid glutamate, is a food additive that popularly used
all over the world as "Flavor enhancer".
Aim of the work: This study aimed to determine the hazardous effects of sodium benzoate, chlorophyllin and mono
sodium glutamate on some physiological parameters in male albino rats.
Materials and Methods: This study had been done on forty male albino rats. The Animals were divided into four groups;
Group I (Control untreated group), Group II (Sodium benzoate-treated group), Group III (Chlorophyllin-treated
group) and Group IV (Mono sodium glutamate-treated group). Blood samples were collected, sera were separated and
used for estimation of some biochemical parameters (liver enzymes, kidney function, glucose, protein profile and lipid
profile) and hormonal levels [testosterone, T3 (triiodothyronine) and T4 (thyroxine)].
Results: There was an increase in the activities of liver enzymes ASAT and ALAT as well as the levels of glucose,
kidney function (urea and creatinine), lipid profile (TC, TG, VLDL and LDL), Insulin and HOMA-IR (insulin resistance)
in the sodium benzoate- and mono sodium glutamate-treated groups. While chlorophyllin-treated group showed the same
results except for glucose level, kidney function, insulin and HOMA-IR. In addition, there was an increase in the level
of (T4) and (T3) in MSG group but these levels decreased in benzoate group. A drop in protein profile (total proteins,
albumin), high-density lipoprotein (HDL) and testosterone hormone in benzoate and glutamate groups as compared to
the control rats.
Conclusion: It could be concluded that some food additive like sodium benzoate and mono sodium glutamate have
extreme effects on liver and kidney function, protein and lipid profiles as well as on thyroid and testosterone hormones.
So, it is recommended to minimize the use of these additives to protect young children and mature people from these
Keywords: Food Additives, Thyroid hormones, Monosodium Glutamate, Sodium Benzoate, Chlorophyllins.
Food additives are substances used in the food
Monosodium glutamate can produce symptoms
industry to maintain consistency, texture, taste, color,
such as numbness, weakness, irritability, sweating,
quality, alkalinity or acidity. There are many food
dizziness and headache. In addition, MSG may cause or
additives that are widely located in two main categories
exacerbate many conditions, including asthma, urticaria,
depending on their purpose (i) safety and prevention of
atopic dermatitis, arrhythmias, neuropathy and
food degradation by bacteria, oxidation or chemical
abdominal discomfort (3). In animals, high doses of
reactions. (ii) improving product taste and appearance.
monosodium glutamate is neurotoxic because it destroys
They are classified according to their functions like:
nerve cells in the hypothalamic nucleus through changes
preservatives, flavor or color agent (1).
in the pituitary-adrenal axis. Moreover, excessive MSG
Monosodium L-glutamate (MSG) is a common
administration may lead to liver and kidney damage.
glutamic acid salt containing 78% glutamic acid and
Sodium benzoate is widely used as preservative
22% sodium salt and water. MSG is the most common
for food and beverages. It is a common preservative in
food additive that has been used as a flavor enhancer at
soft drinks because it prevents the growth of bacteria and
home as well as in the food industry since 1907.
fungi under the acidic conditions found in soft drinks. In
Therefore, most canned foods and fast food such as
addition, it is used in many foods including salads, soft
flavored flakes, canned soups, ready meals, mutton
drinks, jams, fruit juices, as well as in pharmaceutical
meat, bottled soy or Eastern sauces, frozen and tested
industries to keep liquid medicines. It is usually
tuna containing variable concentrations of MSG (2).
chemically produced and added as preservatives in
foods because of its antimicrobial function and its effect
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1865-1868
Mitomycin in Choanal Atresia Repair
Ahmed Abdelfattah1* and Ahmed Ibrahim Zaghloul2
Department of Otorhinolaryngology, Faculty of Medicine Cairo1 and Damietta2, Al-Azhar University
*Corresponding author: Ahmed Abdelfattah, E-Mail: email@example.com
Background: choanal atresia is one of congenital anomalies that needs surgical repair. Nasal re-stenosis and
obstruction are side effects of endoscopic repair. Mitomycin was proposed to decrease postoperative stenosis
Aim of the Work: it was to address the efficacy of adjuvant mitomycin therapy application in providing the
postoperative patency in choanal atresia.
Patients and Methods: this study is a record analysis of surgical outcomes of transnasal endoscopic surgical
choanal atresia repair in Al-Azhar University Hospitals (Cairo and Damietta). The study included records of 30
children with either uni- or bi-lateral choanal atresia. Eighteen (18) children of themwereoperated upon with
adjuvant mitomycin therapy. Meanwhile, records of 12 children were operated uponwithout adjuvant mitomycin
andconsidered as a comparison group. Postoperative stenting was carried out in all participants. The collected
information included demographic information, associated co-morbidities, operative details, and endoscopic
findings. The outcome measures were: granulation tissue formation, need for postoperative dilation and need for
revision surgical intervention.
Results: re-stenosis was reported in 11 (28.9%) patients. The need for revision surgery was reported in 10.3%.
The postoperative dilatation was required in 10 (25.6%) patients, and there was no significant difference between
mitomycin and comparison groups.
Conclusion and Recommendation: the use of adjunctive mitomycin therapy with endoscopic repair of choanal
atresia seems to be effective and safe approach. Multicenter follow up trials should be done to fully evaluate the
value (benefits) of adjuvant mitomycin therapy in choanal atresia repair.
Keywords: Choanal atresia, endoscopic surgical repair, mitomycin, stent
Thisresearch is a record analysis study of
Choanal atresia (CA) is a congenital
surgical outcomes of transnasal endoscopic surgical
anomaly with female predominance. It presented
interventional repair of choanal atresia that
unilaterally in about 70% of cases. As neonates are
conducted in Al-Azhar University Hospitals (Cairo
obligatory nasal breathers, early repair of bilateral
and Damietta). The study was approved by the Ethics
CA is mandatory(1). The goal of ideal surgical repair
Board of Al-Azhar University and an informed
isrestoring the normal nasal passagesafely with no
written consent was taken from each participant in
damage to adjacent tissues and leads to short
hospitalization. Transnasal endoscopic repair is the
The data of this study wereretrieved from
most widely accepted intervention (2,3). However, a
records of 30 children with either uni- or bi-lateral
trans-palatal approach remains necessary in some
choanal atresia, either bony or membranous atresias,
patients (e.g., neonates with severe craniofacial
without any other associated anomalies. These
anomalies or very small nasal fossae)(4).
patients were treated with transnasal endoscopic
Postoperativestenosis is one of common
surgical repair of choanal atresia by the authors
complications of CA repair surgery, secondary to
during the period from January 2014 to November
granulation tissue formation. This stenosis may need
2018. Eighteen (18) children were surgically
dilation by rigid dilators or even balloons and in
managed with adjuvant mitomycin therapy and
some occasions (severe stenosis); a revision surgery
considered as the studiedmitomycin group.
may be performed. Adjunct therapies were proposed
Meanwhile, 12 children were surgically treated
to avoid such problems. Stenting of the chonae(5) and
without adjuvant mitomycin and considered as a
intraoperative topical mitomycinhave been used to
mitomycin efficacy remains controversial (4,6-8).
demographic information, associated co-morbidities,
AIM OF THE WORK
operative details and endoscopic findings.
It is to address the efficacy of adjuvant
All cases underwent the surgical intervention
mitomycin application in treatment of choanal
under general anesthesia. Nasal decongestion was
achieved by oxymetazoline bilateral nasal drops.
PATIENTS AND METHODS
Nasal endoscopy was done by a telescope (0o, 2.7
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1869-1877
Role of Multislice CT in Diagnosis, Staging and Evaluation of
Malignant Pleural Mesothelioma
Dina Ahmed Hassan Torky, Hoda Mahmoud Abdelwahab, Fadila Mamdouh Elsayed
Department of Radiodiagnosis, Faculty of Medicine (girls), Al-Azhar University, Cairo, Egypt
Corresponding author: Dina Ahmed Hassan Torky, Mobile: 01017806339; Email: firstname.lastname@example.org
Background: Malignant mesothelioma is a rare but fatal disease that arises from the epithelial lining of the pleura,
peritoneum, pericardium and tunica vaginalis. Malignant pleural mesothelioma (MPM) is the most common form,
accounting for 80-90% of malignant mesotheliomas
Aim of the work: was to identify the value of CT in diagnosing malignant pleural mesothelioma and applying the
AJCC and the IMIG staging system for MPM. At the time to identify the limitations of CT if any.
Patient and methods: This prospective study included a total of 20 patients with CT findings suggestive of
malignant pleural mesothelioma, diagnosed at Radiology Department, Damanhur Oncology Center. All patients had
undergone multislice CT chest with intravenous contrast for detection and staging of the tumor. This study was
conducted between March 2018 and December 2018. The data collected were tabulated and analyzed statistically.
Results: CT study of the chest for cases of MPM was able to evaluate and diagnose the disease, with most of the
important staging items being easily seen on CT yet this study also showed the limitations of CT in the staging MPM
since CT alone was not able to prove the involvement of the chest wall, diaphragmatic muscle and trans
Conclusions: Chest CT alone is often sufficient for disease staging and treatment planning. Typical CT findings
that suggest MPM include unilateral pleural effusion with nodular irregular pleural thickening which can be
discrete or diffuse with or without inter lobar fissure thickening and nodal metastasis.
Keywords: Multislice CT Malignant Pleural Mesothelioma.
Chest wall invasion manifests as obliteration of fat
Malignant mesothelioma is a rare but fatal disease
planes or chest wall nodules. There is also frequent
that arises from the epithelial lining of the pleura,
contraction of the affected hemithorax with associated
peritoneum, pericardium and tunica vaginalis. MPM is
ipsilateral mediastinal shift, narrowed intercostal
the most common form, accounting for 80-90% of
spaces, and elevation of the ipsilateral hemidiaphragm
malignant mesotheliomas (1). It is the most common
(4). FDG PET/CT which superimposes functional
primary malignant pleural neoplasm (2). The majority of
imaging over the anatomical mapping yields a more
cases are associated with prior asbestos exposure (3).
accurate presentation of mesothelioma (7).
The tumor can invade both visceral and parietal
FDG PET is generally good in differentiating benign
pleura and frequently extends to adjacent structures.
lesions from malignant mesothelioma, which helps in
MPM is locally aggressive with frequent invasion of the
detecting recurrence and provides prognosting
chest wall, mediastinum, and diaphragm (4).
information (staging, survival, mortality, etc) (1).
The prognosis is poor, with a median survival time
It is important to stress that a diagnosis of
of 12 months after diagnosis. Several factors have been
mesothelioma cannot be made exclusively with
shown to correlate with reduced survival time which are
imaging studies. Biopsy is absolutely essential for the
intrathoracic lymph node metastases, distant metastatic
accurate diagnosis of mesothelioma (2).
disease, and extensive pleural involvement (2).
The aim of the current study was to identify the value
The primary role of imaging in malignant
of CT in diagnosing malignant pleural mesothelioma
mesotheliomas lies in preoperative staging and
and applying the AJCC and the IMIG staging system
assessment of treatment response, disease recurrence,
for MPM. At the time to identify the limitations of CT
or metastasis (5). CT with contrast is the most frequently
obtained examination owing to its easy accessibility (5).
It is the most frequently used modality in the
PATIENT AND METHODS
preoperative assessment of patients being considered
This prospective study included a total of 20
for surgical resection (4).
patients with CT findings suggestive of malignant
Low-dose CT has a greater sensibility than chest X-
pleural mesothelioma, diagnosed at Radiology
ray to detect tumor at early and treatable stage in
Department, Damanhur Oncology Center.
screening population (6).
Approval of the ethical committee of Al-Azhar
Key CT findings that suggest MPM include
Faculty of Medicine (girls) and a written informed
unilateral pleural effusion, nodular pleural thickening
consent from all the subjects were obtained. This
and inter lobar fissure thickening (2).
study was conducted between March 2018 and
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1878-1883
Cisplatin Plus Gemcitabine Versus Paclitaxel Plus Gemcitabine as
First-Line Therapy for Metastatic Triple Negative Breast Cancer
Sharehan Hassan Soliman Mustafa, Maha Lotfy Zamzam,
Soheir El-sayed Abdel Mohsen, Ehab Mohammed Hassanen
Clinical Oncology and Nuclear Medicine Department, Faculty of Medicine, Suez Canal University
Corresponding author: Sharehan Hassan Soliman Mustafa, email: email@example.com
Background: Although breast cancer management has generally improved, there is still a standing challenge
represented by the triple-negative breast cancer whose recurrence is highly frequent, disease-free survival
shortened, and the overall survival is extremely poor.
The Aim of Work: Compare between the total response rate of using gemcitabine/cisplatin versus
paclitaxel/gemcitabine regimens to treat the metastatic triple-negative breast cancer cases.
Materials and Methods: A random clinical trial method carried out on patients with metastatic triple-negative
breast cancer who attended to the Department of Oncology and Nuclear Medicine, Suez Canal University, in
2016/2017. A random assignment used to allocate patients who are qualified to: Group (A) to receive cisplatin
/gemcitabine (cisplatin 75 mg/m² on day 1; gemcitabine 1000 mg/m² on days 1 and 8) or Group (B) to receive
paclitaxel/gemcitabine (paclitaxel 175 mg/m² on day1; gemcitabine 1000 mg/m² on days 1 and 8) every 3 weeks
for eight cycles at maximum or until the development of disease progression or the intolerable toxic effect.
Results: Cases of triple-negative breast cancer were 144 (20.9%) and those of metastatic triple-negative breast
cancer were 110 (15.98%). Within a-12-month follow-up period, the total response rate of Group (A) was
significantly higher than Group (B) (69.1% versus 47.3%, respectively). In addition, the median disease-free
survival of Group (A) was significantly higher than that of the Group (B) (mean 7.18 versus 5.49 respectively).
Conclusion: Cisplatin/gemcitabine can be used alternatively, even a superior regimen to paclitaxel/gemcitabine,
for patients with metastatic triple-negative breast cancer.
Keywords: chemotherapy, second line, metastatic cases.
Moreover, the mutations of BRCA, (breast cancer
The pathological definition of triple-negative breast
gene) which are prevalently reported in unselected
cancer is that it refers to estrogen receptor (ER)-
patients suffering from triple-negative breast cancer,
negative, progesterone receptor (PR)- negative, and
are 11.2% higher than those of wider population
HER2-negative disease and its percentage ranges
suffering from breast cancer(7). The characteristics of
from 12 to 17% of all breast cancers(1) .
breast cancer which is associated with BRCA or the
Although breast cancer management has generally
sporadic triple-negative or basal-like breast cancer
improved, there is still a standing challenge
have a consistency with the abnormal DNA repair and
represented by the triple-negative breast cancer
genome-wide instability. In turn, this supports using
whose recurrence is highly frequent, disease-free
the DNA-damaging compounds such as platinum (8).
survival is greatly shortened, and the whole survival
In the past years, a lot of researchers have paid
is extremely poor. However, other types of breast
attention to examining the platinum-based therapy in
cancer have similar therapeutic approaches. Further,
the setting of neoadjuvant or metastatic triple-
for the relapsed triple-negative breast cancer, the
negative breast cancer(8,9). Two random phase 2
median distant disease-free survival ranges from 1 to
studies, GeparSixto and CALGB 40603, indicated
2 years. However, it is only 1 year for the metastatic
that when carboplatin is added to the neoadjuvant
triple-negative breast cancer (2,3).
therapy of triple-negative breast cancer, there were an
The main systematic treatment for triple negative
increase in the number of patients displaying a
breast cancer is the cytotoxic chemotherapy.
complete pathological response (10, 11).
Particularly, when the DNA repair agents, PARP
Further, when the cisplatin is compared to the
inhibitors, EGFR inhibitors, antiangiogenic agents, or
carboplatin, it achieves a higher efficacy in
checkpoint kinase 1 (Chk1) inhibitors (with or
neoadjuvant setting of locally advanced triple-
without chemotherapy) are used as targeted
negative breast cancer, the number of patients
approaches, they do not improve the triple-negative
displaying a complete pathological response
breast cancer outcomes substantially (4,5).
increases, and the overall survival improves
There is a general overlap between the molecular
signature of triple-negative breast cancer and the
In addition, cisplatin has achieved more complete
basal-like breast cancer where their concordance
and partial response than carboplatin in the metastatic
ranges from 70 to 90 %( 6) .
setting(13). Moreover, a phase-2 study carried out in
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1884-1890
Short Letrozole Therapy Vs Extended (Long) Letrozole Therapy for
Induction of Ovulation in Women with Polycystic Ovary Syndrome
Mahmoud M. A. El-Aziz, Mohamed S. Fouad, Tamer F. Ouf
Department of Obs. & Gyn., Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Corresponding author: Mahmoud M. A. Aziz, E-Mail: firstname.lastname@example.org, Mobile: +201008688781
Background: polycystic ovary syndrome (PCOS) is the major cause of anovulatory infertility. Letrozole and
other aromatase inhibitors (AIs) have been introduced as a new treatment option could challenge clomiphene
citrate (CC) for ovulation induction in this group.
Objective: to compare the efficacy of short vs extended courses of letrozole therapy for ovulation induction in
PCOS women. Patients and Methods: this is prospective randomized comparative study done on 60 patients
attended El-Hussein Hospital and previously diagnosed as having PCOS, based on the revised Rotterdam criteria
(2003). Patients were divided randomly into 2 treatment groups, group I, short letrozole therapy (30 patients,
received 5mg of letrozole from 1st to 5th day of menstrual bleeding) and group II, long letrozole therapy (30
patients, received 2.5mg of letrozole from 1st to 10th day of menstrual bleeding). All patients of both groups
monitored by trans-vaginal ultrasound on day 10 of the cycles. HCG injection (5,000 IU IM) was given when at
least one follicle measured 18mm. Intercourse were advised for 24-36h after HCG injection. Serum HCG and
trans-vaginal ultrasound were done 2 weeks after HCG injection in the absence of menstruation for diagnosis of
Results: in long letrozole therapy, total number of follicles, mean number of mature follicles, endometrial
thickness, percentage of patients ovulated after treatment, occurrence of pregnancy were greater when compared
to results of short letrozole therapy.
Conclusion: long letrozole therapy can produce more mature follicles and subsequently more pregnancies than
short letrozole therapy.
Keywords: polycystic ovary syndrome, letrozole.
Aromatase is a cytochrome P-450 hem protein
Polycystic Ovary Syndrome (PCOS) is one of
containing enzyme complex (the product of the
the most common causes of anovulatory infertility,
CYP19 gene) that catalyzes the rate-limiting step in
affecting 8-13% of reproductive-aged women (1). It
the production of estrogens which is the conversion
is by far the most common cause of
of androstenedione and testosterone via three
hyperandrogenic anovulatory infertility and was
hydroxylation step to estrone and estradiol (6).
described more than half a century ago, the
Aromatase activity is present in many tissues
underlying cause of this disorder is still uncertain
such as the ovaries, adipose tissue, muscle, liver,
(2). The classic symptoms of the disease are due to
breast tissue, and in malignant breast tumors. In
increased ovarian androgen production and chronic
premenopausal women, estrogens are produced
anovulation (3). There are several clinical and
primarily in the ovaries, corpus luteum, and
laboratory criteria such as obesity, acanthosis
placenta, although a small but significant amount of
nigricans, oligomenorrhea, hirsutism and acne.
estrogens can also be produced by nongonad
Also, there may be an increase luteinizing hormone
organs, such as the liver, heart, skin, and brain. E2
to follicle-stimulating hormone ratio (LH/FSH), as
is the major product from the whole biosynthesis
well as decreased ovulatory rate (4).
process and is the most potent estrogen during the
Criteria used for diagnosing Polycystic Ovary
premenopausal period in a woman's life, whereas
Syndrome (PCOS) are the Rotterdam Criteria
E1 plays a larger role after menopause, when it is
(2003) of which a woman must have two out of the
synthesized in adipose tissue from adrenal
1- Oligo- or anovulation.
Types of aromatase inhibitor (AIs): AIs all
2- Clinical and / or biochemical signs of
powerfully inhibit estrogen synthesis, they may be
subdivided into steroidal (type I) and nonsteroidal
3- Polycystic ovaries (with the exclusion of
(type II) inhibitors, which interact with the
aromatase enzyme (8). Type II non-steroidal AIs
Aromatase inhibitors (AIs) have been
exert their function through binding to the heme
introduced as a new treatment option that could
moiety of the cytochrome P-450 enzyme (9),
challenge CC for ovulation induction (5).
whereas steroidal AIs may bind covalently and
irreversibly to the aromatase enzyme.
Computerized tomographic study of the normal dimensions of the anterior horn of lateral ventricle in adults
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1891-1901
Role of Topical Mytomycin C Application in Improving
Outcome of Functional Endoscopic Sinus Surgery
Mohammed A. El Dabaa, Atef A. El Maraghy, Mohammed A. Yones,
Yahya M. Dawood and Mahmoud A. Megahed*
Otorhinolaryngology Department, Faculty of Medicine, Al- AZHAR University
*Corresponding author: Mahmoud A. Megahed, Mobile: (+20)01064911737, E-Mail: email@example.com
Background: functional endoscopic sinus surgery, (FESS), is a minimally invasive surgical procedure that
opens up the paranasal sinus ostia with an endoscope. Endoscopic sinus surgery is seen as the standard
treatment in chronic rhinosinusitis and Sinonasal polyposis.
Objective: it was to assess the efficacy of intra and postoperative topical application of Mitomycin C after
endoscopic sinus surgery in reducing adhesions and scar formation and improving outcome of FESS.
Patients and Methods: this study included 60 cases (24 female (40%) and 36 male (60%) ranging in age from
18 to 50 years) with mean 34 bilateral chronic rhinosinusitis with or without sinonasal polyposis undergoing
functional endoscopic sinus surgery. Every patient in this study had been submitted for full history taking,
general examination, full ENT examination routine preoperative laboratory investigations and computerized
tomography study on the nose and paranasal sinuses. Functional endoscopic sinus surgery had been done for
Results: In our study, bilateral nasal obstruction was presented in 46 patients (76.6%), anterior nasal discharge
was presented in 22 patients (36.6%), posterior nasal discharge was presented in 18 patients (30%), headache
was presented in 40 patients (66.6%) and facial pain was presented in 12 patients (20%). Endoscopic
assessment of the patients 2 months after F.E.S.S revealed that the adhesions presented in 32 sides (26.7%)
mainly occurred on the control side 25 (41.7%) while the Mitomycin C side showed minimal adhesions 7
(11.7%) with significant P value (0.04).
Conclusion: Topical application of MMC at end of FESS has beneficial role in prevention of adhesion
formation and synechiae without any side effects/complications.
Keywords: Mitomycin C, Functional Endoscopic Sinus Surgery.
Endoscopic sinus surgery is one of the most
In case of CT opacifcation of the posterior
common operations. Using the endoscope, sinus
ethmoid and/or sphenoid sinus, a posterior
surgery can be performed by the nose and at the
outpatient clinic. However, sinus surgery is used as
a last resort, and most patients do not understand
Synechia and ostial constriction are common
what sinuses do or even what sinuses do. Sinus is a
in the wake of FESS with incidence of 1 to 36%.
bony air cavity surrounding the nose. It relieves the
This is assumed to result from the proximity of two
echo head and the sound of one voice and can help
or more rough mucous surfaces to each other
protect the skull against sharp shock. If pockets are
during wound healing. Although not all synksia
disabled, they can become infected. However, most
formation requires treatment, total bone stenosis
of the "sinus" problems seen in many patients are
and obstruction of critical tracts of flow may lead to
actually problems in the main nasal passages
surgical failure and the need for revision therapy (3).
caused by smoking or allergies. Sinus is normal
The mitomycins are a family of aziridine-
even if the patient is suffering from symptoms of
containing natural products isolated from
obstruction of the nose, pressure and obstruction of
the airway. The only proven method of diagnosis of
lavendulae. Mitomycin C (MMC) has been used to
sinus disease is X-ray or CT scan (1).
reduce the stenosis and scar formation after
In FESS, after mucosal infiltration of 2%
carbocaine with epinephrine, uncinectomy and
otorhinolaryngolgic studies have showed its
middle antrostomy were performed without partial
resection of middle turbinate when possible.
Mitomycin C has been used topically rather
Standard endoscopic anterior ethmoidectomy was
than intravenously in several areas. Mitomycin C is
made, opening the agger nasi and the ethmoidal
used to generate mitotically inactive feeder cells
bulla. When the posterior ethmoid was not involved
used in cell culture systems, such as mitotically
by disease, surgical procedure is ended at this point.
The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (8), Page 1902-1906
Correlation of End-Tidal Carbon Dioxide Tension with Arterial Carbon Dioxide
Tension in Patients with Respiratory Failure on Mechanical Ventilation
Hamdy Zoair, Ahmed Ewis, Islam Ezzat
Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
corresponding author: Islam Ezzat,email: firstname.lastname@example.org
Background: Patients undergo mechanical ventilation need continuous evaluation of their respiratory condition.
Monitoring of end-tidal carbon dioxide (ETCO2) as noninvasive measurement of arterial carbon dioxide (PaCO2) is
a good tool for assessment and management of mechanically ventilated patients.
Aim of the work: The aim of this work is to correlate expiratory end-tidal carbon dioxide tension with arterial carbon
dioxide tension in patients with respiratory failure on mechanical ventilation and its significance.
Patients and methods: This study was carried out on 50 patients on invasive mechanical ventilation with acute or
acute on top of chronic respiratory failure admitted to respiratory I.C.U. at Bab El- Shaeria University Hospital,
Studied patients had obtained two ABG samples one at the onset of mechanical ventilation(M.V.) and the second
when the patient was on weaning mode of mechanical ventilation with continuous capnographic monitoring and
reading record at the onset of ABG sampling.
Results: The study include 31 males (62%),and 19 female (38%),24 patients (48%) had C.O.P.D, 9 patients (18%)
had pneumonia, 8 patients (16%) had O.H.S, 7 patients (14%) had I.L.D and2 patients (4%) had acute severe asthma.
The study shows no statistical significant difference between PaCO2 and ETCO2 at the onset of mechanical
ventilation (74.78 ± 20.19 and67.5 ± 19.23) mmHg and on weaning mode (43.98 ± 8.07 and 42.2±7.2) mmHg. that
PaCO2 measurements vary approximately 2-7 mmHg above ETCO2 values which mean good correlation between
PaCO2 and ETCO2.
Conclusion: - ETCO2 measurement provides an accurate estimation of PaCO2 in ventilation and weaning which
may reduce the need for invasive, high coast monitoring and repeated arterial blood gas analyses.
Keywords: End-Tidal Carbon Dioxide (ETCO2), Respiratory failure (RF), Mechanical Ventilation (MV).
Patients on mechanical ventilation need
analyzer(4). Capnography could be performed by
continuous evaluation of their respiratory condition.
trained medical staff in any setting in which
Frequent physical assessment must be complemented
mechanically ventilated patients are found (5).
by blood gases assessment for complete evaluation .)1(.
Monitoring of end-tidal carbon dioxide tension
PATIENTS AND METHODS
(ETCO2) as a rapid, noninvasive measurement of
arterial carbon dioxide tension (PaCO2) is one of the
This study was carried out on 50 patients on invasive
methods used for evaluation of mechanically
mechanical ventilation with acute or acute on top of
ventilated patients )2(. Capnography means continuous
chronic respiratory failure admitted to respiratory
analysis and recording of carbon dioxide concentration
I.C.U. at Bab El- Shaeria University Hospital in the
of respiratory gas which provides in addition to
period from January2018 to November 2018. 31 male
physical assessment a reliable picture of patient
patients (62%), while 19 patients were females (38%),
24 patients (48%) had C.O.P.D, 9 patients (18%) had
Although the two terms capnometry and
pneumonia, 8 patients (16%) had O.H.S,7 patients
capnography are sometimes considered synonymous,
(14%) had I.L.D and 2 patients (4%) had acute severe
capnometry means the measurement of carbon dioxide
concentration in respiratory gas, but no continuous
The study was approved by the local Ethics
record or waveform. Most bedside capnographs use
Committee. Informed written consent was obtained
infrared absorption to measure carbon dioxide (3) . Gas
prior to enrollment in the study.
sample could be obtained by tow methods for
analysis . The first is the main stream where the adapter
is placed in the breathing circuit. The second is the side
The followings were carried out for all patients:
stream where gas is aspirated from the breathing
) (Full medical history:
circuit and transported through a tube to remote CO2
a- Personal history: name, age, sex, occupation, marital
status, residence, smoking and other habits of medical