The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2325-2329
Left Ventricular Function as An Independent Prognostic Factor for
Coronary Artery Bypass Surgery
*Ahmed M. El Ashkar, **Ahmed N. Khallaf
Cardiothoracic Surgery, *Beni-suef University, Beni-suef, ** Fayoum University, Fayoum, Egypt.
Corresponding author: Ahmed El Ashkar, Phone: 01222149535, E-mail: email@example.com
Background : Studies have suggested that patients with severe impairment of left ventricular function had a poor
outcome following CABG surgery. Objectives: Evaluation of the role of pre-operative left ventricular function on
the early post-operative mortality and morbidity following CABG. Patients and methods: This study was carried
out from August 2016 to January 2017 including 40 patients undergoing CABG surgery. Patients were divided into
two equal groups each containing 20 patients. Group A contained 20 patients with pre-operative ejection fraction >
50%, while group B contained 20 patients with pre-operative ejection fraction < 50%.
Results: Mortality was 2 patients in group A (10%) compared to 5 patients in group B (25%) (P value = 0.031).
The mean ICU stay in group A was 3.29 ± 1.49 days compared to 4.22 ± 1.98 days in group B (P value = 0.028).
Pre-operative renal dysfunction improved in 2 patients (10%) from group A, compared to 1 patient (5%) in group
B (P value = 0.555). Conclusion: Left ventricular function as an independent factor is a good prognostic factor
regarding the early postoperative outcome in coronary artery bypass grafting including mortality, operative times,
ICU stay and hospital stay.
Keywords: Coronary artery bypass grafting; Ejection fraction; Left ventricular function; Prognosis of coronary
artery bypass grafting.
different techniques within a single scan, one of them
Pre-operative left ventricular dysfunction is an
called spin echo, which identifies abnormal
established risk factor for early and late mortality after
myocardium through differences in intrinsic contrasts.
myocardial revascularization. Left ventricular ejection
Another technique is using cine imaging called
fraction is an important determinant of the severity of
balanced steady state free precession (BSSFB). A third
heart failure. Causes and etiologies of systolic heart
technique is infarct imaging using contrast, where
failure include coronary artery disease, conduction
normal heart muscle appears dark while areas of
disease and valvular heart diseases as well as some
infarction appear bright white.
infectious and granulomatous diseases.
CMR perfusion: Contrast appears in the right
Ejection fraction (EF) is commonly measured
ventricle than in the left ventricle before blushing into
by echocardiography, by dividing the volume ejected
the muscle, which is normal (left) and abnormal (right,
by the heart (stroke volume) by the volume of the filled
an inferior perfusion defect). The key disadvantages of
heart (end-diastolic volume) (1).
CMR are limited availability, expense and special
In a healthy 70 kg man, the stroke volume is
skills/technical training needed to perform CMR.
approximately 70 ml and the left ventricular end-
diastolic volume is 120 ml giving an ejection fraction
of 0.58%. Healthy individuals typically have an
Can be performed with a radionuclide or with
ejection fraction between 50% and 65% (2).
an iodine-based contrast in cardiac chamber
A low ejection fraction has its cut off below
40% with symptomatic manifestations constant at 25%
Pre-operative risk stratification:
(3). In clinical practice, LVEF is frequently determined
There are three mortality measures that have
by "eye-balling" 2D echocardiography. This visual
traditionally been used to estimate pre-operative
assessment is reliable when performed by an
outcomes: In-hospital, 30-day and procedural (either
experienced echocardiographer. But due to personal
in-hospital or 30 day) (6).
variations, a more reliable method is to use volumetric
Additionally, because complications occur
measurements as described by the following equation:
more frequently than death, risk-adjusted major
LVEF = (LVEDV LVESV) / LVEDV where
morbidity may differentially Impact quality of care
LVEDV and LVESV are left ventricular end diastolic
and enhance a surgical team ability to assess their
volume and left ventricular end systolic volume
respectively (4).Cardiovascular magnetic resonance
Over the decades, a lot of risk models have
imaging (CMR) is derived from and based on the same
been proposed for the assessment of in-hospital
basic principles as MRI but with optimization for use
mortality in patients undergoing cardiac surgery, such
in cardiovascular system (5). CMR uses several
as Bernstein-Parsonnet model, the New York state
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2330-2333
Patients Risk Factors as Predictors of Surgical Wound Infection
Following Open Heart Surgery
Ahmed M. El Ashkar1 and Ahmed N. Khallaf2
Cardiothoracic Surgery Departments,1Beni-suef University, Beni-Suef, 2Fayoum University, Fayoum, Egypt
*Corresponding author: Ahmed El Ashkar MD, Phone: 01222149535, E-mail: firstname.lastname@example.org
Background: Median sternotomy wound infections are infrequent yet potentially fatal complication following
cardiac surgery. The reported incidence of sternal infections ranges from 0.9 to 20%, and the incidence of
mediastinitis is 12% in most studies. Several studies have examined and identified possible causes and risk
factors associated with sternal infections. They include patient-related risk factors, and procedure-related factors.
Aim of the study is the assessment of the patient's risk factors related to incidence of infection.
Patients and Methods: ninety-eight cardiac surgery patients operated via median sternotomy were included in
the study and the role of patient related factors (age, gender, obesity and diabetes mellitus) in the incidence of
postoperative superficial and deep sternal wound infection was accessed. Results: Sternal wound infection (SWI)
developed in 18 patients (18.36%). 15 patients (15.3%) had superficial SWI while 3 patients (3.06%) had deep
SWI. The most common causative organism in our study was staph. aureus especially MRSA.
Conclusion: Patient-related risk factors such as age, gender, obesity and diabetes mellitus are important risk
factors in the development sternal wound infection.
Keywords: Patient Risk Factors, superficial sternal wound infection, Deep sternal wound infection, Open heart
Median sternotomy wound infections are
median sternotomy in the Department of
infrequent yet potentially fatal complication
Cardiothoracic Surgery at Cairo University Hospital
following cardiac surgery. This complication is
from the first of May 2015 till the end of December
associated with amplified cost of care, prolonged
hospitalization, and increased morbidity and
43 patients underwent coronary artery bypass
graft (CABG), 4 patients underwent CABG + valve
For the benefit of consistency in comparing
surgery, 48 patients underwent valve surgery and 3
data from various reports, sternal wound infection
patients underwent graft repair of ascending aorta.
(SWI) was subdivided into two groups: (A)
All patients were prepared by full history
superficial SWI: wound infection confined to the
taking, full labs including glycated hemoglobin,
subcutaneous tissue and (B) deep SWI (bone and
radiological investigations, echocardiography, and
mediastinum): wound infection associated with
coronary angiography for CABG patients and valve
sternal osteomyelitis with or without infected
patients over 40 years, and preoperative prophylactic
retrosternal space (2).
antibiotics were administered as usual.
Several studies have examined and identified
Ethical considerations: All patients
possible causes and risk factors associated with
included in the study were consented and approval
sternal infections, although with conflicting results.
of the ethical committee was obtained.
They include patient-related risk factors such as age,
gender, obesity and diabetes mellitus, and procedure-
All patients were operated via median
related factors such as prolonged preoperative stay,
sternotomy using standard cardiopulmonary bypass
duration of surgery, use of bilateral mammary grafts,
and closure was achieved using stainless steel sutures
reoperation for control of bleeding and the need for
for the sternum and Vicryl sutures for the soft tissues
repeated blood transfusions (3,4).
and skin. Data such as operative time, CPB time, and
cross clamp time where collected.
AIM OF THE STUDY
The postoperative course for all the patients
Aim of this study is to access the role of
was monitored and data such as length of mechanical
patient related factors in the incidence of
ventilation, ICU stay, patient's hemodynamics and
postoperative superficial and deep sternal wound
inotropic support were collected and analyzed.
infection following open heart surgery.
Patients showing signs of superficial wound infection
had wound swab and blood culture and antibiotic
PATIENTS AND METHODS
therapy was changed accordingly.
This is a prospective study including 98
Criteria for defining and reporting surgical
consecutive cardiac surgery patients operated via
site infections (SSIs) were published in evidence-
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2334-2338
Laparoscopy in Gastro- Intestinal Tumors
Ahmed Abd Elmawgoud El-Tokhy
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Egypt
Corresponding author: A. El-tokhy, Email.email@example.com phone.01153477679
Background: Cancer is a major public health problem worldwide. Many studies have shown that the completion of
adjuvant chemotherapy improves the survival rate.
Objectives: The aim of the current study was to discuss the efficacy and role of diagnostic and therapeutic
laparoscopy as a new trend in managing gastrointestinal tumors.
Patients and Methods: This prospective study included a total of 50 patients, whom had gastro-intestinal tumor
diagnosed by tissue biopsy and histopathology attending at General Surgery Department, Sayed Galaal Al-Azhar
University Hospital. The hospital statistically significant data for the included 50 patients, pre and post diagnostic
laparoscopy and surgical intervention were collected and analyzed.
Results: A significant percentage of intra-abdominal cancers prove to be inoperable because of metastatic or locally
advanced disease despite a preoperative workup suggesting a potentially resectable disease.
Conclusion: It could be concluded that diagnostic laparoscopy is accurate staging tool for gastro intestinal tumors
as staging method prior to surgery that can change plan to start neoadjuvant chemotherapy (CTR) instead of surgery.
Laparoscopic surgery shows also short post- operative patient stay at hospital and early start of CTR.
Keywords: Diagnostic Laparoscopy, Staging of abdominal malignancies, Staging Laparoscopy, Operability,
Laparoscopy dates back to 1901 when George
descripatientsions and inventions of the Trendelenburg
Keeling of Dresden, Germany performed diagnostic
position in 1912, the use of needle insertion to obtain
laparoscopy on the dog's peritoneal cavity. Using a
pneumoperitoneum, and the creation of the dual-trochar
cystoscope introduced through trochar with pulmonary
technique, which opened the door to operative laparoscopy
pneumonia with filtered air. His style was described in
the German Biological and Medical Association as
Most of the abdominal malignancies on exploration
koelioskopie, published in 1902 (1).
were found to be unresectable or non-operable. Despite
Laparoscopy in general surgery was mainly performed
advances in radiology, pre-operative imaging studies are far
for the diagnosis of liver disorders and abdominal trauma,
less accurate in staging. Staging of the malignancy is very
until the intuition of Lukichev in 1983 and Muhe in 1985
important that each patient receives necessary treatment
who performed their personal technique of laparoscopic
with less morbidity (6).
cholecystectomy in humans (2).
Despite advances in technology, the accuracy of
Although its incidence is low, stomach cancer
radiographic evaluation in identifying hepatic metastasis
remains global, the third most common cause of
and peritoneal disease in gastric cancer is limited. In one
cancer-related deaths. An estimated 1 million new
study the accuracy of ultrasound (US) and CT in
cases of stomach cancer were reported in 2008. Two
detecting liver metastasis was only 76 % and 79 %,
out of three cancers occurred in East Asia, Eastern
respectively similarly, peritoneal carcinomatosis was
Europe and South America, with 78% of the deaths
only correctly identified by US and CT in 84 % and 81
occurring, compared to 65% of cancers. The Industrial
% of cases, respectively (6).
World (3). The
Starting laparoscopy is a safe and effective
bowel cancer has steadily increased over the past
starting method in patients with stomach cancer. It
two decades. The overall incidence has steadily
avoids the unnecessary abdomen in a large number of
increased from 11.8 cases per million people in 1973
patients and should be mandatory if new treatment is
to 22.7 cases per million people in the most recent
The aim of the current study was to discuss the
Colorectal cancer is the second most commonly occurring
efficacy and role of diagnostic and therapeutic
cancer in the USA and was estimated and to affect over 150,000
laparoscopy as a new trend in managing
men and women in 2005. Based on epidemiological studies,
there is convincing data that obesity is an important risk factor
for colorectal cancer (5).
PATIENTS AND METHODS
The initial application for laparoscopy was diagnostic
This prospective study included a total of 50
only, however this tool rapidly became popular across the
patients, whom had gastro-intestinal tumor diagnosed by
world for viewing and diagnosing of a wide range of intra-
tissue biopsy and histopathology attending at General
abdominal pathology. The technique improved with the
Surgery Department, Sayed Galaal Al-Azhar University
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2339-2345
Drain or not After Repair of Ventral Hernia with Mesh
Ahmed Abd Elmawgoud. El-Tokhy
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Egypt
Corresponding author: A. El-tokhy, Email.firstname.lastname@example.org phone.01153477679
Background: Abdominal wall hernias are among the most common of all surgical problems. Ventral hernia
repair (VHR) is a commonly performed operation, so hernia defect size affects operative time and surgical
technique for repair of a ventral hernia. Incisional hernia is the most frequent postoperative complication
following general surgery.
Objectives: This study was done to review and assess the difference between insertion of wound drain and the
use of abdominal binder and percutaneous aspiration after open repair of ventral hernias and its effect on
Patients and methods: A total of 100 patients with non-complicated abdominal wall (ventral) hernia were
enrolled to review and assess the difference between insertion of wound drain and the use of abdominal binder
and percutaneous aspiration after open repair of ventral hernias and its effect on postoperative outcome. Patients
were divided into two groups: Group (A) includes 50 patients with insertion of wound drain. Group (B) includes
50 patients with application of abdominal binder immediately postoperatively for 2 weeks.
Results: This study showed distribution of patients according to age, ranging from 27 years to 70 years with
mean age of 49.2 years (±11.6 years). 25% of patients below 39, 50% of patients below 50 and 75% of patients
below 59.75. In our study, 60% of operations were carried out under spinal anesthesia and 40% of operations
were carried out under general anesthesia. The hernial content of 100 patients was intestine in 28 cases, and
omentum in 72 cases. There were developing of significant seroma in (30%) of patients as follow: (17%) at
group A (with drain) and (13%) at group B (without drain). Significant seroma was not seen in (70%) of patients.
Wound infection was developed in (18%) of patients as follow; (12%) for group A (with drain) and (6%) for
group B (without drain). Wound infection not seen in (82%) of patients. As regard recurrence, (2%) of total
count only showing early recurrence that present at group B. Of total count only (9%) complained of persistent
postoperative pain as follows, 6 cases from group (A) and 3 cases from group (B).
Conclusion: It could be concluded that combined abdominal binder and percutaneous aspiration for selected
cases were superior to insertion of wound drains as regards seroma formation, wound infection and postoperative
return to normal activity with no significant difference as regards hematoma, postoperative pain, hospital stay
and patient satisfaction.
Keywords: wound drain, abdominal binder, percutaneous aspiration, ventral hernia, polyprolene mesh.
Ventral hernias are defined as a defect of the
Ventral hernia repairs are mostly elective (90%)
fascia in the anterior abdominal wall with or without a
procedures, but the repair methods are highly variable.
bulge. Clinical presentation varies from small
Repair methods are often not based on current best.
incidental defects to giant and complicated hernias
practices and results can be disappointing. Few
with fistulas and viscera located outside the
surgeons audit or record their outcomes outside of
abdominal cavity covered only by peritoneum and
those countries with national registries (1).
skin (loss of domain). The symptoms range from
This study was conducted to review and assess
minor cosmetic concerns to severe pain and life-
the difference between insertion of wound drain and
threatening conditions such as bowel obstruction,
the use of abdominal binder and percutaneous
incarceration, strangulation and perforation (1).
aspiration after open repair of ventral hernias and its
Ventral hernia is one of the most common
effect on postoperative outcome.
general surgical pathologies. An estimated 20 million
patients with hernias are operated on worldwide every
PATIENTS AND METHODS
year, of which approximately 30% are ventral. An
This prospective controlled trial study included a
incisional hernia will develop in 1015% of patients
total of 100 patients presented with non-complicated
with an abdominal incision and the risk increases to
abdominal wall (ventral) hernia attending at the
up to 23% in those who develop surgical site
Surgical Department, Faculty of Medicine, Al-Azhar
infection. Incidence rates up to 69% have been
University Hospitals. Approval of the ethical
reported in high-risk patients (2).
committee and a written informed consent from all
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2346-2352
Central Corneal Thickness and Intraocular Pressure in Type II Diabetes
Eman Y. Elsayed, Heba M. Abdelrahman, Naglaa A. Elkousy
Department of Ophthalmology, Faculty of Medicine (For Girls), Al-Azhar University
Corresponding author: Eman Yassin Elsayed Ahmed, Mobile:01000420945, Email:email@example.com
Background: Diabetes is a rapidly-growing global health problem with a significant impact on morbidity and mortality due
to diabetes-related complications. Objective: The purpose of this study was to assess the impact of type II diabetes on the
central corneal thickness (CCT) and intraocular pressure (IOP). Patients and Methods: This prospective case-control
study was performed at the ophthalmic department of Al-Zahraa University Hospital. It was conducted on 30
participants with type II diabetes and 10 healthy control (both eyes were included). Diabetics were categorized into 3
groups, diabetics without retinopathy, with non-proliferative diabetic retinopathy (NPDR) and with proliferative
diabetic retinopathy (PDR).Each group contained 10 participants. Complete ophthalmic examination was done for all
participants including, visual acuity, slitlamp, fundus examination, measurement of IOP and CCT. Fundus
photography and measurement of glycosylated hemoglobin A1c (HbA1c) were done for diabetics. Results: Diabetics
with PDR exhibited significantly higher IOP and CCT values compared to other groups. The IOP was significantly
correlated with CCT and with the duration of diabetes.
Conclusion: Diabetics with PDR had a significantly elevated IOP and thicker corneas than normal subjects. These
data emphasize the importance of considering CCT measurements in diabetics for proper interpretation of IOP.
Keywords: intraocular pressure, type II diabetes, central corneal thickness.
(POAG) is the commonest type of glaucoma in
Diabetes mellitus (DM) is a chronic metabolic
diabetic patients, (8)however the relationship between
disorder associated with hyperglycaemia, andcaused
diabetes and POAG is still controversial(9,10).The gold
by defect in insulin secretion and/or action. An
standard instrument for intraocular pressure (IOP)
increasing prevalence of DM is occurring worldwide
measurement is the Goldmann applanation
especially in developing countries.The highest DM
tonometer(11). However, it is calibrated assuming a
burden is concentrated in low-income and middle-
"standard" corneal thickness of 500 µm (based on
income countries(1-5).Patients with type II diabetes
white populations) and hence corneal thickness
constitute more than 70 % of all diabetic patients
would have some effect on the measured IOP values.
Thicker or thinner corneas may lead to either
epidemic(2,4,6).Currently, the prevalence of type II
overestimation or underestimation of IOP,
diabetes in Egypt is about 15.6% of adults aged
respectively. The extreme of error has a wide range of
between 20 and 79 years. The International Diabetes
almost12 mm Hg. As a result, various correction
Federation (IDF) has identified Egypt as the ninth
methods have been proposed(12-13).
country in the world with the highest number of type
Objective: The purpose of this study was to assess
II diabetic patients(6). Diabetes causes long-term
the impact of type II diabetes on the central corneal
systemic complications that have considerable impact
thickness (CCT) and intraocular pressure (IOP).
on the patient as well as the society (3,4).
The disease is divided into two main types: type
SUBJECTS AND METHODS
I and type II diabetes. Type I diabetes is an
This prospective case-control study was conducted
autoimmune disease in which the -cells of the
from July 2018 to January 2019 at the ophthalmology
pancreas do not produce sufficient insulin resulting in
department of Al-Zahraa University Hospital.
absolute insulin deficiency.Type II DM is thought to
Approval of the Ethics Board of Al-Azhar
be induced by complex interaction between genetic
University was obtained and the study adhered to the
together with environmental factors. It is caused by
principles of the Declaration of Helsinki guidelines. A
insulin resistance in peripheral tissues and/or an
written informed consent was taken from all the
insulin secretory defect of the -cell (2,4,6).
subjects after full explanation.
Diabetic patients often develop ophthalmic
Forty participants, aged between 40 and 60
complications, such as corneal abnormalities, iris
years, were enrolled into the study; both eyes were
neovascularization, glaucoma, cataracts and diabetic
included. They were divided into 30 patients with
retinopathy (DR)(7).Primary open angle glaucoma
type II diabetes compared to 10 age matched healthy
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2353-2357
aIncisional Negative Pressure Wound Therapy (INPWT) for
Coronary Artery Bypass Grafting Patients
Ahmed M. El Ashkar, Ahmed N. Khallaf
Cardiothoracic Surgery, * Beni-suef University, Beni-suef, ** Fayoum University, Fayoum, Egypt
Corresponding author: Ahmed El Ashkar, Phone: 01222149535, E-mail: firstname.lastname@example.org
Background: Surgical site infections are major complications of coronary artery bypass grafting using bilateral
internal thoracic arteries. In this study we reviewed the results of using INPWT for high risk patients with coronary
artery bypass grafting (CABG) using bilateral internal mammary arteries.
Patients and methods: From January 2013 to December 2016, patients with coronary artery bypass grafting using
bilateral mammary arteries were enrolled in this study. Patients were from Kasr El-Einy, Beni-Suef and Fayoum
University Hospitals. The total number was 427 patients, where INPWT was used in 161 patient, and conventional
sterilized dressing was done in 266 patients. 2 groups were matched for statistical analysis, the first group was the
control and the second group was where INPWT was used. Results: The results related to sternal wound infections
were similarly attributed to the conventional group (10.9%) and the INPWT group (10.2%) (P=1.00). Patients treated
with INPWT had less rate of infection than those with conventional dressing (5.5% versus 10.2%, P= 0.210), this
difference was not statistically significant. Interaction tests also showed comparable results for SSI (surgical site
infections) among patients with or without significant co-morbidities. Conclusion: This study suggests that the use of
INPWT did not decrease the incidence of sternal wound infections in patients who had CABG surgery using bilateral
internal mammary harvesting (BIMA). A larger randomized study is needed to evaluate the efficacy of this technique.
Keywords: Coronary artery bypass grafting; incisional negative pressure wound therapy; mediastinitis.
incision using povidone-iodine 10%. BIMA harvesting
Surgical site infections (SSIs) are fatal
was done in a skeletonized manner. The sternum was
complications of open heart surgeries. SSIs are the
closed by 4 figure-of-8 stainless steel sutures. The
Achilles heel of coronary artery bypass grafting using
subcutaneous tissues were closed using 1-0 or 2-0 vicryl
bilateral internal mammary arteries (BIMA) (1). This is
sutures. Skin closure was done using 3/0 continuous
probably due to the impaired vascularity following the
subcuticular Monocryl sutures. Tight glycemic control
harvesting of both mammary arteries (2). Although using
was achieved using insulin intravenous infusion intra-
BIMA has improved the long-term results of coronary
and post- operatively. Throughout the study period,
artery bypass grafting (CABG) (3), the risk of surgical
INPWT was used as a preventive method over closed
site infection remains a limiting factor for its wide use
wounds in 161 patients. The remaining patients were
as a method of coronary revascularization (4). Thus,
dressed in a regular way. The prevalence of this
several pre-, intra- and postoperative strategies have
technique was 9.1% in 2013, 24.1% in 2014, 51.7% in
been adopted to decrease the risk of SSIs following
2015 and 42.9% in 2016 (p < 0.001). In the INPWT
BIMA use (5). Recently, negative suction dressings for
group, dressing was done immediately after skin
closed sternotomy wounds have been used with
closure and sterilization, in the operating room and
promising results to decrease the risk of infection (6).
under complete aseptic conditions. The suction pump
The mechanism depends on decreasing the fluids and
was connected and adjusted to a negative pressure of -
the infecting materials at the incision. In this study, the
125 mmHg. The negative suction dressing was removed
efficiency of this method with CABG patients using
after 5-7 days. In the control group, a regular dressing
BIMA has been evaluated.
was done at the operation room, and was changed the
following day then regularly changed according to
PATIENTS AND METHODS
wound inspection every two days.
427 patients with isolated CABG using BIMA were
The criteria of assessment of this study was mainly
operated in Kasr El-Einy, Beni-Suef and Fayoum
the development of surgical site infection (SSI) of any
University Hospitals from January 2013 to December
degree, whether superficial, deep or mediastinitis.
2016. Antibiotic prophylaxis was done by cefazoline
Those presenting with superficial SSI were only treated
1.5 gm prior to the induction of anesthesia, with
with antibiotics and wound care. Those with deeper
intraoperative redosing after 2 hours. Postoperatively,
infections required longer duration of antibiotic
1.5 gm of cefazoline every 12 hours was given for 72
therapy, mostly I.V with reoperation for wound
hours. The incision site was sterilized just before skin
debridement and reclosure in cases of mediastinitis. The
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2358-2365
Incidence of Human Cytomegalovirus in Breast Carcinoma Tissues is Associated
with A Higher Expression of Growth Factor Receptor-Bound Protein 2
Mohamed Fares1*, Hossam Taha Mohamed2,3, Sherif Abdelaziz Ibrahim3, Mohamed Hosney3,
Mohamed I. Rady1, Mohamed El-Shinawi4, Mona Mostafa Mohamed3
1Department of Zoology, Faculty of Science, Al-Azhar University, Cairo, 2Faculty of Biotechnology, October
University for Modern Sciences and Arts, Giza, 3Department of Zoology, Faculty of Science, Cairo University,
4Department of General Surgery, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Mohamed Fares, Tel: +2-01113074575, Email: email@example.com and firstname.lastname@example.org
Background: female mammary carcinoma is the second most common cancer incidence among women and the fifth
most common leading cause of cancer death worldwide. Premenopausal young women are more frequently targeted
by inflammatory breast cancer (IBC), which is the most lethal form of breast cancer. The human cytomegalovirus
(HCMV) has been identified as one of the viral infection with a higher frequency in carcinoma tissues of IBC than
in non-IBC. The adaptor protein growth factor receptor-bound protein 2 (Grb2), was found to be upregulated in
HCMV-infected cells and play as crucial role in cancer progression.
Objective: this study aimed to assess the expression level of Grb2 in carcinoma tissues of IBC and non-IBC with
Patients and Methods: overall, 135 female diagnosed with breast carcinoma were enrolled in this study. Using
conventional and real time polymerase chain reaction (PCR), we determined the incidence of HCMV and assessed
the expression level of Grb2 mRNA in the breast cancer tissue samples.
Results: Grb2 mRNA was significantly upregulated in HCMV+ IBC higher than in HCMV+ non-IBC. According to
the molecular subtype, Grb2 mRNA was significantly higher upregulated in breast carcinoma tissues of HCMV+
hormonal positive (HP) than in triple negative (TN) counterparts.
Conclusion: HCMV infection is associated with a high expression of Grb2 mRNA in IBC and that HP HCMV+
mammary carcinoma tissues confer upregulated Grb2 mRNA, suggesting a potential role of HCMV infection in
enhancing of Grb2 mRNA expression in breast cancer with HP.
Keywords: Growth factor receptor-bound protein 2, human cytomegalovirus, inflammatory breast cancer.
Breast cancer is the most prevalent
variety of cellular functions and acts as a critical
cancer among Egyptian women and comprises
downstream intermediary in several oncogenic
approximately 29% according to National Cancer
signaling pathways (7).
Institute (NCI) (1). The most lethal form of breast
Human cytomegalovirus (HCMV) is an
cancer is inflammatory breast cancer (IBC), which
oncomodulatory virus that has been found to be
targets young women. IBC represents about 2.5% of
involved in breast cancer (8).
newly diagnosed breast cancers in the United States (2)
Grb2 as a cytoplasmic adaptor protein that
and its incidence is higher among AfricanAmerican
associated with activated epidermal growth factor
compared to white women (3). IBC frequency in North
receptor (EGFR) has a functional contribution during
African countries such as Tunisia, Morocco, and
viral replication and pathogenesis (9). While more than
Egypt represents about 10% to 15% of breast cancer
70 cellular proteins were found to be associated with
(4). Recent study conducted by Schairer and colleagues
HCMV virion (the infective form of a virus outside a
at the National Cancer Institute, Egypt, and at Institute
host cell) (10, 11), little is known about their role during
Salah Azaiz (ISA), Tunisia, suggests that the increase
viral replication cycle.
of IBC cases in North Africa may be due to
misdiagnosis of IBC with other types of locally
AIM OF THE WORK
advanced breast cancer (5).
This study aims to examine whether the
There are several signaling molecules which
expression of Grb2 mRNA patients correlated with
are overexpressed in human breast cancer, such as
incidence of HCMV infection in carcinoma tissues of
growth factor receptor-bound 2 (Grb2). The role of
IBC and non-IBC and that correlation was assessed
Grb2 as a signal transducer for several oncogenic
different molecular subtypes of breast cancer.
growth factor receptors and the involvement of Grb2
in multiple steps of the metastasis cascade, therefore
PATIENTS AND METHODS
emerging as a target for antitumor therapeutic
Patients and Samples: outpatients clinics of Ain-
strategies (6). Grb2 serves as an adaptor protein for a
Shams University hospitals from January 2015 till
January 2017 which, were previously diagnosed as
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2366-2373
Comparative Study between Mini-incision and Conventional
Surgical Approaches for Carpal Tunnel Release
Ahmed Maged Al-Mofty, Mostafa Sayed Mekky, Eman Mohamed Ibrahim Mostafa*
Plastic, Reconstructive and Burn Surgery Department, Faculty of Medicine, Al-Azhar University
*Corresponding author: Eman Mohamed Ibrahim Mostafa, E-Mail: email@example.com
Background: Conventional approach is an effective method for carpal tunnel release, however it causes scar
discomfort, pillar pain and cosmetic complaints. Several mini-incision techniques were introduced to avoid such
Aim of the study
The aim of this study is to compare the results of two surgical techniques, the conventional longitudinal incision
over the transverse carpal ligament (TCL), and the mini-incision at the distal wrist crease and near the proximal
border of the TCL for carpal tunnel release.
Patients and Methods: This study included 20 patients with carpal tunnel syndrome. 10 were operated upon by
classical open palmar incision (group A) and 10 through mini-incision technique at distal wrist crease (group
B). Follow up was after 2 weeks, 1, 3 and 6 months. Incisional pain, pillar pain using Visual Analog Scale
(VAS), Levine symptom and function severity scores were evaluated at 3rd and 6th months postoperatively.
Patients' satisfaction about surgery and cosmetic results were evaluated using Visual Analog Patient
Satisfaction Scale (VAPSS). Patients graded their cosmetic results from poor to excellent.
Results: There were no intraoperative complications. Group B showed significantly less incisional and pillar
pain. Patients were significantly more satisfied about cosmetic results in group B. There was no significant
difference between both groups regarding time taken to return to daily life activities.
Conclusion: Conventional and mini-incision surgical approaches are both safe effective methods for carpal
tunnel release. Mini-incision technique provided smaller and less painful scar, hidden in the wrist crease.
Keywords: Carpal tunnel syndrome, mini-incision technique, conventional approach.
Carpal tunnel syndrome (CTS) is
Endoscopic carpal tunnel is done through
considered the most common compressive
smaller incision. However, it is relatively expensive
neuropathy in which median nerve is compressed
surgery that needs specific equipment and
inside the carpal tunnel, secondary to any condition
preparations and has long learning curve. More
that increases the volume of structures or decreases
recently, various open mini-incision techniques have
the space inside the tunnel. It is more common in
been described as; limited palmar incision, double
females, between 40-50 years old. Risk factors
incision of Wilson, wrist mini-incision, have been
include obesity, hypothyroidism, diabetes mellitus,
described by either conventional instruments or
pregnancy, inflammatory arthritis, acromegaly and
special instruments trying to combine the simplicity
repeated and extreme flexion of the wrist at work.
and safety of open release with the reduced tissue
Patients usually complain of constant or intermittent
trauma, postoperative morbidity and cosmetic
paresthesia and pain in the area of the median nerve
outcome of endoscopic method using a short
sensory distribution. Nocturnal pain is common too.
In severe cases, thenar atrophy and weakness of
thumb opposition is observed. Electrophysiological
AIM OF THE STUDY
tests (nerve conduction studies) are often performed
The aim of this study is to compare the results
to support the clinical diagnosis(1).
of two surgical techniques, the conventional
There are multiple approaches for surgical
longitudinal incision over the TCL, and the mini-
carpal tunnel release; open and endoscopic.
incision at the distal wrist crease and near the
Conventional open method is still considered the
proximal border of the TCL for carpal tunnel
gold standard for surgical treatment of carpal tunnel
syndrome. It provides direct visualization and
complications, functional and aesthetic outcomes.
complete section of the ligament, and ability to
identify any anatomic variations or treatment of
PATIENTS AND METHODS
additional pathologies if found. However, it may
This study included twenty patients with
cause tender scar, pillar pain, and cosmetic
CTS operated upon in Al-Hussain and Said Galal
complaints, all related to the long incision and wide
Al-Azhar University Hospitals between December
2017 and January 2019. Ten of them were operated
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2374-2380
Laparoscopic Repair of Bilateral Inguinal Hernia Using Large Butterfly
Mesh Without Fixation Versus Double Meshes with
Stapler Fixation through TAPP Approach
Mahmoud Elsayed Nagaty
General Surgery, Faculty of Medicine, Al-Azhar university, Egypt
Background: Inguinal hernia repair is one of the most frequent elective operations performed in general
surgical practice. Approximately 20% to 30% of patients with inguinal hernia present with bilateral hernias at
Objectives: The aim of this study was to demonstrate the outcome between using a single large butterfly mesh
without fixation to Strengthen the posterior wall versus the use of two separate meshes with stapler fixation
during laparoscopic repair of bilateral inguinal hernia with TAPP technique.
Patients and Methods: A prospective randomized comparative study that was conducted in General Surgery
Department, Al-Hussein University Hospital, Faculty of Medicine, Al-Azhar University from January 2017 to
December 2018. A total of 40 patients with bilateral non-complicated inguinal hernias were included in this
study. The patients were subsequently divided into two comparable groups. Group A: Twenty patients were
scheduled for TAPP repair with double meshes and tacker fixation. Group B: Twenty patients were scheduled
for TAPP repair with a single large mesh without fixation.
Results: Average operating time was 102 minutes in group A, and 72 minutes in group B. Postoperative pain
was less in group B. One patient had transient hematuria in group B. There was one recurrence in group A on
the left side after 8 months and no recurrences were demonstrated in group B.
Conclusion: laparoscopic TAPP using a single large butterfly mesh is safe, time saving and cost-effective
approach for non-complicated bilateral inguinal hernias, especially in patients with direct hernia, large defect
and low BMI.
Keywords: inguinal hernia, butterfly mesh, laparoscopic hernia repair.
PATIENTS AND METHODS
Inguinal hernia repair is one of the most
Forty patients with bilateral inguinal hernias (32
frequent elective operations performed in general
males and 8 females) were included in our study. The
surgical practice (1). Approximately 20% to 30% of
patients were subsequently randomly divided into
patients with inguinal hernia present with bilateral
two comparable groups according to surgeon and
hernias at diagnosis(2, 3). Although the indications of
patient preference after thorough explanation of
laparoscopic treatment of inguinal hernia remain
either techniques in relation to the type of hernia,
controversial, most surgeons agree that patients with
body mass index and economic concern. Group A:
bilateral or recurrent inguinal hernia are those who
Twenty patients were scheduled for TAPP repair
benefit mostly from the laparoscopic approach,
using double separate meshes with tacker fixation.
which is considered the gold standard for treating
Group B: Twenty patients were scheduled for TAPP
such cases(4-6). The benefits of laparoscopic inguinal
repair using a single large butterfly mesh without
hernia repair include a decrease in postoperative pain,
fixation. All patients subjected to pre-operative
shorter hospital stay, and a small recovery Period(7).
assessment in the form of full history, examination,
Laparoscopy can diagnose occult hernia in
the contra-lateral side, also able to diagnose and treat
assessment and abdominal ultrasonography and all
recurrent and contra-lateral hernia at the same time
patients provided a written consent to participate
(8). The recurrences after laparoscopic surgical repair
in the study. The study was approved by the Ethics
has many causes such as incomplete and improper
Board of Al-Azhar University.
dissection, missed or undiagnosed hernia, using mesh
with small size, mesh migration or bad poisoning of
the mesh when the mesh is not fixed (9).
Under general anesthesia, patients were placed in
Recently, the need for and best way of
supine position, with a 10° Trendelenburg tilt with
fixing the mesh have been questioned. Mesh fixation
both arms in adduction position to patient sides. The
with staples or tacks is traditionally used and may
surgeon stands on the contra-lateral side of the hernia,
reduce the risk of mesh displacement, and
and the assistant stands opposite to the surgeon and
equipments were placed to the foot of the table (Fig.
(10). However, fixation is associated with higher costs
1). After pneumoperitoneum, using veress needle
and may increase the rate of acute and especially
three trocars were inserted: first, one 10 mm supra
chronic pain (11).
umbilical for 30° scope and 2nd and 3rd were 5-10
RELATIONSHIP BETWEEN SLEEP DISORDERED BREATHING AND PRO-INFLAMMATORY MARKERS IN ACUTE ISCHEMIC STROKE
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2381-2388
Vitamin B12 Status among Pregnant Women and Its Association with
Obesity and Gestational Diabetes
Mohammed Mohammed Gebril, Tarek Ramadan Abbas,
Mohammad Saad Eldeen Radwan and Mustafa Mohammed Abd El-Kader *
Obstetrics and Gynecology Department, Faculty of Medicine, Al- Azhar University
*Corresponding Author: Mustafa Mohammed Abd El-kader, Phone No.: (+2) 01018564599,
Background: pregnant women in resource-poor areas are at risk of multiple micronutrient deficiencies, and
diets that are low in animal products place women at increased risk of vitamin B12 deficiency.
Aim of the Work: to investigate the vitamin B12 status of pregnant women in Egypt and its relationship
with obesity and gestational diabetes mellitus (GDM).
Patients and Methods: this clinical observational prospective study has been conducted at Bab Al-Shaaria
University Hospital Obstetrics and Gynecological Department from April 2018 to January 2019. To assess
vitamin B12 status among pregnant woman and its association with obesity and gestational diabetes. 80
pregnant women attended to out-patient clinic were included in the study. The evaluation included data
collection through: history taking, examination, anthropometric measurement, maternal blood vitamin B12
level estimation at second and third trimester and blood glucose level.
Results: vitamin B12 deficiency in pregnancy is common particularly in obese women and those with GDM.
Conclusion: vitamin B12 deficiency is silent and common in general population. Causes of vitamin B12
deficiencies are multifactorial and associated with many health problems. Also, obesity is common and its
prevalence is increasing in the world. Therefore, both health problems have gained importance in family
medicine practice in the last decades.
Keywords: Vitamin B12 - Pregnant Women - Obesity and Gestational Diabetes.
produced including macrocytic red blood cells
Vitamin B12 also known as cobalamin, is
with or without anemia, ovalocytosis, hyper-
a micronutrient essential for cellular growth,
segmented white blood cells, pancytopenia,
differentiation, and development (1). Together with
atrophic glossitis, stomatitis, malabsorption due to
folic acid, vitamin B12 is necessary for the
villi atrophy and mucositis (4).
synthesis of DNA, RNA, lipids, and protein in the
The fetus will also bear the consequences
cellular cytoplasm (2).
of low cobalamin levels. An uncorrected
More specifically, vitamin B12 and folate
deficiency will not only lead to impaired fetal
are necessary cofactors for the conversion of
growth in utero but may also make the fetus
homocysteine to methionine, the latter being an
susceptible to a multitude to chronic diseases
important methyl donor required for the synthesis of
including diabetes mellitus, fatty liver disease,
neurotransmitters and phospholipids. Vitamin B12 is
cardiovascular diseases, depression and even
an essential water soluble vitamin that plays a vital
cancer in future (4).
role in the physiological dynamics of human body
The burden of maternal obesity (defined
ranging from production of erythrocytes on one
as body mass index (BMI) greater than 30 kg/m2)
hand to optimal nervous system functioning on the
is rapidly increasing, affecting nearly 35.9% of
other. Whenever there is depletion of vitamin B12
pregnant women in UK (3).
because of poor dietary source or increased cell turn
High BMI is associated with adverse
over, the deficiency can manifest as wide range of
symptoms. If not detected and treated timely, these
miscarriages and maternal deaths. In parallel, the
medical symptoms can present within a short period
incidence of gestational diabetes mellitus (GDM)
of time. It has been suggested that vitamin B12
has also risen affecting 5%18% of all
deficiency may be treated by parental or high dose
pregnancies depending on the diagnostic criteria
oral cobalamin therapy (3).
Pregnant females are at an increased risk
Vitamin B12 and folate are essential
of B12 deficiencies as they are in a state of high
micronutrients required for the synthesis of DNA,
cellular turnover and increased overall dietary
protein, and lipids, in a series of cellular reactions
requirements especially vitamin B12. The rapidly
collectively known as one-carbon metabolism (2).
growing fetus consumes vitamin B12 from the
One step in this process is the conversion of
mother's body, thus posing a threat of deficiency
homocysteine (Hcy) to a methyl donor,
if dietary requirements are not met. In the mother
methionine, for which B12 and folate are
classical cobalamin deficiency features may be
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2389-2396
Comparative Clinical Study between Preoperative
Oral Administration of Paracetamol, Celecoxib and Pregabalin on
Postoperative Pain in Gynecological Laparoscope
Sohair F.M. Ali, Abd Allah M. A. Alshiekh, Mohammed A. Elhosiny
Anesthesiology and Intensive Care Department, Faculty of Medicine Al-Azhar University
Corresponding author: Mohammed A. Elhosiny, email: firstname.lastname@example.org
Background: Since the introduction of laparoscopic surgeries, postoperative pain has been generally reduced.
However, it can still peak, especially during the early postoperative period and becomes the main cause of overnight
hospital stay and prolonged convalescence after this day-case surgical procedure. Thus, optimizing postoperative
pain relief, not only to sub-serve reduction of its intensity but to also enhance the recovery and shorten length of stay
became the broader target of multimodal pain control regimens nowadays. That is why; searching for a drug that
would be effective in reducing pain, safe from major adverse effects and can meanwhile possess an opioid-sparing
potentiality would be a merit so as to improve the success rate of ambulatory day-care surgeries.
Objective: To study the analgesic effects of preemptive single oral dose of paracetamol, celecoxib and pregabalin
in patients undergoing gynecological laparoscope.
Method: Preoperative evaluation, preparation and premedication was assessment, and routine laboratory
investigations was done. Postoperative pain, Level of Sedation was measured.
Results: There was statistical significant difference between the three groups regarding VAS.
There was statistical significant difference between the three groups regarding the total pethidine consumption. Regarding
postoperative level of sedation, blood glucose there was no statistical significant difference between the three groups.
Conclusion: Oral pregabalin in a dose of 150 mg 2 hour before surgery, is significantly attenuating pain intensity
and total meperidine consumption during the first 6 hours postoperatively.
Keywords: Preoperative, Paracetamol, Celecoxib, Pregabalin, Postoperative Pain, Gynecological Laparoscope.
Freedom from pain should be a basic human
Paracetamol (acetaminophen; N-acetyl-p-
right, limited only by our knowledge, to achieve it (1).
aminophenol) is well-absorbed from the proximal
Recent advances in the pathophysiology of pain have
small bowel and is not subjected to significant first-
suggested thatit is possible to prevent or to attenuate
pass metabolism in the liver, with oral bioavailability
the central neuralhyperexcitability that contributes to
estimated between 63% and 89% in adults(4). The
enhanced postoperative pain(2).
minimum plasma paracetamol level required for
Local pain after laparoscopy will be associated
analgesia and antipyresis is thought to be 10 g/ml,
with incisions for the operative ports. Lower
and the therapeutic range is usually stated to be 10-20
abdominal pain may depend on the extent of
g/ml (5). 150 g/ml is considered to be the threshold
intraperitoneal manipulation during diagnostic
laparoscopy. Sterilization operations cause ischemia or
concentration (Cmax) is achieved approximately 45
damage to the fallopian tubes and are generally more
min after 1g orally(7). Paracetamol inhibits both
painful than simple diagnostic procedures, with clips
isoforms of cyclooxygenase (COX); the constitutive
generally causing less pain than other techniques to
COX-1 and the inducible COX-2. Paracetamol
occlude the tubes(3).
displays weak anti-inflammatory activity, few or no
Upper abdominal, shoulder tip, and postural
gastrointestinal side effects and only a small dose-
high back pain after laparoscopy are likely to be caused
dependent alteration of platelet function. Current
by gas retained in the peritoneal cavity. Carbon
evidence points to multisite activity in the central
dioxide is usually used to expand the abdomen to allow
nervous system, involving inhibition of prostaglandin
surgical visualization. Although it is a soluble gas in
synthesis and interaction with both serotonergic and
comparison to oxygen and nitrogen, it can take up to
cannabinoid pathways (8).
two days to be absorbed from the peritoneal
Celecoxib is a tricyclic compound having a
cavity. Pain from the residual gas is of delayed onset
pyrazole ring that exhibits an excellent level of anti-
and may present once the patient has gone home.
inflammatory action against COX-2 enzymes (9, 10).
Hohlrieder et al. found that the worst pain after
Celecoxib is a selective COX-2 inhibitor shown to be
gynecological laparoscopic surgery was felt in the
as effective as traditional NSAIDs as an analgesic for
shoulder in 1% of the patients, two hours after surgery,
acute postoperative pain. Traditional NSAIDs inhibit
but in 70% of the patients 24 hours after surgery(3).
both COX-1 and COX-2isoenzymes. Moreover,
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2397-2405
Immunohistochemical Expression of Cyclooxygenase-2 (COX-2) in Breast Cancer
1Mahmoud Ismail Ahmed Nassar, 2Shaimaa M.M. Bebars, 2Rasha Mohamed Samir Said,
2Taghreed Mohammed Amin Mustafa
1Department of Pathology, Faculty of Medicine, Assiut University,2 Department of Pathology, Faculty of Medicine,
*Corresponding author: Taghreed Mohammed Amin Mustafa, E-Mail: email@example.com,
Background: breast cancer (BC) is the most common type of diagnosed cancers in women. It is still the second
leading cause of cancer-related death among women after lung cancer all over the world. Breast cancer is the first of
top ten cancers in Egypt. It ranks as the first malignancy affecting females, contributing 30% of all female cancers.
It affects 1 in 14 women during their life time.
Aim: This study investigated the association between cyclooxygenase-2 (COX-2) expression in female breast can-
cer versus the expression of ER, PR, as well as its association with other established prognostic indicators like age,
tumor size, lymph nodal status, stage, grade, lymphovascular invasion, insitu component and histological subtype,
and aims to validate the role of overexpression of COX-2 as a prognostic marker in female patients with breast can-
cer in Egypt.
Results: High significant correlation was found between lymph node metastasis, negative ER and PR cases and
COX-2 expression. No significant correlation could be detected between age, tumor size, site, histologic type, grade,
insitu component, LVI and COX-2 expression.
Conclusion: Cyclooxygenase-2 has poor prognostic parameter in breast cancer, as it is over expressed in majority
of breast carcinoma, especially with lymph node metastasis, ER and PR negative hormone receptor.
Keywords: Breast cancer, Cyclooxygenase-2, prognostic marker, immunohistochemistry (IHC), ER\PR receptor,
munity (5). Clinical studies have noted a reduced risk
Breast cancer is the most frequently diagnosed
for breast, lung, prostate, and colon cancers after
cancer and the most common cause of cancer death
treatment with non-selectively COX-2 inhibition by
among women. It accounts for nearly (23%) of all fe-
non-steroidal anti-inflammatory drugs (NSAIDs) or
male cancers worldwide, with more than a million new
selective COX-2 inhibition with COX-2 inhibitors (6).
cases each year. Although BC incidence rates in Egypt
It has been reported that elevated COX-2 ex-
are substantially lower than the rates in the United
pression was more common in larger size breast can-
States and other developed countries, breast cancer is
cer tumors with axillary lymph node metastasis (7).
the most common cancer among women in Egypt.
More studies are needed to confirm the potential role
Prognosis of breast cancer depends on different factors
of COX2 in breast cancer prognosis and studying the
as tumor size, histologic type, stage, and molecular
role of COX2 inhibitors in reducing the risk of breast
Cyclooxygenase (COX) group of enzymes are
important for the conversion of arachidonic acid to
AIM OF THE WORK
prostaglandins. Cyclooxygenase-1 (COX-1) is consti-
To study the expression of (COX-2) in breast
tutively expressed at a constant level throughout the
cancer and the relationship of its expression with the
cell cycle in most of the tissues. The inducible iso-
clinicopathological data of the studied cases, including
form, Cyclooxygenase-2 (COX-2), is often over ex-
(age, size, site of tumor, histological type, grade,
pressed in breast cancer (2).
lymph node metastasis, stage of tumor, estrogen and
Cyclooxygenase-2 derived metabolites may
progesterone positive or negative tumor).
contribute to maintenance of premalignant hyper-
proliferation, transformation, tumor viability, growth,
MATERIAL AND METHODS
invasion and metastatic spread (3). Cox-2 and its prod-
This retrospective study was carried out on 50
ucts, particularly prostaglandin E2 (PGE2), act via
cases of Egyptian (BC) patients. These cases were se-
classical cancer signaling pathways in primary tumor
lected from archives of Pathology department, Faculty
cells to promote tumorigenesis. Evidence has shed a
of Medicine, Assuit University, Aswan University and
spotlight not only on the tumor cell itself, but also the
private laboratories from January 2014 till reaching the
tumor microenvironment, especially macrophages in
target of cases. Cases were collected as paraffin em-
the tumor (4). Over-expression of COX-2 has been de-
bedded blocks. The selected cases included modified
tected in several malignancies including breast cancer,
radical mastectomy (MRM) and conservative breast
and contributes to carcinogenesis by stimulating can-
surgery either lumpectomy or wide excision with axil-
cer cell proliferation, inhibiting apoptosis, increasing
invasiveness and modulating inflammation and im-
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2406-2417
Endovascular Managment for Intracranial Carotid Artery Aneurysms
Yousef Abdel El Gelel Barakat, Mohamed Sayed Esmael Al Shandawely, Ahmed Al-Sherif, Salah
Mohamed Mohamed Meraka*
Department of Neurosurgery, Faculty of Medicine, Al-Azhar University (Assiut)
*Corresponding author: Salah Mohamed Mohamed Meraka, Mobile: (+20)01011141543,
Objective: To assess safety and effectiveness of endovascular managment for different types of intracranial carotid
Patients and Methods: prospective and retrospective review of intracranial carotid artery aneurysms treated by
endovascular procedures in Al-Azhar University Endovascular Center and other centers. Twenty patients met
Results: fourteen medium sized, nine small, four large and one giant aneurysm. Seventeen narrow necks, eleven
wide-necks and seven have involved branches in neck. Twenty-three cases were treated with coiling, three cases
were treated with stent-assisted coiling and two cases were treated with stenting as flow diverter.
Conclusion: pre-procedural conscious patients with GCS15 or 14 associated with better outcome. PcomA,
Ophthalmic and Choroidal aneurysms were associated with better outcome after endovascular procedures. Coiling
of narrow neck aneurysms was associated with better outcome.
Keywords: cerebral aneurysm, endovascular techniques, wide-neck aneurysm, coiling, internal carotid artery
underlying vascular pathology, DSA is the gold
An aneurysm is an abnormal focal
standard for evaluation of the arterial system.As
dilatation of an artery, forms a focal discontinuity and
approximately 20 to 30 percent of the ruptured
a weak spot in the vessel wall, predisposing to
aneurysms hemorrhage again within the first month
aneurysm rupture, the most frequent cause of non
after a SAH, the treatment of ruptured intracranial
traumatic subarachnoid hemorrhage (SAH)(1).
aneurysms is well grounded. The management of
The prevalence of intracranial aneurysms is
unruptured cerebral aneurysms is, however, still
around 2% for adults without specific risk factors,
much more controversial because of incomplete and
12% in patients with polycystic kidney disease, 7%
conflicting data about the natural history of these
with fibromuscular dysplasia, and 5% with
lesions and the risks associated with their treatment(4,
syndromic connective tissues diseases (e.g. Ehlers-
5). The operative treatment of intracranial aneurysms
Danlos type IV)(2).
falls into two main categories, namely microsurgical
The rupture rate of unruptured cerebral
treatment and endovascular techniques. When an
aneurysms in the Familial Intracranial Aneurysm
aneurysm is microsurgically clipped, the base of the
study cohort (1.2% per year) was approximately 17
aneurysm is closed by opposing the aneurysm walls.
times higher than the rupture rate for subjects with an
The goal of microsurgical aneurysm treatment is to
unruptured cerebral aneurysm in the International
achieve complete and permanent exclusion of the
Study of Unruptured Aneurysm Study (0.069% per
aneurysm from the circulation while preserving the
year) with a matched distribution of aneurysm size
parent artery and possible perforating or branching
and location(3). Intracranial aneurysms are classified,
vessels arising from the parent vessel(6).
according to their morphology, into saccular and
The purpose of endovascular aneurysm
nonsaccular aneurysms (fusiform and dissecting) and
therapy is to exclude the aneurysm from the
according to diameter into small, medium, large and
circulation either by endosaccular occlusion or by
flow diversion and parent vessel reconstruction. The
The clinical presentation of aneurysmal
endovascular approach to aneurysm occlusion has the
SAH is often a severe headache of sudden onset, may
theoretical advantage of avoiding craniotomy and
be associated with nausea, vomiting, stiff neck, loss
brain manipulation, but is nevertheless associated
of consciousness, and focal neurological deficits
with numerous challenges (i.e. the risk of
including cranial nerve palsies, (5).
periprocedural aneurysm rupture, occurrence of
If SAH is detected in non-enhanced
computed tomography (CT), computed tomographic
complications, reactions to contrast material, and
puncture site complications)(7).
angiography (MRA) and digital subtraction
angiography (DSA) is performed to detect possible
Subarachnoid Aneurysm Trial) study, retreatment
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2418-2425
Two-Dimensional and Three-Dimensional Echocardiographic Assessment of
Aortic Root Diameter in Patients with Coronary Ectasia
Mohammed Hesham Hassan Ezzat, Mohammed Adel Attia, Islam Ibrahim Ahmed Hassan Abualwafa*
Department of Cardiology, Faculty of Medicine (Damietta), Al-Azhar University, Egypt
*Corresponding author: Islam Ibrahim Ahmed Hassan Abualwafa, Mobile: (+20) 01025252217,
Background: Coronary artery ectasia (CAE) is a well-recognized but relatively uncommon finding encountered
during diagnostic coronary angiography. It is commonly defined as in appropriate dilation of the coronary arteries
exceeding the largest diameter of an adjacent normal vessel more than 1.5-fold. CAE is not an isolated and benign
disease but a reflection of a generalized vascular media defect.
Objective: The aim of this study was to compare 2D-TTEand 3D-TTE measurements of the aortic root diameter
in patients with coronary artery ectasia to assess the presence of aortic root dilatation.
Patients and methods: This prospective observational study included 50 consecutive patients came to the
Department of Cardiology, Al-Azhar University Hospital, New Damietta for coronary angiography. The study
was carried out from November 2017 until December 2018. Injection aortography was used as a gold standard
and to assess the presence of ascending aorta dilatation in those patients.
Results: The present study shows that there was a good correlation between 3D-TTE and aortography at the
levels of aortic annulus, sinuses of Valsalva, sinotubular junction (r =0.98,0.95,0.98) but a rough correlation
between 2D-TTE and aortography at these levels (r =0.49,0.48,0.46) .The present study shows that there was
increase prevalence of aortic root dilatation 13 patients (26%) and ascending aorta dilatation 9patients(18%) in
patients with CAE .
Conclusions: Accuracy of aortic root measurement by 3DTTE was superior to that by 2DTTE, because the values
by 2DTTE were underestimated compared to those measured by 3DTTE and aortography. Increase prevalence
of aortic root dilatation and ascending aorta dilatation in patients with coronary artery ectasia. Dilated Ascending
aorta was associated with a higher prevalence of aortic root dilatation.
Keywords: Two Dimensional, Three Dimensional Echocardiographic, CAE.
Coronary artery dilations, including
coronary ectasia and aneurysms, are a subgroup of
Some coronary dilatations have been described in
coronary artery anomalies and one of the most
association with inflammatory connective tissue
neglected topics in cardiovascular medicine (1).
disorders such as scleroderma or Kawasaki disease
Coronary artery ectasia is a well-
or with a history of cocaine abuse (6).
recognized but relatively uncommon finding
The term "aortic root" refers to the aortic
valve from its position at the left ventricular outlet
angiography (2). Although discovered incidentally,
to its junction with the ascending portion of the aorta
they can cause detrimental events such as sudden
cardiac death (3).
It is the direct continuation of the left
Coronary artery ectasia represents not
ventricular outflow tract. Aortoventricular junction
only an anatomical variant but also a clinical
refers to the junction between the left ventricular
constellation of coronary artery disease like
structures and the aortic valvularsinuses , this
association with myocardial ischemia and acute
representing the anatomic junction , or the semilunar
coronary syndromes. Coronary dilatations are thus
lines of attachment of the arterial valvular leaflets,
classified as anomalies of intrinsic coronary arterial
this locus representing the hemodynamic
anatomy and have been reported in up to 5% of
ventriculoarterial junction (8).
retrospective studies (4).
CAE is not an isolated and benign disease
They can occur either as a diffuse dilation
but a reflection of a generalized vascular media
of the coronary arteries (>1.5 times the normal
defect. Very few studies have reported a higher
diameter) that involves 50% of the artery length,
incidence of coronary dilatations in patients with
aneurysms of the abdominal aorta and its branches
which is called ``ectasia'' or as a localized dilation
in which the aneurysmal dilation of the largest
The aim of this study was to compare 2D-
coronary vessel by 1.5 times is seen in<50% of the
TTEand 3D-TTE measurements of the aortic root
total vessel length. Coronary artery disease is
diameter in patients with coronary artery ectasia to
considered the underlying factor in most of these
assess the presence of aortic root dilatation.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2426-2432
Recent Predictive Parameters for Successful Weaning from
Mechanical Ventilation in Critically Ill Patients
Osama Abdel-Hay Kasem, Ahmed Mohamed Abdel-Galeel, Mohamed Abdel-Gawad
Abdel-Halim Abo El-Suod, Ahmed Hesham El-Sayed Hemdan*
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Hesham El-Sayed Hemdan, Mobile: (+20)01144885689,
Background: Removal of patients from mechanical ventilation (MV) has been termed liberation,
discontinuation, withdrawal and most commonly weaning. Weaning covers the entire process of liberating the
patient from mechanical support and from the endotracheal tube. Although weaning from MV is successful in
most cases, the first attempt fails in 20% of patients. In addition, weaning accounts for over 40% of the total
MV time, the proportion varying in function of the etiology of respiratory failure.
Objective: The aim of this study was to evaluate the recent protocols of successful weaning from mechanical
ventilation of critically ill patients, depending on central venous oxygen saturation, ultrasonographic
assessment of diaphragmatic movement, and serial arterial blood gases to assess failure rate 48 hours after
weaning. Patients and methods: This prospective randomized study included a total of 90 mechanically
ventilated Egyptian patients of both sexes, ASA (I-II) attending at least for 48 hours at intensive care unit, Al-
Azhar University Hospitals. The included subjects were divided into three groups depending on method of
monitoring; group A: serial arterial blood gases, group B: Central venous oxygen saturation and group C:
Ultrasonographic assessment of diaphragmatic movement pre and post spontaneous breathing trial. All patients
were subjected to daily monitoring of the following weaning parameters: static and dynamic compliances and
inspiratory resistance, intrinsic positive end expiratory pressure (Auto PEEP) and Maximum inspiratory
Results: There is highly statistically significant difference between patients as regard weaning outcome. As
the group depended on normal ultrasonographic assessment of diaphragmatic movement, had the largest
number of patients with successful weaning.
Conclusion: Normal ultrasonographic assessment of diaphragmatic movement proved to be the most
important criteria for successful weaning from mechanical ventilation.
Keywords: Weaning, Mechanical ventilation, TTE, ICU
cause delays in weaning, unsuccessful weaning
Use of mechanical ventilation is often
trials, and unsuccessful attempts in extubation is
lifesaving (1). Mechanical ventilation is indicated
when the patient's spontaneous ventilation is
Conceptually, weaning from mechanical
inadequate to sustain life. In addition, it is indicated
ventilation includes both the assessment of a
as a measure to control ventilation in critically ill
patient's readiness to breathe independently and
patients and as prophylaxis for impending collapse
the systematic reduction of ventilatory support. A
of other physiologic function. Physiologic
variety of weaning strategies have been used to
indications include respiratory or mechanical
assess weaning. In the past, determining a patient's
insufficiency and ineffective gas exchange (2).
readiness to be weaned were based on the
The ventilator discontinuation process is an
judgments of individual physicians, who
essential component of overall ventilator
considered objective indicators of gas exchange,
management. Undue delay leads to excess stay,
respiratory mechanics, and the patient's ability to
iatrogenic lung injury, unnecessary sedation and
protect the airway. Use and evaluation of these
even higher mortality. On other hand, premature
indicators often resulted in wide variations in
withdrawal can lead to muscle fatigue, dangerous
weaning practices among providers. More recently,
gas exchange impairment, loss of air entry
the use of weaning protocols has markedly reduced
protection and a higher mortality (3).
the duration of mechanical ventilation. The key to
Approximately 30% of patients treated with
successful weaning may be that protocol is used,
mechanical ventilation experience difficult or
rather than specifically how the protocol is
prolonged weaning (4). For these patients,
constructed or what method of weaning is used (5).
organizational and clinician factors influence the
Mixed venous oxygen saturation (SvO2),
duration and success of weaning. Because of the
which requires invasive measurements via right
risk of further prolongation of mechanical
heart catheterization, and the easier to obtain
ventilation, reintubation, and increased mortality,
central venous oxygen saturation (ScvO2), are two
identification of potentially modifiable factors that
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2433-2440
Assessment of the Prevalence of Abnormal Hysteroscopic
Findings in Infertile Women Undergoing ART
Ahmed H Farag, Mohamed H Salama, Enas S Badrous
Department of Obstetrics and Gynecology, Ain shams university
Corresponding author: Enas S Badrous, Mobile: 01277950095 Email: firstname.lastname@example.org
Background: The endometrium plays an important role in implantation of good quality embryos in ART.
Many studies have proved the negative impact of intra uterine pathologies on reproductive outcome whether
spontaneous pregnancy or ART, because uterine anomalies may be associated with many obstetric
complications such as miscarriage, preterm birth, premature rupture of membrane, malpresentation,
postpartum bleeding and retained placenta. Aim of the work: This study aims to assess the prevalence of
abnormal hysteroscopic findings among infertile women undergoing ART at Ain Shams Maternity University
Hospital over the period from January 2007 to January 2017. Patients and Methods: This descriptive
retrospective study was carried out on infertile couples planned for ART who were sent to ECDU for
hysteroscopy in Early Cancer Detection Unit (ECDU), Ain Shams University Maternity Hospital. Case reports
From January 2007 to January 2017 were reviewed. Results: The most prevalent congenital abnormality was
endometrial polyp (18.4%) followed by uterine septum (6.9%). Conclusion: This study concluded that the
most common uterine abnormality was endometrial polyp (18.4%), followed by uterine septum in 6.9% of
patients. Also, thick endometrium was very common with a prevalence of 12.9%. Therefore, based on this
high prevalence of abnormalities, this study is in agreement with the opinion that all women should be offered
hysteroscopy, even if they have normal vaginal ultrasound and hysterosalpingography, because this is
supposed to increase the detection rate of minor abnormalities, which theoretically will improve the
reproductive outcome. Still, further interventional randomized controlled trials (RCT) are needed to verify the
positive impact of routine use of hysteroscopy prior to ART.
Keywords: abnormal hysteroscopy, infertility, ART.
Also, many experimental and clinical
The mean prevalence of Mullerian duct
studies have emphasized the importance of uterus
anomalies was estimated to be about 7% in the
and intrauterine pathology for spontaneous and
general population (1) and 13.3% in the infertile
post-ART fertility (8), which makes evaluation of
population (2). The female genital tract is derived
the uterine cavity a basic step in investigation of the
from paramesonephric duct (Mullerian) by the lateral
infertile women (9).
fusion of the 2 paired mullerian ducts which unite to
Office hysteroscopy (OH) is increasingly
form the uterus and upper part of cervix. Septal
recommended by many studies as a routine
absorption by apoptosis results in a single cavity (3).
procedure in the infertility work up (10,11,12) because
Normal development of the female genital
office hysteroscopy has the advantages of faster
tract involves a series of events: mullerian duct
ambulation, enhanced cost effectiveness and
elongation, fusion, canalization, and septal
reduced anesthesiological risks.
resorption, therefore, congenital uterine anomalies
Also, correction of most of these
result from abnormal formation, fusion or
abnormalities and restoration of a normal uterine
resorption of the mullerian ducts during fetal life
cavity is possible during OH with reported good
(4). Because of the role of the wolffian
outcome, similar to that achieved in patients with a
(mesonephric) ducts in the development of the
normal hysteroscopy (10,13).
female reproductive tract and the renal
Despite the great advances in the assisted
development, the abnormalities originating from
reproduction technologies, the delivery rate per
the mesonephric maldevelopment are associated
oocyte retrieval was only 25% for ICSI and 27.41%
with mullerian duct anomalies (5).
for IVF (14).
Renal anomalies are frequently associated
There is evidence that performing
with mullerian duct anomalies with a prevalence of
hysteroscopy before IVF can increase the chance of
(20-30%) such as pelvic kidney, renal agenesis,
pregnancy in women who had one or more failed
duplication of the collecting system and ectopic
IVF cycles (15,16).
ureters, hypoplasia, malrotation (6).
This can be explained by its ability to treat
Uterine cavity and its innermost layer; the
uterine abnormalities and therefore restoring the
endometrium play an important role in
normality of the uterine cavity (7).
implantation of the blastocyst (7).
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2441-2446
Role of Breast Magnetic Resonance Imaging in Early Stage Breast Cancer
Rawhia Taha Hasan, Hoda Mahmoud Abdel-Wahab, Manar Ftouh Abbas Khalil *
Radiodiagnosis Department, Faculty of Medicine for Girls, Al-Azhar University
* Corresponding author: Manar Ftouh Abbas Khalil, E-mail: mnarftouh@gmail. com
Background: globally, breast cancer is the most frequently diagnosed cancer and the leading cause of cancer
death in women. The surgical management of patients with early stage operable breast cancer is the main step of
treatment and addresses both the primary tumor and regional lymphatics.
Objectives: this study aims at highlighting the role of preoperative dynamic contrast enhanced breast MRI in
early stage breast cancer and its impact on surgical management.
Patients and Methods: this study was carried out over the period from March 2015 to October 2017 in
Radiodiagnosis Department of Mansoura University Hospitals and Nasser Institute. The study was conducted on
29 female their ages ranging from 30 to 59 years old the study was approved by our Institution's Ethics
Committee, and all patients gave their informed consent before inclusion in the study.
Results: in our study, MRI was requested for different causes varying between dense breast which may obscure
lesions (51.7%), multifocal lobular carcinoma (13.7%), exclude multicentric lesion (10. 3%) and in (24%) of
patients MRI was requested as preoperative routine check. In our study, we found that in 10 patients (34.5%),
MRI revealed additional lesions that were not seen on conventional imaging by mammography and
ultrasound.Six lesions (20.7%) of those additional occult lesions were identified as malignant and all were
ipsilateral. Our study reported that six patients (20. 7%) who had unsuspected abnormalities identified on MRI
had changes in treatment based on MRI findings.
Conclusion: the results of this study confirm previous reports that preoperative MRI of the breast alters clinical
management and detects otherwise occult carcinoma in a substantial number of patients with early breast cancer.
Keywords: Breast Magnetic Resonance Imaging, Early Stage Breast Cancer.
Globally, breast cancer is the most
cancer than mammography and/or breast ultrasound
frequently diagnosed cancer and the leading cause
of cancer death in women (1). In Egypt, according to
Although there is no consensus on whether
the results of the National Population Based Cancer
preoperative MRI in women with breast cancer (BC)
Registry Program, breast cancer is the most
benefits surgical treatment, MRI continues to be
common female cancer. It comprised 32% of
used preoperatively in practice (7).
malignancies in female (2).
The use of preoperative breast magnetic
The surgical management of patients with
resonance imaging (MRI) in patients with breast
early stage operable breast cancer is the main step of
cancer (BC) remains a controversial issue. Despite a
treatment and addresses both the primary tumor and
decade of evidence suggesting a lack of clinical
regional lymphatics. The primary tumor may be
benefit, counterbalanced by evidence that MRI
managed by mastectomy or (lumpectomy with
detects additional disease not seen with
postoperative radiation therapy), and the nodal
conventional imaging in the cancerous breast (8).
regions may be surgically addressed by lymph node
Also breast MRI may be able to better
dissection or sentinel node biopsy which mean
differentiate between dense breast tissue and actual
either breast conservation therapy (lumpectomy and
breast cancers especially in young women compared
radiation therapy) or modified radical mastectomy
to routine mammography and breast ultrasound
(3).The major change in the surgical treatment of
based on the tumor enhancement characteristics (9).
primary breast cancer has been the shift towards
In young women with breast cancer, breast
breast conservation treatment that started over 30
MRI alters surgical management in a significant
years ago (4).
proportion of patients. Finally, multiple studies have
Mammography remained the modality of
advocated the use of preoperative MRI to detect
choice as a primary imaging for surgical decision
occult multicentricity in the ipsilateral breast and
either breast conservation therapy (BCT) with breast
occult cancer in the contralateral breast, although
conserving surgery (BCS) and definitive breast
this could be helpful information for preoperative
irradiation or mastectomy (5).
planning and staging, it simultaneously carries the
Breast magnetic resonance imaging (MRI)
risk of additional procedures, potentially increasing
was shown to be a more sensitive preoperative
mastectomy rates (10).
staging technique for detecting invasive breast
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2447-2450
Splinting after Carpal Tunnel Surgical Treatment: Does It Really Matter?
Mohamed Hazem Mahmoud, Ali Tawfiq El Alfy,
El-Sayed Etewy Ahmed Soudy, Ahmed Farid Ibrahim el-Molla*
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University
*Corresponding author: Ahmed Farid Ibrahim El-Molla, Mobile: (+20) 01285903930, E-Mail: email@example.com
Background: Splinting of the wrist after carpal tunnel release (CTR) has been practiced by many surgeons especially
in North America. The main reason was to prevent possible adverse events of bowstringing of flexor tendons and the
median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect
of splinting after standard CTR had dismal results. The duration of splinting in standard CTR has been either too long
(for 2-4 weeks) or too short (48 hours only).
Objective: The aim of our study was to compare the effects of post-operative splinting for duration of one week with
no splinting. Patients and Methods: All 20 of our patients underwent a standardized open CTR. Post operatively,
they were randomized into a splinted (n=10) and a non-splinted (n=10) group. The splint was kept for 2 weeks.
Patients were reviewed at regular intervals of one week, two weeks and three months. At each follow up, these
patients were clinically assessed for outcome of the Boston questionnaire.
Results: All patients presented with significant improvement in the post-operative evaluation within each group.
However, there was no significant difference between the two groups for any of the outcome measurements at
sequential and at final follow-up. Conclusion: We concluded that wrist splinting in the immediate post-operative
period has no advantage when compared with the non-splinting wrist after a standard open carpal tunnel release.
Keywords: Carpal tunnel syndrome, carpal tunnel release, wrist splint, open carpal tunnel release, nerve
surgeons found that 81% of them splinted their
The carpal tunnel syndrome (CTS) is considered
patients' wrists for two to four weeks following carpal
the most common entrapment neuropathy of the upper
tunnel surgery (11). Cook et al. (13) advocated splinting
extremity caused by compression of the median nerve
for one week as a precaution against the complications
at the wrist. It occurs most often in patients between 30
of tendon bowstringing and nerve entrapment in the
and 60 years old and five times more common in
women than in men (1). Variety of conditions may be
AIM OF THE WORK
associated with carpal tunnel syndrome. These include
The aim of our study was to compare the effects of
pregnancy, inflammatory arthritis, colles' fracture,
post-operative splinting for duration of one week with
amyloidosis, hypothyroidism, diabetes mellitus,
acromegaly and use of corticosteroids and estrogen (2).
Hypothesis: Post-operative wrist splinting in 15º of
Carpal tunnel syndrome generally produces pain,
extension places the carpal tunnel in its most open
paraesthesia, numbness or tingling involving the
position. This allows good circulation to the median
palmar aspect of the thumb, index finger, middle
nerve and prevents compression during activities,
finger, and radial half of the ring finger. Symptoms are
bowstringing of flexor tendons, wound dehiscence,
worse at night and often wake the patient (3).
reduction of pain and entrapment of the median nerve
The patient with mild symptoms of CTS can be
within the surgical incision.
managed with conservative treatment, particularly
local injection of steroids and splinting. However, in
PATIENTS AND METHODS
moderate and severe cases, surgery is the only
The material of this study compromised 20 patients
treatment that provides cure. The basic principle of
all of them suffered from idiopathic CTS. All patients
surgery is to increase the volume of the carpal tunnel
presented at the Outpatient Clinic of Abo Al Mattamer
by dividing transverse carpal ligament to release the
General Hospital. All patients were treated at the same
pressure on the median nerve (5, 6).Post-operative wrist
hospital in the period between October 2016 to June
splinting from a neutral position to 15º of extension
2017. All cases were subjected to clinical and
places the carpal tunnel in its most open position. This
allows maximal circulation to the median nerve,
Inclusion criteria: Both genders will be included and
prevents compression during activities, bowstringing
Idiopathic carpal tunnel syndrome.
of flexor tendons, wound dehiscence, reduction of
Exclusion criteria: Any recognized cause of carpal
pillar pain and entrapment of the median nerve within
tunnel syndrome such as inflammatory arthritis,
the surgical incision (7-8). One to two weeks of splinting
diabetes, hypothyroidism, congestive cardiac failure,
have been recommended following endoscopic
peripheral nerve condition (double crush pathology) or
release(9-11) and one to three weeks following open
carpal tunnel release (12). A survey of American hand
Outcome Measures: Results are assessed following
The Boston questionnaire. This is a disease-specific
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2451-2460
Ultrasound Evaluation of Lower Uterine Segment in
Pregnant Patient with History of Hysterotomy
Emad Abd El Rahman El-Tamamy, Khaled Gaber Sabaa, Ahmed Khaled Wally Momen*
Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Khaled Wally Momen, Mobile: (+20)01223456741, E-Mail: firstname.lastname@example.org
Background: ultrasonography has been widely used in the field of obstetrics & gynecology. Development of more
sophisticated technology in ultrasonography & the huge amount of studies & education by physicians makes
ultrasonographic examination one of the most useful diagnostic techniques in obstetrics & gynecology.
Objective: In this study we aimed to evaluate the gravid uterus in women with a history of previous, 1 or more
hysterotomy, in all 3 trimesters by Trans-vaginal ultrasound (TVUS).
Patients and Methods: This is a prospective, case-control, observational study. The study was carried out in a
private Obstetrics & Gynaecology center Wally center in Fayoum city. The study was carried out in the period
from December 2017 to December 2018. Initially, 100 patients were enrolled, but at the end of the study only 67
patients were involved in the study.
Results: The distance between the leading edge of the placenta to the internal OS is the diagnostic accretion. This
difference between the 5 groups regarding this distance was found to be highly significant (p-value= 0.001) across
all 3 trimesters, which proves that repeated CS deliveries is a major risk factor for placenta praevia. There were 1
case, 3 cases & 2 cases of low-lying placenta found in groups 3, 4 & 5, respectively.
Conclusion: Cesarean section scar pregnancy and rupture uterus are both rare events and were not found in the
sample of this prospective study. However, they are both very important to diagnose as early as possible to prevent
serious morbidity and even mortality.
Keywords: TVUS, Lower uterine segment, CS, Hysterotomy
4. Diagnose & management of ovarian cysts and
Gynecologic ultrasonography refers to the
application of medical ultrasonography to the female
5. Identify adnexal masses.
pelvic organs (specifically the uterus, the ovaries, and
6. Diagnosis of ectopic pregnancy.
the Fallopian tubes) as well as the bladder, the
7. Diagnose gynecologic cancer.
adnexa, and the Pouch of Douglas. The procedure
8. Infertility treatments & follow up.
may identify other medically relevant findings in the
Obstetric ultrasonography is the use of
medical ultrasonography in pregnancy, in which
The examination can be performed by
ultrasound waves are used to create real-time visual
transabdominal ultrasound, generally with a full
images of the developing embryo or fetus in its
bladder which acts as an acoustic window to achieve
mother's uterus(4). The procedure is a standard part of
better visualization of pelvis organs, or by
antenatal care, as it can provide a variety of
transvaginal ultrasound with a specifically designed
information about the health of the mother, the timing
vaginal probe or transducer. Transvaginal imaging
and progress of the pregnancy, and the health and
utilizes a higher frequency imaging, which gives
development of the embryo or fetus(2).
better resolution of the ovaries, uterus and
Hysterotomy is a surgical procedure that
endometrium (the fallopian tubes are generally not
involves making an incision in the uterus to remove
seen unless distended), but is limited to depth of
uterine contents in the endometrium. It can be
image penetration, whereas larger lesions reaching
performed for various reasons including caesarian
into the abdomen are better seen by transabdominal
section, intra uterine fetal surgery, delayed surgical
ultrasound(2). Having a full bladder for the
miscarriage (>14 weeks). Hysterotomy is the widely
transabdominal exam is helpful because sound
preferred technique for open fetal surgery.
travels through fluid with less attenuation to better
Hysterotomy procedure is done the same way as
visualize the uterus and ovaries which lies posterior
caesarian section(5, 6). Pfannensteil incision is done,
to the bladder. The procedure is by definition
dissection of abdominal wall layers, mobilization of
invasive when performed transvaginally(3).
the Urinary bladder & Transverse incision of the LUS
Gynecologic sonography (2):
of the uterus in smiley shape.
1. Assess pelvic organs.
Hysterotomy is a major surgical operation
2. Diagnose acute appendicitis.
that is associated with a number of serious risks and
3. Diagnose and manage gynecologic problems
Infection (e.g. Peritonitis, surgical site
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2461-2466
The Effect of Vitamin D Supplementation on the Androgenic Profile in
Patient with Polycystic Ovary Syndrome
Fahd Abd El-Aal Alomda, Mahmmod Abd El-Latef Hashish, Waleed El-Sayed El-Naggar, Ahmed
Mohammed Abd El-Rahman Mosallam*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Egypt
*Corresponding author: Ahmed Mohammed Abd El-Rahman Mosallam, Mobile: (+20)01273299460,
Background: it is suggested that vitamin D status is associated with androgenic profile in women with PCOS.
Although there are a lot of clinical trials known in this regard, the results were varying.
Objective: This study aimed to evaluate the effect of Vitamin D supplementation on androgenic levels (including
serum total testosterone, free testosterone and sex hormone binding globulins) in adult women with PCOS were
established by the presence of hyperandrogenemia or clinical hyperandrogenism.
Patents and Methods: in the present study, 50 outpatient clinic women were included and divided into two
groups, first group consisted of 25 patients who received 4000 IU daily of Vitamin D3 for 6 months, and the
other group consisted also of 25 patients who received placebo drug blindly.
Results: the results showed significant difference between the two groups regarding different laboratory tests
especially total testosterone level (decreased significantly after vit. D intake) and SHBG (elevated significantly
after vit. D intake) and also significant difference in the hirsutism state after vitamin D administration. But in
contrast, there was no significant difference between free testosterone level before and after vit. D administration.
These results can help in the confirmation of the suggestion that vitamin D intake can help significantly in
decreasing the androgenic profile in a woman patient with PCOS and also in decreasing hirsutism symptom.
Conclusion: vitamin D intake can help significantly in decreasing the androgenic profile and hirsutism in a
woman patient with PCOS and used as a proper treatment for them.
Keywords: Vitamin D, PCOS, Hirsutism.
Polycystic ovary syndrome (PCOS) is the
of androstendione is probably as important as
most common endocrine disorder of women of
testosterone measurement, as peripheral conversion
reproductive age affecting about 4-10% of all
of androstendione to testosterone accounts for 50% to
women(1,2). Classical features of PCOS include
infertility, hyperandrogenism, truncal obesity,
androstendione is elevated in all types of polycystic
abnormal glucose metabolism, insulin resistance (IR),
hirsutism, and acne vulgaris, but diagnostic criteria
3. Serum Di-hyrdo-testosterone (DHT):
included; chronic oligomenorrhea or amenorrhea,
Although DHT is biologically the most active
evidence of androgen excess clinical or biochemical,
androgen and probably the one that interacts with
and polycystic ovaries(2).
cutaneous androgen receptors, measurement of this
Androgen excess and PCOS (AE-PCOS)
steroid has not added much of clinical utility (6).
Society(3) in 2009 cleared Hyperandrogenism
4. Androgens of Adrenal Origin:
includes hirsutism and ovarian dysfunction including
Women with polycystic ovaries (obese and
non-obese) and hyperinsulinemia have a greater
(exclusion of other androgen excess or related
steroidogenic response to ACTH than anovulatory
disorders). One of the main criteria to establish a
patients with normal insulin levels (7).
diagnosis of polycystic ovary disease is
The clinical problem with DHEA-S
measurement is the frequent finding of a moderately
1. Serum Testosterone (T):
elevated DHEA-S level in anovulatory patients with
Serum free testosterone is considered to be a
polycystic ovary disease(5).
better indication of androgenicity than total
testosterone, but the measurement of free testosterone
Vitamin D is a steroid hormone that is
is technically difficult and does not lend itself to
primarily known for its role in skeletal health and
routine clinical use .Total testosterone concentration
calcium homeostasis, but its deficiency has been
in the saliva is highly correlated with free unbound
related to a number of non-skeletal disorders
plasma testosterone and provided a convenient index
of free testosterone activity (5).
dyslipidemia, hypertension, cardiovascular diseases,
2. Serum Androstendione (A):
and autoimmune diseases (8).
In polycystic ovary disease, the measurement
Vitamin D is either produced in the skin in
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2467-2474
Strain/Strain Rate Imaging of Impaired Left Atrial
Function in Patients with Metabolic Syndrome
Sameh Refaat Hassan Allam, Abd El-Aziz Rezk Hassan Sheredah,
Mohammad Al-Deftar, Ahmad Kamal Mohammad Hashem*
Department of Cardiology, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmad Kamal Mohammad Hashem; Mobile: 01143279799; Email: Ahmad.email@example.com
Background: Metabolic syndrome (MS) predisposes to left ventricular dysfunction and heart failure, however,
alterations in left atrial (LA) function in MS are unknown. Objectives: We aimed to use strain/strain rate (SR)
imaging to investigate the effect of MS on LA function. Subjects and Methods: This prospective case control
study included a total of 100 subjects divided in to 75 metabolic syndrome (MS) patients referred to Al-Azhar
university hospital outpatient clinic for evaluation and treatment of hypertension and/or diabetes mellitus and 25
age and sex matched apparently healthy volunteers as a control group. All subjects underwent conventional
echocardiographic examination and assessment of LA function by speckle tracking. Partial correlation and
multiple stepwise regression analyses were used to determine the risk factors for impaired LA function.
Results: Compared with the controls, the MS patients showed significantly lower levels of mean strain, mean
peak systolic SR and mean peak early diastolic SR (P<0.05 for all), with no difference in the mean peak late
diastolic SR. Central obesity, hypertension, dyslipidemia and uncontrolled diabetes were independent risk factors
for impaired LA function.
Conclusion: SR imaging is reliable in assessing LA function in MS patients.
Keywords: Metabolic syndrome, Left atrial function, Speckle tracking, Echocardiography.
Metabolic syndrome (MS) is a condition
A 2D strain echocardiographic method has been
characterized by the accumulation of multiple risk
introduced that measures myocardial deformation by
tracking localized acoustic markers frame by frame
dyslipidemia, hypertension, visceral obesity) for
(speckle tracking). This method has been used for
cardiovascular disease in an individual with a
noninvasive assessment of global and regional
background of obesity and/or lack of exercise (1).
myocardial strain in the left and the right ventricle,
Even more with the change of the modern lifestyle
avoiding the angular sensitivity of tissue Doppler
and diet structure, incidence of MS increased year by
year, it is greatly endangering people's health.
The Aim of this Study: assessment of left atrial (LA)
However, it is not known whether MS is also
function in patients with metabolic syndrome by 2D
associated with abnormal cardiac function. If MS
speckle tracking echocardiography.
indicates persons who have already developed
abnormal left ventricular (LV) function, early
PATIENTS AND METHODS
recognition of MS would be important (2).
This prospective case control study was conducted
Left ventricle diastole occurs in order for the
between March 2018, and March 2019 on (100)
left ventricle (LV) to fill adequately with enough
subjects divided into 2 groups; group I (The patient
blood, at a low enough pressure, to prevent pulmonary
group): (75) metabolic syndrome patients who were
congestion from occurring. This process is referred to
referred to Al-Azhar University Hospital Outpatient
as, diastolic function (3).
Clinic for evaluation and treatment of hypertension
Metabolic syndrome is common and it is
and/or diabetes mellitus and group II (Control Group):
associated with increased cardiovascular morbidity
(25) age and sex matched healthy volunteers as a
and mortality as well as with increased risk of heart
failure through multiple complex metabolic reactions
Approval of the ethical committee and a
most prominent among which are altered insulin
written informed consent from all the subjects were
cytokine activity and intramyocyte and/or interstitial
Diagnosis of MS: according to International
deposition of triacylglycerol plus effect of endothelial
Diabetes Federation (IDF) metabolic syndrome is
defined as the presence of central obesity (was
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2475-2480
Comparative Study between Subinguinal Varicocelectomy and Laparoscopic Varicocelectomy
Ahmed Salah Al-Gamal, Abd El-Fattah Morsi Saied, Ashraf Abd El-Hameed Abd El-Moneim
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Correspondence author: Ahmed Salah Al-Gamal, Tel: +201148738654, +201090804521, E mail: firstname.lastname@example.org
Background: surgical correction of varicocele is the corner stone of its therapy and varicocelectomy is the most
commonly performed operation for the treatment of male infertility. Aim: to compare the outcome of the most common
surgical approaches; sub-inguinal varicocelectomy and laparoscopic varicocelectomy as regards: operative difficulties
& time, complications and efficiency. Patients and Methods: This randomized controlled study was conducted on 40
patients, divided into two groups: group I included 20 patients, were operated upon through the subinguinal approach
and group II included 20 patients, were operated upon through the laparoscopic approach, and comparison between two
groups as regard outcomes and complications. Results: It was found from this study that the operation time was
relatively shorter with the laparoscopic technique (p<0.01), while the length of hospital stay and post-operative
complications did not differ in both methods. Follow up of patients at 3 and 6 months showed a marked improvement
in semen analysis in terms of concentration, the percentage of abnormal forms, movement, and also there was a marked
improvement in testosterone hormone.
Conclusion: In both methods, results were almost the same, but the sub inguinal approach is qualitatively better in
terms of the lack of complications, but with delayed return to work compared with laparoscopic technique.
Keywords: varicocele, varicocelectomy, sub-inguinal, laparoscopy, male fertility.
after obtaining the local Ethics Committee approval.
Varicocele is defined as an abnormal tortuosity and
After obtaining the local ethics committee approval, all
dilatation of the testicular veins (1). Some consider
patients admitted to the Surgery Department signed a
varicocele as an anatomical variant rather than a disease
written informed consent.
since the general incidence of varicocele in the
They were randomized using close-envelope into two
population has been reported to be as high as 15% (2). Its
groups: Group I: 20 patients, operated upon through the
significant pathologic aspect comes out from the fact
subinguinal approach. Group II: 20 patients, operated
that it is generally agreed that a varicocele represents the
upon through the laparoscopic approach.
most common identifiable pathology in infertile men.
A) Inclusion criteria: Patients with primary varicocele,
The incidence in men presenting for infertility is about
symptomatic (scrotal pain and/or infertility), refluxing
35% and in that subset of men with secondary infertility
in clinical examination and duplex assessment.
it is 70- 80% (3). There are different surgical approaches
B) Exclusion criteria: Patients were excluded if: Have
secondary or recurrent varicocele, asymptomatic,
retroperitoneal or Palomo's procedure and inguinal (4).
azoospermic patients, female partner factors of
Subinguinal varicocelectomy is reported to be an
infertility, or medically unfit for surgery.
effective procedure to either eliminate the pain of
Surgical Techniques: Patients were randomized to
varicocele or improve the semen quality in infertility
undergo either the subinguinal approach or the
patients. The low procedure-related complication rate
laparoscopic approach using closed envelopes opened
seems to be in accordance with inguinal and subinguinal
before surgery. Operations were carried out under spinal
techniques (5,6).Laparoscopic varicocelectomy is a
or general anaesthesia.
simple, safe and effective surgical procedure which
Group I: the subinguinal approach
could be proposed as an alternative to open surgical or
Under spinal anaesthesia the patient was placed
percutaneous embolization approaches (7).
in a supine position. The incision was made transversely
with a length of approximately equal to 2.5 cm at the
AIMS OF THE STUDY
level of external inguinal ring, just outside the pubic
This study aims to compare the outcome of the most
tubercle. By retracting the edges of the wound, the
spermatic cord was dissected subinguinally without
varicocelectomy and laparoscopic varicocelectomy as
breaching the inguinal canal and could be identified by
regards: operative difficulties, time, complications and
the appearance of the blue colour of the spermatic veins.
The external spermatic vein was assessed and if
dilated a double ligature was applied. Then the internal
PATIENTS AND METHODS
spermatic fascia was approached through meticulous
Forty patients were treated for varicocele by
dissection. The dilated internal spermatic veins were
either subinguinal varicocelectomy approach or
identified and dissected carefully with mosquito clamps.
laparoscopic varicocelectomy approach at Al-Azhar
With careful manipulation, each dilated vessel was
University Hospitals (Al-Hussain University Hospital
isolated and a double ligature of 3-0 Vicryl was used to
and Sayed Galal University Hospital), Cairo, Egypt,
control the vessel and then cut with a sharp scissor. The
during the period from March 2018 to November 2018,
wound was closed with 3-0 Vicryl sutures.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2481-2491
Effect of Buspirone on the Histological and Immunohistochemical
Alterations on Pancreas of Fetuses in Pregnant Rats
Nahla H. El-Shaer*and Asmaa M. Abd El-Azez**
*Zoology Department, Faculty of Science, Zagazig University, Egypt.
**Zoology Department, Faculty of Science, Al-Azhar University, Egypt
Corresponding author: Dr. Nahla H. El-Shaer, Email: nhalshair@Zu.edu.eg
Aim of the work: Buspar drug(buspirone) is an antianxiety agent for the treatment of anxiety, and there are no
adequate studies of Buspar in pregnant women which made this issue an exciting research area; so that our aim was
to study the effects of buspirone on the structure of pancreatic tissue of the maternally treated rat fetuses.
Material and methods: Buspirone hydrochloride tablets were obtained from Beecham, Haram, Giza, Egypt.
Animals were divided into three groups (Ten pregnant rats in each group). Group I: (The control group) pregnant
rats administrated orally distilled water only; Group II: pregnant rats were given oral dosages of buspirone
hydrochloride at a dose level of 0.27 mg/ 100g b.w./day, daily for 15 days from the 6th day to the 20 th day of
gestation; Group III: pregnant rats were treated with the same manner with buspirone hydrochloride at a dose level
of 0.41 mg/ 100g b.w./ day for 15 days from the 6th to the 20 th day of gestation. Samples were taken from pregnant
rats of all groups which sacrificed at 20 th day of gestation and fetuses were picked out for histological, histochemical
and immunohistochemical studies for pancreatic anti-insulin and caspase-3 monoclonal antibody markers.
Results: Treatment of pregnant rats with buspirone showed histopathological alterations in the pancreas of their
fetuses; these alterations were well marked in the high dose maternally treated fetuses, and resulted in deformity in
the pancreatic tissues. Conclusion: The present study showed that administration of buspirone may result in several
histological and immunohistochemical deformity in the fetal pancreatic tissues.
Keywords: Buspar drug, Caspase-3, Histopathology, Immunohistochemical and fetal pancreas.
useful in giving insight into the etiology, neurobiology
Anxiety is mainly characterized by an unpleasant
and the therapy of human anxiety disorders (11).
state of internal sensation accompanied with many
Buspirone hydrochloride molecular formula is
neurological behaviors (1). These disorders which
associated with anxiety are mostly increased in women
is 421.96(12). Its 5-HT1A receptor partial agonist is
during pregnancy due to changes in the levels of
mainly approved to be useful in generalized anxiety
progesterone and estrogen in the blood levels. These
disorders (13). It is effective in the treatment of
changes can exacerbate these emotional difficulties
depression because of its molecular properties (14) and
(2).Generalized anxiety disorder (GAD) shows a high
it takes from one to three weeks to become clinically
prevalence through the general population (3);
epidemiologically its prevalence ranging from 1.8% to
As anxiolytics, buspirone have an effect on
6.9% among adults (4)and from 0.3% to 5.8% among
glycemic control in diabetics(12), and it was thought to
be responsible for hyperglycemia in rats (16) ,and it was
The main criteria of GAD are excessive anxiety
found to produce a significant alteration in blood
and chronic worry that is difficult to control and
glucose level in healthy humans(17).
frequently occurs concomitantly with other disorder
To date, there is no reviews has been performed to
evaluate the available effect of such a drug despite its
concentrating, muscle tension, sleep disturbances, and
different effects in acute and chronic use. Thus in this
being easily fatigued) and itsduration last for 6 months
study we aim to evaluate the histological and
immunohistochemicaleffect of administration of
These disorders also include Oxidative Stress (OS),
buspirone and the possible alterations in the pancreatic
which occurs due to increasing the levels of reactive
tissue of fetuses of pregnant rats.
oxygen species (ROS) (7). The most harmful effect of
ROS (lipid peroxidation) leads to the breakdown of
MATERIALS AND METHODS
lipids and the formation of a variety of products such 1- Drug:
as malondialdehyde (MDA) (8).
Buspirone hydrochloride, Buspare was obtained as
Many psychoactive agents are currently possible
tablets from Beecham, Haram, Giza, Egypt. It was
for the treatment of anxiety; benzodiazepines are useful
dissolved in distilled water and administrated orally by
first-line agents for most of the anxiety disorders in the
a gastric tube. Daily single oral doses (0.27 mg and 0.41
world(9). Hydroxy tryptamine 1A (5-HT1A) receptors
mg /100g body weight/day) represented the low and
are considered the most important targets for the
high therapeutic doses in humans were calculated for
treatment of mood disorders (10). Animal models are
rats according to Paget and Barnes(18).
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2492-2498
Optical Coherence Tomography Study of Retinal and Choroidal Changes in
Patients with Chronic Obstructive Pulmonary Disease
Mai G. Abd El-Naser*, Heba M. Abd El-Rahman*, Zeinab R. Adawy**, Mona M. Aly*
Departments of Ophthalmology* and Chest**, Faculty of Medicine (For Girls), Al-Azhar University
Corresponding author: Mai Gamal Abd El-Naser, Mobile: 01018321266, Email: email@example.com
Background: Chronic obstructive pulmonary disease (COPD) has multi-systemic implications and comorbidities.
Fine ocular structures are affected by hypoxia and systemic inflammation.
Objective: To evaluate the changes in the retina and choroid in patients with chronic obstructive pulmonary disease
using spectral-domain optical coherence tomography (SD-OCT).
Patients and methods: This prospective case control study included a total of forty COPD patients and twenty age-
and sex-matched healthy individuals as control group; both eyes were included. COPD patients were divided into two
subgroups; a group with mild to moderate COPD and another group with severe to very severe COPD according to the
Global Initiative for COPD guideline. COPD patients were subjected to spirometry. Arterial blood gas analysis was
performed to determine hypoxic state. The subfoveal choroidal thickness (SFCT), macular thickness (MT) and retinal
nerve fiber layer (RNFL) thickness were measured using SD-OCT and compared between groups.
Results: There was no statistically significant difference between groups according to demographic data. Mean SFCT
was statistically significantly thinner in COPD groups than in the control group; and this thinning was more pronounced
with increase in the severity of COPD. As regard to MT, no statistically significant difference was observed between
groups (p=0.691). Peripapillary RNFL was significantly thinner in COPD group than the control group in all quadrants
except the superior one.
Conclusion: Changes in the SFCT and RNFL thickness could be used as indicators for the severity of COPD.
Key words: Chronic obstructive pulmonary disease, subfoveal choroidal thickness, retinal nerve fiber layer thickness,
The current study was conducted to evaluate the
Chronic obstructive pulmonary disease (COPD) is
changes in the retina and choroid in patients with
the fourth leading cause of global death and is a major
chronic obstructive pulmonary disease using spectral-
cause of chronic morbidity and mortality worldwide (1).
domain optical coherence tomography.
It is considered a multi-systemic disease that is related
to abnormal inflammatory response of the airways and
SUBJECTS AND METHODS
the lungs to noxious particles or gases resulting in
Ethical approval: This prospective case control study
progressive permanent air-flow restriction(2-5).
was approved by the Medical Ethics Committee of the
This inflammatory process may ``spill'' over into
Faculty of Medicine (for Girls), Al-Azhar University
the systemic circulation, promoting a generalized
and a written informed consent was obtained from all
inflammatory reaction. Also, the resultant tissue
included participants. It was done adhering to the
hypoxia is implicated in the development of the extra-
principles of the Declaration of Helsinki guidelines.
pulmonary manifestations of COPD (6,7).
The study was conducted at the Chest and
Fine ocular structures are thought to be affected
Ophthalmology Departments of Al-Zahraa University
by hypoxia and systemic inflammation, including the
Hospital, between November 2018 and February 2019.
choroid, macula and retinal nerve fiber layer (RNFL)
that can be thoroughly assessed by means of spectral-
A total of 40 patients with COPD (G1) and 20
domain optical coherence tomography (SD-OCT) (5,8).
healthy controls (G2) of similar age and gender were
SD-OCT is a non-invasive imaging technique that
evaluated within the scope of this study. Both eyes
provides cross-sectional images of the retina and optic
were included if meet the inclusion and none of the
nerve head in high resolution (9). Enhanced-depth
exclusion criteria. COPD subjects were diagnosed
imaging optical coherence tomography (EDI-OCT) is
according to the Global Initiative for Chronic
a recent modification to the standard SD-OCT
Obstructive Lung Disease criteria (GOLD). Based on
technique. It is able to image the choroid with
GOLD, 2017(11), COPD patients were further sub-
reasonable clarity (10).
classified according to disease severity into two
groups; G1a included patients with mild to moderate
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2499-2504
Low Pressure versus Standard Pressure Pneumoperitoneum in
Mahmoud Kassem1,*, Magdy Mahmoud Emam1, Mohammad Arafat Abd El-Maksoud1
1General Surgery Department, Faculty of Medicine, Al-Azhar University.
*Corresponding author: Mahmoud Kassem, Email: Kassem.firstname.lastname@example.org
Background: the laparoscopic cholecystectomy (LC), one of the utmost commonly assumed operations in general
surgery. Adequate working space inside the abdominal cavity is required. Carbon dioxide (CO2) is used with a definite
pressure to establish this working space.
Aim: our study was to compare the hemodynamic symptoms, post-operative shoulder-tip pain and the frequency of
nausea and vomiting between standard and low-pressure CO2 pneumoperitoneum (PP) in patients undergoing LC.
Patients and Methods: a prospective randomized study was done on 50 patients aged 18 to 75 years in Bab El-
Shaaria hospital, Al-Azhar University with symptomatic gallstones. Patients were allocated into two groups: standard
pressure (Group A: 12-14 mmHg) and low-pressure (Group B: 8-10 mmHg). Hemodynamics were assessed pre
insufflation and 15 min post insufflation and desufflation. The frequency of nausea and vomiting were assessed at 0,
8, 16, 24-hour post-operative. Post-operative shoulder- tip was assessed 1, 6, 12, 24-hour post-operative. Statistical
analysis was postulated using SPSS V.25.
Results: a noticeable difference between the two groups was observed with respect to the mean systolic blood pressure
(p=0.003) and the mean heart rate (p=0.001). Furthermore, a significant difference as regard post-operative shoulder-
tip pain, which was higher in the standard pressure group (p< 0.05). There were no major differences between the two
groups concerning the frequency of nausea and vomiting.
Conclusion: low-pressure PP can be used instead of standard pressure considering its low side effects without any
effect on the working space and quality of the surgical procedure.
Keywords: cholethiasis, laparoscopic cholecystectomy, low-pressure, pneumoperitoneum.
LC is one of the utmost commonly assumed
providing adequate working space (5).
operations in general surgery, with over all
This method appears to have little adverse effect on
complication rates are less than 1.5%, and the mortality
the cardiac and respiratory functions and is suitable for
is lower than 0.1% (1). During the operation, suitable
the older patients and for those with long-lasting cardiac
working field is mandatory in the abdominal cavity for
or pulmonary illnesses. Other possible advantages of
acceptable exposition that results in reasonable
low pressures during PP appear to be lower frequency
outcomes and patient protection. Common procedures
of post-operative shoulder-tip pain as well as enhanced
to establish a working field in the abdominal cavity are
quality of life in the week post-operative (6). However,
PP and abdominal wall lifting devices for examples, the
the lower pressures involved in the low pressure LC
laparo-tensor and laparo-lift (2).
might lead to an inadequate exposure of the surgical
PP for LC is most often created by insufflating
field resulting in increased the operating time, intra-
CO2 gas into the peritoneal cavity and then holding it at
operative complications rate and as well as increase rate
constant pressure until the end of surgery when it is
of conversion to standard pressure LC or conventional
released at the time of withdrawal of the ports (3).
Standard pressure PP, using a pressure range of 12-14
mmHg. It is proven that standard pressure PP has been
AIM OF THE WORK
related to multiple adverse events such as decreased
We established the present study to compare the
pulmonary compliance, altered blood gas parameters,
hemodynamic symptoms, post-operative shoulder-tip
impaired functioning of the circulatory system, elevated
pain and the frequency of nausea and vomiting between
liver enzymes and renal functions, and even increased
standard and low-pressure PP in patients undergoing
intra-abdominal venous pressures (4).
An emerging trend has been used, insufflating of
low pressures to create PP in the range of 7-10 mm Hg
PATIENTS AND METHODS
instead of the standard pressure PP in an attempt to
Ethical Committee: after Ethical Committee
lower the impact of PP on human physiology while
approval (06/09/2014) and informed consent from
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2505-2513
Evaluation of Different Varieties of Brachioplasty
Abdel Monem Hota, Moustafa Meky, Mahmoud Nasef, Mohammed El Zoeiky
Departments of Plastic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohammed Abdel Samiee El Zoeiky, E-Mail: Dr.email@example.com, Mobile:01064000624
Background: There has been a renewed interest in upper arm contouring secondary to recent advances in plastic
surgery that have made it safer and more appealing to both the plastic surgeon and the patient. Objectives: the
aim of the work was to describe the aesthetic outcome of different techniques used for correction of arm ptosis to
try to obtain a new treatment-based algorithm for management of brachioplasty. Patients and Methods: This
prospective study included a total of 40 patients with different degrees of arm ptosis, requesting arm contouring
attending at Al-Hussein and Bab Al-Shairia, Al-Azhar University Hospitals. Different techniques used for
brachioplasty as liposuction or skin excision by different types of skin incision according to the degree of fat
deposit, redundancy and skin ptosis, or both were used in this study. Results: Patient's satisfaction within clothes
was 100% in all techniques used in brachioplasty while patients' satisfaction without wearing clothes or light
clothes was 84.6% in surgical resection due to the presence of complications in the form of wound dehiscence in
5 patients (19%) and hypertrophic scar in 4 patients (15.4%) and it was 100% in liposuction patients and it was
83.3 in combined method patients due to the resent of wound dehiscence with ugly scar in 1 patient (16.7%).
Conclusion: Brachioplasty operation whether liposuction alone or surgical excision or combined methods is a
good method to treat patients with arm obesity or post massive weight loss skin ptosis. The proper method was
selected according to the degree of fat deposit, redundancy and skin ptosis.
Keywords: Brachioplasty, arm contour, arm ptosis, liposuction.
Upper arm excess in patients with arm ptosis is
PATIENTS AND METHODS
frequently a source of dis-satisfaction. The arms are
This prospective study included a total of 40
visible in a variety of attire, and patients' express
patients requesting arm contouring attending at Al-
frustration with unsuccessful efforts to disguise this
Hussein and Bab Al-Shairia, Al-Azhar University
obvious deformity (1). Brachioplasty was first
Hospitals. Approval of the Ethics Board of Al-
described by Correa-Iturraspe and Fernandez1 in the
Azhar University and a written informed consent
1950s, but it was associated with frequent
from all the subjects were obtained. This study was
complications and suboptimal results. Since then,
conducted between January 2017 to March 2019. The
numerous surgeons have modified the original
included subjects were 14 obese patients and 26 with
technique, with a subsequent improvement in
excess skin after massive weight loss. The patients'
outcomes. Specifically, the incidence of axillary scar
age was ranged from 26 to 56 years. Thirty-six
contracture was decreased with the advent of the T-
patients were females and 4 were males. Thirty-two
or L-shaped axillary resection patterns and W or Z
patients complained of skin redundancy of the arms
incisions crossing the axilla (2).
post massive weight loss and 8 patients complained
Cosmetically, the optimal placement of the final
of generalized obesity with marked obesity in the
scar was found to lie in the brachial sulcus, such that
arms and difficult in elevation of the arms with pain
with the patient's arms at the side, the incision is
and numbness on elevation (table 1).
virtually imperceptible (3). Only with the patient's
Different techniques used for brachioplasty as
arms abducted can the incision be seen, and even so,
liposuction or skin excision by different types of skin
it is often hidden by the shadow in the sulcus. Less
incision according to the degree of fat deposit,
undermining decreased the incidence of seromas and
redundancy and skin ptosis, or both were used in this
lymphedema flaps (4).
Finally, the incidences of scar widening and
1. Patients with moderate to severe fat deposit and
recurrence of the deformity were decreased with
grade 1 ptosis (<5 cm) with good skin tone:
techniques that anchored the fascia of the arm into the
liposuction was done.
axilla (clavipectoral fascia). As a result of these
2. Patients with severe fat deposit and grade 2 to 3
modifications, brachioplasty has become a safer,
ptosis (5-10 cm) with moderate to poor skin tone:
more effective operation (5).
combined liposuction and brachioplasty were
The aim of the current study was to describe the
aesthetic outcome of different techniques used for
3. Patients with minimal or no fat deposit and with
correction of arm ptosis to try to obtain a new
grade 3 ptosis (> 10 cm) with poor skin tone:
treatment-based algorithm for management of
traditional brachioplasty was done.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2514-2520
Comparison of the Microdose Flare Up GnRH Agonist and Antagonist
Protocol in Assisted Reproduction with Poor Ovarian Response during
Controlled Ovarian Stimulation Cycles
Mohamed Fakhry Elebiary*, Emad Abdelrahman Eltemamy, Abdelmoneim Mohamed Zakaria
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohamed Fakhry Elebiary, Mobile: (+20) 1002558560,
Background: Poor ovarian response presents a significant challenge in artificial reproductive treatment (ART).
Poor responders are estimated to comprise approximately 9- 24% of IVF cycles patients. Recently, the development
of GnRH antagonist protocol offered another approach for ovarian stimulation by blocking the pituitary receptors.
There is evidence that application of GnRH antagonist protocol decreases the duration of ovulatory stimulus and
reduce incidence of ovarian hyperstimulation syndrome (OHSS).
Objectives: The aim of the current study was to evaluate the effect of the antagonist protocol to the microdose
flare up GnRH agonist protocol for poor ovarian responders undergoing IVF/ICSl treatment.
Patients and Methods: A total of sixty patients of IVF/ICSI assigned to be poor responders were randomized
into two groups; group 1 Thirty patients received GnRH antagonist fixed protocol and group 2 thirty patients
received a microdose flare up agonist protocol. Patients characteristics and treatment outcomes were statistically
compared between groups.
Results: Duration of stimulation was highly significantly lower in the antagonist group than that of the microdose
flare up one (antagonist 8.60±1.63 versus microdose flare up 12.06±2.86; p=0.001). Number of ampoules of HMG
was highly significantly lower in the antagonist group than that of the micro dose flare up agonist one (antagonist
23.53±7.33 versus micro dose agonist 71.97±9.35; p=0. 001). The number of oocytes retrieved in the antagonist
group was not different from microdose flare agonist group (5.14±2.45 vs. 5.11±1.29; p=0.953), and the number
of embryos transferred was similar in both groups (2.03±0.08 vs. 2.09 ± 1.05; p=0.674). No significant differences
in pregnancy rates were reported.
Conclusion: we offer using the "GnRH antagonist" as a patient friendly protocol in ART with poor ovarian
response with Immediate mode of action, similar pregnancy rate, time saving, less duration of stimulation and
number of ampoules for stimulation than microdose flare up protocol.
Keywords: GnRH antagonist, ovarian hyperstimulation syndrome, poor ovarian response, IVF/ICSI
or growth hormone releasing hormone (GHRH),
Poor ovarian response presents a significant
transdermal testosterone, aromatase inhibitor, high
challenge in artificial reproductive treatment (ART).
FSH dose, GnRH agonist stop, GnRH antagonist, r
Poor responders are estimated to comprise
FSH versus u FSH and the flare up GnRH agonist
approximately 9- 24% of IVF cycles patients;
protocol. None of the treatments could improve the
however, there is no uniform definition of poor
pregnancy rate in poor ovarian responders(3).
response. Various authors use different definitions of
The micro dose flare up (MF) protocol has
the word, ranging from the number of oocytes
become one of the most common COH protocols used
retrieved, (ranging from 2 to 5), the maximal E2 level
in poor ovarian responders they showed improved
(ranging from 100 to 660 Pg/ml) on the day of hCG,
ovarian response and clinical outcomes. The initial
the total amount of FSH administered during ovulation
release of endogenous gonadotropins induced by low
and/or cycle cancellation due to poor response to
dose GnRH -a with administration of high dose
ovarian stimulation when the gonadotrophins starting
exogenous gonadotropins (4).
dose for induction of ovulation was at least 300
GnRH agonists and antagonists are peptides
IU/day) (1). The management of poor ovarian
containing 10 amino acids (5). Despite the fact that
response is highly controversial. There is no consensus
GnRH agonist protocol is accompanied by some
on the optimum controlled ovarian stimulation (COH)
disadvantages, it has become widely used in clinical
protocol in such patients. Increased amount of
IVF- ET treatment, and its application is associated
gonadotrophins and duration of stimulation with
with an increase in the rate of pregnancy (6).
possible high cancellation rate have always been a
The GnRH antagonists have also been found
problem in poor responders(2).
effective for ovarian gonadotropin release. As a result,
A number of randomized controlled trials
the GnRH antagonist protocol has also been widely
(RCT) have compared different stimulation protocols;
employed in the clinical settings of women with IVF-
however, none has so far been demonstrated to be
ET poor responders treatment.(7)
superior, such as the addition of growth hormone (GH)
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2521-2526
Temporalis Fascia versus Tragal Mucoperichondrium Graft in Myringoplasty
Wael H. Abo Elwafa, Kamel S. Hammad, Ahmed S. Gad, Mohamed K. Ibrahium, and Mohamed S. Khalil
Department of Otorhinolaryngology, Faculty of Medicine, Al- Azhar University
*Corresponding Author: Mohamed S. Khalil, Phone No.: (+20) 01274495586, E-mail: firstname.lastname@example.org
Background: Chronic suppurative otitis media (CSOM) constitutes a major public health problem in children
and adults in the developing world. It is an infection characterized by recurrent middle-ear discharge through a
persistent tympanic membrane perforation.
Objective: the aim of the present study is to compare the surgical and audiological results of temporalis fascia
versus tragal perichondrium in myringoplasty
Patient and Methods: a randomized prospective study concerned with 60 patients for whom myringoplasty was
done. Patients were randomly assigned into two groups; in the first group temporalis fascia graft was used (30
patient) and tragal perichondrium graft was used in the second group (30 patients).
Results: our study included 60 patients, 27 males and 33 females with a range from 19- 45 years. Surgical success
rates for the first and second groups are 80% and 73.3%, respectively. There was 10.5 dB improvement in mean
hearing threshold in fascia group, compared to 8.16 dB improvement in perichondrium group, giving an average
of 9.33 dB improvement in mean hearing threshold of the total series.
Conclusions: mean value of gain among temporalis fascia graft group was higher than tragal perichondrium graft
group. There was statistically significant difference between the two groups regarding gain and no significant
difference in surgical success rate between the two groups.
Keywords: Temporalis Fascia, Perichondrium Myringoplasty.
PATIENTS AND METHODS
Chronic suppurative otitis media (CSOM)
A prospective study was carried out on 60
constitutes a major public health problem in children
patients (27 males and 33 females with a range from
and adults in the developing world. It is an infection
19-45 years) with a complaint of recurrent ear
characterized by recurrent middle-ear discharge
discharge, hearing loss and diagnosed as CSOM
through a persistent tympanic membrane perforation.
tubotympaic type, with dry central perforation for at
This disease is the most common childhood
least 3 weeks without any other external ear, middle
infectious disease worldwide, starting early in life (1).
ear or inner ear diseases.
A consequence of CSOM is hearing loss and a
propensity to recurrent infection and discharge (2).
Exclusion criteria are
Chronic suppurative otitis media may be:
1. Evidence of cholesteatoma.
- Tubotympanic type (safe type)
2. Previous ear surgery.
- Atticoantral type (unsafe type) (3).
3. Recent traumatic perforation.
Surgical repair (myringoplasty) of CSOM
4. Severe tympanosclerosis.
tubotympanic type is indicated to restore hearing
5. Chronic otitis externa.
ability as well as to prevent recurrent otorrhea (4).
6. Systemic diseases as diabetes mellitus
Various graft materials were used in
myringoplasty e.g. temporalis fascia, tragal
perichondrium, subcutaneous tissue, free skin graft,
An approval of the study was obtained
vein graft, dura, etc. The ideal grafting material used
from Al- Azhar University academic and ethical
for tympanic membrane closure should meet certain
committee. Every patient signed an informed
criteria namely, low rejection rate, sufficient
written consent for acceptance of the operation.
quantity, good tensile strength, low metabolic rate,
Each patient was subjected to:
and easy availability. Membranous grafts like
1. Detailed history taking.
temporalis fascia and tragal perichondrium meet
2. Full clinical examination with special, general
these criteria and result in closure of tympanic
and local otolaryngological examination.
membrane perforation in 95% of ears with normal
3. Audiological investigation: pure tone
4. Full investigation for surgical fitness including:
AIM OF THE WORK
The aim of this study is to compare the surgical
CBC, PT, PTT, INR, BT, CT, RBS, LFT, KFT and
and audiological results of temporalis fascia versus
tragal perichondrium graft in myringoplasty.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2527-2530
Bowel Obstruction Following Lap Appendectomy and Open Appendectomy
Osama Abdullah Abdul Raheem and Ehab Motawa El Hussieny
Department of General Surgery, Faculty of Medicine, Aswan University
*Corresponding Author: Osama Abdullah Abdul Raheem, Phone No.: (+20)01155520802,
Background: acute appendicitis is a common indication for abdominal surgery with a life-time incidence between 7
and 9% and appendectomy is one of the most common surgical procedures. Open appendectomy (OA) performed
through the right lower quadrant incision was first described in 1894. It has become the standard treatment of choice
for acute appendicitis, due to its efficacy and safety.
Objective: the aim of the present study was to compare the frequency of readmissions due to bowel obstruction (BO)
after open versus laparoscopic surgery performed for suspected acute appendicitis.
Patients and Methods: this was performed in Aswan University hospital, on 100 patients from April 2015 to April
2017 who underwent laparoscopic and open appendectomy. The merits and drawbacks of LA and OA were explained
to all of the patients with diagnosis of acute appendicitis.
Results: a statistically significant difference was found when comparing the operative time of the LA and OA. The
operating times in OA and LA were 16-37 min (mean 24.7) and 19-45 min (mean 33.1), respectively. The OA was
shorter in duration, with a P value less than or equal to 0.05 (Mann-Whitney test).
Conclusion: laparoscopic appendectomy is equally safe, and can provide less postoperative morbidity in experienced
hands, as open appendectomy. Most cases of acute appendicitis can be treated laparoscopically. Laparoscopic
appendectomy is a useful method for reducing hospital stay, complications and return to normal activity.
Keywords: Bowel obstruction, Appendectomy, Open appendectomy
Successful appendectomy was first described
appendectomy more than 80% compared to 10% after
by McBurney(1). The open surgical approach remained
laparoscopic appendectomy, when patients were
the gold standard for nearly a century. The lifetime risk
laparoscoped three months after surgery(10). It has been
of developing appendicitis is between 7 and 9% with
shown that the tissue trauma of the incision increases
evidence of increasing incidence (2,3).
the total inflammatory response, thereby inhibiting
With the advance of minimal invasive surgery,
fibrinolysis and promoting fibroblast migration and
new approaches for the existing operations have been
proposed. Semm(4) first described the laparoscopic
approach for acute appendicitis in 1983. Now
AIM OF THE WORK
laparoscopic appendicectomy (LA) has become
The aim of the present study is to compare the
common and an acceptable approach in the
frequency of readmissions due to bowel obstruction
management of acute appendicitis (5). LA is associated
(BO) after open versus laparoscopic surgery performed
with decreased postoperative pain, more rapid return to
for suspected acute appendicitis.
daily activities, and improved cosmetic results(6).
However, the literature has shown the association of
PATIENTS AND METHODS
laparoscopy with specific adverse events such as
This was performed in Aswan University
increased intra-abdominal abscess and hospital costs (6).
hospital, on 100 patients from April 2015 to April 2017
Despite OA being associated with low
who underwent laparoscopic and open appendectomy.
morbidity and mortality rates the popular minimally
The merits and drawbacks of LA and OA were
invasive approach showed more advantages such as less
explained to all of the patients with diagnosis of acute
wound infection, less pain, and faster recovery in the
appendicitis. The study was approved by the Ethics
cost of more operating time and hospital cost(7,8). LA can
Board of Aswan University and an informed written
have extra benefits for female patients as decreasing
consent was taken from each participant in the
adhesions and fertility problems and better cosmetic(9).
Adhesion formation is now one of the most
The diagnosis of acute appendicitis was mainly
common causes of intestinal obstruction. Late
clinical. Several methods have been suggested to
complications due to intra-abdominal adhesions include
diminish the diagnostic error like U/S and CT abdomen
chronic abdominal pain, small bowel obstruction
if diagnosis is not clear. The symptoms of appendicitis
(SBO), and female infertility. These chronic conditions
can initially be difficult to differentiate from
can result in a major impairment for the patient, a
gastroenteritis. Early symptoms may include vague
challenge to treat, and represent a major cost for
bloating, indigestion and mild pain which generally is
society(10.11). Reduced adhesion formation is a
perceived as being in the area of the umbilicus. As the
substantive long term advantage of laparoscopic
infection worsens, the pain becomes more prominent in
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (3), Page 2531-2538
Contrast Sensitivity Affection: A Comparative Study between Photorefractive
Keratectomy and Small Incision Lenticule Extraction Pre and Postoperative
Abd Elmagid Mohammad Tag Eldain, Hosny Hassan Mohammad Aly,
Mohammad Moustafa Abd Elhalem Diab*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Mohammad Moustafa Abd Elhalem Diab, Phone No.: (+20) 01092702797,
Background: the cornea is a transparent dome shaped structure at the front of the eye separated from the iris and
pupil by the anterior chamber. It is one of the main refractive media of the eye. Refractive surgery includes
several types such as Photorefractive Refractive Keratectomy (PRK) and Small incision lenticule extraction
(SMILE). Objective: contrast sensitivity affection in comparative study between patients undergoing
photorefractive keratectomy (PRK) or small incision lenticule extraction (SMILE) surgery.
Patients and Methods: twenty cases of different patients' ages; 18-30 years old with myopia from -0.5 D to -
9.00 D were included in this comparative study. Patient with corneal infection, trauma, opacities, operation,
ocular disease or congenital eye disease were excluded from our study. All the selected patients were submitted to
full ophthalmological examination (visual acuity, fundus examination, pantacam, and assess contrast sensitivity
degree before operation and one month after refractive surgery. Measurement of contrast sensitivity was done by
Function Acuity Contrast Test (FACT) before and one month after refractive surgery through several spatial
frequencies (1.5, 3, 6, 12 and 18). Results: we found that contrast sensitivity was affected one month after
refractive surgery in both groups but it is affected in group 1 after PRK more than group 2 that had femto SMILE.
Conclusion: contrast sensitivity was affected in both patients who had PRK or Femto SMILE after one month
from operation but it is more stable after Femto SMILE.
Keywords: Cornea, PRK, SMILE, LASIK
hyperopia, presbyopia, and astigmatism. The
The cornea is a transparent dome shaped
procedure involves using a femtosecond laser to
structure at the front of the eye separated from the
create corneal lenticule which is extracted as whole
iris and pupil by the anterior chamber. It is one of the
through a small incision without the use of an
main refractive media of the eye. The adult cornea
excrimer laser. It's reported to achieve effects similar
measures 11 to 12 mm horizontally and 9 to 11 mm
to laser assisted in site keratomileusis (LASIK) with
vertically. It is approximately 0.56 mm thick at the
excellent post operative outcomes(3).
center, and increases gradually toward the periphery
Starting in 2007, an intra-stromal lenticule
of the cornea where it is about 1mm thick. The radius
method was reintroduced as an alternative to LASIK
of curvature of the anterior surface is about 7.8 mm
called femtosecond lenticule extraction (FLEX)
and that of the posterior surface is about 6.9 mm (1).
intended for patients with extreme myopia. SMILE is
The refractive power of the cornea is 42+ 2D
noted for achieving similar effects as LASIK but
diopters thus the cornea provides about 2/3 of the
with some possible benefits such as faster recovery,
total refractive power of the eye which is 60 diopters
less post operative dry eye, rapid re-innervation of
(1). Idea of photorefractive Keratectomy (PRK)
corneal nerves, and potential biomechanical
involves removing the corneal epithelium either with
advantage. The commencement of this procedure
the excimer laser or manually, Followed by computer
began in September 2011 and is established in
guided ablation of the underlying Bowman's
various locations such as Europe, China, and India.
membrane and anterior corneal stroma for the
The Clinical trial in the USA began in June 2012 and
correction of myopic or hyperopic refractive errors or
has been expanded by the US FDA after initial signs
both (2). After improvements of scan modes and
of success in a small sample of patients; 255 patients
energy parameters; improved visual recovery times
have been treated at five centers in the USA. Outside
were noted, with refractive results similar to LASIK
of the USA, there are 150 centers in a total of 38
following the implementation of FLEX. A procedure
countries that perform the procedure(3).
called small incision lenticule extraction (SMILE)
The measurement of spatial contrast
was developed, involving a small 2-3 mm incision
sensitivity documents visual function more
used to allow for extraction of the whole corneal
comprehensively than visual acuity. The importance
lenticule without the need to create a flap(3).
and usefulness of contrast sensitivity evaluation in
SMILE a relatively new refractive procedure
patients who have undergone refractive surgery
designed to treat refractive errors such as myopia,
procedures is widely recognized. Measurements of