The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2539-2542
Conventional Penetrating Keratoplasty Versus Femtosecond
Laser Assisted Penetrating Keratoplasty
Mohamed Selim El Kadi, Mahmoud Mohamed Ismail, Mohamed Ahmed El Malah, Suzan Fouad Mohamadia*
Ophthalmology Medicine and Surgery Department, Al-Azhar University
*Corresponding author: Suzan Mohamadia, Mobile: (+20)01001994959, E-Mail: email@example.com
Purpose: due to introduction of femtosecond Laser technology as new tool in penetrating keratoplasty (PKP), this
study aims to compare this new tool and conventional PKP, also aims to compare between different shapes of
femtosecond Laser (FSL) assisted PKP. Patients and methods: 40 eyes with different corneal pathologies were
included in this study and they were categorized in to 2 groups. 20 eyes underwent penetrating keratoplasty by
using manual trephination (I) and 20 eyes underwent PKP by using FSL assisted trephination (II).
Results: femtosecond Laser assisted penetrating keratoplasty (FLAK) substantially improved wound healing,
speeds up visual recovery and improved BCVA as it decreased MRA and corneal steepening but consumed more
operative time. Conclusion: FLAK is the future in corneal graft surgery, where healing may not be a problem in
the postoperative period.
Keywords: Conventional PKP, FSL assisted PKP and wound healing.
alignment of wound, also parameters of graft and
Penetrating keratoplasty (PK) has emerged as a
recipient cutting, all of the previous can be achieved
relatively safe means of restoring vision in corneal
easily than conventional cases. The femtosecond Laser
opacities and irregularities. One of the critical steps in
is one of the most revolutionary in the recent medical
PK is wound closure, as adequateness of sutures will
technology. It has been used mainly for creation of
postoperatively determines not only the presence of
corneal flabs for Laser insitu keratomileusis as an
astigmatism but also presence or even graft failure (1).
alternative to mechanical microkeratome. This
Conventional penetrating keratoplasty requires
technology has enabled us to apply for corneal
relatively tight sutures to hold edges together until
healing is sufficient to the intraocular pressure. This
As further advances in hardware and software
usually takes about one year. Astigmatism is often of
technology enable pulsed to be applied in different
irregular type. The most important factors of adequate,
patterns and shapes, mushroom shaped, top hat and
rapid wound healing and lower postoperative
zigzag (3), also straight cut with accurate depth and
astigmatism are centration of corneal trephination in
diameter with accurate measurements and done by
Visu Max with 500 Hz repetition rate has been
perpendicularity and the exact antero-posterior
keratoplasty. They were categorized in to 2 groups.
AIM OF THE WORK
Group (I): twenty eyes underwent penetrating
This study aims to compare FSL assisted PKP as
keratoplasty by using manual trephination. Group
a new tool and conventional PKP, also aims to
(II): twenty eyes underwent PKP by using FSL
compare between different shapes of FSL assisted
assisted trephination, mushroom shaped, top hat or
Inclusion criteria: all patients fulfilled the following
PATIENTS AND METHODS
This work had been conducted at ophthalmic · Patients with corneal opacity
medicine and surgery department, Al-Hussein and · Advanced keratoconus not suitable for hard contact
Sayed Galal Hospitals, Faculty of Medicine, AL-
lenses or corneal rings
Azhar University and at Noor EL-Hayet Hospital
Exclusion criteria :
during the period from March 2016 till March 2019. · Unstable corneas or "open eyes" like corneal
Ethical approval: The study was approved
perforation with lost or very shallow anterior chamber.
by Ethics Board of the Faculty of Medicine, Al- · Pseudophakic with anterior chamber IOL.
Azhar University. There was also a written consent · Uncontrolled glaucoma .
· Active uveitis or before 6 months of recovery.
Forty eyes were included in this study of males · Active viral or bacterial infections.
and females (20 male and 18 female). All patients were · Very severe, vascularized corneal opacities like that
suffering from corneal pathology as keratoconus grade
due to chemical injuries
4, decompensated cornea, corneal dystrophies and · Extreme of ages less than 19 years and more than 70
corneal opacities and were in need for penetrating
years HTH-PKP patients
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2543-2549
The Effect of Laparoscopic Sleeve Gastrectomy on Serum Lipids
Ashraf Ibrahim Attia Alsharkawy, Mohamed Aboulfotouh Ahmed, Ahmed Gamal Eldin Metwally*
Department of General Surgery, Faculty of Medicine for Girls, Al-Azhar University
*Corresponding author: Ahmed Gamal Eldin Metwally, Mobile: (+20) 01063021265
Background:morbid obesity is a growing health problem in the modern world and affects almost 20% of the population.
Obesity associates with increased morbidity and mortality, one of which is dyslipidemia. Bariatric surgery is the only
known method to induce significant weight loss and prevent its regain in morbidly obese patients.
Aim of the work: the aim of this work was to evaluate the effect of laparoscopic sleeve gastrectomy on serum lipids
(Cholesterol - TG - LDL - HDL) and analysis of these data and compare with other results from different centers,
institutes all over the world.
Methods: our study was a retrospective study on 20 patients hospitalized in General Surgery department of Al-zhraa
University hospital who underwent laparoscopic sleeve gastrectomy in order to treat morbid obesity from August
2018 to February 2019.
Results: In our study 3 month after LSG we observed significant changes in lipid profile parameters including
significant decrease in total cholesterol, TG, LDL and significant increase in HDL.
Conclusion: our retrospective study shows that LSG is very good bariatric procedure with excellent results on short
term follow up regarding body weight reduction, BMI. Three months after operation improve metabolism and lipid
profile was accompanied by decrease in Total Cholesterol, Triglyceride and LDL cholesterol and increase in HDL
cholesterol change in significant way.
Keywords: Laparoscopic Sleeve, LDL, HDL, SG, RYGB
USA and Canada and a 7% increase in Europe during
Obesity is a growing health problem in the
the period of 2003-2008. Laparoscopic sleeve
modern world and affects almost 20% of the
gastrectomy (LSG) started to be performed in Poland
population. Obesity associates with increased
in 2005, and one can observe a constant increase in the
morbidity and mortality, and the reason for such
number of procedures from year to year (4).
association appears to be the clustering of
Bariatric surgery is also effective in improving
cardiovascular risk factors in obese individuals, one of
the lipid profile in obese patients, but the type and
which is dyslipidemia. High levels of triglycerides
magnitude of this improvement differs according to the
(TG) and low-density lipoprotein (LDL) cholesterol
procedure. The three most common techniques--Roux-
and low levels of high-density lipoprotein (HDL)
en-y gastric bypass (RYGB), sleeve gastrectomy (SG)
cholesterol are frequently encountered in obese
and adjustable gastric banding (AGB)--increase HDL
and decrease TG levels, but only RYGB, a mixed
Bariatric surgery is the only known method to
malabsorptive and restrictive technique, appears to be
induce significant weight loss and prevent its regain in
capable of reducing total cholesterol (TC) and LDL
morbidly obese patients. Its benefits appear to go
cholesterol. A still unanswered question is whether this
beyond weight loss; Roux-en-Y gastric bypass
improvement in the lipid profile is merely weight-
(RYGB) and sleeve gastrectomy (SG) improve
dependent or otherwise, also results from specificities
carbohydrate metabolism even before any noticeable
inherent to the bariatric procedure itself. Current
weight loss has occurred, this is probably due to their
evidence points towards the importance of weight loss
effect on the gastrointestinal hormonal milieu(2).
Surgical techniques for obesity management
continue to gain broader implementation possibilities.
AIM OF THE WORK
Nowadays, gastric sleeve resection is performed mainly
The aim of this work is to evaluate the effect
laparoscopically. Despite late introduction as a treatment
of laparoscopic sleeve gastrectomy on serum lipids
modality, it is gaining popularity not only as the first step
(Cholesterol - TG - LDL - HDL) and analysis of these
in the staged treatment of super morbid obesity or in
data and compare with other results from different
patients from high-risk groups but mainly as an isolated,
centers, institutes all over the world.
definitive bariatric procedure(3).
Sleeve gastrectomy (SG) was first described in
PATIENTS AND METHODS
1988 as a part of the duodenal switch procedure and in
Our study was a retrospective study on 20
1993 as an independent one-stage procedure. The
patients hospitalized in General Surgery department of
number of laparoscopic sleeve gastrectomies continues
Al-zhraa University hospital who underwent
to increase both in Europe and North America. There
laparoscopic sleeve gastrectomy in order to treat
was an increase from 0% to 4% in the
morbid obesity from August 2018 to February 2019.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2550-2555
Comparison between Sesame Oil and Glycyrrhizaglabra
Effect as Phytoestrogen on Male Albino Rats
Eman G.E. Helal1, Mohamed A. El-Aleem2, Shaimaa S. Ahmed1
Zoology Department, Faculty of Science, Al-Azhar University (Girls), Cairo, Egypt.1
Physiology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt2
*Corresponding Author: Eman G.E. Helal, E-mail: firstname.lastname@example.org, Mobile: 00201001025364,
Background: Phytoestrogen is a plant-derived compound, which has estrogenic effect and it is found in liquorice
root extract and sesame oil. Aim of the work: To investigate some biochemical effects of liquorice root extract
and sesame oil on male albino rats.
Materials and methods: 18 animals were divided randomly into three groups. Group A: Control group, group
B: rats treated with oral dose ofliquorice1 ml/kg body weight/day for one month, and group C: rats treated with
oral dose of sesame oil 1 ml/kg body weight/day. At the end of the experiment, blood samples were collected for
Results: Liquorice and sesame oil induced highly significant decrease in TC, TG, LDL, VLDL,
LDL/HDL(p<0.01)and significant increase in HDL(p<0.05). They also showed highly significantly decrease in
FSH, testosterone and sperm count compared to control group (p<0.02).
Conclusion: The study supports that the high level intake of liquorice root extract or sesame oil caused hormonal
disturbance and decreases sperm count.
Keywords: Liquorice root, Sesame oil, Lipid profile, Albino rats, Physiological parameters.
Glycyrrhizaglabra, a family of Leguminosae, is
a plant that grows in Egypt and other countries of the
rheumatoid arthritis and cardio-protective (4).
world. Its roots possess some nutritional value and
medicinal properties. It is widely used as a cold drink
Sesame belongs to the family Pedaliaceae. It is
and in the preparation of some pharmaceuticals such
one of the richest food source oflignans, amajor type
as hematinic pills (1).
of phytoestrogens known to man since the dawn of
Phytochemical analysis of Glycyrrhizaglabra
civilization (5)and is increasingly incorporated into
(liquorice) root extract showedthat it contains
human diets because ofits health benefits(6). Sesame
saponintriterpenes (glycyrrhizin, glycyrrhetinic acid
lignans such as sesamin, episesamin, sesamolin, and
andliquirtic acid), flavonoids (liquiritin, isoflavonoids
sesamol isolated from Sesamumindicumseeds are
and formononetin) andother constituents such as
implicated as having certain properties such as anti-
coumarins, sugars, amino acids, tannins,starch,
tumorigenic(7)and antioxidant(8). The proximate
choline, phytosterols and bitter principles,which are
analysis of sesame seed indicates that it contains
most likely responsible for its therapeutic
about 50-60 % oil, 8 % protein, 5.8 % water,3.2 %
crude fiber, 18 % carbohydrate and 5.7 % ash. It is
There are many phenols present in liquorice
very rich in minerals such as calcium, phosphorus and
vitamin E(9).The seed oil combats some health
conditions like cold and chronic cough and in turn
formononetin, which are responsible for the plant
prevents bronchial lung disease. In addition, it helps
estrogen activity of this plant, extracts (3).
in improving the blood glucose, glycosylated
Medicinally its root is used widely either as
hemoglobin and lipid-peroxidation(10).Besides to its
tincture or fluid extract or ingredient in over the
broad use in cooking, the oil is also used in the
counter pharmaceutical products for cough,
expectorant, asthma, peptic ulcers and hepatic-
pharmaceuticals(11). Sesamin, the most abundant
protective products. This is because of its anti-
lignan in sesame oil(12)is known to contain unique
amounts of phytoestrogen, and has some effects on
antimicrobial and hepatic-protective activities(4).In
Japan, intravenously, liquorice components are used
for treating hepatitis B and C (National Center for
MATERIALS AND METHODS
Complementary and Integrative Health, 2016). Other
Roots of liquorice plant were purchased from
indications still under research like different cancer
market of Agricultural Seeds and Medicinal Plants,
conditions (Colon, Breast, Hepatic and Prostate),
Cairo, Egypt. Clean roots (10gm) were soaked in cup
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2556-2562
Comparative Study between Medical and Surgical Modalities of
Treatment of Chronic Allergic Nasal Polypi
Ali Khalaf Mahrous, Mohammed Ahmed El Sharkawy, Abd El Hakeem Abd El Salam Ibrahim*
Department of Otorhinolaryngology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
* Corresponding author: Abd El Hakeem Abd El Salam Ibrahim, Tel. No.: (+20) 1007977665,
Background: Nasal polyposis is a common problem facing the otolaryngologist. Its incidence is estimated to be in
the range of 0.2 to 4.3%. It may be associated with other conditions such as bronchial asthma (about 25%-30% of
polyposis patients) and Aspirin sensitivity (12%).
Objectives: The aim of this work was to study the importance of searching and identifying the effect of medical
versus surgical modalities in treatment of chronic allergic nasal polyps.
Patients and Methods: Thirty patients with bilateral nasal polyps were enrolled in this study. They were randomly
arranged into 2 groups. Group I was treated by functional endoscopic sinus surgery while Group II was treated by
local and systemic corticosteroids. The age in Group I ranged from 17 to 66 years with a mean of 42 ± 16.51 years
while the age in Group II ranged from 19 to 60 years with a mean of 39.4 ± 11.24 years. In Group I, 12 patients
(80%) were male while 3 patients (20%) were female. In Group II, 9 patients (60%) were male while 6 patients (40%)
were female. No past history was found in 18 patients (60%) while bronchial asthma was found in 8 patients (26.67%)
and aspirin sensitivity was found in 3 patients (10%). Both bronchial asthma and aspirin sensitivity were found in
one patient in Group II.
Results: The mean Total nasal symptoms score (TNSS) were 22.33 ± 1.21 in Group I and 20.07 ± 3.31 in Group II.
The mean Total Nasal Polyp Score (TNPS) were 4.67 ± 0.82 in Group I and 4.8 ± 0.862 in Group II. The mean Lund-
Mackay Score (LMS) were 10.87 ± 0.74 in Group I and 11 ± 0.66 in Group II.
Conclusion: Patients treated by FESS have less residual symptoms, size and severity of residual polyps and rate of
recurrence than patients treated medically.
Keywords: Medical and Surgical Modalities, Chronic Allergic Nasal Polyps
options, with eosinophilic inflammation, IgE, fungi
Nasal polyposis is a common problem facing
and Staphylococcus aureus as potential targets (4).
the otolaryngologist. Its incidence is estimated to be
Functional endoscopic sinus surgery is the
in the range of 0.2 to 4.3% (1). It may be associated
surgical option (FESS). FESS has evolved over time
with other conditions such as bronchial asthma (about
and many of the surgical procedures currently
25%-30% of polyposis patients) and Aspirin
performed under FESS might be prolonged and
sensitivity (12%) (2). The main problem in
accompanied by bleeding. The use of CT guidance
management of nasal polyposis is its known high
and the evolution of the surgical technique have
incidence of recurrence. Medical treatment is usually
allowed surgeons to become much more aggressive
the first line of treatment; however, a considerable
with the scope of their endoscopic procedures (5).
number of patients may not respond. Patients with
As regard technique of endoscopic endonasal
associated asthma or acetylsalicylic acid (ASA)
surgery, the Messerklinger technique has been the
sensitivity are known to be more prone to lack of
method of choice. This technique is both a diagnostic
response. Non-responsers generally are candidates for
and a surgical concept, whereby limited surgery can
surgical intervention (3).
improve ventilation and drainage of the ostiomeatal
Nasal polyps (NP) are one of the most
complex. A meticulous examination will be done to
common inflammatory mass lesions of the nose,
be able to detect anatomical variants or diseased areas
affecting up to 4% of the population. They present
within the ethmoidal region, causing chronic disease
with nasal obstruction, anosmia, rhinorrhea, post
to develop. Thereby, a limited surgical approach can
nasal drip, and less commonly facial pain. Their
restore normal ventilation and drainage in a functional
etiology remains unclear, but they are known to have
way with little trauma to surrounding structures (6).
associations with allergy, asthma, infection, fungus,
The aim of this work was to study the
cystic fibrosis, and aspirin sensitivity. Surgical
importance of searching and identifying the effect of
treatment has been refined significantly over the past
medical versus surgical modalities in treatment of
20 years with the advent of endoscopic sinus surgery
chronic allergic nasal polyps.
(4). Over the last two decades, increasing insights in
the pathophysiology of nasal polyposis opens
PATIENTS AND METHODS
perspective for new pharmacological treatment
This comparative prospective study included
a total of 30 patients presented with bilateral nasal
Maternal Mortality in Assiut Governorate, Egypt, 2009
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2563-2569
Ologen Implant Application in Subscleral Trabeculectomy versus
Non-Penetrating Deep Sclerectomy in Management of Primary Open Angle
Glaucoma: A Prospective Randomized Study
Mohammed Ahmed El Malah, Asaad Nooreldin*, Mohamed Elmoddather, and Mahmoud Said El Labny
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University (Assuit), Egypt
*Corresponding Author: Asaad Nooreldin, E-mail: email@example.com, Mob: +201026366024
Background: trabeculectomy and deep sclerectomy (DS) aim to lower intraocular pressure (IOP) in cases of
medically uncontrolled primary open angle glaucoma (POAG). The application of Ologen implant is thought to
increase the success rate of both procedures.
Objective: to compare the application of Ologen implant in trabeculectomy versus deep sclerectomy in patients with
uncontrolled POAG. Patients and Methods: this was a follow-up randomized clinical comparative trial included 30
eyes of 26 patients with uncontrolled POAG. They were randomly assigned to two equal groups (n=15 eyes): group
(A) underwent trabeculectomy and group (B) underwent deep sclerectomy. Both procedures were augmented with
Ologen implant. All patients were subjected to full history taking and complete ophthalmologic examination.
Postoperatively, patients were followed up at 6 months. Outcome and complications were assessed.
Results: both groups experienced significant reduction in IOP after 6 months postoperative; preoperative and
postoperative values were 22.8±3.73 mmHg and 11.07±2.63 mmHg, respectively in group (A) and 20.13±2.26 mmHg
and 13.53±2.61 mmHg, respectively in group B, P 0.01. The complete success was 93.0% in group (A) and 80.0% in
group (B), (P= 0.475). Group (A) had significantly higher frequency of postoperative complications compared to
group B (P 0.01).
Conclusion: the application of Ologen implant in both trabeculectomy and deep sclerectomy is effective for IOP
reduction and it resulted in better operative success in patients with POAG. Also, deep sclerectomy using Ologen
implant is a good and safe alternative to trabeculectomy in patients with POAG, but our obtained results need to be
supported by subsequent studies.
Keywords: Ologen implant, Subscleral Trabeculectomy, Deep Sclerectomy, Primary open angle Glaucoma.
complications such as sudden hypotony which is
Glaucoma is a broad term that entails a
frequently associated with trabeculectomy(6).
diverse range of disorders causing progressive visual
The Ologen implant was developed aiming at
field loss and ultimately optic nerve atrophy; it is the
replacing Mitomycin C (MMC) for glaucoma
main cause of irreversible loss of vision globally, even
surgeries, it is a disc-shaped biodegradable collagen
with appropriate treatment(1). The total number of
matrix that was designed to avoid excessive scarring
suspected cases of glaucoma is about 70 million
after trabeculectomy(7). Subconjunctival insertion of
worldwide and unfortunately approximately 10% of
people with glaucoma who receive proper treatment
mechanical separation between the conjunctiva and
still experience loss of vision(2). Primary open angle
the episcleral space and prevents adhesions between
glaucoma (POAG) is the commonest form of
glaucoma, it accounts for 19 % of all blindness among
African Americans compared to 6% in Caucasians(3).
Objective of the study:
Unlike secondary glaucoma, POAG lacks identifiable
The objective of this study is to compare the
risk factors; however, elevated intraocular pressure
application of Ologen implant in trabeculectomy
(IOP) is a known risk factor for POAG(4).
versus deep sclerectomy in patients with uncontrolled
If medical treatment failed to achieve
adequate control of IOP and other ocular effects of
POAG, surgical treatment is mandatory. Surgical
PATIENTS AND METHODS
options include subscleral trabeculectomy which is
This interventional follow-up randomized
the most commonly performed procedure which
clinical comparative trial was conducted at Al-Azhar
allows drainage of AH from within the eye to
University Hospital (Assiut), Egypt from August 2017
underneath the conjunctiva where it is absorbed(5).
to June 2018. The study included 30 eyes from 26
Non-penetrating deep sclerectomy (DS) is another
choice characterized by its non-invasive nature and
Inclusion criteria: established diagnosis of
POAG with IOP >21 mmHg, age above 40 years and
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2570-2580
Hepatic and Epicardial Fat as Early Strong Predictors for Metabolic Syndrome
Mohammed Abdel-Hassib1, Hossam Elashmawy2 and Yasser Elsayed Mohammed3
1Internal Medicine Department, 2Clinical Pathology Department and 3Cardiology Department,
Faculty of Medicine, Al-Azhar University
*Corresponding Author: Yasser Elsayed Mohammed, email: Yasserelsayed97_@yahoo.com
Introduction: hepatic steatosis (HS) has been previously considered as a valuable and long-established indicator
for evaluation of metabolic syndrome (MetS) and cardio-metabolic risks. Recently, epicardial adipose tissue
(EAT) has been proposed and up to be established to carry the same or more than of HS as regarding cardio-
metabolic risks. Hence, both of HS and cardiac steatosis coexist and interact with each other i.e. one reflects to the
other. There are little data assessing the associations of hepatic and epicardial fat in non-metabolic-syndrome
Egyptian adults. Objective: to evaluate the relationship between HS and EAT, and its relation to the components
of metabolic syndrome.
Patients and methods: We studied fifty HS patients accidentally discovered by abdominal ultrasound and fifty
healthy matched controls with normal fat content in the liver (without HS) by ultrasound for comparison. Both
groups underwent complete history taking, general examination, laboratory investigations and 2D transthoracic
echo Doppler study at baseline and 18 months thereafter only for patient's group.
Results: this study showed that, there is a positive correlation between HS and EAT and metabolic syndrome. HS
and EAT are early and sensitive predictors for metabolic syndrome.
Conclusion: hepatic and epicardial fat are early and strong predictors of metabolic syndrome.
Keywords: hepatic and epicardial fat, metabolic syndrome.
While hepatic steatosis (HS) was considered
Recently, there is growing awareness that
as a traditional indicator of metabolic syndrome
the behavior of the accumulated fat is completely
(MetS), epicardial adipose tissue was proposed to
different from body compartment to another e.g.
carry high cardiometabolic risk compared to general
excessive adipose tissue accumulation in the
fat accumulation . Hence; both of HS and cardiac
subcutaneous, intramuscular, and retroperitoneal is
steatosis coexist and interact with each other (One
considered a less metabolically harmful; i.e. less of
reflects to the other i.e. epicardial fat reflects
insulin resistance, lipolysis rate, and steroid
intraabdominal visceral fat). Nowadays and in the
hormone receptors, than those organ where specific
coming, both of HS and EAT becomes novel
(Ectopic) fat accumulates and surrounds internal
therapeutic target for MetS and cardiovascular risks
organs "visceral adiposity" [Central or truncal,
, such as high BP, coronary artery disease (CAD),
hepatic, epicardial, and dorsocervical regions] .
dyslipidemia, carotid atherosclerosis, polycystic
Obesity leads not only to increased fat
ovary syndrome (PCO), insulin resistance, and even
depots in classical adipose tissue locations, but also
type I DM associated with central obesity .
to significant lipid infiltration within internal organs
However, lipid accumulation in cardiac
"visceral adiposity" .
myocytes is also an early sign of pathogenesis of
Different visceral fat compartments have
diabetic cardiomyopathy . Epicardial adipose
several systemic effects and may play a role in the
tissue is a "novel" visceral fat depot with peculiar
development of both insulin resistance and
anatomic and biochemical features .
cardiovascular diseases. In the last couple of years
Anatomically; EAT is a unique fat
special attention has been paid to the epicardial
adipose tissue (EAT), which can be quantified by
pericardium and myocardium, sharing a common
non-invasive cardiac imaging techniques .
embryologic origin (brown adipose tissue and
Non alcoholic fatty liver disease (NAFLD)
splancho-pleuric mesoderm during embryogenesis)
is caused by the excessive accumulation of fat in the
and strong genetic dependence with the visceral fat
liver and commonly associated with obesity and
metabolic syndrome. NAFLD can be considered the
EAT and the myocardium does not have
hepatic expression of the metabolic syndrome.
any fascia separates, thereby sharing the same
microcirculation (branches of coronary arteries). By
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2581-2584
One Year Follow Up after Septal Myectomy for Hypertrophic
Ahmed M. El Ashkar 1, Ahmed N. Khallaf 2
Cardiothoracic Surgery, 1Beni-suef University, Beni-suef, 2Fayoum University, Fayoum, Egypt
Corresponding author: Ahmed El Ashkar, Phone: 01222149535, E-mail: firstname.lastname@example.org
Background: According to the European society of cardiology 2008, hypertrophic cardiomyopathies (HCM) are
defined as increased ventricular wall thickness or mass, in the absence of loading conditions such as hypertension
or valve disease.
Objectives: The aim of the current study was to assess the short term (1 year) outcome of the Septal Myectomy
for Hypertrophic Obstructive Cardiomyopathy (HOaCM).
Patients and Methods: The study included 31 patients who underwent septal myectomy at Kasr El Einy
University Hospital, to assess the short term (1 year) outcome of the procedure. This prospective study was done
during the period between March 2014 and May 2018 excluding any patient with ischemic or rheumatic pathology
or requiring any additional procedure.
Results: All patients had an LVOT peak gradient of more than 50 mmHg. All of the patients had preoperative
mitral regurge. The preoperative septal wall thickness ranged from 1.5 to 3.5 cm with a mean of 2.1±0.7 cm. TEE
showed a pressure gradient across the LVOT ranging from 4 to 20 mmHg with a mean of 7±6 mmHg, which was
statistically significant in comparison to the preoperative values. Echocardiography done at one year follow up
showed a peak systolic gradient across the LVOT ranging from 6 to 40 mmHg, with a mean of 18±8 mmHg.
There was a statistically significant difference between the preoperative and one-year follow-up data (p
value<0.001). However, there was no significant difference between the early postoperative and one-year follow-
up. Conclusion: Septal myectomy for Hypertrophic Obstructive Cardiomyopathy (HOCM) is a safe procedure
with good immediate and short-term results, and with good outcome if done by an experienced surgeon with good
Keywords: Septal myectomy; Hypertrophic obstructive cardiomyopathy (HOCM); Follow up after septal
myectomy; Hypertrophic cardiomyopathies; Idiopathic hypertrophic subaortic stenosis (IHSS).
Hypertrophic cardiomyopathy (HCM) was
feared complication of HCM and is known to be
previously known as hypertrophic obstructive
mostly related to ventricular arrhythmias such as
cardiomyopathy (HOCM) or idiopathic hypertrophic
ventricular fibrillation (VF) and ventricular
subaortic stenosis (IHSS). These two later
tachycardia (VT) (6).
nomenclatures are not accurate and thus not recently
Gross morphological features in HCM include
used as the septal and ventricular myocardium can
increased heart mass (weight), asymmetrical
hypertrophy without casing obstruction (1). According
interventricular septal thickening and small left
to the European society of cardiology 2008,
ventricular cavity. Sometimes, there is also associated
hypertrophic cardiomyopathies are defined as
right ventricular hypertrophy, dilated atria, and
increased ventricular wall thickness or mass, in the
thickened elongated mitral valve leaflets (7,8).
absence of loading conditions such as hypertension or
Hypertrophic cardiomyopathy can be subdivided into
valve disease (2).
2 types: Non-Obstructive: Characterized by
In 2011, the ACC/AHA guidelines included
also the pediatric practice, where the term HCM
supranormal, or even impaired systolic function and
refers only to conditions with LV hypertrophy due to
obstructive: Which maybe Subaortic, midventricular
sarcomeric protein mutations without extracardiac or
and/or apical obstruction (9).
metabolic findings (3). In adults (based on
Clinical significance of LVOT gradient: According
echocardiographic findings) HCM is considered
to the LVOT transgradient HCM can be divided into
when the left ventricular wall thickness exceeds 15
mm, with values of 13 to 14 considered borderline (4).
Basal (rest) obstruction: with a gradient equal to or
The mitral valve is not uncommonly affected
more than 30 mm Hg under resting conditions.
in HCM, whether structurally or functionally causing
Labile (dynamic) obstruction: gradient is less than
systolic anterior motion of the mitral valve (SAM)
30 mmHg under resting conditions but exceeds 30
thus contributing to LV outflow tract obstruction (5).
mmHg when physiologically provoked.
Cardiac conduction anomalies are common in
Non-obstructive: gradient is less than 30 mmHg
HCM patients and sudden cardiac death is the most
even when physiologically provoked.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2585-2587
Loco-Regional Perforator Flaps for Reconstruction of Post Burn Contracted Elbow
Wael Mohamed Ayad, Moustafa Sayed Ahmed Meky and Osama Mohamed Abdel-Hafeez Abdallah*
Department of Plastic & Reconstructive Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Osama Mohamed Abdel-Hafeez Abdallah, Mobile: (+20)01144415159,
Context: the post-burn scar is inevitable problem even with the best treatment as it depends on the depth of the
burn injury, so only superficial dermal burns, heal with no scarring, but the contracture is preventable problem
especially with the best treatment. The post-burn elbow flexion contracture may be associated with heterotropic
calcification of the elbow joint which needs orthopedic team consultation. The elbow reconstruction represents
a demanding procedure for the plastic surgeon.
Objective: aim of this study was to evaluate the validity and application of local arm forearm and regional chest
perforator flaps for coverage after release of post burn elbow contractures.
Patients and Methods: this prospective randomized study was done on 20 patients aged from 6 to 54 years old.
All of them were asking for elective release of postburn flexion contracture of the elbow at outpatient clinics of
Al Azhar University and Al-Ahrar Teaching Hospitals. It was done from March 2018 to March 2019.
Results: we have performed in our study the local and regional perforator flaps as lateral arm flap, medial arm
flap, PBUF flap, PBRF flap, thoracoabdominal pedicle flap. Skin grafting is an easy procedure, however,
success is limited with the technique because there is always the risk of incomplete graft take and prolonged
splinting and physiotherapy is imperative in the postoperative period.
Conclusion: flaps are better for resurfacing the defects after post-burn contractures release. Flaps do not need
vigorous post-operative physiotherapy or splint age and grow with age especially in children.
Keywords: Loco-Regional Perforator Flaps, PBCs
This is short operative time, a cost efficient
distressing problems in both the developed and
option for both the patients and the medical team,
developing worlds. They usually occur following
they are recommended especially for patients with
inadequate primary burn injury management (1).
associated disease, in which a prolonged anesthesia
Children are the most affected by PBCs and
should be avoided, and donor site can be usually
elbow and shoulder joints are the most involved
closed by direct suture, providing a good cosmetic
regions. Management of PBCs of elbow and
result, and only in few cases, where large flaps are
shoulder joints is challenging, because they have a
harvested, skin grafting is mandatory (6).
tendency to recur, and due to the wide range of
The wide interest for this relative new
motion of the joint (2).
technique in reconstructive surgery demonstrates its
In order to have a good coverage of the
efficacy. The pedicled perforator flap in elbow
elbow, there are two requirements. The first is to use
coverage is an optimal alternative to the free flaps. It
good tissue to protect the important structures,
offers excellent cosmetic and functional results and
replacing "like with like". The second is a fast
shorter operative time (2).
postoperative rehabilitation in order to prevent joint
AIM OF THE WORK
Over the last decades, surgeons were in
Aim of this study is to evaluate the validity
search of an ideal flap that would be able to respond
and application of local arm forearm and regional
to these requirements. Away from the skin graft that
chest perforator flaps for coverage after release of
has limited use in the elbow, random, axial and free
post burn elbow contractures.
myocutaneous and fasciocutaneous flaps were used.
Each of these solutions has its own limitation: either
PATIENTS AND METHODS
This prospective randomized study was
immobilization, or bringing different quality tissue
done on 20 patients aged from 6 to 54 years old. All
of them were asking for elective release of post-burn
A step forward in flap design was the
flexion contracture of the elbow at outpatient clinics
pedicled perforator flaps. They provide a simpler
of Al-Azhar University (El Hussein University
alternative to free flaps with less donor site
Hospital) and Al-Ahrar Teaching Hospital in
morbidity. The pedicled perforator flaps for elbow
Zagazig city. It was done from March 2018 to March
reconstruction are a very reliable option for the
plastic surgeon (5).
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2588-2593
Surgical versus Conservative Management of Lumbar Canal Stenosis in Elderly
Ahmed Mohamed Hassan Salem, Mostafa Elsayed Mohamed Elsayed,
Mohamed Ahmed Mohamed Abdallah
Department of Neurosurgery, Faculty of Medicine, Azhar University
*Corresponding Author: Mohamed Ahmed Mohamed Abdallah, Phone No.: (+20) 01068452520,
Background: Degenerative lumbar spinal stenosis is one of the common diseases in elderly, also may occur in younger
ages. Usually presents with back pain, lower limbs pain and claudication pain. Diagnosis is confirmed by radiological
studies such as plain X rays LSS, CT. LSS or MRI LSS.
Objective: The aim of this prospective study was to evaluate the surgical versus conservative management of lumbar
canal stenosis in old patient (age of 60 years old or more). Methods: A prospective comparative study was conducted
on 100 old patients that were divide into two groups, each group 50 patients. The first 50 patients underwent surgical
lumbar canal decompression and the other 50 patients underwent conservative management.
Results: This study showed that elderly patients with moderate to severe lumbar stenosis without spondylolisthesis got
benefit from surgery. They showed reduction in pain reported in the lower limbs (VAS Leg with p < 0.05) and improved
function (Oswestry with p < 0.05) whoever there was no significance change regarding visual analogue scale (VAS)
between the two groups. In addition, there was no significant difference between the result between 6 month and one-
year follow up. Conclusion: In patients with lumbar stenosis in old age, there was improvement in leg pain and function
in patients underwent surgical posterior decompression but there was no difference in back pain compared to patients
underwent conservative management.
Keywords: Surgical versus Management, Lumbar canal stenosis, Elderly.
be the standard treatment. In recent years, however, a
Lumbar canal stenosis is the narrowing of the
spinal canal or the tunnels through which nerves and
decompressive surgery has emerged as a logical
other structures communicate with that canal. Spinal
surgical alternative, sparing anatomical structures and
stenosis was classified by Arnoldi in 1976 into
decreasing the risk for post-operative instability (3).
congenital and acquired causes. Most commonly,
Bilateral foraminotomy and decompression without
lumbar canal stenosis is due to acquired degenerative
laminectomy for lumbar spinal stenosis is a safe and
or inflammatory changes (arthritis) of the
gentle technique for decompressing the spinal canal
intervertebral discs, ligaments and facet joints. These
with excellent possibilities (4).
changes include cartilaginous hypertrophy of the
Transpedicular fixation is used to increase the
articulations surrounding the canal, intervertebral disc
chance of bone fusion while diminishing the need for
herniations or annular bulges, hypertrophy of the
prolonged post-operative immobilization. Fixation
ligamentum flavum and bone spur (osteophyte)
may be on one or both sides (5).
Posterolateral fusion is recommended for
Simple radiological investigations may
patients with stenosis and associated degenerative
reveal degenerative changes such as bone spurs,
spondylolisthesis who require decompression.
decreased disc space and facet hypertrophy in older
Posterolateral and interbody fusion have been used
patients. CT scan will show a more detailed picture of
successfully either alone or in combination together
the bony anatomy. It is less accurate than MRI in
(6). There has been a recent resurgence of interest in
estimating the degree of compromise of the soft tissue
posterior lumbar interbody fusion (PLIF) as a
elements unless combined with a myeloghraphic
biomechanically and possibly clinically superior
effect. Thus the CT scan may underestimate the
fusion technique applicable to a variety of
degree of stenosis. MRI is the preferred modality for
degenerative conditions. PLIF offers advantages such
evaluating and diagnosing lumbar stenosis. It allows
as total discectomy, neural decompression, restoration
visualization of soft tissues, including the neural
of disc space height and solid mechanical arthrodesis.
elements, ligaments, epidural fat, subarachnoid space
The addition of segmental instrumentation using a
and intervertebral discs (1).
pedicel screw and rod or plate construct adjunct to
Surgical treatment for lumbar spinal stenosis
PLIF may offer stability and enhance fusion rates (7).
is indicated in patients with progressive neurological
The use of a tubular retractor system for
deficits or those who fail an appropriate trial of non-
lumbar surgery was popularized by Foley and Smith
operative management for a period of six months. All
(8). As experience has grown with this surgical
the proposed surgical interventions have a common
approach, surgeons are treating patients with lumbar
primary goal of neural element decompression (2).
stenosis using a combination of a tubular retractor
Wide decompressive laminectomy, often combined
system and an operative microscope. This approach
with medial facetectomy and foraminotomy, used to
requires less soft tissue destruction compared to an
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2594-2600
Anatomical Reconstruction of Posterolateral Corner of The Knee
Bahaa Ali Kornah, Mohamed Abdurrahman Alnahas, Ahmed Mohamed Alemam
Orthopedic Surgery, Faculty of Medicine, Al Azhar University
Corresponding author: Ahmed Mohamed Alemam, email: email@example.com
Background: Most injuries of posterolateral corner (PLC) of the knee occur in combination with simultaneous knee
ligament injuries. The incidence of posterolateral lesions associated with anterior cruciate ligament (ACL) tear is as
high as 10% and those associated with posterior cruciate ligament (PCL) tear 27%. PLC injuries have been
increasingly recognized and account for approximately 16% of all knee ligament injuries.
Aim of work: To evaluate management of cases of posterolateral corner instability by anatomical reconstruction with
assessment of post-operative functional outcomes following rehabilitation protocols.
Patient and methods: From August 2017 to January 2019, a case series non-controlled prospective clinical study was
done. The material of this study included twenty (20) patients with chronic posterolateral corner injury. All patients
underwent anatomical PLC reconstruction. Surgery was done at El Hussein, Al-Azhar University Hospitals.
Results: In our study, we found satisfactory highly significant difference between pre and post-operative according
Lyshlom score (P-value 0.001). Conclusion: Anatomical reconstruction of chronic posterolateral corner instability
resulted in satisfactory clinical outcomes in medium term follow-up.
Keywords: Posterolateral corner, Reconstruction.
Most injuries of posterolateral corner (PLC) of the
inadequate data on the anatomy and biomechanics of
knee occur in grouping with synchronized knee
the PLC structures and under-reporting of clinical
ligament injuries. Posterolateral corner injuries are
outcomes following non-operative and operative
often associated with anterior cruciate ligament
treatment. However, lately, the anatomy and
(ACL) and posterior cruciate ligament (PCL) tears (1).
biomechanics have become distinct and good
Isolated lesions of the posterolateral corner
outcomes have been reported after PLC operative
structures estimate about 5.7% of knee sprains (2). The
frequency of posterolateral lesions concomitant with
principles (5). Historically, both repair and
anterior cruciate ligament (ACL) tear is as high as 10%
reconstruction have been used for treating PLC tears.
and those concomitant with posterior cruciate ligament
PLC cases treated by ligament repair have been
(PCL) tear are 27%. Common peroneal nerve is
reported to have a higher reoperation rate when
involved in about 15% of cases (3).
compared to reconstructive techniques (6).
Posterolateral instability may cause significant
Poor outcomes have been reported for grade III
functional limitations. Although formerly considered
PLC injuries treated non -operatively (resulting in
rare, posterolateral corner injuries have been
varus and rotational instability of the knee) and thus,
increasingly recognized and account for nearly 16%
a reconstruction is indicated. A thorough knowledge
of all knee ligament injuries (4). Failure to identify
of the anatomy is necessary for surgical treatment of
these injuries has been proven that is an important
this pathology, since anatomical reconstruction has
cause of recurrent instability and failed cruciate
proved improved outcomes (7).
ligament reconstructions. Persistent instability of
posterolateral corner leads to a varus thrust gait,
PATIENTS AND METHODS
which increases forces on the medial compartment of
the knee. This may result in meniscal injuries and
The material of this study included 20 adult patients
aggravated medial compartment osteoarthritis.
having chronic posterolateral corner injury who have
In order to identify PLC injuries, a high index of
treated by anatomical reconstruction using hamstring
suspicious is mandatory and a detailed physical
tendon grafts in period between August 2017 and
examination should be performed. A comprehensive
January 2019 (including follow up period) at
review of radiographic and magnetic resonance
orthopedic department of Al-Azhar University
imaging (MRI) studies are helpful to better determine
Hospitals. The period of follow up ranged from 4 to 9
the injured structures precisely. In the past, treatment
months with an average of 6 ±1.5 months.
of lateral side instability has been challenging due to
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2106-2605
Value of Semiquantitative Assessment of Right Ventricular Systolic Function with
A Modified Subcostal Echocardiographic View
Deya El-Den Mosa`d Sadek*, Mohammad Ismail Al-Deftar, Wael Mohammad Attia,
Abdul-Halem Mohammad Abo-El-Magd
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Egypt
*Corresponding author: Deya El-Den Mosa`d Sadek, Mobile: 01003510150, Email: firstname.lastname@example.org
Background: the assessment of right ventricular function (RVF) is an important component of routine
echocardiography study. Tricuspid annular plane systolic excursion (TAPSE) is easy and validated method of
RVF but in many patients, this method may be difficult to apply due to inadequate apical window. So, we
proposed that Subcostal Echocardiographic assessment of Tricuspid annular Kick (SEATAK) could be
comparable to TAPSE.
Aims of the study: they were to assess of RVF with a new arising method SEATAK, to determine the sensitivity
& specificity of SEATAK and correlation between SEATAK & TAPSE with the degree of RVF.
Patients and Methods: this study included 100 consecutive patients presented to our echocardiography lab with
different clinical indications. Right ventricular function was assessed by the following parameters: RV Myocardial
Performance Index (RIMP), TAPSE, Peak Systolic velocity of right ventricular basal free wall by TDI (TASV-
TDI), SEATAK and Fractional Area Change (FAC) as reference method for RVF assessment.
Results: according to RVF using FAC, the patient were classified into 2groups,group with FAC 35% and other
with FAC <35%. There was a significant statistical difference between both study groups according to TAPSE
(cm), SEATAK (cm), P-Value 0.05. SEATAK was significantly correlated with TAPSE, TASV-TDI, and FAC
values. SEATAK cutoff value 1.60 cm has the highest combined sensitivity and specificity of 86% &67%
respectively for normal RVF (FAC 35%). Positive& negative predictive values are 72% &83%, respectively.
Area under the curve equals 0.79, P-Value < 0.001.
Conclusion: SEATAK is correlated with TAPSE, TASV-TDI & FAC for evaluation of RVF with cut-off value
of SEATAK for prediction of normal RVF is 1.60 with sensitivity and specificity of 86% &67% respectively.
Keywords: Subcostal echocardiographic assessment of tricuspid annular kick, right ventricular function,
modified Subcostal Echocardiographic view
Echocardiographic assessment of RV
function. TAPSE <17 mm is suggestive of RVSD).
systolic function is valuable for a variety of
TAPSE evaluation in critically ill patients has gained
cardiopulmonary conditions including acute cor-
interest(4). A feasible alternative method had arisen
pulmonale, post cardiotomy RV dysfunction, acute
to assess TAPSE from the subcostal view. This novel
left ventricular (LV) failure, and acute or chronic RV
alternative method is semi quantitative and can be an
systolic dysfunction (RVSD). Recent evidence
alternative to TAPSE and is called SEATAK(4).
shows RVSD is a prognostic factor in critically ill
AIMS OF THE WORK
The right ventricle contraction occurs
They are to assess RVF with a new arising
primarily in the longitudinal plane and can be assessed
method SEATAK, to determine the sensitivity &
with M-mode echocardiography with alignment of the
specificity of SEATAK and correlation between
cursor with the tricuspid annulus in an apical view,
SEATAK & TAPSE with the degree of RVF.
TAPSE; initially described by Kaul et al.(2) in 1984,
it has demonstrated correlation with RV ejection
PATIENTS AND METHODS
fraction and has been shown to be accurate,
reproducible, and easy to estimate. Moreover,
TAPSE has prognostic significance in patients with
observational study, which included 100 consecutive
patients presented to our echocardiography lab with
The most recent American Society of
different clinical indications from January 2018 to
quantification recommend measuring TAPSE as one
The study was approved by the Ethics
of the parameters for assessment of RV systolic
Board of Al-Azhar University and an informed
written consent was taken from each participant in
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2606-2610
Result Evaluation between Laparoscopic Anterior and Posterior
Mesh Rectopexy in Complete Rectal Prolapse
Ibrahim Aboulfotoh Mohammed
General Surgery, Al-Azhar University
Background: The prospectively and retrospective collected databases for identifying outcome in patients of 20
or more years of age with full thickness external rectal prolapse (ERP) treated by laparoscopic ventral rectopexy.
Primary end-points were age, and mortality, morbidity, length of hospital stay and recurrence.
Aim of the study: Evaluation of the comparative result between anterior and posterior mesh rectopexy and better
method of rectopexy. Patient and methods Twenty-four adult patients with complete rectal prolapse underwent
operative treatment for the prolapse between January 2016 and December 2018. The diagnosis of rectal prolapse
was made clinically and confirmed by defecation proctography. Patients underwent pre-operative colonoscopy or
flexible sigmoidoscopy to exclude organic disease. Data on gender, age, mortality, morbidity, length of stay and
recurrence were prospectively collected on an institutionally approved electronic database. Non-parametric data
were described as median and range, while parametric data were presented as average and standard deviation.
Results: 24 patients of median age 38 (20-52 years old). Patients underwent laparoscopic ventral rectopexy. There
was no mortality and 10 (13%) patients had complications. At a median follow up of 8 (2 12) months, two (3%)
patients developed a recurrent full thickness prolapse.
Conclusions: Abdominal procedures are generally better for young fit patients. The results of all abdominal
procedures are comparable. Suture and mesh rectopexy are still popular with many surgeons. The choice depends
on the surgeon's experience and preference. Similarly, the procedure may be done through a laparoscope.
Laparoscopic ventral or dorsal rectopexy is safe to treat full-thickness ERP. Morbidity, mortality and hospital
stay are comparable with published rates with a tenfold lower recurrence.
Keyword: Rectal prolapse, Laparoscopic (anterior and posterior) rectopexy.
of functional disturbances in muscles of the anterior
Complete or full-thickness rectal prolapse is the
abdominal wall, pelvic floor, and anal sphincter
protrusion of the entire rectal wall through the anal
canal. If the rectal wall has prolapsed but does not
These underlying abnormalities may be aggravated by
protrude through the anus, it is called an occult
certain conditions which appear to be associated with
(internal) rectal prolapse or a rectal intussusception (1,
an increased incidence of rectal prolapse. These
2) (Figure 1).
include connective tissue disorders, neurological
illnesses, and high parity (12). Rectal prolapse occurs at
distinguished from mucosal prolapse in which there is
the extremes of age (13).
protrusion of only the rectal or anal mucosa (3, 4). Pre-
In the pediatric population, the condition is usually
requisites for the development of rectal prolapse are:
diagnosed by the age of 3 years, with an equal sex
(1) the presence of an abnormally deep pouch of
distribution. In the adult population, women are more
Douglas (5), (2) The lax and atonic condition of the
commonly affected; the peak incidence is after the
muscles of the pelvic floor and anal canal (6), (3)
fifth decade and, representing 80% to 90% of patients
Weakness of both internal and external sphincters,
with rectal prolapse (14, 15).
often with evidence of pudendal nerve neuropathy (7),
Patients with complete rectal prolapse have markedly
and (4) the lack of normal fixation of the rectum, with
impaired rectal adaptation to distention, which may
a mobile mesorectum and lax lateral ligaments (8).With
contribute to anal incontinence, and consequently
this abnormality, the small intestine, which lies
more than half of the patients with rectal prolapse have
against the anterior wall of the rectum, may force the
co-existing incontinence (16, 17).
rectum out through the anal canal (9).
Constipation is associated with prolapse in 15% to
Complete rectal prolapse (procidentia) is the
65% of patients (18).
circumferential protrusion through the anus of all
Straining may force the anterior wall of the upper
layers of the rectal wall. It is most common in young
rectum into the anal canal, perhaps causing a solitary
children and elderly adults. Rectal prolapse or
rectal ulcer due to mucosal trauma (19).
procidentia is a disabling problem and controversies
The aim of treatment is to control the prolapse,
regarding its management continue to stimulate
restore continence, and prevent constipation or
interest in the study of its aetiology, pathophysiology,
impaired evacuation. This goal can be achieved by:
functional aspects, and concepts of surgical
(1) resection or plication of the redundant bowel
and/or (2) fixation of the rectum to the sacrum (20).
A strong and functional pelvic floor may be restored
The underlying cause of rectal prolapse remains
by placating the pubo-rectalis anterior to the rectum
unclear. It is thought to develop as the result of a series
5. The rationale for rectal fixation is to keep the
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2611-2620
Assessment of LV Function by Three-Dimensional and Three-Dimensional
Speckle Tracking Echocardiography after Percutaneous Coronary
Intervention for Chronic Total Occlusion Coronary Artery Disease
Kamal Ahmed Marghany Mahgoub
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Egypt
Background: Cardiovascular disease is the most leading cause of morbidity and mortality throughout the world
today. Chronic total occlusions are defined as 100% occlusions with TIMI flow 0 with at least 3-month duration.
New echocardiographic techniques is an important noninvasive method for assessing cardiovascular function
Objective: Determination of the impact of revascularization for chronic total occlusion coronary artery disease
on left ventricular function using three-dimensional and three- dimensional speckle tracking echocardiography.
Patients and methods: The present study included (60) patients presenting with chronic total occlusion
coronary artery disease at Al-Azhar University Hospitals, in the period between December 2015 and April 2018.
The study compared the differences in echocardiographic parameters before the procedure (pre-procedure) and
one month after successful PCI to CTO (post- procedure). Two-dimensional (2D) and three- dimensional (3D)
transthoracic echocardiography (baseline and follow up study), 2D Global longitudinal strain (GLS) and 3D
longitudinal strain (LS) speckle tracking echocardiography (base line and follow up study) were done.
Results: Mean left ventricular ejection fraction significantly increased, while the left ventricular end-diastolic
and end-systolic volumes significantly decreased. The left ventricular end-systolic and end-diastolic volumes
and diameters were significantly decreased. The global longitudinal strain (2DSTE and 3DSTE) showed
significant improvement after successful revascularization. Both patients with LVEF 50% and LVEF < 50%
displayed significant improvement in the 2D GLS and 3D LS, also diabetic and non-diabetic patients displayed
significant improvement in the 2D GLS and 3D LS. Improvement in the 2D GLS % was correlated with an
improvement in the 3D LS %.
Conclusion: Restoring the coronary blood flow in chronic total occlusion patients reduces the left ventricular
volumes, dimensions and improves the left ventricular ejection fraction and global longitudinal strain of
Keyword: Chronic Total Occlusions, Left Ventricular Function, New echocardiographic technique,
Percutaneous Coronary Intervention.
dysfunction, as compared with left ventricular
Cardiovascular disease is the leading cause of
ejection fraction, extends its applicability and
morbidity and mortality throughout most of the
makes it a test of additional value in many areas of
world today, representing 31% of all deaths (1).
cardiology (6). Despite promising data, 2D-STE has
Coronary artery disease is the most common
not been sufficiently standardized as a routine
cardiovascular disease and its incidence increases in
method for the diagnosis of myocardial ischemia.
the elderly (2). Population aging and the increase of
Characteristics inherent to the technique affect its
risk factors such as arterial hypertension and
applicability in both acute and chronic phase of the
diabetes associated with obesity have greatly
ischemic event, as previous ventricular deformities
contributed to increased hospitalizations of patients
may affect the interpretation of results (7). The study
with acute coronary syndrome (ACS) (3). Coronary
by dos Santos et al. (8) provides us with a pioneer
chronic total occlusions (CTOs) are defined as
study on the real applicability of left ventricular
100% occlusions with TIMI (Thrombolysis in
longitudinal strain in UA. The authors described the
Myocardial Infarction) 0 flow with at least a 3-
frequency at which 2D-STE is indicated in cardiac
month duration (4). Echocardiography is an
emergencies and evaluated the values of the test in
important noninvasive method for assessing
patients with severe coronary artery lesions. Two
cardiovascular function and mechanics (5).
dimensional speckle tracking echocardiography is
Recently, the use of two-dimensional speckle-
based on tracking the characteristic speckle patterns
created by interference of ultrasound beams in the
measurement of myocardial strain has gained
myocardium and its accuracy has been confirmed
importance for its applicability in the clinical
using son micrometry and magnetic resonance
practice. Its high sensitivity to measure systolic
imaging as reference methods (9). Measurements of
function and identify left ventricular subclinical
S and SRs are more sensitive than standard
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2621-2630
Value of Two-Dimensional Strain Imaging in Prediction of Myocardial Function
Recovery After Percutaneous Revascularization of Infarct-Related Artery
Kamal Ahmed Marghany Mahgoub, Ali Mohammed El Ameen Abd El Mageed and Ahmed
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Egypt.
Background: Acute myocardial infarction (MI) is often accompanied by impaired regional myocardial systolic
function. A novel approach known as two-dimensional speckle tracking echocardiography was used to quantify
regional LV function.
Objective: The aim of the current study was to evaluate of the role of Speckle Tracking Echocardiography in
prediction of left ventricular function recovery after percutaneous coronary intervention to left anterior
descending coronary artery in patients with anterior ST segment elevation myocardial infarction with impaired
left ventricular ejection fraction.
Patients and methods: This study included 50 patients and 15 normal control adult persons. Patients had
suffered from first attack of anterior STEMI. They were admitted at the CCU units of Al-Azhar University
Hospitals from September 2016 to September 2018 and treated with thrombolytic therapy. Each patient was
subjected to conventional transthoracic echocardiography before hospital discharge and before reperfusion.
Speckle tracking echocardiography and resting SPECT were done one week after MI. Percutaneous coronary
intervention to LAD within one week after MI for patients with demonstrated myocardial viability by resting
SPECT. Three months after percutaneous revascularization to LAD, all patients were reevaluated using
conventional TTE and strain imaging. The studied population were divided into 2 Groups; group A: 24 patients
who showed post-PCI LV function recovery and Group B: 26 patients who did not showed post-PCI LV
Results: There was statistically significant increase in the prevalence of diabetes mellitus, smoking and
dyslipidemia in group B. There was high statistically significant difference between the two groups as regard
baseline LVEF (%), baseline wall motion score index (WMSI), mean baseline and follow up WMSI values,
baseline number of affected left anterior descending (LAD) segments as assessed by WMSI, baseline and 90
days follow up mean number of affected LAD segments, baseline strain values at both global LV and territorial
LAD segments. Control group showed mean territorial LAD strain was - 20.41± 0.61, mean baseline territorial
LAD strain of group (A) - 13.20 ± 2.05 and mean baseline territorial LAD strain of group (B) - 8.47 ± 2.12.
Regarding mean baseline territorial LAD strain and mean GLS of the LV, Receiver Operating Characteristic
curve was done between group A and B for obtaining a cut off value of 11.3 % and 11.8 % respectively.
Conclusion: LV global and territorial strain measured by 2D STE is a good predictor of LV function recovery
in STEMI patients after percutaneous revascularization of infarctrelated artery.
Keyword: Acute myocardial infarction, percutaneous revascularization, Speckle tracking echocardiography
whatever the experience of the operator (4). By
There are currently two ways to assess
measuring deformation derived from tissue Doppler
myocardial deformation by echocardiography:
velocity, strain imaging had largely overcome these
tissue Doppler imaging (TDI) and speckle-tracking
limitations. However, the routine clinical use of
Echocardiography (STE). The latter is not based on
these measurements is constrained by problems that
Doppler analysis but on the following of bright
are inherent in the use of Doppler, that relate to
points via gray scale analysis (1). Speckle-tracking
signal noise and angle dependency (5). Speckle-
echocardiography is a noninvasive ultrasound
tracking analysis with automated function imaging
imaging technique that allows for an objective and
(AFI) has been introduced as a reliable
quantitative evaluation of global and regional
echocardiographic technique to assess global LV
myocardial function independently from the angle
longitudinal strain (4). Angle dependency is not a
of insonation and from cardiac translational
problem with 2- dimensional speckle tracking
echocardiography (STE), but this technique is
dimensional speckle tracking can also be used for
dependent on image quality and operates at limited
the assessment of coronary artery disease during
frame rate (6). Single photon emission computed
dobutamine stress echo (3). Automated function
tomography myocardial perfusion imaging is a
imaging (AFI) is clinically applicable and an
powerful modality for the assessment of coronary
effective means of assessing LV function due to its
artery disease, prognostication of CAD and the
short acquisition time, feasibility and accuracy,
determination of viability. It acts as a guide for
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2631-2638
Surgical Management of Destructive Neoplastic Spine Lesions
*Mohammad Fathy1, *Ramadan Shamseldien2, Mohammed Soleiman1, Hatem Saad Elkhouly3
1Department of Neurosurgery, Al-Azhar Faculty of Medicine for Girls,2Department of Neurosurgery, Shebin
Elkom Teaching Hospital, 3Department of Neurosurgery, Al-Azhar Faculty of Medicine Asuit Branch, Egypt.
*Corresponding Authors: Mohammad Fathy, Ramadan Shamseldien, E-Mail: email@example.com,
firstname.lastname@example.org, Phone: 01009600625, 01001251003.
The spine is one of the most common sites of metastasis from distant structures, following the lung and the liver.
Aim: to review the pathological distribution, clinical presentation and different surgical procedures and outcome
of cases with neoplastic spine lesions managed at our departments.
Patients and methods: this is a review of 29 patients presented with destructive spine lesion with compromised
neural structure at different degrees, with no history of trauma or infection. All patients subjected to full
neurological examination and ASIA scoring, and full radiological evaluation. Different surgical approaches were
Results: this a retrospective study of 29 patients, 11males and 18 females. Mean age of presentation was 50years
old. The affected vertebral bodies are 47 distributed among vertebral regions: 6 sacral (12.8%), 16 lumbar (34%),
6 thoracolumbar (12.8%), 12 thoracic (25.5%), 3 cervicothoracic (6.4%), and 4 cervical (8.5%). As regard surgical
procedures, 5 patients CT guided biopsy. One case operated by core biopsy and vertebroplasty. 4 patients were
managed by posterior neural decompression and debunking. 12 patients operated posterior excision and
reconstruction. 3cases approached by anterolateral thoracotomy. 2 cases operated posterior excisional biopsy and
Craniocervical fixation. One case was managed by anterior transoral excision. One case approached through
anterior cervical corpectomy.
Conclusion: in selected cases surgical management of patients with spine neoplastic lesions followed by adjuvant
therapy is considered to relieve pain, decompress neural structures, stabilization and correction of deformed spine,
and local control with also improvement of quality of life but not the survival.
Keywords: Destructive Neoplastic Spine Lesions.
neural arch, while in primary spine lesions certain
Tumors that affect the vertebral column may be
tumors affect the whole body or start from neural
primary spine tumors or secondary tumors from
distant organs. The occurrence of primary tumors is
In neoplastic spine lesions whether primary or
very rare in comparison to metastatic lesions, its
metastatic pain is typically the first presenting
occurrence less than 5% of all spine neoplasm; it is
symptom, its nonspecific and may be overlooked in
recorded to be forty times less than metastatic spine
primary lesions, where's in metastatic lesions its
lesions and has been estimated at 2.58.5 per 100000
progressive unremitting not relived by rest worsen at
people per year (1,2). Up to 70% of patients with
night, generally pain described as constant and
systemic cancer will have spine metastasis, and
localized as a result of periosteal stretch occurring
approximately 61,000 persons, will develop spinal
with tumor expansion, radicular pain usually due to
metastasis each year (3).
compromised neural foramen or thecal sac, or axial
Certain tumors have the preferentiality to
pain, coinciding with motor deficits and these
metastasize to the spine, and the most often tumors
resulted from vertebral collapse, pathological
to do that are breast (72%), prostate (84%), thyroid
fracture and instability (8).
(50%), lung (31%), kidney (37%), and GIT (33%)
As regard radiological evaluation plain
(3,4). The most frequently affected vertebral regions
radiography is an excellent screening tool, but
are lumbar, thoracic and lastly cervical spines,
negative results doesn't exclude malignancy,
although thoracic lesions (70%) are most often
computed tomography (CT) is a superior
presented due to the narrow spinal canal and limited
radiological tool to give bony spine information,
space for the spinal cord in this region, followed by
while magnetic resonance imaging is excellent to
lumbar (20%) and cervical (10%) lesions (5).
give detailed soft tissue and neural tissue
Most spinal metastatic lesions are extradural up
information, isotopic bone scanning have been the
to 97%, while intramedullary and intradural
standard for screening skeletal metastases, however
extramedullary much less common, where the dura
false negative and false positive (super scan) results
make a relative barrier for metastatic spread6.
decrease its sensitivity (1,3).
Vertebral body and especially the posterior half
The surgical intervention in metastatic lesions
firstly involved in metastatic disease followed by
almost is palliative, where's it gives a chance for true
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2639-2645
Correlation between Thrombolysis in Myocardial Infarction and The
Global Registry of Acute Coronary Syndromes Risk Scores and
Severity of Coronary Artery Disease in Patients with Non-ST
Elevation Acute Coronary Syndrome
Mahmoud El-Sayed1*, Abdelrahman Aly2, Ashraf Abotaleb3, Ahmed Gaafar4,
Mohammed Sarhan2, Abdelrahman Elbokary5, Monir Osman2
1Department of Cardiology, Mabaret Misr Alqadema Hospital, 2Department of Cardiology, 3Department of
Clinical Pathology, Faculty of Medicine, Al-Azhar University, 4Department of Cardiology, Faculty of Medicine,
Helwan University, 5 Department of Cardiology, National Heart Institute, Cairo, Egypt
*Corresponds to: Mahmoud A. El-Sayed, Tel: +20-(0)1091294954, E-mail: email@example.com
Background: the prognosis of non-ST elevation acute coronary syndrome (NSTEACS) patients is frequently done
by using thrombolysis in myocardial infarction (TIMI) and global registry of acute coronary events (GRACE) risk
scores. Only few studies were done for prediction ability of the scores with coronary artery disease. Methods: this
prospective cross-sectional study included 100 patients was conducted at Mabaret Misr Alqadema and Al-Azhar
University Hospitals from May 2017 till September 2018. We calculated the TIMI and the GRACE risk scores for
all patients on admission then patients had coronary angiography to detect the extent of the coronary artery disease
(CAD). We assessed the severity of CAD by using Gensini score and vessel score. Results: the TIMI and GRACE
scores have an acceptable predictive value in identifying the extent of the CAD. A TIMI score 3 and GRACE
score 102 was significantly associated with 3 vessel disease and left main disease (p <0.014 for TIMI and p <0.007
for GRACE). On comparison of the two risk scores, the discriminatory accuracy of the GRACE score was non-
significantly superior to the TIMI score in predicting 3 vessel and left main (LM) diseases but the combination of
both scores has a higher accuracy (p <0.006). Conclusions: the CAD is more extensive by coronary angiography
in patients with NSTEACS who had higher TIMI or GRACE risk scores, as they have a good predictive value.
However, when both compared, the GRACE score has a non-statistically significant superiority with multivessel
and LM disease, and combination of both scores has a higher accuracy.
Keywords: NSEMI-ACS, TIMI risk score, GRACE risk score, Gensini risk score, CAD.
CAD group then compared both groups against TIMI
Globally, ischemic heart disease remains the
and GRACE risk scores.
number one cause of morality (1). NSTEACS is more
We excluded from the study patients who had
frequent than STEACS with annual incidence is about
previous coronary artery bypass surgery, myocardial
3 per 1000 inhabitants (2), with similar mortality as
infarction, or previous percutaneous coronary
STEMI at 6 months(3) and higher with a two-fold
intervention (PCI), patients whose systolic blood
difference at 4 years(4).
pressure (SBP) was more than 180 mm Hg or diastolic
Risk models as GRACE and TIMI scores predict a
blood pressure (DBP) was more than 110 mm Hg and
probability for adverse outcomes based on
patients with a missing data for calculating the
combinations of clinical, ECG, and laboratory data
GRACE RS and TIMI RS.
available at presentation assist in identifying patients
For each enrolled patient, we collected the following
at risk for recurrent ischemia and death events (5, 6). the
data; clinical data (full history, cardiac risk factors and
GRACE and TIMI RSs are the most widely used(7),
GRACE is more accurate than TIMI score but it is
echocardiographic, laboratory data (CBC, serum
more complex (8, 9).
creatinine, CK-MB, troponin, coagulation profile and
lipid profile) and CA data.
PATIENTS AND METHODS
Study population and method: This was a
Calculation of the GRACE and the TIMI risk
prospective observational study, which involved 100
NSTEMI patients, during the period from May 2017
GRACE risk score (GRS); It was calculated by using
till September 2018. After approval of the ethical
specific variables (age, heart rate, SBP, creatinine,
committee of the faculty and after individual
Killip class, elevated cardiac markers, ST-segment
written consent, patients had coronary angiography
deviation, cardiac arrest at admission) gathered at
then we divided the study population into 2 groups:
admission, and accordingly patients were divided into
Single or two-vessel CAD group and 3 vessel or LM
low (GRS <108), intermediate (GRS 109-140) and
high (GRS >141) risk groups.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2646-2652
The Relationship between Amniotic Fluid Index (AFI) & Single Largest
Vertical Pocket and Perinatal Outcome in Late Severe Preeclampsia
Abd-Elmonem Mohammed Zakaria, Ashraf Hamdy Mohamed, Khaled Abd-Elhaleem Kamel Badr*
Department of Obstetrics and Gynecology, Faculty of Medicine - Alazhar University
*Corresponding author: Khaled Abd-Elhaleem Kamel Badr, Mobile: (+20) 01026534121, E-Mail: firstname.lastname@example.org
Backgound: the amniotic fluid is a clear fluid that surrounds the fetus, and produced in part by the amniotic cells,
maternal blood during the first trimester of pregnancy and fetal urine and lung fluid during the second trimester of
pregnancy. It serves as a cushion to the fetus allowing musculoskeletal development and protecting it from trauma.
It also maintains temperature and has a minimal nutritive function. Evaluation of AFV through ultrasound
measurement is an essential part in tests of fetal well-being (BPP), by measuring the AFI or the MVP.
Objective: the aim of this study was to evaluate both AFI and single deepest pocket in patients with late severe
preeclampsia, and to correlate both markers with different parameters of fetal outcome.
Patients and Methods: the study was a prospective controlled study involving 100 women with severe preeclampsia
>34w managed at Al Hussein University Hospital and Al Arish General Hospital with the following inclusion criteria,
pregnant patients, age 18- 40 years old, with variable parity and a singleton living fetus >34 weeks gestation, and
with severe preeclampsia. Results: the neonatal outcomes regarding meconium is more with AFI group than MVP
group while the neonatal outcome regarding NICU, RDS & Neonatal death in both groups were similar with no
evidence of a statistical difference between both techniques.
Conclusion: we concluded that AFI had more significant statistical relationship with perinatal outcome, hence AFI
appeared to be a better predictor of perinatal outcome in preeclamptics in late severe preeclampsia.
Keywords: oligohydramnios ultrasound Perinatal outcome
PATIENTS AND METHODS
Despite years of extensive research, hypertensive
The study was a prospective cohort study
disorders with pregnancy remain to be among the most
involving 100 women with severe preeclampsia >34w
significant unsolved problems in obstetrics.
managed at Al Hussein University Hospital and Al
Hypertensive disorders complicate 510% of all
Arish General Hospital all diagnosed with oligo-
pregnancies, and together they are one member of the
hydramnios (MVP<2cm or AFI<5cm) and divided
deadly triad along with hemorrhage and infection
into 2 groups with 50 oligohydramnios patients
that greatly contributes to maternal morbidity and
diagnosed by MVP<2cm and another 50
mortality (1). Preeclampsia syndrome is defined as
oligohydramnios patients diagnosed by AFI<5cm.
hypertension and proteinuria with pregnancy after 20
weeks gestation. Severe preeclampsia is diagnosed by
blood pressure > 160/110, evidence of proteinuria
Pregnant patients age 18- 40 years old.
(>3gm/L), headache, visual disturbance, upper
singleton living fetus > 34 weeks gestation
abdominal pain, oliguria, elevated serum creatinine,
measured by the first day of last menstrual period
thrombocytopenia, elevated serum transaminase, fetal
or by ultrasound scan estimation for those who
growth restriction and pulmonary edema (1).
were unsure of the last menstrual period).
Assessment of fetal well-being in preeclampsia
has been a subject of great interest. By far, ultrasound,
Severe preeclampsia in the study group is defined
Doppler evaluation and CTG are the main diagnostic
as blood pressure of 160/110mmHg on two or
tools in antepartum assessment. Oligohydramnios has
more occasions; four to six hours apart with
long been recognized in preeclampsia especially in
proteinuria of greater than 300mg in 24 hours
cases associated with fetal growth restriction (2).
urine specimen or more than one plus proteinuria
in dip stick specimen.
oligohydramnios in nearly 10% of pregnancies with
Patients diagnosed as oligohydramnios(AFI<5cm
suspected fetal growth restriction. Diagnosis of
or MVP <2cm).
oligohydramnios based on amniotic fluid index (AFI)
Patients undergoing termination of pregnancy by
or single largest vertical pocket has been a subject of
LSCS within 24 hours after diagnosis.
debate and controversy.
Ultrasound measurements was done within 24 hours
AIM OF THE WORK
before termination by single senior ultrasonographer.
The aim of this study is to evaluate the Uncomplicated caesarean sections.
relationship between amniotic fluid index & single
largest vertical pocket and perinatal outcome in late All caesarean sections were managed by average
obstetrician and anesthesiologist.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2653-2660
Histopathological and Cytological Efficacy in The Diagnosis of
Solitary Thyroid Nodules
Mohammed M. Elsawy1, Hatem Salah Eldin Elhabashy1, Marwa Abd ElMonem Soliman2,
Assem Ahmed Mohammed Ahmed1*
1Department of Otorhinolaryngology, Faculty of Medicine, Al-Azhar University
2Department of general Pathology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Assem Ahmed Mohammed Ahmed, Mobile: 01006542535, E-mail: email@example.com
Background: thyroid nodules are found in 4-7% of the population, the preferred diagnostic approach is avoidance of
numerous radiologic evaluations, and early performance fine-needle aspiration.
Objectives: the aim of this study was to evaluate the efficacy of fine needle aspiration cytology (FNAC) and
histopathological assessment in diagnosis of solitary thyroid nodules.
Methods: this study was done on twenty patients diagnosed as solitary thyroid nodule. All the patients' FNAC and
histopathological results were reviewed, confirmed, correlated and evaluated.
Results: there were 4(20%) men and 16(80%) women, with a male-to-female ratio of 1: 4. The patients studied ranged
in age from 17 to 65 years, with the majority ranging in age between 25 and 40 years (30%). According to FNAC
findings, 65% were benign/non-neoplastic and 35% were malignant aspirates. The most common benign lesion
diagnosed by FNAC was a colloid nodule (25%), whereas the most common malignant lesion was papillary carcinoma
(30%). There were no false-positive cases (0%). A false-negative result was found in only two cases (10%). According
to the histopathological findings, 60% were benign/non-neoplastic lesions and 40% were malignant. The most common
benign/non-neoplastic lesions were colloid goiter (25%) and follicular adenoma (15%), whereas the most common
malignant lesion was papillary carcinoma (35%). Conclusion: FNAC is a useful diagnostic method, but it has some
limitations in the diagnosis of subtypes of solitary thyroid nodules such as follicular lesion. Histopathological study
provides a more accurate diagnosis and overcomes these limitations.
Keywords: Solitary thyroid nodule, Fine needle aspiration biopsy (FNAB), Fine needle aspiration cytology (FNAC),
The ultrasound-guided ultrasound needle
Thyroid nodules (TNs) are very common
(USFNA) biopsy is widely used as a diagnostic tool to
diseases in the general population. It was found in 19-
distinguish between benign and malignant thyroid
67% by ultrasound examination (1). Unilateral thyroid
nodules, the most accurate and cost-effective method
nodules are defined as separate swelling in one stratum
available. The use of FNAB significantly enhanced the
without any apparent defect elsewhere(2).
ability to detect thyroid cancer before surgery,
Thyroid nodules are very common. They were
resulting in a 25% reduction in unnecessary surgical
detected in 4% to 7% of the population by palpation
operations and an increase in cancer yield from 14% to
and in 60% of the patients in the post-mortem
at least 30%(1).The majorities of the vesicles are benign
examination. Thyroid complications are more common
and represent colloidal or glandular nodules or
in women than in men, about 4 to 1 times more
hyperplasia, simple abscesses in the thyroid gland,
frequent Thyroid nodules throughout life. The
autoimmune thyroiditis, and lymphoid thyroiditis,
prevalence of thyroid nodules is evident in patients
while the most common malignant biopsy in FNAC is
younger than 21 years of age only; 0.05-1.8%. The
papillary gland cancer (7).
most common cause of unilateral nodules in children
Histological examination of thyroid glands is
is porous benign tumor (3).
the gold standard for determining the true spread and
The majority of unilateral thyroid nodules are
form of thyroid nodules in the population (8).
benign. While Attali et al.(4) reported that 5-20% of all
AIM OF THE STUDY
thyroid nodules turn out to be really malignant.
The aim of this study is to evaluate the efficacy
The value of fine-needle aspiration biopsy
of fine needle aspiration cytology (FNAC) and
(FNAB) for diagnosis of thyroid pathologies has been
histopathological assessment in diagnosis of solitary
established; however, in some specific situations, its
reliability is debatable. This diagnostic tool is
appropriate and valuable for the evaluation of single
PATIENTS AND METHODS
thyroid tumors, but has shown to be less effective for
This study was conducted on 20 patients
that of multinodular thyroid glands (5).
diagnosed with solitary thyroid nodules. All patients
FNAB can be performed by palpation or with
were selected from those attending the outpatient
ultrasound guidance. (USFNA) biopsy has been shown
clinics of ENT department at Bab El-Shereia Hospital,
to decrease false negative resulting from needle
Al-Azhar University from February 2017 to December
misplacement and reduce the rate of non diagnostic
2018. All patients had been subjected to both FNAC
smears from 15% to 30%(6).
and surgery during this period.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2661-2666
Outcome of Snodgrass Repair of Distal Penile
Hypospadias with Stented and Unstented Urethra
Gamal A.M Morsi, Mohamed A. Abdel Azez, Hussein A. Galal, Alsayed M.H Hathout,
Mourad M. Mourad and Mo'men Roshdy Qobaissy
Department of Urology, Faculty of Medicine - Al-Azhar University
Corresponding author: Mo'men Roshdy Qobaissy, Mobile: (+20)01116446440, E-Mail: firstname.lastname@example.org
Background: Hypospadias is the most common congenital malformation of penile shaft occurring in 1 per
300 male births; it is considered a common clinical problem as it causes not only functional problems but also
psychological problems for parents.
Objective: The objectives of this study is to review the result of TIP repair of distal penile hypospadias in
terms of outcome and complications of stenting and unstenting the urethra.
Patients and methods: As a prospective randomized study; this study has included patients with distal penile
hypospadias operated with Snodgrass between year 2011-2018 and had divided to (group A) included 40
patients operated upon with stent preservation for a week (group B) was 20 patients with stent removed at the
end of the operation.
Results: Regarding group (A) the stent of 10 cases had slipped at the first 8 hour postoperative so they have
been added to the count of (group B) and considered as unstented repair. It is clear here in our study that meatal
stenosis rate were different from Snodgrass rate but were similar to other published studies. Other comparable
items as fistula rate, urinary retention and hospital stay, were the same as published studies.
Conclusion: It could tell that removing the catheter can reduce bladder spasm , urinary tract infections, and
patient discomfort and improve the familiar compliance without increasing acute retention episodes and fistula
rate, so that at least in some cases specially in distal types, leaving stent can be avoided.
Keywords: Snodgrass, Distal Hypospadias, Unstented Urethra
short term catheterization had similar outcomes to
Hypospadias is the most common
patients with stents for 7- 14 days (4).
congenital malformation of penile shaft occurring
On the other hand, Buson et al. (5) in 1994
in 1 per 300 male births; it is considered a common
and Minevich et al. (6) in 1999 reported that
clinical problem as it causes not only functional
urethral stenting in distal hypospadias repair
problems but also psychological problems for
decrease the risk of fistula formation while adding
patients and their parents. Its incidence is on rise
only minimal morbidity (6).
with increasing environmental pollution as the
So, the role of stent in TIP technique are
suspected cause. The Birth Defects Monitoring
highly debated with no clear guideline for distal
Program (BDMP) has reported a doubling of the
hypospadias repair and if the absence of stent does
rate of hypospadias incidence since 1970 (1).
not affect the urological results, the impact on
In the classical method of tubularized
postoperative discomfort remains to be evaluated
incised plate (TIP) repair of distal penile
in a comparative trials .
hypospadias, to prevent urethral stenosis and
fistula formation, a stent was used. In a recent
AIM OF THE WORK
description of TIP procedure by Snodgrass himself,
The aim of this randomized prospective
he recommended stent placement for about a week
study is to compare stenting and unstenting urethra
to drain urinary bladder and to act as a scaffold for
in Snodgrass technique for distal penile
urothelial healing (2).
hypospadias and to display results for each method.
Newer studies debate the necessity of
stenting in distal hypospadias repair, for some
PATIENTS AND METHODS
surgeons they claimed that the procedure can be
Study design and period:
performed without leaving a stent, without
As a prospective randomized study; this study has
compromising the surgical outcome, and the
included patients with distal penile hypospadias
necessity of leaving stent after end of operation is
operated with Snodgrass technique (TIP repair)
somewhat questionable (3).
between years 2011-2018 and were divided in two
Aslan et al. (4) studied the factors which
groups, the first group (group A) included 40
determine the duration of stent placement post TIP
patients operated upon with stent preservation for a
urethroplasty; they found that the patients with
week and the other group was 20 patients with stent
removed at the end of the operation. The stent of
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2667-2672
Three-Versus Two-Dimensional Sonographic Biometry in the Third Trimester of
Pregnancy for Predicting Birth Weight and Macrosomia in Diabetic Pregnancies
Kamel Nourel-Deen Abdul-Galeel, Abd Elmonsef Abd Elhamed Sedek, Karim Gamal Radwan*
Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Karim Gamal Radwan, Mobile: (+20)01286245843, E-Mail: email@example.com
Background: diabetes is the most common metabolic disorder affecting pregnancy. Its prevalence seems to be
growing in parallel with the epidemics of overweight and obesity. It`s considered a modern epidemic disease that
affects about 8.3% of adults (accounts for 382 million people of the global population) and 46% of cases are
estimated to be undiagnosed. Recognizing and treating diabetes or any degree of glucose intolerance in pregnancy
results in lowering maternal and fetal complications. Objective: our aim is to test the hypothesis that incorporating
3D fractional thigh volume would be superior to conventional 2D biometry for predicting birth weight and
macrosomia in diabetic pregnancies.
Patients and Methods: the study was done on 160 pregnant women suffering from pre-gestational or gestational
diabetes at El-Hussien and Sayed Galal Hospitals. All women were evaluated by full obstetrical history taking,
physical examination, pelvic examination, transabdominal ultrasound, routine laboratory investigations and
assessment of the route of delivery. Results: one-fifth of the patients had macrosomia, and four fifths had no
macrosomia. There were no statistical significant differences between macrosomia group and no macrosomia
group in maternal age, parity, body mass index, obesity, diabetes, gestational age and gestational age at delivery.
The mean ± SD was lower for the 2D than the 3D projected estimate. Our study showed that there were statistical
high significant regarding birth weight at delivery and difference from 2D/3D (p < 0.001).
Conclusion: we suggest that 2D sonography should remain the standard of care for predicting birth weight and
macrosomia in diabetic pregnancies.
Keywords: Three-Versus Two-Dimensional Sonographic Biometry Trimester, Pregnancy for Predicting Birth
Weight, Diabetic Pregnancies.
findings of several studies that epigenetic alterations of
Diabetes is the most common metabolic
different genes of the fetus of a GDM mother in utero
disorder that affects pregnancy. Its prevalence appears
could result in the transgenerational transmission of
to be increasing in parallel with epidemics of
GDM and type II diabetes are of concern (3).
overweight and obesity. A recent epidemic disease
Fetal macrosomia, defined as fetal weight
affects about 8.3% of adults, representing 382 million
exceeding 4000 or 4500 g regardless of gestational
people worldwide, and it is estimated that 46% of cases
age, is one of the most common complications of
are currently not diagnosed. Recognizing and treating
GDM and is associated with increased risks of
diabetes or any degree of glucose intolerance in
neonatal and maternal morbidity, including shoulder
pregnancy reduces maternal and fetal complications (1).
dystocia, birth trauma, perineal lacerations, and
Pre-gestational diabetes (i.e., diabetes
cesarean delivery. Diabetes, especially when poorly
diagnosed before pregnancy, type 1 or type 2 diabetes
controlled, is a major risk factor for fetal macrosomia.
mellitus) comprises approximately 13 percent of all
This association is partially explained by excessive
diabetes in pregnancy, while gestational diabetes
growth from elevated maternal plasma glucose levels,
mellitus (GDM) is diabetes diagnosed in the second or
resulting in elevated fetal insulin and insulin-like
third trimester of pregnancy that is not clearly overt
growth factor levels, which stimulate glycogen
synthesis, fat deposition, and fetal growth (4).
Fetal macrosomia is a common adverse infant
Moreover, neonates of diabetic mothers of the
outcome of GDM if unrecognized and untreated in
same birth weight are at higher risk for shoulder
time. For the infant, macrosomia increases the risk of
dystocia compared to those of nondiabetic mothers
shoulder dystocia, clavicle fractures and brachial
because of different distributions of body fat (5).
plexus injury and increases the rate of admissions to
Three-dimensional (3D) demonstrated a
the neonatal intensive care unit. For the mother, the
significant improvement over 2D biometry when
risks associated with macrosomia are cesarean
fractional thigh volume, a soft tissue parameter based
delivery, postpartum hemorrhage and vaginal
on 50% of the femur diaphysis length from 3D
lacerations. Infants of women with GDM are at an
sonography, was incorporated into 2D biometry. To
increased risk of becoming overweight or obese at a
obtain fractional ThiV value, the collected volume data
young age (during adolescence) and are more likely to
was reopened by using 4D view program, version 12
develop type II diabetes later in life. Besides, the
(GE medical system) under the fractional limb volume
mode. After placing the caliper at both sides of the
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2673-2678
Comparative Study between Fetal Biometry and Transverse Cerebellar
Diameter in Estimating Gestational Age in Third Trimester
Osama E. Ali, Ibrahim R. Elsawy, Abdelhamed M. Elbedewy
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Abdelhamed M. Elbedewy; Mobile: +201061192867
Background: The exact determination of gestational age is so important in management of the antepartum care, and
for adequate planning of proper intervention or therapy. Tanscerebellar diameter has great advantages in prediction
of gestational age in cases of uncertain dates or in suspected intrauterine growth retardation. There are minimal data
available about the relationship between tanscerebellar diameter and biparietal diameter in third trimester of
Objective: The aim of the present study was to assess the accuracy of transcerebellar diameter (TCD) measurement
in estimation of the gestational age during the third trimester compared to the current fetal biometric measurements
including femur length and biparietal diameter.
Patient and Method: The study included 500 pregnant women with sure and reliable dates fulfilling the inclusion
criteria at the Department of Obstetrics and Gynecology, Al-Azhar (Bab Alsheria ) university Hospital, (inpatient
and outpatient) from May 2018 till November 2018. The entire subjects were in the third trimester of pregnancy seen
at 31 36 weeks, the transcerebellar diameter, the biparietal diameter and femur length were measured for
determination of gestational age.
Results: The results showed that the transcerebellar diameter (TCD) is more accurate than the biparietal diameter
(BPD). There were insignificant statistical difference between transcerebellar diameter (TCD) and femur length (FL)
for determination of gestational age in the third trimester whereas there was a significant difference between the
transcerebellar diameter (TCD) and the biparietal diameter (BPD) for determination of gestational age in the third
trimester. All those data were compared to the last menstrual period.
Conclusion: Transcerebellar diameter is more reliable method of gestational age determination in third trimester of
pregnancy than biparietal diameter. Transcerebellar diameter (TCD) and femur length (FL) can be used as a tool to
assist in the assessment of gestational age in third trimester.
Keywords: Transcerebellar diameter - femur length - biparietal diameter gestational age.
The estimate of the date of pregnancy is
SUBJECTS AND METHODS
mandatory for pregnant women in order to obtain the
This observational study included a total of 500
expected time of delivery, in which different tests will
pregnant women attending at Department of Obstetrics
be conducted to achieve the estimated time. There are
and Gynecology, Al-Azhar (Bab Alsheria) University
methods used to determine the gestational age,
including menstruation and clinical examination, as
well as ultrasound imaging (1).Accurate pregnancy
Approval of the ethical committee and a written
determination is one of the most useful assessments of
informed consent from all the subjects were
pregnancy, which depends on whether or not the
patient is pregnant. In order to decrease the biologic
This study was conducted between May2018 till
variability among fetuses traditional biometry, ancillary
biometric also non biometric measurements will be used
All the subjects were in the third trimester of
in addition those measurements can also be used for the
pregnancy, the transcerebellar diameter, the biparietal
assessment of the gestational age and maturity of the
diameter and femur length were measured for
fetal lung and some specific clinical situations as cases
determination of gestational age.
of oligohydramnios that manifested by fetal head and
The inclusion criteria included women in
abdominal compression resulting in difficult
determination of accurate abdominal circumference and
pregnancy, at 31-36 weeks of pregnancy calculated by
biparietal diameter (2).
the first day of last menstrual periods.
The aim of the current Work was to assess the
The Exclusion criteria were women who were
unsure of dates, or those with anomalous fetus,
measurement in estimation of the gestational age during
intrauterine fetal death, subjects with multiple
the third trimester compared to the current fetal
gestation, and Subjects with medical disorders like
biometric measurements (femur length and biparietal
diameter) according to last menstrual period.
Peribulbar Block using Dexmedtamdine or Magnesium as Adjuvant to Indeigenous Local Anesthestic for Cataract Extraction
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2679-2683
Peribulbar Block Using Dexmedetomdine versus Magnesium Sulphate as
Additives to Local Anesthetics for Cataract Surgery
Manal Foad Abd Elmoniem 1 and Rehab Moustafa Kamel 2*
1 Anesthiology, Intensive Care and Pain Management Department, 2 Ophthalmology Department,
Faculty of Medicine for Girls, Al-Azhar University
*Corresponding Author: Rehab Moustafa Kamel, Phone No.: (+2) 01026332337, E-mail: firstname.lastname@example.org
Background: peribulbar block is commonly used for cataract surgery in adults, most commonly local anesthetics
were injected into peribulbar space, but using only local anesthetics for peribulbar anesthesia is associated with
delayed onset of globe akinesia and, short duration of analgesia and frequent need of block supplementation
Objective: to assess the efficacy and safety of addition of dexmedetomidine versus magnesium sulphate to local
anesthetic mixture for peribulbar block in cataract surgery.
Patients and Methods: the patients were divided randomly into two equal groups: Dexmedetomidine group (D
Group) included 30 patients who received 50 µg dexmedetomidine adjuvant to local anesthetics mixture (lidocaine
and bupivacaine). Magnesium sulphate group (M Group) included 30 patients who received 50mg of Magnesium
sulphate adjuvant to local anesthetics mixture (lidocaine and bupivacaine).
Results: The addition of Dexmedetomidine or Magnesium sulphate to local anesthetic in cataract surgery
accelerates the onset of corneal anesthesia and globe akinesia . The decrease in the IOP is more in D Group . No
significant changes in the hemodynamic measurements in both groups
Conclusion: Use of 50ug dexmedatomedine or 50mg magnesium sulphate 10% with mixture of lidocaine 2% plus
bupivacine 0.5% for peribulbar anesthesia in cataract surgery enhances the onset of globe anesthesia and akinesia .
Dexmedetomidine causes more decrease in intraocular pressure magnesium sulphate .
Keywords: Dexmedetomidine Magnesium sulphate - Peri bulbar block.
local anesthesia is the best method for eye
this study is to compare the safety and efficacy of the
surgeries especially is old patients with systemic
addition of dexmedetomedine or magnesium to
disease who are more liable for complications of
mixture of local anesthetics in cataract surgery by
anesthesia. Retro bulbar technique provides adequate
measuring onset of globe akinesia, corneal anesthesia
anesthesia, decrease in intraocular pressure , akinesia
and adequate time for surgery, Intraocular pressure
and post operative analgesia . (1) But it has many
and hemodynamic parameters ( primary outcome)
complications as globe perforation, retro bulbar
,first request of analgesia and patient and doctor
hemorrhage and brain stem anesthesia (2). Peribulbar
satisfaction (secondary outcome ) .
block with local anesthetics is commonly used for
cataract surgery in adults but using only local
PATIENTS AND METHODS
anesthetics for peribulbar anesthesia is associated
A prospective randomized, comparative
with delayed onset of globe akinesia and, short
non controlled clinical study was carried out at Al-
duration of analgesia and frequent need of block
Zahraa university hospital between June 2017 to
supplementation. To decrease the time of onset of
Auguat 2018 . The study protocol adhered to the
action and increase the duration of analgesia, many
tenets of declaration of Helsinki and was approved
by the ethics board of Al Azhar university. An
bicarbonate, adrenaline, corticosteroids and opioids
informed written consent was taken from each
were added to local anesthetics with limited success
participant in the study .
(3,4,5). Until now no adjuvant is considered superior
The study included 60 patients physical stated
than others in prevention of local anesthetic
ASA I or II of either sexes aged between 20 to 60
complications like dryness of mouth, bradycardica,
years scheduled for elective cataract surgery under
and allergic reaction (6). Magnesium sulphate
(MgSo4) is a non-competitive Nmethyl-D-Aspartate
In this study we excluded morbid obese patient
[NAMDA] antagonist and calcium channel blocker (7)
with body mass index>35, patients with uncontrolled
, it has been used as additive to LA solution to hasten
hypertensions or diabetes, deafness , or with
the onset time of block and prolong the duration of
disturbed level of consciousness. Patients with axial
the anesthesia (8) . Dexmedetomdine is a selective
eye length globe more than 25mm or with posterior
agonist that have an eight fold greater affinity for 2
staphyloma, patients on anticoagulant drugs were
adrenergic receptors ( hypnotic and analgesic effect)
than clonidine . It accelerates central and peripheral
The patients were randomly allocated to one of two
neural blockade when added to LA (9,10) . The aim of
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2684-2689
Different Modalities of Management of Liver Trauma
(Operative and Nonoperative)
Mohammed Aboul Fotouh Ahmed, Hazem Ahmed Mostafa,
Mohammed Mostafa Mohammed Elshiekh Aly*
Department of General Surgery, Faculty of Medicine, Al Azhar University
*Corresponding author: Mohammed Mostafa Mohammed Elshiekh Aly, Mobile: (+20) 01118750587
Backgound: non operative management (NOM) of liver injury has generally become the most frequent
treatment. Current rates of success for NOM for hepatic trauma of selected patients have been reported to be
safe and efficient.
Objective: The purpose of this work is to study and evaluate different modalities in management of liver trauma
regarding the available diagnostic modalities and current management options.
Patients and Methods: thirty patients with hepatic trauma were included in the study. They were classified
according to their vital stability into 2 groups; conservative and operative groups. The conservative group was
formed of 21 patients, while the operative group was formed of 9 patients.
Results: a higher rate of morbidity and mortality during the course of management was found among the patients
of the operative group, while 4 patients (19%) in conservative group suffered from complications 6 patients
(66.7%) in operative group suffered after the operative management. The only mortality case was found in
Conclusion: the operative management of liver trauma is associated with higher grade of injury, higher needs
for blood transfusion, ICU admission and a higher rate of further management, morbidity, mortality and the
presence of co-injuries.
Keywords: Liver Trauma, Operative and Nonoperative management
Today non-operative management has
Abdominal trauma is an emergency
become the first treatment of choice when possible
condition and, if not treated properly, is associated
in patients with blunt liver trauma. Non-operative
with significant morbidity and mortality. Today
management should only be considered in
despite advancement in recognition, diagnosis, and
haemodynamically stable patients lacking signs of
management, the mortality remains high(1). Trauma
other laparotomy-demanding injuries (5).
is the second largest cause of hospital admission
Recently, a "multidisciplinary approach"
with 16% of global burden of all health cost. As per
concept has evolved as the standard of care in the
the estimate of the World Health Organization, by
treatment of complex hepatic trauma. In addition to
2020, trauma will be the first or second leading cause
prompt surgical intervention, when indicated,
of years of productive life lost for the entire world
adjunctive interventional techniques have become a
part of liver trauma management such ashepatic
Hepatic trauma represents a significant
management challenge that requires a high index of
cholangiopancreatography (ERCP), biliary stenting
suspicion, rapid investigation, accurate classification
and percutaneous computed tomography (CT) scan
and well-defined management protocols (2).
guided drainage (6).
During the past decades, there has been an
overall trend from operative towards conservative
AIM OF THE WORK
treatment in the management of liver trauma. Older
The purpose of this work is to study and
studies have shown that almost half of the liver
evaluate different modalities in management of liver
injuries actually had stopped to bleed at the time of
trauma regarding the available diagnostic modalities
and current management options.
The success of non-operative management
of hepatic injuries in children in the early 1980s
PATIENTS AND METHODS
This prospective study was conducted at Al-
management in adults over 15 years ago (4).
Zahraa University Hospital, National Liver Institute,
The introduction and enhancement of the
Shebin Elkom Teaching Hospital, and El bagour
computed tomography (CT) scan has facilitated and
Hospital. The study included 30 patients with
improved selection and management of patients
hepatic trauma during two years; 2017 and 2018.
treated non-operatively (3).
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2690-2698
Phacotrabeculectomy versus Trabeculectomy with Small Incision Cataract
Extraction in Eyes Presenting with Cataract and Glaucoma
Mohammed IA1, Abdelhameed MH2 and Eassa IM3
1 Ophthalmology department -Faculty of medicine, Al -Azhar University (Cairo), 2 Ophthalmology
department- Faculty of medicine, Al -Azhar University (Damietta) and 3 Ophthalmology department-
Faculty of medicine, Al -Azhar University (Damietta)
*Corresponding Author: Mostafa Ismail Eassa, Phone No.: (+20) 01123320632, E-mail: email@example.com
Background: The association of glaucoma with cataract has been more frequent because of increase in life
expectancy and the increased risk of cataract development in patient with glaucoma.
Aim of the work: was to compare the outcome of phacotrabeculectomy versus subscleral trabeculectomy with small
incision cataract extraction in patients with cataract and primary glaucoma.
Patients and Methods: This prospective study included a total of 20 eyes of 19 patients with visually significant
cataract and coexisting primary glaucoma. Patients were categorized randomly in two groups: group A who
underwent phacotrabeculectomy and group B who underwent trabeculectomy with small incision cataract extraction
from the same trab.
Results: Statistically significant improvement was detected in postoperative BCVA and IOP. Preoperative BCVA
ranged from 0.02 to 0.25 with the mean ±SD of 0.15± (0.07) in phacotrabeculectomy group (group A) while in small
incision trabeculectomy group (group B) preoperative BCVA ranged from 0.01 to 0.25 with the mean ±SD of
0.11±(0.1). Preoperative IOP ranged from 30-35 mmHg with mean ±SD of 31.28 ± (1.25) in phacotrabeculectomy
group while in small incision trabeculectomy group preoperative IOP ranged from 30-36 mmHg with mean ±SD of
31.14 ± (1.34).
Conclusions: It could be concluded that there is significant improvement in the BCVA and IOP control after
combined procedure for management of coexistent cataract and glaucoma. This improvement is statistically
significant. There was no statistically significant difference in the final visual acuity, IOP control and postoperative
complication rate between phacotrabeculectomy and small incision trabeculectomy.
Keywords: Cataract, phacotrabeculectomy, small incision, glaucoma.
intra ocular pressure as well as effectiveness of
Cataracts are the leading cause of blindness
glaucoma surgery (5).
worldwide, not only a medical problem but also a
social problem that takes into account population aging
Combined procedure considered in visually
(1). Congenital cataracts may be dementia, shock,
significant cataract and one of the following situations:
complicated because of uvietis, metabolism as diabetic
Drug induced side effects, IOP control on maximum
cataracts and toxicity (2).
tolerated therapy but advanced glaucomatous optic
Glaucoma is an annoying eye disease that
atrophy or uncontrolled glaucoma on maximum
destroys the optic nerve and can lead to irreversible
medications and there is need to restore vision. Some
gradual loss of vision and blindness at the end.
studies have shown that postoperative complication
Glaucoma may be either an open angle representing
rates and IOP were lower when cataract surgery was
90% of all narrow-angle glaucoma or angle-closure
combined with trabeculectomy (6).
glaucoma. Other types are natural stress glaucoma,
Manual small-incision cataract surgery with
congenital and secondary glaucoma such as glaucoma
trabeculectomy also is an acceptable option in the
(3). There is no cure for glaucoma as yet, and vision loss
surgical management of combined cataract and
is irreversible. However medication or surgery can
glaucoma. There are some benefits from small incision
slow-down any further vision loss. Therefore early
cataract surgery in the form of less manipulation, less
detection is essential to limiting visual impairment and
trauma, less side effects of ultrasound and suitable in
preventing the progression towards several visual
certain conditions like small pupil and hard cataract (7).
handicap or blindness (4).
The aim of the current work was to compare
The association of glaucoma with cataract has
the outcome of phacotrabeculectomy versus subscleral
been more frequent because of increase in life
trabeculectomy with small incision cataract extraction
expectancy and the increased risk of cataract
in patients with cataract and primary glaucoma.
development in patient with glaucoma. Moreover, the
PATIENTS AND METHODS
presence of cataract can affect the ability to assess
This prospective study included a total of 20 eyes
glaucoma progression, and cataract extraction affects
of 19 patients with visually significant cataract and
coexisting primary glaucoma attending at the
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2699-2705
Effects of Süßstofftabletten on Some Physiological Parameters in
Male Albino Rats and The Curative Effects of Vitamin E
Eman G.E. Helal1, Mohamed A. Abdelaziz2, Mariam S. El-Gamal1
1Department of Zoology, Faculty of Science (Girls), Al-Azhar University,
2Medical Physiology, Faculty of Medicine, Al-Azhar University
* Corresponding author: Eman Helal, email: firstname.lastname@example.org, mobile:00201001025364, orcid.org/0000-0003-0527-7028
Background: Süßstofftabletten is an artificial sweetener, which is mainly composed of cyclamate and saccharin.
Aim of the work: clarification of Süßstofftabletten effects and the amelioration effect of vitamin E in male albino
rats. Materials and methods: thirty male albino rats weighing from 100 to 120 gm. The period of the experiment was
30 days. The animals were divided into three groups; group 1: control, group 2: rats received Süßstofftabletten (1
tablet/kg b.w./day) and group 3: rats received Süßstofftabletten (1 tablet/kg b.w./day) + vitamin E (6 mg/kg b.w./day).
The following parameters were measured: serum glucose, ASAT, ALAT, serum creatinine, serum urea, protein and
lipid profiles and hormonal levels (insulin, testosterone, serum T3 and serum T4).
Results: there were many disturbances that occurred in the previous parameters, and vitamin E ameliorated most of
these hazardous effects.
Conclusion: the assertions that artificial sweeteners are safe and healthy in use by consumers are false. Natural
sweeteners whose benefits are important and necessary to our bodies must be used instead of artificial sweeteners.
Also vitamin E is very important in our daily diet as it fights many damages that encounter us.
Keywords: Süßstofftabletten, cyclamate, saccharin, vitamin E, ASAT, ALAT, T3, T4, testosterone, insulin.
It is the most important and widely used sweetener, as
Synthetic sweetener is a food additive that
it goes directly through the human digestive system
simulates the effect of sugar on taste. Therefore, they
without being digested (5). Saccharin is a very stable
are called sugar substitutes. Consumers often choose
compound with respect to heat and time so that it can
those foods that are made up of low-calorie sweeteners
be used in hot beverages and in food processing that
because they want a taste of sweetness without adding
involves application of high temperature. There are
calories. The dietary option is that this product may be
different forms of saccharin including sodium
useful in managing obesity or diabetes (1).
saccharin, calcium saccharin, potassium saccharin and
Cyclamate is derived from N-cyclo-hexyl-
acid saccharin. Sodium saccharin is more often used as
sulfamic acid (CHS) and is widely used as a non-
it is more palatable (6). Although, saccharin has been
thermal industrial solution in food and beverage as well
extensively investigated, most of research has produced
as in the pharmaceutical industry. It is odorless and
conflicting reports. Saccharin is widely accepted as a
soluble in water, alcohol, propylene glycol, aspartame
sugar substitute, but consumption of saccharin should
and saccharin. Thus, may be submitted to variations in
be in adherent to the FDA recommended approved daily
temperature (2). Cyclamate is 30 times sweeter than
limit. Furthermore, consumers should be aware of its
sucrose and it has a synergistic sweetening effect when
risks and benefits, as several reports have shown
combined with saccharin. Cyclamate is absorbed
association with bladder cancer, as well as incidents of
partially from the intestine, and a variable amount is
other cancers (5).
converted to cyclohexylamine by microorganisms in
Süßstofftabletten is made and used in
the large bowel. After cyclamate administration in some
Germany. It contains sodium cyclamate and sodium
nonhuman mammals, N-hydroxy cyclohexylamine was
found in urine. Cyclohexanol and cyclohexane have
Vitamins are ideal antioxidants to increase
also been reported as trace metabolites of cyclamate in
tissue protection from oxidative stress due to their easy,
rats, rabbits, guinea pigs, monkeys, and humans,
effective and safe dietary administration in a large range
probably arising from metabolism of cyclohexylamine
of concentrations. One of the most important vitamins
(3). In 1970, Price et al. (4) reported an increased
for the body is vitamin E. In nature, vitamin E
incidence of bladder tumors in rats dosed with a mixture
comprises eight natural fat-soluble compounds,
of sodium cyclamate and sodium saccharin that led to a
including 4 tocopherols [d-alpha-, d-beta-, d-gamma-
ban on the use of cyclamate as an artificial sweetener in
and d-delta tocopherol] and 4 tocotrienols [d-alpha-, d-
a number of countries, including the United Kingdom
beta-, d-gamma- and d-delta-tocotrienol] (7). Vitamin E
and the United States.
is an important antioxidant factor. It is known to possess
Saccharin is an artificial sweetener that has
various physiological functions. A major contributor to
been widely accepted as a sugar substitute. It is 300 to
non-enzymatic protection against lipid peroxidation is
500 times sweeter than sucrose, but it has a slightly
vitamin E, a known free radical scavenger. Vitamin E
bitter aftertaste. It is known under the E number E954.
as a lipid soluble, chain-breaking antioxidant plays a
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2712-2719
Phacoemulsification with Peripheral Iridectomy and Trabeculectomy: Comparing
the Two Procedures in Management of Angle-Closure Glaucoma
Ophthalmology Department, Faculty of Medicine, Al-Azhar University (Assuit), Egypt
Corresponding author: Asaad Nooreldin, E-mail:email@example.com, Mob: +201026366024
Background: glaucoma was ranked as one of the major causes of blindness worldwide. Angle-closure glaucoma (ACG)
is a type of glaucoma characterized by narrowing or closure of the anterior chamber angle.
Objective: to compare the clinical outcomes of phacoemulsification (Phaco) with peripheral iridectomy versus
trabeculectomy in management of ACG. Patients and Methods: this study was a prospective, follow-up non-
randomized clinical trial, carried out on 50 eyes with ACG. Patients were divided into two groups: group A (n= 25);
eyes underwent phacoemulsification with peripheral iridectomy, and group B (n= 25); eyes underwent sub-scleral
trabeculectomy. Intraocular pressure (IOP), visual outcomes and postoperative complications were assessed. Patients
were followed-up for 6 months. Results: postoperative visual acuity was significantly improved in phaco group
compared to that of trabeculectomy group (P <0.001). The mean postoperative IOP was reduced significantly (P < 0.05)
in both groups at all time intervals compared to their preoperative values. Anterior chamber depth increased
significantly postoperatively in group (A) (p<0.001) however, almost no change was noticed in group (B). Meanwhile,
postoperative angle opening distance was increased (p<0.001) in both groups. No significant differences were found
between both procedures in Rim area, Rim volume, cup/disc area ratio and maximum cup depth. Eight cases (32.0%) in
group (A) and 7 cases (28.0%) in group (B) suffered from postoperative complications with insignificant difference.
Conclusion: both procedures are effective in lowering IOP in patients with ACG, but phacoemulsification with
peripheral iridectomy significantly improved visual acuity compared to sub-scleral trabeculectomy with almost the same
rate of complications.
Keywords: Phacoemulsification, Peripheral Iridectomy, Trabeculectomy, Angle Closure-Glaucoma.
Glaucoma was ranked as the second most
There is an evidence demonstrates that
common cause of blindness following cataract and as
peripheral iridotomy is possibly useful in the treatment
the major cause of irreversible blindness, the World
of the early stages of PACG, but it is probably not
Health Organization estimated that about 20 million
effective in reducing intraocular pressure in case of
people will be affected by primary angle-closure
development of glaucomatous optic neuropathy and
glaucoma (PACG) by 2020, and 5.3 million will suffer
extensive synechial angle closure(5).
from blindness(1). Angle-closure glaucoma (ACG) is a
Trabeculectomy is a surgical procedure that has
type of glaucoma characterized by narrowing or closure
been first described as an antiglaucoma procedure by
of the anterior chamber angle. With increasing age,
Cairns, in 1968(6); this modalityis effective in the
some factors causing increased shallowness of the
treatment of various types of glaucoma and is a popular
anterior chamber and iridolenticular contact witch
procedure has undergone numerous modifications(7).
increased intraocular pressure (IOP) and could lead to
Trabeculectomy effectively reduces intraocular pressure
damaging the optic nerve and losing visual field(2).
and improving visual acuity in most patients in short
Several studies reported that cataract extraction
term but by long term, these patients may need
could restore the vision and eliminate a narrow angle in
additional medical or surgical IOP control(8). Although
patients with chronic primary angle-closure glaucoma
the significant success of trabeculectomy, it may cause
or acute primary angle closure(3). Phacoemulsification
some complications related to hypotony and may result
(Phaco) has been usually described for treating PACG
in loss of visual acuity in patients with advanced field
associated with cataract and it represents nowadays the
loss(9). Both phacoemulsification and trabeculectomy
gold standard for cataract surgery, for the objective of
have an effective role in reducing IOP in patients with
reducing IOP and improving visual acuity. But, some
factors could make the use of Phacoemulsification in
treating ACG be difficult such as large lens, narrow
OBJECTIVE OF THE STUDY
pupil and the narrow working space in the anterior
The objective of this study is to compare the
chamber(4). Peripheral iridotomy is a standard procedure
clinical outcomes of phacoemulsification with
commonly used for the treatment of angle closure, it
peripheral iridectomy versus trabeculectomy in
ameliorates pupillary block "the common cause of
treatment of angle-closure glaucoma.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2720-2728
Effect of Different Methods of Reperfusion on Short-Term Outcomes in
Patients with Acute Inferior S-T Segment Elevation Myocardial Infarction
Associated with Ischemic Mitral Regurge
Mohey Mansour El-Abbady, Mohammed Usama Taha, Mohammed Saeed Al-shorbagy,
Ibrahim Abdelfattah Yassin, Haitham Alshahat Ramadan
Department of Cardiology, Al-Azhar Faculty of Medicine, Al-Azhar University and National heart institute, Egypt
Corresponding author: Dr. Haitham Ramadan,National heart institute,Tel: 00201116671227
Background: Follow-up of patients with inferior STEMI having acute significant mitral regurgitation to assess the
effect of mitral regurgitation and the type of reperfusion therapy whether thrombolytic therapy or PCI on the
prognosis of these patients
Patients and methods: This is a prospective, observational, non-controlled study included two hundred and forty
patients with inferior STEMI admitted at National Heart Institute from august 2016 to August 2018. The patients
were classified into 2 groups according to presence or absence of mitral regurgitation, 120 patients in each group.
Group A (ischemic MR) was further subdivided into 2 subgroups, 60 patients who underwent primary PCI and 60
patients who received thrombolytic therapy.
Results: Patients presenting with inferior STEMI and having ischemic mitral regurgitation (IMR) had more, in
hospital, complications regarding life threatening arrhythmias, cardiogenic shock and mortality. On three months
follow-up these patients had more incidence of developing congestive heart failure and low ejection fraction. On
analyzing the data of each subgroup, the patients who had IMR and received thrombolytic therapy had more sever
mitral regurgitation, more in-hospital complications and more incidence of congestive heart failure than those
patients who had IMR but underwent primary PCI.
Conclusion: Patients with inferior STEMI and having IMR are at more risk for developing in hospital complications
and have higher incidence to develop congestive heart failure. However, in these patients those who underwent
primary PCI have much better prognosis than those who received thrombolytic therapy.
Keywords: Inferior STEMI, Ischemic Mitral Regurgitation, Primary PCI.
outcome (9). The effect of primary PCI on IMR
Ischemic coronary insufficiency (IMR) is coronary
incidence has not been specifically studied.
insufficiency caused by coronary artery disease in the
absence of internal valve lesions, which are common
PATIENTS AND METHODS
complications of acute myocardial infarction (AMI) (1)
1. Study design:
that is occurring in 15-64% of patients after the event,
This is a prospective, observational, non-
which is independent indicator of future cardiovascular
controlled study that was performed from august 2016
to August 2018 and included 240 patients presented to
During AMI, mitral regurgitation carries an
the emergency department of the National Heart
adverse prognosis and it has been associated with high
Institute for the first time with acute inferior ST
mortality (3). The presence and degree of IMR are
segment elevation myocardial infarction according to
associated with lower long-term survival in patients
the third universal definition of myocardial infarction.
after a first non-ST-segment elevation acute coronary
Thygesen et al. (10) which requires the presence of
typical chest pain lasting for more than 30 min with
Mild and moderate functional mitral insufficiency
ST-segment elevation >1 mm in 2 of the inferior leads.
lead to a worse prognosis in patients undergoing
The patients were divided into two groups. Group A:
coronary artery bypass grafting (CABG) (5).
included 120 patients with ischemic mitral
In addition, IMR severity is positively associated
regurgitation, this group was divided into 2 subgroups:
with development of heart failure after AMI (6).
Subgroup I: included 60 patients that were treated by
Because of its complex pathophysiology and
primary PCI and Subgroup II: included 60 patients that
heterogeneous clinical presentation. The proper
were treated by thrombolytic therapy. Group B:
treatment of ischemic MR is often debated, and the
included 120 patients of matching age, sex and risk
relative utility of revascularization with and without
factors without ischemic mitral regurgitation that were
concomitant mitral valve surgery is uncertain (7).
treated with either primary PCI or thrombolytic. The
Although primary percutaneous coronary intervention
study was approved by the Ethics Board of Al-
(PCI) for AMI is known to improve outcome (8), and
Azhar University and an informed written consent
that IMR after myocardial infarction (MI) worsens
was taken from each participant in the study.
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2729-2735
Sphincter Sparing Techniques for Treatment of Transsphincteric Anal Fistula
Abdul Salam Amer Emad, Mohamed Fathy Labib and
Gamal Attia Mohamed Mohamed*
Department of General Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Gamal Attia Mohamed Mohamed, Mobile: 00201094455241, E-Mail: firstname.lastname@example.org
Background: anal fistula is a common proctologic problem. It is a common cause of chronic irritation to both patients
and surgeons. It is a disease of antiquity. Even with all that work and research, started 2500 years ago, or may be more,
man didn't find the ideal treatment for perianal fistulas.
Objective: The purpose of this study is to evaluate sphincter saving techniques used in management of transsphincteric
anal fistula as regard rapid recovery, incidence of postoperative stool incontinence and recurrence rate.
Patients and Methods: our study was a prospective study of 60 patients who had transsphincteric anal fistula and were
admitted to Al-Azhar University Hospitals from July 2017 till January 2019. The patients were divided into 3 groups
according to the management procedure, group A was managed by seton technique, group B was managed by ligation
of transsphincteric fistula tract (LIFT) and group C was managed by endorectal advancement flap (ERAF).
Results: there were no differences of demographic data and characters of fistula among the three groups, however some
differences were noticed regarding postoperative morbidity due to early complication including urine retention,
bleeding, hematoma, infection and wound disruption but it was not statistically significant, there were statistically
significant difference regarding postoperative pain, recurrence and incidence of stool incontinence.
Conclusion: high transsphincteric fistula warrants more sphincter sparing techniques to avoid the most likely sphincter
dysfunction which could be happened after traditional surgery like fistulectomy and cutting seton for this type of
complex anal fistula.
Keywords: Anal fistula; sphincter sparing; seton, LIFT, Advancement flap.
Anal fistula, fistula in ano or sometimes called
The ideal way to treat the anal fistula is to cure the
fistula around the anus is a hollow channel lined with
disease without any risk of fecal incontinence. The
granular tissue that connects the primary aperture
different surgical techniques used in treating anal fistula
within the anal canal to a secondary opening in the skin
can be divided into 2 groups: sphincter-sacrificing and
around the anus. Secondary spaces may be multiple and
sphincter-sparing techniques. The sphincter-sacrificing
can extend from the same basic opening(1).
techniques, with or without immediate repair, have a
Perianal fistula is a common condition. It has an
high healing rate but also a high postoperative
incidence of 5.6 per 100000 in women and 12.3 per
incontinence rate, while the sphincter-sparing
100000 in men, the disease occurs predominantly in the
techniques have varied healing rates but little or no
third and fourth decade of life. It is believed that
resultant incontinence. The impairment of continence
infection of the intersphincteric glands is the initiating
has an effect on quality of life, so the sphincter-sparing
events in fistula in ano in a process known as the
techniques are now popular (6).
cryptoglandular hypothesis (2).
The management of anorectic abscess and anal
Numerous methods can be employed for diagnosis
fistula has changed markedly with time. Invasive
of perianal fistula, the basic principles and procedures
methods with high resulting rates of incontinence have
of which include the application of Goodsall's rule,
given way to sphincter-preserving methods that have a
careful physical examination (to find any cord like
much lower associated morbidity(7)..
structure or external orifices, etc.), probing of the tract,
However, the results of sphincter sparing methods
endosonography and a variety of injection and
have been variable, and no one procedure is superior to
radiologic techniques (3)
the others absolutely. It is worth our concern that the
The management of perianal fistula has been
goal of any treatment procedure is to obliterate the tract
documented in the literature for thousands of years,
and to have low recurrence rates while maintaining full
dating back to the time of Hippocrates in 400 BC (4).
However anal fistula repair still remains challenging.
AIM OF THE WORK
Persistent fistulae occur in up to 30% of cases following
The aim of the study was to evaluate the sphincter
definitive surgery despite many improvements in
sparing techniques for management of transsphincteric
surgical skills and techniques (5).
anal fistula and to compare between the most common
The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (4), Page 2736-2744
Adverse Effects of Two Kinds of Food Additive Mixtures (Sodium benzoate +
Monosodium glutamate, Monosodium glutamate + Chlorophyllin and Sodium
benzoate + Chlorophyllin) on Some Physiological Parameters in Male Albino Rats
Eman G.E. Helal*1, Mohamed A. Abdelaziz2, Nahla S.A. EL-Shenawe1
1Department of Zoology, Faculty of Science (Girls), Al-Azhar University, 2Physiology Department, Faculty of
Medicine, Al Azhar University, Egypt
*Corresponding Author: Eman Helal, Email: email@example.com, Mobile: 00201001025364,
Background: Food additives are substances used in food industry in order to improve the food's taste and appearance
by preserving its flavor and preventing it from souring.
Materials and Methods: this study was conducted on twenty-four young male albino rats with an average 120-140 g
body weight. Animals were divided into four groups (6 each). Group I: Control untreated group, Group II: it was
administered sodium benzoate (SB) (5 mg/kg b.w./day) orally and monosodium glutamate (MSG) (15 mg/kg b.w./day),
Group III: it was administered MSG (15 mg/kg b.w./day) and chlorophyllin (CHL) (15 mg/kg b.w./day) and Group
IV administered orally with SB (5 mg/kg b.w./day) and CHL (15 mg/kg b.w./day). Blood samples were collected on
the last day of experiment, for biochemical estimations.
Results: There was marked elevation in levels of fasting glucose, insulin, HOMA-IR, activities of AST and ALT, urea,
creatinine, total cholesterol (TC), triglycerides (TG), LDL-C , VLDL, ratios of TC/HDL-C and LDL-C/HDL-C (risk
factors) in all treated group. Serum thyroid hormones (T3 and T4) increased in Group III. On the other hand, there
was decline in levels of serum total proteins, albumin, testosterone and HDL-C in all treated groups in comparison
with the control group. There was a highly significant reduction in the body weight, T3 and T4 in Group IV, while
Group II showed highly significant increase in body weight and a highly significant reduction in globulin level as
compared to control rats.
Conclusion: The use of these compounds must be limited as it resulted in a vehement disturbance in the biochemical
Keywords: Food Additives, Thyroid hormones, Monosodium Glutamate, Biochemical parameters.
Abbreviation: SB: Sodium benzoate, MSG: Monosodium glutamate, CHL: Chlorophyllin.
average daily intake of MSG is estimated to be 0.3
Food additives are products that are added to the
1.0 g in industrialized countries, but it can be higher
basic foodstuffs to improve their appearance, flavor,
occasional, depending on the MSG content of
taste, color, texture, nutritional value and
individual food items and an individual's taste
conservation. It plays a vital role in today's abundant
preferences. MSG is used in both home and restaurant
and nutritious food supplies. It allows our growing
cooking and it is a common component of Asian diets.
population to enjoy a variety of delicious healthy
According to FDA guidelines, MSG cannot be added
foods throughout the year. The use of preservatives in
to baby food, since it is considered unsafe for that age
the food industry has increased with the advancement
group. Monosodium glutamate is known to elicit toxic
of production techniques (1).
effects such as, impairment in memory retention,
Monosodium glutamate (MSG) is a sodium
damages in the hypothalamic neurons, alterations in
compound of amino acid (glutamic acid) which is the
mitochondrial lipid peroxidation and antioxidant
most naturally occurring non-essential amino acid.
status in different regions of brain and induce
Monosodium glutamate contains 78% glutamic acid,
hyperphagia leading to obesity (2).
22% sodium and water. In its pure form, monosodium
Preservatives that have a very large area of use are
glutamate is a white crystalline powder described as a
the leading chemicals that individuals offer in daily
"pleasant" taste. It was introduced into the food supply
life. So studies looking at the potential toxic effects of
in the 1940's. MSG has a long history of use in food as
preservatives are of great importance today. Some
a flavor enhancer. MSG has a characteristic taste
food preservatives previously reported to be toxic to
called umami "savory deliciousness". MSG is
living. Although preservatives play an important role
metabolized in the liver. The liver plays an important
in food safety, many studies have shown that they have
role in the metabolism of glutamate to arginine. The
toxic and hereditary effects when used for a long time