c:\work\Jor\vol755_1 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2745-2752

Lateral Tarsal Strip, Can It Be One Solution for All Types of
Lower Eyelid Malposition?
Mohamed Al-Taher A. A 1*, Abd El Rahman Awadeen2
1 Department of Ophthalmology, 2 Department of Plastic, Burn, and Reconstructive Surgery,
Faculty of Medicine (Boys), Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohamed Al-Taher Abdel Wahab Abdel Atty, (+20)1010 444 972, drmaltaher75@yahoo.com

Due to the exact nature and complex anatomy of the eyelid, corrective surgeries require a
comprehensive understanding of the anatomy as well as comprehensive preoperative planning and surgical
Aim of the study: the present study was performed to evaluate the functional and cosmetic sequels of the lateral
tarsal strip (LTS) in the correction of lower eyelid malposition
Patients and Methods: this prospective single-arm interventional study was carried on 27 patients (27 eyelids)
with lower eyelid malposition, executed from January 2015 to December 2017. Patients with lower eyelid
malposition in the form of entropion, ectropion, or laxity as a sequence of facial palsy, involutional changes,
spastic entropion and lid laxity with failure of opposition to the artificial shell were included.
Results: Patients were 12 males and 15 females with a mean age of 59.37±10.27 years. Out of them, 17 (62.9%), 8
(29.6%), and 2 (7.4%) were suffered from ectropion, entropion, and lower eyelid laxity, respectively. As for the
functional and aesthetic outcomes, 10 (90.9%) of patients with lower eyelid malposition, as a resultant effect of facial
nerve palsy, have experienced complete healing of the epithelial defects; additionally, 4 (66.6%) of involutional
ectropion candidates showed improvement of the tearing eye. Eventually, 6 (22.2%) participants developed post-
operative complications.
Conclusion: LTS is a simple procedure which proved its safety and efficacy in the surgical correction of lower eyelid
malposition of different types and etiologies
Keywords: Lateral tarsal strip, Eyelid Malposition, Entropion, Ectropion, Facial nerve palsy

punctum eversion aggravate the problem(6). In
The lower eyelid tone and contour play an important
particular, epiphora, and corneal ulceration may
role in maintaining corneal integrity and delivering
manifest as a result of corneal exposure; additionally,
tears along the lower eyelid margin. Eyelid skin is the
the eventual cosmetic misconfiguration has a
thinnest existing in the body due to low dermis layer.
considerable psychological sequence in the patient's
Thus, it is the most vulnerable part of the skin to defects
quality of life. Hence, early intervention is mandatory
to avoid such complications(7).
The resultant defects varied from deprivation of a
Owing to the precise nature of the eyelid and its
small part of the superficial tissue up to the complete
complicated anatomy, eyelid correction surgeries
obscurity of the eyelid(2). These defects may be evolved
necessitate an inclusive understanding of its anatomy
as a consequence of traumatic, iatrogenic or
along with comprehensive pre-operative planning and
involutional changes(3). It is worth noting that the
surgical enforcement(8). Many surgical interventions
deformity of the eyelids embraced special conditions
have been demonstrated to remedy the eyelid
such as entropion, ectropion and laxity of the lid which
malposition comprehending lateral tarsal strip (LTS),
are crucial factors that change the direction and position
lateral Bick's shortening, everting sutures, and wedge
of the eyelid (4).
excision(9). Even though these surgical procedures
The most prevalent types of malposition are
attained apparently prosperous outcomes, the
involutional ectropion and entropion owed by the fact
preferable results were accomplished when the eyelid
that the involutional changes, due to aging, altered the
laxity was corrected(10). The lateral tarsal strip
fibrous and elastic tissues of the eyelid, principally
approach is a promising oculoplastic approach on
those in the medial and lateral canthal tendons(4, 5),
rectifying of the lower eyelid malposition. Not only
resulting in imbalance between eyelid tone and
did it preserve the lateral canthal angle and the sight
configuration on one hand, and the muscles of the
as well, but it also avoids phimosis and disfigurement
eyelid on the other hand. The consequent secondary
of the palpebral aperture(11).
inflammatory changes, tarsal thickening, and

Full Paper (vol.755 paper# 1)

c:\work\Jor\vol755_2 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2753-2758

Congenital Ptosis Correction with an Expanded Polytetrafluoroethylene
(GORE-TEX) sling: Comparative Study Between Crawford and Fox Techniques
Mohamed Al-Taher A.A, Omar H.Salama
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Al-Taher Abdel Wahab Abdel Atty, mobile: (+20)1010 444 972,

Frontalis suspension is the procedure of choice for surgical management of congenital ptosis
associated with poor elevator function.
The aim of the work was to compare the results of two different frontalis suspension surgery
techniques, i.e., the Crawford and Fox techniques, using GORE-TEX for the correction of congenital ptosis with
poor levator function.
Patients and Methods:
fifty eyelids of 30 patients with severe ptosis and poor levator function ( 4 mm) were
randomly divided into two groups: Group A included 26 eyelids of 16 patients corrected with the Crawford
technique, and Group B included 24 eyelids of 14 patients corrected with the Fox technique. The results were
evaluated and statistically compared.
Results: at the end of the follow-up period (18 months postoperatively), most of the patients in both groups
(80.8% of group A, 79.2% of group B) achieved good to excellent cosmetic results. The intergroup difference
was not statistically significant (P < 0.05). Regarding contour, Group A was 96.2 %, and Group B was 95.8 %.
Regarding symmetry, Group A was 88.5%, and Group B was 79.2%.
Conclusion: considering the use of the same sling material (GORE-TEX suture), the Crawford and Fox
techniques are both safe and effective with comparable results in the correction of severe ptosis with poor levator
Keywords: Congenital Ptosis, GORE-TEX, Frontalis suspension, Crowford, Fox.


Nasal eyelid surgery is one of the most
This study included a total of thirty-nine
common eye surgery operations in the field of
patients (68 eyelids) with severe congenital
ophthalmology. The purpose of this surgery is to
blepharoptosis associated with poor levator function
scan the optic axis, reduce the period and correct any
of less than 5 mm. Patients were examined, operated
abnormal anomalies. Another important goal is to
upon and followed upat Al-Azhar University
improve appearance (1).
Hospitals. A written informed consent from all
The choice of surgical procedure depends
patients or their guardians were obtained. This study
on the levator muscle function. Frontalis suspension
was conducted between March 2015 to November
surgery using an exogenous or autogenous material
is often used as the procedure of choice for patients
Nine patients (18 eyelids) were excluded
with severe congenital blepharoptosis and poor
due to insufficient follow up (less than 18 months).
levator function (2). The authors also described
The remaining 30 patients (fifty eyelids) were
different alternative muscular slings, including the
compliant until the end of the follow up period.
orbicularis sling (3), frontalis muscle strip(4)and
Patients were managed with a GORE-TEX frontalis
levator sling(5).
Because of its long-lasting effect and few
Exclusion criteria included patients with
complications, the fascia lata has been established as
mild tomoderate blepharoptosis with fair to good
the gold standard sling material for this procedure
levator function, acquired severe blepharoptosis,
(6). However, several sling materials and several
jaw winking phenomenon, absent or poor Bell's
modifications of the surgical techniques have been
phenomenon, and patients with previous eyelid
used to improve the outcomes and avoid the
drawbacks of fascia lata use. Expanded
A preoperative history was collected and a
polytetrafluro ethylene (GORE-TEX) is one of the
clinical examination was carried out. The history
sling materials that proved to have good efficacy
included the age of onset of blepharoptosis, its
relative to the fascia lata(7).
duration, and a review of old photographs. The
Therefore, this clinical trial was conducted
examination included the measurement of the
to compare the results of frontalis suspension using
marginal reflex distance (MRD1), levator function,
Gore-tex suture material, using either the Crowford
technique or the Fox technique.
phenomena, and Bell phenomena.


Full Paper (vol.755 paper# 2)

c:\work\Jor\vol755_3 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2759-2762
Role of the Renal Arterial Resistive Index in Early Prediction of
Contrast Induced Acute Kidney Injury after Coronary Angiography
Mohammed Tawfik *, Mohamed Khalfallah, Taimoor Moustafa, Mai Salama
Department of Cardiovascular Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
*Corresponding author: Mohammed Elsayed Tawfik Elsayed, Mobile: 01067194723,
E-mail: drmohammedtawfik78@gmail.com
contrast-induced acute kidney injury (CI-AKI) is defined as acute impairment of renal function after
administration of intra vascular iodinated contrast media, and it is considered as the third leading cause of acute
kidney injury in hospitalized patients.
Objectives: This study aimed to evaluate the clinical significance of pre-procedural Doppler based renal arterial
resistive index for the prediction of CI-AI in patients with coronary artery disease (CAD).
Patients and Methods: one hundred patients undergoing cardiac catheterization at risk of CI-AI were studied. All
patients presented with at least two CI-AI risk factors and were free of other identifiable causes of acute kidney
injury or arrhythmia. Doppler RRI was measured before and the one day after catheterization. CI-AI was assessed
and was defined by increase in serum creatinine by 25% above the pre-procedural baseline or rise in serum creatinine
>0.5 mg/dl from baseline value or >25% decrease in e-GFR within 5 days after cardiac catheterization.
Results: fifteen subjects were developed CI- AI within five days post-procedure. Post procedural RRI value was
higher in CI-AI subjects [RRI: 0.76±0.0l with CI-AI patients vs. 0.6l±0.04 without CI-AI P<0.00l]. In addition,
the RRI was increased significantly in the first day after the procedure in patients with CI-AI (p<0.00l). Post
procedural RRI >0.744 predicted CI-AI with a sensitivity of 94% and specificity of 92%.
Conclusions: measurement of the Doppler-based RRI before and early post-coronary catheterization in high-risk
patients enabled early prediction of contrast induced acute kidney injury.
Keywords: Acute kidney injury, Contrast media, resistive index, Cardiac catheterization.


Contrast-induced acute kidney injury (CI-AKI) is
Study Design: This is a prospective study.
defined as acute renal impairment after administration of
Study Setting: This study was conducted at the
intra vascular iodinated contrast media. It occurs most
cardiovascular department, Tanta University Hospital
frequently after coronary angiography. CK-AKI is
and/or Damietta Cardiology Center for coronary
associated with acute renal failure and may require
angiography and percutaneous coronary intervention
urgent dialysis (1).
between August 20l7 and June 20l8.
CI-AKI becomes the third most common cause of
Patients: We enrolled l00 consecutive patients with
new AKI in hospitalized patients and was responsible
either stable angina (SA) or non-ST-elevation acute
for 11% of cases. The risk of CI-AKI has been related to
coronary syndrome (NSTE-ACS).
the radiological procedures performed in the emergency
Inclusion criteria:
room as primary percutaneous coronary intervention (2).
1. Age >l8 years.
The development of renal injury is triggered by
2. Patients presented with stable angina with high pre-
high osmolality and viscosity of contrast media, leading
test probability of CAD or with positive treadmill
to increased renal vascular resistance (3), renal tubular
hypoxia and eventually causing tubular cell apoptosis(4,
echocardiographic dobutamine stress test or non-ST-
elevation acute coronary syndrome that met
Renal resistive index (RRI) has become the
diagnostic criteria as established in ESC NSTE-ACS
clinical method of choice to evaluate the renovascular
2011 guidelines.
hypertension and kidney allograft function with
3. Presence of at least two of the following known risk
assessment of risk of AKI (6, 7).
factors for AKI: Glomerular filtration rate (e-GFR) <
Aim of the study:
90 ml/min/l.73m2, age >60 yrs., peripheral vascular
To evaluate the clinical significance of pre-
disease, diabetes and/or heart failure. (8)
procedural Doppler based renal arterial resistive index,
Exclusion criteria:
along with numerous pre- and intra- procedural risk
1. Significant hemodynamic instability.
factors, for the prediction of CI-AKI in patients with
2. Acute or chronic respiratory failure (blood oxygen
coronary artery disease (CAD) and preserved renal
saturation <90%).
function, referred for coronary angiography and/or
3. Severe heart failure.
percutaneous coronary intervention.
4. Chronic kidney disease or other chronic diseases.

Full Paper (vol.755 paper# 3)

c:\work\Jor\vol755_4 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2763-2768

Role of Multidetecter CT in Diagnosis of Mediastinal Masses
Mahmoud Abdelhamid El Bargisy*, Mahmoud Abdelaziz Dawoud*,
Abdelhady Mohammed Taha**, Omar Ahmed Hassanien*
*Radio-diagnosis & Medical Imaging Department, **Cardiothoracic Surgery Department,
Faculty of Medicine, Tanta University
Corresponding author: Mahmoud Abdelhamid El Bargisy, Mobile: (+20)01221415130

The mediastinum is a vital sector of the thorax that contains vital intrathoracic structures such as the
heart and great vessels, trachea and main bronchi, esophagus, thymus, venous and lymphatic structures, and nerve
tissue. CT is the imaging modality of choice in diagnosis of mediastinal masses. The multiplanar capability of
multidetector computed tomography (MDCT) is extremely helpful in delineating the full extent and source of
vascularity thus helping in pre-operative planning of these patients.
Objective: Detection of the role of multidetector CT in diagnosis and differentiation of mediastinal masses.
Patients and methods
: Forty patients were included in this study (20 females and 20 males), who presented with
signs and symptoms suggestive for mediastinal masses. All patients were subjected to detailed history taking,
clinical examination, laboratory studies, chest xray and MDCT examination. The correlation was done between the
MDCT findings and the final diagnosis. The final diagnosis was made by operative procedures, CT guided biopsy,
histopathological results and conservative management
Results: Lymphoma was the commonest mediastinal mass forming 20% of cases , followed by neurogenic tumors
(neuroblastoma, , neurofibroma , ganglioneuroma and schwannomatosis) forming about 17.5 % , then retrosternal
thyroid (10%), teratoma (5%), thymoma (5%), metastatic lymphadenopathy (5%), esophageal carcinoma (5%),
aortic aneurysm (5%), Bochdalek hernia (5%), hiatus hernia (5%), morgagni hernia (5%), esophageal achalasia
(5%), esophageal leiomyoma (5%) and paraspinal abscess (2.5%). MDCT sensitivity was 92.86% & MDCT
specificity was 100%.
: MDCT has a major and reliable role to play in the evaluation and assessment of the mediastinal
masses; regarding the organ of origin, its density and mass effect upon adjacent structures, distribution pattern and
extent of the lesion.
Keywords: Mediastinal masses, MDCT, Lymphoma, Neurogenic tumors.

inferiorly by the diaphragm, anteriorly by the
The mediastinum is a vital section of the
pericardium and the great mediastinal vessels,
thorax that contains vital structures within the chest
posteriorly by the anterior longitudinal ligament, and
such as the heart, large blood vessels, trachea, major
laterally by the right and left parietal pleura folds (5). It
airways, esophagus, thymus and venous, lymphatic
contains the descending thoracic aorta, esophagus,
and neural structures. The division of the equator
azygos and hemiazygos veins, thoracic duct, lymph
into specific compartments helps generate
nodes, adipose tissue, vagus and splanchnic nerves
differential diagnoses in the initial presentation and
and autonomic ganglia. Masses arising in the posterior
facilitates surgical treatment plans. The most
mediastinum are often neurogenic tumours (6).
common classification is divided into three sections:
Available modalities for mediastinal mass
front, middle and posterior divisions (1).
evaluation include conventional radiography (CR),
The frontal shear is drawn by the anterior shear,
ultrasound (US), MDCT, magnetic resonance imaging
vertical brachial vessels, pericardium, and posterior
(MRI), and nuclear medicine studies (7). Combining
ascending aorta (2). Its upper and lower limits are the
the characteristic imaging appearances with clinical
thoracic portal and diaphragm respectively. Its
information (age, physical examination findings, and
contents include thymus, lymph nodes, fatty tissue and
laboratory analysis) often can provide a precise
internal mammary vessels (3).
diagnosis (8).
The middle mediastinum starts anteriorly from
CT is the imaging modality of choice in
the pericardium and ends posteriorly with the trachea.
diagnosis of mediastinal masses (9). The multiplanar
Important contents of the middle mediastinum are the
capability of multidetector computed tomography
heart, pericardium, the ascending aorta and arch, the
(MDCT) is extremely helpful in delineating the full
superior vena cava and inferior vena cava, the
extent and source of vascularity thus helping in pre-
brachiocephalic vessels, the pulmonary vessels, the
operative planning of these patients (10).
trachea, main bronchi and lymph nodes (4).
Specialized 3D reconstruction techniques of
The posterior mediastinum is the anatomical
MDCT permit the visualization of anatomical details,
region bordered superiorly by the thoracic inlet,
which would be difficult to evaluate using axial

Full Paper (vol.755 paper# 4)

c:\work\Jor\vol755_5 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2769-2774

Visual Outcome of Pars Plana Vitrectomy for Treatment of Premacular Hemorrhage
Ali A Ghali1, Ashraf M Gad Elkareem2, Mohamed Al-Taher AA3
Ophthalmology department, Faculty of medicine, Al-Azhar University, Damietta1,
Asyut2, and Cairo3Branches, Egypt.
Corresponding author: Ashraf Mohammed Gad Elkareem, Email: silicon2030@gmail.com, Tel: +2 01060293796

premacular hemorrhage can lead to painless loss of central vision. Several modalities of treatment have
been described in previous reports.
to evaluate the visual outcome after pars plan vitrectomy (PPV) for treatment of premacular hemorrhage of
different etiology.
Patients and methods: A series of retrospective study 17 eyes of 17 patients presented with premacular hemorrhage
due to different pathologies. Complete ophthalmic evaluation was done including visual acuity (VA), intraocular
pressure (IOP), anterior segment examination, slit lamp biomicroscopy, fundus photography± fluorescein angiography
(FA), and ocular ultrasound ± biometry. PPV was performed using 23gauge system with proper tamponade ± Phaco
with PCIOL.No intraoperative lens touch or iatrogenic retinal tear has been recorded.
Results: BCVA was improved from CF 50 cm in2 cases, hand movement (HM) in 15 cases to 0.1 (Log MAR) in 2
eyes (11.76%), 0.3 in one eye (5.88%), 0.4 in 5 eyes (29.41%), 0.6 in 3 eyes (17.64%), 1.00 in 3 eyes (17.64%), (3/60)
in 2 eyes (11.67%), CF (1/60) in one eye (5.88%). No serious complications weredetected.
Conclusion: PPV is a beneficial surgical treatment for premacular hemorrhage of different pathologies ensuring rapid
visual recovery. The visual outcome is an encouraging and the complications are comparable to other studies.
Keywords: premacular hemorrhage, Nd: YAG laser, vitrectomy.

Opening the posterior vitreous face or the ILM by the
Different pathologies can lead to premacular
Nd:YAG laser is another option for the treatment of
hemorrhage, which is either subhyaloid or sub-internal
premacular hemorrhage, allowing the drainage of the
limiting membrane (ILM) hemorrhage. Retinal artery
subhyaloid or sub-ILM hemorrhage into the vitreous
macroaneurysm, ocular trauma, proliferative diabetic
cavity with a rapid gain of vision (1,2,4,8,11).
retinopathy, acute posterior vitreous detachment,
Few complications of this maneuver as retinal break,
Valsalva retinopathy, retinal artery or vein occlusion,
macular hole, or retinal detachment can occur especially
Terson syndrome, and shaken baby syndrome are
if the size of the blood in front of the macula is small (4).
probable causes of premacular hemorrhage which can
Pars plana vitrectomy can be done as early as possible
for rapid visual recovery and to ensure complete surgical
differentiation between the two subtypes is difficult,
separation of the posterior vitreous face and clearance of
however the subhyaloid entity is characterized with a
the whole hemorrhage.
sharply delineated, hemispherical-shaped hemorrhage

while the sub-ILM hemorrhage is characterized by its
glistening striated surface (5,6). OCT scans above the
It is to evaluate the outcome of pars plana vitrectomy for
precipitated blood level can reveal the sub-ILM
clearance of premacular hemorrhage.
hemorrhage by the presence of, two membranes, a highly

reflective one corresponding to the ILM and an anterior
low reflective one corresponding to the posterior
A retrospective study of 17 eyes of 17 patients
vitreous face (7).
presented with premacular hemorrhage due to different
causes was carried out. the demographic data of patients
hemorrhage can lead to painless loss of central vision (8).
are shown in table (1). The study was done after the
Several modalities of treatment weredescribed in
approval of the Research and Ethical Committee, School
previous studies. Waiting for spontaneous resolution is
of Medical Sciences, Al-Azhar University, Egypt.
an option but it may take several months to resolve the
Complete ophthalmic evaluation was done
hemorrhage during which time permanent macular
including visual acuity (VA) measurement and was
damage can occur due to toxicity of the blood to the
converted to Log MAR values, intraocular pressure
photoreceptors, also by the formation of epimacular
(IOP) measured with the applanation tonometer, anterior
membranes with macular tractional detachment (9,10).
segment examination, slit lamp bio-microscopy using 90

Full Paper (vol.755 paper# 5)

ABSTRACT The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2775-2783

Biliary Disorders in Morbidly Obese Patients Before and After Sleeve Gastrectomy
Essam El-Dien Abd El-Azim Zayed, Abd El-Hafez Abd EL-Aziz Selim,
Mohamed Ahmed Suliman Abd El-Hafez
Department of General Surgery, Faculty of Medicine - Al-Azhar University
Corresponding author: Mohamed Ahmed Suliman Abd El-Hafez, Mobile: 01147585637,email: dr.muhammadsuliman@gmail.com

Obesity is an increasingly serious public health problem on a global level. Morbid obesity is defined
as a Body Mass Index (BMI) of 40 Kg/m2 or more or a BMI of 35 Kg/m2 or more with obesity related
comorbidities. Morbid obesity is associated with an increased incidence of wide spectrum medical and surgical
pathological problems.
Objective: To clarify the relation between morbid obesity, rapid loss of weight after sleeve gastrectomy and
gallstone formation and if there is a need for adding prophylactic cholecystectomy during sleeve gastrectomy to
obtain the best possible results after surgery.
Patients and Methods: A total number of 50 morbidly obese patients were included in the study from September
2018 to April 2019 (prospective study). All patients were treated at Surgery Department of Al-Azhar University
Hospitals. Males and females were considered for inclusion.
Results: In our study, five cases (10%) underwent simultaneous cholecystectomy (selective cholecystectomy) for
their asymptomatic gall stones detected by routine pre-operative pelvi-abdominal ultrasound. Simultaneous
cholecystectomy was associated by a significant increase in the operative time by about 36 minutes without effect
on the post-operative morbidity or hospital stay compared with other patients with no gallstones. Conclusion:
Sleeve Gastrectomy for morbidly obese patients was followed by gall bladder stones in only 6.2%. Therefore,
prophylactic intra-operative cholecystectomy seems to be not indicated and should be replaced by short-term (3
months only) of oral ursodeoxycholec acid during the period of maximum weight loss.
Keywords: Sleeve gastrectomy, morbidly obese.

in a preferential reduction of abdominal fat, an
improvement of obesity-related health risks, an
Obesity is recognized as the most prevalent
improvement in the life quality, and a marked decrease
metabolic disease world-wide, reaching epidemic
in mortality rate (5).
proportions in both developed and developing countries
Clinicians should counsel all morbidly obese
and affecting both adults and children. The WHO has
patients (defined as those with a BMI >30 kg/m2) on
already declared obesity a global epidemic that
lifestyle and behavioral modifications such as
constitutes one of the biggest current health problems (1).
appropriate diet and exercise, and the patient's goals
According to the NICE (National Institute for
for weight loss should be individually set (5).
Clinical Excellence) guidance, people are considered
Pharmacologic therapy can be applied to
to be morbidly obese if they have a body mass index
obese patients who have failed to achieve their goals in
(BMI) of 40 kg/m2 or greater or they have a BMI
weigh loss through diet and exercise alone. However,
between 35 kg/m2 and 40 kg/m2 with a significant
there needs to be a doctor-patient discussion of the
disease (for example, diabetes, high blood pressure)
drugs' side effects, the lack of long-term safety data,
that may show marked improvement if they lose
and the temporary nature of the weight loss achieved
weight (2).
with medications before starting therapy (5).
The co-morbidities of morbid obesity affect
Bariatric surgery is known to be the most
essentially every organ system (3). Obesity itself has a
effective and long lasting treatment for morbid obesity
major effect on health, contributing to and
and related conditions, but now mounting evidence
exacerbating a plethora of illnesses including
suggests it may be among the most effective
hypertension, type 2 diabetes, hypercholesterolaemia,
treatments for metabolic diseases and conditions
stroke, cardio-vascular disorders, hypertension, biliary
including type2 diabetes, hypertensive disorders,
disorders, osteoarthritis, obstructive sleep apnoea
hypercholesterolemia, non-alcoholic fatty liver disease
(OSA) and some types of cancer. Psychological and
and obstructive sleep apnea (OSA) (6).
serious psychosocial disorders are also not uncommon
Weight loss operations could be classified into
amongst obese people (4).
three categories: Restrictive procedures, malabsorptive
The targets for treatment of overweight and
procedures & combination operations employ both
obesity are to reduce body weight, and to maintain
restriction and malabsorption. Open and laparoscopic
lower body weight over the long term. An alternative
approaches refer to how to have access to the
goal is to prevent further increase in body weight as a
abdominal cavity not the type of surgery being
minimum goal in patients who are unable to lose
performed. Both approaches have the same surgical
weight. Successful treatment of obesity should result
principles, risks and effect on reduction of weight (6).

Full Paper (vol.755 paper# 6)

c:\work\Jor\vol755_7 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2784-2793

Awareness of Gestational Diabetes among Antenatal Women at The King Fahd
Military Medical Complex Hospital in Dhahran, Saudi Arabia
Latteefah Saleh Alnaeem
College of Applied Medical Sciences, Obstetrics and Gynecology department, King Faisal University,
AI Hfouf, Kingdom of Saudi Arabia.
*Corresponding author: Latteefah Saleh Alnaeem, E-mail: Latifa_alnaeem@hotmail.com, Mobile No.: +966504935792,
Background: Gestational diabetes mellitus (GDM) has recently gained increasing attention among researchers
and health professionals. This growing interest is attributed to the rising rate in the development of type 2 diabetes
mellitus (DM) during pregnancy and puerperium and later on, as established in GDM patients.
Materials and methods: patients engaged in this survey were informed verbally that their involvement was
voluntary, and that completing the distributed questionnaires implied that they had agreed to take part in the study,
using questionnaires administered data were gathered by an obstetrics and gynecology doctor, questionnaire was
designed following a comprehensive discussion with a team of experts in the field of GDM as it was tested via a
pilot study to insure it's reliability. The final copy of the questionnaire that was used in the actual study included
25 questions, a score of one was assigned to each correct answer and zero to each incorrect or "I don't know"
answer. A higher score showed that the respondent had better knowledge about GDM.
Conclusion: This research found a considerable lack of awareness about GDM of the pregnant women
interviewed. Moreover, the results showed that the respondents were aware that GDM is related to certain factors
such as advanced maternal age, overweight, and obesity, among others. It was noted that the lack of awareness and
knowledge among pregnant women led to poor self-care and management of GDM, which reflects unmet needs.
Keywords: GDM, DM awareness, antenatal, gestational diabetes, Saudi Arabia.


DM is widely known as being among the
offspring's risks of obesity, impaired glucose
most deadly diseases threatening public health
tolerance, and metabolic syndrome.
globally. Based on statistics from the Center for
A literature review of GDM that was
Disease Control and Prevention, "every five
conducted in Saudi Arabia to determine the
minutes, two people die of diabetes-related causes
occurrence of GDM among pregnant women living
and 14 adults are newly diagnosed" (1). In Saudi
in the Jizan region also indicated a high prevalence
Arabia, the International Diabetes Federation
of GDM (5). The study involved 440 pregnant women
recorded 3.4 million cases of DM in 2015 (2). The
chosen via a simple random sampling method. The
estimated cost of the disease in the country reached
outcome showed that the prevalence of GDM among
$900 million in 2010, and is projected increase to
expectant women was 8.2% (5). The study also
more than $6.5 billion by 2020. The rising cost
revealed that there was a considerably higher
places a tremendous economic burden on the
prevalence rate of GDM among overweight women
country's economy (3).
when compared to their counterparts of normal
Gestational DM (GDM) has recently gained
weight. Based on these findings, the authors
increasing attention among healthcare professionals
concluded that the prevalence rate of GDM noted
as a result of growing prevalence of the resultant
during the study period exceeded the global rate.
development of type 2 DM during pregnancy and
They also concluded that some of the factors that
after birth among GDM patients (3). GDM refers to a
exposed pregnant women to GDM included
lack of carbohydrate tolerance of varying severity
neonates weighing more than 3.5 kg, as well as the
with an initial onset during pregnancy, whether or
mother's body mass index (BMI) (5).
not insulin is used (2). GDM is attributed to various
In another study, Alfadhli et al. (6) assessed
conditions, including an increased rate of
the prevalence of GDM and found that the rate of the
preeclampsia and adverse obstetric outcomes that
disease was 51% among Saudi mothers in the
include preterm labor, a high rate of Cesarean
western region. The study was based on the
sections, and complicated perinatal tears. Other
International Association of the Diabetes and
conditions include the possibility of intrauterine fetal
Pregnancy Study Groups' (IADPSG) procedure for
death beyond 40 weeks, neonatal hypoglycemia,
screening and diagnosing GDM; hence, the results
hypocalcemia, polycythemia, and respiratory
were valid and relevant to the study.
distress disease (4). In addition, GDM may affect the
However, there is little or no knowledge

about GDM among expectant Saudi women,

Full Paper (vol.755 paper# 7)

c:\work\Jor\vol755_8 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2794-2800
The SYNTAX Score and Angiographic "No-Reflow" in Patients with Acute
Myocardial Infarction Undergoing Percutaneous Coronary Intervention
Ahmad Hassan Sadek*, Ezz EL Din AL Sawy, Mohammed Saad Al Gammal, and
Mohammad Ahmad Mosaad
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo
*Corresponding author: Ahmad Hassan Sadek, Mobile: (+20)01069724760

in patients with acute myocardial infarction, the immediate therapeutic goal is to establish patency
of the infarct-related artery and to achieve optimal myocardial tissue reperfusion. The Synergy between
percutaneous coronary intervention with TAXUS and cardiac surgery (SYNTAX) score (SS) quantifies the extent
and complexity of angiographic coronary artery disease.
Patients and Methods: a total of 543 patients presenting with acute myocardial infarction undergoing primary
PCI for the STEMI patients and early invasive strategy for the NSTEMI patients, both admitted within 24 hours
from the symptoms onset, were analyzed. SS, thrombolysis in myocardial infarction (TIMI) flow grade score, and
TIMI myocardial blush grade score (MBG) were determined in all patients. No-reflow was considered as the
prescence of TIMI blood flow in the infarct related artery (IRA) 2 or TIMI grade 3 with myocardial blush grade
(MBG) 0 or 1, at least 10 minutes after the end of the PCI procedure.
Results: no-reflow was observed in 26% of patients. The mean SS of the no-reflow group was higher than that of
the TIMI III flow group . On multivariate logistic regression analysis a long target lesion (OR= 8.637, 95% C.I
1.975­37.768, p = 0.004) were found to be significantly associated with no-reflow and were the independent
predictors of no-reflow phenomenon. The cutoff value of SS obtained by the receiver-operator characteristic curve
analysis was 31 for the prediction of no-reflow .
Conclusion: the SS is a predictor of no-reflow in patients with acute myocardial infarction treated with
percutaneous coronary intervention.
Keywords: acute myocardial infarction, percutaneous coronary intervention, No-reflow, SYNTAX score


surgery) score has been shown to be predictive of
In patients with acute myocardial infarction, the
clinical outcome in different clinical settings in patients
successful restoration of epicardial culprit coronary
undergoing percutaneous coronary intervention
artery patencydoes not always guarantee restoration of
myocardial tissue-level perfusion & salvage of

myocardium at risk of ischemia(1). In a variable
proportion of patients with acute myocardial infarction,

however, microcirculatory impairment may persist
Study population:
after epicardial coronary artery recanalization
The study was conducted on 543 patients with acute
following PCI and may attenuate its beneficial
myocardial infarction undergoing primary PCI for the
impact(2). The phenomenon of myocardial no-reflow is
STEMI patientsand early invasive strategy for the
defined as inadequate myocardial perfusion through a
NSTEMI patients, both admitted within 24 hours from
given segment of the coronary circulation without
the symptoms onset to the cath lab. Of Al-Hussein
angiographic evidence of mechanical vessel
University hospital during the period from 11/2015 to
Further, recent studies have revealed that distal
The study was approved by the Ethics Board of
embolizationof thrombusand/or plaque contents are
Al-Azhar University and an informed written
one of the major causes ofno-reflow. It may be
consent was taken from each participant in the
critically important, therefore, to be able to predict
which lesions are high risk for myocardial no-reflow

prior to beginning percutaneous coronary intervention
The study inclusion criteria were patients presenting
with an evidence of myocardial necrosis in a clinical
Accurate detection of 'no-reflow' is thus crucial
setting consistent with acute myocardial ischemia.
because it is independently associated with low
Under these conditions the following criteria meets the
ventricular ejection fraction, adverse left ventricular
diagnosis for myocardial infarction(7): Detection of a
remodeling, malignant arrhythmias, cardiac failure, as
rise and /or fall of cardiac biomarkers values
well as mortality both at short- and long-term follow-
(preferably cardiac troponin (cTn) with at least one of
the following:
The SYNTAX (synergy between percutaneous
o Symptoms of ischemia.
coronary intervention with TAXUS and cardiac

Full Paper (vol.755 paper# 8)

c:\work\Jor\vol755_9 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2801-2805

Review of the Effectiveness of Composite Barrier Mesh Used for
Laparoscopic Ventral Hernia Repair
R. K. Mishra1, Abinadabe dos Santos Pires Soares2, Abdullah Jassim Al-Qattan3
1World Laparoscopy Hospital, Delhi, India, 2Hospital Santa Joana Recife, Graēas, Brazil,
3King Khalid Hospital, Najran, KSA
Corresponding authors: R. K. Mishra, E-mail: md@laparoscopyhospital.com, Abinadabe dos Santos Pires Soares, E-mail:
abinas@zipmail.com.br, Abdullah Jassim Al-Qattan, E-mail: dr.alqattan90@gmail.com

The objective of this research is to provide an overview of the physical and biomechanical properties
of composite barrier meshes frequently used in Laparoscopic Ventral Hernia Repair as well as reviewing the existing
relevant literature assessing the characteristics and effectiveness of both procedures.
A secondary research is used using existing literature review of the preclinical and clinical literature
designed to compare the Composite prostheses with permanent barriers (COMPOSIX, VENTRIO, DUALMESH,
DYNAMESH and TiMESH ) to composite prostheses with absorbable barriers ( PROCEED, C-QUR,
Results: Significant differences were observed between Composite prostheses with regard to its physical and
biomechanical properties. Amongst the permanent barrier meshes, Dualmesh showed the highest suture retention
strength. On the other hand, between the absorbable barrier meshes, Sepramesh proved to have the most significant
suture retention and tears strength. Overall, all meshes established tensile strengths greater than 16-32 N/cm.
Moreover, that composite meshes with absorbable barriers had less complications of adhesions, recurrences and
wound infection compared with meshes with permanent barriers.
Conclusion: Composite meshes with absorbable barriers proved to be superior to permanent ones. Other findings
demonstrated there was no significant difference of effectiveness among absorbable barriers.
Keywords: Absorbable barrier,Laparoscopy, Ventral Hernia, Mesh, Adhesions, Recurrence,Permanent barrier.


fibrinolysis stimulators, or physical barriers such as
Ventral hernia repair must be a real challenge for
anti-adhesives liquids, films, or barrier materials(3).
surgeons. Throughout the past 50 years, hernia repair
In 1950s, Usher has introduced the uncoated
techniques have manifested a substantial evolvement
polypropylene meshes which has led to an evolution in
starting from primary suture repair, to the use of
the Prosthetic mesh materials field(1). Composite barrier
synthetic mesh products in order to form a "tension
mesh materials have become increasingly popular for
free" repair, and eventually minimally invasive
LVHR. These materials have been designated to
laparoscopy techniques(1). Since 1993, when Le Blanc
prevent adhesions between the mesh and the viscera by
reported the first case of laparoscopic incisional hernia
mechanically separating the viscera from injured area
repair with the use of synthetic mesh (2), the surgery of
of the peritoneum until reperitonealization occurs(3).
laparoscopic ventral hernia repair (LVHR) has attained
There are two main types of barriers with different
many improvements. The use of laparoscopic
techniques and meshes improved recurrences,
(permanent). Absorbable barrier layers can be found as
postoperative pain, adhesion formation, length of
the oxidized regenerated cellulose in PROCEED
hospital stay, and wound infection compared with open
Surgical Mesh (Ethicon, Somerville, NJ), the omega-3
fatty acid layer in C-QUR Mesh (Atrium Medical,
Many types of mesh are being used for LVHR.
Hudson, NJ), the polyglicaprone-25 (Monocryl) in
These materials are in direct contact with the abdominal
PHYSIOMESH (Ethicom), the collagen layer in
viscera and might lead to adhesions resulting in pain,
PARIETEX COMPOSITE (Covidien, Mansfield,
bowel obstruction, fistula formation, or adhesiolysis-
related complications like enterotomy and unplanned
carboxymethylcellulose (CMC) and polyethylene
bowel resection during consequent surgical procedures
(1). Common methods to reduce adhesion include
(Bard, Davol, Warwik, RI)(3). Permanent barriers layers
refining surgical techniques to reduce trauma,
can be found as expanded polytetrafluoroethylene
interference with fibrinolysis pathway through
(ePTFE) in COMPOSIX and VENTRIO meshes
(Davol), DUALMESH (Gore Medical, USA) and as

Full Paper (vol.755 paper# 9)

c:\work\Jor\vol755_10 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2806-2812

Refractive Outcome after Phacoemulsification Using Optical
Biometry versus Immersion Ultrasound Biometry
Fatma A. Atwa 1 , Hayam S. Kamel 1, Rehab M. Kamel 1*and Ahmed A. Abd El Fatah 2
(1) Department of Ophthalmology, Faculty of Medicine for Girls, Al-Azhar University ,
(2) National Eye Center, Rod El Farag , Cairo , Egypt .
*Correspondence to: Rehab M. Kamel, Email:rehabmoustafakamel@yahoo.com, Phone No: 01026332337

To compare refractive outcome after phacoemulsification using optical biometry versus immersion ultrasound
biometry (US) .Patients and methods: A prospective, comparative, non-randomized interventional study included 100
eyes divided into 2 groups: Group (A): (Immersion US biometry) included 50 eyes. Axial Eye Length (AEL) was
measured by immersion B scan (immersion A-scan with B- mode guided image). It was further subdivided into Group
(AEL 25 mm) and Group A2 (AEL < 25 mm). Group B (Optical biometry) included 50 eyes. AEL was measured
using optical biometry. It was also subdivided into Group B1 (AEL 25) mm and Group B2 AEL < 25. Intra ocular
lens (IOL) power was calculated using Haigis formula targeting post-operative refraction ­0.5 to -1 D.
Phacoemulsification with posterior chamber IOL was performed. The 2 groups were compared preoperatively for AEL,
Keratometic measurements, uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA) and density of
cataract. They were compared postoperatively for UCVA, BCVA, spherical equivalent (SE) and mean absolute error
(MAE). Results: The study included (100 eyes). Group A1 included 9 eyes (18%) and Group A2 included 41 eyes
(82%). Group B1 included 18 eyes (36%) and Group B2 Included 32 eyes (64%). Preoperative comparisons revealed
insignificant statistical differences between the 2 groups in the mean AEL, IOL power, preoperative UCVA and BCVA,
degree and density of cataract, and K readings. Post operatively there was insignificant statistical differences between
the 2 groups in the mean of UCVA and BCVA. There was insignificant statistical differences between subgroups
A1and B1 and subgroups A2 and B2 in the median of SE and MAE. Conclusion: The immersion B scan biometry and
optical biometry gave comparative results with precise final post-operative refractive outcome.
Keywords: Optical biometry, Immersion ultrasound biometry, phacoemulsification.


Biometry is the process of measuring the axial
mode guided image) is an immersion A-scan with B-
eye length (AEL), the keratometric (K) readings and
mode guided image, which integrates the advantages of
assessing these data and use special formulas to
immersion A scan and the B-scan and overcome the
determine the ideal intraocular lens (IOL) power (1).
weakness of the two methods (7) .The optical method is a
Accurate IOL power calculation is crucial to ensure
non ­contact technique that is highly reproducible,
satisfactory post-operative refractive outcome after
observer-independent and therefore potentially more
cataract surgery (2). Precise measurements of AEL data
accurate (8) . While the partial coherence interferometry
and keratometric values are critical(3). Applantion
(PCI) based models use diode laser infrared light to
ultrasound biometry has been the gold standard for IOL
measure AEL, the low-coherence optical reflectometry
calculation, however the introduction of optical biometry
(LCOR) based models use a super luminescent diode
using partial coherence interferometry (PCI) has
laser (9) .
steadily established itself as the new standard (4).
The differences between ultrasound biometry and
Ultrasound biometry (US) utilizes the ultrasound waves,
optical biometry have clinical implications. The first
emitted by a piezoelectric crystal and delivered with a
difference is that the resolution improves as wavelength
probe with average frequency of 10 MHz. Determination
decreases. As light has a short wavelength compared to
of eye morphometry via ultrasound is based upon the
sound, laser has better resolution. Therefore, the
differential return of the ultrasonic waves by varying
accuracy of AL with ultrasound is approximately 0.10-
tissue types. The AEL can be measured using either
0.12mm compared to 0.012 mm for optical AL. The
contact or immersion techniques. In the contact method,
second difference is that the U/S biometry measures
the probe touches the cornea and may result in corneal
AEL along the anatomic axis or optical axis, from the
compression and a shorter axial length. Immersion A-
corneal vertex to the internal limiting membrane (ILM)
scan eliminates corneal compression by removing probe
of the fovea, whereas the optical biometry measures
contact, as it remains between 5 to 10 mm away from the
AEL from the second principle plane of the cornea (0.05
cornea, allowing more precise measurements and has
mm deeper than the corneal apex) to the photoreceptor
been shown to be superior to contact biometry (5)(6) . The
layer (0.25mm deeper than ILM of the fovea (10) .
immersion B- scan (known as immersion A-scan with B-


Full Paper (vol.755 paper# 10)

Falciform Ligament plug in Laparoscopic Hiatus Hernia Repair The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2813-2818

Falciform Ligament Plug in Laparoscopic Hiatus Hernia Repair
Ibrahim Aboulfotoh Mohammed
General Surgery Department, Faculty of Medicine, Al-Azhar University

A prospective and retrospective collected databases to identify outcome in Laparoscopic para-
esophageal hiatal hernia repair is a challenging procedure. The falciform ligament is used as an autologous onlay flap
to achieve tension-free closure of the crural defect of a para-esophageal hernia (PEH).
Aim of the work: To assess the use of Falciform ligament for hiatus hernia repair and to evaluate the outcomes
Patients and Methods: From December 2015 to august 2018, a total of 24 patients with para-esophageal hiatus
hernia were conducted; Hernias were diagnosed with esophago-gastroscopy, barium contrast X-ray study and
esophageal manometry.
Results: twelve patients underwent falciform ligament plug repair while twelve patients underwent crural
approximation and fundoplication repairs. The classical traditional procedure time for repairs was significantly longer
(p=0.004). Hospital stays, resting lower esophageal sphincter pressure, and mean contraction amplitudes were similar
between groups. Discussion: The well documented advantages of laparoscopic hiatal hernia repair less pain; shorter
hospital stays, and faster recovery and the rates of failure are higher in patients had open repairs.
Use of falciform ligament as a vascularized autologous onlay flap is a safe and effective procedure to
close the crural defect of para-esophageal hiatus hernia.
Keywords: Hiatal hernia, Gastro-esophageal reflux, Laparoscopy, Falciform ligament plug.


The classic definition of para-esophageal
Several surgical techniques were suggested to
hernia (PEH) is a protrusion of the gastric fundus
decrease the rate of recurrence, including efforts at
through the diaphragmatic hiatus while the lower
creating a tension-free repair by the use of synthetic
esophageal sphincter remains in its normal anatomic
and biological mesh(8).
position (type II hiatal hernia). More frequently, both
Synthetic meshes, however, were associated
the fundus and the lower esophageal sphincter are
with serious complications at the hiatus, such as
herniated into the thorax (type III hiatal hernia)(1).
fibrosis, esophageal stricturing, erosion, and gastric
Laparoscopy was introduced in the late 1980's
and was quickly adopted by esophageal surgeons as
Biologic mesh materials were proposed as an
opportunity to provide operative repair without the
alternative to plastic mesh in hopes of avoiding these
morbidity of the open procedures. Since that time, the
potentially catastrophic complications while achieving
feasibility and safety of a laparoscopic approach to
a robust permanent repair(10).
giant para-esophageal hernia repair was established (2).
In theory, these materials cause less foreign
At present, laparoscopy is accepted as the
body reaction and instead act as a temporary matrix for
standard approach for the surgical treatment of
native tissue ingrowth and remodeling. Several
gastroesophageal reflux disease, and it is also widely
investigators found that hiatal hernia reinforcement
used for repair of PEH. Although technically
with biologic mesh is associated with low objective
demanding, this approach provides better exposure of
recurrence rates of 0­11% (11).
the surgical field than open trans-abdominal
When perioperative outcomes are compared
procedures and adds the known general advantages of
directly with open techniques, post-operative
laparoscopy in terms of reduced morbidity, shorter
morbidity and mortality, blood loss, and hospital
hospital stay, rapid recuperation, and decreased pain
length of stay are significantly reduced for the
medication requirements. These advantages may be
laparoscopic approach(12).
especially valuable in the PEH population because
Use of the falciform ligament as a
most patients are elderly and have multiple comorbid
vascularized autologous flap for tension-free repair of
conditions. Because a high percentage of recurrent
a large hiatal defect is an attractive option for
PEHs are initially asymptomatic, contrast imaging is
obtaining tension-free repair of a PEH without the
necessary to accurately detect recurrences(3-5).
risks associated with prosthetic materials or the
Reconstruction of the esophageal hiatus by re-
substantial cost of biologic mesh. There is some
approximation of the left and right hiatal crurae with
variation in anatomy; the blood supply to the falciform
interrupted sutures (posterior hiatoplasty) often results
ligament comes mainly from branches of the left
in significant tension on the repair. Failure of the
hepatic and left inferior phrenic arteries which
posterior hiatoplasty is known to be the most common
anastomose to form an arcade as well as from smaller
cause for hernia recurrence(6,7).
perforators from the parietal peritoneum. It is

Full Paper (vol.755 paper# 11)

c:\work\Jor\vol755_12 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2819-2824
Co-morbidity of Attention Deficit / Hyperactivity Disorder among A Sample of
Egyptian Children with Idiopathic Epilepsy Attending Outpatient Clinic in
Al Hussein University Hospital
Mohamed Abdalla Ghowinam , Mahrous Ibrahim Seddeek
1 Department of Psychiatry, 2Department of Neurology, Al-Azhar University, Cairo, Egypt

Attention deficit/hyperactivity disorder (ADHD) is a complex disorder that affects about 5:8% of
school-aged children worldwide. Many researchers reported increased prevalence of ADHD among epileptic
children. Objectives: Detection of the prevalence of ADHD among a sample of Egyptian epileptic children
attending Al Hussein University Hospital, Neurology clinic, & determination of associated risk factors.
A cross-sectional study was performed at Al Hussein University Hospital, Neurology Clinic, starting
at January 2016 until January 2017. The study was conducted on Egyptian patients aged 3: 18 years with an
affirmed diagnosis of epilepsy for one year or more. Data was gathered using a questionnaire performed by the
interviewer. ADHD was diagnosed according to (DSM-IV TR).
: Our study included 160 epileptic children. In our sample 102 patients had Generalized Tonic-clonic
seizures and 13 had Absence seizures, 45 patients had Partial epileptic seizures. (26.3%) of the epileptic patients
included had ADHD. We reported that partial epileptic seizure type; duration of epilepsy over 2 years and uses
of more than one anti-epileptic drug were significantly associated with increased risk of having ADHD, and that
having Partial epileptic seizures and use of more than one antiepileptic agent were independent predictors for
Conclusions: 26.3% of epileptic children in this study had associated ADHD. Partial epileptic seizure type,
duration of epilepsy over 2 years and use of more than one antiepileptic drug were significantly associated with
Further studies are needed on large number of epileptic children. Keywords Epilepsy, ADHD,
and children.

Governorate. Another study reported that the
Attention deficit hyperactivity disorder (ADHD)
prevalence of ADHD was approximately 6%
is a complex disorder, which can be seen as a
among third grade elementary school children in
disorder of lifetime, developing in preschool years
Assiut City [6]. The prevalence of ADHD is higher
and manifesting symptoms (full and/or partial)
in children with epilepsy [7]. Population studies
throughout the adulthood [1].
suggested that the prevalence of ADHD among
ADHD is defined as a persistent pattern of
epileptic children is ranging between 12 and 17%
inattention and/or hyperactivity-impulsivity that
[8]. Other studies reported that among children with
interferes with functioning or development. For
epilepsy, ADHD has been found to be ranging
fulfilling diagnostic criteria, ADHD must be
between 20% and 50% of patients [9]. Russ and
associated with at least six symptoms of inattention
coworkers [10] reported that the prevalence of
and/or at least six symptoms of hyperactivity and
ADHD was 23% among children with epilepsy in
impulsivity. Symptoms must be severe enough to
the USA. In a community-based study in schools in
interfere with functioning, must occur in at least
UK, Reilly and coworkers [11] reported that the
two settings (i.e., school and home), and must have
prevalence of ADHD was 33% among children
an age of onset before 12 years of age. ADHD can
with active epilepsy. Jones and coworkers [12]
be subclassified into three subtypes predominantly
found that children with epilepsy had statistically
significantly higher rates of attention deficit
hyperactive/impulsive presentation and Combined
hyperactivity disorder (26.4%) in comparison
presentation [2].
group of healthy children (10%).
Based on family history, genotyping, and
Several mechanisms may account for the high
neuroimaging studies, there is clear evidence to
prevalence of ADHD among epileptic patients,
support a biological basis for ADHD. ADHD has
[13] proposed
prevalence approximately 5 to 8 % of school-aged
mechanisms explaining the epilepsy and ADHD
children [3] and about 2.5% ­ 4% of adults [4].
comorbidity. The first hypothesis is that there are
Regarding Egypt Farahat and coworkers [5]
independent circumstantial factors; both ADHD
have reported general prevalence of ADHD 6.9%
and epilepsy are common in childhood and,
among primary school children in Menoufia
therefore, may occur together. The second

Full Paper (vol.755 paper# 12)

c:\work\Jor\vol755_13 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2825-2832
Combined Low Dose Aspirin and Steroids vs Aspirin Only in
Management of Unexplained Recurrent Miscarriage
Fahd A. El Omda, Ahmed T. Abd ElFattah, Ahmed M. Ragab*
Department of Gynecology and Obstetrics, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed M. Ragab; Mobile: 01093784852; Email: manareisa89@gmail.com

recurrent pregnancy loss (RPL) is defined as at least two or three sequential abortions before the
20th week of gestation. RPL occurs in 1% to 5% of all pregnancies.
Aim of the Work: to assess the efficacy of low dose aspirin and steroids therapy versus Aspirin Study in the
management of women with recurrent miscarriage.
Patients and Methods: this randomized clinical trial was conducted in the repeated miscarriage clinics in the
Obstetrics and Gynecology Department, in Al-Azhar University Hospital on 100 pregnant women, who fulfilled
the inclusion criteria and after taking an informed consent. Group 1: included 50 pregnant females administered
with low dose aspirin 75 mg tablet (one tablet twice daily) and prednisolone 5mg two tablets twice daily (20mg).
Group 2: included 50 pregnant females administered with low dose aspirin 75 mg tablet (one tablet twice daily).
Both groups were followed in Elhussein hospital recurrent miscarriage clinic every two weeks by ultrasonography
from the incidence of the pregnancy till delivery.
Results: women treated with prednisolone (PSL) plus LDA had a 32.2% higher live birth rate than group II and
according to on-going pregnancy data was in group I 37/50(74%) and in group II 21/50(42%) OR (C.I. 95% 4.128
[2.142-7.952] RR (C.I. 95%1.875 [1.401-2.505] p<0.001, with a significant difference between the two groups.
There was a significant difference between the two groups as regards the development of bruising (P<0.05).
Conclusion: combination treatment consisting of prednislone and low dose aspirin might be an effective treatment
for women with idiopathic pregnancy loss.
Aspirin, Steroids, Unexplained Recurrent Miscarriage.


Recurrent pregnancy loss (RPL) is defined as
of previous consecutive pregnancies, 4 cases of
two or three consecutive miscarriages at least before
parental chromosomal abnormalities, maternal
the 20th week of pregnancy. RPL occurs in 1% to 5%
thrombosis disorders, and structural defects in the
of all pregnancies. Although many factors, such as
uterus. Finally, the increase in the age of the mother is
environmental factors, stress factors, chromosomal
accepted as the most important risk factor for future
abnormalities, defects of coagulation protein,
abortion in women with recurrent miscarriages and in
anatomic endocrine disorders and the autonomic
the general population.
immune system are involved in about 60% of RPLs,
About 50% of recurrent pregnancy loss cases
in the remaining 40% of cases, the causes of
still remain unexplained, or idiopathic. In this group of
miscarriage are unknown and classified As a non-
patients, fetal chromosomal abnormalities have been
justified RPL (URPL) (1).
reported to be the most common cause of recurrent
Fifty percent of the RPL is caused by anatomical
pregnancy loss, accounting for up to 55% of cases,
factors, immunology, genetics, endocrinology,
thus leaving a remainder of 24.5% of truly
coagulation, and environmental. However, in 50% of
unexplained recurrent pregnancy loss (6).
cases, the cause of abortion is unknown or
Although progesterone appears to be the main
idiopathic(2). RPL is a major health problem, affecting
factor initiating decidualization, a number of other
5% of females of childbearing age. Women of
factors including cytokines appear to facilitate this
childbearing age face significant economic, emotional
event. Failure in either the early blastocyst
and social problems due to RPL(3). Established and
endometrial dialogue or decidualization may lead to
suggested risk factors for recurrent miscarriage are
implantation or pregnancy failure, alteration in the
increasing number of successive previous pregnancy
expression of a number of factors thought to contribute
losses (4), parental chromosomal anomalies, maternal
to the embryo/ endometrial dialogue have been shown
thrombophilia disorders, and structural uterine
at this time in endometrium from women with
anomalies. Finally, increasing maternal age is
recurrent miscarriage (7).
accepted as the most important risk factor for future
The concentrations of different endometrial
miscarriage both in women with recurrent
leukocytes have therefore been investigated in a
miscarriages and in the general population (5).
number of studies to find links to the development of
The proposed and proposed risk factors for
miscarriages (8). We performed this study on women
recurrent miscarriages are an increase in the number
who presented with unexplained recurrent to explore


Full Paper (vol.755 paper# 13)

c:\work\Jor\vol755_14 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2833-2838

Comparison of the effects of Penicillin versus Erythromycin in Treatment Group B
Streptococcus Infection in Preterm Premature Rupture of Membranes
Mohamed Mohamed Gebriel, Adel Aly Elbghdady, Mohamed Elsayed Abo Ghabsha and
Maged Abd Elatef Abd Elftah *
* Department of Obstetrics and Gynecology, Faculty of Medicine - AL-Azhar University
Corresponding author: Maged Abd Elatef Abd Elftah

group B streptococcus (GBS) can cause significant morbidity in pregnant women. Manifestations of
symptomatic maternal infection include chorioamnionitis, endometritis, cystitis, pyelonephritis and febrile GBS
bacteremia. Objective: this work aimed to assess the effectiveness of penicillins versus erythromycin in treatment
GBS infection following PPROM. Patients and Methods: the study included 50 pregnant females presented with
PPROM before 36 weeks gestation who were attending to Outpatient Obstetrician Clinic at El Sayed-Galal
University Hospital. The cases were classified into 2 groups, 25 cases each as follows: Group A (penicillin- treated
group) and group B (erythromycin-treated group). Results: the results of the study showed that there were no
significant difference between the cases within the two study groups as regard the different demographic data, the
obstetric history and the state of the current pregnancy. There was a significant difference between the two groups
as regards the fetal and maternal outcomes being less in group A (penicillin-treated group). Conclusion: our study
revealed the superiority of penicillin over erythromycin in treatment of GBS associated maternal infections.
Keywords: Penicillin, Erythromycin, GBS, PPROM.

mortality because of prematurity, infection, and
Group B streptococcus (GBS) is a type of bacteria
prolonged oligohydramnios (7).
that is naturally found in the digestive and lower
Infection can either be the cause or a consequence
reproductive tracts of both men and women. About 1
of PPROM. It has been reported that positive amniotic
in 4 pregnant women carry or colonized with GBS (1).
fluid cultures are detected in 32.4% of patients and that
Streptococcus agalactiae, often referred to as GBS, is
25 to 29% of patients diagnosed with PPROM
a Gram-positive bacterium that has been identified as
developed clinical chorioamnionitis before delivery (8).
a human pathogen since the early 1900s (2). GBS can
Chorioamnionitis itself can cause neonatal sepsis,
cause significant morbidity in pregnant women.
Manifestations of symptomatic maternal infection
syndrome, and cerebral palsy (9).
include chorioamnionitis, endometritis, cystitis,
A meta-analysis has shown that using
pyelonephritis and febrile GBS bacteremia. Caesarean
erythromycin or penicillin as empirical antibiotics
delivery appears to be a prominent risk factor for
following PPROM is associated with a significant
postpartum endomyometritis (3).
reduction in chorioamnionitis, whereas co-amoxiclav
Group B streptococcal genital colonization has
is associated with increased number of necrotizing
been considered a possible cause of premature
enterocolitis (NEC) (7).
deliveries and premature rupture of membranes
Erythromycin is therefore preferred to co-
(PROM) although definite evidence of a causal
amoxiclav as the first-line regime in the guidelines of
relationship is still lacking. Several prospective
some professional bodies. However, although
studies have also suggested that GBS colonization
erythromycin is a broad-spectrum antibiotic, it is less
may play a causal role in the occurrence of intrauterine
effective at treating GBS infections, which remains as
deaths, late abortions and low birth weight infants (4).
the predominant pathogen in causing early onset
Babies can be infected by GBS several months of age
neonatal sepsis, due to the insensitivity of the GBS
before birth due to their underdeveloped immune
bacterium in some patients (10).
system. Only few babies who are exposed to GBS

become infected, but GBS can cause miscarried,
stillbirth, sepsis, meningitis and pneumonia (5).
This work aimed to assess the effectiveness of
Fortunately, most GBS infection that develops at birth
penicillin versus erythromycin in treatment of GBS
can be prevented if woman, who have tested positive,
infection following PPROM.
receives proper antibiotics (2). When membrane

ruptures before 36 weeks gestation, this is known as
preterm premature rupture of membrane (PPROM) (6).
Study design:
PPROMs complicates 2 to 3% of pregnancy and
This was a retrospective cohort study designed for
accounts for 40% of preterm deliveries (PPROM is
pregnant women diagnosed with PPROM before 36
associated with serious neonatal morbidity and
weeks of gestation and who had delivery between 24


Full Paper (vol.755 paper# 14)

Introduction The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2839-2844

Assessment of Fetal Kidney Length as a Parameter for Detection of
Gestational Age at the Third Trimester of Pregnancy
Samira Al-Mlah, Aziza Nasef, Heba Ahmed Mohammed El-Masry*
Obstetrics and Gynecology Department, Faculty of Medicine (for Girls), Al-Azhar University
*Corresponding author: Heba Ahmed Mohammed El-Masry, E-mail: bobbaelmasry@yahoo.com

the accurate knowledge of gestational age is a keystone in an obstetrician's ability to successfully
manage the antepartum care of a patient and is of critical importance in ante-natal test and successful planning of
appropriate therapy or intervention. Failure can result in iatrogenic prematurity which is associated with increased
perinatal morbidity and mortality. Objectives: the aim of this study is to evaluate the accuracy of fetal kidney length
in estimation of gestational age in normal singleton pregnancies.
Patients and Methods: observational study, the study was conducted at the antenatal outpatient clinics of Obstetrics and
Gynecology at Alzahraa University hospitals and Ahmed Maher Teaching hospital in the period between December 2017
and December 2018. Approval from Ethical Committee at Al Zahraa University was taken. This study included 120
asymptomatic, pregnant women, with singleton pregnancy (30 cases at each gestational age 32, 34, 36 & 38 weeks
gestation). Results: the study shows that fetal kidney length is a good indicator of gestational age and can be used
alone due to its accuracy in comparison to other measurements (BPD, FL &AC) that may be changed in the third
trimester. There was a significant difference between right and left kidney length through different age of gestation
(The Lt KL measurement was larger than the measurement Rt KL). Gestational age in weeks is nearly equal to
MKL. Conclusion: fetal kidney length correlates well with gestational age, so it can be concluded that kidney
dimensions can be helpful in determining the gestational age when menstrual dates are uncertain.
Keywords: Fetal Kidney Length, Gestational Age, Third Trimester of Pregnancy.

termination is necessary as soon as the fetus becomes
Precise knowledge of gestational age is the
mature e.g., pre-eclampsia, chronic renal disease,
cornerstone of the obstetrician's ability to successfully
severe intrauterine growth retardation (IUGR),
manage prenatal care and is critical to prenatal testing
diabetes, placenta praevia centralis and where mothers
and successful planning for appropriate treatment or
are Rh -ve. Accurate GA estimation is also necessary
intervention. Failure can lead to prematurity, which is
where certain tests need to be performed for example
associated with increased perinatal morbidity and
amniotic fluid and serum assays, chorionic villus
mortality (1).
sampling and to plan fetal therapies. A recent trend can
Even if the date of menstruation is true, the
also be included in this list, where women want an
time of ovulation, fertilization and implantation cannot
elective cesarean section on a certain date e.g.,
be known. Women may undergo several "waves" of
11.11.11 or 12.12.12 or the New Year day and also the
vesicle growth during the normal menstrual cycle,
date suggested by the astrologer. A sudden increase in
which may mean ovulation inconsistency during any
operation rates were witnessed on these dates (4).
given cycle. Sperm may remain for 5 to 7 days in the
Ultrasonic measurement of fetal biometry:
female reproductive system, so the "known" pregnancy
Crown rump length (CRL), Biparietal diameter (BPD),
date is not fully reliable. Recent studies suggest that
Femur length (FL), Abdominal circumference (AC) &
the duration of ovulation to implantation can vary by
Head circumference (HC) are considered to be reliable
11 days, which may affect fetal size and growth (2).
when they are performed in first & early 2nd trimester
Even in women who are certain of menstrual
(<24 weeks). Currently there is no single fetal
dating, delayed ovulation is an important cause of
measurement used for accurate estimation of
perceived prolonged pregnancy and is more likely to
gestational age in the 3rd trimester especially in
occur than early ovulation. Some authors have
women who booked late & unsure about their LMPs
suggested that 282 days should be used instead of 280
(5). However, as gestational age progresses, they
to improve dating accuracy, since it is more likely that
become increasingly unreliable because of the
women will ovulate later rather than earlier than
biological variability of size in relation to age, so
predicted. All of these factors seems to make it
accurate dating of pregnancies in the late second
difficult to accurately predict gestational age based on
trimester or in the third trimester remains a problem,
menstrual history (2).
especially in women who consult late for maternity
care and are uncertain of the date of their LMP (1).
Recent studies have indicated that fetal kidney
contraceptive failure, bleeding in early pregnancy and
length (KL) correlates well with gestational age. The
chronic anovulation may interfere with accurate
conclusion of these studies indicates that the fetal
calculation of GA from the date of LMP (3). An
kidney length could be used in the gestational age
accurate GA is of importance in cases where early
estimation where dates are uncertain or women come


Full Paper (vol.755 paper# 15)

c:\work\Jor\vol755_16 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2845-2848
Serum Zinc Levels in Patients with Acne Vulgaris and
Its Relation to The Severity of Disease
Hassan A. Aziz Gaber, Ahmed Abdul-Hameid Abozied,
Ibrahim Mohammed Abd-Elkareem, Youssef Nasser Youssef El-Shazly*
Department of Clinical Pathology, Al-Hussien University Hospital, Al-Azhar Faculty of Medicine
*Corresponding author: * Youssef Nasser Youssef El-Shazly, E-Mail: el_shazly.y@yahool.com, Mobile: 01025297387

Background: acne vulgaris is a chronic inflammatory disease of the skin that affects the individuals of all ages,
especially adolescents. An association between serum zinc levels and acne vulgaris have been reported in some studies.
Objective: the aim of our study was to estimate serum zinc level in patients with acne vulgaris and healthy subjects
and its association with severity of disease.
Patients and Methods: this study was conducted on 60 patients (subdivided into 4 groups according to severity of
disease according to Global Acne Grading System) and 60 normal individuals as a control group.
Results: there was highly significantly statistical difference between all patients and control groups as regard serum
zinc level (mean of serum zinc level in patients and control groups were 49.85 ±19.61 and 63.46 ± 22.95 respectively,
Conclusion: it is concluded that zinc deficiency in acne patients could be one of the causes of acne and also that zinc
levels may not be related to the severity.
Keywords: Acne vulgaris; Zinc; Global Acne Grading System (GAGS); Inflammation; Propionibacterium acnes;
Pilosebaceous unit; Sebaceous glands; Comedones; Retinol binding protein (RBP); Interleukin 6 (IL-6); Tumor
necrosis factor alpha (TNF).


Acne vulgaris (AV) is a disease of the pilosebaceous
are important for regulation of lipid, protein and nucleic
unit that lead to non-inflammatory lesions (open and
acid metabolism, and gene transcription (5).
closed comedones), inflammatory lesions (papules,
Although the exact mechanism by which zinc can
pustules, and nodules) and may cause scarring in some
improve acne vulgaris is not fully understood, recent
patients. AV is an extremely common condition with a
knowledge suggests various mechanisms. For instance,
lifetime prevalence of approximately 85% and occurs
zinc inhibits P. acnes proliferation, maintain
mostly during adolescence (1).
immunologic response by preserving macrophage and
Areas of the body with hormonally sensitive
neutrophil function and stimulates natural killer cells and
sebaceous glands, such as face, neck, chest, upper back,
complement activity (6).
and upper arms are the most sites that affected by acne
Moreover, zinc inhibits interleukin 6 (IL-6) and tumor
vulgaris (2).
necrosis factor alpha (TNF) production and modulates
Pathogenic processes which cause acne lesions are:
expression of integrins, mainly intracellular adhesion
alteration of follicular keratinization that leads to
molecule- (ICAM-) 1 and leucocyte function associated
comedones, increased and altered sebum production
antigen (7).
under androgen control, follicular colonization
This study was performed to evaluate the relation
by Propionibacterium acnes (P. acnes) and complex
between low serum zinc levels and acne vulgaris and its
inflammatory mechanisms (3).
relation to severity of disease.
Acne lesions is divided into: primary lesions,

characteristic for active acne, secondary lesions, which
represent the sequelae of disease. Primary acne lesions
are further subdivided into non-inflammatory lesions
This study was conducted in collaboration between
(comedones) and inflammatory lesions (papules,
the Clinical Pathology and Dermatology and Venerology
pustules, nodules and cysts). Secondary lesions which
Departments at Al-Hussien University Hospital, Faculty
follow primary lesions comprise post-inflammatory
of Medicine, Al-Azhar University.
erythema, hyperpigmentation and scarring (4).
The study was approved by the Ethics Board of Al-
Zinc, a divalent cation, is an essential element for
Azhar University.
humans and a component of more than 300
All patients were collected from Dermatology
metalloenzymes and over 2000 transcription factors that
outpatient Clinic at Al-Hussein University Hospital over


Full Paper (vol.755 paper# 16)

c:\work\Jor\vol755_17 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2849-2856

Primary Fixation of Intertrochanteric Fracture with
Hemiarthroplasty in Elderly Patients
Ibrahim Mostafa, Hesham Safwat, Ahmed Saeed Abdel Raouf Sadeek*
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Saeed Abdel Raouf Sadeek, Mobile: (+20)01098066015, E-Mail:drraouf2011@gmail.com

trochanteric fractures are extracapsular fractures of the proximal femur between the greater and lesser
trochanters. Approximately half of all hip fractures will be trochanteric fractures. Trochanteric fractures occur in a
more aged population than do femoral neck fractures. These elderly people are more affected by osteoporosis and
medical comorbidities.
Objective: the aim of this study was to evaluate the results of primary hemiarthroplasty in management of
intertrochanteric fractures in elderly patients.
Patients and Methods: this study was a prospective study involving 20 patients with unstable trochanteric fractures
performed at Orthopedic Department, Al Hussein and Sayed Galal, Al-Azhar University Hospitals between the
period of September 2017 till March 2019. Patients were checked with X-rays, clinical evaluation, and functional
assessment according to the Harris hip score (HHS).
Results: in the current study, data on the effect of internal fixation versus endoprosthesis on mortality rate are
available only for femoral neck fractures. When adjusted for age, there is no significant difference in the mortality
rates for patients treated with internal fixation or hemiarthroplasty.
Conclusion: It could be concluded that the use of hemiarthroplasty is recommended for cases with old age,
osteoporotic bone, medical comorbidities, preexisting ipsilateral symptomatic degenerative hip disease or patients
with renal failure or pathological fracture with metastases.
Keywords: Hip, Intertrochanteric fracture, Hemiarthropalsty, Elderly patient


plates, sliding hip screw and lately the intramedullary
Hip fractures represent a major cause of disability
devices. In fractures with stable configurations the
and mortality in the elderly. The incidence of all hip
results of osteosynthesis are better as compared with
fractures is approximately 80 per100,000 persons and
fractures with unstable configurations. These implants
is expected to double over the next 50 years as the
have their success when bone quality is good, but in
population ages, generating a major financial burden (1).
elderly individuals with osteoporotic bone and unstable
Intertrochanteric and femoral neck fractures
fracture patterns the complication rate is high such as
account for over 90% of hip fractures, occurring in
screw cut out from head, excessive collapse of
approximately equal proportions (2). Intertrochanteric
fragments leading to shortening, varus, rotational
fractures usually occur in a more elderly group than
femoral neck fractures who are more susceptible to
considerably less with intramedullary implants but
many complications as pneumonia, deep veins
screw cut out and implant breakage still remain (6).
thrombosis, pulmonary embolism, bed sores and
Prosthetic replacement of the femoral head
psychic depression. Also, these patients usually have
appears to be a better alternative in unstable
associated systemic diseases of the cardiovascular
intertrochanteric fractures as it would provide rapid and
early mobilization and return of function which is
osteoporosis and metabolic aberrations combining to
necessary in elderly individuals to reduce morbidity
the poor anesthetic and operative risks (3).
and mortality. The increased blood loss, mechanical
Intertrochanteric fractures are extracapsular
complications like dislocation and the need for calcar
fractures of the proximal femur extending between the
replacement are possible complications for arthroplasty
greater and lesser trochanters. In general, fractures with
comminution of posteromedial cortex, subtrochanteric
The aim of this study was to evaluate the results
extension or reversed obliquity are considered unstable
of primary hemiarthroplasty in management of
intertrochantric fractures in elderly patients.
These fractures are seen in two populations,

elderly patients after a low-energy fall and younger
patients after high energy trauma as fall from high.
This prospective study included a total of 20 patients
Also, elderly patients are susceptible to metastatic bone
with unstable trochanteric fractures attending at
diseases that lead to pathologic fractures (5).
Orthopedic Department, Al Hussein and Sayed Galal,
The management of these fractures evolved from
Al-Azhar University Hospitals. Approval of the
conservative approach, with the help of skeletal traction
ethical committee and a written informed consent
to operative procedures such as fixed angle blade


Full Paper (vol.755 paper# 17)

c:\work\Jor\vol755_18 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2857-2863
Macular and Subfoveal Choroidal Thickness before and after Phacoemulsification
Using Optical Coherence Tomography in Diabetic and Non-Diabetic Patients
Mohamed A. El Malah, Ehab A. El sheikh, Mohamed B. El lakany
Department of ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed B. El Lakany; Mobile: (+20) 1008363992; Email: dr_7amada2012@yahoo.com
Cataract surgery by phacoemulsification is an invasive procedure that has become the most common
intraocular surgery and usually improves the visual outcome. However, it is an inflammatory process to the eye and
in many cases can lead to worsening of pre-existing retinal diseases such as diabetic macular edema or development
of new diseases such as Irvine-Gass syndrome. This inflammatory response is mostly induced by the release of
The aim of this study was to evaluate the effect of uneventful phacoemulsification on the morphology and
thickness of the macula and the choroid.
Patients and Methods:
In 30 eyes from 30 patients (15 non-diabetic and 15 diabetic), central retinal macular thickness, and
subfoveal choroidal thickness, were measured preoperatively and one month and three months after phacoemulsification using
optical coherence tomography.
In non-diabetic patients, central macular thickness was 202.80±22.39 m before phaco and 216.27±23.97 m after
1 month and 208.13±23.59 m after 3 months while Subfoveal choroidal thickness was 203.73±28.66 before surgery and
218.80±31.09 after 1 month and 209.20±30.63 after 3 months. In diabetic patients central macular thickness was 233.33±12.74
before surgery and 253.27±15.89 after 1 month and 246.93±22.39 after 3 months while subfoveal choroidal thickness was
233.80±24.14 before surgery and 252.80±26.59 after 1 month and 243.47±24.45 after 3 months.
Conclusion: Uncomplicated phacoemulsification induces non pathologic increases in subfoveal choroidal thickness and
macular thickness probably due to the inflammatory effect of the surgery but it decreases nearly to normal after 3 months;
however these changes are not accompanied by significant decrease in visual acuity.
Keywords: Phacoemulsification, macular thickness, choroidal thickness, diabetes, optical coherence tomography.

Optical coherence tomography (OCT) is a non
Cataracts are the main cause of poor vision in
invasive method that evaluates biological tissues by in
older people. The removal of white water using lens
vivo imaging. Since its introduction, OCT has
emulsification surgery is one of the most common eye
undergone several improvements and revolutionized
surgery operations (1). Choroid, the highest blood
the diagnostic, monitoring, and therapeutic
circulation in the human body, consists of blood
approaches to many retinal diseases and glaucoma.
vessels, connective tissues, nerves, melanocytes and
Computerized algorithms can be used on the high-
extracellular fluid. Many analyze and research suggest
resolution images obtained by modern OCT devices
that even non-complex emulsification leads to choroid
to identify and measure the thicknesses of discrete
disorders, especially an increase in chorionic
retinal layers, including the retinal nerve fiber layer
thickness (2, 3). Pseudophakic cystoid macular edema
(RNFL), macular ganglion cell complex (GCC), and
(PCME) is the most common cause of low vision after
choroid (6,7).
cataract surgery. The peak occurs after about 4 to 6
Because cataract surgery has an inflammatory
weeks of surgery. These inflammatory effects of
effect to the eye, several studies investigated the
surgery may be associated with subclinical changes
possibility that it may lead to an increase in the
reported in non-active cataract surgery and may also
choroidal and retinal thickness at the posterior pole
be associated with pathological events such as Irvin-
and that this eventual increase in choroidal thickness
Gass syndrome. In honor of S. Rodman Irvine and J.
may be related to the changes in retinal macular
Donald M. Gass (4).
thickness (8, 9). The subfoveal choroidal thickness
The exact pathogenesis of PCME remains
(SFCT) is measured vertically, at the fovea, from the
unknown and is likely to be multifactorial. Indeed,
outer surface of the hyperreflective line ascribed to the
many factors have been proposed such as vascular
retinal pigment epithelium (RPE) to the
instability, vitreomacular traction, ocular hypotony,
hyperreflective line of the inner sclera border (10).
and UV light damage. However, postoperative
Diabetes is a metabolic disease affecting the
inflammation appears to play a major role in its
systemic vasculature. Although the principal changes
development. The surgical procedure releases
in diabetic eyes usually occur in the retinal
inflammatory mediators, such as prostaglandins,
vasculature, additional changes can be also observed
leukotrienes, and cytokines, which lead to the
in the choroidal layer; an important vascular tissue
breakdown of the blood­aqueous barrier and of the
that supplies blood to the outer retina (11).
blood­retinal barrier (5).


Full Paper (vol.755 paper# 18)

c:\work\Jor\vol755_19 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2864-2870

Assessment of The Efficacy of Trastuzumab as Adjuvant Chemotherapy in Correlation
with Clinicopathological Features in Patients with Her/2neu Positive Breast Cancer
Attending Suez Canal University Hospital
Walaa Saeed, Soheir Abdelmohsen, Ehap Hasanin and Maha Zamzam
Clinical Oncology and Nuclear Medicine Department, Suez Canal University
Corresponding author: Walaa Saeed, email: walaasaeed89@gmail.com
Materials and Methods: Retrospectively, data was collected from patients with HER2- positive early stage breast cancer
who were receiving adjuvant trastuzumab. Then analysis of clinicopathological features of 88 patients and their treatment
outcome was done. Results: 61 patients received trastuzumab and 27 patients didn't receive it. In patients who received
trastuzumab (trastuzumab group), the median follow-up period was 24 months (8.0-40.0 months). Relapse-free survival
(RFS) was 31.2 months (95% CI: 28.0-34.4) and overall survival (OS) was 34.9 months (95% CI: 32.3-37.5). The 3-year
OS for all patients was 76.9% and RFS was 62.3%. In non-trastuzumab group: the median follow-up period was 26
months (8.0-40.0 months). They were followed up during the course of treatment and it was found that relapse-free survival
(RFS) was 30.18 months (95% CI: 25.2-35.1) and overall survival (OS) was found to be 32.0 months (95% CI: 27.3-36.6).
So, the 3-year OS for all patients was 59.8% and RFS was 48.3%. 13.1% of the patients in the trastuzumab group had an
asymptomatic decrease in left ventricular ejection fraction by more than 10% which is discovered by the end of the treatment
course. Data obtained from univariate analyses revealed that larger tumor size, positive nodal involvement, and positive
estrogen receptor status were significantly associated (p<0.05) with RFS. Positive lymph node was identified as an
independent prognostic factor with multivariate analyses of covariates displaying p<0.05 (HR=1.8, 95%CI 1.1 - 3, p=0.01).
Keywords: Breast Cancer, Trastuzumab, Her2neu, Survival analysis.

period (4) . From 2006, adjuvant trastuzumab was
By far, breast cancer is found to be the most
accepted to be a standard treatment in patients with HER2
common cancer and is the leading cause of cancer-related
positive breast cancer (2). About 2.8% to 3.3% of
mortality in women worldwide. (1)
There are several factors which are important in
cardiomyopathy, which is the most common side effect of
choosing the treatment strategy including gene expression
trastuzumab. So, resting left ventricular ejection fraction
studies, which have identified different molecular
(LVEF) is used to monitor heart function during and after
subtypes of breast cancer including: luminal A, luminal
the course of treatment (5).
B, epidermal growth factor receptor 2 (HER2) type and
A national study used trastuzumab after adjuvant
triple negative (basal-like type). Those subtypes are
chemotherapy in patients with HER2-positive breast
classified based on histopathological markers including
cancer and revealed that disease-free survival at 3 years
estrogen receptor (ER), progesterone receptor (PR), and
was better in the intervention group who received
human epidermal growth factor receptor 2 (HER2) (2).
trastuzumab compared to the group who did not receive it
HER-2 positive disease has been identified in about
(89% vs. 78%) (6). An international study conducted
15-25% of women with early breast cancer and it is found
based on real life use and effectiveness of adjuvant
to be associated with an aggressive course, a poor
trastuzumab in patients with early breast cancer and
prognosis and a higher risk of recurrence after initial
revealed that 5-year disease-free survival was 80.7% in
treatment (3). The human epidermal growth factor
patients treated with trastuzumab versus 68.2% in patients
receptor2 (HER2) gene encodes for a transmembrane
not treated with it, and also rates of 5-year overall survival
tyrosine kinase receptor protein and it is found to have
were 90.7% and 77.4% respectively (7).
important predictive and prognostic values for invasive
Another study obtained clinicopathological data of
breast cancer (2) .Trastuzumab is a humanized monoclonal
patients with HER2 positive breast cancer and assessed
antibody which acts by targeting the extracellular domain
the efficacy of the use of adjuvant trastuzumab and its side
of the transmembrane tyrosine kinase receptor HER2.
effects including cardiotoxicity revealed that 3-year
When administrated with adjuvant chemotherapy, It has
overall survival for all patients was 92.0% and relapse-
shown its the ability in reducing the risk of relapse and
free survival was 79.6%. The rate of relapse during
death in HER2-positive breast cancer patients (4)
follow-up period was 14.3%. Trastuzumab-associated
The adjuvant trastuzumab (HERA) trial median
cardiotoxicity was found at the rate of 3.3% (2).
follow-up period was 2 years and it showed that 1-year of

adjuvant trastuzumab treatment improved rates of
disease-free survival (DFS) significantly, and the benefit
Approval of the Ethical Committee of the Faculty
also still observed at 4-year and 8-year median follow-up
of medicine, suez canal university has been obtained.


Full Paper (vol.755 paper# 19)

Introduction The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2871-2877

Accelerated versus Conventional Corneal Collagen Cross-Linking in
The Treatment of Keratoconus
Hosny Hassan Mohammad, Sayed Abbas Sayed, Abdelghany Ibrahim Abdelghany and
Mohamed El-Sayyed Mokhtar El-Sayyad
Department of Ophthalmology, Faculty of Medicine ­ Al-Azhar University
Corresponding author: Mohamed El-Sayyed Mokhtar El-Sayyad, Mobile: (+20)01001903723,
E-Mail: m_sayyad@hotmail.com
corneal collagen cross-linking (CXL) is one of the interesting topics in corneal surgery, with several
recent modifications of the original Dresden protocol under investigation. Accelerated CXL is one of the exciting
modifications of the original technique but with few published results. It
the aim of the present study was to compare the effect of accelerated (both continuous and pulse)
crosslinking on the keratoconic cornea versus conventional protocol. We stuck to inclusion and exclusion criteria
of the study.
Patients and methods: in this study we evaluated 90 eyes; 30 eyes received standard Dresden protocol (S-CXL),
30 eyes received continuous light accelerated protocol (cl-ACXL), and 30 eyes received pulsed light accelerated
protocol (pl-ACXL). The refractive status, visual acuity, corneal topography, central corneal thickness and corneal
biomechanics were evaluated preoperatively, at 1st month, 3rd month, 6th month and 12th month postoperative.
Results: all groups showed an improvement of MRSE, UCVA and BCVA one year after surgery. The central
corneal thickness (CCT) markedly decreased at 1st month follow-up, then gradually increased till 12th month but
still below the baseline. Both maximum and minimum keratometry (K-max and K-min) decreased significantly
at 12th month follow-up. The corneal biomechanics; corneal hysteresis (CH) and corneal resistance factor (CRF)
showed no significant changes all over the follow-up period.
Conclusion: the results in this study showed that both continuous and pulsed light accelerated cross-linking are
as safe as standard Dresden protocol in halting keratoconus disease.
Keywords: CXL, Keratoconus.


combination therapies such as excimer laser ablation
Crosslinking is the general term for the
and corneal cross linking remain controversial.
process of forming covalent bonds or relatively short
Additionally, the indications for customized ablation
sequences of chemical (ionic) bonds to join two
and corneal cross linking remain unclear (4).
polymer chains together. When polymer chains are
Developments in CXL procedure also
crosslinked, the material becomes more rigid. Cross-
showed using CXL with intrastromal pocket by
links can be formed by chemical reactions that are
femtosecond laser, one of its advantage was a novel
initiated by heat, pressure, change in pH, or radiation
epithelial sparing and no postoperative pain, as most
(1). Cross-linking of collagen refers to the ability of
patients returned to everyday activities without eye
collagen fibrils to form strong chemical bonds with
irritation or discomfort. Also cross-linking the sclera
adjacent fibrils. In the cornea, collagen cross-linking
was tried, including treatment for malignant myopia,
occurs naturally with aging and as a side-effect of
diabetes due to an oxidative deamination reaction that
Adjunctive CXL with certain corneo-plastic
takes place within the end chains of the collagen. It
procedures, including conductive keratoplasty to
was hypothesized that this natural cross-linkage of
induce corneal steepening or microwave keratoplasty
collagen explains why keratoectasia (corneal ectasia)
to induce corneal flattening, have shown promising
often progresses most rapidly in adolescence or early
results (5).
adulthood but tends to stabilize in patients after
The caveat remains that corneal cross linking
middle-age (2).
is a relatively new procedure that still requires
Biomechanical investigation of human
extensive research and long-term follow-up (4).
keratectatic corneas reveals significant differences in

elasticity compared to normal corneas, indicating a
decreased stiffness of the keratoconus cornea (3).
To evaluate the use of accelerated corneal
Corneal cross linking is steadily becoming
collagen cross-linking (using pulse and continuous
part of routine care for early and moderate
mode) in comparison with conventional cross-linking
keratoconus. Hence, procedures are now being
in the management of keratoconus.
developed to address the residual refractive error and

treatment of more advanced keratoconus. These
procedures include combining corneal cross linking
The study was conducted at Al-Hussein
with other refractive modalities. However, some
University Hospital, Department of Ophthalmology.


Full Paper (vol.755 paper# 20)

ž˙,'E9) The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2878-2887

A Comparative Study between Nifedipine, Ritodrine and Magnesium Sulfate as
Tocolytics in Cases of Preterm Labor and Their Effect on Utero Placental Perfusion
Asem A. Abdo Mousa1, Mohamed A. Mohamed1, Mohamed S. Radwan2,
Khaled F. El Sayed1*
Departments of 1Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University;
2Clinical Pathology Faculty of Medicine, Al-Azhar University; Faculty of Medicine, Al-Fayoum University
*Corresponding author: Khaled F. El Sayed; Mobile: 011140254235, Email: tantawy_wael@yahoo.com

in the developed world, preterm birth (PTB) is a major problem in modern obstetrics; its prevalence
is still rising in many industrialized countries. Early PTB (before 34 weeks) is particularly associated with high
rates of mortality and morbidity.
Aim of the Work:
to compare the efficacy of oral nifedipine, intra venous ritodrine and magnesium sulfate as
tocolytics in cases with preterm labor and evaluate their effects on the utero placental perfusion in order to choose
the safest and most cost-effective drug.
Patients and Methods:
a prospective study that was conducted in El sayed Galal and El Hussien University
hospitals from November 2016 to November 2018. By identifying 150 pregnant women with gestational age from
24-37 weeks gestation with preterm labour pain, intact membranes, singleton pregnancy.
Results: a statistically significant difference was found between groups according to fetal umbilical artery PI
before and after treatment. Also, significant difference between before and after treatment according to fetal
umbilical artery PI in magnesium sulfate group. Also a statistically significant difference between groups according
to fetal middle cerebral artery PI before and after treatment. Also, significant difference between before and after
treatment according to fetal middle cerebral artery PI in nifedipine and magnesium sulfate group.
there was no overall difference between nifedipine, magnesium sulfate and ritodrine, in their efficacy
as tocolytic for preterm labor. However, Nifedipine had fewer maternal side effects followed by magnesium sulfate
than ritodrine. Irrespective of their tocolytic effects, magnesium sulfate has the most significant effect on Doppler
Keywords: Nifedipine, Ritodrine, Magnesium sulfate, Tocolytics, Preterm labor, Utero placental perfusion.

of corticosteroids to enhance fetal lung maturity and
Premature birth remains the leading cause of
reduce neonatal morbidity and mortality (4).
premature death. Preterm infants, known as labor
There is considerable variation in the type of
before 37 weeks of gestation, often suffer from a large
tocolytic agent used in different parts of the world.
immediate morbidity and need prolonged stay in
Magnesium sulphate has been widely used as a
neonatal intensive care units with a high risk of long-
tocolytic in the United States of America (5).
term neurological disease in a proportion of survivors.
Magnesium sulphate can be used as a tocolytic and
Early in preterm labor, the risk increases especially
also in the management of pre- eclampsia, eclampsia
when labor occurs before 32 weeks (1).
and neuroprotective for neonates (6).
Worldwide, around 15 million children were born
The precise mechanism by which magnesium
preterm in 2010 which represents around 11% of live
sulfate exerts a neuroptective benefit is not known, but
births. Around 85% of the children born before 37
it is speculated that it possess anti-inflammatory and
weeks of gestation can be considered to be moderately
anti-excitotoxic effects while also improving cerebral
or late preterm births (32-36 weeks), 10% very preterm
blood flow and stabilizing fluctuations in blood
(28-31 weeks), and 5% extremely preterm (before 28
pressure in the newborn infant (7).
weeks) (2).
Reported side effects of magnesium sulphate include
Numerous factors that can be identified during the
maternal side effects as flushing, sweating, sensation of
periconceptional period are associated with the risk of
warmth, nausea, vomiting, headache, palpitations and
preterm delivery. There are many maternal or fetal
rarely pulmonary edema. Administration of a
characteristics that have been associated with preterm
concentration above the recommended therapeutic range
birth, including maternal demographic characteristics,
can lead to respiratory depression, respiratory arrest and
nutritional status, pregnancy history, present pregnancy
cardiac arrest (8).
characteristics, psychological characteristics, adverse
Neonatal side effects include hypermagnesaemia,
behavior's, infection, uterine contractions and cervical
hyporeflexia, poor sucking, and, rarely, respiratory
length, and biological and genetic markers (3).
depression needing mechanical ventilation (9).
As a result clinicians use tocolytics for pregnancy
To assess the fetal circulation Doppler sonography
prolongation for 48-hours to permit the administration
is used to provide valuable information regarding
neonatal prognosis and fetal well-being in


Full Paper (vol.755 paper# 21)

c:\work\Jor\vol755_22 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2888-2893

Endoscopic Management of ERCP Bleeding
Fawzy M. Mustafa(1) and Hany F. Ali(2)
Department of General Surgery(1) and Clinical Pathology(2), Faculty of Medicine,
Al-Azhar University, Cairo, Egypt
post endoscopic retrograde cholangiopancreatography (ERCP) bleeding is a common complication
and the incidence varies from 1% to 48%. It can be challenging to manage or localize the bleeder through a side-
viewing endoscope. Objective: this study aimed to evaluate the risk factors of post ERCP bleeding and efficacy of
endoscopic intervention therapies.
Patients and Methods: this prospective randomized clinical trial was carried out on 100 consecutive patients at
General Surgery Department Al-Azhar University Hospitals (Cairo) Egypt. All patients underwent ERCP, between
January 2016 and August 2018, All ES procedures were performed by experienced surgeons and the decision to
perform sphincterotomy was based on clinical, endoscopic, and radiologic findings.
Results: comparison of different therapeutic modalities showed that cholangitis was higher in patients who
received epinephrine spray and pancreatitis was higher in patients who received electrocoagulation.
Conclusion: clinically, endoscopic hemostasis therapy is very effective to manage post ERCP bleeding but
increases the complication rate of pancreatitis and cholangitis. Realizing the effectiveness of each therapeutic
modalities and appropriate management of different levels of bleeding are important.
Keywords: ERCP


gastroenterologists experienced in ERCP each time.
Endoscopic retrograde cholangiopancreatography
Furthermore, bleeding that obscures the visual field
(ERCP) is a fundamental tool for the evaluation and
makes identification of the precise location in delayed
management of many pancreaticobiliary diseases (1).
bleeding impossible (5).
The development of safer and relatively non-
The complications of pancreatitis, cholangitis,
invasive investigations such as magnetic resonance
and cholecystitis associated with endoscopic
cholangiopancreatography and endoscopic ultrasound
hemostasis were higher in patients who underwent
has meant that ERCP is now rarely performed without
endoscopic hemostasis than in patients who did not
therapeutic intent (2).
undergo endoscopic hemostasis (6).
The major risk of an ERCP is the development
Post-ERCP bleeding is a serious complication
that can lead to morbidity and mortality. Effective
sphincterotomy is also associated with a risk of
management and prevention of this complication
bleeding (3).
requires knowledge of its risk factors and proficiency
Bleeding is one of the serious complications of
in endoscopic hemostasis techniques through aside-
therapeutic ERCP and can be mostly attributed to
viewing duodenoscope (7).
endoscopic sphincterotomy (ES), which is a

fundamental step of the procedure (ERCP) for
accessing the biliary and pancreatic ductal systems (4).
The aim of the paper is to establish a well-
The timing of delayed post-ES bleeding may be
accepted clinical strategy for management of post
immediate or up to 10 days following ES. A small
ERCP bleeding in patients with or without
amount of post-ES bleeding is common and most
coagulopathy defects.
often resolves spontaneously. Thus, endoscopic

therapy was suggested to be undertaken for the
treatment of endoscopically significant immediate
This prospective randomized clinical trial was
bleeding or clinically significant delayed bleeding.
carried out on 100 consecutive patients at General
However, some cases present with significant
Surgery Department Al-Azhar University Hospitals,
bleeding that requires blood transfusions and urgent
Cairo, Egypt.
endoscopic intervention, such as injection, balloon
All patients underwent ERCP, between January 2016
tamponade, thermal, and mechanical methods
and August 2018. All ES procedures were performed
(hemoclip or self-expandable stent) alone or in
by experienced surgeons and the decision to perform
combination. If refractory bleeding occurs, repeated
sphincterotomy was based on clinical, endoscopic,
endoscopic hemostatic therapy, angiographic
and radiologic findings.
embolization, or surgery is required (5).

Owing to the tangential approach in these
Written informed consent:
patients, the bleeding could not be handled easily with
An approval of the study was obtained
side-viewing endoscope and this urgent procedure
from Al- Azhar University academic and ethical
could not be practically performed by the


Full Paper (vol.755 paper# 22)

c:\work\Jor\vol755_23 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2894-2899

Detection of Creatinine in Vaginal Fluid for Diagnosis of Preterm
Premature Rupture of Membranes
Ismail T. El-Garhy (1), Noha M. Sabry (1), Medhat A. Abdel-Gahfar (2), Ahmed A. Ahmed
Department of Obstetrics and Gynecology, Department of Clinical Pathology,
Faculty of Medicine ­ Al-Azhar University
Corresponding author: Ahmed A. Ahmed; Mobile: 01012503384; Email: ahmeddr107@gmail.com

to evaluate the role of vaginal fluid creatinine level in diagnosis of preterm prelabour rupture of
membranes among patients giving history of amniotic fluid leak.
Objectives: the aim of this study was to evaluate the reliability of vaginal fluid creatinine level in the vaginal fluid
for diagnosis of prelabour premature rupture of membranes.
Patients and Methods: 100 pregnant women with gestational age 24: 37 weeks gestation participated in the present
study divided into 2 groups. Group I (confirmed PROM group) & group II (control non-PROM group). All patients
underwent a sterile speculum examination for detection of amniotic fluid pooling in the posterior vaginal fornix
followed by taking 3ml from vaginal fluid. Creatinine measurement was done using ELISA.
Results: The mean creatinine levels in vaginal fluid in group (I) & group (II) were.70 ± 0.88 and.04 ± 0.18 mIU/mL
respectively. The difference was statistically significant (P value < 0.001). With creatinine cut-off value of 0.25
mIU/ml, the sensitivity & specificity in confirming PROM were 72 and 94% respectively.
Conclusion: Creatinine level was significantly higher in pregnant women with definite PROM. Therefore, vaginal
fluid creatinine can be used as an easy, rapid, reliable and non-invasive test for confirming the diagnosis of PROM
and can be used as an adjunctive test in equivocal cases.
Keywords: Creatinine, preterm prelabour rupture of membranes.


(pulmonary hypoplasia) as well as fetal compression
Prelabour rupture of fetal membranes (PROM)
resulting in malformations similar to those in Potter
refers to rupture of fetal membrane before the onset of
syndrome with prolonged oligohydramnios (6).
labour. While, preterm PROM (PPROM) refers to
The management of patients with PROM,
rupture of fetal membrane before completing 37 weeks
regardless of gestational age is still controversial, thus
gestation (1). The incidence is about 10% of all
it is important to reach accurate diagnosis by
gestation and about 2-4% of preterm pregnancies, with
identifying the presence of specific amniotic fluid
complications such as infection and preterm birth (2).
markers in vaginal environment (7). There are variable
Definitive diagnosis of PROM is very important
methods used to diagnose PROM are based as much on
because failure of diagnosis can lead to unwanted
clinical evaluation as on biological tests, which are
obstetric complications as chorioamnionitis, cord
useful in the cases of clinically asymptomatic patients
prolapse and placental abruption (3).
and/or in the ones with unclear PROM (8). All these
About one-third of women with PPROM develop
tests have advantages and disadvatages, as
potentially serious infections, such as intra-amniotic
measurement of fetal fibronectin, accurate but
expensive and time-consuming (9). Vaginal urea and
endometritis, or septicemia (1). The incidence of
creatinine may be helpful in diagnosis of PROM
placental abruption varies among studies (4%-12%) (4).
because fetal urine is the most important source of
Conservative management of patients was associated
amniotic fluid in the second half of pregnancy. As
with serious complications that occur early in
hypothesized by Kafali and Oksuzler (9).
pregnancy such ad retained placenta or postpartum

haemorrhage (2). The fetus and neonate are more
affected with PPROM related morbidity and mortality
The aim of this study was to evaluate the reliability of
than the mother did. Preterm infants are especicifically
vaginal fluid creatinine for diagnosis of prelabour
vulnerable to many problems, such as respiratory
premature rupture of membranes.
distress syndrome, intra-ventricular hemorrhage,

periventricular leukomalacia, infection (eg, sepsis,
enterocolitis. The incidence of these morbidities vary
This study was a prospective cross sectional study
with gestational age and are higher in the setting of
that was carried out at Al-Hussein Maternity Hospital.
chorioamnionitis (5).
It was based on clinical and biochemical parameters. It
The risk to the fetus is high when PPROM occurs
was performed on a total of 100 pregnant women
before the limit of fetal viability. There is significant
between completed 24 and 36 weeks of gestation. They
risk for maldevelopment of the alveolar tree
were divided into: 50 pregnant women (confirmed


Full Paper (vol.755 paper# 23)

c:\work\Jor\vol755_24 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2900-2907

Study of Serum Immunoglobulins G and M Levels in Children with Down Syndrome
and Their Relation with Recurrent Lower Respiratory Tract Infection
Manar Emad Aldeen Ghazy1*, Heba Said El Mahdy1, Maaly Mohamed Mabrouk2and
Mohamed Shawky Al-Farargy1
Department of Pediatric Medicine1and Department of Clinical Pathology 2,
Faculty of Medicine, Tanta University, Egypt
*Corresponding author: Manar Emad Aldeen Ghazy, Mobile: 01020299644; Email: maysaakubasi@yahoo.com

Children with Down syndrome appear to be more likely susceptible to respiratory tract infections and it
is an important cause of morbidity and mortality among them. Aim of the study: It was to investigate the relationship
between levels of IgG and IgM in Down syndrome and recurrent lower respiratory tract infections. Subjects and
This study was conducted on 40 children who were categorized into 2 groups: patient group, which includes
children with Down syndrome patients presented with LRTIs, their karyotyping revealed trisomy 21 in all cases and
their age range from 1 to 13 years. Control group, which includes 20 healthy children matched for sex and age with
patient group. They were subjected to full history taking & thorough clinical examination, and they investigated for
complete blood picture, C-reactive protein and serum immunoglobulins (IgG & IgM) using ELISA technique. Results:
Plasma levels of immunoglobulin G (IgG) were elevated in Down syndrome with significant increase the frequency
of lower respiratory tract infections and hospital admission. Plasma levels of immunoglobulin M (IgM) were decrease
in down patients with significant increase in the frequency of lower respiratory tract infections and hospital admission.
Conclusion: These findings suggest the importance of estimation and follow up of serum levels of IgG &Ig M in cases
of Ds with recurrent respiratory tract infections.
Keywords: Immunoglobulins, Down syndrome, Recurrent Lower Respiratory Tract Infection.


Down syndrome (DS) is one of the most
have mucus secretions and reduced ciliary beat
common chromosomal anomalies in humans (1), it`s
frequency when compared with controls without DS (8).
caused by having three copies of chromosome 21

instead of two (2). It is approximately 1 in 800 births in
Aim of the study:
the general population, but figures in Egypt vary
It is to investigate the relationship between levels
between 1 in 555 to 1 in 770 (3).
of IgG and IgM in Down syndrome and recurrent lower
Ultrasonographic examination of the fetus in the
respiratory tract infections.
second and third trimesters of pregnancy allows for the

assessment of several facial measurements that are
significantly different in fetuses with trisomy 21 from
This case control study was conducted at Genetic
Unit of Pediatric Department, Tanta University
Amniocentesis and chorionic villus sampling (CVS)
Hospital, during the period from December 2016 to
are the invasive diagnosis of Down's syndrome before
February 2018. The study was approved by the
birth, but carry a risk of miscarriage in 1% of those tests
Ethics Board of Tanta University.

Lower respiratory tract infections (LRTIs) are
A total of 40 children with Down syndrome were
generally more serious than upper respiratory
included in this study and were categorized into 3
infections and it is the leading cause of death among all
groups: Down syndrome group: 20 children [13
infectious diseases (5). In addition, up to 29% of deaths
males and 7 females] with Down syndrome aged from
in DS are associated with pneumonia, influenza and
1-13 years old, was included in the study as patient
aspiration (6).
group. Control group: 20 healthy children [12 males
The increased incidence of respiratory tract
and 8 females] matched with the patient group and
infections in children with DS is likely to be
aged from 1-13 years old. Children with Down
multifactorial. Structural abnormalities in the airways
syndrome free now from infection confirmed by
such as macroglossia, narrow nasopharynx, adeno-
karyotyping and their ages ranged between 1-15 years
were included in the current study. Also children with
tracheomalacia are likely to play a role (7). They also
chronic infection or with evident malnutrition were

Full Paper (vol.755 paper# 24)

c:\work\Jor\vol755_25 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2908-2912

Combined Anterior Cruciate Ligament Reconstruction and High
Tibial Osteotomy in Anterior Cruciate Ligament-Deficient Varus Knees
Ibrahim A. Mostafa, Mohamed A. Al-Nahas, and Hamed Abdelrazak.
Orthopedic Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding authors: Mohamed A.Al- Nahas, Email: Mohmmed.alnahas1979@gmail.com,Tel: 01091294660

: The presence of varus deformity in anterior cruciate ligament (ACL)-deficient knees can be a
source of persistent knee pain owing to medial compartment overload. This deformity may threaten the outcome
of ACL reconstruction because of increased tension on the graft.
Methods: In the period between May 2018 to April 2019, short term pilot study including 10 patients with ACL
deficiency and genu varus were treated by anatomical single bundle ACL reconstruction and open medial wedge
high tibial osteotomy. The selected patients had manifestations of ACL deficiency in association with medial
joint line pain with or without lateral thrust.
This technique achieved knee stability and realignment to normal values. The IKDC score significantly
improved from 37 preoperative to 78 postoperative (p < 0.05).
: The combined procedure of ACL reconstruction and high tibial osteotomy restored knee stability
and reduced pain over the medial compartment. Although the combined procedure has a longer period of
rehabilitation than an isolated ACL reconstruction, the elimination of lateral thrust and preservation of articular
cartilage of the medial compartment are of paramount importance to the future of these knees.
Keywords: ACL, High Tibial Osteotomy, Knee

Chronic anterior cruciate ligament (ACL)
In the period between May 2018 to April
deficiency is considered an important factor in the
2019, short term pilot study including 10 patients
development of degenerative changes and possible
with ACL injuries and varus knees were treated. All
osteoarthritis of the knee joint(1). This may be related
cases were males; the mean age was 25 years (range,
to the alteration of knee kinematic function, repeated
20-40 years).
giving way or trauma to the articular cartilage in

addition to the increased incidence of meniscus
Written informed consent:
injuries. Therefore, early reconstruction of the ACL
An approval of the study was obtained
was suggested to avoid the development of other
from Al- Azhar University academic and ethical
intraarticular pathologies(2,3).
committee. Every patient signed an informed
To avoid deterioration of knee function, it is
written consent for acceptance of the operation.
important to address other pathologies in the knee
Regarding the inclusion criteria, all patients
joint while performing ACL reconstruction such as
had symptomatic ACL deficiency with repeated
meniscus repair or attention to chondral lesions. It
attacks of giving way. The clinical examination of
may also be essential to correct deformities around
these patients revealed positive Lachman and pivot
the knee joint that may increase the load on one of
shift tests. All patients had symptomatic varus knee
the knee compartments or stretch the ACL graft. To
alignment with medial joint line pain that was
stretch the line of thought, it is not uncommon for
aggravated by long standing or walking for more
patients with varus knees and early degeneration of
than 15 minutes. The varus deformity in these
patients varied from primary varus with no lateral
to develop acute ACL injury with subsequent knee
joint laxity to double or triple varus according to
instability and aggravation of medial compartment
Noyes' classification(4). There was a dynamic
symptoms of arthritis(1).
increase of the deformity during the stance phase of
The resulting argument here would be:
gait and decrease of the deformity during the swing
should the ACL be reconstructed in these patients in
phase of gait. This dynamic frontal plane instability
isolation or as a combined procedure to
is known as varus thrust(5). This was present in nine
simultaneously correct the preexisting varus
cases. All patients reported aggravation of their
deformity? In this article, combined ACL
medial joint line pain following the knee trauma that
reconstruction and high tibial osteotomy (HTO)
were performed for patients with deficient ACL and
presence of widespread arthritic changes that
symptomatic varus deformities that were associated
involved different knee compartments with
with medial compartment early degenerative
elimination of the medial joint space was considered
changes and/or lateral thrust.
an exclusion criterion. However, early degenerative

changes with narrowing of the medial joint space on

Full Paper (vol.755 paper# 25)

c:\work\Jor\vol755_26 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2913-2920

Factors Influencing Surgical Outcome of Intermittent Exotropia
Hanan S. Hegazy
Department of Ophthalmology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt.
Corresponding author: Hanan S. Hegazy, Tel: +002 01013755550, e-mail: hanansaied27@yahoo.com

The purpose of this study was to analyze the factors affecting surgical results of intermittent exotropia.
Methods: A prospective interventional study included patients with basic type of intermittent exotropia who had
undergone surgical treatment with a postoperative follow up period of 1 month or more. Surgical success was defined
as an alignment between 10 prism diopters (PD) of exotropia or 10 PD of esotropia at 1 month. The factors investigated
were: sex, age of patients, and age at initial surgery, family history, preoperative angle of deviation, type of surgery,
the tendon width of lateral rectus muscle, refractive error, near binocular single vision, and postoperative alignment.
After data collection, data were analyzed in SPSS version 25 software.
Results: The study included 26 patients, 13 (50%) male and 13 (50%) female followed up for 3 months. All of patients
achieved surgical success but patients with larger preoperative angle of deviation, older age and larger tendon muscle
width showed exotropia with in (10PD) which showed slight improvement during period of follow up while those with
smaller preoperative angle, younger age and smaller tendon muscle width showed esotropia with in (10) PD and
associated with postoperative diplopia relieved during period of follow up with improvement of esotropia.
Conclusion: In intermittent exotropia, age, tendon width, preoperative angle of deviation may predict the surgical
success rate. Younger age, smaller preoperative angle, smaller tendon muscle width, early postoperative small angle
esotropia were associated with a higher surgical success.
Keywords: Intermittent exotropia, surgical outcome, tendon muscle width.


typically recovers to orthophoria within 2 weeks without
Intermittent exotropia X(T) is considered the most
any manipulations(8).
common form of exotropia and is more prevalent among
VonNoorden(9)found that lesser degrees of
Asians(1). It comprises about 50% to 90% of patients with
overcorrection were associated with recurrence of
exodeviation(2). X(T) was defined as a divergent
exodeviation and that higher degrees of overcorrection
deviation intermittently controlled by fusional
increased the risk of reoperation for consecutive
mechanisms(3). X(T) can be treated through nonsurgical
esotropia. Raab and Parks(10) reported that initial (2­10
methods which aim to encourage use of the eyes together
days) postoperative alignment between 11 and 20PD
by eliminating suppression and building fusional
esodeviation remained satisfactory.
reserves (motor control of the eyes) in order to aid
Whereas Scott(11) proposed the surgical goals of 4­14
control of the exodeviation. They include exercises, part-
PD esodeviation, and McNeer(12) of 0­10 PD. There are
time occlusion or minus lens therapy(4) .
multiple factors that may affect prognosis of surgery for
Surgery is mainly used to treat X(T) with a
X(T). Preoperative factors include age at onset of X(T),
satisfactory outcome(5). The commonly used surgical
age at time of surgery, preoperative degree of
methods for X(T) include bilateral lateral rectus
exodeviation, stereopsis, refractive errors, amblyopia,
recession (BLR), unilateral lateral rectus recession and
inferior oblique muscle overaction, and type of
medial rectus resection (R&R) or unilateral lateral rectus
exotropia(13). .
recession (ULR) which is often used to treat small to
Operative factors include surgical procedure, the
moderate angle exotropia(2).
limbal insertion distance (LID) of the LR muscle as
The success was considered when rate in terms of
undercorrection at the time of LR recession might be
ocular motor alignment of within 10 prism diopters (PD)
considered in patients with long LID of the
of orthotropia(6,7).
LR muscle(14).
Additional surgery may be needed for cases with
The tendon width of the lateral rectus also has been
under correction. Many studies have found that long-
reported to be a useful indicator for estimation of the
term post-operative alignment is better when there is
effect of lateral rectus recession in X(T). The mean effect
over-correction in the very early period following
of 1mm lateral rectus recession has been shown to range
surgical procedures so, the usual goal of surgery for
from 2.7 to 3.5 (PD)(15). According to tendon width, the
intermittent exotropia is a small angle of initial
effect of recession has been shown to be larger in cases
postoperative esodeviation. Because small esodeviation
in which the lateral rectus tendon width is narrower.That


Full Paper (vol.755 paper# 26)

c:\work\Jor\vol755_27 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2921-2929

Sleep Disorders in Egyptian MS Patients: Clinical and Polysomnography Study
Seham E. Abd Elsadek1, Manal H. Maabady1, Mohamed A. Shafik2*
1Department of Neurology, Faculty of Medicine, Al-Azhar University, 2Department of Neurology, Faculty of
Medicine, Ain Shams University, Egypt
*Corresponding author: Mohamed A. Shafik, Mobile: 01003088969, Email: mshafik@gmail.com

multiple sclerosis (MS) is an inflammatory disorder of the brain, spinal cord, and optic nerves.
MS affects more than two million people worldwide; sleep disorders are very common in the general
population; their high prevalence rate suggests that MS patients will certainly be suffering from comorbid
sleep disorders.
Objective: study the prevalence of sleep disorders among MS patients by clinical and Polysomnography
(PSG) studies.
Patients and Methods: twenty-five MS patients and 12 healthy controls were examined by expanded
disability status scale (EDSS) for functional disability, Pittsburg sleep quality index (PSQI) for sleep
quality, Epworth sleepiness scale (ESS) for excessive daytime sleepiness, international restless leg syndrome
scale (IRLSS) for restless led syndrome (RLS). PSG studies were done for all subjects for assessment of
quality of sleep and sleep parameters. Magnetic Resonance Imaging (MRI) Brain was done for MS patients g
to subtype it according to McDonald criteria 2010.
Results: seventy six percent of MS patients had poor sleep quality according to PSQI (8.6 ±3.7). While
44% had excessive daytime sleepiness according to ESS (12.2±3.6) and 40% had RLS according to IRLSS.
Patients with progressive MS (PMS) either primary (PPMS) or secondary (SPMS) subtypes had poorer sleep
quality index and excessive daytime sleepiness compared to relapsing remitting MS (RRMS) subtype. PSG
study showed decreased total sleep time (TST) and sleep efficiency index in MS patients with prolonged
sleep latency and decreased rapid eye movement (REM) latency and higher total arousal index and periodic
limb movement (PLM) index than control. EDSS of MS patients had positive correlation with PSQI and
ESS. Also EDSS had inverse correlation with TST and sleep efficiency index on PSG.
Conclusion: sleep disorders are prevalent among MS patients. PPMS and SPMS patients showed more
prevalence of sleep disorder than RRMS with poorer sleep parameters on PSG.
Keywords: Multiple Sclerosis (MS), Polysomnogram (PSG), Pittsburg sleep quality index (PSQI),
Epworth sleepiness scale (ESS), international restless leg syndrome scale (IRLSS), expanded disability
status scale (EDSS).

certainly be suffering from comorbid sleep disorders
Complex interactions between genetic and
as does a large part of the general population. Also; A
environmental factors are implicated in the
causative link between MS and some sleep disorders
pathogenesis of Multiple sclerosis (MS) which is an
have been postulated; for example, the prevalence rate
inflammatory disorder of the brain, spinal cord, and
of RLS is four times higher in MS than in the general
optic nerves of unknown etiology (1,2,3).MS develops
population (10). And some MS patients present
between the ages of 20 and 40years with average
narcolepsy-like symptoms. But; it is difficult to
age of 30years and women are twice more affected
differentiate if these sleep disorders are due to MS or

than men (4).Two million people and more have MS
independent of it (e.g. idiopathic narcolepsy) (11). sleep
worldwide with the highest prevalence rate in
disorders were present among 74% of consecutive MS
North America and Europe (4).
patients in a recent polysomnographic cross sectional
MS considered to be the most common
study (49 out of 66 patients) (12).
disabling non-traumatic neurological conditions in

young adults according to the World Health
Organization (WHO) (5,6). Sleep disorders are very
- To assess the quality of sleep and prevalence
common in the general population. The
of sleep disorders in patients with MS by
prevalence of sleep apnea syndrome is 4% among
clinical and PSG studies.
men and 2% among women in the workforce (7).
- To evaluate the severity of sleep disorders
While, the prevalence of restless leg syndrome
between RRMS and PMS patients.
(RLS) is 10.6% with women more affected than

men (8). Insomnia is prevalent among 6 to 18% of the
general population (9).The high prevalence rate of
Study Design: A case control study.
sleep disorders suggests that MS patients will
Study Period: Between October 2015 and January


Full Paper (vol.755 paper# 27)

c:\work\Jor\vol755_28 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2930-2933
Corneal Endothelial Cell Changes in Type 2 Diabetic Patients
Mahmoud Abd El Haleem Rabea, Mohamed Mohamed Aly Ibrahim, Ahmed Ismail Mohamed Ismail
Ophthalmology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Mohamed Aly Ibrahim, Tel: 01094924717, E-mail: dr_m_aly@hotmail.com

Diabetic eye disease is an end-organ response to the effects of the condition on the human system. The
cornea is a transparent structure protecting the anterior one-sixth of the eye. Chronic hyperglycemia can affect the
corneal layers shape and functions that responsible for corneal transparency.
Comparison of the changes in corneal endothelium namely, cell density (CD), percentage polymegathism,
cell volume (CV) and pleomorphism (6A) along with central corneal thickness (CCT) in patients of type 2 diabetes
mellitus with normal age and sex- matched subjects.
Patients and methods: A case-control study in Sayed Galal University Hospital. 20 eyes of type 2 diabetic patients
and 20 eyes of age and sex matched controls were included in the study. Age, gender, other demographic data, and
relevant diabetic history were obtained. Full evaluation of both cases and controls including both anterior and posterior
segment complete evaluation was done. Non- contact specular microscopy was used to study the corneal endothelial
Results: The mean endothelial cell density (ECD) was non-significantly lower in type 2 diabetics compared to controls
(p value = 0.751.). There was a highly significant reduction in hexagonally in the cases compared to controls and highly
significant increase in coefficient of variation in the cases compared to controls
Conclusion: This study acknowledged that type 2 diabetes causes a significant decrease of hexagonality and increase
CV (polymegathism). However, non-significant reduction of ECD was documented.
Keywords: Diabetes; Cornea; Endothelial cell changes; Specular Microscopy.


Diabetes is one of the major non-infective diseases in
patients, and healthy adults. They were subdivided into
the globe in the current millennium. The International
two groups:
Diabetes Federation recorded its prevalence to be 246
1) 20 eyes (cases) of diabetic patients.
million in 2007 and may reach to 380 million by 2025
2) 20 eyes (control) of healthy adults.
(1). Type II Diabetes mellitus is a metabolic ailment
Each case had a full ocular examination including
characterized by elevated blood glucose due to insulin
uncorrected visual acuity and BCVA then the
resistance accompanied by relative insulin deficiency.
intraocular pressure was determined by Goldmann
Diabetes mellitus types II represent 90% of diabetics
Applanation Tonometry. Anterior segment evaluation
while 10% primarily due to type I and gestational
was done by use of the slit lamp and posterior segment
diabetes. Diabetic eye disease is an end-organ response
evaluation by use of the ninety diopters auxillary lens.
to the effects of the condition on the human systems.
Slit lamp examination was done to rule out any local
The cornea is a transparent structure protecting the
disease that affect the cornea.
anterior one-sixth of the eye (2).
Specular microscopy of corneal endothelium was
Chronic hyperglycemia can affect the corneal layers
carried out using the noncontact Topcon model SP-1P
shape and functions that responsible for corneal
non-contact specular microscope.
transparency (3). Corneal endothelium is the innermost
These machines can auto-tract the cornea and
layer of hexagonal non-replicating neural crest-derived
autofocus on the endothelium without touching the
tissue that is responsible for maintaining corneal
cornea. It also provides high magnification, good
transparent throughout life by pumping excess fluid out
quality image. It has semi-automated, computer-
of the stroma and keeping stroma in its usual dehydrated
assisted cell count assessment and morphometric
state (4). Corneal endothelial cell count is vital for
maintaining corneal clarity (5).
Taking three images; central, nasal and temporal. The
Non-contact Specular microscopy is a non-invasive
"panorama" function of the SP-1P automatically
method of morphological analysis of the corneal
combines those images creating a large area for the
endothelium. It enables the measurement of mean cell
observation and analysis of endothelial cells, and then
count. This provides an index of the corneal endothelial
analyze the cell sizes according to various factors that
layer function.
includes cell density, the CV of cell area (SD/mean),

hexagonality. About 100 cells were counted in each
image analysis.
This study was planned to be case-control study
Further morphometric analysis and automated cell
assessing forty eyes. Comparing mean corneal
analysis was done to obtain mean corneal endothelial
endothelial cell count changes between type II diabetic
analysis and automated cell analysis was done to obtain

mean corneal endothelial cell density (ECD,

Full Paper (vol.755 paper# 28)

c:\work\Jor\vol755_29 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2934-2941

Effect of Sildenafil Citrate When Added to Low Molecular Weight Heparin and
Small Dose Aspirin on Uteroplacental Perfusion in Cases of High-Risk Pregnancy
Asem A. Abdo Mousa (1), Mohamed A. Mohamed (1), Mohamed S. Radwan (2),
Amr M. Sholkamy
(1) Department of Obstetrics and Gynecology, (2) Department of Clinical Pathology, Faculty of Medicine, Al-Azhar
UniversityCorrespondence to: Amr M Sholkamy, Mobile: (+20)01012347145; E-Mail: amr_sholkamy@yahoo.com

incubation with sildenafil citrate limits the effects of vasoconstrictors on myometrial small arteries of
normal pregnancy women and pregnant women with fetal growth restriction. So that phosphodiesterase inhibitors seem
to improve uterine perfusion safely in pregnancies with fetal growth restriction.
Objective: the main aim of this study was to demonstrate the effect of sildenafil citrate when added to low dose aspirin
and low molecular weight heparin on the uterine and umbilical artery Doppler to improve neonatal outcome in patients
with high risk pregnancy.
Subjects and Methods: the study was conducted at Al-Azhar University Hospitals, Cairo, Egypt. From March 2017 to
March 2019 over a period of two years duration. One hundred patients (50 in each arm of the study), who had or have
a high-risk pregnancy, were selected and enrolled into a randomized clinical trial.
Results: there was significant increase in amniotic fluid index (AFI) and umbilical artery Doppler parameters. Group
B (heparin/aspirin) also showed significant improvement in fetal biometry and Doppler parameters but when comparing
the differences between the two groups, none of these changes were statistically significant except for the femur length
measurement and the uterine artery resistance index.
Conclusion: from the results of our study we concluded that heparin and aspirin combination or when sildenafil is also
added have beneficial effects in the treatment of pregnant women whom vascular impairment is expected showing
improvement in the fetal growth parameters and reduction of admission.
Keywords: sildenafil ­heparin - aspirin ­ Outcome.

Pregnancies with fetal growth restriction are
Pregnancy is considered an acquired
expected in elevated peripheral resistance in the maternal
hypercoagulable state due to increased concentration of
arterial system as seen in pregnancies with preeclampsia
coagulation factors, decreased levels of anticoagulants
(6). A poor perinatal outcome is expected in pregnancies
and decreased fibrinolytic capacity (1). The gradual
with high vascular resistance in uterine circulation, but
increase in hypercoagulability during normal pregnancy
the pregnancies in which the resistance values are
predisposes to venous thromboembolism such as deep
normalized in the later trimesters have a significantly
vein thrombosis and pulmonary embolism and to
better outcome (7).
gestational vascular complications, including recurrent
In a normal pregnancy, the trophoblast
pregnancy loss, intrauterine growth restriction (IUGR),
produces nitric oxide (NO) which plays an important role
preeclampsia and placental abruption. These adverse
in vasodilatation in the fetoplacental circulation to
pregnancy outcomes affect up to 15% of gestations and
improve oxygen and nutritional supply to the fetus (8, 9).
are the major cause of maternal and fetal morbidity and
Nitric oxide relaxes arterial and venous smooth muscle
mortality (2). Anticoagulant therapy is indicated during
potently and might inhibit platelets aggregation and
pregnancy for the prevention and treatment of venous
adhesion. Nitric oxide donors, as vasodilating agents,
thromboembolism, systemic embolism in patients with
must be the possible therapeutic approach for embryo
mechanical heart valves and, in combination with
development and fetus growth. The umbilical vein
aspirin, for prevention of recurrent pregnancy loss in
endothelial cells in FGR do not respond to chronic
women with antiphospholipid antibodies (3).
It has been long recognized that in
vasoconstriction (10). As a locally potent vasodilator,
preeclampsia, a severe maternal endothelial dysfunction
nitric oxide helps regulate perfusion by counter
must be identical to placental pathology to that
balancing the effects of other vasoactive agents (11).
underlying fetal growth restriction (4). Vascular
Moreover, increased circulating phosphodiesterase
endothelial activation is also present in pregnancies with
(PDE) activity is suspected in women with preeclampsia
fetal growth restriction without preeclampsia (5).
(12). In pregnancies with fetal growth restriction and
without preeclampsia, a reversible increased myometrial


Full Paper (vol.755 paper# 29)

c:\work\Jor\vol755_30 The Egyptian Journal of Hospital Medicine (April 2019) Vol. 75 (5), Page 2942-2951

Treatment of Bicondyler Tibial Plateau Fracture by Single Lateral Locked Plate
Ahmed Badawy, Hesham Safwat, and Mohamed El-Sheshtawy El-Saedi*
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed El-Sheshtawy El-Saedi, Mobile: (+20)01154405169, E-Mail:

Background :
bicondylar tibial plateau fractures need surgical treatment to achieve good clinical results. The
locking plate combines the technical advantages of an angular stable plate with those of the modern biological
plating technique. Aim of the study: to verify management of bicondylar tibial plateau fractures by single lateral
locked plate including patient selection, fracture type suitable for this kind of surgery, timing of surgery, operative
technique, postoperative instructions and follow up. Patients and Methods: between January 2018 and February
2019, 20 patients with a mean age of 38 years (Range: 24-57 years) with bicondylar tibial plateau fractures with or
without metaphyseal extension. Patients were diagnosed clinically, checked with standard X-rays, CT was done for
all cases. Patients were treated by single lateral anatomically contoured locked plate through LISS or polyaxial
locking plate systems with or without additional screws from medial side. Results: the mean Functional Rasmussen
Knee score at last follow-up was 94.7% ranged between 83.3% and 100%. The mean Anatomical Rasmussen Knee
score at last follow-up was 92.2% ranged between 77.7% and 100%. Mean Functional Rasmussen Knee score of
patients had (Schatzker V fractures) was 96%, however it was 82.5% in those had (Schatzker VI fractures).
Conclusion: surgical treatment of bicondylar tibial plateau fractures with the single lateral locked plate that was
evaluated in our study can lead to a good functional and anatomical outcome and considered an effective system for
providing fracture stabilization provided that the correct surgical technique is used.
Keywords: Tibial plateau fracture, Locked plate, LISS, Polyaxial locking plate.

compromised skin and soft tissue envelope which
The tibial plateau refers to the proximal end of
invite a high rate of complications following attempted
the tibia including the metaphyseal and epiphyseal
open reduction and fixation. Secondly, poor bone
regions as well as the articular surfaces made up of
quality and comminuted fracture patterns, which create
hyaline cartilage. By Arbeitsgemeinschaft für
difficulty in achieving rigid fixation since the purchase
Osteosynthesefragen/Orthopaedic Trauma Association
in osteoporotic and trabecular bone is less than optimal
(AO-OTA) classification, the tibial plateau includes
to permit weight bearing or even to start joint motion
the metaphysis to a distal distance equal to the width
of the proximal tibia at the joint line. Tibial plateau
Surgical treatment of bicondylar plateau
fractures constitute 1% of all fractures and 8% of
fractures foresees stabilization with an external ring
fractures in the elderly (1).
fixator, and internal fixation with medial and lateral
The injury patterns to the tibial plateau depend
plates using two surgical approaches. The need to
on the magnitude of forces, the quality of the bone and
minimize the risk of such complications as soft tissue
the age. It is generally believed that the relatively
damage and instability calls for surgical treatment,
increased strength of the medial tibial condyle
which allows to restore joint congruency as well as
structure, and the normal valgus alignment of the
correct rotational and axial alignment. Several Authors
lower limb are responsible for the higher incidence of
introduced the concept of ``indirect reduction'' of
lateral tibial condylar fractures secondary to low-
fractures, without damaging the surrounding soft
energy forces. Similar amount of forces cause split or
tissues or without operating directly in the fracture
wedge fractures in the young population, or depression
site. Based on these concepts, the Minimal Invasive
fractures in the osteoporotic bone of the elders (2). A
Plate Osteosynthesis (MIPO) has been studied and
thorough history should be obtained, including
developed (5).
determination of the mechanism of injury and the

patient's overall medical status, and functional
demands. Physical examination is necessary to detect To verify management of bicondylar tibial plateau
concomitant ligamentous injuries, neurovascular
fractures by single lateral locked plate including
injuries, and other injuries. Anteroposterior, lateral and
patient selection, fracture type suitable for this kind of
oblique radiographs and Computed Tomography (CT)
surgery, timing of surgery, operative technique,
scans are necessary to evaluate these fractures. The
postoperative instructions and follow up.
exact role of Magnetic Resonance Imaging (MRI) in To investigate the advantages and complications of
evaluating patients with tibial plateau fractures is still
surgical treatment by single lateral locked plate and
evolving (3).
compare with other treatment options.
There are two main challenges in management
of bicondylar plateau fractures. Firstly the

Full Paper (vol.755 paper# 30)