Review OF LITERATURE The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3163-3169
Two-Dimension Echocardiographic Assessment of Left Atrial Volumetric Changes
in Patients with Paroxysmal Atrial Fibrillation After Reversion to Sinus Rhythm
Mohammed Osama Fathy Kayed, Yasser El-sayed Mohammed Hassan,
* Reda Sayed Ahmed Albahnasy Abuhassan
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
* Corresponding author: Reda Sayed Ahmed Albahnasy Abuhassan, Mobile: (+20)01060097502,
Although often referred to as "the forgotten chamber", compared with left ventricle (LV), especially
in the past years, the left atrium (LA) plays a critical role in the clinical expression and prognosis of patients with
heart and cerebrovascular disease, as demonstrated by several studies.
Objective: The aim of the work was to assess the left atrium functional and volume changes during atrial
fibrillation (AF) and after sinus rhythm cardioversion in patients with paroxysmal AF, to detect recovery of
effective mechanical atrial function (EMAF) after cardioversion with preserved bioelectrical function.
Patients and methods: This prospective observational study included a total of 75 subjects divided on two groups:
Group 1 (control)
consisted of 25 apparently normal people with normal sinus rhythm, and Group 2 (patients)
consisted of 50 patients with paroxysmal atrial fibrillation, attending at Damanhur Medical National Institute, for
cardioversion. 25 (50%) of patients were cardioverted pharmacologically either by amiodarone or propafenone and
25 (50%) of patients were cardioverted by DC shock.
Results: Mean age of controls involved in the study was 44.60 ± 9.82 years. 56% of them were males. Mean age
of patients was 51.40 ± 7.23, 54% of them were males. Left Anterior Descending Artery (LAD) showed a
significant decreased after cardioversion and after one month. It showed insignificant decrease after 2 months.
Number of patients who did not recovered effective mechanical atrial function (EMAF) after one month were 6
(12%). Conclusion: Left atrial diameters and left atrial volumes increase in AF and showed significant reduction
by the time after successfully cardioversion. Patients who were underwent DC shock had a slower recovery of
atrial function and of LA volumes reduction, implying a greater degree of atrial dysfunction.
Keywords: 2D, EG, LV, LA, AF, HF.

pump function is influenced by venous return, LV
Although often referred to as "the forgotten
end-diastolic pressures, and systolic reserve (2).
chamber", compared with left ventricle (LV),
Because LA structural remodeling and AF are
especially in the past years, the left atrium (LA) plays
closely related, it is recommended that LA size and
a critical role in the clinical expression and prognosis
anatomy be assessed routinely in all AF patients (3).
of patients with heart and cerebrovascular disease, as
LA size is typically assessed with standard 2-
demonstrated by several studies (1).
dimensional (2D) echocardiography. The LA
Until recently, the LA had been subordinated
anteroposterior diameter derived from a conventional
to the LV, but cardiologists now recognize that LA
parasternal long-axis view is used to estimate LA
function is indispensable to normal circulatory
size. However, because asymmetrical remodeling
performance, conditioning the morbidity and
occurs in LA dilation, it is recommended that LA
mortality in several diseases. So, an early detection of
volumes be assessed using a volumetric method (2).
LA dysfunction is anticipated to provide new insight
The aim of the work was to assess the left atrium
into pathophysiology and clinical management of
functional and volume changes during AF and after
several conditions such as atrial fibrillation (AF),
sinus rhythm cardioversion in patients with
valvular heart disease, hypertension, heart failure
paroxysmal AF, to detect recovery of effective
(HF), and cardiomyopathy (1).
Normal LA function can be divided into 3
cardioversion with preserved bioelectrical function.
distinct phases. During ventricular systole, the LA

serves as a reservoir for blood drained by the
pulmonary veins. During early ventricular diastole,
This prospective observational study included a
the LA is a conduit for the pulmonary venous return.
total of 75 subjects divided on two groups: Group 1
During late systole, the booster pump function of the
(control) consisted of 25 apparently normal people
LA completes the LV filling. Whereas the LA
with normal sinus rhythm, and Group 2 (patients)
reservoir function is determined by atrial compliance,
consisted of 50 patients with paroxysmal atrial
atrial relaxation, and contractility, as well as LV
fibrillation, attending at Damanhur Medical National
systolic function and end-systolic volume, the LA
Institute. Approval of the ethical committee and a
conduit function is influenced by LA compliance and
written informed consent from all the subjects
LV relaxation and compliance, and the LA booster
were obtained.

Full Paper (vol.761 paper# 1)

c:\work\Jor\vol761_2 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3170-3175

The Role of Serum Levels of Insulin-Like Growth Factor-1 and
Brain-Derived Neurotrophic Factor in Predicting Recovery in Stroke
Samah Bastawy1,*, Ali Mahmoud Ahmed 2
1 Department of Clinical Pathology, 2 Department of Neurology, Faculty of Medicine,
Helwan University, Cairo, Egypt
*Correspondence to Samah Bastawy, Email:

Despite the neurotrophins like brain-derived neurotrophic factor and insulin-like growth factor-1 are thought
to have important role in neurorehabilitation, the factors that affect these biomarkers are not well known.
We aimed to investigate the effect of maximal aerobic exercise on serum neurotrophins levels in patients with
chronic stroke and to investigate the factors that affect their resting and exercise-associated levels.
Patients and Methods: Potential factors of resting and exercise-related serum neurotrophins levels were studied among 35
patients with chronic stroke. Resting brain derived neurotrophic factor, resting insulin-like growth factor, exercise-
dependent change brain derived neurotrophic factor, and exercise- dependent change in insulin-like growth factor were
studied using demographic, disease burden, and cardiometabolic factors.
Results: Brain-derived neurotrophic factor did not change after exercise (p = 0.38) while insulin-like growth factor
decreased (p = 0.001). Higher resting brain-derived neurotrophic factor was determined by greater lower extremity
impairment (p = 0.004, r2 = 0.23). The greater response of brain-derived neurotrophic factor to exercise was determined by
higher fluid intelligence (p = 0.01, r2 = 0.18). Resting insulin-like growth factor-1 was not changed by all of the studied
factors. Conclusion: Resting and percent change in brain-derived neurotrophic factor were associated with cognitive and
physical recovery after chronic stroke. On the other hands, insulin-like growth factor-1 was not useful in chronic stroke.
Interestingly, fluid intelligence was positively associated with exercise-related rise in brain-derived neurotrophic factor.
Keywords: Neurotrophins; IGF-1; BDNF; Stroke.


The use of established biomarkers is a part of
correlated with good outcomes. In some studies, the
personalized medicine as it aims to guide the proper
measured serum levels of IGF-1 on admission did not
medical treatment (1). Despite stroke biomarkers, like
show any association with functional outcome (5).
neuroimaging and genetic testing, have been established
Levels of serum BDNF and its function as a
(2), serum levels of neurotrophins (NTs) are relatively low-
predictive biomarker is not well established. Previous
cost biomarkers requiring minimal health-care resources
study in chronic stroke has revealed that serum level of
(e.g. blood sample). Furthermore, NTs, like brain-derived
BDNF was not correlated with NIHSS-defined functional
neurotrophic factor (BDNF) and insulin-like growth
outcome and the levels declined in three months (6).
factor-1 (IGF-1) are proposed to be important factors for
However, another study suggested that serum level of
assessing neurorehabilitation in stroke.
BDNF was stable up to six months after the stroke and did
IGF-1 is an auspicious biomarker for stroke as the
not relate to time since the occurrence of the stroke (7).
low resting levels of serum IGF-1 is correlated with bad
Stanne et al. (8) demonstrated that serum BDNF level <10
outcome. Supportingly, Åberg et al. (3) demonstrated acute
days after the stroke was lower in patients with stroke than
increase in the serum IGF-1(1­10 days) and three months
healthy patients and that decreased levels were correlated
after admission and predicted good outcome for up to two
with bad functional outcome two years later. On the other
years (as defined by Modified Rankin Scale) after the
hand, Santos et al. (7) revealed that BDNF did not have
stroke. Furthermore, Denti et al. (4) revealed that patients
association with motor function. Moreover, there is focus
with stroke and had low levels of IGF-1 were associated
regarding BDNF as a biomarker of psychological
with worse outcome. Increased ratios of serum IGF-1 to
outcomes since lower levels of BDNF has been correlated
bound IGF-1 on admission were proposed to predict good.
with the presence of depression after the stroke. Moreover,
National Institutes of Health Stroke Scale- (NIHSS)
levels of BDNF may be related to BDNF genotype (9(.
defined functional outcome at three months. Among 15
Therefore, although NTs have potential predictive value
patients with acute stroke, patients with increased
for indicating recovery after stroke, their predictive value
circulating IGF-1 had good predicted level of fitness
in stroke is not well-established.
before the stroke. However, there was a debate regarding
NTs have been investigated at both rest and after
whether increased or decreased levels of IGF-1 are
biological stress. They have been revealed to rise,

Full Paper (vol.761 paper# 2)

c:\work\Jor\vol761_3 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3176-3183
Sub-urethral Mini Sling versus Transobturator Vaginal Tape for Treatment of
Female Stress Urinary Incontinence, One Year Follow-up
Mohammed Raafat Abdelalim Hasan, Mostafa Ezzeldeen AbdelMagid, Ibrahim Alaaeldeen Tagreda
Department of urology, Faculty of Medicine, Al-Azhar University
Corresponding author: Mohammed Raafat Abdelalim Hasan; Mobile: +201147285367;
Stress urinary incontinence (SUI) is a common problem in women, which accounts about 50% of
all incontinent women and affects the quality of life. The mid-urethral sling is the mainstay of SUI treatment over
the last years. Tension-free vaginal tape (TVT), has been used as minimally invasive procedure for SUI.
To compare outcomes of sub-urethral minisling and transobturator tape (TOT) for treatment of female
SUI, one year follow up regarding operative time, length of hospital stays, postoperative pain perception, general
postoperative complications, surgical site infections and early recurrence.
Patients and Methods: This comparative study has been conducted in Al-Hussein and Sayed Galal Hospitals;
Al-Azhar University; Cairo; Egypt and it included 96 cases, 8 patients missed communication data, 9 refused to
participate, 34 in minisling group and 45 in transobturator tape (TOT) group. This a retrospective study for follow
up of operated cases during the period from July 2015 to June 2018 at the Urology Department, Al-Hussein, Sayed
Galal University Hospitals; Cairo; Egypt.
Results: In our study, the minisling operation was associated with nearly the same hospital stay of transobturator
tape (TOT). We had early recurrence rate among minisling operation. Finally, the transobturator tape (TOT)
operation was associated with less recurrence rate and recurrence time postoperatively compared to the minisling.
Minisling when compared to transobturator tape (TOT) for treating SUI; transobturator tape (TOT)
yielded better outcomes regarding the postoperative 1 year follow up compared to the minisling.
Keywords: Minisling, Transobturator Tape (TOT), SUI, 1 year follow up.


Many procedures involved suspending and
Stress urinary incontinence (SUI) is a
supporting the bladder neck and proximal urethra in
common problem in women, which accounts about
retropubic space at high position, this method prevent
50% of all incontinent women and affects the quality
their descent during times of increased intra-
of life (1).
abdominal pressure. These techniques were effective,
The mid-urethral sling is the mainstay of SUI
with mean 3-7-year continence rate of 77% (9).
treatment over the last years (2). Tension-free vaginal
Recently sub urethral pubovaginal sling
tape (TVT), was used as minimally invasive
operations have become more common among
procedure for SUI(3). It was associated with many
urologists and gynecologists. In 1942, Aldridge
serious complications because of the blind passage
developed the first sub urethral sling using rectus
through the retropubic space, such as bladder
fascia which avoided the need for a laparotomy,
perforation, vessel and bowel injuries (4).
therefore decreasing morbidity, but a second incision
Subsequently, transobturator slings were
was still required either abdominally (to harvest rectus
developed with comparable cure rates and relatively
fascia) or on the inner thigh (for fascia lata) (10).
less complications compared with TVT (5).
The efficacy and less invasiveness of these
Transobturator approaches were associated with the
procedures led to other procedures such as the trans
risk of persistent groin and thigh pain (6). So tension-
obturator tape (TOT) technique, and more recently
free mid-urethral vaginal sling, which is known as
prepubic TVT. All of these procedures keep the same
single-incision minislings (SIMS) is developed with
principles of mid-urethral, tension-free placement of
the same efficacy and the advantage of avoiding both
a synthetic sling material (11).
retropubic and groin muscle pain (7).
Minisling is the latest in the logical
SIMS looks promising and as effective as
progression of synthetic slings used in the minimally
TOT at short term evaluation, however, a clear
invasive treatment of SUI. However, the next step
statement in favor of the widespread use of SIMS
toward a less invasive, tension-free, mid-urethral
cannot be made due to lack of studies comparing the
sling was to develop a system that could be placed
efficacy of these techniques on long-term.
through one small vaginal incision. The TVT-
The prevalence of urinary incontinence in
SecureTM device uses a single vaginal incision to place
women ranges from 25 to 51 percent, using the
a sub urethral macroporous polypropylene mesh tape
inclusive definition of any leakage at least once in the
without exit wounds. The product can be placed either
past year (8).
in a U-shape, similar to the trans obturator tape

position, or a V-shape, similar to the retropubic tape
position (12).

Full Paper (vol.761 paper# 3)

c:\work\Jor\vol761_4 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3184-3190
Effects of Chronic Use of Tramadol on Uterus and Ovary of Albino Rats
Hatem Ali Ahmed Abd El-Mottaleb1, Shrief Fahmy Mahmoud1, Ashraf Ibrahim Hassan1,
Al-Sayed Mohamed Ibrahim Tealeb2 and Gamal Zakaria Almorsy3
Departments of 1Forensic Medicine and Toxicology, 2Pathology, and 3Clinical Pathology
Faculty of Medicine, Al-Azhar University
Corresponding author: Hatem Ali Ahmed Abd El-Mottaleb,
Mobile: 01007766568
The researches on endocrinopathy related with oral opioids had focused more on males, while fewer
studies had focused on females. Objective: it was to demonstrate the possible chronic tramadol toxic effect
(histopathological & biochemical) on ovary and endometrium of adult female albino rats.
Materials and methods: Twenty-five female rats (control group), were given normal food and water, while one
hundred adult female rats were given 30 mg/kg/day tramadol dissolved in distilled water (which represent 1/10
LD50) on daily basis for each rat for 3 months (An average 0.6ml for each rat). Rats were weighted at the beginning
of the study and then 2 times weekly. At end of this period, blood samples were taken for Biochemical analysis.
Rats' ovaries and uterus were examined by light microscope after staining with Haematoxylin and Eosin, and then
data were analyzed and statistically studied. Results: Our study showed gradual decrease in female body weight and
levels of sex hormones. In tramadol treated group, ovaries showed apparent decrease in the number of growing
follicles and an increase in the number of corpora lutea. The medulla showed dilated congested blood vessels. Many
of the follicles appeared atretic. In the corpora lutea, there were degenerated cells. While endometrium in tramadol
treated group there was apparent atrophic glands and stroma in the surface of the endometrium with appearance of
inflammatory cells in the stroma.
Conclusion: it has harmful histopathological and functional effects on the reproductive organs of female albino rats.
Keywords: tramadol, ovary, uterus, rat.

group, suggesting opioid-induced endocrinopathy (8).
Chronic pain is one of the most common
Symptoms and signs of sex hormone deficiency occur
problems in medicine and despite the recent
in both men and women but are under-reported and are
introduction of new painkillers; opioid analgesic
often clinically unrecognized (8).
drugs are still considered the most effective therapies
The potential effects of long term opioid
for treatment of moderate to severe pain(1). Tramadol
therapy on the endocrine system should be explained
is centrally acting analgesic with weak opioid action.
to patients before opioid therapy is commenced.
Prolonged use of opioids may induce addiction
Monitoring of sex hormones is recommended; if there
resulting in physical and psychological dependence(2).
are deficiencies opioids should be tapered and
Tramadol is a commonly abused drug in Egypt
withdrawn, if this is clinically acceptable.
especially among youth. Tramadol abuse has
If opioid therapy has to continue, hormone
dramatically increased in Egypt since 2008 and has led
replacement therapy should be initiated and monitored
to many admissions to addiction treatment centers(3).
by an endocrinologist (9).
In a study by Abbas et al. (4), done in Zagazig

Governmental Hospitals, Egypt, demonstrated that
tramadol was found to be the second most common
The present study aims to demonstrate the possible
substance abused after cannabis (Bango). According
chronic toxic effects (histopathological and
to the records of Poisoning Control Center (PCC) of
biochemical) of tramadol on both the ovary and the
Ain Shams University Hospitals in Egypt, there are
uterine endometrium of adult female albino rats.
trading jumps in numbers of admitted patients with

tramadol toxicity in the last few years (5). The
widespread of tramadol use is due to its availability

through illegal marketing, its easily illegal smuggling
A) Materials
and its cheap prices (6).

Studies have shown that opioid therapy leads
1- Tramadol hydrochloride (TH) purchased from
to impaired endocrine function and dysregulated sex
Mina Pharm Egypt. Each tablet of tramadol contains
steroid balance in women.Longterm opioid use
exposes women to unique risks, including
2- Kits: Kits for determination of serum Estrogen,
endocrinopathy, reduced fertility (7). More than half of
Progesterone, Follicular Stimulating Hormone (FSH)
the opioid-taking women aged 30­50 had nonsurgical
and Luteinizing hormone (LH) purchased from Roche
amenorrhea (52%), compared with 20% of the control
Diagnostics Sandhofer in Germany.

Full Paper (vol.761 paper# 4)

c:\work\Jor\vol761_5 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3191-3197

Amelioration Effects of Aphanizomenon Flos-aqua (AFA) on
Hazardous Effects of Mixture (Sodium Benzoate, Mono Sodium glutamate and
Chlorophyllin) Intake in Male Albino Rats
Eman G.E. Helal*1, Mohamed A. Abdelaziz2, Neama M Taha3, Nahla S.A. EL-Shenawe1
1Department of Zoology, Faculty of Science (Girls), 2Department of Physiology, Faculty of Medicine (Boys), Al-
Azhar University, Egypt, 3Department of Physiology, College of Medicine, Umm AL-Qura University, KSA
*Corresponding Author: Eman Helal, Email:,
Mobile: 00201001025364,

Background: Food additives are products added to the basic foodstuffs with an aim of improving its aspect, flavor,
taste, color, texture, food value and conservation.
Aim of the work: This study aimed to determine the effects of AFA against the hazardous effects of sodium
benzoate, chlorophyllin and monosodium glutamate. Materials and methods: This study was done on thirty male
albino rats with an average body weight 120-140 g. The animals were divided into three groups (10 rats/each) as
follows: Group 1: control, Group 2: rats treated with food additives mixture (sodium benzoate, chlorophyllin, and
monosodium glutamate) and Group 3: rats treated with mixture, in addition to AFA (blue green algae). Blood
samples were collected, and the separated sera were used for estimation of some biochemical parameters (liver
enzymes, kidney function tests, glucose, HOMA-IR, protein profile and lipid profile) and hormonal levels
[testosterone, triiodothyronine (T3) and thyroxine (T4)].
Results: The study showed an increase in levels of fasting glucose, insulin, HOMA-IR, activities of AST and ALT,
urea, creatinine, total cholesterol (TC), triglycerides (TG), LDL-C, VLDL, ratios of TC/HDL-C and LDL-C/HDL-
C (risk factors) in mixture group. This was accompanied by a significant decrease in protein profile (total protein,
albumin and globulin), HDL-and testosterone hormone levels as compared to the control rats. On the other hand,
these results turned back nearly to the normal values after receiving the AFA (blue green algae).
Conclusion: the present study clearly revealed the therapeutic capability of AFA to fight the grievous effects of
food additives mixture on major physiological parameters.
Keywords: food additives, sodium benzoate (SB), Chlorophyllin(CHL), monosodium glutamate(MSG), AFA
(blue green algea).


and lipid ratio as well as their ability to renounce the
Monosodium glutamate (MSG) is the sodium salt
activity of peroxidase and RBCs (2).
of glutamic acid, an amino acid that is a precursor that
Sodium benzoate was the first preservative
can lead to kidney sugar deficiency. Previous studies,
allowed by the FDA for use in food products. Sodium
which have also been confirmed in recent reports on the
benzoate in the mitochondria of liver cells is
adverse effects of MSG, have focused on their effects
metabolized by binding to the amino acid glycine and
on the hypothalamic-pituitary axis of the brain, leading
excreted as hippuric acid in urine. Natural excretion of
to its neurodegenerative effects, nerve endocrine glands
hippuric acid in urine is approximately1 ­ 2 mL and
and induction of obesity. Recent studies have studied
400 ­. 800 mg of glycine is excreted as hippuric acid in
the metabolic and toxic effects of MSG, with a number
the urine daily. Food consumption containing sodium
of reports showing induction of oxidative stress in
benzoate increases this amount. Glycine excretion from
different tissues of experimental animals after the
the body indicates impaired function of the liver in
administration of chronic doses of MSG. The
metabolic processes in which glycine is essential. In
management of monosodium glutamate was also
addition, low glycine levels in the body can reduce
associated with hyperglycemia conditions based on
creatinine levels, glutamine, urea and uric acid in the
parameters tested in the brain serum and liver of
urine and increases the levels of these substances in the
blood. Hydrogen and hydrophobic bonds are vital in
phosphatase activity and reduced activity of hexokinase
binding sodium benzoate to the amino acid glycine and
in rat liver. Management of monosodium glutamate
it should be noted that the limited sodium benzoate in
was also associated with increased body weight and
foods is enough for this bond. on mice, sodium
motor activity negatively affected and altered
benzoate at a concentration of 560 mg/kg reduced the
metabolism with fat (1).
weight of the ovaries and FSH and LH hormones
Accordingly, this preliminary study investigated
compared to the control group and decreased
the ability of diets containing sodium salt of glutamic
progesterone hormone at a concentration of 280 mg
acid to alter levels of testosterone, estradiol hormones
compared with the control group. Another study
showed that sodium benzoate at concentration of 200

Full Paper (vol.761 paper# 5)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3198-3203

Folic acid Deficiency and Bronchial Asthma Exacerbations in Children
Enas Tawfiq Ali1, Asmaa Abd El Wakeel Ibrahim1,
Mohammed El-Sayed Abo Ghabsha2, Mohammed Shabana Abd Elwhab1*
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohammed Shabana Abd Elwhab, Mobile: 01009018626; Email:

: Little is known about folate and asthma exacerbations. We examined whether folate deficiency is
associated with asthma exacerbations in Children. Aim of the work: was to assess association of folate deficiency with
increased asthma exacerbations in children. Subjects and methods: The study carried out on fifty children known to
have a history of bronchial asthma aged from 6­15 years. All subjects were subjected to thorough medical history,
full clinical examination, laboratory investigations including pulmonary function tests (spirometry) and serum folic
acid levels. Results: this study showed Percentage of asthma in males more than in females. Viral infection, exercise,
exposure to cold and fumes are the commonest precipitating factors. Analysis of Forced Expiratory Volume in the
first second (FEV1) showed that 30% of cases had a level above 80% (mild impairment), 54% had a level between
60 and 80% (moderate) and 16% had a level below 60% (severe). Serum level of folic acid was lowest in the severe
group (1.20.1), followed by the moderate (2.40.3) then the mild group (3.40.4), with a significant difference when
all the groups were compared with each other (p <0.001).There were significant, positive strong correlations between
folic acid level and each of FEV1% and FEV1/FVC%. Serum folic acid level contributed significantly to the degree
of asthma severity, when adjusted for the other variables and indicated that increase in asthma severity with associated
with each decrease in folic acid level. Conclusions: It could be concluded that folate deficiency is associated with
increased degree of severe asthma exacerbations in children.
Keywords: Asthma; children; folate.


in children, Moreover, folate deficiency or a low folate
Asthma is a chronic inflammatory disease common
level has been associated with increased risks of
in the airways characterized by the obstruction of the
wheeze in children (7).
airway variable, and excessive excretion of airway
Brehm et al hypothesized that Folate deficiency is
inflammation and excessive inflammation in the
airway (1).
exacerbations in children with asthma (8).
The prevalence of asthma and allergic conditions is
The aim of the current study was to assess
increasing worldwide and has coincided with the rapid
association of folate deficiency with increased asthma
and ongoing increase in the percentage of the
exacerbations in children.
population residing in urban areas, The higher

prevalence of asthma and allergic conditions in urban
areas compared to the rural areas suggests that urban-
This case study included a total of fifty children
related environmental factors may contribute to the
aged 6­15 years known to have a history of bronchial
pathogenesis of these conditions (2). In susceptible
asthma diagnosed according to Global Initiative for
individuals, airway inflammation may cause recurrent
Asthma (2018-GINA) (1), attending at outpatient clinic
or persistent bronchospasm which causes symptoms,
of Al-Azhar University and Kotor General Hospitals.
such as wheezing, shortness of breath, chest tightness,
Approval of the ethical committee and a written
and cough, particularly at night (3).
informed consent from all the subjects were
Changes in dietary habits or supplementation of
obtained. This study was conducted between April
nutrients may partly explain the current burden of
2018 to March 2019.
asthma in industrialized countries (4).
The studied children were sub-classified according
Folate, a cofactor in the transfer of one-carbon
to severity in three group (mild, moderate and severe).
Exclusion criteria: Children who had to be free of
adenosylmethionine, a key molecule in DNA
respiratory illnesses for 4 or more weeks. Avoid (when
methylation. Because DNA methylation can affect
possible) the use of inhaled short- and long-acting
gene expression, there has been considerable interest in
bronchodilators for at least 12 hours before testing,
the role of folate in the pathogenesis of asthma (5).
Even though multiple studies have examined the

relationship between prenatal use of folate and new-
All children included in the study were subjected to
onset asthma, very few studies have examined whether
the following: Full history taking: Personal data:
folate status is associated with disease morbidity or
name, age, sex and residence. Present history: Age of
disease severity in subjects with established asthma (6).
onset of the disease. Symptoms including wheezes,
High dietary intake of vegetables (a source of
shortness of breath, cough and sputum production.
folate) is associated with 11% reduced risk of wheeze
Atopic manifestations other than asthma (urticaria,

Full Paper (vol.761 paper# 6)

c:\work\Jor\vol761_7 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3204-3210

Comparative Study of Mean Platelet Volume in Preeclampsia versus
Normal Pregnancy in 3rd Trimester
Ibrahim Ahmed Oun, Abdallah Khaleel Ahmed, Mohamed Khedr and Mohamed Aly Abdelmonem Ragab *
Department of Obstetrics and Gynecology, Faculty of Medicine - Alazhar University
*Corresponding author: Mohamed Aly Abdelmonem Ragab, Mobile: (+20)01001255778

Preeclampsia is a pregnancy-specific multisystem disease that is characterized by development of
hypertension and proteinuria after 20 weeks of gestation, resolving by 6-12 weeks postpartum in previous normotensive
women. The pursuit of safe, reliable, and cost-effective screening tests for prediction of preeclampsia has been the goal
of researchers for many decades, with the aim of improving maternal and fetal outcome, despite the fact that the only
current effective treatment remains delivery of fetus and placenta. Objective: The aim of this study is to compare mean
platelet volume (MPV) in pre-eclamptic and normal pregnant women in the third trimester of pregnancy, and to
evaluate whether this parameter have a prognostic significance in determining the presence of preeclampsia.
Patients and methods: This study was done at Kafr Elsheikh General Hospital from January 2018 to December 2018.
80 pregnant women in their third trimester (from 31weeks gestation to completed 37 weeks gestation) were selected to
participate in the study. Result: We found in our study that CBC, and MPV values do not have any determining effect
on the presence of preeclampsia but the platelet count showed difference. In the literature, papers that include
conflicting results especially on MPV values are available, yet this fact is most probably due to the differences between
the methods and/or equipment used.
Conclusion: Our study found that MPV values do not have any determining effect on the presence of preeclampsia.
Keyword: MPV, Preeclampsia, Pregnancy in 3rd trimester.

improving maternal and fetal outcome, despite the fact
that the only effective treatment is delivery because
multisystem disorder that is characterized by
pathologic changes caused by preeclampsia are
development of hypertension and proteinuria with or
reversible once pregnancy has ended (5).
without body edema after twenty weeks of gestation,
In preeclampsia there is a decrease in the platelet
resolving by 6-12 weeks postpartum in previous
count and life span, and increased MPV (6).
normotensive women(1). It occurs in about 5% to 10% of
Conflicting results were published regarding
all pregnancies and results in substantial maternal and
platelet number and volume changes during normal
fetal morbidity and mortality (2).
pregnancy and preeclampsia. Some researchers found no
Although the etiology of preeclampsia is still
difference in platelets count and MPV values between
unclear, recent hypothesis have been proposed that the
preeclamptics and controls (7), whereas others
current most accepted hypothesis is abnormal
demonstrated lower platelet count and higher MPV in
placentation leading to placental ischemia (3).
preeclamptics, referring these changes to increased
Preeclampsia is a syndrome that involves many
platelets consumption in preeclampsia (8).
organs, liver, kidney, placenta, brain, hematopoietic, and

In addition, it is known that different systems used
coagulation system (4). A good diagnostic test for
in measurement of MPV can yield different results up to
preeclampsia would be especially useful in this setting.
40%. This can explain the differences between studies
Conditions that make the diagnosis of preeclampsia
but results still remain solid since all the measurements
superimposed upon chronic hypertension highly likely
were done with the same anticoagulant and with the same
are as follows: A) New-onset proteinuria (0.3 g of protein
system (7).
in a 24-hour urine collection) after 20 weeks' gestation.

B) Any of the following in a woman with hypertension
and proteinuria before 20 weeks' gestation:
The aim of this study is to compare mean platelet
Sudden increase in proteinuria.
volume (MPV) in pre-eclamptic and normal pregnant
Sudden increase in blood pressure in cases in which
women in the third trimester of pregnancy, and to
hypertension was previously well controlled.
evaluate whether this parameter has a prognostic
Thrombocytopenia (platelet count of less than
significance in determining the presence of
100,000 cells per cubic millimeter).
Increase in alanine aminotransferase (ALT) or

aspartate aminotransferase (AST) to abnormal levels
Study design: A case control study was performed.

The pursuit of safe, reliable, and cost-effective
Participation: 80 pregnant women in their third
screening tests for prediction of preeclampsia was the
trimester (from 31 weeks gestation to completed 37
goal of researchers for many decades, with the aim of
weeks gestation) were selected to participate in the study,
they were assigned to 2 groups:

Full Paper (vol.761 paper# 7)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3211-3214
Retinal Nerve Fiber Layer Thickness Affection in Diabetic Retinopathy
Abdallah Hussein Hamed, Ahmed Gomaa El Mahdy, Mohamed Abdo Badawy Mahmoud*
Department of Ophthalmology, Faculty of Medicine for Boys, Al-Azhar University
*Corresponding author: Mohamed Abdo Badawy Mahmoud, Mobile: 01118525863, E-Mail:

diabetic retinopathy is a chronic progressive, potentially sight-threatening disease of the retinal
microvasculature associated with the prolonged hyperglycaemia and other conditions linked to diabetes mellitus such
as hypertension. Objective: Evaluation of the retinal nerve fiber layer thickness in patients with type II diabetes
mellitus. Patients and Methods: Cross sectional design;, there is greater confidence the study has internal validity
due to the systematic subject selection and equity of groups being compared. This is a prospective comparative study
will be carried on forty eyes in patients with Type II Diabetes Mellitus. All investigations were carried out at Al-
Azhar University hospitals. Written and informed consent were taken before the investigations.
Results: The male to female ratio in our study showing in diabetic group without retinopathy 12 to 8, while in the
NPDR group showing 10 to 10 with a total male to female 22 to 18 in the study. In our study, the difference between
NFL thickness measurements between four quadrants (upper, lower, nasal and temporal) between Diabetic group with no
diabetic retinopathy and NPDR group is significant.. Conclusion: All quadrant retinal nerve fiber layer thinning is
associated with peripheral neuropathy in patients with Type 2 diabetes.
Ganglion cell layer, nerve fiber layer, intraretinal microvascular abnormalities.


The diabetic retinopathy is a chronic
endothelial growth factor (VEGF). Angiogenic factors,
progressive, potentially sight-threatening disease of the
like VEGF, stimulate growth of new retinal blood vessels
retinal microvasculature associated with the prolonged
to bypass the damaged vessels. This is referred to as
hyperglycaemia and other conditions linked to diabetes
mellitus such as hypertension (1).
proliferation extends beyond the ILM. This may sound
Diabetic retinopathy falls into two main
like a good idea, but the new vessels are leaky, fragile,
classes: non proliferative and proliferative. The word
and often misdirected. They may even grow off the retina
"proliferative" refers to whether or not there is
and into the vitreous. As the vitreous shrinks with age, it
neovascularization (abnormal blood vessel growth) in
pulls on these fragile vessels and can cause them to tear,
the retina. Early disease without neovascularization is
resulting in a vitreous hemorrhage and sudden vision loss.
called nonproliferative diabetic retinopathy (NPDR).
These vessels may also scar down, forming strong
As the disease progresses, it may evolve into
anchors between the retina and vitreous causing traction
proliferative diabetic retinopathy (PDR), which is
on the retina. If enough force is created, a tractional retinal
defined by the presence of neovascularization and has a
detachment may occur. This is another mechanism by
greater potential for serious visual consequences (2).
which DR can cause sudden vision loss. If the retina is not
In NPDR, Hyperglycemia results in damage to
re-attached soon, especially if the macula is involved,
retinal capillaries. This weakens the capillary walls and
vision may be permanently compromised (2).
results in small outpouchings of the vessel lumens,
This layer contains about 1.2 million ganglion
known as microaneurysms. Microaneurysms eventually
cells as well as a number of other cell types, including
rupture to form hemorrhages deep within the retina,
"displaced" amacrine cells, astrocytes, enthothelial
confined by the internal limiting membrane (ILM).
cells, and pericytes. The thickness of the ganglion cell
Because of their dot-like appearance, they are called
layer is greatest in the perifoveal macula consisting of
"dot-and-blot" hemorrhages. The weakened vessels
between eight and ten rows of nuclei (60­80 m),
also become leaky, causing fluid to seep into the retina.
decreases to a single row outside the macula (10­20
Fluid deposition under the macula, or macular edema,
m), and is absent from the foveola itself (3).
interferes with the macula's normal function and is a
Ganglionic axons travel towards the optic
common cause of vision loss in those with DR.
nerve head within the nerve fiber layer. Thin and
Resolution of fluid lakes can leave behind sediment,
difficult to discernin the far periphery, the nerve fiber
similar to a receding river after a flood. This sediment
layer becomes hicker towards the disc as a result of the
is composed of lipid byproducts and appears as waxy,
convergence of all retinal ganglion axon fibers on the
yellow deposits called hard exudates. As NPDR
optic disc. 44 G.D. Hildebrand and A.R. Fielder The
progresses, the affected vessels eventually become
axons are accompanied by astrocytes in the nerve fiber
obstructed. This obstruction may cause infarction of the
layer and are separated into small bundles by the
nerve fiber layer, resulting in fluffy, white patches
cellular processes of Müller cells and the internal
called cotton wool spots (CWS) (1). In PDR, as
limiting membrane. The exact cross-sectional ordering
mentioned earlier, the retina has a high metabolic
of the axonal fibers of the peripheral and central
requirement, so with continued ischemia, retinal cells
ganglion cells in the retina remains controversial (4).
respond by releasing angiogenic signals such as vascular

Full Paper (vol.761 paper# 8)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3215-3223

Evaluation of Corrective Rhinoplasty in Cleft Lip Nasal Deformity
Ahmed Maged Elmofty, Ahmed Taha Sayed,
Ahmed Mohammed Abd El Fattah Hanno
Department of Plastic, Reconstructive and Burn Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Mohammed Abd El Fattah Hanno,
Mobile: 01093756025, email:
Cleft lip nasal deformities are challenging problems in all aspects and there are debates about timing,
approaches, techniques as well as types of the used grafts.
Evaluation of the results of corrective rhinoplasty in post cleft lip nasal deformity at Al-Azhar
University Hospitals (Al-Hussien and Said Galal Hospitals).
Patients and Methods: This is a prospective clinical study which included thirty patients having post cleft lip nasal
deformity whom underwent corrective rhinoplasty for cleft lip nasal deformity. These patients were managed at Al-
Azhar University Hospitals (Al-Hussien and Said Galal Hospitals) during the period from May 2017 to January
2019. Results: The vast majority of the operated upon patients had an obvious degree of satisfaction after 6 months
to 12 months of postoperative follow up.
Autologous cartilaginous grafts are the most suitable type of nasal grafts, and costal cartilage graft is
the most superior between them. Further studies are needed to justify if primary rhinoplasty is beneficial or it
disturbs the nasal symmetry and leave scared tissues for a potential future intervention.
Cleft nasal deformity, cleft lip.

as well as distinctive nuances. The deformed soft
Primary cleft lip nasal deformity is defined as
tissue and skeletal foundation are further complicated
nasal distortion caused by a cleft lip. Features of
by the long-term effects of anatomic growth and
unilateral and bilateral cleft lip nasal deformity differ
surgical scarring(7).
because of asymmetry, but the anatomical basis is very

similar (1). Cleft lip nasal deformity is present in all
forms of cleft lip with or without cleft palate (2).
Evaluation of the results of corrective
The degree of nasal deformity parallels the
rhinoplasty in post cleft lip nasal deformity at Al-
severity of labial clefting; complete, which is greater
Azhar University Hospitals (Al-Hussien and Said
than incomplete which is greater than the lesser form.
Galal Hospitals).
Even in a mini microform cleft lip, there is a slight

nasal abnormality that often becomes more obvious
with time (1). Nasal deformity is also worse whenever
This is a prospective clinical study which
there is a cleft of the alveolus and secondary palate (3).
include thirty patients having post cleft lip nasal
In primary unilateral cleft lip nasal deformity,
deformity whom underwent corrective rhinoplasty for
the wide piriform aperture and maxillary hypoplasia
cleft lip nasal deformity. These patients were managed
displace the cleft-side alar base laterally, inferiorly,
at Al-Azhar University Hospitals (Al-Hussien and Said
and posteriorly. The anterior nasal spine, anterocaudal
Galal Hospitals) during the period from May 2017 to
septum, and base of the columella tilt toward the
January 2019.
noncleft side. The lower lateral cartilage is splayed
The study was approved by the Ethics
across the cleft and also dislocated from the ipsilateral
Board of Al-Azhar University and an informed
upper lateral cartilage. Framework of the nose is
written consent was taken from each participant in
hypoplastic compared with the noncleft side (4).
the study.
Secondary cleft lip nasal deformity is defined
Inclusion criteria: All patients included in
as those distortions that persist despite primary
this study had the following criteria: 1ry or 2ndry cleft lip
operative maneuvers (5).
nasal deformity. One stage or multi stages procedures
Residual deformity is a result of "failure to
for nasal deformity correction. Male or female. Non
correct," undercorrection, or relapse. Iatrogenic
syndromic. Unilateral or bilateral cleft lip.
deformities include expected (although undesirable)
Exclusion criteria: Patient and parent with
changes and the unintended results of technical error.
unrealistic expectations. Syndromic patients or
For example, as the alar base is moved medially in
associated with other facial anomalies. Any co-
closure of the nasal floor, the lower lateral cartilage
morbidities that affect surgery or anesthesia
bends into recurvatum and a vestibular web often
Preoperative assessment
appears. The alar base may be malpositioned and nasal
Clinical parameters: In the preoperative
tip cartilages may be damaged. Scarring can result in a
evaluation of secondary cleft lip nasal deformity we
stenotic "micronostril" (6).
took a complete, accurate history and reviewed all
The cleft nasal deformity is a common
prior operative notes. Assessment for cleft rhinoplasty
problem that has both consistent and reliable findings,
followed standard and systematic nasofacial analysis.

Full Paper (vol.761 paper# 9)

c:\work\Jor\vol761_10 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3224-3231
Right Ventricular Outflow Tract Time Velocity Integral: A Noninvasive
Echocardiographic Parameter of Right Ventricular Systolic Function In
Cardiomyopathic Patients
Asmaa A. Ali
Cardiology Department, El Zahraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University
Right ventricular dysfunction (RVD) is considered a powerful predictor in patients with left ventricular
dysfunction. So, we should evaluate right ventricular (RV) function in patients with cardiomyopathy to predict RVD and
avoid progression of the disease. Due to the burden of disease, an easily utilized screening tool for identifying such patients
would be helpful to facilitate assessment for advanced therapies.
Aim of the work: to assess RVOT-TVI and its correlation with RV systolic function by different echocardiographic
modalities in patients with dilated cardiomyopathy.
Methods and study population:
70 cases (40 myopathic patients and 30 age and sex-matched healthy persons as a control
group). All cases underwent complete TTE study to measure LV and RV dimensions, volumes and functions. In addition,
TAPSE and RVFAC. RVOT-VTI is calculated. The LV and RV longitudinal strain was also assessed using 2D STE
Results: This study included 70 individuals divided into two groups; G "I" represented 40 patients with cardiomyopathy
and G "II" represented 30 age-and sex-matched healthy subjects as control. Patients with DCM had significantly increased
RV volumes (p<0.001) and significantly lower RV systolic function. In addition, there was significant decreased RVOT-
TVI in cardiomyopathic patients group versus normal group. Moreover, The RVOT-VTI had a significant correlation with
different indices of RV systolic function (RVEF (r=0.457, p<0.001), RV Sm (r = 0.495, p < 0.001) and 2D-RVGLS (r =
0.453, p<0.001), % FAC (r=0.398, p =0.001)).
Conclusion: Right ventricular dysfunction is common in dilated cardiomyopathy. RVOT-VTI is a simple, non-invasive
measure assess RV systolic function in cardiomyopathic patients.
Keywords: dilated cardiomyopathy, RV systolic function, RVOT time velocity integral.

left ventricle (7). This is because the knowledge of RV
Congestive heart failure is always growing health care
function is not affected by the left ventricular (LV)
problem in the United States, as thousands deaths
function and less was known about the role of RV
annually and millions yearly hospitalized [1, 2]. Thus,
physiology and prognosis. Due to the burden of disease,
accurate and timely prediction of high-risk profiles is
an easily utilized screening tool for identifying such
important. As Idiopathic dilated cardiomyopathy (IDCM)
patients and to facilitate its timely assessment for
is the second most common cause of heart failure (HF),
advanced therapies is urgently needed [8].
which is not only caused by disease of the left ventricle

(LV) but also the right ventricle (RV) and may play an
important role in functional capacity of the patients than
Our study was designed to assess RVOT-TVI and
is often recorded [3]. Therefore, the identification of RV
its correlation with RV systolic function by different
systolic dysfunction is of clinical importance however, its
echocardiographic modalities in patients with dilated
evaluation still challenging [4]. As its echocardiographic
assessment is difficult because of its complex anatomy [5].

Right ventricular dysfunction (RVD) is considered a
powerful predictor in patients with left ventricular

dysfunction. So, we should evaluate right ventricular
Study population
(RV) systolic function in patients with cardiomyopathy to
We conducted a retrospective case-control study that
predict early RVD and avoid progression of the disease
enrolled 70 cases (40 myopathic patients and 30 age and
sex-matched healthy persons as a control group). The
Although the 2-D echocardiography is considered
study cases were selected from the Cardiology Out-
an important and integral tool for evaluation of patients
patient Clinic at Al-Zahraa Hospital, Faculty of Medicine
with heart disease but most of its parameters focus on the
for Girls, Al-Azhar University, from March 2018 to April
left chamber function not the right chamber, namely the
2019. A person was considered to have DCM if dilated
right ventricular (RV) systolic function. Early beliefs
LV with systolic function less than 35%.
considered the right ventricle is less important than the


Full Paper (vol.761 paper# 10)

c:\work\Jor\vol761_11 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3232-3236

Prevalence of Pulmonary Disorders in Patients with
End Stage Renal Disease on Hemodialysis
Ahmed E Kabil 1, Fareed Shawky Basiony 1, Mohamed Osama Nour 2, Khaled S. Makboul 3
1Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Egypt
2Department of Public Health and Community Medicine, Al-Azhar Faculty of Medicine, Damietta, Egypt,
Faculty of Public Health and Health Informatics, Umm AL Qura University, Makkah, KSA.
3Department of Internal medicine, Faculty of Medicine, Al-Azhar University, Egypt
Corresponding author: Ahmed E Kabil, Mobile: 01006396601, Email:

Background: The prevalence of patients with end stage renal disease is increasing. Pulmonary diseases have been
suggested to be more common in end stage renal disease patients on haemodialysis.
Aim of the work: It was to evaluate the pulmonary function state and the prevalence of pulmonary disorders in
hemodialysis patients. Subjects and methods: A retrospective study on 61 patients with chronic renal failure on
regular Hemodialysis at El-Hussein University Hospital, Al-Azhar University. Results: The study included 61 chronic
renal failure patients fulfilling the inclusion criteria with mean age 54.23 ± 10.07 years that ranged from 26 ­ 77 years
old. Females represent 62.3%, about one third of patients (31.15%) were smokers and slightly more than half of them
living in rural areas Pulmonary functions were affected in nearly half of them (restrictive 27.87%, obstructive 14.75%
and mixed 6.56%). Variety of pulmonary disorders coexisted in about 69% of patients with 22.95% suffered from
pleural effusion, 16.39% had TB, 11.48% and 8.20% developed pulmonary embolism and pulmonary edema
respectively and finally community acquired pneumonia and uraemic asthma. Conclusion: Respiratory disorders
especially restrictive lung pattern, pleural effusion, pneumonia and pulmonary embolism were associated with end
stage renal disease on regular hemodialysis. Recommendation: Any patient with chronic renal failure, especially
patients on regular hemodialysis should be observed early for detection of any pulmonary diseases or disorders.
Keywords: Renal failure, Hemodialysis, pulmonary disorders.

Fluid overload, together with the marked increase in
Chronic kidney disease (CKD) is that type of kidney
pulmonary capillary permeability can result in
disorder in which there is gradual decline of kidney
pulmonary edema and pleural effusion, abnormalities
functions over a period of months up to years. It may
that may explain, at least in part, the decline in
be asymptomatic in early stages. Later, leg edeoma,
pulmonary functions. Since hemodialysis help in
tiredness, repeated vomiting, loss of appetite, or
removing excess body fluid, it can also lead to
disturbed level of consciousness may develop.
improvement in pulmonary functions by decreasing the
Complications may include cardiac diseases, elevated
water content of both lungs (5).
blood pressure, bone disorders, and anemia (1). Chronic

kidney disease affected about 753 million people
worldwide in 2016, including 417 million females and
The present study was a descriptive, retrospective
336 million males. In 2015, it resulted in 1.2 million
study that conducted at El-Hussein University
deaths. While in 1990, 409,000 deaths were reported.
Hospital, Cairo, Egypt. 61 patients, referred for Chest
The causes that contribute to that large number of
Department for evaluation for any pulmonary disorders
deaths included high blood pressure at 550,000,
during the period from January 2016 to June 2017,
were included in the current study. All patients were
glomerulonephritis at 238,000 (2). Different pulmonary
with end stage renal disease on hemodialysis. The
abnormalities, including pulmonary edema, pleural
study was approved by the Hospital Ethical
effusion, acute respiratory distress syndrome,
Committee and a written consent was obtained
pulmonary fibrosis and calcification, pulmonary
from each patient prior to the procedure. All
hypertension, haemosiderosis, pleural fibrosis, and
patients were subjected to the following: Full history
sleep apnea syndrome, have been reported in these
taking , physical examination, plain chest x-ray:
patients (3).
(postero-anterior and lateral views), complete blood
Impaired pulmonary function may be precipitated
picture, liver and kidney function tests, arterial blood
by the direct effect of circulating uremic toxins or may
gases, pulmonary function test and CT chest if needed
be indirectly caused by fluid overload, anemia,
for confirming the diagnosis of the pulmonary
immune suppression, extraosseous calcification,
complications. All medical records of the patients were
malnutrition, electrolyte disorders, and/or acid-base
retrospectively revised.
imbalances, which are common issues in hemodialysis
Inclusion criteria: All patients had end stage renal
patients (4).
disease and on hemodialysis.

Full Paper (vol.761 paper# 11)

Differential Expression of CD56-Immunostaining of Liver Tissue in Biliary Atresia and Other Neonatal Cholestatic Disorders The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3237-3244
Histological Study of Emerging Role of Exosomes Based Therapeutic in
Management of Hepatocellular Carcinoma Rat Model
Suhaib Naeem1*, Hassan Sabry1, Mohammed Abduh1, and Marwa Matboly2
Departments of 1Histology and Cell Biology, Faculty of medicine,Al-Azhar university, Cairo, Egypt and 2Medical
Biochemistry and Molecular Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Suhaib Naeem, Phone: +201004488927, E-Mail: and

hepatocellular carcinoma (HCC) is the most common type of primary liver cancers with high incidence
and mortality rates. The major risk factor for HCC is cirrhosis, which occurs usually due to HBV and HCV infection.
Exosomes thought that have a major role on the promotion and spread of HCC, which can be uased as therapeutic and
diagnostic marker. Objectives: we aimed to use evaluate their role in HCC assessment and their use as potential
selected diagnostic biomarkers, and to characterize the efficacy of Hesperidin on modulating exosomal production
and exosomal non-coding RNA related HCC expression using animal models.
Materials and Methods: the study included 30 Rats devised to 5 groups 6 on each, controle and DiethyleNitros amine
(DEN) and Acetamidofluorene (2-AAF) to iduce HCC group and Hispiridine treated groups with three different dosos
50 mg, 100 mg and 200 mg respectively for three groups. infants with neonatal cholestasis in three groups. Results:
improvement of all of them, regarding liver histopathology wich the HCC focus regressed , regarding exosomal
abundance in the serumand tissues while the evaluation of exosomal RAB11A-mRNA in rats' samples was performed
by real time PCR, then the results were statistically analyzed by the SPSS software. Finally regarding to liver function
test which the ALT, bilirubin and AFP reduced in the treated groups.
Conclusion: exosomal RAB11A-mRNA as biomarkers for HCC inducedrats and target these exosomal markers
using Hesperidin in animal model and hence we can uses as thrapuetic bases in HCC in the future.
HCC, Exosomes, DEN and 2-AAF and Hispiridine.

regulate cellular processes by `trafficking' molecules
Liver cancer is a leading cause of cancer deaths
from cells of one tissue to another (6).
worldwide, accounting for more than 700,000 deaths
Exosomes originate when endocytic vesicles on the
each year The American Cancer Society's estimates -
plasma membrane are fused to form early endosomes,
of primary liver cancer and intrahepatic bile duct
and mature into late endosomes which undergo inward
cancer in the United States for 2017 are about 40,710
budding, in which vesicles form on the membrane of
of newly diagnosed cases and 28,920 died people of
the endosome and are internalized (7); At this point, the
these cancers(1). In Egypt; liver cancer is a serious if not
endosome contains multivesicular bodies (MVBs),
the most serious cancer problem. It is ranked the first
while the vesicles within the MVB are called
among cancers in males (33.6%) and the third among
intraluminal endosomal vesicles (ILVs) . Rather than
females based upon results of National Cancer Registry
fusing with the lysosome, the MVBs fuse with the
Program (NCRP 2008-2011)(2). The rising rates of
plasma membrane, releasing their internalized ILVs
hepatocellular carcinoma (HCC) in Egypt are due to the
within extracellular space. Once the ILVs are released
high prevalence of hepatitis B virus (HBV) and
into extracellular space, they are considered
hepatitis C virus infection (HCV) among Egyptian
exosome(8). Exosomes carry a variety of contents,
population(3). Therefore; we need effective strategies
including various proteins, DNA, mRNA, microRNA
for early detection and better management of HCC,
(miRNA), long non-coding RNA (lncRNA), and even
which will be of great value in developing countries
viruses. According to the ExoCarta database
with limited resources and high incidence rates of
(, the presence of 41,860
HCC, such as Egypt. It has been well known that tumor
proteins, more than 7540 RNA molecules and 1116
development is a multistage process to accumulate
lipid molecules has been confirmed in exosomes in
alterations at the genetic and/or epigenetic level which
more than 286 studies (9).
ultimately reprogrammed a cell to undergo
Exosomes are excreted by nearly all cells and
uncontrolled proliferation and metastasis (4). The
contain genetic materials and various molecular
expression of initial mutations depends not only on the
signatures. they may be regarded as suitable
internal interaction between oncogenes but also on
biomarkers for cancer diagnosis, allowing for diagnosis
external factors such as exosome, which could change
and prognosis via a minimal invasive procedure. The
the patterns of specific gene expression temporarily (5).
transfer of exosomes between cells allows for
Exosomes are cell-derived vesicles that convey key
intercellular communication an essential component
elements with the potential to modulate intercellular
for biological and pathobiological functions. Based on
communication. They are known to be secreted from
their functions, exosomes are considered molecular
all types of cells, and are crucial messengers that can
cargo (10). Exosomes promote invasive phenotypes,

Full Paper (vol.761 paper# 12)

c:\work\Jor\vol761_13 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3245-3248
Randomized Comparative study between Reversed and Insitu Great
Saphenous Vein Grafts in Infrapopliteal Revascularization
Tawfik Alaaeldein Tawfik Omar*, Abdelaziz Ahmed Abdelhafez, Omar Mokhtar Elhayeg,
Ashraf Abd Elmonem Sayed Ahmed
Departments of Vascular surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Tawfik Alaaeldein Tawfik Omar, Mobile: (+20)01115795756, Email:

Foot ulcer is a disabling complication and not uncommon among patients with DM, the predictive
factors for diabetic foot ulcer development were peripheral neuropathy, duration of diabetes, poor glycemic control,
and peripheral vascular disease which was a major significant risk factor.
Aim of the study
: to determine whether Reversed or Insitu Great Saphenous Vein Grafts is the optimum In
Infrapopliteal Revascularization. Patients and Methods: diabetic patients referred to Vascular Surgery department
of Al-Azhar University Hospitals and Nasr City Hospital were included if they had foot lesions such as ulcers,
gangrene or tissue necrosis and had no palpable pedal pulses. End points were healed, healing, non healing or
amputation. Fifty diabetic foot patients were included.
Results: twenty-four patients reached the end point of adequate healing or complete healing, whereas twenty-six
patients had nonhealing lesions. The Ankle Peak Systolic Velocity (APSV) was significantly higher in patients with
Reversed Great Saphenous Vein Grafts compared with patients with Insitu Great Saphenous Vein Grafts: 57.8cm/s
(±12.72) versus 24.9 cm/s (±9.55), p < 0.001. At a cutoff point of 40 cm/s, the APSV showed sensitivity of 90.91%,
specificity of 100%, positive predictive value of 100%, negative predictive value of 92.3%, with diagnostic accuracy
of 97.4% in predicting healing of diabetic foot lesions. There was a significant difference between the APSV before
and after revascularization: 23.4 cm/s (±6.5) versus 58.8 cm/s (±12.3), p < 0.001. Conclusion: both reversed and
insitu great saphenous vein grafts have good patency in infrapopliteal revascularization.
Keywords: Diabetes mellitus, Diabetic foot ulcer, Ankle Peak Systolic Velocity, Peripheral vascular disease.

committee. Every patient signed an informed written
Foot ulcer is a disabling complication and not
consent for acceptance of the research.
uncommon among patients with DM, the predictive

factors for Diabetic foot ulcer development were
Inclusion criteria:
peripheral neuropathy, duration of diabetes, poor
Diabetic Patients with absent pedal pulses and
glycemic control, and peripheral vascular disease which
complaining of foot lesion (tissue necrosis, ulcer, or
was a major significant risk factor (1).
The ankle-brachial index (ABI) is widely used
Exclusion criteria:
for the assessment of the degree of peripheral
ischemia(2,3). However, this parameter is not accurate in
autoimmune ulcers, ischemic limbs (i.e. rest pain) but
the presence of arterial wall calcification as it gives
without foot lesion.
falsely high results(4). The toe-brachial index (TBI) has

been used as an alternative because digital arteries are
Clinical examination:
less affected by calcification(5,6). However, the incidence
At the initial clinical presentation full history
of digital artery calcification among diabetics is still
was taken from every patient and the clinical data were
significant(7). In addition, it is impossible to measure toe
prospectively collected regarding age, gender, risk
pressures in a substantial number of patients presenting
factors and comorbidities, ABI and full details of duplex
with diabetic foot lesions because the toes are affected
scanning, including APSV. Lesions were treated by
by ulcers or gangrene or have been amputated, which
daily dressings and followed up monthly. Post
makes the TBI invalid or impossible to use(8).

standardized. Patients were followed up until they
reached one of the end points of the study, which were a
This study included 50 diabetic foot patients
healed wound, a healing wound, non healing wound and
who presented to the Vascular Surgery department of
major amputation. A wound was considered completely
Al-Azhar University Hospitals and Nasr City Hospital,
healed if it was fully covered with intact skin. It was
Cairo, Egypt, during the period from April 2017 to April
considered adequately healing if it was completely
2019.The patient population consists of 28 males and 22
covered with healthy granulation tissue, with absence of
females with a mean age 62.2 years (± 7.2).
tissue necrosis or infection. It was considered nonhealed

if it did not show signs of healthy granulation tissue
Written informed consent:
during follow-up.
An approval of the study was obtained from
During follow-up, data were collected regarding
Al- Azhar University academic and ethical
wound status, the details of the management plan,

details of duplex scanning including APSV, ABI.

Full Paper (vol.761 paper# 13)

c:\work\Jor\vol761_14 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3249-3253

An Audit of Cesarean Section in Obstetric Department at Benha Educational Hospital
Mohamed Abdelwahab Seid Ahmed
Department of Obstetrics and Gynecology, Benha Educational Hospital,
Met-Ghamr City, Eldaqahlia Governorate, Egypt
Mobile: 01068730406; Email:

The aim of the study is to make an audit for all females delivered by cesarean section (CS) at the Department of
Obstetrics and Gynecology at Benha Educational Hospital for 6 months, so as to improve the quality of care and perform
continuous quality improvement. Our study concluded that cesarean section was performed for women of different ages
commonly between 18 ­ 45 years. The most common indication of cesarean section was previous cesarean section.
Postoperative stay was mainly between 1 to 4 days. The resident doctors were the main surgical staff who performed
cesarean section and spinal anesthesia was the most common method of anesthesia used.
Keywords: Audit, Cesarean section, Benha Hospital.


There has been a marked increase in the number of
and carried out on all pregnant women giving birth by CS
cesarean sections in many countries during the last years (1-3)
within 6 months from June 2018 till November 2018. This
for example, cesarean sections are now performed in over 22
study included 1500 females that gave birth, 979 (65.3%)
percent of all births in Great Britain (4), and in 30 percent of
delivered by CS, 521 (34.7) delivered by vaginal delivery.
all births in the USA (5,6). Cesarean section is the common
This study is a cross sectional prospective study. The data
surgical procedure done for women in the USA (5, 6). With this
was completed from the data sheet that was prepared for
increase in the number of cesarean sections, the cost of
every female who attended Benha Educational Hospital for
maternity care was increased. (7)
cesarean section.
It was claimed that the cesarean section rate is too
The study was approved by the Ethics Board of
high, and that future increase in the rate should be limited,
Benha Educational Hospital and an informed written
for economic and medical reasons. For example, in the
consent was taken from each participant in the study.
WHO guidelines, it is recommended that the cesarean
The data sheets were checked for the followings
section rate should not be more than 10-15 percent in any
data as: [Full history taking, Thorough clinical examination
country (8). This is supported by studies that show an
increased risk of adverse side effects with cesarean
(Preoperative investigations {CBC, ABO, Rh, Urine
section, particularly if the medical indications are weak
analysis, Fasting blood sugar, PT, PTT, INR,ALT,AST,
(9). Examples of complications after cesarean section are
Urea, Creatinine}, Ultrasonography to assess the
hemorrhage, infection, and thrombosis, and women have
followings:{Gestational age (preterm- full-term- post-term),
an increased risk of complications in subsequent
placental site (fundal posterior- fundal anterior-placenta
pregnancies (such as uterine rupture and placenta previa)
previa marginalis), Liquor Amnii (adequate ­
polyhydramnios -oligohydramnios) and Biophysical
Cesarean section rate in Egypt increased from
profile}, The different indications reported in the data sheet
15.3% in 1992 to 18.5% in 1995 to a high of 20.9% in
were summarized in the following factors:{Previous
2000. Dis-aggregation by type of hospital (public or
cesarean section, Absolute Indications and Relative
private) showed a rising trend of cesarean section in both
Indications which includes: (breech presentation, face
private and public birth (13).

hemorrhage. Maternal causes (preeclampsia, eclampsia, DM
and others), failed induction, failed progress, postdate,
The study was aimed to audit the management of
obstructed labour, Assisted reproductive technique (ART),
cesarean section in Benha Educational Hospital so as to
Amniotic fluid causes (PROM, drained liquor, Severe
improve the quality of patient care and outcome and to
oligohydramnios) and twins, preoperative preparations
drive continuous quality improvement.
(Antibiotic - showering), Sterilization of skin, Fixation of

urinary catheterization or not, Type of anesthesia either:
spinal or general, Surgeon who performed the operation
This study was conducted at the Department of
either resident, assistant specialist or specialist, Type of
Obstetrics and Gynecology, in Benha Educational Hospital
uterine incision either LSCS or USCS, Intraoperative

Full Paper (vol.761 paper# 14)

c:\work\Jor\vol761_15 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3254-3259

Value of Serum Zinc, Magnesium and Copper in Obese and
Normal Weight Children
Hassan Abdel Aziz Gaber, Tarek Abdel Kareim Eldahshan, Sabry Mohammed Ghanem,
Mostafa Ahmed Abdo Abdel Fatah
Departments of Clinical Pathology and pediatrics, Faculty of Medicine, Al-Azhar University
Corresponding author: Mostafa Ahmed Abdo Abdel Fatah, E-Mail:,
Mobile: 01000478283

: Childhood obesity is one of the most serious public health challenges of 21st century. The problem is
global and is steadily affecting many low- and middle-income countries. The rising prevalence of childhood overweight
and obesity represent a major health concern, as obesity is an important risk factor for a number of diseases. A strong
evidence indicating that a disturbance of serum levels of zinc, copper and magnesium plays important role in the
development of obesity and its related diseases. Our aim is to determine the mean zinc, magnesium and copper levels in
obese and overweight children as compared to the levels in normal weight controls to study its relationship with
overweight and obesity.
Objective: We aimed to assess, evaluate and compare serum zinc, magnesium and copper in obese, overweight and
normal-weight children.
Patients and methods: The study was a case-control study conducted on 60 subjects 20 obese children, 20 overweight
children and 20 normal weight children. All of them were subjected to full history taking, complete examination, and
routine investigation including CBC, SGOT, SGPT, RBS, urea, Creatinine, TSH, lipid profile and specific laboratory
investigation including serum zinc, magnesium and copper.
Results: In obese and overweight children, there were increased serum copper levels together with reduced serum levels
of zinc and magnesium regardless age and sex when compared to normal weight children.
Conclusion: In obesity, there were increased serum copper levels together with reduced serum levels of zinc and
magnesium regardless age and sex. Obese and overweight may be at a greater risk of developing imbalance (mainly
deficiency) of trace elements, which may be playing an important role in the pathogenesis of obesity and related
metabolic risk factors.
Keywords: childhood, obesity, overweight, normal weight, zinc, magnesium, copper.


Childhood obesity is one of the most alarming
worldwide that clearly showed a direct link between
challenges developing in today's world. The problem is
obesity and micronutrient deficiencies. Deficiencies of
universal and is steadily affecting many low and middle-
various micronutrients associated with increased BMI
income countries, particularly in urban settings. In urban
have an essential role in the metabolism of a variety of
centers, we can see a rise in sedentary lifestyles and
nutrients and have a key role in regulating hunger and the
unhealthy eating habits at an earlier age (1).
hormones that control it (1).
There is a dramatic rise in the prevalence of
Zinc is essential micronutrient for maintaining
obesity among Egyptian children that has reached
the structure and form of protein molecules; it is in many
alarming levels (2).
cases fundamental to their function as enzymes or
Our knowledge on abundance of trace elements
structural proteins. Diverse physiological processes
in human tissues and fluids has increased significantly
including cell replication are impacted by zinc
due to improvements in analytics. Analytical methods
deficiency. Zinc is necessary for immune defense
have become useful in exploring the relationship between
systems, growth, intestinal function, and brain
basic composition of body fluids and tissues,
development (4).
pathological conditions, and general nutritional status in
Zinc insufficiency in humans is demonstrated for
humans. However, the literature on trace elements status
the first time in 1960 in Iran and then some cases were
in obesity in children and adults is scarce (3).
reported from Egypt and Turkey. Zinc has shown to be
Micronutrients and macronutrients have been
useful for improving appetite and food intake, can affect
implicated as an important factor in regulating various
reduction of anxiety and stress and this may be another
metabolic processes and thus playing a role in the
mechanism for the effect of zinc on appetite (5).
etiology of obesity. Many studies are being conducted

Full Paper (vol.761 paper# 15)

c:\work\Jor\vol761_16 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3260-3267

Prognostic Value of Programed Cell Death-1 Ligand Expression in Colorectal
Cancer and Its Correlation with Cytotoxic Tumor-Infiltrating Lymphocytes
Ghada E. Esheba
Department of Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt
* Corresponding author:Ghada E Esheba ,email:

Background: colorectal cancer (CRC) is a major cause of cancer-related death worldwide. In recent years, targeting
the programed cell death (PD-1)/ programed cell death-1 ligand (PD-L1) immune checkpoint signaling has been tested
as a novel promising treatment strategy in several tumors. Aim of the work: the present study aimed to examine
expression of PD-L1 and CD 8+ T cells in CRC and to evaluate the relationship between their expressions and the
different clinicopathological features. Material and methods: expression of PD-L1 in tumor cells (TC) as well as in
tumor infiltrating immune cells (TIMC) was separately evaluated in 85 cases of CRC by the immunohistochemistry,
in addition, CD8+ T cell count was assessed. Results: 12.9 % of cases showed PD-L1 expression in TC while, 28.2%
showed PD-L1expression in TIMC. PD-L1 expression in TC was significantly associated with higher tumor grade (P
=0.001), lymph node metastasis (LNM) (P =0.006) and lymphovascular invasion (LVI) (P > 0.001). On the other
hand, PDL-1 expression in TIMC was significantly associated with low tumor grade (P=0.016), negative LVI (P =
0.004), high tumor infiltrating lymphocytes (TILs) count (P <0.0001), as well as high CD8+ T cells count (P = 0.002).
High intra CD8-positive T cells was significantly associated with absence of LNM (P =0.013) and negative LVI (P
=0.035). Conclusion: these findings indicated that expression of PD-L1 can be used as a new biomarker to predict
the prognosis of colon cancer and may provide a clue for immunotherapy in the adjuvant treatment of CRC patients.
Keywords: colorectal cancer, PD1, PDL-1, CD8 + lymphocytes.

and limiting cancer cell killing. Subsequently, the anti-
Colorectal cancer is one of the most common
tumor immune response is dramatically impaired. To
cancers in men and women and is a major cause of
switch back this unfavorable situation, several
cancer-related death worldwide. Although significant
blockades of the PD-1/PD-L1 pathway have been
advances in multidisciplinary therapies have improved
developed (1).
the outcome, the overall prognosis remains poor espe-
cially in advanced stages. Furthermore, treatment
signaling can restore the native anti-tumor function of
modalities used for advanced stage CRC have been
T cells and facilitate tumor regression, therefore, PD-
found to be of modest potency and are associated with
L1 and PD-1 expressions have been addressed as
serious toxicities (1-3).Recently, immunotherapy by
predictive markers for tumor response to anti-PD-1 or
using inhibitors against immune checkpoint is
PD-L1 immunotherapy in different malignancies and as
considered as a novel modality for the treatment of
potential targets for cancer therapy (4).Tumor-
various malignancies (4).Programmed death-1 (PD-1)
infiltrating lymphocytes (TILs) mirror the host immune
receptor and its ligand, programmed death ligand-1
response directed against tumors. Furthermore, tumor
(PD-L1), have been reported as the major immune
infiltration by CD8+ cytotoxic T lymphocytes has been
checkpoint targets for immunotherapy in many types of
found to be associated with a good prognosis and an
cancers such as melanomas, non-small-cell lung
improved survival of colorectal cancer patients (6, 8,
cancers, renal cell carcinomas, bladder cancers, ovarian
9).PD-L1 expression in tumor cells has been linked to a
carcinoma and breast carcinomas (5).PD-L1, known also
weak host immune response and eventual bad prognosis
as B7-H1 or CD274 is a transmembrane glycoprotein
in several malignancies, including melanoma and
encoded by the PD-L1 gene and is one of B7 family
esophageal, gastric, hepatocellular, non-small cell lung
members. The latter have been reported to down-
cancer and urothelial carcinomas, however, the
regulate T-cell activation. PD-L1 is expressed by the
prognostic significance of PD-L1 expression in
immune cells such as T and B lymphocytes,
colorectal cancer is still controversial whether its
macrophages and dendritic cells as well as nonimmune
expression indicates a better or worse prognosis (5, 10, 11).
cells as endothelial, pancreatic and human tumors
Also, a previous study showed that PD-L1 expression
(6).PD1, the receptor for PD-L1, is a member of the
in tumor cells in gastrointestinal malignancies is less
CD28 family and is expressed on activated T cells and
frequent compared to other solid tumors such as
can also be induced on activated B cells and natural
melanoma (12). Therefore, this study was conducted to
killer cells (7). PD-1/PD-L1 signaling inhibits CD8
evaluate expression of PD-L1 in both tumor cells and in
cytotoxic immune reaction, T cell migration,
proliferation and secretion of cytokine (such as IFN-
microenvironment (stroma) and to investigate the
and IL-2) production, resulting in T lymphocyte anergy
relationship between PD-L1 expression and the
and/or apoptosis, induction of immunological tolerance
different clinico-pathological variables. Also, this study

Full Paper (vol.761 paper# 16)

c:\work\Jor\vol761_17 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3268-3272
Role of Multislice CT in Assessment of Great chest Vessels Anomalies
Imam Mohamed Abdelaziz, Ahmed Ibrahim Mohamed, Yasmin Ashraf Kamel Abd Elhamid*
Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University, Cairo Egypt
*Corresponding author: Yasmin Ashraf Kamel Abd Elhamid, Mobile: (+20)01066863760; Email:
Multidetector computed tomography (MDCT) is a useful, less invasive technique for diagnosing most
types of vascular variations. CT is superior to radiology for identification of normal anatomy, anatomic variants and
early abnormalities or pathological processes. Objective: The aim of this work was to evaluate the role of MDCT in
Assessment of great chest vessels Anomalies. Patients and methods: The study included 30 patients in the age group
between 2 months up to 30 years with a mean of 3 months. All patients were referred for evaluation Great chest
vessels anomalies suspected to be in association with congenital heart disease. Results: CT provide an accurate
assessment of Aortic vessel (Ascending, Arch and descending parts) four cases diagnosed as moderate to severe
Aortic coarctation, two cases diagnosed as supravalvular and subvalvular aortic stenosis, two cases associated with
right sided Aortic Arch, one case with hypoplastic Aortic Arch and another case had tortuous course of the Aorta.
Substantial benefit of CTA is depiction of airway compromise owing to aortic rings. In the setting of coarctation,
collateral vessels are better displayed. Conclusion: It could be concluded that the nowadays ease of the scan
acquisition, the high spatial resolution and the accurate assessment of modern CT techniques make CT chest
angiography an investigation ideally suited for the great chest vessels anomalies.
Keywords: Multislice CT, Great chest Vessels Anomalies, MDCT.

substantially reduces respiratory artifacts. Furthermore,
MDCT is a useful, less invasive technique for
image synchronization with the cardiac rhythm is now
diagnosing most types of vascular variations. CT is
possible, and this should reduce problems associated
superior to radiology for identification of normal
with heart motion. Multi-slice CT with the evolution
anatomy, anatomic variants and early abnormalities or
from 4- to 16- and, very recently, 64-slice technology
pathological processes (1).
has rapidly become an important complementary
Faster computed tomography (CT) scan, Thinner
imaging technique for both pre- and post-operative
collimation, and the development of multi detector
management of patients with congenital heart disease
computed tomography (MDCT), coupled with the
increasing capability of computers to process large
A tremendous progress of CT scan allowed
amounts of data in short periods of time, have led to an
reduction of motion mis-registration artifacts and
expansion in the ability to create diagnostically useful
provided a volume of data that can be processed into
two dimensional (2D) and three dimensional (3D)
thinner sections. The ability of the computer software
images within the thoracic inlet. The objectives of the
to transform these thin axial sections free of motion
present study were to identify the CT angiographic
artifacts into two dimensional images in the coronal and
appearances of vascular system and study the variable
sagittal planes and into three dimensional images
appearance of arterial and venous anatomy in thoracic
further expanded the CT applications. The principle of
inlet on contrast enhanced, upper chest CT (2). The
"going as fast as possible" still allows good image
vascular anomaly is insufficiently demonstrated by
quality in neonates with congenital heart disease;
conventional radiographic techniques, unless the
furthermore, the short acquisition times minimize
vascular anomaly is interfered with low attenuation
respiratory artifacts (5). So, CT angiography is
lung field. CT is used because it clearly Demonstrates
promising method for both detection and therapy
this area free from superimposition, accurately depicts
planning of great vessels anomalies (6).
the size, shape and abnormalities of the thoracic inlet
The aim of this work was to evaluate the role of
structures Vascular structures are usually readily
MDCT in Assessment of great chest vessels Anomalies.
identified on (CT) scans of the chest with intravenously

administered contrast medium. From a single helical
scan, vascular structures can be reformatted in any
This prospective study included a total of 30
plane or rendered in three dimensions (3D), providing
patients referred for evaluation Great chest vessels
a simplified display of even most complex vascular
anomalies suspected to be in association with
anatomy (3). More recently, helical CT has been
congenital heart disease, attending at Al-Zahra
proposed for 3D anatomical visualization in patients
University Hospitals, Cairo, Egypt.
with congenital heart disease. Helical technology
Approval of the Local Ethical Committee and a
allows volume acquisition in a short period of time and
written informed consent from all the subjects for
provides good-quality 3D vascular images, even for
the use of their imaging and histopathologic data in
neonates and infants. The multi-slice CT technology
future research studies were obtained.
now available has much faster acquisition times, which


Full Paper (vol.761 paper# 17)

c:\work\Jor\vol761_18 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3273-3281

Epithelium-On Versus Epithelium-Off Corneal Collagen Cross-Linking for
The Management of Keratoconus
Mohamed Ahmed Ahmed El-malah, Mohamed Mohamed Aly Ibrahim,
Ahmed Mohamed Khater Mohamed *
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Mohamed Khater Mohamed, Mobile: (+20)01229055765,

Keratoconus is a noninflammatory, bilateral, frequently asymmetrical, and most common corneal
ectatic disorder characterized by central corneal thinning, biomechanical weakening, and steepening of the corneal
curvatures leading to substantial distortion of vision. The estimated prevalence worldwide is 54.5 cases/100,000.
Objective: The aim of the work was to compare epithelium-on and epithelium-off corneal collagen cross-linking
for the management of keratoconus as regards keratoconus progression and visual outcome.
Patients and methods: In this study, 20 eyes of 11 keratoconus patient were included. All were having keratoconus
and presented with diminution of vision, increasing myopia and / or astigmatism. Cases with corneal scarring,
corneal thickness less than 400 m at the thinnest point and active corneal infections were excluded. The
preoperative evaluation of patients showed UCVA, In epithelium-on (group 1) ranging from 0.05 to 0.60 with a
mean 0.29 ± 0.21 and in epithelium-off (group 2) UCVA ranging from 0.05 to 0.50 with a mean 0.23 ± 0.13.
Results: The postoperative results revealed improvement of UCDVA and BSCVA at 6 month postoperative in both
groups. The postoperative manifest refraction spherical equivalent showed stability with mild improvement in both
groups. Keratometric readings showed a decrease in curvature in both groups in the follow up period. Corneal
hysteresis (CH) and corneal resistance factor (CRF) showed no significant difference after 6 months of follow up.
Conclusion: It could be concluded that UVA/Riboflavin cross-linking of ectatic cornea by its two techniques is
effective, safe, stable and do not affect corneal biomechanical characteristics, that leads in the majority of the cases
to a halt the progression of ectasia.
Keywords: Epi-Off cross-linking, Epi-On Cross-Linking, Corneal, Keratoconus


Corneal ectasia is a synonym to a group of
approach, designed to arrest the progression and/or
disorders characterized by an inherent state of tectonic
restore a more normal corneal contour is planned (2).
corneal weakness and /or thinning, leading to
The aim of the work was to compare epithelium-
protrusion, irregular astigmatism, leading to reduction
on and epithelium-off corneal collagen cross-linking
of visual acuity, and rarely a risk of perforation (1).
for the management of keratoconus as regards
These disorders comprise both primary
keratoconus progression and visual outcome.
conditions such as keratoconus, keratoglobus,

posterior keratoconus and pellucid marginal
degeneration, and secondary or iatrogenic corneal
This a prospective comparative interventional
ectasia, which may occur after refractive procedures
clinical trial included a total of 20 eyes of 11
such as LASIK (1).
keratoconic patients attending at Al-Azhar University
Management of keratoconus has always been a
challenge. Glasses, contact lenses and intracorneal
Approval of the ethical committee and a written
rings can correct refractive errors due to keratoconus,
informed consent from all the subjects were
in advanced cases with severe corneal irregularity and
obtained. This study was conducted between 2018 and
stromal opacities, keratoplasty may constitute the last
surgical alternative(1).
All patients were presented with diminution of
The primary ectatic corneal disorders are to a
vision, increasing myopia and / or astigmatism. All
great extent similar in clinical presentation.
patients underwent corneal collagen cross linking, 10
keratoconus, pellucid marginal degeneration and
eyes for epithelium-on CXL and the others 10 eyes for
keratoglobus may actually represent variations in the
eptithelium- off CXL.
phenotypic expression of the same pathogenetic

mechanism (2).
Inclusion criteria:
Keratoconus, pellucid marginal degeneration,
1- Documented keratoconus by pentacam.
and keratoglobus have a basic treatment algorithm.
2- Amsler Krumeich classification graded stage1 to 3.
Visual correction starts with glasses, then by contact
3- Best corrected distance visual acuity( BCDVA) is
lens fitting. Failing these modalities, a surgical
6 36 or more.

4- Manifest refractive spherical equivalent is 6 D or less.

Full Paper (vol.761 paper# 18)

c:\work\Jor\vol761_19 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3282-3290

Management of Intermittent Exotropia in Children
Ahmed Salah Abdel-Rehim1, Abdul-Mongy Elsayed Ali1,
Alaa Abdul-Mongy Abdul-Fattah Sadaka2, Dina Hamdy Mohamed Mohamed*1
1Departments of Ophthalmology, Faculty of Medicine, Al-Azhar University,
2 Departments of Ophthalmology, Faculty of Medicine, Aswan University, Egypt
*Corresponding author: Dina Hamdy Mohamed Mohamed, Mobile: (±20)01148728477

Intermittent exotropia (IXT) is a common form of childhood exotropia, accounting for about 50­90%
of all the exotropia and affecting about 1% of the general population.
Objective: The purpose of this study was to evaluate difference modalities for treatment of intermittent exotropia
either by non-surgical and surgical methods. Patients and Methods: this study included 40 patients of both sexes
with exodeviation divided into 2 groups; Group (A): 20 patients subjected to non-surgical treatment and Group (B):
20 patients underwent surgical treatment; bilateral lateral rectus recession (BLR).
Results: In non-surgical group the success rate was 55% after 12 months of treatment. Overminus glasses are more
effective in control of IXT than part-time occlusion (PTO) and convergence exercise. The success rate was 86%.
While the success rate in PTO was 43% and the success rate of convergence exercise was 33%. Poor compliance in
PTO and convergence exercise therapy affect the treatment effectiveness. In surgical group (BLR) the success rate
was 75%. Under-correction was 20% and the overcorrection was 5%. No complications were found. No lateral
incomitance was observed. Conclusion: Surgical method is more effective in treatment of IXT than non-surgical
methods, but the non-surgical method is more important in younger children. The over-minus glasses is more
effective in treatment of IXT than the other non-surgical method due to poor compliance among children in PTO and
Convergence exercise therapy. A larger trial for a longer duration is warranted to assess the effectiveness of different
modalities of treatment of IXT.
Keywords: Intermittent exotropia, children, IXT

refraction. Overminusing induces accommodative
Intermittent exotropia is the most frequent form
convergence, thus reducing the exodeviation. Another
of divergent strabismus (1). It is characterized by
method is part-time monocular occlusion therapy. By
fluctuations in the visual sensory system involving
occluding the dominant eye, the patient is forced to use
binocular vision with stereopsis when the eyes are
the non-preferred eye, thus providing ant suppression
aligned and suppression with abnormal retinal
therapy. Part-time occlusion therapy may be tried in
correspondence when the deviation occurs (2).
younger patients as a method for delaying surgery, but
Intermittent exotropia can be further classified
it is only a temporary measure. Convergence exercise
into three types based on the difference between the
are useful for convergence insufficiency but for most
distance and near deviations: (1) basic, where the
cases of intermittent exotropia. the use of anti-
distance and near deviations are similar within 10 prism
suppression orthoptic therapy and diplopia awareness
diopters (PD) and the target angle is the distance
are not indicated, as this practice to the patient (6).
deviation (3). (2) divergence excess (pseudo and true),
Surgery is thought to be an effective method for
where the exotropia is larger for distance fixation than
the treatment of intermittent exotropia. Popular
near fixation ( 10 PD). True divergence prolonged
intervention criteria include a reduction in or loss of
binocular dissociation by monocular patching (i.e.,
stereoacuity (at near or distance), deteriorating fusional
Patch test). Pseudo-divergence excess is when the near
control, a large angle of deviation, or a combination; but
deviation increases after the patch test, so the distance
potential thresholds remain poorly defined (7).
and near deviation are similar (3) convergence
The goals of the surgery for intermittent
insufficiency when the near deviation is more than 10
exotropia are to restore alignment and preserve or
PD larger than the distance deviation (4) if there is no
restore binocular function. However, the optimal time
significant distance deviation, with an exodeviation for
for surgical intervention remains unclear. The critical
near, then this is a pure convergence insufficiency. It is
point is the postoperative stereoacuity establishment.
more common in teenagers who report asthenopia (3).
Most surgeons believe that early surgery for children is
Both non-surgical and surgical management
indicated to prevent progression to constant exotropia
techniques may be used, the latter being recommended
and restoration of bifixation, whereas in most adult
for poorly controlled or symptomatic exotropia (5).
patients surgery can only help to achieve orthotropia,
In general, there are many methods for
but not bifoveal fixation (8).
nonsurgical treatment for intermitted exotropia .One
The purpose of this study was to evaluate
method is to prescribe 2 to 3 diopters of myopic
difference modalities for treatment of intermittent
correction over what is required by cycloplegic
exotropia either by non-surgical and surgical methods.

Full Paper (vol.761 paper# 19)

c:\work\Jor\vol761_20 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3291-3298

Cardiac Arrhythmia and Blood Pressure Variability in Hemodialysis Patients
Ali Mohammed Al-Ameen*, Mohammed Adel Atia*, Mohammed Sayed Bashandy*, Osama Mohammed
Ahmed** and Bahaa El-din Mahmoud Nawar*
* Cardiology Department, and **Internal Medicine Department, Faculty of Medicine - Al-Azhar University
*Corresponding author: Bahaa El-din Mahmoud Nawar, Mobile: (+20)01003186862, E-Mail:

end-stage renal disease is a global public health burden bearing high morbidity and mortality, and
cardiovascular disease is a major cause of mortality in hemodialysis patients. Objective: the aim of this study is
detection of arrhythmia and blood pressure variability in hemodialysis (HD) patients. Patients and Methods: this
prospective observational study included 100 chronic renal failure patients on regular HD came to the hemodialysis
center of Al-Azhar University Hospital, New Damietta and Kafr Elsheikh General Hospital. The study was carried
out over a period of eight month from July 2017 until September 2018. Results: the intradialytic (ID) blood pressure
was normal in 38%, ID hypertension was reported in 44% and ID hypotension was reported in 18% of HD patients,
also we found that arrhythmia was developed in 84% of HD patients and the prevalence of arrhythmia was VES in
56%, PAC in 50%, SVT in 4%, AF in 8.0%, sinus tachycardia in 26% and sinus bradycardia in 20%. The sympathetic
over activity (LF/HF ratio < 1.5) was reported in 38%; and high risk standard deviation of normal-to-normal intervals
(SDNN) was reported in 22% and moderate risk in 70.0% while low risk was reported in 8.0% of HD patients.
Conclusion: cardiac arrhythmias are common findings in patients with chronic renal failure on regular hemodialysis.
Keywords: Cardiac Arrhythmia, Blood Pressure Variability, Hemodialysis Patients.

End-stage renal disease is a global public health
burden bearing high morbidity and mortality, and
This prospective observational study included 100
cardiovascular (CV) disease is a major cause of
chronic renal failure patients on regular HD came to
mortality in hemodialysis patients (1). Several
the hemodialysis center of Al-Azhar University
electrocardiographic methods can be used to assess
Hospital New Damietta and the Kafr Elsheikh
cardiac arrhythmia risk, including measurement of the
General Hospital. The study was carried out over a
(QT interval and dispersion, signal averaged ECG and
period of eight month from July 2017 until
heart rate variability) (2). Cardiovascular (CV)
September 2018.
autonomic neuropathy and the related risk of arrhythmia
Blood access was through arterio-venous fistula.
may partially explain the observed high rate of (CV)
Dialysis was performed for 4 hours, three times
mortality besides the traditional risk factors, including
weekly using conventional heparin. Blood flow rate
was usually 300­350 ml/min with a dialysate flow
Cardiovascular autonomic neuropathy can be evaluated
rate of 500 ml/min. Ultrafiltration varied according
by heart rate variability (HRV)(3).
to patient's actual weight. The membrane used was
It has also been reported that left ventricular
polysulfone with surface area suitable for each
(LV) mass is increased from the earliest stages of renal
patient. Bicarbonate was the buffer used throughout
disease (near normal renal function), linked to increased
the study for all patients.
QT interval and dispersion, and with minor rhythm
Inclusion criteria:
abnormalities, providing link with the high risk of Ability to achieve the dry weight as determined
sudden death in this population too. Left ventricular
clinically by the nephrologist.
hypertrophy (LVH), systolic and diastolic dysfunction, Controlled hypertension on antihypertensive
and autonomic neuropathy were found among patients
with end stage renal disease (4).
Age more than 18 years old.
Intradialytic hypertension, an increase in blood
Exclusion criteria:
pressure from pre to post-hemodialysis, is a current and Unmeasurable T wave.
persistent phenomenon in hemodialysis patients that has Atrial fibrillation.
been shown to be an independent risk factor for

increased morbidity and mortality(5).Blood pressure
Bundle branch block.
monitoring is common method to evaluate blood Pacemaker.
pressure variability in hemodialysis patient beside to the
Antiarrhythmic drugs that lengthen the QT interval.
Holter ECG monitoring to evaluate heart rate rhythm
Patients with impaired systolic function (EF<40%).
and variability(6).

All patients were subjected to:
I- Before participation in the study, the study protocol
The aim of this study is detection of arrhythmia
was explained for each patient, and an informed oral
and blood pressure variability in hemodialysis patients.
consent was provided by each patient. Also, An


Full Paper (vol.761 paper# 20)

c:\work\Jor\vol761_21 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3299-3306
Histological Study of Effect of Exposure to Emamectin Benzoate on the
Kidney of Adult Male Albino Rats and the Possible Protective Effect of
Ginger Nanoparticles
Mervat Shaker Mehanna, Fatma Al-Zahraa Nabil Mohammed Al-Shahed, Marwa Kamal Taha
Department of Histology, Faculty of Medicine for Girls, Al-Azhar University
Corresponding author: Marwa Kamal Taha, email:


Background: pesticides are pivotal for pest control. However, due to their cumulative nature humans are vulnerable to
daily sub-lethal exposure with increased risk for clinical disorders including kidney diseases. Oxidative stress is the
main proposed mechanism for pesticides biohazards. Aim of this study: to clarify the effect of exposure to emamectin
benzoate (EMB) on structure and ultrastructure of the kidney of adult male albino rats and the possible protective effect
of aqueous ginger nanoparticles extract (GNE) on these changes.
Materials and Methods: four groups were incorporated in this study, six animals each. GI: control group; GII: received
aqueous GNE (100 mg/kg/d); GIII: received EMB (5 mg/kg/d); GIV: received EMB and aqueous GNE. Initial/final
body weight (BW) variations and biochemical tests of serum creatinine (sCr) and blood urea nitrogen (BUN) were
assessed. After one month, both kidneys from all groups were excised under anesthesia and prepared for light and
electron microscopic assessment. The results were statistically evaluated. Results: comparing mean final BW among
all groups revealed insignificant decrease in BW of GIII. There was a significant increase in the mean final sCr and
BUN in GIII which was improved in GIV (p< 0.001). There was a significant increase in area percent of both collagen
fibers deposition and Bax immune-expression in GIII which was markedly diminished in GIV (p< 0.001). Morphologic
alternations were detected in kidney of rats of GIII which was ameliorated in GIV. Conclusion: EMB altered kidney
morphology and aqueous GNE exerted an ameliorative effect.
Keywords: kidney, EMB, nanoparticles, ginger.


Pesticides are used for pest management for
agriculture and health care. Because of their unwise use,
Emamectin Benzoate (Hypnose 5% SG, SAFA

TARIM. A.S, Turkey) in the form of white powder, was

threaten biodiversity, food and water
resources. Thus, biopesticides have become a
generously provided by Agricultural Research Centre,
reasonable alternative (1).EMB is a broad spectrum
Plant Protection Research Institute; El-Dokki, Giza,
biopesticide, belongs to avermectins (AVMs) that are

widely used as pesticides as well as in human and

veterinary medicine. Although once considered safer,
Preparation of ginger nanoparticles (GN):

EMB potential hazard to the environment and human
Plant material:
well-being was recently revealed with induction of
Dried Nigerian white ginger rhizomes (Zingiber
oxidative stress is the main proposed mechanism
officinale) were purchased from local market, Egypt.
(2).Kidney diseases
They were ground using hammer mill at 2890 rpm,

constitute heavy burden upon
economy and health care system. The commonest risk
sieved using a 250m sieve, then was brought down to
factors are diabetes mellitus, hypertension and obesity.
nanosize by dry milling, where 20gm of dried ginger
However, lately, chronic kidney disease of unknown
powder was introduced to the planetary ball mill device
cause reported from different countries including Egypt
(Retsch PM 400, Germany) with 2 mm zirconia beads
has drawn the attention. It is a multifactorial, but the
milled for 4 hours at 550 rpm (5), performed at the
most accepted hypothesis is genetically susceptible
Egyptian Petroleum Research Institute-Nanotechnology
individuals with unfavourable work conditions-e.g. heat
Centre; Nasr City,Cairo,Egypt.

stress and dehydration associated with exposure to

agrochemicals i.e. pesticides and fertilizers- are at major
Preparation of the extract:
risk (3).Ginger (Zingiber officinale) has long been used
The aqueous extract was freshly prepared
in several forms to alleviate various complaints. Its
according to the method of Norhidayah et al.(5), then
basic elements are famous for their antioxidant, anti-
filtrated through filter paper (wattman-5). The filtrate

inflammatory, cytoprotective, hepatoprotective and
was then collected and stored at 4°C until used.

renoprotective bioactivity (4). Nanotechnology is a

promising emerging science. Its privilege is alternating
Characterization of GN:
substance characteristics via converting its size to
Dynamic light scattering (DLS) for particles size and
nanoscale. Milling herbs to nanoscale increase their
exposed surface area and porosity, hence, enhancing
Assessed by using Malvern Zetasizer ZS
their active compounds solubility and bioavailability (5).
(Malvern, UK); performed at Egyptian Petroleum

Full Paper (vol.761 paper# 21)

c:\work\Jor\vol761_22 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3037-3038
Comparative Study between The Refractive Outcome Following
Phacoemulsification and Small Incision Cataract Surgery
Abdel Mongy El Sayed Ali1, Abdulla Mohammed Al Amin Abdulla1,
Ahmed Ibrahim Howaidy2, and Reham Mahmoud Ahmed Mohammed2*
Department of Ophthalmology, Faculty of Medicine, 1Al-Azhar University and 2Aswan University
*Corresponding author: Reham Mahmoud Ahmed Mohammed, Mobile: (+20)01060649543, E-Mail:

phacoemulsification is the preferred technique for cataract surgery for most surgeons. An alternative
surgical technique MSICS has been gaining popularity, because of this technique has been shown to yield comparable
surgical outcomes as phacoemulsification.
Objective: In our study we compared the two techniques as regard their effect on visual acuity, surgically induced
astigmatism (SIA).
Patients and Methods: forty patients were included in this study. Patients were divided into two groups: Group A (20
patients) underwent phacoemulsification and Group B (20 patients) underwent MSICS.
Results: both groups were studied preoperatively and postoperatively regarding uncorrected visual acuity (UCVA), best
corrected visual acuity (BCVA) andsurgically induced astigmatism (SIA). We found that both techniques give excellent
postoperative visual results and that the SIA was 0.43±0.25 in phacoemulsification group and 0.61 ±0.55 in MSICS
group at 3 month postoperative with no statistical difference between both groups (p=0.348) .
Conclusion: according to our study, it is recommended for all surgeons to master MSICS technique for its excellent
results which are comparable to phacoemulsification. For the beginners it could be considered like a step to
phacoemulsification due to many common steps between the two techniques, also for expert surgeons it could be useful
and can replace phacoemulsification efficiently in very hard nuclei and could be done if conversion is decided during
phacoemulsification surgery.
Phacoemulsification, SIA, MSICS

Driven by the need for more cost effective options,
Senile cataract is an age related, vision impairing
an increasing trend in developing countries is the use of
disease characterized by gradual, progressive thickening
manual suturless small incision cataract surgery (SICS),
of the lens. It is one of the world's leading causes of
which some have claimed is comparable to
avoidable blindness (1). All techniques of cataract
phacoemulsification in terms of obtaining excellent
extraction are being modified to achieve best
visual outcomes, faster, less costly and has fewer
uncorrected visual acuity and early rehabilitation (2).
The evolution of cataract surgical techniques over

the past several decades has been associated with a
progressive decrease in the size of the cataract incision.
It is to compare between the postoperative visual
Wound size has progressively decreased from 12.0 mm
outcomes of cataract extraction performed by
in intracapsular cataract surgery about to 10.5 mm in
conventional ultrasonic phacoemulsification and
early extracapsular surgery and about 5mm with the
suturless small incision cataract surgery in senile
advent of phacoemulsification. The widespread use of
cataract as regard surgical induced astigmatism (SIA).
foldable intraocular lens (IOL) has allowed the cataract

wound to decrease to 3.0 mm or smaller (3).
MSICS has the advantages of relatively small
Study Design:
suturless incisions regarding early wound stability, less
The study was conducted as a prospective,
postoperative inflammation, and no suture-related
randomized study, where 40 eyes of 40 patients were
complications such as those in conventional ECCE. It
assigned randomly from the outpatient clinic among
also has the advantage of being manual with no
patients complaining of gradual painless drop of vision
ultrasound-related complications such as those in
and diagnosed as senile cataract.
The subjects of the study were divided into two
In phacoemulsification, the duration of surgery,
groups: Group A: 20 eyes who underwent cataract
phacoemulsification power used, and even the incidence
extraction using conventional phacoemulsification.
of intraocular complications vary with the nucleus
Group B: 20 eyes who underwent cataract extraction
density. In MSICS, the time spent on nucleus delivery
using the Small Incision Cataract Surgery (SICS).
does not vary from patient to patient. Hence, the manual

small incision techniques are gaining popularity, as they
Written informed consent:
are quick, relatively inexpensive techniques for large-
An approval of the study was obtained from Al-
scale cataract management in the developing world(5).
Azhar University Academic and Ethical Committee.

Full Paper (vol.761 paper# 22)

c:\work\Jor\vol761_23 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3319-3323

Assessment of Pulmonary Function in End Stage Renal Disease
Patients on Regular Hemodialysis
Ahmed Muhammed Hasan*, Ahmed Mohammed Alashkar, Nabil Fathy Esmael, Atef Abou Elfotouh Ibrahim
Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Muhammed Hasan, Mobile: (+20)01017655957; Email:

Background: end-stage renal disease (ESRD), is the last stage of chronic kidney disease. When your kidneys fail, it
means they have stopped working well enough for you to survive without dialysis or a kidney transplant.
Objective: it was to assess the pulmonary function in patients with ESRD after hemodialysis.
Patients and Methods: Prospective study which was done in tertiary level care center.Thirty ESRD patients who were
on hemodialysis regularly were studied.
Results: The mean FEV1/FVC% which was observed in the patients of this study was 67.8±20.8% of the predicted
value, after hemodialysis, the mean FEV1/FVC% increased up to 82.3±20.1% of the predicted value, and this increase
was statistically significant with P value <0.006. The mean of the forced expiratory flow 25-75% (FEF 25-75%) of the
studied patients pre-dialysis was 53.1±33% of the predicted value, after hemodialysis, the mean of the FEF 25-75%
increased up to 58.3±34.6% of the predicted value and that was statistically significant with P value <0.05. The mean
of the peaked expiratory flow rate (PEFR) was 47.8±31.7% of the predicted value and after hemodialysis, the mean
PEFR increased to 52.1±30.9% of the predicted value and that was statistically significant with P value <0.05).
Conclusions: pulmonary function tests decrease significantly among ESRD patients who undergo hemodialysis
regularly pre and after the sessions of hemodialysis. Most ESRD patients were with abnormal pulmonary functions,
mainly of a restrictive pattern.
Keywords: ESRD, Regular Hemodialysis.

syndromes is hemoptysis from diffuse alveolar
End stage renal disease (ESRD) is irreversible
hemorrhage, along with renal insufficiency associated
and progressive disease which characterized by
with either acute glomerulonephritis or other vasculitis.
irreversible loss of kidney function. The ESRD is
However, patients may develop alveolar hemorrhage
terminal and final pathway that resulted eventually in
without presence of renal involvement, which may
most of the patients suffering from medical problems
appear later(5).
affecting their renal function. Patients with ESRD need
Many of these disorders such as Wegener's
renal replacement therapy once they are established the
granulomatosis, Microscopic poly-angitis, mixed cryo-
ESRD stage via and that may either be achieved by
globulinemia, Henoch-Scho¨nleinpurpura, immune-
dialysis (hemodialysis or peritoneal dialysis) or need
complex-associated, Good-Pasture syndrome and SLE.
kidney transplantation so as to be able to keep
The deteriorated pulmonary function may be
functioning normal renal life. There was an observed
attributed to the effect of the circulating toxins from the
increase in the morbidity and mortality in ESRD patients
renal uremia or indirectly as an effect from the increased
because of the presence of the renal replacement therapy
fluid load, immune response, electrolyte imbalance,
(HD or renal transplantation). Despite that ESRD may
anemia, malnutrition, and/or acid-base disturbance(7).
appear as a single organ dysfunction, it also affects
The increased of body fluid is a serious and very
multiple organs with variable and numerous
common problem which may cause serious
complications which resulted in multi-organ dysfunction
complications in HD patients.
so the systemic complications presented in ESRD
In the inter-dialytic period, weight differences are
patients are very important (1).
commonly seen in ESRD patients on the regular
One of the most important of these
hemodialysis may be attributed to the increased body
complications is the respiratory system dysfunction
fluid load (8). The increased fluid load, Permeability of
related to renal dysfunction which is a very common
the pulmonary capillary may increase, which can lead to
complication in ESRD patients (2). Rising in the blood
pulmonary edema and pleural effusion; such
urea level, may be the cause that affects the respiratory
abnormalities can explicate the reducedpulmonary
system in the form of pulmonary edema, pleural effusion
normal function (9, 10).
and acute respiratory distress syndrome (ARDS) (3).
Since hemodialysis clears the increased body
Directly or indirectly, renal failure affects
fluid and the uremic toxins, this can be the cause of the
mechanical and ventilatory functions of lung and also
improvement of the pulmonary functions by reducing
drugs and hemodialysis (HD) contribute to the change in
water content of the lungs and excreting the excess toxins
air flow (4). Pulmonary renal syndrome is a group of
resulted from uremia. Many mechanisms may be the
diseases that affects both the pulmonary and the renal
cause of the deteriorated pulmonary function and the
functions (5,6). The most presenting symptom of these
altered bronchial responsiveness presented in ESRD

Full Paper (vol.761 paper# 23)

c:\work\Jor\vol761_24 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3324-3328
Comparative Study between Absorbable Carboxymethyl Cellulose and Non-
Absorbable Merocel Nasal Packs after Sinonasal Surgery
Atef Abdallah El Maraghy, Mohamed Abd Elmoniem Younis, Yehia Mohamed Dawood,
Mamdouh Makram Mohammed *
Department of Otorhinolaryngology, Faculty of Medicine ­ Al-Azhar University
*Correspondence author: Mamdouh Makram Mohammed, Mobile: (+20) 01226275568, E-mail:

Background: Nasal packings can help in control of postoperative bleeding and healing following functional
endoscopic sinus surgery (FESS) and nasal surgeries, but traditional non-resorbable packs have several inherent
drawbacks. Objectives: This study was done to evaluate the effect of carboxy methyl cellulose (CMC) gel and merocel
nasal packs after sinonasal surgery regarding postoperative bleeding, pain, pressure headache and formation of
synechia. Patients and Methods: A total of 40 patients who had undergone sinonasal surgery were studied
prospectively. At the end of the operation each patient was packed with dissolvable CMC gel in the right side of the
nose and merocel in the left side. The haemostatic effect of the CMC and merocel was assessed during the recovery
period. Results: six (15%) of the patients packed with CMC had primary postoperative bleeding during the recovery
period. Bleeding appeared in four (10%) patients packed with merocel. We observed significant intergroup differences
in the level of pain and pressure headache. The CMC group was superior to merocel group and there was a significant
low level of pain and pressure headache in the CMC group. Two (5%) of CMC patients and six (15%) of merocel
patients developed a synechia at the 4 weeks period. Four (10%) of CMC patients and Ten (25%) of merocel patients
developed synechia at the 8 weeks period post operative. Conclusion: We found that dissolvable CMC pack is
associated with very low levels of localised pain, pressure headache and with low levels of postoperative bleeding and
synechia formation.
Keywords: Endoscopic sinus surgery - Carboxymethyl cellulose ­ Merocel - Resorbable - Nasal synechia -Nasal
packing - Nasal complications.

treatment. Modern nasal packings consist of resorbable
Functional endoscopic sinus surgery (FESS) is
materials, which make their removal unnecessary, thus
one of the most frequently performed operative
giving the patient more comfort (8, 9).
procedure in the head and neck field. It has become a
standard therapy for chronic rhinosinusitis including
This study was done to evaluate the effect of
nasal polyposis that is refractory to conservative
carboxymethyl cellulose (CMC) gel and merocel nasal
measures (1). While the surgical technique of sinonasal
packs after sinonasal surgery regarding postoperative
surgery are well standardized, there are no common
bleeding, pain, pressure headache and formation of
guidelines concerning both the need to perform a nasal
packing at the end of the operation and the materials

these packings should be made of. While some authors
recommend nasal packing other try to avoid its use (2, 3).
Patients were recruited from the Otolaryngology
The purpose of postoperative nasal packing lies in the
Clinic of EL-Sahel Teaching Hospital. The total number
prevention of adhesions and synechiae, an improved and
of enrolled patients was 40 (18 males and 22 females)
accelerated wound healing, and most importantly the
aged from 19 to 45 years old. Forty patients were
control of possible postoperative bleedings (4). The most
randomly selected to be packed with CMC after surgery
common complications of endoscopic sinonasal surgery
in the right side of the nose and packed with merocel
are postoperative formation of synechiae in the middle
nasal pack in the left side. Written informed consent was
meatus with incidence ranges from 1% to 36%.
obtained from all patients, and all eligible patients were
Synechiae in the middle meatus can block the normal
informed regarding the procedure. In addition,
mucociliary drainage pathway of the sinuses and lead to
approval of Al-Azhar Ethical Committee was
disease recurrence (5).
obtained. All surgical procedures were performed under
Nasal packing remains the most common procedure to
general anaesthesia and were performed by the same
surgeon. We included patients who were older than 18
postoperative bleeding. Conventional packing products
years of age and had bilateral chronic rhinosinusitis that
such as vaseline gauze strip and expandable polyvinyl
was refractory to pharmacological treatment, patients
acetate (Merocel) are non-absorbable materials. New
with deviated nasal septum, concha bullosa,
biodegradable packing materials with various degrees of
hypertrophied inferior turbinate, previous paranasal
efficacy have also been developed for example, floseal,
sinus surgery and fungal sinusitis. Patient exclusion
merogel/meropak, nasopore and carboxymethyl
criteria included patients with immunodefficient
cellulose (6). The use of conventional nasal packings for
disorders, cystic fibrosis, bronchial asthma, intolerance
the patients is highly uncomfortable and induces local
to aspirin, sinonasal neoplasia, and documented
pain and pressure (7). The removal of nasal packings has
been described as the most painful part of the whole

Full Paper (vol.761 paper# 24)

c:\work\Jor\vol761_25 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3329-3334

Comparative Study between Airway Pressure Release Ventilation and
Synchronized Intermittent Mandatory Ventilation in Treatment of
Acute Respiratory Distress Syndrome
Abo Bakr Helal El-Asmar, Taha Abd Elhamid Awad, Ahmed Attia El-Didamony
Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmed Attia El-Didamony, email:


Background: Various animal and human studies have demonstrated that airway pressure release ventilation (APRV)
may have advantages over conventional ventilation in the management of acute respiratory distress syndrome
(ARDS); however, it is still not used consistently because of the few studies in this regard.
Aim of the work:
The aim of this work is to compare outcomes of APRV in patients with ARDS with synchronized
intermittent mandatory ventilation (SIMV) where positive end expiratory pressure (PEEP) is used.
Patients and methods:
the study included (50) patients with ARDS, they were randomly divided into two groups,
group (A) patients were given APRV pattern, and group (B) patients were given (SIMV+PEEP). Data were obtained
before and throughout the period of mechanical ventilation and up to 60 days. Changes in arterial blood gases,
hemodynamics and LIS and outcome measures were compared in both groups.
demographic and baseline clinical data were similar in both groups with no differences. Follow up data
showed that APRV was associated with better oxygenation, less ICU length of stay, more ICU-free days, less
ventilation days, more ventilator free days and more sedation free days in comparison to SIMV+PEEP (p>0.05).
However, there were no significant differences between groups regarding mortality, length of hospital stay and rates
of tracheostomy and successful extubation (p<0.05). Conclusion: In comparison to SIMV+PEEP, APRV can
significantly improve oxygenation, decrease need for sedatives, increase free ventilation days and shorten duration
of ICU stay; however, APRV has no advantage over SIMV+PEEP regarding mortality.
Key words: Acute respiratory distress syndrome, Airway pressure release ventilation, mechanical ventilation.


Acute respiratory distress syndrome (ARDS) is
Respiratory I.C.Us at Al-Azhar University
the most severe form of acute lung injury (ALI) which
Hospitals (Al-Hussein and Bab Elshareya). This study
still has high rates of morbidity and mortality.
was conducted over thirty months-period, from
Mechanical ventilation stills the backbone of patient
October 2016 to April 2019. The exclusion criteria of
management (1). One of the newly developed and
the study were as follows: age of <18 years or>60
successfully used strategies in patients with ARDS is
years, presence of significant chronic pulmonary
lung protective strategies (LPS). However, use of low
disorder (chronic obstructive pulmonary disease,
tidal volumes during LPS may be associated with
idiopathic pulmonary fibrosis, suppurative lung
atelectasis due to decreased alveolar inflation (2).
disease or diffuse alveolar hemorrhage) or presence of
Airway pressure release ventilation (APRV) is
cardiac disorder (rheumatic or ischemic heart disease).
one of newly introduced modes in ARDS
The study was approved by the local Ethics
management. It is a pressure controlled mode that uses
Committee and informed written consent from the
two levels of pressures with inverted ratio ventilation.
patients was obtained before enrollment in the
Release of airway pressure during APRV simulates
expiration while elevated baseline pressure improves

oxygenation. One of the advantages of this mode is
that it allows spontaneous breathing (3). In clinical
All patients underwent the followings:
practice, APRV has shown to be safe and comfortable
1- Full clinical history taking
for ARDS patients as it can decrease the risk of
2- Complete clinical examination, including both
ventilator-induced lung injury, does not adversely
local and general examinations.
affect hemodynamics and because of spontaneous
3- Determination of associated significant co-
breathing it can reduce patient-ventilator asynchrony
4- Routine laboratory testing with certain emphasis
on (complete blood picture, liver function test,
Study design
serum creatinine, serum sugar, ESR and arterial
This study was carried out on fifty (50) patients
blood gases serial analysis).
diagnosed as having ARDS according to Berlin
5- Chest x-ray.
definition, were mechanically ventilated in the

Full Paper (vol.761 paper# 25)

c:\work\Jor\vol761_26 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3335-3354

Histological Effects of Sofosbuvir on The Kidney of Male Albino Rats and
The Possible Protective Role of Vitamin C
Gamal Soliman Hassan El Gharabawy, Ezz Elden Alsharkawy Abdallah,
Hassan Fathy Kaabo, Ahmed Mohamed Ahmed Abdel Aleem*
Department of Histology, Faculty of Medicine- Al Azhar University
*Corresponding author: Ahmed Mohamed Ahmed Abdel Aleem; Mobile: (+20)1062656364;
Aim of the work
: hepatitis C virus (HCV) infection is a major worldwide public health issue. Direct Acting
Antiviral Drugs (DAA) is a revolution that occurred in treatment of hepatitis C virus (HCV). The Second class of
DAA is HCV NS5B polymerase inhibitors (Which included Sofosbuvir) was shown to be effective in suppression
of HCV replication and became an important component of currently recommended regimens.
Material and Methods: forty adult male albino rats (Rattus norvigicus) weighting 140±20g were selected for this
36-days experiment The rats were randomly categorized into six groups (10 animals each for the first four groups
and the remaining groups V&VI were served as the recovery groups). The kidney was excised and prepared in two
different techniques for light & electron microscopic examination. For light microscopy serial sections (5 um thick)
were stained with hematoxylin-Eosin technique for studying the morphological changes; periodic Acid Schiff
technique (PAS) for studying of general carbohydrate ; Masson's trichrome stain for detecting the collagen fibers
and transmission electron microscopy (TEM) to detect the ultrastructural changes induced by Sofosbuvir.
the present study showed that group II which received the therapeutic dose of Sofosbuvir (0.06
mg/gm./body weight) showed renal tubular affection compared to the control rats. Tubular affection included
massive tubular vacuolization especially cells of the proximal and distal convoluted tubules. Group III which
received the toxic dose of Sofosbuvir (0.25 mg/gm./body weight) resulted in glomerular affection compared to the
control rats.
the present study provided promising results about reduction of Sofosbuvir nephrotoxicity by the
concomitant use of vitamin C.
Keywords: hepatitis C virus (HCV) infection, Sofosbuvir, vitamin C, rat, kidneys, histology .


Vitamin-C is an antioxidant supplement that
Egypt has the highest HCV prevalence
exhibits its powerful scavenging effects against
worldwide which was estimated nationally at 4.1%.
activated oxygen species and various free radicals by
HCV genotype 4 is also the predominating strain in
neutralizing ROS and decreasing oxidative damage to
Egypt as has been revealed in more than 90% of the
cell membranes (6). Due to the limited information
infections (1). Treatment of hepatitis C has evolved over
concerning the effect Sofosbuvir on the kidney, the
the years. An initial study used IFN monotherapy.
present study was designed to assess changes induced
Subsequently, combination of ribavirin and IFN or of
by Sofosbuvir on kidneys of male albino rats and the
IFN to which polyethylene glycol (PEG) molecules
possible protective effects of vitamin C.
have been added (ie, PEG-IFN) were used (2).

Revolution had occurred in the last decade for
treatment of hepatitis C virus (HCV) infection by
Forty adult male albino rats (Rattus
introduction of the direct acting antiviral drugs (3). The
norvigicus) weighting (140±20g) were selected for this
Second class of direct acting antiviral drugs indicated
36-days experiment. The rats were randomly
for HCV infection was HCV NS5B polymerase
categorized into six groups (10 animals each for the
inhibitors, which included Sofosbuvir which was
first four groups and the remaining groups V&VI were
shown to be effective in suppression of HCV
recovery) and they were orally treated as follows:
replication and became an important component of
Group I: animals served as the control group.
currently recommended regimens. Unfortunately,
Group II: animals were treated with orally the
Sofosbuvir had some side effects which included
therapeutic dose of Sofosbuvir group (0.06
carcinogenesis , mutagenesis, impairment of fertility,
mg/gm./body weight) dissolved in 0.9% NaCL daily
pancytopenia, severe depression , disturbances in lactic
for 21 days
acid homeostasis with presentations ranged from
Group III: animals were treated orally with the toxic
asymptomatic chronic hyperlactatemia to acute life-
dose of Sofosbuvir group (0.25mg/gm. /body weight)
threatening lactic acidosis (4). In order to minimize side
dissolved in 0.9% NaCL daily for 21 days.
effects of Sofosbuvir, we looked for antioxidant. An
Group IV: animals were treated with orally the
study had been promoted the nephro-protective effects
therapeutic dose of Sofosbuvir plus vitamin C, in
of vitamin C (5).
which rats were administrated orally the therapeutic
dose of Sofosbuvir (0.06 mg/gm./body weight) plus

Full Paper (vol.761 paper# 26)

c:\work\Jor\vol761_27 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3355-3365

Assessment of Clinical Governance in Primary Health Care Services:
A Case Study on Dakahlia Governorate, Egypt
Thoraya A. Abd El Fatah(1), Nagafa A. Ali(1), Emad M Elazazy(2), Nabil L Dowidar(3),
Heba M. Abd Elgalil(1), Soso S. Mohamed(1),
(1) Department of Community and Occupational Medicine, Faculty of Medicine for Girls, Al-Azhar University
(2) Cambridge regional UK, (3) Medical Research Institute, Alexandria University
*Correspondence author: Soso S. Mohamed, Mobile: (+20) 01006197894, E-mail:

universal health coverage and the health-related sustainable development goals can only be achieved
with a stronger emphasis on Primary Health Care (PHC). In spite of the essential role of clinical governance (CG) in
enhancing quality of services provided by PHC facilities, a scientific framework with precise criteria for evaluating
them has not been developed so far in Egypt.
Objective: to assess the CG in PHC in Egypt considering PHC of Al-Dakahlia governorate as a case study and to
clarify the barriers for implementing CG at PHC.
Subjects and Methods: a cross sectional study was conducted over a period of one year at 8 PHC facilities in selected
two districts; Al-Sinbelawin and Aga in Al-Dakahlia governorate, Egypt. The assessment of CG indicators was through
multi-level approaches from different perspectives of 327 PHC utilizers, 40 PHC providers, 10 PHC executive directors
who were drawn from the selected districts. Thirteen experts in PHC and CG in Egypt were also participated.
Results: CG index for PHC facilities was scored higher percentage degree by PHC directors (91.0%) than by PHC
utilizers, providers and the experts (70.0%, 59.6% & 53.3% respectively). The CG indicators showed disparities
between the participating groups. Experts reported several challenges for CG implementation as shortage of clear
policies, lack of awareness about governance culture and lack of experience in this field.
Conclusion: the successful CG framework should be based on plan & implement as a team and create better
relationships between directors and all stakeholders.
Clinical governance, Primary health care, Egypt.


and 80,000 beds nationwide, 61% of these facilities
Clinical governance isn't new concept. It was
implemented as a family practice approach based on
introduced in the late-1990s in the United Kingdom
formal accreditation(8). It witnessed several health
following exposure to number of failures within the
gains during the past decades as 95% of the population
National Health Service (NHS) (1).
has access to primary health care within 5 km(9).
It is widely accepted that clinical governance
In Egypt, different means were considered to
(CG) provides a unique and comprehensive strategy
improve the quality and safety of care delivered within
for bringing all local activities into a single coherent
the primary care sector through implementation of
program for continuous quality improvement as a
Continuous Quality Improvement (CQI) and Quality
systematic model (2). It encourages everyone in the
Assurance (QA) initiatives(10). Furthermore, Egypt has
organization to work for improving quality and safety
experienced a number of initiatives for health reform
of patient care(3).
in the public sector from 1997 to-date. Building blocks
Primary health care (PHC) is considered as the
of Health Sector Reform Program (HSRP) were as
cornerstone for universal health coverage (UHC) (4).
following: establishment of a new family healthcare
Also, the health-related sustainable development goals
model, separation of finance from provision of
(SDGs) can only be achieved with a stronger emphasis
healthcare, decentralization, application of quality and
on PHC(5). However, there is a sharp decline in its
accreditation, and coverage of new population groups
usage in many developing countries. That may be
with insurance scheme (11). Another initiative is the
attributed to failure of health system to respond to
new universal health coverage law that received
many problems as lack of access to essential drugs and
parliamentary approval in mid-December 2017 after
lack of health care workers(6). In addition to scarceness
years of discussion and planning (12). Egypt has clearly
of strategies for implementation and its monitoring for
set UHC as a priority objective for health sector
accountability(7). Renewing PHC and placing it at the
development. Article 18 in 2014 constitution has paved
center of efforts to improve health are critical to
the path for UHC through implementation of social
respond to rapidly changing world (5).
health insurance (SHI). The MOHP "white paper" has
Egypt has a population of 92.1 million and has
confirmed that UHC is a strategic vision for health
approximately 5314 PHC facilities with 14,973 general
sector development and the health pillar in the SDGs.
practitioners and 256 certified family physicians (FPs)
Strategy-Egypt 2030 has incorporated the objectives of

Full Paper (vol.761 paper# 27)

c:\work\Jor\vol761_28 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3366-3372

Comparative Study between Contralateral and Ipsilateral Approaches in
Endovascular Treatment of High Superficial Femoral Artery Lesions
Mohamed Abd El-Hamid Abd El-Rahman1, Hany Abd El-Momen Abd El-Fattah1, Maged Mohamed Abd
El-Aziz Ghanem2, Mahmoud Mohamed Mohamed Metwally3, Mohamed Ibrahem Abdo Ibrahem1*
1Department of Vascular Surgery, 2Department of Radiodiagnosis,
3Department of Clinical Pathology, Faculty of Medicine ­ Al-Azhar University
*Correspondence author: Mohamed Ibrahem Abdo Ibrahem, Mobile: (+20) 01145711155,
peripheral arterial disease (PAD) is defined as a slowly progressing, occlusive vascular disease of
the extremities primarily due to atherosclerosis which can involve vasculitis and thrombosis. The incidence of PAD
is increasing worldwide due to an overall increase in diabetes, obesity, and other cardiovascular disorders.
the purpose of this study was to compare the outcomes, including the safety, of antegrade and retrograde
puncture for SFA angioplasty access especially when lesion occurs in proximal part of SFA. The effect of these
approaches upon procedure time and radiation dose was also assessed.
Patients and Methods: a group of 40 consecutive patients (19 men, 21 women) were randomized for antegrade
puncture or retrograde puncture of the common femoral artery. Following retrograde puncture the guidewire was
turned' and placed into the superficial femoral artery. The time for gaining access, screening time, radiation dose,
and complications were recorded.
Results: there was no significant difference in the time to achieve arterial access between the two groups but the
retrograde puncture required a substantially longer screening time and resulted in a higher radiation dose than
antegrade puncture.
Conclusion: antegrade puncture is the standard means of obtaining access to the common femoral artery to carry
out infrainguinal intervention. The antegrade approach has the advantage of permitting the use of shorter tools, and
additional support for manipulating catheters and guidewires.
Keywords: Endovascular treatment, PAD, SFA.

Subsequently, Gruentzig popularized the concept of
Peripheral arterial disease (PAD) is defined as a
catheter directed balloon angioplasty. Angioplasty
slowly progressing, occlusive vascular disease of the
disrupts the atherosclerotic plaque by displacing it
extremities primarily due to atherosclerosis which can
radially. This action results in stretching of the
involve vasculitis and thrombosis. The incidence of
adventitia thereby increasing the lumen diameter in
PAD is increasing worldwide due to an overall
the treated vessel (4).
increase in diabetes, obesity, and other cardiovascular
By definition, a dissection is created and if
disorders (1).
significant, can be flow limiting. Currently, the most
The 2005 ACC/AHA guidelines on PAD posited
commonly utilized endovascular revascularization
that 5-year outcomes on limb morbidity of PAD
options are percutaneous transluminal angioplasty
patients is 70­80% having stable claudication or
(PTA) with provisional stenting or primary stenting.
walking pain, 10­20% having worsening claudication
Provisional or selective stenting is indicated for the
or resting pain, and 1­2% evolving to critical limb
treatment of flow limiting dissections and/or
ischemia (CLI). Patients with resting pain and CLI
persistent, hemodynamically significant stenosis or
have two to four times increased chance of coronary
recoil after PTA. This approach is recommended by
arterial disease and cerebrovascular disease with
the Trans-Atlantic inter-Society Consensus document
increased mortality (2).
II (TASC II) when treating SFA disease. However,
Peripheral arterial disease (PAD) of the superficial
both PTA alone and primary stenting can successfully
femoral artery (SFA) is the most common cause of
treat SFA disease. Therefore, the debate continues as
intermittent claudication. Atherosclerotic disease of
to which endovascular treatment is superior (4).
the SFA is localized to the region of Hunter s canal.
The superficial femoral artery (SFA) has long
An isolated occlusion or stenosis of the SFA often
presented endovascular specialists with a unique
results in decreased perfusion of the leg, resulting in
challenge. This vessel is subjected to various forces,
demand related, reversible, ischemic pain localized to
such as compression, torsion, flexion, extension, and
the calf. Ischemic rest pain and tissue loss, also known
contraction, which caused many treatments to fail.
as critical limb ischemia (CLI), are uncommon
However, maintaining patency in the SFA was also
manifestations of isolated SFA disease. CLI is more
crucial for preserving patients' quality of life and
commonly observed when occlusive disease of the
limbs (5).
SFA is combined with occlusive disease involving the
Numerous modalities now exist for treating the
below knee popliteal artery or tibial arteries (3).
SFA. Self-expanding stents, covered stent grafts,

Full Paper (vol.761 paper# 28)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3373-3379

Effect of Paracetamol and Dexamethasone with Lidocaine in
Intravenous Regional Anesthesia of Upper Limb Surgeries
Saad El-Deen Mahmoud El-Khateeb, El-Desoky Mohammed Ibraheem Nouh,
Mohammed Abd-Elsalam Abd-Allah Ali
Department of Anaesthesiology and Intensive Care, Faculty of Medicine ­ Al-Azhar University
Corresponding author: Mohammed Abd-Elsalam Abd-Allah Ali, email:

Upper limb surgeries may be done under general anaesthesia or other methods such as nerve block or
regional anaesthesia such as intravenous regional anesthesia (IVRA). Intravenous regional anesthesia has many
advantages such as cost effectiveness, day case surgeries and reduced hemorrhage risk.
Objective: The primary objective was to evaluate the effect of paracetamol and dexamethasone when combined with
lidocaine on the depth and duration of IVR anesthesia in upper limbs. The secondary objective was to evaluate the
onset of tourniquet-associated pain, time of 1st analgesic request, total opioid consumption and haemodynamic
Patients and Methods: Patients of this study were classified into 4 groups, 1st group received 3 mg/kg lidocaine 2%
completed by normal saline to 40 cc total volume without any additives and named as group L. 2nd group received 3
mg/kg lidocaine 2% plus 8 mg dexamethason completed by normal saline to 40 cc total volume and named as group D.
3rd group received 3 mg/kg lidocaine 2% plus 250 mg paracetamol completed to 40 cc total volume and named as
group P. 4th group received 3 mg/kg lidocaine 2% plus 8 mg dexamethasone plus 250 mg paracetamol completed to
40cc total volume and named as group LDP. These groups were evaluated for haemodynamics and onset of sensory
and motor block and time of recovery of sensory and motor block as well as intraoperative VAS score and fentanyl
Results: As regard average values of intraoperative VAS, 4th group had the lowest numbers then 2nd group, 3rd group
then 1st group which had the highest numbers. As regard the time to 1st analgesic request, the 1st group showed the
shortest time meanwhile the 4th group showed the longest time to 1st analgesic request while 2nd and 3rd groups were in
between. Total opioid consumption was the least among the 4th group in comparison with the other three groups
especially the 1st one, which showed the highest consumption. Finally, 4th group proved to be the best one as regarding
good anaesthesia and analgesia and reduction in intraoperative pain score as well as reduction in opioid consumption.
Conclusion: Paracetamol and dexamethasone when combined to lidocaine in intravenous regional anaesthesia in upper
limb produce synergistic effect on sensory and motor block, reduce intraoperative pain score and decrease amount of
intra operative opioid consumption.
Intravenous regional anesthesia, dorsal root ganglia.

with lidocaine on intraoperative pain score. In addition,
Surgeries of upper limb may be done under general
evaluation of the onset of tourniquet associated pain,
anaesthesia or other methods such as nerve block or
time of 1st analgesic request, total opioid consumption
regional anaesthesia such as intravenous regional
and haemodynamic stability.
anesthesia (IVRA). Intravenous regional anesthesia was

developed by German Surgeon August Bier in 1908.
This technique is still useful and recommended for limb
Setting: The study was carried out in AL-Azhar
surgeries, especially when general anaesthesia (GA) is
University Hospitals.
highly associated with risks such as difficult intubation

or other condition at which patient cannot tolerate GA
(1). This technique has many advantages such as cost
Institutional Ethics Committee of The Faculty of
effectiveness, day case surgeries and reduced risk of
Medicine, Al-Azhar University was obtained. 80
hemorrhage (2). However, it is also associated with a
Patients scheduled for elective upper limb surgery were
many side effects as local anaesthetic toxicity, failure of
enrolled in this prospective blind randomized study. All
action, delayed onset of block, tourniquet pain, fatigue
patients were counseled for the study protocol and a
and hypotonia of affected limb following deflation of
written informed consent was obtained from the study
the tourniquet (3).
The ideal anesthetic agent that is to be used in this

type of block should be of rapid onset, long duration,
Inclusion criteria: Age 20-60 years old. ASA I-II.
low dose and minimal side effects (4).
Elective upper limb surgery.

Exclusion criteria: Patients that refuse regional
anaesthia. Patients who had allergy to lidocaine.
The primary aim of this work was to evaluate the
Patients who had sustained open fractures of upper
combined effect of paracetamol and dexamethasone
limb. Hepatic patient. Cases, which were complicated

Full Paper (vol.761 paper# 29)

c:\work\Jor\vol761_30 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (1), Page 3380-3391

Role of Diffusion-Weighted MRI in Hepatocellular Carcinoma Patients Following
Transarterial Chemoembolization (TACE)
Mohammed Taha Abd El Hak1, Nadia Abd El Sater Metwally 1, Ahmed Sobhy Mohammed Abdrabo 2.
Radiodiagnosis, Faculty of Medicine (for Girls, Cairo), Al-Azhar University 1,
Radiodiagnosis, Al-Azhar University (El Bank El Ahli Hospital) 2.
Corresponding author: Ahmed Sobhy Mohammed Abdrabo , 3

Hepatocellular carcinoma is one of the commonest cancers all over the world with very high mortality
rates. TACE is used to deliver chemotherapeutic agents locally to the tumor.
Aim of the work: The purpose of this study was to evaluate the role of diffusion-weighted MRI and ADC value in
comparison with dynamic MRI in the assessment of response and necrosis to treatment of hepatocellular carcinoma after
transcatheter arterial chemoembolization.
Patients and Methods:
Precontrast T1, T2, STIR, respiratory triggered diffusion-weighted (b factor 20, 500 and 800
s/mm2) and dynamic contrast enhanced MR images obtained in 50 patients with HCC who underwent TACE. Diffusion-
weighted MR images, gadolinium-enhanced MR images after TACE were assigned confidence levels for postoperative
HCC recurrence.
Results: Dynamic MRI had a sensitivity of 90.5%, a specificity of 96.6%, a positive predictive value of 95 %, a negative
predictive value of 93.3% and overall agreement of 94%. Compared to 95.83%, 69.23%, 74.19%, of 94.74% and 82%
respectively of diffusion-weighted imaging. The difference between the malignant and negative groups' ADC variables
were statistically significant (P value 0.006). The ROC curve showed that the area under the curve is C = 0.728 with SE
= 0.075 and 95% CI from 0.582 to 0.874.
Conclusion: Diffusion-weighted MR imaging has lower specificity compared to dynamic MRI with increased false
positives. We suggest that the increase is due to intra-lesional hemorrhage or liquefactive necrosis causing diffusion
restriction. Diffusion-weighted imaging may act as a supplementary sequence to compensate the dynamic MRI in
patients who could not hold their breath adequately.
Keyword: HCC - Post TACE - DWI - Locoregional treatment - Liver.

Generally, surgical resection is the gold standard
HCC is a frequent and aggressive malignant
therapy for HCC, unfortunately; only 10­15% of HCC
tumor, estimated to range sixth by incidence and second
patients are eligible for liver resection due to the severity
by mortality in the global cancer statistics. The high
of underlying cirrhosis or the diffuse distribution of the
ratio of mortality to incidence (0.95) and the close
tumor. Another treatment option is liver transplantation
geographic correlation between incidence and mortality
which is theoretically the best treatment for HCC.
reflects the dismal prognosis. However, longer survival
Currently, ablative therapies are alternative choice for
can be reached in early diagnosed and properly treated
patients with liver tumors who are not eligible for
cases. Liver cirrhosis of any aetiology represents the
surgery. These therapies are known to have low
single largest risk factor of HCC and is found in 70­90%
morbidity and mortality, as well as being less expensive
of cases. Worldwide, hepatitis B virus (HBV) infection
than surgical resection with the ability to perform these
accounts for more than 50% of HCC cases. In
procedures on outpatients (3).
comparison to non-infected individuals, the relative risk
TACE, using iodized oil mixed with anticancer
of HCC is increased 100-fold in HBV-infected persons,
agents, has been widely used. Iodized oil is used as a
and the risk further increases if HBV-infected patient
vehicle to transport the anticancer drug, and the embolic
develops cirrhosis, has longer duration of infection and
material enhances the effect of the anticancer drug (4).
higher virus burden in blood. The yearly risk of HCC in
TACE affects the tumor to the maximum impact
HBV-infected patients is 2%, although nowadays an
of chemotherapy by selective or super-selective
increasing proportion of HCCs develops in non-fibrotic
liver or on the background of mild fibrosis (1).
chemotherapeutic agents and decreasing the tumoral
In the past few years with significant advances in
blood supply by the embolization of particles leading to
surgical treatments and locoregional therapies, the short-
term survival of HCC has improved but the recurrent
chemotherapeutic agents and HCC (3).
disease remains a big problem. The pathogenesis of
Besides, detecting and diagnosing the lesions,
HCC is a multistep and complex process, wherein
contrast enhanced computed tomography (CT) and
angiogenesis plays an important role (2).
magnetic resonance imaging (MRI) are widely used in

Full Paper (vol.761 paper# 30)