c:\work\Jor\vol764_1 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3835-3839

The Efficacy of Serum Biomarkers and Ultrasound Parameters in
Prediction of Outcome in Threatened Abortion
Hanaa Omer Badr El Dien, Asmaa Mahmoud Abd Elwahab, Eman Mostafa Abdalla*
Department of Obstetrics and Gynecology, of Medicine, Al-Azhar University
*Correspondence author: Eman Mostafa Abdalla, Mobile: (+20)01060970951, E-mail: Emanm5387@gmail.com

miscarriage, also known as a spontaneous loss of pregnancy before the fetus reaches viability.
Objectives: the aim of this study is to evaluate the association between ultrasonographic findings and maternal
serum biomarkers levels and prediction of pregnancy outcome in threatened miscarriage. Patients and Methods: a
prospective observational study was conducted at Al-Zahraa University Hospital through the period from April 2018
to May 2019 involving 76 women in their first trimester threatened abortion. Results: there was a statistically
significant difference between group 1 and group 2 regarding cancer antigen (CA) 125, -hCG, progesterone, yolk
sac diameter (YSD), fetal heart rate (FHR) and crown-rump length (CRL). The sensitivity, specificity, PPV and
NPV of CA 125 at 37.2 IU/ml were 86.0, 84.3, 84.6 and 85.7, respectively, for -hCG at 19447 IU/ml were 80.6,
78.0, 78.4 and 79.8, respectively, for progesterone at 12.3 ng/ml were 90.1, 88.0, 88.2 and 89.8, respectively, and for
FHR at 122 b pm were 96.1, 94.1 respectively.
Conclusion: combining of measurement of serum progesterone at a level of 12.3 ng/ml to FHR at 122 bpm repre-
sent noninvasive, early, fast and excellent predictor of pregnancy outcome in women with threatened abortion.
Keywords: CA125; -hCG, Progesterone; Fetal heart rate, CRL, GSD, YSD, Threatened abortion.

Miscarriage is a spontaneous loss of pregnancy
(CA 125), pregnancy associated plasma protein A
before the fetus reaches viability, miscarriage is defined
(PAPP-A), human placental lactogen (HPL), alpha
as the loss of a pregnancy before 24 weeks of gestation
fetoprotein (AFP), inhibin A and activin A(4).
in the UK. The National Center for Health Statistics,
Progesterone production in early pregnancy reflects
the Centers for Disease Control and Prevention and the
the interaction between the trophoblast and corpus
World Health Organization define abortion as
luteum. There is positive association between the rise
termination of pregnancy before 20 weeks of gestation
in serum -hCG and progesterone production by the
or with a fetus of less than 500 g (1).
corpus luteum. It was shown that the spontaneous
Miscarriage is a physically and mentally traumatic
pregnancy failure decreases with increasing maternal
event that frequently has long-term psychological
serum progesterone levels(5).
consequences. Every effort should therefore be made to
maintain viable pregnancies in women with threatened
The aim of this study is to evaluate the association
miscarriage. Our understanding of pregnancy has
between ultrasonographic findings and maternal serum
advanced considerably in recent years, and the quality
biomarkers (progesterone, -hCG and cancer antigen-
of much of the evidence available regarding the
125) levels to predict pregnancy outcome in threatened
efficacy and safety of the various treatment options is
not in line with current standards(2).
Ultrasound consider the backbone of modern
This prospective observational study was held in
obstetrics and gynecology practice. Its examination has
the period from April 2018 to May 2019 on 76
become the "golden standard" in follow-up of the
pregnant patients who attended the Outpatient Clinic or
development and complications of early pregnancy.
the Emergency Department. Ethical approval and
Many sonographic markers in early pregnancy can
Written informed consent:
predict the prognosis of the outcome of pregnancy;
An approval of the study was obtained from Al-
these include gestational sac diameter (GSD), yolk sac
Azhar University academic and ethical committee.
diameter (YSD), crown-rump length (CRL), and fetal
Every patient signed an informed written consent for
heart rate (FHR), which were considered as one of the
acceptance of the procedure.
main parameters for the prediction of outcome of
Our study included 76 pregnant patients attended
pregnancy (3). Threatened miscarriage affects one fifth
the Outpatient Clinic or The Emergency Department of
of women, with the uncertainty about its prognosis, and
Obstetrics and Gynecology from April 2018 to May
many biochemical markers have been studied to predict
2019, at Al-Zahraa University Hospital complaining of
its outcome. Various biochemical markers have been
uterine bleeding or bloody vaginal discharge and / or
studied to establish if they are able to predict the
lower abdominal pain.
outcome of threatened miscarriage (i.e. identify those at
Women included in the present study were
risk of subsequent miscarriage), however results have
diagnosed as first trimester threatened miscarriage,
been conflicting. Some of the commonly studied
presenting with uterine bleeding or spotting, mild or no
biochemical markers are serum human chorionic
pain, had singleton spontaneous pregnancy, and
gonadotropin (hCG), progesterone, cancer antigen 125
pregnancy was between 7th and 13th week of gestational

Full Paper (vol.764 paper# 1)

a The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3840-3845

Assessment of Macular Thickness Using OCT in Patients with
Diabetic Retinopathy in Relation to HbA1c
Mohammed Ahmed Wahdan, Ahmad Elsayed Hodieb, Mohammad Hassan Elsayed ElBaz*
Ophthalmology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohammad Hassan Elsayed ElBaz, Mobile: (+20) 01127810916

diabetic retinopathy (DR) is the specific micro vascular complication of diabetes mellitus (DM) and
affects 1 of 3 with DM. DR remains a leading cause of vision loss in working adult population. Patients with severe
levels of DR are reported to have poor quality of life and reduced physical, emotional and social wellbeing.
Objectives: to evaluate the relation of macular thickness to HbA1c in patients with diabetic retinopathy.
Patients and Methods: this study included 30 eyes of 16 patients with a diagnosis of diabetic retinopathy (DR).
Patients were recruited from Retinal Clinic in Bab El-Shearyah University hospital and asked to participate in this
study. This study was designed as an observational, cross-sectional and non-coherent study in the period from
12/2018 to 5/2019.
Results: the controlled HbA1c group and uncontrolled HbA1c group were comparable in age, sex, type of diabetes
mellitus and best corrected visual acuity, but controlled HbA1c group had shorter duration of diabetes mellitus and
lower glycosylated haemoglobin level than uncontrolled HbA1c group. Six (40.0%) patients of controlled HbA1c
group were hypertensive patients and 11(73.3%) patients of uncontrolled HbA1c group were hypertensive patients.
Conclusion: intensive glycemic control might affect retinal vasculature and decrease ischemia and affect the
development and progression of diabetic retinopathy.
Keywords: Macular Thickness, OCT, Diabetic Retinopathy, HbA1c


complications among which the vascular dysfunction
The world is currently facing an epidemic
leading to macular edema which resembles the most
risk called diabetes, according to WHO estimates.
important vision threatening complication (8).
The number of people with diabetes worldwide will
Proliferative diabetic retinopathy develops
rise to 360 million by 2030 (1).
following the occlusion of retinal capillaries leading
Diabetes mellitus is divided into two types,
to retinal ischemia, which promotes the development
type 1 in which insulin production is predominantly
of neovascularization, a process by which new blood
damaged, and type 2 which is characterized by
vessels proliferates on the surface of the retina,
increased resistance to insulin, it's familial and
however these vessels are fragile and bleed easily,
related to limited physical activity and life style.
The resulting accumulation of blood in the vitreous
Diabetic retinopathy is the specific micro vascular
cavity from these hemorrhaging vessels seriously
complication of diabetes mellitus and affects 1 of 3
impairs vision. This may be permanent due to further
with DM. DR remains a leading cause of vision loss
complications as traction retinal detachment leading
in working adult population. Patients with severe
to registered blindness. It has been estimated that
levels of DR are reported to have poor quality of life
and reduced physical, emotional and social wellbeing
retinopathy 50% of patients will become blind within
5 years following diagnosis (9).
Diabetic retinopathy affects up to 80% of all
Optical Coherence tomography (OCT) has
patients who have had diabetes for 10 years or
become part of the standard care in ophthalmology. It
provides cross sectional and three dimensional
Despite these alarming statistics, research
imaging of the anterior segment, retina and optic
suggests that at least 90% of these new cases can be
nerve head with micrometer scale-depth resolution
reduced if there is careful treatment and eye control
With the help of (OCT), it's now possible to
The longer the person has diabetes the higher
measure the macular thickness objectively and to
his or her chances of developing diabetic retinopathy
follow the progression of diabetic retinopathy
(5). Each year in United States, diabetic retinopathy
quantitatively (11).
accounts for 12% of all new cases of blindness (6).
Periodic glycosylated hemoglobin (HbA1c)
Diabetic retinopathy is a progressive disease
measurements can reflect the long term control of
predominantly affects the integrity of microscopic
hyperglycemia. Intensive glycemic control had been
vessels found in the retina, DR can be divided into
proved to be effective in decreasing incidence rate of
two clinical stages non proliferative and proliferative
development and progression of diabetic retinopathy
diabetic retinopathy (7).
in type 1 and type 2 diabetes mellitus as demonstrates
The significant morbidity and mortality of
by diabetes control and complications trials (12).
diabetes mellitus predominantly results from its


Full Paper (vol.764 paper# 2)

Introduction The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3846-3852

Comparative Study of Open Reduction Internal Fixation with Proximal
Humerus Interlocking System and Closed Reduction and Pinning with
K ­Wire in Proximal Humeral Fracture
Younes Akel, Mohammed El Nahas, Saddam Rabei Ali Shafei
Orthopaedic Surgery Department, Faculty of Medicine, Al Azhar University
* Corresponding author: Saddam Rabei Ali Shafei, E-mail: Shafei.saddam@gmail.com

Treatment of proximal humerus fractures may be conservative or operative. Each procedure has
some limitations and complications. A major disadvantage of conservative treatment is failure to obtain early
mobilization, which results in a high rate of shoulder stiffness and pain and malunion or nonunion is likely
with certain fracture types. Objective: To compare functional outcomes and complications after open reduction
and internal fixation of proximal humerus fractures (type 2 and 3 Neer classification) by proximal humeral internal
locking osteosynthesis system (PHILOS) versus percutaneous fixation with K- wires.Patients and methods: Our
study was conducted upon 20 Patients (M=7, F=13) in elderly group with two parts (10 patients) and three parts (10
patients) proximal humerus fractures according to Neer's classification patients was randomized to either (group 1)
who were treated by open reduction and internal fixation with PHILOS plate and (group 2) who were treated with
percutenous K- wire fixation. Results: The mean follow up UCLA score was 30 points (range from 26 to 34)
points in (group 1) and 31 points (range from 27 to 35) points in (group 2), values varied depending upon the
fracture type with worst in 3 parts fractures. Conclusion: we obtained satisfactory results in both groups with each
procedure having its advantages and short comings. We found that fixation with percutaneous K-wires presented an
efficient treatment option with the advantages of minimal invasions and soft tissue dissection and PHILO'S plate
fixation provided stable fixation with minimal implants problems and enabled early range of motion exercise to
achieve acceptable functional results.
Keywords: Proximal humeral, fracture, PHILOS plate, percutaneous K-wires.

Open reduction and internal fixation included
Fracture of the proximal humerus is a
extensive surgical exposure and risks of damage to
common and debilitating injury occurring mainly
the vascular supply of the fragments. Fixed angle
in elderly and accounts for 4-5% of all fractures.
locking plates enable fixation of many complex
Typical age of fracture is between 65 and 75
fractures. It has the advantages of anatomical
years and about 51% of such fractures are displaced
reduction and early mobilization. It may however be
(1). The proximal humerus is uniquely adapted to
associated with higher rates of infection, damage to
allow wide range of motion of the shoulder. Mobility
arteries and nerves and avascular necrosis of humeral
is gained at the expense of stability. In fracture of the
head (4). A percutaneous method of fixation allows
proximal humerus, biomechanics of this joint is
for minimal soft tissue dissection thereby protecting
disturbed if fracture fragments are not properly
the blood supply to the fracture fragments which
reduced and fixed (2).
promotes rapid healing and minimizes the chances of
Defining appropriate treatment protocols is
avascular necrosis. This is even more important in
complicated by poor reproducibility and reliability of
the elderly population as it allows a rapid return of
the commonly used classification system devised by
function and independence. Numerous reports
Neer. Neer's classification evaluates the proximal
described percutaneous techniques of fixation of the
humerus in four parts as the anatomical head, the
proximal humerus fractures. Percutaneous fixation is
greater and lesser tuberosities and the surgical neck.
believed to be best suited for two-part and some
Any translations more than 1 centimeter or
three-part fractures (5).
angulations more than 45 degrees in any part of the
Closed reduction and percutaneous pinning
humerus are defined as displacement.
may allow displaced fractures of the proximal
The treatment of proximal humerus fractures
humerus to be reduced and stabilized by Kirschner
has been a subject of intense discussion and
wires, alone or wires clamped into a locking device,
controversy for the last century with supporters of
has a low risk of neurovascular complications or
both operative and non-operative methods. Several
interference with glenohumeral joint motion,. The
treatment modalities have been proposed depending
latter prerogatives may be of considerable importance
upon the fracture pattern, patients' age, level of
when treating patients in poor general condition (6).
activity and bone stock, amount of displacement of

the fragments and associated medical co-morbidities:
conservative treatment, open reduction and internal
The aim of the study is to compare the
fixation (ORIF), percutaneous fixation and joint
functional outcome of the proximal humerus fracture
replacement (3).
fixation using k-wires fixation versus locked plates.

Full Paper (vol.764 paper# 3)

c:\work\Jor\vol764_4 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3853-3858

Measurement of Psychological Stress in A Group of Journalists Working in One
of The Private Journalism Institutes in Egypt
Mohammad Abdelwahid Riyad, Mohammad Elsayed Ramadan, Ramadan Abd-Al-Azeem
Department of Neuropsychiatry, Faculty of Medicine, Al-Azhar University
*Correspondence author: Abd-Al-Azeem Ramadan Abd-Al-Azeem Alkhadrawy, Mobile: (+20) 201000639180

mental health problems are rising in number and severity between journalists & media field
workers. Keeping mental well-being of media field workers is a must that is so hard to be achieved by most
Objective: This research aims to study the prevalence of stress &associated psychological disorders
(depression- anxiety) and their association with some factors.
Patients and Methods: a cross-sectional-questionnaire based study was conducted among journalists working
in one of the private journals in Egypt. Depression, Anxiety and Stress Scale-42 (DASS-42) was used to assess
stress & associated psychological disorders along with a socio-demographic questionnaire designed by the
researcher. A total of 100 journalists participated in the study, they compose about 83% of the whole journalists
working in the organization, Overall, the prevalence of stress, anxiety and depression was 61%, 57%, and 64%
among studied sample respectively.
Results: higher stress scores were significantly associated with lower age group& lower job satisfaction. Higher
anxiety scores were significantly associated with demanding psychological support from family and friends &
exposure to work-related trauma. Higher depression score was associated with lower job satisfaction &using
smoking as stress relief.
Conclusion: high percentage of journalists was suffered from stress, anxiety and depression. The associated
factors include lower age, low job satisfactionlevel, smoking, and exposure to work-related trauma. Further
studies need to be conducted to identify other associated factors related to working as a journalist.
Keywords: psychological stress, journalists working, Egypt.

an adverse or unexpected situation. Pathological
anxiety interferes with the ability to cope
Organization (WHO) mental health disorders are
successfully with life challenges(4).
one of the leading causes of disability worldwide,
While many symptoms of depression
three of the ten leading causes of disability in people
include, persistent sad, anxious or ``empty"
between the ages of 15 and 44 are mental disorders,
feelings, feelings of hopelessness, feelings of guilt,
the other causes are often associated with mental
worthlessness and/or helplessness, irritability,
restlessness, and loss of interest in activities or
The current mental health action plan for
hobbies once pleasurable(5).
2013­2020, published by the WHO(2) showed that a
It seems that man's occupation affects his
collective evidence based effort is required to
personality, thinking, and behavior, physical &
improve mental health.
psychological disorders. Certain disorders are
Stress is a term that refers to the sum of the
common among workers of a certain occupation so
physical, mental and emotional strains or tensions
they are occupational disorders(6).
on a person. Feelings of stress in humans result
Journalists are a special occupational group
from interactions between persons and their
of people that are exposed to high levels of stress
environment that are perceived as straining or
every day in different ways, One of the most
exceeding their adaptive capacities and threatening
common problems of working as a journalist is
their well-being. The element of perception
repeated exposure to trauma, due to covering news
indicates that human stress responses reflect
of violence, disasters & other accidents, researchers
differences in personality as well as differences in
reported that repeated exposure to trauma can result
physical strength or health(3).
in different psychological effects include altering
Anxiety is a psychological, physiological,
basic world assumptions, drug abuse, PTSD,
and behavioral state induced in animals and humans
Depression & anxiety(7).
by a threat to well-being or survival, either actual or

potential. It is characterized by increased arousal,
Several studies reported high rates of
expectancy, autonomic and neuroendocrine
psychological morbidity among journalists &
activation, and specific behavior patterns. The
workers in the field of media using various
function of these changes is to facilitate coping with
instruments(8,9), Newman et al.(8) reported during

Full Paper (vol.764 paper# 4)

c:\work\Jor\vol764_5 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3859-3866

Assessment of CD56+ CD69+ Natural Killer Cells in the Peripheral Blood of
Women with Repeated Implantation Failure (RIF) undergoing an
Intra Cytoplasmic Sperm Injection (ICSI) Cycle
Yahia Abd El-Salam Wafa 1, Salah El-Beltagy 2, Osama Mohammed Deif1,
Mohammed Moustafa Abd El Hameed1
Departments of 1Obstetrics and Gynecology and 2 Clinical Pathology Faculty of Medicine, Al-Azhar University
*Correspondence author: Mohammed Moustafa Abd El Hameed, Mobile: (+20) 01222546572,
E-mail: Medocology@hotmail.com
infertility is an increasing medical and social problem. Delayed childbearing exposes couples to increased
risk of causes of infertility including endometriosis, pelvic infection, and poor egg and sperm quality. Many infertile couples
turn to in-vitro fertilization (IVF).
to analyze and compare between the peripheral blood NK cells (CD56+ CD69+) in women with repeated
ICSI failure.
Patients and Methods:
the current study is a case control study. One hundred women were included and divided into
two groups: The study group included 50 women with history of unexplained infertility and repeated implantation
failure in their ICSI attempts and a control group which included 50 normal, non-pregnant and fertile women.
the current study revealed that there was a highly statistically significant difference between control and case
groups regarding CD3- CD56+dim NK percentage with a p-value <0.0001. The current study revealed that there was a
statistically significant difference between control and case groups regarding CD3- CD56+dim CD69+ NK cells
percentages with a p-value 0.001.
Conclusion: there was a highly statistically significant difference between control and case groups regarding CD3-
CD56+dim NK percentage. Also the study showed that total CD56+dim NK had a very good predictive value as it had a
sensitivity of 80.0%, a specificity of 66.7%, a PPV of 73.3% and a NPV of 78.8%.
Keywords: CD56+ CD69+, Natural Killer Cells, IVF, RIF, ICSI


CD16 is a low-affinity receptor for IgG
There is still no formal consensus definition for
complexes (FcRIII) and is expressed on the majority of
repeated IVF failure (RIF), although suggestions
NK cells as well as on neutrophils, a small T cell
included the failure of at least three cycles of IVF or two
population, and some activated macrophages. CD16 is
cycles of IVF plus two cycles using frozen embryos (1).
the receptor responsible for NK-mediated antibody-
Assumed etiologies for RIF may be attributed to
dependent cellular cytotoxicity (6).
many factors. These can be grouped into four categories:
CD56 is an isoform of the neural cell adhesion
decreased endometrial receptivity, embryonic defects,
molecule (NCAM), expressed on essentially all NK
operators' skills and factors with combined effect.
cells, a small population of cytotoxic T lymphocytes,
Decreased endometrial receptivity is due to: uterine cavity
and some neural-derived tissues. Based on the intensity
abnormalities, thin endometrium, altered expression of
of CD56 expression, NK cells can be divided in two
adhesive molecules, immunological factors, and
populations. CD56dim cells are more cytotoxic, whereas
thrombophilia (2).
the CD56bright subset is the main source of NK cell-
Natural killer (NK) cells are bone marrow-
derived immunoregulatory cytokines (7).
derived lymphocytes that function in the destruction of
CD69 belongs to the C-lectin type superfamily.
foreign, infected, or malignant cells and in the
It is a functional triggering molecule on activated NK
promotion of immune responses. A diverse repertoire of
cells and is one of the earliest cell surface activation
cell surface receptors control their activation, killing,
markers. Besides mediating NK cell cytotoxicity, it also
cytokine production, and proliferation (3).
mediates other NK cell functions such as proliferation,
NK cell function is tightly regulated by
tumour necrosis factor (TNF-a) production and
balancing between activating and inhibitory receptors.
expression of other activation antigens (8).
This balance is critical in preventing maternal rejection
In peripheral blood, CD56dim/CD16+ NK cells
of the fetus and it is thought to be impaired in recurrent
predominate in numbers and are mostly cytotoxic
spontaneous abortions (RSA) and infertility (4).
against specific targets and these cells have direct
CD antigens are proteins, glycoproteins, and
contact with chorionic villi at the intervillous space,
glycolipids serve as surface receptors and ligands, that
whereas uterine natural killer (uNK) cells are
regulate cell signaling, cell adhesion and adaptive
predominantly a CD56bright/CD16+ represent and are
immunity. CD molecules are commonly utilized in cell
mostly cytokine producers (9).
sorting techniques and cell populations are usually
In non-pregnant endometrium, there is a
defined as either positive or negative; they control
significant increase in the numbers of uterine natural
inhibition and activation; proliferation and effector
killer (uNK) cells from the mid secretory phase onward,
functions (cytotoxicity and cytokine production) (5).
where they are found close to stromal cells and around

Full Paper (vol.764 paper# 5)

c:\work\Jor\vol764_6 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3867-3873

Comparative Study between Loop Saphenous Vein and Prosthetic
Thigh Vascular Access Graft for Haemodialysis
Mohamed Abdel Hamid Abdel Rahman, Ashraf Mohamed Ewida, Ayaman Abd El-Hamid Farag*
*Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ayaman Abd El-Hamid Farag; E-Mail: dr_aymanelsamalosy@yahoo.com;
Phone: 02-0111225124 - 01553011983
renal disease is an international problem with a high mortality and morbidity especially in the low-
income countries. Haemodialysis can help patients, but with multiple complications and challenges associated with
the procedure. One of these challenges is exhausted veins in the upper limb.
Aim of the work: this study aimed to compare using of great saphenous vein bridge fistula versus prosthetic vascular
graft, for creating bridge between superficial femoral artery and vein, for the purpose of regular haemodialysis.
Patients and Methods: 40 chronic renal failure patients were included. Patients were subjected to full history, clinical
examination, investigations and Doppler/duplex scanning for both arterial and venous systems. Follow up was done
immediately at the first postoperative day then at one week, 3 weeks, 3 months, 6 months, 9 months and after one year
as regards patency, functioning of the graft as well as complications.
Results: early death within 30 days of surgery did not occur. Thrombosis was more frequent in PTFE AV graft loop
group while all insufficient graft flow (< 200 mL/minute) cases were in SVI group. The numbers of puncture site
complications were similar; however, bleeding was more frequent in PTFE group (p = 0.011). None of the patients
showed clinical signs or symptoms of graft infection
Conclusions: autogenous arteriovenous fistula reveals better primary patency rate than that of prosthetic arteriovenous
graft with statistically significant results (p = 0.04). Autogenous arteriovenous fistula showed statistically better
secondary patency rate (p = 0.001).
Keywords: Renal failure, Haemodialysis, Graft, Fistula.

(4). However, according to numerous research results,
In the light of the ever increasing number of
autogenous arteriovenous fistula showed better results
patients with end-stage renal disease, the ageing
than prosthetic arteriovenous graft (5).
dialysis population and their prolonged longevity,
There are various studies comparing the PTFE grafts
surgeons are increasingly encountered with difficult
with biological grafts concerning the infection, patency
access problems, such as exhausted upper extremity
rate, complications etc. Huber et al. (6) recommend
access sites and central venous outflow obstruction
native AVFs as the first step of treatment and in other
resulting from previous catheterization (1).
circumstances offer autologous solutions as possible
In Egypt, we have a good opportunity to reduce
primary and secondary patency, lower complication
the incidence of kidney failure (chronic and acute)
rate and cost when compared with PTFE grafts.
substantially by appropriately chosen models. This is

because many of the causes of renal failure are
eminently preventable. In fact, a rough estimate is that
The aim of this work is to compare using of great
these programs, if successful, can reduce the incidence
saphenous vein bridge fistula as a venous auto-graft,
by as much as 40% (2).
versus prosthetic vascular graft, for creating loop A-V
The constant evolution of angioaccess techniques
fistula or A-V graft in the thigh (bridge between
in the presence of such circumstances has led to the
superficial femoral artery and vein), in patients with
development of arteriovenous access at different
chronic renal failure with exhausted upper extremity
anatomic sites, such as the lower extremity. Femoral
accesses, for the purpose of regular haemodialysis, as
prosthetic arteriovenous access placed either in the
regards patency (primary and secondary), function
upper thigh or in the mid-thigh in a loop configuration,
criteria (fistula thrill and murmur) and complications.
as well as autogenous arteriovenous access using the

transposed superficial femoral vein, have evolved as
alternative access procedures in patients with difficult
This study was conducted on forty patients with
access problems (3).
end stage renal disease (13 males and 27 females). 15
There are no opposition on the fact that ideal
patients had diabetes mellitus and 11 patients had
haemodialysis access should be durable and has low
hypertension. Patient were divided randomly into two
risk of infection and frequency for revision operation to
equal groups, autologous saphenous vein was
maintain patency. It is true that there are a few
interposed between superficial femoral artery and vein
researches with analytical results saying there is no
in 20 patients (Group 1). PTFE synthetic graft was
interposed between superficial femoral artery and vein
arteriovenous fistula and prosthetic arteriovenous graft

Full Paper (vol.764 paper# 6)

c:\work\Jor\vol764_7 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3874-3881

Evaluation of Subclinical Left Ventricular Systolic Dysfunction Using Two
Dimensional Speckle Tracking Echocardiography in Patients with Psoriasis
Attia Morsy Skokr1, Ahmed Rashad Elshahed2, Youssef Fathy Nosir1,
Muhammad Abdullah AbdelSallam1
Departments of 1Cardiology and 2Dermatology,
Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Muhammad Abdullah AbdelSallam, Mobile:(+20) 01008851030, Email: crazy.doctor1990@gmail.com

dermatologists as well as cardiologists have been studying cardiologic complications of psoriasis for
many years. The reason for an increased cardiovascular morbidity in psoriasis seems to be the chronic systemic
inflammatory process. Aim of the Work: to evaluate and detect subclinical LV dysfunction by 2D speckle tracking
echocardiography in psoriatic patients. Patients and Methods: we selected 100 psoriatic patients (group 1) sub-
classified them into two equal subgroups; subgroup (1a) involved 50 psoriatic patients recently diagnosed and on
topical treatment and subgroup (1b) included 50 psoriatic patients on systemic treatment. The study also included 30
apparently healthy individuals' age and sex matched with the patients' group represents the control group.
Results: in comparison with healthy subjects, patients with psoriasis were found to have lower LV function using 2
D speckle tracking. The 2-D speckle method appears to be useful in the detection of LV systolic dysfunction in patients
with psoriasis A statistically significant difference was found between sub-groups according to duration of Disease
(years), psoriatic arthritis, PASI score and high sensitive CRP. Conclusion: the 2 D speckle tracking method appears
to be useful in the detection of LV systolic dysfunction in patients with psoriasis. Subclinical left ventricular systolic
dysfunction in psoriasis is linked with the inflammatory up-regulation, and enhanced pro-fibrotic activity may be
involved in this process. These putative mechanisms may be responsible for the observed higher incidence of heart
failure in this disease condition and should be considered as a potential target for preventive and therapeutic measures.
Keywords: subclinical LV dysfunction, 2D speckle tracking echocardiography, psoriasis.

markers of risk of CVD and such ECG markers may
It is increasingly recognized that psoriasis is also
then represent unmeasured confounders in previous
associated with an increased risk for cardiovascular
studies of CVD risk in psoriasis (7).
(CV) disease which cannot be explained by traditional
Ejection fraction (EF), tissue Doppler imaging
CV risk factors. Some reports have emphasized that the
(TDI), Doppler strain and, recently, speckle tracking
development of CV risk factors and major adverse
echocardiography (STE) have been commonly used in
cardiac outcomes such as myocardial infarction, stroke,
the assessment of LV function (8).
and CV mortality are increased, especially in patients
The EF is the most widely used index of LV
with severe psoriasis (1).
function, but because of its visual component, the
It is generally believed that psoriasis does not
assessment of endocardial excursion is subjective and
impair left ventricular (LV) systolic function
has high interobserver variability (9).
(2). However, one publication has revealed subclinical
Two dimensional strain imaging is a novel
LV dysfunction to be more frequent in psoriatic
technique which assesses LV systolic functions more
arthritis (PsA) (2).
objectively and quantitatively and does not have the
The systemic inflammatory response in psoriasis
drawbacks of EF, TDI, and Doppler strain; thus, it has
is regulated by T helper 1 and T helper 17 lymphocytes,
become more commonly used in recent years (8).
which play a key role in its pathogenesis, leading to

endothelial damage with premature progression to
atherosclerosis (3).
The purpose of this study is to evaluate subclinical
A number of imaging techniques, including
left ventricular systolic dysfunction using two
echocardiography, magnetic resonance imaging, and
dimensional speckle tracking echocardiography in
scintigraphy, have been used in the assessment of LV
patients with psoriasis.
systolic function (4).

Arterial stiffness has been identified as an
independent prognostic factor for patients with CV
This cross-sectional comparative study involved
disease (CVD) (5). An increased pulse wave velocity
100 psoriatic patients collected from the Dermatology
(PWV), a noninvasive index of arterial stiffness,
clinic of Al-Azhar University Hospitals; the patients
predicts CV events in different clinical conditions.
were screened for the study enrollment prospectively.
Increased arterial stiffness negatively affects cardiac
The study was performed at Cardiology Department,
structure and function with systolic and diastolic
Faculty of Medicine, Al-Azhar University at the period
abnormalities (6). It seems likely that patients with
from October 2018 to June 2019.
psoriasis may display changes in the ECG that may be


Full Paper (vol.764 paper# 7)


Results of Treatment of Oblique and Spiral Phalangeal Fractures of the
Hand by Mini Lag Screws
Rashed Emam Rashed, Galal Mansour Hegazy , Hazem Saeed Abd Allah Abusamada *
Orthopedic Surgery Department, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Hazem Saeed Abd Allah Abusamada,Phone No.: (+2) 01014681498,E-mail:

Fractures of the hand represent a considerable burden upon the society in terms of medical costs and
reduced workplace productivity.
Aim of the work: The study aimed to evaluate the clinical outcome of patients with oblique and spiral phalangeal
fracture managed with mini-screws fixation.
Patients and Methods: A total of 20 patients presented with oblique and spiral phalangeal fractures were treated by
mini-screw fixation and were followed for a minimum of 6 months. The mean age of the patients was 33 years, ranging
from 19 to 46 years. Eleven cases were males and nine were females.
Results: The functional results were graded as excellent in 14 patients (70%), good in two patients (10%), fair in
two patient (10%), and poor in two patients (10%). The excellent and good results were considered as satisfactory,
while the unsatisfactory included the fair and poor results. Thus, satisfactory results were found in 16 patients
(80%), and the unsatisfactory ones were found in four patients only (20%).
Conclusion: Mini screw fixation offers an effective, simple and reliable method for treatment of oblique and spiral
fracture with low incidence of complication.
Keywords: Oblique and Spiral Phalangeal Fractures - Mini Lag Screws.

tolerated and is difficult to assess on plain
Hand fractures represent a major burden to
radiographs. It is best judged clinically by asking the
society in terms of medical costs and low productivity
patient to flex all the fingers simultaneously If
of the workplace (1).
scissoring or malrotation is present with composite
Fractures of the metacarpals and phalanges are the
digital flexion, open reduction and internal
most common fractures of the upper extremity (2). They
fixation(ORIF) should be considered (6).
account for up to 10% of the upper extremity fractures (3).
Stable bony construct has to be restored for early
Roughly 70% of all metacarpal and phalangeal fractures
mobilization. Early mobilization minimizes adhesions
occur between the ages of eleven and 45 years (4).
and is the key to good clinical outcome (8). Various
Phalange column fractions are broadly classified into:
treatment modalities have been described for the
transverse, oblique, spiral, and mantled. Each type of
treatment of oblique and spiral fracture. The treatment
fracture presents distinct abnormalities that may lead
options include closed reduction with cast or splint
to complications if they are not recognized or treated
immobilization, percutaneous fixation with mini
incorrectly (5).
screws or Kirschner wires (K-wires) and open
Selection of the optimal treatment depends on
reduction with either pins or inter-fragmentary screw
many factors, including fracture location (intra-
fixation (9 & 10).
articular or extra-articular), fracture geometry

(transverse, spiral, oblique or comminuted), deformity
(angular, rotational or shortening), whether the
The aim of this study was to evaluate the clinical
fracture is open or closed, whether osseous and soft
outcome of patients with oblique and spiral phalangeal
tissue injuries are associated and intrinsic fracture
fracture managed with mini-screws fixation.
stability. Additional considerations include the

patient's age, occupation and socioeconomic status as
well as the presence of systemic illnesses, the
surgeon's skill, and the patient's compliance (6).
During the period from January 2018 to January
Melone (7) in 1986 noted that approximately 10% of
2019, a total of 20 patients with oblique and spiral
phalangeal and metacarpal fractures are irreducible by
phalangeal fractures were treated by mini-screw
closed manipulation or percutaneous pinning and require
fixation in the Department of Orthopedic Surgery of
open reduction. Oblique and spiral phalangeal fractures
Al-Azhar University Male Hospitals, Cairo and Kafr
are unstable, even if reduced and are difficult to hold
El Dawar Hospital, Egypt. The 20 patients followed
in reduction these fractures are prone to rotational
and constituted the basis of this prospective study. The
malalignment and shortening with inadequate
shortest follow up period was six months, while the
treatment. Oblique and spiral phalangeal fractures are
longest was twelve months with a mean follow up
usually the result of torsional forces and can cause
period of nine months. The fracture was open in four
rotational malalignment. Malrotation is poorly
cases and the wound was about one cm and clean.

Full Paper (vol.764 paper# 8)

c:\work\Jor\vol764_9 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3891-3900
In Vitro Evaluation of Anticancer Potential of Echispyramidum Venom
(Viperidae) and Related Genetic and Apoptotic Profile Alterations
Gomaa H. Mahmoud1*, Samy A. Saber1, Abir A. El-Fiky2, Aly F. Mohamed3
Department of 1Zoology, Faculty of Science (Boys branch), Al-Azhar University; 2ANDI COE in
Antivenom Research and 3R&D Sector VACSERA
*Corresponding author: Gomaa Hamed, Mobile: (+20) 01020661649, Email: ghamed2013@yahoo.com


Background: cancer is basically a disease of uncontrolled cell division. Its development and progression are usually
linked to a series of changes in the activity of cell cycle regulators.
Objective: the present study aimed to investigate the anticancer potential of Echispyramidum venom against
HepG2 and HCT 116 cancer cell lines in comparison with the Cisplatin as positive control.
Patients and Methods: cell viability performed using MTT assay was cell type and concentration dependent was
inversely proportional with the tow substances (Echispyramidum) venom as well as Cisplatin had IC50 of 11.8 and
112.7 µg/mL and 13.4 and 71.2 µg/mL developed in HCT116 and HepG2 cell lines respectively.
Results: both of Echispyramidum venom and Cisplatin showed DNA accumulation at the Pre-G1 and G2/ M Phases
of cell cycle. Apoptotic profile of treated cells showed up regulation of apoptotic genes (P53, Bax and Casp-3) and
down regulation of anti-apoptotic gene (Bcl-2) in a significant way compared with untreated cell control. Also,
apoptotic profile was assured via cellular changes detected microscopically in H&E stained cells. Microscopic
examination showed apoptotic and slightly necrotic features in case of venoms while Cisplatin induced a number
of apoptotic bodies and necrotic cell colonies.
Conclusion: it can be concluded that Echispyramidum venom has a clear anticancer potential to human liver and
colorectal cancer cells that was proven through the cell cycle arrest profile, induced apoptosis detected via detection
of the levels of expression of pro and anti-apoptotic genes, as well as histological alteration detected.
: Echispyramidumvenom, liver cancer,colorectal cancer, Cisplatin, cytotoxicity, apoptosis, anticancer.

Cancer is a disease arises from single abnormal
chemotherapy, radiotherapy, gene therapy and hormone
cell with mutated DNA(1). It is caused by disturbance in
therapy which were found to affect both cancerous cells
the balance between the growth promoting and growth
and intact cells as well as causing severe side effects.
inhibitors leading to progressive and uncontrolled cell
As a result, the use of naturally extracted drugs is
proliferation disregarding the normal process of cell
becoming a more attractive alternative as opposed to
division and absence of the programmed cell death
traditional drugs. Snake venom is a complex mixture of
process "apoptosis(2). According to WHO(3), the global
bioactive peptides, proteins, enzymes, and toxins
cancer burden is estimated to have risen to 18.1 million
including cytotoxins, cardiotoxins and neurotoxins,
new cases and 9.6 million deaths in 2018. One in 5 men
which exhibits cytotoxic activities. Snake venom
and one in 6 women worldwide develop cancer during
targets cellular metabolism alterations rendering it a
their lifetime, and one in 8 men and one in 11 women
potential anticancer and anti-oxidizing complex. Thus,
die from the disease. Worldwide, the total number of
snake venoms can induce the blockage of some specific
people who are alive within 5 years of a cancer
ion channels, inhibiting angiogenesis and subsequently
diagnosis, called the 5-year prevalence, is estimated to
suppressing metastasis, and activating the intracellular
be 43.8 million.
pathways causing apoptosis(4,5).
Liver cancer (841,084 cases, 5% of the total) is
One of the most dangerous snakes in the world
the sixth most common cancer worldwide and the fourth
and lives in Egypt is E. pyramidum. E. pyramidum
most common cause of cancer death (782,000 deaths,
venom consist of specific enzymes like PLA2,
8.2%). Colorectal cancer (1.8 million cases, 10.2% of
phospholipase A2; SVSP, snake venom serine protease;
the total) is the third most commonly diagnosed cancer
SVMP, snake venom metalloprotease; LAAO, L-
and the second most common cause of cancer death
amino acid oxidase; CRiSP, Cysteine-Rich Secretory
(881,000 deaths, 9.2%). In Egypt, the cancer burden is
Protein; CTL/SNACLEC, C-type lectins and C-type
estimated to have risen to 128,892 new cases and 85432
lectin like; DIS, disintegrin and VEGF, vascular
deaths in 2018, while the number of prevalent cases (5-
endothelial growth factor(6).
year) is 257,288 cases. Also, Liver cancer (25,399
PLA2 is considered the main component of the
cases, 19.7% of the total) is the first most common
vipersvenom which causes hydrolysis of membrane
cancer in Egyptand the first most common cause of
phospholipids which induces the release of
cancer death (25,084 deaths, 29.4%), while colon
lysophospholipids and fatty acids resulting in the
cancer (3,477 cases, 2.7% of the total) is the eighth most
pharmacological effects within cells such as membrane
commonly diagnosed cancer and the ninth most
damage, disruption of membrane-bound protein and
common cause of cancer death (2,051 deaths, 2.4%).
functional disturbances of the cellular cascade, and

Full Paper (vol.764 paper# 9)

c:\work\Jor\vol764_10 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3901-3906

Assessment of Left Ventricular Remodeling Index in Hypertensive Patients
Using Two- and Three-Dimensional Transthoracic Echocardiography
Mohammad H. Ezzat, Kamal A. Marghany, Mohammed A. Abd Elghany
Department of Cardiology, Faculty of Medicine, Al-Azhar University
Corresponding author: Mohammed A. Abd Elghany, Mobile: (+20) 01032200051,
Email: dr.mohammedatef1990@gmail.com

Hypertensive heart disease (HHD) and coronary artery disease (CAD) generally develop left ventricular
remodeling. Therefore, it is of great importance for how to assess HHD and CAD's left ventricular remodeling which
can influence vital diagnosis, therapeutic decisions and prognosis. Aim of the Work: to assess left ventricular
remodeling index in HTN patients compared to normal patients using 2D and 3D transthoracic echocardiography.
Patients and Methods:
This study included 120 subjects at Cardiology Department, Faculty of Medicine, Al-Azhar
University during the period from October 2018 to June 2019. They were divided into two groups: Group A (Patient
group): which included (100) hypertensive patient. Group B (Control group): which included (20) age and sex matched
apparently healthy individuals. Results: There were no significant differences in age and sex inter-group. LVRI
detected by RT3DE and 2DE showed significant differences inter-group (1.72±0.04 vs 1.94±0.07, 1.73±0.04 vs
2.17±0.05); and significant differences in patient (1.94±0.07 vs 2.17±0.05), but no significant differences in control
group (1.72±0.04 vs 1.73±0.04). Correlation analysis indicated that there was a good positive correlation between
LVRI detected by RT3DE and 2DE in control and patient groups (r=0.91, 0.79, all P<0.001).
LVRI derived from RT3DE can provide more superiority to LVRI derived from 2DE as an index for
evaluating left ventricular remodelling.
Left Ventricular Remodeling Index, Hypertension, Two- and Three-dimensional Transthoracic

ventricular volume, left ventricular mass without
Hypertension is one of the major risk factors for
geometric assumptions, which resulted in higher levels
coronary heart disease (CHD), myocardial infarction
of agreement and reproducibility with the CMR
(MI), cerebrovascular accidents (CVA), chronic renal
reference values (4).
failure (CRF), and congestive heart failure (CHF).

Essential hypertension is defined as an increase in BP
([BP] >140/90 mm Hg) of unknown cause that increases
The aim of this study is to assess left ventricular
the risk for cardiovascular (CV) diseases such as cerebral,
remodeling index in HTN patients compared to normal
cardiac, large artery, and renal events. However,
subclinical vascular target organ damage (TOD) occurs
very early in the course of hypertension and can be

identified with noninvasive testing. These subtle CV
findings include left ventricular hypertrophy (LVH),
This study included 120 subjects at Cardiology
diastolic dysfunction, microalbuminuria, abnormal
Department, Faculty of Medicine, Al-Azhar University
vascular compliance, and abnormal cognitive dysfunction
during the period from October 2018 to June 2019.
or vascular dementia (1).
They were divided into two groups:
As well known, hypertensive heart disease (HHD)
Group A (Patient group): which included (100)
generally develops left ventricular remodeling.
hypertensive patient.
Therefore, it is of great importance for how to assess
Group B (Control group): which included (20) age
HHD's left ventricular remodeling which can influence
and sex matched apparently healthy individuals.
vital diagnosis, therapeutic decisions and prognosis (2).
Inclusion criteria:
Echocardiography, as a technique of assessment of
Hypertensive patients diagnosed according to the
left ventricular remodeling, has noninvasive, safe,
hypertension diagnostic standard and left ventricular
convenient and repeatable advantages over other
thickening [inter-ventricular septal thickness >11 mm]
methods (3).
measured by two-dimensional echocardiography (5).
Recent advances in capability of new combination
Exclusion criteria:
of ultrasound system, computer processing and
Serious arrhythmia, poor echocardiographic images,
commercial software, RT3DE resolved many of the
patients with cardiac intervention (PCI or CABG),
limitations associated with the evaluation of left
patients with congenital heart disease, patients with
ventricular volume from 2DE images and significantly
conduction abnormalities, pacemaker and bundle branch
improved the accuracy of these measurements, and
block, patients with valvular disease, ischemic heart
provided fast, accurate and available assessment of left
disease, congestive heart failure, EF < 50%, DM were

Full Paper (vol.764 paper# 10)

c:\work\Jor\vol764_11 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3907-3911

Intravitreal Ranibizumab Alone or Ranibizumab Combined with Thermal
Laser Therapy for Diffuse Diabetic Macular Edema
Ashraf Mohammed Gad Elkareem
Ophthalmology Department, Faculty of Medicine, Al-AzharUniversity, Assiut Branch, Egypt
E-mail: silicon2030@gmail.com, Tel: +201060293796

Diffuse diabetic macular edema (dDME) is one of the most frequent squeal of diabetes mellitus and
deteriorates visual acuity in the working group of population.
to compare the effectiveness of intravitreal ranibizumab alone or ranibizumab combined with thermal laser
therapy for treatment of diffuse diabetic macular edema.
Patients and methods:forty five eyes of 45 patients suffering from diffuse diabetic macular edema were requriuted
and classified into two groups; intravitreal ranibizumab alone group (IR group) included 24eyes of 24 diabetic
persons, injected with 0.5 mg ranibizumab (0.1ml) at baseline, 1st month, and 3rd month. A twenty-one eye of 21
diabetic patients was injected with 0.5 mg ranibizumab at baseline, 1st month, and 3rd month followed with macular
grid argon laser photocoagulation three weeks after the 1st injection (combined group).
Visual acuity as log MAR value, central macular thickness (CMT) measured with optical coherence tomography
(OCT), and intraocular pressure (IOP) were assessed at baseline, 3 and 6 months post-injection.
Results: the baseline log MAR visual acuity and macular thickness significantly improved in both groups at three,
and six months post-injection. However, the combined group showed more improvement with stable results at the
end of follow up period of six months. The mean IOP was 14.1±1.3 mmHg and 13.9±1.4mmHg at the end of follow
up in IR and combined groups respectively.
Conclusion: both groups achieved improvement of visual acuity and reduction of the macular thickness but the
effect was more pronounced and long-lasting in the combined therapy group.
Keywords: Ranibizumab, diabetic macular edema, argon laser, diabetic retinopathy, diabetes mellitus.


a Significant number of patients still have persistent
Visual deterioration in diabetic retinopathy (DR)
macular edema after multiple monthly injections (7,8).
patients is related to the development of macular

edema(1). Prolonged duration of diabetes and poor
control of blood sugar are the main risk factors
It is to evaluate the effectiveness of intravitreal
associated with progression of DR and the occurrence
injection of ranibizumab alone or combined with
of diabetic macular edema (DME)(2). The main
macular laser therapy for treatment of diffuse diabetic
pathology involved in the development of DME is
macular edema.
microvascular leakage secondary to breakdown of the

inner blood retinal barrier with increased vascular
permeability, these will lead to accumulation of fluid in
This is a randomized prospective comparative study
the retinal layers(3).
carried out between November 2017 and October 2018
Although its specific mechanism of action is still
and recruited forty-five eyes of 45 patients having
unclear, macular laser photocoagulation remains the
diffuse DME according to the ETDRS criteria. The
gold standard treatment of DME(4). The Early
study was carried out in the Ophthalmology
Treatment Diabetic Retinopathy Study (ETDRS)
Department, Al-Azhar University Hospital, Assiut.The
demonstrated that focal/grid macular laser treatment
study was done after approval of the Research and
reduced the risk of visual loss in 50% of the studied
Ethical Committee, School of Medical Sciences, Al-
patients, but fails to improve visual acuity especially in
Azhar University, Egypt. Informed consent was taken
patients with diffuse DME(4). However, other recent
from each patient.
studies demonstrated good visual restoration in about
These patients were divided randomly into two
31%, and visual deterioration in about 19% of laser
groups; intravitreal ranibizumab group (IR group)
treated patients(5).
included 24eyes of 24 persons with type 2 diabetes
Vascular endothelial growth factor (VEGF) is the
mellitus (DM), 15 males and 9 females, injected with
main mediator involved in the pathogenesis of DME
0.5 mg ranibizumab (0.1ml) at baseline, 1st month, and
leading to increased retinal vascular permeability(6).
3rd month. A twenty-one eye of 21 patients with type 2
Hence the use of anti-VEGF agents as a first-line
DM, 13 males and 8 females, was injected with 0.5 mg
therapy for the treatment of DME was suggested(7).
ranibizumab at baseline, 1st month, and 3rdmonth and
Although the effectiveness of anti-VEGF as a
grid argon laser photocoagulation was done three weeks
monotherapy for DME, some studies have shown that
after the baseline injection (combined group).

Full Paper (vol.764 paper# 11)

c:\work\Jor\vol764_12 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3912-3918

Forgotten Double-J Ureteral Stents: Prevalence, Risk factors and Complications
Gamal Eid Gamal El-Kholy, Hassan kotb Mohamed Keritna, Tarek Abdallah Mohamed salem
Department of Urology, Faculty of Medicine, Al-Azhar University
Corresponding author: Gamal Eid Gamal El-Kholy; Mobile: +201145553391;
Email: gamalelkholy2007@yahoo.com

Background: Ureteral JJ stents (DJS) are a common part of urological practice and are used for the management of
upper urinary tract obstruction and ureteral surgery, despite their advantages; ureteral stents are not without possible
Objective: This study aimed to record the prevalence and possible reasons behind neglected DJS and its
complications. The difficulties associated with their removal and risk factors correlate with these difficulties.
Patients and Methods: A cohort study including 517 patients presented with fixed DJS presenting to Department of
Urology, Al-Azhar University Hospitals; Cairo; Egypt. With neglected DJS (indwelling for more than 6 months).
We noted the complications of neglected stents (urinary tract infection, gross hematuria, encrustation, migration and
stent fragmentation), the treatment modalities and risk factors for these complications.
Results: From the entire patients, 239 (46.2%) had a neglected stent with mean stenting duration 11.11 ± 8.6
months. A total of 26.8% of patients received urine acidification, 26.4% were stone formers, 32.2% presented with
urinary tract infection (UTI) and 33% had gross hematuria. Encrustations on the stent were recorded in 17.2% of
patients and fragmented stent in 4.6% and 2.5% migrated stent up. The stent was removed by cystoscopy in 201
cases (84.1%). Other cases needed combined endoscopic and/or open surgical procedures. Lack of urinary
acidification was a significant risk factor for UTI and complex interventions for stent removal (P = 0.013 and 0.017,
respectively). Stent fragmentation were more likely with longer duration of stenting (P = > 0.001).
Conclusion: Neglected DJS are associated with significant morbidity, urine acidifications is protecting against
DJS, encrustations, Urinary acidification.


The use of dual ring stents (DJS) has become an
difficulties associated with their removal will be studied
integral part of the practice of modern urinary tract.
and risk factors correlate with these difficulties will be
Indicators of inclusion in DJS include almost any
surgical intervention involving ureters and a variety of

renal surgeries (1).
By allowing urine flow through both internal
Combined retrospective and prospective cohort
and external routes, DJS provides a channel for
study including patients with neglected DJS (indwelling
discharge of urine from the kidney to the bladder to
for more than 6 months) presenting to Department of
relieve obstruction, pain or infection associated with it.
Urology, Al-Hussein and Sayed Galal Hospitals, Al-
Despite the obvious advantages of DJS, its use can be
Azhar University, Cairo, Egypt in the period from
associated with complications (2). However, different
January 2016 to February 2019.
complications may occur with short- or long-term use
The study included all patients with neglected
of indwelling stents. These complications vary from
DJS more than 6 month underwent stent removal. A
minor side effects to major complications as (hematuria,
ureteral stent in situ for a prolonged period with regular
UTI, migration, fragmentation, encrustation, stone
change every 6 months and long term DJS (silicon JJ)
formation, urinary tract obstruction, and renal failure).
were excluded from the study.
Most of these complications require removal of the

stent (3).
Ethical approval:
The removal of ureteric stents is one of the
The study was approved by the Ethics Board
simplest endourologic maneuvers, yet the removal of
of Al-Azhar University. All study material were kept
the neglected ureteric stent may be one of the most
in separate lockers; not accessed except by study
complicated endourological maneuvers as the loss of its
investigators. A signed consent was obtained from each
tensile character due to neglect may lead to its
patient included in this study.
breakage, fragmentation, encrustation and stone

Study procedures and data collection:

The medical records of all patients with
neglected fixed DJS who were treated at our University
To record the prevalence and possible reasons
Hospitals were reviewed for: Demographic and
behind neglected DJS and its complications. The
historical data (age, gender, marital status, residence,

Full Paper (vol.764 paper# 12)

c:\work\Jor\vol764_13 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3919-3923

Evaluation of Serum Level of Calprotectin in Patients with Psoriasis and
Its Relation to The Clinical Severity of The Disease
Amr Mohamed Zaki1, Mohamed Abdelmawgoud Amer1,
Nagah Mohamed A. Mohamed2, Mohamed Ahmed El-saeed Abdelkhalik1*
Departments of 1Dermatology & Venereology and 2Clinical Pathology & Immunology,
Faculty of Medicine, Al-Azhar University
*Correspondence author: Mohamed Ahmed El-saeed Abdelkhalik, Mobile: (+20) 01016873338,
E-Mail: mohamedshazly1135@gmail.com
Psoriasis is a common chronic immune mediated papulosquamous disease. Its prevalence around 2-3%
of the general population,and is characterized by an exaggerated proliferation of keratinocytes secondary to an
activated immune system. Objective: the aim of this work was to investigate the relationship between serum
Calprotectin and psoriasis vulgaris and to correlate with disease severity.
Patients and Methods: the present study was conducted on 50 patients with psoriasis (group A) and 30 healthy
control subjects (group B). Both groups were subjected to full history taking, clinical examination and estimation of
serum level of calprotectin using ELISA technique. PASI score was used to assess disease severity in group A.
calprotectin level was significantly higher in cases group than in control group. A positive statistical
correlation between the calprotectin level and the disease severity (PASI score) was observed but not with age, sex,
nor duration of disease. Conclusion: calprotectin can be used as a marker of psoriasis severity and progression.
Calprotectin may play a role in the pathogenesis of psoriasis.
Keywords: Calprotectin, Psoriasis, autoimmune diseases.

cells involved in the induction of pro-inflammatory
Plaque-type psoriasis is the most common form,
cytokines by keratinocytes and stimulation of pro-
affecting 80 ­ 90% of patients. Patients present with
sharply demarcated, erythematous plaques covered by
silvery white scales, most commonly on the extensor

surfaces and the scalp. Patients may experience
extracutaneous manifestations commonly including nail
The aim of this work is to investigate the
involvement and psoriatic arthritis in up to 20% of
relationship between serum Calprotectin and psoriasis
patients (1). The genetic, immunological and
vulgaris and to correlate with disease severity.
environmental factors contribute to the pathogenesis of

psoriasis. However, its precise etiology is not yet fully
elucidated (2).
The present study was conducted at
In the last decades, S100 proteins have been
Dermatology outpatient clinics of Al-Azhar University
increasingly emerging as a key player of innate
Hospital, Elhousin university hospital. It included two
immunity, important in the pathogenesis of various
groups as follow:
inflammatory, metabolic, and neoplastic disorders.
Group A (cases group): included 50 patients presented
They are produced as monomers and spontaneously
clinically with plaque psoriasis randomly selected from
form dimers/multimers(3).
Dermatology outpatient clinics.
S100A9 together with S100A8 proteins forms a
Group B (control group): included 30 healthy subjects as
heterodimeric complex, termed calprotectin(4).
Calprotectin is a calcium-binding cytosolic

protein that belongs to theS100 family, which presents
Written informed consent:
in regenerative cellssuch as neutrophils, monocytes,
An approval of the study was obtained from
macrophages, epithelial, and endothelial cells (5). It was
Al-Azhar University Academic and Ethical
suggested that this protein might be a promising marker
Committee. Every patient signed an informed written
of inflammation (6).
consent for acceptance of the operation.
Calprotectin is related to disease activity in
Inclusion criteria: Cases with Psoriasis vulgaris.
several inflammatory and autoimmune diseases, such
Exclusion criteria:
as: SLE (7), Rheumatoid arthritis (8), Still's disease(9),
Patients on topical or systemic therapy for psoriasis
Acute gouty arthritis (10). Fecal calprotectin has good
during the last fourweeksprior to the study.
diagnostic value to identify IBD and differentiates it
Any apparent sign of acute or chronic inflammation
from functional disorders of the gut. It can be used to
(e.g., hepatitis, arthritis, inflammatory bowel diseases).
detect disease activity, predict relapse, and monitor
Connective tissue diseases.
response to therapy in IBD(11). Evidence is accumulating
Liver or renal impairment.
for a role of calprotectin in the pathogenesis of psoriasis,
including a direct chemotactic effect on various immune
Acute or chronic infections.

Full Paper (vol.764 paper# 13)

c:\work\Jor\vol764_14 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3924-3932

Assessment of RV Systolic Function by Two-Dimensional Speckle Tracking
Echocardiography in Patients with Preeclampsia before and after Labor
Mohamed H. Hassan(1), Abd EL Hamid I. Abd EL Hamid (1),
Ahmed O. Abdel-Motaal (2), Hazem A. Mahmoud (1)
(1) Department of Cardiology and (2) Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar
University, Cairo.
Corresponding author: Hazem A. Mahmoud, Mobile: (+20) 01061056031, E-mail: ramyhazem94@gmail.com

preeclampsia (PE) is one of the most common causes of maternal mortality and morbidity worldwide.
Although cardiovascular (CV) risk is increased after PE, a direct causative relationship has not yet been determined.
Aim of the Work:
to evaluate and detect subclinical RV dysfunction by 2D speckle tracking echocardiography in
preeclamptic patients before and after labor.
Patients and Methods: 60 pregnant women were selected for this sectional comparative study which was conducted
at Cardiology Department, Faculty of Medicine, Al-Azhar University during the period from October 2018 to June
comparison between before labor and 6 weeks after labor of the right ventricle of the preeclamptic patients
showed that tricuspid annular plane systolic excursion (TAPSE) was 22.33 ±3.08 and 26.48 ±2.20, respectively with
change of 4.15 (18.6%), with a statistically highly significant difference (p <0.001), end-systolic pulmonary arterial
pressure (ESPAP) was 14.65 ±1.63 mmHg and 8.35 ±1.76 mmHg, respectively with change of -6.3 (43%), it showed
a statistically highly significant difference (p <0.001), fractional area change (FAC) was 50.55 ±2.25 and 53.40 ±1.66,
respectively with change of 2.85 (5.6%), it showed a statistically highly significant difference (p <0.001), right
ventricular index of myocardial performance (RIMP) was 41.45 ±2.11 and 33.28 ±2.34, respectively with change of
-8.17 (19.7%).
two-dimensional speckle echocardiography proved to be acceptable, and applicable for assessing right-
sided heart function in patients with preeclampsia. Using this image modality demonstrated significant differences
in right ventricular measurements to overcome further morbidity and mortality of those patients.
Keywords: RV systolic function, two-dimensional speckle tracking echocardiography, preeclampsia labor.

the analysis of predicting factors for essential
Preeclampsia is a pregnancy-specific disorder
hypertension in preeclampsia might be meaningful (6).
that complicates 2%­8% of pregnancies worldwide (1).
Transthoracic echocardiography (TTE) is a
Traditionally the condition is diagnosed in the case of
common noninvasive diagnostic tool that can be safely
de novo development of hypertension (> 140/90
used during pregnancy to evaluate cardiac structure
mmHg) and proteinuria during the second half of
and function with two-dimensional (2D) scan, M-
pregnancy (>20 weeks of gestation) (2).
mode, and Doppler. Particularly, tissue Doppler
Preeclampsia is often classified based on the
imaging (TDI) is a new method of non-invasive
gestational age at onset of the disease; early-onset
myocardial strain measurement, which has potential
preeclampsia is defined as the onset of preeclampsia
advantages in evaluating additional risk factors for
before 34 weeks of gestation and late-onset preeclampsia,
cardiac performance status (7). Proper use of TTE in
as the onset of preeclampsia at or after 34 weeks of
preeclampsia can be useful to determine the severity
gestation (3).
and to predict the prognosis (4).
Preeclampsia is associated with an increased risk of
Echocardiography is a noninvasive, widely
developing cardiovascular disease in later life. The
available, fast, and fairly accurate technique for the
cardiovascular disorders and preeclampsia share various
assessment of right ventricular (RV) function, despite
pathophysiologic mechanisms. Preeclampsia is related to
several limitations related to RV geometry and shape
and the need for RV-focused views that will be
hypertension, vasomotor dysfunction, endothelial damage,
discussed in detail later, and it is considered a good
inflammation, and metabolic disturbance (4).
first-line tool for the evaluation of the right heart. The
However, the underlying pathophysiologic
recent application of newer myocardial deformation
mechanisms of preeclampsia that could produce
techniques to the right ventricle has allowed the earlier
increased risk of long-term cardiovascular disorder are
detection of subtle RV dysfunction, upgrading the role
not defined (5).
of echocardiography in everyday clinical practice.
Although a direct correlation was been
Myocardial deformation can be studied using different
determined yet, a higher risk of essential hypertension
ultrasound techniques, but the most used are two-
was reported in early onset preeclampsia. Therefore,
dimensional (2D) and three-dimensional (3D) speckle-
tracking echocardiographic (STE) strain. STE imaging

Full Paper (vol.764 paper# 14)

c:\work\Jor\vol764_15 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3933-3939
Value of Duke Treadmill Score in Setting Priority of
Patients for Coronary Angiography
Mohsen Ali Salama, Mohamed Saad Elgamaal, Aymen Elsaeed Sadek, Ahmed Yehia Hafez
Department of Cardiology, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Yehia Hafez, Mobile: (+20)01010849482;
Email: yehiaahmedyehia2018@gmail.com

exercise treadmill test remains a good test in identification of coronary artery disease(CAD).
The Duke Treadmill Score (DTS), shown to predict CAD better than ST segment deviation alone.
Aim of the work: To determine the potential of DTS in setting priority of patients for coronary angiography.
Patients and methods: This was a prospective study that was done from July 2017 to October 2018 and included 150
patients referred to Damannhour Teaching Hospital for evaluation of chest pain. Patients underwent: history, clinical
examination, ECGs, Echocardiography, Treadmill exercise ECG with calculation of DTS then coronary angiography
that was correlated with DTS and other variables. Results: There were 59 patients(39.3%)with high DTS and 91patients
(60.7%) with intermediate DTS. For the intermediate Duke's risk group the result of coronary angiography distributed
on normal (26.4%), single vessel disease (33%), two vessel disease (22%), and three vessels disease or left main disease
(18.7%). For high Duke's risk group the result of coronary angiography showed mainly three vessels disease or left main
disease (54.2%), two vessels disease (27.1%), single vessel disease (6.8%) and normal vessel (11.9%), The P value
was<0.001.Adding patient's risk factors to intermediate DTS group were statistically significant in the diagnosis of CAD
,the P value was<0.001. Conclusion: The DTS is a good predictor for CAD. Intermediate risk DTS group exercise test
results should be managed individually according to clinical data.
Keywords: Coronary artery disease; Exercise ECG Stress testing; Duke Treadmill Score; Coronary angiography.

Nowadays, coronary artery disease (CAD) is the
This was a prospective observation study that
leading cause of death all over the world. Approximately
was done from July 2017 to October 2018 and included
50% of all deaths occur due to CAD. Hence, it is
150 patients referred to Cardiology Department at
important to diagnose patients with CAD (1­3). Despite
Damannhour Teaching Hospital for evaluation of chest
the numerous advances in imaging technology within
pain. The study was approved by the Ethics Board of
recent years, coronary angiography remains the
Al-Azhar University and an informed written
definitive examination for establishing the presence, site
consent was taken from each participant in the study.
and severity of CAD in living patients(4).

Because of the invasiveness and costs of
Exclusion criteria:
coronary angiography, which prevent its application on
1. Prior cardiac catheterization.
a large scale. Coronary atherosclerosis is commonly
2. Revascularization procedure.
assessed indirectly by means of noninvasive less
3. Resting ST segment or T wave abnormalities such
expensive laboratory tests(5).
as left bundle branch block, Wolff-Parkinson
The exercise treadmill test remains a good test
White or left ventricular hypertrophy in the
in identification of coronary artery disease(6).
baseline 12-lead ECG that might interfere with the
The low sensitivity and specificity of exercise
interpretation of the exercise ECG stress.
electrocardiogram stress testing for diagnosis of
4. Contraindications to exercise ECG testing:
coronary artery disease have stimulated increased use
a. Acute myocardial infarction (< 2 d).
and development of noninvasive stress imaging tests(7).
b. Unstable angina with recent rest pain.
In 1991, Mark and coauthors(8) described a
c. Untreated life-threatening cardiac arrhythmias.
prognostic exercise treadmill score (Duke's score) that
d. Advanced atrioventricular block.
was depend on the duration of exercise, degree of ST-
e. Acute myocarditis or pericarditis.
segment deviation in mm (depression or elevation), and
f. Critical aortic stenosis.
the presence and severity of chest pain during exercise.
g. Severe hypertrophic obstructive cardiomyopathy.
This treadmill score has been shown to stratify prognosis
h. Uncontrolled hypertension.
accurately for both inpatient and outpatient coronary
i. Acute systemic illness (pulmonary embolism, aortic
artery disease populations (9).
The Duke Treadmill Score (DTS), traditionally

a prognostic tool, was recently used as a diagnostic tool
and shown to predict coronary artery disease better than
All the patients were subjected to the following:
the ST segment deviation alone (10).
1- History:

With a special emphasis on age, gender and major
aim of the work: To determine the potential of DTS in
documented risk factors for coronary artery disease or
setting priority of patients for coronary angiography.
any cardiac condition, Symptoms , number of episodes
Received:5/2/2019 accepted:7/3/2019


Full Paper (vol.764 paper# 15)

c:\work\Jor\vol764_16 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3940-3949

Role of Cardiac MRI in assessment Non-Ischemic Cardiomyopathy
Mostafa Fadel Sonbol, Mahmoud Ibrahim Elshamy, Anas Mohamed Sabry Elhadary*
Department of Radio-diagnosis, Faculty of Medicine, Al-Azhar University
*Correspondence author: Anas Mohamed Sabry Elhadary; Mobile: (+20) 01020335834,
E-mail: anaselhadary55@gmail.com
cardiomyopathies encompass a broad spectrum of myocardial conditions which can affect the heart
as a primary disease process or as part of a systemic disorder, evolving toward heart failure or cardiovascular death.
Objective: this study aimed to identify the role and diagnostic potential of cardiac magnetic resonance imaging to
diagnose and differentiate various types of cardiomyopathy.
Patients and Methods: this study included 50 patients with suspected different types of non-ischemic
cardiomyopathies referred from outpatient clinic of Cardiology at Al-Hussein University hospital from November
2018 to July 2019. Results: all patients showed mild to moderate mitral regurge (100% of cases), tricuspid regurge
was seen in 3 cases (75% of cases) and aortic regurge was seen in 4 cases (50 % of cases). The most value of MRI
study of these patients was to differentiate whether if heart failure is related to 1ry dilated cardiomyopathy or other
causes such as ischemia as they have different management in each group.
Conclusion: CMR is a valuable (minimally or non-invasive) imaging technique in patients with suspected or known
to have non-ischemic cardiomyopathies. It helps to identify the underlying cause, predict prognosis and
responsiveness to therapy and affect management as well follow-up and most recently as primary prevention
diagnostic tool.
Keywords: MRI, CMR, Ischemic Cardiomyopathy.

Through its ability to characterize the
Cardiomyopathy is defined as `a myocardial
myocardium by using multiple different imaging
disorder in which the heart muscle is structurally and
parameters, it provides insight into the etiology of the
functionally abnormal in the absence of coronary heart
underlying heart failure and its prognosis(2).
disease, hypertension, valvular heart disease and

congenital heart disease sufficient to cause the
CMR is widely accepted as the reference
observed myocardial abnormality (1).
standard for quantifying chamber size and ejection
In the investigative work up for a suspected
cardiomyopathy, typically a considerable number of
techniques such as late gadolinium enhancement
tests are performed, ranging from the more routine and
(LGE) and other quantitative parameters such as T1
straightforward tests including ECG, echocardiogram,
mapping, bothnative and with measurement of
and exercise treadmill, to the more invasive including
extracellular volume fraction;T2 mapping; and T2*
coronary angiography, electrophysiological studies,
mapping have been validated against histological
and endomyocardial biopsy. It is key to identify a
findings in a wide range of clinical scenarios.In
potentially treatable substrate and then to risk stratify
particular, the pattern of LGE in the myocardium can
patients for treatment including consideration of an
help determine the underlying etiology of the heart
failure. The presence and extent of LGE determine
resynchronisation device(2).
cardiomyopathies. The use of CMR should increase as
resonance (CMR) provide the potential to address all
its utility in characterization and assessment of
these important issues in a single scan setting
prognosis in cardiomyopathies is increasingly
complementing other non-invasive tools and genetic
recognized (3).
testing. The cost-effectiveness of non-stress CMR has
Contrast-enhanced CMRI can play a role in the
been highlighted recently pointing out the ability of
CMR to act as a cost-reducing gatekeeper to invasive
cardiomyopathy and ischemic cardiomyopathy
coronary angiography in specific clinical settings (1).
through the identification of myocardial scarring or
fibrosis as presence of delayed enhancement. This
Cardiomyopathies (NICMP) are approached from a
would reduce the costs and inherent risk associated
clinical point of view outlining the diagnostic and
with invasive cardiac catheterization on which the
prognostic role of CMR as an integral part of the
diagnosis of cardiomyopathy is still dependent (3). In
clinical decision making algorithm(2).
addition, CMRI in non-ischemic cardiomypathy
Cardiac magnetic resonance (CMR) is a
valuable tool forevaluation of patients with, or at risk
outcomes(4). Cardiac magnetic resonance imaging is
for, heart failure and has a growing impact on
frequently used as a part of the cardiac workup and can
diagnosis, clinical management, and decision making.
be used to accurately identify the distribution of scar

patterns, scar characterization, and measure the

Full Paper (vol.764 paper# 16)

c:\work\Jor\vol764_17 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3950-3956

Role of CT and MRI in Diagnosis of Pericardial Diseases
Ahmed Abd Al-Fattah Aborashed, Mohamed Ismail Ahmed, Abdullah Mohamed Wali Ali*
Department of Radio-diagnosis, Faculty of Medicine ­ Al-Azhar University
*Correspondence author: Abdullah Mohamed Wali Ali, Mobile: (+20) 01062122664,
E-mail: abdullahwali033@gmail.com

Pericardial disease is an important cause of morbidity and mortality in patients with cardiovascular
disease. Although the pericardium is usually sufficiently thick to be identified on CCT and CMR, visualization at
the most common site of pericardial defects, the lateral, posterior, and inferior left ventricular wall, can be poor
because of a paucity of fat.
Objective: The aim of this study was to evaluate the role of CT & MRI in the diagnosis of pericardial diseases.
Patients and Methods: 30 patients with cardiac abnormalities were included. All patients' data of preoperative
were reported. Range of age was 15-59 years. 20 patients were male and 10 patients were female.
Results: In our study MR imaging showed accuracy of 93% for differentiation between constrictive pericarditis and
restrictive cardiomyopathy on the basis of depiction of thickened pericardium. In our study on MR images, an intact
pericardial line may be observed if an adjacent tumor extends to the pericardium but not through it. Tumors that
have invaded the pericardium may be recognized by focal obliteration of the pericardial line and the presence of
pericardial effusion. Hemorrhagic pericardial effusions secondary to metastases usually have high signal intensity
on SE images.
Conclusion: CT and MR imaging should be used when findings at echocardiography are difficult to interpret or
conflict with clinical findings.
Keywords: CT, MRI, Pericardial diseases.

resonance imaging (CMR) are important methods for
The pericardium represents a simple, two-
aiding in diagnostic evaluation (3, 5).
layered, fibroelastic sac that surrounds the heart and
Echocardiography is the method of choice for
provides lubrication and protection. Normally, it is a
thin-walled structure (< 3 mm) with minimal
competently performed in patients with good acoustic
pericardial fluid (< 50 ml). The normal pericardium is
windows, echocardiography accurately detects all
fairly distensible, precluding excessive constraint of
pericardial effusions and provides clinically relevant
the ventricles (1). The pericardium has been described
information about their size and hemodynamic
as an intracardiac pressure modulator, limiting acute
importance. The technique is less reliable than MRI
distention of any cardiac chamber (2).
and CT in detecting pericardial thickening/constriction
Pericardial diseases are important causes of
and calcification as well as small loculated effusions,
morbidity and mortality in patients with cardiovascular
but is still extremely useful in these conditions (6).
disease. Inflammatory diseases of the pericardium
In the evaluation of pericardial disease, CT
constitute a spectrum ranging from acute pericarditis to
and MRI traditionally have been used as adjuncts to
chronic constrictive pericarditis. Other important
echocardiography. However, CT and MRI are
entities that involve the pericardium include benign
particularly useful as sensitive and noninvasive
and malignant pericardial masses, pericardial cysts,
methods for evaluating loculated or hemorrhagic
diverticula, as well as congenital absence of the
pericardial effusion, constrictive pericarditis and
pericardium (3).
pericardial masses. Both CT and MRI provide
The pericardium may be secondarily involved
excellent delineation of the pericardial anatomy and
by a large group of systemic diseases, such as infective,
can aid in the precise localization and characterization
autoimmune, and neoplastic processes. Moreover,
of various pericardial lesions, including effusion,
iatrogenic causes ­ for example, after cardiac surgery
constrictive pericarditis, pericardial thickening,
or radiation therapy-represent an important cause of
pericardial masses and congenital anomalies. Both
pericardial related morbidity and mortality (4).
modalities provide a larger field of view than doe's
Clinical diagnosis with a detailed examination
echocardiography, allowing the examination of the
is often complemented by ECG, chest x-ray (CXR) and
entire chest and detection of associated abnormalities
echocardiography, as well as potentially hemodynamic
in the mediastinum and lungs. Soft tissue contrast on
catheterization depending on the nature and severity of
CT scans and MR images also is superior to that on
the symptoms. While these tools have a broad and
echocardiograms. Given the many potential
well-established role in the diagnosis of pericardial
applications of these modalities in the evaluation of
disease, newer modalities, such as cardiac computed
pericardial diseases, familiarity with the CT and MR
tomography (CCT) and cardiovascular magnetic
imaging features of these diseases is important for
optimal management of the patient (3, 7).

Full Paper (vol.764 paper# 17)

c:\work\Jor\vol764_18 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3957-3962
Bleeding time after magnesium sulphate infusion in cases of preeclampsia
Ismaeil Mohamed Abd El- Azeim Mira 1 , Abd El- Monsef Abd El- Hamed Sedek 1,
Ahmed Fathy Abd EL- Aziz 2 , Ahmed Ayman Marey 1*
Departments of 1 Obstetrics & Gynecology and 2 Clinical Pathology, Faculty of Medicine,
Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Ayman Marey, Mobile: 01068807860, Email: Hamada_mar3e@yahoo.com

preeclampsia is a pregnancy-associated multisystem disorder that affects 3-5% of all pregnancies .
It remains a leading cause of maternal and neonatal morbidity and mortality in the world . Magnesium sulphate is
the drug of choice in the management of impending eclampsia and eclampsia. Magnesium sulphate has an anti-
coagulating effect, which has been used early in preeclampsia to delay the advance of the disease . This action
however, is considered as a disadvantage, because it can prolong the bleeding time.The prolongation of bleeding
time may preceipitate postpartum haemorrhage. Objective: the objective of this study was to observe the effects of
magnesium sulphate on bleeding time in patients with preeclampsia. Patients and Methods: a study was conducted
between April 2018 and February 2019. Fiffty patients with preeclampsia were included in the study. Bleeding time
was measured through modified Ivy method. These measures were recorded before, immediately and 24 hours after
discontinuation of magnesium sulphate. Results: after magnesium sulphate therapy; bleeding time is increased ,
haemoglobin level and haematocrit level are decreased.
Conclusion: bleeding time in patients with severe preeclampsia was prolonged with magnesium sulphate infusion
This is clinically important because it worsens the present conition and causes possible complications.
Keywords: C-reactive protein, gestational diabetes.


prolong the bleeding time through the following
Magnesium Sulphate is a drug that belongs to the
mechanism: It stimulates prostacyclin, which is a
miscellaneous group of anti-convulsants . Magnesium
potent platelet aggregation inhibitor that inhibits
prevent or controls convulsions by blocking
adenosine diphosphatase, which is required by
neuromuscular transmission and decreasing the amount
platelets to induce aggregation (15).
of acetylcholine liberated at the endplate by the motor
All through the magnesium sulphate therapy, the
nerve impulse (1,2).
patient must be monitored carefully in order to avoid
The daily requirements of magnesium are 4 to 6
toxicity. This entails the following (16,17) :
mg/Kg body weight/day in adults(3).The recommended
1. Urine output: Which should not be below 100 ml/4
daily allowance in pregnancy is 450 mg/day (4,5).
hours , as magnesium sulphate is mainly excreted by
Magnesium is absorbed in the proximal part of
the kidney.
the small intestine and to some extent from the colon
2. Patellar reflex: Avoid its sluggishness or absence, as
(6).Magnesium is mainly excreted through the kidney
it is the first sign of toxicity.
once it is absorbed, but the unabsorbed fraction is
3. Respiratory rate: Should not below 12/minute.
excreted through faeces (7).
4. Serum level of magnesium: Therapeutically
Magnesium Sulphate has been extensively used
effective plasma levels of magnesium are 4-7
in cases of preeclampsia; it has many benefits in such
mEq/L. Patellar reflex disappears when the plasma
patients e.g. :
level reaches 10 mEq/L. When plasma magnesium

Prophylaxis against eclampsia (8,9).
level rises above 12 mEq/L, respiratory depression

Hypotensive .
and paralysis develops and arrest follows (18).

As a tocolytic agent .
Despite its undesirable, sometimes even life-
Magnesium Sulphate acts by :
threatening side effects, the role of magnesium sulphate
Blocking the neuromuscular transmission and
in the management of severe preeclampsia and
decreasing the amount of acetyl choline liberated at
eclampsia has been well established for seizure
the endplate by the motor nerve impulse (10).
prophylaxis. Also, it lowers the blood pressure (19,20).
Reducing cerebral irritability, but does not cause
Kyncz and Cibils (21) observed that blood loss
deep sedation (11).
increased among patients with preeclampsia who
Causing some peripheral vasodilatation and
received magnesium sulphate infusion . The bleeding
decreased responsiveness of vascular smooth
time was checked before infusion of magnesium and at
muscles to sympathomimetic amines (12).
completion of infusion and it was found that bleeding
Having anti-coagulating effect, which has been
time more than doubled among patients who need the
used early in preeclampsia to delay the advance of
drug. This finding was also reported in previous works
the disease (13,14) .This action, however, is
considered as a disadvantage, because it can


Full Paper (vol.764 paper# 18)

c:\work\Jor\vol764_19 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3963-3967

Outcome of Extracorporeal Shockwave Lithotripsy in
Congenital Malformed Kidneys
Mahmoud Nader Abdelrazik Ahmad*, Hussein Abdallah Galal, Ayman Kotb Koritinah
Department of Urology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mahmoud Nader Abdelrazik Ahmad, Mobile: +201224805339,
Email: mahmoudnader607@gmail.com
urolithiasis has an important role in the structure of the urological pathology, due to its high incidence,
frequency of recurrence and complications it may cause, it reduces the medium life span from 5 to 20% of the patients.
The management of kidney stones with congenital kidney anomalies and abnormal variations continue to pose
challenges to urologists.
to evaluate the stone free rate and complication rate of renal Extracorporeal Shockwave Lithotripsy (SWL)
in patients with congenitally malformed kidney and the predictors of SWL outcome will be determined.
Patients and Methods:
this is a retrospective study that has been conducted in Al-Hussein and Bab El-Shaarya
University hospitals in Cairo, Egypt. It includes 50 patients with renal calculi in congenitally malformed kidney, all
patients underwent SWL treatment in Al-Hussein and Bab El-Shaarya University hospitals using Dornier compact
sigma lithotripser and Dornier lithotripser SII from January 2013 to January 2019.
of the total SWL procedures performed to 50 patients with average age 46.3 year and average size of the
stone was 15.38 mm, the stone free rate was 74 %, The complication rate was 6%, 1 patient complicated by acute
pyelonephritis, 1 patient complicated by perinephric hematoma and 1 patient complicated by steinstrasse.
SWL has become the favored treatment for management of kidney stones with congenital renal
malformations due to high stone free rate and low incidence of complication.
Extracorporeal Shockwave Lithotripsy, Lithiasis, renal malformations, Stone-free.


Urolithiasis has an important role in the
SWL has become the favored treatment for most
structure of the urological pathology, due to its high
urinary tract stones, variable success rates in the
incidence, frequency and complications, it reduces the
management of stones in anomalous kidney have been
average life expectancy of 5 to 20% of patients, where
reported for SWL, ranging from 31% to 100% (7).
recurrence is detected in 50-67% of cases(1).
Despite SWL has been considered the first line
Congenital anomalies occur more often in the
treatment for stone in a mal-formed kidney, the
kidney than in any other organ. Horseshoe, malrotated
associated urinary stasis which leads to the diminution
and ectopic kidneys, as well as duplex systems, are the
of the ureteric peristalsis, could interfere with clearance
most encountered in this respect (2).
of stone fragments after SWL (8).
The association of both renal abnormalities
In the case of patients which present
and stones is of clinical relevance (3). Conditions such
urolithiasis associated with a malformed kidney the
as the abnormal position of the ureteropelvic junction,
positioning on the treatment table is of great
aberrant vascularization or the presence of an isthmus
importance, Patients which have a horseshoe or
might determine urinary stasis and stone disease,
malrotated kidney are placed in a ventral decubitus
especially if urinary infection and consecutive stone
position because of the anterior orientation of the renal
disease, especially if urinary infection and metabolic
pelvis. The same position is used for patients with
abnormalities are present (4).
ectopic kidneys to avoid the bone structures of the
The management of kidney stones with
pelvis (9).
congenital kidney anomalies and abnormal variations
We searched in this object to evaluate the stone
continue to pose challenges to urologists. The
free rate and complication rate of renal SWL in patients
treatment options include open surgery, extracorporeal
with congenitally malformed kidneys and predictors of
shock wave lithotripsy (SWL), percutaneous
SWL outcome, due to little of searches in this object
especially in our community, one of the studies in this
ureterorenoscopy (rigid or flexible) (5).
object stone free rate was 71.77 % (10).
SWL is considered the first-line treatment for

the majority of patients with urolithiasis especially
because stone recurrence is estimated to be about 50%
To evaluate the stone free rate and complication
over the next 10 years and patient with congenitally
rate of renal SWL in patients with congenitally
malformed kidneys may associated with other
malformed kidney and the predictors of SWL outcome
congenital anomaly and abnormal blood vessels that
will be determined.
make us to think in SWL firstly before any invasive



Full Paper (vol.764 paper# 19)

c:\work\Jor\vol764_20 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3968-3976

Role of CT Guided Celiac Plexus Block for Intractable Abdominal Pain
Amr Mahmoud Zayed, Mahmoud Ibrahim Elshamy, Amr Alaa Ramadan El sakka *
Department of Radiodiagnosis, Faculty of Medicine ­ Al-Azhar University
*Correspondence author: Amr Alaa Ramadan El sakka; Mobile: (+20) 01116107784; E-mail: amr_elsakka_2010@yahoo.com

Over the last decades, the incidence of pancreatic cancer has increased. It is the seventh most common
cause of cancer deaths especially in the developed world.
Objective: This study aims to evaluate the efficacy of computed tomography (CT) guided celiac plexus neurolysis
(CPN) to relieve intractable abdominal pain caused mainly by abdominal malignancy.
Patients and Methods: This prospective study included 20 adult patients; some of them were referred from Oncology
Department and others were from outpatient clinic. Patients had abdominal pain owing to abdominal cancer during
the period from October 2018 to May 2019 in Al-Hussien and Bab-Alsheria Hospitals, Al- Azhar University.
Results: CT-guided celiac plexus block was successfully carried out for the patients. 13 of them (65%) were males
and 7 (35%) were females, with mean age of 57.05 years. Abdominal pain in the 20 patients was owing to infiltrative
or metastatic hepatocellular carcinoma in ten (50%) patients, pancreatic cancer in six (30%) patients, lymphoma in
two (10%) patients, gastric cancer in one (5%) patient, and metastatic lung in cancer one (5%) patient.
The current study disclosed the incremental value of the CT-guided CPN via using different techniques
with injection of 20­40 mL of 95% of ethanol neurolytic solution as an ideal palliative treatment for eradication of
severe pain mainly caused by unresectable pancreatic cancer.
Keywords: CT, celiac plexus block, intractable abdominal pain

Celiac plexus block was used in various upper
This prospective study was carried out on 20 adult
abdominal malignant and non-malignant pain
patients referred from Oncology Department having
syndromes with variable success. Pain signals stemming
abdominal pain owing to abdominal cancer during the
from visceral structures that are innervated by the celiac
period from October 2018 to May 2019 in Al-Hussien
plexus can be interrupted by blocking the celiac plexus
and Bab-Alsheria Hospitals, Al-Azhar University.
or the splanchnic nerves. These structures include the

pancreas, liver, gallbladder, mesentery, omentum, and
Ethical approval
gastrointestinal tract from the lower esophagus to the
The study protocol was approved by the
transverse colon(1).
Medical Ethical Committee of Faculty of Medicine,
The most common application of neurolytic celiac
Al-Azhar University.
plexus block is upper abdominal malignancy, especially
After an informed consent was taken from each
pancreatic cancer; this was first described by Kappis in
patient included in the study, all the patients underwent
1914 (2).
CT-guided CPN with unilateral or bilateral paramedian
Cancer-related pain remains a common
needle entry using anterior and posterior approach
problem in oncologic practice and has a major influence
on patient's comfort, tolerance of therapies, and

probably survival. Timely interventional cancer pain
Inclusion criteria
therapies complement conventional pain management
The inclusion criteria were abdominal pain due to
by reducing the need for high-dose opioid therapy and
abdominal cancer, pain not controlled by analgesics, and
the associated toxicity (3).
patients having adverse effects of analgesic drugs.
Abdominal viscera including pancreas, liver,

gallbladder, adrenal, kidneys, and the gastrointestinal
Exclusion criteria
tract from the level of the gastroesophageal junction to
The exclusion criteria were patient's refusal of the
the splenic flexure of the transverse colon are innervated
procedure, patients with coagulopathy, and patients with
by the celiac plexus. So, pain owing to tumors in these
marked ascites.
viscera may be relieved through the use of a neurolytic

celiac plexus block (4, 5).

Patient preparation: All the patients included were
subjected to detailed medical history, general
This study aims to evaluate the efficacy of
examination, and other investigations such as
computed tomography (CT) guided celiac plexus
abdominal ultrasound, CT abdomen, and coagulation
neurolysis to relieve intractable abdominal pain caused
profile. The patients were asked to stop analgesics over
mainly by abdominal malignancy.
the night before the procedure, fast for 8 h, and were

informed about the complications and hospital stay time

Full Paper (vol.764 paper# 20)

Computerized tomographic study of the normal dimensions of the anterior horn of lateral ventricle in adults The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3977-3981

Effect of Treatment of Hepatitis C by Directly Acting Antivirals (DAA) on
Chronic Hepatitis C, B Coinfected Patients
Afify F.A. Ahmed; Neveen G. Elantouny; Amal A. Zidan* and Mohamed M.H. El Rasad*
Internal Medicine and Clinical Pathology* Departments, Faculty of Medicine, Zagazig University
*Correspondence author: Mohamed M.H. El Rasad; Mobile: (+20) 01007099510

Persons with hepatitis C virus (HCV) who are co-infected with hepatitis B virus (HBV) may be at risk
for reactivation of HBV infection during or following HCV treatment. HBV and HCV share similar modes of
transmission, and co-infection with the two viruses does occur.
This study aimed to evaluate the effect of HCV anti-viral treatment (DAAS) on HBV in HCV and HBV Co-
infected patients.
Patients and methods: The study was performed in Internal Medicine Department (Outpatient Clinic and the
Inpatient Ward), Mahalla Hepatology Teaching Hospital, Gharbia, Egypt during the period from August 2016 to
November 2017 on 20 HCV and HBV co-infected patients ranged from 18-70 years old.
The age of patients ranging from 26 to 65 years old (median 44). Male represent 55% and female represent
45% which showed male predominance. Patients were treated by different types by Hcv antiviral treatment (DAAS)
like (SOF+DAC), (SOF+SIM), (SOF+DAC+RBV). At baseline, 12 patients had detectable HBV viral load, 5
Patients had positive (HBsAg) and undetectable HBV viral load and 3 patients had negative (HBsAg) and
undetectable HBV viral load. Total number of HBV reactivated cases were 12 patients, 3 of them reactivated by
increasing HBV DNA, and 5 of them reactivated by both increasing HBVDNA and ALT flare.
Conclusion: HBV reactivation is a severe, life-threatening consequence of chemotherapy and immunotherapy in
patients with chronic hepatitis B infection. Reactivation may be associated with DAA therapy in patients with
HCV/HBV co-infection. HBV reactivation can be prevented through the use of pretreatment screening and anti-HBV
prophylactic treatment.
Keywords: Hepatitis C, direct acting antiviral, chronic hepatitis C, chronic hepatitis B.

life should stop," said WHO Regional Director Dr Ala
Viral hepatitis is a global health problem
Alwan (2). Before beginning direct-acting antiviral
affecting hundreds of millions of people worldwide.
treatment for hepatitis C virus (HCV) infection,
An estimated 1.45 million people die annually from all
patients should be screened for hepatitis B virus (HBV)
types of viral hepatitis, mostly from liver disease and
infection, according to an updated guideline from the
cancer caused by these infections. Every day,
American Association for the Study of Liver Diseases
thousands of people are newly infected because they
and the Infectious Diseases Society of America (2).
lack access to information and services for prevention
Patients with low or undetectable levels of
and treatment. Many of these people are unaware of
HBV who do not meet the criteria for HBV treatment
their infection until diagnosed and have the potential to
should be carefully monitored during direct-acting
transmit the viruses to others. This year, WHO and its
antiviral treatment for co-occurring HCV, the guideline
partners are urging policy-makers, health workers and
recommends that some patients have developed very
the public to take action to prevent infection and death
serious illness as a result of reactivation, so vigilance is
from hepatitis (1).
Egypt was chosen to host World Hepatitis Day
Co-infection with HBV and HCV is a fairly
2015 as the country has demonstrated a high level of
frequent occurrence, particularly in areas where the
commitment by tackling hepatitis comprehensively in
two viruses are endemic and among subjects with a
their plan of action for prevention, care and treatment
high risk of parenteral infections (3).
2014­2018 (1).
The clinical relevance of HBV/HCV co-
The Ministry of Health has set up 32 specialized
infection for disease severity and adverse outcomes, as
centres and introduced a new hepatitis C drug last year,
well as for selection of treatment options is important
which is the first highly-effective and approved direct-
although information concerning many aspects of dual
acting antiviral drug for the nationwide treatment of
infection remains largely incomplete. Accumulating
hepatitis C infection. This medication is safer than
evidence suggest that co-infection by HBV and HCV is
previous medications and has been shown to cure more
heterogeneous with respect to varying states of
than 90% of those completing treatment in
replication for each virus and profiles of immunity (4).
combination with other drugs. "Viral hepatitis has long
Laboratory evaluation for all possible viral
been neglected; yet hepatitis B and C are preventable,
causes including HBV and HCV should be arranged in
hepatitis B is manageable and hepatitis C is curable.
patients presenting with acute hepatitis. Acute hepatitis
People are unnecessarily suffering and we are
can result from simultaneous infection by the two
unnecessarily losing lives. This suffering and loss of
viruses. In addition, for cases of CHB or CHC

Full Paper (vol.764 paper# 21)

INTRODUCTION The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3982-3992
The Role of MR Arthrography in Evaluation of
Femoroacetabular Impingement Syndrome
Mohamad Farouk Agag, Mahmoud Ibrahim Elshamy, Anas Abd Alaziz Ahmad*
Department of Radio-diagnosis, Faculty of Medicine ­ Al-Azhar University
*Correspondence author: Anas Abd Alaziz Ahmad; Mobile: (+20) 112 926 2313; E-mail: anossof@gmail.com

Background: Femoro
acetabular impingement (FAI) is defined as an abnormal femoral acetabular contact that occurs
within the normal range of motion caused by alterations of the acetabulum and/or the femoral head or neck. Objective:
The purpose of this study was to compare the diagnostic performance of MR arthrography (MRA) with arthroscopic
correlation for detecting labral tears and articular cartilage abnormalities. Materials and Methods: MRA was
performed in 29 patients (16 males, 13 females with symptomatic FAI. The MRI images assessed for presence of labral
tears, chondral lesions and osseous abnormalities. Arthroscopic correlation was obtained in all cases. Results: The
sensitivity, specificity, PPV, and NPV of MRA for detecting labral tears were 87.5 %, 71.4%, 91.3% and 62.5%,
respectively. The sensitivity, specificity, PPV, and NPV of MRA for detecting chondral damage were 76.5%, 91.7%,
86.7% and 78.6% respectively. Conclusion: MRA appears to be an accurate imaging modality in the evaluation of
labral tears. MRA is less accurate in the diagnosis of cartilage abnormalities in the hip.
Keywords: MR arthrography - Hip ­ FAI - Labral tears - Chondral lesions.

with 2D reconstruction. MRI: Nowadays is considered
The concept of impingement was reintroduced by
a good diagnostic tool in the preoperative assessment
Amanatullah et al. (1with the recognition that mal-
of the IBP joint, because of its accuracy in the
united femoral neck fractures that healed in
evaluation of anatomic bone variants, and to assess the
retroversion could cause abnormal contact between the
exact extent of the damage already present within the
femoral neck and acetabular rim leading to accelerated
joint and of cartilaginous and labral injuries.
posttraumatic osteoarthritis. Over the past 2 decades, 2.
MR arthrography: Is considered the best imaging

Amanatullah et al. postulated that unrecognized
modality for routine evaluation of the internal hip
developmental alterations and mal-orientations of the
hip may be the underlying cause of primary or
The most important advantages of this method
idiopathic hip osteoarthritis (2).
include better visualization of the joint anatomy owing
FAI is one of the causes of chronic hip pain, and it
to easy differentiation of the joint surface and a higher
is an important factor in the development of
soft tissue contrast obtained by intra-articular
gadolinium dilution (7). Arthroscopy: Is the current
impingement are young (3). Patients present with groin
"gold standard" for diagnosing intra-articular hip joint
pain with hip rotation, in the sitting position, or during
pathological conditions and abnormalities (8).
or after sports activities. Typically, they are aware of
It is important to know that surgical treatment of
their limited hip mobility long before symptoms appear
FAI is only suitable in patients without advanced
(4).FAI is divided into two types: cam and pincer,
degenerative changes and without extensive articular
however, a mixed pattern is believed to often be
cartilage damage, also it is important to identify the
present, with one of the two types predominating and it
type of FAI because surgical treatment differs for each
can be differentiated on the basis of a predominance of
type. So, preoperative radiological assessment before
either a femoral or an acetabular abnormality (5).
such an invasive procedure is necessary for accurate
The role of imaging in FAI is to evaluate the hip
diagnosis of acetabular labral tear and to rule out other
for abnormalities associated with impingement. The
abnormalities involving the hip joint (9).
main important imaging techniques for the assessment

of FAI are conventional radiography, 3D computed
tomography, and MR, especially MR arthrography (6).
The purpose of this study was to evaluate the
Conventional radiography: Is very useful for the
diagnostic value of conventional MRI and MR
identification of morphological bone alterations and to
exclude arthritis, avascular necrosis or other joints
femoroacetabular impingement. We aimed to compare
problems. 3D computed tomography: 3D computed
the MR arthrography results with hip arthroscopic
tomography represents an accurate tool to assess
findings (Gold Standard) to assess its diagnostic value
abnormalities of the femoral head-neck junction with
in evaluating acetabular labral tears and articular
cartilage defects.
tomography with 3D surface rendering provides a
virtual reality confirmation of the offset deformity for
The study included 29 patients (16 male and 13
both the surgeon and patient, which is very difficult
female), their ages ranged from 18 to 45 years with

the median age of 31 years. Mean age was 30.9 years.

Full Paper (vol.764 paper# 22)

Pregnancy Rates After Laproscopic Adhesiolysis Of Post Ceasarean Adhesions The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3992-3996

Pregnancy Rates after Laproscopic Adhesiolysis of Post Ceasarean Adhesions
Fayza Alaa El-Din Ghorab*, Hesham Abdel-Aziz Salem, Ahmed Tawfik Morsy, Ayman Shehata Dawood
Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University
*Corresponding author: Fayza Alaa El-Din Ghorab, Email: Elsherbinyortho@gmail.com, Mobile: (+20)01066949905

although cesarean delivery is a relatively simple procedure, it is associated with some long-term
sequelae such as peritoneal adhesions that may result in infertility, chronic pelvic pain, or bowel obstruction.
Objective: it was to evaluate the efficacy of laproscopic adhesiolysis for post caesarean adhesions evidenced by the
pregnancy rates.
Patients and Methods:
this study was a single armed clinical trial study, which was done at Obstetrics and
Gynecology Department of Tanta University Hospital in the period from October 2017 to March 2018. Fifty patients
with secondary infertility after previous caesarean delivery were included. Three patients dropped off follow up.
pregnancy rate in studied patients, 22 (47%) patients got pregnant, while 25 (53%) patients had no
Conclusions: there is high incidence of pelvic adhesions in patients with an unexplained secondary infertility
following a caesarean delivery, which is mainly periadenxial type. There is a significant increase in pregnancy rate
after laproscopic adhesiolysis.
Keywords: Caesarean section, Adhesions, Laproscopy, Pregnancy.

the effectiveness in pregnancy rates of microsurgery
There has been an increase in the rate of
and operative laparoscopy in adhesiolysis. Adhesions
Caesarean deliveries over the last 25 years in most
were found to be the sole infertility factor in 15%.of
developing countries (1). For example, in Egypt,
the patients (5).
according to the latest data, more than half of women

give birth to CS by making little difference between
urban and rural areas. Several possible causes of high
The aim of this study is to evaluate the efficacy
CS rates have been reported repeatedly in studies from
of laproscopic adhesiolysis for post caesarean
many countries such as fear of pain; concerns about
adhesions evidenced by the pregnancy rates.
postnatal vaginal adjustments; the mistaken belief that

CS is safer for the child (1).
Although cesarean delivery is a relatively
This is a single armed clinical trail study which
simple procedure, it is associated with some long-term
was done at Obstetrics and Gynecology Department of
sequelae such as peritoneal adhesions, that may result
Tanta University Hospital in the period from October
in infertility, chronic pelvic pain, or bowel obstruction
2017 to March 2018. It includes fifty patients (three
and may increase the technical difficulty of subsequent
patients were dropped from follow-up) with secondary
abdominal or pelvic surgery(2).
infertility after previous caesarean delivery according
Adhesions formation after caesarean section
to inclusion & exclusion criteria.
may be related to operative technique, genetic
Inclusion criteria: Age up to 35 years.
Patients with prior CS delivery suffering from
infection. Adhesions formation after caesarean section
secondary infertility with suspicious clinical and/or
may change not only uterine position and mobility but
also its functional anatomy leading to secondary
finding) pointing to the possibility of post caesarean
section adhesions e.g.: Fixed RVF uterus, Immobile
Operative procedures, such as lysis of
adenxial mass by clinical examination. c- Ovarian or
adhesions, tuboplasty and salpingectomy for hydro -
uterine displacement in ultrasound examination. -
salpinx or pyosalpinx at the time of laparoscopy can
Ovarian or uterine displacement in ultrasound
enhance conception (4).
examination. HSG may show (abnormal tubal course,
Severe adnexal adhesions are associated with
abnormal dye loculation in the pelvis and halo effect of
worsening pregnancy rates, and treatment of adnexal
the dye around the tube).
adhesions appears to improve pregnancy rates. Among
Exclusion criteria: Causes of infertility other
infertile women with adnexal adhesions, successful
than post caesarean adhesions e.g. (male, uterine,
pregnancies were shown to be lower in women with
ovarian factors). History of abdominal or pelvic
untreated adhesions than in those who underwent
operation other than caesarean section. History of
adhesiolysis (16%­45% after 24 months) (5).
An early study looked at pregnancy rates after
Contraindication to laproscopic surgery e.g. patients
adhesiolysis and showed a wide range from 38% to
with severe respiratory morbidity or decompensated
57%. That study followed patients for 2 years assessed
heart disease.

Full Paper (vol.764 paper# 23)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 3997-4006

Comparative Study between Ultrasound Guided Pectoral Nerves Block and
Thoracic Paravertebral Block as Postoperative Analgesia in Breast Surgeries
Mohamed Amr Abo-Sabaa, Ali Abdallah El kumity,
Yasser Abdallah Ahmed Amr
Department of Anesthesiology and Intensive Care, Faculty of Medicine - Al-Azhar University
Corresponding author: Yasser Abdallah Ahmed Amr, Mobile: 01000479616, email: yasseramr2016@yahoo.com

Breast surgery is an exceedingly common procedure and is associated with an increased incidence of
acute and chronic pain in 25­60% of cases. Regional anesthesia techniques may improve postoperative analgesia
for patients undergoing breast surgery.
This study aimed to compare the efficacy and safety of an ultrasound-guided Pecs II block versus
TPVB for postoperative analgesia after breast surgeries.
Patients and Methods: The present study was conducted on sixty female patients ASA I-II, their ages ranged from
18- 65 years old scheduled for unilateral breast surgery. The patients were allocated randomly into two groups
(n=30) according to type of regional anesthesia administrated. (PECS block or TPVB).
Results: The results demonstrated that PECS block caused hemodynamic stability, decreased the intensity of post-
operative pain, reduced postoperative analgesic requirement, prolonged the time needed for first request of analgesia and
decreased PONV. Therefore it can be considered as quite safe procedure and effective as well for intraoperative and
postoperative pain control in breast surgeries.
PECS blocks can produce excellent pain relief during the first twelve postoperative hours. They hold
great promise due to their simplicity, easy-to-learn techniques and relative lack of contraindications and
complications. It maintained hemodynamic stability. Also, it produced low pain scores and less total (morphine)
consumption in the early postoperative period after unilateral breast cancer surgery.
Arterial blood pressure, Non-steroidal anti-inflammatory drugs, Paravertebral block. Ultrasound.


nerves, the intercostobrachial, intercostals III-IV-V-VI
There is an interest in the use of regional
and the long thoracic nerve. These nerves need to be
anesthesia for breast surgery as it gives good
blocked to provide complete analgesia during breast
postoperative pain control with decreasing opiate
surgery (4).
dosage and side effects. When combined with general

anaesthetics, it allows great reduction in general
anaesthetics side effects. So, early recovery, low
The aim of this study was to compare the
incidence of nausea and vomiting (1).
efficacy and safety of an ultrasound-guided Pecs II
Thoracic paravertebral blocks are considered
block versus TPVB for postoperative analgesia after
the ``gold standard'' regional anesthesia technique for
breast surgeries.
patients undergoing breast surgery. They provide

anesthesia or analgesia to the chest wall and may be
utilized as the primary anesthetic or for postoperative

Design: Prospective, double blind randomized
pain management. Further, paravertebral blocks have
clinical study.
been associated with decreased opioid consumption

Setting: The study was carried out in AL-Azhar
resulting in decreased related side-effects (2).
University Hospitals.
On the other hand, attributed to the recent

Ethical Considerations: After approval of
application of ultrasound (US) in anesthetic practice,
The Institutional Ethics Committee of The
several interfascial plane blocks have been described
Faculty of Medicine, Al-Azhar University. 60
recently. Pectoral nerve block (Pecs) is a novel
Patients scheduled for breast surgery were
interfascial plane block which can provide analgesia
enrolled in this study. All patients were
after breast surgery (3).
counseled for the study protocol and a written
The pectoral nerves block (Pecs block) is an
informed consent was obtained from study
easy and reliable superficial block. Once the pectoralis
muscles are located under the clavicle the space

Inclusion Criteria: Patients undergoing breast
between the two muscles is dissected to reach the
surgeries. Age: (20-60) years. Female gender.
lateral pectoral and the medial pectoral nerves. The
ASA class (I-II) patients.
main indications are breast expanders and subpectoral

Exclusion Criteria: Previous surgery for breast
prosthesis where the distension of these muscles is
extremely painful. A second version of the Pecs block
Inflammatory breast cancer. Scheduled free flap
is called ``modified Pecs block'' or Pecs block type II.
reconstruction. ASA Physical Status 4. Any
This novel approach aims to block at least the pectoral
contraindication to regional analgesia (including

Full Paper (vol.764 paper# 24)

ABSTRACT The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 4007-4012

Antiproliferative Effect of Metformin on the Endometrium in cases of
perimenopausal bleeding
Ismaeil Mohammed Elgarhy, Noha Sabry, Ahmed Mohmmed elfeky
Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Mohmmed elfeky, Mobile: 01064112746, email: ahmedabdelmohsen20009@gmail.com

based on numerous epidemiologic and experimental studies it has been speculated that unopposed
estrogen has a central role in development of endometrial benign, premalignant and malignant lesions. Endometrial
cancer is the most common malignancy of the female genital tract, and the fourth most common cancer in women in
developed countries. EC is the seventh most common cancer in women worldwide.
Objective: To examine the effect of metformin on disordered proliferative endometrium and simple endometrial
hyperplasia in comparison with progesterone to assess metformin clinical usefulness in these situations.
Patients and Methods: All patients who referred for abnormal uterine bleeding (perimenopausal) and underwent
endometrial office biopsy or D&C in our hospital and their tissue diagnosis was disordered proliferative endometrium
(DPE) or simple hyperplasia (SH) were included in this study. Past medical history gathered from patients' interview
records and patients with history of metformin sensitivity, renal failure, anorexia, anemia, skin rashes, diabetes mellitus,
gynecologic neoplastic disorders and patients on estrogen or progesterone were excluded. Patients who fitted with including
criteria were categorized in two groups in randomized fashion.
Results: Our findings in this study revealed that metformin could be effective as well as progesterone in resolving of
benign enodometrial proliferative lesions.
Conclusion: The current study showed that treatment of the patients with abnormal endometrial proliferation (DPE and
SH) with metformin induced endometrial atrophy and prevents abnormal cell growth and prevents perimenopausal
bleeding subsequently.
Endometrial cancer, medroxyprogesterone acetate, insulin-like growth factors.


menstrual cycle of solid ladies, empowering insulin to
In light of various epidemiologic and test
influence stromal cell decidualization (6).
ponders it has been theorized that unopposed estrogen
In light of the connection between endometrial
has a focal job being developed of endometrial
hyperplasia, insulin, and its middle people, insulin
benevolent, premalignant and threatening sores (1).
sensitizers has turned into the most well known subject
Endometrial disease is the most well-known
of examination for their antiproliferative impacts (7).
threat of the female genital tract, and the fourth most
Metformin is an oral biguanide utilized in
basic malignancy in ladies in created nations. EC is the
diabetes, insulin obstruction, and polycystic ovarian
seventh most normal disease in ladies around the world
disorder. Ongoing reports demonstrate that metformin
(2). Endometrial adenocarcinoma is gone before by a
may diminish the neoplastic multiplication of cells by
progression of histopathological change considered
means of balancing the glucose metabolism, insulin
endometrial hyperplasia that is amiable to treatment.
affectability and intracellular sign pathways (8).
Endometrial hyperplasia is treated with progesterone
All the more as of late, metformin has been
and its engineered structure, medroxyprogesterone
accounted for to hinder the attack of human endometrial
acetic acid derivation (MPA). MPA can likewise be
carcinoma cells, in vitro (9).
utilized in cutting edge or recurrent EC, in chose cases
Anovulatory cycles are normal at menarche and
who wish to save their ripeness (3).
menopause and as a rule incite generous endometrial
The job of progesterone on the endometrium is
multiplication including disarranged proliferative
essentially to incite cellulary separation and to estrange
estrogen intervened cell expansion. The progesterone
hyperplasia without atomic atypia (10).
demonstrates its antitumour impact by authoritative to
Drawn out anovulatory cycles due to PCO or
the atomic receptors, and enacting the interpretation of
other hyperestrogenic states, for example, estrogen
a few qualities, which are associated with cross-
discharging tumors frequently lead to expanded
converse with other flagging pathways, for example,
endometrial multiplication and cause complex
development factors and their receptors (4).
hyperplasia with or without atypia, endometrial polyps
As of late, an expanding assortment of proof
or type I endometrial carcinoma (11).
proposes that weight, diabetes and insulin obstruction
In spite of the fact that there is no uncertainty
are solid hazard factors for EC, and insulin-like
respect to job of estrogenic specialists in creating of
development factors (IGFs) assume a noteworthy job in
carcinogenesis and malignant growth movement (5).
comprehension of hereditary and sub-atomic premise of
Besides, it has been demonstrated that insulin
endometrial carcinoma lead to another phrasing for
receptor quality articulation is managed all through the

Full Paper (vol.764 paper# 25)

c:\work\Jor\vol764_26 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 4013-4016

Injection in Facet Joint Arthropathy
Eissa Ragheb, Mohamed Negm , Abd El Rahman Abdalla
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University
Corresponding author: Abd Elrahman Abdalla, Mobile: (+20) 01000783211, Email: abdo1ortho@gmail.com

Facet syndrome is an articular disorder related to the lumbar facet joints and their innervations, and
produces both local and radiating pain. Objective: The purpose of this study was to evaluate the outcome of steroid
injection in treatment of facet joint arthropathy. Patient and Methods: This study was held on 23 patients suffered
from chronic low back pain due to facet arthropathy at Al-Azhar University and Alharam Specialized Hospitals. There
were 11 males and 12 females with mean age 46.27 years (28 to 60 years). History, clinical examination, x-ray, MRIs
were done to all patients. Results: Pain was evaluated by VAS. The mean VAS pre injection was 8.1 ± 0.83 ranging
from 6:10. Immediately post injection, the mean was decreased to 3.7 ± 0.85 ranging from 2:5. Six weeks after
injection the mean was decreased to 3.6 ± 0.98 ranging from 2:5. Twelve weeks after injection the mean was elevated
to 5.3 ± 0.91 ranging from 4 to 6. The mean ODI improved from 36.5 ± 6.9 to 21.1 ± 4.2 three months post injection.
Conclusion: intra-articular facet joint injection is crucial in the diagnosis and treatment of facet joint syndrome. It is
an easy to perform and effective treatment for temporary pain relief. The pain relief is sustained longer in patients
with grade G2 and G3 of facet joints
Keyword: facet joint, intra-articular injection, facet arthropathy, steroids.

The identification of the facet joints as a source of
This prospective study was approved by the
back pain was demonstrated in 1976 with the
Ethical Committee of Al-Azhar University. A total of
experimental induction of pain through direct injection
23 patients with facet arthropathy were treated in Al-
of saline solution into the facet joints of healthy
Azhar University and Alharam Specialized Hospitals.
individuals (1, 2). Subsequent studies involving the intra-
All patients had signed an informed consent form.
articular injection of anesthetic solution to relieve pain
We included patients with chronic low back pain due to
supported the theory of a possible facet component in
facet arthropathy with failed conservative treatment for
the origin of low back pain (3).
more than 6 months.
The diagnosis of facet joint arthritis is based on
Exclusion criteria: (a) Known diagnosis of low back
clinical criteria. However, the use of invasive diagnostic
pain of spinal infection or neoplastic etiology, (b)
tests, such as the provocative test and pain relief test,
Medically unfit patients as uncontrolled diabetes,
has grown over the years (4, 5).
systemic arterial hypertension, or glaucoma, (c)
Treatment for facet joint arthritis is mainly
Pregnancy, (d) radiculopathy and (e) acute lumbar
conservative, involving medication and rehabilitation
fractures . There were 13 females and 12 males with
(6). However, minimally invasive procedures have been
mean age 46.2 ± 5.1 years ranging from 34 to 55 years.
used with increasing frequency for direct treatment of
History and local examination were done. The low back
the pain site and are currently among the most
pain duration among the participants was 2.6 ± 0.7 years
commonly used procedures for the treatment of pain (7).
ranging from 1-4 years. The pain was aggravated by
One such treatment is medial branch block through
extension and flexion in all patients while by twisting in
radiofreqitency denervation and facet joint injections (8).
11 patients (47.8%). The pain was radiating to buttocks
The aim of intra-articular facet injections with
in 16 patients (69.6%) and to thigh in one patient
corticosteroids in combination with an anesthetic
(4.3%). The pain was relieved by rest in 15 patients
solution is to block the nociceptors and produce an anti-
(65.2%). 7 patients (30.4%) had no response to
inflammatory effect (8).
medications and 16 patients (69.6%) had low response.

X-ray and MRI were routinely done to all patients. Pain
was evaluated by VAS and ODI scores pre and post
The purpose of this study was to evaluate the
injection. Positioning: The patient lies prone on the
outcome of steroid injection in treatment of facet joint
table with a pillow placed under the front of the
abdomen for comfort. Fluoroscopy should be placed in

a direct posteroanterior orientation with slight oblique

position (figure 1).


Full Paper (vol.764 paper# 26)

a The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 4017-4020

Comparative Study between Surgical Bypass and Angioplasty in
Treatment of Superficial Femoral Artery Occlusion
AbdEl-Fattah Aly Ismail Aly, Ahmed Mohammed Abdul-Rahman Tahoun,
Elsayed Basiony Moghazy Abu-Eliazid, Ahmed Attia Shaaban Soliman*
Vascular Surgery Department, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Attia Shaaban Soliman,email: Email: surgeon.attia2018@gmail.com
Critical limb ischemia is the most advanced stage of peripheral arterial occlusive disease. the prognosis
is poor, with amputation rates up to 30 % and mortality up to 25 % after 1 year. Aim of the Work: to compare the
results of primary bypass versus primary percutaneous transluminal angioplasty (PTA) in symptomatic superficial
femoral artery (SFA) occlusive lesions in terms of complications, restenosis, symptom recurrence, re-interventions,
major amputation and mortality. Patients and Methods: This prospective randomized comparative study was conducted in
the Vascular Surgery Department at Al-Azhar University Hospitals. The study included 30 patients randomized into two
groups (15 patients for Bypass surgery and 15 patient for angioplasty) suffering from SFA occlusion. Satisfying all the
inclusion criteria mentioned below, after the clearance from the ethical committee was obtained, all patients were included in
the study. Results: The present study was conducted on 30 patients, 19 males (63.33%) and 11 females (36.67%). . The early
patency rate was 93.33% in the group with `Bypass', and 86.67% in the group with angioplasty. The late limb salvage rate in
the group with `Bypass was 73.33 % while in the group with PTA was 66.66 %. Mortality occurred in two patients (13.3 %).
Conclusion Endovascular intervention is the preferred method of revascularization in many scenarios; surgical
revascularization is reserved for specific clinical scenarios and for cases where percutaneous therapy is not feasible or durable.
Bypass surgery, Endovascular Treatment, Revascularisation, Femoral Artery Occlusion.

(SFA) stenoses or occlusions, surgery is better than
Peripheral arterial disease (PAD), defined as a
chronic occlusive disease of the lower extremities, is

a major and growing health problem, estimated to
affect more than 200 million individuals around the
to compare the results of primary bypass
globe. Aging of the world's population, combined
superficial femoral artery occlusive lesions in terms
hypertension are the critical risk factors and
of complications, restenosis, symptom recurrence, re-
significant socio-economic disparities exist. Most
interventions, major amputation, and mortality.
individuals with PAD are asymptomatic, and the most

common symptom is intermittent claudication (IC). A
small minority (< 10%) develop chronic limb-
Study design: a prospective randomized comparative
threatening ischemia (CLTI). Progression of disease
study. The study was approved by the Ethics
from IC to CLTI may occur in up to 20% of patients,
Board of Al-Azhar University. Patients gave
associated with similar risk factors but especially
consent for either type of treatment, surgery or
diabetes, smoking, and renal disease(1). Treatment of
CLI aims at wound healing, improvement in the
Study population: diabetic patients with the femoral
quality of life, limb loss prevention, and prolonged
arterial occlusive disease.
survival. Current strategies propose open or

Patient's number: it is the study of 30 patients.
endovascular revascularization, but not specifically

Study venue: Al-Azhar University Hospitals.
targeted to the location of ischemia(2). The treatment
Inclusion criteria in the study:
options for PVD include modification of
1. Patients with age between 40 - 80 years.
atherosclerotic risk factors, medical treatment,
2. Symptomatic patients after failing medical
surgery and endovascular revascularization, including
balloon percutaneous transluminal angioplasty (PTA),
3. A 5­15 cm occlusive lesion of the superficial
femoral artery.
The two principal treatment alternatives are
4. Patients
bypass surgery and balloon angioplasty has many
Consensus (TASC) B, C.
possible relative advantages and disadvantages. In
5. Patients with disabling claudication.

angioplasty (PTA) with or without stenting has
Exclusion criteria in the study:
consequently not only replaced bypass as the primary
1 Patients with multi-level arterial lesions i.e.
mode of revascularization, but it also challenges
aortoiliac, femoropopliteal.
conservative measures as the primary therapy(4). With
Acute on top of chronic ischemia.
respect to patency, for long superficial femoral artery
Asymptomatic patients.

Full Paper (vol.764 paper# 27)

c:\work\Jor\vol764_28 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 4021-4028

Effect of Metformin, Pioglitazone and Rosuvastatin on
Induced Non-alcoholic Fatty Liver in Rats
Ahmed Labib Abdul-Kafy, Hammouda Hassan Sharaf, Adel Ibrahim Abdul-Aziz,
Mohammed Gaber Keshka*
Department of Pharmacology, Faculty of Medicine, Al-Azhar University, Egypt
*Correspondence author: Mohammed Gaber Keshka, Mobile: (+20) 01002309232, E-mail: tantawy_wael@yahoo.com

non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases
affecting up to 30% of the general population worldwide.
Objective: the aim of this work was to study the effects of metformin, pioglitazone and rosuvastatin on
serum lipids cholesterol and triglycerides (TG), liver enzymes aspartate aminotransferase (AST) and
alanine aminotransferase (ALT), random blood sugar (RBS), oxidative stress malondialdehyde (MDA),
and histopathological changes in induced non-alcoholic fatty liver in rats.
Patients and Methods: fifty male albino rats weighing 100-120 grams of local strain were used.
Animals were purchased from Nile Pharmaceutical Company. They were kept in suitable cages at room
temperature with the natural light-dark cycle. They were maintained on a standard diet of commercial
rat chow and free tap water. They were kept for 10 days for adaptation to the new environment before
the start of the experiment. Results: triglycerides decreased significantly in all treated groups as
compared to hypercholesterolemic control group. ALT decreased significantly in all treated groups as
compared to hypercholesterolemic control group. AST decreased significantly in all treated groups as
compared to hypercholesterolemic control group. Blood glucose decreased significantly in Metformin
and Rosuvastatin treated groups as compared to hypercholesterolemic control group.
Conclusion: the three drugs could be utilized as a treatment option to guard against fat deposition in the
liver or progression of steatosis to fibrosis and cirrhosis. However, further studies are required to
examine the molecular mechanisms underlying the beneficial effect of the insulin sensitizers in NAFLD
Keywords: Metformin, Pioglitazone, Rosuvastatin, Non-alcoholic, Fatty Liver in Rats.


scientific community, and there are no licensed
defined as a chronic liver condition characterized
therapies. Moreover, lifestyle modifications, such
by hepatic fat accumulation in the absence of
as diet and physical exercise, may be proven to be
other identifiable cause such as alcohol abuse,
effective, but they are challenging to implement(5).
viral or autoimmune hepatitis, alpha-1 anti-trypsin
Various studies have shown that statins
deficiency, medications like corticosteroids and
may have additional effects that improve hepatic
estrogens, and other conditions(1).
insulin sensitization in animal models and humans
(6). Considering the close relationship between IR
encompasses a spectrum of hepatic pathologies,
and the pathogenesis of fatty liver disease, insulin
ranging from simple steatosis to non-alcoholic
sensitizers could be regarded as the treatment of
steatohepatitis (NASH), cirrhosis, hepatocellular
choice. Metformin and Pioglitazone are the most
carcinoma (HCC) and end-stage liver disease (2).
popular drugs tested against NAFLD (7).
Non-alcoholic fatty liver disease is highly

associated with several components of metabolic
syndrome, particularly obesity, increased plasma
The aim of this work is to study the effects of
metformin, pioglitazone and rosuvastatin on serum lipids
intolerance, and type 2 diabetes mellitus (T2DM)
cholesterol and triglycerides (TG), liver enzymes
with insulin resistance (IR)(3).
aspartate aminotransferase (AST) and alanine
High-fat diet (HFD) accounts for the
aminotransferase (ALT), random blood sugar (RBS),
largest incidence of obesity in the world. Diet-
oxidative stress malondialdehyde (MDA), and
induced weight loss and life style modifications,
histopathological changes in induced non-alcoholic fatty
liver in rats.
changes in the diet, have beneficial effects on
This study was conducted in accordance with
NAFLD and help manage IR. However, only a
ethical procedures and policies approved by Animal
small percentage of patients with NAFLD can
Care and Use Committee of Faculty of Medicine, Al-
implement these measures efficiently (4).
Azhar University, Cairo, Egypt. The study was
Despite the abundance of clinical trials,
approved by the Ethics Board of Al-Azhar
NAFLD therapy remains a challenge for the

Full Paper (vol.764 paper# 28)

INTRODUCTION The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 4029-4033

The Use of Trastuzumab in Metastatic Breast Cancer
Shawky El-Hadad 1, Hassan Khalid 2, Ahmed El-Agamawi 2,
Mohsen Salah El-Dien Zekry 2, Hanan El-Shahat El-Morsi 2*
Clinical Oncology Department, 1 Cairo University, 2 Al-Azhar University
Corresponding author: Hanan El-Shahat El-Morsi, Mobile; (+20) 01092983129, E-mail: tantawy_wael@yahoo.com

Breast cancer is the most common malignancy in women in US and the second cause of cancer
death. It comprises 14 % of all new cancers, and 6.8 % of all cancers deaths.
Objectives: To evaluate the value of targeted therapy (trastuzumab) in HER-2 positive metastatic breast cancer
patients previously treated with anthracycline in the adjuvant setting, in terms of related toxicities, objective
response, overall survival, and progression free survival.
Patients and Methods: This study included 80 patients with history of primary carcinoma of the breast with
HER2neu positive and evidence of metastases. Half the cases received a combination of trastuzumab plus
paclitaxel aiming to treat their disease compared with other group, which received paclitaxel alone to asses the
effect of trastuzumab.
Results: Adding trastuzumab to paclitaxel showed significant positive impact on treatment, objective response,
progression-free survival (PFS) and overall survival (OS). In the attempt to evaluate the variable prognostic
importance, such as positive family history, performance status, disease grade and tumor size all showed significant
impact on objective response, PFS and OS.
Conclusion: The metastatic form of the breast cancer is of dismal prognosis. Targeted therapy created a new
avenue in the management of this grim disease. This study show that adding trastuzumab to paclitaxel had
significantly improved the objective response, PFS and OS.
Keywords: Trastuzumab, Metastatic Breast Cancer.

factor and also as predictive biomarker for HER-2
Breast cancer is the most common malignancy
targeting therapy. Metastatic patients with HER-2
in women in US and the second cause of cancer death.
positive tumors are known to have aggressive disease
It comprises 14 % of all new cancers, and 6.8 % of all
and poor prognosis, with shorter overall survival
cancers deaths (1). The estimated metastatic breast
(OS) and disease free survival time (5).
cancer is at least 154,000 patients in US, among them
Receptor activation requires three variables,
6 % are de novo (2).
a ligand, a receptor, and a dimerization partner. After
Commonly metastases arise months or years
a ligand bind to a receptor, it interact with another
after the patient has completed treatment for early or
receptor of identical or related structure in a process
locally advanced breast cancer.
known as dimerization in order to trigger
The risk of metastatic breast cancer varies
phosphorylation and activate signaling cascades. This
according to:
process is associated with increased cell proliferation,
(1) The biology of the tumor.
cell motility tumor invasiveness, progression regional
(2) The stage at the time of original diagnosis.
and distant metastasis, accelerated angiogenesis, and
(3) The treatment for the original cancer (3)
reduce apoptosis (6).
Chemotherapy is the first line of treatment for
The use of taxanes in treating breast cancer
metastatic breast cancer that are:
has been growing exponentially since the mid -1990s.
(1) Hormone receptor negative
Anthracycline and taxanes based treatment regimens
(2) Hormone receptor positive but no longer
are standard first line therapies for MBC. The goals
respond to hormone therapy.
of treatment in MBC include prolonged survival,
(3) HER-2 negative and HER-2neu positive in
symptoms control and maintenance of quality of life
combination with anti HER-2 treatment (3)
(7). Paclitaxel is among the most active chemotherapy
Metastatic breast cancer (MBC) is an
for treatment of patients with advanced breast cancer
incurable disease, and systemic treatment aims to
(ABC), and metastatic breast cancer (MBC) following
prolong survival, control disease progression, control
anthracycline­containing chemotherapy (8).
symptoms, and enhance patient quality of life (4).

The human epidermal growth factor receptor
2 (HER-2, HER-2neu, c-erbB-2) gene. It is localized
To evaluate the value of targeted therapy
to chromosome 17q and encodes a transmembrane
(trastuzumab) in HER-2 positive metastatic breast
tyrosine kinase receptor protein that is a member of
cancer patients previously treated with anthracycline
the epidermal growth factor receptor (EGFR) or HER
in the adjuvant setting, in terms of related toxicities,
family. The overexpression or HER-2 or its
objective response, overall survival, and progression
amplification occurs in 15% - 20% of invasive breast
free survival.
cancers. HER-2 has been validated as a prognostic

Received:2/5/2019 Accepted:1/6/2019

Full Paper (vol.764 paper# 29)

c:\work\Jor\vol764_30 The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (4), Page 4034-4038

Effect of Smartphone Addiction on Neck Function among
Undergraduate Physical Therapist Students
Rania N. Karkusha*, Dalia M. Mosaad*, Basant S. Abdel Kader**
* Basic Science Department, Faculty of Physical Therapy, Cairo University, ** Basic Science Department,
Faculty of Physical Therapy, Misr University for Science and Technology
Corresponding author: Basant S. Abdel Kader, Mobile: 01091445676, Email: pasantsaed@gmail.com

Background: the prevalence of gadget was increased between university students. They use it for entertainment rather than
learning. The long use of smartphone would be risk factor to musculoskeletal disorder, early neck pain, neck problems and
poor work habits that load cervical region. Purpose: this study was conducted to study the effect of smartphone addiction
on cervical range of motion and neck function among undergraduate students in the faculties of physical therapy.
Design: Cross-sectional one­shot, controlled observational study. Methods: one hundred students selected from different
physical therapy colleges in Cairo and Giza using short version of smartphone addiction scale (SAS sv). For selection, the
students were assigned into two groups; Group A, consisted of 62 students who were non­addicted smartphone users and
Group B, consisted of 38 students who were addicted smartphone users. Cervical range of motion (ROM) assessed by
CROM and Copenhagen neck function disability index was used to assess neck function.
Result: There were no statistical significant differences between both groups regarding BMI., regard to the cervical range
of motion there were statistical significant differences between both group in all direction (flexion, left lateral flexion, right
lateral flexion, left rotation and right rotation) except extension and Copenhagen neck functional disability index was
significantly higher among smartphone addicted group. Conclusion: Smartphone addiction affects cervical range of motion
and neck function so, it is recommended that physical therapy students should not use smartphone in addicted manner to
prevent long term neck disability. Ergonomics advises for smartphone use will be preventive therapy programmers.
Keywords: smartphone addiction, neck function, undergraduate students in the college of physical therapy.

to find the relation between smartphone addiction and
In Egypt, the percentage of the number of mobile phone
limitation of ROM of cervical joints, further
users increased from 75% in 2012 to 80% in 2013 on a
considerations are required to outline the negative
sample of 1,000 users. More than 73% of the internet users
impacts of addiction of smartphones on cervical mobility
are tertiary students, which include university students (1),
and to implement preventive measures (11).
also a different national survey revealed that smartphone
Aim of the study is to determine the effect of smartphone
addiction is twice more prevalent among teenagers than
addiction on cervical range of motion and cervical
among adults (2). Nowadays, the use of visual display
functions among physical therapy college students.
terminal (VDT) of computer and smartphones in almost

all homes and organizations is very common (3). ,
individuals utilize smartphones for different tasks on a
The present study was concerned with the effect
daily basis, might lead to bad postures (4).
prolonged use of smartphone on range of motion among
Furthermore, the usage of smartphones was reported to
undergraduate physical therapist. It was conducted in
cause significant alterations in upper cervical posture (5). It is
different faculties of physical therapy as Cairo University
also known that misalignment of the upper cervical posture
outpatient clinic, Egyptian Chines University, Egyptian
can induce alterations in muscular tone, musculoskeletal
Veterans and War Victims Association Physical Therapy
dysfunction. Other studies found that smartphone use would
Department, where different physical therapy universities
lead to muscular fatigue and text neck, which are the most
students spent the training courses there (BADR University,
common condition, as well as a decreased cervical range of
MTI University and 6 October University).
motion (6, 7). Studies that tested physical exposure related
to the use of smartphones are lacking today therefore, it is
Study design: Cross-sectional one­shot, controlled
necessary to evaluate the physical changes that occur
observational study design.
during the use of smartphones, and determine their use as
Study variable: (dependent variables: smartphone
a risk factor that could induce musculoskeletal system
addiction, independent variable: range of motion and
disorders, In a previous study the cervical mobility in the
neck function)
mobile addiction group was significantly decreased in
Duration of data collection: from November 2018 to
lateral flexion, cervical flexion, and cervical extension (8,
9, 10)
. The Young study (10) concerned with effect of mobile
January 2019
phone addiction on mobility of cervical region during use
Trial repetition: three repetitions for each CROM
of smartphone recommended that further study is needed

Full Paper (vol.764 paper# 30)