The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4040-4045
Macular Changes after Uneventful Phacoemulsification in High Myopic Patients
Younis Alsaeid Abd - Elhafez, Mahmoud Mohammed Ahmed Ali and Mohamed Hassan Elkashef*
Ophthalmology Department -Faculty of Medicine, Al -Azhar University
*Corresponding Author: Mohamed Hassan Elkashef, Phone No.: (+20)01093079759,
Background: Pathologic myopia is one of the leading causes of irreversible visual impairment worldwide, particularly
in younger individuals.
Objective: to evaluate the influence of uneventful phacoemulsification on macular thickness and macular changes in
the postoperative period in high myopic patients.
Patients and Methods: This is a prospective study which included 30 eyes in patients with high myopia -6 D or
with axial length 26 mm underwent cataract surgery. Participants did not have any eye disorders except for myopia
and cataract. Results: Statistically significant improvement was detected in postoperative best corrected visual acuity
(BCVA) and intraocular pressure (IOP). As regard BCVA, preoperative mean was 0.116±0.064 and range was from
0.01 to 0.25 Decimal. 1 weak postoperative mean was 0.495±0.145 and range was from 0.32 to 1.00, P-value was
<0.01. 1-month postoperative mean was 0.466±0.16 and range was from 0.16 to 1.00, P-value was <0.01. 3 months
postoperative mean was 0.401±0.17 and range was from 0.01 to 0.63, P-value was <0.01. As for IOP preoperative
mean was 15.73±1.14 mmHg and range was from 13 to 18 mmHg. Postoperative mean was 14.01±0.87 and range was
from 12 to 15 mmHg. P-value <0.01.
Conclusions: There was no statistically significant macular change after phacoemulsification in high myopic patients.
There was statistically significant improvement in the BCVA and IOP control.
Keywords: Cystoid Macular Edema; Epiretinal Membrane; Macular Hole; Myopia; Optical Coherence Tomography;
Schisis; Vitreomacular Traction.
Myopia is a relatively common ocular disorder, and
of the entrance of liquefied vitreous in the subhyaloid
the prevalence of high myopia in the population was
space and subsequent dissection of the remaining
estimated to be approximately 0.5% to 1% (1).
adhesions between the posterior vitreous cortex and
Pathologic myopia is one of the leading causes of
internal limiting membrane (8).
irreversible visual impairment worldwide, particularly
in younger individuals (2). These morphological changes
AIM OF THE WORK
are probably the underlying cause for the characteristic
To evaluate the influence of uneventful
finding of myopic maculopathy such as staphyloma,
phacoemulsification on macular thickness and macular
fuchs spot, lacquer crack and chorioretinal atrophy (3).
changes in the postoperative period in high myopic
Highly myopic eyes tend to develop cataracts earlier
than normal eyes, with higher prevalence of nuclear and
posterior subcapsular cataracts (4).
PATIENTS AND METHODS
In most cases, phacoemulsification does not change
This prospective study included a total of 30 eyes of
macroscopic funduscopic appearance of the retina.
30 patients with visually significant cataract attending at
However, noninvasive imaging techniques such as
the outpatient clinic of Al-Azhar University Hospitals.
cross-sectional imaging of the retina with optical
coherence tomography (OCT) have shown that macular
thickness may increase subclinically after surgery. This
Approval of the Ethical Board of Al-Azhar
subclinical thickening can be detected in many cases of
University and a written informed consent from all the
uneventful surgery, with a peak occurring 46 weeks
subjects were obtained.
after surgery (5).
This study was conducted between the period from June
Spectral-domain OCT (SD-OCT) is exceedingly
2018 to March 2019.
helpful in diagnosing and differentiating macular
Inclusion Criteria: High myopic error - 6 diopters or
pathologies such as epiretinal membranes, full-thickness
axial length 26 mm, high myopic patients with no
or lamellar holes, cystoid macular edema (CME),
clinical fundus changes, patients with senile cataract and
myopic foveoschisis, and dome-shaped macula (6).
refractive lens exchange in high myopic patients with
Phacoemulsification is associated with an increased
age more than 50 years old.
rate of posterior vitreous detachment (PVD) in the
Exclusion Criteria: Patients who refused to participate
postoperative period (7).
in the study, media opacity that interfere with
Posterior vitreous detachment (PVD) progression
preoperative evaluation, congenital or traumatic
has been described during phacoemulsification because
cataract, macular edema, disease and/or diabetic
retinopathy, previous intraocular surgery, topical
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4046-4054
Possible Protective Effect of Ginger Extract and Beetroot Juice Against Cisplatin
Induced Testicular and Cytogenetic Toxicity in Adult Male Albino Rats
Asmaa A. Elshiekh1, Hala R. Elkolaly1, Noura M. Tawfeek1, Amira A. Mohamed2 and Aml A. Mohamed1
1Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine for Girls, Al-Azhar University,
2Department of Genetic and Cell Biology, National Research Centre, Dokki, Egypt
*Corresponding author: Asmaa Abdo Elshiekh, E-Mail: firstname.lastname@example.org, Mobile: 01288160100
Background: cisplatin (Cis) is an efficient platinum-derived anticancer drug. It has been successfully used in clinical
oncology against diverse types of cancers. Testicular toxicity of cisplatin is of great concern because of increasing
number of longer survival of cancer patients treated with cisplatin.
Objective: the present study aimed to investigate the possible protective role of ginger extract and red beetroot juice
against testicular and cytogenetic toxicity induced by cisplatin.
Materials and Methods: sixty adult male albino rats were divided randomly into 6 groups (10 rats each). All groups
were received the treatment once daily for 5 weeks, 4 days per week. At the end of experimental period samples were
collected and then the levels of malondialdehyde (MDA), reduced glutathione (GSH), catalase (CAT), and
testosterone hormone were measured.
Results & Conclusion: cisplatin treated animals recorded a significant increase in MDA level and a significant
decrease in reduced glutathione (GSH) and catalase activities .Significant improvement occurred on co administration
of GE or BRJ to cis treated animals .Significant decrease in serum concentration of testosterone in cis treated animals
was recorded ,which improved significantly by co administration of GE or BRJ. A significant reduction in sperm
count and motility and a significant increase in sperm head and tail abnormalities were noticed in cis treated animals
which improved significantly on co-administration of GE or BRJ. Histopathological lesions which were observed in
cis treated animals improved on co-administration of GE or BRJ. Finally BRJ caused more improvement in all theses
parameters when compared with GE.
Keywords: Cisplatin (Cis), cytogenetic, chromosomal aberrations, testes, ginger extract (GE), beetroot juice (BRJ).
The modern life style and environmental
through their oxidative stress injury and suppression
pollution have been the causes of increased cancer
of the antioxidant defense system(5).
burdens in the world. Chemotherapy is one of the
Use of Cis in the treatment of tumors is
most important methods used in cancer therapy (1).
restricted due to its toxic effects including
Cisplatin is one of the most potent
nephrotoxicity, hepatotoxicity and cardiotoxicity(6).
chemotherapy drugs widely used for cancer
Toxic effect of cisplatin on different systems
treatment. The discovery of cisplatin, Cis-Diamine
like cardiovascular system and reproductive system
Dichloro Platinum (II) or CDDP), was a corner stone
are of great concern because of increasing number of
which triggered the interest in platinum (II) and other
longer survival of cancer patients treated with
metal-containing compounds as potential anticancer
Cisplatin-based chemotherapy results in
It has been reported that cisplatin (Cis) show
activity against a broad spectrum of many solid
abnormalities in spermatozoa and temporary or
tumors, including cervical, ovarian, testicular,
permanent azoospermia. Pathogenesis of testicular
bladder and lung cancers as well as solid tumors
damage after cisplatin exposure is generally
resistant to other drug regimens(3).
attributed to oxidative damage(8).
The main mechanism of cisplatin cytotoxic
Animals administered Cis develop severe testicular
effect is believed to result from its interaction with
damage characterized by germ cell apoptosis, Leydig
DNA, through the formation of covalent adducts
cell dysfunction and testicular steroidogenic disorder
between certain DNA bases and the platinum
leading to infertility. Spermatogenesis is affected by
compound leading to cytotoxic lesions in tumors and
CP by inhibiting nucleic acid synthesis of germ cells.
other rapidly dividing cells (4).
CP also inhibit testosterone production by damage of
The toxicity of Cis seems to be dose
dependent due to the cumulative effect of the drug,
Antioxidants are found in every living cell
where the accumulation of Cis produces obvious
and all biological species and scavenge reactive
necrotic changes within the tissues of the affected
organs. The generation of reactive oxygen species
antioxidants in human diet, within intracellular
(ROS) and nitrogen species (NS) is one of the
antioxidants, and enzyme system protect against the
possible mechanisms responsible for Cis toxicity
potentially harmful effects of excessive oxidative
stress and prevent various pathologic diseases.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4055-4061
Comparative Study between Medical Thoracoscope and Intrapleural Fibrinolytic
Therapy in Complicated Parapneumonic Effusion and Empyema
Ibrahim Mohammed El-sayed Radwan1*, Eisa Ibrahim Afify1, Ahmed Alsaeed Alsehrawey2,
Fawzi Mohamed Abd-Elfatah Omar1*
Departments of 1Chest Diseases*and 2Clinical Pathology**
Faculty of Medicine, Al- Azhar University, Egypt
*Corresponding author: Fawzi M. Omar, Mobile: (+20) 01067926511, E-mail: Fawzi1984.email@example.com
Background: patients with parapneumonic effusion and empyema must be managed probably to avoid surgery and
decortication, the use of medical thoracoscope and instillation of streptokinase intra pleural through intercostal tube
consider a modality of dealing with that medical situation.
Aim of study: it was to compare the therapeutic yield of medical thoracoscope and intrapleural fibrinolysis by
streptokinase in complicated parapneumonic effusion and empyema.
Patients and methods: this study was conducted at Endoscopy Unit in Chest Department, Al- Hussin Hospitals,
Al-Azhar University and Damanhur Chest Hospital in the period between May 2016 and May 2019. This study
included 50 patients with complicated parapneumonic effusion and empyema. They were divided into 2 groups:
Group A (25 patients): managed by medical thoracoscopy, Group B (25 patients): managed by intercostal tube
drainage (ICT) plus intrapleural instillation of streptokinase as fibrinolytic agent.
Results: twenty three (92%) patients improved and 2(8%) failed in group A (thoracoscopic group) and 16(64%)
patients improved and 9(36%) not completely improved in group B (Streptokinase group) with significant statistical
Conclusion and Conclusion: we conclude that medical thoracoscope is very effective, successful and safe in
management of such cases. Also, the use of streptokinase as fibrinolytic is safe and effective but not with the same
degree of medical thoracoscope. Patients with parapneumonic effusion and empyema must be managed probably to
avoid the risk of surgery and other complications.
Keywords: Medical thoracoscope, Streptokinase, Parapneumonic effusion, Empyema
At least 40% of all patients diagnosed with
(STK) acts by lysing fibrin strands, thus opening pus
pneumonia will have an associated pleural effusion,
pockets to drain(6,7).
although the minority of these will require active
intervention(1, 2). Parapneumonic pleural effusion refers
AIM OF WORK
to any effusion secondary to pneumonia or lung
The aim of this study is to compare the
abscess Included patients had frank pus, pH< 7.20,
therapeutic yield of medical thoracoscope and
positive Gram stain or culture It becomes
`complicated' when an invasive procedure is necessary
complicated parapneumonic effusion and empyema.
for its resolution, or if bacteria can be cultured from the
PATIENTS AND METHODS
Empyema is a term derived from the Greek
This study included 50 patients with
verb empyein (`to suppurate') and literally refers to
complicated parapneumonic effusion and empyema.
frank pus in the pleural space (2). Complicated
Included patients had frank pus, pH <7.20 or positive
parapneumonic effusions and empyema are more
Gram stain or culture. The patients were divided into 2
common at both extremes of age(2, 3).
groups: Group A (25 patients); managed by medical
Patients will have an identifiable risk factor at
thoracoscope and Group B (25 patients); managed by
presentation, which may include immunosuppressive
intercostal tube drainage (ICT) plus intrapleural
states (most frequently HIV infection, diabetes
instillation of streptokinase as fibrinolytic agent. All
mellitus and malnutrition), alcohol, intravenous drug
patients were subjected to full history, routine
abuse, poor dental hygiene or gastrooesophageal
laboratory investigations, CXR, CT chest and sonar
reflux(2). Intrapleural fibrinolytic therapy by
chest for evaluation and follow up.
streptokinase (STK) has shown benefit in various
All patients after giving written consent were
Fibrinolytic therapy decreases viscosity,
subjected to the following:
breaks loculations and pleural peel, resolves pleural
1- Clinical history and examination.
sepsis, and decreases the need for invasive surgical
2- Routine laboratory tests (CBC, liver and renal
intervention There are few case reports, and clinical
functions), CXR, chest ultrasound, CT chest, ABG,
trials reported from India. Intrapleural streptokinase
pleural fluid analysis, Biochemical analysis (pH,
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4062-4067
Frequency and Predictors of Extra-articular Manifestations in
Patients with Rheumatoid Arthritis
Dalia A. ElSherbiny
Internal Medicine Department, Rheumatology Division, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding author: Dalia AbdelHamid ElSherbiny - Mobile: +20 1227437707,
Aim: To evaluate the frequency and the predictors of extra-articular manifestations (EAMs) in rheumatoid arthritis (RA)
Patients and Methods: This study included 100 adult rheumatoid arthritis patients. A full medical history and a thorough
clinical and rheumatological examinations, along with laboratory and radiological investigations were done. RA disease
activity using the modified disease activity score (DAS28), validated Arabic version of the health assessment questionnaire
(HAQ-A) and the simplified erosion narrowing score (SENS) were calculated. Results: EAMs were detected in 73 patients
(73%) of the RA patients; the most common EAMs were subcutaneous rheumatoid nodules (45%), followed by anemia
(43%), ocular affection (23%), pulmonary affection (interstitial lung disease ILD) (15%), neuropathy (10%) while renal and
cardiac involvements were (2%) and (1%) respectively. There were statistically significant higher levels of age, disease
duration, disease activity (DAS28), severe functional disability (HAQ-A), joint damage (SENS), rheumatoid factor (RF)
positivity and CRP levels among RA patients with EAMs than those without EAMs. The multivariate regression analysis
of the possible predictors of RA EAMs showed that disease duration (OR 1.8, 95% CI. 1.2-2.9, p=0.006) and disease activity
DAS28 (OR 1.6, 95% CI 1.0-2.4, p=0.045) independently affect the occurrence of EAMs in RA patients.
Conclusion: Extra-articular manifestations are common among rheumatoid arthritis patients. Disease duration and disease
activity were independent predictors of extra-articular manifestations occurrence in rheumatoid arthritis.
Keywords: Extra-articular manifestations; Rheumatoid arthritis; Disease activity score(DAS28); Frequency; Predictors.
Rheumatoid arthritis (RA) is the most common
inflammatory joint disease, affecting 1-2% of the
The World Health Organization (WHO) and the
population worldwide . RA is a chronic systemic
Declaration of Helsinki recommendations were followed,
inflammatory disease that can involve other tissues and
in terms of protecting the rights and well-being of the
organs as well as synovial joints. Extra-articular
studied people . The nature of the present study was
manifestations (EAMs) are all the conditions and
explained to all participants. The laboratory and
symptoms which are not directly related to the locomotor
radiological procedures represent standard care pose no
system . Most organs can be involved . Extra-articular
ethical conflicts. Informed written consent was obtained
manifestations of RA occur in about 40% of patients,
from all participants. At the end of the study, all patients
either in the beginning or during the course of their disease
were informed about the results of the study and received
. Epidemiological studies of extra-articular RA
appropriate recommendations and treatment. The study
manifestations have emphasized their major role as
was approved by the local ethical committee at the
predictors of premature mortality in patients with RA .
Faculty of Medicine, Ain Shams University.
Extra-articular RA is a serious condition, and RA patients
with EAMs should be aggressively treated and monitored
All patients were subjected to the following:
- Detailed medical history taking and full clinical
Aim of this study is to detect the frequency and the
examination with special emphasis on musculoskeletal
predictors of EAMs in rheumatoid arthritis; and to
and extra-articular manifestations including pulmonary
evaluate its relationship with the disease activity and other
manifestations. Assessment of RA disease activity state
RA disease measuring parameters
was done by using disease activity score (DAS28). A score
2.4 was considered to be in disease remission, mild RA
SUBJECTS AND METHODS
disease activity 3.6, moderate >3.6 5.5, and high
This study was an observational cross-sectional study
disease activity >5.5 . Functional disability was
that included one hundred RA patients who fulfilled the
evaluated using a validated Arabic version of the health
American Colleague of Rheumatology / European League
assessment questionnaire (HAQ-A) completed by each
against Rheumatism (ACR/EULAR) 2010 classification
criteria . They were selected from Rheumatology
- Routine laboratory and serological investigations were
Outpatient Clinic and Internal Medicine Department of
performed including: complete blood count (CBC): using
Ain Shams University Hospital.
coulter JS + cell counter, erythrocyte sedimentation rate
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4068-4076
A Morphometric and Statistical Study for Determination of Sex from Certain
Bony Pelvic Parameters in Assiut Governorate by Using Plain X-Ray Films
Sherif Fahmy Mahmoud, Nagy Mohammed Al Fadaly, Huda Abdel Karim Abdel Samie,
Gamal El Din Ibrahim Abdel Halim, Abdel Rahman Zaki Abdel Rahman *
Department of Forensic Medicine and Toxicology, Faculty of Medicine, Al-Azhar University
*Correspondence author: Abdel Rahman Zaki Abdel Rahman, Mobile: (+20) 0 114 638 5665,
Background: The identification of sex from human remains is of fundamental importance in forensic medicine and
anthropology, especially in criminal investigations as well as in the identification of missing persons and in attempts
at reconstructing the lives of ancient populations.
Objective: The aim of this study was to assess specific pelvic parameters (Human sacrum and subpubic angle
measurements) in Assiut Governorate population by using plain x-ray films.
Patients and methods: The study was conducted on 500 plain x-ray films, which were obtained and collected from
the Radiology Department- Al-Azhar Faculty of Medicine (Assiut branch), out of which, 250 were males and 250 were
females in the age group of 2570 years belonging to Assiut population to assess the sacral and subpubic angle
Results: Statistically significant increase in the length of sacrum in males compared to females. The sacral length in
males varied from 86120 mm with the mean value of 100.06 ± 9.00 mm, while the sacral length in females varied
from 78120 mm with the mean value of 93.00 ± 9.46 mm.
Conclusion: The present study concluded that the subpubic angle is the best criterion for sex determination of pelvis.
It was found that 66.4% of males' bones and 58.4% of females' bones could be identified by using subpubic angle
Keywords: Sex, Pelvic parameters, Human, Plain x-ray films.
drastically reduce the time taken in the identification of
Identification of sex based on morphological
individuals, thus shortening the legalities associated with
marks is subjective and likely to be inaccurate, but
the same. Usually, skull is either used alone or in
methods based on measurements and morphometry are
conjunction with pelvis to determine sex of unknown
accurate and can be used in determination of sex (1).
skeletal remains (7). The pelvis is the most reliable source
It has been established that socio-environmental
for sex dimorphism among human bones, but when a
factors (e.g. nutrition, food, climate, pathologies, etc.)
complete pelvis is absent in such cases, other bones can
influence the development and in turn the appearance of
be an important aid in identification (8). The different
bones. Numerous studies have demonstrated that skeletal
parts of the bony pelvis had been studied to find out these
characteristics differ in each population and have
differences in both sexes and their significance in sex
emphasized the need for population-specific osteometric
identification. One of the most parameters used is the
standards for sex determination (2). Sexual dimorphism
shape and the contour of the articulated pelvis regarding
refers to those differences in size, structure and
the shape and diameters of the pelvic inlet and outlet (9).
appearance between male and female at an equal age (3).
Sex-dependent differences have been noted in
Determination of sex is an integral part and first step in
the pelvic bone anatomy, and so it follows that
the development of the biological profile in human
differences exist in the male and female sacrum (10). The
osteology. Sex determination is necessary to make age,
sacrum can be used for sexual dimorphism as in
ancestry and stature estimations (4). Gender
anthropological work. The knowledge of sacral index
determination of skeleton remains a part of
discriminates function analysis and demarking point
archaeological and medicolegal examinations. The
(DP), which is also essential in medicolegal practice for
methods vary and depend on the available bones and
age, sex and race determination of an individual. The
their condition. The only method that can give a totally
well known method for determination of male or female
accurate result is the DNA technique, but in many cases,
type from the sacrum has been called the "Sacral Index".
for several reasons, it cannot be used (5). When the entire
Sacral Index is one of the important indices used to
adult skeleton is available for analysis, sex can be
identify the gender of the bone which is computed by
determined up to 100% accuracy, but in cases of mass
multiplying the width of the sacrum by 100 and dividing
disasters where usually fragmented bones are found, sex
it by the height (length) of the sacrum. In women the
determination with 100% accuracy is not possible and it
breadth of the sacrum as a rule is longer than the height
depends largely on the available parts of skeleton (6).
when compared to men. Therefore, the aacral index also
Identification of sex of an individual is one of the
differs between men and women and hence it is used as
most important aspects of medicolegal cases and
a parameter to identify sex (11).
anthropological research. Availability of simple,
female has a larger sub-pubic angle compared to
economical, quick and accurate modalities can
that of a man and this is obviously indicative of child
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4077-4084
Prenatal Diagnostics for Neurosurgical Pathologies
Hamdy Mohamed Bhiry, Adel Ragab Al Melesy, Ahmed Mohamed Kamer Eldawla abdelmotaal*
Department of Neurosurgery, Faculty of Medicine, Al-Azhar University
*Correspondence author: Ahmed Mohamed Kamer Eldawla abdelmotaal, Mobile: (+20)01002074740,
Background: The advance in the prenatal diagnostics, particularly in imaging tools during the pregnancy (ultrasound
and magnetic resonance) allowed the early diagnose of many fetal diseases, including the neurological conditions.
This progress brought the neurosurgeons the possibility to propose treatments even before birth.
Objective: The aim is to study the role and effect of prenatal diagnostics for neurosurgical pathologies as regard to
early detection and management.
Conclusion: Further progress is necessary to enable fetal neurosurgery in becoming the main technique used in treating fetal
neurosurgical diseases. However, we believe that correct prenatal diagnosis and adequate selection of fetuses with
myelomeningocele, hydrocephalus, and occipital encephalocele may contribute to the benefits provided by neurosurgical
procedures during the fetal period.
Keywords: Prenatal Diagnostics, Neurosurgical Pathologies
extended to other conditions such as hydrocephalus
The advance in the prenatal diagnostics,
and encephaloceles. However, each one of these
particularly in imaging tools during the pregnancy
diseases has nuances in the diagnostic evaluation that
(ultrasound and magnetic resonance) allowed the early
should fit the requirements to perform the fetal
diagnose of many fetal diseases, including the
procedure and overbalance the benefits to the patients
neurological conditions. This progress brought the
neurosurgeons the possibility to propose treatments
even before birth (1).
AIM OF THE WORK
The neurosurgeon can be called on to interpret
The aim is to study the role and effect of prenatal
the meaning of diagnostic studies and must be ready to
diagnostics for neurosurgical pathologies as regard to
meet this emerging challenge and benefit from
early detection and management.
knowledge about which anomalies may require pre- or
postnatal intervention, where the birth should take place I.
and how the baby should be born (2).
Different types of tests are available during
The prenatal neurosurgical consultation serves
pregnancy, but they can be classified into two main
three primary purposes. First, it enables prospective
parents to learn from a physician knowledgeable about
A screening test shows if a pregnancy is at
the care and prognosis of infants with a particular
`increased risk' of a birth defect. Different screening
condition. Second, it enables the prospective parents and
tests are available in the first or the second trimester
the neurosurgeon to get a head start forging a therapeutic
of pregnancy. These results indicate the risk that a
alliance. Finally, prospective parents can participate in
baby may have a syndrome. A screening test does not
decisions about specific interventions such as fetal
give a definite answer, but it does tell us which babies
surgery, the timing and route of delivery, and any surgery
have an increased risk of having a pathology. The
that may be required soon after birth (3).
results may then help you decide if you want to have
a diagnostic test (8).
determination of gestational age and fetal number,
A diagnostic test can identify a condition,
evaluation for malformations, testing of fetal well-
and is very accurate. Diagnostic invasive tests (e.g.
being, and assistance with invasive diagnostic and
chorionic villus sampling and amniocentesis)
therapeutic procedures (4).
however, increase the risk of miscarriage. This is why
Amniocentesis, the first available prenatal
diagnostic tests are not routinely offered to all women.
chromosomal diagnostic testing option, was first
Instead, tests are offered in two stages. All women
described in the 1950s (1). Amniocentesis became
should be offered a screening test which carries no risk
increasingly safe and is now used for several purposes,
of miscarriage or harm to the baby (8).
evaluations. Chorionic villus sampling (CVS) is
another diagnostic test and can be performed earlier in
Ultrasonography is the method most
commonly used for fetal imaging because it allows
Myelomeningocele is the most recognized
real-time examination of the fetus and avoids radiation
disease that can be treated during pregnancy with a
exposure. Ultrasonography is exquisitely sensitive to
high rate of success. Additionally, this field can be
the interfaces between solid tissue and water;
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4085-4091
Open Wedge High Tibial Osteotomy versus High Fibular Osteotomy in
Management of Osteoarthritis Knee
Ahmed Shamma, Mohammed Elnahas, Loay Hassanin Mahmoud Ibrahim*
Orthopedic Surgery Department, Faculty of Medicine, Al-Azhar University
*Corresponding author: Loay Hassanin Mahmoud Ibrahim , Email: firstname.lastname@example.org
Background: osteoarthritis is the most common inflammatory joint condition and is expected to have an increasing
prevalence in middle-aged and elderly patients.
Objectives: to evaluate the functional outcome of open wedge High Tibial Osteotomy (HTO) versus High Fibular
Osteotomy (HFO) with segment resection in management of medial compartment osteoarthritis of the knee.
Patients and Methods: we compared 10 cases of HTO and 10 cases of HFO complain with uni-compartment knee
Results: success in HTO depends on good technique. The determination of the exact localization of the osteotomy site,
not to fracture lateral cortex, frequent assessment of the correction angle at every step of the operation, avoidance of
overcorrection, the selection of an appropriate Puddu plate size fit for the osteotomy gap. During follow up, mean
improvements obtained in KSS scores was 26.70. According to this assessment scale, preoperative score was deemed
worse, and postoperative scores was good. HFO relieves pain and improves joint function in human knee osteoarthritis.
This new surgery is simple, safe and affordable. Pain relief after surgery occurs in almost all patients. HFO may delay or
replace TKA in a subpopulation of patients with knee osteoarthritis.
Conclusion: HFO is a simple, safe, fast and affordable surgery to relieve pain and improve joint function and the
medial joint space in human knee osteoarthritis.
Keywords: High Tibial Osteotomy, High Fibular Osteotomy, Osteoarthritis Knee.
loss of cartilage, sclerosis, and focal osteonecrosis of
inflammatory joint condition and is expected to have
the subchondral bone. Biomechanically, the disease
an increasing prevalence in middle-aged and elderly
is characterized by alteration of the tensile,
patients. Symptomatic disease in the knee occurs in
compressive and shear properties and hydraulic
approximately 6% of adults 30 years of age or older.
permeability of the cartilage (3).
From 1995 to 2005 number of people affected with
Management of OA currently focuses on the
symptomatic OA has grown from 21 million to
relief of pain and the improvement of function
nearly 27 million in the United States (1).
through a comprehensive treatment plan that includes
Osteoarthritis is the most common form of
pharmacologic and non-pharmacological therapies.
arthritis in the knee. It is a degenerative, "wear-and-
For most patients pharmacologic management begins
tear" type of arthritis that occurs most often in people
with analgesia using acetaminophen or NSAIDs,
50 years of age and older, but may occur in younger
Tramadol and narcotic medications can be useful
people, too (2).
adjunctive therapies. Topical NSAIDs, salicylates,
OA diseases are a result of both mechanical
and capsaicin can be useful as adjuncts or in patients
and biological events that destabilize the normal
for whom systemic medications are problematic.
coupling of degradation and synthesis of articular
Intra-articular gluco-corticoids should be reserved for
cartilage chondrocytes and extracellular matrix, and
the short-term management of acute pain flares and
subchondral bone. Although they may be initiated by
used with caution, given their short duration of effect
multiple factors, including genetic, developmental,
and potential for long-term harm. Glucosamine and
metabolic, and traumatic, OA diseases involve all of
chondroitin and intra-articular hyaluronic acid, there
the tissues of the diarthrodial joint (2).
is controversies about their clinical benefits. The
Pathologically, the disease is characterized
future of OA prevention and treatment may involve
by irregularly distributed loss of cartilage more
nutritional supplements such as vitamin D or
frequently in areas of increased load, sclerosis of
selenium, but conclusive trials have not been
subchondral bone, subchondral cysts, marginal
completed. Likewise, numerous potential targets for
osteophytes, increased metaphyseal blood flow, and
therapy are under intense investigation (4).
variable synovial inflammation. Histologically, the
Non pharmacologic Management relays upon
disease is characterized early by fragmentation of the
Patient education, weight loss, Exercise (low-impact
cartilage surface, cloning of chondrocytes vertical
aerobic exercise program; walking, biking, or
clefts in the cartilage, variable crystal deposition,
swimming or other aquatic exercise, Quadriceps-
remodeling, and eventual violation of the tidemark by
strengthening exercises), Heat modalities, modified
blood vessels. It is also characterized by evidence of
activities of daily living, Knee braces and Orthotics
repair, particularly in osteophytes, and later by total
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4092-4098
Assessment of Autologous (Platelet-Rich-Plasma) as A Monotherapy for
Treatment of Dry Eye Disease
Mohamed Mahmoud Wahdan, Mohamed Mohamed-Aly Ibrahim,
Mohammad Farag Abdelsalam Elaraby*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Correspondence author: Mohammad Farag Elaraby, Mobile: (+20)100 412 0019, E-mail: email@example.com
Background: treatment of dry eye disease (DED) depends on minimizing inflammation and improving various
components of the tear film. Artificial tears remain an important part of patient comfort, with many lipid- and gel-
based formulations for a healthy ocular surface. Objective: the work aimed to evaluate the role of autologous
platelet-rich plasma (PRP) as a monotherapy for treatment of dry eye disease, versus artificial tears use.
Patients and Methods: a prospective comparative study. The study included 55 eyes of 30 patients with moderate to
severe dry eye disease. The study was performed at Ophthalmology Department in Alazhar University Hospitals.
Results: in our study PRP group of patients all are improved in all parameters and all of them were statistically
significant. Symptoms OSDI score decreased indicating improvement in 86.6% of patients. TBUT improved in
66.6% of cases. CFS improved up to disappearance of staining in 33% of cases and fair improvement in 53.3%, total
improvement was 86.6%. Schirmer test improved in 40% of cases. BCVA improved in 26.6% of patients,
improvement was not more than one line. Conclusion: PRP is very effective in treatment of moderate and severe
cases of DED at the level of subjective symptoms, TBUT, CFS, BCVA, and Schirmer test.
Keywords: Platelet-Rich-Plasma, Dry Eye Disease.
Dry eye disease (DED) is one of the most
AIM OF THE WORK
popular ocular morbidities. Twenty-five percent of
The work aims to evaluate the role of
patients who come to Ophthalmic clinics report
autologous PRP as a monotherapy for treatment of dry
symptoms of dry eye, making it a growing public
eye disease versus artificial tears use.
health problem and one of the most common conditions
seen by ophthalmologists (1).
PATIENTS AND METHODS
Many and different causes of dry eye disease as
The study included 55 eyes of 30 patients with
perimenopausal stages in women, increasing age,
moderate to severe dry eye disease.
hormonal diseases, and certain drugs are just a few risk
Study design: A prospective comparative study.
factors that can result in dryness on the ocular surface.
Setting of study: The study was performed at
Other causes include long-term contact lens wearing,
Ophthalmology Department in Alazhar University
smoking, and laser refractive eye surgery. Activities
Hospitals. This study period from October 2018 to
like watching television, extended computer use, and
reading can trigger and/or aggravate dry eye symptoms.
Inclusion criteria: Moderate to severe dry eye
Low relative humidity, such as an office environment
and air-conditioned places, can be detrimental to the
tear film. Allergies, coexisting autoimmune diseases, or
rosacea also can contribute to symptoms related to dry
o Corneal ulcers.
o Facial palsy.
The standard treatment for dry eye is topical
use of artificial tears, although the expected results are
not satisfying and often ineffective. This has led to the
use of other therapeutic methods based on blood
Each patient was subjected to the following:
derivatives. Autologous serum (AS) has been suggested
1- Ethical approval and written informed consent:
to be a more efficient treatment for severe DED rather
An approval of the study was obtained from Al-
than preservative-free artificial molecules, with varying
Azhar University academic and ethical committee.
success rates (3).
Every patient signed an informed written consent for
Platelet rich plasma (PRP) and plasma rich in
acceptance of the operation.
growth factors (PRGF) have also been reported as
2- Dry eye severity was determined by the Dry Eye
successful therapies for moderate to severe dry eye,
Workshop (DEWS) severity scheme,
with advantages over AS due to its higher
concentration of anti-inflammatory cytokines, growth
factors and other platelet derivatives, which could be
with high benefit for the required ocular surface
Demographic data: name, age and gender.
restoration in cases of moderate and severe dry eye (4, 5).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4099-4105
Immediate Outcomes of Trans Radial Approach versus Anatomical Snuff
Box Access for Coronary Procedures
Mamdouh Helmy El Tahaan, Abd EL Hamid Ismael Abd EL Hamid, Ahmed Abd El Samad*
The Department of Cardiology, Faculty of Medicine, Al-Azhar University
*Correspondence author: Ahmed Abd El Samad, Mobile: (+20) 01011097009, E-mail: firstname.lastname@example.org
Background: Radial Artery catheterization is a fundamental approach that is used as a procedural access in the
different catheterization interventions in more than 90% of procedures due to low prevalence of access-related
Aim of the work: The aim of the study was to develop and to implement a new radial artery access (located at hand) for
performing endovascular interventions. Also, our object to reduce the rate of access-related complications by comparison
between the traditional radial access and new trans distal radial approach by history and Doppler investigation and follow
up. Materials and methods: This was a clinical trial study that included 100 patients who presented to the Cardiology
Departments in El Sayed Galal Hospital to perform planned trans radial coronary angiography and coronary intervention
for diagnosis and treatment of ischemic heart events. The study was carried out on 100 patients that were divided into two
groups, one group had 50% of patients underwent the procedure through the traditional Trans radial approach and the other
half of the patients underwent the procedure through the new approach (The Anatomical Snuffbox).
Results: the results revealed that Complication higher in radial but not significant (12% in Snuff- box group and 24% in
Conclusion: To be proficient with both approaches, the operator needs to understand the differences between these two
routes in terms of patient preparation, procedural technique, catheter selection and laboratory setup.
Keywords: Radial Artery, Snuff Box, Catheterization Clinical Trial.
to the point of strongest pulse proximal in the
anatomical snuffbox. After successful puncture in the
interventional procedures was first introduced in 1993
anterior wall of the radial artery, soft tip coronary wire
(1). Feasibility and safety of this technique initially
0.014 mm is used to pass a tortuosity that exist in the
provoked some euphoria among some interventional
radial artery traditional site of puncture. A small skin
specialists, but later there was a realization of
incision is done, followed by introduction of 5 Fr radial
disadvantages of Radial artery catheterization including
sheath subsequently underwent an administration of
radial artery spasm, vessel thrombosis and different
200 mcg of nitroglycerine and a weight- adjusted dose
types of wall lesions of the access artery. Traditionally,
of heparin. The operator takes up a position at the level
the optimal radial artery puncture site was considered
of the patient's knee to manipulate the wire and the
to be at the distal third of forearm because of the
coronary catheters (Right and Left Judkins catheters) to
superficial position of the artery closely to the radial
do the coronary procedures (1). In this area, the radial
bone that facilitates puncture and following hemostasis.
artery is surrounded by soft tissues of hand, which is
Another site for the puncture is anatomical snuffbox
essential for the adequate hemostasis. Performing the
where the artery lies closely to the skin along the
endovascular interventions via forearm, radial artery
surface of radio carpal joint that serves as "basement (2).
(FRA) is considered preferable due to the lower risk of
The distinctive feature of this area is its location
access site bleeding. This is because of the above-
distally to the superficial palmar branch of radial artery
mentioned anatomical proximity of the radial artery to
that communicates with superficial palmar arterial arch
the "bone basement (3). Arterial wall damages in access
and other feature of this area is that it is surrounded by
site are multi-faceted: perforation and/or pulsatile
soft tissues of hand, which is essential for the adequate
haematoma (false aneurysm), injury of proximal major
hemostasis. Technique of radial artery intervention
blood vessels and arteriovenous fistula. Post-
through anatomical snuffbox access starts by placing
catheterization radial artery occlusion is the most
the right arm comfortably on a cushion on the right side
common complication of radial access. It is reported by
of the patient. After disinfection, the patient is covered
different authors to occur in 0-10% of case. There are
with a sterile drape. The operator took up a position
three fundamental causes of the access artery
near the patient's forearm for subcutaneous injection of
occlusion; arterial puncture, arterial catheterization (4)
3 cc xylocine (2).
and incorrect puncture hemostasis (5).
To bring the artery to the surface of the fossa, the
The post-catheterization impairment of the radial
patient was asked to grip slightly his thumb under the
artery does not manifest only with occlusion but also
other four fingers, with the hand slightly abducted.
with stenosis. The pulsation over a length of the radial
Then, under angle of 21 degrees, radial artery is
artery is preserved but its use as an access artery seems
punctured with a 45 G needle. The needle was directed
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4106-4109
Topographic Study of Corneal Periphery in Selected Rheumatic Diseases
Ahmed I. Kamel, Mahmoud M. Khalil, Hatem M. Ahmed, Mohammed H. Ragheb*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding Author: Mohammed H. Ragheb, Mobile: (+20)01014481889, E-mail: email@example.com
Background: many of autoimmune diseases associated with ophthalmological complication, such as Peripheral
Objective: to evaluate the potential changes in the peripheral corneal thickness in selected rheumatic autoimmune
Patients and Methods: a case control study was been held in Al-Azhar University Hospitals on 80 eyes for 40 patients
and subjects. The patients and subjects was been examined by Pentacam examination.
Results: as regard peripheral corneal thickness, the mean peripheral thickness of RA patients was 668.6 ± 32.1
micron, the mean peripheral thickness of SLE patients was 667.5 ± 34.8 micron, the mean peripheral thickness of
SNA patients was 637.8 ± 86.7 micron and the mean peripheral thickness of control patients was 681.2 ± 12.8 micron
(p-value = 0.045).
Conclusion: the peripheral corneal thickness was thinner in autoimmune patients than in normal subjects.
Keywords: peripheral keratitis, autoimmune diseases, pentacam.
in Al Azhar University Hospitals and they were
The immune system is a host defense system
matched by a control group.
includes many biological structures and processes that
Patients and subjects were categorized into 4
protects against disease(1). There are many systemic
autoimmune diseases that are associated with ocular
Group (1): Twenty eyes of normal subjects.
manifestation include: rheumatoid arthritis, systemic
Group (2): Twenty eyes in patients with rheumatoid
lupus erythematosus, juvenile rheumatoid arthritis and
Group (3): Twenty eyes in patients with systemic
The common ocular manifestations of systemic
autoimmune diseases include tear deficiency leading to
Group (4): Twenty eyes in patients with seronegative
dry eyes, or keratoconjunctivitissicca, episcleritis,
scleritis, synechiae and pupillary miosis, retinal
Written informed consent:
vasculitis and peripheral ulcerative keratitis (PUK)(3).
An approval of the study was obtained from Al- Azhar
Peripheral ulcerative keratitis (PUK) is a group of
University academic and ethical committee. Every
inflammatory diseases whose final common pathway is
patient signed an informed written consent for
peripheral corneal thinning(4).
acceptance of the operation.
Corneal topography is exceptionably useful for
examining characteristics of the cornea such as shape,
Age: 18-60 years.
Patients with definite rheumatic autoimmune disease
Scheimpflug cameras, such as the Pentacam, is a non-
invasive objective device that allows evaluation of the
ankylosing spondylitis & juvenile rheumatoid
AIM OF THE WORK
To evaluate the potential changes in the
Autoimmune disease diagnosed patient at least 6
peripheral corneal thickness in selected rheumatic
PATIENTS AND METHODS
Patients with corneal opacity or scar other than that
This study was been ethically approved by
caused by rheumatic autoimmune diseases.
al-Azhar Committee as a case control study was been
Patients with glaucoma.
held in Al-Azhar University Hospitals. The study was
Patients with history of ocular surgery.
carried out from December 2018 to May 2019 on 80
Patients with active uveitis.
eyes for 40 patients and subjects to compare the
Contact lens users.
peripheral corneal changes in selected rheumatic
autoimmune diseases with each other and with healthy
Severe dry eye.
persons, by using Pentacam examination, (SIRIUS @
3D Rotating Schimflug camera & topography system).
Any chronic use of eye drops other than tears
Rheumatic patients were taken by random
sample from the Rheumatology clinics and department
All patient and subjects were subjected to the
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4110-4118
Perioperative Use of Levosimendan in Patients with Left Ventricular Systolic
Dysfunction Undergoing Cardiac Surgery on Cardiopulmonary Bypass
Gamal Lotfy Abd Elrahman, Mostafa Mohammed Sabra, Amr Soliman Abd Elmageed,
Abd Elkader Abd Elrhman Abd Elkader Elbakery*
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University
*Correspondence author: Abd Elkader Abd Elrhman Abd Elkader Elbakery, Mobile: (+20) 01004581413,
Background: Patients undergoing cardiac surgery are becoming older and with greater comorbidities, carrying an
increased risk for perioperative complications, which result in higher mortality and higher costs for the health care
service. Objective: Our study is randomized, double-blind, placebo-controlled, multicenter clinical study to evaluate the
efficacy of levosimendan given preoperatively in high-risk patients with Left ventricular ejection fraction (LVEF) 35%
undergoing cardiac surgery on cardiopulmonary bypass (CPB).
Patients and methods: This study was carried out in Cardiothoracic Department, Natinaol Heart Institute, Al
Hussin hospital, Air Forced Specialized Hospital, and Saudi German Hospital. 60 patients treated with study drug
were enrolled, the study population was drawn from patients with an LVEF 35% scheduled to undergo cardiac
surgery with planned CPB. Results: Our results showed that the relative risk for postoperative mortality at 60 days
was reduced by 10% in the levosimendan group when compared with the control group [4 of 30 (13%) in the
levosimendan group vs 7 of 30 (23%) in the control group] with p value =0.5, however the incidence of 30-day
out-of-hospital complications was not statistically different between the two groups. In the levosimendan group,
no significant reduction in the rate of renal replacement therapy was observed [7 of 30 (23.3%) in the levosimendan
group vs 8 of 30 (26.7%) in the control group].
Conclusion: Levosimendan is safe and well tolerated in patients undergoing cardiac surgery with cardiopulmonary
bypass who have low LVEF and are at risk of the development of postoperative low cardiac output syndrome
Keywords: Levosimendan, Left Ventricular Systolic Dysfunction, Cardiac Surgery, Cardiopulmonary Bypass.
increased cellular energy demands and oxygen
Low cardiac output syndrome (LCOS) is
consumption, can trigger arrhythmias and can even
generally more common among patients with impaired
be cardiotoxic (5).
left ventricular function, and is managed with inotropic
Inotropic support is frequently initiated in
agents and, eventually, mechanical support such as
the perioperative period to improve post-bypass
intra-aortic balloon pump, extracorporeal membrane
ventricular function. However, inotropes include the
oxygenator or ventricular assist devices. Although
potential risk of increased myocardial oxygen
recent advances in pharmacologic and mechanical
consumption, which can result in cardiac ischemia,
treatments, short-term mortality risk for patients with
with subsequent damage to hibernating but viable
LCOS remains up to 15 times higher compared to an
myocardium, and arrhythmias. This prompted a
uneventful postoperative course(1).
debate on the potential harm associated with
Most of the available inotropic agents have
inotropic therapy in cardiac surgery. Indeed, the use
detrimental side effect or have a poor safety profile,
of perioperative and postoperative inotropes was
thus exposing the patient to treatment-related risks and
found to be associated with increased mortality and
complications. The prevention and the effective
major postoperative morbidity. Levosimendan is
treatment of LCOS is one of the pivotal requirement to
considered to be the ideal inotropic agent to support
improve outcomes in cardiac surgery, as preoperative
cardiac function in case of LCOS after cardiac
reduced left ventricular function was recognized as
surgery. Levosimendan is a calcium-sensitizing
the main risk factor for LCOS (2).
inotrope with a peripheral vasodilatory effect related
Also perioperative myocardial dysfunction is
to the ATP-sensitive potassium channel opening, and
associated with organ failure, prolonged intensive-care
is able to increase cardiac output with minimal
stay, delayed recovery and prolonged hospital
increase in myocardial oxygen consumption (6).
The effects of levosimendan as an inodilator
Postoperative acute kidney injury can be part
are based on a triple mechanism of action that provides
of cardiorenal syndrome, which is a classic example
positive inotropy with a neutral effect on oxygen
of organ dysfunction that can arise due to
hypoperfusion, which triggers a sympathoadrenergic
cardioprotective, anti-stunning and anti-ischemic
response, hyperglycemia and inflammation (4).
Phosphodiesterase inhibitors, like milrinone, do the
same by inhibiting cAMP degradation, this results in
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4119-4123
Comparative Study between Total Thyroidectomy and Hemithyroidectomy in
Treatment of Solitary Thyroid Nodules Diagnosed as Follicular Lesions by
Fine-Needle Aspiration Cytology
Mohamed Mahdy Abdelnassef1, Mohamed Ebrahim Shalamesh1,
Atef Mohamed Al-Mahdy1, Ebrahim Hassan Mohamed2
Departments of 1General Surgery * 2General Pathology, Faculty of Medicine - Al-Azhar University
Corresponding author: Mohamed Mahdy Abdelnassef, Mobile: (+20)01115948254, E-mail: firstname.lastname@example.org
Background: Thyroid nodular (TN) lesions are a common clinical problem in the world. These are more common
in women and in areas of iodine deficiency. Exposure to ionizing radiation in childhood and adolescence increases
the risk of solitary thyroid nodule and thyroid carcinoma.
Objective: Determination of the optimal surgical approach for individuals undergoing thyroidectomy for solitary
thyroid nodule identified as indeterminate follicular lesion on preoperative fine needle aspiration cytology (FNAC)
diagnosis and to estimate the long term outcome of patients treated by lobectomy for solitary follicular thyroid
Patients and methods: From June 2017 to June 2019, 50 patients having a solitary thyroid nodule with a cytological
diagnosis of "indeterminate follicular lesion" were selected prospectively.
Results: There were 26 women and 24 men with a mean age of 56 years (range: 28-83). Hemithyroidectomy (HT)
was performed in 25 patients (50%) and a total thyroidectomy (TT) in 25 (50%). Postoperative morbidity was 3.50%
in patients who underwent HT and 9.75% in those who underwent TT. At the histological analysis 3 (12%) patients
of hemithyroidectomy group had a malignant lesion.
Conclusions: Considering the high rate in which HT represents the adequate treatment, and the low rate of re-
operation morbidity, HT seems to be the preferable initial surgical approach for indeterminate follicular lesions.
Long-term ultrasonographic follow-up seems advisable.
Keywords: Fine-needle biopsy, Follicular lesion, Hemithyroidectomy, Total thyroidectomy.
entire capsule is considered a follicular adenoma (1).
Follicular adenoma and follicular carcinoma of the
Vascular invasion is defined as tumor penetration into a
thyroid gland are tumors of follicular cell differentiation
large caliber vessel within or outside the capsule. Tumor
that consist of a microfollicular architecture with
invasion of a large vessel with an identifiable wall and
follicles lined by cuboidal epithelial cells. The ratio of
an endothelial lining is definitive morphologic evidence
follicular adenoma to follicular carcinoma in surgical
of vascular invasion. Vascular invasion is the most
specimen is approximately 5 to 1. Follicular carcinoma
reliable sign of malignancy (2).
has microscopic features that are similar to a follicular
Follicular carcinoma is divided into minimally
adenoma. Most patients with a follicular adenoma are
invasive and invasive variants based on morphologic
clinically and biochemically euthyroid. Approximately
criteria. Minimally invasive follicular carcinoma is an
1% of follicular adenomas are "toxic adenomas", which
encapsulated tumor with microscopic penetration of the
are a cause of symptomatic hyperthyroidism. Fine
tumor capsule without vascular invasion (3). Follicular
needle aspiration cytology (FNAC) is the most
carcinoma accounts for 10% of all cases of thyroid
important test for diagnosing follicular thyroid lesion
malignancy in iodine sufficient areas and 25%40% of
however FNAC cannot distinguish follicular adenoma
thyroid malignancies in areas of iodine deficiency. It
from follicular carcinoma on the bases of cytological
occurs more often in women and older patients with a
analysis as it cannot detect capsular and vascular
female-to-male ratio of 3:1 and a mean age of 60 years
at the time of diagnosis. Most follicular cancers are
Follicular carcinoma has microscopic features that
nonfunctional, but there are rare cases of functioning
are similar to a follicular adenoma. However, a
follicular cancers. Ten to 15% of patients with follicular
follicular carcinoma tends to be more cellular with a
carcinoma present with metastatic disease, most
thick irregular capsule and often with areas of necrosis
commonly involving the lung followed by bone. The
and more frequent mitoses. A follicular carcinoma
brain, liver, and skin are less common sites of systemic
cannot be distinguished from a follicular adenoma
metastases (1, 4).
based on cytological features alone. It is distinguished
from a follicular adenoma on the basis of capsular
AIM OF THE WORK
invasion, vascular invasion, extrathyroidal tumor
To determine the optimal surgical approach for
extension, lymph node metastases or systemic
individuals undergoing thyroidectomy for solitary
metastases. Capsular invasion is defined as tumor
thyroid nodule identified as indeterminate follicular
extension through the entire capsule. A follicular
lesion on preoperative FNAC diagnosis and to estimate
neoplasm with tumor invasion into but not through the
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4124-4132
The Predictive Value of Non-Invasive Blood Ammonia Level for the
Presence of Oesophageal Varices in Patients with Liver Cirrhosis
Mohamed Abdelhakeem Aboushady1, Arafat Abdelazeem Kassem1,
Mohamed Saad Eldeen Radwan2, Abdou Ragab Ahmed Ismail1*
Departments of 1Internal Medicine and 2Clinical Pathology, Faculty of Medicine, Al-Azhar University
*Correspondence author: Abdou Ragab Ismail, Mobile: (+20)01009042439, E-mail: email@example.com
Background: portal hypertension leads to the formation of portosystemic collateral veins in liver cirrhosis. Rupture of
esophageal varices is common and can be fatal. Gastroesophageal varices are present in 50% of patients with cirrhosis.
Their presence correlates with the severity of liver disease.
Objective: the aim of this work was to investigate the diagnostic utility of blood ammonia level as a noninvasive
predictor for presence of oesophageal varices and correlate it with variceal size in patients with liver cirrhosis.
Patients and Methods: this cross-sectional study was carried out in the department of Internal Medicine,
Gastroenterology and Hepatology Unit, Al-Hussein University Hospital. A total of 70 consecutive patients and 20
normal healthy volunteer were included in the study.
Results: There was a highly significant increase in the mean values of ammonia levels, spleen and portal vein diameters
in cirrhotic patients with OV in comparison to patients without OV. There was a highly significant decrease in the mean
values of haemoglobin in patients with OV in comparison to other patients without OV For detection of OV. There was
a highly significant increase in the mean values of serum ammonia in patients with OV in comparison to other patients
Conclusion: the blood ammonia level may be clinically useful as it correlates with and is an independent predictor for
both endoscopic risk signs and risk factors of bleeding, and therefore, it could be used in cirrhotic patients to decrease
the number of screening endoscopies they are subjected to.
Keywords: Non-Invasive Blood Ammonia Level, Oesophageal Varices, Liver Cirrhosis
Portal hypertension leads to the formation of
Therefore, the identification of nonendoscopic,
portosystemic collateral veins in liver cirrhosis. Rupture
noninvasive methods that can accurately predict
of esophageal varices is common and can be fatal.
Gastroesophageal varices are present in 50% of patients
esophageal varices in cirrhotic patients can helpto
with cirrhosis. Their presence correlates with the severity
identify patients at greatest risk and thereby reduce the
of liver disease. Patients without varices develop them at
necessity of endoscopic screening(6).
a rate of 8% per year(1), and the progression from small to
large varices occurs in 10 to 20% of cases yearly. Variceal
AIM OF THE WORK
hemorrhage occurs at a yearly rate of 5 to 15%(2).
The aim of this work is to investigate the diagnostic
The most important predictor of hemorrhage is the
utility of blood ammonia level as a noninvasive predictor
size of varices, with the highest risk of first hemorrhage
for presence of oesophageal varices and correlate it with
(15% per year) occurring in patients with large varices(3).
variceal size in patients with liver cirrhosis.
The risk of first variceal bleeding in patients with large-
or medium-sized varices is significantly reduced by
PATIENTS AND METHODS
betablockers (30% in controls vs 14% in beta blocker
This cross-sectional study was carried on in the
department of Internal Medicine, Gastroenterology and
On the basis of these studies recent practice
Hepatology Unit, Al Hussein University Hospital. A total
guidelines have recommended that all patients with
of 70 consecutive patients and 20 normal healthy
cirrhosis undergo screening upper GI endoscopy to detect
volunteer were included in the study. All subjects were be
esophageal varices at the time of diagnosis and after that,
grouped as group one that comprises 40 patients with
surveillance endoscopies should be performed every 2 to
liver cirrhosis and endoscopic evidence of esophageal
3 years in cirrhotic patients without varices and that
varices, group two that comprises 30 cirrhotic patients
patients with small varices be endoscoped every 1 to 2
without endoscopic evidence of esophageal varices, and
years, and annually in the setting of decompensation(5).
group three which included 20 normal healthy volunteer,
Since, the prevalence of medium/large varices is
served as control.
approximately 15 to 25%(6), the majority of subjects
Group 1 was again divided into two subgroups
undergoing screening endoscopy either do not have
according to the size of esophageal varices, group 1A:
varices or have varices that do not require prophylactic
Cirrhotic patients with small esophageal varices (F1),
therapy. In other words, a large number of patients will
group 1B: Cirrhotic patients with medium and large
be subjected to unnecessary, invasive procedures.
esophageal varices (F2, F3).
Patient and methods
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4133-4137
Evaluation of Pre-Peritoneal Mesh Repair in Management of Ventral Hernia
Sameh Gabr Attia, Mohamed Ibrahim Shalamesh and Ahmed Shokry Helal*
Department of General Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Shokry Helal, Mobile: (+20)01007005494, E-Mail: firstname.lastname@example.org
Background: Ventral hernias are defined as a defect of the fascia in the anterior abdominal wall with or without a
bulge. Clinical presentation varies from small incidental defects to giant and complicated hernias with fistulas and
viscera located outside the abdominal cavity covered only by peritoneum and skin. It includes incisional hernias,
paraumbilical hernias, umbilical hernia, epigastric hernias, and spigelian hernias, respectively.
Objective: The aim of the present study was to evaluate the functional outcome of pre-peritoneal mesh repair in
management of ventral hernia. Patients and methods: This was a case control study of incisional hernia repair by
pre-peritoneal mesh implantation that was carried out on 40 subjects collected consecutively at Kafr El-Sheikh
General Hospital and Sayed Galal University Hospital. Diagnosis was based on clinical criteria.
Results: Regarding to symptoms, 34 cases showed swelling (85%), only 5 cases had swelling and pain (12.5%) and
a case showed swelling, pain, and vomiting (2.5%). Chest infection was the most common complication seen with 3
cases (7.5%), wound infection and persistent pyrexia were seen in 2 cases for each (5%) and cellulitis, seroma and
post-operative ileus were seen in only one case for each (2.5%).
Conclusion: follow up findings showed no complications except recurrence in only one case. Therefore our study
affirms that pre-peritoneal mesh repair or sublay mesh is the ideal repair technique and highly recommended for
Keywords: Pre-peritoneal mesh repair, Ventral hernia.
Selection of the most cost-effective
Ventral hernia is one of the most common
appropriate mesh is determined by the approach, the
general surgical pathologies. An estimated 20 million
position of the mesh and the risks for surgical site
patients with hernias are operated on worldwide every
occurrences. The surgeon needs to weigh up
year, of which approximately 30% are ventral. An
properties of different types of meshes. These have
incisional hernia will develop in 1015% of patients
different advantages in terms of tissue ingrowth,
with an abdominal incision and the risk increases to
encapsulation, shrinkage, pore size, anti-adhesive
up to 23% in those who develop surgical site infection.
characteristics, risk of sepsis and explanation, in vivo
Incidence rates up to 69% have been reported in high-
disintegration, foreign body reaction, abdominal wall
risk patients (1). Ventral hernias are defined as a defect
compliance, burst strength and cost (5).The objective
of the fascia in the anterior abdominal wall with or
should be to select a mesh, which promotes healing
without a bulge. Clinical presentation varies from
and strengthens the repair, while reducing sepsis, thick
small incidental defects to giant and complicated
plates of granulation and chronic pain (6). Current
hernias with fistulas and viscera located outside the
thinking is that neither tensile strength nor mesh-
abdominal cavity covered only by peritoneum and
weight are important determinants for good outcome,
skin (loss of domain) (2). The symptoms range from
rather than adequate pore size of between 1-4 mm,
minor cosmetic concerns to severe pain and life-
coupled with a mesh of adequate burst pressure offer
threatening conditions such as bowel obstruction,
the most critical balance between good tissue
incarceration, strangulation and perforation (3).
ingrowth and protection from central mesh failure (3).
Abdominal hernia repair is one of the most
common operations in general surgery. Abdominal
AIM OF THE WORK
operations are often complicated by incisional
The aim of the present study was to evaluate the
hernias. The commonly reported incidence varies
functional outcome of pre-peritoneal mesh repair in
from 2 to 20%. In high risk groups with long-term
management of ventral hernia.
follow-up, this percentage may be as high as 96% (4).
Wound healing is complex and is influenced
PATIENTS AND METHODS
by patient genetics (ratios of certain collagen and
A case control study of incisional hernia repair by
fibroblast subtypes), patient co-morbidities affecting
pre-peritoneal mesh implantation that was carried out
fibroblast-migration, biomechanical factors such as
on 40 subjects collected consecutively at Kafr El-
movement of the abdominal wall and pressure
Sheikh General Hospital and Sayed Galal University
dynamics. Anatomical factors such as blood supply,
Hospital. Diagnosis was based on clinical criteria.
potential spaces and technical factors relating to the
repair or closure also play a role. Mesh provides a
All patients presenting with anterior abdominal wall
scaffold to facilitate granulation, fibroblast deposition
and reorganization (3).
a. Umbilical hernias
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4138-4143
Effect of Adding L-Carnitine to Clomiphene Resistant PCOs
Women on the Ovulation and the Pregnancy Rate
Ahmed Taha Abd-Elfattah1*, Mahmoud Abd-Ellatif Hashish2,
Fahd Abd El-aal Elomda1, Hossam Ibrahim Megahed1
Departments of 1Obstetrics & Gynecology and 2Clinical Pathology, Faculty of Medicine,
Al-Azhar University, Cairo, Egypt and Etay Elbaroud General Hospital, Ministry of Health
*Correspondence author: Ahmed Taha Abd-Elfattah, Mobile: (+20) 01006257839, E-mail: email@example.com
Background: polycystic ovary (PCO) syndrome is an endocrionologic disorder that affecting about 6-10% of women
in their reproductive age. Conception rate with clomiphene citrate treated cycles is about 40% only and the number of
ovulated oocyte decrease significantly with repeated cycles of ovulation.
Objective: evaluation of the effectiveness of usage of clomiphene citrate with L-carnitine (LC) in induction of ovulation
in clomiphene citrate resistant patients. Patients and Methods: Randomized controlled study included a total number
of 50 women with clomiphene-resistant PCOs. They were divided into 2 groups, group (A) where patients received 100
to 150 mg clomiphene citrate from day three until day seven of the cycle and L-carnitine (LC) 3g daily till positive
pregnancy test and group (B) received 100 to 150 mg clomiphene citrate with placebo.
Results: There was statistically significant difference (p-value <0.05) between both groups as regard infertility duration
(months), ovulation rate, no. of chemical pregnancies and no. of clinical pregnancies. There was highly statistically
significant difference (p-value < 0.001) between both groups as regard days until HCG injection, endometrial thickness
(mm), no. of pre-ovulatory follicles >17 mm and E2 on day of HCG injection.
Conclusion: Adding L-carnitine to clomiphene from the follicular phase and extending through the luteal phase in
patients with clomiphene-resistant PCOS, at the given dose and duration, may be of beneficial to the quality of ovulation
and the clinical pregnancy rate.
Keywords: L-carnitine, clomiphene-resistant, PCOs, pregnancy.
Polycystic ovary syndrome (PCO) syndrome is
Carnitine is a quaternary ammonium compound
one of the most common female endocrinological
that can be synthesized from the two amino acids lysine
disorder, affecting about 6-10% of women in their
and methionine (8). In living cells, it helps in transport of
reproductive age. Mostly it presented with anovulation
fatty acids from cytoplasm into the mitochondria during
and hyperandrogenism together with hyperinsulinaemia
the breakdown of lipids in the process of generating
and insulin resistance (1).
energy. It is present as nutritional supplement (8).
Clomiphene citrate (CC) is considered the
standard drug for ovulation induction(2), Conception rate
There are two forms of stereoisomers of carnitine:
in clomiphene treated cycles is about 4o% only, however
1- Carnitine which biologically active.
the induced ovulation rates are between 80-85% (1).
2- D-carnitine which biologically inactive (9).
It was found that Repeated ovulation induction
Carnitene plays an essential role in energy production,
decrease the quality of mitochondrial DNA and increase
oxidative stress and glucose metabolism (10).
8-hydroxydeoxy- guanosine in oocytes (3).
Carnitine can stabilize organelle, and also protect the
The use of kinetic analysis has previously
cell from apoptosis (11).
proved that the ovulated oocyte number decrease
Usage of carnitine in the treatment of insulin
markedly with repeated cycles of ovulation. In addition,
resistance has gained attention since the role of
it was reported that a decrease in the gene expression of
accumulation of acyl-coa derivatives in the development
mitochondrial transcription factor A and a more
of insulin resistance was suggested. Furthermore, some
incidence of oocyte with abnormally distributed
recent studies point towards l- carnitine insufficiency as
a case of developing insulin resistance during stats of
It is common to start clomiphene citrate with
chronic metabolic stress, such as type2 D.M. and obesity
5omg then increase the dose up to 15omg and continuing
that can be reversed by carnitine.
the latter dose for three consecutive cycles. If no,
It was found that Women with PCO had lower
ovulation occurred, this is called clomiphene citrate
level of serum l- carnitine. The decrease was correlated
resistance (5). There were many trials to improve the
to hyper androgenic and hyper-insulinaemia markers (12).
pregnancy rate in CC induction cycles through adjuvant
treatment such as n-acetyl cysteine (6).
AIM OF THE WORK
Treatment of insulin resistance in women with
It is to evaluation of the effectiveness of usage
PCO with an insulin sensitizer such as metformin dose
of clomiphene citrate with L-carnitine in induction of
increase pregnancy rate (7).
ovulation in clomiphene citrate resistant patients.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4144-4147
The Value of Mastectomy Flap Fixation on Seroma Formation after Mastectomy
Ahmed Abd El Aal Sultan*, Ahmed Mohamed Abd El-Wahab, Magdy Salah El-Din Hussain
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Abd El Aal, Tel: +201005056641, E-mail: firstname.lastname@example.org
Background: seroma occurs in most patients after mastectomy. It is thought to be caused by the fact that mastectomy
leaves a lot of an "empty space" under the skin where the breast tissue used to be.
Aim of the work: it was to study the effect of closure of dead space by suture fixation of the mastectomy flaps to the
underlying chest wall on the amount and duration of postoperative drainage and seroma formation.
Patients and Methods: the current study included 40 female patients with breast carcinoma scheduled for modified
radical mastectomy and they were randomized into two groups according to suture fixation of the mastectomy flaps to
the underlying chest wa1l. Group I, 20 patients undergone suture fixation of the mastectomy flaps to the underlying
chest wa1l raw by raw, closing every potentia1 space. Group II, 20 patients where the wound was c1osed in the
Results: the flap fixation technique is a valuable procedure that significant1y decrease the incidence of seroma
formation, the need for frequent visits to the physician for seroma fluid aspiration, the tota1 amount of drained fluid
and also allowing for earlier remova1 of the drains as well as avoidance of complications resulting from the occurrence
Conclusion: This method appears to have much many advantages that over-exceed its disadvantage of time
consumption during the operation. It should be tried on a much wider scale to prove its validity in decreasing the
incidence of seroma formation and its subsequent complications.
Keywords: breast, cancer, mastectomy, seroma, flap fixation.
chest wall structures, obliterate dead space, and allow
Severa1 post-mastectomy complications were
rapid remova1 of fluid as it forms. For this, severa1
reported such as necrosis of skin flaps, wound
techniques of flap fixation or wound drainage, as well
dehiscence, hematoma, seroma formation, and
as limitation of postoperative shoulder movement and
surgical site infection. Among them, seroma, a
injecting different chemical substances as thrombin,
c1inically evident subcutaneous collection of serous
tranexamic acid and fibrin glue have been investigated
f1uid within a surgical cavity, is the most frequent
to improve primary healing and minimize seroma
post-operative complication after breast cancer
surgery, developing in approximately 30% of cases(1).
It is unclear if their pathophysiogenesis is of lymphatic
AIM OF THE STUDY
origin (also called lymphocele) and/or "simply"
The purpose of our study is to evaluate the
related to inflammatory exudates, with various
effect of post mastectomy dead space obliteration
predictive factors being proposed. Seromas may
(DSO) on seroma formation by suturing skin flaps to
require repeated and long lasting punctures, which can
underlying muscles, also to assess the effect 0f
be complicated by infections that affect all patients'
0bliterating the axillary dead space by sutures. In
quality of life. The aims of this work were to analyze
addition, Factors predicting the formation of seroma
the seroma situation at our institution and to try to
were analysed and reported.
define patients at risk for such events (formation of
seromas, their punctures, and the related infections),
PATIENTS AND METHODS
especially comparing patients who underwent a
The present study is a prospective (follow-up)
mastectomy vs. a lumpectomy(2).
clinical trial that included 40 patients, presented to Al-
Pathogenesis of seroma formation is poorly
Hussain University Hospita1, in Cairo, Egypt, for
understood. Many factors take part in the formation of
elective modified radica1 mastectomy, during the
seroma. Dead space formation could be one of the
period from Apri1 2018 till March 2019, after
1eading mechanisms of postoperative seroma
obtaining the loca1 Ethics Committee approval. All
formation(3). Type of operation, use of electrocautery,
patients admitted to the Surgery department signed a
elderly patient, obesity and 1onger and higher drain
written informed consent. They were randomized
outputs, are associated with increased risk. However,
using close-envelope into two groups:
Kuroi et al.(4) reported that the age of the patient, neo-
Group I: 20 patients underwent modified radica1
adjuvant chemotherapy, tota1 number of retrieved
mastectomy. Multiple stitches (using fine absorbable
axillary lymph nodes, the number of positive axillary
sutures) were taken between the subcutaneous tissues
lymph nodes, and the tumor size were not associated
of the skin flaps and the underlying muscles in rows at
with increased seroma formation. Ideal wound closure
various parts of the flap and at the wound edge. Special
should minimize lymph spillage and serum oozing,
attention was taken to the obliteration of the largest
provide a means of holding skin flaps securely to the
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4148-4154
Comparison between a 595-nm Pulsed Dye Laser and a 1064-nm Nd:YAG
Laser for Treatment of Chronic Cutaneous Lupus Erythematosus with
Clinical & Histopathological Outcome Evaluation
Abdel Shakour Abdel Hafiz Al-Mohamady ; Hussein Mohamed Hassab El Naby ,
Shady Mahmoud Attia ; Sara Abdel Hafez El-Hussiny
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Sara Abdel Hafez El-Hussiny, Mobile: (+20)01118521314, E-Mail: email@example.com
Background: Chronic cutaneous lupus erythematosus (CCLE) is limited to the skin, commonly affecting the face,
frequently disfiguring and sometimes therapeutically challenging. Cutaneous lupus erythematosus has been treated
with different laser in many studies and reports with promising results, presenting another new line of CCLE treatment.
Aim of the work: This work aimed to evaluate and compare between the efficacy and safety of pulsed dye laser (PDL)
versus ND: YAG laser for CCLE treatment.
Patients and methods: This comparative study included a total of twenty patients with CCLE who had active lesion
and with histologically confirmed lupus erythematosus, attending at Dermatology Outpatient Clinic of Al-Azhar
University Hospitals. The patients were divided into 2 groups; group (A): 20 patients were treated by PDL and group
(B): 20 patients were treated by ND:YAG laser. The degree of CCLE and clinical response evaluation was assessed
using CLASI system. Results: In both groups A & B clearance rate was equal (50%) and Improvement rate was 100%
with significant decline in ``active'' CLASI after laser treatment in both groups. P-value was 0.04 in group A and
0.005 in group B, without significant difference between both groups.
Conclusion: PDL and ND: YAG laser are safe and effective in CCLE treatment with insignificant difference between
them. So, we recommend early laser usage as main treatment of CCLE particularly for refractory cases for other
treatment line or as an adjunctive therapy to decrease incidence of atrophy and scarring.
Keywords: Chronic cutaneous lupus erythematosus, PDL, ND: YAG laser.
Hemoglobin has highest absorption peaks from
Lupus erythematosus (LE) is a chronic,
585 to 595 nm wavelengths and another high absorption
multisystem and autoimmune disease that has many
peak from 800 to 1,100 nm wavelengths (6).
different symptoms, CLE has three main subtypes:
PDL is effective to a depth of only 1 mm to 2
Acute CLE (ACLE), subacute CLE (SCLE) and chronic
mm. The longer wavelength of the ND: YAG laser is
CLE (CCLE) (1).
better for deeper blood vessels treatment with lesser
CCLE include several presentations: Disciod
melanin absorption decreasing the risk of post
LE is the commonest presentation and other variants
inflammatory pigment alternation (7).
include: hypertrophic or verrucous LE, LE panniculitis,
The aim of the current work was to assess and
tumid LE and chilblain lupus (2).
compare between the efficacy and safety of pulsed dye
Treatments of CLE include topical and systemic
laser and ND: YAG laser in CCLE treatment.
PATIENTS AND METHODS
azathioprine, and clophosphamide. Occasionally,
This comparative study included a total of
twenty patients with active CCLE lesions with
mycophenolate mofetil have been reported (3). Physical
treatments for CLE include laser therapy. The efficacy
attending to Dermatology Outpatient Clinic of Al-
of PDL and other type of laser has been shown in many
Azhar University Hospitals, Cairo, Egypt.
studies, case reports and series (4).
Approval of the Ethical Committee and a written
The working mechanism of pulsed dye laser is
informed consent from all the subjects were
selective photothermolysis of the cutaneous lesional
blood vessels, which may modify the inflammatory
This study was carried out during the period
process and engender improvement of CLE lesions.
between October 2014 and August 2018.
Therefore, PDL treatment may affect only active CLE
The 20 patients were divided into 2 groups;
lesion with a lesser extent atrophy and scar (5). 1,064-nm
Group (A): 10 patients to be treated by PDL and Group
ND: YAG laser treatment may be added to other
(B): 10 patients to be treated by a 1,064-nm long-pulse
therapeutic options of CCLE lesions especially when
ND: YAG Laser.
other traditional therapies have failed or are
contraindicated, the selective damage of the lesion 1. Patients aging 18 years or more.
blood vessels may be the working mechanism (6).
2. Patients who have at least one active CLE lesion.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4155-4161
Corneal Endothelial Changes Following Refractive Lens Exchange
Mohamed Z. Eid, Sayed M. Elsayed, Mohamed A. Yousef
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo Egypt
Corresponding Author: Mohamed A. Yousef; Mobile: 01004467987
E-mail: Mohamed Abdelbaset.firstname.lastname@example.org
Background: clear lens extraction (CLE) by phacoemulsification and posterior chamber intraocular lens (PC IOL)
implantation in a series of highly myopic and hyperopic eyes was effective and had an acceptable predictability and a
low rate of complications especially on corneal endothelium.
Aim of the work: to study corneal endothelium changes (number and morphology) following phaco-aspiration in
refractive lens exchange procedure (1 month and 6 months postoperatively)
Subjects and methods: a non-randomized prospective study was carried out from October 2018 to May 2019 on
twenty five eyes of 14 subjects with age (38-48) years old with high myope> 8 D and high hyperopia > 6 D; these
patients were not candidate for corneal refractive surgery or phakic IOL procedure. They were selected from outpatient
Ophthalmology Clinics of Al-Azhar University Hospitals in Cairo. The patients were examined by specular
microscopy before and after refractive lens exchange procedure (1 month and 6 months postoperatively)
Results: Log MAR BCVA improved from (0.47) preoperatively to (0.5904) at the end of the 6th month with P-value
0.35. Changes in endothelial cell count from (2.650) cells/mm2 before surgery to (2.372) cells/mm2 1 month after
surgery to (2.358) cells/mm2 6 months after surgery with P-value <0.001. Error of refraction improved from (-14.94)
in myope and (7.98) in hyperope preoperatively to (-1.42) in both groups at the end of the 6th month after surgery with
Conclusion: CLE surgery by phaco-aspiration technique is less harmful to the corneal endothelium because it uses no
Keywords: Refractive Lens Exchange, Corneal Endothelium.
Ideal candidates for refractive surgery are people
with healthy eyes who are not satisfied with wearing eye
They were examined by specular microscopy before and
glasses or contact lenses (CL). So, the goal of any
after (at 1 and 6 months). Clear lens extraction by
refractive surgery is to decrease dependence on eye
phaco-aspiration technique was performed to study
glasses or CL(1). In lens based refractive surgery,
changes of corneal endothelium.
refractive surgery is done either by altering the natural
crystalline lens i.e. clear lens extraction (CLE)(2), or by
placing an intraocular lens inside the eye in front of
The study protocol was adhered to the tenets of the
patient's natural lens i.e. phakic IOLs (PIOLs)(3). Clear
declaration of Helsinki and was approved by the
lens replacement is a viable procedure for both myopia
ethical board of Al-Azhar University. All subjects had
and hyperopia with possible intraocular correction of
informed about the details and the risk of the procedure
astigmatism using toric IOLs(4). CLE is similar to
and signed an informed written consent.
phacoemulsification surgery, however less ultrasound
power is needed(5). Surgeons have often reported that the
corneal endothelium experiences various kinds of
* Inclusion criteria
surgical trauma during phacoemulsification and Age group: (38 48) years old.
intraocular lens (IOL) implantation(6). Specular Myopic errors over 8 D, not candidate for corneal
microscopy is a non-invasive technique to access the
refractive surgery or phakic IOL procedure.
structure and function of the corneal endothelium(7).
Hyperopia over 6 D, not candidate for corneal refractive
surgery or phakic IOL procedure.
AIM OF THE WORK
The aim of the work is to study corneal Previous ocular disease or trauma affecting the corneal
endothelial cell changes (number and morphology)
endothelium or with corneal scar.
following phaco-aspiration in refractive lens exchange Any form of clinically significant cataract.
procedure (1 month and 6 months postoperatively).
Previous corneal or intraocular surgery.
Pre-existing macular degeneration or macular pathology.
SUBJECTS AND METHODS
Retinal holes or tears or subclinical retinal detachment.
A non-randomized prospective study included 25 eyes
of 14 subjects with high refractive errors that were not
candidate for corneal refractive surgery or phakic IOL
procedure at Al-Azhar University Hospitals at Cairo from
October 2018 to May 2019.
Onset, course and duration of diminution of vision.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4162-4168
Comparison of Outcomes of Early Versus Delayed Laparoscopic
Cholecystectomy in Acute Calcular Cholecystitis
Mohammed Mohammed El-Kordy, Al Sayed Basiony Aboulyazid, Ahmed Fakhry Ahmed Mahmoud*
Department of General Surgery, Faculty of Medicine Al-Azhar University, Cairo, Egypt
*Correspondence author: Ahmed Fakhry Ahmed Mahmoud, Mobile: (+20) 01028018712,
Background: acute cholecystitis is the most common cause of hospitalization for gastrointestinal disease.
Although cholecystectomy is the definitive management, the timing of surgery in relation to the first episode of
acute cholecystitis remains an area of considerable practice variation.
Objective: The aim of this study was to evaluate the results of early laparoscopic cholecystectomy versus
conservative management and delayed elective cholecystectomy in acute calcular cholecystitis.
Patients and Methods: the present study is a prospective randomized study done during the period from
November 2018 to June 2019. The study included 40 patients with acute calcular cholecystitis presented to
Al-Azhar University Surgical department. They had been classified randomly by taking every two patients; one
patient to the group A, the other patient to group B, and each group consisted of 20 patients.
Results: the mean operative time in the early group was more than the mean operative time in the delayed group.
The conversion rate to open cholecystectomy in the early group was less than the conversion rate in the delayed
group. The mean total hospital stay in the early group was less than the mean total hospital stay in the delayed
group. Finally the overall complications in the early group were less than complications occurred in the delayed
group. Conclusion: early laparoscopic cholecystectomy for patients with acute cholecystitis has both medical
and socioeconomic benefits and it is the preferred approach in comparison to delayed approach.
Keywords: Laparoscopic Cholecystectomy, Calcular Cholecystitis.
Acute cholecystitis is one of the most
The main complication of acute cholecystitis
significant acute diseases inthe WesternWorld, and
is recurrent biliary colic and cholestasis. The latter
may be associated with only mild pain andnausea
may lead to ascending cholangitis, andwhile this can
or become a severe, life-threatening illness due to
be managed with antibiotics, other complications
complications. Acute cholecystitis is mainly caused
cannot be cured conservatively such as gangrenous
by gall stones, while cholestasis ismainly associated
changes, gall bladder perforation and biliary leakage,
with super infection with bacteria, in general species
and acute necrotic gallstone pancreatitis. Liver
of enterobacteria, enterococci, bacteroides and
abscesses and underlying incidental carcinoma
have also beenreported in some cases(5). Early LC is
Following the first episode of acute
usually performed within a week of the onset
cholecystitis, the annual risk of gallstone-related
ofsymptoms, when local inflammation obscures
complications can increase up to 30%; and
optimal view and raisesconcerns about increased
laparoscopic cholecystectomy (LC) is the first-line
intraoperative complications. Alternatively, LCcan
definitive surgical management(2).
be delayed (usually for 6 weeks of symptom onset),
The management of patients with gall stone
when acuteinflammation is resolved. Nevertheless,
diseases has been revolutionized during the last
recent meta-analyses suggestedthat early LC (within
decade with the introduction and evolution of
1 week of symptom onset) is safe and feasible(6).
laparoscopic cholecystectomy. The laparoscopic
Aim of the work:
technique for cholecystectomy was first performed by
The aim of this study was to evaluate the
Philippe Mouret in Lyon, France in 1987 and was
results of early laparoscopic cholecystectomy versus
developed and spread among general surgeons all
conservative management and delayed elective
over the world. Laparoscopic cholecystectomy has
cholecystectomy in acute calcular cholecystitis.
become the gold standard in the treatment of
symptomatic cholelithiasis and has revolutionized
PATIENTS AND METHODS
minimally invasive procedures(3).
The present study is a prospective
The risk of developing second and
randomized study done during the period from
subsequent episodes of acute cholecystitis is higher
November 2018 to June 2019. The study included 40
than the risk of suffering an initial
patients with acute calcular cholecystitis presented
episode.Laparoscopic cholecystectomy is therefore
to Al-Azhar University Surgical department, El
usually recommended, butwhether this should be
Hussein hospital. They had been classified randomly
performed immediately or after giving antibiotic
by taking every two patients; one patient to the group
treatment to allow the acute condition to subside is
A, the other patient to group B, and each group
consisted of 20 patients.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4169-4175
Comparison between The Efficacy of Intracoronary Nitroglycerin versus
Nitroglycerin Plus Glycoprotein Inhibitors for Treatment of Patients with
Thrombolysis in Myocardial Infarction Flow Less Than Three during
Primary Percutaneous Coronary Intervention
Ahmed Mohamed Kamal Motaweha, Mohamed Ahmed Mosaad Zaki a,
Mahmoud Abd El-Naser Ahmed Hussienyb*
aDepartment of Cardiology, Faculty of Medicine, Al-Azher University
bDepartment of Cardiology, Al- Agoza Hospital
*Corresponding author: Mahmoud Abd El-Naser Ahmed Hussieny,
Email: email@example.com, Mobile: (+20)01121429150
Background: Primary percutaneous coronary intervention (PPCI) is currently the cornerstone of management in
patients with ST-segment elevation myocardial infarction (STEMI).
Aim of the work: comparison between the efficacies of intracoronary nitroglycerin (NTG) versus nitroglycerin plus
glycoprotein inhibitors (GP) IIb/IIIa for treatment of patients with thrombolysis in myocardial infarction flow less
than three during primary percutaneous coronary intervention.
Patients and methods: we prospectively enrolled 30 patients with STEMI undergoing PPCI randomized to receive IC
NTG only (n = 15) versus NTG plus GP IIb/IIIa inhibitors (n = 15) during PPCI. The primary outcome was the
incidence of angiographic MVO as defined by thrombolysis in myocardial infarction flow less than 3 or thrombolysis
in myocardial infarction flow 3 with myocardial blush grade less than 2.
Results: NTG plus GP IIb/IIIa inhibitors were associated with better primary outcome compared to NTG only TIMI 3
& MBG > = 2 (40%vs 73.3%, respectively; P = 0.036). There was a trend towards improved left ventricular ejection
fraction with NTG plus GP IIb/IIIa inhibitors (44.33 ± 9.76 vs 52.87 ± 11.23, respectively; P = 0.035). In addition,
NTG plus GP IIb/IIIa inhibitors was associated with lower incidence of 30-day major adverse cardiovascular events
(26.7 vs. 66.7% respectively; P = 0.028).
Conclusion: In PPCI, NTG plus GP IIb/IIIa inhibitors resulted in significant improvements in no-reflow and MVO
with a better safety profile compared to NTG only. Larger trials should be conducted to confirm these results.
Keywords: Acute myocardial infarction, Microvascular obstruction, Primary percutaneous coronary intervention, No
reflow, Nitroglycerin, Platelets glycoprotein IIb/IIIa inhibitors.
Primary percutaneous coronary intervention
aggregation. IIb3 engagement is required for
(PPCI) is currently the cornerstone of management in
aggregation through all pathways, blocking this
patients with ST-segment elevation myocardial
receptor inhibits platelet aggregation more effectively
infarction (STEMI) (1).
Despite successful recanalization by angioplasty,
3050% of the patients have poor outcomes because of
pharmacological benefits, studies directly comparing
microvascular obstruction (MVO) (2, 3). The two main
these NTG and GP IIb/IIIa.NTG for the prevention of
indicators of MVO are Thrombolysis in Myocardial
NR and MVO during PPCI are not available and hence
Infarction (TIMI) flow and myocardial blush grade
this is still a topic of debate (9). We sought to compare
(MBG) (4, 5). MBG is a more sensitive indicator
the safety and efficacy of these two medications in the
compared to TIMI flow, and some patients will show
prevention of this life-threatening complication.
reduced myocardial reperfusion by MBG even with
achievement of TIMI 3 flow (5). Potential mechanisms
AIM OF THE WORK
of MVO include vasospasm, distal embolization of
Comparison between the efficacy of intracoronary
thrombus or debris, oxygen free radical-mediated
nitroglycerin (NTG) versus nitroglycerin plus
endothelial injury (ischemicreperfusion injury),
glycoprotein inhibitors (GP)IIb/IIIa for treatment of
capillary plugging by erythrocytes and neutrophils, and
patients with Thrombolysis In Myocardial Infarction
intracellular/interstitial edema (6, 7).
flow less than three during primary percutaneous
Some medications have been shown to be effective
in the management of NR and MVO. Among these NTG
and GP IIb/IIIa.NTG is a nitric oxide donor that results
PATIENTS AND METHODS
in vasodilation of vascular smooth muscles by
increasing the formation of cGMP through guanylate
This prospective observational study that was
cyclase stimulation. GP IIb/IIIa antagonizes IIb3
conducted from May 2018 to February 2019 and
selectively and competitively to inhibit platelet
included 30 patients who presented to the Emergency
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4176-4181
Effect of Blood and Fistula Flow Rates on Dialysis Adequacy, Phosphate
Removal and Cardiac Function in Hemodialysis Patients
Ahmed Alaa-Eldin Ahmed (1), Ahmed Salama Al Adl (2), Tarek Mustafa Emran (3),
Sharif Kamal Hussein(4), Ayman Mahmoud Abdel-Fattah(2)
(1) Internal Medicine Department, Faculty of Medicine, Al-Azhar University, Cairo (2) ; Internal Medicine Department,
Faculty of Medicine, Al-Azhar University, Damietta (3) ; Clinical Pathology Department, Faculty of Medicine, Al-Azhar
University, Damietta (4); Radiology Department, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
Corresponding author: Ahmed Salama Al Adl ,email:Salama139@azhar.edu.eg
Background: dialysis adequacy refers to the delivery of a dose of dialysis considered high enough to promote an
optimal long term outcome. Quantification of the dialysis dose is an essential element because the adequacy has a
profound effect on patient morbidity and mortality. Aim of the study: assessment the effect of blood and fistula flow
rates on dialysis adequacy, phosphate removal and cardiac function in hemodialysis patients. Patients and Methods:
this study was conducted on eighty patients with regular hemodialysis (HD) selected from Al-Azhar University
Hemodialysis Unite in New Damietta. The studied patients were divided into two main groups according to blood flow
rate (BFR) as follows: Group A 40 patients on BFR 250 mL/min and Group B 40 patients on BFR 350 mL/min.
Results: there was statistically significant decrease of pre dialysis phosphate in group A in comparison to group B.
There was statistically significant increase of KT/V, UUR and PRR in group B in comparison to group A.
Arteriovenous fistula (AVF) Qa had negative correlation with TAPSE while it had positive correlation to all
echocardiography findings except EF and heart rate (HR), kt/V and URR in group A. AVF Qa had positive correlation
to all echocardiography findings except (EF, HR and TAPSE), kt/V, URR and PRP in group B
Conclusion: increasing of blood and fistula flow rates are effective in increasing dialysis adequacy and phosphate
reduction ration and it is more evident where using high-flux hemodialysis.
Keywords: Hemodialysis; Arteriovenous Fistula.
PATIENTS AND METHODS
Dialysis adequacy refers to the delivery of a dose of
1. Study Design: This study was conducted on eighty
dialysis considered high enough to promote an optimal
(80) patients with regular hemodialysis (HD) selected
long term outcome (1).
from Al-Azhar University Hemodialysis Unite in New
Urea reduction ratio (URR) is a method of measuring
Damietta during periods from Oct. 2018 to Jul 2019.
adequate dialysis that correlates with patient outcome (1).
The studied patients were divided into two (2) main
Rafik et al. (2) found that the most common marker to
groups according to blood flow rate (BFR) as follows:
quantify dialysis adequacy is Kt/V index. Basile et al.(3)
Group A: Forty (40) patients on BFR 250 mL/min and
suggested that patients at greater risk for the
Group B: Forty (40) patients on BFR 350 mL/min
development of high output cardiac failure are those with
2. Ethical Aspects
Qa 2000 ml/min.
The study protocol was accepted by the local
To achieve an adequate Kt/V, many factors could be
Ethics and Research Committee, and consent was
optimized as follows: dialyzer size and characteristics,
signed by the patients.
dialysis time, dialysis frequency, dialysate flow rate, and
blood flow rate (BFR). However, the use of some of
3. Exclusion criteria:
these methods is not always possible due to clinical
Patients with duration of HD therapy of less than
intolerance and economic constraints (4).
three months and patients with central venous line.
Quantification of the dialysis dose is an essential
4. Inclusion Criteria:
element in the management of chronic hemodialytic
Patients with duration of HD therapy of at least
treatment because the adequacy of the dose has a
three months, three dialysis sessions per week; 4 hours
profound effect on patient morbidity and mortality (5).
each, Fresenius 4008S, bicarbonate buffer and age of
Roozitalab et al. (6) found that failure to reach the target
patients ranged from 20 to 70 years
Kt/V could have multiple reasons, including inability to
5. Study Protocol:
provide the prescribed BFR due to inefficient access,
All patients underwent history taking, clinical
error in estimating dry weight, inaccurate dialyzer
examination, arteriovenous fistula examination,
specified clearance, clotting in the dialyzer, shorter
laboratory investigations included, renal function tests:
dialysis sessions and in appropriate dialyzer selection.
serum creatinine, blood urea, parathyroid hormone
(PTH) by full automated analyzer, serum sodium,
AIM OF THE STUDY
potassium, calcium, and phosphorus by full automated
Assessment the effect of blood and fistula flow
rates on dialysis adequacy, phosphate removal and
Radiological investigation: A) Echocardiography:
cardiac function in hemodialysis patients.
Each patient underwent echocardiography performed by
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4182-4188
Macular Thickness Asymmetry Measurements in Relatives of
Primary Open Angle Glaucoma Patients
Sherien R. Ramadan *, Mona M. Aly, Samia H. El Ashry
Department of Ophthalmology, Faculty of Medicine (For Girls), Al-Azhar University
*Corresponding Author: Sherien R Ramadan; Mobile: 00201026822888; email: firstname.lastname@example.org
Background: A family history of glaucoma was found to carry a relative risk of 2.1 times for being associated with at
least possible primary open angle glaucoma (POAG) in middle aged and older individuals. Around half of all POAG
patients have a positive family history and their first degree relatives have an approximately 9-fold increased risk of
Objective: the aim of the present study was to demonstrate possible early macular alterations in young relatives of POAG
patients using spectral domain optical coherence tomography (SD-OCT) posterior pole asymmetry analysis (PPAA) map.
Patients and methods: in a prospective comparative study; 40 subjects were classified into 2 groups: group of young
healthy relatives of POAG patients and another group of young healthy subjects as control. All participants had OCT of
the PPAA, retinal nerve fiber layer (RNFL), ganglion cell complex (GCC) and hemi-field macular thickness.
Results: There was no statistically significant difference between the relative and control group in aspect of RNFL,
macular hemi-fields and PPAA measurements (P-value >0.05).
Regarding GCC thickness, there were statistically significant differences between both groups in the superior, inferior
and nasal thickness measurements.
Conclusion: Young healthy relatives of POAG patients didn't show any early glaucomatous damage when compared
with controls except for GCC thickness which showed statistically significant decrease.
Keywords: Primary open angle glaucoma, Optical coherence tomography, Posterior pole asymmetry analysis, Retinal
nerve fiber layer, Ganglion cell complex.
retinal thickness map is a color-coded map that provides
Glaucoma is a group of chronic progressive
mean retinal thickness value of grid centered on the
neuropathies that cause morphological changes to the
foveal pit. The grid is positioned symmetrically to the
optic nerve head (ONH) and retinal nerve fiber layer
fovea-disc axis (6).
(RNFL) that are associated with visual field defects (1).
The current study was conducted to demonstrate
Primary open angle glaucoma (POAG) is the most
possible early macular alterations in young relatives of
common type of glaucoma and globally considered the
primary open angle glaucoma patients using Spectralis
most common cause of irreversible blindness, with an
SD-OCT posterior pole asymmetry analysis map.
estimated 70 million affected individuals (2). POAG can
be defined as progressive characteristic optic disc
PATIENT AND METHODS
changes which are usually associated with
This prospective comparative study included forty
corresponding visual field defects (3).
subjects classified into two groups; group I of young
The presence of a family history of glaucoma was
healthy relatives of POAG patients and another group
found to have a relative risk of 2.1 times for being
II of young healthy subjects as control. Their age ranged
correlated with at least possible OAG. However, the
from 17-40 years.
relative importance of family history may vary
according to the closeness of relationship of a patient to
An informed written consent from all the subjects
an affected family member (first, second or even third
and the approval of the Medical Ethics Committee
degree). Around half of all POAG patients have a
of Al-Azhar University were obtained. It was done
positive family history and their first degree relatives
adhering to the principles of the Declaration of
(parents, siblings or children) have an approximately 9-
fold increased risk of developing glaucoma (4).
Inclusion criteria included:
Spectral-domain optical coherence tomography
Young relatives of POAG patients (having at least
(SD-OCT) is considered one of the most promising
one POAG relative (1st or 2nd degree)) with spherical
image modalities in evaluating glaucoma. Heidelberg
equivalent between -1.5 and +1.5 diopters with best
corrected visual acuity (BCVA) 20/20 in both eyes.
Germany) customized the most recent retinal thickness
Normal age-matched healthy adults with a normal eye
protocol to obtain retinal thickness measurement of the
examination and a spherical equivalent between -1.5
central of the posterior pole (5). The posterior pole
and +1.5 diopters with BCVA 20/20 in both eyes.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4189-4194
Serum Fibrinogen as Adetection of Severity of Postpartum Hemorrhage
Abd El-monam Mohamed Zakaria, Abd El-Monsef Abd El-Hamid Sedek,
Mekky Abdel-Monem Aly, Mohamed Ali Mohamed Mohamed*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed Ali Mohamed Mohamed, Email: email@example.com,
Mobile: (+20) 01091133258
Background: postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or
1,000 ml of blood within the first 24 hours following childbirth. The most common cause is poor contraction of the uterus
following childbirth. However, the placenta being delivered, a tear of the uterus or poor blood clotting are other possible
Objective: the aim of the present work was to study the role of serum fibrinogen as a predictor for the severity of
Patients and Methods: this prospective multicenter study was conducted from February 2017 to October 2017 at
Department of Obstetrics and Gynecology, Sayd Galal Hospital, Al-Azhar University.
Results: PPH was severe for 43 of the 100 (43%) women included, but not for 75 (57%). Among the women with
severe haeb hemorrhage, no women required embolization, 12 ligation of the uterine arteries, and 7 hysterectomy; 7
were transferred to intensive care, 37 received transfusions, and 42 had a postpartum hemoglobin level that decreased
more than 4 g litre. None of the women died.
Conclusion: the fibrinogen level at PPH diagnosis is a marker of the risk of aggravation and should serve as an alert to
Keywords: Fibrinogen, post partum Hemorrhage
women may feel cold, their blood pressure may drop
Postpartum hemorrhage (PPH) can be
(hypotension), and they may become unconscious(5).
classified as primary (early) or secondary (late).
Treatments may include intravenous fluids,
Primary PPH, the most common and severe, occurs
blood transfusions, and the medication ergotamine to
within the first 24 hours after delivery. Secondary PPH
cause further uterine contraction. Efforts to compress
occurs 24 hours to 12 weeks after delivery. Most cases
the uterus using the hands may be effective if other
of morbidity and mortality due to PPH are the result of
treatments do not work. The aorta may also be
primary PPH, while secondary PPH results from
compressed by pressing on the abdomen. The World
retained placental fragments, subinvolution of the
Health Organization has recommended non-pneumatic
placental site, infection, and coagulation defects
anti-shock garment to help until other measures such as
(bleeding diatheses) which cause abnormal excessive
surgery can be carried out (1, 6).
Disseminated intravascular coagulation (DIC)
Prolonged labor, retained placenta products,
is a syndrome characterized by the systemic activation
of blood coagulation, which generates intravascular
thrombin and fibrin, resulting in the thrombosis of
hydroamnios, halogenated anesthesia, previous episode
small- to medium-sized vessels and ultimately organ
of uterine atony, increasing maternal obesity and raised
dysfunction and severe bleeding (7).
body mass index, caesarian delivery and induction of
labor are risk factors for PPH(3).
AIM OF THE WORK
Coagulation plays an important role in
The aim of the present work is to study the role
postpartum hemostasis. Primary and especially
of serum fibrinogen as a predictor for the severity of
secondary coagulation disorders are risk factors for
PPH that have not been sufficiently evaluated.
Pregnancy-induced hypercoagulability tends to reduce
PATIENTS AND METHODS
the risk of hemorrhage naturally. Pregnancy-related
The study design and patients:
coagulation changes are expressed by a progressive and
A prospective, multicenter study design was
significant increase in the fibrinogen level, while the
chosen to conduct this research. The study included
standard indicators, such as prothrombin time (PT) and
patients with PPH.
activated coagulation time (ACT), vary little (4).
PPH was defined according to Cortet et al. (1) as a
Signs and symptoms of PPH may initially
blood loss exceeding 500 ml during the 24 h after delivery
include: an increased heart rate, feeling faint upon standing
or a peripartum hemoglobin decrease of more than 20 g
and an increased respiratory rate As more blood is lost the
litre-1. Severe PPH was defined by the occurrence of one of
the following events(1):
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4195-4201
Clinico-Seroepidemiological Evaluation of Toxocariasis in Asthmatic Egyptian Children
Samir A. Shahat1, Khaled Abd El-Aziz Mohammad2, Mohammed Youssef Saad2, Tarek M. Emran3,
Soma Abdallah Mohamed4, Mahmoud Elsayed Ali Elshahat2
1Department of Medical Parasitology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
²Department of Medical Parasitology,3Department of Clinical Pathology, Faculty of Medicine,
Al-Azhar University, Damietta, Egypt.
4Department of Pediatrics, Faculty of Medicine (girls), Al-Azhar University, Cairo, Egypt
Corresponding author: Mahmoud Elsayed Ali Elshahat, e-mail: firstname.lastname@example.org
Background: Toxocariasis was recorded as one of the most commonly zoonotic helminthic infections in the world and
still a poorly diagnosed disease hence largely unknown either to health professionals and/or the general of Egyptian
population. The excretory-secretory antigens of T. canis larvae (TES) are widely used for both the diagnosis and
seroepidemiological studies. Aim of the work: The aim of the present study was to assess the relationship between
toxocariasis and bronchial asthma in asthmatic children through means of a case-control study in Cairo, Egypt and to
determine its relation to epidemiological risk factors, laboratory tests and clinical signs.
Patients and Methods: The study included two groups (Group1): asthmatic group included 72 children with confirmed
asthmatic bronchitis and (Group 2): non-asthmatic group included 72 children selected randomly as a control group.
The sociodemographic data was assessed as risk factors for toxocariasis based on a questionnaire collected from the
children's parents or guardians. The selected cases were subjected to stool analysis to exclude other parasitic infection,
CBC for eosinophilia and immunoblot assay for detection of Toxocara canis IgG.
Results: Out of 72 asthmatic patients toxocariasis IgG was positive in 16 cases (22.2%), negative in 56 cases (78.6%)
compared to 5 positive cases (6.9%), and 67 negative cases (93.1%) in control group. There was a significant relation
between positive antiToxocara IgG and asthmatic bronchitis. This study confirmed a significant correlation between
the seroprevalence of Toxocara and possible socioepidemiological factors as contact with pets, geophagia and residence.
Conclusion: Rising knowledge of toxocariasis will enable pediatricians to consider it as a cause of asthmatic bronchitis
in their patients, initiate appropriate treatment, and educate patients and parents on how to avoid becoming infected.
Keywords: children, bronchial asthma, toxocariasis, seroprevalence, immunoblot IgG.
hypergammaglobulinemia, fever, hepatomegaly, cough,
Toxocariasis is caused by two species of the
wheeze, abdominal pain, and elevated serum IgE level
ascarid nematodes Toxocara canis and to a lesser extent
(7). Eosinophilia is one of the most outstanding
T. cati which is considered as one of the most commonly
characteristic of the VLM in naturally infected humans
zoonotic disease. Also, Toxocara leonina which cause
and experimental models of infection (3).
mixed infections in cats and dogs can be able to infect
Humans in the life cycle of Toxocara are
humans; therefore, it has zoonotic and public health
considered as paratenic hosts in which the larvae cannot
develop into adult worms and therefore, the
Accidental intake of embryonated eggs of
parasitological examination of feces does not contribute
Toxocara canis or Toxocara cati, (the intestinal parasites
to the laboratory diagnosis (8). The diagnosis of
of dogs and cats, respectively) is the source of infection
toxocariasis is generally based on clinical signs and
to humans where only few larvae are needed to cause
symptoms, which are non-specific, epidemiological data
the disease (2). In humans the primary route of
(contact with dogs or cats, geophagia, onychophagy,
transmission of Toxocara is contact with contaminated
consumption of undercooked or raw meats) and
soil (3), in addition to, direct contact with dog carrying
laboratory findings (9).
eggs in their fur (4). Also, another different route of
The immunoblot or Western blotting assay is a
transmission involves consumption of raw vegetables
test that combines the high sensitivity of the immune-
grown in contaminated gardens, geophagia as well as
enzymatic tests with the high resolution of sodium
persons with poor hygiene (5).
dodecyl sulfate-polyacrylamide gel electrophoresis
No clinical manifestation occurred in most cases
(SDS PAGE). This method has been successfully
when infected larvae migrate through the human tissues
adapted for the confirmatory serodiagnosis of various
(6). However, visceral larva migrans is induced (VLM) in
parasitized individuals with the presence of anti-
schistosomiasis, hydatidosis, cysticercosis, taeniasis,
Toxocara antibodies, which affects mainly young
fasciolosis and strongyloidiasis (10).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4202-4212
Evaluation of Chandelier Assisted Pars Plana Vitrectomy for Management of
Abdelhafez, Y.,(1) Mohamed, I. A.,(2) Ghali, A.(1) and Omran, M.(1)
(1) Department of Ophthalmology, Faculty of Medicine Al-Azher University, Damietta
(2) Department of Ophthalmology, Faculty of Medicine Al-Azher University Cairo
Corresponding author: Mohamed Y. Omran, E.mail:my.omran22@Gmail.com, Phone: 00201010941536
Background: ERM is a vision affecting disorder, frequently developed secondary to advanced PDR. DR remains one
of the leading causes of legal blindness in the working- age population.
Aim of the work: evaluation the safety, efficacy and feasibility of the chandelier assisted PPV for management of
Patients and methods: 43 eyes in 36 patients presented with ERM of different etiologies. After full ophthalmic
examination, all patients underwent chandelier assisted PPV with silicone oil or gas tamponade without or with
phacoemulsification and posterior chamber IOL implantation.
Results: Combined phacoemulsification and PPV was done in 12 cases (27.9%), 2 cases were Pseudophakic while lens
sparing PPV was done in 29 cases (67.4%). Complete ERM removal was achieved in 38 cases (88.4%) and incompletely
removed in five cases (11.6%). Residual tractional RD was observed in two cases (4.7%). Iatrogenic breaks were
occurred in 7 cases (16.3%). Endo-laser photocoagulation was done in 33 cases (76.7%). Silicone oil tamponade was
used in 33 cases (76.7%), gas in 8 cases (18.6%) while air tamponade was used in 2 cases (4.7%). There was
improvement of BCVA in 31 cases (72.1 %), while 10 cases (23.3%) remained the same and worsened in 2 eyes (4.7%)
due to recurrent proliferation, consecutive optic disc atrophy and development of neo-vascular glaucoma.
Conclusion: Chandelier assisted bimanual PPV is an effective, safe and an attainable technique for management of
ERM, learning curve with this technique and coast benefit ratio may be considered.
Keywords: Chandelier, Bimanual vitrectomy, Epiretinal membrane.
Epiretinal membrane (ERM) is a common
visual symptoms impacting the quality of life up to
disorder of the vitreoretinal interface defined as fine,
visual loss (9).
semi-translucent, fibro-vascular proliferation on the
The clinical significance of ERM is the
inner retinal surface resulting in visual impairment of
tendency of membrane to thicken and contract leading
variable degrees (1). ERM can be classified as primary
to retinal distortion and the appearance of superficial
"idiopathic" or secondary to another etiology either
retinal folds or traction lines, becoming opaque and
systemic disease or ocular pathology such as posterior
gray. All these will further induce macular edema,
uveitis (2), cytomegalovirus retinitis (3), retinal vein
vitreous hemorrhage (VH) and even tractional retinal
occlusion, blunt force trauma, retinal detachment and
detachment (TRD), these complications may severely
repair, argon laser photocoagulation, cataract
damage patient's visual function (6).
surgery(4,5) and diabetic retinopathy (DR) which is
Clinical examination of pre-retinal macular
considered the commonest cause of ERM worldwide (6).
fibrosis reveals a semi-translucent membrane obscuring
The exact pathogenesis of ERM is still
the underlying retinal features and may be associated
unknown but presence of inflammatory cells with
with superficial or full-thickness retinal folds or traction
involvement of cellular proliferation, migration, and
lines and vascular tortuosity or dilation. Severe forms
adhesion suggests that secondary ERM formation may
of ERMs can involve retinal hemorrhages, exudates,
be as an abnormal wound healing response (7,8).
vascular abnormalities, edema, macular pseudo-holes,
The patient with ERM has variable clinical
and macular holes, resulting in vision related disabilities
presentation; may be completely asymptomatic,
diagnosed on routine examination, or present with
Pars plana vitrectomy with ERM peeling is
impairment of vision in the form of metamorphopsia,
the standard treatment of the ERM which restore
micropsia or macropsia, photopsia, decreased visual
structure with frequently residual visual impairment
acuity (VA), up to loss of central vision(5,8). Usually
(10,11). Surgical outcome is influenced by a number of
cases with Cellophane maculopathy are asymptomatic
factors including the patient age, location and extent of
while more severe forms of ERM cause significant
the TRD, and the duration of macular heterotopia. Older
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4213-4219
Evaluation of Both Single Layer Simple Interrupted Extramucosal Sutures and
Single Layer Interrupted Connell Sutures for Intestinal Anastomosis in
Children in Elective and Emergency Laparotomy
Soliman Mohamed Soliman1, Ibrahim Ahmed Ismail Gamaan1, Ahmed Abdel-Aal El-Sayed Sultan2,
Mohamad Mobarak Alsakka3, Abdelaleem Abdelaleem Aly Elgendy4,
Mohammed Gomaa Ahmed El-Sayed Fouda2
Departments of 1Pediatric Surgery, 2General Surgery, 3Radiology,
4Clinical Pathology - Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohammed Gomaa Ahmed El-Sayed Fouda,
Email: email@example.com, Mobile: (+20) 01001811056
Background: Intestine anastomosis in pediatric surgery is a relevant matter because of the frequency of the
procedure, nonetheless, there is no general agreement about the most appropriate surgical technique, nor are there
records comparing the different methods in children. To validate the better technique in children, it is necessary to
have clinically comparative experimental studies.
Objective: the aim of this work is to evaluate both single layer simple interrupted extramucosal and single layer
interrupted Connell sutures for intestinal anastomosis in children in elective and emergency laparotomy as regard
technical, functional and financial aspects.
Patients and Methods: his study was carried out on 40 patients candidate for intestinal anastomosis in elective
and emergency laparotomy managed at Pediatric Surgery Department, Al-Azhar University in Cairo throughout
the period from January 2017 to May 2019.
Results: As regard the most frequent diagnosis or cause for anastomosis in our study, jejunal atresia was the most
common cause of anastomosis with 9 cases (45%) in the extramucosal group and one case (5%) in the Connell
group, then the intussusception with 2 patients (10%) in the extramucosal group, and 7 patients (35%) in the
Connell group, then ileal atresia, 3 patients (15%) in the extramucosal group, and one patient (5%) in the Connell
group. Conclusion: We concluded that both techniques for intestinal anastomosis are effective, safe and successful.
We prefer single-layer interrupted extramucosal technique in elective and emergency laparotomy due to less
operative time, and valuable cost-effectiveness.
Keywords: Single Layer Simple Interrupted Extramucosal Sutures, Single Layer Interrupted Connell Sutures,
Intestinal Anastomosis, Children in Elective and Emergency Laparotomy.
clean gut at the time of operation and meticulous
About 1% of all patients who undergo surgery,
surgical technique (6).
younger than 1 year of age, require a bowel
Single layer technique was proven superior to
anastomosis for various reasons. The gut anastomosis
two-layer method with respect to luminal reduction
heals by same mechanism like that of wound healing
tissue strangulation and strength of anastomosis (7).
The single layer continuous anastomosis was first
The submucosa is the strongest layer of gut
described by Hautefeuille as an innovative technique.
wall(2), therefore ideal anastomotic technique is the
It is an established fact that extramucosal single layer
one which includes apposition and approximation of
anastomosis can be done by two methods either
submucosa of gut wall (3).
continuous or interrupted techniques (8).
As intestinal anastomosis is a commonly
performed surgical procedure both in emergency and
AIM OF THE WORK
elective settings in surgical practice; therefore its leak
The aim of this work is to evaluate both single
and disruption is a common cause of postoperative
layer simple interrupted extramucosal and single layer
mortality and morbidity and economical burden. The
interrupted Connell sutures for intestinal anastomosis
basic principles of gut anastomosis were established
in children in elective and emergency laparotomy as
more than a century ago and have gone through the
regard technical, functional and financial aspects.
process of evolution (4).
There are different techniques for intestinal
PATIENTS AND METHODS
anastomosis. Conventional methods, which range
from sutured (single layer interrupted or continuous,
This study was carried out on 40 patients
double layer) to stapling techniques. Unconventional
candidate for intestinal anastomosis in elective and
methods include compression rings, tissue glue and
emergency laparotomy managed at Pediatric Surgery
laser welding (5). Healing of the anastomosis depends
Department, Al-Azhar University in Cairo throughout
upon several factors, like tension at the suture line, an
the period from January 2017 to May 2019. Patients
adequate blood supply at the two ends of the intestine,
were randomly subdivided into 2 groups; Group A
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4220-4227
Exercise Electrocardiography Testing in Patients with Calcific Non-obstructive
Coronary Lesions at Cardiac Multislice Computed Tomography
Eslam Shawky Abdelaziz, Ashraf Al-Amir Abdelfattah, Mahmoud Gabr Ahmed Abdellateef
Cardiology Department, Faculty of Medicine, Al-Azhar University, Egypt
*Corresponding author: Mahmoud Gabr Ahmed Abdellateef, Email: firstname.lastname@example.org,
Mobile: (+20) 01090293399
Background: Non-obstructive coronary artery disease (NoCAD), cardiac syndrome X (CSX), conduit vessel
endothelial dysfunction and microvascular angina are all terms used to describe patients that have chest pain yet no
obstructive coronary artery disease on coronary angiography.
Objectives: the purpose of this study was to evaluate exercise ECG (Ex-ECG) test in patients with subclinical
atherosclerosis who were diagnosed by multi-slice computed tomography (MSCT) coronary angiography to have non-
Patients and Methods: 100 patients were recruited in the current study (their age ranged from 30 66 years), they
were classified into three groups: group (A) 30 patients with non-calcific normal coronaries by MSCT, group (B) 35
patients with non-calcific non-obstructive lesions (zero calcium score) by MSCT and group (C) 35 patients with
calcific non-obstructive lesions (calcium score < 400 HU) by MSCT.
Results: There was statistically highly significant difference between the three groups as regard results of exercise
ECG test (P value=0.001). Positive exercise ECG test results occurred with calcific and mixed plaques in group (C)
more than soft plaque in group (B), and there is significant difference between two groups with (P-value = 0.001).
Positive exercise ECG test results in group (C) occurred more frequently with higher calcium score ranged from (59
Conclusions: MSCT angiography and calcium scoring system can provide valuable results which is helpful in
avoiding an extra unnecessary invasive coronary angiography in patients for whom exercise ECG test results seemed
to be positive or for whom high cardiovascular mortality risk from ischemia is not present.
Keywords: Electrocardiography, Calcific Non-obstructive Coronary Lesions, Cardiac Multislice Computed
It was demonstrated that enhanced coronary
(NoCAD), cardiac syndrome X (CSX), conduit vessel
artery calcification is significantly related to
endothelial dysfunction and microvascular angina are
endothelium dysfunction in patients with suspected
all terms used to describe patients that have chest pain
CAD. Endothelial dysfunction may play an important
yet no obstructive coronary artery disease on coronary
role in the process of coronary artery calcification(4).
Multi-detector row computed tomography
Among the markers of subclinical atherosclerosis
(MDCT) is a promising non-invasive method of
that have proved predictive of future cardiac events are
detecting coronary artery disease. A new generation of
coronary endothelial dysfunction and coronary artery
MDCT with 320-detector rows CT has become
available in the clinical setting. The accuracy of MDCT
In particular, patients with endothelial
for evaluating stenosis of coronary arteries in the
dysfunction make up roughly two-thirds of the patients
clinical settings was reported in previous studies by
with NoCAD and display increased risk of aggregate
comparison with angiography(5).
cardiovascular events. Despite the serious nature of this
However, for the diagnosis of obstructive
entity, patients with NoCAD are often reassured
coronary artery disease (CAD), Ex-ECG frequently has
without due consideration to diagnostic or treatment
false-positive results, which are more common in
women than in men. Due to the relatively higher
Calcification of the coronary arteries plays a key
prevalence of false-positive Ex-ECGs, women with ST-
role in the pathophysiology of atherosclerosis.
segment depression but non-obstructive CAD are often
Coronary calcification is an active process culminating
given non-cardiac diagnoses, and further cardiologic
in extracellular matrix deposition of calcium by
testing or treatment is not pursued. Thus, the utility of
osteoblast-like cells that has some resemblance to bone
ST-segment depression for the diagnosis of IHD in
formation. Sub intimal coronary calcification is almost
women, which can be caused by processes other than
exclusively associated with the presence of coronary
atherosclerosis and is considered the hallmark of
coronary atherosclerosis. Coronary calcific lesions are
AIM OF THE WORK
considered advanced lesions and calcification
In this study we aim to evaluate exercise ECG
following plaque rupture of a high-risk plaque is
test in patients with subclinical non-obstructive
thought to be part of the healing process(3).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4228-4234
Evaluation of Lateral Pelvic Lymph Nodes Involvement in Rectal Carcinoma
Abd Elfattah Tawfek Elsheekh, Khaled Omar Elkhateb, Ahmed Mohamed Gouda Embaby*
Department of General Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Mohamed Gouda Embaby, Email: email@example.com,
Background: worldwide, colorectal cancer is the third most commonly occurring cancer in men and the second most
commonly occurring cancer in women. There were over 1.8 million new cases in 2018.
Objective: evaluation of lateral pelvic lymph node involvement among patients with middle and low rectal carcinoma.
Patients and Methods: a descriptive prospective study was conducted at Surgical Unit of Oncology Bab Elshaarya
University Hospital, Al Azhar University, during the period between November 2018 and July 2019 (a total period of 8
months), in which 20 patients of middle and low rectal carcinoma were identified.
Results: all patients had rectal adenocarcinoma; 17 patients (85%) with grade 2 and 3 patients (15%) with grade 3. Of
the 20 identified patients, 15 patients (75%) had vascular invasion and 5 patients (25%) had no vascular invasion. Only
4 patients (20%) had positive lateral pelvic lymph nodes and 11 patients (55%) had positive mesorectal lymph nodes.
All patients with positive lateral pelvic lymph nodes had also positive mesorectal lymph nodes.
Conclusion: total Mesorectal Excision (T.M.E.) is a standard operation for rectal carcinoma due to high incidence of
mesorectal lymph node metastases. Transanal total mesorectal excision (TaTME) is a promising technique in rectal
surgery especially in low rectal cancers. Most of patients had positive mesorectal lymph nodes and all patients with
positive lateral pelvic lymph nodes also had positive mesorectal lymph nodes.
Keywords: Lateral lymph node, Rectal carcinoma, Total Mesorectal Excision.
Patients with lower rectal cancer have an
subject to neoadjuvant cheomoradiotherapy followed
increased risk of lateral lymph node (LLN) metastasis
by total mesorectal excision (TME) surgery (5).
because the lower rectum drains both upwards through
Magnetic resonance imaging (MRI) is assumed to
the superior rectal vessels and laterally along the middle
be an optimal diagnostic modality for tumor staging in
rectal vessels and then to the internal iliac vessels. The
rectal cancer due to its high soft-tissue contrast (6).
rates of LLN metastasis in rectal cancer have been
However, there is a wide-ranging accuracy of 62±85%
reported to range from 8.6% to 29% (1).
and a relatively poor sensitivity for lymph node staging
Based on this, pelvic sidewall dissection has
become a standard procedure for lower rectal cancer in
Japan, although it is rarely performed in other countries.
AIM OF THE WORK
One reason that pelvic sidewall dissection is not
Evaluation of lateral pelvic lymph node
performed in other countries may be because positive
involvement among patients with middle and low rectal
LLN would represent systemic spread rather than
regional disease (2).
Gilchrist first described the lymphatic spread of
PATIENTS AND METHODS
rectal neoplasms in 1938, and the term `lateral lymph
A descriptive prospective study was conducted at
node' (LLN) was devised to encompass the common,
Surgical Unit of Oncology Bab Elshaarya University
external and internal iliac and obturator nodes in
Hospital, Al Azhar University, during the period
relation to rectal malignancies. The spread to these areas
between November 2018 and July 2019 (a total period
accounts for a significant proportion of the disease, with
of 8 months), in which 20 patients of middle and low
a reported incidence of 1025 per cent (3).
rectal carcinoma were identified. Patients fulfilling the
The standardization of the technique of total
inclusion criteria were treated with lateral pelvic
mesorectal excision (TME) with accurate dissection of
lympahdenectomy plus ultralow anterior resection, low
the anatomical plane enveloping the rectum and
anterior resection or intersphincteric resection to study
mesorectum constitutes major progress in rectal cancer
the percentage of lateral pelvic lymph node involvement
surgery. TME has achieved much lower local
in middle and low rectal carcinoma and it's correlation
recurrence rates (4).
with radiology; The number and groups of pelvic LN
Moreover, progress in chemoradiotherapy has
involved; and its relation with site; grade and stage of
achieved good local control and better survival rates in
the primary tumor; Operative complications of study
many Western countries.In Japan, rectal cancer with
LLN involvement is considered a locally-advanced
disease, and autonomic nerve-preserving LPND has
now become a standard surgical treatment. However,
1. Operable Cases of primary middle and low rectal
LLN disease in Western countries is generally
considered metastatic in nature, and patients are usually
2. Medically and anesthetically fit patients.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4235-4239
Efficacy of Pulsed Dye Laser Plus Topical Calcipotriol and Corticosteroid
Combination versus Topical Calcipotriol and Corticosteroid
Combination Alone in Treatment of Nail Psoriasis
Azmy Ahmed Abdel-latif, Ibrahim Mearaj Ibrahim, Shady Mahmoud,
Walaa Abdel-hady Awwad Mahgoub*
Department of Dermatology and Venereology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Walaa Abdel-hady Awwad Mahgoub, Email: W_prp@yahoo.com,
Mobile: (+20) 01065468814
Background: psoriasis is a chronic, inflammatory skin disease that causes significant distress and morbidity.
Objective: the aim of this study was to compare the efficacy of PDL plus topical calcipotriol and corticosteroid
combination versus topical calcipotriol and corticosteroid combination in the treatment of nail psoriasis.
Patients and methods: thirty patients with bilateral fingernail psoriasis were recruited from the Dermatology
Outpatient Clinic at Al Hussein Hospital, Al Azhar University and Al-Haud Al-Marsoud Hospital between September
2014 and February 2017.
Results: regarding treatment sessions, total treatment sessions, follow up sessions or total follow up sessions, there was
no statistically significant difference (p-value > 0.05) between right hand and left hand. There was no statistically
significant difference (p-value > 0.05) between the 2 subgroups (< 30 years and > 30 years), (male and female) or (skin
type 3 and type 4) as regard 1st, 2nd, and 3rd treatment session. There was highly statistically significant (p-value < 0.001)
positive correlation between (1st Rt. Vs 2nd Rt.) and (2nd Rt. Vs 3rd Rt.) treatment sessions. Also, statistically
significant (p-value < 0.05) positive correlation between (first Rt. Vs 3rd Rt.) treatment sessions.
Conclusion: laser therapy had been shown to be effective and safe for nail psoriasis. It could be used alone or combined
with different therapeutic modalities, being especially beneficial with topical treatments.
Keywords: Pulsed Dye Laser Plus, Topical calcipotriol, Corticosteroid combination, Psoriasis.
Psoriasis is an immunologic disease with a
of patients. De Jong and colleagues (5) reported that
genetic predisposing predominantly triggered by
93% of patients with psoriasis with nail disease
abnormal CD4 and CD8 T-cell expansion. This
considered their condition to be a significant cosmetic
activation eventually leads to the infiltration of
handicap, 58% found that it interfered with their job,
inflammatory cells into the epidermis, resulting in the
and 52% described the pain as a symptom (6).
characteristic cutaneous lesions found in psoriasis. The
The treatment of nail psoriasis largely depends
maintenance of these lesions requires an expanded
on the severity of symptoms. Local or topical therapies
superficial vascular network, which begins prior to the
along with ultraviolet (UV) therapy should be attempted
onset of lesion formation (1). Psoriasis varies in
initially. However, the efficacy of these methods is
presentation and can involve the skin, joints, and nails,
limited, as penetration through the nail plate and nail
either alone or in combination. Nail psoriasis is
matrix is difficult. Systemic therapy may be needed in
common in those suffering from psoriasis, with reported
patients with severe disease or if topical treatment fails.
incidences varying from 10% to 78% (2). Nail
Systemic treatment is not recommended for patients
involvement is more commonly found in patients with
with psoriasis limited to the nails (7).
psoriatic arthropathy than in those with uncomplicated
In 2009, Fernandez-Guarino et al. (8) were the
first to study the efficacy of 595 nm pulsed dye laser
The nail lesions were identified as nail matrix
(PDL) in nail psoriasis treatment, using a 6-millisecond
disease (pitting, leukonychia, red spots in lunula, nail
pulse duration which is longer than the pulse duration
plate crumbling) and nail bed disease (oil drop
used in previous psoriasis vulgaris studies. The study
discoloration, onycholysis, nail bed hyperkeratosis,
revealed excellent results, with a 33% improvement
splinter hemorrhage). The Nail Psoriasis Severity Index
after 12 weeks of monthly sessions and 58%
(NAPSI) is an objective numeric grading tool used to
improvement after 24 weeks of treatment from the PDL
evaluate disease severity. To obtain a patient's NAPSI
score, the nail is divided into 4 quadrants; each quadrant
A more recent study, Oram et al. (9) used a 1.5-
then is evaluated based on the presence or absence of
millisecond pulse duration, which also demonstrated
signs of the nail bed and/or nail matrix disease and is
good results of PDL treatment of nail psoriasis (7, 9).
given a score.
The sum of the individual scores for each
AIM OF THE STUDY
quadrant is the patient's NAPSI score (4). Nail psoriasis
The aim of this study was to compare the efficacy
has a significant adverse influence on the quality of life
of PDL plus topical calcipotriol and corticosteroid
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (5), Page 4240-4245
Evaluation of Right Ventricular Systolic Function in Patients with Right Bundle
Branch Block Using Two-Dimensional Speckle Tracking Echocardiography
Mohy E. Mansour Elabbady, Abdelmohsen M. Aboualia, Ahmed S. Attia
Cardiology Department, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed S. Attia, Email: firstname.lastname@example.org, Mobile: (+20) 01067766599
Background: the prevalence of right bundle branch block (RBBB) is estimated to be 0.2-2.3% in healthy
individuals in many previous studies. The prevalence of RBBB increases with age, higher in men, diabetics and in
patients with hypertension.
Objectives: the purpose of this study was to evaluate the right ventricular systolic function in patients with right
bundle branch block with structurally normal heart disease using conventional and speckle tracking 2D
Subjects and Methods: forty patients with right bundle branch block (RBBB) were classified into 2 groups each
of 20 patients; complete right bundle branch block (CRBBB) and incomplete RBBB (IRBBB), beside 20 normal
individuals matched in age and sex served as controls.
Results: Tricuspid annular plane systolic excursion (TAPSE) and right ventricle free wall longitudinal strain (RV
FWLS) were not statistically significant in patients with RBBB, there was decrease in CRBBB than normal
individuals. In right ventricle global longitudinal strain (RV GLS), tricuspid lateral annular systolic velocity (S'),
Tei index by both tissue and pulsed Doppler assessment, fractional area change (RV FAC%) and RV basal diameter;
and in incomplete right bundle branch block in the mean of RV STE GLS%, S', Tei index by both tissue and pulsed
Doppler. Conclusion: Isolated right bundle branch block has an effect on the RV morphologic characteristics,
systolic function compared with healthy individuals by 2D, M-mode, Doppler and speckle tracking
Keywords: Right Ventricular Systolic Function, Right Bundle Branch Block, Two-Dimensional Speckle Tracking
echocardiography (STE) has been introduced for the
Right bundle branch block (RBBB) in an
evaluation of RV function (10-11).
electrocardiogram (ECG) is seen in course of interruption
2D speckle imaging is useful for differentiating
of the normal electrical activity in the His-Purkinje
active and passive movements of myocardial segments,
system. The normal activation sequence is changed in
and to quantify and evaluate components of myocardial
RBBB, resulting in appearance of a widened QRS
function, such as longitudinal myocardial shortening,
complex and changes in the directional vectors of the R
which are not visually assessable(12).
and S waves (1).
The prevalence of RBBB is estimated to be 0.2-
AIM OF THE WORK
2.3% in healthy individuals in many previous studies (2-4).
The aim was to evaluate the right ventricular
The prevalence of RBBB increases with age, higher in
systolic function in patients with right bundle branch
men, diabetics and in patients with hypertension (5).
block with structurally normal heart disease using
Although right bundle branch block (RBBB) was
conventional and 2D speckle tracking echocardiography.
considered a benign finding that does not imply increased
risk when found in asymptomatic healthy individuals.
SUBJECTS AND METHODS
However, a large study published in the European Heart
This cross-sectional comparative study involved
Journal 2013 showed that individuals free from CVD,
forty patients with RBBB and twenty, age and sex
incidentally discovered complete RBBB was associated
matched, apparently healthy free from RBBB as a
with 30% increased mortality risk mainly due to CVD. In
control. They are collected from the Cardiology
contrast, IRBBB was not associated with cardiovascular
Departments, Faculty of Medicine, Al-Azhar University,
risk factors or adverse outcomes during 33 years of
El-Hussein Hospital at the period from October 2017 to
It was shown that RV function represents a
Ethical approval and written informed consent:
predictive value for the outcome in patients with acquired
An approval of the study was obtained from Al-
heart disease. Therefore, an accurate estimation of RV
Azhar University academic and ethical committee.
systolic function is of pivotal importance (8-9).
Every patient signed an informed written consent for
Because the complexity of RV anatomy,
acceptance of the operation.
conventional echocardiographic evaluation is often
All studied populations were classified into:
challenging to assess RV function. So, the novel Group (1): (Control group): included 20 apparently
technique, two-dimensional (2D) RV speckle tracking