The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4246-4253
Relation between Fundus Autofluorescence and Optical
Coherence Tomography in Age Related Macular Degeneration
Mohamed Nabil Mohamed Sharaf*, Hassan Mohamed Hegazy, Mohamed Abdul
Ophthalmology Department, Faculty of medicine, Al-Azhar University
*Correspondence author: Mohamed Nabil Mohamed Sharaf, Mobile: (+20)01099854861,
E mail: Mohamednabil91@azhar.edu.eg
Background: age-related macular degeneration (AMD) is a macular neurodegenerative disease that nowadays
constitutes one of the main socioeconomical health issues worldwide, affecting the elderly population. The
exponentially increasing prevalence of AMD is linked to progressive aging of the population, and it is the
leading cause of legal blindness in the developed world.
Objective: the study was designed to assess the relation between fundus autofluorescence (FAF) and Optical
Coherence Tomography (OCT) in cases of age related macular degeneration.
Patients and Methods: this study is prospective randomized, non-interventional uncontrolled cross-sectional
study was conducted on thirty patients. These patients already diagnosed to have age related macular
degeneration either dry or wet form by fundus examination.
Results: it was found from this study fifty eyes of thirty patients having AMD, Sex distribution in female more than
male, age distribution revealed that the age ranged from 50 to75 years, FAF and OCT cannot replace FFA in cases of CNV.
Conclusion: FAF provides the opportunity to evaluate the retinal functional status. OCT obtains a detailed
picture of the retinal anatomy.
Keywords: Age related macular degeneration, FAF, OCT.
Age-related macular degeneration (AMD) is a
Fundus autofluorescence (FAF) imaging is a
multifactorial disease that represents the most common
noninvasive technique that can acquire a topographic
cause of irreversible visual impairment among people
map of the lipofuscin distribution in the retinal pigment
over the age of 50 in Europe, the United States, and
epithelium (RPE) cells. Earlier studies have shown that
Australia, accounting for up to 50% of all cases of
excessive accumulation of lipofuscin in the RPE cells
central blindness (1).
can occur in various retinal diseases, e.g. retinitis
Risk factors of AMD are heterogeneous, mainly
pigmentosa and age-related macular degeneration (3).
including increasing age and different genetic
Autofluorescence pattern observed in the FAF
images depends on accumulation of lipofuscin, and a
environmental/epigenetic factors, that is, cigarette
normal FAF pattern indicates the presence of intact
smoking, dietary habits, and phototoxic exposure. In the
photoreceptors and normal RPE function. On the other
aging retina, free radicals and oxidized lipoproteins are
hand, an abnormal hyperautofluorescence level
considered to be major causes of tissue stress resulting
indicates increased metabolic load on the RPE due to
in local triggers for parainflammation, a chronic status
degenerated photoreceptor outer segments. A
which contributes to initiation and/or progression of
hypoautofluorescent pattern indicates an absence or
many human neurodegenerative diseases such as AMD
death of photoreceptor cells following RPE atrophy or
the presence of materials that block the FAF signals (4).
AMD is primary characterized by the development
Optical coherence tomography (OCT) is now a
of drusen, Retinal pigmented epithelium (RPE)
standard of care in ophthalmology and is considered
dystrophy, macular pigmentary changes, and/or
essential for the diagnosis and monitoring of many
thickening of Bruch's membrane (2). Advanced AMD
retinal diseases (5).
can manifest as either dry form or wet one. In dry AMD,
It is a noninvasive imaging technique that
geographic atrophy with RPE and photoreceptors
provides high-resolution, cross-sectional images of the
degenerative changes occurs. Conversely, wet AMD is
retina, retinal nerve fiber layer and the optic nerve head
characterized by the presence of choroidal
neovascularization (CNV) with exudative and
Spectral-domain optical coherence tomography
hemorrhagic phenomena leading to fibrotic scar
(SD-OCT) provides new insights into the understanding
of age-related macular degeneration (AMD) but limited
Due to its heterogeneous presentation, it can be
information on the nature of hyperreflective tissue at the
challenging to distinguish AMD from several macular
level of the retinal pigment epithelium (7).
diseases that can mimic the features of AMD. This
FAF imaging is an imaging method that provides
clinical overlap may potentially lead to misdiagnosis
conventional techniques. It permits to topographically
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4254-4261
Effect of Carbon Tetrachloride (CCL4) on Liver in
Adult Albino Rats: Histological study
Haytham EL Sayed Ali EL Sayed1, Lotfy EL Sayed Morsy1, Tamer Mosad Abo Emara1, Rania A. Galhom2
1Histology and Cell Biology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
2Human Anatomy and Embryology Department, Faculty of Medicine, Suez Canal University, Esmaillia, Egypt.
Background: The liver is a vital organ that plays a key role in the detoxification of endogenous and exogenous
substances. Variety of pathological factors including viral hepatitis (especially hepatitis B and C), alcohol and drug
abuse, metabolic diseases, autoimmune diseases and congenital abnormalities can cause hepatic injury. Chronic
hepatic disease is quite common in daily clinical practice. Liver cirrhosis is the final stage of all chronic hepatic
diseases. Liver transplantation is the treatment of choice for chronic liver failure, although, it faces several
Aim of the work: to evaluate the toxic effect of carbon tetrachloride (CCL4) on the liver structure.
Materials and methods: Twenty male rats of average weight 200 grams and aged 6-8 weeks were included in
this study. The Rats were divided into the following two groups: Group I (control group): ten male rats were
subdivided into two subgroups, one of them acted as negative control and the other received the equivalent volume
of the solvent olive oil. Group II (experimental group): ten male rats were injected intraperitoneally (IP) by CCL4
twice weekly for four weeks.
Results: Histological examination of liver specimens showed that CCl4 caused patchy and variable pathological
changes in the liver tissue along with significant increase in collagen fiber content.
Conclusion: The induced liver fibrosis by CCL4 in rats showed markedly pathological effects on hepatic stroma
Keywords: Carbon Tetrachloride CCL4, Liver, Albino Rats
Carbon tetrachloride is the organic compound
hepatotoxicity, especially necrosis and fatty liver, has
with the formula CCL4. It was originally synthesized
long been a challenging subject of many researchers
by the French chemist Henri Victor Regnault in 1839
from various fields over the past 50 years. Even
by the reaction of chloroform with chlorine, but now
though the mechanisms of tissue damages are different
it is mainly produced from methane. It was formerly
among chemicals and affected tissues, CCL4 played a
widely used in fire extinguishers, as a precursor to
role as a key substance of tissue injury. A number of
refrigerants and as a cleaning agent (1).
studies were conducted and various hypotheses were
CCL4 does not occur naturally, it is a clear
raised. As a result, several important basic
liquid with sweet smell that can be detected at low
mechanisms of tissue damages were emerged,
levels (2). CCL4 is a common environmental pollutant.
involving metabolic activation, reactive free radical
Workers are at high risk of exposure to high levels
metabolites, lipid peroxidation, covalent binding and
through inhalation and dermal contact. On the other
disturbance of calcium homeostasis (6).
hand, the general population may be exposed to low
Liver is an important organ which plays a
levels of CCL4 through inhalation from the
central role in metabolic homeostasis. It also has an
atmospheric environment (3).
amazing regenerative capability after liver mass loss
Because of its harmful effects, its uses are
(7). Iredale et al. (8) described liver fibrosis as a
now banned and it is only used in some industrial
pathological condition characterized by an excessive
applications. The primary routes of potential human
deposition of collagen and other components of ECM.
exposure to CCL4 are inhalation, ingestion and dermal
They added that the liver fibrosis was originally
considered progressive and irreversible, but several
Weber et al. (5) mentioned that CCL4 is also well
clinical studies had shown that it could be reversed if
known for hepatic toxic actions. They reported that it
the causative agents were adequately removed or if
causes acute liver damage like necrosis and steatosis.
patients were treated effectively.
This effect is due to the release of free radicals which
Hepatic fibrosis was historically thought to
are composed of trichloromethyl (CCL3) and peroxy
be a passive and irreversible process due to the
trichloromethyl (OOCCL3) radicals. These free
collapse of the hepatic parenchyma and its substitution
radicals can generate lipid peroxide which may cause
with a collagen-rich tissue. Currently, it is considered
cell membrane damage, alteration in enzyme activity
to be a model of the wound healing response to chronic
and finally induction of hepatic injury and necrosis.
liver injury (9).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4262-4268
Seroepidemiological Evaluation of Toxocariasis in Egyptian Children
Suffering from Recurrent Urticaria
Ahmed Mohamed Bayoumy¹, Rabie Bedier Atallah², Khaled Abd El-Aziz Mohamed³,
Tarek Khameis Zaalouk¹, Mustafa El-Shahat Ghazy³, Mohamed Ahmed El-Kenany³
Department of Medical Parasitology, Faculty of Medicine, 1Boys and 3Damietta, Al-Azhar University
Department of ²Dermatology, Faculty of Medicine, Al-Azhar University, Damietta
*Corresponding author: Ahmed Mohamed Bayoumy, e-mail: firstname.lastname@example.org
Background: human toxocariasis is one of the most common zoonotic helminthiases reported all over the world. Large
spectrum of clinical diseases due to toxocariasis including cutaneous diseases particularly urticaria has been identified
by recent diagnostic laboratory tests. Objective: it was to evaluate the Toxocara seroprevalence in children diagnosed
with chronic urticaria (CU) and to identify its possible relationship with epidemiological, laboratory and clinical
aspects, through a casecontrol study presented at the Dermatology Outpatient Clinic of Al-Azhar University Hospital
in New Damietta City. Patients and Methods: seventy children diagnosed with CU and seventy healthy controls were
included in the study. Sociodemographic risk factors for toxocariasis were analyzed based on a questionnaire collected
from the children's parents or guardians, then all of the children were subjected to thorough clinical examination, stool
examination to exclude other parasites and blood samples were collected and tested for eosinophilic count by CBC as
well as estimation of anti-Toxocara IgG antibodies by means of western blot (WB) test. Results: Toxocara IgG was
positive in 18.5% (n=13). It was significantly higher than among the cross-matched 70 healthy controls (4.2%). This
study confirmed the possibility of significant association between the seroprevalence of Toxocara and possible
socioepidemiological factors as contact with pets or soil, geophagia as well as state of house. Regarding clinical
manifestations and laboratory investigations, bronchial asthma, rhinitis and conjunctivitis were found to be
significantly associated with Toxocara seroprevalence.
Conclusion: Toxocara infection should be considered as an important cause of recurrent urticaria among children
population in developing countries.
Keywords: Chronic urticaria, Toxocariasis, Children, IgG, Seroprevalence.
Toxocariasis is a helminthic zoonosis caused by the
Urticaria is a pathological condition characterized
round worm Toxocaracanis that infects dogs and less
by itchy erythematous, edematous blisters with
frequently by Toxocara cati, which infects cats.
temporary rashes. It is a common disease that is seen in
Children may be infected by the ingestion of Toxocara
15-25% of people in at least one part of their lifetime.
spp. eggs through hand contamination, soil ingestion,
Urticaria is classified as acute or chronic according to its
direct contact with dogs and cats, and with objects
duration. Clinical findings above six or more weeks are
contaminated with infective eggs of these parasites(1).
defined as CU. About 75% of the urticarial cases are
When humans who are incompatible hosts
idiopathic. Drugs, food and helminthic infections seem
accidentally ingest infective eggs and larvae, they
to be the etiological factors. It is reported that urticarial
become free in the intestine and pass through the
lesions are observed in approximately 80% of
intestinal epithelium to reach the blood vessels, where
they can migrate to various visceral organs and tissues
of the body without developing into the adult form(2).
toxocariasis may be associated with rash, pruritus and
Toxocariasis was described in three clinical forms:
chronic urticaria. According to some researches,
visceral larva migrans (VLM), ocular larva migrans
hypereosinophilia is the main reason of the skin
(OLM) and subclinical or covert toxocariasis. The
symptoms which is explained by the release of
spectrum of the clinical manifestations varies widely
cutaneous chemotactic factor with the effect of
from symptomless cases to systemic infections(2). The
eosinophils. Another clue is the histamine release
clinical syndrome of VLM may be acute or subacute,
caused by the proteinase activity of Toxocara excretory-
secretory (TES) antigens(5).
Seroprevalence of toxocariasis has been reported to
manifestations, central nervous system involvement,
fluctuate between 2 and 92.8% according to
pulmonary involvement, pyrexia and eosinophilia(3).
geographical region and age group(6). Studies
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4269-4273
Comparative Study between Conservative Breast Surgery and
Modified Radical Mastectomy in Triple Negative Cases
Eid Rezk El Gammal, Ayman Mohamad Abdulmohaymen, Bashir Adel M. M. Abdulmutaleb*
Surgical Oncology Department, Faculty of Medicine, Al-Azhar University
*Corresponding author: Bashir Adel M. M. Abdulmutaleb ,Mobile: (+20) 1004543591, Email: email@example.com
Background: Breast cancer has a significant concern in modern researches due its mortality and associated
Aim of the Work: The aim of this work is to compare conservative breast surgery (CBS) and modified radical
mastectomy (MRM) regarding oncologic and cosmetic outcomes in women with primary breast cancer negative
for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 triple-negative breast
Patients and Methods: This retrospective study included 20 patients presented by breast cancer. All patients underwent
surgery at Al-Azhar University Hospitals. 10 patients were treated by conservative breast surgery and 10 patients were
treated by modified radical mastectomy.
Results: We investigated Overall Survival in patients with TNBC treated with mastectomy compared with those
receiving CBS. The analysis indicated that patients with CBS had better survival than patients with mastectomy in
Overall Survival (P < 0.001).
Conclusion: patients with CBS exhibited improved in TNBC may be associated with the baseline characteristics
between two groups. Most patients in the CBS group presented with better survival than did patients in the mastectomy
group. CBS was favored over mastectomy.
Keywords: Breast cancer, Conservative breast surgery, Modified radical mastectomy.
In particular, triple-negative breast cancers
Breast cancer is the most common cancer in
(TNBCs), which account for approximately 10% to
women throughout the world (1). Breast conserving
17% of all patients with breast cancer(5), present
surgery and radiotherapy have been shown to provide
poorly differentiated tumors lacking expression of
similar local control and survival rates to radical
ER, PR, and HER2 on immunohistochemical
procedures in the surgical treatment of early breast
analysis; they are characterized by a high
cancer (2). In 1994, lumpectomy with simultaneous
proliferation rate and increased aggressiveness
bilateral reduction mammoplasty were performed as
compared with other subtypes (6).
a solution for cancer breast with macromastia and
Because endocrine and HER2-targeted therapies
oncoplastic breast surgery was defined for the first
chemotherapy followed by adjuvant RT is the
Currently, patients with breast cancer are
standard of care for patients with TNBC. The paucity
managed using clinical and histologic parameters,
of therapeutic options emphasizes the urgent need to
such as tumor size, lymph node (LN) status, and
optimize the current locoregional management of
patients with TNBC and reduce their risk of
immunohistochemical assessment of hormone
locoregional recurrence (LRR) (7).
receptors (ie, estrogen receptor [ER], progesterone
receptor [PR]) and human epidermal growth factor
AIM OF THE WORK
receptor 2 (HER2) testing. Locoregional management
The aim of this study is to compare CBS with
of breast cancer has been implemented based on
MRM regarding oncologic and cosmetic outcomes
results of randomized controlled trials comparing
with primary breast cancer negative for estrogen
CBS and MRM (4).
receptor, progesterone receptor, and human
In these studies, locoregional outcome was not
epidermal growth factor receptor 2 (triple-negative
investigated with respect to molecular and/or biologic
breast cancer [TNBC]).
heterogeneity of breast cancer. Indeed, genomic and
molecular profiling have paved the way to a
PATIENTS AND METHODS
paradigm shift toward new molecular classification
with at least three major molecular subtypes (5)
comparative study which was approved by the Ethics
associated with differences in survival and response
Board of Al-Azhar University.
to treatment. To approximate these molecular
Study population: breast cancer patients.
subtypes, most studies are focused on biologic
Patient's number: 20 patients.
subtyping using ER, PR, and HER2 as biomarkers (6).
Study venue: Al-Azhar University Hospitals.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4274-4278
Glycemic State of Type 2 Diabetic Chronic Kidney Disease Patients after
Vitamin D Replacement Therapy
Haitham A.Azeem*, Ayman Abdel Aziz*, Alaa Mohammed Hashim**, Mohammed Ahmed*
* Internal Medicine Department, ** Clinical Pathology Department, Faculty of Medicine, Al-Azhar University
Corresponding Author: Haitham A.Azeem, Mobile: (+20)01015803333, Email: firstname.lastname@example.org
Background: Diabetes mellitus (DM) is a metabolic disorder characterized by chronic hyperglycaemia as a result
of insulin deficiency, insulin resistance or both.
Objective: To assess the impact of vitamin D replacement therapy on glycemic state in type 2 diabetic chronic
kidney disease (CKD) patients.
Patients and Methods: 70 patients previously diagnosed as type 2 DM (according to guidelines used by National
Institute of Health USA) attending Al-Azhar Assuit University Hospital, internal medicine department and
outpatient clinics was included in our study where vit. D was replaced in our groups and its impact on glycemic
state was analyzed by bivariate and multivariate analyses.
Results: Our study is a prospective study revealed a significant negative correlation between 25(OH)D levels and
HbA1c values before and after vit. D replacement therapy.
Conclusion: Vitamin D replacement therapy had a beneficial effect on glucose hemostasis via a significant
reduction in HbA1c, this emphasizes the potential therapeutic implications of vitamin D supplementation as a
promising preventative and therapeutic agent for improved glycemic control among type 2 DM patients with CKD.
Keywords: HbA1c, Type 2 DM, Chronic Kidney Disease, Vit. D replacement, Intervention study.
AIM OF THE WORK
Diabetes mellitus (DM) is a disordercharacterized
To assess the impact of vitamin D replacement
by chronic hyperglycaemia as a result of insulin
therapy on glycemic state in type 2 diabetic chronic
deficiency, insulin resistance or both. Diabetes has a
kidney disease patients.
high prevalence with the total number of people with
diabetes expected to rise from 366 million in 2011 to
PATIENTS AND METHODS
552 million in 2030 (1).
This was a prospective study conducted on 70
Vitamin D has emerged as a potential modifier risk
patients previously diagnosed as type 2 DM
for diabetes. Vitamin D is thought to affect various
(according to guidelines used by National Institute of
mechanisms related to the pathophysiology of both
Health USA) attending Al-Azhar Assuit University
types of diabetes, including pancreatic beta-cell
Hospital, internal medicine department and outpatient
dysfunction, impaired insulin action and systemic
clinics in the period from October 2018 to March
inflammation; either directly via activation of the
vitamin D receptor, or indirectly via regulation of
Our study patients were classified into three
calcium homeostasis (2).
groups according to the US Institute of Medicine
Vitamin D deficiency impairs insulin secretion
recommendations for vitamin D.
from pancreatic beta-cells (3) it also increases insulin
1. Deficient group: included patients with serum
resistance (4), hence contributing significantly to the
25(OH)D3 less than 20ng/ml.
pathogenesis of the two types of diabetes and may
2. Insufficient group: included patients with serum
therefore predispose to the two types of diabetes(5).
25(OH)D3 of 20-29.9 ng/ml.
The effect of vitamin D on pancreatic beta-cells and
3. Sufficient group: included patients with serum
subsequently on insulin release is mediated via
25(OH)D3 >30 ng/ml.
vitamin D receptor (VDR). Vitamin D may affect
All patients were matched with sex, age and
insulin synthesis and secretion by acting directly via
binding of its active form to the VDR expressed in
pancreatic -cells Vitamin D is thought to promote
All patients were subjected to the following:
insulin secretion through increasing the cytosolic
· Full history taking, including age, sex, and
calcium concentration in beta-cells. This is supported
detailed drug history.
by the presence of the vitamin D response element
· Clinical examination, with emphasis on blood
(VDRE) in the human insulin gene promoter and
pressure, waist circumference, body mass index
transcriptional activation of the human insulin gene
caused by the active form of vitamin D (6). So, we
· Abdominal ultrasonography, for detection of
performed our study to assess the glycemic state of
kidney abnormalities and electrocardiography to
type 2 diabetic chronic kidney disease patients after
detect and exclude any cardiac abnormalities.
vitamin D replacement therapy.
· Routine laboratory investigations including: CBC,
Liver and Kidney functions, fasting and 2hr.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4279-4284
Ipsilateral Femoral Neck and Shaft Fracture Management
Single Implant versus Multiple Implants
Ahmed AbdElhamid Shamma1, Mohammed AbdElaziz Hassan1 and Ahmed Mohammed Saber Agour*2
1Department of Orthopedic Surgery, Faculty of Medicine, Al Azhar University, Egypt
2Department of Orthopedic Surgery, Elbajour General Hospital,Menoufia, Egypt
*Corresponding author: Mohammed Saber Agour, Email:ahmedagour1980, Mobile: (+20)01090497229
Introduction: Fracture of shaft and ipsilateral neck of femur is a challenging problem to orthopaedics surgeons.
The treatment is often difficult, and there are many protocols for the management of these fractures.
Objectives: To assess the efficiency of multiple implants method for management of ipsilateral fracture neck and
shaft femur using plate and screws or retrograde nail for femoral shaft fractures and cannulated screws or sliding
hip screw for femoral neck fracture, evaluate the efficiency of reconstruction nail as a single implant method for
management of fracture both neck and shaft femur as well as to compare the results of two management methods.
Material and Methods: A total of 20 adult patients with ipsilateral femoral neck and shaft fractures were included
in our study. Standard radiographs were obtained. Patients were divided into single implant group (Group I; 10
patients) and multiple implants group (Group II; 10 patients). All patients were followed prospectively for a
minimum of 1 year. Fracture union was confirmed radiologically, and functional evaluation was done as per Harris
Results: 70% of both groups achieved successful fracture union with the remaining 30% with either nonunion,
malunion or necrosis of the femoral head but with non- significant difference between both groups.
Conclusion: Upon comparing single versus multiple implants methods, equivalent results, were clinically and
radiologically obtained with both techniques. However, it is difficult to draw a definite conclusion as the number of
cases is relatively small. A study with a larger population scale probably gives a definite conclusion.
Keywords: Ipsilateral Femoral Neck, Shaft Fracture, Single implant, Multiple implants.
challenging secondary procedure and increased risk of
Fracture of shaft and ipsilateral neck of femur
is a challenging problem to orthopedic community.
Treatment Options to be considered in this
These types of fractures accounts for only 19% of
type of fractures include; 1-antegrade femoral nailing
femoral shaft fractures, but these are much more
of the shaft with cancellous screws placed anterior to
difficult to manage than either injury in isolation and
the nail for fixation of the neck(7). 2-reconstruction-
require a modified treatment approach(1).
type intramedullary nailing (8).3-various plate
These injuries usually occur as a result of high
combinations [including a sliding hip screw (DHS) or
energy mechanism such as a motor vehicle crash or fall
cancellous screws for femoral neck and a plate for the
from height (2). It has been documented that they
shaft] (9).4-retrograde intramedullary nailing of the
caused by a longitudinal compression force on a flexed
shaft and screw fixation of the neck.(10) 5- Long sliding
and abducted hip due to the frequency with which the
hip screw that can fix both neck and shaft (11).
injury is seen in vehicle crash front seat drivers and
Each method has its own advantages and
disadvantages. The three major issues related to
Compared to isolated femoral shaft injuries,
management of these fractures are optimal timing of
those fractures with an associated femoral neck injury
surgery, which fracture to stabilize first, and the
are more likely to be highly comminuted (Winquist III
optimal implant to use (12).
or IV) indicating a higher energy mechanism. On the
Most authors recommend prompt, but not
other hand, an associated femoral neck fracture is more
emergent, surgery with priority given to anatomic
likely than an isolated neck fracture to be non-
reduction and stabilization of the neck fracture by
displaced at presentation (2560%)(4). One possible
either closed or open methods. Fixation of the shaft
explanation for this is that at the time of injury, the
fracture follows as patient condition allows. However
femoral shaft absorbs the majority of the force
some others recommend starting by fixation of the
imparted to the femur resulting in a high degree of shaft
shaft to allow manipulation of the neck by internal and
comminution but decreasing the amount of force
external rotation during reduction (1).
ultimately transferred to the femoral neck(5-6).
A short delay of 56 days in stabilizing
Failure to recognize a non-displaced or
ipsilateralund is placed femoral neck and shaft
minimally displaced associated neck fracture prior to
fractures does not seem to affect the ultimate
fixation of the shaft can lead to displacement, a
functional outcome (13).
decrease in neck fixation options, a technically
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4285-4291
Impact of Intrauterine Injection of Human Chorionic Gonadotropin at Embryo
Transfer on Intra Cytoplasmic Sperm Injection Outcome
Mona M.R. Mourad, Yehia A.S. Wafa, Shokry A.Z. El Awady, Ahmed Abou El Serour
International Islamic Center for Population Studies and Research, Al-Azhar University
*Corresponding author: Mona M.R. Mourad, Email: email@example.com, Mobile: (+20) 01007823410
Background: for successful embryonic implantation, a healthy embryo at blastocyst stage and a functional
endometrium ready to receive it are basic requirements. There is growing research evidence that reveals the
importance of embryonic endometrial synchrony for the accomplishment of a successful conception.
Objectives: The aim of this research study is to assess the impact of hCG intrauterine injection procedure before
embryonic transfer on enhancing pregnancy and implantation rates.
Patients and methods: a prospective randomized clinical research trial that was conducted on 600 cases undergoing
embryo transfer via an ICSI program at the ART unit of the International Islamic Centre for Population Studies and
Research (IICPSR), Al Azhar University. Cases were categorised randomly into 2 research groups. In the first group
(study research group), intrauterine of 500 IU HCG were injected before the embryonic transfer procedure. The
second group (control research group), has gone through embryonic transfer without prior injection of hCG.
Results: chemical and clinical pregnancy rates were statistically significantly more frequent among research study
group (HCG intra uterine injection group). In addition multiple pregnancy was statistically significantly higher within
research study group. Implantation Rate was statistically significantly higher among study group. Interestingly no
statistical significant difference between study and control groups as regards early and late ovarian hyper-stimulation.
Conclusion: there is a possible role of HCG in enhancing and improving endometrial receptivity and increasing
implantation and pregnancy rates. Future research efforts should consider racial, ethnic and genetic differences in
response to HCG intrauterine injection.
Human chorionic gonadotropin (HCG) is a
The hypothesis that infertile women
hormone produced by the placenta after embryonic
undergoing IVF/ICSI may benefit from the
implantation. HCG is a glycoprotein hormone
intrauterine infusion of HCG before embryo transfer
formed of 237 amino acids with a molecular weight
was based on the findings of the previous studies
of 36.7 k Daltons, around 14.5 subunit-hCG and
which reported that hCG is secreted in human
22.2 k Daltons -subunit HCG. It permits the
cleavage-stage embryos and at the time of
corpus luteum to secrete progesterone hormone
implantation. It has been shown to enhance the
during the first gestational trimester (1-5).
endometrial receptivity in both human and non-
HCG injection is widely implemented for final
human primates. After the first report of benefit
maturation induction in fertility management
effect of the intrauterine hCG (IU-hCG) infusion on
protocols. In the presence of one or more mature
pregnancy outcome by Mansour et al. (20), several
ovarian follicles, ovulation could be triggered by the
research studies have been conducted to evaluate this
administration of HCG. HCG is a multifaceted
intervention on ART outcomes. Some studies found
hormone with a very wide range of actions. HCG
significant improvement on pregnancy outcomes
determines fetal fate by regulating maternal innate
while some other did not. In a recent Cochrane
and adaptive immune responses, allowing the
review, researchers concluded that administration of
acceptance of the foreign fetal antigens (6-8).
IU-hCG in a dose of 500 IU or greater in fresh
Various research studies have focused on the
cleavage-stage embryo transfer cycles is associated
correlation between endometrial receptivity and
with promising pregnancy outcomes (17-20).
infertility. Even though the blastocyst can implant in
various human tissues, astonishingly in the
AIM OF THE WORK
endometrium, this physiological phenomenon can
The aim of this research study is to assess the
only happen during a self-limited period of time
impact of hCG intrauterine injection procedure
(implantation window) (9-11).
before embryonic transfer on enhancing pregnancy
HCG has a cornerstone role in cellular
and implantation rates.
physiological differentiation / proliferation and
could trigger apoptosis. HCG is one of the key
PATIENTS AND METHODS
molecules during the process of implantation, it
A prospective randomized clinical trial that
effectively modulates several metabolic pathways
was conducted on 600 cases undergoing embryo
within the decidua, contributing to endometrial
transfer via an ICSI program at the ART unit of the
International Islamic Centre for Population Studies
and Research (IICPSR), Al-Azhar University.
RELATIONSHIP BETWEEN SLEEP DISORDERED BREATHING AND PRO-INFLAMMATORY MARKERS IN ACUTE ISCHEMIC STROKE
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4292-4297
Inflammatory Markers in Obese Children
Soheir Bahgat Fayed, Ragaa Abdelsalam Mohamed, Hala Mohamed Ali Abdelsalam,
Noha Helmy Mosaad Mohamed El Fatairy*
Department of Pediatric, Faculty of Medicine for Girls, Al-Azhar University
*Corresponding Author: Noha Helmy Mosaad Mohamed El Fatairy, Phone No.: (+2) 01000781038,
Background: Childhood obesity has become a crucial problem in both developed and developing countries. In
2018, the World Health Organization estimated 41 million infants and children were obese. This number is
predicted to increase to 70 million by 2025.
Aim of the Work: To assess: Inflammatory markers: (tumor necrosis factor (TNF)-alpha- high sensitive CRP
(HS- CRP) in obese children and the impact of obesity and inflammatory markers as risk factors for morbidity in
Patients and Methods: This study was a cross-sectional comparative study. The study group comprised forty
obese and thirty control Egyptian children who were recruited from pediatric outpatient's clinic of Al-Zahra
University Hospital and National Nutrition Institute. They were 24 females (60%) and 16 males (40%) obese
children. Their ages ranged between 4-8 years.
Results: We found that there was statistically significant increase in high birth weight, decreased physical activity,
formula feeding, junk food, high serum of tumor necrosis factor alpha (TNF-alpha) and high sensitive CRP (hs-CRP)
in obese children than control group.
Conclusion: Inflammatory mediators as hs-CRP and TNF alpha are elevated in obese and overweight children
more than healthy control group, which may indicate the presence of chronic inflammation.
Keywords: Tumor necrosis factor-alpha - High-sensitivity C-reactive protein - Lipid profile.
Children are identified as a priority target
at risk of cardiovascular events and may even be
group of obesity interventions worldwide. Without
stronger predictors of these events than are traditional
adequate intervention to prevent and manage
risk factors (e.g., plasma total cholesterol,
childhood obesity, obese children will face chronic
triglycerides, low-density lipoprotein, and high-
lifelong diseases, including cardiovascular disease,
density lipoprotein) (5).
diabetes and cancer. Coping with childhood obesity is
Overall, these studies demonstrate that
a cornerstone in preventing long-term complications
inflammatory markers are increased in obese children,
and reducing premature deaths from chronic non-
leading to the development of risk factors for chronic
communicable diseases (NCDs) (1).
diseases that are typically associated with adults (6).
With the increase in adiposity that occurs
with weight gain, a persistent low-grade inflammatory
AIM OF THE WORK
state is created. The most commonly studied
Was to assess:
inflammatory markers associated with obesity are the
1) Inflammatory markers: (tumor necrosis factor
cytokines, tumor necrosis factor and interleukin-6,
(TNF)-alpha and high sensitive CRP (HS- CRP) in
and the acute-phase reactant, C-reactive protein (2).
Increased levels of inflammatory markers
2) The impact of obesity and inflammatory markers as
lead to physiological mechanisms that negatively
risk factors for morbidity in obese children.
affect health. Inflammatory markers have been shown
to damage the innermost layers (intima media) and
PATIENTS AND METHODS
lining (endothelium) of blood vessels through the
The current study was cross sectional
stimulation of atherosclerotic lesions that also cause
descriptive comparative study. It was conducted on
hypertension and thrombosis (3).
70 children aged from 4-8 years. All Children were
In addition to cardiovascular dysfunction,
selected from outpatient clinic of Al-Zahraa
inflammatory markers affect metabolic control by
University Hospital and National Nutrition Institute,
negatively influencing insulin sensitivity and glucose
Cairo, Egypt from October 2017 to February 2018.
transport. Thus, obese individuals with elevated levels
They were divided into two groups:
physiological adaptations that negatively affect
metabolic and cardiovascular health (4).
Included 40 obese children according to
Early identification of inflammatory markers
Centers for Disease Control and
may provide another component to identifying those
Prevention (CDC) aged from 4-8 years of both sexes(7).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4298-4306
The Role of Procalcitonin As an Early Biomarker in Diagnosis of Sepsis
Ekram Yasein Ebid, Sarah Younes AbdelAziz, Mai Abuzied Mohamed Abuzied*
Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University
*Correspondence author: Mai Abuzied Mohamed Abuzied, Mobile: (+20)01000957143,
Backgound: Sepsis is the systemic response to infection by microbial organisms. A differential diagnosis of
infection caused by either bacteria or other microbial organisms is essential for effective treatment and prognostic
assessment. Procalcitonin (PCT) is an accurate biomarker that is effective in identifying patients with sepsis and
can be used in the diagnosis of bacterial infections.
Objictive: The aim of the current study is to explore the utility of PCT in early diagnosis of sepsis and determine
its prognostic role in assessment of treatment response.
Patients and Methods: This study included patient group (40 patients with diagnosis of sepsis; 20 males and 20
females with ages ranged from 5-98 years) and 40 control group who matched well with patients as regard age and
sex. Study groups was subjected to complete history taking, clinical examination for signs of sepsis, laboratory
investigations as Complete Blood Count, C reactive protein, Blood culture, serum Procalcitonin level.
Results: The PCT is significantly higher in patients more than the control group. When the CRP values are compared
with those of PCT in patients, they both show similar effects in diagnosis of sepsis. PCT indicates an early response
for patients to treatment (values were less than 105, reaching the normal level in serum) while CRP values were not
indicating any treatment response.
Conclusion: Procalcitonin is an important biomarker in the diagnosis of sepsis and it is a useful indicator for the
effectiveness of treatment.
Keywords: Procalcitonin, biomarkers for sepsis, C-reactive protein, comparative study.
Sepsis is a global public health problem and
optimize the use of antibiotics in the hospitals, and its
generates more than 3,000,000 hospitalizations per
utilization may safely lead to significant reduction of
year. Despite advances in modern medicine, it remains
unnecessary antimicrobial therapy (2).
the leading cause of death in the critically ill patient in
noncoronary intensive care units, with an estimated
AIM OF THE WORK
overall mortality of about 30%, corresponding to 5.3
The aim of the current study is to explore the
million deaths a year. To improve survival, early
utility of PCT in early diagnosis of sepsis and
recognition of sepsis has become the primary goal of
determine its prognostic role.
many societies, promoting research and thus
promoting the development of new biomarkers (1).
SUBJECTS AND METHODS
An ideal biomarker should allow, with high
diagnostic accuracy, an early and rapid recognition of
This is a case-control study. It was conducted
sepsis. Procalcitonin (PCT) is a recently rediscovered
in Faculty of Medicine, Al-Azhar for Girls University
biomarker that fulfills many of these requirements,
and Misr University for Science and Technology
especially in comparison to "older" and commonly
hospitals during the period from Febrauary 2018 to
used biomarkers, as CRP. PCT has demonstrated
superior diagnostic accuracy for a variety of infections,
including sepsis (2).
Procalcitonin is a protein of 116 amino acids
Informed consent was obtained from all
with a molecular weight of 13 kDa, produced in the C
individual and the study protocol was approved by
cells of the thyroid gland, from its precursor
Al-Azhar Medical Research Ethical Committee.
preprocalcitonin. In response to a bacterial infection,
Eighty subjects were included in this study;
the molecular patterns associated with pathogens
they were classified into two groups as follows:
stimulate the C cells, beginning their production. In A. Patient group: It included 40 patients with diagnosis
sepsis the major producers of PCT are macrophages
of sepsis. They were 20 males and 20 females. Their
and monocytic cells of different organs, especially in
ages ranged from 5-98 years with median age of 62.58
the liver. In the presence of bacterial endotoxin, PCT
can be identified in the plasma within 23 h, peaking B. Control group: It included 40 apparently healthy
after 1248 h (3).
volunteers. They were 20 males and 20 females. Their
Procalcitonin can be useful for antimicrobial
ages ranged from 5-93 years with median age of 60.5
stewardship, which is a systematic approach to
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4307-4311
Review of Spinal Pedicle Screws
Bahaa Ali Kornah, Faisal Hasan Zayed, Ahmed Kotb Ahmed Elkomy*
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Kotb Ahmed Elkomy, Email: firstname.lastname@example.org, Mobile: (+20) 01552990033
Background: Pedicle screws are medical implants which are implanted posteriorly into the vertebrae of the spine and
longitudinally connected to a rod to form a construct which corrects spinal alignment or promotes stabilization. Pedicle
screw fixation is considered to be the gold standard of spinal internal fixation due to its many benefits in a variety of
debilitating spinal conditions. Objective: The aim of the work is to evaluate the use of spinal pedicle screws for different
lesions in the past, in the present and in the future. Conclusion: Some successful applications of pedicle screws include
surgical treatment of scoliosis reduction and stabilization of spondylolisthesis, stabilization of unstable spinal fractures,
simple lumbar degenerative disc disease, primary or metastatic tumors of the lumbar spine, and surgical revision of
symptomatic pseudoarthrodesis of the lumbar region.
Keywords: Spinal, Pedicle Screws.
Pedicle screws are medical implants which are
implanted posteriorly into the vertebrae of the spine
and longitudinally connected to a rod to form a
construct which corrects spinal alignment or promotes
stabilization. Pedicle screw fixation is considered to be
the gold standard of spinal internal fixation due to its
many benefits in a variety of debilitating spinal
conditions (1) . The first use of pedicle screws in 1959
has been credited to Boucher who used a longer facet
screw across the pedicle (2).The first deliberate attempt
to put pedicle screws through the isthmus of the pedicle
was done by Harrington and Tullos (3). The plates
used by Roy-Camille in 1979 had a fixed screw-hole
distance for application (4).
In contrast, Gaines et al. developed the variable-
Figure (1) General outline of the spine (6).
screw placement (VSP) plate, which allowed better
placement of pedicle screws according to individual
Bones and Joints
patient anatomy and provided greater clinical latitude
in comparison to the Roy- Camille plate (1, 4). This
The Vertebral Column
technology is now almost exclusively used when
Originating at the cranium, the human vertebral
securing fusion constructs in the thoracolumbar spine,
column consists of a series of 33 inferiorly extending
due to the purported improved fusion rates and rigidity
vertebrae divided into five sections. The superior most
afforded by these constructs. Furthermore, studies
section of the vertebral column is the cervical which
have found that pedicle screws are biomechanically
consists of seven vertebrae that make up the neck,
advantageous when compared to predecessors,
followed by twelve vertebrae in the thoracic, five in
including previous rod and hook systems (5).
the lumbar, and five and four fused vertebrae making
up the sacrum and coccyx, respectively.
AIM OF THE WORK
Each of the cervical, thoracic, and lumbar
The aim of the work is to evaluate the use of spinal
vertebrae are separated by intervertebral discs, which
pedicle screws for different lesions in the past, in
allow for flexibility of the spine. In general, due to the
the present and in the future.
larger loads that are placed on inferior vertebrae as
opposed to those more superior, the size of each
Basic Spinal Anatomy
individual vertebra increases inferiorly down the spine
until reaching L5 and then decreases again at the
The important components of the lumbar spine
sacrum and coccyx (7).
Bones and joints.
All 12 thoracic vertebrae support ribs and thus
show facets for the articulations of these structures.
The first and last four have peculiar manner of costal
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4312-4318
Impact of Adenoidectomy on Bronchial Asthma in Children
EL-Sayed Attia Siam1, Marwan Ahmed Ibrahim1,
Sameh Abdel-Aziz Ahmed Mansour2, Mahmoud Abu El-hamd Ali Mahmoud1*
Departments of Otorhinolaryngology1, Pediatrics and Neonatology2,
Faculty of Medicine, Al-Azhar University
*Corresponding author: Mahmoud Abu El-hamd Ali Mahmoud, Email: email@example.com,
Mobile: (+20) 01148159472
Backgoudn: asthma is one of the most prevalent chronic diseases of childhood, data from the American national health
interview survey revealed the prevalence in children 14 years of age and younger to be 9.0%.
Objictive: the aim of this work is to assess the effect of adenoidectomy on bronchial asthma. The conclusions of this
study may aid in counseling patients and their families regarding the impact of surgical intervention on the modulation
of asthma symptoms.
Patients and Methods: this was a prospective case series study. Patients were selected from those attending asthma
pediatric clinic at Al-Azhar University Hospitals (Sayed Galal and Al-Hussain hospitals). After exclusion and inclusion
criteria were applied, 50 children with diagnosis of chronic adenotonsillitis associated with bronchial asthma were
enrolled in the study.
Results: there was a significant improvement of asthma control test and SN-5 questionnaire results in both urban and
rural inhabitants comparing preoperative and postoperative state. There was a non-significant difference between urban
and rural residence regarding improvement of bronchial asthma after. There was a significant improvement in both sexes
regarding asthma control test and SN-5 questionnaire results comparing preoperative and postoperative state. On the
other hand, there was a non-significant difference between male and female gender regarding such improvement after
AT. Conclusion: adenotonsillectomy in asthmatic patients with chronic adenotonsillitis may lead to significant
improvement in asthma symptoms control and most of the patients are able to eliminate their medications and improve
quality of their life style.
Keywords: adenoidectomy, bronchial Asthma, children
The unified airway suggests a common mechanism
Hypertrophy of the adenoid tissue (AH) is a common
behind the pathophysiology of asthma and rhinitis.
morbidity of childhood which is associated with nasal
Inflammation associated with rhinitis may cause the
obstruction, snoring, sleep apnea, recurrent otitis media,
upregulation of inflammatory mediators leading to
recurrent rhinosinusitis infections, and craniofacial
changes in lower airways. Studies have suggested that
multiple viral infections introduce inflammatory
The most common cause of upper airway obstruction
mediators leaving an immune "memory effect". This
in children and adolescents is adenoid hypertrophy (AH)
memory effect may cause an exacerbated response to
which is a natural response to increased immunologic
future viral infections (6).
activity in early life (2).
Childhood asthma and obstructive sleep apnea
Excess of lymphatic tissue filling a disproportionate
(OSA), both disorders of airway inflammation, were
volume of the upper airway is observed especially in
associated in recent observational studies. Although
pre-school children. Adenotonsillar hypertrophy is the
primary cause of sleep-related breathing disorders
adenotonsillectomy (AT), it remains unclear whether
(SRBD). Patients suffering from SRBD present snoring,
adenotonsillectomy also improves childhood asthma or
mouth breathing, pauses and stops in breathing,
wheezing, enuresis, ineffective sleep. Complications of
sleep apnea may manifest as pulmonary hypertension
AIM OF THE WORK
and right ventricle hypertrophy (cor pulmonale) (3).
The aim of this work is to assess the effect of
Asthma is a heterogeneous disease, usually
adenoidectomy on bronchial asthma. The conclusions of
characterized by chronic airway inflammation. It is
this study may aid in counseling patients and their
defined by the history of respiratory symptoms such as
families regarding the impact of surgical intervention on
wheeze, shortness of breath, chest tightness and cough
the modulation of asthma symptoms.
that vary over time and in intensity, together with
variable expiratory airflow limitation (4).
PATIENTS AND METHODS
Others have argued that a common mechanism may
Type of study: Prospective cohort study.
cause both upper and lower airway disease, and that
children who have symptoms severe enough to warrant
This study was conducted over 50 children aged
adenotonsillectomy are also at increased risk of asthma
2.5-13 years suffering from mild presistent
and atopic disease (5).
bronchial asthma and adenoid hypertrophy.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4319-4324
Comparative Study Between Total Intravenous Anesthesia Versus Volatile Induction
and Maintenance Anesthesia with Sevoflurane for Bariatric Operations
Anwar Mohamed Mostafa Alhasanin, Mostafa Mohamed Mohamed El-Sayed,
Mohamed Abd El Nasser Zaki Basiouny*
Anesthesiology and Intensive Care Department, Faculty of Medicine, Al-Azhar University
* Corresponding author: Mohamed Abd El Nasser Zaki Basiouny, E-mail: firstname.lastname@example.org
Background: Morbid obesity is defined as a body weight 160% above the ideal weight for survival or 40 kg/m2
or >35 with serious comorbidity. Long-term surveys revealed that surgical intervention has been the only method to
effectively sustain weight loss in these patients.
Objectives: To compare total intravenous anesthesia applied with propofol-fentanyl to sevoflurane single breath
and maintenance anesthesia.
Patients and Methods: This prospective randomized clinical study was approved by the ethics committee in Al-
Azhar University and a written informed patient's consent was obtained. This study included 50 patients of both
sexes, admitted for bariatric surgery carried out at Al-Azhar University Hospitals (El-Hussein and Bab El-Sharia).
They were randomly allocated into two equal groups, TIVA group: 25 patients will receive total intravenous
anesthesia applied with propofol-fentanyl. Group VIMA: sevoflurane single breath induction and maintenance
group: 25 patients will receive - sevoflurane single breath induction and maintenance.
Results: Total intravenous anesthesia using (fentanyl and propofol). Volatile induction and maintenance anesthesia
(Inhalational anesthesia) using (fentanyl and sevoflurane). The following parameters were assessed between the 2
groups: Hemodynamics, SPo2 and ET Co2 were continuously monitored and recorded at 15 min interval.
Conclusion: This study showed that both TIVA and VIMA were effective in bariatric surgeries. Regarding
neuroendocrine stress response, TIVA group was provided suppressed hormone levels suggesting that there was
suppression of stress response unlike VIMA group that showed even raised serum levels of those hormones.
Keywords: total intravenous anesthesia, volatile induction, maintenance anesthesia, sevoflurane, bariatric
AIM OF THIS STUDY
Obesity is defined as a body weight that is
To compare total intravenous anesthesia (TIVA)
160% higher than the ideal weight for survival or 40
applied with propofol-fentanyl to sevoflurane single
kg / m 2 or> 35 with serious joint morbidity. Long-
breath and maintenance anesthesia.
term studies have revealed that surgical intervention
Also, to investigate hemodynamics, blood gases,
is the only way to maintain the effectiveness of
stress response and recovery characteristics of the
weight loss in these patients. Various processes have
two different anesthetic techniques and determined
been developed to treat pathological obesity. The
convenient technique for bariatric surgery.
choice of anesthesia technique for general anesthesia
in obese patients remains controversial (1).
PATIENTS AND METHODS
Many surgical procedures were designed to manage
obese patient and were considered as a method of
This prospective randomized clinical study was
management of obesity. Obese patients have a
approved by the ethics committee in Al-Azhar
challenge in dose calculations and adjustments due to
University and a written informed patient's
different volume of distribution that indeed need
consent was obtained.
accurate calculation for drugs to match weight (2).
The study was carried out at Al-Azhar University
Sevoflurane has been suggested to be the long
Hospitals (El-Hussein and Bab El-Sharia).
awaited, ideal inhalational anesthetic for its
properties of being pleasant smelling, relatively non-
This study included 50 patients of both sexes,
irritating to the airways and its low blood-gas
admitted for bariatric surgery carried out at Al-
solubility which allows rapid induction and recovery
Azhar University Hospitals (El-Hussein and Bab
from anesthesia (3).
Clinicians have taken advantage of these attributes to
They were randomly allocated into two equal
adopt it for volatile induction and maintenance
groups, 25 patients each (n= 25):
(VIMA), especially in the day surgery setting, since it
Group (TIVA): (TIVA) group: 25 Patients will
has a potential to allow `fast-tracking' of patients (4).
receive total intravenous anesthesia applied with
A contrasting but also popular technique for day
surgery is total intravenous anesthesia (TIVA) with
Group (VIMA) - sevoflurane single breath
propofol which boasts rapid induction and recovery
induction and maintenance group-: 25 patients
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4325-4331
Value of 3D Speckle Tracking Echocardiography in Assessment of Left
Ventricular Systolic Dysfunction in Hypertensive Patients
Mohy E. Mansour El-Abbady, Taher Said Abd El-Kareem*, Mohammed Naiem Zidan*
Cardiology Department, Faculty of Medicine and * Islamic Cardiac Center,
Background: Hypertension is the most prevalent cardiovascular (CV) disorder, affecting 2050% of the adult
population in developed countries.
Objectives: The aim of this study is to test the capability of real-time three-dimensional speckle tracking
echocardiography (RT3D STE) in characterizing early abnormalities of left ventricular LV systolic dysfunction in
hypertensive patients with normal LV systolic function by standard 2D echocardiography.
Subjects & Methods: The study population included 150 consecutive hypertensive patients without complication
and another age and sex matches 50 healthy controls. ECG, 2D and 4D echocardiography were performed for all
Results: There was evidence of ECG voltage criteria of LVH in about 72% of hypertensive patients which absent in
healthy controls. By comparing both group there were no statistically significant difference regarding EF%, AO, ESD,
EDD, EDV.ESV, while there were statistically higher significant value in the patients group regarding RWT,
LVPWD, IVSD and LV mass with (P<0.001) compared to controls where there were low statistically significant
higher value in the patients group regarding LA dimension and volume (P<0.05).
Conclusion: 3D strain is an applicable technique; it can detect subtle or substantial changes of LV even with normal
ejection fraction. The left ventricular strains (GAS, GLS and GRS) correlate negatively Keywords: hypertension, left
ventricular systolic dysfunction, ECG, echocardiography
Hypertension is the most prevalent cardiovascular
SUBJECTS AND METHODS
(CV) disorder, affecting 2050% of the adult
The study population included 150 patients with
population in developed countries. The prevalence of
uncomplicated arterial hypertension coming for
hypertension increases with age, rising steeply after
follow-up and to receive their monthly medications at
the age of 50, and affecting more than 50% of this
the outpatient's clinics of Al-Hussein University
Hospital and Islamic Cardiac Center, Al-Azhar
The overall prevalence of hypertension in adults is
University, Cairo, Egypt between January 2018 and
around 30 - 45%. This high prevalence of
March 2019. Also, 50 healthy controls recruited from
hypertension is consistent across the world,
normal asymptomatic personnel of the University
irrespective of income status, i.e. in lower, middle, and
staff and workers with examinations and
higher income countries. Hypertension becomes
investigations were considered to participate in this
progressively more common with advancing age, with
a prevalence of >60% in people aged >60 years (2).
Patients diagnosed as hypertensive with blood
An innovative evaluation of left ventricular
pressure 140/90 and sinus rhythm, according to the
function has recently become available by 2D speckle
latest ESC guidelines (6):
tracking echocardiography (STE), a non-Doppler
technique that allows to quantify myocardial
Ethical approval and written informed consent:
deformation in the different spatial direction (3). 3D
An approval of the study was obtained from Al-
Strain has the potential to become the reference
Azhar University academic and ethical committee.
method to assess myocardial function and detect early,
Every patient signed an informed written consent for
subclinical myocardial involvement in many heart
acceptance of the operation.
diseases (4). 3D Strain derives several parameters,
including longitudinal, circumferential, radial strain
and global area strain (5).
Decreased LVsystolic function.
AIM OF THE WORK
Significant valvular heart disease.
The aim of this study is to test the capability of
Ischemic heart disease.
echocardiography (RT3D STE) in characterizing
Congenital heart disease.
early abnormalities of left ventricular LV systolic
dysfunction in hypertensive patients with normal LV
systolic function by standard 2D echocardiography.
Inability to give informed consent.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4332-4339
Comparison between 2, 4 and 6 Minute Sitting Positions versus Immediately
Lying Down on Hemodynamic Variables, Fluid and Ephedrine
Requirement after Spinal Anesthesia in Elective Cesarean Section
Gamal Farook Mohamed Amer, El-Desoky Mohamed Ibraheem Nouh, Ali Abdel El moteleb Ali Ali
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Al-Azhar University
Corresponding author: Ali Abdel El moteleb Ali Ali, Mobile: 01148518954
Background: hypotension is one of the most common complications of spinal anesthesia in patients undergoing
cesarean section. In this regard, the patient's position may affect the incidence of hypotension.
Objective: to compare the incidence of hypotension and ephedrine requirement after spinal anesthesia with variable
time in sitting position before lying down.
Patients and Methods: a total of 100 patients, scheduled for cesarean section under spinal anesthesia, with 10 mg of
hyperbaric bupivacaine 0.5% (2 ml) mixed with 25 µg (0.5 ml) fentanyl, were randomly divided into 4 groups (25
patients per group). Groups M2, M4 and M6 remained in a sitting position for 2, 4 and 6 minutes after the induction
of spinal anesthesia, respectively, while group M0 was immediately placed in a lying position.
Results: there were highly significant differences between the four groups as regard the incidence of hypotension
based on Chi-square test; **p-value <0.001 HS. The frequency of hypotension was higher in group M0 in comparison
with other groups. There was high consumption of ephedrine and fluid in group M0 than other groups as the total
dose used in group M0 was bigger than other groups while M6 had the smaller dose.
Conclusion: the present study revealed that the patient's position is an important factor, which affects the frequency
of hypotension, ephedrine and fluid requirements, and the onset of sensory block during the administration of spinal
anesthesia for cesarean section.
Keywords: Systolic blood pressure, Spinal anesthesia, Ephedrine, Sitting position.
Spinal anesthesia has been regarded as a
Therefore, allowing the patient to remain in the
reasonable anesthetic option for cesarean delivery
sitting position, instead of immediately lying down,
since 1977. The advantages of this technique include
could delay the spread of anesthesia and reduce the
avoidance of airway complications and depressant
incidence of hypotension.
agents, as well as the mother's ability to remain
awake and enjoy the birthing experience (1).
AIM OF THE WORK
Spinal anesthesia is frequently accompanied by
This randomized prospective control study
hypotension, which may be defined in absolute terms
aim to compare the incidence of hypotension and
as a systolic blood pressure (SBP) 90 or in relative
ephedrine requirement after spinal anesthesia with 10
terms as a percentage (20% fall from baseline). The
mg of hyperbaric bupivacaine 0.5% (2 ml) mixed
incidence of hypotension can be as high as 70-80%
with 25 µg (0.5 ml) fentanyl in 4 groups. Groups M2,
when pharmacological prophylaxis is not used, the
M4 and M6 remained in a sitting position for 2, 4 and
severity depends on the height of the block, the
6 minutes after the induction of spinal anesthesia,
position of the parturient and whether it is elective or
respectively, while group M0 (control group) was
emergency cesarean section (2).
immediately placed in a lying position.
Several strategies, including uterine displacement,
lower legs compression and the administration of
PATIENTS AND METHODS
fluids and vasopressors, have been shown to decrease
Setting: The study carried out in Al-Azhar University
the occurrence of this hypotension however, none has
shown to eliminate the need to treat it. In contrast,
Ethical Considerations: After approval of The
patient position has had variable effects on the
Institutional Ethics Committee of The faculty of
incidence of hypotension after spinal anesthesia (3).
Medicine, Al-Azhar University; 100 patients
Prevention of aortocaval compression is
scheduled for elective cesarean section under spinal
universally recommended to prevent hypotension and
anesthesia were enrolled in this prospective
avoid the risk of an abrupt fall in venous return with
randomized study. All patients were counseled for the
subsequent collapse of cardiac output (CO) and blood
study protocol and a written informed consent was
pressure (BP). It can be achieved by using a wedge
obtained from study participants.
under the right hip or lumbar region, by tilting the
Inclusion criteria: Age 18-45 years old. ASA I and
table or by manually displacing the uterus to the left
II with gestational age of > 37 weeks. Elective
cesarean section. Height from 155 cm to 175 cm and
Maternal position may affect the speed of onset of
Weight from 60 kg to 110 kg.
sensory block and thus the hemodynamic effects(5).
Evaluation Of QT Interval In Diabetic Ketoacidosis In Medical Intensive Care Unit
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4340-4345
Uterine Artery Tourniquet Versus Vaginal Misoprostol to Decrease
Blood Loss during Transabdominal Myomectomy
Ali El-Shabrawy Ali, Manal Mohamed Behairy, Basem Mohamed Hamed, Eman El-Sayed Abdel-Aziz*
Faculty of Medicine, Zagazig University, Department of Obstetrics & Gynecology, Sharkia Egypt
*Corresponding author: Eman El-Sayed Abdel-Aziz, Email: email@example.com, Mobile: (+20)1022291664
Background: Uterine fibroids are tumor of the smooth muscles and the connective tissue of the uterus. They are
considered to be the most common benign tumor of the pelvis. Conservative surgery remains the main approach
for management of uterine myomas. Myomectomy is considered to be an important option for women who
desire future childbearing or simply want to preserve their uterus.
Objective: The aim of the study was to compare between the effect of pericervical uterine artery tourniquet
(surgical) and perioperative vaginal misoprostol (medical) regarding their efficacy to decrease blood loss during
trans- abdominal myomectomy.
Methods: Prospective randomized controlled clinical trial. The study was approved by the Ethical Research
Committee. The study was conducted in Obstetrics and Gynecology Department, Zagazig University Hospital.
The study included 36 women with symptomatic myomas randomized into Group A included 18 patients who
underwent uterine artery tourniquet and Group B included 18 patients who received single dose of 400 g
vaginal misoprostol one-hour before surgery.
Results: The present study showed that there was statistically significant difference between both groups
regarding intra-operative blood loss, operative time, the need for blood transfusion and amount of fluid within
the post-operative drain.
Conclusion: Pericervical mechanical tourniquet in comparison with pre-operative vaginal misoprostol is more
effective method in; reducing both intra-operative and post-operative blood loss, and shortening of operative
time during transa-bdominal myomectomy.
Keywords: Uterine Artery Tourniquet, Vaginal, Misoprostol, Blood Loss, Transabdominal Myomectomy.
myomectomy may transect these vessels and increase
Uterine fibroids are hormone-sensitive tumors in
blood loss during the myomectomy (4).
smooth muscles. Serum tumors are the most common
Many interventions have been performed to
uterine tumors in women in the reproductive age
group. There are associated symptoms; dysmenorrhea
Interventions on uterine arteries: as pericervical
and menstrual bleeding leading to anemia, lower
mechanical tourniquet (physical occlusion of the
abdominal pain and pressure on neighboring organs.
uterine blood supply by mechanical tourniquet is one
Submucosal and intramural fibroids, which distort the
of the most effective interventions to decrease blood
endometrial cavity are considered to impair fertility (1).
loss during transabdominal myomecyomy (5), uterine
Treatment of fibroids should be individualized, and
artery embolization (6,7), bilateral uterine artery
the associated symptoms may be an important factor
ligation, vasopressin (synthetic or natural), a
in whether myoma is removed or not. Myomectomy
vasoconstrictive solution of bupivacaine plus
still remains the gold standard for treatment for
epinephrine, utero-tonics ( such as oxytocin and
patients who wish to preserve their uterus and desire
misoprostol) (9) and antifibrinolytic agents such as
future pregnancy. The procedure can be accomplished
tranexamic acid and gelatin-thrombin haemostatic
by either laparoscopy or laparotomy (2).
Treatment options for myomas are typically
individualized based on the severity of the symptoms,
PATIENTS AND METHODS
the size and location of the fibroid lesions, the
I- Technical Design
patient's age, their chronological proximity to
menopause and the patient's desire for future
The study was conducted in Zagazig University
pregnancy. The usual goal of therapy is to relief the
Hospital. The patients were recruited from the
symptoms. The treatment options range from the use
Outpatient Gynecology Clinic. The study included 36
of ancient Chinese method (acupuncture) to
women with symptomatic leiomyomas, all of them
hysterectomy (total removal of the uterus and its
underwent transabdominal myomectomy.
leiomyoma contents) (3).
Type of the study:
The presence of fibroids in the uterus distorts
Prospective randomized controlled interventional
normal vascular architecture. So, the arcuate arteries
may change their axis, rather than transversely, so,
either vertical or transverse incisions during
The study population was allocated into 2 groups
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4346-4352
Management of Postoperative Ventriculoperitoneal Shunt
Complications in Pediatric Patients
Abd Elkafy Sharaf Eldin Ebrahim, Usama Mohamed El Shokhaiby, Ahmed Aly Alkholy
Department of Neurosurgery, Faculty of Medicine, Al-Azhar University, Cairo
Corresponding author: Ahmed Aly Alkholy, Mobile: 01111819719, email: firstname.lastname@example.org
Background: Postoperative ventriculoperitoneal (VP) shunt complications in pediatric patients involves impaired
absorption of CSF from the subarachnoid space to the venous circulation via the arachnoid villi. It also involves
obstruction in flow of CSF from the ventricles to the subarachnoid space. Objective: To assess the proper
management of postoperative shunt complications. Patients and Methods: Retrospective study conducted in the
Neurosurgery Department of Al-Azhar University Hospitals and El-Sahel Teaching Hospital. Pediatric patients
from both genders including infants and pediatric patients till 12 years old who were having postoperative
ventriculoperitoneal shunt complications were assessed clinically and radiographically for the best management that
include either surgical or medical ones or both .Results: The management of postoperative VP shunt malfunction is
essential shunt revision of either proximal or distal catheters or the whole system if shunt disintegration is
suspected. The most common organisms in shunt infection were gram positive organisms (coagulase negative staph.
and staph. aureus). Conclusion: The most effective management plan is shunt revision. To prevent VP shunt
malfunction, we have to make sure of intraoperative closed, sterile and functioning shunt system.
Keywords: Cerebral spinal fluid, ventriculoperitoneal shunt, computed tomography.
lethargy, seizures and increasing head circumference).
Hydrocephalus is defined as dilatation of the
The initial diagnostic study is often a plain computed
ventricular system of brain resulting from an
tomography (CT) scan of the head. It clearly
imbalance between the production and absorption of
demonstrates the ventricular size and usually identifies
cerebral spinal fluid (CSF). This imbalance results in
whether a mass lesion is present or not (3).
an increased volume of CSF, dilation of the ventricular
system, and often increased intracranial pressure
AIM OF THE WORK
(ICP). Hydrocephalus onset can be acute and occur
This study was conducted to assess the proper
over hours or days. It may also be chronic and occur
management of postoperative shunt complications.
over months or years. Hydrocephalus can occur as an
isolated condition or one associated with numerous
PATIENTS AND METHODS
Retrospective study conducted in the
Hydrocephalus can then be classified as either
Neurosurgery Department of Al-Azhar University
Hospitals and El-Sahel Teaching Hospital.
Patients' clinical and imaging progress were
complications in pediatric patients involves impaired
reviewed to assess the postoperative shunt
absorption of CSF from the subarachnoid space to the
complications with trial of available methods to
venous circulation via the arachnoid villi. It also
prevent these complications.
involves obstruction in flow of CSF from the
ventricles to the subarachnoid space (1).
Patients presented with hydrocephalus are
This study was approved from the Ethical
treated with CSF shunt insertion. CSF shunt
Committee Faculty of Medicine Al-Azhar University
technology is one of the great advances in modern
after obtaining consents from parents
medicine. The survival rates and quality of life of
Inclusion criteria: Cases with hydrocephalus
dramatically since the introduction of shunts almost 50
postoperative complications (proximal obstruction
years ago. CSF shunt infection is one of the serious
distal end failure infection) within one year. Both
complications of shunt insertion that have decreased
genders with age group including infants and pediatric
over the years as smaller devices with biocompatible
patients till 12 years old.
materials have been introduced and as the surgical
technique and devices used to insert a shunt have been
complications due to other CSF diversionary devices
In infants and small children, typical
Postoperative complications with VP shunt in adults.
symptoms such as irritability and vomiting occur with
Diagnosis: Patients were diagnosed by
many other medical problems. Imaging studies are
clinical picture including medical and surgical ones.
indicated when these symptoms occur in the context of
Evaluation of cases:
findings suggestive of an intracranial process (e.g.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4353-4358
Mini- Laparoscopic Simple Nephrectomy Critical Assessment through
A Randomized Trial
Ahmed Y Abo Alsaad
Urology Department; Al-Azhar University, Faculty of Medicine (Damietta)
Background: The conversion from open to laparoscopic simple nephrectomy was considered as an initial and most dramatic
step toward progression, the second step is trying to miniaturization of the endoscope and instruments, in this study we
aimed to evaluate miniaturization of laparoscopic simple nephrectomy looking for reduction perioperative morbidity and
enhance cosmoses without significant operative disability.
Patient and Methods: We prospectively reviewed 120 patients (60 in each group) who underwent trans-peritoneal
conventional laparoscopy (CL) or mini laparoscopy (ML) simple nephrectomy between April 2015 and May 2018. The CL
was done using 3 to 4 ports ranged from 5 to12 mm in diamond manner distribution. ML was done using same ports number
and distribution ranged from 3- 5 mm except umbilical one was 10 mm. All operations were performed by same surgeon
Results: However, ML experienced a significant longer operative time, significant more blood loss and insignificant
increased conversion rate. The Post-operative data in the interest of ML were as follows; significantly lower pain scores,
lower hospital stay, earlier return to activities and significant increase of cosmoses score of patients, Lastly, port site hernia
was 6.7% in CL group and none in ML group (p = 0.042)
Conclusion: ML trans-peritoneal simple nephrectomy is associated with lower post-operative pain, hospital stay, early
return to normal activity, better cosmoses and less port site hernia. However operative time, blood loss and conversion rate
are potentially more than CL.
Keywords: Laparoscopy, simple nephrectomy, conventional laparoscopy, mini-laparoscopy.
perioperative pain and morbidity have yet to be
One of the driving forces behind the development of
determined. During the last years, several mini-
laparoscopy has always been to decrease the morbidity of
a classic open surgery. After first laparoscopic
laparoscopic urological procedures either diagnostic or
nephrectomy, which had been carried out by Clayman et
intervened have been successfully performed [5,6]. But, up
al. . Its beneficial outcome over laparotomy was proven
to now, overall available evidence across the literature
via Rozenberg et al. . This conversion was the initial
remains poor in fair assessment of mini-laparoscopic
and most dramatic step in this progression. Simple
nephrectomy as compared to conventional maneuver in
nephrectomy is the standard procedure for the removal of
the presence of expert surgeon and suitable equipments.
non-functioning benign kidney. Simple laparoscopic
We aimed to prove that mini-laparoscopic (ML)
nephrectomy may be a challenging procedure especially
nephrectomy can reduce the invasiveness of standard
during fibrous tissue dissection in post inflammatory
technique, improving cosmetic outcome and recovery
renal condition such as recurrent renal infections, renal
without significant operative and peri operative
stone diseases and previous renal surgeries. These
challenging conditions were considered as relative
contraindication to laparoscopy .
PATIENT AND METHODS
By the time surgeons have gotten more experience
We prospectively reviewed the records of 120
as well as rapid development of optical technology and
instrument design, laparoscopy gave a good chance to
nephrectomy for various renal conditions at our
miniaturization of the endoscope and instruments.
department between April 2015 and May 2018.
Looking for reduction of perioperative morbidity and
enhancement of cosmoses without significant operative
Ethical approval: The institutional ethics committee
disability. Mini-laparoscopy is defined as surgery with
for research approved the study ; informed consents
instruments that are 3-5 mm in diameter by the fact that
were obtained from all patients participating in the
ML allows minimal abdominal scar. Meanwhile,
study. Those who signed the informed consent were
preserving the key principle of triangulation. Early
results suggested that mini-laparoscopic procedures in the
hands of experienced laparoscopic surgeons appear to be
Exclusion criteria: Patients who had a contraindication
safe and effective with minimally perceptive scarring .
to laparoscopic surgeries (e.g. coagulopathy, American
Although promising, clear advantages in reducing
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4359-4366
Role of Multidetector Computed Tomography in the Diagnosis of Congenital
Thoracic Vascular Anomalies
Ahmad Abdlfattah Aborashed, Mohamed Ismail Hammad, Mohamed Aldosokey Saad Shaalan*
Department of Radio-Diagnosis, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed Aldosokey Saad Shaalan,
Email: email@example.com, Mobile: (+20) 01022848021
Background: multidetector row computed tomography (MDCT) provides reliable diagnostic information on the
normal anatomy of the aorta, pulmonary arteries & veins and vena cava, as well as congenital anomalies in pediatric
and adult patients.
Objective: in this study, we assess the role of multidetector CT scan in the evaluation and its ability to diagnose
congenital thoracic vascular anomalies as well as it is importance to recognize these anomalies early for proper
treatment and follow up, and also to prevent morbidities and mortalities.
Patients and Methods: the study was done in National Heart Institute, Ministry of health Egypt. It included a total of
80 patients (50 males and 30 females, their age ranged between, 2 days to 64 years and the mean age was 11.6±18 years),
who underwent MDCT (using GE 16/64- multislice CT) angiography from December 2018 to June 2019 and had
diagnosed of congenital thoracic vascular anomalies, or asymptomatic (incidentally discovered).
Results: a total of 80 patients had done 16/64-MDCT angiograms were considered to be of adequate diagnostic image
quality. Twenty-seven patients diagnosed as systemic arterial (aortic) anomalies corresponding to 33.7% in all cases, the
right aortic arch anomalies (9 cases) are represented the most frequent cases (11.2 %).
Conclusion: The ability to diagnose congenital vascular thoracic anomalies has evolved tremendously in the past 20 years.
Traditional methods of plain radiographs and barium swallow studies as well as invasive angiography have now been
supplanted with MR imaging and MDCT, minimally invasive methods that provide superb resolution and a large field of
Keywords: Multidetector Computed Tomography, Congenital Thoracic Vascular Anomalies
anatomy & disease. MDCT with multiplanner & three-
Congenital vascular anomalies of the thorax represent
dimensional reconstructions has become an important
an important group of entities that can occur either in
examination in the evaluation of systemic & pulmonary
isolation or in association with different forms of
vasculature and the trachea-bronchial tree (3).
congenital heart diseases. From a clinical viewpoint,
they can be totally silent or, because of associated
AIM OF THE WORK
cardiac anomalies or compression of the airway and
In the present study, we assess the role of
esophagus, result in cardiovascular, respiratory, or
multidetector CT scan in the evaluation and its ability to
feeding problems that result in morbidity and mortality.
diagnose congenital thoracic vascular anomalies as well
It is extremely important to have a clear understanding
as it is importance to recognize these anomalies early
of these entities, their imaging characteristics, and their
for proper treatment and follow up, and also to prevent
clinical relevance (1).
morbidities and mortalities.
The imaging armamentarium available to diagnose
Multidetector CT scan is not only for diagnosis of
these diverse conditions is ample and has evolved from
the congenial vascular anomalies but also for follow up
such traditional methods as chest radiography, barium
of post- operative sequalae.
esophagography, and angiography to new modalities
that include echocardiography, multidetector row CT
PATIENTS AND METHODS
(MDCT), and magnetic resonance imaging (MRI).
Selection of patients:
These imaging modalities have added safety, speed, and
The study was done in National Heart Institute,
superb resolution in diagnosis and, as in the case of
Ministry of health Egypt, included a total of 80 patients (50
MDCT, provide additional information about the
males and 30 females, their age ranged between 2 days to
airway and lung parenchyma, resulting in a more
64 years and the mean age was 11.6±18 years), who
comprehensive examination with greater anatomic
underwent MDCT (using GE 16/64- multislice CT)
angiography from December 2018 to June 2019 and had
Multidetectors CT scan is a noninvasive & rapid
diagnosed of congenital thoracic vascular anomalies, or
technique used for evaluation of the pediatric vascular
asymptomatic (incidentally discovered).
disease as an alternative to conventional angiography.
Three dimensions (3D) images allow excellent display
of vascular anomalies that can be used as a vascular road
The study was approved by the Ethics Board of Al-
map by surgeons (2).
Azhar University and an informed written consent was
Multidetector row computed tomography (MDCT)
taken from each participant in the study.
has changed the approach to imaging of thoracic
Anatomy of the Vitreous
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4367-4374
Ranibizumab Versus Aflibercept for Treatment of Diabetic Macular Edema
Attiat Mostafa Elsayed, Mostafa Mahmoud Mostafa, Ashraf Abdul-Ati Abdul-Moati Mohamed*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ashraf Abdul-Ati Abdul-Moati Mohamed, Mobile: (+20)01111500934,
Background: Diabetic macular edema, a manifestation of diabetic retinopathy that impairs central vision, affects
approximately 750,000 people in the United States and is a leading cause of vision loss. The increasing prevalence of
diabetes worldwide highlights the importance of diabetic macular edema as a global health issue.
Objective: The aim of this study is to compare the clinical effects and complications of intravitreal injection of
Ranibizumab and aflibercept as anti-VGEFs for treatment of patients with diabetic macular edema.
Patients and methods: This cross-sectional comparative study involved 40 eyes of 32 patients approved to have
diabetic macular edema. All subjects had age and sex matched and they are collected from the Ophthalmology
Department, Al-Agoza Police Hospital and Sayed Galal Hospital at the period of March 2017 to March 2019.
Results: Comparison between both groups I and II as regard UCVA and BCVA shows a statistically non-significant
difference (P>0.05). Visual acuities before and after 6 months of injection in both groups were compared and showed
a statistically significant difference as regard VA change (P < 0.05) in Ranibizumab group (I) and highly statistically
significant difference (P <0.01) in Aflibercept group (II). Although the effect of both groups in treatment seems to be
comparable, significance of aflibercept was superior to ranibizumab as it showed more success in treatment of DME.
Conclusion: Our findings suggest a possible benefit of aflibercept over ranibizumab for treating DME. This study
equally suggests better efficacy of aflibercept compared to ranibizumab, in patients with worse levels of initial visual
Keywords: Ranibizumab, Aflibercept, Diabetic Macular Edema.
Diabetic macular edema (DME) is one of the most
States reported using anti-VEGF therapy for initial
common causes of vision reduction in patients with
management of vision loss from diabetic macular edema
diabetic retinopathy (1). More recent meta-analysis of
involving the macular center (6).
22,896 diabetic patients showed that the prevalence of
Two commonly used intravitreous VEGF inhibitors
DME was 6.81%. There are several therapies for DME
-- aflibercept (Eylea, Regeneron Pharmaceuticals), and
bevacizumab (Avastin, Genentech) have been shown to
corticosteroids, subthreshold micropulse diode laser
be beneficial and relatively safe for the treatment of
photocoagulation, and pars plana vitrectomy (2).
diabetic macular edema. Of the anti-VEGFs only
Diabetic macular edema, a manifestation of diabetic
aflibercept and ranibizumab are approved by the Food
retinopathy that impairs central vision, affects
and Drug Administration (FDA) for this indication (6, 7).
approximately 750,000 people in the United States and
To provide comparative efficacy and safety data, the
is a leading cause of vision loss. The costs associated
Diabetic Retinopathy Clinical Research Network
with visual disability and treatments of diabetic macular
(DRCR.net), sponsored by the National Institutes of
edema are high. The increasing prevalence of diabetes
Health, conducted a randomized clinical trial to compare
worldwide highlights the importance of diabetic macular
intravitreous aflibercept and bevacizumab for the
edema as a global health issue (3).
treatment of diabetic macular edema involving the
Intravitreal (IV) injections of vascular endothelial
center of the macula and causing vision impairment (8).
growth factor (VEGF) antibodies have become the gold
standard therapy for DME worldwide. Several clinical
AIM OF THE WORK
trials strongly suggest that repeated intravitreal
The aim of this study is to compare the clinical
injections of anti-VEGF antibodies significantly
effects and complications of intravitreal injection of
improved the visual acuity of patients with DME (4).
Ranibizumab and aflibercept as anti-VGEFs for
However, frequent anti-VEGF injections are prohibitive
treatment of patients with diabetic macular edema.
for most patients because of the high costs of the anti-
VEGF drugs (2).
SUBJECTS AND METHODS
Vascular endothelial growth factor (VEGF) is an
This cross-sectional comparative study involved 40
important mediator of abnormal vascular permeability in
eyes of 32 patients approved to have diabetic macular
diabetic macular edema. Intravitreous injections of anti-
edema. All subjects had age and sex matched and they
VEGF agents have been shown to be superior to laser
are collected from the Ophthalmology Department, Al-
photocoagulation of the macula, the standard treatment
Agoza Police Hospital and Sayed Galal Hospital at the
for diabetic macular edema since the 1980s (5). In 2013,
period of March 2017 to March 2019.
an estimated 90% of retinal specialists in the United
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4375-4385
Single-Incision Mini Sling Compared with Transobturator Sling for
Treating Stress Urinary Incontinence in Women
Yahia Abd El Salam Wafa, Ahlam El Said Kamel, Mohammed Maghawry Maghawry El Sayed*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohammed Maghawry Maghawry El Sayed, Email: firstname.lastname@example.org,
Background: Stress urinary incontinence (SUI) is a common disorder that affects a large number of women and their
quality of life. It is defined as the involuntary leakage of urine on effort or exertion, or on sneezing or coughing
according to the standardized terminology of the International Continence Society.
Objective: The aim of this study was to compare both the efficacy and safety of the single-incision mini- sling (SIMS)
against the traditional trans-obturator (TOT) sling for the surgical management of SUI in women including; objective
and subjective cure rates, patient's satisfaction, and complication rates.
Patients and methods: This study was a prospective, double-blind clinical trial conducted on 100 women complaining
of symptoms of stress urinary incontinence, with or without urge incontinence, based on patient complaint, cough
stress test and ICIQ-SF score.
Results: Regarding the cough stress test after one year follow up, the number of participants who reported negative
results showed continuous progress in group (B) [42 women (89%)] after 38 (79.2%) in 6th month visit. On the other
hand, group (A) women showed a little drop [44 women (91.7%)] after 46 (93.9%) in 6th month visit. Yet, the two
groups showed insignificant difference at this follow up stage (P= 0.74).
Conclusion: The 1-year follow-up results of this prospective trial indicate that both procedures appear to be equally
effective for the treatment of SUI as regard the objective cure rates, whereas the SIMS procedure showed higher
subjective cure rates than the TOT procedure.
Keywords: Single-Incision Mini Sling, Transobturator Sling, Stress Urinary Incontinence, Women, clinical trial.
of potential advantages that attracted the attention of
Management options vary between conservative
many surgeons worldwide: shorter length polypropylene
and surgical procedures. Conservative approaches for
mesh, insertion through a single vaginal incision,
treatment of stress urinary incontinence (SUI) include
avoiding both retropubic and groin trajectories (in
pelvic floor exercises, electrical stimulation, laser
retropubic tension-free vaginal tape (RP-TVT) and
application and duloxetine therapy (1).
transobturator tension-free vaginal tapes (TO-TVT));
Although there is renewed interest in
and the ability to perform the procedure under local
conservative therapies for stress urinary incontinence,
anaesthesia and therefore a shorter recovery and earlier
surgery remains the primary choice in managing this
return to normal activities (2).
condition. Surgical options include paravaginal defect
repair, the Marshall-Marchetti-Krantz procedure, open
AIM OF THE WORK
and laparoscopic Burch urethropexy, and sling
The aim of this study was to compare both the
procedures (1). As regards sling use, it was found that
efficacy and safety of the single-incision mini- sling
midurethral slings techniques achieved high cure rates in
against the traditional trans-obturator sling for the
women with SUI and have become the mainstay for
surgical management of SUI in women including;
surgical treatment of SUI in women over the last 2
objective and subjective cure rates, patient's satisfaction,
decades (2). One of the modalities of such procedures is
and complication rates.
the transobturator midurethral tape (TOT). It was
introduced to minimize the complications of the previous
PATIENTS AND METHODS
retropubic tapes, which include injury to the bladder,
major vessels, and bowel. TOT has shown similar safety
The present study is a prospective clinical study
and efficacy to Tension-free vaginal tape (TVT) in a
aimed to compare both the efficacy and the safety of the
recently published randomized trials and meta-analyses
single-incision mini sling (SIMS) and TOT sling for
treating stress urinary incontinence in women.
In an effort to maintain efficacy while
Study Setting and Timing:
eliminating some of the side effects, a new generation of
Obstetrics and Gynecology Department of Al-
tapes has been developed, called 'single incision tapes or
Hussein hospital, Al-Azhar University, Cairo Egypt.
'mini-slings'. They are designed to be shorter (in length)
Obstetrics and Gynecology Department of Ahmad
than standard mid-urethral slings and do not penetrate
Maher teaching hospital, General Organization of
the tissues as deeply as standard slings. It was therefore
Teaching Hospitals and Institutes, Cairo Egypt.
thought that they would cause fewer side effects while
being effective (4). Single incision tapes have a number
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4386-4389
Laboratory Evaluation of Immunotherapy in Treatment of Allergic Airway Diseases
Mohamed Saed Elshorbagy1, Ismael Abdelmonem Atia2,
Nagah Mohamed Abou-Mohamed1 and Abdelsalam Fathy Abdelsalam Mohamed1*
1-Immunology Unit of Clinical Pathology Department, 2- Chest Diseases Department,
Faculty of Medicine, Al-Azhar University
*Correspondence author: Abdelsalam Fathy Abdelsalam Mohamed, Mobile: (+20) 01016704537,
Background: Immunotherapy is a well-established therapeutic approach for treatment of IgE-mediated allergic diseases. It's
the only modality that targets the definite cause of allergy, blocks the pathophysiologic aspect of the disease and possibly
prevents the development of a new sensitization. Objective: The aim of this work is evaluation of the response of allergic
airway diseases to allergen specific immunotherapy. Patients and methods: We enrolled 50 patients with allergic airway
diseases receiving subcutaneous immunotherapy (SCIT) shots and 30 control patients on pharmacotherapy. The study evaluated
clinical assessment of allergic symptoms, medication used and laboratory markers (including specific and total IgE and
eosinophil count) before and after 2 years of immunotherapy. Results: Our results showed that there was a significant decrease
in total and specific IgE and eosinophil count after SCIT. Also, SCIT effectively reduced the allergic symptoms and the need
Conclusion: Subcutaneous immunotherapy could alleviate allergic symptoms and reduce airway inflammation in allergic
Keywords: allergic airway diseases, allergy immunotherapy, allergy injections, subcutaneous immunotherapy, IgE.
immunotherapy from other treatment modalities.
Respiratory allergies are a major health problem
Therefore, spending time, effort, and money on
in both developed and developing countries. Over the
immunotherapy represents an investment that will return
past four decades, there has been a significant increase
sustained benefits from improved prognosis and a relieved
in the prevalence of allergic disease. Respiratory
burden of disease. The future aim for allergy
allergies are the most common chronic diseases among
immunotherapy is to expand the evidence base concerning
adolescents and young people. The increase is
the benefits of disease modification (4).
particularly problematic in children (1).
Asthma is a chronic inflammatory disorder of the
AIM OF THE WORK
airways associated with airway hyper-responsiveness and
The aim of this work is evaluation of clinical
airflow obstruction. Allergic rhinitis implies a blocked or
and some laboratory markers of allergy in allergic
runny nose, sneezing, and itching secondary to
patients (bronchial asthma + allergic rhinitis) under
immunoglobulin IgE-mediated inflammation of the nasal
subcutaneous allergen specific immunotherapy for 2
mucosa. Rhinitis often occurs in combination with
conjunctivitis. The genetic predisposition to develop IgE-
mediated sensitivity to common aeroallergens is the
PATIENTS AND METHODS
strongest predicting factor for the development of
This study was performed on eighty (80) persons with
rhinoconjunctivitis as well as asthma. The allergic
allergic airway diseases (bronchial asthma + allergic
reaction is biphasic, with an immediate reaction occurring
rhinitis), with mean age 27 years. They were divided into 2
within minutes following allergen exposure and a late-
main groups: Fifty (50) allergic patients as a case group
phase reaction occurring hours later (2).
(Group 1) were treated by immunotherapy and
Clinical guidelines recommend a combination of
pharmacotherapy and thirty (30) allergic patients of matched
patient education, allergen avoidance, pharmacotherapy,
age and sex as control group (group 2) treated by
and allergy immunotherapy for treatment. Drugs are
available for the treatment of allergic symptoms, but many
patients report insufficient symptom control. Importantly,
pharmacotherapy has no effect on the progression of the
Patients were recruited from Chest Clinics in Al-
disease and treatment has to be administered repeatedly
Hussein University Hospital and received the
as long as symptoms prevail, which often means life-
immunotherapy and investigated at Immunology Unit in
the Clinical Pathology Department.
Allergy immunotherapy is a causal treatment targeting
the underlying allergic disease, affecting basic
immunological mechanisms and resulting in the induction
Research participants were selected randomly as regard
of immunological tolerance. Induced tolerance implies
identification, age, sex.
disease modification, the clinical effects of which are
The study was approved by the Ethics Board of Al-
sustained symptom relief after completed treatment and/or
Azhar University and an informed written consent
prevention of disease progression. The capacity to alter the
was taken from each participant in the study.
natural course of the disease differentiates allergy
Chapter 3:Nursing role to relieve Minor Discomforts
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4390-4395
Efficacy of Intralesional Methotrexate in the Treatment of Plantar Warts
Hamed Mohamed Abdo, Emad Mahmoud Elrewiny, Mohammed Shaban Elkholy*
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohammed Shaban Elkholy, Mobile: (+20) 1068281377, Email: email@example.com
Background: Warts are tumors or growths caused by infection with Human Papilloma virus (HPV). Currently,
over 170 HPV types have been identified. They are common presenting disease in children and adolescents which
spread by direct contact or autoinoculation.
Objective: The present work aimed to study the efficacy and safety of intralesional injection of methotrexate
(MTX) for treatment of plantar warts and its possibility to be an alternative for the ordinary treatment.
Patients and methods: sixty Egyptian patients presented with plantar warts were enrolled into our study. The
patients were recruited from the Dermatology Outpatient Clinic of Al-Azhar University Hospital in the period
from January 2019 to June 2019. Patients were classified into; control group (30 patients) that were Injected by
normal saline and study group (30 patients) that were injected by MTX.
Results: In intralesional MTX group, 2 patients (6.7%) showed complete improvement, 8 patients (26.7%)
showed partial improvement and 20 patients (66.7%) showed no improvement. In intralesional saline group, 3
patients (10%) showed complete improvement, 4 patients (13.3%) showed partial improvement and 23 patients
(76.7) showed no improvement.
Conclusion: In this study, there was no statistically significant difference between the therapeutic responses to
intralesional MTX injection and saline. Intralesional MTX injection was safe but less effective. No serious side
effects were reported. Reported adverse events were local reactions in the form of swelling, pain and infection.
Keywords: Intralesional Methotrexate, Plantar Warts
PATIENTS AND METHODS
Warts are benign proliferations of skin and mucosa
Sixty Egyptian patients presented with
caused by the human papilloma virus (HPV).
plantar warts were enrolled into our study. The
Currently, Over 170 HPV types have been identified.
patients were recruited from the Dermatology
Certain HPV types tend to infect skin at particular
Outpatient Clinic of Al-Azhar University Hospital in
anatomic sites, however, warts of any HPV type may
the period from January 2019 to June 2019.
occur at any site. Warts are transmitted by direct or
indirect contact, and predisposing factors include
Ethical approval and written informed consent:
disruption to the normal epithelial barrier (1).
Informed written consents were obtained from all
There are several modalities for treatment
patients. The approval from the Research Ethical
of warts including cryotherapy, electrocoagulation,
Committee of the Faculty of Medicine, Al-Azhar
topical salicylic acid, topical 5-fluorouracil, and laser
University Hospitals also was obtained.
surgery. All of these treatment options can be painful,
time consuming, and/or expensive, and none is
Both males and females.
considered the gold standard (2). Treatments for warts
Age: 18-60 years old.
have also included intralesional injections of
Single or multiple plantar warts.
tuberculin purified protein derivative (PPD), measles,
mumps, and rubella (MMR) vaccine and Candida
Pregnancy and lactation.
albicans antigen (candidin). This treatment approach is
Age <18 or > 60 years old.
known as intralesional immunotherapy as it is thought
Immunosuppression or being under any kind of
that these modalities activate the immune system to
recognize the virus, leading to wart clearance (3).
Methotrexate (MTX) is an anti-proliferative,
History of any bleeding/clotting disorder.
anti-inflammatory and immuno-modulating agent, which
Using of anticoagulants e.g warfarin or NSAIDs
was approved by the US food and drug administration
(FDA) in 1971 (4).
Chronic systemic diseases such as chronic renal
AIM OF THE WORK
failure, hepatic insufficiency and cardiovascular
To study the efficacy and safety of
intralesional injection of methotrexate for treatment of
Concurrent use of systemic or topical treatments of
plantar warts and its possibility to be an alternative for
the ordinary treatment.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4396-4401
Outcome Predictors of Augmentation Urethroplasty Using
Dorsal Onlay Buccal Mucosal Graft
Ahmed Mohammed El-Shazly*, Hassan Abdelazim Mohammed, Mamdouh Ahmed Farid
Department of Urology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Mohammed El-Shazly, Mobile: (+20)1143939192, Email: firstname.lastname@example.org
Background: The incidence and timing of stricture recurrence and factors affecting urethroplasty outcomes remains
incompletely characterized. Objective: To evaluate and determine the factors predicting the outcome of dorsal onlay buccal
mucosal graft (BMG) urethroplasty. Patients and Methods: We analyzed the records of 115 patients underwent dorsal
onlay BMG urethroplasty at Al-Azhar University Hospitals in Cairo, Egypt, from January 2015 to April 2018, with a
minimum of 12 months of followup. The risk factors examined were patient age, stricture etiology, site, length, width,
diabetes, hypertension, smoking, obesity, previous visual internal urethrotomy (VIU) and urethroplasty, early postoperative
complications, extravasation at first periurethral ascending cystourethrogram (ACUG) and stricture width.
Results: Average patients age was 38 years. Stricture free rate was 90.4% and mean followup period was 47.5 months (range
12 to 67). Average stricture length was 5.9 cm, average stricture width was 6.3 mm, 63.4% of patients were with previous
VIU, and 9.5% were with previous urethroplasty. On univariate analysis, etiology, site of stricture, previous four or more
times VIU, DM, obesity, stricture length, postoperative (post op.). wound infection and leakage at first periurethral ACUG
were associated with stricture recurrence. On multivariate analysis panurethral stricture (HR 280.6, 95% CI 9.1-8622.8, p
=0.001), traumatic stricture (HR 17.1, 95% CI 2.4-123.4, p =0.005) were independent predictors of stricture recurrence.
Stricture width, previous urethroplasty, the number of failed endoscopic procedures less than 4 times, smoking, HTN and
patient age did not affect the recurrent stricture rate.
Conclusion: panurethral and traumatic strictures were independent predictors of stricture recurrence.
Keywords: Dorsal onlay urethroplasty, predictors of urethroplasty failure, stricture length.
follow up, stricture location and small cohort size. These
The urethra is a unique tube of epithelium and
factors make it difficult to draw meaningful conclusions
there is no better tissue than the urethra to replace.
from the existing literature. Some of the inconsistency can
However, in the case of a narrowing of the long frontal
be explained by the fact that to our knowledge no group has
urethra, the process of circumcision and primary
examined a comprehensive list of all known potential
anastomosis (EPA) is impossible. Skin flaps and dermis
confounding variables. This increases the risk of
have been used to rebuild these long restrictions. However,
underestimating or overestimating the association between
the skin of the penis is not suitable for all cases, especially
a given variable and the treatment outcome. Factors most
lactus sclerosis (LS) or recurrent cases that do not contain
often associated with stricture recurrence after
sufficient skin. BMG gained much interest because of its
urethroplasty in general are stricture length, prior failed
excellent short and long-term results, low postoperative
procedures (urethroplastic or endoscopic), smoking and
complication rate and relative ease of use (1).
lichen sclerosis. Other occasionally identified factors
BMGs were used in penile, bulbar and even
include diabetes, stricture etiologies, preoperative
panurethral strictures using different techniques with a high
uroflowmetry findings and surgeon experience (6).
success rate (2-4). Stricture recurrence remains a reality. The
In this series we studied factors most often
incidence and timing of stricture recurrence after definitive
associated with stricture recurrence after urethroplasty such
as stricture etiology, stricture length, history of previous
characterized. A review of the literature reports recurrence
intervention, overall comorbidity and obesity, in addition
rates ranging from 8.3% to 18.7%, with wide variation in
to a new non studied variable; stricture width.
incidence likely related to differences in stricture and
AIM OF THE WORK
patient characteristics, surgical approach and technique,
To evaluate and determine the factors predicting
length of follow-up, and method of surveillance (5).
the outcome of dorsal onlay BMG urethroplasty.
There is inconsistency in the literature regarding
which factors are associated with stricture recurrence after
PATIENT AND METHODS
urethroplasty in studies with univariate as well as
This observational retrospective and prospective
multivariate analysis. These inconsistencies could be
study included all patients who underwent dorsal onlay
related to the surgeon preference of urethroplasty
buccal mucosal graft urethroplasty at Al-Azhar University
Hospitals (Al-Hussein and Sayed Galal), Cairo, Egypt,
inhomogeneity of urethroplasty populations, duration of
during the period from January 2015 to April 2018.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4402-4405
Nasolabial cyst: Transnasal Marsupialization versus Sublabial Technique
Ahmed M. Abdelfattah1* and Ahmed Ibrahim Zaghloul2
Otorhinolaryngology Department, Faculty of Medicine, 1Cairo and 2Damietta,
Al-Azhar University, Egypt
*Corresponding author: Ahmed M. Abdelfattah, E-mail: email@example.com
Background: nasolabial cyst is relatively rare soft tissue lesion of nasal alar region. It is nonodontogenic in origin.
Surgical sublabial excision is the treatment of choice for nasolabial cyst (NLC). However, it is associated with high
complication rate. The transnasal marsupialization was introduced as an alternative modality of surgery.
Aim of the work: to compare between both approaches to assess the intra-and post-operative outcome.
Patients and Methods: twenty two patients presented by unilateral nasolabial cyst were included in the study and
divided into two equal groups: endoscopic transnasal marsupialization (TM group; 11 patients) and sublabial surgical
excision technique (SL group; 11 patients). For all patients, operative time, postoperative pain, postoperative
complications and recurrence of the NLC were documented.
Results: the operative time was significantly shorter in TM when compared to SL group (18.54±3.01 vs. 44.63±5.4
minutes respectively). Postoperative VAS was lower in TM when compared to SL group (3.09±0.83 vs. 6.09±1.13
respectively). The overall complications were significantly lower in TM group (18.2%) when compared to SL group
Conclusion: the transnasal endoscopic marsupialization is preferred than conventional sublabial approach as it had
shorter operative time, less postoperative pain and lower overall complications rate.
Keywords: nasolabial cyst, sublabial, transnasal, marsupialization.
surgical excision of NLC and may be associated with
Nasolabial cyst (NLC) is a developmental cyst
better complication profile.
of non-odontogenic origins. It typically arises in the
maxillofacial soft tissue(1,2).usually, the NLC is related to
AIM OF THE STUDY
soft tissue of ala nasi or to the nasolabial(3), and may
It is to compare between transnasal
secondarily comprise the bone(4).
marsupialization approach and standard sublabial
The incidence of NLC is about 0.7% of all cysts
surgical excision technique as regard to intra-and post-
of the jaws(1,5), and about 2.5% of all cysts of non-
odontogenic origin(6,7). However, Choi et al.(8) reported
8 cases of NLC in only one year and proposed that NLCs
PATIENTS AND METHODS
maybe more common than previously reported.
The present study is a prospective randomized
The NLC is usually unilateral. However,
trial. It was carried out at Al-Azhar University Hospitals;
bilateral existence was reported in about 10%(5,7). The
Damietta and Bab-elsheria. The study included 22
NLC is asymptomatic unless it was progressed to cause
patients who were presented by nasolabial cyst (10 from
nasal obstruction, complication by infection or lead to
Al-Azhar Damietta University Hospital and 12 from
development of deformity by size enlargement(3,5).
Bab-elsheria University Hospital). They were equally
Many therapeutic interventions were presented
and randomly allocated into one of two groups: the first
for the management of the NLC e.g., endoscopic
included those who were underwent endoscopic
marsupialization, surgical excision, aspiration, drainage
transnasal marsupialization (TM group) and those who
and injection of sclerotic materials. All these modalities
underwent sublabial surgical excision technique (SL
group). All patients had unilateral nasolabial cyst.
marsupialization, had a high rate of recurrence(6).
Diagnosis of NLC was made on the basis of anatomic
surgical excision through a sublabial approach
location, computed tomographic findings, and
has been the most popular and well-established
procedure for the management of nasolabial cysts as it
In the transnasal endoscopic marsupialization
provides wide surgical field with complete excision of
group, marsupialization was done under local
the cyst. However, the transnasal endoscopic
anesthesia. The anesthesia was accomplished by cotton
marsupialization presents a good alternative as it is a
pledget soaked in a solution of 2% lidocaine and 0.1%
simple, less invasive, easy to perform and effective
epinephrine. Then, the anterior nasal cavity, vestibular
procedure(1,3). However, after successful transnasal
area, and mucosal surface over the cyst were infiltrated
endoscopic marsupialization, the cyst may be converted
locally with 2% lidocaine containing 1: 100,000
to a paranasal sinus filled with air(6).
epinephrine. An elliptical incision was made over the
Here, we hypothesized that transnasal
roof of the projected cyst. The rigid, straight, 4-mm
marsupialization could be as effective as the standard
diameter 0 and 30 nasal endoscopes were used and the
NLC opening was widened with a microdebrider to at
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4406-4416
Early High Frequency Oscillatory Ventilation in Prone Position in
Pediatric Acute Respiratory Failure
Mona Mohammed Hamam*, Khaled Talaat Muhammad,
Sahar Abd-Elazim Abd-Elaziz and Ahmed Ibrahim Harkan
Department of Pediatric Medicine, Faculty of Medicine, Tanta University, Egypt
*Corresponding author: Mona Mohammed Hamam, Mobile: 01155844537; Email: firstname.lastname@example.org
Background: High frequency oscillatory ventilation (HFOV) is a form of nonconventional ventilatory support
employed for severe respiratory failure in children.
Aim of the study: Was to compare the impact of early high frequency oscillatory ventilation (within 24 hours of
endotracheal intubation) versus pressure controlled mechanical ventilation (P-CMV) and /or late high frequency
oscillatory ventilation in patient with acute respiratory failure in prone position. Patients and Methods: Thirty-nine
pediatric patients (19 males and 20 females) aged (2 to 156 months) were admitted in pediatric intensive care unit
(PICU), Tanta University Hospital. They were categorized into 3 groups: Group I; 15 patients were monitored on
early HFOV (within 24 hours from intubation). Group II; 18 patients were monitored on P-CMV. Group III; 6
patients were monitored on late HFOV (24 hours after intubation). All patients were subjected to scoring systems for
Pediatric Risk for Mortality (PRISM III) and Sequential Organ Failure Assessment (SOFA) they were also
monitored for [pulse oximetry, blood pressure, oxygenation Index, oxygenation saturation index, lung mechanics
(compliance and resistance), ventilation parameters (HFOV and P-CMV) and Trans-Esophageal Doppler. Results:
PP had superiority over SP in improvement of oxygenation / ventilation parameters demonstrated by the increased
(PaO2, SaO2,pH) /decreased PaCO2, OI, OSI, FiO2 without harmful affection on HD. PP improve lung mechanics
demonstrated by increased lung compliance with decreased airway resistance. PP can be safely applied in pediatrics.
Conclusion: Early HFOV had superiority over CMV/late HFOV showed by the improvement in
Keywords: High Frequency Oscillatory Ventilation, Prone Position, Pediatric, Acute Respiratory Failure.
The use of protective ventilatory strategies that
admitted in PICU, Tanta University Hospital. They
prevent further lung injury associated with MV is a
were divided in to 3 groups: Group I: 15 patients
major concern. HFOV and PP are protective
were monitored on early HFOV (within 24 hours from
ventilatory strategy, as they optimize alveolar
intubation). Group II: 18 patients were monitored on
recruitment and lung volume, as well as improve
P-CMV. Group III: 6 patients were monitored on late
oxygenation. HFOV appears to represent an important
HFOV (24 hours after intubation).
therapeutic option in ventilatory support of children
with respiratory failure (1).
Inclusion criteria: All mechanically ventilated
HFOV results in a tidal volume that is smaller than
patients with ARF admitted to PICU of Tanta
the anatomic dead space and is considered an
University Hospital on either: HFOV or P-CMV
advanced mode of ventilation (2).
Exclusion criteria: Patient expected to be extubated
AIM OF THE STUDY
within 24 hours or contraindicated for prone position
It was to compare the impact of early
or cases with inability to introduce cardioQ probe like
high frequency oscillatory ventilation (within 24 hours
of endotracheal intubation) versus pressure controlled
mechanical ventilation (P-CMV) and /or late high
Written informed consent was obtained from the
parents or guardians of each child. The study was
ventilation in patient with acute respiratory failure in
approved by the Ethics Committee of Faculty of
Medicine, Tanta University.
PATIENTS AND METHODS
Collection of data: All the studied patients were
This prospective study was carried out during
subjected to the following:
the period from June 2017 to October 2018 upon 39
1. Detailed history taking with special emphasis
and 20 females) aged from 2 to 156 months and were
o Demographic data: name, age, sex and socio-
- Early High Frequency Oscillatory Ventilation in Prone Position in
- Pediatric Acute Respiratory Failure
- This prospective study was carried out during the period from June 2017 to October 2018 upon 39 pediatric patients (19 males and 20 females) aged from 2 to 156 months and were admitted in PICU, Tanta University Hospital. They were divided in to 3 grou...
- Inclusion criteria: All mechanically ventilated patients with ARF admitted to PICU of Tanta University Hospital on either: HFOV or P-CMV
- Exclusion criteria: Patient expected to be extubated within 24 hours or contraindicated for prone position or cases with inability to introduce cardioQ probe like esophageal stricture.
- Written informed consent was obtained from the parents or guardians of each child. The study was approved by the Ethics Committee of Faculty of Medicine, Tanta University.
- Collection of data: All the studied patients were subjected to the following:
- 1. Detailed history taking with special emphasis on:
- o Demographic data: name, age, sex and socio-economic status.
- o Cause of PICU admission.
- o Initial symptoms: date of onset of symptoms, its duration and course of illness.
- o Cardiac symptoms as dyspnea, cyanosis, edema and palpitation.
- o Pulmonary symptoms as: wheezes, respiratory distress and cough.
- 2. Thorough clinical examination including vital signs with special emphasis on:
- o Anthropometric measurements: weight, height and vital data.
- o Cardiac and respiratory systems, e.g.: heart sounds, murmurs, breathe sounds and additional sounds.
- 3. Routine Laboratory Investigations:
- o Complete Blood Count (CBC).
- o C- reactive protein (CRP).
- o Arterial blood gases (ABGs) sample taking from arterial blood [blood gas analyzer Stat Profile ® pHOx ® Series plus nova biomedical UK: Innovation house Aston lane South, Runcan, Cheshire WA7, 3FY, UK].
- 4. Scoring systems for patients:
- o Pediatric Risk for Mortality (PRISM) III scoring was obtained from each patient immediately on admission (3).
- o Sequential Organ Failure Assessment (SOFA) scoring was obtained from each patient 48 hours after admission (4).
- 5. Monitoring: All patients were turned to the PP for half an hour. Before and at the end of PP time, the patients were monitored for the selected measurements that were repeated twice in consecutive two days. They were monitored for:
- o Noninvasive investigation:
- - Pulse oximetry (Bedside monitor, BSM-4113K, Nihon Kohden Corp., Tokyo, Japan) over full-perfused area (mostly over digits of upper limbs) to continuously monitor SaO2.
- - Blood pressure (Bedside monitor, BSM-4113K, Nihon Kohden Corp., Tokyo, Japan).
- o Oxygenation Index: (FiO2 × MAP/ PaO2) × 100 (5).
- o Oxygenation Saturation Index: (FiO2 × MAP/SaO2) × 100
- o Lung mechanics(6):
- B- Resistance; Raw=P plat /peak inspiratory flow rate.
- o Ventilation parameters e.g.:
- 2-P-CMV: FiO2, TI, PIP, RR and PEEP. Ventilation was accomplished using a Raphael color ventilator, [Model X1, Hamillton medical, Hamilton Medical AG, CH- 7403Rhazuns, Switzerland]
- o Trans-Esophageal Doppler (7).
- o CardioQ-ODM manufactured by Deltex Medical of Chichester UK was used [Cardio Q ODM, Model No 9051-6935, DELTEX MEDICAL LTD PO19 8 TX UK, 2008].
- o Pediatric Doppler probes were used: (KDP72) Doppler Probe (Product Code: 9081-7001) 72-hour pediatric oral Doppler probe.
- Ethical approval:
- The study was approved by the Ethics Board of Tanta University and an informed written consent was taken from each participant in the study.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4417-4426
Prevalence and Risk Factors of Pneumothorax among
Patients in Pediatric Intensive Care Unit
Noha Hasab El Naby Radwan*, Khaled Talaat Muhammad,
Sahar Abd-Elazim Abd-Elaziz and Ahmed Ibrahim Harkan
Department of Pediatric Medicine, Faculty of Medicine, Tanta University, Egypt
*Corresponding author: Noha Hasab El Naby Radwan; Mobile: 01001239362; Email: Noha_Radwan@yahoo.com
Background: Pneumothorax should be considered a medical emergency and requires a high index of suspicion and
prompt recognition and intervention. Aim of the work: was to study the prevalence and risk factors of pneumothorax
among children in Tanta PICU. Subjects and Methods: Sixty pediatric patients aged from 2 to 180 months (29 males
and 31 females) admitted to PICU, Tanta University Hospital and were divided into 3 groups: Group 1: 20 patients on P-
CMV. Group II: 20 patients on HFOV: Group III: 20 non-ventilated patients. Each group was further divided into two
subgroups: Subgroup I (SGI): without pneumothorax, Subgroup II (SGII): with pneumothorax. All patients were
subjected to scoring systems for Pediatric Risk for Mortality (PRISM III) and Sequential Organ Failure Assessment
(SOFA). They were also monitored for [pulse oximetry, blood pressure, oxygenation index, oxygenation saturation
index, lung mechanics (compliance and resistance), ventilation parameters (HFOV and P-CMV) and trans-esophageal
Results: Incidence of pneumothorax in patients on P-CMV is higher than who on HFOV and non- ventilated group. The
significant risk factors of pneumothorax were HR, RR, pH, PCO2, HCO3, PaO2, SaO2, OI, MAP, FIO2, PIP, CO, CI,
SVRI, SOFA and PRISM III score. X-ray showed equal results to CT chest in the diagnosis of pneumothorax without the
disadvantage of exposure to high radiation accompanied the use of CT. Conclusion: Pneumothorax in P-CMV patients
occur with higher ventilatory settings. Most cases of pneumothorax have underlying lung disease as pneumonia and
ARDS. Mortality rate is higher among patients with pneumothorax.
Keywords: Pneumothorax, Pediatric, Intensive Care Unit, Risk factors
Pneumothorax is defined as the accumulation of air
between the visceral and parietal pleura that leads to
Ethical approval: Written informed consent was
partial or complete collapse of lung (1).
obtained from the parents or guardians of each child.
Ironically, the higher incidences of pneumothorax in
The study was approved by the Ethics Committee
ventilated neonates with mild increase among those
of Faculty of Medicine, Tanta University.
receiving CPAP and dramatic increase with mandatory
modes of ventilation have been addressed by only few
Collection of data: All the studied patients were
Aim of the work was to study the prevalence and risk
day of admission to Tanta PICU:
factors of pneumothorax among children in Tanta PICU.
1. Detailed history taking with special emphasis on:
Demographic data: name, age, sex, socio-economic
PATIENTS AND METHODS
This prospective study was carried out during the
Cause of PICU admission.
period from July 2017 to November 2018. Cases were
Initial symptoms: date of onset of symptoms and its
selected from Pediatric Intensive Care Unit (PICU),
duration and course of illness.
Tanta University Hospital. It included 60 pediatric
Cardiac symptoms as dyspnea, cyanosis, edema,
patients aged from 2 to 180 months (29 males, 31
females) and were divided into 3 groups:
Pulmonary symptoms as: wheezes, respiratory
Group 1: 20 patients on P-CMV.
distress and cough.
Group II: 20 patients on HFOV.
2. Thorough clinical examination including vital
Group III: 20 non-ventilated patients. Each group
signs with especial emphasis on:
was further divided into two subgroups: Subgroup I
Anthropometric measurements: weight, height and
(SGI): without pneumothorax, Subgroup II (SGII): with
Cardiac and respiratory systems, e.g.: heart sounds,
Inclusion criteria: All patients admitted to PICU aged
murmurs, breath sounds and additional sounds.
from 2 months to180 months.
3. Routine Laboratory Investigations
Exclusion criteria: Patients with congenital lung
- Prevalence and Risk Factors of Pneumothorax among
- Patients in Pediatric Intensive Care Unit
- This prospective study was carried out during the period from July 2017 to November 2018. Cases were selected from Pediatric Intensive Care Unit (PICU), Tanta University Hospital. It included 60 pediatric patients aged from 2 to 180 months (29 males, ...
- Group 1: 20 patients on P-CMV.
- Group II: 20 patients on HFOV.
- Group III: 20 non-ventilated patients. Each group was further divided into two subgroups: Subgroup I (SGI): without pneumothorax, Subgroup II (SGII): with pneumothorax.
- Inclusion criteria: All patients admitted to PICU aged from 2 months to180 months.
- Exclusion criteria: Patients with congenital lung disease.
- Ethical approval: Written informed consent was obtained from the parents or guardians of each child.
- The study was approved by the Ethics Committee of Faculty of Medicine, Tanta University.
- Collection of data: All the studied patients were subjected to the following on the first day of admission to Tanta PICU:
- 1. Detailed history taking with special emphasis on:
- 2. Thorough clinical examination including vital signs with especial emphasis on:
- 3. Routine Laboratory Investigations
- 4. Scoring systems for patients:
- 5. Monitoring: All the patients are monitored for:
- A) Noninvasive investigation:
- B) Oxygenation Index(5): (FiO2 × MAP/ PaO2)× 100
- C) Oxygenation Saturation Index: (FiO2 × MAP/SaO2) × 100
- D) Lung mechanics:
- o Resistance; Raw=P plat/peak inspiratory flow rate (6).
- E) Ventilation parameters e.g.:
- 2-P-CMV: FiO2, TI, PIP, RR and PEEP. Ventilation was accomplished using a Raphael color ventilator, [Model X1, Hamillton medical, Hamilton Medical AG, CH- 7403Rhazuns, Switzerland].
- F) Trans-Esophageal Doppler (7).
- o CardioQ-ODM manufactured by Deltex Medical of Chichester UK was used [Cardio Q ODM, Model No 9051-6935, DELTEX MEDICAL LTD PO19 8 TX UK, 2008].
- o Pediatric Doppler probes were used: (KDP72) Doppler Probe (Product Code: 9081-7001) 72-hour pediatric oral Doppler probe.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4427-4431
A Comparison Between Bevacizumab and Mitomycin C in
Treatment of Primary Pterygium
Alaraby Abd Elghany Nassar, Abd Elmagid Mohamed Tag Eldin, Khalid Fathy Abd Elnaby Ashour*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Khalid Fathy Abd Elnaby Ashour,
Mobile: (+20)1000235237, Email: email@example.com
Background: A pterygium is a fleshy, wing-shaped growth from the conjunctiva, crossing over the limbus onto the
cornea. The tissue is fibrovascular and can occur over the nasal or temporal cornea. It can be a bilateral process and
asymmetric with one eye affected by a larger pterygium than the other.
Objective: To compare between the effects of intraoperative subconjunctival injection of Bevacizumab (Avastin) and
intraoperative topical Mitomycin C on the outcome of primary pterygium surgery as regard efficacy and complications.
Methods: Prospective, randomized, comparative clinical study was done on twenty eyes of twenty patients complaining
of primary pterygium of variable duration that were surgically treated by simple excision. In addition to surgical excision,
postoperative subconjunctival injection of bevacizumab was done for 10 eyes (group A), and postoperative application
of mitomycin C (MMC) was done for 10 eyes (group B). The postoperative outcome was followed clinically for a
minimum of 6 months and the main outcome criteria were recurrence rate and postoperative complications.
Results: A significant high recurrence rate was found in bevacizumab group (60%) in comparison to MMC group (10%).
In group A subconjunctival hemorrhage was detected in 2 cases while no complications were detected in group B.
Conclusion: A single intraoperative subconjunctival injection of bevacizumab had decreased the recurrence rate after
primary pterygium excision which seems to be marginally superior to bare sclera excision alone, but does not give a
more desirable recurrence rate with insignificant complications as subconjunctival hemorrhage which resolved within 2
Keywords: Pterygium, Bevacizumab, Mitomycin C.
factors. It also may damage DNA in predisposed
A pterygium is a fleshy, wing-shaped growth from the
individuals. However, integration of factors associated
conjunctiva, crossing over the limbus onto the cornea.
with pterygium occurrence has not been reported (2).
The tissue is fibrovascular and can occur over the nasal or
Despite evolutional and modification of pterygium
temporal cornea. It can be a bilateral process and
excision techniques, recurrence continues to be a limiting
asymmetric with one eye affected by a larger pterygium
factor for success (3).
than the other. In addition, two pterygia can affect a single
The challenge continues to find an adjunctive agent
eye, one nasally and the other temporally. The pterygium
with long-term safety and efficacy (4).
consists of collagen tissue that is hyperplastic and
Bevacizumab (Avastin) is a recombinant, humanized
anti-VEGF monoclonal antibody. It was approved by the
(degeneration of collagen fibers) (1).
United States food and drug administration as a first line
Pterygia can impair vision through altered tear film,
treatment for metastatic colorectal cancer in combination
induced astigmatism, photophobia, epiphora, and
with chemotheraby (5). It was used for treatment of
binocular diplopia due to contraction of the Tenon's
neovascular age related macular degeneration, retinal
capsule, which limits eye movements. Also pterygia can
vein occlusion, proliferative diabetic retinopathy,
cause many symptoms such as eye irritation, foreign body
rubeosis iridis, neovascular glaucoma and other vision
sensation, and dryness. In mild climates, it is unusual for
threatening diseases (6).
a pterygium to grow over the visual axis, but patients are
often concerned about the cosmetic appearance of their
AIM OF THE WORK
eye. In potentially susceptible individuals, the pterygium
To compare between the effects of intraoperative
can grow across the entire corneal surface, impairing
subconjunctival injection of Bevacizumab (Avastin) and
intraoperative topical Mitomycin C on the outcome of
Inflammation and fibrovascular proliferation may be
primary pterygium surgery as regard efficacy and
considered as important factors in occurrence. DNA
damage has been reported to initiate pterygium
development. Hereditary predisposition may be the
PATIENT AND METHOD
underlying factor for pterygium occurrence. Ultra violet
Prospective, randomized, comparative clinical
(UV) light has been shown to induce proinflammatory
study was done on twenty eyes of twenty patients
cytokines, chronic inflammatory cells, and growth
complaining of primary pterygium of variable duration
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4432-4435
Study of Anxiety Symptoms in Mothers of ADHD Children
Mahmoud Abd ELrahman Hammoda, Ali Esmail Abd ELrahman , Mahmoud Kamal Ahmed Samada *
Department of Psychiatry, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mahmoud Kamal Ahmed Samada, Email: firstname.lastname@example.org,
Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood onset psychiatric
disorders that is characterized by inattention, hyperactivity and impulsivity. ADHD can affect social, cognitive and
academic performance of children. All these impairments of psychosocial functioning can affect the quality of life of
both patients and their families. Based on that, it is suggested that parents, especially mothers of ADHD children, display
higher levels of depression and anxiety.
Aim of the work: This study aimed to compare anxiety symptoms in the mothers with ADHD children with control
group. Patients and Methods: Fifty mothers of the ADHD children as study group and fifty mothers with children
without any psychiatric disorder as control group. All were evaluated with to a semi-structured interview and Taylor
Manifest Anxiety Scale. Results: This study showed that 19 in mothers of study group (32%) had no anxiety symptoms
while 31(68%) had anxiety symptoms and 13 (26%) had above sever anxiety. In the control group 35 (70%) had no
anxiety and 15(30%) had anxiety symptoms while 3 (6%) had above sever anxiety. There was statistically significant
difference between the two groups (p value = 0 .05). There was no significant relation between intensity of maternal
anxiety and the intensity of ADHD symptoms in their children.
Conclusion: The present study suggested that the presence and intensity of anxiety symptoms in mothers of ADHD
children are higher than the control group and there was no significant association with ADHD symptoms in children.
Key words: Anxiety symptoms in mothers, Attention-deficit, hyperactivity disorder children.
deficit, hyperactivity and impulsivity, can affect the
Children with Attention Deficit Hyperactivity
quality of life of both patients and their families (8).
Being a parent to an ADHD child is a
developmentally excessive levels of inattention, over-
challenging and sometimes frustrating task. Dealing
activity and impulsiveness that are most frequently
with behavioral problems of these children may
identified and treated in the primary school (1). Rates
exacerbate parenting inadequacies and social
are higher for boys than for girls and for children under
difficulties. Dealing with different problems of ADHD
12 years of age compared to adolescents (2). Prevalence
children can lead to adverse effects on parents' mental
estimates vary based on method of ascertainment,
health (9). Parents of ADHD children assess their
diagnostic criteria used, and whether functional
family environment as less supportive and more
impairment criteria are included (1). The majority of
stressful than the comparison group. Lower parental
children with ADHD continue to show some cognitive
coping abilities than other parents were reported (10).
impairment (e.g. poor executive functioning and
Some clinical and epidemiological studies have shown
impaired working memory) relative to same-age peers
that parents, especially mothers of ADHD children,
through their teen years and into adulthood (3).
display higher levels of depression and anxiety (11). In
ADHD is a chronic disorder with deficits in
one of the first published studies of parenting
the neurotransmitter systems that affect executive
behaviors of clinically anxious mothers, displayed
functioning. Etiology is primarily genetic (4). Several
significantly that anxious mothers are less warmth and
environmental factors have been identified as putative
positive affect than control mothers. In the same study,
risk factors for ADHD such as maternal stress during
clinically anxious mothers were also more critical,
pregnancy, prenatal exposure to tobacco, alcohol and
controlling and possessive of their children. Thus,
other drugs/environmental toxins, pregnancy/ birth
parental anxiety appears to negatively influence the
quality of parentchild relationship (10).
influences related to ADHD or core ADHD symptoms
The aversive parenting behaviors may not
including neonatal anoxia and seizures as well as brain
only result from parents' own symptoms of distress,
injury (5). Psychosocial adversity and high levels of
but also the characteristics of their children. This
family conflict were also associated with ADHD.
notion is supported by findings that the quality of
Recent findings have related ADHD to more specific
parentchild relationships improves when children are
familial issues such as inconsistent parenting after
treated with medication, behavioral and combined
controlling for parental ADHD (6).
ADHD can affect social, cognitive and
academic performance of children. Without
Aim of the work: The aim was to compare anxiety
appropriate interventions, many of ADHD children
symptoms in a group of mothers with ADHD children
experience problems both at home and at the school (7).
with control group and to study the relation between
All these impairments, of psychosocial functioning
maternal symptoms and symptoms of ADHD in their
that goes beyond the core symptoms of attention-
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4436-4444
Attenuation of Pneumoperitoneum-Induced Hypertension by
Intraoperative Lidocaine Infusion in Laparoscopic Cholecystectomy
Abdelazim Abdelhalim Hegazy, Mostafa Mohamed Mohamed El-Sayed,
Ahmed Mohamed Mahmoud Al Wakel
Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Mohamed Mahmoud Al Wakel, Mobile: (+20)1143939192,
Background: Laparoscopy has now become the standard technique and is considered gold standard for
cholecystectomy but the intraoperative requirements of laparoscopic surgery produce significant physiological
changes, which pose many challenges for the anesthesiologist.
Objective: The aim of this work was to evaluate the effect of intraoperative IV lidocaine infusion for attenuation of
Patients and Methods: After approval of the Medical Ethical Committee at Al-Azhar University Hospitals,
Department of Anesthesia, and after patient written consent, 90 patients of American Society of Anesthesiologists
(ASA) physical status I or II, scheduled for laparoscopic cholecystectomy were enrolled in this randomized,
controlled, prospective, double-blind, clinical trial study.
Results: Regarding the intraoperative and postoperative hemodynamics, in the present study it was observed that
patients who received intravenous lidocaine (1.5 mg/kg bolus before skin incision and abdominal inflation followed
by 1 mg/kg/h or 2 mg/kg/h and stopped immediately after abdominal deflation) were associated with a reduction in
intraoperative BP and HR without any associated hemodynamic instability in comparison to patients who did not
received lidocaine with no statistically significant difference between the two doses of lidocaine. Conclusion: This
study showed that the intraoperative infusion of lidocaine of two different doses in patients undergoing laparoscopic
cholecystectomy was associated with attenuation of blood pressure, heart rate, decreases the intensity of postoperative
pain, and early recovery of bowel function without causing significant adverse effects, with more satisfaction for both
patients and surgeons.
Keywords: Pneumoperitoneum-induced hypertension, Intraoperative lidocaine infusion, Laparoscopic
true incidence of hypertensive episodes is unknown,
Normal intra-abdominal pressure (IAP) is 0
but its incidence seems to be higher at the beginning
to 5 mmHg. Increases in IAP above 10 mmHg are
of insufflations, when the increasing intra-abdominal
clinically significant, and above 15 mmHg can result
pressure increases the venous return by reducing the
in an abdominal compartment syndrome, which
blood volume in the splanchnic vasculature (4).
affects multiple organ systems (1).
Intravenous lidocaine is known as having
Pneumoperitoneum (the act of insufflating
the peritoneal cavity with gas, most often carbon
properties and is used for attenuating stress response
dioxide; CO2) and different patient positions required
to laryngoscopy and intubation (5). The prolonged
for laparoscopic surgery results in various
analgesic effect of lidocaine, which extends well
pathophysiological changes. Both mechanical and
beyond the infusion time, could potentially also be
neurohumoral factors contribute to these alterations in
explained by sustained concentrations of lidocaine in
cardiovascular and respiratory physiology. The
the cerebrospinal fluid. In addition, lidocaine
increase in intra-abdominal pressure (IAP) produced
metabolites have analgesic effects by inhibiting the
by pneumoperitoneum, results in direct mechanical
effects on blood flow (2).
The origin of pain after laparoscopic
Systemic absorption of CO2 (most common
cholecystectomy is complicated. Thus, a combination
pneumoperitoneum), and reverse Trendelenburg
of inflammatory, incisional, somatic, and visceral
position cause pathophysiological changes in various
components, multimodal analgesic regimens and
systems of the body leading to increase in plasma
various treatments are suggested, which include
level of norepinephrine, epinephrine, and plasma
opioids, non-steroidal anti-inflammatory drugs
renin activity. All these factors together contribute to
(NSAIDs), dexamethasone, injection of local
increase in heart rate, mean arterial pressure, and
anesthetics into the surgical wound, and removal of
increased systemic and pulmonary vascular resistance
residual carbon dioxide(7).
along with reduced cardiac output (3).
The analgesic properties of lidocaine can
Hypertensive episodes are dangerous because
persist even after the reduction of its plasma levels,
of their potential risk for hemorrhagic stroke,
favoring the theory of the blockade of nervous
pulmonary edema and cardiac decompensation. The
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (6), Page 4445-4451
Occupational Stress among Banking Employees at El Mansoura City
Mohamed El-Hady Emam Salim, Alaa Abdel Wahed Aboel Maged Shams Eldine,
Omar Omar Zidan, Mohamed Mahmoud Aboal Asaad*
Department of Community Medicine and Industrial Medicine, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed Mahmoud Aboal Asaad, Email: email@example.com,
Mobile: (+20) 01092428002
Background: The International Labor Organization reported a number of worrying issues for workers in
financial services; these included greater pressure on time, problems with ergonomics, conflicting roles, work
demands, difficult relationships with customers, and a rising number of cases of stress and violence.
Aim of the study: To assess the prevalence of occupational job stress among banking employees, to find out risk
factors of occupational job stress and to recommend interventions that could prevent occupational stress among
Subject and methods: A study was conducted on 568 banking employees at El-Mansoura City. A cross sectional
study using standardized questionnaire, and interventional study included application of stress management
health education intervention program, were implemented. Evaluation was done six months after conduction of
the intervention to measure the degree of success of the program.
Results: the total number of the employees was 568; the majority of age group were between 25-45 years
representing 79.1%. Among the studied participant 50.2% of them were working in national banks and 49.8%
were working in private banks. 22.4% were manager while 57% were banker A and 20.6 were banker B. About
22.8% of national banks employees showed high stress level, while only 12% of private banking employees
showed high stress level.
Conclusions: this study showed statistical significance difference between national and private bank employees
as regard the prevalence of health complaint. Age, gender, occupational degree and social relations at work
among these study participants showed statistical significant difference between national and private banking
Keywords: Occupational stress, Banking employees, Stress management. Health education interventional
Stress is defined as any physical, chemical, or
Work place stressor include unclear
emotional factor that causes bodily or mental unrest,
requirement, role overload, high stress times with no
a feeling of emotional or physical tension (1).
down times, big consequences for small failures,
Physical and chemical factors that can cause
lack of personal control, lack of recognition, poor
stress include trauma, infections, toxins, illnesses,
leadership. Occupational stress spreads gradually
pain after surgery, and injuries of any sort.
and continuously over time, sending people into
Emotional causes of stress and tension are numerous
downward spiral from where it is hard to recover (4).
and varied, and usually occur in situations that
The best methods of stress management
people consider difficult or challenging. Different
depend on both the organization and the individual.
people consider different situations to be stressful.
Some of the methods which can be used by
Stress is not just psychological stress, but can be any
individuals cope with stress are exercise programs,
force that impairs the stability and balance of bodily
relaxation techniques, which often include deep
functions. Often, physical stress leads to emotional
breathing methods, meditation, all of them provides
stress and emotional stress often appears as physical
deep physiological and psychological rest(3). Time
stress, e.g. stomach cramps, headaches, etc., (2).
management, realistic goal setting, redesigning
Stress causes a variety of health problems on
work, developing greater employee participation,
the individual, including physical, psychological
increasing feelings of personal accomplishment, and
and behavioral such as heart disease and stroke,
basically by learning to behave more effectively will
gastrointestinal problems, respiratory disorders and
aid in stress management (5).
emotional difficulties, family conflicts, sexual
The employees in some particular jobs feel
dysfunction, sleep disturbances, depression, and
that they are trapped, and treated more like machines
burnout, also drug and alcohol abuse, smoking,
than individuals. Among the 12 most stressful jobs
accident proneness, violence and appetite disorders
are managers, administrators and supervisors, and
among the 28 high stress jobs are bank tellers(6).
According to Central Bank of Egypt (CBE), the