The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4452-4458
Assessment of Retinal Nerve Fiber Layer Thickness Using Optical Coherence
Tomography in Patients with Type 2 Diabetes Mellitus
Hesham Fawzy Khalil, Abd El-Mongy El-Saied Ali,
Mohamed Mohamed Aly Ibrahim, Ahmed Fathi Mohammed Hatata*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmed Fathi Mohammed Hatata, Mobile: (+20)01096279847, Email: firstname.lastname@example.org
Background: Diabetic retinopathy (DR) is the most common ocular complication of diabetes mellitus (DM) and
considered one of the leading causes of blindness in developed countries. Diabetic retinopathy is predominantly a
microangiopathy in which high glucose levels can make small blood vessels particularly, vulnerable to damage.
Objective: The aim of this work was to assess the thickness of peripapillary retinal nerve fiber layer (RNFL) measured by
Swept Source optical coherence tomography (SS-OCT) in patients with Type 2 Diabetes Mellitus (DM).
Patients and Methods: The study was an observational cross-sectional study. The study was conducted on 40 eyes
of diabetic patients from the outpatient clinic in ophthalmology department of Al-Azhar University Hospitals. All
patients were subjected to a complete ophthalmic examination including OCT.
Results: The current study showed a negative correlation between parameters related to DM (duration of DM, and
state of glycemic control measured by HbA1C) and all the parameters related to RNFL, and RGCL thickness but this
correlation was statistically insignificant, and there was statistically significant decrease in superior RNFL thickness
in patients with mild DR than patients with no DR, however, this difference was statistically insignificant in all
parameters related to RGCL thickness in the two groups.
Conclusion: Optical coherence tomography (OCT) provides non-invasive, quantitative and objective measurement
of RNFL thickness, optic nerve head, and RGCL thickness with high resolution and accuracy. This could be the
method of choice for monitoring the neurodegenerative changes in DR.
Keywords: Retinal Nerve Fiber Layer Thickness, Optical Coherence Tomography, Diabetes Mellitus.
Diabetic retinopathy (DR) is the most
Optical coherence tomography (OCT) enables
common ocular complication of diabetes mellitus
interpretation of a variety of eye diseases (9). It also
(DM) and considered one of the leading causes of
provides an objective and quantitative measurement of
blindness in developed countries (1). Diabetic
RNFL thickness and optic nerve head with high
retinopathy is predominantly a microangiopathy in
resolution and accuracy (10).
which high glucose levels can make small blood
Different authors have reported clinical decrease
vessels particularly, vulnerable to damage. Direct
in total central retinal or single cellular layer thickness in
hyperglycemic effect on retinal cells is also likely to
diabetic eyes with or without signs of DR compared to
play a role (2).
control groups (subjects without DM).(15, 16)Others have
Normal vision depends on many factors, one of
shown reduction in the inner retinal thickness in the
them is the normal function of the retinal neurons to
macular area in diabetic patients with mild DR, this may
produce a good quality of vision. Deterioration of quality
represent initial loss in ganglion cells in the pericentral
of vision starts early in diabetes, before clinical
areas followed by thinning of retinal nerve fiber layer in
retinopathy becomes an evident, this probably indicates
the peripheral macula (5).
the early signs of neuronal dysfunction (3) . Retinal nerve
Vujosevic and Midena has concluded that
fiber layer (RNFL) is one of the important structural
automatic layering of retinal structures by SD-OCT may
neuron in the retinal layers which is often shown to be
be a useful tool in diagnosing and monitoring early
affected in the early pathological stages of diabetic
intraretinal changes in diabetic retinopathy(11).
retinopathy. RNFL thinning or defects have been
Subsequently, detection of early RNFL thinning may
reported by several studies in people with diabetes(4, 5).
help ophthalmologists to provide effective treatment of
Retinal nerve fiber layer loss also has been
diabetic retinopathy and early prevention, thus reducing
reported in diabetic patients without diabetic retinopathy
but their blood glucose was poorly controlled(1). In this
The aim of this work was to assess the thickness
regard, defect in RNFL could be considered another
of peripapillary retinal nerve fiber layer (RNFL)
ocular association of diabetes other than diabetic
measured by Swept Source optical coherence
tomography (SS-OCT) in patients with Type 2Diabetes
Assessment of RNFL loss is crucial because
RNFL loss is irreversible and may contribute to diabetic
optic nerve dysfunction (7, 8).
SUBJECTS AND METHODS
This observational cross-sectional study included
a total of 40 eyes of diabetic patients attending at the
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4459-4468
The Prognostic Value of Left Ventricular Function on Sepsis Outcomes in
Critical Care Unit Patients
Hossam Eldeen Salah Shabanh1, Abdellah Hussein Al-sadek1,
Ibrahim Farag-Allah Said2, Ahmed Mohammed Said Sallam*1
Departments of 1Internal Medicine & 2Cardiology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Ahmed Mohammed Said Sallam, E-mail: email@example.com
Background: Sepsis is the most prevalent life menacing condition presupposed patients' admission to intensive care
units. The underlying cardiovascular consequences of sepsis comprehended marvelous increase of the cardiac output,
reduction of the peripheral vascular resistance along with impaired capillary permeability.
Aim of the study: The present investigation was implemented to retrieve the prognostic value of LVF assessment
using speckle tracking echocardiography (STE) among Egyptian adults, who admitted to the intensive care unit as a
resultant impact of sepsis or septic shock.
Methods: Patients admitted at the Critical Care Unit, who initially diagnosed with sepsis or septic shock within 8
hours. After fulfilling their criteria and being aged more than 18 years, they were eligible for inclusion in the study.
All participants were submitted to rigorous history taking, clinical evaluation, laboratory assessment, and STE. The
study embraced an overall 50 patients..
Results: Left ventricular longitudinal strain (LVGLS) was the only parameter which attained statistically significant
highly positive correlation with SOFA score among septic shock patients (r = 0.794, p = 0.021). The results of this
model revealed that LVGLS (p<0.001) attained high ability in the prediction of Sepsis-related Organ Failure
Assessment (SOFA) score and Acute Physiologic and Chronic Health Evaluation (APACHE) score.
Conclusions: The capability of STE investigation for the detection of left ventricular dysfunction among septic or
septic shocked critically ill patients is a promising and feasible approach, which have a crucial impact on the prognosis
of such patients.
Keywords: Septic shock, Sepsis, speckle tracking echocardiography.
Sepsis is the most prevalent life menacing condition
cellular function of the heart, but they also had a crucial
presupposed patients' admission to intensive care units
rule in the prognosis and the detection of the appropriate
(1). This is because its underlying sequels such as
treatment strategies (10, 11).
The myocardial function has been frequently
oxygenation, and multi-organ failure, which in turn
evaluated based upon ejection fraction (EF), 2D
leads to increased risk of mortality (2). To date,
echocardiography and M mode echocardiography (12).
approximately 750,000 septic cases are diagnosed
Conversely, these diagnostic tools had several
annually in the United States, which unfortunately
limitations in order that their results are influenced
harvested more than 200,000 death per year (3, 4).
dramatically by pre-load, after load, and heart rate (13).
The underlying cardiovascular consequences of
Thereafter, the optimal and the early detection of septic
sepsis comprehended marvelous increase of the cardiac
cardiomyopathy is remaining challengeable owed to the
output, reduction of the peripheral vascular resistance
obscurity of adequate test with high sensitivity and
along with impaired capillary permeability (5). These
specificity for early diagnosis and proper monitoring of
complications altered significantly the cardiac function,
the myocardial function (14). To overcome these
which in turn develop septic cardiomyopathy (6, 7).
obstacles, STE has been evolved with a considerable
Throughout the past era, evaluation of cardiac
quantitative and objective assessment of the left
function was assessed using Swan-Ganz Catheter; in
ventricular function (LVF) regardless of the insonation
addition, echocardiography has been established as a
pivotal diagnostic tool in the appreciation of the
The present investigation was implemented to
morphological and functional characteristics of the heart
retrieve the prognostic value of LVF assessment using
among septic patients (8, 9). Subsequent to that, new
STE among Egyptian adults, who were admitted to the
modalities have been established recently, particularly
Intensive Care Unit at El-Hussein University Hospital as
a resultant impact of sepsis or septic shock.
echocardiography (STE) and tissue Doppler (10). Not
only did these techniques attain precise evaluation of the
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4469-4473
Vestibular Assessment in Chronic Noise Exposure Subjects
Ali A. Ali1, Atef A. El-Maraghy2, Ahmed M. Ahmed 1, Hany A. Mohany1
1Audiovestibular Unit, Department of Otolaryngology, Faculty of Medicine Al-Azhar University
2Department of Otolaryngology, Faculty of Medicine Al-Azhar University, Cairo, Egypt.
*Corresponding author: Hany A. Mohany, Mobile: (+20)1221971274, Email: firstname.lastname@example.org
Background: The damaging effect of noise on vestibular disturbance is well known, first described in 1890 by
Haberman in tinkers with occupational hearing loss. Others have reported vestibular disturbances and abnormalities,
such as balance disorders, dizziness, vertigo, and even spontaneous nystagmus in workers exposed to various kinds of
occupational noise. Objective: To evaluate vestibular function in subjects with chronic noise exposure.
Subjects and methods: Eighty subjects were included in the study, divided into 2 groups: 60 subjects exposed to noise
in laundry with mean age 41.53±11.15 (study group) and 20 subjects not exposed to noise with mean age 38.60±6.48
(Control group). All subjects underwent audiovestibular evaluations (puretone audiometry, tympanometry,
vedionystagmography, and posturography).
Results: This study demonstrated elevated hearing threshold at audiometric frequencies 2-8 KHz (pv <0.001) and
speech discrimination (pv <0.001). in addition, marked caloric weakness and reduced SOT composite scores (pv =
<0.001), reduced SOT equilibrium scores in noise exposure subjects (pv<0.001), reduced SOT sensory scores in VEST
and PREF (Pv <0.001). Furthermore, there was a positive correlation between duration of exposure and auditory and
Conclusion: this study revealed apparent effect of noise on auditory and vestibular system.
Keywords: Noise, Auditory System, Vestibular System, Noise Induced Hearing Loss.
university during the period from December 2014 to
Noise is defined as "unwanted sound" with various
November 2018. It consisted of of 60 subjects exposed
deleterious effects on health. The most significant
to noise working in laundry and its subgroups.
physiological effect of exposure to noise is either
temporary or permanent hearing loss. Partial
Consistent of 20 normal adult volunteers, age and
disappearance of the organ of Corti was found with
gender matched with patient group without history of
destruction of the hair cells, the extensive damage being
otologic disorders or noise exposure.
in the lower basal coil(1).
Unfortunately, noise-induced hearing loss (NIHL)
is so common that a majority of the workers believe that
No current or past history of general medical,
it is part of their normal working life course. It has been
neurologic or otologic findings known to adversely
estimated that 1.1 million people are exposed to exces-
affect hearing or balance, compensate for balance
sive noise at work; among these, 0.17 million are
related problems or interfere with test requirements.
predicted to suffer significant ear damage as a direct
result of noise (2).
The vestibular portion of the auditory system helps
1- Audiometer: interacoustic AC40.
in maintaining balance in association with the ocular and
2- Immittancemeter: Grason-Stadler GSI 39,
the central nervous system. The vestibular end organs
Autotymp. Middle Ear analyzer.
and the cochlea have a common evolutionary origin and
3- Videonystagmography (VNG): Computarized 2-
utilize the same basic principle of mechano-electric
channel VNG biomedical using monocular
transduction with the help of the sensory hair cells (3).
goggles. Micro-medical technologies Inc.,
The damaging effect of noise on vestibular
spectrum software, chatham, Illinois, USA.
disturbance is well known, first described in 1890 by
4- Computerized Dynamic Posturography (CDP):
Haberman in tinkers with occupational hearing loss.
Neurocom Smart Equites, International. Inc.,
Others have reported vestibular disturbances and
Clackamas, Oregon, USA.
abnormalities, such as balance disorders, dizziness,
5- Sound level meter (SLM): precision, Bruel &
vertigo, and even spontaneous nystagmus in workers
KJaer type 2235.
exposed to various kinds of occupational noise (4).
6- Sound treated room, (locally made).
Aim of the work: To evaluate vestibular function
in subjects with chronic noise exposure.
Ethical consideration and Written informed
SUBJECTS AND METHOD
An approval of the study was obtained from Al-
Azhar University academic and ethical committee.
Every patient signed an informed written consent for
This study was conducted at the Audiology Clinic, Al
acceptance of the operation.
Hussein hospital, Faculty of Medicine, Al-Azhar
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4474-4482
Corneal Endothelial Changes by Specular Microscopy after Uncomplicated
Phaco-Emulsification of Hard Senile Cataract Graded by Pentacam
Adel Abdelrahman Osman, Sayed Mostafa El-Sayed, Amr Ehab Fahmy*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Amr Ehab Fahmy, Mobile: (+20)01141237382,
Background: Cataract is the most prevalent ophthalmic cause of reversible blindness and it is one of the primary
concerns of the public health perspective surgery which is the primary and only treatment method known.
Objective: Assessment of corneal endothelial changes by using specular microscopy, after uncomplicated
phacoemulsification in moderately hard nuclear 3 senile cataract.
Patients and Methods: The present study was performed on 30 eyes of 30 individuals preoperative assessed by
pentacam to detect grade 3 nuclear cataract to be selected in our study, then corneal endothelium assessed by
specular microscopy to evaluate the corneal endothelium to be reference and to be compared to 1st and 3rd month.
Results: A highly significant decrease in ECD 1st month post-operative and a significant decrease in ECD 3rd month in
relation to pre-operative state. Highly significant increase in the coefficient of variation 1st month postoperative and
non-significant increase in the 3rd month in relation to preoperative state. Highly significant decrease in the
percentage of hexagonality 1st month and 3rd month post operatively. There is a highly significant reciprocal
correlation between age and pre-operative endothelial cell density. 3rd month post-operative decrease in ECD is
significant correlated to male sex.
Conclusion: A major finding of our manuscript is that the harder the senile cataract the more time and surgical
manipulation was done in spite of the same surgeon and the same operative condition lead to more endothelium
lost and the more variation between the cells and decrease in the percentage of hexagonal post-operative.
Keywords: Corneal Endothelial, Specular Microscopy, Uncomplicated Phaco-Emulsification, Senile Cataract
Graded by Pentacam.
outcomes. Maintenance of corneal clarity relies
Age-related cataract, is not a rare disease even
heavily upon the functionality of healthy endothelial
in those who are middle aged, approximately 17.5% of
persons 43 to 54 years of age had some evidence of
cells and an intact pumping system designed to
lens opacity (1).
remove fluid from the corneal stroma. It is well known
Cataract extraction by phacoemulsification is
that some degree of endothelial cell loss will be
the most frequently performed ophthalmic surgery
present after any cataract surgery (7).
around the world, in which an ultrasonic device vibrating
Endothelial cell loss after cataract surgery is an
at a very high speed is inserted into the eye through a
inevitable consequence of the procedure. Nonetheless,
very small corneal incision, and today it focuses on rapid
important steps taken during cataract surgery and the
visual rehabilitation after surgery (2).
perioperative period may influence the rate of endothelial
Ultrasonic phacoemulsification offers several
cell loss and thus potentially improve the visual outcome
advantages, including a small incision and rapid
of this common surgical intervention. Proper patient
postoperative visual recovery, and has become the
selection and education, meticulous surgical technique,
preferred treatment for cataract (3).
and good postoperative care are important for
The remaining endothelium which cover the
maintaining a clear cornea with excellent visual potential
posterior corneal surface after injury is maintained by
(7). Senile opacification of the crystalline lens is a
a gradual increase in the size of the remaining cells,
commonly observed age-related phenomenon. Due to
which result in increased cellular pleomorphism and a
its high prevalence, cataract surgery is the most
decrease in the percentage of hexagonal cells (4).
frequently performed surgical procedure worldwide.
The most common used method for cataract grading is
phacoemulsification in the immediate postoperative
Lens Opacities Classification System III (LOCS III)
period is a serious complication postoperatively and
often leads to patient dissatisfaction and worsening the
An established disadvantage of the old methods
visual outcome (5).
using clinical parameters is the subjective nature for the
Endothelial injury may occur during cataract
grading process as the case of use of LOCS III as a
surgery due to a number of factors, such as corneal
grading method and similar methods, there are multiple
distortion, emulsifying of nuclear fragments,
discrepancies in routine performance. For example, slit-
intraocular lens (IOL) contact, and release of free
lamp settings and the evaluator's expertise can play a
radicals (6). Protection of corneal endothelium during
cataract surgery is critical for achieving good visual
Pentacam nucleus staging based on the
Scheimpflug principle that state that, the plane of the
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4493-4498
Study of The Effect of Repetitive Transcranial Magnetic Stimulation on
A Sample of Children with Autism Spectrum Disorder
Ali Ismail Abd alrahman, Amgad Ahmed Moshref Gabr, Tarek Ibrahim Mohamed Elfekey*
Department of Psychiatry, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Tarek Ibrahim Mohamed Elfekey, E-mail: email@example.com,
Background: Autism Spectrum Disorder (ASD) is a behaviorally defined complex neurodevelopmental syndrome.
ASD is one of the most common child psychiatric disorders. Despite the long history of research on ASD, no much is
known yet about the exact biological causes and how the disorder can be effectively treated.
Objective: To study clinical effect of repetitive Transcranial Magnetic Stimulation (rTMS) on a sample of children
with autism spectrum disorder.
Patients and Methods: the sample consisted of 30 children. Their ages ranged from 4 to 10 years old. After being
diagnosed clinically according to DSM-5 through a designed semi-structured interview and through application of
childhood autistic rating scale CARS and assessment of the degree of clinical severity of autism spectrum disorders
according to DSM-5.
Results: The results of the study after the completion of 12 sessions of rTMS, there was a significant difference and
improvement in the severity of the clinical symptoms for ASD except for the level of activity and listening response
and use of the body by comparing the severity of symptoms before and after rTMS. Comparing results before and after
rTMS by the level of clinical severity of autism according to DSM-5; at the level of severity in social communication,
the improvement was statistically significant (p-value 0.001). At the level of severity in restricted and repetitive
behaviors the improvement was statistically highly significant (p-value <0.001). Conclusion: this study concluded that
rTMS over left dorso-lateral prefrontal cortex may be safe and effective way of providing a relief of ASD symptoms.
Keywords: ASD neurobiology TMS rTMS.
connectivity. Due to its neurodevelopmental character,
Autism spectrum disorder (ASD) is one of the
and the large phenotypic heterogeneity among
most common child psychiatric disorders, with a
individuals on the autism spectrum, the neurobiology of
prevalence estimated at 1.1% of the population (1).
autism spectrum disorder is inherently difficult to
Children diagnosed with ASD differ from typically
describe. Nevertheless, significant progress has been
developing children on many cognitive and behavioral
dimensions, and therefore the term `spectrum' is used to
underpinnings of autism spectrum disorder across the
emphasize its full scope. The spectrum consists of a
human life span and in identifying the molecular
heterogeneous group of disorders, including Autism,
pathways that may be affected in autism spectrum
Asperger's Syndrome, Pervasive Developmental
disorder. Moreover, novel methodological frameworks
Disorder- Not otherwise specified (PDD-NOS),
for analyzing neuroimaging data are emerging that
Childhood Disintegrative Disorder, and Rett syndrome
make it possible to characterize the neuroanatomy of
(2). ASD significantly impairs social interactions. For
autism spectrum disorder on the case level and to stratify
example, individuals with ASD are often unable to
individuals based on their individual phenotypic make
understand and interpret nonverbal behaviors in others,
which can result in a failure to develop peer
The individual components of the neural systems
underlying ASD are well established and include: (1)
The diagnosis of ASD is based on observations
Fronto-temporal and fronto-parietal regions such as the
and assessments of behavior using Diagnostic and
medial, orbitofrontal (OFC) and inferior-frontal (IFG)
Statistical Manual of Mental Disorders (DSM) or
cortices, the posterior parietal cortex, the superior
International Classification of Diseases (ICD) criteria.
temporal sulcus (STS) and the fusiform gyrus. (2)
However, postmortem, genetic and neuroimaging data
Limbic brain regions such as the amygdala
indicate that the behavioral ASD phenotype is the
hippocampal complex, the thalamus and cingulate
product of atypical brain development (4). Several twin
regions. (3) The fronto-striatal circuitry including parts
studies demonstrated that ASD is heritable.
of the basal ganglia, the anterior cingulate cortex (ACC)
Monozygotic twins have a higher concordance rate than
and the dorsolateral prefrontal cortex (DLPFC). (4) The
dizygotic twins, 90% and 10%, respectively (5).
However, the exact etiology is unknown, and it is likely
Moreover, many of the neural structures that
that a combination of multiple genetic and
have been reported as atypical in ASD overlap with the
environmental factors could result in ASD (6).
set of brain regions that are integral parts of the so-called
Autism spectrum disorder is a complex
`social' and `emotional' brain, which encompasses a set
neurodevelopmental disorder, which is accompanied by
of brain regions involved in wider aspects of social
differences in brain anatomy, functioning and brain
cognition and emotional processing. For example, brain
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4499-4505
Correlation between Autoimmune Thyroid Diseases and
Helicobacter Pylori Infection
Mohammed Nabil Raafat1, Magdy Abd Al-Kareem El Dahshan1, Mohammed Salah Hussein1,
Tarek Abd Al-Kareem El Dahshan2, Mohammed Ahmed Abd-Elghany1*
1Department of Internal Medicine, Faculty of Medicine, Al-Azhar University
2Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohammed Ahmed Abd-Elghany, Mobile: (+20)01006226268;
Background: Helicobacter Pylori (H. Pylori) usually acquired in childhood, it colonizes the gastric mucosa of about
50% of the world's population at some time in their life. In eastern countries, H. pylori infection has a prevalence of
approximately 70%. Objective: To correlate between H. pylori infection and autoimmune thyroid diseases (AITD).
Patients and Methods: This is a cross-sectional study done on 200 patients selected as a convenient sample with
upper GI upset. They were selected from gastroenterology outpatient clinics at Al-Hussein and Alexandria Police
Hospitals, during the summer months of 2018. They were classified according to the results of stool H. pylori Ag
testing into two groups; positive and negative (each group 100 patient).
This is cross-sectional study done on 200 patients selected as a convenient sample
Results: Our results indicated that patients with H. pylori infection were more susceptible to AITD. There was
significant association between H. pylori infection and both Hashimoto's and Graves' disease. H. pylori infection had
shown to be associated with elevated liver enzymes, anemia, and IL 17.
Conclusion: There is a significant positive relationship between H. pylori infection and Hashimoto's disease (HT).
There is a significant positive relationship between H. pylori infection and Graves' disease (GD).
Keywords: Autoimmune Thyroid Diseases, Helicobacter Pylori.
involvement of infectious agents in other autoimmune
Helicobacter pylori (H. pylori) infection is
diseases, such as systemic lupus erythematosus (SLE)
confirmed to correlate with chronic gastritis, peptic ulcer
and rheumatoid arthritis (RA) remains controversial.
disease, mucosa associated lymphoid tissue (MALT)-
Chronic infection with H. pylori serves as a source of
lymphoma, precancerous changes in the stomach
persistent antigenic stimulation and underlies the
(atrophy, intestinal metaplasia), and gastric cancer (1).
pathogens' ability to induce a systemic inflammatory
At the same time, H. pylori eludes the
immunological response evoked by the host. H. pylori
The prolonged interaction between the
have acquired several abilities that help them to escape
bacterium and host immune mechanisms makes H.
clearance through the host immune system. Then H.
pylori a plausible infectious agent for triggering
pylori interact with the immune system (2).
autoimmunity. Molecular mimicry of H. pylori antigens
Autoimmune diseases are characterized by
was found to activate cross-reactive T cells which may
dysregulation of the immune system resulting in a loss
lead to autoimmune gastritis (6).
of tolerance to self-antigen. The exact etiology for the
Autoantibodies, such as IgM rheumatoid factor,
majority of these diseases is unknown; however, a
anti-single stranded DNA antibody and anti-
complex combination of host and environmental factors
phosphotidyl choline antibodies, were demonstrated to
are believed to play a pivotal role. Numerous pathogens
be produced by B cells after their activation by H. pylori
were implicated as possible environmental agents
components, particularly urease (7).
contributing to the development of autoimmune disease
A role of microbial heat shock proteins (HSP) in
in susceptible individuals. Polyclonal lymphocyte
the pathogenesis of autoimmune diseases has been
activation, molecular antigen mimicry, epitope
postulated because of the high level of sequence
spreading, bystander activation, and activation by a
homology with human HSP. A possible role of HSP 60
super-antigen, were all proposed as possible mechanistic
produced by H. pylori in pathogenesis of Sjögren's
links between the development of autoimmunity and
syndrome is proposed (8).
exposure to infectious agents. Discussion of these
Eradication of H. pylori infection in patients
mechanisms was previously detailed in the medical
with immune thrombocytopenic purpura (ITP) was
literature. In their review of the role of infectious agents
shown to be effective in improving platelet counts in
in autoimmunity, Getts et al., suggested that
50% of cases (9).
autoimmune disease is triggered by these mechanisms
Cross-reactivity between bacterial and thyroid
working `simultaneously and/or sequentially' (3).
antigens was proposed as a mechanism in H. pylori
Evidence for the role of infectious agents in
induced AiTD (10).
diseases such as rheumatic fever and Guillain-Barre
Indeed, amino acid sequence similarities
syndrome is convincing (4). However, evidence for the
between CagA H. pylori and thyroid peroxidase were
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4506-4513
Effect of Neodymium-YAG Laser Posterior Capsulotomy on Intraocular Pressure
Adel Mohamed Abdul Wahab Khalil, Sanaa Ahmed Mohamed, Amel Mahmoud Hanafy*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Amel Mahmoud Hanafy, Mobile: (+20)01068795515,
Background: Posterior capsule opacification (PCO) also known as Secondary cataract is the most common
complication following cataract surgery. It can occur between few months and many years after implantation of
intraocular lenses (IOLs), with incidence figures ranging from <5% to as high as 50%.
Objective: The aim of this study was to determine the frequency of intraocular pressure elevation after Nd: YAG laser
posterior capsulotomy for treatment of PCO.
Patients and Methods: A prospective non-randomized study that was conducted at Al Zahraa University Hospital.
The study included a total of 40 eyes of 31 patients. All patients underwent Nd: YAG laser posterior capsulotomy.
Patients were followed up at 4 hours, 1 day, 1 week and 1 month after laser capsulotomy. Nine cases were bilateral, 15
were males (48%) and 16 were females (52%).
Results: The majority of patients (90%) showed significant improvement in visual acuity after capsulotomy and about
87.5% of patients had final BCVA of 6/6-6/12, visual acuity after 24 hours was 6/9 in 20 eyes (50%) and 20 eyes
(30%) had VA of 6/12. All the 40 patients had visual acuity improvement of 1 or more lines after capsulotomy. No
one had further decline in visual acuity after capsulotomy.
Conclusion: The present study depicts the Nd: YAG laser capsulotomy as a good, successful treatment of PCO,
because it was found to be modern, non-invasive, effective mode of treatment of PCO with lesser complications and it
does not require hospitalization.
Keywords: Neodymium-YAG, Laser Posterior Capsulotomy, Intraocular Pressure.
Posterior capsular opaification (PCO) causes
Nd: YAG laser techniques have been described for
decreased vision, glare and other symptoms similar to
posterior capsulotomy in patients of PCO. The two
that of original cataract. It causes reduction in visual
posterior capsulotomy techniques most commonly
acuity and contrast sensitivity by obstructing the view
used nowadays are cruciate technique and circular
or by scattering the light that is perceived as glare by
the patient. It also decreases the field of view during
A number of complications can occur after
therapeutic and diagnostic procedures and also causes
YAG laser capsulotomy such as elevation of
uniocular diplopia (1).
intraocular pressure, rupture of anterior vitreous face,
There are three main sources of cells with a
damage to intra ocular lens, hyphema, acute iritis, and
potential to cause opacification of capsular bag. 1-
cystoid macular edema (CMO). Unusual complications
Cuboidal epithelial cells lining the anterior capsule
include corneal endothelial damage, macular hole,
these have no propensity for migration, they undergo
vitreous hemorrhage, retinal detachment, macular
fibrous metaplasia and proliferate in situ. 2-The cells at
hemorrhage and endophthalmitis (4). Raised intraocular
the equatorial lens bow have an increased level of
pressure (IOP) is considered as the frequent
mitotic activity. These cells are migratory; therefore
complication of Nd: YAG laser posterior capsulotomy
they grow along the posterior capsule giving rise to
but usually it is a transient complication (5).
bladder cells. 3-Finally, the residual cortical fibers
The increase in intraocular pressure (IOP) after
from the equatorial lens bow become dislodged and
Nd: YAG capsulotomy is due to reduced outflow
float freely with in the bag. They may remain localized
facility because of trabecular meshwork blockage by
or migrate centrally into the visual axis. Elsching's
the capsular debris and vitreous particles floating in the
pearls, posterior capsular wrinkling and fibrosis are
anterior chamber (6). It is reported that the higher the
various types of PCO. The central part of posterior
laser energy and the higher the number of laser pulses,
capsule is opened either surgically or using the YAG
the higher the incidence of IOP elevation. This rise in
laser which is considered as the standard treatment.
IOP may be significantly high and may threaten the
Surgical capsulotomy may cause drastic complications
as endopthalmitis (2).
Neodymium-doped yttrium aluminum garnet (Nd:
AIM OF THE WORK
YAG) laser capsulotomy, which was first described in
The aim of this study was to determine the
1980, is an effective technique and so-called gold
frequency of intraocular pressure elevation after Nd:
standard to treat visually significant posterior capsular
YAG laser posterior capsulotomy for treatment of
opacification (PCO) in pseudophakic eyes (3). Several
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4514-4523
Assessment of Musculoskeletal Ultrasound Guided Injection of The New
Regenerative Medicine Techniques (Neural Prolotherapy and Platelet Rich
Plasma) Impact versus Well Established Techniques (Steroid Injection) in
Cases of Carpal Tunnel Syndrome Secondary to Rheumatoid Arthritis
Ahmed A. Abdel-Aziz 1, Hegazy M. Al-Tamimy2, Ahmed M. Fahmy 3 Mahmoud S. Abd Allah4
1,2,3,4 Department of Rheumatology and Rehabilitation, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Corresponding Author: Mahmoud S. Abd Allah; Mobile: 011539.2532; Email: Samymahmoud662@yahoo.com
Background: Rheumatoid arthritis is a systemic rheumatic disease characterized by symmetrical, often erosive
and deforming poly-arthritis with extra-articular manifestations in 1020% of patients, especially those with high
titers of rheumatoid factor. Extra articular pathology includes bursitis, tendonitis and neuritis, which results from
entrapment, nerve ischemia due to vasculitis or drugs used to treat this condition. Carpal tunnel syndrome is the most
common compression neuropathy associated with rheumatoid arthritis.
Aim of the Work: To evaluate the efficacy of Neural Prolotherapy and Platelet Rich Plasma in treatment of carpal
tunnel syndrome secondary to rheumatoid arthritis.
Patients and Methods: Ninety patients with Rheumatoid Arthritis (RA) that were all fulfilling the 2016
ACR/EULAR classification criteria for RA. All were over the age of sixteen years at time of diagnosis, complaining
of burning pain or paresthesia in the median nerve distribution of the hand. They were recruited from Rheumatology
and Rehabilitation Department at Al-Hussein and Sayed Galal University Hospitals during the period from December
2018 to July 2019.
Results: Neural Prolotherapy and Platelet Rich Plasma (PRP) have improved all measured parameters like visual
analogue scale (VAS), nerve conduction studies and neuromuscular ultrasonography parameters in carpal tunnel
syndrome secondary to rheumatoid arthritis.
Conclusion: Neural Prolotherapy and Platelet Rich Plasma proved to be effective treatments of carpal tunnel
syndrome secondary to rheumatoid arthritis.
Keywords: Rheumatoid arthritis, Carpal tunnel syndrome, Steroid, Neural prolotherapy and Platelet Rich Plasma.
Rheumatoid arthritis is a systemic rheumatic
the diagnosis of carpal tunnel syndrome (8).
disease characterized by symmetrical, often erosive
Glucocorticoids not only have anti-inflammatory
effects, but they can also play a role in the recovery of
manifestations occur in 1020% of patients, especially
myelination after a peripheral nerve injury (9). Injection
those with high titers of rheumatoid factor. Extra
of glucocorticoids into the region of the carpal tunnel
articular pathology includes bursitis, tendonitis,
is intended to reduce tissue inflammation and aid
neuritis, and vasculitis (1). Rheumatoid neuropathy
recovery (10). 5% dextrose (D5W) has been commonly
could result from nerve entrapment, drug toxicity,
used in peripheral entrapment neuropathy, because
vasculitis, amyloidosis and autoimmune phenomenon
D5W possesses osmolarity similar to that of normal
(2). Carpal tunnel syndrome is the most common
saline and no harmful effects have been reported from
compression neuropathy associated with rheumatoid
animal and human studies (11).
arthritis. Pain and/or paresthesias at night as well as
It is hypothesized that D5W could decrease
weakness, loss of dexterity and thenar atrophy can
neurogenic inflammation (12). Perineural injection of
occur (3). Symptoms of neuropathy may be overlooked
PRP proved to be significantly more effective than
or overestimated in the presence of severe joint disease,
platelet poor plasma (PPP) in visual analogue scale
restriction, pain and deformities. Careful examination
(VAS) and two-point discrimination test. This result is
is thus warranted while evaluating such patients (4).
in favor of the positive effect of PRP in nerve
Clinical neuropathy may present with a wide variety of
regeneration (13). Platelet rich plasma may be effective
symptoms, such as pain, paresthesia, and muscle
in controlling median nerve injury (14).
weakness (5). Most compressive neuropathies can be
diagnosed clinically, electromyography and nerve
AIM OF THE WORK
conduction studies can confirm the diagnosis and
The aim of the work is to evaluate the efficacy
usually are required before surgery (6). The
of the new regenerative medicine techniques (Neural
neuromuscular ultrasound can detect pathologies that
Prolotherapy and Platelet Rich Plasma) in treatment of
may predispose or lead to entrapment neuropathy (7).
carpal tunnel syndrome secondary to rheumatoid
Over the past years, high-resolution ultrasonography
has been proposed as a useful tool for
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4524-4532
Ultrasonographic Assessment of Diaphragmatic Function and Its Correlation with
Chronic Obstructive Pulmonary Disease Severity
Abd El-hay Ibrahim Abd El-hay, Houssam Eldin Hassanin Abd Elnaby,
Mohamed Mohy Mohamed Erfan El-gamal*
Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mohamed Mohy Mohamed Erfan El-gamal, E-mail: firstname.lastname@example.org,
Background: chronic obstructive pulmonary disease (COPD) is currently the fourth leading cause of death in the
world, and it is projected to be the third leading cause of death by 2020. More than 3 million people died because of
COPD in 2012, accounting for 6% of all deaths globally.
Objective: the aim of this study is to assess the diaphragmatic function in COPD patients using the ultrasonographic
technique, and to study its correlation with severity of the disease.
Patients and Methods: this study was carried out during the period from November 2018 to June 2019, on sixty
patients with clinically stable chronic obstructive pulmonary disease (COPD), during their follow up in the outpatient
clinic of Chest Department, Bab-Al-Sha'reia University Hospital.
Results: thickness of the diaphragm (TD) at different lung volumes and capacities (RV, FRC and TLC) estimated by
U/S, was found to be progressively decreased with increasing COPD severity. TD was found to be decreased
significantly in COPD patients when compared with controls. The only exception was the presence of a non-significant
relationship between TDRV in control and mild COPD groups, which may denote that diaphragmatic thickness is not
markedly affected in early COPD at low lung volumes.
Conclusion: U/S is a simple, easily learned, non-invasive and reliable method that can be used in assessment of the
diaphragmatic function and kinetics. There is a significant negative correlation between diaphragmatic function
(assessed by measuring diaphragmatic thickness and excursion through U/S) and COPD severity.
Keywords: Ultrasonographic, Diaphragmatic Function, Chronic Obstructive Pulmonary Disease.
Chronic obstructive pulmonary disease (COPD)
AIM OF THE WORK
is a progressive disease characterized by incomplete
The aim of this study is to assess the
reversible airflow limitation (1).
diaphragmatic function in COPD patients using the
Many factors play vital role in the pathogenesis
ultrasonographic technique, and to study its correlation
of COPD including: chronic inflammation, alterations
with severity of the disease.
in repair mechanisms, oxidative stress, protease-
antiprotease imbalance, airways remodeling, in addition
SUBJECTS AND METHODS
to numerous cellular and mediators involvement (2).
This study was carried out during the period
Systemic effects of COPD influence its
from November 2018 to June 2019, on sixty patients
progression, and they include loss of fat-free mass
with clinically stable chronic obstructive pulmonary
(FFM) and muscle wasting. Long-term administration
disease (COPD), during their follow up in the outpatient
of steroids (even low doses), used widely in the
clinic of Chest Department, Bab-Al-Sha'reia University
treatment of COPD, can also contribute to respiratory
Hospital. These patients were diagnosed and classified
muscle weakness with wasting of the diaphragm (chief
into four groups according to GOLD 2019 as following:
respiratory muscle) (3).
First group: included 15 patients with mild stage.
Patients affected by emphysematous COPD
Second group: included 15 patients with moderate
with loss of FFM and muscle wasting show profound
alterations regarding the mass and thickness of the
Third group: included 15 patients with severe stage.
diaphragm. The study of the diaphragm is thus
Fourth group: included 15 patients with very severe
considered a key point in the evaluation of patients with
COPD, and several methods are employed such as
Twenty age and sex matched healthy
magnetic resonance scans (4), phrenic nerve conduction
volunteers, served as a control group, were also included
study (5) and invasive assessment of trans-diaphragmatic
in the study.
The use of ultrasonographic (U/S) techniques
Clinically stable patients diagnosed as COPD
for the assessment of both diaphragmatic excursion and
according to GOLD guidelines 2019, in different stages
thickness of the diaphragm (TD) at different lung
of disease severity.
volumes in healthy and diseased individuals was
Subjects were excluded from the study if they
had any of the following conditions:
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4533-4537
Outcome of Adjustable Suspensory Fixation for Femoral Graft in ACL Reconstruction
Adnan A. Alim Al Sebaie, Mohamed Ibrahim Abulsoud, Ahmed Mohamed Mahmoud Salem
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Ahmed Mohamed Mahmoud Salem, Mobile: 01027227236;
Background: The incidence of torn anterior cruciate ligament (ACL) has greatly increased, with today's increasing
enthusiasm for sports activities. As a result, reconstruction of the torn anterior cruciate ligament became a common
surgical procedure in orthopaedic surgery.
Objective: To evaluate short term clinical outcome of adjustable suspensory fixation for femoral graft in ACL
Methods: All patients treated for ACL reconstruction with an ipsilateral hamstring between March 2017 and March
2018 were evaluated. Subjects were assigned to TightRopeTM (TR) femoral fixation. All patients were evaluated with
the Lachman test, pivot-shift test, 2000 International Knee Documentation Committee (IKDC) knee examination.
The subjective evaluation was performed using the Lysholm knee score. CT examination was performed to evaluate
femoral and tibial tunnels enlargement at four different levels. All patients were assessed at a 12 month follow-up
visit. Power analysis was performed a priori in accordance with the femoral and tibial tunnels enlargement values
from the CT scans.
Results: The group was homogenous at baseline with regard to age, gender, BMI, dominance and disease duration. At the
final follow-up, no statistically significant differences were found according to subjective and objective clinical outcome
measures. According to the femoral tunnel enlargement, no statistically significant difference was found between tunnel
at operation and 12 months later.
Conclusion: In transtibial ACL reconstruction, the use of adjustable-loop length device products, on the femoral
side, led to better clinical and radiological results.
Keywords: Tunnel widening, ACL, Femoral tunnel, Adjustable Suspensory fixation device.
motion within the bone tunnel and optimizing graft-to-
Fruitful foremost cruciate tendon (ACL) remaking
bone healing (6). In contrast, other authors demonstrated
relies upon a few variables, including stable beginning
obsession, natural bone join coordination, and sufficient unite
that the TR shows more slippage and less stiffness
quality. The join obsession decision is basic for a decent
compared to the EB. Those mechanical proprieties can
careful outcome. It limits lengthening and counteracts
most likely facilitate tunnel widening (7,8).
disappointment at the unite connection locales before
The point of this investigation was to assess
reconciliation is finished (1).
clinical outcome and femoral and tibial passages
In any case, the strategy that creates the best
augmentation in patients who experienced ACL transtibial
outcome stays obscure. As of late, the EndoButton® (EB;
recreation utilizing a customizable circle length
Smith and Nephew) has turned out to be one of the most
suspensory obsession gadget, the TR. The speculation is
well-known obsession gadgets. It is a suspensory
that the flexible circle gives better outcome. Our essential
obsession framework, and a few examinations have
target was to assess whether an ACL transtibial procedure
officially exhibited its mechanical quality (2,3).
remaking with the TR produces a femoral passage
The writing reports that one of the hindrances of
development utilizing a PC tomography (CT) examine
the suspension framework is the dynamic growth of the
after a subsequent time of a year. The optional goal was to
femoral bone passage breadth (4). In fact, it was reported
assess whether passage augmenting influences clinical
that suspensory fixation results in an increased rate of
tunnel widening compared with aperture fixation (5).
Recently, a new fixation device, the Tight RopeTM
(TR; Arthrex, Naples, FL, USA), was introduced; it is a
Participants: All patients treated by the two
second-generation adjustable loop length suspensory
senior authors for ACL reconstruction with ipsilateral
fixation device that can be tightened intraoperatively. The
semitendinosus (ST) and gracilis (G), between March
adjustable graft loop has a four-point, knotless locking
2017 March 2018 were retrospectively enrolled in this
mechanism that relies on multiple points of friction to
study. The exclusion criteria for all patients were
create resistance to cyclic displacement and slippage under
advanced joint arthritis with complete loss of joint
tension. Some authors also believe that the tensioning
space, age more than 45 years, young patients with open
sutures at the button end reduce the loop length and tension
physis and multiple ligaments injury of the knee.
on the graft strands in the same direction of graft
advancement into the socket. This allows an optimal graft-
All patients agreed to participate in the study and
to-socket fill, reducing longitudinal (`bungee-effect') graft
signed an informed consent form in accordance with the
Declaration of Helsinki. The study protocol was
radiodiagnosis master research protocol
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4538-4544
Effect of Steroid Loaded Middle Meatal Gelfoam Sheet on
Endoscopic Sinus Surgery Outcome
Gamal Abd-Elhameed Abd-Elmaksoud, Magdy Ibrahem Gouda, Khalid Ahmed Khater*
Department of Otorhinolaryngology, Faculty of Medicine, Zagazig University
*Corresponding author: Khalid Ahmed Khater, Mobile: (+20) +201062383789, Email: email@example.com
Background: Endoscopic sinus surgery (ESS) represents the overall accepted type of surgical treatment for chronic
rhinosinusitis with nasal polyposis (CRSwNP) refractory to medical treatment. Presence of postoperative Middle meatal
adhesions are a potential cause of surgical failure. Triamcinolone is recently proposed as a solution for these adhesions.
Objective: This study was designed to evaluate the effect of steroid loaded middle meatal gelfoam sheet on endoscopic
sinus surgery outcome regarding middle meatal adhesions and synechiae formation in patients with CRSwNP refractory
to medical treatment.
Patients and Methods: This prospective, randomized, single-blinded, placebo-controlled study was conducted on 62
nasal cavities of 31 patients with bilateral CRSwNP. At the end of ESS, randomly gelfoam sheet loaded with
triamcinolone was placed in one middle meatus and another gelfoam sheet loaded with saline in the contralateral middle
meatus for 1 week.
Results: Our results as regards topical application of steroids to the middle meatus showed a statistically significant
difference between the steroid side and the saline (control) side in reduction of synechia formation after ESS. Therefore,
topical application of steroids is effective in minimizing synechiae formation after ESS. It is also safe and no local or
systemic complications were noted during the study.
Conclusion: Results of our study demonstrated that the steroid loaded middle meatal gelfoam sheet has a role in
minimizing middle meatal adhesions and synechiae formation after endoscopic sinus surgery for patients with CRSwNP.
Keywords: Steroid Loaded Middle Meatal Gelfoam Sheet, Endoscopic Sinus Surgery Outcome.
middle-meatal spacers and showed improved early and late
Chronic rhinosinusitis (CRS) is a chronic endoscopic outcomes (8).
inflammation of the sinonasal mucosa and clinically
associated with 4 cardinal symptoms: nasal obstruction,
AIM OF THE WORK
drainage, a decreased sense of smell and facial pain or
This study was designed to evaluate the effect
pressure persisting for more than 12 weeks. In some
of steroid loaded middle meatal gelfoam sheet on
patients with CRS, massive hyperplastic inflammatory
endoscopic sinus surgery outcome regarding middle
growth of nasal polyps (NP) into the nasal cavity is
meatal adhesions and synechiae formation in patients
observed (1). The etiology of NP is still unknown. One of
with CRSwNP refractory to medical treatment.
the most popular theories consider polyps a consequence
of conditions, which cause chronic inflammation in the
PATIENTS AND METHODS
sinonasal mucosa characterized by variable cellular
infiltrate and stromal edema (2). Patients having chronic
This was a prospective, randomized, single-
rhinosinusitis with nasal polyposis (CRSwNP) refractory
blinded, placebo-controlled study comparing the
to medical treatment often undergo endoscopic sinus
efficacy of triamcinolone-soaked gelfoam nasal
surgery (ESS) (3).
packing with that of normal saline nasal packing in 31
The aim of ESS is to open the ostia of sinus and
patients who had undergone bilateral ESS for bilateral
thus improve mucociliary clearance and sinus drainage
CRSwNP refractory to medical treatment.
pathways, as well as to facilitate the wide distribution of
topical medications (4).
Otorhinolaryngology, Head and Neck Surgery
Postoperative outcomes sometimes are suboptimal
Department Zagazig University Hospital between
due to the inflammatory nature of the sinonasal mucosa
April 2018 and June 2019 .
leading to osteal stenosis, synechiae formation, middle
turbinate lateralization and recurrent polyposis (5).
Postoperative adhesions in the middle meatus decrease
Approval from Institutional Review Board
sinus ventilation and mucus drainage leading to persistant
was obtained and an Informed consent from all
symptoms (6). Therefore, the patency of the antrostomy site
candidates in the research.
and minimizing mucosal inflammation are significant
targets during early postoperative care for better outcome.
Assuming that the mean of perioperative
Common treatment forms involve topical nasal steroid
sinus endoscopy scale (total score) was 4.65 ± 4.5 for
sprays, off-label topical steroid formulations and systemic
triamcinolone group and 7.71 ± 4.04 for saline group;
steroids (7). Adequate drug delivery and patient compliance
the sample size was 62 nasal cavities in 31 patients.
are more provided by topical steroid therapy. Many recent
By using Open EPI, the confidence interval is 95 %
studies have estimated the role of off-label drug-eluting
and the power of test is 80 %. At the end of ESS, each
Hepatotoxicity and nephrotoxicity evaluation after repeated dose of acetamiprid in albino rats
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4545-4552
Evaluation of the Repeated Exposure of Hexaflumuron on Liver and
Spleen Tissues and Its Mutagenicity Ability in Male Albino Rat
Mohamed A. Noaishi*, H. H. Abd alhafez, and Sanaa A. Abdulrahman
Mammalian and Aquatic Toxicology Department, Central Agricultural Pesticides Lab. (CAPL), Agricultural
Research Center, Ministry of Agriculture, Egypt.
*Corresponding author: Mohamed Abdelfattah Noaishi, Mobile: +201004088153, Email: firstname.lastname@example.org
Background: Hexaflumuron (HFM) is an insect growth regulator (IGR); it is highly effective against a wide range
of pests. Aim of the work: Due to the lack of toxicological assessments of this insecticide especially the
formulation type, the objective of the present study was aimed to investigate the toxicological effects of repeated
exposure of HFM formulation on adult albino rats. Materials and methods: Three groups were administered daily
by gavage for (28 days) at dose of 11, 4, and 2.5 mg/kg b.wt respectively. In addition to control group. Results:
The results of acute toxicity indicated HFM exhibited moderate to some extent high toxicity toward the treated
rats. Slight tremors and bleeding from nose were observed. The repeated exposure results revealed the high and
middle doses exhibited methemoglobinemia. Also, the HFM treatment led to increase in AST and ALT levels. The
urea and creatinine levels were not significantly increased except the level of creatinine in high dose. According
to the histopathological findings the middle and low doses of HFM revealed greater injurious in liver and spleen
tissues than induced by high dose. HFM induced a statistically significant increase in the micronucleus (MN)
frequency in a dose-dependent manner compared with a negative control group. Conclusion: So, it is obvious the
middle and low doses induced damage in the liver and spleen organs while the high dose induced damage in blood,
bone marrow, and kidney organs.
Keywords: Hexaflumuron, histopathology, spleen, liver, methemoglobinemia, micronucleus assay.
DFB binding with a sulfonylurea receptor (SUR) is
Hexaflumuron is a Benzoylphenyl urea
the target of chitin synthesis inhibition in the
(BPU) insecticides; it is an insect growth regulator
drosophila melanogaster insect (3). But later Meyer et
(IGR) that works by inhibiting a chitin synthesis. It
al. (4) suggested that the (SUR) is dispensable in
disrupts the molting process in insects, which results
drosophila melanogaster embryos for chitin synthesis
in death at immature stages. It is highly effective
and other factors may be involved in chitin synthesis.
against a wide range of pests, primarily in
In the mammalian it is created that SUR receptors
Lepidoptera, Coleoptera, Homoptera and Diptra. In
and their agents, e.g. (BPUs), work together to boost
Egypt, this insecticide is used for control tuta
the endogenous release of insulin from pancreatic -
absoluta insect in tomatoes and cotton leaf worm and
cells. And the significant negative impact of
boll worms (1). The acute oral LD50 of HFM as un
sulfonylureas agents is hypoglycemia, which can be
active ingredient for rats is more than 5000 mg/kg
a significant problem in extended treatment (5). Other
b.wt. It is classified as unlikely to be hazard (2). But
mode of toxicity of (BPUs); is attributed to the ability
the toxicity of the HFM formulation may differ from
to induce methemoglobinemia, an abnormal form of
that of the active ingredient. A previous study
hemo-globin, the iron in the molecule of hemoglobin
reported that the estimated LD50 of the HFM
is converted to its trivalent oxidation state (Fe3+)
formulation (locally made) were 110 and 105 mg/kg
instead of its common divalent state (Fe2+). This shift
b.wt for male and female respectively (unpublished
in the hemoglobin molecule converts it into oxidized
data). In addition, the treated rats exhibited nose
hemoglobin and has become inappropriate for the
bleeding and noticeable tremors in neck. Death
transport of oxygen, resulting in certain kinds of
happened after several days of administration. So the
big difference in LD50 value between the active
Methemoglobinemia may be inherited or acquired
ingredient and the formulation was of concern. This
from the environment, but the acquired form is more
observation leads to investigate the toxicity and the
frequently caused by different drugs and toxins (7).
side effects of this insecticide especially the
Previous literature revealed the acute oral studies in
formulation type. But unfortunately there is limited
rats and mice with active substance 25% DFB
literature available on the toxicity of HFM on non-
indicated marginal effects on methemoglobin levels
target organisms, and diflubenzuron (DFB) is
at a dose of 10 g/kg b.wt (8). Same observ-ation on
another haloaromatic substituted of (BPUs) with an
dietary dogs study (8.3 mg/kg/day for 28 days) of
analogous insecticidal mode of action and has similar
technical HFM elevated methemoglobin levels in
toxicological properties, so, we review the toxicity of
both sexes (9). Also in fish study the DFB (25 mg/ L)
DFB as additional reference. Also DFB is considered
caused a reduction in the number of erythrocytes and
the first discovered insecticide of BPUs group. A
hemoglobin content after 96 h of exposure (10). These
pharmacological research recently disclosed that
previous findings concluded that BPU compounds
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4553-4556
Predictors of Success of Shock Wave Lithotripsy for Ureteral Stones Based on
Computed Tomography Scan parameters
Abdelrahman A Hassan, Hussein H Mahmoud, Hassan A Mohammed and Mohammed S Abdelbaky.
Urology Department, Al-Azhar Faculty of Medicine, Cairo, Egypt
Background: For shock wave lithotripsy has proven to be an effective, safe and truly minimally invasive option for the
treatment of nephrolithiasis. Various technical factors as well as patient selection can impact the success of the
Objective: The aim of this study was to identify the parameters on NCCT that may predict the success of shock wave
lithotripsy (SWL) in ureteral stones.
Patients and Methods: 102 patients who underwent SWL for ureteral stones at sayed Galal University Hospital from
January 2015 to August 2018 diagnosed by non-contrasted computed tomography were studied. The failure was defined
as remnant stones 4 mm. We assessed age, sex, body mass index, stone size, location, skin-to-stone distance (SSD),
presence of JJ and the presence of secondary signs (hydronephrosis, renal enlargement, perinephric fat stranding, and
tissue rim sign).
Results: 102 patients with success rate 61.8%, stone size, stone density were significantly associated with outcome of
SWL. While SSD, JJ and secondary signs (hydronephrosis, perinephric fat stranding and tissue rim sign) were
insignificant. On multivariate analysis, stone size and stone density were the independent factors affecting the outcome
Conclusions: The study demonstrated that stone size and density are significant and independent predictors of outcome
in patients with upper ureteral stones. However SSD and signs of impaction still have to be evaluated.
Keywords: Outcome, Shock Wave Lithotripsy, Ureteral Stones.
Exclusion criteria: Patients with incomplete data,
From the beginning of its clinical introduction in
missed follow up, active UTI, bleeding tendency and
the early 1980s (1). Shock wave lithotripsy (SWL) has
elevated serum creatinine.
become a standard treatment for renal and ureteral
we assessed age, sex, weight, height, body mass index
calculi as a safe, effective and noninvasive modality (2).
(BMI), stone size, density, skin-to-stone distance
Radiographic assessment of the stone is important
(SSD), Hounsfield unit (HU), presence of JJ and
to choose the best treatment. Non-contrast computed
presence of secondary signs (hydronephrosis, renal
tomography (NCCT) is recommended as the standard
enlargement, perinephric fat stranding, and tissue rim
diagnostic imaging modality in urinary stone disease (3).
Several factors have been studied to predict the success
of SWL (4). These factors may be related to the patient
The study was approved by the Ethics Board of Al-
(skin to stone distance: SSD), or to the stones [size,
Azhar University and an informed written consent
location, density (Hounsfield unit and density), and
was taken from each participant in the study.
presence of JJ]. Secondary signs including the presence
or absence of hydronephrosis, renal enlargement,
The BMI was measured for each patient by
perinephric fat stranding, and tissue rim sign are also
dividing the patient's weight in kilograms by height in
assessed on CT scan (5).
square meters. The SSD was measured on NCCT as the
Identification of these factors in clinical setting
distances at 0°, 45° and 90°. The average is calculated
will increase the efficacy and decrease the cost by
as the SSD. The HU for each stone was determined by
reducing the number of unnecessary treatment sessions
using a 5-mm collimation width from the top of the
kidneys to the level of the pubic symphysis. Three
regions of interest were analyzed. The HU average of
AIM OF THE WORK
three regions represented the HU for that stone.
The aim of this study was to identify the parameters on
Secondary signs included the presence or absence of
NCCT that may predict the success of SWL in ureteral
hydronephrosis, perinephric fat stranding and tissue rim
visualization of the dilated renal pelvicalyceal system.
PATIENTS AND METHODS
Perinephric fat stranding was defined as the stranding
This study included 102 patients who
of adipose tissue around the kidney. Tissue rim sign was
underwent SWL at Sayed Galal Hospital from January
recognized as the observation of the annular soft tissue
2015 to August 2018.
caused by edematous ureteral wall surrounding the
The inclusion criteria: Solitary and radio-opaque
stones. SWL sessions were generated using Dornier
ureteric stone of size 5 mm to 20 mm.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4557-4563
Traumatic Brain Injury Associated with Hyponatremia
Samy M Selim
Neurosurgery Department, Faculty of Medicine for Girls, Al-Azhar University
Background: Traumatic brain injury (TBI) is a one of the commonest injuries treated at the Neurosurgery Department. The
incidence rate is approximately 3% in the general population and the mortality rate is about 30% of all injury deaths.
Hyponatremia leads to high morbidity and/or mortality in TBI patients. Our study discusses the epidemiology of TBI
associated with hyponatremia. Methods: Retrospective analysis of 80 patients with TBI between February 2017 and
November 2018 was performed. The relationship between the incidence of hyponatremia in TBI patients and age, sex, GCS,
type, severity of injury and whether the patient was submitted to surgery or not. Results: Out of 80 TBI patients recruited
for the study, 25 of them suffered from hyponatremia. Hyponatremia following TBI wasn't related to age, sex but it was
related to the type of injury, the Glasgow Coma Scale (GCS) score 8, surgical history. TBI with hyponatremia usually
had longer stay in the hospital and bad outcome. Conclusions: Sever TBI patients (GCS score 8), intracranial hemorrhage
and/or skull base fracture are susceptible to developing hyponatremia and require additional treatment aiming to
normalization of serum sodium levels to prevent deterioration of their condition.
Abbreviations: ANP, Atrial natriuretic peptide; CSWS, Cerebral salt wasting syndrome; SIADH, Syndrome of
inappropriate secretion of antidiuretic hormone; TBI, Traumatic brain injury.
Keywords: Traumatic brain injury; Hyponatremia; Cerebral salt wasting syndrome; Syndrome of inappropriate secretion
of antidiuretic hormone.
increases inpatient mortality, recent data suggest that even
Traumatic brain injury (TBI), means an change in
mild degrees of hyponatremia may give an adverse
brain functions due to external force(1). It is considered as
prognosis on different patient groups(7).
socioeconomic burden and leads to high morbidity and
The common causes of hyponatremia in TBI are
mortality around the world. It contributes to 30% of all
inadequate salt intake in the diet, cerebral salt wasting
injury-related deaths, its annual cost is around $60 billion
(CSW) and syndrome of inappropriate secretion of
in US(2). Hyponatremia is one of the most common
antidiuretic hormone (SIADH)(9); one study mentioned that
electrolyte abnormalities in neurosurgical patients and is
80% of cases of hyponatremia are secondary to SIADH(10).
often observed in patients with TBI, subarachnoid
Hyponatremia in TBI may be due to excess
hemorrhage (SAH), sellar lesions, and intracranial
infection(3). It is more common than hypernatremia(4). The
adrenocorticotrophic hormone (ACTH) insufficiency,
incidence of TBI associated with hyponatremia is 33%
SIADH or CSW and sometimes multifactorial (see table
from all cases of TBI(5,6), usually within the first 5 days
1). In clinical practice, to prevent cerebral
after cerebral insult(7). SAH is one of the commonest
vasoconstriction, we use high volumes of intravenous
insults associated with hyponatremia, over 50% of patients
fluids and it is sometimes complicated by hyponatremia in
develop it and about 20% of them experience a decrease in
many neurosurgical units. Although the etiology of
serum sodium concentration to <125 mmol/L.
hyponatremia in TBI was been studied retrospectively,
Hyponatremia is a common cause of disability and/or
most of it lack reliable hemodynamic, hormonal and
death in TBI patients if not diagnosed and treated as early
biochemical data to give accurate diagnosis(7).
as possible(5,6). Although acute severe hyponatremia
Table 1. The causes and management of neurosurgical hyponatremia(7).
Blood Volume Status
See Table 2
Acute ACTH deficiency Euvolemic
be 0900 h cortisol <300 nmol/L
in stressed patient
Negative fluid balance
Cerebral salt wasting Hypovolemic
Profound diuresis and sodium Aggressive IV fluids
loss Low CVP and BP.
Usually SIADH initially,
Depends on stage
then progressing to CSWS
Stop IV fluids
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4564-4569
Estimation of the Prophylactic Effect of the Egyptian Propolis Extract against
Aluminum Silicate Toxicity on Some Organs of
Albino Rats: Growth Performance and Histochemical Studies
Ali H. Abu-Almaaty1 , Yasmin M. Abd El-Aziz1*, Nahed A. Omar2
, Ahmed M. Abdeen3
1- Zoology Department, Faculty of Science, Port Said University, Port Said,2-Zoology Department, Faculty of
Science, Damietta University, Egypt.3-Zoology Department, Faculty of Science, Mansoura University, Egypt
* Corresponding author: Yasmin Mohamed Abd El-Aziz, Tel: +20 1005718455 ,
Background: the liver is a critical organ because it contains most of the accumulated metals where toxic effects can
expected. Also, the lung is directly affected by receiving aluminum as aluminum silicate. Exposure of aluminum leads
to production of free radicals that damage living organs and tissues. Aim of the work: this study aimed to evaluate the
nucleic acid content in liver, lung and cerebellum tissues intoxicated by aluminum silicate (AlS) and the possible
ameliorative effect of propolis extract (PP).
Material and methods: Forty male albino rats (weighting 100-120 grams) were categorized randomly into four
groups, ten rats on each group (n=10). The 1st group considered as the healthy control group. The 2nd group received
200 ml PP/kg b.wt., day after day by stomach gavage. The 3rd group was injected intraperitoneally by 20 mg AlS/kg
b.wt., twice weekly. The 4th group was treated with AlS in addition to PP as the same doses as in the 2nd and 3rd groups.
After two months for each group. Liver, lung and cerebellum organs were harvested. Results: decreased body weight
gain of rats was realized with weakly stained nucleic acids contents in liver, lung and cerebellum tissues that intoxicated
by AlS. While, using the supplemented treatment (PP) at the same time with the induction of AlS compound showed
an ameliorative effect on the nucleic acid contents.
Conclusion: propolis has anti-oxidant by inhibiting AlS toxicity on nucleic acids in the different experimental organs
Keywords: aluminum silicate, propolis extract, nucleic acids, liver, lung, cerebellum.
the toxicity of aluminum silicate (AIS) admitted to rat
In the last decades, aluminum (Al) is imagined
models among their organs (liver, lung and cerebellum
as the third most massive element in the environment
tissues). The toxicity evaluation was measured by their
in which it is mixing with silicon, oxygen, nitrogen and
growth performance and histochemical investigations
other elements. It is found in the common nature and in
(demonstration of nucleic acids). In addition to the
the earth from the ground to water. In the other hand,
ameliorative effect of propolis extract (PP) in rats
silica is considered as the second most using element
suffered from AlS toxicity.
which plays a focal role in running the solubility of
alumino-silicate minerals that comprise two thirds of
MATERIALS and METHODS
the minerals in the earth coat (1). Whereas, aluminum
Extraction of propolis
silicate (AlS) is found in many industrial applications
The Egyptian raw propolis was taken from
like porcelain dishes, ceramic pots, clays, glasses,
beehive in the Faculty of Environmental Agricultural
stones, pharmaceutical products such as aspirin,
Science, Sinai University, North Sinai, Egypt. The
vaccines, antacids, antiperspirants and allergen
propolis extract was prepared by the procedure of
admission from which the element enters the animal
Cunha et al. (11).
body (1-3). Aluminum distributes in varying human
tissues including liver, lung, brain, heart, blood, kidney,
bone and other organs (4-6) and the silica caused
Forty male albino rats (Rattus norvegicus)
fibrogenic, carcinogenic and mutagenic cases (7).
weighting 100-120 grams. The rats were purchased
Propolis is bee glue and known as a resinous material
from the Faculty of Veterinary Medicine, Suez Canal
that is collected from vary plants excretions at any
University, Ismailia, Egypt. Rats were housed in plastic
climate. The bee workers are used this resin for
cages and received water and diet ad libitum at good
protection of their beehives versus predators or for
conditions for eight weeks (experimental period).
sticking any opens and scratches which occurring from
Animals were categorized randomly into four groups,
the different seasons. At folk medicine, the Greek
ten rats in each group (n=10 rats). The first group was
physicians used the raw propolis for improving of the
considered as the control one. The second group was
gastrointestinal functions, anti-aging, inhibit tumor,
received 200 ml of propolis extract per kg b.wt., day
anti-fatigue as well as others benefits. The propolis has
after day by stomach gavage tube. The third group was
powerful anti-inflammatory and antioxidant properties
injected intraperitoneally (IP) by 20 mg of aluminum
which that defense the damaging affects against
silicate per kg b.wt., twice a week. The forth group was
aluminum toxicity (8-10). This study aimed to evaluate
treated with aluminum silicate plus propolis extract as
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4570-4576
Study of The Relationship between Severity of Liver Cirrhosis and
Pulmonary Function Tests
Nabil Farouk Awad1, Abd-Allah Mohammad Elbalsha1, Mohamed Zakria Abo Amer2,
Mohamed Helmy Elsayed Ibrahim1*
Departments of Chest Diseases 1 and Tropical Medicine 2, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed Helmy Elsayed Ibrahim, Mobile: (+20) 01552935770,
Background: Cirrhosis is a condition in which the liver does not function properly due to long-term damage. This
damage is characterized by the replacement of normal liver tissue by scar tissue.
Objective: The aim of this work is to study the relationship between severity of liver cirrhosis according to the Child-
Pugh score and pulmonary function tests (namely spirometry and arterial blood gas).
Patients and Methods: The study is a cross sectional one, which was carried out on 50 patients admitted in the inpatient
wards, or in regular follow-up in the out-patient's clinics of the Gastroenterology Departments, in Al-Azhar University
Hospitals between November 2018 and May 2019.They were divided into 3 groups according to Child Pugh Classification
(A, B and C).
Result: The prevalence of hypoxia was (30%) in all studied groups (50 patients), the hypoxia was present in patients with Child
C and Child B (62%) and (29.4%) respectively but none of Child A had hypoxia. It was noted that all pulmonary functions
were worst in patients Child class C when compared to other groups. However, patients Child B had also significantly worse
pulmonary functions when compared to patients class A. We also showed that pulmonary functions are significantly correlated
with synthetic liver function, Child and MELD score. The deterioration of liver functions and rise of patients score is
accompanied by worsening of all pulmonary functions.
Conclusion: Patients suffering from severe liver cirrhosis and ascites, have significant reduction in (PaO2) and (SaO2) in
association with restrictive pulmonary function pattern (up to 100% of patients with massive ascites).
Keywords: Liver Cirrhosis, Pulmonary Function Tests, Child Pugh Classification.
AIM OF THE STUDY
The severity of cirrhosis is commonly
The aim of this work is to study the relationship
classified with the Child-Pugh score. This scoring
between severity of liver cirrhosis according to the
system uses bilirubin, albumin, INR, the presence and
Child-Pugh score and pulmonary function tests
severity of ascites and encephalopathy to classify
(namely spirometry and arterial blood gas).
patients into class A, B or C. Class A has a favorable
prognosis, while class C is at high risk of death. This
PATIENTS AND METHODS
system was devised in 1964 by Child and Turcotte,
The study is a cross sectional one, was carried
and modified in 1973 by Pugh and others (1).
out on 50 patients admitted in the inpatient wards, or
Pulmonary complications such as hepato-
in regular follow-up in the out-patient's clinics of the
pulmonary syndrome, porto-pulmonary hypertension
, hepatic hydrothorax and spontaneous bacterial
University Hospitals between November 2018 and
empyema are observed frequently in these patients (2).
Pulmonary function tests (PFTs) are an important
Clinical work up:
tool in the investigation and monitoring of patients
with respiratory pathology. They provide important
The study included 50 patients with liver
information relating to the large and small airways,
cirrhosis 16 males and 34 females, in our study. The
the pulmonary parenchyma and the size and integrity
mean age of the patients was 47.5 ± 17.2 years. The
of the pulmonary capillary bed. Although they do not
patients will be recruited from outpatient clinic (and/or)
provide a diagnosis per se, different patterns of
inpatient department consecutively and divided into 3
abnormalities are seen in various respiratory diseases
groups according to Child Pugh Classification.
which helps to establish a diagnosis (3).
Group (I) Child A: 17 patients with liver cirrhosis (child
Liver cirrhosis is often accompanied by arterial
pugh score <7)
hypoxemia in the absence of cardiopulmonary
Group (II) Child B: 17 patients with liver cirrhosis
(child pugh score 7-9)
In addition, abnormalities in pulmonary function and
Group (III) Child c: 16 patients with liver cirrhosis
impaired gas exchange may occur in as many as 45
(child pugh score 10-15)
50% of patients (5). Certain pulmonary functions may
The mean age of the patients was 38.6 ±
be impaired in chronic liver disease. In general, a
13.1years, 49.6± 12.9years, 48.6 ± 5.0years in groups
reduction in total lung capacity, airway obstruction,
I, II, III respectively.
impairment in diffusion capacity, and restrictive types
of abnormalities such as increase in the alveolar
arterial oxygen difference are manifested (6).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4577-4587
Bone Mineral Density and Trabecular Bone Score in Patients with
Non-Radiographic Axial Spondyloarthropathy
Hesham Salah Hamoud, Mohamed Magdy Ghit, Mohammad Abd Elmoez Ali,
Islam Mohamed Elsayed Khaled*
Department of Rheumatology and Rehabilitation, Faculty of Medicine, Al-Azhar University
*Corresponding author: Islam Mohamed Elsayed Khaled, Mobile: (+20) 01092620140, Email: email@example.com
Background: spondyloarthropathies (SpA) are a group of chronic inflammatory rheumatic conditions that share
multiple clinical features including axial and/or peripheral arthritis, enthesitis, absence of serum rheumatoid factor
and presence of common extra articular manifestations.
Objective: the aim of this work is to study bone mineral density and trabecular bone score at patients with non-
radiographic axial spondyloarthropathy.
Patients and Methods: this study is a cross sectional study in which 200 patients having chronic back pain selected
from those attending the outpatient clinic and inpatient of Al-Azhar University Hospitals, Damietta and were divided
into two groups: 1- (Group A, study group): (160) patients had inflammatory low back pain fulfilling Calin criteria
for inflammatory low back pain. 2- (Group B, control group): (40) patients had mechanical low back pain not fulfilling
criteria of inflammatory back pain.
Results: regarding results of clinical examination, there was significant increase of arthritis, dactylitis, enthesitis and
psoriasis in Group A when compared to Group B (43.3%, 16.7%, 30.0%, 20.0% vs 3.3%, 0.0%, 3.3% and 3.3%
respectively). In addition, there was significant increase of arthritis plus dactylitis and arthritis plus enthesitis in Group
A when compared to Group B (16.7%, 30.0% vs 3.3% and 0.0% respectively).
Conclusion: results of the present study proved that, both bone mineral density and trabecular bone scores showed
early changes in patients with non-radiographic axial spondylo-arthropathy. In addition, both correlated with each
other and with results of axial magnetic resonance imaging. Thus, they are advocated in diagnosis of nr. SPA.
Keywords: Bone Mineral Density, Trabecular Bone Score, Non-Radiographic Axial Spondyloarthropathy.
The spondyloarthropathy family comprises of
The standard technique for measuring bone
Ankylosing Spondylitis (AS), psoriatic arthritis,
mineral density (BMD) is dual energy X-ray
reactive arthritis, inflammatory bowel disease
absorptiometry (DXA). Measurements are usually
associated SpA, juvenile SpA and undifferentiated
taken in the femur and in the lumbar spine in the
SpA (uSpA) (1).
anterior-posterior projection (8).
These diseases are strongly associated with the
Trabecular bone score (TBS), a new
genes of the Major Histocompatibility Complex
noninvasive tool for the measurement of bone
(MHC), in particular the Human Leucocyte Antigen
microarchitecture, could be used complementary to
(HLA) B27 an (HLA) B15 (2).
aBMD in the evaluation of bone quality in AS patients
Non-radiographic axial SpA (nraxSpA)
(9). It provides a surrogate estimate of bone
comprises those patients who may have clinical and
microarchitecture, obtained using proprietary
laboratory features of SpA but do not have definite
software to analyze lumbar DXA scans (10).
radiographic sacroiliitis and may have early MRI
features on the sacroiliac joints (3).
AIM OF THE WORK
Most of the studies also show that patients with
The aim of this work is to study bone mineral
axial SpA (axSpA) have a higher prevalence of than
density and trabecular bone score at patients with
that expected in the general population (4). The
non-radiographic axial spondyloarthropathy.
EULAR SpA imaging task force recommends
screening for osteoporosis in SpA (5).
SUBJECTS AND METHODS
The prevalence of vertebral fractures has been
shown to be increased in ankylosing spondylitis (AS)
This study is a cross sectional study in which
from the early stages onwards (6).
200 patients having chronic back pain selected from
Osteoporotic fractures lead to increased
those attending the outpatient clinic and inpatient of
morbidity and mortality, as demonstrated by the data
Al-Azhar University Hospitals, Damietta and were
on disability-adjusted life years (DALYs; i.e., the
divided into two groups:
number of years lost due to ill health, disability, or 1- (Group A): (160) patients having inflammatory low
early death), which are employed to estimate overall
back pain fulfilling Calin criteria for inflammatory
disease burden indeed, in Europe, the estimated
low back pain.
number of DALYs lost because of osteoporosis is 2.0 2- (Group B): (40) patients having mechanical low back
pain not fulfilling criteria of inflammatory back pain.
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4588-4590
Early Results of Fibular Osteotomy for Treatment of
Medial Compartment Osteoarthritis
Adnan Elsebaiy(1), Hesham Safwat (1) , Ahmed Abdel Rahman Ashiry(2)
Professor at Department of Orthopaedic Surgery, Al-Azhar Faculty of Medicine, Cairo (1)
Resident Doctor at Department of Orthopaedic Surgery, El-Fayoum General Hospital (2)
Corresponding Author: Ahmed Abd Elrahman Ashiry Mob: 01009951568, email: firstname.lastname@example.org
Background: knee O.A was treated by total knee arthroplasty but it is new procedure still under trial for treatment of
medial compartment knee O.A. Objective: To assess the early results of proximal fibular osteotomy as a new surgery for
pain relief and improvement of functions of the knee in patients with medial compartment OA.
Patients and methods: From July 2016 to September 2018, 10 patients who underwent proximal fibular osteotomy for
medial compartment osteoarthritis. Preoperative and postoperative knee society score (KSS) and visual analogue scale
(VAS) were obtained to assess knee functions and pain
Results: median knee society score (KSS) show improvement postoperatively from 83 to 105 and visual analogue scale
(VAS) decreased postoperatively from 8.5 to 4.
Conclusions: This study shows that proximal fibular osteotomy (PFO), a new surgery, can effectively relieves pain and
improves knee function in patients with medial compartment osteoarthritis.
Key words: Early results, Proximal fibular osteotomy, Medial compartment knee O.A.
Osteoarthritis (OA) of the knee is one of the most
common progressive diseases that has an increased
incidence and prevalence in people over the age of 40
evaluated the early results of PFO according to visual
years. Around 10% of all people older than 60 years of
analog score (VAS) and Knee society score (KSS).
age have radiological signs of knee O.A, and about half
of those complain of clinical symptoms of
PATIENTS AND METHODS
musculoskeletal diseases. OA is common cause of
From July 2016 to September 2018, 10 patients who
disability and limitation of daily activities and work (1).
underwent PFO at El- Fayoum and Al-Azhar University
Genu varus deformities, characterized by a
mechanical femoro-tibial axis less than 180° on full leg
sociodemographic data are shown in table 1.
standing antro-posterior (AP) radiograph and narrow
Inclusion criteria: (i) Medial compartment knee OA
joint space medially, are common in patients with knee
with varus knees (ii) Good lateral joint space in weight
OA and affect 74% of patients with idiopathic OA. It was
bearing films (iii) Patient's age above 45 (iv) Severe pain
reported, that the medial compartment of the knee bears
for the patient to request for surgical intervention.
around 60% to 80 of the load in healthy knees. It is
Exclusion criteria: (i) Tricompartmental arthritis (ii) Post
believed that the load is distributed along the mechanical
traumatic OA (iii) Fixed flexion deformity (iv) Very obese
axis, which is generally medial to the center of the knee
patient (v) Bone on bone in standing AP X-ray.
High tibial osteotomy and total knee arthroplasty
Table (1): Sociodemographic data of patients
are the two methods used for treating knee OA. High
tibial osteotomy is a technically demanding procedure
and may result in complications, including neuro-
vascular injury, iatrogenic fracture, and nonunion (4,5).
Total knee arthroplasty (TKA) can relieve pain, correct
lower limb alignment, and improve function. However,
for younger, active patients or patients with moderate
OA, it may not be the treatment of choice (6).
Surgical technique: Under spinal anesthesia;
In 2015, Zhang et al. reported that proximal
patients were supine on a standard radiolucent orthopedic
fibular osteotomy (PFO) improves joint function and
table. The lower limb tourniquet was inflated. The fibular
relieves pain in human knee OA (7). This new surgery is
head was identified to avoid injury of the common
safe, simple and affordable. Pain relief occurs after
peroneal nerve. A lateral incision 3 to 5 cm was made at
surgery in almost all patients. PFO may replace or delay
the proximal third of the fibula. The fascia was opened in
TKA in a subpopulation of patients with medial
line with the septum between the peroneus and soleus, the
compartment knee osteoarthritis. In the present study, we
RELATIONSHIP BETWEEN SLEEP DISORDERED BREATHING AND PRO-INFLAMMATORY MARKERS IN ACUTE ISCHEMIC STROKE
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4600-4607
The Effects of Dexmedetomidine on Airway-Related Complications During
Emergence from General Anesthesia in Nasal and Paranasal Surgeries
Nabeel Ibrahim Fathy Elmasry, Maamoun Mohamed Ismael, Amr Soliman Hamroush, Ahmed Gamal
Anesthesiology and Intensive Care Department, Faculty of Medicine, Al-Azhar University
* Corresponding author: Ahmed Gamal Moustafa Hegazy, E-mail: email@example.com
Background: Stimulation of various sites, from the nasal mucosa to the diaphragm, can evoke laryngospasm. To
reduce airway reflexes, tracheal extubation should be performed by special technique or with drugs that do not
depress ventilation. However, tracheal extubation during rhinoplasty may be difficult because of the aspiration of
blood and the possibility of laryngospasm. Dexmedetomidine has sedative and analgesic effects, without affecting
Objectives: To evaluate the effects of dexmedetomidine on airway-related complications during emergence from
general anesthesia (GA) in nasal and paranasal surgeries.
Patients and Methods: This prospective randomized clinical study was included 90 patients of both sexes,
admitted for elective nasal and paranasal sinus surgery. They were randomly allocated into three groups 30 patients
each, Group A: Standard awake extubation technique. Group B: fully awake "no stimulation extubation" technique.
Group C: Dexmedetomidinegroup, who received intravenous (I.V) dexmedetomidine 0.5-1 g/kg bolus in 100 ml
of normal saline over 10 minutes before the end of surgery by 10 minutes, The dexmedetomidine bolus was
followed by 0.2 g/kg/hr which was stopped immediately when extubation was done.
Results: The following parameters were assessed between the three groups: hemodynamics, airway-related
complications, extubation time. Group C: was associated with a significant increase in extubation quality compared
with group A and group B regarding hemodynamics, airway-related complications, extubation time.
Conclusion: This study showed that the dexmedetomidine group associated with minimal circulatory reflexes and
airway-related complications further to the advantage of short extubation time compared with the "no stimulation"
Keywords: Airway, Awake, Complications, Emergence, Nasal sinus, surgery, Technique, Tracheal, "no
stimulation" dexmedetomidine, Tracheal extubation, Rhinoplasty.
Intubation and extubation are associated with
responses during extubation in the past but with
cardiovascular and various airway responses leading
to tachycardia, hypertension, arrhythmia, myocardial
The "no stimulation" extubation technique
ischemia, cough induction, bronchospasm, increased
has been suggested and avoids extubation under light
bleeding, increased intracranial and intraocular
plan of anesthesia and ensures extubation only when
consciousness is returned. It requires absolutely no
Extubation under deep anesthesia decreases
stimulation during emergence and performing
cardiovascular stimulation and reduces the incidence
extubation only when the patient wakes up
of coughing and straining on the tube. However, the
spontaneously and opens his eyes (12).
incidence of respiratory complications has been
Recently dexmedetomidine, a potent 2-
found to be greater after extubation under deep
adrenoreceptor agonist has been used to facilitate
anesthesia, regardless of the type of operation (2).
extubation in surgical intensive care unit, but its role
Smooth extubation requires the absence of straining,
in the attenuation of hemodynamic and airway
reflexes during extubation in GA is still scarce. The
effects of single dose of dexmedetomidine in
Many theories have been described for
attenuation of the airway and circulatory reflexes
sudden increase in heart rate (HR) and blood pressure
during extubation still under research (13).
(BP) during extubation such as surge of
catecholamines, airway irritation, intense pain
AIM OF THIS STUDY
following surgery, and emergence. Although these
The aim of the work was to evaluate the
changes are transitory, it could be a major concern
effects of single dose of dexmedetomidine on
for an anesthesiologist (4).
circulatory reflexes and airway-related complications
Much attention has been paid to attenuate
during emergence from GA in nasal and paranasal
these changes during extubation. Intratracheal LA
instillation,(5) I.V lignocaine,(6) short acting opioids
complications (coughing, bucking, laryngospasm,
such as fentanyl and remifentanil,(7) esmolol,(8)
oozing from the wound, the incidence of vomiting),
labetalol,(3) diltiazem,(10) and verapamil(11) have been
extubation time between three groups and determined
used to attenuate these hemodynamic and respiratory
convenient technique for tracheal extubation were
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4608-4615
Ultrasonographic Enthesis Evaluation in Patients with
Recurrent Acute Anterior Uveitis with and without Spondyloarthropathy
Asaad Nooreldin1*, Mohamed Ismail Abdelkareem2, Ahmed Moslam Ibrahim2, and Amr Mohamed Mahmoud2
Departments of 1Ophthalmology and 2Rheumatology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
*Corresponding Author: Asaad Nooreldin, Tel: +2010263666024, Email: firstname.lastname@example.org
Background: spondyloarthritis (SpA) is a group of chronic diseases recognized by arthritis and extraarticular lesions e.g.
uveitis, enthesitis, dermatological affection. About 35% of SpA patients may present with recurrent attacks of acute anterior
Purpose: it was to detect whether patients with idiopathic recurrent AAU who were positive or negative for Human
Leukocyte Antigen B27 (HLAB27) had a frequency of enthesis lesions compared to that seen in patients with SpA.
Patients and Methods: a prospective study of enthesis evident on musculoskeletal ultrasound examination was done on
sixty patients and twenty controls, the eighty were categorized into 4 groups; group 1 included 20 patients with known SpA
group 2 included 20 with recurrent AAU HLAB27 positive and didn't have SpA aspects group 3 included 20 with recurrent
AAU HLAB27 negative and didn't have SpA and group 4 included 20 healthy controls. Using Madrid Sonography
Enthesitis Index (MASEI) twelve enthesis locations were assessed in each participant.
Results: a total of 960 entheses sites were examined by ultrasonography in all 80 participants. The MASEI cut-off limit of
18 points was 75%, 60%, 45%, and 10% of the participants in the 4 groups; respectively. The MASEI score was
significantly higher in groups 1&2 than in groups 3&4. The differences between the two groups were statistically significant.
Conclusion: a high percent of HLAB27 positive patients with idiopathic recurrent AAU without characteristics of SpA
have enthesis lesions with about percent to those seen in patients with known SpA.
Keywords: Enthesis, ultrasound, acute anterior uveitis, and spondyloarthritis.
undiagnosed SpA(6). Spondyloarthritis, is considered one
Spondyloarthropathies are a group of systemic
of the most frequent rheumatic diseases, its prevalence
inflammatory troubles share a general manifestation
about 0.5%1.9% in general population(7).
which include arthritis of the axial and/or distal joints,
The most common systemic disease associated
inflammatory backache, enthesitis, skin and gut
with acute anterior uveitis is spondyloarthritis, on the
manifestations(1). The term spondyloarthritis (SpA)
other side, the most frequent non-skeletal manifestation
includes ankylosing spondylitis (AS), psoriatic arthritis
among patients with SpA is uveitis(7,8). So, eye affection
(PsA), SpA associated with enteropathic (inflammatory
may be the key manifestation of undiagnosed
rheumatologic disease(7). It is estimated that more than 1/3
undifferentiated SpA (i.e. a presentation with typical
of patients with spondyloarthropathy have SpA. On the
manifestations of SpA without any manifestations of any
other side, half of AAU cases are idiopathic regardless of
the previously mentioned four subtypes)(2). Remarkably,
their link to HLA-B27(9).
the Assessment of Spondyloarthritis International Society
Enthesis is the zones where tendon, ligament, or
(ASAS) classification criteria(3) have recommended that
joint capsule attached at a bone to facilitates easy joint
recurrent attacks of acute anterior uveitis (AAU) in
motion and assist in transmission of tensile load from soft
patients who known to be positive for Human Leucocytic
tissues to bone(10). Inflammation of enthesis, a
Antigen B27 (HLAB27) must be included in the series
specific manifestation of SpA, is believe to be the
of SpA. An early diagnosis of SpA is important, however
hallmark lesion in the disease(11). Enthesitis occurs due to
it looks that early diagnosis is still challenging for
inflammation at adhesion parts of tendons to bones and
physicians. There is about 5 years delay in the diagnoses
comprises the main pathophysiological and clinical
of SpA according to different literature(4).
features of SpA(11). The lower extremity enthesis is more
In addition, axial SpA keeps going to be working
commonly affected than upper extremity entheses
for years. Furthermore, it doesn't disappear over time;
because the lower entheses are more exhibited to
most of functional disability happens in the early few
years in the course of the disease(4). AAU is the most
Imaging studies are more sensitive and specific
common feature of uveitis; it may precede other clinical
than clinical examination in the diagnosis of enthesitis,
manifestations, and be the key presentation for diagnosis
and even ultrasonography might be superior to MRI in
About half of the patients presenting with acute
Ultrasonography (US) the best tool to evaluate
recurrent anterior uveitis are positive for HLA-B27 and
periarticular soft tissue as it is sufficient for discovering
more than half of these HLA-B27 positive patients have
both early (edema and thickening) and late changes
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4616-4621
Helicobacter Pylori Seropositivity
in Hyperemesis Gravidarum During Pregnancy
Esmail El-Garhy, Yehia A. Wafa, Ahmed Okasha
Department of Obstetrics & Gynecology, Faculty of Medicine, Al-Azhar University
Corresponding author: Ahmed Okasha; Mobile: +201005087129; Email: email@example.com
Background: Prevalence of hyperemesis gravidarum varies from 0.3 to 1.5% of all live births. The exact cause is not
well known and is probably multifactorial. It is the most common cause of hospitalization in the first half of pregnancy
and second only to preterm labor for pregnancy overall. The etiology of emesis gravidarum remains unknown. But a
number of possible causes have been studied as endocrinal, immunological, psychological, metabolic, genetic and even
infectious such as helicobacter pylori infection.
Aim of the Work: To assess the value of screening for helicobacter pylori seropositivity in hyperemesis gravidarum
for better evaluating and improving the cure rate especially in resistant cases.
Patients and methods: A prospective controlled comparative study was conducted on 100 pregnant women in the first
trimester, where 50 of them were suffering from hyperemesis gravidarum (group A) and another 50 healthy women
were chosen as a control group (group B). They were recruited from the outpatient clinic of Al-Galaa Maternity
Teaching Hospital, Cairo, Egypt from January 2019 till August 2019. After approval of the local ethics committee, a
written consent was obtained from each woman before inclusion in the study. Fasting and post prandial sugar, Liver
and kidney function tests, thyroid function tests, CBC, urine and electrolyte examination as well as serum examination
for IgG of helicobacter pylori were done for each one.
Results: Serum helicobacter pylori IgG antibodies seropositivity and acetonuria was significantly higher in group A
than in group B while serum sodium and potassium levels were significantly lower in patients with hyperemesis
gravidarum than control group.
Conclusion: The treatment of H. Pylori infection may reduce the risk of hyperemesis gravidarum and its complications.
Keywords: Hyperemesis gravidarum, Helicobacter pylori, Morning sickness.
Nausea and vomiting during pregnancy, which
retardation, and in severe cases maternal and fetal death
is also known as `morning sickness', affects between
may happen (4).
7080% of all pregnancies in the first trimester.
The Helicobacter pylori (H. pylori) is
Usually, it starts between 4 and 8 weeks of gestation,
considered as an important cause of gastritis in human
however the symptoms might continue till the 16th18th
beings and as an essential factor in the pathogenesis of
week. It is generally a mild condition and self-limited.
peptic ulcer. Many findings suggest that Helicobacter
A small number of pregnant women have a more acute
pylori is also involved in the pathogenesis of cancer and
sequalae, with the most severe form known as
lymphoma of the stomach (6).
hyperemesis gravidarum (1). In almost 1-10% of
In developing countries, 70% to 90% of the
pregnancies, symptoms may continue till 20-22
population is infected by the bacteria, while in
industrialized countries the prevalence is smaller,
characterized by persistent nausea and vomiting
ranging between 25% and 50% (4).
accompanied by ketosis and loss of weight (>5% of the
Many methods of Helicobacter pylori testing
weight before pregnancy). It may cause hypovolemia,
exist. Noninvasive tests for Helicobacter pylori
electrolytes disturbance and acid-base imbalance,
infection include the blood antibody test, the
nutritional deficiencies, and even - in severe cases -
stool antigen test, or with the carbon urea breath test (in
death. Severe cases with hyperemesis require
which the patient drinks 14C or 13C labelled urea, then
hospitalization in 0.3-2% of pregnancies(3).
the bacterium metabolizes the labelled urea producing
Prevalence of hyperemesis gravidarum varies from 0.3
labelled CO2 that can be detected in the breath of the
to 1.5% of all live births. (4) The exact etiology of
patient). The other method for Helicobacter pylori
hyperemesis gravidarum is not well known and is
infection detection is endoscopic biopsy check with
probably multifactorial in which psychological factors,
a rapid urease test, histological examination, and
disturbance of gastrointestinal motility, hormonal
microbial culture (7).
changes, infections, immunological, metabolic and
In essence, serology samples the whole stomach
anatomical factors appear to intervene (5). It is the most
whereas biopsy only samples a small portion, and the
common cause of hospitalization in the first half of
inflammatory process may be patchy, so serologic
pregnancy and second only after preterm labor for
analysis is considered more sensitive than diagnostic
pregnancy overall. It can be associated with serious
methods involving biopsy. The development of
maternal morbidity such as Wernicke's encephalopathy
Helicobacter pylori-specific fluorescent serum antibody
and fetal morbidity such as intrauterine growth
test helps for easy and suitable screening for H. pylori
infection and because of its simple, cheap and non-
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4622-4627
Significance of Neuropilin-1 Expression, Ceruloplasmin oxidase and Copper in
Egyptian Children with B-Lineage Acute Lymphoblastic Leukemia
Nawal M. Abdel Qawy1, Alshaymaa M. Alhabibi1, Sahar A. Khalil2, Marwa M. Abdelfattah*3
1Department of Clinical Pathology, Faculty of Medicine for Girls, Al-Azhar University,
2Department of Pediatric Oncology, National Cancer Institute,
3Central Public Health Laboratories, Ministry of Health, Cairo, Egypt
*Corresponding author: Marwa M. Abdelfattah, Mobile: (+20)01003832597, E-mail: firstname.lastname@example.org
Background: Neuropilins are transmembrane glycoproteins that act as receptors for vascular endothelial growth factors
(VEGF) and are involved in the process of tumor angiogenesis. Ceruloplasmin is a member of the multi copper oxidase
family. It has antioxidant properties that play a central role in protection of the body against advanced oxidation protein
Objective: This study was aimed to assess the expression of Neuropilin-1(NRP-1) on blasts of B-lineage precursor
lymphoblastic leukemia (ALL) to be used in the diagnostic panel of this disease. We also aimed to assess the alteration
of the levels of ceruloplasmin oxidase and copper as a compensatory mechanism to minimize the effects of reactive
oxygen species resulting from leukemias.
Subjects and Methods: This study was conducted on 40 children with newly diagnosed B-lineage precursor
lymphoblastic leukemia. 40 age-matched controls were enrolled to serve as control. The expression of NRP-1 on
peripheral blood samples was evaluated by flow cytometry as the proportion of positive cells expressing the marker.
Ceruloplasmin oxidase and copper levels were assessed by immunoturbidimetric assay.
Results: There was highly significant increase in the proportion of positivity of NRP -1 in patients compared with
control group (P<0.001) Ceruloplasmin oxidase and copper levels were also higher in patients compared with control
Conclusions: It could be concluded that NRP-1 is a valuable marker for diagnosis of B-lineage ALL. There is an
increase in the levels of ceruloplasmin oxidase and copper which at the time of diagnosis of B-ALL.
Keywords: Neuropilin-1 (NRP-1), Ceruloplasmin oxidase, Copper, B- lineage precursor lymphoblastic leukemia.
Neuropilins (NRPs) are multifunctional, non-
as a mediator of leukemia associated angiogenesis as
tyrosine kinase surface glycoproteins that are expressed
well as asan autocrine growth regulator in leukemic cells.
in all vertebrates with an important role in a wide range
Angiogenesis is an important requirement for the
of physiological processes including development,
development and progression of hematological
axonal guidance, angiogenesis, immunity, as well as in
pathological conditions such as cancer (1).
They are often upregulated in various clinical
There are two isoforms, neuropilin-1 (NRP-1 or
disorders, including cancer, where they increase the
CD304) and neuropilin-2 (NRP-2). NRP-1 and NRP-2
oncogenic activities of malignant cells by promoting
are expressed in various immune cells, such as
survival, inducing angiogenesis and lymphangiogenesis
macrophages, dendritic cells (DCs), T cells, B cells, and
and contribute to therapy resistance(6).
mast cells where they regulate a myriad of functions,
Malnutrition has long been recognized as an
including development, migration and recruitment,
important component of adverse outcomes among
communication between different immune cells as well
patients with cancer, including increased morbidity and
as regulation of immune response, under normal
mortality and decreased quality of life. Different studies
physiological condition and during pathological
tried to establish relationship between trace elements and
disorders. They are also detected in osteoclasts and
malignant diseases (7).
osteoblasts where they regulate bone homeostasis (2).
Ceruloplasmin is copper binding glycoprotein, it
NRP-1 is characterized mainly in T cell subsets,
hasantioxidant properties due to its ability to react with
and to a lesser extent in macrophages and DCs. In
and scavenge toxic oxygen species such as superoxide
comparison, NRP-2 is less studied and poorly
and hydrogen peroxide. An imbalanced production of
reactive oxygen species plays a role in the pathogenesis
NRPs were demonstrated to act as coreceptors
of a number of human diseases as cancer, atherosclerosis,
for vascular endothelial growth factor (VEGF) and the
neurodegenerative disease and allergy (8).
class III Semaphorin family of molecules by interacting
The aim of the current study was to study the
with VEGF receptors and Plexins, respectively.
expression of NRP-1in patients with B-lineage precursor
However, other ligands for NRPs have also been reported
lymphoblastic leukemia to determine if it could be used
for routine diagnosis. Also, it determines the changes in
VEGF is an important cytokine that contributes
the levels of ceruloplasmin oxidase and copper in those
to disease evolution in various neoplasms and described
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4628-4638
Comparison of the Effect of Nitroglycerin, Magnesium Sulphate and
Dexmedetomidine as Hypotensive Agents in Lumbar Spine Surgery
Osama Helal Ahmed, Tawfik Mohamed Nour-Eldin, Waheed Mohamed Ali, Marwa Ali Abd El Zaher*
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Al-Azhar University, Assuit, Egypt
*Corresponding Author: Marwa Ali Abd El zaher, Phone No.: (+2) 01065856550, E-mail: email@example.com
Background: in orthopedic procedures more blood is lost from raw bone and muscle surface than from identifiable
blood vessels. Moderate hypotensive anesthesia was found to significantly decrease the average blood loss by nearly
40%, reduce the need for transfusion by 45% and shorten the average operating time by nearly 10%.
Objective: The aim of the current study was to compare magnesium sulphate and dexmedetomidine with nitroglycerin
as regard hypotensive effect as primary outcome, volume of blood loss, blood substitution and pattern of recovery as
secondary outcome during lumbar spine surgery. Patients and Methods: This prospective, controlled, comperative,
randomized, double blind study included a total of ninty patients aged 21-50 years of both sex, ASA I-II scheduled for
elective lumber spine surgery, attending at Department of Orthopedic, AL-Azher university Hospital in Assuit as single
center study. Patients have received either dexmedetomidine, magnesium sulfate or nitroglycerine.
Results: There were highly significant difference (P <0.000) with duration of surgery between different study groups
with duration of surgery shortest in dexmedetomidine group followed by magnesium sulfate group and then
nitroglycerine group. There were highly significant differences between different study groups with fluid maintenance
with higher volume in nitroglycerine group then magnesium sulfate group and then dexmedetomidine group. There
were highly significant differences (P <0.000) with systolic blood pressure between study groups at A1 and
hypotensive agent discontinuation with lowest systolic blood pressure in dexmedetomidine group followed by
magnesium sulfate group and then nitroglycerine group.
Conclusion: nitroglycerine, magnesium sulfate and dexmedetomidine could induce hypotension, but
dexmedetomidine showed more favorable hemodynamic profile as regard blood pressure and heart rate.
Keywords: Nitroglycerin, Magnesium Sulphate, Dexmedetomidine, Hypotensive agents, Lumbar spine surgery.
The decrease in arterial pressure is achieved by
In orthopedic procedures more blood is lost from
vasodilatory effect of NTG on arterial and venous bed
raw bone and muscle surfaces than from identifiable
resulting finally in decreased venous and right heart
blood vessels. A radioactive isotope study of blood loss
filling and so decreased cardiac output.Nitroglycerine
in major orthopedic procedures showed that estimates of
causes either no change or slight tachycardia during
blood losses were, on average, 50% of the true measured
continuous infusion as slight increase in heart rate is
loss (1). Laminectomy and spinal fusion are associated
reflex phenomenon, baroreceptor response secondary to
with increased blood loss due to bleeding from the
hypotension produced (6).
extensive epidural venous plexuses and poses possibility
I.V. magnesium sulphate may be a good agent for
of nerve injury root level if not visualized properly. Nerve
deliberate hypotension because magnesium intervenes in
roots are at jeopardy during laminectomy and decrease
the activation of membrane Ca ATPase and NaK
hemorrhage adds to safety of surgery in this area (2).
ATPase involved in transmembrane ion exchanges
Moderate hypotensive anaesthesia was found to
during depolarization and repolarization phases, and thus
significantly decrease the average blood loss by nearly
act as a stabilizer of cell membrane and intracytoplasmic
40%, reduce the need for transfusion by nearly 45% and
organelles (7).The antagonist effect of magnesium at N-
shorten the average operating time by nearly 10% (2).
methyl-D-aspartate (NMDA) receptors has led to studies
Deliberate hypotension is defined as the
of its adjuvant effect in perioperative analgesia (8).
intentional reduction of the systemic perfusion pressure.
Dexmedetomidine (DEX) is a potent highly selective 2
Deliberate hypotension is defined as reduction in systolic
adrenergic agonist, possessing a differential specificity
blood pressure (SBP) to 80-90mm Hg (30% decrease in
for the 2: 1 receptors (9). DEX has sedative, analgesic,
the SBP from the baseline pressure) or a decrease in the
anesthetic sparing effect, and sympatholytic properties
mean arterial pressure (MAP) to 50-65 mm Hg in
(10). The central and peripheral sympatholytic action of
normotensive patients (3).
DEX is mediated by 2 adrenergic receptors (11) and is
Many anesthetic agents and vasoactive drugs are
manifested by dose-dependent decrease in arterial blood
used frequently to produce controlled hypotension,
pressure, heart rate, cardiac output and norepinephrine
vasodilators, autonomic ganglion blockers, -adrenergic
The aim of the current study was to compare
blockers, and calcium channel blockers (4). It was in 1985
magnesium sulphate and dexmedetomidine with
M Guggiari et al., used nitroglycerine (NTG) for the first
nitroglycerin as regard hypotensive effect as primary
time to produce induced hypotension in aneurismal brain
outcome, volume of blood loss, blood substitution and
surgery and proved that it can be used as a sole agent for
pattern of recovery as secondary outcome during lumbar
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4639-4642
Randomized Comparative Study between Direct and Indirect Tibial
Revascularization in Management of Critical Limb Ischemia
Abdelaziz Ahmed Abdelhafez*, Omar Mokhtar Elhayeg, Hany Abd Elmomen Abdel fatah
Department of Vascular surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Abdelaziz A Abdelhafez, Mobile: (+20)01000004564, Email: firstname.lastname@example.org
Background: The importance of the angiosome concept in critical limb ischemia remains controversial.
Aim of the study: to assess the outcomes of direct re-vascularization (angiosome-targeted tibial angioplasty alone)
(DR) versus indirect re-vascularization (IR) non angiosome target, in isolated tibial lesions.
Patients and Methods: thirty patients were included and presented to vascular surgery department of Al-Azhar
University Hospitals with infra-popliteal arterial lesions, randomly distributed into two equal groups;15 patients was
treated with (DR) while 15 patients treated with (IR).
Results: fifteen patients reached the end point of adequate healing: (9 patients with `DR' technique and 6 patients
with `ID' technique) and 9 patients underwent major amputations. The limb salvage after one year was 70%.
Conclusion: direct re-vascularization (DR) of the tibial vessels appears to improve wound healing and limb salvage
rates compared with IR, with no effect on patency, morbidity, mortality or re-intervention rates.
Keywords: Diabetes mellitus, critical limb ischemia, direct revascularization, indirect revascularization,
difference between DR and IR for revascularization and
Peripheral arterial occlusive disease (PAOD) is a
healing of foot ulcers to recommend DR in CLI
major disease that limits active aging in elderly people.
patients. The proposed explanation for these
Complications of PAOD are the leading cause of
contradicting studies is that blood flow can be restored
hospitalization and amputation for people with lower
to the foot either through inter-angiosomal choke vessel
limb ischemia, and account for billion-dollar
connections or through the pedal arch .
expenditures annually in the United States .
However, we will perform a systematic review
Critical limb ischemia (CLI) according to the
and meta-analysis investigating the efficacy of DR,
European consensus document is defined as advanced
comparing it with conventional IR for the treatment of
stage of chronic PAOD manifested with either: Rest
pain, non-healing ulcer, gangrene and/or ankle or toe
pressure of 50 or 30 mmHg .
PATIENTS AND METHODS
CLI estimated to develop in 500 to 1000
This study included 30 patients who presented to
individuals per million persons per year in the general
vascular surgery department of Al-Azhar University
populations. CLI has important functional implications
Hospitals Cairo, Egypt with infra-popliteal arterial
and a major impact on the quality of life with high
lesions, randomly distributed into two equal groups;15
morbidity and mortality rates. The quality of life indices
patients was treated with (DR) while 15 patients treated
of patients with CLI have been reported to be similar to
with (IR) during the period from July 2017 to June
those of terminal cancer patients .
Treatment goals for lower legs critical limb
Ethical approval and written informed consent:
ischemia (CLI) patients are to increase wound healing,
An approval of the study was obtained from Al-
improve quality of life, prevent limb loss, and prolong
Azhar University academic and ethical committee.
Every patient signed an informed written consent for
Early revascularization is the backbone modality
acceptance of the research.
for limb salvage in CLI. The concept of angiosomes,
first described by Ian Taylor, provides practical
information on the application of vascular anatomy for
Patients with infra inguinal arterial occlusive
reconstruction . Therefore, the angiosome concept
disease who will be diagnosed with the clinical
suggests that recanalization of the artery that is directly
presentations of incapacitating claudication or critical
supplying the ischemic and/or ulcerated angiosome,
limb ischemia with angiographic confirmation of infra-
instead of revascularizing one of the other 2 major
arteries might be more successful .
It is unclear whether direct revascularization
with the angiosome concept (DR) can provide superior
Patients with poor tibial collateral circulation, no
results for CLI patients than that of conventional
target runoff. Mild claudicants or asymptomatic lesions,
indirect revascularization (IR) without the angiosome
unsalvageable limb, acute ischemia, pregnancy, known
concept . There are few studies endorsing DR in CLI
allergy to heparin, aspirin, or other antithrombotic
due to its favourable outcome compared with IR.
agents, life expectancy < 12 months.
However, other studies did not find a significant
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4643-4648
The Effect of Ketamine as Adjuvant in Ultrasonic Guided
Supraclavicular Brachial Plexus Block
Ezzat Mahmoud EL-Soudy, Alaa Mahamed Ahmed Atia, Wahed Mahamed Ali,
Ahmed Ismail Abdel Sabour*
Department of Anesthesia and I.C.U, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
*Corresponding author: Ahmed Ismail Abdel Sabour, Mobile: (+20)01097845491, Email: email@example.com
Background: many of the surgical procedures are done daily all over the world. Patients get benefit from the amazing
advances in both surgical and anesthesia techniques. However, despite the progress in understanding the physiology of
pain and the pharmaceutical properties of painkillers, many patients are still suffering from severe postoperative pain
after surgery. Objective: The aim of the current study was to determine the effect of the addition of 25 µg/kg body
weight ketamine to 0.5% bupivacaine supra-clavicular brachial plexus block on quality of block, the time of onset and
postoperative analgesia time. Patients and Methods: it is a prospective double blinded controlled study that was
carried out on 150 patients ASA I II, aged 18-50 years with different upper limb surgeries of the forearm and the
hand in Assiut and Al-Azhar University Hospitals.
Results: ketamine was more effective with a mean complete sensory block onset of 11.93±2.95 minute in the ketamine
group compared to12.60±3.00 minutes in the control groups. The study also showed that ketamine hastened the onset
of complete motor block, with a mean complete motor block onset of 17.33±3.79 minute in the ketamine group
compared to 19.67±4.45 minutes in the control group. As regard analgesia duration, the present study showed that
ketamine group prolonged the analgesia duration.
Conclusion: It could be concluded that addition of (25 µg/kg) ketamine to bupivacaine improves onset of the block,
postoperative pain-free time (VAS) and reduces the consumption of postoperative analgesics in patients undergoing
different upper limb surgeries of the forearm and the hand.
Keywords: Ketamine, Ultrasonic guided, Supraclavicular brachial, Plexus block
The addition of ketamine to epidural lidocaine or
Brachial plexus blocks are commonly achieved
bupivacaine increases the duration of regional anesthesia
via an interscalene, supraclavicular, infraclavicular, or
and postoperative analgesia. It has been seen that peri-
axillary approach. The supraclavicular level is an ideal
incisional use of 0.3-0.5% ketamine combined with local
site to achieve anesthesia of the entire upper extremity
anesthetic in surgical wounds enhances analgesia by a
just distal to the shoulder as the plexus remains relatively
peripheral mechanism (6).
tightly packed at this level, resulting in a rapid and high-
Ketamine is a well-known anesthetic agent with
quality block. For this reason, the supraclavicular block
potent local effect on peripheral nerves. This local effect
is often called the ``spinal of the arm.''(1).
of ketamine is most probably by blocking the voltage-
Kulenkampf described the first percutaneous
operated sodium channels(7).
supraclavicular block of the brachial plexus in the early
The effect of ketamine on (NMDA) N-methyl-D-
1900s. However, the original technique was associated
aspartate antagonism abolishes peripheral afferent
with a high incidence of pneumothorax. (2).
noxious stimulation (8).
With the increased availability of ultrasound in
The use of 0.5 mg/kg body weight ketamine as an
clinical practice ,the ability to identify and avoid vascular
adjuvant to local anesthetic agent in caudal anesthesia can
and pleural structures as well as allow real-time
double or triple the analgesic period and reduces the need
visualization of the needle has come The evidence for the
of analgesia (9).
use of ultrasound in regional anesthesia is growing it
The aim of the current study was to determine the
shortens block performance time, improves sensory and
effect of the addition of 25 µg/kg body weight ketamine
motor block, and reduces the need for block
to 0.5% bupivacaine supra-clavicular brachial plexus
block on quality of block , the time of onset and
Whilst there is evidence that the use of ultrasound
postoperative analgesia time.
decreases the incidence of pneumothorax and local
anesthetic systemic toxicity, there is no evidence that it
PATIENTS AND METHODS
reduces the incidence of peripheral nerve injury (4).
This prospective double blinded controlled study
Ketamine is a non-competitive NMDA receptor
included a total of 150 patients ASA I II, aged 18-50
antagonist, which is used for premedication, analgesia,
years with different upper limb surgeries of the forearm
sedation, induction, and maintenance stage of general
and the hand, attending at Assiut and Al-Azhar
anesthesia. Ketamine has been also used as local,
regional, and central analgesic (5).
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4649-4661
Role of External Fixator Combined with T-Plate Internal Fixation in The
Treatment of Comminuted Distal Radial Fractures
Mostafa Hussien Hegazy, Waleed Mohammed Ewees, Ashraf Atef Mahmoud,
Mostafa Abdel Fadil Alakbawy*
Department of Orthopedics, Faculty of Medicine, Tanta University
*Corresponding author: Mostafa Abdel Fadil Alakbawy, Mobile: (+20)01007129424, Email: firstname.lastname@example.org
Buckhound: A technique of external fixator combined with T-plate internal fixation for intra-articular fractures of
the distal radius is based on the finding that the separate t-plate fixation do not give complete stability to the fracture.
However, if it is combined externally by external fixator, you get a solid synthesis of the fractured radius. This
enables early mobilization of the wrist without the use of plaster cast.
Objective: The aim of the study was to evaluate the results of external fixator combined with palmar T-plate
internal fixation for the treatment of comminuted distal radial fractures.
Patients and methods: This was a prospective study that was conducted on 20 patients. Patients were treated by
the external fixator combined with T-plate internal fixation. All patients were attending to the Emergency
Department and Outpatient Clinic of Orthopedic Surgery Department in Tanta University Hospitals.
Results: Patients had excellent range of motion, normal ROM of the arm, shoulder and hand. No significant
differences in the radiographic parameters were detected between fracture fixation and fracture healing.
Complications were few. At final follow-up evaluations, patients had well to excellent results with respect to range
of motion scores. Stable fixation allowed starting active and passive motion of the wrist without compromising
postoperative alignment. The poor results in this case were due to late intervention, osteoporosis due to old age and
poor general condition of the patient, which resulted in incomplete union.
Conclusion: External fixator combined with T-plate internal fixation is an efficacious treatment option for intra-
articular distal radius fractures with excellent long-term results.
Keywords: External fixator combined, T-plate internal fixation, treatment of comminuted distal radial fractures.
superior to those with other methods such as non-
Severe comminuted distal radial fractures are
locking plate fixation (4), dorsal plate fixation (5) and
defined as unstable fractures that mostly involve the
percutaneous Kirschner wire fixation (6).
surface of the radiocarpal or distal radioulnar joint.
Although the use of a palmar T-shaped locking
The aim of treatment is resetting articular surfaces,
plate combined with a dorsal plate (7) or the technique
restoring radial length, correcting ulnar deviation and
of combining volar plating with locked radial column
palmar angle, resetting the radiocarpal or distal
plating or K-wire fixation (8) can achieve satisfactory
radioulnar joint, and maintaining the structure after
results, they incur greater trauma and more late
reset. Inappropriate treatments can cause the
degeneration of the wrist joint, pain, stiffness, and
In contrast, another study indicated that palmar T-
other symptom as well as obvious changes in the
plate fixation is superior to the external fixator with
articular surface of the distal radius, ulnar deviation,
respect to the restoration of radial height and wrist
palmar angle and radial shortening, which severely
limit the forearm rotation and wrist function. Distal
radial fractures classified as type A or B (according to
AIM OF THE WORK
the AO/ASIF classification) can be treated by plaster
The aim of the study was to evaluate the results of
external fixation with satisfactory therapeutic results
external fixator combined with palmar T-plate
internal fixation for the treatment of comminuted
In case of fractures involving the articular surface
distal radial fractures.
and unstable comminuted fractures, it is difficult to
maintain good results by using common external
PATIENTS AND METHODS
fixation. This can easily cause distal radial shortening,
decrease the palmar and ulnar inclination angles and
This prospective study was performed on 20
cause uneven articular surface. These consequently
patients. Patients were treated by the external fixator
cause secondary pain and joint dysfunction (2).
combined with T-plate internal fixation. All patients
Plate fixation is increasingly being applied in the
were attending to Emergency Department and
treatment of comminuted distal radial fractures, and
Outpatient Clinic of Orthopedic Surgery Department
short-term follow-up demonstrates satisfactory
in Tanta University Hospitals. The study was
conducted in the period from June 2016 to June 2017.
The post-healing functional score after the
Patients were followed up for about 16 weeks at least.
application of palmar T-shaped locking plates is
These intra-articular fractures were classified
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4662-4668
Serum Cholinesterase Level as a Biomarker in Detecting Liver Injury in
Patients with Chronic Hepatitis C
Salem Soliman Ahmed Salama1, Bahy El-Deen El-Sayed El-Bahnasawy1,
Mahmoud Abd Ellatif Hashish2, Mustafa Mohammed Mustafa Al Ebiary*1
1Department of Internal Medicine, Faculty of Medicine, Al-Azhar University
2Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University
* Corresponding author: Mustafa Mohammed Mustafa Al Ebiary,
Mobile: (+20)01015665492, E-mail: email@example.com
Background: hepatitis C virus can cause both acute and chronic hepatitis. The acute process is self-limited, rarely
causes hepatic failure and usually leads to chronic infection. Chronic HCV infection often follows a progressive
course over many years and can ultimately result in cirrhosis, HCC and the need for liver transplantation.
Objective: the aim of this study is to evaluate serum cholinesterase (CHE) level as a biomarker for detecting liver
damage in patients with chronic hepatitis C.
Patients and Methods: the current study was carried out on 50 subjects selected from the outpatient's clinic of
Internal Medicine Department of Sayed Galal Hospital, Al-Azhar University and admitted to the internal
department. The study was performed in the period between July-2014 to July -2019.
Results: Sensitivity of cholinesterase is 100%, its specificity is 100% and its accuracy is 100%, in predicting liver
injury in patients with chronic hepatitis C. Cholinesterase is positively correlated with Hb, platelets and albumin.
Cholinesterase is negatively correlated with ALT, AST and ALP, total & direct bilirubin, PT, INR, urea, creatinine
and AFP. There is significant increase of cholinesterase among compensated compared with decompensated
cirrhotic patients. There is significant decrease of cholinesterase among compensated cirrhotic patients compared
with controls. There is significant decrease of cholinesterase among decompensated cirrhotic patients compared
Conclusion: cholinesterase is an excellent biomarker of cirrhosis with good sensitivity and specificity.
Cholinesterase shows good correlation with albumin, PT, INR and Child-Puch score. Cholinesterase distinguishes
decompensated cirrhosis from compensated cirrhosis well.
Keywords: Cholinesterase, Liver, Hepatitis C virus
Cholinesterase is a family of enzymes that
Hepatitis C virus (HCV) can cause both acute
catalyze the hydrolysis of the neurotransmitter
and chronic hepatitis. The acute process is self-limited,
acetylcholine into choline and acetic acid (3).
rarely causes hepatic failure and usually leads to
There are 2 types; Acetyl cholinesterase also
chronic infection. Chronic HCV infection often
known as erythrocyte cholinesterase found in RBCs
follows a progressive course over many years and can
cell membrane and pseudo-cholinesterase known as
ultimately result in cirrhosis, hepatocellular carcinoma
plasma cholinesterase which is synthesized mainly in
(HCC) and the need for liver transplantation (1).
hepatocyte and is released into blood and its activity is
Cirrhosis of the liver is a frequently encountered
reduced in liver dysfunction due to reduced synthesis
disease (2). Liver cirrhosis is a clinical condition
wherein blemish tissue replaces normal tissue of the
In contrast to cholinesterase activity, the
liver. As the healthy tissue is replaced by blotted
activities of the other serum enzymes associated with
tissue, there is an obstruction in the flow of blood
clinical assessment of liver function, increase due to
through the liver affecting its function (3). Liver
excessive release from this cellular source after cell
cirrhosis rarely causes signs and symptoms in its early
membrane damage (3).
stage, but as liver deteriorations the signs and
In gastroenterology, the Child-Pugh score is
symptoms appear (4).
used to assess the prognosis of chronic liver disease,
Liver function tests (LFTs) that measures the
mainly cirrhosis. Although originally used to predict
level of serum liver enzymes usually reflects
mortality during surgery, this score is now used to
hepatocyte integrity or cholestasis rather than liver
determine the prognosis as well as the required
strength of treatment and the necessity for liver
Five laboratory assays are commonly called liver
function tests (serum alanine and aspartate
However, the cirrhotic patients particularly
transaminases, serum alkaline phosphatase, serum
those with Child-Pugh grades B and C with ascites or
protein and albumin). These tests are neither specific
hemorrhagic tendency are usually treated with
to the liver nor true measures of liver functions (6).
albumin or blood transfusion which may affect the
numerical value for calculating the Child-Pugh score.
The serum cholinesterase is not easily affected by this
The Egyptian Journal of Hospital Medicine (July 2019) Vol. 76 (7), Page 4669-4674
Characterization of The Type of Response to Different HCV Antigens and
Quantification of Viral Load in Newly Diagnosed Hepatocellular Carcinoma Patients
Dina Usama Sharaf El Din (1), Magdy Amin (2), Hadir El Mahlawy (3), Samah Radwan (3)
(1) Department of Pharmacy, National Cancer Institute, (2) Department of Microbiology, Faculty of Pharmacy, Cairo
University, (3) Department of Clinical Pathology, National Cancer Institute, Cairo, Egypt
* Corresponding author: Dina Usama Sharaf El Din, email: firstname.lastname@example.org
Background: Hepatitis C virus (HCV) is a blood born virus that is considered a major cause of chronic liver disease and
hepatocellular carcinoma (HCC) worldwide. HCV is thought to induce HCC either indirectly or directly by the effect of its
viral proteins on different host cell proteins and signaling pathways.
Objective: The aim of the study was to characterize the type of response to different HCV antigens, quantify HCV viral
load, transforming growth factor- beta and miRNA 122 in patients with newly diagnosed Hepatocellular Carcinoma.
Patients and methods: This study was done on three groups: the first group consisted of 40 newly discovered hepatocellular
carcinoma patients with HCV infection. The second group consisted of twenty HCV infected patients with other types of
cancer (other than HCC). The third group consisted of 20 healthy individuals served as a control group. Serum was separated
for detection of the four parameters. Results: TGF- showed a very weak negative correlation with the miRNA 122 serum
levels that is statistically non-significant. Results also showed that miRNA 122 may not be useful in differentiating between
liver cirrhosis from HCC patients and it is associated with the severity of the disease rather than the viremia count.
Conclusion: Study showed no correlation between the four investigated parameters (HCV antigens, HCV viral load, TGF-
- serum levels of miRNA 122) in an attempt for early diagnosis of HCV induced HCC.
Keywords: Hepatitis C - Hepatocellular Carcinoma- HCV antigens- Viral load- TGF- - miRNA 122.
Hepatitis C virus (HCV) is a blood born virus which
mitochondrial membrane; interfering with the electron
has a major contribution to chronic liver disease and
transport chain causing oxidative stress (9).
hepatocellular carcinoma worldwide (1). Hepatocellular
E1 and E2 glycoproteins of the HCV are found to
carcinoma (HCC) is the fourth common cancer in Egypt
trigger epithelial -mesenchymal trans-differentiation
and the second cause of death in both men and women.
induction through enhancing the signaling pathways of
71% of the Egyptian HCC cases were found to be HCV
TGF- and VEGF (10). E1/E2 proteins are found to
interfere with the electron transport chain (ETC) in the
HCV is thought to induce hepatocellular carcinoma
mitochondria, decrease the content of NADPH and
either indirectly by causing chronic inflammation, insulin
increase the production of reactive oxygen species from
resistance, oxidative stress, fibrosis and genetic instability
ETC complex I substrates leading to reduced activity of
or directly by the effect of its viral proteins on various host
ETC complex I (11). E2 interferes with the host immune
cell proteins and signaling pathways (3).
response by inhibiting protein kinase R and inhibiting the
The core protein of HCV is found to cause
activation of natural killer cells and T cells (12). E2 protein
hypermethylation of the promoter region of the tumor
of HCV has been found to enhance cell proliferation
suppressor RBL2 gene leading to uncontrolled cell
through activation of the MAPK/ERK signaling pathway
division (4), it activates the Ras/Raf/MAP Kinase signal
transduction pathway through the activation of Raf-1
The non-structural protein NS2 of HCV induces cyclin
kinase, it also activates - catenin / Wnt signaling
E expression and activates cyclin D/ CDK4 which is a
pathway through the activation of the - catenin and its
significant cell cycle checkpoint for the transition from
stabilization (5). The core protein also is found to inhibit
the G1 phase to S phase promoting proliferation. It can
the growth inhibitory pathway of the cytokine TGF- and
also prevent apoptosis by interfering with the p53
shifting its activity to the pro-fibrinogenic property of the
pathway where it phosphorylates Chk2 but doesn't
TGF- by interacting with SMAD3 directly (6). Moreover,
phosphorylate the p53, thus the p53 is retained in the
HCV core protein inhibits the expression of the PRAR-
receptors in the liver leading to hepatic steatosis (7). The
The non-structural protein NS3 of HCV is found to
core protein also inhibits the activation of the anti-
activate the Ras/Raf/MAPK signaling pathway by
apoptotic NF- pathway leading to the induction of
inhibiting protein kinase A which has negative feedback
apoptosis in hepatocytes (8). The HCV core protein
mechanism on Ras/Raf/MAPK pathway. NS3 prevents
interacts with the endoplasmic reticulum and the
the translocation of protein kinase A from cytoplasm to