The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4881-4888
Autologus Hair Transplantation Vs Skin Expansion in Management of
Cicatricial Alopecia; A Comparative Study
Mohamed Hassan Mohamed Abdel-Aal, Ahmed Abo Hashem Azab, Amr Mohamed Mohamed Adss*
Department of General Surgery, Faculty of Medicine, Zagazig University
* Corresponding author: Amr Mohamed Mohamed Adss, Mobile: (+20)01001890194, E-mail: firstname.lastname@example.org
Background: The bad impact of cicatricial alopecia among population lead to increase the desire of correction of
that type of hair loss. Although, there are many methods of hair restoration but the efficacy of each, indications
and possible hazards has not yet been clearly identified.
Objective: To compare between hair transplantation using follicular unit extraction and skin expansion surgeries
in the field of hair restoration in secondary cicatricial alopecia regarding aesthetic outcome, operative duration,
optimum patient selection and complications of both techniques.
Subjects and methods: Twenty four patients suffering from alopecia were involved in this study 15 males
(62.5%) and 9 females (37.5%). Patient's age ranged from 7 to 26 years old. Patients were divided into two groups
according to the procedure done. Group (A) 12 patients done hair transplantation surgeries. Group (B) 12 patients
done scalp expansion surgeries. Results: There was a non-significant difference between both groups regarding
the mean age or the mean operation duration (P > 0.05). The mean values of the surface area of alopecia, in tissue
expander group (B) was significantly larger than that of hair transplantation in group (A) (P < 0.001). However the
time since exposure to the causative injury was significantly longer in group (A) than that of group (B) (P < 0.01).
Hair transplantation tends to have less recovery time highly indicated in adults with smaller non-dependent areas
of alopecia, while expanders with long recovery period solve bigger problems of alopecia in younger patients.
Conclusion: Multiple factors interfere with the surgical plan age, gender, occupation, size and site of alopecia and
time since injury. Both hair transplantation and skin expansion are very useful in the field of cicatricial alopecia
treatment. While hair transplantation has less hazards during anesthesia, less post-operative scars and less
recovery time, skin expansion is a good solution for bigger problems like big area of alopecia or younger patients.
Keywords: Alopecia, hair transplantation, skin expansion and hair restorative surgeries.
Neumann et al. (5) reported the first clinical
The term "cicatricial alopecia" refers to a
use of tissue expansion in 1957 when he expanded the
scarring that ends up with loss of hair that outcomes
scalp for ear reconstruction. In 2005, Leedy et al.
from a various set of disorders that devastate the hair
reported reconstruction of nearly half the scalp with
follicle, substitute it with scar tissue and cause
hair-bearing tissue using tissue expansion (6). Surgical
persistent hair loss (1). Cicatricial alopecias are sorted
excision of scarred areas over the scalp used to treat
as primary and secondary. In primary cicatricial
small areas of scarring alopecia, to treat larger areas
alopecias the stable portion of the hair follicle (stem
(scars wider than 5 cm), tissue expanders may be
cells of the bulge area and the infundibulum) is the
inserted in the normal scalp adjacent to the scarred
target of the destructive inflammatory course and the
area and progressively filled with saline over 812
cause varies from autoimmune diseases like lichen
weeks. The stretched hair-bearing skin is then
Plano pilaris (LPP), discoid lupus erythematosus
advanced, or rotated, to fill the surgical defects created
(DLE), pseudopelade of Brocq, to infections like
by excision of scarred areas (7). Excision of scar tissue
folliculitis decalvans (2). Secondary cicatricial
has the following advantages: can be performed in one
alopecias, result from damage of the hair follicle
session, is not dependent on donor area and doesn't
subsidiary to a non-follicle-directed process or
depend on graft survival. Although, it has some
external injury, such as burns, radiation, trauma or
disadvantages including multiple linear scars and
severe infections like tinea capitis (3).
having high rate of complications. Skin expanders can
Surgical correction of cicatricial alopecias is
treat large areas but may need maultiple sessions. On
highly valuable. While the affected area is most often
the other hand, hair transplant has advantages
treated with hair transplantation. Alternative
including one linear strip in follicular unit transection,
approaches include alopecia reductions (the excision
minimal scarring in folicular unit extraction and lower
of the hairless region) and or flap procedures, alone or
rate of complications. While, the disadvantages
sometimes in conjunction with hair transplantation (1).
include that it requires good donor area, may induce
Hair transplant consists of harvesting hair from a
koebnerization, might need multiple sessions and graft
donor area (usually the occipital and postero-parietal
survival might be suboptimal (8).
scalp) using a single strip excision or small punch
Aim of the work: The study aimed to compare
excisions used to harvest individual follicular units
between hair transplantation using follicular unit
(FUE) and grafting them into the recipient site (4).
extraction and skin expansion surgeries in the field of
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4889-4893
Association of Retinal Nerve Fiber Layer Thickness and Degree of Myopia Using
Spectral Domain Optical Coherence Tomography
Attiat Mostafa El-Sayed Mostafa, Mahmoud Mohamed Saleh, Ismail Mostafa Belal Mahfouz *
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
* Corresponding author: Ismail Mostafa Belal Mahfouz, Mobile: (+20)34411440110, E-mail: email@example.com
Background: High myopia is defined as refractive error above -6.0 D and axial length above 26 mm. High
myopia and its complications are considered to be one of the most significant causes of blindness and
visual impairment in young people.
Objective: To evaluate the effect of the degree of myopia on the peripapillary retinal nerve fiber layer (RNFL)
thickness by spectral-domain optical coherence tomography (OCT).
Patients and Methods: The study had been carried out in Embaba Ophthalmic Hospital during the period of June
2018 to February 2019. The study included 60 eyes, divided equally into 3 groups: Group A: Mild myopia
(spherical equivalent between -0.5 and -3.0 D). Group B: Moderate myopia (spherical equivalent between -3.1 and
-5.99 D). Group C: High myopia (spherical equivalent more than -6.0 D).
Results: This study showed that RNFL thickness was lower in the high and moderate myopic eyes compared with
low myopic eyes in all quadrants except in temporal quadrant. A highly significant positive correlation was evident
between spherical equivalent and RNFL thickness in each quadrant. A highly significant negative correlation
between axial length and RNFL thickness was found in each quadrant.
Conclusion: High myopia should be considered in the interpretation of OCT data because of thinning of RNFL
thickness and normative database corrected for refractive error and axial length should be incorporated. It is difficult
for OCT to discriminate between high myopes with and without glaucoma. Therefore, clinical signs of glaucomatous
nerve fiber damage are very important.
Keywords: Myopia, Retinal Nerve, Fiber Layer Thickness, Optical Coherence Tomography
arm and a reference arm, is emitted by a super
Myopia and its ocular morbidity represent a
luminescent diode at a wavelength of approximately
840 nm (7).
socioeconomic perspectives considering its high
Optical coherence tomography (OCT) is an
prevalence and increasing rate. High myopia defined
objective and accurate method for RNFL thickness
as refractive error more than -6.00 D and axial length
measurement. Compared with other RNFL analyzers,
more than 26 mm, is among the leading causes of
such as scanning laser polarimetry and Heidelberg
visual impairment in young population (1). Among its
retinal tomography, OCT provides high-resolution
potential morbidity, myopia was proposed to be a risk
images with a quantitative analysis of the retinal
for glaucoma (2).
Myopic eyes are at a two-three times higher
spectral-domain (SD) - OCT, ultra-high resolution
risk of developing glaucoma than emmetropic eyes (3).
three- dimensional images of the retina and optic disc
Nevertheless, this relationship remains
can be obtained with ultra-high speed (8).
obscure. Retinal nerve fiber layer (RNFL) thickness is
an important parameter to follow the extent of
AIM OF THE WORK
glaucomatous damage (4).
To evaluate the effect of the degree of myopia
However, it remains uncertain whether RNFL
on the peripapillary retinal nerve fiber layer thickness
thickness varies with the refractive state of the eye or
by spectral-domain optical coherence tomography.
not. Therefore, it is important to investigate whether
any correlation exists between RNFL thickness and
PATIENTS AND METHODS
axial length or refractive state of the eye (5).
The study had been carried out in Embaba
Several explanations for RNFL thinning in
Ophthalmic Hospital during the period of June 2018
myopia were reported. Myopic globe elongation may
to February 2019.
serve to stretch and thin the RNFL because of
mechanical forces (6).
The study included 60 eyes, divided equally into 3
Optical coherence tomography (OCT) is an
essential tool for noninvasive in vivo analysis of
1. Group A: Mild myopia (spherical equivalent
retinal tissue for diagnosis and management of retinal
between -0.5 and -3.0 D)
disease and glaucoma. This technique is based on the
2. Group B: Moderate myopia (spherical
degree of absorption or dispersion of light traversing
equivalent between -3.1 and -5.99 D).
the tissue. The light, which is divided into a detection
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4894-4898
The Relation between Helicobacter Pylori Seropositivity and
Hyperemesis Gravidarum in Pregnant Women during First Trimester
Emad Abdel rahman El tamamy, Ahmed Taha Abdel Fattah and
Mohamed Hemdan Aboelfotoh Ibrahim Hemdan
Deparmtent of obstetrics & gynecology Faculty of Medicine Al-Azhar University Cairo, Egypt
Corresponding author: Mohamed Hemdan Aboelfotoh Ibrahim Hemdan, Mobile: 01004048410;
Background: Nausea and vomiting during pregnancy are the most common conditions affecting pregnancy, occurring
in about 80% of all pregnancies and the condition always disappears on the 16th to 18th weeks of gestation. This may
be mild and does not affect the general condition of the pregnant women (the condition is called emesis gravidarum),
or it may be severe enough to affect the patient physically and psychologically, causing intractable vomiting, weight
loss (0.5%), electrolyte imbalance, dehydration and impairment of liver and kidney functions. Helicobacter pylori
(HP) is one of the most common bacterium affecting humans. It is gram-negative and helix-shaped microaerophilic
bacterium transmitted by the oro-oral or feco-oral route. It is more prevalent in developing countries and affects young
children. Acute infection manifests as acute gastritis and stomach pain, whereas chronic infection causes chronic
gastritis and peptic ulcer, 2% of which may develop into stomach cancer.
Aim: The aim of our study was to investigate the association between H pylori infection and hyperemesis gravidarum.
Methods: Forty five pregnant women with hyperemesis gravidarum and 45 asymptomatic pregnant women in a
prospective study were enrolled. Serum immunoglobulin G for Helicobacter pylori was assayed in the sera of the two
groups. Results: Regarding maternal age, gestational age and socioeconomic status, there was no statistical difference
between both groups. There was a marked statistical difference between both groups in terms of Helicobacter pylori
Conclusions: There is a powerful correlation between H pylori and hyperemesis gravidarum.
Keywords: Helicobacter Pylori, hyperemesis gravidarum, human chorionic gonadotropin.
gastrointestinal disorders, hyperthyroidism, underlying
Nausea and vomiting during pregnancy is a
chronic illness, psychological and rarely, hereditary
common problem with a frequency of 75% to 80% of
pregnancies. Usually, it starts between first and second
Helicobacter pylori is a gram-negative
missed menstrual period and can continue up to 14-16
bacterium colonized in the gastric mucosa associated
weeks of pregnancy (1). Mild cases are called emesis
with increased production of reactive oxygen species
gravidarum, have no pathological significance so long
(ROS), where plasma antioxidant like ascorbic acid is
as it does not restrict the woman's daily life (2).
reduced (6). As a result, HEG may be considered as an
Hyperemesis gravidarum complicates 0.3-2% of all
oxidative stress state determined by high ROS activity
pregnancies. It is often defined as intractable nausea and
and low antioxidant state. H.pylori is one of the most
vomiting during pregnancy. It is severe enough to affect the
common infectious diseases on the world. It is more
general condition of the pregnant women and may require
prevalent in developing countries, rather than in
hospitalization. The most commonly accepted definition
developed countries (7). The prevalence of H. pylori
is that hyperemesis gravidarum is a severe form of nausea
infection of the Egyptian population among adults was
and vomiting with weight loss greater than 5% of pre
about 90% (8).
pregnancy body weight with dehydration, acidosis from
Goldberg et al. (9) performed a systematic
starvation, alkalosis from loss of hydrochloric acid,
review on 14 case-control studies about the relationship
hypokalemia, ketosis, acetonuria, and ptyalism. It is a more
between HP and HEG in 2007. The study exhibited a
serious and persistent emesis that interferes with fluid
relationship, however, heterogeneity between studies
intake and nutrition. Furthurmore, the condition appears
has limited the results. In contrast in a study by
during the first trimester and is unassociated with other
Jacobson et al. (10), a relationship between HP and HEG
medical conditions, such as cholestasis, hepatitis,
was not reported and therefore, there was no consensus
preeclampsia, viral syndrome, Meniere's disease, or
on the role of HP on the genesis of HEG.
influenza (3). Hyperemesis gravidarum (HEG) is a
The purpose of our study was to evaluate a
multifactorial disease; however, the etiology of HEG is
relationship between H. pylori and hyperemesis
uncertain. A variety of mechanisms may play a role in
this disease, such as endocrine factors like estradiol,
human chorionic gonadotropin (HCG), progesterone
PATIENTS AND METHODS
and immunologic factors. In addition, personal factors
A prospective study was conducted in El Galaa
as increase body weight has been considered as possible
Teaching Hospital on 90 pregnant women who were
underlying cause (4).
divided into 2 groups: group "A" (study group)
Hyperemesis gravidarum is diagnosed clinically
comprised 45 pregnant women who had hyperemesis
after the exclusion of other causes such as
gravidarum and group "B" comprised 45 normal
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4899-4905
Prevalence of Obesity and Overweight among Primary Schools
Children in Qena, Egypt
Amira M.M. Hamed1, Alaa-Eldin A. Hassan1, Mohammed Mahmoud Sayed Younis1,
Al-Mostafa Mohammed Kamal*2
1Faculty of Medicine, Department of Pediatrics, Al-Azhar University, Assuit branch, Egypt
2Qeft Teaching Hospital, Ministry of Health, Qena, Egypt
*Corresponding author: Al-Mostafa Mohammed Kamal, Email: firstname.lastname@example.org,
Mobile: (+20) 122 602 0554
Background: Obesity is a significant public health concern affecting more than half a billion people worldwide giving
rise to a range of health problems. This is due to its various and serious health hazards on one side and its preventable
nature on the other side. Objective: This study aimed at identification of prevalence of overweight and obesity and
its risk factors among children between 6 - 12 years of age in Qena, Egypt.
Methods and populations: A cross sectional study was conducted on 1000 students were chosen randomly from all
grades of primary schools (6 -12 years) in the period from January, 2019 to June, 2019.
Results: The overall prevalence of obesity and overweight was 13.9% and 16.2% respectively. Girls were more obese
than boys, (OR= 7.26, 95% CI: 4.6-10.19). Current study revealed that 71.2% of the obese and 66.7 of overweight
children were from urban areas (OR= 0.172, 95 % CI: 0.115- 0.257) and 38.5% of the overweight children and 97.2%
of the obese children had an obese parent (OR = 134.4, 95% CI: 47.06 - 372.6). There was a statistical significant
association between prevalence of overweight and obesity in school children and education of the mother (OR = 10.2,
95% CI: 6.2- 16.6).
Conclusion: About one out of seven of 6-12 year-old-children in Qena city were obese. Locality of residence, gender,
guardian education, obese guardian, feeding formula in early life, bad dietary habit (fast food consumption and missed
breakfast) and lack of physical activity were likely to be the predictors of this alarming issue.
Key words: Childhood, Overweight, Obesity.
or "fat patterning" (10). Obese children and adolescents
Obesity is a significant public health concern
have been shown to be more likely to skip breakfast and
affecting more than half a billion people worldwide (1).
consume a few large meals per day than their leaner
In 2018, more than 1.9 billion were overweight and 600
counterparts who are more likely to consume smaller
million were obese. 39% of children and adolescents
frequent meals (11). Most of children who miss breakfast
less than 18 years were overweight in 2018 and 13%
will easy to weight gain. Conversely, breakfast
were obese. More than 41 million children under the
consumption is an important factor to determine the
age of 5 years were overweight or obese in 2018. In
quality of diet and energy intake that affect school
Egypt, the estimated prevalence of overweight
children health status (12).
increased from 4% in 1990 to 7% in 2011 and is
Reported associations of food groups with
expected to increase (2). In Port Said city the overall
childhood obesity include low intake of fruits and
prevalence of overweight and obesity in governmental
vegetables, high intake of fast foods and sweets and
pupils (612 years old) was 17.7 % and 13.5%
high intake of sugar-sweetened beverages such as soft
respectively (3). In Cairo, the overweight and obesity
drinks (13). Snacks tend to be higher in energy density
prevalence was 11% and 3.8 % respectively (4). In
and fat content than meals and high snack consumption
Alexandria the overall prevalence of overweight and
has been associated with high intake of fat and sugar
obesity in governmental pupils (612 years old) is 16.8
(14). Increasing body weight increases mortality because
and 9% respectively (5). In El-Sharkia, overall
of coronary heart diseases risk. The risk of developing
prevalence of overweight and obesity showed 20% for
DM and some types of cancers increase with obesity
overweight and 10.7% for obesity (6). In Assuit city, the
(15). Parents must be more aware of the role they can
overall prevalence of overweight and obesity among
play in preventing obesity in their children (16). The
primary school children aged from 6 to 11 years
earliest school-based obesity interventions are based on
was11.24% and 12.28% respectively (7). Obesity is
the program that was conducted during school hours.
often defined simply as a condition of abnormal or
This program consisted of intensive exercise and
excessive fat accumulation in adipose tissue, to the
nutrition education program delivered over a 5-6 month
extent that health may be impaired (8).
The BMI-for age percentile has been used as a
reliable and accurate estimate for body fatness in
AIM OF THE WORK
children and adolescents. BMI-for age 85% percentile
This study aimed at identification of prevalence of
is considered overweight. BMI-for age 95%,
overweight and obesity and its risk factors among
percentile is considered obese (9). Skinfold thickness is
children between 6 - 12 years of age in Qena, Egypt.
useful for describing subcutaneous body fat distribution
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4906-4912
The Role of Umbilical Cord Thickness and Glycated Hemoglobin (HbA1c) Levels for
Prediction of Fetal Macrosomia in Patients with Gestational Diabetes Mellitus
Osama Elsaeed Ali Ismail, Ibrahim Ramadan Alsawy Rady, Mahmoud Fayez Mohamed Fathi*
Department of Obstetrics and Gynaecology, Faculty of Medicine, El-Azhar University
* Corresponding author: Mahmoud Fayez Mohamed Fathi, Mobile: (+20) 0109926 8044,
Background: Diabetes with pregnancy is a known clinical risk factor associated with fetal macrosomia. The rationale
for performing an elective cesarean section includes a potential reduction in perinatal complications, especially those
related to macrosomia.
Objective: This study aimed to assess the accuracy of HbA1c and umbilical cord thickness in prediction of fetal
macrosomia in diabetic pregnant women.
Patients and Methods: The study included 100 diabetic pregnant, 27 - 28 weeks gestation, gathered from Inpatients
and Obstetric Outpatient Clinic of Bab Alshariya University Hospital attending for routine antenatal care.
Results: At a criterion of > 211 mm2, the umbilical cord area measured at 27 28 weeks of gestation was able to
predict high birth weight (macrosomia), with a sensitivity of 90.5% and a specificity of 91.7%. The area under the
curve for the ROC was 0.9294, with a 95% confidence interval of 0.8608 to 0.9702, which was found to be statistically
highly significant (p = 0.0001). When compared the ROC curves of both the umbilical cord area and the glycated
hemoglobin, it was found that umbilical cord area is more reliable in predicting fetal macrosomia at the right criterion,
the difference between the predictive efficiency for both parameters was found to be statistically highly significant.
Conclusion: Macrosomia is a cause of the worst of obstetric emergencies such as shoulder dystocia, birth asphyxia
and postpartum haemorrhage. Shoulder dystocia cannot always be predicted accurately. However, predicting
macrosomia can help to identify the population at risk of such complications.
Keywords: Umbilical cord thickness, Glycated hemoglobin (HbA1c), Macrosomia, Gestational diabetes mellitus.
The umbilical cord is responsible for maternal-
dependent upon the placenta for its supply of nutrients
fetal blood flow. Normally, it is composed of two
and oxygen from the mother. Previous research found
arteries permeated with venous blood and a vein that
that the placental weights in the macrosomic fetuses
transports arterial blood, cushioned by a special type
were significantly higher than those with normal
of mucous connective tissue known as Wharton's jelly
weight and placental weight was positively correlated
(WJ) and by remnants of the allantoids (1).
with birth weight (7). Fetal macrosomia is associated
There is a significant differences in mean
with a higher frequency of operative deliveries, post-
gestational age, mode of delivery, birth weight and
partum hemorrhages, birth injury during vaginal
adverse perinatal outcome between fetuses with
delivery and neonatal hypoglycemia. Known maternal
umbilical cord thickness below the 5th percentile (lean
risk factors are only identified in 40% of women who
umbilical cord) vs those with umbilical cord thickness
deliver macrosomic babies (8). Macrosomia has been
above the 5th percentile (non-lean cord) in the first and
suggested as one of the possible risk factors for
early second trimesters of gestation (2).
obesity in many studies (9). Children with macrosomia
Reported risk factors of macrosomia are body
tend to gain weight faster than those born at normal
mass index (BMI) before pregnancy, gestational
weight. Abnormal weight gain in the uterus and during
weight gain, gestational diabetes mellitus (GDM),
infancy may have an adverse influence on health in
mother's age and gender (3).
childhood and adult life. Studies show that
GDM is associated with many adverse pregnancy
macrosomic infants have a higher risk of developing
outcomes such as macrosomia and CS delivery (4). At
obesity and metabolic disorders (10).
the same time macrosomia is a well-known indicator
Diabetes represents a major public health concern
of maternal diabetes in fetus which is strongly
and efforts to control hyperglycemia are an important
associated with prematurity, respiratory distress
element of the management of patients with type 2
syndrome, birth trauma, fetal death and adverse
diabetes (11). Hyperglycaemia is measured using
maternal outcome (5). Obesity in pregnancy is also
hemoglobin A1c (HbA1c) test, which assesses the
recognized as a risk factor for many maternal and
average level of blood glucose in the preceding 60-120
neonatal adverse outcomes including macrosomia,
days. For diabetic patients an HbA1c target of 6.5%
increased rate of cesarean section (CS), preeclampsia
(48 mmol/mol) is recommended (11).
and gestational diabetes (GDM) (6). In addition, the
Gestational diabetes mellitus (GDM) affects 2-
placenta, as the interface between mother and fetus, is
6% of pregnant women and is associated with
central to prenatal growth control. The fetus is
increased risk of important adverse perinatal
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4913-4919
Carbetocin Versus Misoprostol in Prevention of Postpartum
Hemorrhage in High Risk Patients
Ismail Abd El Mobdy Ismail, Mohamed Salah El Deen Fahmy, Hany Ahmed Farouk,
Ismail Abd El Mobdy Ismail *
Department of Obstetrics and Gynecology, Faculty of Medicine, Aswan University
* Corresponding author: Ismail Abd El Mobdy Ismail, Mobile: (+20) 01002495993, E-mail: email@example.com
Background: Postpartum hemorrhage (PPH) is a significant problem and a major cause of maternal mortality and
morbidity, resulting in up to 28% of maternal deaths. It is a potentially life-threatening complication of both vaginal
and cesarean delivery, the prevalence of PPH is approximately 6% of all deliveries.
Objective: The aim of this study is to compare the effectiveness and safety of carbetocin and misoprostol for the
prevention of atonic postpartum hemorrhage in high risk patients.
Patients and Methods: this study is a prospective clinical study which was conducted at the Department of
Obstetrics and Gynecology, Aswan University Hospital, in the period from September 2017 till September 2018.
One hundred cases were involved in the study and divided into 2 equal groups.
The study was approved by the medical ethics committee of Aswan University Hospital and a written informed
consent is obtained from all patients.
Results: Significant difference was found between the two studied groups as regard mean volume of blood loss.
Carbetocin group showed the lowest volume of blood loss. As regard uterine tone after treatment, carbetocin group
showed the highest tone compared to misoprostol groups. Significant difference was found between the two groups
as regard need for additional uterotonics. The results demonstrated an increased use of additional oxytocics in the
misoprostol group (32% of cases) VS (12% of cases) in carbetocin group.
Conclusion: According to the results of this study, it's concluded that carbetocin is more effective in controlling the
amount of blood loss during delivery and eventually help in the prevention of postpartum hemorrhage in high risk
Keywords: Carbetocin, Misoprostol, Postpartum Hemorrhage.
Postpartum hemorrhage (PPH) is defined as blood
suggested as an alternative to injectable uterotonic
loss in excess of 500 ml at vaginal delivery or 1000 ml
agents for preventing PPH (9). It is cheap, heat stable,
at cesarean section. Loss of these amounts within 24
and can be administered through multiple routes (10).
hours is termed early or primary PPH, whereas such
Misoprostol has been widely recommended for the
losses are termed late or secondary PPH if they occur 24
prevention of post-partum hemorrhage when other
hours after delivery (1).
methods are not available. Rectal route is the most
Hemorrhage still continues to be reported as one
common regimen reported for the treatment of post-
of the leading causes of maternal mortality and
partum hemorrhage (11).
morbidity. Intraoperative estimation of the blood loss
Carbetocin, a long-acting oxytocin analogue that
seems to be complex and misleading as it is impaired by
bind to oxytocin receptors with higher affinity, its
the amount of amniotic fluid and blood from the
contractile effect of uterus is apparent within two
minutes (12). A 100-g dose of carbetocin has been
The hemorrhage can result from uterine atony,
recommended for preventing PPH in high risk patients.
retained placental tissue including that from abnormal
An advantage of carbetocin over others uterotonics is
placentation, maternal genital tract trauma and
that, owing to its long half-life, it is administrated as a
coagulopathies (3). Uterine atony is the major cause of
single intravenous dose (13).
hemorrhage accounting for up to 80% of PPH cases (4).
Oxytocin has a short half-life, whereas carbetocin
Risk factors for PPH include suspected or proven
is an oxytocin derivative exerting its effect via the same
placental abruption, known placenta previa, multiple
molecular mechanisms as oxytocin, has a longer half-
pregnancy, pre-eclampsia and gestational hypertension,
life, and has been reported to decrease the use of
previous PPH, obesity (BMI >35), anemia (<9 g/dl),
additional oxytocin (12).
delivery by elective caesarean section, induction of
Currently 100 µg of carbetocin is used for the
labor, retained placental tissues, prolonged labor (> 12
prevention of PPH. The hemodynamic effects of an
hours) and big baby (> 4 kg) (5).
oxytocin bolus consist of systemic vasodilatation, with
Several uterotonics agents are used to prevent
hypotension, tachycardia, and an increase in cardiac
PPH because of uterine atony, including oxytocin (6),
output and pulmonary artery pressure, resulting in brief
ergot alkaloid (7) and prostaglandin (8).
hypotension and tachycardia in a dose-dependent
Misoprostol is a prostaglandin (E1) analogue
with strong uterotonic properties and has been
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4920-4924
Laparoscopic Cholecystectomy with Low Tension
Pneumoperitoneum under Spinal Anesthesia with Sedation
Mahmoud Abo Amra Mahmoud 1, Emad Adham Ibrahim1, Tareq Sobhey El-Naggar2,
Mohammed Shaban Mohammed1.
Departments of General Surgery (1) and Anesthesiology (2), Faculty of Medicine Al-Azhar University (Assiut)1,
* Correspondences Author: Mohammed Shaban, Mobile:01090989358,
Introduction: Cholecystectomy is the commonest operation of the biliary tract. It is known that open upper surgery
under spinal anesthesia and laparoscopic cholecystectomy under general anesthesia.
Objective: In the present study study we performed laparoscopic cholecystectomy under spinal anesthesia with low
tension pneumoperitoneum with sedation to evaluate, analyze and document whether laparoscopic cholecystectomy
could be performed under spinal anesthesia and to assess the benefits and harms of low-tension pneumoperitoneum.
The study was approved by the medical ethics committee of Al-Azhar University Hospital in Assiut and a written
informed consent was obtained from all patients.
Materials and Methods: A prospective observational study with symptoms of cholelithiasis who underwent
laparoscopic cholecystectomy under spinal anesthesia with low tension pneumoperitoneum (7-9 mmHg) was
conducted on 40 patients in Surgery Department of Al-Azhar University Hospital in Assiut from December 2018 to
June 2019. Results: We successfully performed the operations in 27 patients without major complications. Only 13
patients (32.5%) who converted to general anesthesia due to anxiety despite using sedation. The operation was
converted to open cholecystectomy in one case only (2.5%) due to disturbed anatomy and adhesions. Mean age was
45 years (range 21-57years). BMI was 32. All patients were satisfied on follow up.
Conclusion: Laparoscopic cholecystectomy under spinal anesthesia with low-tension pneumoperitoneum with
sedation by experienced surgeons is safe, cost-effective, feasible, associated with minimal postoperative pain and
Keywords: Cholecystectomy, Laparoscopic cholecystectomy, Laparoscopy, Low tension pneumoperitoneum,
Cholecystectomy is the commonest operation of
metabolic and physiologic parameters viz. liver
the biliary tract. Laparoscopic cholecystectomy is
function tests and cardiopulmonary parameters, have
considered the gold standard for therapy of
any clinical significance (1).
General anesthesia is routinely used for this
cholecystectomy refers to minimally invasive
operation. To our knowledge, spinal anesthesia has not
procedure in which the gallbladder is removed through
been reported in the medical literature as an anesthetic
small incisions in the abdomen associated with less
method for laparoscopic cholecystectomy. On the other
pain, reduced hospital stays, and earlier return to daily
hand, for open cholecystectomy, although general
activities. Over 500,000 minimally invasive
anesthesia is often used, spinal anesthesia has been
cholecystectomies are performed annually, with the
infrequently reported as the anesthetic procedure of
majority being removed through a laparoscopic
choice (4). Generally, spinal anesthesia was found to be
associated with less post-operative mortality and other
Creation of pneumoperitoneum (PP) by carbon
serious complications than general anesthesia (5).
dioxide (CO2) insufflation is the most widely accepted
In some minor laparoscopic procedures, spinal
technique for adequate working space and patient
anesthesia has been found to be associated with less
safety (2).The standard pressure for PP lies between 12-
emesis, less postoperative pain, shorter postoperative
15 mm Hg; however, decreased pulmonary
stay, better patient satisfaction, and improved overall
compliance, altered blood gas parameters, decrease in
safety (6). Spinal anesthesia has been used with
cardiac output, impaired renal perfusion and raised
liver enzymes have been observed at these pressures (3).
laparoscopy, infertility procedures, and tubal
These effects may be explained by decrease in renal,
sterilization (7). Both laparoscopic inguinal hernia
hepato-portal and splanchnic blood flows, along with
repair and laparoscopic appendicectomy have also been
performed under spinal anesthesia (8). However, for
pneumoperitoneum. Several studies have compared the
laparoscopic cholecystectomy, spinal anesthesia has
effects of reduced pressure (7-9 mm Hg) with standard
not been reported as the sole anesthetic technique, but
pressure (12-15 mm Hg) during LC. These studies
only as a conjunct to general anesthesia to increase the
illustrate the feasibility of low-pressure PP, along with
postoperative analgesic effect (9). In reviewing
some advantages in terms of postoperative pain.
laparoscopic surgery, Motamed et al. noted that all
However, it is still unclear whether changes in
laparoscopic procedures are merely a change in access
Introduction & aim of the work
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4925-4932
Circulating Angiogenic microRNA-27b and Thrombospondin-1 (TSP-1)
Level in Patients with Diabetic Retinopathy
SamiaSouka Moustafa1, MaisaNour El-Din Shawkey1, Aida Ahmed Abd Elhameed1,
Mohamed Maher EL Hefny2, RaghdaAbd-ElsalamNagaty Hanady1*
1Department of Chemical Pathology, Faculty of Medicine, Al-Azhar University,2Department of Ophthalmology,
Research Institute of Ophthalmology-Ministry of Scientific Research
* Corresponding author:RaghdaAbd-ElsalamNagatyHanady, Mobile: (+20)01008141591,
Background: Diabetes mellitus (DM) is a chronic disease characterized by insulin deficiency or its peripheral
resistance resulting in hyperglycemia and non-enzymatic glycation of protein.The chronic hyperglycemia of diabetes
is associated with long-term damage, dysfunction, and failure of different organs, especially the eyes, kidneys,
nerves, heart, and blood vessels. MicroRNAs (miRNAs) are a class of highly conserved 1925 nucleotide noncoding
RNAs that regulate gene expression.
Objective:This study aimed to assess plasma miR-27b expression in diabetic retinopathy patients as an early
diagnostic parameter in both proliferative and non-proliferative and to assess the correlation between plasma levels
of miR-27b with the clinico-pathological parameters of diabetic patients as well as determination of the level of
Patients and Methods: This study was conducted on 60 diabetic retinopathy Egyptian patients that were recruited
from the Research Institute of Ophthalmology - RIO (Medical Retina Clinics) during their routine screening for
Results: Micro RNA 27b shows a highly significant difference (increase) among PDR compared to non-PDR &
control groups (P value: 0.001) and shows a moderately significant increase in expression in PDR group compared
to control group (P value: 0.01). This significant increase in microRNA between PDR group and control group has
the ability of being a non-invasive biomarker for diagnosis of PDR versus control group, as miRNA-27b expression
showed AUC = 0.889 with (95% CI 0.7441.000). The best cut-off point of miRNA-27b is 1.95 with 88.9%
sensitivity & 100% specificity and the p value <0.001(highly significant).
Conclusion: TSP-1 can act as a predictor for transformation of non-retinopathy stage to PDR stage. miRNA-27b
has the ability to differentiate between the PDR and control group and could be considered a non invasive biomarker.
Keywords: Diabetes mellitus, microRNA-27b, Thrombospondin-1, Diabetic retinopathy.
clinical evidence showed that in addition to
microvascular changes, inflammation and retinal
Diabetes mellitus (DM) is a chronic disease
neurodegeneration might contribute to diabetic
characterized by insulin deficiency or its peripheral
retinal damage in the early stages of DR. Further
resistance resulting in hyperglycemia and non-
enzymatic glycation of protein(1). The chronic
mechanisms may provide targets for the
hyperglycemia of diabetes is associated with long-
development of new early interventions (3).
term damage, dysfunction, and failure of different
In the last decade, miRNAs have received
organs, especially the eyes, kidneys, nerves, heart
substantial attention as potential players of diabetes
and blood vessels. Several pathogenic processes are
microvascular complications, affecting the kidney,
involved in the development of diabetes. These range
the retina, and the peripheral neurons. Compelling
from autoimmune destruction of the pancreatic -
evidence indicates that abnormally expressed
cells with consequent insulin deficiency to
miRNAs have pivotal roles in key pathogenic
abnormalities that result in resistance to insulin
processes of microvascular complications, such as
action. The basis of the abnormalities in
fibrosis, apoptosis, inflammation and angiogenesis.
carbohydrate, fat, and protein metabolism in diabetes
Moreover, clinical research into innovative both
is deficient action of insulin on target tissues(2).
diagnostic and prognostic tools suggests circulating
Diabetic retinopathy (DR) is the most
miRNAs as possible novel noninvasive markers of
common complication of diabetes mellitus (DM). It
diabetes microvascular complications (4).
has long been recognized as a micro vascular disease.
Zampetaki and his colleagues(5) had
The diagnosis of DR relies on the detection of micro
identified miR-27b and miR-320a as being
vascular lesions. The treatment of DR remains
significantly and independently associated with high
challenging. The advent of anti-vascular endothelial
DR risk. Complementing this analysis, they also
growth factor (anti-VEGF) therapy demonstrated
elucidated the potential mechanism using cultured
remarkable clinical benefits in DR patients.However,
human endothelial cells and identified anti-
the majority of patients failed to achieve clinically
angiogenic thrombospondin-1 (TSP-1) as a common
significant visual improvement (3).
target of these two miRNAs.
Therefore, there is an urgent need for the
development of new treatments. Laboratory and
AIM OF THE WORK
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4933-4937
Prevalence of Cardiovascular Disease Risk Factors in Shaqra, Saudi Arabia
Feras Mansour Almarshad1*, Abdulaziz Abdulrahman Alrashed2,
Khalid Ibrahim Aljammaz2, Ali Mohammed Alduhayshi2, Jaber Saleh Alhadlaq2
1 Department of Internal Medicine, 2 Medical Student, College of Medicine,
Shaqra University, Shaqra, Saudi Arabia
*Corresponding Author: Feras Mansour Almarshad,ORCID ID: https://orcid.org/0000-0002-9468-1489,Email: firstname.lastname@example.org
Background:According to the report of World Health Organization (WHO), cardiovascular diseases (CVDs)
accounted for most noncommunicable disease (NCD) deaths (17.5 million NCD deaths) during 2012 worldwide.
Surveillance of CVD risk factors is a key strategy for effective CVD prevention.
Aim:To identify the extent of CVD risk factors of developing cardiovascular disease events among Shaqra population
of Saudi Arabia.
Method:This community-based cross-sectional study was conducted on a total of 369 participants including 267
(72.3%) males and 102 (27.6%) females aged 18-45 years from Shaqra City of Saudi Arabia. Blood Pressure, BMI,
blood glucose, smoking status and family history of CVD risk factors were estimated.
Results:Prevalence of hypertension was 10.3% and diabetes 1.6%. Tobacco consumption was 24.8%. Obesity was
23.30%. Family history of HTN and DM was 50.09%.
Conclusion:High prevalence of hypertension, obesity and tobacco consumption was seen in Shaqra population which
will predispose to CVD risk. Campaigns to raise the awareness of CVD risk factors will boost the quality of life of
the peoples and will add years to live.
Key Words: Cardiovascular disease, hypertension, diabetes mellitus, smoking, obesity.
Cardiovascular diseases (CVDs) are the first
In this study, we determined the common
leading cause of death worldwide (1). According to the
prevalence factors for the CVDs including blood
World Health Organization (WHO) in 2011, CVDs
pressure, blood glucose, obesity, and smoking during
accounted for 17.3 million deaths per year (2), and the
the "Public Awareness Programme" organized by the
ratio of deaths caused by CVDs among all deaths
medical students of the College of Medicine at Shaqra
increased from 1:5 in 1990 to 1:4 in 2010 (3). CVDs
at Al-Basateen Mall in February 2019.
risk factors such as smoking, obesity, BMI and
lifestyle are most common causes for life-threatening
diseases (4). These risk factors can be controllable like
A cross-sectional study was conducted in February
hypertension, diabetes mellitus, obesity, and
2019 where data was collected from a "Public
hyperlipidemia by lifestyle modifications (5).
Awareness Programme" campaign conducted at Al-
Therefore, caring for this risk factor is one of the
Basateen Mall, Shaqra city, Saudi Arabia. We briefed
important goals in preventing CVD (6). Various
male and female visitors of Al-Basateen mall about
worldwide studies assessed the prevalence of CVD
cardiovascular risk factors.
risk factors. Almost 50% of the deaths of those aged
below 70 were found to be attributed to CVD deaths,
while in western countries, it is about 25%, a
substantial difference (7). Lifestyle development in
The Institutional Ethical Committee approved the
childhood and adolescence reduces mortality from
research protocol with approval number:
CVD and may prevent long-term disability. CVD are
asymptomatic; therefore, preventive measures are
A brief questionnaire was answered by each male
very important factor (8). One systemic review
and female participant about medical history, smoking
indicates high prevalence of CVD risks in gulf
status, medications, and family history. Blood
countries (9). One study indicates the prevalence of
pressure (BP) measurement was taken as per the
CVD mortality rate in the Kingdom of Saudi Arabia is
American Heart Association recommendations (14). BP
46% (10). This significantly high percentage might be
readings were obtained for each male and female
related to the lack of awareness of cardiovascular risk
participant. The analysis was based on JNC-8
factors. Sedentary life, smoking and high
recommendations to define HBP. We considered HBP
consumption of fast food have increased in
if the systolic blood pressure (SBP) exceeded 140 mm
community, despite the fact that they can be prevented
Hg and/or the diastolic blood pressure (DBP)
(11, 12). In Jeddah, research had studied the prevalence
exceeded 90 mm Hg (15).
of undiagnosed CVD risk factors in adults aged 20-40
Body mass index (BMI) of the participants was
and indicated that CVD risk factors are common in
calculated as weight (kg) divided by the square of
young adults (13).
height (m2). Participants were categorized according
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4938-4946
Standard versus Accelerated Collagen Cross-Linking in Treatment of
Keratoconus: Visual, Refractive, and Topographic Outcomes
Ibrahim M. Amer* and Asaad Nooreldin
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Assuit, Egypt
*Corresponding author: Ibrahim M. Amer, E-Mail: amer_eye_80yahoo, Mobile: (+2)01011168920
Background: collagen cross-linking (CXL) is an effective, safe and rapidly progressive treatment modality for
treatment of mild to moderate keratoconus not only in hindering the progression of the disease but also in improving
the visual, refractive and topographic results. Objective: the study aims to compare the outcomes of standard and
accelerated cross-linking in treatment of keratoconus. Patients and Methods: the present prospective study
evaluated 99 eyes of 52 patients with keratoconus. They were classified into two groups; group (1) included 50 eyes
(received standard CXL; 3Mw/cm2, 30 min) (SCXL group) and group (2) 49 eyes (treated by accelerated CXL;
9Mw/cm2, 10 min) (ACXL group). Spherical equivalent, uncorrected visual acuity, best-corrected visual acuity, and
topographical analysis of the cornea were assessed at baseline and within 3 years postoperative. Simulated
keratometry was measured in terms of Sim K-1, Sim K-2, K-max, cylindrical value, thickness of the cornea (at the
thinnest point) and Q-value were evaluated. Results: postoperative uncorrected distance visual acuity and corrected
distance visual acuity didn't significantly changed in both groups. Postoperative spherical equivalent significantly
decreased in standard CXL compared to accelerated CXL. Standard CXL had a greater effect in decreasing Simk-1,
Simk-2, k-max and k-mean. K-max decreased from 52.33±5.55 to 50.35±5.14; P=0.07 and in accelerated group
from 54.58±4.35 to 52.74±4.41; P=0.04. Also, postoperative corneal pachymetery (at thinnest location) was found
to be more stable in standard CLX group. Conclusion: both standard and accelerated CXL are effective in early
keratoconus management with better results in standard CXL procedure.
Keywords: Standard, Accelerated, Collagen Cross-Linking, keratoconus.
affected by riboflavin concentrations (20-22). Many
Keratoconus (KC) is the dystrophy of the
studies proved that CXL is effective and safe in
cornea characterized by thinning of the corneal stroma
avoidance of the progression of keratoconus and
accompanied by secondary ectasia(1). Consequently,
improving topographic and visual variables (23-26).
this could lead to abnormal astigmatism and myopia
Standard CXL (SCXL) protocol has a major drawback
and is strongly related to gradual impairment of vision
which is the prolonged irradiation duration with a total
(2-4). KC is one of the commonest corneal disorders that
treatment duration of > 60 minutes, this pushed the
affect about 3/1000 person of all races(5) and it is
researchers to develop accelerated CXL (ACXL)
frequently widespread among adolescents and has
protocols to be more suitable and comfortable for
usually variable presentation(6). This disorder is usually
patients. ACXL protocols aim to lower the time of
progressive for nearly 2 decades(7-9). Later on, what
UVA exposure through increasing the fluency of it to
happens to keratoconus patients remains unknown (10).
ensure the same total dosage. In accordance with
Keratoconus pathogenesis is multifactorial, these
Bunsen and Roscoe rule, the photochemical reaction is
include environmental and genetic causes and atopy
correlated frankly with the total energy dose regardless
(11,12). The main risk factors of KC include eye rubbing,
of the duration of the dose (27). Nowadays, the ACXL
ultraviolet rays and contact lens usage for a long
protocols can be done in a shorter duration such as 3, 5
period (13-15). The management of keratoconus depends
or 10 min using different energy doses, this short
on the its severity; in mild cases, glasses or soft contact
duration of exposure might decrease the adverse
lenses may be sufficient however, in severe cases rigid
effects on the cornea such as corneal haze, thinning,
and scleral lenses are required. Furthermore,
and infection, but on the other hand, this might affect
keratoplasty is confined for severe and advanced cases
CXL efficacy (28).
with impaired vision who could not use contact
AIM OF THE STUDY
Corneal collagen cross-linking (CXL) was first
This study aims to compare between the
described by Wollensak et al.(19) using an ultraviolet-A
clinical results outcomes of standard and accelerated
protocol with an intensity of 3 mW/cm2 at 370 nm for
cross-linking in management of keratoconus and to
30 minutes (Dresden protocol), here, the UVA
follow-up the patients up to 3 years.
photochemical interaction and riboflavin (vitamin B2)
induces cross-linking between the macromolecules of
PATIENTS AND METHODS
the corneal stroma. Many studies have demonstrated
This is a single-center prospective (follow-up)
that the absorption coefficient of UVA is linearly
study. It was conducted in a private center (Modern
correlated with riboflavin concentrations (from
Eye Center) in Assiut city, in Upper Egypt; during the
0:0.5%), this reflects that the clinical outcomes may be
period from January 2016 to January 2019. The study
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4947-4951
Evaluation of the Effect of Intracameral Injection of Bevacizumab in the
Treatment of Neovascular Glaucoma
Salim Mohamed Osemy*, Mahmoud Abd El-Badie Mohamed. Emad Abd eI-Aal Saleem
Ophthalmology department, Faculty of Medicine, Al-Azhar University (Assuit), Egypt
*Corresponding author: Salim M. Osemy, E-mail: email@example.com
Background: neovascular glaucoma (NVG) is a severe condition resulting from ischemia caused by conditions such as
central retinal vein occlusion (CRVO), diabetic retinopathy (DR) and chronic uveitis. In NVG, there is neovascularization
of the iris (NVI) and anterior chamber angle (NVA) mediated by vascular endothelial growth factor (VEGF) leads to
elevation in the intraocular pressure (IOP). Intracameral injection of Bevacizumab show good result in regression of iris
Objective: it was to determine the effect of intracameral injection of bevacizumab on the neo-vessels over the iris, and on
the IOP in patients with NVG.
Patients and Methods: this research is a comparative, prospective, non-randomized study. Fifteen patients of neovascular
glaucoma (NVG) (21mmHg) (with rubeosis iridis) were divided into four groups. Group 1 had peripupillary vessel
dilatations, group 2 had early neovascularization mainly in the chamber angle plus to peripupillary vessel dilatations, group
3 had prominent rubeosis with/without neovascular glaucoma, group 4 had most advanced rubeosis and injected with a
single intracamerlar bevacizumab (0.05 ml at the limbus in the upper temporal quadrant) at Al-Azhar University hospital
between March 2017-March 2018.
Results: after six months of following up the 15 patients, only group 1 showed complete regression of iris
neovascularization; group 2, group 3 showed partial regression at first but finally there was recurrence of iris
neovascularization; and group 4 didnot show response at all to the treatment.
Conclusion: regression of iris neovascularization was inversely proportional to the pre-injection grade. Lower grades were
associated with a better response.
Keywords: Neovascular glaucoma, Central retinal vein occlusion, Diabetic retinopathy, Bevacizumab.
Neovascular glaucoma (NVG) is a devastating
2. Secondary open angle glaucoma stage.
ocular disease, often caused as an end stage
3. Secondary angle closure glaucoma stage.
complication of retinal ischemia. It is caused by a fibro-
vascular membrane that develops over the surface of iris
Clinically, new vessels are first detected as
and angle. It is rarely, occurs as a primary condition but
small tufts at pupillary margin. The new vessels have an
always associated with other abnormalities, most
irregular size and irregular course and they branch
commonly some forms of ocular ischemia such as
frequently and also lie on the iris surface rather than the
Central retinal vein occlusion and Diabetic retinopathy
stroma as normal vessels do (5).
(1). The most accepted theory on the pathogenesis of
Various anti-VEGF agents have been tried in
NVG is that ischemia of retina liberates an angiogenic
neovascular glaucoma. Intravitreal and intracameral
factor that diffuses forward and causes new vessel
injection of Bevacizumab have shown a dramatic
formation on iris and angle which include vascular
endothelial growth factor (VEGF), fibroblast growth
neovascularization of the iris (6,7).
factor (FGF), transforming growth factor-alpha (TGF-
Also, bevacizumab had excellent efficacy
a), trans-forming growth factor-beta (TGF-b), tumor
against the permeability and the proliferative effects of
necrosis factor-alpha (TNF-a), insulin like growth factor
VEGF isoforms. It is found to be effective in slowing
(IGF), inter-leukin-6 (IL-6) and platelet derived growth
tumor growth through its effect on angiogenesis(8).
factor (PDGF)(2). This process stimulates a cascade
leading to activation, proliferation and migration of
PATIENTS AND METHODS
endothelial cells with the formation of new, leaky,
This study included 15 patients of neovascular
fragile blood vessels (3).
glaucoma (NVG) with neo-vessels extending on the iris
The clinical and histological events that lead
border (rubeosis iridis) will be divided into four groups
from a predisposing factor through rubeosis iridis to
according to iris neovascularization's. Group 1 has four
advanced neovascular glaucoma may be thought in three
eyes, group 2 has also 4 eyes, group 3 has 3 eyes, and
finally group 4 has 4 eyes. All groups were injected with
1. Rubeotic stage.
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4952-4955
Subconjunctival Bevacizumab versus Mitomycin C Adjunctive to
Ekram R. Abdallah*, Mahmoud Abd El-badie Mohamed, Hossam Eldeen Saad Abou Saif
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University (Assuit), Egypt
*Corresponding author: Ekram R. Abdallah, E-mail: firstname.lastname@example.org
Background: trabeculectomy was considered gold standard procedure for glaucoma treatment. Mitomycin C (MMC)
and bevacizumab (BVZ) has been used to increase trabeculectomy success rates.
Objective: to compare the outcome of subscleral trabeculectomy with subconjunctival injection of BVZ with that of
trabeculectomy with MMC.
Patients and Methods: a prospective, non-randomized, comparative study design was used. Thirty eyes from thirty
patients with uncontrolled glaucoma were enrolled. Fifteen eyes underwent subscleral trabeculectomy with
intraoperative use of MMC (0.2mg/ml for 3 minutes) (group I) and 15 eyes underwent subscleral trabeculectomy with
subconjunctival bevacizumab injection (1.25mg/0.1ml) (group II). The outcome measures were the best-corrected
visual acuity, intraocular pressure (IOP), number of IOP-lowering medications, complications, and bleb morphologic
features (based on the Indiana Bleb Appearance Grading Scale).
Results: thirty eyes of thirty patients fulfilled inclusion criteria and assigned to one of two study groups. Each study
group included fifteen eyes of fifteen patients. Participants were 14 males and 16 females. Mean ages of patients
assigned to MMC and BVZ were 54.0±7.33 and5.7±6.9 years respectively. The difference in mean age was statistically
insignificant among treatment groups (p=0.740). Mean number of pre-operative anti-glaucoma medications used by
MMC and BVZ treatment groups were 2.47±0.52 and 2.47±0.52 with no significant difference among treatment groups
(p=1.00). Conclusions: adjunctive subconjunctival bevacizumab with trabeculectomy is effective in controlling the
IOP profile and the post-operative IOP reduction showed no statistically significant different in both group at all post-
operative visits. Comparable success rates were achieved in the two groups.
Keywords: subscleral trabeculectomy, Bevacizumab, Mitomycin C, intraocular pressure.
March 2018. Thirty eyes of thirty patients were enrolled
Trabeculectomy has been considered the gold
in the study.
standard procedure since 1968(1).The main cause of
Ethical and approval considerations:
failure following trabeculectomyis the post-operative
Patients were enrolled after the approval of
wound healing response thatleads to subconjunctival
Ethical Committee of Al-Azhar Faculty of Medicine
scarring in the filtering tract and bleb(2).
in Assiut. The risk benefits and alternatives to surgery
Anti-fibrotic agents such as Mitomycin C
were discussed with the patients and informed consents
(MMC) has been used to modulate the wound healing
process and increase surgical success. Among these
The study excluded patients with angle closure
several factors involved in this process, angiogenesis
glaucoma, inflammatory, neovascular, traumatic
seems to play an important role providing a variety of
glaucoma, history of prior failed trabeculectomy
mediators related to the healing process. Blocking
surgery, history of ocular infection in recent two weeks
angiogenesis by administration of anti-vascular
and patients with corneal ulcers or perforations, which
endothelial growth factor (anti-VEGF) agents decreases
prevent proper measurement of intraocular pressure
fibroblast proliferation and scar tissue formation(3).
(IOP). The study subjects underwent trabeculectomy
Intravitreal administration of bevacizumab
surgery augmented by either MMC 0.2mg/ml or BVZ
(BVZ) (Avastin), one of the most commonly used anti-
1.25mg/0.05ml when they had uncontrolled IOP under
VEGF agents in ocular diseases, has been shown to
maximum anti-glaucoma medications, or due to poor
improve trabeculectomy success rates in eyes with
socio-economic status. The demographic data, function
secondary glaucomas, more specifically, in those with
of bleb, and ocular examinations results, including
measurements of best corrected visual acuity (BCVA) at
a distance using Landolt C chart, refractive status using
Objective of the study:
an autorefractometer (KR-8100; Topcon Corporation,
It is to compare the outcome of subscleral
Tokyo, Japan), IOP measured by Goldman applanation
trabeculectomy with subconjunctival injection of BVZ
tonometry (CT-80; Topcon Corporation) and fundus
(1.25mg/0.1ml) with that of trabeculectomy with MMC
bio-microscopy to assess retina and optic disc by + 90 D
(0.2mg/ml for 3 minutes).
Volk non-contact lens.
PATIENTS and METHODS
Sterilization was done by using betadine 10%
randomized, interventional study was conducted at Al-
for the surgical field. Betadine 5% eye drops was used
Azhar University hospital in Assiut from June 2016 to
for the conjunctival sac. Application of sterile drops was
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4956-4963
Impact of Temporal Lobe Epilepsy on Central Auditory Processing in Children
Naema Mohammed Ismail1, Amany Ahmed Shalaby 2, Ghada Saed Abdel Azim 3, Eman Ismail Abd-Ellatif 1
1Department of ENT, Audiology unit, Faculty of Medicine (for Girls), Al-Azhar University,
2Department of ENT, Audiology unit, Faculty of Medicine, Ain Shams University,
3Department of Neurology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
* Corresponding author: Ghada Saed Abdel Azim, Email: email@example.com
Background: Anatomical and functional integrity of the auditory pathways, from peripheral to central structures, is
essential for proper processing of auditory stimuli and a satisfactory development of language, speech, and learning.
Neurological disorders, such as epilepsy, are one of the possible causes of central auditory disorders.
Objective: The aim of the current work was to study the effect of temporal lobe epilepsy on auditory temporal resolution
ability in children.
Patients and methods: Thirty children suffering from temporal lobe epilepsy, with age ranged from 12 to 16 years, were
included in this study. Also, 10 apparently healthy children with age and gender matched with the study group were taken
as a control group. All children were subjected to full history taking, clinical examination, cognitive and basic audiological
evaluation. Also, questionnaire for central auditory processing disorders in children was applied and assessment of temporal
resolution ability using Gaps In Noise (GIN) test.
Results: Children with temporal lobe epilepsy had significantly increased gap detection threshold (GDTh) values, and lower
percentage of correct gap detection than control group. 86.7% of epileptic children demonstrated abnormal scores for
approximate GIN threshold (gap detection threshold above 6 msec, with sensitivity and specificity of 80% and 100% for
right ear and 86% and 100% for left ear.
Conclusion: Temporal resolution deficit is a comorbidity in children with temporal lobe epilepsy and is increased with
longer duration of epilepsy. Impairment was not affected by age, gender, medications or duration of treatment. Also, there
was no significant difference between both ears in GIN test, reflecting no laterality effect.
Keywords: Temporal lope Epilepsy; Auditory Temporal Resolution; Gaps in Noise Test.
Central auditory processing refers to perceptual
cortical processing, neuronal organization, and functional
processing of auditory information in the central nervous
specialization of the brain (5).
system (CNS). If there is any defect in central auditory
The topography of spikes in TLE, with epileptic
processing, the sound will not be recognized properly,
resulting in information error (1).
temporoparietal, and temporal regions, suggests that they
Central Auditory Processing Disorder (CAPD) is
may originate near auditory and language cortices.
defined as a deficit in neural processing of auditory
Electrical discharges are close to the final point of the
information in the central nervous system. According to
auditory pathway in this type of epilepsy (6).
American Speech-Language Hearing Association
It has been recognized that some patients with
(ASHA), CAPD may coexist with other disorders and
epilepsy, especially TLE, have speech recognition
may be associated with difficulties in higher order
impairments or speech processing difficulty, (7) even
language, learning, and communication functions (2).
though they have normal auditory function. This suggests
Epilepsy is a brain disorder characterized by
that patients with TLE may have functional deficits in
recurrent and unpredictable interruptions of normal brain
central auditory processing (CAP) (2).
function, called epileptic seizures. Epileptic seizure is a
Temporal auditory processing (TAP) is defined as
transient occurrence of signs and/or symptoms due to
the perception of the temporal envelope or the alteration
abnormal excessive or synchronous neuronal activity in
of durational characteristics of a sound within a restricted
the brain (3).
or defined time interval. Some authors argued that TAP
Temporal Lobe Epilepsy (TLE) is one of the most
may be the underlying component of many auditory
common types of epilepsy in childhood, which may
processing abilities, including the processing of both
reflect the vulnerability of the temporal lobe to a variety
verbal and nonverbal acoustic signals such as speech
of cerebral insults (4).
perception in quiet and in background noise, localization,
The occurrence of epileptic seizures in the
discrimination, binaural integration, and binaural
developing brain may impair neurophysiological
maturation of neural networks involved in the acquisition
Among temporal auditory skills that can be
of cognitive skills that are fundamental to the learning
assessed by behavioral tests, there are temporal resolution
process. The dysfunction may be due to an abnormal
and temporal ordering. Such abilities require an accurate
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4963-4969
In Vitro Evaluation of Antiviral / Virucidal Activity of Naja Nubiae
(Elapidae) Venom Against Rift Valley Fever and
Herpes Simplex Virus Type -1 (HSV-1) Using Cell Culture
Kareem A. Yonys*, Samy A. Saber, Abir A. El-Fiky, Aly F. Mohamed
Department of Zoology, Faculty of Science, Al-Azhar University, Cairo, Egypt
*Corresponding author: Kareem Ahmed, Mobile: (+20) 01158643103, Email: firstname.lastname@example.org
Background: Venoms are pretentious products secreted by snake, invertebrates and scorpions. Venoms composed
of different proteins, toxic fractions, enzymes and hormones. Some fractions proved bioactivity including anti-
coagulation. antimicrobial and anticancer activity.
Objective: The aim of the current study was to in vitro evaluate the Antiviral / virucidal activity of Naja nubia
(Elapidae) venom against Rift Valley Fever (RVFv) and Herpes simplex virus type -1 (HSV-1) using cell culture.
Materials and methods: Toxicity of tested venom was performed using cell culture to determine the safe
concentration using MTT assay. Antiviral activity was conducted by precultured cell treatment with safe
concentration of snake venom for 24 hr. then virus was dispensed as 0.1 ml / well in quadrate for each dilution.
TCID50s of snake venom safe concentration treated and untreated cells were determined. The difference is the
antiviral activity. Virucidal was conducted by mixing one part of virus models with nine parts of the safe
concentration of snake venom at 37oC. The infectivity titer / time interval was determined according to Reed and
Result: Data record revealed that the cell viability was concentration dependent recording an IC50 of 9.3 µg/ ml.
Also, venom showed a very limited antiviral activity but the virucidal activity was time dependent and showed a
depletion rate in the order of 0.72 log (10) and 0.94 log (10) /hr. for RVFV and HSV-1 respectively indicating that
RVFv was moderately sensitive than HSV-1.
Conclusion: It could be concluded that Naja Nubiae venom is a potentially virucidal agent than antiviral one with
persistent inactivation potential.
Keywords: Naja nubiae, Antiviral, Virucidal, Rift valley forever virus, Herpes simplex type 1, cell culture, MTT.
more individuals and 600 fatalities. In addition, in 1979,
Viruses are capable of rapidly mutating and
the disease moved to Madagascar. RVF emerged in
infecting host cells, sometimes aided by virus-coded
Saudi Arabia and Yemen in the 21st century and
peptides that counteract immune defense of host cells.
reported 200 deaths. It came to Sudan in 2007 (2).
Although a large amount of compounds for inhibiting
RVF has economic effects as it then transmits
multiple viral infections and disease progression have
animals to humans, causing fever followed by
been recognized, the discovery of more efficient agents
complications in the eyes. Infection with RVF virus can
is urgent. Furthermore, Very few viral vaccines are
lead to elevated mortality rates in newborn livestock
accessible, and not all are effective, in proportion to the
and adult abortions (3).
wide variety of viral diseases. Thus, new antiviral
A few commercially available antiviral drugs can
substances extracted from natural products, including
cause serious and significant adverse effects,
those extracted from venom animals, have been
particularly for patients receiving lifelong therapy for
illnesses such as HIV. In addition, viruses have the
Venoms are complicated mixtures of hundreds of
ability to trick and infect host cells rapidly. All of these
molecules, mostly peptides that present a wide range of
facts together have led to the prospecting of new
biological activities and have developed to target the
antiviral drugs, particularly from natural products, as
biochemical machinery of various pathogens or host
they make up more than 25% of the new drug
cellular structures. In addition, non-venomous
prototypes approved in recent decades (4).
compounds have antiviral activity. Peptides described
Among natural product sources, animal venom
from animal venoms presenting antiviral activity,
has disclosed a huge potential for drug discovery (5,6,7),
strengthening them as significant instruments to
and despite the damaging action mechanism of animal
develop new virucidal agents. Rift Fever Virus (RVF),
venom, most of them have potential medicinal
Dengue viruses are members of the Bunyaviridae
characteristics to cure illnesses. So, the present work
family and the genus phlebovirus; has been separated
aimed to evaluate the antiviral / virucidal activity of
from sheep and animals in Kenya. By 1944, and was
Naja nubiae (Elapidae) venom against RVFV and HSV-
separated from the Semliki Forest in Uganda. In 1950-
1 as an economy impact virus infection on the human
1 a large outbreak occurred in South Africa. It reached
and animal level.
Egypt in 1979-1980, with an infection of 200,000 or
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4970-4975
Comparative Study between Efficacy of Two Quadruple DAAs
Therapy in Treatment of HCV Relapsers
Amgad A. Elzahaby (1), Kamel S. Hammad (2), Waleed M. Mousa (1), Ahmed S. Elkhapaty(3)
(1) Department of Tropical Medicine and Gastroenterology, (2) Department of Clinical pathology,
Faculty of Medicine, Al-Azhar University, Cairo, (3) Kafr-Elsheikh Liver Research Center of Hepatology
Corresponding author: Ahmed S. Elkhapaty, Mobile: 01024203148, email: email@example.com
Background: Chronic hepatitis C virus (HCV) is considered as a major cause of liver diseases. The standard treatment
of HCV infection is a combination of direct-acting antiviral agents (DAAs). Relapse is defined where HCV RNA
remained undetectable at the end of therapy but rebounded to pretreatment levels once DAA therapy was discontinued.
Aim of the study: This study was performed to compare efficacy and safety of two quadruple DAAs regimens
(Sofosbuvir/Daclatasvir/Simeprevir and Ribavirin Vs. Sofosbuvir/Ombitasvir/ Paritaprevir/ ritonavir - Ribavirin) in
treatment of HCV relapsers.
Patients and Methods: Retrospective cross-sectional study of 90 experienced patients previously treated with
Sofosbuvir and Daclatasvir ± Ribavirin for 3 months and relapsed. The patients were divided into two groups, each
group included 45 patients: Group I treated with (Sofosbuvir and Daclatasvir -simeprevir--Ribavirin) while Group II
treated with (Sofosbuvir-Ombitasvir/Paritaprevir/ritonavir - Ribavirin).
Results: The study showed an excellent response to both regimens of treatment. In group I; the sustained virologic
response rates at 24th week were 44/45 (97.8%); 100% (29/29) in non-cirrhotic and 93.8% (15/16) in cirrhotic patients.
while group II SVR 24 rates were 93.3% (44/45); 92.9% (26/28) of non-cirrhotic patients, and 94.1% (16/17) of cirrhotic
patients. while group II SVR 24 93.3% (44/45) of overall patients, 92.9% (26/28) of non-cirrhotic patients, and 94.1%
(16/17) of cirrhotic patients. Additionally, the most common adverse events reported were easy fatiguability, headache,
nausea, generalized weakness, photosensitivity - in group I only.
Conclusion: It could be concluded that the current combination regimen is well tolerated and achieved excellent SVR
Keywords: two quadruple DAAs therapy, HCV relapsers.
quadruple DAAs therapies (Sofosbuvir plus Daclatasvir,
HCV infection causes both acute and chronic
Simeprevir and Ribavirin) Versus. (Sofosbuvir plus
hepatitis. Incident infection is associated with early
Ombitasvir, paritaprevir ritonavir and Ribavirin
symptoms in about 20% of persons. Spontaneous
Regimen) of treatment of HCV relapsers after Sofosbuvir
clearance occurs within six months of infection in 15
plus Daclatasvir with or without Ribavirin therapy.
45% of infected individuals in the absence of treatment.
The remaining 5585% develop chronic infection, which
PATIENTS AND METHODS
can lead to progressive fibrosis and cirrhosis. The risk of
This retrospective cross-sectional study included a
cirrhosis ranges from 15% to 30% after 20 years of
total of 90 HCV infected patients previously treated with
infection with HCV (1).
Sofosbuvir and Daclatasvir ± Ribavirin for 3 months but
WHO estimated that in 2015, 71 million persons were
detectable HCV RNA within 24 weeks of completing
living with chronic HCV infection worldwide (global
treatment, attending at Kafr Elsheikh Research Center of
prevalence: 1%) and that 399,000 had died from cirrhosis
Hepatology. Written informed consent from all the
or hepatocellular carcinoma (HCC) every year (1).
subjects were obtained. This study was conducted
The highest prevalence of HCV infection is present in
between January 2017 to December 2017.
Egypt, with 92.5% of patients infected with genotype 4,
3.6% patients with genotype 1, 3.2% patients with
multiple genotypes, and < 1% patients with other
Current protocol was approved by the ethical
genotypes (2). It should be evident that treatment failure
committee of the Department of Tropical Medicine
with direct acting antiviral agents is rare, occurring in
and Committee of Faculty of Medicine, Al-Azhar
approximately 5% of patients. The most common pattern
university, and then by the ethical committee, Al-
of virological failure with
Azhar university. Permission obtained from Egyptian
DAA therapy is due to relapse, where HCV RNA
National Committee for Control of Viral Hepatitis
remained undetectable at the end of therapy but
rebounded to pretreatment levels once DAA therapy was
The patients were divided into two groups, each group
included 45 patients: Group I treated with (Sofosbuvir
and Daclatasvir -simeprevir--Ribavirin) while Group II
The aim of the current study was to comparing
efficacy and safety of two different regimens of
Ombitasvir/Paritaprevir/ritonavir - Ribavirin).
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4976-4981
Sutureless Phacovitrectomy in Vitreoretinal Diseases of
Presbyopic Patients with Clear Crystalline Lens
Ahmed Hassan Abdel Wahab, Mostafa Mahmoud Mostafa, Ahmed Salah Abdel-Rehim
Department of Ophthalmology, Faculty of Medicin, Al-Azhar University
* Corresponding author: Ahmed Hassan Abdel Wahab, Mobile: (+20) 01001110348, E-mail: firstname.lastname@example.org
Background: Patients with vitroreinal diseases require surgical intervention frequently have coexisting lens
opacification. Cataracts increase in prevalence with age, as do vitreoretinal pathologies such as macular holes,
epiretinal membranes, and retinal detachments. Diabetes is another contributing factor that results in the development
of both retinal disease and cataracts. In addition, vitrectomy itself causes cataracts to progress.
Objective: The aim of the work to review the results and complications of combined phacoemulsification and
vitrectomy in presbyopic patients with clear crystalline lens and compare it with the results and complications of
Patients and methods: This study carried on 40 presbyopic patients with clear lens having complex vitreoretinal
disease in which vitrectomy is essentially required such as primary rhegmatogenous retinal detachement, recurrent
rhegmatogenous retinal detachement, full thickness macular hole Stages 3,4,5, idiopathic epiretinal membrane,
proliferative diabetic retinopathy and vitreous hemorrhage.
Result: There is no difference between the groups regarding sex, diagnosis, used material, VA, and IOP. VA showed
improvement in both groups at the same degree post operatively. But there is no change in the IOP postoperatively
compared to the preoperative measurement in both groups. The only complication that showed significant difference
between the two groups is the visually significant PCO which occurred in 2 cases (9.5%) in the Combined Phaco
Vitrectomy compared to 10 cases of PSC in the PPV alone group (43.5%).
Conclusion: Our study provides evidence that combing phaco and vitrectomy has more efficacy vitrectomy alone
then phaco regarding visual acuity improvement with lower incidence of complications.
Keywords: Sutureless Phacovitrectomy, Vitreoretinal Diseases, Presbyopic Patients, Clear Crystalline Lens.
Phacovitrectomy is now considered when lens
opacities are mild or even nonexistent particularly in
retinal assessment. Visual recovery is also not delayed
by subsequent cataract development (4).
"nonessential" phacovitrectomy (1).
However possible disadvantages of combined
Presbyopic eyes have lost the ability to
phacovitrevtomy include longer surgical time,
accommodate, and this, combined with the inevitable
increased risk of postoperative inflammation, slight
postvitrectomy cataract, makes lens removal at the time
increase in proliferative vitreoretinopathy rate,
of retinal detachment surgery desirable (2).
posterior capsule opacification and risk of
Cataract surgery on vitrectomized eyes can be
iris/intraocular lens capture (2).
technically challenging due to the lack of vitreous
support with a deep anterior chamber and "infusion
AIM OF THE WORK
deviation syndrome" with variable anterior chamber
The aim of the work to review the results and
depth and pupil size (2).
complications of combined phacoemulsification and
There are many advantages of the combined
vitrectomy in presbyopic patients with clear crystalline
procedure such as; excellent visualization of peripheral
lens and compare it with the results and complications
retina, faster visual rehabilitation, avoiding the need for
of separate surgeries.
later cataract surgery, achieving emmetropia in many
patients and reducing the cost as well as avoiding the
PATIENTS AND METHODS
difficulties of postvitrectomy cataract surgery (2).
This study carried in Al-Azhar University, Al-
Phacovitrectomy also allows more complete
Hussein and Bab Al-Sharia Hospitals from January
anterior vitrectomy and access to the anterior retina and
2014 to March 2019 on 40 presbyopic patients, with
vitreous base without risking lens trauma. This allows a
clear lens having complex vitreoretinal disease in
better gas fill, potentially improving tamponade of
which vitrectomy is essentially required such as
peripheral retinal breaks, especially inferiorly(3).
primary rhegmatogenous retinal detachement, recurrent
rhegmatogenous retinal detachement, full thickness
vitrectomy improves postoperative retinal visualization
macular hole Stages 3,4,5, idiopathic epiretinal
without the obscuring effect of the cataract, thus
membrane, proliferative diabetic retinopathy and
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4982-4986
Evaluation of Meibomian Glands Dysfunction in Type Two Diabetic Patients
Nada N. El Sawy, Doaa A. Mahmoud , Wafaa A. Madbouly
Department of Ophthalmology, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt.
Correspondence author: Nada N. El Sawy , Tel no.01288108730, Email: email@example.com
Background: Diabetes Mellitus is one of the most common leading causes of blindness. Cataract and retinopathy are well-
known as ocular complications of diabetes, problems involving the ocular surface; dry eyes in particular, have been reported
in diabetic patients. Aim of the Work: to evaluate Meibomian glands function in patients with type 2 diabetes Mellitus.
Materials and Methods: this prospective observational study compared changes in Meibomian glands and tear film
function in type 2 diabetic patients with non-diabetic patients. It included 20 eyes of 11 patients with type two diabetes
mellitus and 20 eyes of 11 healthy non-diabetic controls. Meibomian glands function was evaluated by grading of
Meibomian gland loss by meibography. Tear film function was assessed by dry eye questionnaire, measuring tear breakup
time (TBUT), the Schirmer I test & corneal and Conjunctival fluorescein staining.
Results: dry eye questionnaire results were significantly higher scoring in diabetic group comparing with non-diabetic.
TBUT was significantly lower in diabetic, especially with longer diabetic duration, comparing with normal control.
Schirmer 1 test, corneal and conjunctival fluorescein staining, was significantly higher in diabetic patients compared with
normal control. Meibography showed significant high scoring in diabetic patients that represent significant decrease in
Meibomian gland number compared with controls.
Conclusion: our data suggest that type 2 diabetes predisposes to various changes on the ocular surface Meibomian gland
dysfunction (MGD) in type 2 diabetic patients is more severe compared with nondiabetic patients. It should be noted at an
early stage and treated appropriately in order to prevent more severe eye complications. Therefore, close attention should
be paid to the ocular surface, especially in long-term diabetes mellitus. Further studies are needed to increase the sample
size and include fluctuations in blood sugar as a key factor in studying the ocular surface.
Keywords: Meibomian Glands Dysfunction, Type Two Diabetic Patients.
Diabetes Mellitus is one of the most common
of tear film(4). Infrared Meibography is a non-contact
leading causes of blindness. Cataract and retinopathy are
imaging study exclusively for the purpose of observing
well-known as ocular complications of diabetes,
the morphology of Meibomian glands in vivo. This
problems involving the ocular surface; dry eyes in
system uses a background illumination device with an
particular, have been reported in diabetic patients (1).
Infrared light transmittance filter that illuminates the MGs
The Meibomian gland synthesizes and produces
to assess their integrity(5).
lipids and proteins which form the outer layer of the tear
film. These lipids decrease evaporation and promote
AIM OF THE STUDY
stability of the tear film. The International Workshop on
The aim of this study is to evaluate the changes
Meibomian Gland Dysfunction suggests that MGD is the
of ocular surface and Meibomian Glands in type 2
most prevalent cause of evaporative dry eye and may play
diabetic patients comparing with normal population.
a role in aqueous-deficient dry eye (2).These patients
suffer from a variety of corneal complications including
MATERIALS AND METHODS
superficial punctuate keratopathy, trophic ulceration, and
It is a prospective observational study included
persistent epithelial defect. Dry eye is an important
20 eyes of 11 patients with type two diabetes mellitus and
contributor to these problems as dry eye can lead to vision
20 eyes of 11 healthy controls. It was carried out at
deficit, scarring and perforation of the cornea and
outpatient clinic of Zahraa university hospital except
secondary bacterial infection (1). Insulin is essential for
Meibography which was done at Al-Durra specialized eye
optimal sebaceous gland activity, and is known to induce
center from (October 2018 to March 2019).
glandular cell proliferation and lipid accumulation. Lack
of Insulin, in turn, would promote dysfunction. Also,
Insulin stimulates the proliferation of immortalized
The study protocol adhered to the tenets of the
human Meibomian gland epithelial cells (HMGECs),
declaration of Helsinki and was approved by the
whereas high glucose was found to be toxic for these
ethical board of Al-Azhar University. All subjects
epithelial cells (3). Hyperglycemia contributes to lipolysis
enrolled gave informed consent prior to their inclusion in
in adipocytes, and this response, if occurring in the
the study. Patients who had been previously diagnosed
Meibomian glands, could dramatically reduce the quality
with type 2 diabetes mellitus by a physician were enrolled
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4987-4992
Magnesium Sulfate versus Fentanyl as Adjuvant to Epidural
Levobupivacaine in Surgeries below Umbilicus
Osama Helal Ahmed, Waheed Mohamed Ali, Yasser Mamdouh Kamel
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
* Corresponding author: Yasser Mamdouh Kamel, Mobile: (+20) 01061012226, E-mail: firstname.lastname@example.org
Background: Epidural anesthesia is performed to provide anesthesia for surgical procedures carried on lower
abdomen, pelvis, and lower limbs. It offers superior pain relief and early mobilization especially when local anesthetic
is combined with an adjuvant. Noxious impulses from damaged tissue evoke long lasting alterations in the central
Objective: The aim of the current study was to evaluate and compare between the effectiveness of adding
magnesium sulphate versus addition of fentanyl to epidural levobupivacaine in onset of sensory and motor block,
duration of analgesia , quality of block , intraoperative hemodynamics, post-operative pain control and post-operative
Patients and Methods: The present study is a prospective randomized double blind controlled comparative study
conducted for patients scheduled to undergo elective surgeries below umbilicus in Al-Azhar University Hospital in
Assiut. After obtaining Institutional Ethics Committee approval and written informed consent, 90 patients ASA I/II
were enrolled into the study.
Results: this study demonstrated that magnesium, and fentanyl are effective as useful adjuvants to local anesthetic for
epidural anesthesia. Magnesium sulphate is associated with a shorter onset of action of the epidural block with less
nausea, vomiting and pruritis incidence, fentanyl have a prolonged duration but more incidence for those side effects.
Conclusion: It could be concluded that magnesium sulfate and fentanyl are good adjuvants to local anesthetics when
given epidurally, fentanyl provides more duration of analgesia but with more incidence of nausea vomiting and pruritis
when compared to magnesium sulfate, but magnesium sulfate show more incidence of pain with injection.
Keywords: Magnesium Sulfate, Fentanyl, Epidural Levobupivacaine, Surgeries Below Umbilicus.
to that of epidural magnesium when administrated as an
Epidural anesthesia is a safe, inexpensive
adjuvant to levobupivacaine in patients' surgeries
technique, with the advantage of prolonged
below umbilicus (4).
postoperative pain relief. It has become common
The aim of the current study was to evaluate
practice to use a polypharmacological approach for the
and compare between the effectiveness of adding
treatment of postoperative pain, because no drug has yet
magnesium sulphate versus addition of fentanyl to
been identified that specifically inhibits nociception
epidural levobupivacaine in onset of sensory and
without associated side effects (1).
motor block, duration of analgesia , quality of block ,
There are a lot of adjuvants that can be added to
intraoperative hemodynamics, post-operative pain
local anesthetic drugs when given epidurally. A variety of
control and post-operative side effects.
adjuvants are used for epidural infusion to enhance
analgesia while minimizing side effects, like opioids,
PATIENTS AND METHODS
Clonidine, Epinephrine, Ketamine, Sodium bicarbonate,
This prospective randomized double blind
Anticholinesterases, Magnesium etc. (2).
controlled comparative study included a total of 90
patients ASA I/II scheduled to undergo elective
postsynaptic effects in the dorsal horn and affect the
surgeries below umbilicus, attending at Al-Azhar
modulation of nociceptive input but do not cause motor
University Hospital, Assiut. Written informed consent
or sympathetic blockade. Magnesium is the fourth most
from all the subjects were obtained.
plentiful cation in the body. It has antinociceptive
Ethical consideration and Written informed
effects in human models of pain. These effects are
consent: An approval of the study was obtained
primarily based on the regulation of calcium influx into
from Al-Azhar University Academic and Ethical
the cell that is natural physiological calcium antagonism
and antagonism of N-methyl-d-aspartate (NMDA)
receptor. It has been reported that epidural magnesium
Types of surgeries included within the study: 60
is proved to prolong the duration of spinal opioid
patients orthopedic surgery, 12 patients general surgery,
analgesia in humans. Co-administration of epidural
12 patients urological surgery and 6 patients plastic
magnesium for postoperative epidural analgesia has
provided a pronounced reduction in patient-controlled
epidural consumption without any side-effects (3).
On the basis of these evidences, this study was
All patients were prepared preoperatively. The
undertaken to compare the effects of epidural fentanyl
whole procedure was explained to the patients. Full
LISTS OF ABBREVIATIONS, FIGURES AND TABLES
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 4993-5001
Sutureless Glueless Conjunctival Autograft for Primary Pterygium Surgery
Abd Allah Alhusseiny Abdel Gawad, Riad Alzaher Hassan, Ahmed Mostafa Ismail*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
* Corresponding author: Ahmed Mostafa Ismail, Mobile: (+20) 01010000204, E-mail: email@example.com
Background: Pterygium is a fibrovascular growth of an abnormal conjunctival tissue that progressively encroaches
the limbus and then onto the cornea invading its superficial layers. It is a common ophthalmic condition seen mostly
in dry, dusty areas.
Objective: The aim of the current study was to evaluate the sutureless glueless conjunctival autograft for primary
pterygium surgery as regard technique, complications and success rate.
Patients and methods: This prospective study included a total of 30 patients with primary nasal pterygium, attending
at Outpatient Clinic of Ophthalmology Department, Al-Azhar University, Damietta. This study was conducted between
March 2017 to March 2018. Results: When comparing post-operative values at the end of third month with the first
month we have found no difference in corneal state for all patients. The patient with corneal opacity was as the first
month and had no difference in corneal state or BCVA. We detected one patient (3.3%) having recurrent pterygium.
Finally when comparing post-operative values at the sixth month with the third month, we have found another patient
who was reported with recurrent pterygium. Thus, the recurrence rate was 2 patients (6.7%) among all studied patients
and the other values were approximately the same.
Conclusion: This study suggests that sutureless glueless conjunctival autograft technique is a safe, simple, easy of
performance, has less surgical time and very effective for the management of primary pterygium.
Keywords: Sutureless Glueless Conjunctival Autograft, Pterygium.
involvement of matrix metalloproteinases (MMPs),
Pterygium occurs predominantly on the nasal
cytokines, and growth factors (GFs). The presence of an
limbus, although temporal pterygium rarely occurs in
inflammatory mass on the ocular surface may
isolation. Double-head pterygium, that is nasal and
predispose the patient to a "pseudo-dry eye syndrome"
temporal pterygia in the same eye is rare. In studies by
Dolezalová, the incidence was found to be (2.5%) (1).
Conjunctival autografting after pterygium excision
Histologically, pterygium is characterized by
seems to be the best method, giving both long-term
centripetal growth of a leading edge of altered limbal
safety and effectiveness in reducing the recurrence rate
epithelial cells followed by a squamous metaplastic
(2% 39%) (8).
epithelium with goblet cell hyperplasia and an
The conjunctival autograft is attached with sutures,
underlying stroma of activated, proliferating
which may be associated with complicated surgical
fibroblasts; neovascularization; inflammatory cells; and
techniques, prolonged operating time, prolonged
extracellular matrix (ECM) remodeling (2).
postoperative patient discomfort, and suture-related
It is thought to be caused by increased light
exposure, dust, dryness, heat and wind. Although it can
Scanty data exists evaluating success of sutureless
be easily excised, it has a high rate of recurrence ranging
and glue free limbal conjunctival autograft for the
from (24% to 89%) (3).
management of primary pterygium (10). The results were
Recently, with the popularity of conjunctival
very encouraging as they suggested that sutureless and
autograft and use of antimetabolites such as mitomycin
glue free limbal conjunctival autografting following
C and 5-Fluorouracil the incidence of recurrence has
pterygium excision is a simple, safe, effective, without
been greatly reduced up to (12%) (4).
much complications and economical option for the
UV light may produce damage to the cellular DNA,
management of primary pterygium (9).
RNA, and extracellular matrix and may induce
The aim of the current study was to evaluate the
expression of cytokines and growth factors important in
sutureless glueless conjunctival autograft for primary
the development of pterygium (5).
pterygium surgery as regard technique, complications
It was described that the pterygium was associated
and success rate.
with human papilloma virus (HPV) with the
predisposing factor as dry heat and it also behaves as a
PATIENTS AND METHODS
neoplasm revealed by the presence of 8-
This prospective study included a total of 30 patients
hydroxydeoxyguanosine in the pterygial tissue that
with primary nasal pterygium, attending at Outpatient
suggested the role of oxidative stress as a key factor in
Clinic of Ophthalmology Department, Al-Azhar
its causation (6).
inflammation, tissue invasion and degradation,
Written informed consent from all the subjects were
angiogenesis, fibrosis, proliferation and apoptosis with
obtained. This study was conducted between March
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5002-5007
Effect of Diabetic Retinopathy on Retinal Nerve Fiber Layer Thickness
Mohamed Tarek Abdelmoneim, Abdulla Mohamed Elamin, Alaa Abdelmongy Sadaka,
Hossam Abdelfattah Husein*
Department of Ophthalmology, Faculty of Medicine Aswan University
* Corresponding author: Hossam Abdelfattah Husein, Mobile: (+20) 01026808348, E-mail: firstname.lastname@example.org
Background: Diabetic retinopathy is one of the most common causes of vision loss in developed countries.
Objective: The objective of this study was to assess the effect of diabetic retinopathy (DR) on the retinal nerve fiber layer
(RNFL) thickness. Patients and methods: This study was carried out on 55 eyes of 35 patients designed as a prospective,
interventional case series at Sohag Hospital from January, 2016 to December, 2016. A complete ophthalmologic
examination was performed including best-corrected visual acuity (BCVA) using the ETDRS charts, intraocular pressure
(IOP) measurement, slit-lamp biomicroscopic examination, fundus examination and fluorescein angiography. Results:
The RNFL (inferior and total) thickness at each follow-up was increased significantly from baseline to 1 month and 6
months post-PRP then decreased significantly from 1 month to 6 months follow up (p < 0.001). The superior RNFL was
increased significantly from baseline to 1 month post-PRP and then decreased at 6 month follow up (p < 0.001). While no
significant change from 1 month to 6 months follow up (p > 0.05).
Conclusion: Increase in the macular Ganglion cell (GC) thickness and RNFL at 1 month of follow-up that may be related
to laser induced intraretinal inflammation which triggers increased capillary permeability and ensuing axonal edema due
to the cytokine release.
Keywords: Diabetic retinopathy, Retinal nerve fiber layer thickness.
PATIENTS AND METHODS
Diabetic retinopathy (DR) is one of the most
This study was carried out on 55 eyes of 35 patients
important facet of diabetes and a major cause of visual
designed as a prospective, interventional case series at
loss and blindness in individuals between 20 and 65 years
Sohag Hospital in the period from January, 2016 to
of age (1).
December, 2016. A complete ophthalmologic
According to Diabetic Retinopathy Study Group
examination was performed, including best-corrected
(DRS), severe visual loss (acuity poorer than 5/200) may
visual acuity (BCVA) using the ETDRS charts,
occur in 37% of untreated eyes having high-risk
intraocular pressure (IOP) measurement, slit-lamp
characteristics of proliferative diabetic retinopathy
biomicroscopic examination, fundus examination,
(PDR) within six years (2). Ganglion cell analysis
(GCA) algorithm of Cirrus Optical coherence
tomography (OCT) can successfully detect and measure
Ethical approval and written informed consent :
the thickness of the macular ganglion cellinner
An approval of the study was obtained from
plexiform layer (GCIPL) with excellent intervisit
Aswan University academic and ethical committee.
Every patient signed an informed written consent for
Diabetes can also damage nonvascular cells of the retina.
acceptance of the study.
In autopsy samples, retinal ganglion cells are lost, at least
in part, through apoptosis (4). Histological studies of
neural components of the retina have revealed that
Patients with severe non-PDR and PDR were defined by
early treatment diabetic retinopathy study (ETDRS) by
potentially cause neural cell degeneration (5). In addition,
the presence of one of the following criteria between 40
numerous studies have evidenced that alteration of
and 60 years of age:
different metabolic pathways in diabetes induces
(1) Severe intra-retinal hemorrhages in four
functional deficits and loss of different types of retinal
cells including ganglion cells, bipolar cells, and
(2) Venous beading in at least two quadrants.
eventually photoreceptors (6).
(3) Moderate to severe intra-retinal microangiopathy
OCT has been proposed as a powerful tool for retinal
in at least one quadrant.
measurement and it provides detailed information with a
(4) Capillary dropouts in more than one quadrant.
high resolution (7). It also allows direct measurement of
retinal nerve fiber layer (RNFL) thickness by in-vivo
visualization of the retina and RNFL (8).
The following patients were excluded from the study:
(1) Advanced and high-risk PDR.
AIM OF THE WORK
(2) Patients with densely opaque media (as cataract or
The objective of this study was to assess the effect of
diabetic retinopathy (DR) on the retinal nerve fiber layer
(3) Glaucomatous patients.
(4) Hypertensive patients.
(5) Patients with any other associated retinopathies.
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5008-5015
Carbetocin Versus Oxytocin in Prevention of Atonic Postpartum Hemorrhage
Esmael Mohamed Talaat Elgarhy, Ashraf Hamdy Mohamed, Mohamed Mahmoud Mohamed Abdelfatah*
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
* Corresponding author: Mohamed Mohamed Mahmoud Abdelfatah, Mobile: (+20)01068673424, E-mail:
Background: Death due to pregnancy remains an important cause of premature mortality of women worldwide. An
estimated 500,000 women die from this cause every year with up to quarter of deaths occur due to hemorrhage.
Objective: The aim of this study was to compare the effectiveness and safety of carbetocin versus oxytocin in the
prevention of atonic postpartum Hemorrhage (PPH) after vaginal deliveries and cesarean sections.
Patient and Methods: This computerized random cross sectional prospective comparative study included a total of
400 pregnant women who were going to deliver, attending at Obstetric and Gynecological Department at El-Mataria
Teaching Hospital in Corporation with Obstetric and Gynecological Department, Faculty of Medicine, Al-Azhar
University. This study was conducted between October 2017 to October 2018.
Results: Carbetocin was proved statistically to be more effective in preventing uterus atony and thereby PPH in
comparison with oxytocin.
Conclusion: It could be concluded that carbetocin is a better uterotonic agent in comparison with Oxytocin in the
management of atonic postpartum hemorrhage after delivery either vaginal or cesarean section as it decreases
incidence of occurrence of PPH and post-partum blood loss.
Keywords: Carbetocin, Oxytocin, Atonic Postpartum Hemorrhage
Uterotonic drugs increase the tone of the
Post-partum hemorrhage is the leading cause
uterine muscles and were initially introduced for the
of morbidity and mortality among pregnant ladies
treatment of PPH (6).
throughout the world causing 140,000 deaths each year
Oxytocin is the most widely used uterotonic
globally. This corresponds to the one woman dying in
agent but has a half-life of only 410 min, that is why it
every 4 minutes and it is the 5th most common cause of
is better administered as a continuous intravenous
maternal mortality throughout the world (1).
infusion to achieve sustained uterotonic activity (7).
Postpartum hemorrhage was classified into
Carbetocin is a synthetic long-acting oxytocin
two types, primary and secondary, Primary is defined
agonistic analogue with prolonged half-life prolonging
as blood loss of greater than 500 ml due to vaginal
its pharmacological effects. Its prolonged uterine
delivery and loss of 1000 ml due to C-section within
activity may theoretically offer advantages over
first 24 hours of delivery. Secondary is defined as
oxytocin in the management of the third stage of labor.
excessive vaginal blood loss or heavy lochia discharge
The side-effect profile of carbetocin was not found to be
occurring at least 24 hours after the end of the third
different from that of oxytocin but may prove to be
stage of labor (2).
advantageous when compared to syntometrine (8).
Another definition of Primary Postpartum
The aim of this study was to compare the
Hemorrhage "PPH" is that blood loss sufficient to cause
effectiveness and safety of carbetocin versus oxytocin
hypovolemia, a 10% drop in the hematocrit or requiring
in the prevention of atonic PPH after vaginal deliveries
transfusion of blood products (regardless of route of
and cesarean sections.
Risk factors for PPH include; past history of
PATIENTS AND METHODS
PPH, multiple pregnancy, fetal macrosomia, primi-
This computerized random cross sectional
gravida, grand multi-parity, older age, preterm births,
prospective comparative study included a total of 400
genital tract injuries, non-use of oxytocics for PPH
pregnant women who were going to deliver, attending
prophylaxis, labor induction, cesarean birth and intra-
at Obstetric and Gynecological Department at El-
uterine fetal deaths (4).
Mataria Teaching Hospital in Corporation with
It is axiomatic that postpartum hemorrhage
Obstetric and Gynecological Department, Faculty of
occurs unpredictably, and no patient is immune from it,
Medicine, Al-Azhar University. Written informed
it simply states that it is an equal opportunity killer (5).
consent from all the subjects were obtained. This study
In many International and local studies, it was revealed
was conducted between October 2017 to October 2018.
that the main cause of PPH is uterine atony which is
responsible for at least 80% of cases followed by
Approval of the Ethical Committee, Faculty of
vaginal hematoma, cervical or vaginal tear, adherent
Medicine, Al-Azhar University was obtained.
placenta, uterine angle extension and retained placenta
The included subjects were randomly divided into two
groups; Group I (Carbetocin group) included 200
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5016-5025
Mustardé Versus Incisionless Otoplasty for Protruding Ear
Mohamed Hassan Abdel-Aal, Mohammad Reda Ahmad, Mansour Mohamed Morsy, Mohamed Elsayed
Department of General Surgery Faculty of Medicine, Zagazig University
* Corresponding author: Mohamed el sayed Abdel wahed, Mobile: (+20) 01116373887, E-mail:
Background: Prominent ear is one of the most common facial deformities affecting children. The aesthetic and
psychosocial concerns surrounding an ear deformity serve as a catalyst for parents to seek correction, thereby propagating
the strong desire for otoplasty at an early age.
Objective: is to assess the role of Mustardé technique and incisionless otoplasty technique regarding aesthetic outcome
in surgical treatment of protruding ear, complications and postoperative care.
Subjects and methods: 24 patients (18 males and 6 females) suffering from prominent ear deformity (4 unilateral and
20 bilateral) were included in the present study. The reconstructive procedures were done for 44 ears divided by the
procedure done into 2 groups. Group A: Mustardé procedure (21 ears, 8 patients with bilateral prominent ear and 2
patients with unilateral prominent ear); and group B: Incision-less procedure (23 ears, 9 patients with bilateral prominent
ear and 2 patients with unilateral prominent ear). An approval of the study was obtained from Zagazig University
academic and ethical committee and an informed written consent was obtained from each patient for acceptance of the
Results: The mean values of the duration of operation in Mustardé procedure (group A) was significantly longer than
that of Incision-less procedure (P < 0.001). The follow up period (months) revealed non-significant difference between
both groups (P> 0.05). Mustardé procedure (group A) has a significant high percentage of reduction in auriculo-cephalic
distance (P < 0.01), when compared with that of incision-less procedure, the percentage of reduction of the auriculo-
temporal distance, and auriculo-mastoid distance of Mustardé procedure (group A) had a non-significant high values
when compared with those of incision-less procedure (P> 0.05).
Conclusion: Both Mustarde and the incision-less suture techniques provide satisfactory results; however, the incisionless
suture technique appears to be easier with less surgical time.
Keywords: Mustarde, Incisionless otoplasty, Protruding ear
sutures only (7). He described a well-known suture
technique to create an anti-helical fold by an open
The protruding ear, also known as prominent ear, is
approach. The procedure, which needs a skin incision,
one of the most common facial deformities affecting
may lead to complications such as bleeding, keloid
children. The aesthetic and psychosocial concerns
formation, and a visible scar because of poor wound
surrounding an ear deformity serve as a catalyst for
healing. The procedure may also require a prolonged ear
parents to seek correction, thereby propagating the strong
dressing. Because of these disadvantages, an incision-less
desire for otoplasty at an early age (1).
otoplasty technique with permanent subcutaneous sutures
It is the most common congenital auricular deformity
was developed by Fritsch (8) and Haytoglu et al. (9).
and typically occurs bilaterally. Approximately 5% of the
Although many researches evaluated the efficacy and
population suffers from some degree of ear prominence,
aesthetic outcome of the several techniques of prominent
presenting as a cosmetic concern rather than a
ear surgical management, no global agreement on the
physiological deficit (2).
optimal technique for surgical correction (10).
Assessment of prominent ear depends on multiple
No universal agreement about regimen of special care
factors such as ear size, position, rotation, contour,
should be taken in postoperative stage to ensure the newly
projection and several other factors (3).
shape ear (11). Therefore, this work was designed to
Protruding ear usually manifests at an early age.
compare aesthetic outcome of the cases done by
However, the appropriate time for corrective surgery
Mustardé technique and Incisionless Otoplasty
should balance auricular growth, cartilage pliability,
psychological burden secondary to the auricular
Aim of the work is to assess the role of Mustardé
deformity, and patient maturity level. In the golden
technique and incisionless otoplasty technique regarding
window between ages 4 and 6, these elements align,
aesthetic outcome in surgical treatment of protruding ear,
thereby allowing optimal execution of reconstructive
complications and postoperative care.
techniques to improve the cosmesis of the ear (4).
There are many procedures in the literature that
attempt to describe a unique surgical approach to treat
prominent ear. First attempts were done by Diefennbach
SUBJECTS AND METHODS
(5) followed by several attempts reaching nowadays (6).
This study was conducted in the Department of General
Mustardé technique is considered as one of the most
Surgery, Faculty of Medicine, Zagazig University within the
popular techniques in repairing protruding ear using
period from June 2018 to March 2019.
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5026-5031
Association between Colonization with Group B Streptococcus and Preterm Delivery
Yahia Abd El Salam Wafaa1, Muhammad Hesham Hassan1, Mohamed Ibrahim Mostafa1, Nagham Abed
Mohamed Elameer2, Amr Ahmed Sayed Ali Mohammed1*
1Department of Obstetrics and Gynaecology, Faculty of Medicine, Al-Azhar University,2 Clinical Pathology, Al-Galaa
Maternity Teaching Hospital
* Corresponding author: Amr Ahmed Sayed Ali Mohammed, Mobile: (+20)1001341521, E-mail: email@example.com
Background: Despite major advances in perinatal care, preterm delivery (PTL) is still the predominant cause of perinatal
mortality and a major cause of neurological morbidity in surviving infants.
Objective: the objective of this study is to find any association between maternal group B streptococcus (GBS) colonization
and preterm delivery.
Patients and Method: This study is a prospective study including 100 pregnant women between 28 36 weeks of gestation
from those who attended the Emergency Department at Al-Galaa Maternity Teaching Hospital from April 2015 to August
2015. All patients were tested for genital colonization with Group B streptococcus (GBS) by taking low vaginal swab that
was sent for microbiological examination.
Results: In this study there was a significant difference between positive and negative cases as regard obstetric data. As
regard preterm labor, 80% of positive swab cases had preterm labor compared to 46.2% of negative swab cases and this was
statistically significant. Positive vaginal swab cases are at 7 times higher risk to have preterm labor compared to negative
Conclusion: GBS vaginal colonization was associated with premature labour in the studied population. Women with GBS
vaginal colonization qualify for intrapartum chemoprophylaxis. The study results suggest that the early prenatal screening
for GBS may identify pregnant women at risk of PTL.
Keywords: Group B Streptococcus, Preterm Delivery.
meningitis. GBS may also be a cause of stillbirth and
Although the determinants of preterm delivery
premature labor (5).
are uncertain, evidence suggests maternal genital tract
colonization with specific organisms can play a role in
AIM OF THE WORK
preterm rupture of membranes and preterm delivery.
The objective of this study is to find any
Bacterial products such as phospholipases A2 and C,
association between maternal GBS colonization and
endotoxin, and induction of the cytokine cascade can
stimulate the prostaglandin pathway and initiate labor (1).
Reproductive tract infections or colonization
PATIENTS AND METHOD
associated with preterm delivery include Chlamydia
This study is a prospective study including 100
trachomatis and bacterial vaginosis (2).
pregnant women between 28 36 weeks of gestation from
Up to 36 % of pregnant women are colonized
those who attended the Emergency Department at Al-
with GBS in the vagina or rectum. GBS colonization
Galaa Maternity Teaching Hospital from April 2015 to
during pregnancy can be transient, intermittent, or
All patients were tested for genital colonization with
Preterm delivery in group B streptococcus (GBS)
Group B streptococcus by taking low vaginal swab that
colonized mothers is a recognized risk factor for early
was sent for microbiological examination.
onset neonatal GBS disease (GBS-EOD), but whether
Ethical approval and written informed consent:
maternal GBS genital colonization is related to preterm
An approval of the study was obtained from Al-
delivery is unclear (4).
Azhar University Academic and Ethical Committee.
It is universally accepted that group B
Every patient signed an informed written consent for
streptococcal infection is a major cause of neonatal sepsis
acceptance of the operation.
resulting in serious neonatal morbidity and mortality. It is
probable that in early onset neonatal infection
1-Age: between 20 - 40 years.
transmission from maternal genital tract occurs just prior
2-Gestational age: between 28-36 weeks.
to or during labour (3).
GBS is also associated with late onset disease
(LOD) affecting neonates and infants between one week
1-Preterm premature rupture of membranes (PPROM).
and three months old, resulting in bacteremia and/or
2-Pregnant <28 weeks
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5032-5039
Optical Coherence Tomography Evaluation of Retinal Nerve Fiber
Layer and Ganglion Cell Layer Thickness before and after Argon Laser in
Treatment of Diabetic Retinopathy
Mohamed Tarek Abdelmoneim, Abdulla Mohamed Elamin, Alaa Abdelmongy Sadaka,
Hossam Abdelfattah Husein*
Department of Ophthalmology, Faculty of Medicine, Aswan University
* Corresponding author: Hossam Abdelfattah Husein, Mobile: (+20) 01026808348, E-mail: firstname.lastname@example.org
Background: Diabetic retinopathy (DR) is one of the most common microvascular complications of diabetes with the
potential to cause severe vision loss and blindness and a devastating effect on quality of life.
Objective: Discuss the macular ganglion cell and retinal nerve fiber layer (RNFL) changes after laser treatment as a
management of diabetic retinopathy.
Patients and Methods: This study was carried out on 55 eyes of 35 patients designed as a prospective, interventional
case series at Sohag Ophthalmic Diagnostic Laser Unit between January 2016 and March 2017. A complete
ophthalmologic examination was performed, including best-corrected visual acuity (BCVA) using the ETDRS charts,
intraocular pressure (IOP) measurement, slit-lamp biomicroscopic examination, fundus examination, fluorescein
angiography, and 3D optical coherence tomography (OCT) 2000.
Results: The value of RNFL (superior and total) in the GRID group is more than in the pan-retinal photocoagulation
(PRP) group which increased at 1 month post laser (not significant) then significantly decreased at 6 month follow up.
The value of RNFL (inferior) in the GRID group is more than in the PRP group which significantly increased at 1 month
post laser then decreased at 6 month follow up table 4.
Conclusion: Significant ganglion cell (GC) and RNLF decrease at the sixth month of follow-up can be attributed to
axonal loss secondary to direct or indirect effects of PRP treatment. SD OCT is a very valuable tool to document the
RNFL thickness changes following the argon laser photocoagulation.
Keywords: Optical coherence tomography, Retinal nerve fiber layer, Argon laser in treatment, Diabetic retinopathy
decrease in the peripapillary nerve fiber layer thickness
Diabetes mellitus (DM) has become a global health
problem fueled by increased caloric consumption and
Diabetic macular edema is associated with increased
the resultant obesity epidemic (1).
vascular leakage in the central part of the retina, and it
Retinal nerve fiber layer (RNFL) measurements
is a feared complication of DM. For decades, diabetic
using optical coherence tomography (OCT) programs
macular edema was treated with focal/grid
for nerve head indicate that the highest degree of
photocoagulation (ETDRS-Group 1987) in which laser
variability can be attributed to interpatient differences.
shots are applied directly to leaking microaneurysms
The recently developed OCT provides the
(focal treatment) or are delivered in a grid pattern on the
ophthalmologist with the opportunity to customize
thickened edematous part of the retina (grid treatment).
scans and to tailor a single scan circle to examine RNFL
In many subjects with diabetic macular edema, both of
thickness. Custom scans can be useful to help the
the mentioned modalities are often required and are
ophthalmologist differentiate normal from early
performed during the same treatment session (6).
glaucomatous peripapillary RNFL(2).
AIM OF THE WORK
Ganglion cell analysis (GCA) algorithm of Cirrus
Discuss the macular ganglion cell and retinal
OCT can successfully detect and measure the thickness
nerve fiber layer changes after laser treatment as a
of the macular ganglion cellinner plexiform layer
management of diabetic retinopathy.
(GCIPL) with excellent intervisit reproducibility (3).
PATIENTS AND METHODS
The use of laser photocoagulation in the treatment
This study was carried out on 55 eyes of 35 patients,
of diabetic retinopathy is one of the best examples in
designed as a prospective, interventional case series at
which laser energy revolutionized the treatment of a
the Sohag Ophthalmic Diagnostic Laser Unit between
serious disease (4).
January 2016 and March 2017. A complete
Although pan-retinal photocoagulation (PRP)
ophthalmologic examination was performed, including
proved to be an effective treatment strategy for severe
best-corrected visual acuity (BCVA) using the ETDRS
diabetic retinopathy, the laser intensity utilized is
charts, intraocular pressure (IOP) measurement, slit-
decided by the physician. Most physicians agree that
lamp biomicroscopic examination, fundus examination,
laser intensity that causes damage to the entire retinal
fluorescein angiography, and 3D OCT 2000 (Topcon,
layer should be avoided. It was reported that a high-
Inc., Tokyo, Japan)
intensity laser beam can cause destruction of the entire
retinal layer, including ganglion cells (GC). Damage to
GC results in loss of the RNFL and a sequential
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5040-5048
Identification of Silicone Oil Maculopathy by OCT after Vitrectomy for
Rhegmatogenous Retinal Detachment
Ibrahim M. Amer
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Assuit, Egypt
Corresponding author: Ibrahim Mohamd Ahmed, E-Mail: email@example.com,
Background: silicone oil (SO) is used as a vitreous replacement and has been shown to be effective in repairing
complicated retinal detachment. Its use, however, may have several disadvantages.
Aim: to study the macular changes after SO injection as tamponade in vitrectomy for rhegmatogenous retinal
detachment (RRD). Patients and Methods: a prospective, interventional and non-randomized study was performed on
75 eyes (75 patients) of RRD. The patients underwent primary vitrectomy with SO tamponade. All the patients were
examined at baseline and postoperatively at day one, one week, one month, and three months. Each visit examination
included best corrected visual acuity (BCVA), indirect ophthalmoscopy slit-lamp biomicroscopy, fundus examination
by binocular indirect slit-lamp biomicroscopy, measurement of intraocular pressure, and optical coherent tomography
(OCT) at 1,3 months postoperatively. Results: 71 of the 75 eyes, had a successful vitrectomy with reattached retina
under SO tamponade and 4 eyes were excluded. The patients' mean age was 48±4.5 years. Preoperatively, the macula
was on in 41(57.75%) eyes and off in 30(42.25%) while retinal detachment (RD) was total in 18(25.35%) eyes and
subtotal in 53(74.65%) eyes. Central macular thickness (CMT) was 177-850 microns. Three months after vitrectomy,
CMT was 154-708 microns. While no statistical significant difference was detected between 1 month to 3 months after
vitrectomy (P=0.175). Postoperative OCT changes include attenuated IS/OS junction in 16(22.54%) eyes, macular
edema in 15(21.13%) eyes, epiretinal membrane in 13(18.31%) eyes.
Conclusions: OCT is a beneficial tool for identification of silicone oil maculopathy even in clinically normal maculae.
Keywords: Silicone oil, maculopathy, OCT
or with proliferative vitreoretinopathy of intermediate
Silicone oil (SO) was used as a vitreous
severity (PVR up to grade B).
substitute since 1960s and proved efficacy as a long
All cases had been underwent primary
term tamponade for repair of complex retinal
vitrectomy with silicone oil 2000 centistokes (cSt)
tamponade (Geuder silicone oil Siluron 2000 cSt
Silicone oil is chemically inert(2). However, its
FLUORON GmbH, Germany).
use may be associated with several disadvantages
The patients were selected from the Modern
including emulsification, cataract, glaucoma, and
Eye Center at Assiut city, where the author practice,
keratopathies(1,3-5). Therefore, removal of silicone oil is
from December 2016 to December 2018.
important to avoid such complications(6,7). In addition,
The patients underwent primary vitrectomy
silicone oil may result in microstructural retinal
with SO tamponade, and investigated by OCT Swept
damage(8,9) that may affect visual functions(10,11).
source (SS-OCT) DRI triton OCT (TOPCON, Japan).
Because retinal changes under silicone oil
Ethical and approval consideration:
tamponade and after its removal are difficult to evaluate
The protocol was approved by the Ethical
clinically, the utilization of SDOCT scan demonstrate
Committee of Al-Azhar Faculty of Medicine, Assuit,
these retinal changes(12). The existence of SO in the
Al-Azhar University. Then, formal informed consent
vitreous doesn't alter the reproducibility of OCT
was taken from each patient.
measurements for foveal thickness(13).
Retinal changes resulting from SO injection
They were patients with RRD (phakic or
could manifest in the form of macular dysfunction with
pseudophakic) with or without PVR of intermediate
lesions in the ganglion cells and horizontal-bipolar cell
severity (PVR up to grade B).
synapses process in the outer plexiform layer(14,15),
epiretinal membrane (ERM), sub silicone membrane
They were preexisting macular pathology as
and macular hole(16), cystoid macular edema(17), and
age-related macular degeneration and macular hole,
photoreceptor and nerve fiber layer damage(18,19).
recurrent retinal detachment following a previous
failed vitrectomy, postoperative media opacities
AIM OF THE STUDY
This study aimed to assess the macular changes
interfering with OCT imaging, eyes with uveitis,
after SO injection as tamponade in vitrectomy for
retinal vascular diseases, optic nerve changes and
rhegmatogenous retinal detachment (RRD).
history of ocular surgery, other than cataract surgery.
All the patients were examined at baseline, day
PATIENTS AND METHODS
This is a prospective interventional non-
one, first week, first month, and 3 months
randomized study. It included 75 eyes of RRD without
postoperatively. Each visit examination included best
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5049-5055
Assessment of Nutrition State in Children with Heart Diseases
Hanan M.Abdelmoneim, Bahaa Elamir Hawary, Alaa Magdi Eldoctour Soliman*
Department of Pediatrics, Faculty of Medicine Aswan University
* Corresponding author: Alaa Magdi Eldoctour Soliman, Mobile: (+20)01009118747, E-mail: firstname.lastname@example.org
Background: It is well- known that children with congenital heart diseases (CHD) are at high risk for nutrition and
growth restrictions. Objective: The purpose of this study was to assess growth restriction in infants and young children
with heart disease and investigate the relationship between poor growth, feeding difficulties, cardiac classification, and
nutrition intervention on outcomes. Materials and Methods: This study was performed on 100 children, 50 of them
with symptomatic CHD (patient group). They were recruited from the Pediatric Cardiology Outpatient Clinic at Aswan
Heart Center from March to August, 2016. A group of 50 apparently healthy children matched in age and sex represented
our control group. CHD was diagnosed or excluded by clinical findings and echocardiographic and other routine tests.
Results: We found there was some growth restriction in children with CHD compared to normal children in same age
group. The growth deficiency was wasting rather than stunting and it was found to be the most common type of
malnutrition in our study. No relationship between cardiac complexity, classification (cyanotic vs. acyanotic) and
variables including growth parameters. Close nutritional monitoring should be included routinely for all children with
CHD regardless of cardiac classification. Age at time of corrective surgery affects the potential for nutritional recovery
and catch-up growth. Conclusion: Children with CHD require unique nutritional challenges. It is important to start
dealing with nutrition status in congenital heart diseases as a preventable association rather than common consequence.
Nutritional screening for diagnosed CHD cases will help in early detection of growth faltering, consequently it will
provide access to early nutrition intervention and improve patient outcomes.
Keywords: Congenital Heart Disease, Malnutrition, Immunonutrition, Nutrition in CHD.
Congenital heart disease (CHD) is a significant
of prevention are nutrition interferences (oral intake or
health problem. It affects between 0.3% and 1.5% of all
nutrition support) and close follow up. Delivering well
pregnancies. Children with CHD are known to show
tolerated nutrition intervention help in promoting weight
marked decreases in their growth patterns compared to
healthy children in same age group. It is also known that
surgery and the load of chronic disease and cardiac failure
AIM OF THE WORK
result in significant metabolic and nutritional stress.
The purpose of this study was to assess growth
Moreover, insufficient nutritional intake in the post-
restriction in infants and young children with heart disease
operative period results in further challenges to restor
and investigate the relationship between poor growth,
normal growth parameters (1).
feeding difficulties, cardiac classification and nutrition
Understanding the degree of growth restriction,
intervention on outcomes.
type of feeding difficulty, cardiac classification/diagnoses
and pre-surgery nutrition intervention in children with
PATIENTS AND METHODS
CHD have a beneficial to restructure proper clinical
interventions. Wavering growth preadmission and low
This was a casecontrol observational study of 50
growth parameters are usually allied with the increased
children in age group (0-60 months) with symptomatic
hospital length stay and recurrent admissions. Nutritional
congenital heart disease. They were enrolled from
screening and follow up may detect growth wavering,
Pediatric Cardiology Outpatient Clinic at Aswan Heart
enable access to early nutrition intervention and improve
Center between March to August, 2016. A group of 50
patient consequences (2). Cautious assessment and
apparently healthy children matched in age and sex
awareness of the nutritional needs in the hospitalized
represented our control group. Informed consent was
critically ill child is significant. Insure appropriate
obtained from parents and other caregivers before
nutrition in those patients by the two main methods
(enteral and parenteral) help in better outcome (3).
The ability to enhance and modulate the immune system
In addition, the study was approved by the Ethical
activity by interventions with particular nutrients is
Committee of Faculty of Medicine, Aswan University.
termed immuno-nutrition. When we prescribe a specific
diet, it is important to consider that nutrients are not only
(1) The 50 children with symptomatic CHD were
elements to influence body growth. They also have a
crucial powerful force improving the whole body health
Medical history as well as clinical examination.
through their ability for regulation of immune system (4).
They were classified according to clinical
Nutrition restrictions and malnutrition in the child with
presentation and echocardiography finding into two
congenital heart disease could be avoidable. The main line
subgroups (cyanotic, acyanotic).
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5056-5059
Endovascular Treatment of Cerebral Aneurysms Not Presented by Classic
Subarachnoid Hemorrhage (First Year Experience by Neurologist)
Eman M Khedra, Ahmed Bassionyb, Hany Zaky-Eldinb, Bastawy Fawalc, Ahmed Shoybc
a Department of Neuropsychiatry, Faculty of Medicine, Assiut University, Assuit, Egypt and the
Academic Director of Neuropsychiatry Department, Faculty of Medicine, Aswan University, Aswan,
b Department of Neuropsychiatry, Faculty of Medicine, Ain shams University, Cairo,
c Department of Neuropsychiatry, Faculty of Medicine, Aswan University, Aswan, Egypt
corresponding author: Ahmed Shoyb ,email: email@example.com
Saccular intracranial aneurysms are localized enlargement lesions of the vasculature, most commonly sited at
bifurcation points in the circle of Willis. Often they will stay asymptomatic during the life. Its common presentation
is rupture that leads to subarachnoid hemorrhage (SAH) but had other presentation as ischemic stroke or compressive
symptoms. Material and Methods: we recruited 16 patients with intracranial aneurysm that had presentations other
than subarachnoid hemorrhage and was treated by endovascular intervention and evaluated clinically and
angiographically before procedure and 3-6 months after procedure
Results: the mean age of patients was 5.75±11.1 ranging between 23 69 years. 10 patients were females and 6 were
males. 7 patients (43.8 %) were hypertensive which was the commonest risk factor in those patients. 6 patients (37.5%)
had ICA aneurysm. Conclusion: endovascular therapy of intracranial aneurysms is a safe and effective method of
therapy with less morbidity and mortality rates.
Keywords: subarachnoid hemorrhage, rupture aneurysm, coiling,
Ethical approval no: ASU 44-1-16.
angiography (MRA) when necessary, and six vessel
The prevalence of intracranial aneurysms are
digital subtraction cerebral angiography (DSCA)
about 1 to 5 percent in adult population. Often they will
followed by endovascular aneurysmal therapy. Clinical
stay asymptomatic during the course of life(1). Rupture of
and radiological (3D MRA or DSCA) follow-up was
an intracranial aneurysm is the most serious
done 3- 6 months after discharge. A "good" outcome was
complication that lead to aneurismal subarachnoid
defined as a mRS score of 02 at discharge; a "poor"
hemorrhage (ASAH), which accounts for 5% to 10% of
outcome was defined as a mRS score of 36 at discharge.
all strokes. ASAH causes more morbidity and mortality
than other stroke types(2). Most unruptured intracranial
Technique of intervention and peri-procedural
aneurysms (UIAs) are detected incidentally and
increasingly because of improved quality and higher
All procedures were done through femoral
frequency of neuroimaging for nonspecific symptoms,
puncture. Six vessels DSCA was done for all patients.
such as headache and vertigo(3). For these patients, two
Once saccular cerebral aneurysm was recognized,
management opportunities exist: preventive aneurysm
complete assessment of its angiographic features was
repair or observation with follow-up imaging.
done using three-dimension angiography or two-
dimension angiography in different projections. Our
PATIENTS AND METHODS
angiographic assessment aimed to identify the aneurysm
We recruited patients who were submitted to
site, size, presence of daughter aneurysm arising from the
main sac, and presence of branch arising from the
asymptomatic cerebral saccular aneurysms between
aneurysm. Bleeding aneurysm was identified via the
august 2017 and august 2018. All the patients had
distribution of the blood in the CT scan, the distribution
satisfied the following: ruptured aneurysm (presented by
of the vasospasm, and aneurysmal shape (lobulated
cerebral hematoma or subdural hematoma) or unruptured
aneurysm or presence of daughter aneurysm).
presented by mass effect or accidentally discovered (> 5
Systemic heparinization was done once the
mm) in anterior circulation, posterior circulation
endovascular therapy was decided. Then, selective
aneurysm and aneurysm in patient with past or family
catheterization of the target vessel (either the internal
history of subarachnoid hemorrhage.
carotid or the vertebral artery) was done using 6F guiding
catheter. Using coaxial system, the pathway to the
Written consents were obtained from all patients
aneurysm was navigated and then the aneurysmal sac
before the procedures. The study was approved by
was selectively catheterized using micro-catheter and
Aswan University, Faculty of Medicine Ethical
treating it with optimum endovascular method either
Committee. Ethical approval no: ASU 44-1-16
simple coiling, remodeling technique or flow diversion.
All patients experienced clinical assessment together
Successful procedural outcome was well-defined as the
with Modified Rankin Scale (mRS) and NIHSS score on
target aneurysm having complete angiographic occlusion
admission and 3-6 months follow up after procedure,
or residual neck according to Modified Ray- MondRoy
brain CT scan, cerebral CT angiography (CTA) or MR
Classification (MRRC) into; class I (complete
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5060-5067
Effect of Specific Nutritional Program on Patients with Chronic Renal Failure on
Hemodialysis on El-keman Village Luxor Governorate
Mona Mostafa Aboserea1, Hala Ahmed El-Maghawry1, Mostafa Saad Ahmed Mohamed*2
1Department of Public health & Community Medicine, Faculty of Medicine, Zagazig University
2Department of Family Medicine, Faculty of Medicine, Zagazig University
* Corresponding author: Mostafa Saad Ahmed Mohamed, Mobile: (+20)01143858555, E-mail: firstname.lastname@example.org
Background: Chronic renal failure is a universal community health problem. It is important to the patient to be on
a specific healthy diet program.
Objective: The present study was conducted to evaluate the effect of a specified nutritional program on the health
status of renal patients on hemodialysis.
Patients and methods: This was an interventional study that was conducted in the renal dialysis unit in El-keman
village, Luxor Governorate. It included 60 patients with chronic renal failure on hemodialysis. An educational
nutritional program was designed for the studied group. The patients were assessed pre- and post-intervention. The
collected data were analyzed by using SPSS program version 19 with considering statistical significance when P
value < 0.05.
Results: The mean age of the studied participants was 46 years with age ranging from 20-60 years old. Nearly
56.7% of the patients were males and 51.7% of them were of low social class. Regarding the Mini Nutritional
Assessment (MNA), there was highly statistically significant difference in MNA score before and after intervention
(25.07 versus 22.45 respectively) and there was marked significant reduction in malnutrition percentage after the
intervention. Creatinine, urea, AST, ALT and cholesterol significantly decreased after intervention compared to
the levels before it. There was highly statistically significant improvement in hemoglobin level after intervention.
Conclusion: It can be concluded that proper nutrition is important for patients on hemodialysis as good nutritional
status of the patients affects greatly their quality of life and health status.
Keywords: Specific Nutritional Program / Chronic Renal Failure / Hemodialysis.
Chronic kidney disease (CKD) or chronic
Dietary modifications depend on the level of renal
renal failure is a universal community health problem.
insufficiency as well as the present nutritional status.
It is defined as a decrease in the renal function from
High prevalence of malnutrition exists in patients with
mild damage to moderate and severe chronic kidney
renal failure. Several surveys have reported protein
calorie malnutrition in up to 40% of this subset of
It is very important to the patient to be on a
patient population. Malnutrition in renal failure is
specific healthy diet program. Diet is very important
multifactorial, but inadequate oral intake is considered
for patient care. It is important to have the right amount
the major contributing factor (5).
of protein, calories, fluids, vitamins and minerals each
So the present study was carried out to
day. The main objective of diet prescription in CKD is
improve the health statues of chronic renal failure
to slow chronic renal failure progression and to prevent
patients on hemodialysis by evaluation of the effect of
its metabolic complications such as hypophosphatemia
a specified nutritional program on the health status of
and hyperkalemia. Dietary restriction covers three
those patients through the following objectives: 1-To
principal components: potassium, phosphorus and
assess the role of program on changing of the
nutritional status of chronic renal failure patients on
Hemodialysis is a process where the patient's
hemodialysis after a Specified Nutritional Program. 2-
blood is passed through a dialysis venous catheter, via
To apply some biochemical analysis of chronic renal
a dialysis fluid solution in a hemodialysis machine, to
failure patients on hemodialysis before and after a
be filtered externally then returned to the patient (3).
Specified Nutritional Program.
Hemodialysis is a lifesaving treatment and
prolongs life expectancy, but is highly taxing on a
SUBJECTS AND METHODS
patient's overall fitness. Many patients undergoing
The current study was an interventional study
regular hemodialysis treatments suffer from protein
that was conducted in the renal dialysis unit in El-
energy wasting, which causes the patients to lose one
keman, village Luxor Governorate during the year
to three kilos of lean body mass per year. Losing body
2017-2018. It was selected as a place of study for the
mass is associated with reduction of the overall well-
following reasons: 1- There are 117 Health Unit in
being and activity of the patient. This is associated with
Luxor governorate, 11 of them are approved to be
worsening of the nutritional status and consequently
family medicine units and only one of them has
increased hospitalizations and mortality among those
Hemodialysis unit (El-keman), 2- The Hemodialysis
patients undergoing regular hemodialysis treatments
unit of El-keman have large database of history of
patients and medication used, 3- Higher number of
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5068-5073
Efficacy and Safety of Eltrombopag for the Treatment of Chronic Idiopathic
Thrombocytopenic Purpura in Children and Adolescents
Tamer Hasan Hassan, Marwa Zakaria Mohamed, Sameh Nabil Khalil Nada*
Department of Pediatrics, Faculty of Medicine, Zagazig University
*Corresponding author: Sameh Nabil Khalil Nada, Mobile: (+20) 01013111775, E-mail: Merna.email@example.com
Background: Chronic ITP is a very common disease in children. Most treatment options have focused on slowing
platelet destruction like corticosteroids and IVIG. These treatments are not always effective, or have only a transient
effect, and treatment related adverse events often restrict further use. Impaired platelet production has been evolved as
a potential disease mechanism for ITP. As a result, growth factor and growth factor analogue stimulation of
megakaryopoiesis has also been investigated.
Objective: is to evaluate the efficacy and safety of eltrombopag for the treatment of children and adolescents with
Subjects and methods: It was a prospective cohort study which was conducted on
forty patients (22 males and 18 females) with chronic ITP. They were treated with eltrombopag for a period ranged
from 6 months to 2 years after failure of first line of treatment (steroids, IVIG or both). Patients started eltrombopag
with mean initial platelet count 14.4 X 103/ uL and were evaluated after at least 6 months of therapy. The study was
approved by the academic and medical ethics committee of Zagazig University and a written informed consent was
obtained from all patients.
Results: Thirty patients (75%) responded to eltrombopag with a mean platelet count of 100.9 X103/ uL while 10
patients (25%) did not respond to the drug. Mean platelet count was significantly higher after eltrombopag therapy
(100.9 ± 65.97 versus 14.4 ± 8.87, P < 0.001). The longer the duration of treatment, the higher the mean platelet count
after treatment (r = 0.4, P < 0.001). Only 43.3% of responders received combined treatment with IVIG and steroids
versus 20% of non-responders (p = 0.006).
Conclusion: Eltrombopag is an effective, well tolerated and safe drug to restore platelet counts at levels high
enough to prevent bleeding events in children with chronic ITP.
Keywords: Eltrombobag, Chronic ITP, Treatment, Children, Efficacy, Safety.
Immune thrombocytopenic purpura (ITP) is an
to splenectomy including IVIg, IV anti-D, Rituximab,
autoimmune disease in which antiplatelet antibodies
accelerate the destruction of platelets. In addition,
platelet production can be impaired because the
Recent consensus statements and guidelines
antiplatelet antibodies can also damage megakaryocytes
recommend thrombopoietin-receptor (TPO-R) agonists
(1). Its prevalence being approximately 8 per 100,000
as second and third line of treatment (7).
Eltrombopag is the first oral, nonpeptide TPO-R
It is characterized by transient or persistent decrease
agonist approved for the treatment of chronic ITP in
of the platelet count to less than 100 × 109/liter. The
patients with insufficient response to at least one other
term `newly diagnosed ITP' is used to describe all cases
at diagnosis. Persistent ITP is defined as ITP lasting
It increases platelet production by binding to the
between 3 and 12 months from diagnosis while chronic
transmembrane domain of the TPO-R. It does not
ITP is defined as the presence of ITP for more than 12
compete with endogenous TPO in vitro and it induces
proliferation and differentiation of BM progenitor cells
Patients with ITP have an increased risk of bleeding
in the megakaryocytic lineage (9).
ranging from minor to life-threatening events and a
Several studies have shown that as a result of
diminished health related quality of life HRQoL (4).
eltrombopag treatment for up to 6 months, platelets
The treatment goal in chronic ITP is to increase and
increase to 50 × 109/liter in up to 80% of patients (10).
then maintain platelets in a safe range to prevent
bleeding; in addition, improving HRQoL is an
The aim of the study is to evaluate the efficacy and
important goal for the majority of patients. Since most
safety of eltrombopag for the treatment of children and
fatal bleeding occurs with platelet counts lower than 30
adolescents with chronic ITP.
× 109/liter (5). Current guidelines suggest that treatment
should only be considered in symptomatic patients with
SUBJECT AND METHODS
counts less than 30 × 109/liter (3, 6).
The prospective cohort study was conducted at
Guidelines issued by different groups recommend
hematology outpatient clinic of Zagazig University
corticosteroids as first-line therapy and splenectomy as
Hospitals during a period from January 2018 to August
one of several second-line therapies. Different options
exist for patients who do not undergo or do not respond
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (2), Page 5074-5080
The Value of Iron Metabolism Dynamic Changes in Response to Direct Anti-Viral
Agents among Egyptian Chronic HCV Patients
Assem El-Sherif 1, Fathy G. Abd El-Razek1, Mohammed S. Hussein1, Mohammed El Shorbagy 2, Ahmed
Eliwa1*, Mohamed El Kassas 3
1Internal Medicine Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
2Clinical Pathology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
3Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt.
*Corresponding author: Ahmed Eliwa, Mobile: (+20)01094044973, E-Mail: firstname.lastname@example.org.
Background: Like other viruses, hepatitis C virus (HCV) needs constituents of host cells to proliferate and iron is
considered as one of the most important constituents. So, chronic HCV often appears to be associated with disturbances
in iron homeostasis. Objective: The aim of this study was to evaluate the iron metabolism dynamic changes in response
to direct antiviral agents (DAAs) among Egyptian chronic HCV patients.
Patients and Methods: This prospective cohort study was conducted on 180 subjects, 150 of them had chronic HCV
whom received different DAAs regimens at one of the specialized HCV treatment facilities (Group A), as well as another
30 healthy volunteers (Group B), in the period from January 2017 to September 2018. The study was approved by the
medical ethics committee of Al-Azhar University Hospitals and a written informed consent was obtained from all
patients. Result: Before treatment, serum iron, ferritin, transferrin saturation and triglycerides were significantly higher
among HCV patients when compared to controls (p<0.001), while serum TIBC, transferrin, hepcidin, hepcidin/Ferritin
ration, cholesterol were significantly lower in HCV patients in comparison with controls (p<0.001). Following treatment
with DAAs, serum iron, ferritin, transferrin saturation and triglycerides were significantly decreased. On the other hand,
serum TIBC, transferrin, hepcidin, hepcidin/Ferritin ration and serum cholesterol were significantly increased. The
improvement of HbA1c was associated with an improvement in iron overload parameters. Conclusion: Rapid decrease
in serum ferritin during IFN/RBV free treatment may reflect a quick regression of inflammation after inhibition of viral
replication. The improvement in the iron parameters associated with improvement in triglyceride and glucose
metabolism may also suggest an improvement of metabolic functions of the liver following HCV eradication.
Keywords: HCV, Hepcidin, Iron, Lipid, DAAs.
accumulation in chronic HCV may provide new tools
Hepatitis C virus (HCV) is a blood-born pathogen
for the management of chronic HCV or for the
and it is a significant global health concern in many
prevention of its complications or both. Many
countries including Egypt (1). Following the acquisition
hypotheses have been advanced to explain the
of the virus, acute HCV infection can progress to
accumulation of iron in chronic HCV, including local
chronic infection, which is associated with several
release of iron from necrotic hepatocytes, incidental
morbidities, such as liver cirrhosis and cancer. HCV-
carriage of hemochromatosis mutations and HCV-
related morbidity strains healthcare systems worldwide,
induced perturbation of liver iron homeostasis either
with approximately 71 million people chronically
directly or indirectly through immunologic and host
infected globally. Direct-acting antivirals (DAAs), a
response. With the discovery of hepcidin, the liver has
highly efficacious HCV treatment, can clear HCV
emerged as the central organ in the regulation of
infection and may substantially reduce disease burden
systemic iron homeostasis (9). Serum hepcidin and
(2). As such, global targets have been set by the World
hepcidin/ferritin ratio were significantly lower in
Health Organization (WHO) to eliminate HCV
chronic HCV patients than negative persons (10).
infection by 2030 (3).
Following interferon therapy, both hepcidin and
Iron is an essential micronutrient for the human
hepcidin / ferritin ratio were elevated (10). Elevated
body. It has important roles in oxygen transport,
serum ferritin level is common in patients with chronic
oxidative phosphorylation and other enzymatic
HCV and predicts poor response to treatment with
functions (4). The liver produces the majority of proteins
pegylated interferon and ribavirin (11). Rapid decrease in
involved in iron metabolism including hepcidin and
serum ferritin during interferon/ ribavirin free treatment
transferrin. The main characteristic of transferrin is its
may reflect rapid regression of inflammation after
ability to reversibly bind iron which allows it to be a
inhibition of viral replication (11).
cellular iron donor or iron acceptor (5).
Chronic infection causes iron accumulation by
Chronic HCV patients frequently develop mild to
hepcidin suppression which has been proposed as major
moderate iron overload (6). Many experimental and
mechanism responsible for causing glucose intolerance
clinical studies suggest that, excessive iron in chronic
by influencing insulin signaling. The accumulated iron
HCV is a cofactor promoting the progression of liver
causes increased glucose production by hepatocytes,
damage and increasing the risk of fibrosis, cirrhosis and
increased fatty acid oxidation and decreased glucose
HCC (6,7,8). Elucidating the mechanism (s) of iron
oxidation in skeletal muscles and adipocytes and altered