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The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5293-5297
Tolerance and Effectiveness of Oral Direct Acting Antivirals in Treatment of
HCV Egyptian patients with Decompensated Liver Cirrhosis
Magdy Aldahshan1, Samy Zaki2, Ramadan Eldamarawy1
1Internal Medicine Department, 2Tropical Medicine Department, Faculty of Medicine, Al-Azhar University, Cairo Egypt
ABSTRACT
Background: Medical treatment of decompensated cirrhosis due to hepatitis C virus (HCV) remains a clinical
challenge even in the era of direct-acting antiviral drugs (DAAs). We evaluated the efficacy and safety of DAAs in
the management of HCV-related decompensated cirrhosis.
Objective: The current study aimed to evaluate the efficacy and safety of DAAs in managing HCV patients with
decompensated cirrhosis and the impact of achieving sustained virological response on improving the quality of life,
short term survival and if viral eradication would step down CTP score.
Patients and Methods: The study included a treatment group I (n=25) composed of HCV patients with
decompensated cirrhosis Child B and group II (n=22) with decompensated cirrhosis Child C. both groups received
DAAs (sofosbuvir 400 mg, daclatasvir 60 mg) plus ribavirin as tolerated for 3 months and follow-up was done for 6
months.
Results: In both treated groups, there were improvements in platelet count, albumin, Child-Torcout-Pugh (CTP)
(p=0.001) and a significant reduction in the frequency of hepatic encephalopathy (HE). Also, there was improvement
in quality of life of both treated groups.
Conclusion: Treatment of HCV with decompensated cirrhosis with DAAS had improved CTP score, quality of life
and survival.
Keywords: Direct Acting Antivirals, HCV, Decompensated Liver Cirrhosis
INTRODUCTION
PATIENTS AND METHODS
The treatment varieties for patients with HCV-
Study design and patients selection
related decompensated cirrhosis remain a challenge.
The study was conducted from the first of
With the introduction of oral direct-acting antiviral
November 2017 till March 2019 in The Internal
(DAAs), SVR had been achieved in more than 90% with
Medicine Department of Al-Azhar University
reduced risk of decompensation that needs liver
Hospitals (a tertiary referral center) in Egypt.
transplantation. Reduced rates of SVR in decompensated
50 patients with decompensated cirrhosis were
cirrhosis were explained by the extensive porto-systemic
selected to receive DAAs. Patients were included if
collaterals and advanced fibrotic parenchyma which
HCV-related decompensated cirrhosis was proved by the
provides dormant foci for viral reactivation (1). Achieving
positivity of HCV RNA, elevated transaminases, ascites
SVR is expected to improve portal hemodynamics and
or frequent attacks of hepatic encephalopathy and CTP
hepatic venous pressure gradient (2).
score >7 (5).
DAAs may induce rapid loss of anti-HCV
Patients were excluded if they had compensated
immune responses with re-differentiation of memory T
cirrhosis; exposure to previous antiviral therapy;
cell, T-lymphocyte deactivation, and normalization of
hepatocellular carcinoma; grade III, IV hepatic
NK-cell function leading to loss of immunological
encephalopathy; other causes of liver diseases, previous
barrier against carcinogenesis (3).
liver transplantation; patients with cardiomyopathy (left
Viral clearance is expected to be associated with
ventricular ejection fraction less than 50%).
reduced morbidity and mortality rates (4); however, the
Then treated patients were divided into two
important question that should be asked is SVR
groups; group I (n=25) Child B classification and group
beneficial in reversing the functional hepatic impairment
II (n=22) Child C classification. Three patients died from
although it appears that they reached a point of no return.
sepsis and bleeding in group II during treatment so, were
excluded from study.
AIM OF THE WORK
The study patients were collected from the first of
The current study aimed to evaluate the efficacy
November 2017 till March 2019 and then the period
and safety of DAAs in managing HCV patients with
follow-up was extended to three months after treatment.
decompensated cirrhosis and the impact of achieving
A complete history taking and meticulous clinical
sustained virological response on improving the quality
examination were done for all of the patients to document
of life, short term survival and if viral eradication would
features of liver cirrhosis and decompensation.
step down CTP score.
5293
Received:26/07/2019
Accepted:26/08/2019
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The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5298-5306
Diagnosis of Placenta Accreta by Uterine Artery Doppler Velicometry in
Patients with Placenta Previa
Ibrahim Mahrous Kandil1, Mohamed Ali Mohamed1, Ahmed Mohamed Taha2
1 Obstetrics & Gynecology Department, Faculty of Medicine, Al-Azhar University, Egypt
2 Obstetrics &Gynecology Department, Beni-Suef General Hospital, Ministry of Health, Egypt
ABSTRACT
Background: Placenta accreta occurs in the complete or partial absence of the decidua basalis. Women with previous
cesarean delivery or placenta previa are known to be at greater risk of placenta accreta.
Objectives: to evaluate ultrasound accuracy in diagnosing placenta accreta and its variants and to detect the potential
value of uterine artery Doppler in diagnosing placenta accreta and to assess the impact of antenatal diagnosis in
Egyptian population.
Patients and Methods: This prospective study was conducted on (100) pregnant women diagnosed as placenta previa
by ultrasonography and were candidates for either emergency or elective repeated CS or hysterectomy (if the diagnosis
of placenta accreta is confirmed). All these patients were randomly selected from the Obstetrics Clinic at Beni-Suef
General Hospital during their 3rd trimester. The study was approved by the medical ethics committee of Al-Azhar
University academic and ethical committee and a written informed consent was obtained from all patients.
Results: The results obtained from this study indicated no statistically significant differences regarding the mean
values of uterine artery Doppler PI and RI between cases of placenta accreta and non accreta (p value =.078 & 0.58
respectively) in correlation with histopathological assessment. Our results showed no statistically significant
correlation regarding mean values of uterine artery Doppler PI and RI between cases of placenta accreta and placenta
non accreta (p values = 0.341, 0.953 respectively) in correlation with intra-operative assessment.
Conclusion: Several ultrasound criteria can be used in diagnosis of placenta accreta, as this study showed their high
accuracy. They include loss of retroplacental clear zone, presence of abnormal placental lacunae, myometrial thinning
and utero-vesical hypervascularity. On the other hand, both loss of retroplacental clear zone, abnormal placental
lacunae can predict which patient will mostly have CS hysterectomy.
Keywords: Uterine Artery Doppler, Placenta Accreta.
INTRODUCTION
that transvaginal ultrasonography is superior to
Placental attachment disorder (PAD) or Morbidly
transabdominal sonography in the diagnosis of placenta
Adherent Placenta (MAP) or the most recent synonym
previa and invariably correct in ruling it out (6).
Abnormally Invasive Placenta (AIP) encompasses a
Trans-abdominal ultrasound and trans-vaginal
spectrum of conditions characterized by abnormal
ultrasound are complementary for diagnosis. Also, trans-
adherence of the placenta to the implantation site. It can
vaginal ultrasound is safe in cases of placenta previa and
be classified according to their degree of trophoblastic
allows complete examination of the lower uterine
invasion through the myometrium and the uterine serosa
segment (7).
into placenta accreta, increta and percreta (1).
The `European Working Group on Abnormally
Morbidly adherent placenta (MAP) is generally
Invasive Placenta' (EW-AIP) is an international non-
associated with excess blood loss, bladder injuries and
profit group consisting of 29 obstetricians,
hysterectomies and its incidence has increased
gynecologists, pathologists and anesthesiologists and
significantly over the last 50 years (2).
basic science researchers from 11 European countries.
Maternal mortality from placenta accreta is
The aim of the group is to advance diagnosis and
estimated to be 6-7 % regardless of the type of the
treatment and to promote research and knowledge on
operation (3).
AIP in order to improve comparability of future studies,
Despite the modern advances in imaging
to increase diagnostic capabilities and to facilitate
techniques, no single diagnostic method affords
international collaboration; the EW-AIP here proposes
complete assurance for the presence or absence of
standardized definitions of the AIP imaging descriptors
placenta accreta (4).
they are established and published in the "American
Antenatal diagnosis of MAP and multidisciplinary
Journal of Obstetrics and Gynecology" in 2016(8).
team approach has the potential of reducing maternal and
fetal intrapartum complications. This includes less
PATIENTS AND METHODS
maternal blood loss, with fewer transfusion
A total of randomly chosen100 women with
requirements, reduction of hysterectomy rate as well as
placenta previa were enrolled prospectively at Obstetrics
intra operative urologic and gastrointestinal injuries and
Clinic at Beni-suef General Hospital during their follow
maternal deaths (5).
up visits in the 2nd and 3rd trimesters and underwent
The safe use of transvaginal ultrasound in cases of
ultrasound examination by expert ultra-sonographer.
placenta previa has been confirmed and it has been found
5298
Received:26/07/2019
Accepted:26/08/2019
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The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5307-5312
The Impact of Repeated Cesarean Sections on Perioperative Maternal Morbidity
Ibrahim Mahrous Kandil1, Abdelsattar Mohamad Farhan1, Montaser Mostafa Shaker2,
1 Obstetrics & Gynecology Department, Faculty of Medicine, Al-Azhar University, Egypt.
2Obstetrics & Gynecology Department, Beni-Suef General Hospital, Ministry of Health, Egypt.
ABSTRACT
Background: Rates of cesarean delivery vary internationally, but generally, it has shown a worldwide increase.
Repeated cesarean deliveries was found to be associated with increased maternal morbidity, including placenta
previa, placenta accreta, hysterectomy, adhesions, bladder injury, postoperative hemoglobin deficit and need for
blood transfusion.
Objective: In our study, we evaluated the outcome of emergency cesarean deliveries conducted at Bani Suef General
Hospital and the impact of repeated cesarean deliveries on that outcome.
Patients and methods: We recruited 300 patients admitted at the Casualty Department. The patients were divided
equally into 3 groups (100 patients in each group) as follows: group 1: Patients with previous one cesarean delivery,
group 2: Patients with previous two cesarean delivery and group 3: Patients with previous three or more cesarean
deliveries.
Results: The operative duration was statistically significantly longer in patients with previous three or more cesarean
deliveries (group 3) than patients with previous one cesarean delivery (group 1) or previous two cesarean delivery
(group 2) [74.4, 44.4, 56.4 min respectively, p < 0.001]. The estimated blood loss was found to be higher in group
three than one and two attributed to higher incidence of placenta previa and placenta accrete in group three. The
incidence of adhesions (omental and bladder) was significantly higher in group three, but the incidence of bowel
adhesion was the same in group three and two (which was statistically not significant) .
Conclusion: The rate of complications was higher in group three (bladder and bowel injuries, scar dehiscence,
placenta previa, placenta accreta, hysterectomy and post-operative ICU admission).
Keywords: Repeated, Cesarean delivery, Morbidity.
INTRODUCTION
Repeated cesarean deliveries were found to be
Cesarean delivery is defined as the delivery of a
associated with increased maternal morbidity, including
fetus through surgical incisions made through the
placenta previa, placenta accreta, hysterectomy,
abdominal wall (laparotomy) and the uterine wall
adhesions, bladder injury, postoperative hemoglobin
(hysterotomy). It represents an alternative route for
deficit and need for blood transfusion. One major
delivery when vaginal delivery might pose a risk to the
complication of repeated cesarean delivery is uterine
mother or the fetus (1). Rates of cesarean delivery vary
scar rupture during pregnancy with subsequent adverse
internationally, but generally, it has shown a worldwide
fetal and maternal consequences (5).
increase (2).
In view of the complications associated with
There are several factors contributing to the
repeated cesarean delivery, in developed countries,
increased rates of cesarean delivery including:
women are usually offered sterilization at the 3rd
increasing maternal age, increasing rates of induction of
cesarean delivery. However, this is not applicable in
labour, a decline in vaginal birth after cesarean delivery
eastern cultures where large families are usually desired
due to risk of uterine rupture, decline in vaginal breech
and any attempt to limit cesarean deliveries to 2-3 is
delivery, decreased use of operative vaginal delivery
likely to be rejected resulting in facing high order
and fear from medical-legal concerns (3).
cesarean deliveries (6).
There are various indications for cesarean delivery
which may be performed for maternal indications or
AIM OF THE WORK
fetal indications or both. However, the leading
In our study, we evaluated the outcome of
indications are previous cesarean delivery, breech
emergency cesarean deliveries conducted at Bani Suef
presentation, dystocia, and fetal distress. These
General Hospital and the impact of repeated cesarean
indications are responsible for 85% of all cesarean
deliveries on that outcome.
deliveries (4). Despite the advancement in anesthesia
and surgical techniques making cesarean delivery safer
PATIENTS AND METHODS
than it has ever been, it can still be associated with short
This was a prospective cross sectional study
term and long term complications. Compared with a
conducted at the Casualty Unit of Obstetrics and
vaginal delivery, maternal mortality and especially
Gynecology Department, Bani Suef General Hospital in
morbidity is increased with cesarean delivery to
the period from October, 2018 to March, 2019. A total
approximately twice the rate after a vaginal delivery (3).
number of 300 patients were divided equally into 3
groups (100 patients in each group) as follow:
Group 1: Patients with previous one cesarean delivery.
5307
Received:27/07/2019
Accepted:27/08/2019
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The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5313-5321
Effect of Conditioned and Co Culture Media from The Umbilical Cord
Mesenchymal Stem Cells on Heptoma Cell Line (Huh7)
Marwa. M. Hussein*, Swelim. H. H, Hanaa A. Amer, Fatma A. Abu Zahra, Mourad M. Hadier
Department of Zoology, Faculty of Science- Ain Shams University
*Corresponding author: Marwa. M. Hussein, Mobile: (+20)01210103878, E-mail: marwasoada@yahoo.com
ABSTRACT
Background: this study aimed to detect a new way for cancer control. Hepatoma cell line HuH7 was the model for
cancer and was treated with two types of the media. The first was the conditioned media (in which mesenchymal
stem cells were cultured), the second media was co-culture media in which mesenchymal stem cells and HuH7 cells
were cultured. Objective: this work was designed to evaluate the efficiency of using the media in which
mesenchymal stem cells alone (Conditioned media) or co-culture with HuH7 (Co-cultured media) were housed on
controlling the viability, growth and mortality of HuH7, by applying different techniques. Result: at specified times
(0, 48,72,96 hours) after incubation in each medium cells were tested. The morphological study showed that in both
conditioned and co-culture media, HuH7 cells were suffered from damage and this was directly proportional with
increase of time. (3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide) tetrazolium reduction assay
(MTT) showed that there was a significant difference between the four groups in conditioned and co-culture media.
In the biochemical study for conditioned and co-culture media, there was a significant difference between the four
groups in FP and GOT, but there was a non-significant difference between the four groups in albumin, GPT, ALP
and GT. Conclusion: the conditioned and co-culture media from mesenchymal stem cells alone or co-culture
with HuH7 proved to be efficient in control of cancer cell survival.
Key words: hepatoma cell line (HuH7), Umbilical cord Mesenchymal Stem Cell (UMSC), proliferating cell nuclear
antigen (PCNA) and Vascular Endothelial Growth Factor (VEGF).
INTRODUCTION
1. Mesenchymal Stem Cells (MSCs)
Hepatocellular carcinoma (HCC) is the most
Mesenchymal stem cells from umbilical cords
common primary malignancy of the liver. It is the 5th
(n = 11; gestational ages, 39,40 weeks) were collected,
most common cancer in men, worldwide, and 7th
obtained from consenting patients with a surgeon, and
among women, with over half a million new cases
processed within 2-3 hours after caesarean births
diagnosed annually worldwide. It is the second
attending The Women's Hospitals and Obstetrics of
leading cause of cancer related mortality in the world
Ain Shams University. These samples were collected
(1). Egypt has the highest prevalence of HCV in the
from the 1st of October 2013 to the 1st of March 2016.
world (predominantly genotype 4), Up to 60%, have
2. Isolation of MSCs from Umbilical Cord (UC)
been reported in older individuals, in rural areas such
UCs were washed with Dulbecco's PBS for
as the Nile Delta and in the lower social classes (2). In
several times, cut to small pieces and filled with 0.1%
Egypt, HCC was reported to account for about 4.7%
collagenase type for cell digestion (Sigma-Aldrich,
of chronic liver disease (CLD) patients. HCC has been
St. Louis) in phosphate buffer saline (PBS) and
recorded to be the commonest cancer in the Egyptians
shacked in water bath at 37°C for 60 min. Each UC
(23.8%), but a higher level was reported in males
was washed with proliferation medium and the
(33.6%) than females (13.5%). Different liver
detached cells were harvested after gentle massage of
diseases can be treated by using stem cells like liver
the UC. Cells were centrifuged at 300 g for 10 min,
cirrhosis, genetic liver diseases and liver necrosis (4).
re-suspended in proliferation medium and seeded in
In response to liver injury or loss of liver mass,
25-cm2 flasks at a density of 5×105 cells per ml. After
proliferation of mature liver cells is the first-line
72 hrs of incubation, non-adherent cells were removed
defense to restore liver homeostasis (5). Mesenchymal
and culture medium was replaced every 3 days. On
stem cells (MSCs) play several simultaneous roles to
day 14, the adherent colonies of cells were removed
limit inflammation through releasing cytokines,
by using trypsin EDTA, and counted. Cells were
aiding healing by expression of growth factors (5).
identified as being MSCs by their morphology,
adherence, and their power to differentiate into
METHODS
osteocytes and neurocytes.
Ethical approval:
3. Identification of UC-MSC by flow cytometer
The study was approved by the Ethical approval
The UC-MSC were digested and stained with anti-
was granted by Ethics and Research Committee
CD44- fluorescein isothiocyanate (FITC), anti-CD34
of the Medicine Ain Shams Research Institute
FITC, anti-CD105and FITC, anti-CD19FITC,
(MASRI), Faculty of Medicine, Ain Shams
(Becton Dickinson, Franklin Lakes, NJ, USA) or the
University.
isotype monoclonal antibody (mAb). The cells were
collected by using FACS Calibur (Becton Dickinson,
5313
Received:27/07/2019
Accepted:27/08/2019
c:\work\Jor\vol774_5
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5322-5337
A Study on Intestinal Parasitic Infections Among Immunocompetent Egyptian
Children Attending Al-Hussein University Hospital, Cairo
Morsy R. Geneidy
Medical Parasitology Department, Faculty of Medicine (Boys), Al-Azhar University, Cairo, Egypt
ABSTRACT
Background: Parasitic infections are still a dangerous public health problem in the world, especially in developing
countries including Egypt representing a major cause of morbidity and mortality mainly among children.
Methods: This cross-sectional study included 400 randomly chosen immunocompetent children of both sexes. Their
ages ranged from 6 months up to 12 years old. All children were subjected to a structured questionnaire sheet, stool
examination using: Direct smear and concentration techniques (formol ether sedimentation and Modified ZiehlNeelsen
stain). The study was approved by the medical ethics committee of Al-Azhar University Hospitals and a written informed
consent was obtained from all children's parents or gardeners.
Results: Among the examined individuals, parasites were detected in only 139 ones (34.75%) mainly in the first two
years of age and more common among males 35% than females 34%. By species, the parasitic prevalence rate was,
G.lamblia 49 (12.25%), E.vermicularis 35 (8.75%), E. coli 22 (5.5%), E. histolytica/dispar 7 (1.75%), H. nana 4 (1.0%)
and mixed infections 22 (5.5%). Positive results are more common among rural children 38% and low social classes.
Low level of parent's education, low family income, high crowding index, and bad hand hygiene were considered high-
risk factors of parasitic infections. Conclusion: Rural residency, bad hygiene, and low social class, as well as
crowdedness, were the most significant risk factors associated with parasitic infections among children
Keywords: Immunocompetent children, Intestinal parasites, Egypt.
INTRODUCTION
immunocompetent children of both sexes presented with
Intestinal parasitic infections are considered a serious
diarrhea or other gastrointestinal manifestations. Their
public health problem all over the world, especially in
ages ranged from 6 months up to 12 years old and they
developing countries including Egypt. They considered
attended the outpatient Clinics of Pediatrics, Al-Hussein
as a major cause of morbidity and mortality in childhood
University Hospital, Cairo, Egypt.
because they cause malnutrition, iron deficiency anemia,
Inclusion criteria
growth retardation as well as other physical and mental
Immunocompetent infants and children aged 6 months up
problems (1).
to 12 years old of both sexes.
They are considered as one of the most common
Exclusion criteria
infections worldwide where 3.5 billion peoples are
Children with diarrhea associated with other illnesses like
infected with some kinds of intestinal parasites (2).
hepatitis, respiratory infection, lactose intolerance and
School children represent a high-risk group for
surgical
conditions
like
appendicitis
and
parasitic infections due to the facility of direct
immunocompromised children.
interpersonal contact (3). The prevalence of infections
Ethical approval:
depends on the socioeconomic level of the society, poor
The study was approved by the medical ethics
sanitation and environmental conditions, inadequate
committee of Al-Azhar University Hospitals and a
personal hygiene and absence of clean drinking water
written informed consent is obtained from all children's
supplies as well as climatic factors (4). Also, the lack of
parents or gardeners.
awareness about the mode of infection and transmission
All the studied patients were subjected to the following:
of parasitic infections increases the risk of infection. So
1- Structured questionnaire.
that, a better understanding of the previous factors, as well
2- General and abdominal clinical examination.
as how social, cultural and behavioral awareness affect
3- Examination of a perianal specimen for pinworm
the epidemiology and control of intestinal parasitic
eggs or Taenia egg or gravid segments.
infections may help to design a good and effective control
4- Stool examination: -
guideline of these infections (5).
Fresh fecal specimens were collected from all
The aim of this work: was to determine the intestinal
patients in clean labeled, dry disposable plastic cups.
parasitic profile among immunocompetent children
They were examined as soon as they received by the
presented with diarrhea or other gastrointestinal
naked eye for consistency, presence of adult worms,
manifestations who attended Al-Hussein University
blood or mucus. Liquid or watery stool specimens
Hospital.
were examined first followed by semi-formed stool
specimens. Stool samples were examined by:
SUBJECTS AND METHODS
A- Direct wet mount method: (6).
A cross-sectional study was carried out from October
B- Formol ether concentration (6).
2017 to December 2018 and included 400
5322
Received:28/07/2019
Accepted:28/08/2019
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The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5338-5344
Assessment of Heart Rate Variability in Heart Failure Patients
Abdelaziz Rizk Hassan, Mohamed Sami Abdelsamea, Hany Khamees Rashed Elhelw
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Hany Khamees Rashed, Mobile: (+20)1099067073, email: hanyelhelw27@gmail.com
ABSTRACT
Background: Heart rate variability (HRV) depicts the functional status of the autonomic nervous system and its
effects on sinus node. Objective: The aim of the study was to analyze heart rate variability (HRV) parameters in
patients with heart failure with reduced ejection fraction (HFrEF) and to assess correlation between HRV
parameters and functional capacity of the study group (assessed by NYHA class and 6 MWT).
Subjects and Methods: This study included a total of 80 patients with chronic heart failure with reduced ejection
fraction, attending at the Outpatient Clinic, Department of Cardiology, Al-Azhar (Al-Hussein) University Hospital.
This study was conducted between December 2018 to October 2019. Patients were divided into four groups
according to New York Heart association functional classification (NYHA). All patients were subjected to cardiac
tests mainly ECGs, Echocardiography and 24 hours Holter monitoring.
Results: High statistically significant difference was found between the four groups regarding HRV parameters
(SDNN rMSSD, pNN50 and LF/HF ratio) and 6MWT duration. There was positive correlation between premature
ventricular contractions (PVCs) burden and ANS indices (LF/HF).
Conclusion: Disturbed cardiac autonomic function was found in patients with heart failure with reduced ejection
fraction (HFrEF). HRV parameters have strong positive correlation with NYHA functional class and with 6MWT
distance in patients with HF. Impaired autonomic function was associated with higher PVCs burden even in
patients with same NYHA class.
Keywords: Heart Rate Variability, Heart Failure Patients
INTRODUCTION
decrease in activity of the parasympathetic nervous
Heart failure (HF) is a common, progressive,
system (8).
complex clinical syndrome with high morbidity and
Indeed, when the heart dilates, vagal and
mortality (1). It is a phenomenon involving pump
sympathetic afferent cardiac fibers increase their
failure with subsequent inability to meet the body
firing, and this afferent sympathetic excitation leads
needs and may involve either right ventricle (RV) or
to the tonic and reflex inhibition of cardiac vagal
left ventricle (LV) or more often both, which causes
efferent activity. This phenomenon can be expected
an altered pathological condition (2).
to occur whenever the heart dilates in heart failure
Decreased exercise capacity is the main symptom
probably due to the systolic dysfunction. In cases of
in HF patients; therefore, the physician should
diastolic dysfunction in which the heart does not
provide an estimation of the functional class (New
dilate, the mechanisms in which the vagal activity is
York heart association NYHA) of the patient based
reduced have not been fully determined (9).
on an assessment of the patient's daily activity and the
There are several compensatory mechanisms that
limitations imposed by the patient's symptoms of HF
occur as the failing heart attempts to maintain
(3). Subset of HF patients has symptoms out of
adequate function. These include increasing cardiac
proportion to the resting hemodynamics and left
output via the FrankStarling mechanism, increasing
ventricular ejection fraction (LVEF) (4).
ventricular volume and wall thickness through
LVEF is well recognized in the adverse clinical
ventricular remodeling, and maintaining tissue
outcomes of patients with acute heart failure,
perfusion with augmented mean arterial pressure
however, it loses statistical power when applied to
through activation of neurohormonal systems.
patients with chronic and advanced heart failure. In
Although initially beneficial in the early stages of
this setting, RV function determines exercise capacity
heart failure, all of these compensatory mechanisms
and survival (5). Heart failure with reduced ejection
eventually lead to a vicious cycle of worsening heart
fraction (HFrEF) is now the preferred term for HF
failure (10).
with LVEF<40% (6).
Analysis of heart rate variability on the basis of
Chronic heart failure refers to patients with
routine 24-hour Holter recordings has been shown to
diagnosed heart failure for a period of time (arbitrarily
provide a sensitive measurement of cardiac control by
defined as a minimum of 3 months) and follows that
the autonomous nervous system (ANS) (11).
these patients have received some heart failure
HRV is a non-invasive measure reflecting the
treatment (7).
variation over time of the period between consecutive
The incidence and progression of heart failure are
heartbeats (RR intervals). In fact, heart rate (HR),
associated with an increasing severity of autonomic
which continuously fluctuates over time, is under the
derangements, specifically a compensatory increase
influence of control mechanisms aimed at
in activity of the sympathetic nervous system and a
maintaining a dynamic stability called homoeostasis
5338
Received:27/07/2019
Accepted:27/08/2019
c:\work\Jor\vol774_7
ejhm.journals.ekb.eg
Retracted article
1
c:\work\Jor\vol774_8
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5350-5354
Endoscopic Treatment of Sessile Colorectal Polyp
Fawzy. M. Mustafa
Department of General Surgery, Faculty of Medicine - Al-Azhar University
Cairo Egypt
Correspondence to: Fawzy. M. Mustafa; Telephone number: (+20)01033319730, 00966548951348;
Email: fawzymetwallymustafa@gmail.com
ABSTRACT
Background: Endoscopic resection of sessile colonic polyps' presents a number of unique challenges. Large sessile
polyps are associated with the greatest risk of postpolypectomy bleeding, perforation and polyp recurrence, with massive
submucosal scarring making subsequent attempts at endoscopic resection problematic.
Objective: This study aimed to evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal
benign-appearing polyps.
Patients and methods: This prospective study was carried out on forty (40) consecutive patients at General Surgery
Department, Al-Azhar University Hospitals, Cairo, Egypt between January 2014 and August 2016. All patients were
subjected to clinical evaluation including history taking, general examination, abdominal and per-rectal examinations.
Results: Of the 40 cases with removed polyps, 10 cases were excised by cold biopsy forceps, 4 cases were excised by
cold snare, 12 cases were excised by hot snare and 14 cases were excised by EMR with mucosal lifting according to the
size of the polyp. Complications included nonspecific abdominal pain in 5 patients (12.5%) that were treated
conservatively and bleeding in 3 (7.5%), two cases during procedure while 1 case presented 7th day post procedure. One
case transferred into open surgery due to perforation. All cases were treated endoscopically. Post-polypectomy
surveillance permitted the detection and treatment of recurrent polyps in 3 cases that treated endoscopically with piece
meal excision.
Conclusion: This study showed that polypectomy of benign sessile colorectal polyps performed by an expert endoscopist
is feasible, effective, and safe, even on an outpatient basis.
Keywords: Endoscope Polypectomy sessile polyps EMR (Endoscopic Mucosal Resection).
INTRODUCTION
AIM OF THE WORK
Colon polyps are protrusions occurring in the
This study aimed to evaluate feasibility, safety and
colon lumen most commonly sporadic or with
the effectiveness of endoscopic treatment of colorectal
syndromes. Incidence of colorectal polyps increases with
benign-appearing polyps.
age. A prevalence of 30% in the people over the age of
50. The majority of benign neoplasms detected at
PATIENTS AND METHODS
screening colonoscopy is small and removed easily with
This prospective study was carried out on forty
widely employed biopsy and snare polypectomy
(40) consecutive patients at General Surgery Department,
techniques )1). Paris classification divides polyps into
Al-Azhar University Hospitals, Cairo, Egypt between
different types based on morphology. It is considered as
January 2014 and August 2016. All patients were
reference point for polyp definition as well as endoscopic
subjected to clinical evaluation including history taking,
resection (2).
general examination, abdominal and per-rectal
During colonoscopy, several factors determine
examinations.
whether a polyp is best suited for endoscopic removal vs
surgical removal. Size is important when considering
Laboratory investigations:
endoscopic resection. However, large size alone is no
Complete blood count, prothrombin time & activity,
longer a contraindication for endoscopic removal (3).
INR, liver and kidney functions and fasting and
A large, sessile, nonpedunculated lesion is
postprandial blood glucose level.
associated with higher rates of high-grade dysplasia and
carcinoma and has challenges for endoscopic eradication.
Imaging evaluation included: Trans abdominal
Endoscopic mucosal resection (EMR) is used as
ultrasonography, barium enema and computerized
minimally invasive curative resection of benign and
tomography (if indicated).
early-stage (T1a) malignant lesions throughout the
gastrointestinal tract (4).
5350
Received:30/07/2019
Accepted:30/08/2019
INTRODUCTION
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5355-5366
Optical Coherence Tomography Assessment of Macular and
Choroidal Thickness in Patients with Proliferative Diabetic Retinopathy in
Relation to Hemoglobin A1C
Abdullah Hussain Hamed, Hassan Metwally Bayoumi, Abdulmonem Mohammad Abdulmonem*
Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Abdulmonem Mohammad Abdulmonem; Mobile: (+20) 01060178928;
Email: drabdelmonem2020@gmail.com
ABSTRACT
Background: Diabetic retinopathy affects up to 80 % of all patients who have had diabetes for 10 years or
more. Despite these intimidating statistics, research indicates that at least 90% of these new cases could be
reduced if there were proper treatment and monitoring of the eyes blindness.
Objective: To evaluate the relation of macular and choroidal thickness to HbA1c in patients with
proliferative diabetic retinopathy.
Patients and methods: This study included 40 eyes of 33 patients with a diagnosis of proliferative diabetic
retinopathy (PDR). Patients were recruited from Retinal Clinic in Imbaba Eye Hospital and they were asked
to participate in this study. This study was designed as an observational, cross-sectional and non-coherent
study in the period from 5/2018 to 4/2019.
Results: the results showed that the macular thickness was higher and the choroidal thickness was lower in
uncontrolled HbA1c group than controlled HbA1c group. We assumed that increase level of glycosylated
hemoglobin lead to increase macular thickness and decrease choroidal thickness and increase incidence of
diabetic macular edema and choroidal atrophy.
Conclusion: Optical coherence tomography is a sensitive and noninvasive diagnostic tool in the evaluation
of macular and choroidal thickness. Hypertension is also an important risk factor in the development of
diabetic retinopathy, diabetic macular edema and diabetic choroidopathy.
Keywords: Optical Coherence Tomography, Macular and Choroidal Thickness, Proliferative Diabetic
Retinopathy, Hemoglobin A1C.
INTRODUCTION
Diabetic retinopathy (DR) is the most
Proliferative diabetic retinopathy develops
common cause of blindness in Europe, affecting
following the occlusion of retinal capillaries
1.9% of patients with DM. Furthermore, 2.64% of
leading to retinal ischemia, which promotes the
diabetic patients have visual sight-threatening
development of neovascularization, a process by
diabetic retinopathy (STDR) (1).
which new blood vessels proliferate on the surface
The prevalence of diabetic retinopathy (DR)
of the retina. However, these vessels are fragile
remains high at 40% of diabetic patients.
and bleed easily. The resulting accumulation of
Globally, there are approximately 93 million
blood in the vitreous cavity from these
people with DR, 70 million with proliferative
hemorrhaging vessels seriously impairs vision.
diabetic retinopathy (PDR), 21 million with
This may be permanent due to further
diabetic macular edema (DME) and 28 million
complications such as traction retinal detachment
with a sight- threatening retinopathy as
leading to registered blindness. It has been
proliferative diabetic retinopathy (PDR) (2).
estimated that without treatment for PDR, 50% of
Diabetic retinopathy affects up to 80 % of all
all patients will become blind within 5 years
patients who have had diabetes for 10 years or
following diagnosis (7).
more (3).
Optical Coherence Tomography (OCT) is a
Despite these intimidating statistics, research
high-resolution, cross-sectional imaging technique
indicates that at least 90% of these new cases
that allows detailed assessment of retinal
could be reduced if there were proper and vigilant
thickness and morphologic evaluation of the
treatment and monitoring of the eyes (4). The
neurosensory retinal layers. OCT imaging has
longer a person has diabetes, the higher is his or
rapidly been integrated into diagnosis and
her chances of developing diabetic retinopathy (5).
management of DME in routine clinical practice
Diabetic retinopathy is a progressive disease
and clinical trials (8).
predominantly affects the integrity of the
One major advantage of OCT is that it allows
microscopic vessels found in the retina. DR can be
measurement of retinal thickness from the
broadly divided into two clinical stages: non
tomograms by means of computer image-
proliferative and proliferative diabetic retinopathy
processing techniques, OCT is more sensitive to
(PDR)(6).
small changes in retinal thickness than slit-lamp
biomicroscopy (9).
5355
Received:29/07/2019
Accepted:29/08/2019
c:\work\Jor\vol774_10
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5367-5372
Evaluation of QT Dispersion and Tp-e interval in Children with Hypothyroidism
Mohamed Hesham Hassan Ezzat1, Mohamed Samy Abdel-Samae1, Mohamed Basiony Taha*2
1Department of Cardiology, Faculty of Medicine. Al-Azhar University, 2Department of Cardiology, Matrouh
Specialized Cardiothoracic and Interventional Catheterization Center, Egypt.
*Corresponding author: Mohamed Basiony Taha, Mobile: 002-01093149693, Email: dr.mohamedbasiony@gmail.com
ABSTRACT
Background: Several studies in adults, showed increased dispersion of QT and corrected QT (QTc), peak-to-end interval
of the T wave (Tp-e), Tp-e/QT ratio and Tp-e/QTc ratio in hypothyroidism. However, there were few studies in children
with hypothyroidism. Objective: This study aimed to evaluate the relationship between hypothyroidism in children and
increased QTd, QTc, Tp-e, Tp-e/QT ratio and Tp-e/QTc ratio. zPatients and methods: In this study we compared 50
hypothyroid children with 30 healthy children in respect of serum thyroid stimulating hormone (TSH), serum level of free
triiodothyronine (fT3) and level of free thyroxine (fT4). Hypothyroidism diagnosed with TSH above the laboratory
accepted upper limit and normal or decreased fT4 values. The patient and control group data were compared by calculating
the QT interval, corrected QT(QTc), QT dispersion (QTd), QTc dispersion (QTcd), Tp-e, Tp-e/QT ratio and Tp-e/QTc
ratio on 12-lead surface electrocardiogram (ECG).
Results: In the hypothyroid group, the mean age was 10.36 ± 4.18 years old (ranged from 1-17 years). Regarding the
control group, the mean age was 9.09 ± 4.58 years old (ranged from 1-17 years). The QT max, QTc max, QTd, QTcd,
Tp-e, Tp-e/QT and Tp-e/QTc values were determined to be significantly higher in hypothyroid children than the control
children (p=0.03, p=0.026, p< 0.001, p=0.004, p=0.003, p=0.034 and p=0.027 respectively). QT max, QTc max, QTd and
QTcd in the hypothyroid group were 330 ± 38 ms, 406 ± 26 ms, 37 ± 17 ms and 39 ± 17 ms respectively. While in the
control group, they were 315 ± 23 ms, 393 ± 26 ms, 18± 13 and 27 ± 16 respectively. Conclusion: It could be concluded
that there was a significant increase in QTd, QTcd, Tp-e, Tp-e/QT ratio and Tp-e/QTc ratio values in children with
hypothyroidism similar to that seen in adults. The use of 12- lead ECG for the measurements of QTd, QTcd and Tp-e can
be considered necessary for the monitoring of children with hypothyroidism and in the evaluation of the risk of
cardiovascular disease.
Keywords: Hypothyroidism, QT dispersion, thyroid stimulating hormone, children.
INTRODUCTION
wave peak and the end of the T-wave, is considered as
Hypothyroidism is the most common disorder arising
the transmural dispersion index of ventricular
from hormone deficiency. About 4.6% of the U.S.
repolarization. In addition, the Tp-e/QT and Tp-e/QTc
population age 12 and older has hypothyroidism,
ratio can be used as predictors of ventricular
according
to
the
National
Health
and
arrhythmogenesis (9). Studies have shown that Tp-e
Nutrition Examination Survey (NHANESIII) (1).
interval, Tp-e/QT and Tp-e/QTc are prolonged in
According to the time of onset it is divided into
hypothyroidism patients (8, 10).
congenital
and
acquired.
Congenital
Cardiac electrical activity has been shown to be
hypothyroidism affects 1 in 1,500-3,000 newborns in the
affected in subclinical hypothyroidism patients with
U.S. each year (2). According to the level of endocrine
normal serum T3 and T4 levels. It has been considered
dysfunction it is divided into primary and secondary or
that this effect could be associated with TSH (4).
central and according to the severity into clinical and
subclinical hypothyroidism. Therapy of choice is the
AIM OF THE WORK
administration of thyroxine and the prognosis is very
This study aimed to evaluate the relationship between
good (3). Cardiac repolarization impairment was
hypothyroidism in children and QTd, QTc, Tp-e, Tp-
observed in ECG and action potential of hypothyroid
e/QT ratio and Tp-e/QTc ratio.
patients and experimental animal models (4, 5). Several
clinical groups correlated serum TSH levels with the
PATIENTS AND METHODS
repolarization abnormalities (6). Studies have shown that
The study was a case-control one that was carried
QT, QTc, QTd and QTcd are increased in adult
out on 50 children with hypothyroidism and (30) children
hypothyroidism patients (7, 8). The mechanism of the
with normal thyroid function as control group. The study
cardiac effect in these patients is a matter of debate. It has
was conducted in Cardiology department of Al-Azhar
been reported that cardiac K+ and L-type Ca++ channels
University Hospital. The study included both sexes
affection related to serum T3 and T4 in hypothyroid
below the age of 18 years old. Patients with structural
patients and in turn repolarization anomalies develop (4).
heart diseases were excluded by trans-thoracic
The Tp-e interval, which is the distance between the T-
echocardiography. Subjects complaining of any hepatic
5367
Received:1/08/2019
Accepted:1/09/2019
c:\work\Jor\vol774_11
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5373-5379
A Comparative Study between Use of Propofol-Ketamine and Propofol-Fentanyl
in Total Intravenous Anesthesia for Laparoscopic Surgeries
AL-Sayed Mostafa Stohy, Abd El-Wahab Abd El-Sattar Saleh,
Ahmed Salah El-deen Mohamed Zahakna
Department of Anesthesiology and Intensive Care, Faculty of Medicine - Al-Azhar University
ABSTRACT
Background: Total intravenous anesthesia has advantages over traditional inhalational anesthesia. It has the
advantages of hemodynamic stability, ease of titration using targeted control infusion systems, less organ toxicity,
preservation of hypoxic pulmonary vasoconstriction, and reduction of intra- cerebral pressure, risk reduction of
postoperative nausea and vomiting, less atmospheric pollution and more economic. Propofol as a strong anesthetic
but has no property of internal analgesia; so, a quick action opioid like fentanyl is usually used for helping in
analgesia. Aim of the work: The aim of this study was to compare between propofol-ketamine and propofol-
fentanyl as a drug combination used for total intravenous anesthesia in laparoscopic surgeries as regarding
hemodynamic state, intraoperative analgesia, recovery time, postoperative analgesia, nausea and vomiting as well as
emergence reactions. Patients and Methods: This comparative study was conducted between July 2017 and June
2019 at Sayed Galal University Hospital on 40 adult patients with sex and age matched. Their age ranged between
20-50 years old. They were randomly divided into two equal groups depending on drug combination used,
Propofol-Ketamine Group (I) and Propofol-Fentanyl Group (II). The study was approved by the medical ethics
committee of Al-Azhar University Hospitals and a written informed consent was obtained from all patients.
Results: The mean intraoperative blood pressure in Group (I) was higher than Group (II) with statistically
significant difference between both groups p0.001. The comparison between the mean of pain (VAS) score,
sedation (Ramsay's score) and recovery time of patients in both groups shows that means were higher in Propofol-
Ketamine Group than Propofol-Fentanyl Group and there was statistically significant difference between them
p0.05. In this study, nausea/vomiting were more common in Group (I) than Group (II) with statistically significant
difference between them (p0.05). Emergence reaction (unpleasant dreams or hallucinations) were more evident in
Group (I) with statistically significant difference.
Conclusion: There was no significant difference in the average number of heart beats and peripheral oxygen
saturation. The combination of Propofol-Ketamine leads to more hemodynamic stability. The combination of
Propofol-Fentanyl leads to faster recovery than the combination of Propofol-Ketamine for procedural sedation and
analgesia in patients undergoing laparoscopy. Nausea/vomiting were more common significantly in group (I).
Emergence reaction was more evident in group (I) and was statistically significant.
Keywords: Anesthesia, Propofol, Ketamine, Propofol-Fentanyl, Laparoscopic Surgeries.
INTRODUCTION
Total intravenous anesthesia is a method of
Propofol as a strong anesthetic but has no
administration of general anesthesia exclusively by
property of internal analgesia; so, a quick action
intravenous route (1).
opioid like fentanyl is usually used for helping in
It has the advantages over traditional
analgesia. Using opioid with propofol drug reduces
inhalational anesthesia in the form of hemodynamic
the essential dose amount, but it increases the
stability, ease of titration using targeted control
respiratory depression.
infusion systems, less organ toxicity, preservation of
Ketamine is a sedative and analgesic drug
hypoxic pulmonary vasoconstriction, and reduction of
that can be used for analgesia alone or with other
intra- cerebral pressure, risk reduction of
drugs (4).
postoperative nausea and vomiting, less atmospheric
Fentanyl in combination with propofol leads
pollution and more economic (2).
to analgesia and more quick recovery and less side
Laparoscopic
procedures
have
been
effects. Theoretically, ketamine and propofol
traditionally performed under general anesthesia
combination just like fentanyl and propofol
(GA). Controlled ventilation under GA has been
combination can cause dose reduction (5).
proven ideal to combat the respiratory changes
The combination of ketamine and propofol
induced by pneumoperitoneum. Induction agents
can reserve the efficacy of these two drugs and can
involve the use of rapid and short acting IV agents
also minimize their adverse effects. Some researchers
such as thiopentone and propofol as well as
believe that the reduced side effects of this
inhalational agents such as sevoflurane and
combination may be attributed to the reduced dosages
desflurane, especially for day care laparoscopic
of the drugs since the observed side effects are dose
procedures (3).
dependent. Furthermore, since the cardiovascular
effects of these drugs are opposite, the drugs seem to
5373
Received:1/08/2019
Accepted:1/09/2019
c:\work\Jor\vol774_12
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5380-5385
Assessment of Left Ventricular Diastolic Dysfunction by
2D Speckle Tracking in Hemodialysis Patients
Abd El Mohsen Mostafa Abdo, Attia Morsy Shokr, Ahmed Mohamed El Ashkr, Mohamed Safwat Helmy*
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mohamed Safwat Helmy; Email: dr.91mido@gmail.com, Mobile: (+20) 01098847465
ABSTRACT
Background: Diastolic dysfunction is widespread among patients on dialysis and is associated with increased
morbidity and mortality. Echocardiographic speckle tracking strain rate analysis may allow assessment of left
ventricular diastolic function.
Objectives: The purpose of this study was aimed to test the capability of speckle tracking diastolic strain rate to
assess the clinical and subclinical left ventricular diastolic dysfunction in end stage renal disease patients who are
on dialysis.
Subjects and Methods: This prospective study included a total of 45 subjects, 30 of them were on dialysis,
attending at the Outpatient Clinic, Department of Cardiology, Faculty of Medicine, Al-Azhar University Hospital
and Nasr City Police Hospital. The included subjects were divided into three groups; Group (A) included fifteen
healthy control subjects, Group (B) included fifteen patients with dialysis with normal diastolic function and
Group (C) included fifteen patients with dialysis with diastolic dysfunction.
Results: No significant differences were observed between control subjects and study population as regard age,
sex, DM, smoking and Dyslipidemia. In the current study, comparison between the three groups revealed
statistically significant difference in mean values of HTN. Comparison between the three groups revealed highly
statistically significant differences in echocardiographic parameters that included E/A, E/e, LA volume, TR
velocity and speckle tracking diastolic strain rate used in evaluation of Diastolic function " P value 0.001 ".
Conclusion: Two-dimensional speckle tracking could be used in assessment of diastolic dysfunction among
people on dialysis dependent on speckle tracking diastolic strain rate.
Keywords: Left Ventricular Diastolic Dysfunction, Two-Dimensional Speckle Tracking Echocardiography,
dialysis patients.
INTRODUCTION
tracking diastolic strain rate and left ventricular
In dialysis patients, both cardiovascular and
diastolic function in hemodialysis patients. In
non-cardiovascular mortality are significantly
addition to determine whether LV spickle tracking
increased as compared to the general population (1).
diastolic strain rate could be used to detect diastolic
In particular, cardiovascular mortality contributes to
dysfunction (DD).
40% of all-cause mortality in these patients, mainly
due to sudden cardiac death (2).
SUBJECTS and METHODS
Several parameters, such as left ventricular
This prospective study included a total of 45
hypertrophy (LVH) and left ventricular (LV) systolic
subjects, 30 of them were on dialysis, attending at the
dysfunction, have been identified as independent
Outpatient Clinic, Department of Cardiology,
predictors of cardiovascular outcome in dialysis
Faculty of Medicine, Al-Azhar University Hospital
patients. Next to that significant diastolic heart
and Nasr City Police Hospital. This study was
dysfunction, as assessed by tissue Doppler imaging
conducted between January 2019 and September
(TDI), has also demonstrated significant incremental
2019.
prognostic value for all-cause mortality and
cardiovascular death (3).
Ethical approval and written informed consent :
Similar to the general population, diastolic heart
The study was approved by the Medical Ethics
failure in dialysis patients often exists without the
Committee of Al-Azhar University Academic and
presence of significant systolic heart failure (4, 5).
Ethical Committee and a written informed consent
Therefore, accurate evaluation of LV diastolic
was obtained from all patients.
dysfunction is crucial in the management and risk
The included subjects were divided into three
stratification of dialysis patients, especially in those
groups; Group (A) included fifteen healthy control
with preserved ejection fraction. Particularly, LV
subjects, Group (B) included fifteen patients with
diastolic function and its determinants might
dialysis with normal diastolic function and Group
represent an important target for therapeutic options
(C) included fifteen patients with dialysis with
aimed at improving the abysmal prognosis of this
diastolic dysfunction.
group of dialysis patients with preserved ejection
fraction.
Inclusion criteria
The aim of the current work was to observe the
The patient with LV ejection fraction (EF) 55%,
relationship between left Ventricle (LV) spickle
5380
Received:2/08/2019
Accepted:2/09/2019
c:\work\Jor\vol774_13
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5386-5391
Partial Resection Versus Complete Resection of Costal Cartilage in Breast
Reconstruction by DIEP Flap
Mohamed M. El-Ghor*, Abdelhady Omar, Tarek M. El-Banouby, Ahmed Taha, Abdelfatah El-Shekh
Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohamed M. El-Ghor; Mobile: (+20) 01145999220
ABSTRACT
Background: Breast reconstruction is a vital component of the overall treatment plan of breast cancer patients.
Surgical breast reconstruction is not only desired by most patients, but is recommended by law in many countries.
Aim of the Work is to compare between partial resection and complete resection of costal cartilage in breast
reconstruction by DIEP flap as regard postoperative pain mainly and other factors as operative time, blood loss,
blood transfusion, and hospital stay.
Patient and Methods: Forty patients were recruited in this study and were divided into 2 groups, 20 patients
underwent breast reconstruction by DIEP flap with partial resection of costal cartilage and 20 patients underwent
breast reconstruction by DIEP flap with complete resection of costal cartilage.
Results: DIEP flap with partial resection of costal cartilage does in fact cause less postoperative pain than DIEP
flap with complete resection of costal cartilage.
Conclusion: The DIEP flap is an excellent choice for breast reconstruction, and is usually the first choice of flap
for breast reconstruction in our practice. Over the past 3 years in our practice it has shown to be safe and reliable
and provide a breast reconstruction with a superior long-term result with minimal donor site morbidity.
Keywords: Costal Cartilage, Breast Reconstruction, DIEP Flap, Blood loss, Blood transfusion.
INTRODUCTION
Breast cancer is one of the most common
partial and complete resection of costal cartilage
cancer affecting females all over the world. It is
and their effect on postoperative pain (4).
considered one of the major health problems as it
represents 37% of total female cancers and 17% of
AIM OF THE WORK
total cancer cases. It is the most common cause of
Is to compare between partial resection and
death due to cancer among women all over the
complete resection of costal cartilage in breast
world (1). The use of autologous tissue allows the
reconstruction by DIEP flap as regard postoperative
reconstruction of a breast which looks and feels
pain mainly and other factors as operative time,
most like a normal breast. The advent of perforator
blood loss, blood transfusion, and hospital stay.
flaps now allows for minimal donor site morbidity
and good flap durability. The abdomen is an ideal
PATIENT AND METHODS
source of tissue for breast reconstruction. Most
Prospective non randomized comparative
patients who develop breast cancer are at an age
study of 40 breasts, which underwent breast cancer
when they also have excess skin and fat overlying
surgery and reconstructed using DIEP flap. partial
the abdomen. The fat is typically soft and easy for
resection of costal cartilage was performed in 20
the surgeon to shape and closely approximates the
patients while complete resection of costal cartilage
feel of a normal breast (2).
was performed in 20 patients during dissection of
Pain management is a primary factor in the
internal mammary artery
postoperative care of plastic surgical patients. They
Inclusion criteria: Patient with early breast cancer
are largely treated in ambulatory surgery centers,
stage I and II (when conservative breast surgery is
and failure to control pain in that setting has
not
applicable),
patient
well
for
breast
negative effects. It increases the time in the surgery
reconstruction.
center, delays recovery, and can lead to
Exclusion criteria: Patients with locally advanced
unanticipated readmissions to the facility or to a
breast cancer stage III, stage IV. Patient with
hospital. Hospital inpatients also require careful
medical disease contraindicating long anesthetic
pain management (3).
procedure as heart failure, patients who prefer other
Pain control is key peri-operatively and must
modalities of breast reconstruction, when DIEP flap
be taken into account by the physician from the
is contraindicated e.g. previous abdominal surgery
initial consultation and discussed in detail with the
as abdominoplasty.
patient (3).
In the majority of cases; the dissection of
Ethical approval and written informed consent :
internal thoracic artery necessitates at least one
An approval of the study was obtained
costal cartilage resection which is the main factor
from Al-Azhar University Academic and Ethical
of pain. So, in this study we will compare between
5386
Received:2/08/2019
Accepted:2/09/2019
ABSTRACT
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5392-5398
Surgical Reconstruction after Excision of Pilonidal Sinus with
Modified Limberg Transposition Flap
Ahmed Shawky Abd El-Aziz, Mohammed Abd El-Aal Nafea,
Abd El-Hafiz Hosny Abd El-Hafiz*
General Surgery Department, Faculty of Medicine, Al-Azhar University
*Corresponding author: Abd El-Hafiz Hosny Abd El-Hafiz, Mobile: (+20)01116707766, email: islamhosny91@gmail.com
ABSTRACT
Background: Pilonidal sinus is a common infectious process which occurs in buttocks and sacral area which
involves a wide range of symptoms that are different from an asymptomatic sinus to acute and chronic sinus track.
Aim of the work: The aim of the study was to evaluate the outcome of modified Limberg transposition flap in
surgical reconstruction after excision of pilonidal sinus.
Patients and Methods: This prospective study was conducted at the Department of General Surgery, Al-Azhar
University Hospitals (Al-Hussin & Sayed Galal hospitals). This study was carried out on 30 consecutive patients
with primary non recurrent sacrococcygeal pilonidal sinus from 11/2018 to 6/2019 to allow a minimum follow-up
period of at least 5 months for the last case operated upon.
Results: Operative time and postoperative pain with mean operative time 47.37 ± 5.67, postoperative pain: 18
patients (60%) with mid pain, 10 patients (33.3%) with moderate pain, only 2 (6.7%) with severe pain. The
complications among study group were 4 patients (13.3%) with wound seroma, 3 patients (10%) with wound
hematoma, 3 patients (10%) with wound infection, 2 patients (6.7%) with wound gapping, only one patient (3.3%)
with flap necrosis. The mean time for wound healing is 20.57 ± 5.72, 17 patients (56.7%) less than 20 days and 13
patients (43.3 %) more than 20 days, mean hospital stay is 3.63 ± 0.85, 17 patients (56.7%) = 3 days hospital stay
and 13 patients (43.3%) more than 3 days hospital stay.
Conclusion: Surgical reconstruction after excision of pilonidal sinus with modified Limberg transposition flap is
an effective method for the management of pilonidal disease, especially when dealing with recurrent pilonidal
sinus.
Keywords: Surgical Reconstruction, Excision, Pilonidal Sinus, Limberg Transposition Flap.
INTRODUCTION
The sinuses are asymptomatic until infected
Pilonidal sinus is a common infectious
where the symptoms of intermittent pain, tenderness,
process which occurs in buttocks and sacral area
and intermittent serous-purulent fluids manifest.
which involves a wide range of symptoms that are
Other manifestations include sinus abscess that is
different from an asymptomatic sinus to acute and
acute and is at the upper and outer left position than
chronic sinus track (1).
vents (6).
The disease was first described in 1833 by
Primarily non-surgical treatment for this
Mayo. It occurs mostly in young adults and its
disease is not recommended and is only
incidence is 26 cases per 100,000 and in men is twice
recommended for patients who have the least
women. the peak incidence ranged between 15-24
symptoms such as hygiene sacrococcygeal region and
years of age and rarely occurs after age 40 (2).
shaving regional hair weekly. There are several
The etiology of this disease is not fully
methods for surgical treatment, but the method
understood, some are believed to be congenital in
should be appropriate for everyone with clinical
origin, and some consider it an acquired disease and
features of the disease (7).
the reason to this is that this condition can be seen in
The ideal treatment should be the minimum
folds between the fingers of hairdressers and
required hospitalization after surgery, be simple, with
shepherds and dog trainers which can be due to the
minimal pain, the patient soon returned to his work,
penetration of the hair as a foreign body and cause
minimal risk of complications and should be treated
reactions in the subcutaneous tissue (3).
easily in case of the recurrence. Various therapeutic
Hull and Wu (4) suggested that hair in this
approaches, each with advantages and disadvantages
area come in clusters and like a drill bit into the skin
are presented in recent years (8).
and gradually in-depth down.
Skin flaps have been described to cover a
Sondenna et al. (5) proposed that during
sacral defect after wide excision. Similarly, this
puberty and due to the rapid growth of gluteus
keeps the scar off the midline and flattens the natal
muscles, the distance of hair follicles, sebaceous
cleft. The techniques available include the (1) cleft
glands and apocrine glands increases leading to
closure, (2) advancement flap (Karydakis procedure),
increase the probability of foreign body entrance into
(3) local advancement flap (3-plasty rhomboid flap or
the skin and cause holes, which is the precursor of
V-Y advancement flap), and (4) rotational flap
the formation of pilonidal sinus.
5392
Received:4/08/2019
Accepted:4/09/2019
ABSTRACT
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5399-5404
Correlation Between Audiological, Clinical and Radiological Findings in
Patients with Microtia
Gehan Abdel-Rahman El- Zarea1, Ali Khalaf Mahrous1, Abd Ellah Nazeer Yaseen2, Ahmed Taha Mohamed*1
1Audio Vestibular Medicine Unit, Department of Otorhinolaryngology, 2Department of Radiodiagnosis, Faculty of
Medicine, Al-Azhar University
*Corresponding author: Ahmed Taha Mohamed, Mobile: (+20)1025279054
ABSTRACT
Background: Microtia is a congenital abnormality of the auricle. The main problems of patients with microtia are
hearing loss and cosmetic abnormalities of the affected ear. Most patients with microtia have normally formed inner
ears and have no sensorineural hearing loss. High resolution computed tomography (HRCT) scan and hearing
assessment are important for evaluation of patient with microtia.
Objective: The aim of the current work was to evaluate the relation between audiological, clinical and radiological
findings in patients with microtia.
Patients and Methods: This is a descriptive cross-sectional study of 30 patients with microtia, who were selected
from outpatient clinic of El-Hussein University Hospital, Cairo, Egypt, from August 2018 to September 2019. All
subjects were subjected to full history taking, Otological examination, general examination, basic audiological
evaluation, and radiological evaluation. Relations were evaluated between hearing level, clinical degree of microtia
according to Marx et al. (1) classification and CT scoring as assessed by the CT scoring system of Jahrsdoerfer et
al. (2).
Results: The hearing level correlated significantly with severity of microtia. However, there was no significant
association between degree of microtia and CT scoring as assessed by the CT scoring. Also, no significant correlation
between hearing level and the total CT scoring.
Conclusion: The principle "The better developed the external ear, the better the hearing level" has been proved in
Egyptian cases with microtia. It may not be possible to predict external and middle ear abnormalities based on
microtia grades. Therefore, both audiology testing and radiology investigation are two independent evaluations
before hearing reconstruction surgery.
Keywords: Microtia, external auditory canal, middle ear anomalies, temporal bone, atresia, hearing, high-resolution
computed tomography, pure tone audiometry.
INTRODUCTION
It is possible that the anatomical anomalies
Microtia is a congenital anomaly of the ear that
such as fixation of the stapes or round window closure
ranges in severity from mild structural abnormalities to
have an effect on the hearing level. So, high
complete absence of the ear (anotia) and can occur as
resolution computed tomography (HRCT) is
an isolated birth defect or as part of a spectrum of
indispensable for the surgical planning because it
anomalies or a syndrome. Microtia is often associated
provides important anatomic information (5).
with hearing loss and patients typically require
More than 80% of patients with microtia have
treatment for hearing impairment and surgical ear
aural atresia resulting in conductive hearing loss, with
reconstruction (3).
air conduction hearing typically reduced by 4065 dB,
Abnormalities of the middle ear structure
whereas bone conduction is normal in 90% of the
associated with microtia include stapes deformity,
affected ears (7).
absence of oval or round windows, aberrant course of
There are several grading systems for
facial nerve, poor pneumatization of the middle ear
microtia. In the Marx classification, all of the features
space, and fusion of malleus and incus (4).
of a normal auricle are present in grade I, but the pinna
The incidence of inner ear abnormalities
is smaller than normal. In grade II, some anatomical
associated with microtia is estimated between 10% and
structures are still recognizable. In the most common
47%. This condition is often accompanied by various
form, grade III (the peanut-shell type), only a rudiment
temporal bone anomalies (5).
of soft tissue is present (8).
Mostly, microtia is a unilateral anomaly with
Jahrsdoerfer et al. (2) developed a grading
a right-side dominance (6). The reported prevalence
system based on temporal bone HRCT and appearance
varies among regions, from 0.83 to 17.4 per 10,000
of the auricle for determining good surgical candidacy
births, and considered to be higher in Hispanics,
and accurate prediction of the surgical outcome.
Asians, Native Americans, and Andeans. The etiology
Nevertheless, the relationships between preoperative
of microtia and the cause of this wide variability in
hearing level and abnormalities of the temporal bone
prevalence are poorly understood. Strong evidence
have not been elucidated.
supports the role of environmental and genetic causes
The occurrence of microtia is of public health
(3).
importance in part due to the psychosocial sequelae,
5399
Received:3/08/2019
Accepted:3/09/2019
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The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5405-5412
Role of Early Pharmacoinvasive Strategy in Management of Patients with
Acute ST Elevation Myocardial Infarction
Mansour Mustafa, Khaled Naguib, Abdelaziz Rizk Hassan, Abdelaziz Rizk Hassan,
Hisham Mohammed Abd-Elhamid*
Department of Cardiology, Faculty of Medicine - Al-Azhar University
*Corresponding author: Hisham Mohammed Abd-Elhamid, Mobile: (+20) 01002520363, Email: hisham.buda@gmail.com
ABSTRACT
Background: Myocardial reperfusion with rapid recanalization of infarct-related artery is the key to success in the
management of ST-elevation myocardial infarction (STEMI). Timely reperfusion is crucial for minimization of infarct
size and thereby for preservation of left ventricular function and reduction in mortality in STEMI patients.
Objective: The aim of this study was to determine the effectiveness of early routine percutaneous coronary
intervention (PCI) post-fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to baseline risk status
(assessed by GRACE score).
Patients and methods: Our study was conducted on 120 patients presented with ST-elevation myocardial infarction
who presented within 12 hours after the onset of symptoms to our hospital and were eligible for firbrinolytic therapy.
Results: In general pharmaco-invasive strategy was associated with reduction of death, reinfarction, revascularization
and composite MACE at 1 & 6 months follow up. In the subgroup analysis of the high risk patients who underwent
routine early PCI, the reduction in improvement was associated with using BMS. Moreover, patients treated with
BMS showed higher rate of revascularization than those treated with conservative strategy. The patients treated with
DES showed reduction in re-infarction, revascularization and composite MACE within 6 months. The using of BMS
versus DES in the non-high risk group didn't show significant difference on 6 months follow up.
Conclusion: The baseline risk stratification will add advantage in choosing the strategy of reperfusion and even the
type of stent used during PCI.
Keywords: PCI, STEMI, GRACE, MACE.
INTRODUCTION
AIM OF THE WORK
Prompt reperfusion is the key aspect of the optimal
The aim of this study was to determine the
management of ST-elevation myocardial infarction
effectiveness of early routine percutaneous coronary
(STEMI). Although, primary percutaneous coronary
intervention (PCI) post-fibrinolysis for ST-elevation
intervention (PCI) is the preferred approach if
myocardial infarction (STEMI) in relation to baseline
performed in experienced centers in a timely manner (1),
risk status (assessed by GRACE score).
it is not always feasible for the majority of STEMI
patients who present to hospitals without on-site PCI
PATIENTS AND METHODS
facilities (2). The current treatment paradigm recognizes
The patients were selected from Al-Azhar
that delays to primary PCI can substantially diminish its
University Hospitals the period from October 2013 to
efficacy (3). Accordingly, at present, immediate
October 2015.
fibrinolysis remains the treatment of choice for many
Selected 120 patients presented with STEMI were
STEMI patients in developed countries (2).
included in this study, they were divided according
Recent research has focused on improving the
protocol of management into two groups:
management of STEMI patients after fibrinolysis (4).
Group I: Included 60 patients treated with standard
Several randomized controlled trials have shown that
conservative treatment (early transfer only for failed
early routine PCI in conjunction with potent
reperfusion, otherwise catheterization > 24 hours if
antithrombotic treatment to counteract the platelet
indicated). The group was subdivided into high risk
activation and prothrombotic state induced by
and non-high risk subgroups according to GRACE
fibrinolysis (pharmacoinvasive strategy) is superior to a
score:
conservative approach guided by documented ischaemia
Group I a: Included 30 patients with GRACE score
or need for rescue PCI (5). However, treatment outcomes
< 155
in relation to baseline risk status have not been
Group I b: Included 30 patients with GRACE score
examined.
155
In this study, we have tried to explore any
Group II: Included 60 patients treated with
differential treatment effects of a pharmacoinvasive
pharmacoinvasive strategy (transfer for routine
strategy compared to the standard treatment in STEMI
early PCI within 3- 24 hours after the start of
patients stratified by the Global Registry of Acute
fibrinolytic therapy). The group was subdivided into
Coronary Events (GRACE) risk score, which is a
high risk and non-high risk subgroups according to
validated powerful predictor of in-hospital mortality (6).
GRACE score:
We hypothesized that risk scores can potentially guide
Group II a: Included 30 patients with GRACE
the selective use of the pharmacoinvasive strategy in the
score < 155
optimal management of STEMI.
5405
Received:1/08/2019
Accepted:1/09/2019
c:\work\Jor\vol774_17
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5413-5420
Relationship between LA Strain by 2D Speckle Tracking and LV Diastolic
Function in Patient with Different Grades of LV Diastolic Dysfunction
Wael Mohammed Attia, Alsayed Ali Abdou Almarghany, Mahmoud Abd El salam Ahmed
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Mahmoud Abd El Salam, Email: mahmoud_cardio5800@yahoo.com;
Mobile: (+20) 1012859078
ABSTRACT
Background: Diastolic function assessment is complex and multipara metric because most conventional parameters
do not follow the progression of diastolic dysfunction (DD). Strain imaging is an emerging index of LA function, with
recent data demonstrating that LA strain is diminished in diastolic heart failure. However, LA strain is not part of the
standard assessment of diastolic function. We hypothesized that LA strain decreases with worsening DD in a stepwise
fashion and could thus be useful in evaluating DD.
Objectives: The aim of the current work was to observe the relationship between left atrial (LA) strain and left
ventricular diastolic function. In addition to determine whether LA strain could be used to detect diastolic dysfunction
(DD) and classify its degree when present. Patients and Methods: This prospective study included a total of 60
patients with diastolic dysfunction and 20 healthy control individuals, attending at outpatient clinic and
Echocardiography Laboratory, Cardiology Department, Al-Hussein University Hospital. They were subjected to detailed
echocardiographic examinations of the LV systolic and diastolic function and Lt atrial strain by 2D speckle tracking.
Results: There were statistically highly significant differences between the four groups as regard results of GLS
strain (P value=0.001) and peak LA strain (P value=0.001).
Conclusions: It could be concluded that LA strain measurements are feasible and allow accurate categorization of
DD, because unlike the traditional parameters, it changes progressively with severity of DD. LA strain may become a
useful tool for diastolic assessment in future clinical practice.
Keywords: Two-Dimensional Speckle Tracking Echocardiography, Left atrial strain, Diastolic Dysfunction.
INTRODUCTION
The principal role of the left atrium (LA) is to
hypothesized that LA strain measurements may hold
modulate left ventricular (LV) filling via its reservoir,
promise as a simple noninvasive tool to aid in the
conduit, and booster functions. The LA manifests
determination of DD severity. The aim of this study was
adaptive changes in its structure and mechanics, and
to determine whether LA strain could be used as an
these changes are well described in the setting of
accurate diagnostic criterion for the presence and
abnormal patterns of LV filling, known as diastolic
degree of DD, when compared with the current standard
dysfunction
(DD).
The
use
of
Doppler
guidelines. Independent group of patients (validation
echocardiography is a cornerstone for the diagnosis and
cohort) and compared with the diagnosis conferred by
categorization of diastolic function. Although there are
guideline-based DD assessment.
already well-established algorithms available for DD
staging that are widely used in the clinical setting, the
AIM OF THE WORK
criteria required for diagnosis incorporate multiple
The aim of the current work was to observe the
echocardiography-based parameters and can be
relationship between left atrial (LA) strain and left
cumbersome to acquire and interpret. Furthermore,
ventricular diastolic function. In addition to determine
individual patients may demonstrate a spectrum of
whether LA strain could be used to detect diastolic
diastolic indices that do not clearly meet the strict
dysfunction (DD) and classify its degree when present.
definition of a particular DD type, thereby making
interpretation challenging at times (1,2).
SUBJECTS AND METHODS
Strain imaging using 2-dimensional speckle
This prospective study included a total of 60
tracking of the LA has been used for the assessment of
patients with diastolic dysfunction and 20 healthy
left atrial function (3,4). LA strain is angle-independent,
control individuals (normal ventricular function and
and thus less susceptible to the limitations of Doppler
ECG, and no cardiac risk factors), attending at
echocardiographic assessment of strain (5). Alterations
outpatient clinic and Echocardiography Laboratory,
in LA strain have been described in patients with
Cardiology Department, Al-Hussein University Hospital.
hypertension, atrial fibrillation and diastolic heart
This study was conducted between .
failure (HF) (68). However, there is limited data
describing the changes in LA strain across DD groups,
Ethical approval and written informed consent:
nor are there available thresholds proposed for use in
The study was approved by the Medical Ethics
the clinical evaluation of diastolic function. We
Committee of Al-Azhar University and a written
informed consent was obtained from all patients.
5413
Received:3/08/2019
Accepted:3/09/2019
c:\work\Jor\vol774_18
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5421-5426
Intravitreal Ranibizumab Monotherapy or Combined with Laser for
Diabetic Macular Edema (OCT guided study)
Hassan Mohammed Higazy, Abdalla Mohamed Alamine Abdalla, Mahmoud Abd Elhaleem Ali*
Department of Ophthalmology, Faculty of Medicine- Aswan University
*Correspondence to: Mahmoud Abd Elhaleem Ali; Mobile: (+20)01066799990,
Email: Mahmoud.abdelhalim@aswu.edu.eg
ABSTRACT
Background: Diabetic retinopathy (DR) is the most frequent ocular complication of diabetes mellitus and the
leading cause of blindness in the working age population in developing countries.
Objective: The aim of this study was to compare central macular thickness using optical coherence tomography
(OCT) between Ranibizumab 0.5 mg monotherapy over Ranibizumab 0.5 mg combined with laser based on mean
average change in best-corrected visual acuity (BCVA) over 6 months in diabetic macular edema (DME).
Patients and methods: The study was carried out on forty eyes of patients aged 30-75 years old, with type 1 or 2
diabetes mellitus and have visual impairment due to DME. The patients were selected from the Outpatient
Ophthalmology Clinic of Aswan University Hospital.
Results: Both groups achieved improvement of visual acuity and reduction of the macular thickness but the
effect was more pronounced and long lasting in the combined therapy group.
Conclusion: The use of more than one line of treatment in combination for patients with diffuse DME could
provide more sustained results with the need for less frequent injections and decreasing the recurrence or
persistence rate of DME.
Keywords: Intravitreal Ranibizumab Monotherapy, Diabetic Macular Edema, BCVA, OCT.
INTRODUCTION
Diabetic macular edema (DME) is the main cause
Several studies on anti-VEGF agents for DME
for decreased visual acuity in patients with DM (1).
suggested that VEGF inhibitors are effective in
Nearly half of those developing DME will lose two
treating DME, but in these cases Ranibizumab was
or more lines of visual acuity within two years.
analyzed together with other VEGF inhibitors,
DME with visual impairment affects approximately
including pegaptanib, aflibercept, and bevacizumab
1-3% of diabetic population worldwide (2).
(8).
Focal/grid laser photocoagulation (laser), the
standard of care for DME since1985, was shown by
AIM OF THE STUDY
the Early Treatment Diabetic Retinopathy Study
The aim of this study was to compare central
(ETDRS) to reduce the risk for significant vision loss
macular
thickness
using
optical
coherence
by 50%, but complete cessation of vision loss and/or
tomography (OCT) between Ranibizumab 0.5 mg
improvements in visual acuity are rarely observed (3).
monotherapy over Ranibizumab 0.5 mg combined
Based on studies, the levels of vascular
with laser based on mean average change in best-
endothelial growth factors (VEGF) are increased in
corrected visual acuity (BCVA) over 6 months in
the retina and vitreous of eyes with DR and DME.
diabetic macular edema (DME).
Inhibiting VEGF may provide an alternative
therapeutic approach for this condition (4). Anti-
PATIENTS AND METHODS
VEGF agents have been reported to be efficacious in
Patients
treating DME (5). Among the anti- VEGF
Randomized prospective interventional study. The
therapeutics, ranibizumab (RBZ) is an antibody
study was carried out on forty eyes of patients aged
fragment with high binding affinity for VEGF-A,
30-75 years, with type 1 or 2 diabetes mellitus and
specifically developed for intraocular use commonly
had visual impairment due to DME. The patients
used as an intravitreal therapeutic option in treating
were selected from the Outpatient Ophthalmology
diabetic macular edema resulting in improving the
Clinic of Aswan University Hospital.
central macular thickness and best-corrected visual
acuity (BCVA) (6). Ranibizumab currently approved
Ethical consideration and Written informed
by the US Food and Drug Administration for
consent
intraocular use, the infusion of 0 .5 mg of
Ranibizumab into the vitreous cavity has been
An approval of the study was obtained from
performed without significant intraocular toxicity.
Aswan University Academic and Ethical
Therefore, it is of interest to uncover which treatment
Committee. Every patient signed an informed
modality is more effective and safe for DME (7).
written consent for acceptance of the operation.
5421
Received:4/08/2019
Accepted:4/09/2019
c:\work\Jor\vol774_19
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5427-5433
Sensitivity and Specificity of Computerized Tomography Coronary Angiography
for Evaluation of Coronary Stents of Variable Sizes and Sites
Islam Shawky Abdelaziz, Ahmed Abdelraouf Mahdy, Hamed Mohamed Hamed Abdelhafez*
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Egypt
ABSTRACT
Background: Coronary artery stenting has become the most important non-surgical treatment for symptomatic coronary
artery disease. However, in-stent restenosis occurs at a relatively high rate and this problem has led to the routine use of
invasive angiography for assessing stent patency.
Objective: The aim of the study is to determine sensitivity and specificity of Computerized Topography Coronary
Angiography (CTCA) for evaluation of coronary stent patency regarding its different sites and sizes.
Patients and methods: The study population consisted of 40 patients presented for follow up after previous coronary stent
implantation within at least 6 months regardless presence or absence of symptoms suggestive of in-stent restenosis. It was
carried out at Nasr City Police Hospital in the span of one year from June 2018 to June 2019. The study was approved by
the medical ethics committee of Al-Azhar University Hospitals and a written informed consent was obtained from all
patients. Results: The current study revealed a good diagnostic accuracy of the MSCT coronary angiography (91.2%).
Sensitivity, specificity, PPV and NPV were 88.2%, 92%, 83.3% and 94.3% respectively. We also concluded the higher
diagnostic accuracy of ISR in LAD compared to other vessels as well as higher diagnostic accuracy of ISR of proximal stents
and stents of diameter > 3mm. Conclusion: It was concluded that the 320-slice CT coronary angiography is a robust test that
can be used confidently to diagnose patients with coronary stents and more importantly to rule out significant coronary in-
stent restenosis in patients with high likelihood of having significant ISR.
Keywords: Sensitivity, specificity, computerized tomography, coronary angiography, coronary stents.
INTRODUCTION
DES still exists, and its prevalence is not negligible
Coronary artery disease (CAD) (including
because the population treated with DES is large (5).
acute MI) is responsible for about half of
Stent thrombosis (ST) has complicated
cardiovascular deaths. Mortality from cardiovascular
coronary artery stent implantation since its inception
disease is expected to reach 23.4 million in 2030 (1).
and is associated with considerable morbidity and
The main non-surgical option for re-
mortality due to abrupt vessel closure. Several case
vascularization of the myocardium in patients
reports and observational studies suggest that ST may
suffering from obstructive coronary artery disease is
occur unusually late in patients treated with DES, a
coronary artery stenting (2).
phenomenon referred to as very late ST (6).
Coronary stents, which were first developed in
Conventional coronary angiography (CA) is
the mid-1980s have ultimately replaced "plain old
considered the reference standard for evaluation of
balloon angioplasty" (POBA) as the preferred method
coronary artery stenosis, ISR, and the patency of
of performing percutaneous coronary intervention
coronary artery bypass grafts. However, the risk of
(PCI) after the observed improvements in angiographic
potentially serious adverse effects and the costs
and clinical outcomes seen with their use. Most PCI
associated with such effects have led to a search for
procedures involve a coronary stent, and therefore,
noninvasive alternatives. Good diagnostic accuracy
interventional cardiologists are faced with a wide
has been reported with the use of alternative coronary
choice of coronary stents to implant. This choice
imaging modalities such as multi-slice computerized
ranges from conventional bare-metal stents (BMS) and
tomography (MSCT) and magnetic perfusion imaging
drug-eluting stents (DES) that are widely used in
(MRI) (7). Non-invasive examination of coronary artery
contemporary practice to newer stents such as DES
disease is an attractive and rapidly evolving possibility.
with biodegradable polymers, DES that are polymer-
Since the introduction of (MSCT), Computerized
free, DES with novel coatings, dedicated bifurcation
tomography coronary angiography (CTCA) has
stents, self-expanding stents, and biodegradable stents
emerged as a new tool in the diagnosis and monitoring
(3). Restenosis after angioplasty and stent implantation
of coronary heart disease. Additionally, noninvasive
has been considered the most significant problem in
assessment of coronary stents is an attractive potential
coronary interventional treatment. Stent restenosis
application of MSCT technology (8).
(ISR) is defined as a reduction in lumen diameter after
There have been remarkable technological
(PCI). It is determined by an excessive tissue
advances in cardiac computed tomography (CT) in
proliferation in the luminal vessel of the stent called
recent years, and diagnostic cardiac catheterization has
"neo-intimal proliferation", or by a new-occurring
been used in conjunction with CTCA in many patients.
atherosclerotic process called "neo-atherosclerosis" (4).
CTCA exhibits a high negative predictive value
DES have dramatically reduced the rates of
(NPV), which is helpful in avoiding unnecessary
restenosis and target lesion revascularization (TLR)
catheterization procedures, Factors favoring the use of
compared with BMS, However, a low rate of ISR after
CTCA for the assessment of stent patency are the
5427
Received:3/08/2019
Accepted:3/09/2019
c:\work\Jor\vol774_20
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5434-5441
Study of Interferon--Inducible Protein 10 (IP 10) Level as a Diagnostic and
Prognostic Marker in Patients on Sofosbuvir and Daclatasvir as
Antiviral Therapy of Chronic Hepatitis C.
Mostafa Yousef ELmishad1, Alsayed Ahmed Gouda1, Ali Saad Elden Nada2, Ahmed Hussin Al-Dehna1.
1Department of Microbiology and Immunology, Faculty of Medicine, Al-Azhar University,
2Department of Hepatology, National Hepatology Institute Al- Menofia University
ABSTRACT
Background: Hepatitis C virus (HCV) belongs to the family Flaviviridae. Elevated plasma levels of the interferon-
-inducible protein 10 (IP 10) is common in HCV infection.
Objective: study of IP 10 level as a diagnostic and prognostic marker in patients on sofosbuvir and daclatasvir as
antiviral therapy of chronic HCV in comparison with HCV RNA level estimated by PCR.
Patients and methods: ELISA estimation of IP 10 serum level and quantitative PCR for hepatitis C RNA virus
done for 40 chronic HCV patient before , within and after undergoing antiviral therapy in the form of Sofosbuvir and
Daclatasvir ± Ribavirin. In addition, ELISA estimation of IP 10 serum level was done to 20 apparently healthy
individuals as a control group.
Results: IP 10 serum concentrations were significantly higher in patients than in control group. Sofosbuvir and
daclatasvir significantly decreased IP 10 serum level concentrations and this change in concentrations was
statistically highly significant. HCV PCR mean were 39×104 ± 78×104 log IU/ml) before start of treatment then
declined to undetectable level after one month of treatment till 3 months after the end of treatment. This change in
concentrations was statistically significant.
Conclusions: IP 10 may be used as a prognostic but not diagnostic marker for treatment efficacy in chronic HCV
infected patients subjected to sofosbuvir/daclatasvir combination therapy.
Keywords: Interferon--Inducible Protein 10, IP 10, Chronic Hepatitis C, direct acting antiviral therapy, Sofosbuvir,
Daclatasvir.
Abbreviation:
DAAT: Direct acting antiviral therapy, ELISA: enzyme linked immunosorbent assay, HBV: Hepatitis B virus, HCV:
hepatitis C virus, IP 10: interferon--inducible protein 10, NK: natural killer, PCR: Polymerase chain reaction, RNA:
Ribonucleic acid, SVR: sustained virological response, Th: T helper.
INTRODUCTION
and pathogen burden. In both HCV-monoinfected and
The hepatitis C virus (HCV) belongs to the family
HCV/HIV coinfected patients, elevated IP 10 levels
Flaviviridae, these viruses are structurally similar and
were positively correlated with liver damage (as
contain positive single-stranded RNA surrounded by a
indicated by high liver fibrosis scores and liver enzyme
protective lipid bilayer. The Flaviviridae family is
levels) (4).
divided into three genera, Flavivirus, Pestivirus, and
Several studies have reported that IP-10 may be a
Hepacivirus where the hepatitis C virus (HCV) is
prognostic marker for HCV treatment efficacy in HCV
included (1).
infection. Elevated pretreatment serum IP-10
In Egypt 15% of an estimated population are HCV
concentrations correlate with non-response to Peg-
positive, 93% of HCV-infected individuals are
IFN/RBV therapy (5).
infected with genotype 4, which includes 17 confirmed
Sofosbuvir/daclatasvir combination is associated
subtypes, which cause approximately 13% of
with a high rate of SVR in genotype 1 or 4 patients
infections worldwide, with prevalence varying by
who are assumed to be difficult to treat. Adding
geographic region (2).
Ribavirin increases the SVR rate in treatment-
Elevated plasma levels of the interferon--inducible
experienced and cirrhotic patients (6).
protein 10 (IP- 10) is common in HCV infection. IP-
10 is a chemokine produced by endothelial cells,
AIM OF THE WORK
activated T cells and hepatocytes during HCV
The study of IP 10 level as a diagnostic and
infection, exerting its effects mainly through a G
prognostic marker in patients on sofosbuvir and
protein-coupled receptor CXCR3. IP-10 signaling
daclatasvir as antiviral therapy of chronic HCV in
through CXCR3 induces different effects depending
comparison with HCV RNA level estimated by PCR.
on the site of receptor binding. One central effect of
IP-10 is trafficking of activated, IFN- producing NK
PATIENTS AND METHODS
cells, T cells and monocytes to the site of infection,
This study was carried out in Al-Araby
promoting a TH1 response (3). The IP-10 levels were
International Hospital during the period between
positively correlated with the extent of organ damage
January 2018 to March 2019 on 40 patients diagnosed
5434
Received:4/08/2019
Accepted:4/09/2019
c:\work\Jor\vol774_21
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5442-5447
Ranibizumab Monotherapy or Combined with Laser versus Laser
Monotherapy for Diabetic Macular Edema
Hassan Mohammed Higazy, Abdalla Mohamed Alamine Abdalla, Mahmoud Abd Elhaleem Ali*
Department of Ophthalmology, Faculty of Medicine- Aswan University
*Correspondence to: Mahmoud Abd Elhaleem Ali; Mobile: (+20)01066799990,
Email: Mahmoud.abdelhalim@aswu.edu.eg
ABSTRACT
Background: Diabetic macular oedema can occur at any stage of retinopathy and is typically characterized by
retinal thickening and leakage of extracellular fluid, which are linked with hypoxia and up regulation of vascular
endothelial growth factor (VEGF).
Objective: The aim of this study was to compare central macular thickness using optical coherence tomography
(OCT) between Ranibizumab 0.5 mg monotherapy vs Ranibizumab 0.5 mg combined with laser based on mean
average change in best-corrected visual acuity (BCVA) over 6 months in diabetic macular edema (DME).
Patients and methods: The study was carried out on forty eyes of patients aged 30-75 years old, with type 1 or 2
diabetes mellitus and have visual impairment due to DME. The patients were selected from the Outpatient
Ophthalmology Clinic of Aswan University Hospital. Results: Visual acuity measured as log MAR values in Group
A, when comparing the baseline visual acuity with that at the end of follow-up period, there was a significant
improvement in vision. Some patients achieved improvement of two lines at the end of six months. In Group B,
there was a significant improvement in vision when comparing the baseline reading with the six months reading
with an average gain in visual acuity of two or more lines. The central macular thickness improved in both groups
without statistically significant difference between them in the first three months post-injection. However, the
combined group achieved the highest reduction in the macular thickness at the end of follow-up period. Conclusion:
Ranibizumab monotherapy provided significantly superior benefit over standard-of-care laser in patients with visual
impairment due to DME being rapidly improved and sustained BCVA over the 6-month treatment period.
Keywords: Ranibizumab Monotherapy, Diabetic Macular Edema, BCVA, OCT.
INTRODUCTION
been reported that the significant reduction of the
Diabetic macular edema (DME) has an
plasma levels of VEGF in patients with DME were
estimated prevalence ranging from 0-3% in persons
found after the intravitreal injection of ranibizumab (3).
diagnosed as diabetics for the first time. This incidence
increases to 30% after 10 years of onset of diabetes (1).
AIM OF THE STUDY
Diabetic Retinopathy results in retinal ischemia
The aim of this study was to compare central
(i.e., microaneurysms, hemorrhages, cotton wool spots,
macular thickness using optical coherence tomography
intraretinal microvascular abnormalities, or macular
(OCT) between ranibizumab 0.5 mg monotherapy over
edema) and/or signs of increased retinal vascular
ranibizumab 0.5 mg combined with laser based on
permeability. Loss of vision is a consequence of
mean average change in best-corrected visual acuity
various pathophysiological mechanisms including
(BCVA) over 6 months in diabetic macular edema
neovascularization
that
may
cause
vitreous
(DME).
hemorrhage, retinal detachment, or capillary
nonperfusion (2). Retinopathy occurs in most patients
PATIENTS AND METHODS
with DM of longer duration, though its incidence can
Study design: Randomized prospective interventional
be reduced by aggressive control of hyperglycemia and
study.
hypertension (3).
Patient selection:
Laser photocoagulation, a traditional standard
The study was carried out on forty eyes of patients
treatment for DME, has been widely used for several
aged 30-75 years old, with type 1 or 2 diabetes
decades in spite of some limits (3). Laser
mellitus and have visual impairment due to DME. The
photocoagulation prevents degradation of vision by
patients were selected from the Outpatient
reducing leaky microaneurysms and inhibiting
Ophthalmology Clinic of Aswan University Hospital.
extravasation of fluid into the macula, which is the
Inclusion criteria:
purpose of laser photocoagulation (4).
1. Stable medication for the management of diabetes
Until the introduction of anti-VEGF agents,
within 3 months before study.
which are known to reduce total retinal thickness, IVR
2. Visual impairment due to focal or diffuse DME.
also become an effective. Ranibizumab, one of the
3. BCVA 6/9-6/60 based on (ETDRS).
anti-VEGF agents, is the first antigen-binding
4. Decreased vision due to DME and not for other
humanized monoclonal antibody segment that has the
causes.
FDA approval for therapeutic strategy for DME. It has
Exclusion criteria:
1. Presence of significant ocular disorders affecting
vision e.g. Cataract, glaucoma and uveitis.
5442
Received:1/08/2019
Accepted:1/09/2019
c:\work\Jor\vol774_22
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5448-5454
Total Knee Replacement in Severe Varus Knees
Mohammed Salah Aldin Abd El Hafeez, Mahmoud Sedek Hassan,
Mohamed AbdElaziz Hassan, Anass Abd El Halim Salim*
Orthopaedic Surgery Department, Faculty of Medicine, Al- Azhar University
*Corresponding author: Anass Abd El Halim Salim, Mobile: (+20)01002372315, email: arnolld.mr32@yahoo.com
ABSTRACT
Background: Varus deformity is predominantly the commonest deformity in candidates for total knee arthroplasty.
Obtaining a well-positioned and stable prosthetic construct with restoration of the normal mechanical axes of the
limb and joint line have been shown to have an important bearing on the final outcome of knee replacement
operations. Objective: The aim of this work is to study the results and outcome of total knee replacement in severe
varus knees and how to manage the ligamentous laxity and bone defect to improve the alignment of the limb.
Patients and methods: This study was carried out in the period between January, 2016 and July, 2019. A prospective
study was conducted involving 32 patients with 40 knees with a severe varus deformity, indicated for total knee
arthroplasty. The implants used for these cases are total knee, however PCL sacrificing or CCK were used, according
to the knee problem, the condition of the ligaments and the bone defect.
Results: The results of our study showed that the average knee society score (KSS) showed a highly significant
increase postoperatively to be 93.0±4.5 in compared with average preoperative KSS of 30.2±15.0. The average knee
function score at the last follow up was 75.3+10.0 (range from 65 to 80) compared with average preoperative knee
25.7+20.1 (range from 5 to 40).
Conclusion: Sequential medial soft tissue release must be performed to provide adequate stability without over
releasing. PCL must be released in severe fixed varus deformity especially if accompanied by flexion deformity.
Keywords: Total knee replacement, Severe varus knees, Arthroplasty
INTRODUCTION
pathoanatomy usually involves erosion of medial tibial
Arthroplasty is an operation to restore
bone stock with medial tibial osteophyte formation, and
pain-free motion to a joint and function to the muscles,
contractures of the medial collateral ligament (MCL),
ligaments, and other soft tissue structures that control the
posteromedial
capsule,
pes
anserinus,
and
joint(1).
semimembranosus muscle. Elongation of the lateral
Knee replacement surgery is one of the most
collateral ligament is a late event.
successful surgeries in orthopedics. Hundreds of
A flexion contracture may coexist, which is
thousands of these operations are now carried out every
manifested by contractures of both posterior capsule and
year worldwide with excellent results. Knee replacement
posterior cruciate ligament. The ideal alignment is
becomes necessary when the knee joint has been
achieved through soft tissue releases aimed at balancing
damaged from any cause and the resulting pain cannot
the collateral ligaments, and by placing the components
satisfactorily be controlled by other means. The usual
in the correct orientation. If the proper alignment is not
problem that can end up in the need for total knee
achieved, or if the ligaments are inadequately balanced,
replacement is chronic arthritis(2).
the components will be overloaded medially and
The goal of primary total knee arthroplasty is to
subjected to excessive stresses, which may result in the
reestablish the normal mechanical axis with a stable
eventual failure of the arthroplasty via either component
prosthesis that is well fixed. This is achieved by both the
loosening or accelerated wear. Intraoperatively, it is
bone resection and the soft tissue balance. The femoral
imperative to reassess each step of the soft tissue release
component should be aligned with 5 to 10 degrees valgus
so as not to overcorrect the deformity and create valgus
angulations in the coronal plane and 0 to 10 degrees of
instability(5).
flexion in the sagittal plane. The tibia should be resected
at 90±2 degrees to the long axis of the tibia in the coronal
AIM OF THE WORK
plane. In the sagittal plane, the posterior slope is dictated
The aim of this work is to study the results and
by the prosthetic design, but it appears preferable to
outcome of total knee replacement in severe varus
recreate the posterior slope of the natural tibia(3).
knees and how to manage the ligamentous laxity and
Total knee arthroplasty has become a highly successful
bone defect to improve the alignment of the limb.
joint reconstruction procedure. Surgical outcomes,
patient satisfaction, and implant survival have improved
PATIENTS AND METHOD
steadily since its inception and the operation has become
Patients: In the period between January, 2016 and
widely accepted to afford relief of pain, restoration of
July, 2019, a prospective study was conducted
range of motion and function(4).
involving 32 patients with 40 knees who underwent
Varus deformity of the knee is one of the most
primary total knee arthroplasty with severe varus
common deformities seen at the time of total knee
osteoarthritis and deformities.
arthroplasty. When a fixed deformity is present, the
5448
Received:4/08/2019
Accepted:4/09/2019
Evaluation of the Effect of Topical Heparin on the Treatment of Facial Burn
ejhm.journals.ekb.eg
Retracted
1
c:\work\Jor\vol774_24
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5461-5464
MR Spectroscopy of the Brain in Cases of Carotid Artery Stenosis
Ali Abd El-Hady El-Sayed, Ahmed Muhammad Mostafa, Islam Abdullah Muhammed Roshdy*
Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Islam Abdullah Muhammed Roshdy, E-Mail: islamriad2016@gmail.com, Mobile: (002)01016884699
ABSTRACT
Background: stenosis or occlusion of the internal carotid artery (ICA) causes a reduction in arterial pressure distal to
the stenosis or occlusion. This reduction leads to hypoperfusion which causes chemical changes in the brain and can be
detected by proton magnetic resonance spectroscopy (1H-MRS).
Objective: The aim of the current study was to explore the value of proton magnetic resonance spectroscopy imaging in
patients with internal carotid artery stenosis or occlusion.
Patients and Methods: This study included a total of 30 non infarcted patients with stenosis or occlusion of unilateral
internal carotid artery, attending at the Department of Radiodiagnosis, Faculty of Medicine, Al-Azhar University (Al-
Hussein) Hospital. Patients underwent MR spectroscopy to detect metabolic changes of the brain. Results: In 30 non-
infarcted patients, there was decreasing in N-acetylaspartate (NAA) and increasing in choline in the hemisphere
compared with the contralateral side. In addition, there was lactate peaks which found only in 8 patients. Conclusion:
1H-MRSI can reveal abnormal metabolic changes which occur in cerebral tissues with no infarction. However, internal
carotid artery may show stenosis or occlusion at an initial stage, which in turn may help guide management decisions
and preoperative assessment.
Keywords: 1H-MRS, MRI, Carotid artery stenosis, Stroke, ICA, Cerebral ischemia, Transaxial; Semiovale, VOIs.
INTRODUCTION
.
Patients with stenosis or occlusion of internal carotid
Inclusion criteria: All patients either male or female
artery might be suffer from transient neurological
who are presented by suspected carotid artery stenosis.
deficits. Patients with these symptoms are at high risk
of upcoming stroke (1).
Exclusion criteria: Patients who are known to have
Conventional magnetic resonance imaging (MRI) is
brain ischemia by conventional MRI.
difficult to assess the degree of cerebral ischemia before
Patients were 19 males and 11 females. Their ages
cerebral infarction happens, which is crucial for
ranged between 36 and 72 years. All the patients were
management decisions either medical treatments or
subjected to the following: demographic and clinical
revascularization.
data collection, which included patient's name, age,
MRI is less sensitive than 1H-MRS in revealing
gender, full history taking, past history of related
ischemic injury and measuring the metabolic changes
significance, color Doppler to detect the degree of
that may occur before the morphological changes. As a
stenosis. Cerebral metabolic changes of the brain were
result, 1H-MRS may provide important clinical data in
studied in the non-infarcted patients at the stenotic side
the diagnosis and management of cerebral ischemia at a
of internal carotid artery and compared with the healthy
much earlier stage (2).
side.
The aim of current study was to explore the value of
1H-MRSI was performed with a multivoxel
proton magnetic resonance spectroscopy imaging in
technique, the volumes of interest (VOIs) were selected
patients with internal carotid artery stenosis or
in the non-infarcted white matter of the bilateral
occlusion.
centrum semiovale in patients with ICA stenosis or
occlusion and taken away from cerebrospinal fluid in
SUBJECTS AND METHODS
sulcus as far as possible.
This study included a total of 30 non infarcted
patients with stenosis or occlusion of unilateral internal
MR Protocol:
carotid artery, attending at the Department of
MR investigations were performed on a 1.5 T
Radiodiagnosis, Faculty of Medicine, Al-Azhar
whole body system (Magnetom Trio Tim; Siemens,
University (Al-Hussein) Hospital. This study was
Erlangen, Germany) and were composed of two parts:
conducted between December 2018 to May 2019.
MRI and 1H-MRSI.
Ethical approval:
The study was approved by the Ethics Board of
Statistical analysis
Al-Azhar University. Written informed consent from
Recorded data were analyzed using the statistical
all the subjects were obtained after explanation how
package for social sciences, version 20.0 (SPSS Inc.,
much it is helpful in diagnosis and treatment.
Chicago, Illinois, USA). Quantitative data were expressed
5461
Received:5/08/2019
Accepted:5/09/2019
c:\work\Jor\vol774_25
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5465-5496
Effect of Pretreatment with Transdermal Testosterone on Controlled Ovarian
Stimulation and Outcome in Poor Ovarian Responders Undergoing ICSI
Yehia Wafa, Abdelaal Elghandour, Ahmad Elsayed Abdelaal
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Ahmad Elsayed Abdelaal, Mobile: (+20)1001040266,
E-Mail: dr_ahmedelsayed@hotmail.com
ABSTRACT
Background: Controlled ovarian stimulation (COS) has contributed to improving the pregnancy rate of women who
undergo in vitro fertilization (IVF) by increasing the number of developing follicles and oocytes. Poor ovarian
response to controlled ovarian stimulation (COS) remains a major problem in assisted reproduction.
Objective: To investigate the effectiveness of treatment with transdermal testosterone gel (TTG) before controlled
ovarian stimulation (COS) in low responders undergoing intracytoplasmic sperm injection (ICSI).
Patients and Methods: A total of 300 patients who were defined as poor responders using BOLOGNA criteria were
randomized into TTG pretreatment group and control group. For TTG pretreatment group, 10 g of TTG (5 %
testosterone) for 1520 days with a 5 mg/d nominal delivery rate of testosterone were applied daily for 15-20 days
in the cycle preceding COS for IVF.
Main Outcome Measure(s): COS results and IVF outcome.
Result(s): There were no differences in patients' characteristics between the two groups. Total dose and days of
human menopausal gonadotrophins (HMG) used were significantly lower in the TTG pretreatment group than in the
control group. The numbers of oocytes retrieved, mature oocytes, fertilized oocytes, and good-quality embryos were
similar in both groups. Embryo implantation rate, clinical pregnancy rate per cycle and live birth rate did not show
any statistically significant difference between the two groups.
Conclusion: Transdermal testosterone pretreatment did not significantly increase the number of retrieved oocytes,
clinical pregnancy rate or live birth rate in poor responders undergoing ICSI trials, however it reduces the total dose
and number of days of HMG administration.
Keywords: Transdermal testosterone gel, controlled ovarian stimulation, IVF, low responders, ICSI
INTRODUCTION
The treatment success of in vitro fertilization (IVF)
fertilization/intracytoplasmic
sperm
injection
is based on various factors, including the number of
(IVF/ICSI) treatment (3).
retrieved oocytes. Failure to recruit adequate follicles,
Androgens, produced primarily by theca cells, play
from which the oocytes are retrieved, is called a "poor
a critical role for an adequate follicular steroidogenesis
response." The incidence of poor ovarian response
and for a correct early follicular and granulosa cell
(POR) in controlled ovarian hyperstimulation (COH)
development. They are the substrate for the aromatase
has been reported in 924% of intracytoplasmic sperm
activity of the granulosa cells, which converts the
injection-embryo transfer (ICSI-ET) cycles (1).
androgens to estrogens. Moreover, androgens may
Since POR represents several controversial
increase FSH receptor expression in granulosa cells
issues in the clinical, scientific and psychological
amplifying the effects of FSH and thus potentially
sense, an ESHRE Campus Workshop was organized
enhance responsiveness of ovaries to FSH.
in Bologna, 19 20 March 2010 involving all the
Furthermore, inadequate levels of endogenous
ESHRE Special Interest Groups (SIGs) and the
androgens are associated with decreased ovarian
majority of research groups who have significantly
sensitivity to FSH and low pregnancy rates after IVF
contributed to the field. The main objective of the
(3).
workshop was to reach a consensus on the definition
The main androgen treatments involve direct
and diagnosis of POR(2).
androgen
supplementation
[including
A definition was proposed in which a patient must
dehydroepiandrosterone (DHEA) and testosterone] and
exhibit two of the following: (1) Being over the age of
the indirect increase of intra-ovarian androgen levels.
40 (40 age) or any other risk factor for POR (pelvic
The latter has been achieved through aromatase
infection, ovarian endometrioma, ovarian surgery,
inhibitors (anastrozole and letrozole), which are able to
chemotherapy, and short menstrual cycle). (2) Previous
elevate intra-ovarian androgen levels by blocking the
POR (with conventional stimulation protocol 3
conversion of androgen substrate to estrogen. Among
oocytes). (3) Abnormal ovarian reserve test (the
the androgens and androgen modulators mentioned
number of antral follicles < 57 or anti-Mullerian
above, transdermal testosterone treatment is most
hormone (AMH) < 0.51.1ng/mL) (2).
attractive due to its easy application, convenience,
Clinicians have attempted to improve the ovarian
painlessness to the patient and most importantly its
response in poor ovarian responders by using
safety as, in contrast to oral androgen treatment,
androgens or androgen modulators prior to in vitro
androgen is not first metabolized in the liver (4).
5465
Received:5/08/2019
Accepted:5/09/2019
ABSTRACT
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5470-5481
Role of Diffusion Weighted MRI in Assessment of Renal Lesions
Sayed Ahmed Ghoneim, Ahmed Abd Elfattah Abo Rashid, Hytham Mahmoud Nafady,
Mahmoud Mamdouh Mahgoub Aziz Eldin
Department of Diagnostic Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Mahmoud Mamdouh Mahgoub Aziz Eldin,
Mobile: (+20)1011829202, email: hewany234@gmail.com
ABSTRACT
Background: Renal lesions are being discovered with increasing frequency due to rapid development and advances
in cross-sectional imaging studies being applied in clinical practice.
Objective: The aim of the current work was to evaluate the ability of MRI with diffusion images and ADC values
in assessment, characterization of renal lesions and its ability to differentiate benign from malignant lesions.
Patients and Methods: This prospective study included a total of thirty patients with suspected renal lesions,
referred from Urology and Internal Medicine Departments of Suez Canal authority hospital. This study was
conducted between January 2019 and July 2019. Patients were examined by MRI with diffusion images and ADC
values.
Results: The mean apparent diffusion coefficient (ADC) value of normal renal parenchyma was higher than the
mean ADC values of benign and malignant lesions. The mean ADC value of all benign lesions was higher than that
of malignant lesions. However, there was overlap between ADC values of inflammatory, solid benign lesions and
ADC values of malignant lesions.
Conclusion: There is overlap between ADC values of inflammatory, solid benign lesions and ADC values of
malignant lesions. Using of ADC value alone may lead to inaccurate assessment of renal lesions. The combination
of conventional MRI and ADC value in the diagnosis of renal lesions can increase the diagnostic accuracy.
Keywords: Diffusion, MRI, renal lesions, parenchyma.
INTRODUCTION
impairment or allergies to contrast agents. These
Accurate assessment of renal lesions is
limitations have led to the growing desire for other
important for establishing whether tumors require
surgical intervention or not. CT and MRI are the
useful imaging techniques, such as diffusion-weighted
primary investigative tools for diagnosing and
(DW) MRI, which can enhance analysis by providing
characterization of cystic or solid renal masses
both qualitative and quantitative tissue characterization
discovered accidentally by ultrasonography (1).
(3).
To determine whether (solid or cystic) renal
Diffusion-weighted imaging (DWI) is a
lesion is benign or malignant, the mass is initially
functional technology that develops image contrast
examined by ultrasound (US), computed tomography
based on the inhibition of migration of water molecules
(CT), MRI, or a combination of these techniques. MRI
in tissues by tissue microstructures. As a result of the
offers an alternative to US and CT for the evaluation of
dense cellularity, malignant tissue has restricted
renal lesions. MR imaging can be particularly helpful
diffusion, which is reflected by a low mean apparent
when renal lesions are detected but are not well
diffusion coefficient (ADC) (4).
characterized by other imaging modalities as US and
Diffusion-weighted imaging (DWI) sequences
CT (2).
characterize the restriction of random (Brownian)
Renal lesions are commonly evaluated using
movement of water molecules within tissues. The
contrast-enhanced computed tomography (CT) and
strength of diffusion weighting is characterized by the
magnetic resonance imaging (MRI), with attempts to
b value. Through linear regression, images taken at
identify enhancing soft tissue foci suggestive of
various b-values can be used to calculate the apparent
malignancy. Despite all efforts false-negative results
diffusion coefficient (ADC) in a particular region of
can occur when imaging substantially necrotic or cystic
interest (3). Restriction to the molecular diffusion in
malignant lesions, which may be mistakenly written off
neoplastic tissues can be related to the greater cellular
as complex renal cysts because of a lack of extensive
density in the tissues, generated by the high index of
enhancement (3).
neoplastic replication with a consequent reduction in
On the other hand, oncocytomas or non-
the width of intercellular spaces, and to the ultra-
lipomatous angiomyolipomas (AML) may show
structural alteration of the kidney tissue (5).
enhancement, and such false-positive results will
Renal abscess and focal pyelonephritis can
prompt
radiologists
to
recommend
surgical
both mimic a malignant renal mass. Similarly, an
intervention (3). Contrast-enhanced studies are also
extensively necrotic RCC may masquerade as a
commonly precluded in patients who have renal
complex cystic/inflammatory lesion. Both may exhibit
areas of fluid attenuation/intensity and show little
5470
Received:6/08/2019
Accepted:6/09/2019
c:\work\Jor\vol774_27
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5482-5487
Effectiveness and Safety of Silodosin in Treatment of Premature Ejaculation:
Placebo Double Blind Control Study
Yahya Mohamed Ibrahim Hodeeb, Mohamed Saeed Mohamed Hasan,
Mohammed Abdelhafez Beyali Abdelhafez
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Al-Azhar University
ABSTRACT
Background: Premature ejaculation (PE) is a common sexual problem, many epidemiological reports have shown
that approximately 2030% of men have complaints of PE.
Objective: The aim of this study was to evaluate the effectiveness of silodosin 4mg in treatment of premature
ejaculation.
Patients and methods: This study was conducted on 160 subjects with premature ejaculation. The patients were
recruited from Dermatology and Andrology Outpatient Clinics in Al-Azhar University Hospitals .
Results: According to our results, there is highly statistically significant difference (p-value < 0.001) between
patient group (559.3 ± 159.9) and control group (248.4 ± 83.7) as regard intravaginal ejaculatory latency time
(IVELT) post-treatment (p-value < 0.001). Also, we found highly statistically significant difference (p-value <
0.001) between premature ejaculation profile questionnaire (PEPQ) pre- and post-treatment in patients' group. As
silodosin caused improvement of control over ejaculation, satisfaction with sexual intercourse, personal distress
related to ejaculation and interpersonal difficulty. At the end of the study only 11 (13.75%) patients reported that
they had a decreased semen volume as a side effect of silodosin, which disappeared completely after
discontinuation of the drug.
Conclusion: we found that, silodosin 4 mg is a promising idea in treatment of premature ejaculation, as it is
effective, cheap, safe and available in Egyptian market. We recommend administration silodosin 4mg 2 hours
before sexual intercourse for treatment of premature ejaculation.
Keywords: Silodosin, Premature Ejaculation.
INTRODUCTION
existing lifelong and acquired PE: variable PE and
Premature ejaculation is defined as a
subjective PE.
deviation from the normal length of intravaginal
Treatment for PE has included oral
ejaculatory latency time (IVELT), which is the time
medication, such as SSRI, topical agents and
taken from vaginal penetration to ejaculation.
behavioral and cognitive therapy. Recently,
Control over the moment of ejaculation and sexual
dapoxetine, a novel fast acting SSRI, was approved
satisfaction of the man and woman are possible
for the on-demand treatment of PE in several
components and are included in the standard
countries. However, SSRI have possible SSRI-
classification systems and guidelines of large
related adverse effects. Although, the safety and
urological organizations (1). Premature ejaculation
efficacy of some treatments for PE have been
was classified as lifelong (primary) or acquired
reported, safer and more effective treatment options
(secondary). Lifelong PE is characterized by its onset
are still required (4).
from the first sexual experience and remains a
The prostate and the seminal vesicles play a
problem throughout life. Ejaculation occurs too
vital role in the physiology of ejaculation and the
quickly, either before vaginal penetration or < 1-2
smooth muscle of both of these organs contains
min afterwards. Acquired PE is characterized by its
alpha-1 receptors. Considered the gold standard for
gradual or sudden onset, with ejaculation being
the treatment of lower urinary tract symptoms in men
normal before onset of the problem. Time to
with benign prostatic hyperplasia, alpha-1 blockers
ejaculation is short but not usually as fast as in
have been reported to cause ejaculatory dysfunction
lifelong PE (2).
(5). Although this ejaculatory dysfunction was
Waldinger and Schweitzer (3) identified a
originally thought to be caused by retrograde
disparity in the prevalence of objectively measured
ejaculation, studies have shown that it is caused by
PE i.e., IVELTs of <1 minute in the general
contraction failure of the seminal vesicles, resulting
population (~2.5%) and the subjective self-reporting
in emission reduction (6). The most common alpha-1
of men with PE with IVELT greater than 1 minute in
blockers used in the treatment of PE include
other studies being much higher. As a consequence
tamsulosin, silodosin, terazosin and alfuzosin, with
of this, they attempted to rationalize this difference
all showing a statistically significant increase in
by adding two new subtypes on top of the pre-
IVELT (7).
Silodosin showed 85.7% success rate in
treatment of PE in a study done by Akin et al. (8).
Other studies had been highlighted that a therapy
5482
Received:7/08/2019
Accepted:7/09/2019
c:\work\Jor\vol774_28
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5488-5496
Association of Significant Coronary Arterial Disease, Coronary Calcification and
Carotid Intima Media Thickness with Glycosylated Hemoglobin Levels in Patients
without History of Diabetes Mellitus Sent for Coronary CT Angiography
Ahmed Adel Saber Taha
Cardiology Department, Faculty of Medicine, Ain Shams University
*Corresponding author: Ahmed Adel Saber Taha, E-mail: ahmed.adel28989@gmail.com, Mobile: (+20)01065453522
ABSTRACT
Background: Diabetes mellitus (DM) is a risk factor for the development of the coronary heart disease (CHD),
and individuals with DM have more extensive atherosclerosis, more cardiac events, and higher prevalence of
silent ischemia as compared with individuals without DM.
Objective: The aim of the study is to assess the association of significant coronary arterial disease, coronary
calcification and carotid intima media thickness with glycosylated hemoglobin levels in patients without
history of diabetes mellitus sent for coronary CT angiography.
Patients and methods: This prospective study included 39 patients who underwent 320 Multi-slice CT
coronary angiography (Aquilion ONE 320 MSCT) at (Nasr-City Police Hospital) through the period from May
2017 to April 2018. They divided into 3 equal groups according to HbA1c (G1, non-diabetic, G2, pre-diabetic
and G3 diabetic). The study was approved by Ain Shams University academic and ethical committee and an
informed written consent was obtained from all patients.
Results: At level of multi-slice CT coronary, CCS was significantly higher in Group C than in Group A and
B. But no significant difference could be picked in subgroup analysis between Group A and Group B. There
were no significant differences among groups as regarding significant coronary artery stenosis. But there was
a trend towards significance in Group C; however, it failed to reach significance mostly because of the small
sample size. At level of carotid Doppler US, there were significant differences between groups as regarding
bilateral CIMT. But this significance was mainly between Group C and the other groups in subgroup analysis.
As regarding correlation, age and HbAlc had a positive strong correlation with CCS, LT CIMT, and RT CIMT.
Conclusion: HbAlc positively correlates with coronary and carotid atherosclerosis and patients with mild
elevation of HbAlc has significantly more CIMT than individuals with normal HbAlc.
Keywords: DM, CAD, CHD, CT angiography, CIMT, HbAlc.
INTRODUCTION
etiology. It is the end result of the accumulation of
For decades the diagnosis of diabetes
atheromatous plaques within the walls of the
mellitus was based on plasma glucose criteria,
coronary arteries that supply the myocardium with
either fasting plasma glucose (FPG) or 2-hour
oxygen and nutrients (5).
value in the 75 g oral glucose tolerance test
Several tools can be used for the diagnosis
(OGTT) (1). In 2009, an international expert
of CAD. Among which Multi-Slice Computed
committee, that included the representatives of the
Tomography (MSCT) that plays an important role
American Diabetic Association (ADA), the
as a non-invasive tool for assessing coronary
International Diabetes Federation (IDF) and the
atherosclerosis and diagnosing of CAD. Recent
European Association for the Study of Diabetes
advances in MSCT technology have continuously
(EASD) recommended the use of HbA1c test to
improved the quality of non-invasive cardiac
diagnose diabetes, with threshold of >6.5% and the
imaging. As a result, various studies have
ADA adopted this criterion in 2010 (2).
demonstrated a high accuracy of coronary
Glycated hemoglobin, assessed clinically
angiography (CA) with 64-slice CT for the
by HbA1c, is a time integrated marker of average
diagnosis of CAD (6).
blood glucose concentration increasingly used in
Prevalence and degree of intima media
the screening and management of diabetes, and it is
thickness in the carotid arteries has been related to
more closely related to the risk of complications
risk factors for cardiovascular disease (7).
than are single or episodic measures of glucose
The value of carotid artery disease in the
levels (3). There is consistent evidence that HbAlc
prediction of severe coronary artery disease has
levels control results in lower incidence of micro
been assessed in cohort studies of patients with
vascular and macro vascular complications in both
suspected ischemic heart disease 8).
type 1 and type 2 DM (4).
The most common cause of death due to
AIM OF THE WORK
cardiovascular diseases is coronary artery disease
The aim of the study was to assess the
(CAD), which is a progressive inflammatory
association of significant coronary arterial disease,
disease with underlying atherosclerosis in its
coronary calcification and carotid intima media
5488
Received:7/08/2019
Accepted:7/09/2019
c:\work\Jor\vol774_29
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5497-5506
The Impact of Type II DM on the Left Ventricular Function after
Early Invasive Management in Middle Aged Patients with Non-St-Segment
Elevation Myocardial Infarction
Mohsen Ali Mahmoud Salama, Kamal Ahmed Marghany, Amany Mohamed Seddik,
Sherif Mohamed Ibrahim Halawa
Department of Cardiology, Faculty of Medicine, Al-Azhar University
ABSTRACT
Background: Cardiovascular diseases are presently the leading causes of death in industrialized countries and
expected to become so in emerging countries by 2020. Among these, coronary artery disease (CAD) is the most
prevalent manifestation and is associated with high mortality and morbidity.
Objective: The aim of this study was to assess the impact of Type II DM on the left ventricular function
measured by 2D Speckle tracking Echocardiography in middle aged patients presenting with NSTEMI who will
undergo PCI.
Patients and methods: This study was carried on sixty middle aged patients (according to WHO, it should be 55
years of age) admitted with NSTEMI who undergoing (PCI) during their admission at Al-Hussein University
Hospital, Mostafa Kamel Military Hospital and the International Cardiac Center (ICC) at Alexandria. They
divided into two equal groups (Diabetic group and Non-diabetic control group).
Results: The result showed that diabetes had a bigger effect on the initial systolic function but with early
intervention.The difference in systolic function in both study groups was insignificant though it was a bit better
in non-diabetics. Regarding to the site of significant LAD lesion, statistical difference was found in osteal LAD
lesions (more in diabetics) and mid LAD lesions (more in non-diabetics).
Conclusion: Early intervention in diabetic patients lessens the effect of CAD on the myocardium even if the
disease tends to be stronger than non-diabetics early on. The 2D speckle tracking echocardiography is a promising,
feasible, and non-invasive modality to evaluate myocardial deformation.
Keywords: Type II DM, Left Ventricular Function, Early Invasive Management, Non-St-Segment Elevation
Myocardial Infarction, CAD.
INTRODUCTION
Acute myocardial infarction (MI) is an area of
(MVD) and often requires coronary revascularization in
coagulative necrosis of cardiac muscle due to prolonged
addition to optimal medical therapy to control angina (5).
ischemia. There are two subtypes of acute MI, ST-
Adverse left ventricular (LV) remodelling begins
elevation MI (STEMI) and non-ST elevation MI
in some patients with acute myocardial infarction (AMI)
(NSTEMI) (1).
even after percutaneous coronary intervention (PCI),
Atherosclerosis is the disease primarily
and according to previous studies, the incidence is
responsible for most acute MI cases where 90% of them
around 30%35% LV remodelling leads to heart failure
results from an acute thrombus that obstructs a coronary
and increases the risks for cardiovascular events and
artery. Plaque rupture is considered to be the major
mortality(6).
trigger of coronary thrombosis, following plaque
Left ventricular remodelling occurs in some
rupture, platelet activation and aggregation, coagulation
patients of AMI with preserved EF even after PCI. The
pathway activation, and endothelial vasoconstriction
2D speckle tracking echocardiography is a promising,
occur and lead to coronary thrombosis and occlusion (2).
feasible, and non-invasive modality to evaluate
Among patients presented with NSTEMI, 2 15
myocardial deformation (7).
% show severe ongoing angina, profound or dynamic
ECG changes, major arrhythmias, or haemodynamic
AIM OF THE WORK
instability upon admission or thereafter. Coronary
The aim of this study was to assess the impact of
angiography should be planned as soon as possible (3).
Type II DM on the left ventricular function measured
Patients with type 2 diabetes mellitus (T2DM)
by 2D Speckle tracking Echocardiography in middle
have a higher risk of developing coronary artery disease
aged patients presenting with NSTEMI who will
(CAD) than do patients without T2DM. Additionally,
undergo PCI.
75% of T2DM patients die as a consequence of
cardiovascular diseases including CAD (4).
PATIENTS AND METHODS
In patients with T2DM, CAD tends to be a more
This study was carried on sixty middle aged patients
complex disease characterized by small, diffuse,
(according to WHO, it should be 55 years of age)
calcified, multivessel involvement [multivessel disease
admitted with NSTEMI who undergoing (PCI) during
their admission at Al-Hussein University Hospital,
5497
Received:9/08/2019
Accepted:9/09/2019
c:\work\Jor\vol774_30
The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (4), Page 5507-5513
Role of Cardiac MR Imaging in Evaluation of Left Ventricular Diastolic
Function in Ischemic Heart Disease
Ali Abd Elhady Elsayed, Mamdouh Helmi Eltahan, Ahmed Mohamed Abou Elfotouh,
Mahmoud Mohamed Abou Mandour
Department of Diagnostic Radiology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mahmoud Mohamed Abou Mandour,
E-mail: dr.mandour1985@gmail.com, Mobile: (+20) 01090114543
ABSTRACT
Background: Diastolic dysfunction and coronary artery disease (CAD) are interrelated. The complications of CAD,
myocardial ischemia or infarction, are major causes of diastolic dysfunction.
Objective: The aim of this study was to determine the accuracy of CMR in assessment of left ventricular diastolic
function in ischemic heart disease patients by using a combination of left atrium size measurement and phase-contrast
evaluation of transmitral flow. Also, to evaluate the extent of myocardial scarring in these patients and to correlate
between the degree of myocardial scarring and the degree of left ventricular diastolic dysfunction.
Patients and methods: In the current study a total number of 22 patients with known ischemic heart disease were
enrolled for contrast enhanced CMR examination between January 2019 and October 2019. All patients underwent
CMR and echocardiography. Two of the 22 patients were excluded from the study because of technical difficulties or
failure of data acquisition (patient did not hear or did not obey breathing instructions). So, 20 patients were included in
the present study.
Results: our study showed feasibility of routinely performing evaluation of MV flow to assess diastolic function using
CMR. We were able to obtain clinical variables including E:A ratios and deceleration times, which agreed with those
obtained using TTE.
Conclusion: In patients with CAD, extent of myocardial scarring reliably predicts the degree of diastolic dysfunction.
LGE-CMR provides a powerful means to noninvasively assess the degree of myocardial scarring.
Keywords: Cardiac MR imaging, Left ventricular diastolic function, Ischemic heart disease, CAD, CMR.
INTRODUCTION
Cardiovascular magnetic resonance (CMR) offers a
The interest in diastolic dysfunction, which is
variety of alternative applications for evaluation of
present in various heart diseases, has been growing for
diastolic function; moreover CMR has much more
many years. Over the past 2 decades, the concept of
superiority to the echocardiography in myocardial
heart failure with preserved ejection fraction has
assessment (5).
emerged. It was previously described as "diastolic heart
failure" because diastolic dysfunction was thought to be
AIM OF THE WORK
its main mechanism. Heart failure with preserved
The aim of this study was to determine the
ejection fraction represents approximately 40%50% of
accuracy of CMR in assessment of left ventricular
all cases of heart failure, and its prevalence is increasing
diastolic function in ischemic heart disease patients by
(1).
using a combination of left atrium size measurement
Moreover, heart failure with preserved ejection fraction
and phase-contrast evaluation of transmitral flow. Also,
has become a diagnostic and therapeutic challenge,
to evaluate the extent of myocardial scarring in these
since its morbidity and mortality are similar to those of
patients and to correlate between the degree of
heart failure with deteriorated left ventricular (LV)
myocardial scarring and the degree of left ventricular
ejection fraction (LVEF) (2).
diastolic dysfunction.
Ischemic heart disease is the leading cause of
death worldwide as it accounts for 22% of all deaths (3).
PATIENTS AND METHODS
Also, ischemic heart disease is one of the main causes
Study population:
of diastolic heart failure and the presence of diastolic
A total number of 22 clinically diagnosed
dysfunction predicts a poor prognosis in patients with
patients as ischemic heart disease were enrolled
coronary artery disease (CAD) (4).
for contrast enhanced MRI examination of the
Assessment of left ventricular (LV) function
heart from January 2019 to October 2019. All
with cardiac magnetic resonance (MR) imaging is often
patients
underwent
cardiac
MRI
and
limited to evaluate systolic function, including analysis
echocardiography.
of regional wall motion, measurement of mass and
Two patients were excluded from the
volume, and estimation of ejection fraction. Currently,
study due to unsatisfactory images. So, 20
echocardiography is the method of choice for diastolic
patients were included in the present study.
function testing in clinical practice. Various
Patients presented with ischemic chest
applications are in use and recommended criteria are
pain (defined as a retro-sternal or precordial
followed for classifying the severity of dysfunction.
diffuse
burning,
heaviness,
or
squeezing
5507
Received:8/08/2019
Accepted:8/09/2019