c:\work\Jor\vol775_1 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5514-5519

Predictive Factors for the High Perianal Fistula Recurrence After
Placement of Seton
Mohammed Sobhy Taema, Abd El Fattah Morsi Saied, Mustafa Mohammed Ahmed EL Sheikh
Department of General Surgery, Faculty of Medicine - Al-Azhar University

The placement of seton is one of the common sphincter-saving procedures for high fistula-in-ano
(FIA). It has been described since Hippocrates who first used horse hair as a seton for the treatment of anal fistula.
Objective: The aim of this study is to investigate the predictive factors for recurrence and to evaluate the efficacy
and complications of seton treatment for high transsphincteric perianal fistula.
Patients and methods:
Our study was a prospective study, on a sample size of 50 patients (43 males and 7 females)
of high perianal fistula, carried out in Bab-Alsharia University Hospital.
In our study 66.7 % of recurrent cases had history of previous fistula surgery. Fecal incontinence was
recorded in 3/50 (6%) patients in our study. Factors associated with higher rates of fecal incontinence (FI) after
fistula surgery included high transsphincteric or suprasphincteric fistula, horse-shoe fistula, female patients, and
patients older than 45 years.
Conclusion: Factors that significantly predicted the recurrence of FIA were previous fistula surgery, anterior anal
fistula, and presence of secondary tracks or branches as with supralevator extension, and horse-shoe fistula. Female
patients and horse-shoe fistula were the significant risk factors for developing FI after the placement of seton.
Keywords: High Perianal Fistula Recurrence, Placement of Seton.

surgical management were advocated. These surgical
An anal fistula is an abnormal track between the
modalities include single or two-stage seton, advancement
anal canal mucosa and the perianal skin. The usual
flap techniques and ligation of intersphincteric fistulous
history of this condition consists of an intermittent pain,
tract (LIFT) (8).
itching, and discharge of pus, feces or blood (1).
Currently, several different materials have been
The vast majority of anal fistula are secondary
used as setons, including silk, braided silk, rubber
to infection of the anal gland which presents as
band, silastic tube, linen, polypropylene, braided
perianal abscess, which may spontaneously burst or
polyester, vascular loop, nylon, cable tie, and others
inadequately drained (2). Other causes of perianal
fistula include; inflammatory bowel disease, trauma,
There is a continuing demand to decrease the
fungal or mycobacterial infection and neoplasm (3).
complications associated with seton use. The most
The most comprehensive and practical
common weak points of this technique are the high
classification and the one most widely used presently is
rates of continence disturbances, prolonged discharge
that devised by Sir Alan Parks who classified perianal
and numerous visits to check and adjust the seton. The
fistula according to its location to anal sphincter muscle
tight (cutting) seton is any string-like material which
into four main groups: intersphincteric, transsphincteric,
when passed and tied within the fistula track develops
suprasphincteric or extrasphincteric. These groups can
gradual transection of the external sphincter muscle as
be further subdivided according to the presence and
a result of pressure necrosis with a negligible splitting
course of any extensions or secondary tracks(4).
of the cut ends. In this way, it preserves sphincter
Surgical treatment remains the gold standard
continuity during the cutting process (10).
for the management of anal fistula in adults as it

achieves adequate drainage of infection and complete
eradication of the fistulous track (5). In contrast to
The aim of this study is to investigate the
pediatric FIA which can resolve spontaneously with
predictive factors for recurrence and to evaluate the
conservative treatment (6).
efficacy and complications of seton treatment for high
The surgical treatment of FIA varies according to
transsphincteric perianal fistula.
the type of fistula; for simple fistulas lay open of the

track is usually sufficient reaching a success rate of
around 90%. Complete excision of the track or
fistulectomy is another option for the treatment of
A prospective study, on a sample size of 50
simple FIA; however, the larger wound of fistulectomy
patients of high perianal fistula, carried out in Bab-
takes longer to heal and does not provide distinct
Alsharia University Hospital.
advantages over fistulotomy regarding the incidence of
Inclusion criteria:-
recurrence of fistula (7).
Patients with high perianal fistula.
For the more complicated types of FIA that involves
Exclusion criteria:-
parts of the anal sphincter complex, other modalities of
Patients with synchronous anorectal problems

Full Paper (vol.775 paper# 1)

c:\work\Jor\vol775_2 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5520-5527
Effect of Both Phytoestrogen and Xenoestrogen on Some Sexual Hormones in
Male Albino Rats and Illustration of The Effect of Arctium Lappa L
(A. Lappa) on Their Actions
Eman G.E. Helal 1, Nora Abdulaziz Aljalaud 2, Mohamed A. Abdelaziz 3, Abeer Zakaria 1
1-Zoology Department, Faculty of Science, Al- Azhar University (Girls),
2-Biology Department Collage of Science Imam Abdulrahman Bin Fasial University,
3- Physiology Department, Faculty of Medicine, Al-Azhar University,
*Corresponding Author: Eman G.E. Helal, E-mail: emanhelal@hotmail.com, Mobile: 00201001025364,


Background: Xenoestrogens are chemically distinct industrial products potentially able to disrupt the endocrine system
by mimicking the action of endogenous steroid hormones. Phytoestrogens are naturally occurring non-steroidal plant
chemicals that can act like the female hormone estrogen. Arctium lappa (burdock) root has traditionally been
recommended as an aphrodisiac agent.
The aim of the study was to clarify the effect of both bisphenol-A (BPA) and anise oil together on some
sexual hormones and illustration the effect of A. lappa on their actions.
Materials and methods:
The study was conducted on thirty male albino rats. The animals were divided into three groups:
Group I, control untreated group, Group II, rats treated with bisphenol-A and anise oil and Group III, rats treated with
BPA and anise oil in addition to A. lappa. Blood samples were collected to estimate biochemical parameters. Results:
The biochemical results showed highly significant increase (p < 0.01) in the activities of ALT, AST, urea, creatinine,
FSH, prolactin, total cholesterol, triglycerides, LDLC, VLDL, LDL/HDL and TC/HDL levels. While, there was highly
significant decrease (p < 0.01) in HDLC, total protein, albumin, globulin, testosterone and, LH. All these results turned
back to the normal values after receiving the A. lappa as compared to normal group.
it could be concluded that phytoestrogen and xenoestrogen have undesirable effects and it's recommended
to minimize the utilization of these compound to protect people from its hazardous effects.
Keywords: BPA, Anise oil, A. lappa, Hormonal assay, Biochemical parameters.

The herbs chosen for this study, contain
The endocrine disrupter is defined as an
phytoestrogens as shown from their chemical
exogenous substance or mixture that alter functions of
constituents. Anise (Pimpinella anisum L.), is a
endocrine system and consequently causes adverse
flowering plant in the family Apiaceae. It's also called
effects in an intact organism (1). These compounds that
aniseed (5). Anise is a natural herbal plant that grows
have endocrine disruption properties and activate
widely in Egypt and many Arab countries. Anise is
estrogen receptors are called xenoestrogens
commonly used in human nutrition to regulate the
(environmental estrogens). These compounds like
balance of somatic and sexual hormones. It contains
estrogen in their effect but differ in structure (2). They
essential oils and fatty acids, the main component of
can be either synthetic or natural chemical
the essential oils is anethole and the biological
compounds. Synthetic xenoestrogens include some
properties are inhibiting bacterial (6) and stimulating
widely used industrial compounds, such as bisphenol-
secretion of digestive enzyme and appetizing (7). The
A (BPA), which is an estrogenic chemical able to
taste and smell of the fruit are mainly due to the
interact with human estrogen receptors (ER). Many
essential oil, which is 80-90% trans-anethole, with
lines of evidence reveal that BPA has an impact as an
other components consisting of cis-anethole, safrole,
endocrine disruptor even at low doses. BPA is a
estragole, p-anisaldehyde, anisketone, linalool and b-
chemical used for lining metal cans and in
farnesene 11. The seeds of anise contain 1.5-6%
polycarbonate plastics, such as baby bottles (3). In
essential oil, 10-20% fixed oil and 18% protein. The
rodents, BPA is associated with early sexual
main constituents of the essential oil are 90%
maturation, altered behavior and effects on prostate
anethole, 2-4% gamma-himachalene, < 1% p-
and mammary glands. In humans, BPA is associated
anisaldehyde, 0.9-1.5% methylchavicol, 3% cis-
with cardiovascular disease, diabetes and male sexual
pseudoisoeugenyl 2- methylbutyrate and 1.3% trans-
dysfunction in exposed workers. Food is a major
pseudoisoeugenyl 2-methylbutyrate (8). The main
exposure source. BPA can contaminate the
constituent of the anise oil anethole, has been
environment in significant amounts by leaching from
considered as the active estrogenic agent. Anethole
products (plastic food and water containers, dental
causes premature thelarche, which is a common
sealants and some cash register receipts) and as
disorder characterized by breast development, usually
byproducts of manufacturing (4).
younger than 2 years, with no other signs of puberty.
Premature thelarche is usually associated with adrenal

Full Paper (vol.775 paper# 2)

c:\work\Jor\vol775_3 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5528-5533

The Association between Helicobacter Pylori Infection and Hyperemesis Gravidarum
Mahmoud Abd-Eltawab Sultan1, Mohammad Salah Eldin Hassanein1,
Attia Mohammad Attia1, Abd-Elaleem Abd-Elaleem Elgendy2, Osama Gamal Mohammad1
1Department of Obstetrics & Gynecology, 2Department of Clinical Pathology,
Faculty of Medicine, Al-Azhar University
Hyperemesis gravidarum is the severe form of nausea and vomiting of pregnancy. The reported
incidence of Hyperemesis gravidarum is about 0.5-2.0%. For the diagnosis of hyperemesis gravidarum there must be
presence of three or more vomiting episodes during the day, weight loss of over 5% and ketonuria. Studies have
recently suggested that there is an association between emesis gravidarum and hyperemesis gravidarum with
Helicobacter pylori infection. Serologically positive H. pylori infection has been demonstrated in hyperemesis
Objective: To detect if there is association between hyperemesis gravidarum and infection with helicobacter pylori.
The study included 200 women that were classified into two groups. Group (1) 100 women with
hyperemesis gravidarum and group (2) 100 women with usual antenatal care. Serum H. pylori titre was measured for
detection of seropositivity incidence in both groups.
Results: Regarding H. pylori IgG titre, there was significant difference between study group and control group.
This study concluded that there is significant correlation between Helicobacter pylori infection and
occurrence of emesis gravidarum.
Keywords: Helicobacter Pylori ­ Interleukin ­ Virlence Factors Toxin.

elevated serum hormones concentrations as steroid
Emesis gravidarum, nausea and vomiting of
hormone and gastric motility disturbances in early
pregnancy are a multifactorial conditions with
pregnancy (6). Studies have recently suggested that there
significant adverse effects on quality of life and health
is an association between emesis gravidarum and
of mother and fetus that warrants recognition,
hyperemesis gravidarum with helicobacter pylori
investigation, and treatment (1). Nausea and vomiting are
infection (7, 8, and 9).
common symptoms during pregnancy. Often, they are
Helicobacter pylori is a gram-negative,
regarded as an unpleasant but normal part of pregnancy
microaerobic, spiral bacterium that colonizes the
during the first and early second trimesters. The first
stomachs of approximately half the world's population
known report of nausea & vomiting during pregnancy
and consequently is of major public health concern (10).
was documented approximately 4000 years ago (2).
Erroneously called morning sickness symptoms
inflammation in the stomach (gastritis), which may
usually start between the first and second missed
progress to peptic ulcer disease and stomach cancer. In
menstrual period and can continue up to 14 to 16 weeks.
the gastric epithelium, helicobacter pylori infections
Although nausea and vomiting tend to be worse in the
morning, they may continue throughout the day (3).
"sialylated" carbohydrates. The ability to bind to the
Nausea and vomiting of pregnancy (NVP) is best
glycosylated epithelial cells is considered to be essential
thought of as a spectrum disorder with varying degrees
for helicobacter pylori to cause persistent infection and
of symptoms in different women. Symptoms can range
disease (11).
from mild nausea to unbearable bouts of nausea and

vomiting throughout the day (4).
Hyperemesis gravidarum is the severe form of
To detect if there is association between hyperemesis
the nausea and vomiting of pregnancy. The reported
gravidarum and infection with helicobacter pylori.
incidence of hyperemesis gravidarum is about 0.5-2.0%

(5). For most women, NVP is a self-limited condition
during early pregnancy with no long-term negative
Ethical approval:
impact on their health or the health of their fetuses.
The study was approved by the Ethics Board of Al-
However, NVP affects a woman's life, both personally
Azhar University and an informed written consent
and professionally. For instance, almost 50% of
was taken from each participant in the study.
pregnant women who experience nausea and vomiting
This study was carried out in Gynecology and
believe it negatively affects their relationship with their
Obstetric Department, Bab-Elshaaria Hospital, Faculty
spouse and 55% feel depression (4).
of Medicine, Al-Azhar University, Cairo. This study
The etiology of nausea and vomiting of
included 200 pregnant women at 6-18 weeks of
pregnancy remains unknown. But a number of possible
gestation. They were recruited from Outpatient Clinic.
causes have been investigated as psychological factors,
They were divided into 2 groups: Group A (study group)

Full Paper (vol.775 paper# 3)

c:\work\Jor\vol775_4 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5534-5541

Epidemiological Typing of Methicillin Resistant Staphylococcus aureus
Isolated from Surgical Site Infection Following Caesarean Section in an
Egyptian University Hospital
Asmaa M. El-Nasser1, Azza Hassan El Salakawy1, Azza Ahmed Mira1,
Daad Fathallah Ibrahim1 and Hala Fathy El-Sharaky2
1Department of Medical Microbiology & Immunology. 2Department of Obstetrics & Gynecology, Faculty of
Medicine for Girls, Al-Azhar University, Cairo, Egypt.
Corresponding author:Asmaa M. El-Nasser,email: asmalnasser_8080@live.com,Mob: 01221567354

Surgical site infection (SSIs) is one of the most common healthcare-associated infections. It comprises
a great risk to hospitalized patients in terms of morbidity, mortality and economic cost.
Objectives: To identify the causative organism(s) responsible for surgical site infection following Cesarean section
and to trace the source of that infection.
Patients & methods: A total of 623 clinical samples and swabs were collected from Obstetrics & Gynecology
Department at Al-Zahraa University Hospital. The study included 300 patients with provisional diagnosis of SSI from
whom, wound swabs were taken, in addition to 23 swabs from medical staff and 300 environmental samples. Samples
were subjected to conventional bacteriological identification, biochemical reactions, antibiogram and genotyping by
Random Amplified Polymorphic DNA (RAPD) assay of the dominated isolates.
Results: Out of 300 wound swabs from patients with SSI following CS surgery, 62 (20.7%) yielded aerobic microbial
growth. Eighty three out of 323 swabs (26%) collected from health care workers (HCWs) & environment were positive
on culture. The most common organism isolated from both sources (clinical & environmental specimens) was
Methicillin resistant Staphylococcus aureus (MRSA) isolates 35/623 (5.6%). Genotyping of MRSA isolates revealed
20 distinct Random Amplified Polymorphic DNA (RAPD) patterns, indicating high rate of genetic heterogeneity
among MRSA isolates.
Conclusion: There were clonally related MRSA isolates obtained from operating room and from patients, indicating
that the operating room was accused as a source of infection.
Keywords: Surgical Site Infection, Methicillin-resistant Staphylococcus aureus, Random Amplified Polymorphic

Prevention of such infections is the responsibility of all
Surgical site infection remains the second most
individuals and services providing health care (5).
common adverse event occurring to hospitalized patients

and a major source of morbidity following surgical
Aim of the study: The study aimed to identify the most
procedures (1). Surgical site infection is a type of health
prevalent causative organism(s) responsible for surgical
care associated infection in which wound infection
site infection following Cesarean section and to trace the
occurs after an invasive or surgical procedure within 30
source of that infection.
days postoperative (2). There are many factors that are

thought to affect the susceptibility of wound to infection
including diabetes, systemic steroid use, extremes of
Patients: The study included 300 female patients
age, poor nutritional status, prolonged pre-operative
underwent Cesarean section. The patients were
hospitalization and wound contamination (3).
admitted to Al-Zahraa University Hospital with age
For most SSIs, the source of infection is the
ranged from 20 to 41 years (mean 27 ± 4.6) years old.
normal flora of the patient's skin, mucous membranes,
They were randomly selected with clinically diagnosed
or even the hollow viscera. Exogenous sources of SSI
SSI within 30 days post-operative, based on presence of
pathogens include surgical personnel, operating room
at least one of the following criteria:
environment including air, tools, and instruments.
- Purulent discharge with or without laboratory
Exogenous flora is primarily aerobes, especially Gram-
positive organisms (e.g. staphylococci and streptococci)
- Organisms are identified from fluid or tissue by a
(4). Although the total elimination of wound infection is
culture or non-culture based microbiologic testing
not possible, a reduction in the infection rate to a
minimal level could have significant benefits in terms of
- At least one of the following symptoms & signs: pain or
both patient comfort and medical resources used.
tenderness, fever (>38°C), localized swelling or redness
at the site of surgical operation (6).

Full Paper (vol.775 paper# 4)

Introduction The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5542-5548

Three-Dimensional Endometrial Volume and Power Doppler Angiography for
Prediction of Endometrial Carcinoma in Woman with Postmenopausal Bleeding
Esmael Mohammed Talaat Elgarhy 1, Mohammed Abd El-Kreem Kassem 2,
Mahmoud Abd El-Ghaffar Morsi Alzayat 1
Obstetrics and Gynecology Department, 1 Faculty of Medicine, Al-Azhar University, 2 Medical Military Academy

A woman is considered menopausal after cessation of menstruation for one year. The goal of
evaluations of postmenopausal bleeding (PMB) is to achieve the diagnosis with greatest accuracy, the least risk and
expense for the patient. Transvaginal ultrasound (TVS) is imaging technique of choice for first line investigation of
endometrial abnormalities as a possible cause of abnormal uterine bleeding, malignant and benign endometrial
patterns can often be determined by TVS which can help diagnosis.
Objectives: This study aims to assess the accuracy of endometrial volume and vascularization index assessed by
three-dimensional ultrasound in prediction of endometrial carcinoma in woman with postmenopausal bleeding.
Patients and Methods: This study was conducted in Ghamra Military Hospital on 100 women with
postmenopausal bleeding.
Results: Our results revealed that both endometrial thickness, volume, and 3D-PDA indices may discriminate
between endometrial cancer and benign conditions in women with postmenopausal bleeding. All parameters of our
study were not significant in diagnosis of cancer in women with postmenopausal bleeding.
Conclusion: The diagnostic performance of the measurement of the size of the endometrium by three-dimensional
ultrasound with respect to the distinction between benign and malignant endometriosis was higher when compared
to the measurement of the thickness of the endometrium with 2D ultrasound.The Doppler flow indicators have
three-dimensional power as good diagnostic tools in predicting endometrial cancer But it cannot rule out the
presence of malignant tumors endometriosis.
Keywords: Three-Dimensional Endometrial Volume, Power Doppler Angiography, Endometrial Carcinoma,
Postmenopausal Bleeding.

being a blind procedure with possible complications,
A woman is considered menopausal after
only curettes 60% of the endometrial cavity and
cessation of menstruation for one year (1). The goal of

evaluations of PMB is to achieve the diagnosis with
missing a pathology such as: polyps and submucous
greatest accuracy, the least risk and expense for the
myomas (6).
patient. Transvaginal ultrasound (TVS) is imaging
With the advent of hysteroscopy in the last
technique of choice for first line investigation of
two decades, focus has shifted from endometrial
endometrial abnormalities as a possible cause of
biopsy to hysteroscopic­guided biopsy as a "gold
abnormal uterine bleeding (2), malignant and benign
standard" diagnostic tool in the evaluation of
endometrial patterns can often be determined by TVS
postmenopausal bleeding (7).
which can help diagnosis (3).
Hysteroscopy permits direct visualization of
Current three dimensional ultrasound (3D
cervical canal and uterine cavity. Diagnostic
U/S) technology allows storage of complete volumes
hysteroscopy is both accurate and feasible in
and has capacity for routine clinical applications. All
diagnosis of intrauterine abnormalities. As diagnostic
objects stored in these volumes can be represented in
hysteroscopy predominantly performed in the
the multiplanar mode (coronal, transverse, sagittal) as
outpatient clinic, and therapy in an inpatient setting,
well as in form of surface images.
an accurate diagnosis is important to direct treatment
The major advantage of multiplanar mode is
at the specific pathology and avoid needless surgery.
that it enables simultaneous visualization of all three
Moreover, "it may contribute to prognosis of
mutually perpendicular sectional planes on display
expected quality of life" (8), but the diagnostic
screen (4). Many physicians prefer to start with EMB,
accuracy for hysteroscopy is high for endometrial
because it provides tissue samples for a histological
cancer, polyps and submucous myomas but only
diagnosis. It is easily performed, and causes minimal
moderate for endometrial hyperplasia (9).
cramping. The test does have limitations, such as

difficulty in obtaining adequate tissue samples (5).
Dilatation and curettage (D&C) procedure
This study aims to assess the accuracy of
itself, although highly diagnostic, yet it has many
endometrial volume and vascularization index
limitations, including the need for general anesthesia,
assessed by three-dimensional ultrasound in

Full Paper (vol.775 paper# 5)

c:\work\Jor\vol775_6 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5549-5555

Correlation of Serum Markers and Ultrasound Markers in the Prediction of
Threatened Miscarriage Outcome
Ali El-Shabrawy Ali 1, Hala Elsayed Mowafy 1, Mustafa Taha Abd El-Fattah 1,
Ibrahim Ali Ibrahim El-Gohary 2*
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, 2 Department of
Obstetrics and Gynecology Mit Ghamr General Hospital, Egypt
*Corresponding author: Ibrahim Ali Ibrahim El-Gohary, E-mail: monayahia92@gmail.com, Mobile: (+20) 1117991788

First-trimester bleeding is one of the most common obstetric complications, occurring in 25% of all
pregnancies. The clinical diagnosis of threatened miscarriage is presumed when bloody vaginal discharge or bleeding
appears through a closed cervical os during the first half of pregnancy.
Objective: The aim of the present study was to investigate the relationship between sonographic findings,
progesterone level and serum CA-125 in women presenting with symptoms of threatened abortion and first
trimesteric pregnancy outcome.
Subjects and Methods: This a case-control study included a total of 120 pregnant women between 7- and 13-
weeks' gestation in which a singleton embryo with evident cardiac activity was initially documented completed
the study, attending at Gynecological and Obstetric Department in Zagazig University Hospital and Mit Ghamr
General Hospital. This study was conducted between July 2016 to February 2018.
Results: There was no significant difference among groups in CRL and GSD but YSD was significantly higher
among cases. CA 125 was significantly higher in actual miscarriage with a level 47.9IU/ml (±31.52) between those
who had actual miscarriage before 13 weeks and 17.4IU/ml (±10.67)between those who continued pregnancy after
13 weeks while progesterone showed level 11.1ng/ml (±10.38)between those who aborted before 13 weeks and a
level of 11.6ng/ml (±6.19) between those who continued. GSD and YSD significantly higher in actual miscarriage
as the mean was 51.4mm (±18.56) and 6.73mm (±0.6) respectively for those who aborted and 38.52mm and 6.11mm
respectively for those who continued pregnancy.
Conclusion: The use of ultrasound and maternal serum CA-125in the first trimester represents non-invasive, early
and fast methods that can be considered as a good predictor for the outcome of pregnancy in cases with threatened
Miscarriage, progesterone, CA-125, GSD, CRL, YSD.

combinations, have proven helpful in ascertaining
Missed abortion (MA) is diagnosed when a
if a live intrauterine pregnancy is present (6).
pregnancy ceases to develop, but there is a delay in
the expulsion of the products of conception. MA is
transvaginal technique, is the most important tool
a complication of early pregnancy that occurs in
in the evaluation of early pregnancy or missed
15% of all clinically recognized pregnancies (1).
miscarriage. It permits direct examination of the
Various risk factors have been established, such as
products of conception in utero, eluding any
age extremes (more commonly > 35 years), prior
damage caused during their natural expulsion or
miscarriage, prolonged exposure to stress,
surgical evacuation (7).
abnormalities in uterine anatomy (presence of
Several studies looked into the variations in
adhesions or tumors) and use of substances like
size and shape of the gestational sac and/or the
cigarettes, alcohol, and certain drugs (2).
embryo-fetus incases of miscarriage (8).
Serum progesterone measured in early
Nonetheless, the yolk sac (YS), the first
pregnancy is the most powerful single predictor of
ultrasonographically evident structure within the
pregnancy outcome in natural conceptions (3). It is
gestational sac, has been studied less intensively.
essential to study women after natural conceptions
The YS is usually identifiable as a round structure,
without exogenous progesterone support, when the
made up of an anechoic center, and bordered by
relation between serum progesterone and viability
anechogenic, round, regular and well-defined
of the first trimester pregnancy was evaluated (4).
rim.It is the primary source of fetomaternal
Lower progesterone levels prior to
exchange before the establishment of placental
miscarriage, low body mass index but also obesity
circulation (9).
have shown to be significant risk factors as well (5).
Its functions include nutritional, metabolic,
Serum cancer antigen 125 (CA-125) and serum
hematopoietic, endocrine, and immunologic roles
progesterone values measured alone or in various
during early embryonic development (10). Bagratee

Full Paper (vol.775 paper# 6)

c:\work\Jor\vol775_7 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5556-5562
Comparative Study between Intralesional Injection of Vitamin D3 and Candida
Albicans Antigen in Treatment of Plantar Warts
Mohamed Abd-Elmonem Abd-Elaal, Hassan Mamdouh Abd-Elaziz, Karim Atwa Ahmed
Department of Dermatology, Venereology and Andrology, Faculty of Medicine,
*Corresponding author: Karim Atwa Ahmed, E-mail: kaak_25@yahoo.com, Mobile: (+20) 01117501990 Al-Azhar University, Cairo, Egypt

Numerous therapeutic modalities have been used either singly or in combination to treat recalcitrant
warts. However, a single treatment that is entirely effective in all patients is not yet explored. This might be attributed
to the absence of specific antiviral medications against human papilloma virus (HPV) infection.
Objective: The aim of this work was to compare efficacy of intralesional vitamin D3 in treatment of plantar warts in
comparison to candida albicans antigen.
Patients and methods:
This study included a total of 40 patients suffering from plantar warts, attending at
Dermatology and Andrology Outpatient Clinic, Dermatology Department, Al-Azhar University Hospitals. The
included subjects were randomly divided into two groups; Group A (Candida antigen group) consisted of 20
patients, subjected to intralesional injection of candida albicans antigen and Group B: (Vitamin D3 group)
consisted of 20 patients, subjected to intralesional injection of Vitamin D3.
Results revealed that there were no statistically significant correlations between age, sex of patients,
duration of treated warts and clinical response in both treatment groups. However, a statistically significant
correlation existed between the number of treated warts and response in Vitamin D group. Complete response
occurred in patients with low number of warts. At the end, our results showed that there was no statistically
significant correlation in complete response between candida antigen and vitaminD3. Both treatments show
comparable efficacy and safety in treatment of plantar warts.
Conclusion: Treatment of multiple warts by intralesional injection of candida antigen or vitamin D3 is safe and
effective, with good cure rates, excellent safety profile and minimal recurrences.
Keywords: Vitamin D3, Candida Albicans antigen, Plantar warts.


known as intralesional immunotherapy. Topical vitamin
Warts are common epidermal growths caused by
D has been used successfully for wart treatment in some
various strains of human papillomavirus (HPV)
cases (6).
afflicting all age groups. They have an unsightly
The effect of vitamin D derivatives on warts is
appearance and are mostly asymptomatic but sometimes
speculated to be derived from its potential to regulate
may be painful, as in the case of palmoplantar warts (1).
epidermal cell proliferation and differentiation and to
The virus initially targets the basal cells and
modulate cytokine production (7).
undergoes a latent phase of slow replication. As the
Upregulation of vitamin D receptors in the skin
epidermis grows superficially, the virus induces
leads to the induction of antimicrobial peptide
hyperplasia and hyperkeratosis (1).
expression (8).
Plantar warts are typically refractory to treatment,
Candida antigen is made from the culture filtrate and
and multiple treatment sessions are required to clear
cells of two strains of Candida albicans. It is indicated
lesions completely (2).
in origin for use as a recall antigen for detecting
Recalcitrant warts are resistant to conventional
delayed-type hypersensitivity by intracutaneous
therapeutic options and, despite treatment, continue to
(intradermal) testing, the inflammatory response
increase in size and number (3).
associated with the DTH reaction is characterized by an
Warts are usually treated by traditional destructive
infiltration of lymphocytes and macrophages at the site
modalities such as cryotherapy, electrocoagulation,
of antigen deposition. Specific cell types that appear to
topical salicylic acid, topical 5-fluorouracil, and laser
play a major role in the DTH response include CD4 and
surgery. All of these treatment options can be painful,
CD8 T lymphocytes (9).
time consuming, and/or expensive, and none is
The aim of this work was to compare efficacy of
considered the gold standard (4).
intralesional vitamin D3 in treatment of plantar warts in
Treatments for warts have included intralesional
comparison to candida albicans antigen.
injections of tuberculin purified protein derivative

(PPD); measles, mumps, and rubella (MMR) vaccine;
Mycobacterium vaccine and Candida albicans antigen
This study included a total of 40 patients suffering
from plantar warts, attending at Dermatology and
While the mechanisms of vaccine and antigen
therapy have not been elucidated, it is thought that the
Department, Al-Azhar University Hospitals.
host immune system is activated to recognize the virus,

leading to wart clearance. This treatment approach is


Full Paper (vol.775 paper# 7)

c:\work\Jor\vol775_8 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5563-5569

Prognostic Value of Insulin-Like Growth Factor 1 in Hodgkin Lymphoma
Fathy Ghamry Abd El Razek Elghamry1, Essam Abdelwahed Hassan2, Mamdouh Attia Mohamed3,
Hosameldeen Salah Shabana1, Mostafa Ahmed Mostafa Sabrh*1
1Department of Internal Medicine, Faculty of Medicine ­ Al-Azhar University
2Department of Internal Medicine and Clinical Hematology, Faculty of Medicine ­ Al-Azhar University
3Department of Clinical Pathology, Faculty of Medicine ­ Al-Azhar University
*Corresponding author: Mostafa Ahmed Mostafa Sabrh, E-mail: mostafa_sabrh86@yahoo.com,
Mobile: (+20) 01006336024
(HL) (formerly,
Hodgkin disease) is a potentially
curable lymphoma with distinct histology, biologic behavior, and clinical characteristics. The disease is defined in
terms of its microscopic appearance (histology) and the expression of cell surface markers (immunophenotype).
In this study we aim to evaluate the serum level of IGF-1 as prognostic factor in patients with Hodgkin
lymphoma and its impact in outcome of treatment.
Patients and methods: This study was conducted in the Internal Medicine Department of Al-Azhar University,
during the period from January 2018 to December 2018. It was carried on 60 patients diagnosed with HL. All
patients had a confirmed histopathological examination as HL before inclusion in the study. Patients were
classified into (3 equal groups) according to (Ann Arbor staging classification scheme): Group -1: 20 patients with
HL in stage I &II. Group -2: 20 patients with HL in stage III. Group -3: 20 patients with HL in stage IV. An
approval of the study was obtained from Al-Azhar University academic and ethical committee. Every patient
signed an informed written consent for acceptance of the operation.
Results: In our study, patients with HL had significantly higher levels of IGF-1 in advanced stages than limited
stages. Since serum levels of IGF-1 is a potent proliferative agent affecting almost every cell type and a powerful
antiapoptotic agent affecting apoptotic responses to a variety of agents of numerous cell types. These two effects
result in a state of hyperproliferation. Such an imbalance between cell proliferation and death. Also, our study
showed the higher level of IGF-1, the good response to aggressive chemotherapy.
Conclusion: IGF-1 may be a prognostic factor in HL and may be useful for the identification of a subgroup of
patients who may benefit from aggressive chemotherapy.
Keywords: Insulin-Like Growth Factor 1, Hodgkin Lymphoma.

prognostic value for patients with HL remains to be
Hodgkin's lymphoma (HL) is characterized
by the disruption of the normal lymph node
Insulin produced by the pancreas and insulin-
architecture by the presence of Hodgkin/Reed­
like growth factors (IGFs) produced mainly by the
Sternberg (HRS) cells, which are usually in a
liver regulate cellular growth and metabolism. There
minority within a background of reactive by stander
are two IGFs, namely IGF-1and IGF-2, which each
cells that are mainly composed of T and B
bind insulin-like growth factor-1receptor (IGF-1R)
lymphocytes and other cell types (1). Although there
and insulin-like growth factor-2 receptor (7).
have been important advances in treatment,
The IGF-1/IGF-1R signaling pathway,
approximately 20% of patients do not respond, or
which is a subfamily of receptor tyrosine kinases,
relapse after receiving the optimal initial therapeutic
has shown in previous studies to have an association
strategy, and may require adapted first-line treatment
with tumor cell proliferation, transformation,
survival and resistance to chemotherapy (8). This
The International Prognostic Score (IPS)
association has been noted to influence the incidence
has been the gold standard for predicting prognosis
and prognosis of prostate, breast and colorectal
of the patient with HL (3). However, the prognostic
cancers (8, 9).
value of the IPS is limited to advanced stage HL and
The IGF-1/IGF-1R signaling pathway is
does not fully reflect the biological spectrum of HL.
closely associated with proliferation and survival in
Several biologic factors have been suggested as
the hematological malignancies of multiple myeloma
predictors of prognosis in patients with HL,
(10) and mantle cell lymphoma (11). Furthermore,
including those identified by gene expression
studies of IGF-1R-targeted therapy in IGF-1R-
(4) or immunohistochemistry-based
expressing pulmonary non-small cell carcinoma are
detection (5, 6). However, whether they have
currently underway (12, 13).

Full Paper (vol.775 paper# 8)

Introduction The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5570-5578

Outcome of Pedicular Fixation of Unstable Dorsolumbar Fractures
Mohammad Salah Eldein Abd Elhafez, Mohammad Ibrahim Abulsoud,
Mahmoud Moursy Saleem Moursy
Department of Orthopedics and Traumatology, Faculty of Medicine ­ Al-Azhar University

The spine is made of 33 individual bones stacked one on top of the other. This spinal column provides
the main support for your body, allowing you to stand upright, bend, and twist as well as protecting the spinal cord
from injury.
Objective: The aim of this study was to evaluate the post-operative clinical outcome of transpedicular screw and rod
fixation in unstable thoracolumbar fractures by using Mc Nab's criteria in patients collected from Sohag General
Hospital and Sohag University Hospital.
Patients and methods: A prospective study included patients admitted to Orthopedic and Traumatology Department
of Sohag General Hospital suffering from unstable fracture of thoracolumbar area. The study was conducted on twenty
patients suffering from thoracolumbar fractures attending to Department of Orthopedics and Traumatology, Sohag
University Hospitals, Sohag General Hospital and Al-Azhar University Hospitals from June 2018 till December 2018.
Results: In comparison between cases, which conserved and those operated as regard vertebral height loss, angle of
kyphosis, oswestry disability index and visual analogue score, we found that p value was not significant in these
parameters and its value was 0.15, 0.46, 0.15, and 0.88 respectively. Which means that decision making correlated to
patient score. As regards type of operative fixation done, there were non-significant comparison between type of
fixation done and the mentioned parameters. All changes in the parameters explain that these parameters correlate
with TLICS and prove the validity of this classification.
Conclusion: Posterior short segment pedicle screw fixation is good and enough for treatment of thoracolumber
fractures (burst fracture) when neurological condition of the patients is intact.
Keywords: Pedicular fixation of unstable dorsolumbar fractures, transpedicular screw.


The vertebral column is composed of
alternating vertebrae and intervertebral (IV) discs
This was a prospective study conducted in
supported by robust spinal ligaments and muscles. All
Orthopedic and Traumatology Department of Sohag
of these elements, bony, cartilaginous, ligamentus and
General Hospital suffering from unstable fracture of
muscular are essential to the structural integrity of the
thoracolumbar area. Twenty patients suffering from
spine (1). The spine serves three vital functions including
thoracolumbar fractures attending at Department of
protection of the spinal cord and spinal nerves,
Orthopedics and Traumatology of Sohag university
transmitting the weight of the body, and providing a
hospitals, Sohag General Hospital and Al-Azhar
flexible axis for movements of the head and the trunk.
university hospital from June 2018 till December 2018.
The vertebral column is capable of extension, flexion,
Some cases were obtained retrospectively from the data
lateral flexion (side to side), and rotation. However, the
base of the department.
degree to which the spine is capable of these movements

varies by region. These regions, including the cervical,
Ethical approval and written informed consent:
the thoracic, the lumbar, and the sacro coccygeal spine
An approval of the study was obtained from Al-
that form four curvatures (2).
Azhar University Academic and Ethical Committee.
The thoracic and the sacro-coccygeal
Every patient signed an informed written consent for
curvatures are established in fetal development, while
acceptance of the operation.
the cervical and the thoracic curvatures develop during

infancy. The cervical curvature arises in response to
Type of interventions:
holding the head upright, while lumbar curvature
1. Posterior pedicle screws fixation to one level
develops as an infant begins to sit upright and walk (3).
above the fractured vertebra and one level

below it.
2. Decompression of neural canal was done in
The aim of this study was to evaluate the post-
cases with neurological affection.
operative clinical outcome of transpedicular screw and
3. Vertebral fusion was done with decompression
rod fixation in unstable thoracolumbar fractures by
by using autogenous bone grafting to prevent
using Mc Nab's criteria in patients collected from
metal failure, instability and progression of
Sohag General Hospital and Sohag University Hospital.

Full Paper (vol.775 paper# 9)

c:\work\Jor\vol775_10 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5579-5588

Urinary Level of Tumor Necrosis Factor Alpha in Patients with Type ­2
Diabetic Nephropathy
Youssef Khalel Ahmed1, Amin Mahmoud Amin Hegazy1, Mohammed Abdel-Hamed Keder2
and Mohamed Ahmed Mohamed Moustafa1
Departments of Internal Medicine1 and Clinical Pathology2 Faculty of Medicine, Al-Azhar University,
Cairo, Egypt.
Corresponding author: Mohamed Ahmed Mohamed Moustafa, E-mail: aboaiana@gmail.com

Diabetic nephropathy is the principal cause of end stage renal disease (ESRD) in the
Western world, with renal disease as a major cause of morbidity and mortality in the diabetic population.
Inflammation is a potential factor in the development and progression of DN and recent data indicate
that diabetes includes an inflammatory component which may contribute to diabetic complications.
Objectives: Aiming to investigate possible correlation between the presence and degree of albuminuria
and urinary tumor necrosis factor-alpha as a marker of inflammation in diabetic nephropathy in type 2
diabetes mellitus.
Patients and Methods: This study was conducted at El-Hussein University Hospital on 60 patients
with type-2 diabetes mellitus and 20 healthy volunteers for the matched age and sex. Diabetic patients
were divided into 3 groups according to the degree of proteinuria. Controls: 20 healthy controls, Group
20 type 2 diabetic patients without albuminuria, Group B: 20 type 2 diabetic patients with micro-
albuminuria. Group C: 20 type 2 diabetic patients with macro-albuminuria.
Results: urinary TNF-alpha and serum hs-CRP were significantly higher in diabetic than controls. It
was also significantly higher in patients with macroalbuminuria than those with microalbuminuria and
normoalbuminuria. There was significant positive correlation between urinary TNF- and urine protein
excretion in diabetic patients as well as age, CRP, duration of diabetes and glycemic control.
Conclusion: urinary TNF- is independently and significantly correlated with the presence and degree
of albuminuria in diabetic nephropathy in type 2 diabetes mellitus. This suggests that TNF- play a
significant role in the pathogenesis and progression of renal injury in diabetes.
Keywords: Diabetic nephropathy; Tumor necrosis factor-alpha.


Diabetic nephropathy (DN) is a
initiation and progression of diabetic
metabolic disorder with high morbidity and
nephropathy. Tubulointerstitial infiltration by
inflammatory cells is evident in renal biopsies
nephropathy incidence is not entirely explored,
from patients with diabetic nephropathy (3).
but its incidence has already occurred widely
The interest for the use of biomarkers for
and is estimated to be increased in prevalence.
early DN derives from the observation that
It occurs in 20-40% of people with type 2
patients with type 2 diabetes pass through a
diabetes mellitus (DM) and the most frequent
period of pre-diabetes and may experience renal
cause of end stage renal disease (ESRD) (1, 2).
impairment at the time of diagnosis. Although
Until recently, diabetic nephropathy has been
microalbuminuria has been considered as the
exclusively attributed to the interaction
earliest marker of DN in clinical practice, 29.1­
between metabolic parameters (activation of
61.6 % of individuals with type 2 diabetes could
polyols, exozamines, diacylglycerols, and
have renal impairment even before the onset of
advanced glycosylated end products-AGEs)
microalbuminuria (4).
hemodynamic factors (systemic hypertension,
Thus, it is necessary to implement
different strategies for detecting early DN in
angiotensin II, endothelin I), and oxidative
patients with type 2 diabetes aiming to delay its
stress, governed by genetic and environmental
progression and improve outcomes. Increased
factors. However, more recent evidence
levels of urinary biomarkers can be detected in
type 2 diabetic patients before the onset of
inflammation may play a key role in the

Full Paper (vol.775 paper# 10)

c:\work\Jor\vol775_11 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5589-5596

Intradermal Sterile Water Injection versus Epidural Bupivacaine in
Painless First Stage of Labor

Saeed Mohammed Faied, Abdalla Mohammed Abdalla,
Ahmed Youssef Mohammed Youssef *

Anesthesiology and Intensive Care Department, Faculty of Medicine, Al-Azhar University

* Corresponding author: Ahmed Youssef Mohammed Youssef, E-mail:

Background: Many women have moderate to severe low back pain during labor. It has been shown that
injection of sterile water can reduce the pain of 1st stage. This method is very cheap, easy to learn and can
be used as alternative method for reducing the labor pain.
Objectives: The aim of this study was to compare the effectiveness, women satisfaction safety and safety
of intradermal sterile water injection and epidural bupivacaine in decreasing the pain of1st stage of labor.
Patients and Methods: After approval of Institutional Ethical Committee and obtaining written informed
consent from eligible parturient women, 120 healthy parturient divided into 3 groups. 1st group epidural
bupivacaine plus fentanyl, Initiated with 10 ml of bupivacaine 0.125% with 2 micrograms/ ml of fentanyl
and maintained with 10 ml/ h of the same mixture. 2nd group intradermal injection of sterile water 0.1 ml,
while 3rd group intradermal injection of 0.1 ml normal saline.
Results: The study reported good pain relief in epidural and sterile water group compared to normal saline
group. Pain relief was comparable in both the epidural and sterile water group. Complications were more
demonstrated in epidural compared to the sterile water and the normal saline groups. A good maternal
satisfaction in epidural and sterile water group with no satisfaction in the normal saline group.
Conclusion: The evidence from this study suggests that sterile water injections are safe and effective
method for relieving pain of the 1st stage of labor similar to epidural bupivacaine analgesia.

Keywords: Sterile Water, Labor Pain.

Normal vaginal delivery pain is drastically
ability, facilitating participation in the birth
hard to tolerate, especially during the first stage.
process. Epidural analgesia reduces pain-induced
Some women experience abdominal pain, some
maternal hyperventilation during labor, preventing
others have lower back pain, and some have both
left shift of the hemoglobin dissociation curve in
types. Although the pain of giving birth usually
the mother, which can have detrimental effects on
appears with the onset of uterine contractions,
fetal hemoglobin saturation (3). Stress intensity is
sometimes lower back pain is also experienced in
influenced by numerous factors such as previous
the intervals between uterine contractions. About
pain experiences, education, culture, expectations,
30% of women suffer from constant back pain
environmental factors and support from caregivers
simultaneously to contractions and apparently lack
. Some draw backs are linked with regional
of rest in the intervals between contractions makes
analgesia techniques as pain at the puncture site,
tolerance of pain much more difficult (1).
fear of needles and recall of the procedure (5).
Visual analogue score that usually used as
Stress response leads to release of
scoring system for pain assessment in different
catecholamines and other vasopressors. At full
studies, is used also for assessment of labor pain (2).
term, uterine vasculature is maximally dilated, but
still responds to these vasopressors causing uterine
Recently, epidural analgesia has become one
vasoconstriction and decrease the uterine and
of the most frequently used analgesic techniques for
placental blood flow which adversely affect the
birth. The advantage of this technique is its ability
neonates (3). Therefore, the prevention from
to provide analgesia during labor as well as
maternal stress is potentially important. This can be
excellent anesthesia for delivery, as it is titrated to
prevented by giving patients detailed information
maintain the patient's sense of touch and motor
Received: 11/8/2019
Accepted: 11/8/2019

Full Paper (vol.775 paper# 11)

c:\work\Jor\vol775_12 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5597-5610

Comparative Study between Circum-areolar Skin Reduction and Standard
Long Scar Techniques for Treatment of Severe Degrees of Gynaecomastia
after Massive Weight Loss

Ismael Mahmoud Selim, Fawzy Ahmad Hamza, Mustafa Sayed Ahmed Meky
Plastic and Burn surgery Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
*Corresponding author: Ismael Mahmoud Selim, E-mail: ismaelshtya@azhar.edu.eg
Reshaping of the male chest following massive weight loss is challenging and
there are many techniques for its management.
This study was to compare circum-areolar skin reduction for the treatment of severe
gynaecomastia in massive weight loss patients with other standard long scar techniques.
Patients and methods: Patients with massive weight loss whom their redundant and ptosed breast
and patients whom their weight was stable for at least 6 months before surgical intervention for
the treatment of gynaecomastia. Those patients were included in the study. Patients were subjected
to either circum-areolar or other long standard scar techniques in 2 equal groups. Patients were
evaluated subjectively and objectively.
Results: As for patient's satisfaction, there was statistically significant higher satisfaction
(p=0.039) among patients submitted to circum-areolar approach regarding the overall chest
contour (80% vs 50%) and nipple-areola complex aesthetics (90% vs 60%). Objective assessment
showed better outcome for circum-areolar scar in cases of moderate skin laxity and minimal
glandular tissue, while other long standard scars could be appropriate with patients having massive
skin laxity and marked glandular atrophy.
Conclusion: Circum-areolar skin reduction technique is an effective, safe, and promising approach
in the management of gynaecomastia after massive weight loss, which is an accomplished
advancement relative to other standard long scar techniques. Circum-areolar skin reduction
technique is the best for the patients with moderate skin redundancy where it preserved glandular
tissue and no presence of side or back rolls. While, long scar techniques are favorable in patients
with severe skin redundancy and atrophied glandular tissue with side or back rolls.
Keywords: Severe Gynaecomastia, Massive Weight Loss, Circum-areolar Approach, Inferior
Pedicle Approach.
The Romer and Pelizaeus Museum of
in a monumental tomb in Giza, close to the
Hildesheim, Germany, hosts a large
pyramids, Hemiunu represented with
collection of Ancient Egyptian artworks,
marked gynecomastia (1) (Figure 1).
one of the most remarkable of which is the
sculpture of Hemiunu (fl.2570 BC) the
architect of the Great Pyramid of Giza,
Egypt. Hemiunu was a leading political
figure of his time who served as vizier
(minister). In this statue, discovered in 1912
Received: 11/8/2019
Accepted: 11/8/2019

Full Paper (vol.775 paper# 12)

c:\work\Jor\vol775_13 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5611-5620

Optical Coherence Tomography Angiography Compared to Fluorescein
Angiography in Central Retinal Vein Occlusion
Khaled Selim*, Mostafa Mahmoud* and Ali Maher Ibrahim El-Shaarawy**
* Department of Ophthalmology, Faculty of Medicine, Al-Azhar University
**Memorial Institute of Ophthalmic Research
Corresponding Author: drali_sha3rawy@yahoo.com
Background: Retinal vein occlusion is the second most common cause of retinal vascular disease
worldwide after diabetic retinopathy.
Objective: It is a prospective comparative study to evaluate the optical coherence tomography
angiography appearance of superficial and deep capillary plexa in eyes with central retinal vein
occlusion in comparison to conventional finding in fluorescein angiography. The study was approved
by the medical ethics committee of Al-Azhar University Hospitals and a written informed
consent is obtained from all patients.
Patients and Methods: A total of 19 eyes of 17 patients (with a known clinical diagnosis of CRVO;
any stage, any type), were recruited. All patients underwent standard ophthalmological examination
together with multimodal imaging procedures including; color fundus photography, fluorescein
angiography and optical coherence tomography angiography. Quantitative flow analysis of the SCP has
been performed for selected 15 images of 15 eyes with CRVO versus a single eye of a normal control.
Results: Optical coherence tomography angiography can qualitatively demonstrate all the macular
complications of CRVO including; ischemia, capillary dilation, microaneurysms, collateral vessels,
edema and intraretinal hemorrhages, with superiority to fluorescein angiography especially in the
presence of retinal hemorrhages and retinal edema. OCTA with the help of the co-registered en face
OCT images, can demonstrate laser scars, at the level of the choriocapillaris and can help in detecting
disc edema. Statistical analysis of the incidence of the different pathological findings in CRVO, has
revealed more severe affection of the deep capillary plexus than the superficial one.
Conclusion: OCTA allows stratigraphic analysis of the retinal and choroidal vasculatures. It also allows
performing quantitative flow analysis of the retinal vasculature providing an easily interpretable
noninvasive objective tool for the management and monitoring the progression of CRVO.
Keywords: Central Retinal vein occlusion, Optical coherence tomography angiography, Fluorescein


Retinal vein occlusion is the second
collateral circulation (4). Diagnosis of retinal
most common cause of retinal vascular disease
vein occlusion can be achieved clinically or by
worldwide after diabetic retinopathy (1) and
investigations including fundus fluorescein
around 6 million of people in the world have
retinal vein occlusion (RVO) (2).
tomography (OCT) and the recent optical
coherence tomography angiography (OCTA).
pathophysiology of central and branch retinal
Fluorescein Angiography has been the
venous occlusion is thrombosis (3) resulting in
gold standard for the diagnosis of various
elevated venous pressure and consequent
vascular diseases. It is particularly useful in
macular edema, retinal ischemia, and rupture of
highlighting the retinal perfusion especially that
the retinal vessel wall with intraretinal
of the macular area including visualizing
hemorrhage. In longstanding cases, after
vascular filling defects, areas of capillary
absorption of the intraretinal hemorrhage, there
nonperfusion, and retinal vessel tortuosity,
are several retinal vascular abnormalities, such
dilation, aneurysms, and leakage (5).
as retinal ischemic changes in the form of
capillary nonperfusion, capillary dilation,
However, fluorescein angiography
microaneurysms, telangiectatic vessels, and
does not image the radial peripapillary or the

Full Paper (vol.775 paper# 13)

c:\work\Jor\vol775_14 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5621-5632

Comparative study between El-Ganzouri airway risk index alone and in
combination with upper airway ultrasound in preoperative airway
Mohamed Amr Abo Sabaa, Gamal Farouk Amer, Abd Elwehab Abd Alsatar Saleh, Mohamed
Abd ElrahmanAbd Elkader Elbakery
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Al-Azhar University
The upper airway is an extraordinarily complex anatomical region. Anticipating and
preparing for difficulty in airway management is crucial to avoid airway catastrophes.
Aim of our study was to evaluate the combination of El-Ganzouri airway risk index (EGRI)
with the ultrasound of the airway (measuring the hyomental distance and distance from epiglottis to
midpoint between the two vocal cords) as a fast, easy and noninvasive method in the examination of
the airway and prediction of difficult airway.
Patients and methods:
Preoperative airway assessment will be carried out for 60 adult patients
randomly allocated in Al-Azhar University Hospitals.
Results: The hyomental distance at cutoff point of 5.6 cm, (below which the intubation difficulty is
high), sensitivity and specificity of Cormack-Lehane grade with hyomental distance in study group
was75.0% and 94.4% respectively with accuracy of 85%. For the epiglottis to vocal cord distance the
cut off value of 1.2 (below which the intubation difficulty is high) the sensitivity of epiglottis to vocal
cord distance was 75.0% and the specificity was 100% with accuracy of 92%.
Conclusion: We concluded that combination of EGRI with epiglottis to vocal cord distance and
hyomental distance is a very sensitive and specific tool for prediction of difficult airway and may be
superior to standard methods of assessment.
Keywords: El-Ganzouri airway risk combination, Upper airway ultrasound, Preoperative airway
Management of the airway remains a major
frequency of 1­8% (3). Other authors defined
contributor to death and brain damage in
difficult laryngoscopy as a separate identity that
anesthesia, emergency medicine, and intensive
occurs when "it is not possible to visualize any
care settings (1). Examination of the airway is an
portion of the vocal cords with conventional
essential component of the anesthesiologist's
laryngoscopy." This typically corresponds to
pre-operatively. Several bedside physical
a Cormack and Lehane Grade 3 or 4
airway assessment tests are available including
laryngoscopic views (4).
an assessment of mouth opening and dentition,
Mallampati classification, thyromental distance
The rate of complications is affected by
measurement and evaluation of neck mobility.
definitions used and by the clinical setting. The
These methods are quickly and easily
incidence of failed intubation is 1 in 1­2000 in
performed at the bedside, but unfortunately,
the elective setting, 1 in 300 during rapid
their sensitivity and specificity for accurate
sequence induction (RSI) in the obstetric
setting, and 1 in 50­100 in the emergency
management is not very robust (2). They may
department (ED), intensive care unit (ICU), and
also be difficult to apply in emergency and
pre-hospital setting. The rate of CICV requiring
critical care settings, where patients are
ESA may rise to 1 in 200 in the ED (5).
frequently confused, uncooperative and unable
to follow directions. Despite the availability of
Various clinical criteria are used to evaluate
patient's airway prior to induction of anesthesia
unexpected difficult intubations occur with a
like Mallampati classification, Wilson scoring
system, Samsoon and Young scoring system
Received:11/8/2019 accepted:11/9/2019

Full Paper (vol.775 paper# 14)

c:\work\Jor\vol775_15 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5633-5642

Assessment of remodeling index and its relation to coronary heart disease in
patients with types 2 diabetes by MDCT coronary angiography
Mansour Mohamed Mostafa Aref, Samy Hassan Nouh, Sameh Mosad Ibrahem, Wael Anwar Hasseb,
Ahmed Mohamed Mansour Eltantawy Mansour*
Department of Cardiology, Faculty of Medicine ­ Al-Azhar University
*Corresponding author: Ahmed Mohamed Mansour Eltantawy Mansour, Mobile: (+20) 01281012817,
E-Mail: dr_mansour2014@yahoo.com
Cardiovascular diseases (CVDs) are the primary cause of mortality worldwide with 17.3 million
deaths per year and an estimation of 23.6 million in 2030, placing it as a relevant issue for the public health
Objectives: This study aimed to assess the Remodeling Index (RI) and its relation to coronary heart disease
in patient with type 2 diabetes mellitus (T2DM) by multi-slice coronary CT angiography (MSCTA).
Patients and methods: This prospective observational study was conducted in Cardiology Department and
Radiology Department in El-Agouza, Academy, Nasr City Police Hospital. The study included 250 patients
with coronary remodeling of which 200 patients with type 2 diabetes (group I) and 50 are non-diabetics (group
II) matched in age and sex with the patients' group I (P > 0.05). All patients referred for MSCT coronary
Results: As regard remodeling index of the two groups were 1.11 ± 0.34 and 0.81 ± 0.29 in groups (I) and (II),
respectively. They showed a statistically highly significant difference between the two groups (p < 0.001). The
level of < 75th percentile was found in 74% and 100% of patients in groups (I) & (II), respectively, while level
of >75th percentile was found in 26% of group (I) and not found in group (II) and they showed a statistically
very highly significant difference (p < 0.001).
Conclusion: Patients with T2DM are susceptible to premature CAD with more calcified and non-calcified
plaques. Early prevention program using computed tomography angiography might be helpful in identifying
diabetic patients with subclinical atherosclerosis.
Keywords: Remodeling Index, Coronary heart disease, Types 2 diabetes, MDCT coronary angiography
Coronary heart disease (CHD) is the
abnormalities that are consequent to coronary
largest contributor of CVDs and mortality rate is
artery disease (2).
due in prevalence to atherosclerosis, a chronic
inflammatory condition of the arterial wall.
angiography (CTA) has been well established as a
Unfortunately, myocardial infarction (MI) is still a
valuable non-invasive imaging modality for the
first common manifestation of CHD and, in about
diagnosis of coronary artery disease (CAD) with
50% of patients, angina pectoris is the first
high accuracy and negative predictive value when
symptom of the pathology (1).
compared to invasive coronary angiography (ICA)
(3). Coronary CTA could also serve as a useful
increased early detection of CHD, although the
alternative to ICA for guidance of treatment in
invasive approach restricts their feasibility mainly
certain indications (4). In addition, serum/plasma
to symptomatic patients. Among them, for their
biomarkers can be mini-invasively extracted also
higher spatial resolution, intravascular ultrasound
in asymptomatic patients in order to analyze at
(IVUS), X-ray angiography (XRA) and computed
different levels (e.g. cellular, biochemical,
tomography coronary angiography (CTCA)
epigenetic and/or transcriptional) atherosclerosis
provide a direct evaluation and quantification of
and CHD development (5). However, according to
coronary artery alteration, while cardiac magnetic
previous studies, the ability of coronary CTA to
resonance (CMR) and nuclear medicine techniques
reliably assess luminal stenosis is significantly
(single photon computed tomography (SPECT),
impaired in the presence of moderately to severely
and positron emission tomography (PET)) provide
calcified lesions due to blooming and beam
indirect information of CHD, estimating
hardening artifacts, which make it difficult to
clearly delineate the border between opacified
lumen and calcium (6). On a side note, the fact that
Received:13/8/2019 accepted:13/9/2019

Full Paper (vol.775 paper# 15)

c:\work\Jor\vol775_16 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5643-5654

Study of Left Ventricular Function in Patients with Acute Myocardial Infarction
and Neutrophilia

Ahmed Kamal Matawaa1, Mohsen Ali Salama1, Mamdouh Attia Mohamed2, Abd El-Aziz Rizk Hasan1,
Mohamad Fawzy Abo-El-Naga Abd El-Rahman1

Department of Cardiology, epartment of Clinical Pathology, Faculty of Medicine Al-Azhar
University, Cairo, Egypt
*Corresponding author: Mohamad Fawzy Abo-El-Naga Abd El-Rahman, E-mail:
dr.m.fawzy2004@gmail.com, Mobile: (+20) 1002059419

Acute myocardial infarction is frequently associated with leukocytosis and elevated neutrophil
count. Neutrophilia may occur in response to myocardial necrosis which is a potent acute phase stimulus that
is associated with a local and systemic inflammatory response.
Objective: The aim of this study was to evaluate the left ventricular systolic function in patients with ST-
segment elevated myocardial infarction and neutrophilia.
Patients and Methods:
This prospective study included fifty patients with acute ST-segment elevated
myocardial infarction at Cardiology Department, Al-Azhar university Hospitals within the period between
January 2016 and June 2018. The patients were divided into two groups: Group (A): Thirty patients with
neutrophilia. Group (B): twenty patients without neutrophilia.
Results: Patient's ECG in 1st period showed that all patients had positive ECG in both groups while at 2nd and
3rd periods all patients had negative ECG in both groups with statistically significant differences between 1st
period and other period (2nd and 3rd period) where P <0.001 at all. According to neutrophil count there was
statistically significant difference between the studied groups in all period where P<0.001 at all period. There
was statistically significant difference between the studied groups where P<0.001 at baseline and after 48 hours
as regard to EF and FS. There was statistically significant difference between the studied groups according to
patients RWMA where P<0.001 at baseline and P= 0.002 after 48 hours.
Conclusion: Patients with STEMI associated with neutrophilia are significantly associated with early
development of congestive heart failure.
Keywords: Left ventricular function, Myocardial infarction, Neutrophilia


The relationship between inflammation and
injury in acute coronary syndrome has been
myocardial infarction (MI) was suggested more
previously prescribed. It was found that relative
than 50 years ago. Since then, overwhelming
neutrophilia in patients with ST-elevated
evidences supporting this relationship have been
myocardial infarction is significantly associated
with early development of congestive heart failure
epidemiological and clinical studies (1).
and impaired epicardial flow (5).
Determining peripheral leukocyte count is
Leukocytosis, predominantly neutrophilia,
an inexpensive and widely available way to assess
has previously been described following ST
the presence of any inflammation. According to the
elevation myocardial infarction (STEMI). The
literature, MI is usually accompanied with
exact contribution of this phenomenon to the
peripheral leukocytosis and the leukocytosis is
clinical outcome of STEMI is yet to be shown (6).
associated with higher rates of short-term mortality
High neutrophil counts have been related to
and heart failure after myocardial infarction (2).
Neutrophilia may occur in response to
atherosclerosis and a poor clinical prognosis (7).
myocardial necrosis which is a potent acute phase

stimulus that is associated with a local and systemic
The aim of this study was to evaluate the left
inflammatory response (3). Also, there are some
ventricular systolic function in patients with ST-
reports regarding the value of monocyte count in
segment elevated myocardial infarction and
predicting heart failure following MI (4).
The potential role of neutrophil in promoting


permeability and mediating ischemia-reperfusion
Received:12/8/2019 accepted:12/9/2019

Full Paper (vol.775 paper# 16)

INTRODUCTION The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5655-5661

Evaluation of Efficacy of Standard Treatment of Non-Purulent Cellulitis

Abdalla Abd Al-Hamid Sallam1, Mohammed Rashed Abd Al-Hamid2, Mohammed Abd Al-Aale Yusuf
Ali Nafie1, Abdalla Mohammed Al-Hady Abd Al-Aziz1

1Department of General Surgery, 2Department of Clinical Pathology, Faculty of Medicine, Al-Azhar
University, Cairo, Egypt

*Corresponding author: Abdalla Mohammed Al-Hady Abd Al-Aziz, Mobile: (+20) 1020279742, E-Mail:

Cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and
subcutaneous tissues, a process usually related to acute infection that does not involve the fascia or muscles.
Cellulitis is characterized by localized pain, swelling, tenderness, erythema, and warmth, cellulitis has been
classically considered to be an infection without formation of abscess (nonpurulent), purulent drainage, or
Objective: The aim of the current work was to evaluate the efficacy of standard treatment for cases of
cellulitis and identify other treatment options if needed in local community.
Patients and methods:
This prospective study was conducted at Department of General Surgery, Al-Azhar
university hospitals (Al-Hussin & Said Galal hospitals). This study carried out on 100 consecutive patients
with non-purulent cellulitis from 23/2/2017 to 1/5/2018 to allow a minimum follow-up period of at least 4
months for the last case follow upon. Clinical response to dicloxacillin, amoxicillin, and cephalexin was
Results: Age, sex, presentation, sit of non purulent cellulitis and result were recorded. Cellulitis was found
to be more common in geriatric patients and slightly more in females. Most patients had lower limb cellulitis,
and only little patients had an additional sit as orbit, hand and genitalia. 83 cases have good clinical response
and 17 cases have poor clinical response within 7 days to dicloxacillin, amoxicillin, and cephalexin.
Conclusion: Dicloxacillin, amoxicillin, or cephalexin are effective in most cases of cellulitis with gram
positive organisms as Streptococcal and staphylococcal species.
Keywords: Non-Purulent Cellulitis, dicloxacillin, amoxicillin, cephalexin

The term cellulitis is commonly used to indicate a
spread (red lines streaking away from the area of
nonnecrotizing inflammation of the skin and
infection), Circumferential cellulitis and Pain
subcutaneous tissues, usually from acute infection
(see the image below). Cellulitis usually follows a
Indications for emergent surgical evaluation are as
breach in the skin, although a portal of entry may
not be obvious; the breach may involve
hemorrhage, Skin sloughing, Skin anesthesia,
microscopic skin changes or invasive qualities of
Rapid progression, Gas in the tissue and
certain bacteria. Signs and symptoms: nonpurulent
Hypotension (3).
cellulitis is associated with the 4 cardinal signs of
Generally, no workup is required in
infection, as follows: Erythema, Pain, Swelling and
uncomplicated cases of cellulitis that meet the
warmth. Physical examination findings that
following criteria: Limited area of involvement,
suggest the most likely pathogen include the
Minimal pain, no systemic signs of illness (eg,
following: Skin infection without underlying
drainage, penetrating trauma, eschar, or abscess is
tachycardia, hypotension) and no risk factors for
most likely caused by streptococci; Staphylococcus
serious illness (eg, extremes of age, general
aureus, often community-acquired MRSA, is the
debility, immunocompromise). The Infectious
most likely pathogen when these factors are
Disease Society of America (IDSA) recommends
present (1, 2).
the following blood tests for patients with soft-
Violaceous color and bullae suggest more
tissue infection who have signs and symptoms of
serious or systemic infection with organisms such
systemic toxicity: Blood cultures, CBC with
as Vibrio vulnificus or Streptococcus pneumoniae.
differential, And levels of creatinine, bicarbonate,
The following findings suggest severe infection:
creatine phosphokinase, and C-reactive protein
Malaise, chills, fever, toxicity, Lymphangitic
(CRP) (4).

Full Paper (vol.775 paper# 17)

c:\work\Jor\vol775_18 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5662-5667
Quality of Life after Different Types of Ileal Diversions Following Radical
Mahmoud Abdel Hameed Mahmoud, Mohamed Abd Allah Hindawy, El Sayed Mohamed Hathout.
Urology Department, Faculty of Medicine, Al Azhar University
*Corresponding author: Mahmoud Abdel Hameed Mahmoud, Mobile: (+20) 01007953352, E-Mail:
Radical cystectomy remains the gold standard in treatment of muscle invasive bladder cancer.
Objective: To evaluate the quality of life (QOL) for patients underwent ileal conduit (IC) versus orthotopic
ileal neobladder (INB) urinary diversions (UD) after one year post radical cystectomy (RC).
Patients and methods: Our study was a retrospective study that included patients with MIBC who underwent
RC and UD from January 2014 to Julie 2018 that passed one-year post RC. There were two groups of patients
as follows: IC and INB groups. QOL was evaluated by the Functional Assessment of Cancer Therapy­ Bladder
Cancer (FACT-BL). The erectile function (EF) was assessed by the International Index of Erectile Function-5
(IIEF-5) questionnaire.
Results: Overall, 125 patients underwent RC with UD were screened for eligibility. Twenty patients (16%)
died, 11 patients (8.8%) failed to reach to them, 6 patients (4.8%) underwent other UD and 2 patients (1.6%)
refused participation in this study thus 86 patients (68.8%) were eligible for the study and were analyzed. The
mean patient's age was 61.6 ± 6.3 in both groups (p value 0.199). There were significant differences between
both groups in physical, social, emotional, functional, additional concerns, urinary and GIT symptoms that
were significantly better in INB group (p value < 0.001). There was no significant difference between both groups
regarding the EF.
Conclusions: the INB is better than the IC UD in most of QOL domains, which include physical, social,
emotional, functional, additional concerns, urinary and GIT symptoms. But sexual function remains equal bad
in both groups.
Keywords: Urinary diversion, Quality of life, Radical cystectomy
Bladder cancer (BC) is the seventh most
Various methods are used for UD after RC,
commonly diagnosed cancer in the male
including ileal conduits (IC), cutaneous continent
population worldwide, while it drops to eleventh
urinary diversion, and orthotopic neobladder (INB)
when both genders are considered, the worldwide
reconstruction (5). The type of UD after RC has a
age-standardized incidence rate (per 100,000
great impact on different aspects of QOL including
person/years) is 9.0 for men and 2.2 for women (1).
physical, sexual, psychosocial, day life activities
According to the first published national
and distress related to body image (6). The concept
population-based study for the period between
of QOL differs significantly between cultures,
2008 and 2011, BC is the 3rd most common
countries, and races (7).
malignancy (6.9%) in Egypt with more
There are multiple questionnaires available to
predominance in males 78 % than females 22% (2).
measure QOL. These questionnaires can be general
For patients with clinical T2-T4a, N0, M0 disease,
or disease-specific. Bladder specific questionnaires
Radical cystectomy (RC) and bilateral pelvic
include functional assessment of cancer therapy for
lymph node dissection remains the gold standard
patients with bladder cancer (FACT-BL),
therapy by which all other treatment modalities
European Organization for Research and
should be compared. RC provides excellent local
Treatment of Cancer Core Quality of Life
control with pelvic recurrence rates as low as 4%
Questionnaire (EORTC-QLQ)-30 and Bladder
in patients with node negative disease (3). The
Cancer Index (BCI) questionnaires (8).
choice of the suitable UD technique depends on
Aim of the work:
multiple factors including the patient age,
associated co-morbidities, continence status, renal
To evaluate the quality of life (QOL) for patients
function, surgical margin and surgeon experience
underwent ileal conduit (IC) versus orthotopic ileal

Full Paper (vol.775 paper# 18)

c:\work\Jor\vol775_19 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5668-5676
Recent Advances and Surgical Applications of Monoclonal Antibodies

Selim Elnemr, Ahmed Abd El Aal Sultan, Samh Massoud Saad Nassar

Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

*Corresponding author: Samh Massoud Saad Nassar, Mobile: (+20) 1019136662, E-Mail: samehnassar7@gmail

Monoclonal antibodies plays an important role in surgical disease practice specially
cancers, Crohn's Disease and ulcerative colitits. Monoclonal antibodies is a type of biological therapy
that utilizes a person's natural immune defense system to fight diseases. Monoclonal antibodies for
cancers is essentially the stimulation of immune system via a variety of reagents such as vaccines
infusion of T cells or cytokines. These reagents reacted through one of several mechanisms: 1- By
stimulating the antitumor response either by increasing the number of effector cells or be production
one or more soluble mediators such as lymphokines. 2- By decreasing suppressors mechanisms. 3- By
altering tumor cells to increase their immunogenicity and make them more susceptible to
immunological defenses. 4- By improving tolerance to cytotoxic drugs or radiotherapy such as
stimulating bone marrow function with granulocyte colony stimulating factor (G- CSF). Monoclonal
antibodies is a type of immunotherapy but there is another types of immunotherapy such as nonspecific
immunotherapies and cancer vaccines mechanism of monoclonal antibodies in surgical disease.
Objective: This work was aimed to study the role of monoclonal antibodies in surgical disease as a new
tool to surgical armamentarium.
Conclusion: It could be concluded from this study that monoclonal antibodies helps the body to fight
disease and infection. Monoclonal antibodies are used to treat many types of carcinoma and cancers.
Keywords: Surgical Applications, Monoclonal Antibodies


Since their development more than 30
immunoglobulin molecules (IgG, IgM, IgA,
years ago, monoclonal antibodies have taken
IgE) that are secreted from a population of
their place as established and effective cancer
identical cells. The commercial utility of these
therapies. Early investigations into the
highly specific molecules lies in the simplicity
effectiveness of monoclonal antibodies were
by which large quantities of IgG or other
disappointing: the murine origins of the first
antibodies with identical binding sites are
monoclonal antibodies led to host-immune
generated by in vivo or in vitro methods (1).
reactions against them, leading to rapid

clearance of the antibodies and rendering
Over the last decade, anti-epidermal
treatment possibly ineffective, and in some
growth factor receptor (EGFR) monoclonal
cases, dangerous. Since then, advances in
antibodies (mAbs) have been firmly established
technology, especially in the development of
as essential drugs for the treatment of metastatic
chimeric and humanized antibodies, have
colorectal cancer (CRC). Cetuximab and
greatly improved their therapeutic applications
panitumumab have been approved by American
and European drug agencies (2).

Based on the work of Köhler and
Milstein (1), who produced the first monoclonal
indispensable cornerstone of clinical oncology.
antibody (mAb) in 1975, numerous mAbs have
been approved for treatment of various diseases
comprise the IgG class, although numerous
by the US Food and Drug Administration
(FDA) in oncology (alemtuzumab, rituximab,
antibodies of the IgM, IgG, IgA and IgE classes
ofatumumab, bevacizumab), rheumatology
directed specifically against tumor-associated
antigens. In particular, for the IgE isotype class,
gastroenterology (infliximab, certolizumab
several recent studies could demonstrate high
pegol), dermatology (efalizumab, ustekinumab)
tumoricidic efficacy (3).

Full Paper (vol.775 paper# 19)

c:\work\Jor\vol775_20 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5677-5680

Adult Hepatoblastoma: an Update
Bilal O Al-Jiffry
Department of surgery, Taif University

Abstract: Diagnostic and therapeutic protocols of adult hepatoblastoma are lacking because it is a rare
condition, though, the pediatric one is the commonest hepatic tumor in children. The present study
aimed at revision of the English literature of the published case reports and the systematic reviews of
this rare tumor to elucidate the recent trends and update the etiological, pathological, diagnostic, and
therapeutic concerns of hepatoblastoma in adult.
Keywords: adult, hepatoblastoma, update, English literature.

Adult hepatoblastoma is a rare hepatic
reported in their systematic review that genetic
neoplasm though this tumor is the commonest
abnormalities are found in both childhood and
pediatric hepatic tumor [1, 2]. The etiology of the
adult types with various gene expression
tumor is not quit known though many authors
patterns [1]. Though infantile hepatoblastoma
correlated the development of the tumor with
occurs in normal liver, some cases of adult type
genetic factors and underlying liver diseases as
are associated with cirrhosis (11/64, 17.2%) and
hepatitis B, liver fibrosis, and cirrhosis [1-3].
chronic viral hepatitis B infection (10/64,
Diagnosis is difficult because no specific signs
15.6%). Rougemont et al. recorded the
and symptoms are present [1-4]. Workup may
association of liver cirrhosis or fibrosis with
show increased level of alpha fetoprotein with
adult hepatoblastoma in about 30% of cases and
normal or mild derangement of liver function
this difference may be related to smaller
[4]. Computed tomography scan (CT) usually
number of cases studied by the author [3].
shows stippling calcification more than other
Demographic data: Adult hepatoblastoma
hepatic tumors [4, 5]. Some authors advocated
may occur at any age and the reported mean age
needle biopsy which is not accepted by the
is about 40 years; however, the majority of
majority of other investigators for the fear of
cases were recorded in young adults [1]. Males
bleeding due to hypervascularity in addition to
are slightly more affected than females (1.14:1)
the possibility of dissemination [1-6]. The main
lines of treatment include preoperative
Pathological features:
chemotherapy for tumor down staging followed
Histologically; Ishak modified the original
by partial or total hepatectomy with orthotopic
classification of hepatoblastoma as follow:
predominant epithelial cells (epithelia type) and
chemotherapy [7-15]. Successful local control is
mixed mesenchymal and epithelial components
(mixed type) [17].
embolization (TACE), radiofrequency ablation,
Gross appearance: About 50% of the reported
or ethanol injection [1, 4, 7]. Recent reports found
cases were capsulated and two thirds of cases
that one year survival is around 25% with
had nodular surface [3]. The tumor consistency
expected worse outcome in patients above 45
was described to be firm, soft, or mixed which
years [1, 3, 16-19]. The present study aimed at
was the commonest form [17]. The majority of
revision of the English literature of the
the tumors had yellowish to grayish cut surface
published case reports and the systematic
with scattered necrotic and hemorrhagic foci
reviews of this rare tumor to elucidate the recent
and was divided into lobules by white fibro-
trends and update the etiological, pathological,
collagenous strands [3, 17].
diagnostic, and therapeutic concerns of
Diagnosis: Vishnoi et al. emphasized that the
hepatoblastoma in adult.
diagnosis of the adult hepatoblastoma is
Etiology: Adult hepatoblastoma is a rare
difficult due to lack of clinical, laboratory, and
condition and to date only 64 cases were
imaging specificity and diagnoses were settled
reported in 59 articles from 1958 to 2019 [1, 2, 4].
in the majority of the reported cases after
The etiology of the disease is not exactly known
surgery or autopsy [4]. There are no specific
and further investigations are required to
presenting symptoms or signs [1-6]. The most
correlate the reported risk factors with the
common presentation in the recorded cases was
pathogenesis of the tumor [2]. Wang and Liu
abdominal pain followed by enlarging

Full Paper (vol.775 paper# 20)

c:\work\Jor\vol775_21 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5681-5689

Association between Neutrophil to Lymphocyte Ratio and Inflammatory
Markers in Hemodialysis Patients
Hafez Ahmed Abd El-Hafeez1, Ahmed Mohammed Al-Alashkar1, Nagah Mohamed Abo
Mohamed2, Mohammed Ibrahim Khalil Zoheir1
1Department of Internal Medicine, Faculty of Medicine, Al-Azhar University
2Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University
*Corresponding author: Mohammed Ibrahim Khalil Zoheir, Mobile: (+20) 01558336585, E-Mail: dr_Zohair@ yahoo.com
Background: End stage renal disease patients on regular hemodialysis patients have higher rate of
mortality and morbidity compared to the general population.
This study aimed to study the association between neutrophil-to-lymphocytic ratio and other
inflammatory markers (IL-6, high sensitive CRP, PLR, etc) in hemodialysis patients.
Patients and methods:
This study was designed to assess inflammation in hemodialysis patients and
study the association between high sensitive CRP (hs-CRP) and the other inflammatory markers in
those patients. Initially, forty two patients with end stage renal disease (ESRD), on regular hemodialysis
in dialysis unit, Internal Medicine Department, AL-Hussien Hospital, Faculty of Medicine, Al-Azhar
Results: We calculated the cut off point for IL-6 that best indicates the presence of inflammation in
hemodialysis patients, we found that it was value more than 30 ng/l with sensitivity 96.6, specificity
69.2%, with AUC: 00.77 and P < 0.004. Moreover, we calculated the cutoff point for PLR that is
consistent with presence of inflammation in hemodialysis patients, we found that it was more than 180.2
with sensitivity 82.2%, specificity 92.3% with AUC .087 and p value equals 0.0001. In addition to
calculating the cut off point for NLR that best indicates the presence of inflammation, we found that it
was 1.6 with sensitivity 93.1%, specificity 92.3%, with AUC: 0.92 and P < 0.001.
Conclusion: We can assess cardiovascular condition of our hemodialysis patients along with their
morbidity and mortality with measuring these inflammatory markers which are nonexpensive and has
high sensitivity and specificity.
Keywords: Neutrophil to Lymphocyte Ratio, Hemodialysis Patients, ESRD, CVD
Both cardiovascular diseases and infection are
Several studies have revealed that elevated
linked to inflammation and ESKD has recently
neutrophil count was strongly associated with
been considered a state of chronic
malnutrition and inflammation and that
inflammation, which is the cornerstone of
decreased lymphocyte count had a weaker
pathogenesis of atherosclerosis, is increased in
ESRD patients compared to normal population.
decreased lymphocyte count were also
It is thought that early detection of
independent predictor of mortality in
inflammation might improve the quality of the
hemodialysis patients (3). Recently, neutrophil ­
life of those patients and decrease rate of
to- lymphocyte ratio is considered a novel
morbidity and mortality (1).
cheap and available indicator, which reflect the
extent of inflammation and atherosclerosis and
Patients on RHD have increased level of
predicts the clinical outcome and estimate
inflammatory mediators including C- reactive
survival in cardiac and non-cardiac including
protein, tumour necrosis factor and IL6, as it
ESRD (4). The neutrophil to lymphocyte ratio is
plays major role in malnutrition, inflammation
obtained by dividing the absolute neutrophil
and atherosclerosis as well as overall mortality
count by the absolute lymphocyte count. It is a
rate in these patients (2). Leukocyte are
marker of poor prognosis in several disorders
considered among the classic inflammatory
like malignancies, chronic kidney disease and
markers due to their role in pathogenesis of
myocardial function (3). Based on that, the
atherosclerosis and its complications by
present study was designed to evaluate the NLR
mediating several biochemichal pathways (2).

Full Paper (vol.775 paper# 21)

c:\work\Jor\vol775_22 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5690-5697
A Comparative Study of the Results of Three cm versus Six Cm Distance
from Pyloric Sphincter in Sleeve Gastrectomy

Ahmed Maher *, Magdy Mahmoud Mostafa, Mohammad Arafat Abd El-Maksoud

Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
* Corresponding author: Ahmed Maher, Bab El-Shaaria Hospital, E-mail: dactaraaaa@hotmail.com

: Obesity is excessive fat accumulation. Now, laparoscopic sleeve gastrectomy (LSG) is
gaining popularity as a primary, staged and provisional operation for its proven safety and simplicity.
Complete removal of the gastric fundus makes adequate weight loss and plays a key role in reducing
co-morbidities, ghrelin production, and eliminate inlet of the stomach to become small enough so that
the patient will feel full quickly.
Objective: The aim of this study was to assess the results of resecting the stomach 6-cm versus 3-cm
from the pylorus regarding weight loss, reflux development, nausea and vomiting
Patients and Methods: This randomly selected prospective study included a total of 30 morbidly obese
patients, attending at Department of General Surgery, Bab El-Shaaria, and Al-Azhar University
Hospital for doing sleeve gastrectomy. According to the starting point of stomach resection, the
included subjects were randomly divided into two groups; each was 15 patients. Group (A) started 3
cm from the pylorus towards the gastro-esophageal junction and Group (B) started 6 cm from the
pylorus. These patients followed up over a period of 2 years for postoperative nausea; vomiting and
reflux symptoms and their weight loss.
group A patients (3 cm groups) were >14 times at a higher risk to have minor complications
in the form of nausea; vomiting and reflux compared to group B patients (6 cm groups) without any
difference between both groups regarding BMI changes over a period of six months.
It could be concluded that leaving an antral pouch of 6 cm size while performing this
procedure is recommended for better outcome with minor complications.
Keywords: Obesity, laparoscopic sleeve gastrectomy, bariatric surgery

Obesity is excessive fat accumulation, and not
Roux-en-Y gastric bypass (RYGB) in super-
simply being overweight. The average human
super obese patients, body mass index (BMI)
body usually consists of 18% body fat, which in
>60 Kg/m2 or in high-risk patients[4, 5]. SG has
essence is energy stored for fasting and
been indicated as a definitive treatment in
starvation times. Thus, obesity can be defined
patients with BMI > 40 kg/m2 or BMI >35
as `over-storage of body fat beyond 18%'.
kg/m2 associated with co-morbidities [6] It has
Usually, body fat above 30% is considered
also been proposed for patients with moderate
obesity. According to this definition, obesity
obesity BMI <35 kg/m2 and metabolic
should be judged by measuring stored fat in the
syndrome [7].
body [1] .

At present, obesity can be evaluated by three
The aim of this study was to find out the results
methods: (1) Comparison with standard body
of resecting the stomach 6-cm versus 3-cm
weight, (2) Physique index and (3)
from the pylorus regarding weight loss, reflux
Measurement of subcutaneous fat thickness[17]
development, nausea and vomiting.
.Sleeve gastrectomy (SG) was introduced as a

multi-purpose bariatric operation [2]. SG
involves removing the fundus and greater
This randomly selected prospective study
curvature portion of the stomach, leaving only
included a total of 30 morbidly obese patients,
a lesser curvature tube [3].
aged 17 to 60 years, attending at Department of
General Surgery, Bab El-Shaaria, Al-Azhar
SG was initially described as a first-step
University Hospital for doing sleeve
procedure followed by either bilio-pancreatic
gastrectomy. Written informed consent from all
diversion with duodenal switch (BPD-DS) or

Full Paper (vol.775 paper# 22)

c:\work\Jor\vol775_23 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5698-5709

Posterolateral Approach for Dorsal Spine Fractures
Ahmed Salem1, Ahmed El-Narsh2, Ma'mon Abo-Shosha1, Mohamed Abd El-Hameed Abd El-
Kader El-Heeny1
1Department of Neurological Surgery, Faculty of Medicine, Al-Azhar University, 2Department of
Neurological Surgery, Faculty of Medicine, Minia University

Despite the great evolution in neurosurgical techniques, management of fractures of the
thoracic spine still represent a major conflict in neurosurgery due to the different causes leading to
fracture and the different methods available for management. The thoracolumbar region anatomically
from D11-L2 which loss the stabilization effect of the rib cage. The spinous processes are more
horizontal, which provides increase mobility.
Objective: The aim of this study is to evaluate the efficacy and success of posterolateral approach for
treatment of dorsal spine fractures surgically.
Patients and methods:
This was a prospective study of 30 patients of both sexes having all types
fractures in the dorsal region (whether traumatic or pathologic) managed in the period between October
2015 and September 2017 in Neurosurgery Department Minia and Al-Azhar University hospitals. The
study was approved by the medical ethics committee of Minia and Al-Azhar University Hospitals and
a written informed consent was obtained from all patients.
Results: Among the 30 patients, 14 of them managed by transpedicular screws fixation, 11 patients
managed by costotransversectomy with pedicular screws fixation, and 3 patients managed by
costotransversectomy with pedicular screws fixation and interbody cage insertion while one case
managed by LECA with pedicular screws fixation and another one case with LECA with both pedicular
screws and interbody cage insertion. Among the 30 patients managed 25 of them improved and 5
patients did not show any improvement during management.
Conclusion: The ideal methodology in managing fractures should be meticulous pre-operative,
operative, and postoperative management. The preoperative management should entail detailed and
through clinical neurological evaluation to point out the presence of preoperative neurological deficit
and their extent.
Keywords: Dorsal Spine Fractures, LECA, CT, Surgery, Management

pathologies of the thoracic, and lumbosacral
approach has passed through different stages
spine (4).
that created a breakthrough in management of
A costotransversectomy approach
spine fractures either traumatic or pathologic.
enables posterior stabilization with a more
The main historical aspects of the evolution of
thorough decompression of the canal than can
transpedicular fixation of the spine were
be achieved with a transpedicular approach
analyzed according to the literature. The main
because it enables more thorough bony removal
historical stages in the development of
transpedicular fixation of the spine were
The lateral extracavitary approach
identified: vertebral screw fixation (1), pedicle
(LECA) to the thoracic and lumbar spine was
screw plate system (2), external transpedicular
originally developed by Capener (6) for the
fixation ­ Fixateur Externe (3), internal
treatment of tuberculous spondylitis. The
transpedicular fixation ­ Fixateur Interne,
original procedure was modified to expand its
transpedicular titanium implants. They played a
application to other anterior spinal column
significant role in the formation of modern
pathologic findings (eg, fractures, infection,
surgical technologies for posterior metallic
thoracic disk disease) and to allow for the
placement of posterior instrumentation (7). This
multifunctional transpedicular fixation devices,
modified LECA differs from Capener's spinal
which are now considered to be the gold
exposure in the configuration of the skin
standard of posterior fixation for various
incision and in the mobilization of the erector
spinae muscle group, which are dissected along
Received:14/8/2019 accepted:14/9/2019

Full Paper (vol.775 paper# 23)

c:\work\Jor\vol775_24 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5710-5717
Orbital Volume Evaluation post Orbital Fractures Restoration
Ahmed Sabry Ahmed, Tarek Mahmoud El-Banoby, Amr Ahmed AL-Sayed Shoaib
Department of Plastic Surgery - Faculty of medicine ­ Al Azhar University
The orbits are bony structures of the skull that house the globe , extra ocular muscles
(EOM), nerves, blood vessels, lacrimal apparatus and adipose tissue. Each orbit protect the globe, while
the supportive tissues therein allow the globe to move in three dimensions (horizontal ­vertical-
Objectives: Evaluation of orbital volume after orbital fractures reconstruction by software orbital
volume measurement using CT scan.
Patients and methods: This study was conducted on 20 patients with a unilateral orbital blowout
fracture treated surgically at Department of Plastic and Reconstructive Surgery in AL-Azhar University
Hospitals from October 2018. To October 2019 and followed for 3 months were identified and included
in this study.
Results: 5% of patients had positive limitation of EOM and 90% of patients were good Pt. acceptance
post-operative. 5% of patients were dystopia post-operative, all of patients had no infection,
enophthalmouse or extrusion.
Conclusion: We must exert great effort to prevent occurrence of these injuries through a joint
cooperation with civil society through the dissemination of culture and means of safety on the highways.
Rules and basics of craniofacial osteosynthesis must be known to craniofacial surgeon starting from
wiring osteosynthesis.
Keywords: Orbital Volume, Orbital Fractures Restoration, osteosynthesis, CT scan.
Clinical presentations associated with orbital
buttress (ZMB) can appear relatively well
fractures vary in severity depending on the
aligned while there is still significant lateral
presence of ocular trauma and the location of
rotation of the malar complex in its posterior
the fracture. Symptoms include pain with
component. If one examines the lateral wall or
motility, diplopia with limitation of motion,
slides an elevator here, misalignment will easily
hypesthesia and trismus. Clinical signs include
be made known by a step-off in this region.
ecchymosis, crepitus, bone step-off, ptosis,
Every effort should be made to over-rotate the
enophthalmos and strabismus. Diplopia and
posterior aspect of the fragment in cases of
limitation of ocular movement are caused by
uncertain fragment position to cause relative
various conditions. These include orbital
compression of the orbital contents (3).
hemorrhage and edema, muscular edema or
Furthermore, orbital volume measurements can
hemorrhage, cranial nerve palsy and
be considered important for treatment planning
entrapment of soft tissue or muscle itself (1).
by providing an accurate estimation of orbital
The approach to the fracture site depends upon
implant volume, which is necessary for optimal
the type of injury, surgeon experience and
reconstruction of enophthalmos. However,
available equipment. Subciliary, subtarsal,
several problems can arise when CT scans are
transconjunctival, transwound, transscar, and
used to measure the orbital volume with
bicoronal incisions are the most commonly
utilized (2).
Difficulties in measuring the exact orbital
In a case of ZMC assessing for the accuracy of
volume include: (1) bony orbital cavities, which
reduction at the completion of the case can be
are roughly the shape of a quadrilateral pyramid
difficult. In general, the most accurate area to
with its base directed forward and laterally, not
check for adequacy of reduction and prevent
exactly located horizontally or perpendicularly
future complications is the ZS suture along the
to the axial or coronal plane, (2) bony defects,
lateral orbital wall. Rather deceivingly, the
which in some locations can introduce errors in
infraorbital rim and zygomaticomaxillary
measurement (eg, orbital apex, inferior orbital
fissure, superior orbital fissure, lacrimal sac and

Full Paper (vol.775 paper# 24)

c:\work\Jor\vol775_25 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5718-5726

Internet Addiction and Internet Gaming Disorder and Associated Insomnia
among a Sample of Al-Azhar University Students, Clinical Study
Mohamed Abdel Fattah Soliman Al Gammal, Mohamed Mohamed Ali Elsheikh, Abdelrahman
Ahmed Elrefaey Abozahra
Department of Psychiatry, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Abdelrahman Ahmed Elrefaey Abozahra,
E-mail: abdelrahmanabozahra19@gmail.com, Mobile: (+20)01120029140
Objective: The aim of this cross-sectional study was to examine and compare the prevalence of internet
addiction and internet gaming disorder with examination of related sleep problems. Also identifying
risk factors associated with them .
Patients and methods: Data were collected from 60 students of Al-Azhar University. From randomly
selected 6 different faculties. We found a high prevalence rate of Internet Addiction (IA) among them.
This prevalence was higher than Internet Gaming Disorder (IGD) prevalence. Both of IA and IGD are
inversely correlated to sleep quality. Theoretical faculties are at higher risk for IA and IGD.
Middle Socioeconomic status (SES) of adolescents' parents is related to IA but not related to IGD. 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: According to the results of the Internet Addiction Test (IAT), 46.7% of the sample had
moderate internet addiction, 3.3% had severe internet addiction and 40% had mild internet addiction.
According to results of (IGD) Scale 50% were at risk to develop Internet Gaming Disorder
(IGD)&13.6% were disordered. According to Pittsburgh Sleep Quality Index (PSQI), (60%) of the
participants were suffering from poor sleep Quality.
Conclusion: The current study has revealed a high prevalence rate of Internet Addiction (IA) among
Al-Azhar university students. This prevalence was higher than Internet Gaming Disorder (IGD)
prevalence. Both of IA and IGD are inversely correlated to sleep quality.
Keywords: IAT, IGD, PSQI, DSM­5.
Internet addiction is a global phenomenon that
global internet usage has grown nearly six-fold
has been a topic of increasing interest to
over the last decade (3). The percentage of
clinicians, researchers and stakeholders such as
internet users in Egypt was 21.6% in 2010,
teachers, parents and community groups.
which became 37.82% in 2015 (around 35
Clinical research on behavioral addictions
million users) (4). Beard recommends diagnostic
investigated many models of addiction:
criteria of Internet Addiction. Five criteria are
needed for diagnosis between pre-occupation,
compulsive sexual behavior. Similar addiction
loss of control, negative mood if kept offline
models have been applied to technological
and negative consequences from pathological
overuse (1).
internet usage (5).
Generally speaking, IA has been characterized
Internet gaming is one of the most popular
internet activities. It can be pleasurable and
rewarding but some individuals develop
regarding internet use that lead to impairment
pathological manner of usage of such activity.
or distress in several life domains (2).
Through the past few years, researchers'
interest towards this pathological behavior
In contemporary society approximately 40% of
increased and Internet Gaming Disorder (IGD)
the world population is online. Furthermore,
was listed in Diagnostic and Statistical Manual

Full Paper (vol.775 paper# 25)

c:\work\Jor\vol775_26 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5727-5732

Local and Regional Flaps in Thumb Reconstruction
Wael Mohamed Ayad, Essam Ali Taman, Mohammed Fathi Elsaid
Department of Plastic Surgery - Faculty of medicine ­ Al-Azhar university

The thumb represents a critical role in overall hand function particularly by pinching and
grasping thus, representing about 40% of actual hand function.
Objective: Evaluation of different local and regional flaps in thumb reconstruction regarding function,
sensation and aesthetic outcome.
Patients and methods:
The study included 20 patients with thumb defect admitted to Al-Azhar University
Hospital in New Damietta for prospective cohort study.
Results: Homodigital island flap was used in two cases (10 %), this type of flap proved to have excellent
cosmetic and sensory results very close to FDMA flap, with privilege over FDMA flap in large defects where
Homodigital flap proved to be better and provided adequate skin coverage. The flap was reliable, with good
vascular and sensory supply, and provided thumb reconstruction in a single stage. 8 cases (40%) by volar
advancement flap. Moberg flap was used in 8 cases. The flap was reliable, with good vascular and sensory
supply, and provided thumb reconstruction in a single stage. This flap was found to be sufficient to cover no
more than the distal one third of the distal phalanx of the thumb. Minimal flexion limitation at the inter-
phalangeal joint occurred then returned to normal in all patients. Postoperatively, no flap loss occurred.
Conclusion: V-Y, The Moberg`s flap, cross finger flap, the first dorsal metacarpal artery flap and homo-digital
island flap. The volar advancement flap (Moberg's Flap) is the simplest and easier sensate flap used for
reconstruction of thumb defects in distal third of distal phalanx less than one centimeter.
Keywords: Thumb Reconstruction, VY flap, Moberg flap, Cross-finger flap, Littler's neurovascular island


Post traumatic hand deformity especially
perforator flaps. These perforators increase flap
thumb causes major financial burden starting from
flexibility and reliability in clinical applications (5).
lack of productivity due to partial loss of function
Skin flaps may be preferred since they maintain
or residual pain up to retirement and disability.
their original color and texture, undergo less
These deformities are expected to rise especially in
contraction and have their own blood supply (6).
low and middle-income countries (1). Skin/soft-
There is deferent local flaps designed for thumb
tissue envelope of the hand is a complex structure
reconstruction as VY flap, Moberg advancement
that not only covers the underlying structures but
also has specialized functional and sensory
neurovascular island flap, first dorsal metacarpal
components. The thick glabrous skin of the palm
artery (FDMA) flap, and Reverse homodigital
withstands shearing forces encountered during
dorsoradial flap (7).
daily activities and provides discriminatory

sensory function that transfers touch, pain and
temperature, whereas the dorsal skin is pliable and
Evaluation of different local and
mobile that permits a wide range of motion of the
regional flaps in thumb reconstruction regarding
hand such as fingers pinch and grip (2).
function, sensation and aesthetic outcome.
The excellent results, with respect to

restoring contour, sensibility of the pulp, and
aesthetics of the finger will justify the more tedious
The study included 20 patients with thumb
and time-consuming treatment of fingertip
defect admitted to Al-Azhar University Hospital in
and thumb injuries (3). There are a wide range of
New Damietta for prospective cohort study during
options for thumb reconstruction ranging from
the period from November 2018 to October 2019.
grafts, pedicled flaps that can be easier, dependable
They were 18 Males and 2 females.
and time saving in centers lacking facility and

equipment up to sophisticated micro-vascular
Ethical approval:
replantation especially with traumatic injuries to
The study was approved by the Ethics
the thumb with soft tissue or bone loss (4).
Board of Al-Azhar University and an informed
There are multiple perforators in the finger
written consent was taken from each
and thumb dorsum region from the proper digital
participant in the study.
artery, which are suitable for pedicled free-style

Inclusion criteria:

Full Paper (vol.775 paper# 26)

c:\work\Jor\vol775_27 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5733-5741

The Ameliorative Potential of Saffron Against the Histological and
Immunohistochemical Changes in Kidney of Albino Mice Due to
Streptozotocin-Induced Diabetes Mellitus
Samir A. Nassar, Amal M. Hashim, Nahla H. Al-Shaer and Sahar M. Abd El-Salam
Zoology Department, Faculty of Science, Zagazig University, Egypt
Corresponding author: Samir A. Nassar; email: sanassar@zu.edu.eg., Tel.+201003699657

multiple-organ failure is the chief inducer of death in diabetes mellitus and hyperglycaemia-
induced oxidative stress is responsible for serious complications including nephropathy. Medicinal plants with
antioxidant activity may ameliorate oxidative status and improve the histological and immunohistochemical
lesions resulted in chronic hyperglycemia in diabetes.
Aim of the work: this study aimed to assess the beneficial effects of aqueous saffron extract (ASE) in
streptozotocin (STZ)-induced diabetic mice by investigating the histopathological and immunohistochemical
pattern in kidney tissues of different experimental groups.
Material and Methods: fasted mice were intraperitoneally (IP) injected by a single dose of a STZ (60 mg/kg
body weight). After 24 hours, animals with fasting blood glucose over than 300 mg/dl were considered diabetic.
The experimental groups were; control (1), saffron (2), diabetic (3) and diabetic + saffron (4). The treatment was
started on the same day of STZ administration with oral gavage of ASE (80 mg/kg body weight) along with
drinking water. At the end of the experimental period (45 days), fasting blood glucose was measured by blood
strips using an Accu-Chick Performa device (Germany). Furthermore; histopathological and
immunohistochemical studies were performed.
Results: Results showed that ASE significantly decreased blood glucose level and caspase-3 immunoexpression
in treated diabetic mice as compared to untreated diabetic ones. Moreover, ASE improved the histopathological
pattern to show a less injury.
Conclusion: administration of ASE showed significant ameliorative effects on the biochemical, histopathological
and immunohistochemical parameters in kidney tissues of treated diabetic mice.
Keywords: saffron, STZ, diabetic nephropathy, histology, caspase-3, mice.


Diabetes mellitus (DM) is a metabolic disorder
with a high prevalence rate. Its prevalence is

assumed to be around 6% up to 2025 [1]. DM is
Forty adult male Albino mice weighing 25-30 g, 8
characterized by hyperglycemia and is related to
weeks old were used in this study. Animals were
chronic disorders of carbohydrate, protein and lipid
housed under standard laboratory conditions (five
metabolism. If diabetes is not cured in time, it causes
rats per cage, an ambient temperature of 25 ± 2°C,
serious complications such as atherosclerosis,
under a 12-h light/12-h dark cycle and open access
neuropathy, retinopathy and nephropathy [2].
to food and water). All experiments performed in
It has been confirmed that hyperglycemia
accordance with the health guidelines for
supports oxidative stress with both enzymatic and
laboratory animals prepared by Zagazig
nonenzymatic mechanisms [3]. Saffron is a widely
University. After the acclimatization period,
used food additive; it is used in traditional medicine
animals were equally categorized into 4 groups as
for the treatment of numerous diseases including
follows: control (1), saffron (2), diabetes (3) and
depression, cognitive disorders, seizures and cancer
diabetes + saffron (4). Streptozotocin (STZ) (Sigma-
Aldrich, USA) was dissolved in distilled water for
Therefore, the aim of the present study was to
rapid and effective induction of diabetes after 24
investigate whether saffron supplementation could
hours and injected intraperitoneally as a single dose
ameliorate histological and immunohistochemical
(60mg/kg BW) to G3 and G4 [5, 6]. Blood samples
changes in the kidney of albino mice due to
were taken from the tail vein directly to the glucose
streptozotocin-induced DM? It is an attempt to
strips for all studied groups.
record a prophylactic role for saffron in

hyperglycemia supporting the recent trend of
Ethical approval:
alternative medicine. The onset which in turn may
This study was conducted in accordance with
minimize the risk of diabetic complications that
ethical procedures and policies approved by
became direct causes for human death.

Full Paper (vol.775 paper# 27)

c:\work\Jor\vol775_28 The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5742-5751

Cognitive Functions in Breastfed versus Artificially Fed in Preschool Children
Sara Hamed Ibrahim1, Somaya Mohamed Abd El ­Ghany1,
Tagreed Mohamed El Shafie2 , Marwa El Hady1
Pediatrics1 and Psychiatry2 Departments, Faculty of Medicine for girls -
Al­Azhar University
Breastfeeding has been widely researched and reviewed in relation to cognitive performance in
children, but early reviews have not provided compelling evidence linking breastfeeding to cognitive
Objective: To assess the effect of breastfeeding duration and exclusivity on the cognitive development of a
group of preschool Egyptian children.
Methods: The current study was a cross sectional comparative study that included 90 apparently healthy
preschool Egyptian children aged 3 - <6 years who were classified into three equal groups according to their
type of feeding in early infancy. Assessment of neurocognitive function and IQ was done using the following
3 tests: Stanford-Binet test 5th edition Arabic version (2003), Kaufman Assessment Battery for Children
(2004), Illinois Test of Psycholinguistic Abilities (ITPA) (2001).
There was significant increase in IQ detected by kauffaman test in breastfed group than either mixed
or artificially fed, while no significant difference was found in IQ between mixed and artificial fed groups.
There was significant increase in psycholinguistic age in breastfed group in comparison to artificially fed
groups, while no significant difference was found between breastfed and mixed fed or mixed fed and artificially
fed groups. Children who were breastfed had better scores in Total IQ than either artificially or mixed fed.
Also, there was significant increase in total IQ scores in mixed than artificially fed groups. A significant
positive relation was found between the total duration of breastfeeding and Binet total IQ score.
Conclusion: The effect of breastfeeding is dose-dependent, the longer the duration of breastfeeding, the more
is the benefit, the strongest effect for cognitive function in breastfed children was more prominent in
psycholinguistic age.
Keywords: Breastfed; Artificially fed, Egyptian Children.


Cognitive development in childhood is
regarding breastfeeding exposure and adequate
vital for an individual's capacity to learn and take
control for confounding factors are necessary for
advantage of the opportunities available within a
valid estimates of the relationship between
particular environment (1).
breastfeeding and later intelligence (5).
Individuals scoring higher on intelligence

tests in early childhood are usually more successful
in professional careers and achieve a higher level
To assess the effect of breastfeeding
of education and better socioeconomic status,
duration and exclusivity on the cognitive
which may in turn positively affect their health
development of a group of preschool Egyptian
status (2). Breastfeeding is recognized as the best
source of nutrition for all infants, and the World

exclusive breastfeeding until 6 months of age.
This cross sectional comparative study was
carried out on 90 apparently healthy preschool
breastfeeding for a child's mental health result
children aged 3-<6 years who were classified into
from the fact that maternal milk is a rich source of
three equal groups according to their type of
fatty acids and other bioactive components
feeding in early infancy: Group I: included 30
essential for the brain development of infants (3).
children who were exclusively breast fed 4-6
Despite the long-standing history of
months and continued breastfeeding with
research concerning breastfeeding and cognitive
complementary feeding up to at least 18 months,
ability, few well-controlled studies have examined
Group II: included 30 children who were
the potential benefits of breastfeeding on specific
artificially fed and Group III: included 30 children
cognitive processes (4).
who were mixed fed.
Failure to account for partial versus
Cases were randomly selected from
exclusive breastfeeding or breastfeeding duration
medium social class preschool nurseries from
could lead to underestimation of the true effect of
March 2015 to June 2017. All mothers enrolled in
breastfeeding on child intelligence. Detailed data

Full Paper (vol.775 paper# 28)

ABSTRACT The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5752-5758

Evaluation of Autologous Platelet Rich Fibrin in Cleft Palate Repair
Soliman Mohammed Soliman1, Abdelaziz Yehya Mahmoud1, Ahmed Abdelaal Elsayed2,
Mahmoud Abdellatif Hashish3, Mohammed Fawzy Saleh Mohammed1
1Department of Pediatric Surgery, 2Department of General Surgery, 3Department of Clinical Pathology, Faculty
of Medicine, Al-Azhar University
Corresponding author: Mohammed Fawzy Saleh Mohammed, Mobile: 01011701522

Clefts of the lip and/or palate (CLP) are common birth defects of complex etiology. Management
of this problem is somehow challenging depending on many factors. The main goal of treatment is mostly
functional for the sake of creating normal feeding pattern, acquaintance of normal hearing and hence normal
speech development. These goals carry a great impact on social and psychological status of the patient and his
family. The repair of cleft palates ideally involves an interdisciplinary team contributing together to achieve this
Objective: Evaluation of the role of platelet-rich Fibrin (PRF) on wound healing following primary cleft palate
repair. Patients and Methods: It was a prospective study done at the Department of Pediatric Surgery, Al-Azhar
University, Cairo, Egypt. A total of forty patients (both sexes) were selected randomly and performed surgery
using PRF which was placed during surgical procedure using two flap palatoplasty between the nasal and the
oral mucosa. Then, the patients were followed up for six months to evaluate its efficacy in wound healing by
monitoring incidence of fistula. All cases in the study group showed complete healing with no fistula or wound
dehiscence all over the follow up period except one patient developed oronasal fistula.
Results: In this study, post-operative bleeding tendency decreased in patients with preoperative injection of local
anesthetic with vasoconstrictor agent and the extent of the surgical field. We measured the amount of bleeding
with number of gauzes used by the parents to collect blood from the patients' mouth. Actually, it was blood mixed
with saliva in addition to the remaining serum from the PRF.
Conclusion: The use of PRF showed satisfying healing for most of the cases under study along the whole follow
up period.
Autologous Platelet Rich Fibrin, Cleft Palate.

The concept of this thesis came from utilizing
Cleft lip and palate (CLP) are considered as
recent tissue engineering techniques to overcome the
one of the most common congenital anomalies.
previously mentioned challenges.
Regardless of the race, cleft palate affects about
Platelet rich fibrin (PRF) is a new generation
1:2.000 live births worldwide (1).
of platelet concentrate that is very easy to prepare and
There is no specific etiology identified for
handle with no need for biochemical materials. Its
CLP. It is a multifactorial anomaly with other
production depends on accumulation of platelets that
contributing factors that may include radiation,
release cytokines and growth factors.6 Fibrin
maternal hypoxia, teratogenic drugs, nutritional
adhesives have been already used in cardiothoracic
deficiency, chemical exposures (2).
and vascular surgery for sealing of diffuse
The pathological sequalae of cleft palate
microvascular bleeding. Also, they were used for
include feeding and nutritional difficulties, recurrent
sealing of wound borders in general and plastic
ear infections, hearing problems, abnormal speech
surgery (6).
development and distortion of facial growth (3).
One of the challenging problems in wound
Evaluation of the role of platelet-rich Fibrin
healing that occur after surgical repair of cleft palate
(PRF) on wound healing following primary cleft
is cleft recurrence or fistula development. It occurs
palate repair.
due to local wound breakage because of tension or

compromise in the vascularity of the flap. The
recurrence of primary cleft palate fistula is reported
Study design: prospective study.
as high as up to 76 % (4).
Study settings: Forty patients with cleft palate were
Cleft demands a long term treatment plan and
selected from the outpatient clinic, Department of
a multidisciplinary management by qualified cleft
Pediatric Surgery, the Al Hussein and Sayed Galal
team. Specialists from the major areas of cleft care
University Hospitals, Al-Azhar University, Cairo,
should collaborate to give the child pleasant outcome
Egypt. After repair they followed for 6months started
and self-confidence that comes out from intelligible
1 June till 30 November 20119.
speech, healthy teeth and pleasant facial appearance
Ethical approval:

Full Paper (vol.775 paper# 29)

INTRODUCTION The Egyptian Journal of Hospital Medicine (October 2019) Vol. 77 (5), Page 5759-5765

Corneal Hysteresis before and after Corneal Collagen Cross Linking for
Magdy Ezz-Eldin Tawakol, Abd El-Magid M. Tag El-Din, Amr Gamal Hassan*
Department of Ophthalmology - Faculty of Medicine, Al Azhar University
*Corresponding author: Amr Gamal Hassan, Mobile: (+20) 01123121500, E-Mail: dr.amr-gamal89@yahoo.com

Corneal collagen cross-linking (CXL) has been used as a treatment option in patients with either
keratoconus or iatrogenic corneal ectasia after LASIK. The purpose of corneal cross-linking is to stabilize the corneal
stroma and to delay the progression of these two pathologic entities.
Objective: The aim of this study is to compare the corneal hysteresis before and after corneal collagen cross-linking
using riboflavin and ultraviolet-A light by the epithelial-off technique for treatment of keratoconus.
Patients and methods: This study is a single-centre prospective interventional study. It was conducted between
April 2018 to December 2018 and included 30 eyes of 18 patients with a mean age 27.08 years (range from 17- 30).
They were 12 female eyes and 18 male eyes; all underwent corneal collagen cross-linking using riboflavin and
ultraviolet-A light at Kobry El Kobba Military Specialized Eye Hospital.
Results: All patients were evaluated preoperatively for their uncorrected corrected visual acuity (UCVA), best
corrected visual acuity (BCVA), k-reading, spherical equivalent and pachymetry (using Pentacam), and corneal
biomechanical properties (using ocular response analyzer (ORA). The mean age was 27.08±7.86 years, and
postoperative follow up was at 1 and 4 months. The mean CH was 7.93±1.79 mmHg preoperatively, 8.27±1.22 mmHg
at 1 month, 8.99±1.24 mmHg at 4 months, which show a statistically significant increase in the mean CH pre- and
postoperatively, while CRF the other parameter, show a highly statistically significant decrease pre- and
Conclusion: CXL is a promising new treatment modality for keratoconus patients and may affect corneal
Keywords: Corneal Hysteresis, Corneal Collagen cross-linking, Keratoconus, Riboflavin, Ultraviolet-A light.


camera Scheimpflug imagery (Pentacam) provides a
inflammatory corneal disorder. It leads to decreased
multitude of corneal refractive (keratometric),
vision by distorting the anterior corneal surface, and
topometric, tomographic, and pachymetric data. In
inducing apical thinning, high irregular astigmatism,
addition, specific anterior-surface irregularity indices
and central scarring of the cornea. Several modalities
have been developed for the grading and classification
such as hard contact lens, intracorneal stromal ring
of keratoconus development, as well as the
implantation, and penetrating keratoplasty are used to
postoperative assessment. During the last decade,
treat keratoconus. All these techniques only correct the
Corneal collagen cross-linking (CXL) technique had
refractive error of the cornea with no effect on the
gained wide spread successful use in the treatment of
progression of keratoconus. The only treatment that is
ectasias, and many studies had reported that CXL is able
believed to have the ability to stop or decrease the
to halt progression, stabilize the disease, reduce corneal
progression of keratoconus is collagen cross-linking
curvature and improve visual acuity (2).
Corneal collagen cross-linking (CXL) had been
thermomechanical and morphological properties of the
shown to stop disease progression in keratoconus over
cornea. It increases stiffness and rigidity of the anterior
90% of eyes. This procedure significantly increases the
corneal stroma and enhances corneal resistance to
biomechanical strength of the cornea by photochemical
proteolytic enzymes by inducing photochemical
crosslinking of individual collagen fibers by utilizing
crosslinking and covalent bindings between individual
riboflavin and ultraviolet-A light (3).
collagen fibers. CXL halts the progression of
The ocular response analyzer (ORA) is used to
keratoconus with a failure rate of approximately 3% and
measure in vivo corneal biomechanical properties, which
a complication rate of 1% (1).
are presented by two parameters corneal hysteresis (CH),
Since CXL alters the corneal shape and
and the corneal resistance factor (CRF). It also provides
structure, it would be helpful to assess resulting changes
measurements of Goldmann-correlated intraocular
in quantitative descriptors of the cornea, which can
pressure (IOPg) and corneal compensated IOP (IOPcc)
affect the clinical outcome of this procedure. Previous
which are independent of the influence of corneal
studies have shown that CXL improves visual acuity,
biomechanical properties (4).
average keratometry values, and definable measures of
Corneal hysteresis (CH) is explained by the
corneal topography regularity. This aimed to evaluate
viscoelastic structure of the human cornea and its
the effect of CXL on corneal biomechanics. Rotating

Full Paper (vol.775 paper# 30)