The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 356-361
Occurrence and Recurrence of Hepatocellular Carcinoma after Direct Acting
Antivirals in Compensated Chronic Hepatitis (C) Cirrhotic Egyptian Patients
Enas Ahmed Reda Alkareemy1, Mohammed Zain El-Din Hafiz1,
Soumaia Ahmed Mohammed Ahmed2, Ahmed Saad Allah Abd el Aal Ahmed*2
1Departemnt of Internal Medicine - Faculty of Medicine - Assiut University,
2Departemnt of Internal Medicine - Faculty of Medicine - Aswan University
*Corresponding author: Ahmed Saad Allah Abd el Aal Ahmed, Mobile: (+20) 01006818903,
Background: Egypt had been vexed by the highest load of chronic hepatitis C in the world. It represents a vast market
of the new direct-acting anti-viral drugs (DAAs); effectively treating chronic hepatitis C virus (HCV) infection.
Objectives: The aim of this study is to detect the occurrence and recurrence of hepatocellular carcinoma (HCC) during
the follow-up after antiviral treatment with direct acting antiviral therapy in patients with chronic HCV infection and in
patient with chronic HCV prior history of treated hepatocellular carcinoma who achieved complete response.
Subjects and methods: This was prospective study including 150 patients with compensated chronic hepatitis C virus
infection and 150 patients with compensated chronic hepatitis C virus infection prior history of treated hepatocellular
carcinoma. The patients were attending Aswan university hospital and viral hepatitis unit in addition to Viral Hepatitis
Unit and were prospectively collected at the end of December 2019. The patients were divided into two groups: Group
(A): patients with chronic HCV infection who were treated with direct acting antivirals. Group (B): patients with chronic
HCV infection prior history of treated hepatocellular carcinoma who were treated with direct acting antivirals.
Results: The results of the study revealed that there was no significant difference between the studied groups as regard
time needed for HCC to occur after DAA.
Conclusion: Surveillance programs should be widely endorsed during and after DAAs therapy for patients at HCC risk,
even for those who had been achieved HCV cure.
Keywords: Chronic hepatitis C, Direct acting antiviral, Egypt, Hepatocellular carcinoma.
Conflicts of interest: no conflicts of interest were encountered.
Acknowledgement: The authors are grateful for the patients without whom this study would not have been done.
Hepatocellular carcinoma (HCC) is one of the
Hepatitis C virus (HCV) is a major global
most dreadful sequels of hepatitis C virus (HCV)-
healthcare problem. The WHO estimated that up to 3%
related cirrhosis. New direct-acting antivirals (DAA)
of the world's population were infected with the virus,
have successfully created a new era of HCV
equating to more than 170 million individuals
elimination (6). However, their role in moderating the
worldwide, with significant associated morbidity and
incidence of HCC in those patients is still
Egypt has the highest prevalence rate of hepatitis
During the previous decades, pegylated
C virus (HCV) in the world, making it the most
interferon (PEG-IFN) plus ribavirin therapy for
challenging public health problem facing the country
patients with chronic hepatitis C (CHC) cured hepatic
(2). Studies show that 14.7% of the Egyptian population
C virus (HCV) infection in approximately 50% of
carries HCV antibodies and 9.8% have an active
treated patients (7). Emerging treatments with IFN-free
direct-acting antiviral agents (DAA) for patients with
In 2015, Egypt Health Issues Survey showed that
chronic CHC directly target HCV replication and have
10% of Egyptians between 15 59 years of age had
been widely used globally since 2014. Compared to
been infected with HCV infection, while 7% were
conventional IFN-therapy, the sustained virological
chronic active hepatitis C patients (4).
response (SVR) rate is higher and the side effects are
A mathematical model was used to estimate the
reduced with DAA therapy (8).
2014 prevalence in Egypt. Assuming that 65,000
In recent years, a dramatic improvement in HCV
patients were treated annually with pegylated (PEG)
therapy followed the introduction of oral medicines
interferon and ribavirin (RBV) with a sustained
that directly inhibited the replication cycle of HCV.
These medicines, called direct-acting antivirals
patients were cured, that an estimated 150,000 new
(DAAs), target three important regions within the
infections occur annually leading to 100,000 chronic
HCV genome: NS3/4A protease, NS5A and NS5B
HCV infections and that 150,000 persons with HCV
RNA-dependent polymerase. These medicines have
die (120,000 of causes other than liver disease and
led to higher sustained virological responses (SVRs)
than interferon-based regimens, are shorter in
seroprevalence was modeled to 10.6% and viremic
treatment duration, are orally administered and have
prevalence to 7.3% in 2014 (5).
fewer side effects. Individual DAAs vary in
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 362-368
Effect of Treating Chronic Hepatitis C Infection with Direct-Acting
Antivirals on The Risk of Recurrence Hepatocellular Carcinoma
Enas Ahmed Reda Alkareemy1, Mohammed Zain El-Din Hafiz1,
Soumaia Ahmed Mohammed Ahmed2, Ahmed Saad Allah Abd el Aal Ahmed*2
1Department of Internal Medicine, Faculty of Medicine, Assiut University,
2 Department of Internal Medicine, Faculty of Medicine, Aswan University
*Corresponding author: Ahmed Saad Allah Abd el Aal Ahmed, Mobile: (+20)1006818903, Email: firstname.lastname@example.org
Background: Hepatitis C virus (HCV) is a major global healthcare problem. The WHO estimates that up to 3% of
the world's population has been infected with the virus, equating to more than 170 million individuals worldwide,
with significant associated morbidity and mortality. Objective: The aim of this study was to detect effect of treating
chronic hepatitis C infection with direct-acting antivirals on the risk of recurrence hepatocellular carcinoma.
Subjects and methods: This prospective study included a total of 150 patients with compensated chronic hepatitis
C virus infection and 150 patients with compensated chronic hepatitis C virus infection with prior history of treated
hepatocellular carcinoma by ablation, resection, chemoembolization or liver transplantation, attending at Viral
Hepatitis Units, Departments of Internal Medicine, Assiut and Aswan University Hospitals. This study was
conducted between December 2017 and December 2019. Results: The present study shows that 33.3% of HCC had
history of treatment with surgical resection, 46.7% had history of Radiofrequency ablation (RFA), 13.3% of
Transarterial Chemoembolization (TACE) and 6.7% with liver transplantation. There were highly significant
differences between the two studied groups as regard ALT, total bilirubin, creatinine and AFP levels. There were no
significant differences between the two studied groups as regard albumin, INR, platelets, total protein and WBCs.
There were no significant differences between the studied groups as regard Hepatocellular carcinoma "occurrence or
recurrence" and time needed for HCC to occur after direct-acting antiviral agents (DAAs).
Conclusion: It could be concluded that antiviral treatment should not be delayed in hepatocellular carcinoma patients
in order to avoid further liver deterioration and extrahepatic complications of HCV.
Keywords: HCV, HCC, DAA, SVR, Hepatocellular carcinoma
The development of safe and effective treatments
rate of HCC dropped from 7.2/1000 person-years
for hepatitis C virus (HCV) infection has been a major
among patients with no SVR to 1.1/1000 person-years
concern for hepatologists in the last few decades. The
among those who achieved a SVR (3). Solid data on the
era of interferon (IFN)-based treatment regimens was
long-term outcome of cirrhotic patients treated with
plagued with frequent, severe adverse events
these new regimens are still unavailable, however, and
necessitating a strict follow-up and prompt
DAA registration trials did not distinguish between
management of complications, while sustained
patients with and without a history of HCC (4).
virologic response (SVR) rates were often not very high
To date, controversial data have emerged on
HCC occurrence/recurrence after HCV eradication
The last few years have seen a major step forward
with IFN-free treatment regimens. Most reports come
in the treatment of HCV with the introduction of all-
from single-center, often retrospective, observational
oral therapies. Direct-acting antiviral agents (DAAs)
studies, with differences in patients' characteristics and
have since revolutionized the management of HCV
length of follow-up. The picture consequently remains
patients, achieving high eradication rates with an
unclear for now, with a marked heterogeneity, even in
excellent safety profile. The restrictions that IFN
terms of the control groups considered: some authors
treatments imposed have been consigned to history and
compared DAA-treated patients with those treated with
SVR rates have consistently exceeded 90%, regardless
IFN-based regimens; others compared them with
of the chosen antiviral schedule. These unexpected,
untreated patients; and retrospective cohorts belonging
striking results led to the assumption that HCV could
to different eras were often involved. This might be
be virtually eradicated and on a global level,
partly attributable to several factors (5).
interrupting the natural history of the disease without
For a start, HCC onset was not an endpoint in the
incurring any severe side effects (2).
initial DAA registration studies. Secondly, trials
Bearing in mind that chronic HCV infection is
included patients with both chronic hepatitis C (CHC)
one of the main risk factors for the onset of
and cirrhosis, with or without a history of HCC, and
hepatocellular carcinoma (HCC), lower rates of the
usually with a follow-up after treatment too short for
latter's occurrence/recurrence were expected in the
the purpose of assessing HCC onset or recurrence. The
HCV-eradicated population, whatever the stage of their
incidence of HCC is also difficult to compare between
liver disease was. Accordingly, as previously seen for
patients given DAAs as opposed to IFN-based
patients successfully treated with IFN, the incidence
regimens because the former group also includes
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 369-373
Prediction of Spontaneous Abortion Risk by the Use of First Trimester
Ultrasound Measurements and Maternal Serum Progesterone Level
Mahmoud Attia Seksaka1, Amany Mohammed Abdelghany1,
Entesar Roshdy Mahdy 1, Mohammed Elsayed Fadaly Mahmoud*2
1Obstetrics and Gynecology Departments - Faculty of Medicine, Zagazig University
2Resident of Obstetrics and Gynecology, Al-Ahrar Teaching Hospital
*Corresponding author: Mohammed Elsayed Fadaly Mahmoud, Mobile: 01090178902,
Background: Prompt diagnosis of early pregnancy failure is a difficult dilemma. There is no single test
currently available which immediately differentiates continuing from non-continuing intrauterine or tubal
pregnancy. First-trimester ultrasonography is routinely performed to confirm pregnancy location and assess
Objective: The aim of this study was early detection of spontaneous abortion risk.
Material and methods: This study was conducted in the Department of Obstetrics and Gynecology, Zagzaig
University. Sample size was 40 patients. Assuming that mean difference between Group (A) who miscarried
and group (B) who continued pregnancy after 20th week in the mean gestational sac diameter 17.9 ± 3.3 and
20.7 ± 3 respectively.
Results: 40 patients with mean age 27.55 ± 3.77 years old ranging from 21 to 37 years. All group were in
7th week of pregnancy. Parity was distributed as 25% were primigravida (PG) and about two third were 1-2
and only 10% had parity >2. MSD, CRL, MSD-CRL and FHR parameters were distributed as 19.98 ± 4.97,
8.42 ± 1.71, 11.56 ± 3.5 and 135.6 ± 15.13 respectively. Women in the abortion group had significantly
lower MGSD, CRL, MGSD-CRL ratio and FHR values in comparison with women in the non-abortion
group (12.9 ± 2.4 vs. 22.4 ± 2.9, 6.1 ± 0.91 vs. 9.2 ± 1.1, 6.8 ±1.6 vs. 13.1 ± 2.3 and 115.0 ± 8.2 vs. 142.0 ±
9.6 respectively) with p-value: < 0.001.
Conclusion: Measuring serum progesterone, and first-trimester ultrasound measurements of MGSD, CRL,
MGSD/CRL ratio and FHR were good predictors of early pregnancy failure and can be used as a risk
assessment model that can predict the risk of early spontaneous abortion.
Keywords: Spontaneous abortion risk, First Trimester Ultrasound, Maternal Serum Progesterone Level
List of abbreviations:CRL, crown-rump length; ELISA, enzyme-linked immunoassay; FHR, fetal heart
rate; GSD, gestational sac diameter; MGSD, mean gestational sac diameter; NPV, negative predictive value;
PPV, positive predictive value; ROC, receiver operator characteristic; SD, standard deviation; TVS,
During pregnancy, it is secreted from corpus
Spontaneous miscarriage is the inevitable
luteum and placenta (3).
termination of pregnancy before 20 weeks of
The maintenance of normal pregnancy up to 7
gestation or spontaneous expulsion of fetus below
to 8 weeks of pregnancy is dependent on
500g (1). Spontaneous miscarriage accounts for
progesterone synthesis by corpus luteum under the
about 15% of pregnancies. 1% of it is recurrent.
effect of human chorionic gonadotropin, from the
More than 80% of abortion occurs in the first 12
7th week onward the placenta takes over the
weeks of pregnancy; at least half result from
dominant role of steroid production. Progesterone
chromosomal anomalies (2, 3).
is known to have inhibitory effects on smooth
Spontaneous abortion is categorized as
muscle contraction (3). Serum progesterone
threatened, inevitable, incomplete, complete, or
measurement is a reliable biochemical test in
missed. Abortion can be further categorized as
establishing the diagnosis of early pregnancy
sporadic or recurrent (3).
Ectopic pregnancy, gestational trophoblastic
revolutionized the diagnosis of early pregnancy as
disease (GTD) and implantation bleeding are
it can detect a pregnancy at an earlier stage,
differential diagnosis for miscarriage (1).
whether it is normal and therefore reassuring, or
Progesterone is a C-21 steroid hormone,
abnormal and require intervention (3, 4).
belongs to a class of hormones called
Embryonic bradycardia and absence of yolk
progestogens (2). Progesterone is produced in
sac or even a smaller yolk sac diameter than
adrenal glands, the gonads (specifically after
expected for any gestational age are predictors of
ovulation in the corpus luteum), and the brain.
poor pregnancy outcome during the first 12 weeks
(5). The shape of gestational sac, the echogenicity
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 374-380
Role of Nuclear Medicine in Renal Transplantation
Sara Saber Ahmed Abd-Elbaset 1, Waleed Ahmed Mohamed Diab 2,
Mohamed Soliman Gaber 1, Wafaa Abd-Elhamed El-sayeed 1
1 Clinical Oncology and Nuclear Medicine Department, Faculty of Medicine, Sohag University,
2 Nuclear Medicine Department, Faculty of Medicine, Assuit University
Background: Precise diagnosis of renal transplant complications is very important as many complications are
potentially treatable if detected early. CT, MR imaging, and nuclear medicine studies play a complimentary role.
Nuclear medicine renal scans (using radioactive 99mTc DTPA or 51Cr-EDTA) are considered the gold standard for
the evaluation of kidney function because of their accuracy
Objective: To spotlight on the important role of nuclear medicine on the preparation of both donor and recipient,
follow up and early detection of any abnormality in the transplanted kidney with smooth noninvasive techniques.
Conclusion: Renal scintigraphy (RS) has its merits for the evaluation of complications after kidney transplantation,
especially for urological and/or vascular complications. Early diagnosis of vascular and urological complications can
contribute to a more specific surgical intervention and better post-transplant outcomes. RS should be used in case of
non-acute complications, and if the ultrasound (US) provides insufficient results. Radionuclide imaging has the
unique advantage of relating perfusion to function. Comparative studies between renal scintigraphy and Doppler
sonography seem to have similar performance in the evaluation of renal transplant perfusion.
Keywords: Nuclear medicine, Renal transplantation
Acknowledgement: This publication is a part of the partial fulfillment of Master Degree of nuclear medicine.
The authors have acknowledgement of gratitude toward Professor Ahmed Kandeel for revision and tuning of this
Authors' disclosures of potential conflicts of interest: The author(s) indicated no potential conflicts of interest.
The kidney is a very important filtering organ of
Detection of the changes in the transplanted
the body. When the kidney reaches stage 5 chronic
kidney function is very important to make the
kidney disease, its mean end-stage renal failure, renal
appropriate management. Accurate and noninvasive
transplantation is the preeminent therapy. Although it is
diagnostic measures take an important place in the early
the best option of treatment, lack of kidney donors is
still challenging. Therefore, all efforts should be
ultrasonography (US), radionuclide imaging, CT, and
directed toward the long term survival of the
MRI provide anatomical and functional information for
transplanted kidney. However, graft dysfunction (e.g.,
the differential diagnosis of renal graft dysfunction as a
acute rejection) is one of the serious barriers to prolong
result of surgical or parenchymal complications. Renal
the survival rate of the transplanted kidney. Currently,
scintigraphy is a modality capable of measure graft
the gold standard of diagnosis of graft dysfunction is
function, not only qualitatively but also quantitatively.
renal biopsy. Although biopsy is helpful, it is not
For this purpose, the most commonly used tracers are
preferred due to it is invasive nature, high morbidity
iothalamate, 51Cr-EDTA, and 99mTc-DTPA, which
rates, and it is expensive. Therefore, noninvasive
their plasma clearance reflects the glomerular filtration
imaging modalities have become the subject of research
rate. 131-OIH has been used for the measurement of
and interest, giving the promise to replace, or at least to
effective renal plasma flow (ERPF) for a long time;
decrease, the use of biopsy in diagnosing graft
however, since 1990, 131-OIH has been replaced by
other tubular agents such as 99mTc-MAG3 and 99mTc-
Although renal transplantation is the treatment
choice, it is still associated with many complications.
A renal scan is very important to determine as
These complications can be divided into two subgroups,
accurately as possible the renal function in potential
that is, parenchymal complications include acute
living renal transplant donors, especially those with
tubular necrosis (ATN), delayed graft function (DGF),
limited renal function (Cr Cl <90 mL/m/1.73 m2), age
antibody-mediated rejection (ABMR), or Tcell-
older than 50 years, and cardiovascular risk factors that
mediated rejection (TCMR), and damage caused by
might favor development of long-term kidney diseases
nephrotoxic drugs, surgical complications are rare and
(3). Following nephrectomy months to years, donors
include decreased blood caused by anastomotic
experience a 2540% absolute reduction in their
complications, vascular thrombosis, hematoma, fluid
glomerular filtration rate (GFR) compared to their pre-
collection, or lymphoceles, ureteral obstruction or
donation level (4). Compensation on the part of the
remaining kidney reaches 70% of initial function (5).
Received: 1/1 /2020
Accepted: 10/2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 381-383
Endoscopic Resection of a Granular Cell Tumor: A Case Report
Omar Ahmed AL Omair
Internal Medicine Department, College of Medicine, King Faisal University, Saudi Arabia
Background: Granular cell tumors (GCTs) are benign soft tissue tumors that are thought to originate from Schwann
cells. They are relatively rare, and presentation in the gastrointestinal tract is even more uncommon.
Case report: In this paper, we present a 26-year-old female patient who was incidentally diagnosed with an esophageal
GCT. The tumor was initially detected by endoscopy, evaluated by endoscopic ultrasonography (EUS), then resected
using an endoscopic mucosal resection technique.
Keywords: Endoscopic, Granular Cell Tumor.
international normalized ratio (INR) was 1.08, random
Granular cell tumors are rare, generally benign
blood sugar (RBS) level 4.37 mmol/L, urea 2.16
tumor of neural origin (Schwann cell tumors) that can
mmol/L, and creatinine 78.65 mmol/L.
occur at any site of the body but are usually found on the
When EGD was done, it showed a medium size
tongue, subcutaneous tissues, and breast. Located in
lesion around (1 cm), yellow-colored, non-obstructing,
gastrointestinal tract is uncommon, and most commonly
non-circumferential lesion in the middle third of the
presented in the esophagus.
esophagus (26 cm from the incisors) (Figure-1). No other
GCTs were first described in the tongue by
lesions or masses were found in the stomach nor
Abrikossoff in 1926 and were previously called granular
duodenum, but a diffuse nodular mucosa was found in
cell myoblastomas or Abrikossoff's tumors. Esophageal
the antrum and body of the stomach. Histopathology of
GCTs, however, were first reported in 1931. (1-3) Large
the gastric biopsies showed evidence of Helicobacter
GCTs (>1 cm) can leads to dysphagia. Because most
GCTs have a low risk of malignancy (<2%), and most
patients are asymptomatic, the management approach is
While the prevalence of esophageal GCTs is
unclear, there is a study showed that these tumors
account for less than 1% of all benign esophageal
tumors, and most patients were diagnosed by upper
esophagogastroduodenoscopy (EGD) while going under
the procedure for other indications. (5)
In this report, we present a case of a 26-year-old
female who was found to have an esophageal GCT while
being screened for endoscopic abnormalities before
intragastric balloon placement.
A 26-year-old obese female, not known to have
Figure1: Endoscopic picture of around 1 cm,
any chronic conditions, presented to the endoscopy unit
yellow colored, non-obstructing, non-
for assessment before possible placement of an
circumferential lesion in the middle third of the
intragastric balloon. The patient had no history of
dysphagia, abdominal pain, weight loss nor any other
gastrointestinal complaints. She also denied alcohol
consumption, smoking, and drugs.
The EGD was followed by an upper
The patient was vitally stable before the
gastrointestinal endoscopic ultrasound. The esophageal
procedure, and her physical examination was
mass that was found earlier was isoechoic, and there was
sonographic evidence suggesting local invasion into the
Her laboratory findings a hemoglobin level of 11.7
deep mucosa (layer 2) (Figure-2). Otherwise, there were
g/dL, hematocrit of 35.5%, white cell count (WBC) of
no significant endosonographic abnormalities in the
5.8 × 109/L, and a platelet count of 330 × 109/L. Her
stomach, examined duodenum, liver nor pancreas
Received:2 /1 /2020
Accepted:11 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 384-391
Laparoscopic Mini- Gastric Bypass in Management of
Morbid Obesity A Prospective Study
Hussein Ali Mostafa Abd Al-Motalib1, Osama Yassin Mostafa Taha2,
Abdel Aal Ali Sleem3, Ahmed Mostafa Maghraby Mohamed*1
1Department of General and laparoscopic surgery, Faculty of medicine Aswan University,
2Department of Plastic and Bariatric surgery, Faculty of Medicine Assiut University,
3Department of General surgery, Faculty of Medicine - Sohag University
*Corresponding author: Ahmed Mostafa Maghraby Mohamed, Tel: +201064600048,
Background: In recent years, a surgical technique known as single-anastomosis gastric bypass (SAGB) or mini-
gastric bypass (MGB) has been developed. Its frequency of performance has increased considerably in the current
decade. This procedure proposes a simplification of Roux-en-Y bypass by performing a single anastomosis, with
a significant reduction of technical complexity, shorter operative time and a potential reduction in morbidity and
Objective: This study aimed to evaluate if laparoscopic mini gastric bypass operation is safe and effective for
treatment of different cases with morbid obesity and its associated comorbidities
Material and methods: This was a prospective study of 100 patients with morbid obesity submitted to
laparoscopic MGB from March 2018 to January 2019. This study was conducted in the Bariatric Surgery Unit, at
Assuit university hospital and Osama Taha group clinic. Demographic and clinical data were prospectively
collected from the preoperative evaluations.
Results: The most important findings of this study were the safety and the high efficacy, which were translated
into no mortality, very acceptable complications (early complication rate 4% and late complication rate 6 %).
High excess weight loss (EWL) 72.26 ± 5.18 % and remission rate 92% of patients who had diabetes, as 100.0%
of patients who had fatty liver, 96.0% of patients who had hyperlipidemia, 95.0% of patients who had sleep apnea
and 94.0% of patients who had hypertension.
Conclusion: MGB/ one-anastomosis gastric bypass (OAGB) is a simple, safe, effective, easy to learn and easy to
reverse procedure. It has acceptable complications and mortality rates.
Keywords: MGB, EWL, Morbid Obesity.
proposes a simplification of Roux-en-Y bypass by
Obesity, defined as a body mass index (BMI) >
performing a single anastomosis, with a significant
30 kg/m2, is a chronic illness identified in children,
reduction of technical complexity, shorter operative
adolescents and adults worldwide. According to the
time and a potential reduction in morbidity and
World Health Organization, there are 42 million
mortality. Several studies have demonstrated the
obese children under the age of 5 (1, 2).
benefits provided by this procedure, including excess
Globally, a total of 1.9 billion and 609 million
weight loss and resolution of comorbidities
adults were estimated to be overweight and obese in
equivalent or even higher than those observed after
2015, respectively, representing approximately 39%
the Roux-en-Y gastric bypass. It is simpler and
of the world's population. The use of bariatric
potentially more cost-effective, since less stapler
surgery has increased dramatically during the past
cartridges are necessary (4).
decade it is currently the only modality that provides
This study was to evaluate if laparoscopic mini
a significant, sustained weight loss for morbidly
gastric bypass operation is safe and effective for
obese patients, with resultant improvement in
treatment of different cases with morbid obesity and
obesity-related comorbidities. A prospective,
its associated comorbidities.
controlled Swedish study involving 4047 obese
patients, half of whom had undergone bariatric
MATERIAL AND METHODS
procedures, followed up over 14.7 years, found that
This was a prospective study of 100 patients with
when compared to usual care, bariatric surgery was
morbid obesity submitted to laparoscopic MGB from
associated with a significantly reduced number of
March 2018 to January 2019. This comprised the
cardiovascular deaths and a lower incidence of
initial part of our series and data were analyzed after
cardiovascular events in obese adults (3).
all patients completed a follow up of 1 year.
In recent years, a surgical technique known as
Patient inclusion was according to criteria by the
single-anastomosis gastric bypass (SAGB) or mini-
National Institutes of Health Development Panel
gastric bypass (MGB) has been developed; its
(body mass index (BMI) > 40 kg/m2 or BMI > 35
kg/m2 with severe related comorbidity) (5), age after
considerably in the current decade. This procedure
Received:4 /1 /2020
Accepted:13 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 392-399
Management of Inflammatory Pancreatic Fluid Collections and Walled-off
Pancreatic Necrosis: A Retrospective Study Over Five Years
Mahmoud Khairallah1, Ahmed Khairallah2, Mohamed Ibrahim Kassem1,
Ahmed El Sayed Shaaban1, Mostafa Refaie El Keleny1
1Department of General Surgery, Alexandria University, 2Departement of Internal Medicine,
National Research Centre, Egypt
Corresponding author: Mahmoud Khairallah, Email: Mahmoud.email@example.com
Background and objective: Acute pancreatitis (AP) is an inflammatory process of the pancreas, with variable
involvement of peri-pancreatic tissues and remote organ systems. In this study we discuss surgical and conservative
management of acute pancreatitis and its local complication.
Methods: This retrospective study was carried out on 128 patients, who were admitted to Gastrointestinal Surgery
Unit, Main Alexandria University Hospital, Alexandria University, and who were complaining of acute pancreatitis
with fluid collections and sequels (PP, ANC and walled-off pancreatic necrosis (WOPN). Medical information was
retrieved retrospectively from patient's files recorded in Main Alexandria University Hospital and from computerized
data system in Gastrointestinal Surgery Department, between October 2013 October 2018.
Results: Forty-five patients with acute edematous pancreatitis with free collection were managed conservatively
successfully. Thirty-two patients with PP underwent drainage, endoscopic (n=17), or open (n=15) approach. Twenty-
three patients with WON underwent drainage and debridement whether by open (n=11), endoscopic (n=9), or PCD
(n=3) approaches. Twenty-eight patients with necrotizing pancreatitis, 16 patients were managed conservatively, 12
patients needed intervention either, PCD (n=9) or open surgical necrosectomy (n=3).
Conclusions: The operative management of acute pancreatitis is focused on managing the acute complications, and
the long-term sequelae. However, the evolution of videoscopic and endoscopic techniques have greatly expanded the
Keywords: Acute pancreatitis, Necrotizing pancreatitis, Pseudo pancreatic cyst, Walled off necrosis.
The first stage is related to the pathophysiology
of the inflammatory cascade; usually lasts a week.
It is an inflammatory condition of the
During this phase, the severity of acute pancreatitis is
pancrease and clinically characterized by acute
related to organ failure secondary to the patient's
abdominal pain and elevated level of pancreatic enzymes
systemic inflammatory response elicited by acinar cell
in the blood, in some cases it can be fatal (1).
injury. The second stage is characterized by local
Worldwide, the incidence of acute pancreatitis
complications after one or two weeks (better assessed by
ranges between 5 and 80 per 100,000 population, with
CT Balthazar score), occurs only in patients with
the highest incidence recorded in the United States and
moderately severe or severe pancreatitis (5).
Finland (1). The incidence of acute pancreatitis in USA
anges from 4.9 to 35 per 100,000 per year (2).
Acute pancreatitis is best defined clinically as
the patient presenting with 2 of the following 3
Common etiologies of AP are summarized as
follows, provided that gallstones and alcoholism
(1) Symptoms, such as epigastric pain, consistent with
constitute 75% of causes (3):
i. Obstructive (Gallstones, biliary sludge and
(2) A serum amylase and lipase greater than 3 times the
microlithiasis, tumors, helminthes), and functional
upper limit of normal.
(Sphincter of Oddi dysfunction).
(3) Radiologic imaging consistent with the diagnosis
ii. Alcohol, toxins, drugs.
via computed tomography (CT).
iii. Metabolic disorders (Hypertriglyceridemia,
iv. Iatrogenic e.g. post endoscopic retrograde
1. Intravenous fluid administration
v. Trauma (4).
2. Good analgesia
Acute pancreatitis has two distinct stages.
3. Antibiotics in sever pancreatitis
Received:18 /9 /2019
Accepted:27 10/ /2019
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 400-405
Outcome of Single Anastomosis Gastric Bypass in
100 Obese Diabetic Patients, A Prospective Study
Hussein Ali Mostafa Abd Al-Motalib1, Osama Yassin Mostafa Taha2,
Abdel Aal Ali Sleem3, Ahmed Mostafa Maghraby Mohamed*1
1Department of General and Laparoscopic Surgery, Faculty of medicine, Aswan University,
2Department of Plastic and Bariatric surgery, Faculty of Medicine, Assiut University,
3Department of General surgery, Faculty of Medicine, Sohag University
*Corresponding author: Ahmed Mostafa Maghraby Mohamed,
Tel: (+20)1064600048, Email: firstname.lastname@example.org
Background: Type 2 diabetes mellitus ((T2DM) is one of the most challenging health problems of the twenty-first
century. A further 318 million adults are estimated to have impaired glucose tolerance, which puts them at high
risk of developing the disease. (T2DM remission has been reported to varying degrees after all current bariatric
operations. Objective: The aim of this study was to evaluate if laparoscopic mini gastric bypass (MGB) operation
is effective for treatment of (T2DM associated with morbid obesity.
Material and methods: This prospective study included a total of 100 patients with morbid obesity submitted to
Laparoscopic MGB from March 2018 to January 2019. This comprises the initial part of our series, and data was
analyzed after all patients completed a follow up of 1 year. This study was conducted in the Bariatric Surgery Unit,
at Assuit university hospital and Osama Taha group clinic. Demographic and clinical data were prospectively
collected from the preoperative evaluations. Results: Diabetic patients showed significant decrease in random
blood sugar (RBS) and HA1c in 1 year follow up after surgery. The mean RBS preoperative was 294.40±57.13
while after 1 year follow up was 182.38±4.71 and significant decrease in HA1C from mean 8.24±1.91 to 5.61±1.20
1 year after surgery. Remission was achieved in 92% with (86.0%) of patients have complete remission, and (6.0%)
of patients have partial remission. In this study The DM complete remission rates for those with disease duration
< 2years, 2-5 years and > 5 years were 93.02%, 66.67% and 25% respectively.
Conclusion: It could be concluded that one-Anastomosis Gastric Bypass (OAGB) can be an excellent alternative
to Roux-en-Y Gastric Bypass (RYGB) for the treatment of diabetes and obesity. Pre-operative medications and
duration of disease may be used to predict postoperative diabetes remission.
Keywords: Anastomosis, Gastric bypass, Obese diabetic patients
T2DM is one of the most challenging health
tract, resulting in improved T2DM control. Such a
problems of the twenty-first century. It is estimated
result does not solely depend on weight loss. In some
that there are now 415 million adults aged 2079 with
cases, the effects can be observed days after bariatric
diabetes worldwide, including 193 million who are
operations, before substantial weight loss, precluding
undiagnosed. A further 318 million adults are
a direct antidiabetic effect. The term (bariatric( is
estimated to have impaired glucose tolerance, which
gradually being replaced by (metabolic(, because the
puts them at high risk of developing the disease (1).
operations previously recommended for morbid
Furthermore, T2DM is the leading cause of kidney
obesity (defined as BMI >40 kg/m2 or >35 kg/m2 with
failure, non-traumatic lower limb amputations,
co-morbidities) have demonstrated excellent results in
coronary heart disease, stroke, and visual impairments
T2DM remission. In 2011, the IDF released its
among adults (2).
position statement that bariatric surgery is an accepted
Studies have shown that BMI is a powerful
option for T2DM patients with BMI >35 and may be
predictor of T2DM. Visceral fat is an important source
an alternative therapy for patients with BMI < 35 who
of inflammatory cytokines such as tumor necrosis
do not respond to standard medical therapy. Metabolic
factor alpha (TNF-), transforming growth factor
surgery includes conventional bariatric operations
(RYGB, biliopancreatic diversion [BPD] with or
plasminogen activator inhibitor type 1 (PAI-1) that can
without duodenal switch, sleeve gastrectomy, and
directly affect insulin-mediated glucose uptake
MGB) and new procedures (ileal interposition)
(insulin resistance). On the other hand, there is a
designed to have metabolic effects irrespective of
reduction of secretion of other factors such as
massive weight loss (3).
adiponectin that reduce insulin resistance. This
Reversal of T2DM occurs due to mechanisms
imbalance leads to a pro-inflammatory state which is
such as the increase in insulin sensitivity associated
related to an increased risk of cardiovascular
with an improvement in -cell function, as a
complications (1). Metabolic surgery involves any
consequence of increase of GLP-1 production.
intervention that alters the food passage through the GI
Received: 4/1 /2020
Accepted:13 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 407-411
Ultrasound Guided Pectoral Nerve Block Versus Ultrasound Guided Thoracic
Paravertebral Block to Supplement General Anesthesia in Simple Mastectomy
Mona R. Salem a , Nadia G. El-Sharkawi b, Inas El-Shazly b , Mohamed A. Mansour b*
a Department of Anesthesia, International Nozha Hospital, Cairo,b Department of Anesthesia, Intensive Care
and Pain Management, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
* Corresponding author: Mohamed A. Mansour,
Background: Breast surgery, can be associated with significant postoperative pain.
Objectives: This study was conducted to compare pectoral nerve block (PECS) and thoracic paravertebral block (TPVB)
as supplements to general anesthesia for alleviation of patients' postoperative pain after breast surgery.
Patients and Methods: This prospective cohort study included 60 female patients with ASA I-III, and body mass index<
30 kg/m2 undergoing mastectomy. Patients were allocated into two equal groups (PECS and TPVB groups). Both types
of nerve block were ultrasound-guided. After 30 minutes, general anesthesia was induced. When the mean arterial pressure
(MAP) or heart rate (HR) exceeded 20% of the preoperative value, increments of fentanyl 25 µg were given intravenously
at 5 minutes intervals. Paracetamol and ketorolac were used for postoperative analgesia. Postoperative pain intensity was
measured using visual analogue scale (VAS). The measured parameters included time to the first call for analgesia,
intraoperative and postoperative MAP and HR, intraoperative fentanyl consumption, the amount of analgesics used in the
first 24 postoperative hours and patients' satisfaction and complications.
Results: The PECS Group showed significantly lower intraoperative fentanyl consumption, longer duration before the
first postoperative call for analgesia, lower VAS till 18 hours postoperatively, lower postoperative consumption of both
paracetamol and ketorolac, and higher satisfaction score as compared to TPVB group. There were no complications in
both groups. Conclusions: Pectoral nerve block was superior to thoracic paravertebral block in terms of intraoperative
analgesic consumption, duration of analgesia, postoperative pain score, postoperative analgesic consumption, and
Keywords: ultrasound, pectoral, block, paravertebral, mastectomy.
informed consent was obtained from each patient
Breast surgery may be associated with
before being involved in the study.
significant postoperative pain (1). Thoracic paravertebral
block is known to block pain stimuli from procedures on
Eligibility criteria and study design
the thorax that are lateral to the paravertebral muscles
This prospective cohort study was conducted on
such as breast surgery (2).
60 adult female patients undergoing mastectomy. We
Recently, pectoral nerve block type I (PECS I)
included patients 20 to 60 years-old, ASA physical
was introduced. It is a kind of superficial nerve block that
status I to III, with a body mass index less than 30
is easy and reliable. It is directed to both the lateral and
medial pectoral nerves through the plane between both
Exclusion criteria: were coagulation or neurological
pectoralis muscles (the major and the minor) (3). A newer
disorders, chronic use of analgesics, infection at the
version of pectoral nerve block was recently introduced.
injection site and patient refusal.
It is called ``modified PECS block'' or type II PECS
Patients were divided into two equal groups
block. The latter type of block is directed to block the
according to the type of the block performed; PECS
intercostal nerves, which is essential for several types of
group and TPVB group. Both blocks were ultrasound
guided. An intravenous catheter was placed in the
In the present study, we compared thoracic
contra-lateral upper limb. No premedication was given
paravertebral block (TPVB) to pectoral nerve block
since full cooperation of patients during the block
(PECS) to identify which technique is superior in
performance was required. Basic monitoring included
alleviating patients' postoperative pain after breast
ECG, pulse oximetry, and non-invasive blood pressure
In PECS group, the patient acquired a supine
PATIENTS AND METHODS
position with head tilt to the other side of the block.
The ipsilateral arm was abducted to 90 degrees. A high
The study was approved by the Ethics
frequency linear ultrasound transducer (10-12 MHz)
Committee, Faculty of Medicine, Cairo University. An
was placed in the infraclavicular region in a
parasagittal plane caudal to the lateral third of the
Received:5 /1 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 412-416
Prevalence of Neck Pain Among Otolaryngologists
Nawal Abd El-Raouf Abou-Shady1, Rasha M. El Rewainy1,
Walaa E. El-Den Mohamed Mustafa1, Ibrahim M. Hamoda2.
1Department of Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University,
2Department of Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Kafr El-Sheikh University.
*Corresponding author: Walaa Essam El-Den Mohamed Mustafa, E-mail: email@example.com, Mobile: (0020)1005789709
Background: otolaryngologists spend their workdays in performing markedly precise procedures in small works
places i.e. the patients' ear, nose and throat. Due to this, they frequently adopt awkward neck, back and shoulder
postures while using devices like otoscope, endoscope and microscope. So, the otolaryngologists' job profile puts
them at high risk for musculoskeletal disorders like neck pain. Purpose: of the study was to investigate the prevalence
of work-related neck pain among otolaryngologists - head and neck surgeons. Patients and Methods: specific
questionnaire based on Visual Analog Scale and Neck Disability Index was given to one hundred otolaryngologists,
head and neck surgeons of both gender, age from 30 to 40 years selected from ENT Departments in Hospitals of
Ministry of Health. Results: The statistical analysis revealed that the prevalence of work-related neck pain
among otolaryngologists was (69%). Regarding the severity of pain, (80%) reported pain as mild pain while (20%)
reported pain as moderate. Conclusion: It could be concluded that work related neck pain is common among
Egyptian Otolaryngologists, making otolaryngologists at a high-risk group. There is a need to improve ergonomics
in the clinical and operative room settings and to educate otolaryngologists on ergonomic principles.
Keywords: Neck pain, Otolaryngologists, Musculoskeletal disorders
Purpose of the study:
Work-related musculoskeletal disorders are prone
The purpose of the study was to investigate the
to occur, when there is a mismatch between physical
prevalence of work-related neck pain among
requirements and physical capacity. Otolaryngologists
otolaryngologists, head and neck surgeons and to
are not immune to musculoskeletal strain and injury,
determine risk factors of demographic and workload
particularly in the neck and shoulders, are common
among otolaryngologists (1).
SUBJECTS AND METHODS
There are increased reports of prevalence of work-
This cross-section study included a total of one
related musculoskeletal disorders (WRMSDs) in
hundred otolaryngologists, head and neck surgeons,
surgeons performing minimal access surgeries. Because
selected from E.N.T Departments in Hospitals of
of the character of the specialty, otolaryngologists spend
Ministry of Health in the period from January 2019 to
their workdays in performing markedly precise
procedures in small works places i.e. the patients' ear,
Ethical approval: the study was approved by the
nose and throat. Due to this, they frequently adopt
awkward neck, back and shoulder postures while using
P.T.REC/012/002667. Written informed consent of all
devices like otoscope, endoscope and microscope (2).
the subjects was obtained.
Neck pain is one of the most frequent complaints
among the general population, especially for health care
professionals and otolaryngologists, who are likely to
1) Age ranged from 30-40 years.
develop work-related neck pain (3).
2) Body mass index (BMI) ranged from 25 to35 (kg/m2).
Neck pain is second only to low back pain as the
3) Both genders are involved in the study.
most common musculoskeletal disorder in population
surveys and primary care and as in low back pain, it
1) History of bone diseases.
poses a significant health and economic burden and a
2) Suffering of cervical radiculopathy before working
frequent source of disability (4).
As a point of reference, epidemiological studies have
3) Head or cervical subluxation or fracture.
reported: Point prevalence of neck pain to be 4.9%
4) Systemic disease as rheumatoid arthritis.
5) Head or cervical surgery.
prevalence ranging between 30% and 50%(6), with one
6) Pregnant women.
systematic review reporting a mean rate of 37.2% (7).
Lifetime prevalence to be between 22% to 70%(8).
1) Recording data sheet. ( Name, Gender, Age, Years
of experiences, Work status, Type of chair, Average
Received:6 /1 /2020
Accepted:15 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 417-422
Rare Occurrence of Chemotherapy-Induced Regression of Focal
Nodular Hyperplasia: A Case Report and Literature Review
1Department of Radiology, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
Corresponding author: Johara AlMulhim, E-mail: Dr.firstname.lastname@example.org
Background: Chemotherapy exerts a multitude of effects on all organ systems including the liver. Chemotherapy-
induced liver changes are widely discussed in the literature and include hepatitis, hepatic steatosis, cholestasis,
nodular hyperplasia, and veno-occlusive disease among others. The exact mechanism of which nodular hyperplasia
is affected by chemotherapy is controversial but some experts suggest an alteration in blood supply might lead to
exaggerated focal regeneration.
Objectives: This study aimed to discuss an unusual effect of chemotherapeutic agents on pre-existing focal nodular
hyperplasia with a short literature review.
Patient and methods: A case report of 67 years old bedridden male patient presenting to the hospital with a 1-
month history of gross hematuria who was treated with chemotherapy.
Results: Our case showed an interval size reduction of a pre-treatment documented FNH in a patient with muscle-
invasive urinary bladder cancer who was treated with a chemotherapy regimen of GemCarbo. This report also
emphasizes the importance of enhanced MRI with hepatobiliary contrast agents in the evaluation of equivocal liver
lesions in cancer patients to avoid misdiagnosis of distant metastasis.
Conclusion: FNH is a common focal hepatic lesion and frequently seen in oncology patients during either initial
evaluation or at follow up. Diagnostic radiologists should be aware of the expected imaging findings of various
types of hepatic lesions and the effect of the medications the patient is receiving to avoid over-staging oncology
Key words: Chemotherapy, FNH, MRI.
vitally stable with a normal abdominal physical
The idea of chemotherapy for the treatment of
examination. Upon reviewing his laboratory results, the
various types of cancers first came to light during the
only abnormalities were anemia (Hg: 10.9 g/dL) and
early 20th century . The first line of chemotherapeutic
positive urine RBCs (250/hpf). The treating urologist
agents was generally cytotoxic. Thereafter, multiple
ordered an enhanced CT scan of the abdomen and
chemotherapeutic agents have evolved with multiple
pelvis which showed a large urinary bladder base
mechanisms of actions including cytotoxic agents and
fungating, partially calcified mass invading the urinary
those that affect the cell on molecular level interfering
bladder neck and prostate (Figure 1). No synchronous
and altering the programmed cell growth, nutritional
urothelial cancer was detected. However, there was a
supply, and cell differentiation . Chemotherapeutic
sizable right hepatic lobe arterially enhancing lesion
agents exert innumerable effects all-over the human
without significant washout (Figure 2).
body through different pathways.
The reporting radiologist raised the possibility of
The presence of pre-existing focal liver lesions in
the hepatic lesion being focal nodular hyperplasia
newly diagnosed cancer patients is not uncommon.
(FNH) rather than a genuine metastasis and ordered an
Indeed, as focal nodular hyperplasia ranks second in the
enhanced liver magnetic resonant imaging (MRI) using
list of common benign hepatic lesions, preceded only
a hepatobiliary specific agent (Primovist). the lesion
by hemangiomas . The effect of medications,
demonstrated slightly high signal intensity on T2
including chemotherapeutic agents, on these benign
weighted images, arterial hyperenhancement and
lesions, is not frequently reported.
contrast uptake in the hepatobiliary phase consistent
In this report, we will discuss an unusual effect
with the presumed diagnosis of FNH (Figure 3). No
of chemotherapeutic agents on pre-existing focal
other hepatic lesions were seen.
nodular hyperplasia with a short literature review.
Ethics approval and consent to publication
cystoprostatectomy but failed due to significant pelvis
Ethics approval for case reports is not required by the
adhesions. A cystoscopic biopsy confirmed the
IRB. Written informed consent was obtained from the
presence of muscle-invasive bladder cancer and,
patients for this publication.
therefore, the patient was started on chemotherapy
course of Gemcitabine and Carboplatin (GemCarbo).
After completion of three cycles, a reevaluation-
We report a 67 years old bedridden male patient
enhanced CT scan of the abdomen and pelvis was
presenting to the hospital with a 1-month history of
performed showing a good response of the bladder
gross hematuria. Upon evaluation, the patient was
tumor with post-chemotherapy changes (Figure 4),
Received:6 /1 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 423-428
A Short Review on Progressed Hepatocellular Carcinoma: Radiological
Findings and Histopathological Diagnosis
Khalid Suliman AlJoqiman1, Johara AlMulhim1, Mohammed Abdulrahman AlTuriqy2
1Department of Radiology, College of Medicine, King Faisal University, Al-Ahsa, 2 Department of Radiology,
College of Medicine, Majmaah University, Saudi Arabia.
Corresponding author: Johara AlMulhim, E-mail: Dr.email@example.com
Background: Hepatocellular carcinoma (HCC) is, by far, the most common liver malignancy. The risk factors for the
development of HCC are numerous with liver cirrhosis, chronic hepatitis B and C viral infections and alcohol abuse on
top of the list. Several studies were devoted to evaluate the complex radiological appearance of HCC and its correlation
with histopathologic grade/stage as well as possible mimickers of HCC, all of which have a significant impact on
diagnosis and management of patients with HCC.
Objectives: Evaluation of the radiological findings of HCC and its correlation with histopathologic grade/stage as well
as mimickers of HCC.
Methods: This is a review article of some of the existing literature regarding radiological findings and histopathologic
diagnosis of progressed hepatocellular carcinoma.
Conclusion: Imaging findings of progressed HCCs are complex and different from the standard findings of well-
differentiated HCCs. Evaluation of enhancement and washout patterns, as well as the possibility of the presence of
microvascular invasion, should be undertaken by the reporting radiologist and delivered comprehensively to the treating
multidisciplinary team for proper management.
Keywords: Radiology, HCC, CT, MRI, Liver.
recommendations regarding surveillance for adult
The prevalence of hepatocellular carcinoma (HCC)
patients with cirrhosis (4). The imaging modality for
has been increasing worldwide, especially in North
surveillance of patients with cirrhosis is transabdominal
America and Europe during the last few decades (1, 2).
ultrasound (US) and once a focal nodule is discovered in
This tremendous increase in incidence can be attributed
a patient with liver cirrhosis, further imaging workup
to multiple factors including the rising prevalence of
with either contrast-enhanced magnetic resonance
hepatitis B and C viral infections, alcohol abuse and
imaging (MRI) or computed tomography (CT) is usually
nonalcoholic fatty liver disease among others (1). Liver
recommended (4, 5). Both modalities require the
cirrhosis of any etiology is considered one of the
intravenous administration of contrast which might be
strongest risk factors for developing HCC. Also, HCC is
contraindicated in patients with certain degrees of renal
the most common primary liver malignancy in cirrhotic
impairment or allergies.
and non-cirrhotic livers (3). For all of the aforementioned
Liver Reporting & Data System (LI-RADS) is
facts, there has been extensive research and institutional
applied only for patients with high risk for developing
reviews on surveillance, diagnosis, and management of
HCC including liver cirrhosis, hepatitis B viral infection
HCC. In the presence of risk factors, the diagnosis of
and current or prior HCC. LI-RADS must not be applied
HCC relies solely on imaging findings alone, further
to patients without risk factors, with vascular origin of
emphasizing the importance of a clear, well-structured
cirrhosis or to patients who are under 18 years old. LI-
surveillance and diagnostic approach. In not a small
RADS major criteria include central (non-rim) arterial
group of patients, the diagnosis is often complex due to
phase hyperenhancement, central (nonperipheral)
different histological stages/grades of the tumor. The
radiologist should be aware of such radiological-
threshold growth. It is recommended that threshold
histopathologic findings correlation in order to predict
growth is to be evaluated on the same sequences between
the tumor behavior and response to therapy as well as
studies (5). LI-RADS also describes ancillary features to
include/exclude the patient from the liver transplant list
help the radiologist in categorizing the lesion of interest
after discussion with the multi-disciplinary treating team.
and can sometimes be used to upgrade or downgrade the
lesion. The ancillary features favoring malignancy, in
2. LI-RADS FOR HCC DIAGNOSIS
general, are ultrasound visibility as a discrete nodule,
Liver cirrhosis patients are at a significantly
corona enhancement, fat sparing in a solid mass,
increased risk for the development of HCC, several
restricted diffusion, mild-moderate T2 hyperintensity,
worldwide scientific institutes have published
and hepatobiliary phase hypointensity (4). While some
Accepted:15 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 429-430
Unusual Cause of Transient Unilateral Fixed Dilated Pupil in
Infant with Bronchiolitis: A Case Report
Abdullah Al-Shamrani1, Reham M. Babiker2, Waleed A. Okash2, Naif I. Al-Oudah2, Rola A. Sleiman2
1Prince Sultan Medical Military City (PSMMC), 2 Dr. Sulaiman Al-Habib Medical City-Rayan Hospital
Corresponding author: Abdullah Al-Shamrani, Email: firstname.lastname@example.org,
Orcid.org/0000-0001-7157-1706, Mobile no.: 00966553367555
Background: Unilateral anisocoria has a variety of causes, some of which could be life-threatening. Mydriasis can represent
a serious neurological finding in intensive care units. Bronchiolitis is the most common cause of intensive care in the infancy
period. Ipratropium bromide is anticholinergic and commonly used in the intensive care unit (ICU). Anisocoria is due to the
overactivation of the sympathetic nervous system or hypoactivity of the parasympathetic nervous system.
Objectives: Assessment of cases of anisocoria in infants with bronchiolitis under ipratropium bromide therapy.
Patient and methods: A case report study of a 9-month-old infant with a fixed dilated pupil. He was admitted into the ICU
and given ipratropium bromide.
Results: Ultimately, the patient's symptoms of pupillary dilation resolved over 24 hours with the discontinuation of
ipratropium bromide, with a complete recovery. The case presented here is typical of anticholinergic side effects, and the
evidence of this benefit is even more limited, which might lead to frustrating observations among patients and health care
providers. Conclusion: Anisocoria is not an uncommon finding in patients receiving ipratropium bromide. Paediatricians
should follow the Saudi Bronchiolitis Guideline recently published in 2018, in which no indication of ipratropium bromide
in bronchiolitis was clearly stated.
Keywords: Anisocoria, pupil, bronchiolitis, ipratropium bromide, mydriasis.
Consent was obtained from parents for the publication of
Patient information: A 9-month-old boy who presented
the child's details and to publish figures 1 and 2 in this
to the Emergency Department with cough, fever and
dyspnoea. He was admitted to the PICU for respiratory
Diagnostic assessment: An ophthalmologist consulted a
distress as a case of acute bronchiolitis. He was stabilized
fixed dilated pupil and confirmed that anisocoria faded
and then transferred to the paediatric ward on nebulized
slowly after nebulized ipratropium bromide was
ipratropium bromide 0.5 ml delivered via a face mask
discontinued. Mydriasis completely resolved within 24
every 4 hours.
hours of its onset (Figure 2).
Physical examination: demonstrated that a child with
minimal respiratory distress had vital signs on arrival to
the General Paediatric Ward. The respiratory rate was
40/minute and the heart rate was 120/m with a saturation
level of 94% in room air. He was afebrile with scattered
wheezing in the chest. The rest of his general examination
confirmed a fixed dilated left pupil that was nonreactive
to light (Figure 1). The rest of the cranial nerves were
normal, and the child was very alert with normal
Figure (2): Recovery of mydriasis in the left pupil after
24 hours of stopping the nebulized ipratropium bromide.
Bronchiolitis is very common and is the leading
cause of hospital admission in the infancy period (1, 2).
Currently, there are no effective therapies for the
management but only supportive. This condition
represents an area of controversy despite the current Saudi
National guidelines for its management (3). A wide range
of medications are commonly used in the management of
acute bronchiolitis, but evidence of their effectiveness is
li mited. Among such medications is ipratropium bromide,
Figure (1): Fixed dilated left pupil and absence of light
which is often used as an adjuvant to bronchodilators to
reflex induced by ipratropium bromide.
relieve bronchospasm and to minimize the associated
nasal secretion (4). Ipratropium bromide is an
Received: 7/1 /2020
Accepted: 16/2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 431-434
Renal Resistive Index as One of The Predictors of Cardiac
Diastolic Dysfunction in Type 2 Diabetic Patients
Hend M. Abdelhakam1*, Ehab M. Moussa2, Salah Argoon3, Mahmoud Ashry4
Departments of 1Internal Medicine, SVU, Qena, 2Radiology, Assiut University, Assiut,
3Internal Medicine (Endocrinology Unit), Assiut University, Assiut,
4Internal Medicine (Cardiology and Critical Care Unit), Assiut University, Assiut, Egypt
*Corresponding Author: Hend M. Abdelhakam, Email: Hendhakam@gmail.com, Phone: +0201003161920
Background: Renal resistive index (RRI) is markedly affected by renal and systemic conditions. Aortic
stiffness with affected pulse pressure in type 2 diabetic patients is associated with backward overload effect
on the heart. This had led to consider RRI as a preferred marker for prediction of an increased total
Aim: This study interested in detecting the relationship between the renal resistive index and the cardiac
diastolic dysfunction in individuals with type 2 diabetes.
Patients and methods: A hospital based, cross-sectional study was conducted on 79 type 2 diabetic patients
with no symptoms of cardiovascular involvement. They were subjected to echocardiographic evaluation of
diastolic dysfunction and renal duplex for measurement of RRI.
Results: The results of the current study revealed a significant relationship between renal resistive index and
diastolic dysfunction (p < 0.001).
Conclusion: Worsening indices of diastolic function in subjects with type 2 diabetes paralleled increases in
RRI, which was detected as one of the independent predictors of diastolic dysfunction in these results.
Keywords: Diastolic Dysfunction, Renal Resistive Index, Type 2 DM.
Renal resistive index (RRI) is markedly
17200358 and an informed consent was obtained
affected by renal and systemic conditions (1). RRI
from each participant.
gives prognostic information regarding micro and
Procedure: The patients were subjected to full
macroangiopathy (2). The role of RRI is not limited to
history taking and clinical examination including
detection of renal arteriosclerosis, there is growing
fundus examination supported by relevant
evidence demonstrated that RRI has many intra and
investigations. The following were carried out:
extra renal determinants and is associated with
increase of cardiovascular morbidity (3). Attempts to
reduce cardiac morbidity and mortality in type 2
· Information obtained using a questionnaire
included: sex, age, consanguinity (first-degree
pathophysiology and new risk factors other than
relatives), history of diabetes, premature
conventional factors and this was the aim of our
hypertension, smoking habits, any other diseases
and the use of current medications including
PATIENTS AND METHODS
antidiabetics (oral glucose-lowering medications
A hospital based, cross-sectional study was
and/or insulin), lipid-regulating agents and
conducted on 79 patients known to have type 2
diabetes mellitus (DM), and who clinically had no
symptoms of cardiovascular involvement (with
Imaging and Laboratory Investigations
normal ECG). The recruited patients were selected
Blood glucose levels (FBG, RBG), HbA1C, lipid
from those attending the Diabetes Clinics at the
profile, renal function tests and the electrolytes, urine
Endocrine Centre, Assiut University hospitals.
routine and microscopy, estimated glomerular
Patients with type 1 DM, other cardiac
filtration rate, and chest x-ray.
ischemic · Transthoracic echocardiogram (TTE) was performed
cardiomyopathy) and congestive heart failure or end
by (Philips Medical Systems, Bothell, Washington,
organ failure were excluded from the study. The
USA, 3.5 Mhz transducer) in the left lateral decubitus
study was conducted in the period from March, 2017
position. Recordings and measurements were
to December, 2019.
echocardiography parameters. Left ventricular
diastolic dysfunction (DD) was divided into grade I
Research Ethics Committee approved the
(impaired LV relaxation), grade II (pseudo-normal
research protocol on 19/11/2014 under number
filling pattern) and grade III (restrictive filling
Received: 07/ 01/2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 435-441
Evaluation of QT Intervals in Compensated and
Decompensated Chronic Hepatitis C Cirrhotic Patients
Osama Ahmed Khalil1, Mohamed Samy Fawzy2, Ashraf Khalifa EL-Naggar1, and Entesar Kamel Sayed*3
1 Internal Medicine Department, Faculty of Medicine, Zagazig University, Zagazig Egypt,
2 Medical Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt,
3Internal Medicine Department, Ahmed Maher Teaching Hospital, Egypt
*Corresponding authors: Entesar Kamel Sayed Sayed, Mobile: (+20)1007397091, Email: email@example.com
Background: Cirrhotic cardiomyopathy is chronic cardiac dysfunction in cirrhotic patients with no previous
structural heart disease. QT prolongation is one of the most important cardiac alterations related to cirrhosis.
Objective: This study was aimed to evaluate QT interval duration among compensated and decompensated chronic
Hepatitis C (Ch HCV) cirrhotic patients and to detect its relation to biochemical changes in cirrhosis and its effect
on patients' outcome. Patients and Methods: A cross sectional study was conducted on 52 Ch HCV patients
divided into two groups according to presence of signs of decompensation. Patients underwent clinical, laboratory
and electrocardiographic evaluation. Cirrhosis severity was classified according to the Child-Pugh score. The QT
interval in lead II (QTII), maximum QT (QTmax), heart rate corrected QTmax (msillisecond) obtained manually
using by a 12-lead electrocardiogram. Results: Decompensated patients had non-significantly lower values of QTII
and QT max. There was significant difference between both groups regarding QT maxc. 80.8% versus 38.5% of
decompensated and compensated patients had prolonged QTC. There was significant relation between child class
and QT parameters. There was significant relation between QT maxc prolongation and serum Albumin, sodium,
ammonia, Urea, AFP and APACHE-II. There was significant relation between outcome and both QT max and QT
maxc. Cutoff of QT max n predicting mortality was435 with sensitivity 80% and specificity 69%. QT maxc cutoff
508 predicted mortality with sensitivity 80% and specificity 84%.
Conclusion: A prolonged QT maxc was prevalent among cirrhotic patients and this positively correlated with
disease severity and high mortality.
Keywords: Cirrhosis, prolongation, cardiomyopathy.
with chronic liver disease (5). As it is associated with
Liver cirrhosis is a progressive pathological
ventricular arrhythmias as well as sudden cardiac death
process characterized by fibrosis and nodular
in both congenital and acquired conditions (6).
regeneration. A variety of well-known etiologies can
Most of previous studies have shown that end
cause cirrhosis, such as hepatitis virus infection
stage liver disease (ESLD) is associated with several
(hepatitis B and C virus), drugs (including alcohol),
electrophysiological changes; specifically, increased
prevalence of QT prolongation (7). While the exact
nonalcoholic steatohepatitis. In addition to liver
mechanism for QT prolongation is still unknown, both
damage, cirrhotic patients have renal, pulmonary,
improvement in liver function and liver transplantation
hemodynamic and cardiac dysfunction that increase
have been associated with significant shortening in the
morbidity and mortality (1).
QT interval in studies with small sample sizes (3).
Cirrhotic cardiomyopathy has been used to
This study was aimed to find out frequency of
describe chronic cardiac dysfunction in cirrhotic
prolongation of QT interval corrected to heart rate
patients with no previous structural heart disease (1). It
among chronic hepatitis C cirrhotic compensated and
is defined by the finding of one or more of the following
decompensated patients, to test the effect of
changes: normal or augmented systolic function at rest
prolongation of QTc interval on short-term patient
but poor contractile response to stress; diastolic
outcome and to find most important predictors of
dysfunction; structural abnormalities in cardiac
prolonged QTc interval in those patients.
chambers; and electrophysiological changes. These
abnormalities occur to a varied degree in up to 50% of
PATIENT AND METHODS
cirrhotic patients (2-3). Most patients with cirrhotic
This Prospective cohort cross sectional study
cardiomyopathy are asymptomatic and, for this reason,
included a total of 52 Ch HCV patients, attending at
complementary exams are important to identify them.
Internal Medicine department of Zagazig University
The electrocardiography (ECG) is a low-cost and
hospitals and Ahmed Maher teaching hospital. Written
noninvasive method that may help to identify patients
informed consent of all the subjects was obtained. This
with cirrhotic cardiomyopathy (4).
study was conducted between November 2018 to June
QT prolongation is one of the most important
cardiac alterations related to cirrhosis and is easily
determined by ECG. A prolonged QT interval is
Approval for doing the research was obtained from
associated with a higher mortality rate among patients
Internal Medicine and Medical Biochemistry
Received:8 /1 /2020
Accepted:7 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 442-445
Role of Laparoscopy in Diagnosis and Treatment of Acute Abdominal Pain
Mohammed Fathi Sharaf, Eslam Taha Ghalwash, Abd Al Rahman Mohammed Ali
Department of General and Laparoscopic Surgery, El-Hussein University Hospitals,
Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Corresponding author: Name: Abd Al Rahman Mohammed Ali, E-Mail: firstname.lastname@example.org, TEL: 002 01000317976
Background: Abdominal pain is a common presentation at the surgical department. Emergency laparoscopy in
patients with "acute abdomen" is a part of common surgical practice.
Aim: Evaluation of the role of laparoscopy in management of acute abdominal pain
Methods: 100 patients with acute abdominal pain presented to the Department of Surgery, Al-Azhar University,
El-Hussein and El Minia Health Insurance Hospitals were included in the study during the period from April 2018
to April 2019. They were divided into two groups: known preoperative diagnosis (therapeutic n= 67 patients) and
unknown (diagnostic and therapeutic n= 33 patients). Their ages ranged between 12 and 60 years old (35 patients
were males and 65 patients were females). Laparoscopy was performed for all patients under general anesthesia.
Results: The definitive diagnosis was established in 99 % of cases. 64 % of those cases were managed successfully
by use of laparoscopy and conversion rate was 33 %. Time required for each operation varied according to the
procedure, intraoperative morbidity was 7 %, post-operative complications were 11 %. The mortality of study was
1%. Conclusions: laparoscopic intervention for abdominal emergencies is as safe, feasible and effective. It results
in minor trauma, has a rapid postoperative recovery, and reduces morbidity. Laparoscopy can help to avoid
unnecessary non- therapeutic laparotomies. It can also help to guide the operating surgeon for choosing the proper
Keywords: Acute abdomen, Emergency, Laparoscopy
The term "Acute abdomen" is generally used to
Acute abdominal pain is a common presentation. It
describe any acute abdominal pain, with duration of
accounts for 5-25% of all emergency department visits
less than one week that may require urgent or
annually. Each year, about 450 females and 180 males
immediate intervention, including emergency surgery.
per 100,000 are hospitalized for acute abdominal pain.
Although acute abdominal pain is often caused by an
It may affect the very young, the very old, either sex,
intra-abdominal pathology, it may also be a
and all socioeconomic (5). However some causes are
manifestation of an extra- abdominal disease (e.g.
frequent in the pediatric population (like appendicitis)
thoracic or systemic pathology) (1).
or are strictly related to the gender (i.e. gynaecological
Acute abdominal pain can present a diagnostic
causes). It is also important to consider special
dilemma. Clinical examination often fails to yield a
populations such as the elderly or oncologic patients
diagnosis in patients with acute abdomen, particularly
when the symptoms and signs are compounded by
obesity. Blood investigations may be diagnostic in
PATIENTS AND METHODS
some cases, but in most other scenarios they simply
The study was carried out at the Emergency
indicate the presence of an inflammatory process.
Department, El-Hussein University Hospital and El
Radiological investigations may suggest a diagnosis,
Minia Health Insurance Hospital over one year
but may often provide false-negative results (2).
period. 100 patients who underwent diagnostic and/or
Laparoscopy as a minimally tool can accurately
therapeutic laparoscopy for "Acute abdomen"
and quickly confirm the diagnosis and reduce both
between April 2018 and April 2019.
delay in diagnosis and non-therapeutic laparotomy
rate. Above all with the improvement in the
technology and skills there is an expanding potential
All patients with acute abdominal pain less than 7
for carrying out therapeutic procedures at the same
days. Age between 12-60 years old, hemodynamically
setting. Laparoscopy can be considered in acute
stable and controlled coagulopathy.
abdominal pain for following reasons; diagnosis,
diagnosis and treatment, and to determine the best
incision just before laparotomy (3).
Cases below 12 or above 60 years old,
The rapidly increasing popularity of laparoscopy
haemodynamic instability till stabilization of the case,
may be attributed to several factors including its
uncontrolled coagulopathy, multiple previous
applicability, high diagnostic yield, therapeutic
laparotomies and elective abdominal or pelvic surgical
management in the same sitting (in cases where on
procedures. Patients with intestinal obstruction with
table diagnosis is possible), ability to manage most
diffuse abdominal distension. Those who did not give
coexisting conditions, low patients morbidity and
consent. Accidents and trauma patients. Patient with
reduced hospital stay and expenditure (4) .
any contraindication to pneumoperitoneum. The
Received:8 /1 /2020
Accepted:17 /2 /2020
RELATIONSHIP BETWEEN SLEEP DISORDERED BREATHING AND PRO-INFLAMMATORY MARKERS IN ACUTE ISCHEMIC STROKE
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 446-456
Cancer Oral Tongue: A Retrospective Epidemiological, Pathological and Clinical
Analysis with Correlation to Treatment Outcome
Hesham Mahmoud El Wakiel, Amro Lofty Farag,
Ahmed Hassan Abdel Aziz, Ahmed Gamal Ali El Sayed
Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University
*Corresponding author: Name: Ahmed Gamal Ali, e-mail: email@example.com
Background: early cancers are managed by single modality treatment (surgical excision of the primary tumor or
radiotherapy (3DCRT, IMRT or brachytherapy)) with or without elective neck dissection. While locally advanced
resectable disease is managed by surgery (excision of the primary tumor with modified radical neck dissection)
followed by postoperative radiotherapy with or without chemotherapy. This should be considered for cases with
adverse pathological features.
Purpose: this is a retrospective study to analyze the epidemiological, pathological and clinical factors in cancer
oral tongue and correlate them to clinical outcomes [response to treatment and survival rates (disease free
survival, progression free survival and overall survival)] to explore best options of care for the patients.
Patients and Methods: at the Department of Clinical Oncology and Nuclear Medicine, Ain Shams University
Hospitals and Nasser Institute, Cancer Center; patients with a histologically confirmed diagnosis of oral tongue
cancer were included in this retrospective analysis. The study included 40 cases from Nasser Institute, Cancer
Center and 18 cases from Ain Shams University Hospitals. The study period was 6 years from January 2011 to
Results: fifty eight recorded cases were included in the study and subsequent descriptive analysis was performed.
One patient who didn't receive any treatment was omitted from the study.
Conclusion: as regard treatment; most of the patients underwent surgery followed by adjuvant concurrent chemo
radiotherapy especially in patients with close or positive surgical margins or patients who didn't undergo LN
dissection. This affected DFS.
Keywords: Cancer Oral Tongue - Lymph nodes - Liver Function Test - Kristen Rat Sarcoma virus.
tumor or radiotherapy (3DCRT, IMRT or
Cancer tongue represents about 2% from all
brachytherapy)) with or without elective neck
new cancer cases, 60% from the oral cavity cancers
dissection. While locally advanced resectable disease
which is a part from the head and neck cancers; the
is managed by Surgery (excision of the primary
fifth most common cancer worldwide. Smoking,
tumor with modified radical neck dissection)
alcohol, spicy food, nitrosamine in salted fish in china
followed by postoperative radiotherapy with or
and infections (HPV and chronic syphilis) are the
without chemotherapy. This should be considered for
major risk factors. Erythroplakia and leukoplakia are
cases with adverse pathological features (3).
considered precancerous lesions. Mutation in the P53
Locally advanced unresectable disease is
gene may lead to genetic susceptibility (1).
managed by definitive radiotherapy with concurrent
Patients of South Asian origin are at
chemotherapy which may be appropriate for selected
increased risk. Male to female ratio is (2:1).
cases where cure is still possible. Induction
Squamous cell carcinoma (SCC) is almost the only
chemotherapy may be considered for selected cases:
histological type; well, moderately and poorly
platinum based e.g.: cisplatin either alone or in
differentiated according to the degree of
combination with Taxanes and 5FU (4).
keratinization and presence of cell nests. Commonly
Biological therapies as Cetuximab can be
presents as a non healing ulcer for more than 3
considered as EGFR is over expressed in 90% of the
weeks, exophytic mass, patch, pain referring to the
cases but does not correlate with the clinical
ear, ankyloglossia and enlarged neck lymph nodes (2).
response. Mutation in the KRAS gene correlates with
Core biopsy from the primary lesion, CT
poor response to cetuximab. KRAS wild-type status
Neck and chest with contrast, MRI for better soft
predicts benefit from cetuximab. 95% of the cases
tissue definition and even PET CT which has a great
are KRAS wild-type (5).
value in advanced cases are the investigations which
Patients unable to tolerate intensified
are always needed. Also routine laboratory tests
treatment or those with metastatic disease receive
(liver function tests, kidney function tests, complete
palliative treatment whenever appropriate. Patients
blood count) are always needed before surgery or
with ECOG performance status (3 or 4) are for best
before chemotherapy (10).
supportive care (6).
Early cancers are managed by single
Five years survival rate is more than 80% for
modality treatment (surgical excision of the primary
those presenting with early-stage localized disease,
Received:10 /4 /2018
Accepted: 9/5 /2018
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 457-461
Effect of Dexamethasone as A Local Anesthetic Adjuvant for
Peribulbar Block in Vitreoretinal Eye Surgeries
Dalia S. Tawfik, Sara R. Mahmoud, Noha A. Osama
Department of Anesthesia, Research Institute of Ophthalmology, Cairo, Egypt
Corresponding author: Noha A. Osama, Email: firstname.lastname@example.org
Background: Off label use of dexamethasone as an adjuvant to local anesthesia has been utilized to prolong single
Objectives: To assess the beneficial effect of dexamethasone on peribulbar block in vitreoretinal surgeries.
Patients and Methods: Patients undergoing vitreoretinal surgeries were randomized into 2 groups (10 patients
each). They were given peribulbar block in the form of single medial canthus injection in a mixture of 8-10 ml of
lidocaine 2% and bupivacaine 0.5% added to hyaluronidase 30 IU given by 25G, 1" needle. Group 1 received the
block in addition to 4 ml dexamethasone. All patients got preoperative sedation in the form of 20 mic fentanyl, 1
mg midazolam and 20 mg propofol.
Primary outcomes were onset of the block, pain during injection according to the visual analog scale (VAS) score,
the need to supplement the block or sedation during surgery. Secondary outcomes were hemodynamics (heart rate,
mean arterial blood pressure, oxygen saturation), patient satisfaction and surgeon satisfaction.
Results: The mean onset of sensory and motor block in group 1 was significantly less (6.2+1.9) than group 2
(9.9+0.3 minutes). The pain score in group 1 was significantly lower (4+0.8) than group 2 (6+0.9), and the need
for supplementation of the block or sedation during surgery differed significantly between the groups in favor for
group 1 where the need for both was much less.
Conclusions: Addition of dexamethasone to peribulbar block in vitreoretinal surgery speeds up the onset of the
block and adds to its efficacy.
Keywords: dexamethasone, peribulbar, vitreoretinal.
Surgeries for posterior segment are lengthy
procedures and associated with relatively significant
There have been major advances in every
postoperative pain. The addition of adjuvants to
aspect of the management of the ophthalmic surgical
local anesthesia in peribulbar block could be a
patient. These include shift to day case and increased
method to prolong the duration of the block. Many
focus on the patient. Day case ophthalmic surgery
drugs have been added, such as adrenaline, sodium
under local anesthesia is now preferred by most
bicarbonate, hyaluronidase, narcotics and ketamine
patients, surgeons and other staff. It is associated
with the least disruption to the patient's normal
In recent years, dexamethasone, a potent
activity, besides decreasing the demand on limited
long-acting glucocorticoid, has been studied as an
health resources (1).
adjuvant to local anesthesia in peripheral nerve
The goal of anesthesia for ophthalmic
blocks. It is a very potent, highly selective and has
surgery is to provide pain free surgery, to facilitate
analgesic properties. Dexamethasone might improve
the surgical procedure, to minimize the risk of
the quality and duration of peripheral nerve blocks
systemic and local complications and also to reduce
over local anesthesia alone. It may relieve pain by
the risk of surgical complications. Most patients
reducing inflammation and blocking transmission of
undergoing ophthalmic surgeries are elderly with
nociceptive C fibers and by suppressing ectopic
multiple chronic diseases. This may increase their
neuronal discharge, steroids induce vasoconstriction
risk of morbidity and mortality under general
and decrease the systemic absorption of local
anesthesia. Therefore, regional anesthesia is
preferred over general anesthesia in patients
undergoing ophthalmic operations (2,3).
PATIENTS AND METHODS
The choice of anesthetic technique depends
on some patient's factors as: the patient's ability to
This research work obtained an ethical
tolerate manipulations around the eye without
approval from the Ethical Committee of the
blepharospasm, and to maintain the required posture
Research Institute of Ophthalmology and an
for the duration of surgery. It also depends on some
informed written consent from each patient.
surgical factors: the type and size of the incision, the
This prospective randomized study was
complexity of the procedure, the risk of
carried out at the Research Institute of
complication, the duration of the operation and the
Ophthalmology, during the period from 2014 to
experience of the surgeon (4).
2015. Twenty adult patients (18-83 year), either sex,
Received:9 /1 /2020
Accepted:18 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 462-468
Fetuin-A as a Marker of Insulin Resistance in Type 2 Diabetic
Patients in Zagazig University
Fawzy Abdelfatah El-Messallamy1, Jehan Saeed Abdo Soliman2,
Sally Mahmoud Saeed Shalaby3, Heba Abdel-Rahman Kamel Abdel-Rahman*3
1Department of Internal Medicine, 2Department of Biochemistry, Faculty of Medicine, Zagazig University,
Sharkia, 3Department of Internal Medicine, Faculty of Medicine, Banha University, Qaluobya, Egypt
*Corresponding author: Heba Abdel-Rahman Kamel Abdel-Rahman
Mobile: (+20) 01068028415; E-mail: email@example.com
Background: Fetuin-A is responsible for instigating insulin resistance by inhibiting tyrosine kinase receptors.
Objective: To investigate the relationship of fetuin-A with and insulin resistance in type- II diabetics either obese
or non-obese of Zagazig University, Shatkia Governorate, Egypt.
Patients and Methods: This is a case-control study that was conducted at the Internal Medicine Department of
Zagazig University. Seventy-five participants were divided into three groups. Group-A (n =25) normal healthy
individual, Group-B (n =25) non-obese type 2 diabetic patients and Group C (n=25) obese type 2 diabetic patients.
Type 2 diabetic patients with no morbidities. Serum fetuin-A and insulin levels were performed by ELISA kits
while fasting blood glucose (FBG), 2HPP and HA1C were determined by the enzymatic kit method. A comparison
of groups was done and correlation was achieved by using Spearman correlation.
Results: The results demonstrated a significant difference in mean values of fetuin-A, BMI, WHR, fasting blood
glucose (FBG), 2HPP, HA1C, insulin level and Homoeostasis Model Assessment of Insulin resistance (HOMA-
IR) in type-II diabetics when compared to normal healthy individuals and obese type-II diabetics (p<0.01). The
fetuin-A level was higher in obese more than non-obese type II diabetics.
Conclusion: The study concluded that fetuin-A might be accountable for insulin resistance in type-II diabetes
mellitus either obese or non-obese. So the high levels of Fetuin-A responsible for insulin resistance.
Keywords: Fetuin-A, Insulin Resistance, Type-II Diabetes Mellitus, Obesity, HOMA-IR.
Type-II diabetes mellitus is a complex
Obesity is caused by a chronic energy
metabolic disorder characterized by persistent
imbalance, increased dietary intake and low physical
hyperglycemia due to deficiency of insulin
activity. Obesity plays an important role in increased
production or peripheral tissue resistance to in action.
risk of Type-II diabetes, cardiovascular diseases, and
Long term hyperglycemia is responsible for affecting
cancer (7). The beneficial effects of moderate weight
the structural and functional comorbidities, which
loss (5%10%) on hyperglycemia, hyperinsulinemia,
gives rise to complications like diabetic neuropathy,
hyperlipidemia, and insulin resistance are well
hyperlipidemia, cerebrovascular diseases and
Program (DPP), has demonstrated that lifestyle
atherosclerotic coronary heart disease (1).
intervention with modest weight loss decreased the
Fetuin-A is a multifunctional plasma factor that
incidence of T2DM and delayed the progression from
secreted mainly by hepatocytes, also called Alpha 2-
obesity to T2DM (9).
Heremans Schmid Glycoprotein (AHSG) (2), Fetuin-
To best of our knowledge, there is a great
A act by inhibition of insulin receptor tyrosine kinase
relationship between fetuin-A and insulin resistance
activity and this is related to insulin resistance,
in type-II diabetic patients either obese or non-obese.
metabolic syndrome and increased risk of type-II
diabetes mellitus (3).
AIM OF THE STUDY
Fetuin-A blocks the insulin from attaching to its
The present study aimed to investigate the
receptors, creates a pathway and causes insulin
level of fetuin-A levels in obese and non-obese type
resistance concerning type-II diabetes mellitus
2 diabetes mellitus patients.
pathophysiology. Fetuin-A gene is discovered at the
locus 27 on the(q) arm of chromosome 3, which is
PATIENTS AND METHODS
also related to type-II diabetes mellitus and
This is a case-control study that carried out on
cardiometabolic disorders (4).
75 participants admitted to the Internal Medicine
Metabolic syndrome is related to many
Department at Zagazig University Hospitals. The
underlying mechanisms as insulin resistance,
participants were divided into three groups: Group1:
inflammation, hormonal changes, and decreased
25 non-obese non-diabetic individuals, Group 2: 25
physical activity (5).
non-obese Type-II diabetic patients and Group 3: 25
Studies have shown a strong association
obese Type-II diabetic patients.
inhibitory effect of fetuin-A on adipose tissue,
lipolysis and free fatty acid efflux (6).
Received:12 /1 /2020
Accepted:21 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 469-480
Value of Multi-Slice Computed Tomography in The Evaluation of Postoperative
Complications After Laparoscopic Sleeve Gastrectomy
Amgad S. Abdel-Rahman*, Fatma M. M. Salama*, Sayed H. M. Mohamed**
* Department of Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt,
** Department of Radiology, National Liver Institute, Menoufia University, Menoufia, Egypt.
Corresponding author: Amgad S. Abdel-Rahman, email: firstname.lastname@example.org
Background: Obesity is a medical condition that have an adverse effect on health. Bariatric surgery is considered
nowadays as one of the most effective treatment for obesity. CT is one of the best modalities that is performed after a
bariatric procedure to assess for complications.
Purpose: The aim of this work was to highlight CT radiological features of postoperative surgical complications after
laparoscopic sleeve gastrectomy (LSG) using abdominal multi-slice computed tomography (MSCT), and 3D
volumetric rendering if needed.
Patients and Methods: 182 patients with post sleeve gastrectomy suspected complications were subjected to CT of
the abdomen and pelvis. Post-processing was performed with multi-planner reformation generating coronal and sagittal
images together with the raw axial images for assessment of the integrity of the sleeved stomach and detection of any
encountered complication with 3D reconstruction if needed to asses gastric pouch volume.
Results: CT detected complications in 43 patients (23.6%) out of the 182 patients who underwent laparoscopic sleeve
gastrectomy. The complications reported in our study were hematoma occurred in 13 patients (7.1%), leakage occurred
in 10 patients (5.5%), abscess formation occurred in 6 cases (3.3%), splenic infarction occurred in 5 patients (2.7%),
solid organ injury occurred in 2 patient (1%), Porto-mesenteric thrombosis occurred in 7 patients (3.8%), intestinal
obstruction occurred in 2 cases (1%), port site ventral hernia occurred in 3 cases (1.6%), abdominal wall hematoma
occurred in 3 cases (1.6%), enlarged gastric pouch occurred in 4 cases (2.2%), hiatus hernia occurred in 2 cases (1%).
Conclusion: It could be concluded that sleeve gastrectomy became an increasingly popular surgery for obesity, so the
radiologists must recognize and identify the normal postoperative anatomy as well as the possible complications of
this procedure. MSCT with the 3D volumetric study is an important imaging tool to diagnose accurately the
complications of sleeve gastrectomy.
Keywords: Laparoscopic sleeve gastrectomy (LSG), Multi-slice CT (MSCT), Body mass index (BMI).
Developed and developing countries are affected by
laparoscopic adjustable gastric banding (LAGB) and
obesity which is a growing health problem that can lead
sleeve gastrectomy (LSG) that markedly decrease
to health, social and financial problems. Around the
gastric capacity inducing early satiety; mal-absorptive
world, obesity is substantially increasing and 66% of
surgical procedures as not commonly done
American adults were reported overweight and 32%
biliopancreatic diversion and jejunoileal bypass that
endured from obesity according to centers for Disease
alter the GIT and hence interfering with nutrient
Control and Prevention, while, around 30% of adult
absorption from small bowel; and combined restrictive
Egyptians were reported obese in Egypt according to a
and mal-absorptive procedures as Roux-en-Y gastric
survey organized in 2011-2012. Together with obesity,
bypass (RYGB) that primarily reduce weight by
numerous chronic diseases as diabetes mellitus and
restrictive rather than mal-absorptive interference (3).
cardiovascular problems are increased (1, 2).
The most commonly used surgical approaches,
Obesity is considered if body mass index (BMI)
exceeding 90 % of the procedures, are laparoscopic
ranges from 30 to 35 kg/m2, and if more than 3540
sleeve gastrectomy (LSG), Roux-en-Y gastric bypass
kg/m2, morbid obesity is considered. Bariatric surgery
(RYGB), and laparoscopic adjustable gastric banding
should be considered for endured people who couldn't
lose weight despite following diet and exercise
Post-operatively, within the first two days, patients
regimen, as it is the most invasive choice in treating
are imaged by upper GI fluoroscopic series, especially
obesity. Bariatric surgery has substantially increased in
when a leak is suspected (3, 4).
the United States and was done five times in 2003 as in
However, if small bowel obstruction, internal
hernia, or abscess was suspected or with non-specific
The three main categories of bariatric surgery
complaints, MDCT is preferred (4). Gastric pouch
inducing weight loss are restrictive procedures as
volume can be assessed by 3D volumetry after bariatric
Received:2 /3 /2020
Accepted:30 /3 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 481-488
The Effect of High Flux versus Low Flux Dialyzers on
Serum Fibroblast Growth Factor-23 (FGF-23) and Its Cardiovascular
Implications in Prevalent Hemodialysis Patients
Walid Ahmed Bichari, Mariam Gamal Aabed, Ashraf Hassan Abdelmobdy*
Department of Internal Medicine, Faculty of Medicine, Ain Shams University
*Corresponding author: Ashraf Hassan Abdelmobdy, Mobile: (+20)01093989048, E-Mail: email@example.com
Background: Cardiovascular disease is the main cause of death in patients with end stage renal disease. Fibroblastic
growth factor- 23 (FGF-23) is a novel phosphaturic hormone produced in the osteocyte. Patients with kidney disease
complain of elevated levels of FGF-23 in response to hyperphosphatemia.
Patients and Methods: This was a cross-over prospective study conducted on 30 patients on regular hemodialysis.
The study period was 6 months, laboratory investigations for FGF-23, complete blood picture, s. urea (pre-dialysis
and post-dialysis), serum albumin, serum electrolytes (Ca++ & PO4), alkaline phosphatase, PTH, serum ferritin, and
lipid profile as well as echocardiography were obtained in the start of the study, after 3 months on maintained low-
flux hemodialysis and 3 months after switching the patients to high-flux hemodialysis.
Results: There was a highly significant reduction of FGF-23 level with high-flux dialyzers than with low-flux
dialyzers. The adjusted difference in the absolute change in FGF-23 levels between the three months period of low-
flux dialysis and the three months period of high-flux dialysis showed a highly significant reduction with high-flux
than with low-flux (p= 0.000). There was a significant reduction of serum levels of PTH, calcium, phosphorus levels
with high-flux dialyzers than with low-flux dialyzers, the adjusted difference was (p= 0.022), (p= 0.000), and (p=
Conclusion: FGF-23 levels were significantly higher in hemodialysis patients than in normal population. FGF-23
was better eliminated by high-flux dialyzers than low-flux dialyzers and high FGF-23 levels were associated with
increased incidence of cardiac valve calcification. FGF-23 positively correlated with right ventricular systolic
Keywords: Cardiovascular, Low-flux, High-flux, FGF-23, Hemodialysis patients
Patients with end stage renal disease, treated
populations of pre-dialysis CKD, incident and
with hemodialysis, have an annual mortality rate of
prevalent ESRD and kidney transplant recipients
approximately 20%. Cardiovascular disease is the
demonstrate that elevated FGF23 levels are
main cause of death, with the annual death rate from
independently associated with progression of CKD
CVD at 9%, which is approximately 1020 higher than
and development of cardiovascular events and
in the general population (1). Vascular calcification is
also common in patients with end-stage renal disease
Aim of study to compare between the effect of
(ESRD) who are treated with regular dialysis and it
low-flux versus high-flux dialyzers on serum level of
may contribute to the very high mortality rate from
FGF-23, and to study the association between FGF-23
cardiovascular causes in such patients. Arterial
and echocardiographic parameters in hemodialysis
calcification can result from the deposition of mineral
along the intimal layer of the arteries in conjunction
with atherosclerotic plaques or from calcium
PATIENTS AND METHODS
deposition in the medial layer of the arteries that is due,
This was a cross-over prospective study
at least in part, to disturbances in mineral metabolism
conducted on 30 patients on regular hemodialysis
maintained on thrice weekly sessions in Dar Elshefaa
fibroblastic growth factor 23 (FGF23) is a
hemodialysis unit, 4 hours each. The study Period was
novel phosphaturic hormone produced in the
6 months (from March to August 2016). Patients were
osteocyte (3). In patients with kidney disease, normal
on low flux polysulfone filters (Fresinius F6), then
serum phosphate levels are maintained despite a
switched to high-flux polysulfone filters (F6).
declining nephron mass, in part by progressive
Laboratory investigations included FGF-23, complete
"secondary" increases in FGF-23 levels (4). Increases
blood picture, s. urea (pre-dialysis and post-dialysis),
in FGF23 levels help maintain serum phosphate in the
serum albumin, serum electrolytes ( Ca++ & PO4 ),
normal range in CKD. Prospective studies in
alkaline phosphatase, PTH, serum ferritin, and lipid
Received:11 /1 /2020
Accepted:20 /3 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 489-496
Evaluation of the Corneal Thickness and Endothelial Changes
Following Uncomplicated Phacoemulsification in Diabetic and Non-Diabetic
Patients by Pentacam and Specular Microscopy
Motaz Bellah Abdel Hameed Erfan1, Hossam El-Den Mohamed Khalil2,
Hazem Effat Haroun2, Ahmed Tharwat AG*1
1 Department of Ophthalmology, Faculty of Medicine, Misr University for Science and Technology
2 Department of Ophthalmology, Faculty of Medicine, Beni-Suef University
*Corresponding author: Ahmed Tharwat, Mobile: +201207782340, Email:firstname.lastname@example.org
Background: Diabetes mellitus (DM) is an important health problem that induces unrestful complications. It causes
significant morbidity owing to specific microvascular complications such as diabetic retinopathy, diabetic cataract,
diabetic keratopathy, and diabetic optic nerve diseases.
Patients and Methods: This is a prospective, comparative case series study assessing the corneal endothelial status in
20 diabetics and 20 non diabetics before, after 1 day, 1 week and 1 month of uneventful phacoemulsification using
phaco-chop technique. Central corneal thickness (CCT), as well as endothelial cell density (ECD), coefficient of
variation (CV) and percentage of polymegathism or hexagonality were measured by specular microscopy. The corneal
thickness at 0, 2 and 4 mm from center of the cornea and corneal volume at 3, 5 and 7 mm from the center of the cornea.
Changes were compared between both groups using pentacam in the same follow up period.
Results: Preoperative CCT was found to be significantly higher in diabetic than in non-diabetic group. ECD and CV
were insignificantly higher in diabetics in contrast with the percentage of hexagonality, which was found to be
insignificantly lower preoperatively. Diabetics showed insignificant higher loss in endothelial cell count as compared
to non-diabetics. Furthermore, the diabetics showed a slower recovery trend in the endothelial healing response as
evidenced by lower change in the CV%. Postoperative CCT measurements demonstrated no significant variations
between groups evidenced by specular microscopy as well as changes in corneal thickness and volume evidenced by
Conclusion: The present study revealed no significant differences between preoperative and postoperative values
neither in terms of mean ECD values, nor in corneal thickness and corneal volume between diabetic patients and non-
diabetic patients undergoing phacoemulsification employing phaco-chop technique.
Keywords: Cataract Surgery, Corneal Thickness, Endothelial Changes, Specular Microscopy, Pentacam, Diabetes
diabetes have been found to have morphologically
The corneal endothelium has a vital role in the
abnormal endothelium that is pleomorphism and
maintenance of corneal transparency. This is
polymegathism (5). Thus, an elderly diabetic patient
accomplished by its effectiveness in keeping the corneal
stroma in a state of continuous dehydration through its
vulnerable to greater endothelial damage during
two main actions; active fluid pump and barrier
surgery. This hypothesis has been supported by few
function. Any compromise in these activities has a
previous studies (6, 7 and 8) but still remains controversial.
direct effect on corneal transparency (1).
Inoue et al. (9) in their study showed that presence of
The corneal endothelium is known to undergo
type 2 diabetes mellitus is irrelevant to any of the
damage during phacoemulsification (2). The endothelial
parameters of corneal endothelial cells in patients
cell count is also known to decline with age (3). With
undergoing cataract surgery.
increase in life expectancy as most of the patients
In a recent study, Storr- Paulsen et al. (10)
undergoing phacoemulsification belong to the elderly
showed that type 2 diabetes has no impact on corneal
age group, endothelial damage during surgery becomes
cell density or morphology in participants with good
an important factor.
glycemic status. In another study, it was reported that
Diabetes mellitus (DM) is among the most
diabetes can affect both the corneal thickness and the
prevalent and morbid chronic diseases affecting
corneal endothelium. Hyperglycemia alone can lead to
millions worldwide. According to the Global Burden of
endothelial alterations that can convert a routine surgery
Disease report, the prevalence of diabetes rose from
into a high-risk surgical case (7).
approximately 333 million in 2005 to approximately
435 million in 2015(4). DM leads to various ocular
AIM OF THE WORK
complications such as diabetic retinopathy, diabetic
To evaluate the corneal thickness changes
cataract, diabetic keratopathy and diabetic optic nerve
using pentacam and endothelial changes using specular
diseases. Diabetes mellitus also has been found to be
microscopy in diabetic patients as compared to non-
detrimental to the corneal endothelium. Patients with
diabetics after uneventful phacoemulsification surgery.
Received:13 /1 /2020
Accepted:22 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 497-502
The Diagnostic Value of Cervicovaginal and Serum Ferritin in Relation to
Spontaneous Preterm Birth: Observational Study
Ibrahim Saif Elnasr, Hesham Ammar
Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
*Corresponding author: Ibrahim Saif Elnasr:, Mobile: (+20) 1003086747,
email: Ibrahimalisaifelnasr@gmail.com, ORCID ID; https://orcid.org/0000-0002-5055-228X
Background: Preterm labor is a major cause of neonatal complications. Some researchers have demonstrated that
increased serum ferritin level and cervicovaginal ferritin concentrations is associated with preterm labor.
Objective: The aim of the current work was to detect the role of serum and cervicovaginal ferritin concentrations in
mid gestation in predicting preterm labor in patients with no well-known risk factors for preterm delivery.
Patients and methods: This prospective cohort observational study included a total of 100 pregnant women with
singleton pregnancies between 20 and 24 gestational weeks, attending at the Department of Obstetrics and
Gynecology, Menoufia University Hospital between March 2017 to March 2019. Cases were distributed between 2
groups; Group 1 delivered full-term and group 2 delivered preterm. Cervicovaginal and serum ferritin was measured
for them. All cases were followed up till delivery.
Results: There is a strong relation between spontaneous preterm delivery and increased levels of serum and
cervicovaginal ferritin when measured at gestational age 2024 weeks. Serum ferritin level 110.5 ng/mL gave
sensitivity 86.7% and specificity 94.1% in preterm delivery prediction. Cervicovaginal ferritin level 25.5 ng/mL
gave sensitivity 86.7 % and specificity 64.7% in preterm delivery prediction.
Conclusion: It could be concluded that increased serum and cervicovaginal ferritin concentrations in mid gestation
are dependable markers for predicting preterm delivery
Keywords: cervicovaginal ferritin, preterm delivery, serum ferritin, spontaneous preterm delivery
kom, Menoufia, Egypt. This study was conducted
Preterm delivery (PTD) is a large healthcare
between March 2017 to March 2019.
problem worldwide, its incidence increases in
middle-income and high-income societies that can
cause major short-term and long-term medical and
Written informed consent of all the subjects was
developmental problems in infants (1). Also, suspected
obtained after counseling and explanation of the
preterm delivery is the largest cause of pregnant women
benefits and unexpected risks of any procedure. The
hospital admission (2).
study protocol was reviewed and approved by the
It is, therefore, vital to understand the basic mechanisms
local ethics committee at Menoufia University
of preterm labor (PTL) because even if existing
preventive interventions were fully scaled, fewer than
20% of preterm births would be prevented (3).
Exclusion criteria: Women with multiple pregnancies,
Ferritin is an iron storage protein. It is an acute phase
hypertension, smoking, polyhydramnios, placenta
reactant. Ferritin level increases in inflammation and
previa, diabetes mellitus, chronic underlying diseases,
infection. Some researchers have demonstrated that
known short cervix or uterine malformation, and
increased serum ferritin level is associated with preterm
previous preterm delivery or surgery of the cervix.
The included subjects were distributed between
Some researchers had considered cervicovaginal ferritin
two groups; Group (1) consisted of 85 pregnant women
as a predictor for preterm labor with using other
who delivered at full term and Group (2) consisted of
parameters in order to get better results (5-6).
15 pregnant women who delivered preterm.
All women were subjected to complete history
The aim of the current work was to detect the role of
serum and cervicovaginal ferritin concentrations in mid
examination. Obstetrical US was done for each case.
gestation in predicting preterm labor in patients with no
well-known risk factors for preterm delivery.
Local (vaginal) examination: Sterile speculum was
used before any pelvic examination to obtain a
PATIENT AND METHODS:
This prospective cohort observational study
included a total of 100 pregnant women with singleton
pregnancies, between 20 and 37 years age, average
body weight, and between 20 and 24 gestational weeks,
Measurement of cervicovaginal ferritin:
attending at the Department of Obstetrics and
Before local pelvic examination a pipette was
Gynecology, Menoufia University Hospital, Shibin El-
used to obtain mucous sample from external os and
Received:14 /1 /2020
Accepted:23 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 503-508
Incidence of Acute Kidney Injury in HCV Infected Patients
Receiving Direct-Acting Antivirals
Hayam Aref1, Mostafa Ahmed2, Ahmed Abdelmoniem Emara*1, Salma Fathy Rezk1,
Haitham Ezzat Abdelaziz 1
1Department of Internal Medicine and Nephrology, Ain Shams University, Cairo, Egypt
2 Kobry El Kobba Military Hospital, Cairo, Egypt
*Corresponding author: Ahmed Abdelmoniem Emara, Mobile: +201006721401, E-mail: email@example.com
Background: Egypt had high burden of HCV infection worldwide. The new direct-acting antivirals (DAAs) can
target almost all steps of HCV life cycle.
Objective: Study of the incidence of acute kidney injury (AKI) in HCV infected patients receiving DAAs.
Patients and methods: A prospective study that was conducted in the Virology Clinic in Kobry El-Koba Military
Hospital on 63 male patients who were eligible to treatment by DAAs, who received treatment with sofosbuvir,
daclatasvir and ribavirin combination. They were divided into Group A: 33 patients with eGFR > 90 ml/min and
Group B: 30 patients with chronic kidney disease (CKD) stage II-III (eGFR<90 and >30 mL/min). The fluctuations
in serum creatinine and eGFR were measured while on-therapy and for 3 months follow up after end of treatment.
Results: total of 63 male patients, treatment-naive were included. Group A (33 patients) with eGFR > 90 mL/min.
Group B (30 patients) with eGFR < 90 mL/min. There was a significant difference between different readings of
serum creatinine in both groups on therapy and on follow up during the next 3 months after the end of therapy. The
incidence of AKI was more observed in patients with eGFR > 90 ml/min in comparison with those with eGFR < 90
ml/min and >45 ml/min, but with no statistical significance.
Conclusion: AKI events during and after end of therapy with DAAs were observed especially in patients with normal
baseline serum creatinine. Patients with CKD stage II-III experienced improvement in their kidney functions during
and after end of therapy.
Keywords: Hepatitis C virus, Direct acting new antiviral drugs, Acute kidney injury.
defined as any of the following; increase in serum
A cross sectional survey was conducted by the
creatinine by 0.3 mg/dL within 48 hours; or increase
Egyptian Demographic Health Survey (EDHS) in 2008
in serum creatinine to 1.5 times of baseline, which
on a large nationally representative sample including
have occurred within the prior 7 days; or urine volume
hepatitis C virus (HCV) biomarkers. It estimated the
< 0.5 ml /kg/hr for 6 hours (6).
prevalence of HCV among the 1559 years age group
Unfortunately, there are no randomized
to be 14.7% (1). According to this data, Egypt has the
clinical trials that document the definitive effect of
highest HCV prevalence worldwide (2).
treatment on renal or patient survival. The available
Up to 25% of chronically infected HCV
data are obtained from small cohorts, treated with the
patients eventually develop cirrhosis and related
old interferon/ribavirin protocols. Metanalysis of these
studies has displayed conflicting data, which may be
related to heterogenecity of patient demographics,
Treatment success of HCV has been defined in
stage and the nature of kidney disease, the extent of
terms of sustained virologic response (SVR), which is
liver injury and associated extrarenal manifestations,
the absence of detectable levels of viral RNA in the
blood after 24 weeks of completion of therapy (4).
In a metanalysis of 11 studies comprising 107
The new direct acting new antiviral agents
patients treated with interferon with or without
(DAAs) target the HCV-encoded proteins involved
ribavirin, there was a regression in proteinuria to a
with replication. These include non-structural (NS)
variable extent in those who achieved end-of-treatment
components, such as RNA- dependent RNA
viral response. A few patients developed relapse when
polymerase (NSSB), the protein NSSA (a role in the
the viral clearance was un-sustained. There was no
formation of the replication complex), and the proteins
significant change in serum creatinine in all studies
NS3 and NS4A (serine protease and cofactor) (5).
apart from 2, where the GFR was increased. No report
The fixed-dose combinations currently
of post-treatment biopsy (7).
available include sofosbuvir/ledipesvir (400 mg/90
Sofosbuvir is eliminated mainly by the renal
mg), ombitasvir/peritaprevir/ ritonavir (two pills of
route and its use in CKD stage 4 or 5 or in patients on
12.5 mg/75 mg/50 mg of each agent, respectively) plus
haemodialysis is out of the licence recommendations.
dasabuvir (250 mg), sofosbuvir/daclatasvir (400 mg/60
The substantially higher concentrations of sofosbuvir
mg), sofosbuvir/simeprevir (400 mg /150 mg) and
and, its renally excreted metabolite GS- 331007 as
ribavirin. According to KDIGO (Kidney Disease:
compared to patients without renal impairment have
Improving Global Outcomes) guidelines (6), AKI is
raised more concerns. In the target 2.0 real world
Received:15 /1 /2020
Accepted:24 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 509-518
Effect of Venous Congestion on Worsening Renal Function in
Decompensated Heart Failure Patients
Abdelbassit ElShaarawy1, Adel Gamal Hassan 2, Ahmed Abdelmoniem Emara 1,
Haitham Ezzat Abdelaziz
1Department of Internal Medicine and Nephrology, 2Department of Cardiology,
Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Ahmed Abdelmoniem Emara, Mobile: +201006721401, E-mail: firstname.lastname@example.org
Background: Cardiorenal syndrome has been defined as the simultaneous dysfunction of both the heart and the kidney.
In this setting, worsening renal function (WRF) is a common finding.
Objective: The aim of work was to determine whether venous congestion, rather than impairment of cardiac output, is
associated with the development of WRF in patients with decompensated heart failure (DHF).
Patients and Methods: This observational prospective study included a total of 30 adult Egyptians patients with DHF,
attending at Ain Shams University Hospitals. Inclusion criteria: 1. Left ventricular ejection fraction < 50%. 2. CVP >
10 mmHg. 3. Right ventricular systolic pressure > 40 mmHg. ECHO was done for all subjects. Follow up of s.
creatinine, GFR with MDRD equation, CVP, MABP and body weight were done daily for a week.
Results: At follow up, 11 (36.7%) subjects developed WRF and 19 (63.3%) did not. that there was an incremental risk
in WRF with increasing baseline CVP, as it appears to be a near linear relationship, because if the baseline CVP
reached >19 or > 24 mmHg, we observed a sharp increase in the incidence of WRF approaching 51% and 71%,
respectively. Furthermore, the mean baseline CVP was higher in subjects who developed WRF (26.2±3.3 mmHg)
versus those who did not (18.1±1.9 mmHg) ( p<0.001).We have also noticed that baseline EF was significantly lower
in subjects who developed WRF .We also noticed that Subjects who developed WRF had lower eGFR at baseline.
Conclusions: It could be concluded that in the setting of DHF, venous congestion (high CVP) may be the most
important driving factor of WRF rather than low COP.
Keywords: Heart failure; Renal function; Kidney; Hemodynamic; Venous congestion.
PATIENTS AND METHODS
Heart and kidney performance are strictly
This observational prospective study included a total
interconnected, and communication between these two
of 30 adult Egyptians patients with DHF, attending at
organs occurs via a variety of pathways, including
hemodynamic and nonhemodynamic mechanisms (1).
This unique relationship and the interdependence of
Ain Shams University Hospitals. Written informed
the kidneys and the heart are well recognized. These
consent of all the subjects was obtained.
critical and dynamic connections between both acute
and chronic cardiac dysfunction and acute and chronic
kidney disease and the way dysfunction of one organ
The study protocol was reviewed and approved by
affects the other have been led to the characterization of
Ethical Committee of Faculty of Medicine, Ain
the cardiorenal syndrome (CRS) as a separate entity (2).
Even though decreased forward flow as a result of
decreased cardiac output in Acute Decompensated Heart
The included 30 patients were 18 years old,
Failure (ADHF) can cause acute deterioration in kidney
presented with DHF and treated with intravenous or oral
function, there are many reasons why this mechanism
loop diuretics while continuing other needed
fails to completely explain the development of the CRS.
medications as angiotensin converting enzyme
Data from human studies have shown that increased
central venous pressure (CVP) and jugular venous
spironolactone as tolerated.
pressure (JVP) on examination are associated with
worsening in kidney function. as well as increased
Inclusion criteria: patients with Left ventricular
mortality. Also, renal dysfunction is one of the most
ejection fraction (EF) < 50%, CVP > 10 mm Hg, Right
important comorbidities in chronic HF patients and is
ventricular systolic pressure (RVSP) > 40 mmHg).
aggravated, or becomes more evident, during episodes
of acute heart failure (3).
Exclusion criteria: those on Renal replacement therapy,
Aim of the work was to determine whether venous
patients with immunologic or malignant diseases,
congestion, rather than impairment of cardiac output, is
hepatorenal syndrome, current infections (sepsis),
associated with the development of WRF in patients
congenital heart disease, intravenous inotropic support
with decompensated heart failure (DHF).
on admission and those on mechanical ventilation.
Received:15 /1 /2020
Accepted:24 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 519-531
Histological and Histochemical Studies on Kidneys of the Pregnant
Rats and Their Foetuses under the Effect of Buspirone Hydrochloride
Hanaa A. Abd El-Gawwad
Zoology Department, Faculty of Science, AL-Azhar University, Egypt
Background: anxiety is a powerful central nervous system depression that can slow normal brain function. Buspirone
is often prescribed to reduce the feelings of tension; this drug is also known as sedative drug.
Aim of the work: this study aimed to detect the effect of buspirone hydrochloride on kidney of the pregnant rats and
their foetuses (histological and histochemical studies).
Material and methods: the current study was applied on thirty pregnant female rats that were categorized into three
groups (ten pregnant rats in each group): Group1 (the control pregnant rats that were orally administrated with distilled
water, group II (pregnant rats were given oral dosage of buspirone hydrochloride at dose level of 0.27 mg /100 g body
weight /day daily for 15 days from the 6th day to the 20th day of gestation and group III (pregnant rats were treated with
buspirone hydrochloride at a dose level of 0.41 mg/100 gm body weight/day for 15 days from the 6th to the 20th day of
gestation. Kidney tissues were taken from pregnant rats and picked out from their foetuses of all groups which killed on
the 20th day of gestation for the histological and histochemical studies.
Results: maternal and foetal kidney tissues of both treated groups showed numerous changes post-treatment with
buspirone that well-marked at the high concentration dose.
Conclusion: the present study showed that administration of Buspirone drug resulted in several histological and
histochemical alterations in the kidney tissues.
Keywords: Pregnant, Foetuses, Buspirone, Histological and Histochemical Changes, Kidney.
Anxiety is a powerful central nervous system
gastric tube. The daily single oral dose was 0.27 mg and
depression that can slow normal brain function.
0.41 mg/100 g body weight/day, respectively. The
Buspirone is often prescribed to reduce the feelings of
dose for rats was calculated according to the method
tension; this drug is also known as sedative drug (1).
Paget and Barnes formula on the basis of the human
Anxiety becomes a disorder when the individual
experienced regularly and refers to specific psychiatric
disorders that involve extreme fear or worry and
includes generalized anxiety disorder, panic disorder
Adult Albino rats (Sprague Dawely strain) were
and panic attacks, agoraphobia, social anxiety disorder,
used in this experiment with average weight from150 to
selective mutism, separation anxiety and specific
200 g. They were taken from the animal house of EL-
Nasr pharmaceutical chemicals company. Rats were
A number of psychoactive agents are currently
caged separately, males in cages and females in another
available for treatment of anxiety. The source of
cages and fed on an ordinary diet. Adult females and
anxious behaviour is usually undefined or unknown (1).
males were mated in the proportion of two females for
In contrast to normal adaptive anxiety, anxiety disorders
one male overnight. Each morning a vaginal smear was
affect the individual performance of daily life tasks(3)
taken to check for the presence of vaginal plug. Zero
representing a high cost for public health care all over
day of pregnancy was considered to be the day on which
the world (4-5).
sperms or plugs were found in the vagina.
Buspirone is a good novel anti-anxiety drug
which has neither a benzodiazepine structure nor any
The experimental design:
other benzodiazepine-like properties. Since buspirone is
Thirty pregnant female rats were categorized into
known to block dopamine auto receptors and increase
3 groups (Ten pregnant female rats in each group):
dopamine metabolism, it was compared to classical
antipsychotic drugs for sub chronic and chronic effects
Group 1 (control): pregnant healthy normal rats
on dopaminergic function (6).
administrated with distilled water.
This study aimed to detect the effect of buspirone
Group 2 (low dose B1): pregnant rats were treated oral
on kidney of the pregnant female rats and their foetuses
dose of buspirone hydrochloride equivalent to 0.27 mg
(histologically and histochemically).
/100gm body weight/day for 15 days from the 6th day to
the 20th day of gestation.
MATERIAL and METHODS
Group 3 (high dose B2): pregnant female rats were
treated with oral dose of buspirone hydrochloride
Buspirone hydrochloride was taken as tablets from
equivalent to 0.41 mg/100g body weight/day for 15
Beecham, Haram, Giza, Egypt. The drug was dissolved
days from the 6th day to the 20th day of gestation.
in the distilled water and given orally by a
The histopathological and histochemical studies:
Received:13 /1 /2020
Accepted:22 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 532-537
Evaluation of Nutritional Status of Children with Acute
Lower Respiratory Tract Infection
Mohammad Nagieb AboElfotoh1, Ehab Mahmoud Rasheed 1,
Samar Mahmoud Sharaf 2, Noha Abdel Baset Tohamy*1
1 Departments of Pediatric, 2 Departments of Clinical Pathology - Faculty of Medicine, Zagazig University
*Corresponding author: Noha Abdel Baset Tohamy; Mobile: (+20)01003220889; E-mail: email@example.com
Background: Pediatric respiratory disease remains an important cause of morbidity in both developing and
developed world. Several risk factors are associated with acute respiratory infection (ARIs), some of them are
un-modifiable (e.g. age and sex of the child), while others are modifiable and these include nutritional and
environmental modifiable risk factors (e.g. lack of breastfeeding and severe malnutrition).
Objective: This study was designed to evaluate nutritional status of children with acute lower respiratory tract
Patients and methods: This study included 40 children, aged from 1 to 5 years suffering from acute lower
respiratory tract infection (ALRI). The children were subjected to complete history, clinical examination and
laboratory investigation as estimation of serum level of zinc and pre-albumin.
Results: In children with ALRI, there was non-significant difference between children with pneumonia,
bronchitis and bronchopneumonia as regard breast feeding, supplementation, MAC, Zinc and pre-albumin,
however, the difference between them was significant as regarding BMI and nutritional status.
Conclusion: The results of this study concluded that there is positive relation between nutritional status of child
and acute LRTI. There was significant decrease in mortality and morbidity due to RTI after improvement of
nutritional status of children. The level of zinc and pre-albumin were affected by nutritional status of children.
Keywords: Zinc, Prealbumin, Nutritional Status, Children, LRTI.
Pediatric respiratory disease remains an
SUBJECTS AND METHODS
important cause of morbidity in both developing and
Type of the study: This was a cross sectional
developed world. Pneumonia or ALRI cause over 2
million deaths annually among children younger than
Study setting: Conducted in Pediatric
5 years of age. Responsible for about 19% of all
Outpatient Clinics, Pediatric Department,
children deaths. Pneumonia is the leading cause of
Zagazig University Hospitals.
children mortality (1). Improvements in nutrition are a
Study period: From October 2017 to March
keystone of current global efforts to reduce the
burden of mortality and morbidity due to ALRIs
Sample size: Total sample size included 40
among children living in developing countries (2).
children from 1 to 5years old.
Clinical studies indicate that determination of
Study group: 40 children from 1 to 5 years old
the pre-albumin level may allow for earlier
with ALRTI selected randomly from those
recognition of and intervention formal. Synthesis of
attending the outpatient pediatric clinic.
pre-albumin increases above baseline levels within
Consent: This study was ethically approved
48 hours of protein supplementation in children with
from Institutional Reviewer Board (IRB), in
severe protein calorie malnutrition and returns to
Faculty of Medicine, Zagazig University and
normal levels within eight days. These observations
consents from parents of children, participating
and others led to the recommendation that pre-
in this research, were taken.
albumin levels should rise 2 g/dL (20 g/L) per day
with adequate nutritional support (3).
Zinc deficiency is widely prevalent in the
1. Age: 1-5 years old children.
developing areas of the world, which also have a high
2. Sex: both sexes are included.
incidence of ALRI. Zinc deficiency has been a
3. Children with acute lower respiratory tract
particular focus of attention because of its high
frequency in developing countries and its debilitating
effects on immune function (4).
1. Absence of informed consent.
2. Children with other chronic disease (renal
AIM OF THE WORK
The aim of our study was to evaluate
3. Children with gastrointestinal disease.
nutritional status of children with acute lower
4. Children with total parenteral nutrition (TPN) in
respiratory tract infection.
the previous month.
Received:18 /1 /2020
Accepted:27 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 538-543
Association between Vitamin D Deficiency and Recurrent
Acute Diarrhea in Children
Azza Ibrahim El- Desouky1, Mona Mohammed El Shaffi1,
Samar Mahmoud Sharaf2, Heba Ibrahim Salem Mohammed*1
1Department of Pediatrics, 2Department of Clinical Pathology, Faculty of Medicine, Zagazig University
*Corresponding author: Heba Ibrahim Salem Mohammed; Mobile: (+20)01151963676; E-mail: firstname.lastname@example.org
Background: Vitamin D deficiency is highly prevalent among children worldwide. It causes impairment of the
immune response to infection and decreased activity of gut antimicrobial peptides. The impact of vitamin D deficiency
on the severity of acute diarrhea among children may be helpful for diarrheal management.
Objective: To assess vitamin D deficiency and its correlation with recurrent acute diarrhea in children.
Subjects and Methods: This study included 60 children, (1 to 5 years old) suffering from recurrent acute diarrhea
more than 6 times per last year. They were subjected to complete history, clinical examination laboratory investigation
and supplementation of vitamin D for three months for children who had vitamin D deficiency or insufficiency.
Results: Vitamin D deficiency was found in 56.7%, insufficient in 21.7%, and sufficient in 21.7% in children with
recurrent acute diarrhea. There was a statistical difference as regards the number of acute diarrhea attacks and vitamin
D deficiency. Hemoglobin level was decreased below normal in (55%) of children with deficiency. Stool examination
detected Enterobius vermicularis, Giardia lamblia, Entamoeba histolytica, and Ascaris lumbricoides in (26.7%,
8.3%and 3.3%, and 1.7%) respectively. Seventy-five percent of the studied children were supplemented with vitamin
D which significantly decreases the number of diarrheal attacks.
Conclusion: This study pay attention to the role of vitamin D in the susceptibility to infection-related illness in
children. There is a positive correlation between vitamin D deficiency and iron-deficiency anemia. A significant
decrease in the number of attacks of acute diarrhea after vitamin D supplementation was noted.
Keywords: Vitamin D, Recurrent Acute Diarrhea, Children.
SUBJECTS AND METHODS
Diarrhea is defined as the passage of loose or
watery stool than is normal for the child or increase in
- Type of the study: an interventional cross-sectional
the frequency of stools for the child. It isn't a disease; it
is a symptom for many diseases but its risk comes from
- Study setting: The study was conducted on pediatric
being the second cause of death in children under five
out Patient Clinics, Pediatric Department, Zagazig
years. Each year diarrhea kills about 760,000 children
under five years (1).
- Study period: May 2017 to November 2017.
Diarrhea may be acute which lasts less than two
- Sample size: 60 patients (31 males, 29 females) with
weeks and chronic which continues more than two or
recurrent acute diarrhea.
three weeks. Recurrent diarrhea is any large volume of
- Inclusion criteria: Children aged between 1-5 years
stools or frequent loose stools that arise and resolve over
old or with a history of recurrent acute diarrhea at
and over again (2).
least 6 attacks for one year.
Micronutrient deficiency may affect both innate
- Exclusion criteria: Children with other causes of
cell-mediated immunity and adaptive antibody response
chronic diarrhea as malabsorption syndrome, celiac
and has shown to increase diarrhea-related morbidity
disease, ulcerative colitis, and chronic infection as
and mortality (3).
T.B, children with history or signs and symptoms of
One of these micronutrients is vitamin D. It was
rickets and severe malnutrition.
proposed that there is an association between vitamin D
Patients were divided into three groups according to
deficiency and the current acute diarrhea. The interest
vitamin D level, vitamin D deficiency (level < 20
has been grown over the last years about its role in non-
ng/mL). Vitamin D insufficiency (level between 20
skeletal medical conditions. The active metabolite of
& 30 ng/mL). Vitamin D sufficiency (level 30
vitamin D is 1, 25 dihydroxy vitamin D (calcitriol)
which has an important role in regulating the immune
response. It inhibits the proliferation of B cell and blocks
1- Complete history was taken from the parents of the
its differentiation and immunoglobulin secretion (4). It
also suppresses the proliferation of T cells and inhibits
2- Family socioeconomic scale (SES): A modified
dendritic cell differentiation and maturation (5).
form of Fahmi and El-Sherbini scale (7) was used.
3- Full clinical examinations: Anthropometric
AIM OF THE WORK
measurements for BW, HT, and BMI. Vital signs
Our study aims to assess vitamin D and find its
HR, BP, and RR.
correlation with recurrent acute diarrhea in children.
Received:16 /1 /2020
Accepted:25 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 544-547
The Effectiveness of Ultrasound-Guided Percutaneous Aspiration of
Simple Renal Cysts in Hospitals of Aljouf Region, Saudi Arabia
Mohammed Jayed S. Alenzi
Department of Surgery, College of Medicine, Jouf University
Background: Percutaneous renal cyst aspiration and sclero-therapy are considered as single, a safe and minimally invasive
procedure currently practicing by numerous uro-surgeons currently in the treatment of simple symptomatic cysts.
Objectives: This study was designed to assess the effectiveness and complications of ultrasound (US) guided percutaneous
aspiration of renal cysts with 99% ethanol as sclerosing material in the treatment of simple symptomatic renal cysts.
Methodology: This observational prospective study was done among 42 patients who had a total of 47 symptomatic simple
renal cysts. It was carried out during the period from 2014 to 2017 in the Outpatient Clinic of MOH. The patients' age
ranged between 23-62 years including male (19) and females (23). An US guided ablation of renal cyst was done under
local anesthesia. After that, an equal volume of contrast medium was injected through the needle into the cyst cavity to
delineate the cyst wall. The sterile 99% ethanol, with one fourth of total cyst volume was injected into the cyst after complete
aspiration of the contrast medium. After that, the ethanol was aspirated, and volume was measured.
Results: The complications were minimum including, hematuria in 8 patients (17%), low-grade fever in 7 patients (14.8%)
and mild flank pain in 5 (10.6%) patients were observed. During the follow-up after the sclerotherapy, out of 47 cysts, 20
(42.5%) cysts with different sizes showed statistically significant (P < 0.05) complete resolution and not appeared again
during the later follow-up sessions. The overall success rate in the current study procedure was 100%.
Conclusion: Percutaneous aspiration with a single injection of 99% ethanol sclerotherapy gave a high success rate in the
treatment of simple renal cysts with good optimization of sclerosing material and effective aspiration skill of uro-surgeon.
Keywords: Renal cyst, percutaneous aspiration, sclerotherapy.
Simple renal cysts are common, increase in
However, there is an increased chance for the re-
incidence with age and are found in 27- 50% of the
accumulation of fluid due to the secretory epithelium
population over 50 years of age (1). More complex cysts
lining of the cysts (5).
have a potential of being malignant. In 1986, Bosniak (2)
In 1981, Bean (4) introduced the use of ethanol as
introduced a classification system, which was modified
sclerosing material in cyst drainage. Later on, several
later on, for defining renal cysts complexity based on
modifications with different contrast materials in
computed tomography (CT) findings (3, 4).
sclerotherapy has been developed.
The diagnostics and management of renal cysts are
The good success rate will be achieved by only the use of
closely intertwined based on radiological categorization
optimum sclerosing material in sclerotherapy. In this
and proper differentiation between benign and malignant
regard, ethanol (95% or 99%) grabbed the attention as the
lesions making it clinically important when determining
best choice in the treatment of simple cyst by numerous
which patients should be offered surgical intervention.
urologists (5, 9, and 10).
Generally, most of the renal cysts are asymptomatic and
Since, ethanol rapidly impaired the cyst secreting cells
discovered incidentally during some imaging studies.
and slowly entered into the fibrous capsule of the renal
Patients with symptomatic and complicated renal cysts
cyst (4). Hence, the cyst can be easily removed without
are undergoing for treatment. The symptoms of simple
damage to the other area of the kidney (11).
renal cysts include flank pain (5) hematuria (5, 6) and
Many factors reflect the high success rate of ethanol
occasionally renal mass (5).
sclerotherapy including, ethanol concentration, the cyst
Percutaneous renal cyst aspiration and sclerotherapy
volume in relation with ethanol volume, the sclerotherapy
are considered as single, a safe and minimally invasive
duration per session, number of injections required in
procedure currently practiced by numerous urosurgeons
relation to cyst volume and duration of continuous
in the treatment of simple symptomatic cysts (2, 7).
aspiration before and after sclerotherapy (12).
Nowadays the role of sclerosing material plays an
The current study aimed to evaluate the effectiveness
important role in the achievement of good cyst resolution
and complications of ultrasound (US) guided
as compared to simple aspiration of cysts methods
percutaneous aspiration of renal cysts with 99% ethanol
without sclerosing material. Earlier studies reported that
as sclerosing material in the treatment of simple
cyst drainage without sclerosing material may have less
symptomatic renal cysts.
success rate of cyst resolution ranging from 30-80% (8).
Received:17 /1 /2020
Accepted:26 /2 /2020
The Egyptian Journal of Hospital Medicine (April 2020) Vol. 79, Page 548-552
Effect of HCV Eradication on Glycemic Control of Type 2 Diabetes Mellitus
Islam Ahmed Mohamed Sayed*1, Faried Fawzy Abd-elHafez 2, Hatem Mahmoud Salem 2
1Internal Medicine Department, AlAhrar Teaching Hospital, 2Internal Medicine Department,
Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Islam Ahmed Mohamed Sayed Ahmed,
E-mail: email@example.com, Mobile: (+02) 1022501130
Background: Hepatitis C virus (HCV) is a major cause of chronic liver disease, including cirrhosis and liver cancer.
Type 2 diabetes mellitus (T2DM) is a common comorbid condition in approximately one-third of individuals with
chronic HCV infection.
Objective: This study aimed at assessing the effect of the new direct acting antiviral drugs (DAAs) for chronic
hepatitis C (HCV) on glycemic control of type 2 DM.
Patients and method: This prospective cohort study was done on 32 diabetic patients with hepatitis C in the Internal
Medicine Department, Al-Ahrar Teaching Hospital. The patients underwent history taking, clinical examination and
laboratory studies including routine investigations and fasting blood glucose and glycosylated hemoglobin before
and after treatment with direct antiviral agents (DDAs).
Results: This study comprised 32 patients with diabetes. Their mean age was 57.65 ± 7.67 years. The females
constituted (62.5%). There was statistically non-significant difference change before and after treatment regarding
TLC, total bilirubin, HcvAb or HBSAG. There was statistically significant change between before and after
treatment regarding hemoglobin, platelet count, prothrombin time (all of them increased after treatment), INR,
s.creatinine, ALT and AST (all of them decreased after treatment). There was statistically significant difference
between PCR1 and PCR 2 before and after treatment. All patients had negative PCR after treatment with complete
response to DDAs. There was statistically significant decrease between FBG after treatment while there is
significant decrease in HbA1c after treatment.
Conclusion: HCV eradication leads to a statistically significant reduction in fasting glucose and HbA1c in patients
with type 2 diabetes, which is an indirect indicator of improvement of insulin sensitivity in patients with T2DM.
Keywords: HCV, DAAs, Glycemic, Diabetes Mellitus.
agents was associated with improved diabetes in a
Chronic hepatitis C (HCV) affects 12% of the
significant portion of patients with an average
world population and is a primary cause of liver
reduction in HbA1c of clinically significant
morbidity and mortality including liver cirrhosis and
hepatocellular carcinoma (1). Insulin resistance (IR) is
a feature of HCV infection reported up to 70% of
AIM OF THE WORK
cases and is involved in changes in glucose
This study aimed at assessing the effect of the
metabolism and in the development of type 2 diabetes
new direct acting antiviral drugs (DAAs) for chronic
mellitus (T2DM) that is observed with a higher
hepatitis C (HCV) on glycemic control of types 2
prevalence in patients with HCV infection compared
to non-infected subjects of HCV-related liver disease
and extra-hepatic manifestations (2).
Ethical and patients' approval:
The landscape of HCV management is changing
A written informed consent was handled from the
dramatically with the advent and approval of the new
patients to contribute in the study. Approval for the
oral direct acting antiviral (DAA) medications (3).
research was gotten from Internal Medicine and
Several studies have also confirmed a multifold
Medical Biochemistry Departments, Zagazig
increase in the prevalence of glucose abnormalities in
University Hospitals after receiving Institutional
patients with HCV as compared to controls. As such,
Review Board (IRB) approval.
the virus has been implicated in the development of
insulin resistance (IR) by modulating cellular gene
Study Design, Study Setting, and Study
expression and interfering with insulin signaling
pathways (4). T2DM remains a strong risk factor for
A prospective cohort study was conducted in
HCC development in cirrhotics after sustained
Internal Medicine Department at Al-Ahrar teaching
virologic response (SVR) has been obtained (5-6), but
hospital through the period from September 2018 to
a good glycemic control seems to reduce the
incidence of HCC (7-8).
Sample size: It was calculated to be 32 cases as degree
Treatment of HCV with direct-acting antiviral
of improvement after HCV eradication on glycemic
This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:19 /2 /2020
Accepted:28 /2 /2020