c:\work\Jor\vol802_1
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 754-759
Enhanced Peripheral Blood T lymphocyte Apoptosis in Pulmonary Tuberculosis:
Correlation with Disease Severity as Reflected by Mycobacterial Load
Amal Abd El Nabi Ayoub, Effat Moustafa Hassan, Azza Hassan El Salakawy and Amany M. Tawfeik*
Department of Microbiology, Faculty of Medicine, Al Azhar University
*Corresponding author: Amany M. Tawfeik, Mobile: (+20) 01227101474, Email: m_h_salama@yahoo.com
ABSTRACT
Background: Pulmonary tuberculosis (TB) is one of the major causes of illness and mortality worldwide. Control
of TB requires coordinated efforts of both innate and adaptive immune systems. Apoptosis is a genetically regulated
physiological process that when dysregulated can contribute to the pathogenesis of various diseases including TB.
Objectives: The frequency of apoptotic T cells among peripheral blood mononuclear cells in patients with active
pulmonary TB was studied and correlated with results of sputum bacterial load that reflects disease severity.
Patients and methods: The study included 28 newly diagnosed tuberculin positive patients under anti-TB
chemotherapy, classified into 3 groups according to sputum smear grading for AFB. In addition, 11 age matched
apparently healthy individuals were included as a control group. PBMCs were stained for flowcytometric analysis
using the TUNEL method.
Results: Increased frequency of apoptotic T cells was observed in 71.4% of patients compared to controls. Patients
with higher smear grades (grades 2+ and 3+) showed increased frequency of apoptosis compared to those with low
smear grade (1+).
Conclusion: Increased apoptosis may explain the T cell depletion/sustained low T cell responses observed in
patients with active pulmonary TB. Its strong association with bacterial load make it a possible in vitro readout of
pathogen burden that can be used for fast tracking the response to treatment. Targeting molecules involved in
apoptosis may be an approach for an adjunctive anti-TB therapy that rescues T lymphocytes protective activity
especially for infections caused by MDR and XDR MTB strains.
Keywords: Blood T lymphocyte, Apoptosis, Pulmonary Tuberculosis, Mycobacterial.
INTRODUCTION
in determining the clinical outcome. With effective
Pulmonary tuberculosis (TB), an infectious
CMI, the infection either resolves or becomes latent (6).
disease caused by Mycobacterium tuberculosis (MTB)
However, around 5-10% of latently infected individuals
remains one of the major causes of illness and mortality
exhibit an active disease at some point of their life time,
worldwide, especially in developing countries (1).
when the immune response is suppressed (7).
Despite the diagnosis and treatment along with the
Understanding the immunopathogenesis of TB is still
availability of a vaccine for nearly 100 years, the global
incomplete. Considerable insight into the mechanisms
infection rate of MTB is high (2). The Centers for Disease
of protective immunity and the many ways by which
Control (CDC) and WHO statistics showed that about
MTB induces immune responses and evades elimination
10 million new cases and around 1.6 million TB-related
by these responses is fundamental(8).
deaths are reported annually. The severity of this global
Apoptosis
is
a
genetically
regulated
problem is further worsened in recent years by the
physiological cell death process critical for tissue
increased incidence and spread of multidrug-resistant
homeostasis and regulation of immune response.
(MDR) and extensively-drug resistant (XDR) strains
Recent studies have shown that the physiological
raising a specter of untreatable disease and a return to
process of apoptosis can be transformed into a
the pre-antibiotic era (3). Africa accounts for more than
pathological process that may contribute to the
31% of the global burden of TB (3). Egypt has an
pathogenesis of various infectious diseases including
intermediate level of incidence and mortality (24 and 3
TB (9). It has been suggested that dysregulation of
per 100 000 population respectively) (4).
apoptosis can cause impaired cellular responses leading
In human TB infections, the pathogen is
to maintenance of infection (10). The majority of
eliminated in only 10% of people while a persistent
previous studies investigating apoptosis in response to
asymptomatic (latent ) infection predominates
MTB infection have focused on macrophage apoptosis
providing a compelling evidence of the ability of the
(11).
immune system to control, though not to eliminate, the
The present study was conducted on samples of
infection (5). Cell- mediated immunity (CMI) involving
peripheral blood from patients with active pulmonary
interactions between macrophages and MTB-specific-
TB to evaluate spontaneous T lymphocyte apoptosis as
CD4 and CD8 T lymphocytes with production of
a potential immunopathogenic mechanism contributing
interferon gamma (IFN-) plays a clear and central role
to the prolonged hyporesponsiveness state observed
This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC B -
Y SA) license (http://creativecommons.org/licenses/by/4.0/)
754
Received:25 /4 /2020
Accepted:4 /6 /2020
c:\work\Jor\vol802_2
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 760-765
Assessment of Intelligence Quotient in School-Aged Children Who Are
Breastfed Versus Artificial-Fed
Hisham Samy Abdel-Hameed, Ehab M. Rasheed, Shimaa Adel Ali Yousef*
Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
*Corresponding author: Shimaa Adel Ali Yousef, Telephone: +201024683929, E mail: mosad8rashed@gmail.com
ABSTRACT
Background: Food can affect the brain throughout the entire life cycle. Cognition refers to the mental processes
involved in the acquisition of knowledge and the integration of these processes into responses such as the
intelligence quotient (IQ).
Objective: The purpose of this study was to compare intelligence quotient of children aged 6-10 years who were
breastfed in their post-natal life versus those who were not exposed to breastfeeding.
Patients and methods: A case control study was conducted on 56 children in Zagazig University Children
Hospital, during the period from October 2018 to March 2019. They were divided into two groups. Group I: 28
healthy children who were exclusively breastfed. Group II: 28 healthy children who were artificially-fed. All cases
were subjected to: A constructed questionnaire assessing breastfeeding practices during the first two years as well
as the current health status over the past years and current and past behavioral disorders. Clinical examination was
done. Dietary assessment was done to assess current feeding and food intake practices. Special test; Wechsler and
Primary Scale of Intelligence was done for all participants to assess the cognitive functions.
Results: This study showed that, higher IQ in the breastfed group as compared to the artificially-fed group.
Conclusion: Cognitive function of the child is increased with the increased duration of exclusive breastfeeding up
to six months of age. The education of the mother positively influenced the IQ among children who were
exclusively breastfed for 6 months but not the other groups.
Keywords: Intelligence quotient, Breastfed versus, Artificial fed.
INTRODUCTION
Nutrition will affect the brain over the life cycle,
with important consequences for mental health and
It is important to know if slower infant weight
degenerative diseases. Many aspects of nutrition, from
gain is associated with weaker cognition in healthy
whole diets to particular nutrients, influence brain
infant populations, since rapid weight gain can cause
structure and function. Cognition refers to the mental
some harm, including increased risk of obesity and
processes involved in the processing of information
related disorders later in life (3).
and the incorporation of these processes into reactions
Breast milk provides optimal nutrition for a
such as learning, attention, memory, intellect (IQ) and
growing infant, with compositional changes adapted
consciousness (1).
to the changing needs of the baby. Human milk
Adequate supply of nutrients, beginning at the
contains ample minerals and nutrients for the first six
early stages of life, is essential to ensuring healthy
months of life.
physical and mental growth and long-term health. Low
There is a clear association between
availability or access to food of sufficient nutritional
breastfeeding and cognitive development in babies.
quality or exposure to conditions that hinder the
This cognitive capacity is measured by IQ tests.
absorption and use of nutrients has contributed to large
Breastfeeding is important for brain growth and
parts of the world's population being undernourished,
intelligence because it includes high amounts of long
poor in vitamin and mineral content, or overweight
chain polyunsaturated fatty acids such as
and obese, with major variations between population
docosahexaenoic acid (D.H.A) and arachidonic acid
groups. Such conditions are frequently present at the
(A.A). This also contains cholesterol, amino acids
same time and interconnected. Such developmental
such as taurine, and even lactose broken down into
processes build on each other over time such that a
glucose and galactose in the body. They are all
small change in either of the processes can have a
essential nutrients for brain and central organ tissue (4).
significant and long-lasting effect on brain structure
and function. Postnatal nutrition, in particular
AIM OF THE WORK
breastfeeding, may not only control brain growth, but
The aim of this study was to study the association
may also influence the child's developmental
between optimal infant feeding practices and the
milestones (2).
cognitive function in school aged children.
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/)
760
Received:26 /4 /2020
Accepted:9 /6 /2020
c:\work\Jor\vol802_3
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 767-772
Vitamin D Receptor Polymorphisms in Children with Chronic Immune
Thrombocytopenic Purpura
Mervat Abd-Allah Hesham1, Laila Metwaly Sherif1, Aml Fawzy Abd-Elmaaguid2,
Shehab Mohamed Nageeb Mohamed Saad1
Departments of 1Pediatrics , 2Biochemistry, Faculty of Medicine - Zagazig University
*Corresponding author: Shehab Mohamed Nageeb Mohamed Saad, Mobile: (+20)01024683929,
E-mail: mosad8rashed@gmail.com
ABSTRACT
Background: Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by autoantibody-
mediated-enhanced platelet destruction. Chronic ITP was defined as thrombocytopenia persisting for more than 12
months. Previous studies have found that vitamin D receptor (VDR) polymorphisms are associated with the incidence
and severity of certain autoimmune diseases.
Objective: This study aimed to detect the frequency and role of VDR gene polymorphisms on pathogenesis of chronic
ITP in children. Patients and methods: A case control study that was conducted at Hematology Unit of Pediatric,
Medical Biochemistry and Molecular Biology Departments at Zagazig University Hospital during a period from
November 2017 until November 2018. The study was conducted on 40 participants divided into two groups: case
group including 20 children with chronic ITP (8males and 12 females) and control group including 20 age- and sex-
matched healthy children (6males and 14females).
Results: This study showed that the patients' group had a lower serum vitamin D level than the control group with a
statistical significant difference (24.2 ± 9.64 ng/ml and 33.75 ± 11.1 ng/ml respectively). There was also a highly
significant difference between chronic ITP cases and control regarding distribution of SNP of VDR gene (Cdx2) where
GG was founded in 65% of ITP cases versus 35% in control. Also, AA was founded in 30 % of control versus 5% of
cases. Conclusion: Vitamin D receptor gene (Cdx2) polymorphism was found to be associated with higher incidence
of chronic childhood immune thrombocytopenic purpura. Also chronic ITP in children was found to be associated
with lower level of serum vitamin D.
Key words: ITP, Vitamin D, Association.
INTRODUCTION
chromosome 12q13.1, and it has several polymorphic
Childhood Immune thrombocytopenia (ITP) is one
regions (5).
of the most common benign hematologic disorders. It is
More than 30 different human tissues such as the
characterized
by
isolated,
immune-mediated
brain, heart, stomach, pancreas, lymphatics, skin,
thrombocytopenia. The etiologies of ITP are unclear but
gonads, and prostate tissue are composed of cells
are likely genetic or acquired factors (1). Moreover, ITP
including T and B lymphocytes that express the VDR
is considered an autoimmune syndrome involving
(6). Previous studies have found that VDR
antibody-and cell-mediated destruction of platelets and
polymorphisms are associated with the incidence and
suppression of platelet production that may predispose
severity of certain autoimmune diseases (7). In humans
to bleeding. Recent recommendations suggest that ITP
and animals lacking vitamin D receptor polymorphism
might be used to designate all cases of immune-
(VDR) function or lacking vitamin D offer insight into
mediated thrombocytopenia whether primary or
the immunological functions of vitamin D. Expression
secondary (2). Chronic ITP was defined as
of VDR by immune system cells suggest that vitamin D
thrombocytopenia persisting for more than 12 month
influences immune system function (8). Over 470
with normal or increased marrow megakaryocytes and
common single nucleotide polymorphisms (SNPs) have
no secondary immune or non-immune abnormalities
been identified in the VDR gene (9).
that could account for the thrombocytopenic state. The
These polymorphisms modulate the activity of the
severity of bleeding tendency and thrombocytopenia
VDR gene and their frequency differs across multi-
was assessed according to the previously described
ethnic groups. The Cdx-2 polymorphism is located in
criteria (3).
the promoter region of VDR, and it carries a G to A
Vitamin D act via binding to an intramuscular
sequence change that affects the function of the
receptor, vitamin D receptor (VDR), present in target
transcription factor (10).
tissues and cells. This receptor belongs to the super
In caucasians, several common allelic variants
family of transacting transcriptional regulatory factors
have been studied: 1) Cdx-2 (a single base change G to
(4). Vitamin D receptor binds to 1, 25-hydroxy vitamin
A, located upstream in the 5' UTR of the gene) that
D, which is the active form of vitamin D, and mediates
significantly alters the transcriptional activity of the
its biological activity. The VDR gene is located on
VDR promoter region. 2) FokI (a single base change C
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/)
766
Received:28 /4 /2020
Accepted:7 /6 /2020
INVESTIGATION OF THE ASSOCIATION BETWEEN THE RADIOLOGICAL AND PATHOLOGICAL FEATURES OF HCC
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 773-781
Investigation of the Association Between Imaging and Pathological
Characteristics of HCC
Mansour Mohamed Kabbash1, Hussein Ali Mostafa1, Stephen Wigmore2,
Sherif Elprince Sayed1, Abdelrahman Mohamed Kamel Amin*1
1Department of General and Onco-surgery, Faculty of Medicine, Aswan University
2Department of Hepatobiliary Surgery, Faculty of Medicine, Edinburgh University
*Corresponding author: Abdelrahman Mohamed Kamel Amin, Email: playsurgery@yahoo.com,
Mobile: (+20)01553596111
ABSTRACT
Background: Hepatocellular carcinoma (HCC) is the most typical primary viscus malignancy and also the second
leading reason behind cancer-related death worldwide.
Objectives: To study the association between the tomography and pathological options of HCC for getting an honest
designation on the lesions of HCC for getting the best treatment and prognosis of these lesions.
Patients and Methods: Study of the imaging criteria of HCC which includes the arterial enhancement and venous
washout in both CT and MRI within a background of cirrhosis, and it's a possible association with the vascular density
and microvascular invasion seen in the biopsy. We enrolled consecutive cirrhotic patients with HCC liver resection in
2 years (from January 2018 till December 2019).
Results: Our results on the number of lesions cleared that, the number of lesions ranged from 1 in number that
observed in 68 (66.02 %) and 2 that observed in 11 (10.68 %), followed by 3, 4, and 5 lesions that observed in 1 (0.97
%) of the examined patients. The higher incidences of the lesions observed in middle hepatic vein 55 (53.40 %) right
lobe of the liver 16 (15.54 %) , seg 2/3 10 (9.71 %), right liver 5 (4.86 %), left liver 5 (4.86 %) and in left lateral liver
4 (3.88 %).
Conclusion: The association between the Imaging and pathological features of HCC including microvascular invasion
and density which is very important for getting an honest designation on the lesions of HCC and for getting the best
treatment and prognosis of these lesions.
Keywords: HCC, CT, MRI, T2WI, HBP, DWI .
INTRODUCTION
HCC usually originates from the cirrhotic liver
portal/delayed washout, that represent the characteristic
(1), with 28% of liver disease patients developing HCC
tube-shaped structure profile of HCC on dynamic CT or
annually. For accomplishment best treatment of HCC,
tomography (2).
we tend to should rely on the great designation of HCC
Indeed, these HCCs with atypical imaging
for investigations of the feature of the HCC (2).
options stay an enormous diagnostic challenge for
The typical imaging options of HCC principally
radiologists nowadays. Moreover, in at-risk patients,
originate from the histopathologic characteristics of
there will be several HCC mimickers like intrahepatic
nodular progressed HCCs instead of those of early
cholangiocarcinoma
(ICC),
combined
HCC-
HCCs. Among the numerous pathophysiologic
cholangiocarcinoma (cHCC-CC), arterioportal (AP)
alterations
that
will
occur
throughout
shunt,
and
hemangioma.
Therefore,
precise
hepatocarcinogenesis, neovascularization is that the
differentiation of HCCs from these mimickers on
most significant part that helps to supply the
surgical imaging studies would be of nice clinical
characteristic imaging options of progressed HCCs (3).
importance, guiding the suitable treatment strategy (5).
Recent tips, together with those of the European
HCCs may also show many different
Association for the Study of the Liver and European
characteristic imaging options that will be useful in their
Organization for analysis and Treatment of Cancer
differentiation from different benign liver lesions. First,
(EASL-EORTC), the yank Association for the Study of
neoplasm capsules are discovered in some seventieth of
disease (AASLD), and also the Korean liver disease
progressed HCCs with expandable growth (3).
Study cluster and also the National Cancer Center
The capsule look is outlined as a peripheral rim
(KLCSG-NCC), yield the noninvasive designation of
sweetening discovered within the portal blood vessel or
HCC mistreatment contrast-enhanced X-radiation (CT),
delayed phases of contrast-enhanced CT or tomography
resonance imaging (MRI), or ultrasound (US) on the
(6). This capsular look ought to be differentiated from rim
idea of its typical imaging options (4).
sweetening that's solely seen within the blood vessel
The hallmark imaging options of HCC are blood
part, which is common in cholangiocarcinoma (CC) or
vessel part hyperenhancement (APHE) and
metastases from carcinoma (7).
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/)
773
Received:24 /4 /2020
Accepted:3 /6 /2020
c:\work\Jor\vol802_5
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 782-788
Phosphate Disturbance in Critically Ill Children in Zagazig University
Pediatric Intensive Care Unit
Tarek Abd El-Rahman Atiyyah1, Sahar Abd Elraouf ElShaarawy1, Aml Said Al- Shal2,
Asmaa Mohammed Hussein Mohammed*1
Departments of 1Pediatrics and 2Biochemistry, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Asmaa Mohammed Hussein Mohammed, Mobile: (+20)1008003365,
Email: dr.asmaaaaaa@gmail.com
ABSTRACT
Background: Phosphorus is very important for normal cellular structure (cell membrane and nucleic acids).
Phosphorus has an important role in the cell metabolism, ATP production, and homeostasis.
Objectives: The aim of the work was to determine the prevalence and some of risk factors of hypophosphatemia in
sick children, and to evaluate the prognostic effect of serum phosphorous level on the outcome in terms of morbidity
and mortality in critically ill children during their stay in the pediatric intensive care unit.
Patients and methods: This prospective cohort study included a total of 50 critically ill children, attending at
Department of Biochemistry and Pediatric Intensive Care Unit (PICU), Department of Pediatrics, Zagazig University
Hospitals. This study was conducted between April 2017 to August 2018. Patients age ranged from 2 months to 129
months and according to serum phosphorus level cases were classified into those with hypophosphatemia and others
with normal phosphate level. The severity of illness was determined by using SOFA score.
Results: Revealed that there was statistically significant decrease in phosphorus level at day 1 and day 3 between
hypophosphatemia and normal phosphate level groups. The prevalence of hypophosphatemia was 46% at first day
of admission and 70% at third day of admission. Significant increase of PTH and total bilirubin in hypophosphatemia
group, and significant decrease of calcium in hypophosphatemia group compared to normophosphatemia group. The
cases were followed and compared regarding; morbidity (need for mechanical ventilation, and length of PICU stay),
degree of organ failure (SOFA score) and their outcome (discharge from PICU or death).
Conclusion: It could be concluded that hypophosphatemia is considered a common co-morbidity in critically ill
children in PICU. Hypophosphatemia more prevalent in those with respiratory problems, and higher SOFA score.
Keywords: Hypophosphatemia, SOFA score, PICU, PTH.
INTRODUCTION
intensive care units (PICUs); hypophosphatemia is
Electrolytes disturbance develops frequently in
associated with cardiac dysfunction, respiratory
critically ill children during the course of stay in the
failure, delayed weaning from the ventilator,
pediatric
intensive
care
unit
(PICU),
prolonged hospital stay and hematological disorders.
hypophosphatemia is one of the most frequently
Low concentrations of serum phosphorus is an
encountered electrolyte disorders in the PICU (1).
important cause of myopathy and rhabdomyolysis,
Hypophosphatemia refers to any serum phosphorus
and is a life-threatening factor that causing death in
level <3.8 mg/dl for children below 2 y old and <3.5
children with protein energy malnutrition disorders (5).
mg/dl for children more than 2 y old (2).
The prevalence of hypophosphatemia is higher
Critically ill children are at high risk for
in critically ill children than in adults, and it is
developing hypophosphatemia due to the presence of
commonly present during admission. There is an
several causative factors, the mechanisms of
association between correction of low phosphorus
hypophosphatemia in pediatric intensive care units
level and improvement in the clinical outcome (1, 6).
may be due to decreased absorption, increased renal
Therefore, the present study was conducted to
loss or internal redistribution of inorganic phosphate
determine the prevalence and some of risk factors of
due to alkalosis (3).
hypophosphatemia in sick children, and to evaluate
Regardless of the continuous monitoring of the
the prognostic effect of serum phosphorous level on
serum levels of electrolytes: sodium, potassium, and
the outcome in terms of morbidity and mortality in
calcium ions in critically ill children admitted to
critically ill children during their stay in the pediatric
PICUs, phosphorus is not routinely investigated in
intensive care unit.
these patients, hypophosphatemia occurs in 45% of all
hospitalized cases in the PICU patients (4).
SUBJECTS AND METHODS
Low serum level of phosphorus cause
This prospective cohort study included a total
problems in patients admitted to the pediatric
of 50 critically ill children, attending at Department
This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC B Y-SA) license (http://creativecommons.org/licenses/by/4.0/)
782
Received:22 /4 /2020
Accepted:1 /6 /2020
c:\work\Jor\vol802_6
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 789-792
Serum Leptin Versus C-Reactive Protein in The Early Diagnosis of Neonatal Sepsis
Ahmed Galal Siam1, Mohammed Arafa 1, Mai Mohammed Malek2, Enas Abdelhamid Hussein Hussein*1
Departments of 1Pediatrics and 2Microbiology and Immunology,
Faculty of Medicine, Zagazig University, Sharkia. Egypt.
*Corresponding author: Enas Abdelhamid Hussein Hussein, Mobile: +201024683929, E-mail: mosad8rashed@gmail.com
ABSTRACT
Background: Neonatal sepsis is a systemic inflammatory reaction that is triggered by an infective agent. When
sepsis occurs, multiple redundant inflammatory cytokines are released into the blood stream, including, leptin, C-
reactive protein (CRP).
Aim of the Study: was to compare the sensitivity of serum leptin and C-reactive protein in early diagnosis of
neonatal sepsis.
Patients and Methods: This was a prospective cohort study conducted in the Zagazig General Hospital and
included (34) newborn infants. The tests used were, blood culture, C - Reactive protein Level, and serum leptin
level.
Results: 76.5% of the studied group had +ve culture results. The most frequent organism was staph 12 (35.3%).
There was a statistically significant increase in CRP and Leptin among +ve cases compared to ve cases. There was
a positive statistically significant correlation between serum leptin levels and CRP. The sensitivity of CRP in the
diagnosis of sepsis at the cut off 18 was 65.4%, specificity was 50% and the accuracy was 61.8%. While the
sensitivity of Leptin in the diagnosis of sepsis at the cut off 0.07 was 84.6%, specificity was 87.5% and the accuracy
was 85.3%.
Conclusion: Leptin is an effective diagnostic marker for sepsis and more accurate when compared with CRP
Key words: Neonatal Sepsis, C-reactive protein, Leptin.
INTRODUCTION
Neonatal Sepsis is a systemic inflammatory
Medicine, Zagazig University, this prospective
reaction that is triggered by an infective agent (such
cohort study was carried out over 12 months from
as bacteria, viruses, fungi, or parasites) (1).
April 2017 to March 2018 at Pediatrics and
Cytokine levels are an obvious choice as a
Microbiology
and
Medical
Immunology
marker of sepsis. The systemic release of
Departments, Faculty of Medicine, Zagazig
inflammatory cytokines occurs several hours before
University, Sharkia, Egypt.
other markers of systemic inflammation, such as acute
Patients: This study included 34 neonates. They were
phase protein release and leukocytosis, suggesting
classified according to culture results into:
their potential importance as diagnostic parameters in
1- Group 1 included newborns whose blood
systemic inflammatory response syndrome (SIRS)
culture was -ve
and sepsis. When sepsis occurs, multiple redundant
2- Group 2 included newborns whose blood
inflammatory cytokines are released into the blood
culture was +ve.
stream, including tumor necrosis factor- (TNF-),
interleukin-6 (IL-6), leptin, C-reactive protein (CRP)
Inclusion criteria:
and procalcitonin (PCT) which are important for
Infants born to mothers with at least one of the
mediating the inflammatory response (2).
following risk factors for neonatal sepsis:
The hormone leptin (molecular weight of 16-
1- Premature
rupture
of
membranes
kDa) is mainly generated by adipocytes and
(PROM)>24 hours.
contributes to the regulation of energy balance by
2- More than three vaginal examinations after
informing the brain of the volume of adipose tissue in
ROM.
the body, thereby regulating food intake and energy
3- Intrapartum fever (oral temperature >38Cº).
expenditure (3). This study aimed to compare the
4- Foul-smelling liquor.
sensitivity of serum leptin and C-reactive protein in
5- Untreated or partially treated urinary tract
early diagnosis of neonatal sepsis.
infection in the antenatal period.
SUBJECTS AND METHODS
Exclusion criteria:
Ethical approval:
1- Patient's refusal.
After review and approval by the Institutional
2- Newborn babies born at less than 28 weeks.
Review Board (IRB) committee at the Faculty of
3- Newborn babies weighing less than 1,000 g.
This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC B Y-SA) license (http://creativecommons.org/licenses/by/4.0/)
789
Received:29 /4 /2020
Accepted:8 /6 /2020
c:\work\Jor\vol802_7
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 793-797
Serum Level of Heart Type Fatty Acid Binding Protein Before and after
Treatment of Congestive Heart Failure in Children
Hanaa Abdel Fattah Mohamed1, Eman Mahmoud El-Moghazy1,
Somia Hassan Abdallah2, Alshaimaa Mohamed Hassan Ali*1
Departments of 1Pediatric and 2Medical Biochemistry, Faculty of Medicine, Zagazig University
*Corresponding author: Alshaimaa Mohamed Hassan Ali, Neonatology Resident, Alahrar Teaching Hospital,
Zagazig, Egypt, Telephone: 01157198404, E mail: alshaimaa.hassan @yahoo.com
ABSTRACT
Background: Heart failure (HF) in children is a clinical and pathophysiological syndrome that results from
ventricular dysfunction, volume or pressure overload, either alone or in combination. This study aimed to
estimate serum level of H-FABP before and after treatment of congestive heart failure, and correlate its level
with severity of the disease. Patients and methods: The study was cohort control study. It included 30
infants and children; their ages ranged from two months to four years with heart failure diagnosed clinically
and were admitted to Cardiology Unit of Pediatric Department, at Zagazig University Hospitals during the
period from November 2017 to April 2018. They were divided into four groups, first group aged (2-12
month), second group (13-24 m), third group (25-36 m) and fourth group (37-48 m). Echocardiographic
assessment of the heart was done using conventional Doppler echocardiography. Serum heart type fatty acid
binding protein (H-FABP) level (estimated on patient admission and 1 week after treatment) was determined
by quantitative sandwich enzyme linked immunosorbent assay (ELISA) technique.
Results: There was a significant difference in the serum level of H-FABP in our patients before treatment
(2.156 ± 1.156 ng/ml) compared with after treatment (0.882 ± 0.716 ng/ml). There was a significant positive
correlation between serum H-FABP level and Ross classification.
Conclusion: H-FABP may be used as diagnostic and prognostic predictor of adverse outcome in children
with heart failure.
Keywords: Heart failure (HF), Heart-type fatty acid-binding protein (H-FABP), Serum level.
INTRODUCTION
response to treatment and help in staging of heart
Heart failure (HF) is defined as an
failure and determine risk (4).
abnormality of cardiac structure or function
Fatty-acid-binding protein 3, muscle and
leading to failure of the heart to deliver oxygen at
heart (FABP 3) is one of nine known cytosolic
a rate commensurate with the requirements of the
FABPs ranging in size from 14 to 15 kDa. It is
metabolizing tissues, despite normal filling
most ubiquitously expressed in heart, skeletal
pressures or only at the expense of increased
muscle, and other tissues (5).
filling pressures. Heart failure in children differs
Heart type fatty acid binding protein is a
from the adult in many aspects; the causes,
soluble protein which is present in cardiocytes. It
symptoms and signs differ among children of
participates in the absorption and transport of fatty
different age groups and differ between children
acids, and released to the blood from membranes
and adults. The time of onset of HF help us to
within 0-3 h after HF (5).
search for the cause of it. Clinical presentation of
The present study was conducted to
HF in young children is not specific so it requires
estimate serum level of H-FABP before and after
highest degree of suspicion (1).
treatment of congestive heart failure, and correlate
Because 87% of cases of new-onset HF
its level with severity of the disease.
only reach a diagnosis when the patient is in a
state of severe decompensation (2), early diagnosis
PATIENT AND METHOD
and effective treatment remain significant
The study was cohort control study. It
challenges which should be addressed (3).
included 30 infants and children; their ages ranged
Cardiac biomarkers are useful as
from two months to four years with heart failure
diagnostic and prognostic tools, especially in
diagnosed clinically and were admitted to
patients with atypical signs and symptoms. High
Cardiology Unit of Pediatric Department, at
complication in HF led to the search for suitable
Zagazig University Hospitals during the period
cardiac biomarker that diagnose heart failure as
from November 2017 to April 2018. They were
early as possible, predict outcome, reflect
divided into four groups, first group aged (2-12
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/)
793
Received:29 /4 /2020
Accepted:8 /6 /2020
c:\work\Jor\vol802_8
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 798-802
Two Sofosbuvir Containing Regimens in Egyptian Hepatitis C Related
Compensated Liver Cirrhosis: Impact on Clinical Outcome and Liver Stiffness
Nahed A Makhlouf 1*, Youssef M Swifee 1, Mohamed M Darwish1, Nasr K. Khalil2,
Amal A. Mahmoud 3, Ahmed Medhat1, 2, Rasha O Refaie 4, Zainab G Mahran1
1 Department of Tropical Medicine and Gastroenterology, 3 Department of Clinical Pathology,
Faculty of Medicine, Assiut University, 2 Assiut Viral Hepatitis Treatment Center,
4 Internal Medicine Department, Helwan University, Egypt.
Corresponding Author: Nahed Ahmed Makhlouf, E-mail: nahedmak@yahoo.com,Orcid: 0000-0003-2949-4369
ABSTRACT
Background/Aim: The current study aimed to evaluate the impact of sustained virological response (SVR) after two
sofosbuvir (SOF) containing regimens on the clinical outcomes, non invasive markers of hepatic fibrosis and liver
stiffness. Patients and Methods: The study included 200 patients with compensated HCV cirrhosis. Group 1: received
SOF and Ribavirin (RBV) for 6 months, Group 2: received SOF, Daclatsvir (DAC) and RBV for 3 months. Hepatitis C
Virus Ribonucleic Acid (HCV RNA) by Polymerase Chain Reaction (PCR) was done at baseline, end of treatment
(EOT), SVR12, SVR48. Model for end stage liver disease (MELD) score was calculated, the aspartate aminotransferase
to platelet ratio index (APRI) and Fibrosis-4 (FIB-4) scores were done. FibroScan was done at baseline and SVR48.
Results: SVR12 occured in 75% and 96% in group 1 and 2, respectively. There was improvement in both of APRI and
FIB-4 scores at EOT in the two groups, and maintained to SVR48. A significant improvement in mean liver stiffness
(LS) occurred at SVR48 compared to baseline in the study groups. Improvement in LS was observed more in group 2.
There was a significant decrease in the mean value of MELD score in group 2 and non-significant decrease in group 1
at SVR48 in comparison to pre-treatment mean value.
Conclusion: SOF/DAC/RBV was effective treatment regimen in compensated liver cirrhosis. This regimen resulted in
significant improvement in MELD score, and liver stiffness at SVR48.
Keywords: Sofosbuvir; Daclatsvir; Cirrhosis; Outcome; MELD; LS.
INTRODUCTION
Hepatitis C virus (HCV) infection is of growing
or 3) infection, for treatment naïve G3 patients with
international concern (1). Individuals with HCV may
compensated cirrhosis + addition of weight based RBV
experience chronic fatigue, depression and lower quality
and for all HCV genotypes with decompensated liver
of life (2). HCV leads to cirrhosis, hepatocellular
cirrhosis or post liver transplant recurrent infection with
carcinoma (HCC), and liver transplantation. The HCV-
initial low dose of RBV (10).
related disease load increases as the infected persons
Clinical trials have demonstrated the safety and
progress to advanced stage of liver disease (3).
efficacy of these SOF-based regimens, and their
Pegylated interferon alfa (PEG-IFN-) and
approval. However, to the best of our knowledge, few
ribavirin (RBV) for 24 or 48 lead to sustained viral
studies were done to evaluate effect of SVR on fibrosis
suppression (SVR) in 65% among those with HCV
regression especially in genotype 4.
genotype 4 (4). Another Egyptian study reported 60%
SVR in Egyptian genotype 4 patients received
AIM OF THE WORK
interferon-2a plus ribavirin for 48 weeks (5). Sofosbuvir
To assess the effect of sustained virological
(SOF) inhibit HCV NS5B viral polymerase and it was
response (SVR) after two SOF containing regimens on
recommended by FDA (2013) for treatment of chronic
the clinical outcomes, non invasive markers of hepatic
hepatitis C caused by genotypes 1-4 (6).
fibrosis and liver stiffness in Egyptian HCV
Understanding of HCV life cycle and viral
compensated liver cirrhosis
enzymes (7), have led to generation of new direct-acting
antiviral agents (DAAs) (8). Those included NS3/NS4A
PATIENTS AND METHODS
protease inhibitors, NS5B polymerase inhibitors and
Populations:
NS5A inhibitors with a broader spectrum (9).
A prospective observational study was
Daclatasvir (DAC) is indicated for use with
conducted on 200 patients with compensated HCV
sofosbuvir for therapy of treatment naïve or PEG-IFN-
related liver cirrhosis (treatment-naive) (genotype 4).
and RBV experienced cases with chronic HCV (G 1a
HCV treatment was given according to National
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/)
798
Received:30 /4 /2020
Accepted:9 /6 /2020
c:\work\Jor\vol802_9
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 803-808
Cognitive impairment in asthmatic Children in Pediatric Department,
Zagazig University Hospitals
Mahmoud Abdel-Hameed Mahmoud*1, Mohamed Sanad Naguib1,
Osama Mohamed Gado2, Ahmed Hosny Mohamed1
Departments of 1Pediatric and 2Psychiatry, Faculty of Medicine, Zagazig University.
*Corresponding Author: Mahmoud Abdel-Hameed Mahmoud, Mobile: +201092009627,
E-mail: drmahmoud27@yahoo.com
ABSTRACT
Background: Asthma is a heterogenous disease, usually characterized by chronic airway inflammation. The
variable expression of asthma symptoms has prompted the shift from the concept that asthma is a single disease to
the new concept of asthma as a syndrome.
Objectives: this study aimed to evaluate and assess cognitive impairment of children with asthma.
Subjects and methods: This was a descriptive cross-sectional study of children with asthma that has been approved
from Institutional Review Board (IRB). Assuming that the total number of bronchial asthma patients attending to
Pediatric Outpatient Clinic Pulmonology Unit, Pediatric Department, Zagazig University Hospital.
Results: With 290 asthmatic children in 6 months and prevalence of low Wechsler Intelligence Scale for Children
Third Edition (WISC-R) score was 88%, at CI 95%. So, the total sample size was 104 patients (male 58.7% and
female 41.3%) calculated by EPI-INFO 7. There was a statistically significant difference between severity of asthma
and IQ (verbal, performance and full IQ).i.e., with increasing severity of asthma there was significant decrease in
IQ.
Conclusion: Cognitive impairment in affected children is related to asthma severity. Asthmatic children have lower
cognitive abilities as regarding general intelligence. Children with chronic asthmatic chest troubles represent a
population at possible high risk for cognitive and psychological maladjustment.
Key words: Asthma, Cognitive impairment, Pediatric.
INTRODUCTION
an umbrella term for several distinct conditions that
Asthma is a heterogenous disease, usually
share common respiratory symptoms (6). Severity of
characterized by chronic airway inflammation. It is
asthma was assessed as mild intermittent, mild
defined by the history of respiratory symptoms such as
persistent, moderate persistent or severe persistent
wheezes, shortness of breath, chest tightness and
with a range of severity levels represented as 7%, 61%,
cough that vary over time and in intensity, together
24% and 8%, respectively. A variety of psychological
with variable expiratory airway flow limitation (1). It is
and neurodevelopmental findings have been described
one of the commonest chronic diseases worldwide. It
in children with persistent asthma, including an
has been estimated that over 300 million people have
increased risk of poor school performance,
asthma, and its prevalence is increasing in both adult
internalizing disorders, such as anxiety and affective
and pediatric population (2, 3). Furthermore, asthma
disorders, behavior problems, attention deficits and
imposes a combined considerable personal and social
deficient neurocognitive performance(7).
burden, both in terms of direct costs (like
Managing asthma effectively involves three
emergent/hospital admissions, increased health
critical components, all of which are necessary to
service utilization, and medications cost) and indirect
maintain normal pulmonary functioning. These
costs (such as absenteeism of caregivers and patients
components are: 1) consistent use of prophylactic and
from work and premature death) (4). Therefore, it is
therapeutic
medications;
2)
avoidance
of
considered as a major public health problem which
environmental irritants and allergens; and 3) accurate
deserves paying attention to develop cost-effective
recognition, response, and monitoring of symptoms(8).
prevention and management approaches.
A common explanation behind the effects of
There have been few studies of the epidemiology
asthma on neurocognitive outcomes relates to the
of asthma in Egypt (5). Zedan and his working group
asthma medication itself and specifically the inhaled
determined the prevalence of bronchial asthma in the
corticosteroids (ICS) due to the reporting of behavioral
Nile Delta region of Egypt. They found that the overall
disturbances, developmental disabilities and psychosis
prevalence of childhood asthma was 7.7 % in this
in children using ICS (9). Other explanations suggested
region (6).
that environmental factors are behind this
The variable expression of asthma symptoms has
comorbidity, such as parents' smoking habits, low
prompted the shift from the concept that asthma is a
birth weight and low socioeconomic status that could
single disease to the new concept of asthma as a
contribute negatively to the child's health and his
syndrome. It is now generally accepted that asthma is
cognitive development as well (10).
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/)
803
Received:5 /5 /2020
Accepted:14 /6 /2020
c:\work\Jor\vol802_10
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 809-814
Intestinal Fatty-Acid-Binding Protein in Neonatal
Necrotizing Enterocolitis
Ehab A. Al-banna1, Hadeel M. Abd El-Rehman1, Lamiaa M. M. Kamel2, Ahmed E. M. Ahmed1*
1Departments of Pediatrics & 2Clinical Pathology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Ahmed El-Sayed Mohamed Ahmed, Mobile: (+20) 01094442192,
E-mail: elzawahry89@gmail.com
ABSTRACT
Background: Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) medical and surgical
emergency occurring in neonates. It is an acute inflammatory disease with a multifactorial etiology; the
condition is characterized by variable damage to the intestinal tract ranging from mucosal injury to full-
thickness necrosis and perforation.
Objective: Our work aimed to detect the role of I-FABP in plasma in early diagnosis of NEC and prediction
of severity of NEC among neonates at neonatal intensive care units, children's hospital, Zagazig University.
Patients and Methods: About 160 preterm neonates aging less than 35 weeks and weighing less than 2500
gm were included in this study to evaluate which of them will develop NEC, after follow up 24 of them
developed NEC and still alive until the last samples were obtained from them. These neonates were diagnosed
and classified according to Later Modified Bell's Staging for NEC.
Results: I-FABP level was highly increased in more complicated cases. We can predict NEC by the cut of
value of IFABP 3.2 ng\ml with sensitivity 95.8%, specificity 95.8% at 1st 24 hours, and at diagnosis by 9.2
ng\ml with sensitivity 95.8%, specificity100%, and accuracy 0.99%.
Conclusion: Serum IFABP can serve as a serological biomarker for early diagnosis of NEC for premature
neonates with high accuracy and can predict the severity of the disease.
Keywords: Biomarker, Necrotizing Enterocolitis, Intestinal, Necrosis, Preterm Neonates and I-FABP.
INTRODUCTION
The plasma i-FABP increased in serum of
Necrotizing enterocolitis (NEC) is a common
patients with NEC and sepsis and even in otherwise
gastrointestinal disorder of newborns associated
healthy people after abdominal surgery, trauma, or
with high morbidity and mortality. It is also the
alcohol consumption (4).
leading cause of aberrant growth and
neurodevelopment among surviving preterm
AIM OF THE WORK
infants (1).
Our work aimed to detect the role of I-FABP in
The best biomarkers should reflect the major
plasma in early diagnosis of NEC and prediction of
steps in early disease pathogenesis. To detect NEC
severity of NEC among neonates at neonatal
early in preterm with high risk, several biomarkers
intensive care units, Children's hospital, Zagazig
were investigated in the past decades, including
University.
markers of epithelial damage, smooth muscle
PATIENTS AND METHODS
injures, inflammation, and pathogen invasion.
This study was a case-control study. It was
Fatty-acid-binding proteins (FABP) comprise a
conducted on preterm infants selected from the
group of cytoplasmic small molecular mass
Neonatal Intensive Care Units (NICUs) of the
proteins (14-15 kDa) with high organ sensitivity (2).
Pediatric Department at Zagazig University
Intestinal fatty acid-binding protein (i-FABP)
hospital during the period from March 2018 until
constitutes up to 2% of the cytoplasmic protein
March 2019.
content of the mature enterocyte. The plasmic
About 160 preterm neonates aging less than
contents, including i-FABP, are liberated into the
35 weeks and weighing less than 2500 gm were
circulation upon intestinal epithelial injury. I-
included in this study to evaluate which of them
FABP can pass the glomerular filter with fractional
will develop NEC, after follow up for 10days 24 of
renal excretion of 28% and a half-life of 1 min (3).
them developed NEC and still present in our study
As a consequence, plasma i-FABP levels
until the last samples were obtained from them.
may reflect the extent of intestinal epithelial cell
These neonates were diagnosed and classified
damage. It is a noninvasive test to identify gut wall
according to Later Modified Bell's Staging for
integrity loss and gut wall inflammation in infants
NEC.
with gastrointestinal symptoms suspected of NEC,
The 24 preterm neonates who developed NEC
Therefore, the plasma i- FABP (i-FABPp) is a
were defined as the case group.
promising biomarker in early diagnosis of NEC.
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/)
809
Received:6 /5 /2020
Accepted:15 /6 /2020
Microbial
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 815-819
Serum 25-Hydroxyvitamin D in Patients with Juvenile Idiopathic Arthritis
Mohamed Almalky1, Mervat Hesham1, Ayman Marei2, Mogeep El-Rahman Ibrahim*1
Departments of 1Pediatrics & 2Microbiology and Immunology, Faculty of Medicine, Zagazig University.
*Corresponding author: Mogeep El-Rahman Dyaa Ahmed Mostafa Ibrahim, Mobile: +20)01033808665,
Email: mogeepdyaa@gmail.com
ABSTRACT
Background: Vitamin D has been implicated in the pathogenesis of a lot of autoimmune diseases. While the roles
of vitamin D in rheumatic arthritis in adult have been investigated, less is known about the role of vitamin D in
juvenile idiopathic arthritis (JIA).
Objectives: Evaluation of the level of serum 25(OH) vitamin D in patients with juvenile idiopathic arthritis and its
relationship to the disease activity.
Methods: This was a case-control study included 36 children who were divided into two equal groups of matched age
and sex. The first group (case group) consisted of 18 patients with JIA. The second group (control group) consisted
of 18 healthy children. 25(OH) vitamin D level is measured in both groups and its relation to disease manifestations
and disease activity using JADAS 27 score was determined.
Results: The mean value of vitamin D serum level was significantly lower in patients than in healthy control. There
was a negative correlation between vitamin D level and both disease activity and number of joints affected among the
studied patients.
Conclusion: Serum vitamin D levels were reduced in children with JIA. In addition, there was a significant negative
correlation between serum vitamin D levels and both the number of affected joints and the disease activity as measured
by JADAS 27 score.
Keywords: Juvenile idiopathic arthritis, vitamin D, 25 hydroxy vitamin D, JADAS 27 score.
INTRODUCTION
normal levels for vitamin D in children, cutoff levels
Vitamin D is a steroid hormone synthesized in
proposed for adults have been used in studies with
the skin through sunlight exposure or ingested in the
children making it difficult to do an accurate
diet and its active form is 1, 25 dihydroxy vitamin D
assessment of its level in children with JIA and to
(1, 25[OH]2 D) (1). It is not only a regulator of calcium
assess its relation to disease activity and outcome (5).
and phosphate homeostasis, but also has numerous
The aims of this study were to evaluate vitamin D
extra-skeletal effects including the significant impact
status in patients of juvenile idiopathic arthritis (JIA)
on the cardiovascular system, central nervous system,
compared to normal children of matched age and sex
endocrinal system and immune system as well as on
(case control study), and also to examine whether there
cell differentiation and cell growth (2). As JIA (the most
is an association between serum level of 25-
common chronic rheumatic disease in childhood) is an
hydroxyvitamin D ]25(OH)D
[ and disease activity in
autoimmune disease, deficiency of vitamin D may play
JIA.
a role in its pathogenesis through its immune effect.
The mechanisms by which vitamin D affects the
SUBJECTS AND METHODS
pathogenesis and severity of JIA are multiple and
1. Technical design:
include modulation of transcription pathways leading
· Site of study: This is case-control study that was
to cytokine production, regulation of the expression of
done in Pediatric Department, Zagazig University
cyclooxygenase 2 and lipoxygenase genes, and it may
Hospitals.
directly interferes with cytokine gene expression and
signaling, favoring a change from a T helper-1 (Th-1)
· Sample size: In this study 36 children were
into a Th-2 cytokine profile, as well as a decrease in
included, divided into two equal groups of
Th-17 response (3).
matched age and sex. The first group (case group)
So, suppression of autoimmune diseases
consisted of 18 patients with Juvenile idiopathic
generally and JIA specifically involves the vitamin D
arthritis, while the second group (control group)
hormone interaction with T helper lymphocytes, which
consisted of 18 healthy children.
in turn suppress the inflammatory responses of T
The number of cases was estimated according
helper-1 lymphocytes(4).
to the prevalence of JIA in Sharkia governorate
There is a controversy regarding the level of
and the number of cases of JIA regularly followed
vitamin D that influences both the prevalence and the
up in Department of Pediatrics, Zagazig
outcome of JIA 8. Since there is no clearly defined
University Hospital (6).
· Inclusion criteria:
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Commons Attribution (CC BY-SA) license (htt p://creativecommons.org/licenses/by/4.0/)
815
Received:8 /5 /2020
Accepted:17 /6 /2020
c:\work\Jor\vol802_12
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 820-826
Serum Soluble Glycoprotein VI (sGPVI) to Predict the 28th Day In-Hospital
Mortality in Adult Patients with Sepsis
Sabry Abd Allah Shoeib1, Ayman Fathy Abd ElHalim2, Mohamad Ahmad Abd ElHafez1,
Ashraf Abd ElRaof Dawod3, Essam Ali Abd ElMohsen4, Sameh Abo ElNasr Abd ElSalam ElBaz1*
1Department of Internal Medicine and Hematology, 3Department of Medical Biochemistry, Faculty of Medicine,
Menoufia University, 2Department of Internal Medicine and Hematology, Faculty of Medicine, Zagazig University,
4Department of Internal Medicine and Hematology, El Maadi Military Hospital, Egypt
*Corresponding author: Sameh Abo ElNasr Abd El Salam ElBaz, Mobile: (+20)1006896109, E-Mail: samehelbaz@ymail.com
ABSTRACT
Background: Sepsis is a complicated syndrome resulting from the inappropriate expression of host factors in
response to infection and is a major cause of death in patients that are hospitalized in emergency departments and in
critical care units.
Objective: The purpose of the present study was to identify the role of serum soluble glycoprotein VI (sGPVI) in
predicting the 28th day in-hospital mortality in adult patients with sepsis.
Patients and methods: This observational prospective cohort study included a total of 90 adult patients aged 18
years old with clinically suspected sepsis, recruited from Medical Intensive Care Units of Menoufia University
Hospital and Kafr El-Sheikh general hospital. The included subjects were diagnosed using quick SOFA score and
according to survival at the 28th day, they were divided into two groups; Group A (survivors) consisted of 69 patients
(76.7%) and Group B (non survivors) consisted of 21 patients (23.3%).
Results: As regard clinico-laboratory data (qSOFA, sGPVI, SGOT, respiratory rate, ESR, WBCs) and complications
(hospital stay), they are significantly increased (P value < 0.001) in non-survivor studied patients in comparison with
survivor ones. Concerning platelet count, it is significantly reduced (P value < 0.001) in non-survivor studied patients
in comparison with survivor ones. As regard clinico-laboratory data (qSOFA, SGOT, respiratory rate, ESR and
WBCs) and complications (hospital stay), they are positively correlated with sGPVI with a statistically significant
difference in non-survivor studied patients. Concerning platelet count, it is negatively correlated with sGPVI with a
statistically significant difference in non-survivor studied patients.
Conclusion: It could be concluded that glycoprotein VI is a valuable prognostic predictor during sepsis being more
reliable than other widely used indicators and severity scores, such as qSOFA, WBCs, platelet count and CRP.
Keywords: Sepsis, sGPVI, qSOFA, CRP.
INTRODUCTION
Sepsis has been redefined as life-threatening organ
and endothelial cells to initiate the release of
dysfunction caused by dysregulated host responses to
proinflammatory mediators that cause vasodilatation
infection and septic shock as a subset of sepsis in which
and changes in endothelial cell function resulting in
particularly profound circulatory, cellular and
altered blood flow distribution, increased vascular
metabolic abnormalities are associated with a greater
permeability and tissue oedema in an attempt to limit
risk of mortality than with sepsis alone (1).
the spread of the infection. Coagulation, complement
Sepsis cases represent either a new organ
and contact systems are also activated, further
dysfunction or worsening of chronic organ dysfunction
promoting the inflammatory response. Endogenous
such as those seen in comorbid conditions in the
danger-associated molecular patterns (such as heat-
context of suspected or proven infection (2).
shock proteins) are also released and interact with
The literature on prevalence of organ dysfunction
PRRs to promulgate the inflammatory response (5).
outside the critical care environment is limited and
The biomarkers of sepsis can be classified as
when estimated appears frequently (3). Alongside this
markers of acute-phase protein (C-reactive protein
underestimated incidence globally, the short-term
[CRP], procalcitonin [PCT], lipopolysaccharide-
mortality from sepsis is improving (4).
binding protein), cytokine/ chemokine biomarkers
Essentially, the sepsis response is triggered by an
interleukin (IL-6),(IL-8), and markers of other
invading pathogen, usually of bacterial origin but also
pathophysiologic processes (coagulation factors and
viral or fungal, or a pathogen-produced substance, such
soluble cell surface receptors). Currently, complement
as endotoxin, called a pathogen-associated molecular
factors (C3a, C5a, and the soluble form of the C5a
pattern. These bind to pattern recognition receptors
receptor, sC5aR) have been defined as early markers of
(PRRs) present on macrophages, polymorphonuclear
sepsis and sepsis severity. CRP and PCT are the most
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/)
820
Received:7 /5 /2020
Accepted:16 /6 /2020
c:\work\Jor\vol802_13
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 857-864
The Influence of the MDR1 C3435T Polymorphism on Methotrexate
Responsiveness in Rheumatoid Arthritis Patients
Shahira Fathy El Fedawy1, Abeer Shehab1, Rania A. Abo-Shady1,
Samah A. El-Bakry2, Dina Ragab1, Sara Salem1, Nermeen Samy*2
1Department of Clinical Pathology, 2Department of Internal medicine and Rheumatology,
Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Nermeen Samy, Mobile: (+20) 1223744672, E-Mail: dr.nermeen81@gmail.com
ABSTRACT
Background: Methotrexate (MTX) is most widely used for the treatment of rheumatoid arthritis (RA). However,
different clinical responses have been observed in patients treated with MTX. Objective: The aim of the work was
to determine the influence of the MDR1 C3435T polymorphism on Methotrexate responsiveness in RA patients.
Patients and Methods: A cross sectional study included 90 RA patients. Demographics, clinical features,
medication history, and the disease activity score (DAS28) were carefully recorded. Genotypes of the C3435T
polymorphism were determined by real time polymerase chain reaction for all patients. According to disease activity
score, patients were classified into 2 groups: group (1): MTX responders (DAS28 score 3.2) and group (2): MTX
non-responders (DAS28 score >3.2).
Results: Of the 90 RA patients, 80 were females (88.9%) and 10 were males (11.1%). No statistically significant
difference was found in genotype or allele frequencies between MTX responders and non-responders groups.
However, patients who had C allele were 1.65 times more likely to be non-responder to MTX treatment when
compared to those who had the T allele. The most common MTX adverse effects reported were Gastrointestinal
upset in 31.1% followed by undesirable hair loss in 11.1%. The probability of having GIT adverse effects was
observed to be higher among the cases with (CT) genotype than the other genotypes but without statistical
significance.
Conclusion: It could be concluded that no significant association could be detected between MDR1 gene C3435T
polymorphism and responsiveness to methotrexate in the studied rheumatoid arthritis patients.
Keywords: Rheumatoid arthritis, MDR1 C3435T SNP, MTX sensitivity.
INTRODUCTION
Rheumatoid
arthritis
is
a
systemic
As achieving response early in the disease process
inflammatory disease that leads to severe joint damage
is the key to minimizing the joint damage, there is a
and affects around 1% of the population worldwide. Its
need to identify patients with a higher risk to
exact cause is unknown, but genetic and environmental
experience treatment inefficacy and to predict non-
factors are contributory (1). Disease-modifying anti-
responsiveness to MTX treatment. Pharmacogenetics,
rheumatic drugs (DMARDs) are used in treatment of
the inheritance of drug response, holds the promise not
RA to decrease inflammation, delay bone erosion and
only to explain interindividual variability in drug
disease progression, and improve functional ability in
response, but also to predict efficacy and adverse drug
RA patients (2).
events in individual patients. This so-called
Methotrexate (MTX) is still the most commonly used
personalized medicine or tailored therapy (4).
DMARD and considered to be the gold standard for
The treatment response is influenced by several
treatment of RA. The combination of its perceived
factors including female gender, DAS at baseline,
efficacy, acceptable safety profile, and low cost, as
rheumatoid factor (RF), smoking and differences in
well as decades of clinical experience, makes MTX the
drug metabolism. Many genetic factors may be
cornerstone of treatment for RA (2).
associated with these differences (4).
However, in routine clinical practice, different
Translocation of endogenous compounds, as well
clinical responses have sometimes been observed in
as drugs, across biological membranes occurs not only
patients treated with MTX. This indicates the presence
via passive diffusion, but also by carrier-mediated
of individual differences in MTX sensitivity.
processes. Knowledge of cell- and tissue-specific
Moreover, 30% of patients discontinue therapy within
transporter expression, as well as characterization of
a year of starting the treatment, usually because of
the substrates of individual transporters leads to a
undesirable side effects. Research into the reasons
better understanding of the role of these transporters in
behind patients' unresponsiveness or occurrence of
the treatment efficacy and adverse events of various
adverse events has generated considerable interest (3).
drugs (5).
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/
)
827
Received:11 /5 /2020
Accepted:21 /6 /2020
ACKNOWLEDGEMENT
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 835-844
Thyroid Dysfunction and Critical Illness in Intensive Care Unit
Patients of Aswan University Hospital
Marwa Ahmed Abdelhameid Ahmed*1, Mohammad Alyamany Kobiesy2,
Mohamed Zein EL-Dein Hafez2, Asmaa Osama Bakr3
Departments of 1Internal Medicine & 3Clinical Pathology, Faculty of Medicine, Aswan University,
2Department of Internal Medicine, Faculty of Medicine , Assiut University
*Corresponding author: Marwa Ahmed Abdelhameid Ahmed, Mobile: (+20)01067854019,
E-Mail: dr_marwaabdelhamed@yahoo.com
ABSTRACT
Background: Thyroid hormones play an essential role in human metabolism. Critical illness is often associated
with alterations in thyroid hormone concentrations in patients with no previous intrinsic thyroid disease.
Objective: This study was conducted to evaluate frequency of thyroid dysfunction in Intensive Care Unit patients
of Aswan University Hospital and to correlate between thyroid dysfunction and susceptibility for mechanical
ventilation. Patients and methods: This was a cross-sectional non randomized study was conducted at
Internal Medicine Intensive Care Units and Surgical Intensive Care Unit of Aswan University Hospital on
200 patients who were eligible to inclusion/exclusion criteria of the study. Thyroid function test of TSH,
FT3 and FT4 levels were investigated for all patients and were compared and correlated with the clinical
data of those patients. Results: Thyroid function abnormalities are common in critically ill patients who didn't
have abnormal thyroid functions before and more common in female patients than males. There was a correlation
between abnormal thyroid functions in critically ill patients and their mortality and more in sick euthyroid syndrome
patients. There was no relation between abnormal thyroid functions in critically ill patients and their increased
susceptibility for mechanical ventilation.
Conclusions: Thyroid function abnormalities are common in ICU patients, reflecting the prognosis and affect the
clinical outcome for those patients.
Keywords: Thyroid, Critical, Illness, ICU.
INTRODUCTION
decreases 5`deiodinase activity, thereby, decreasing T4
Thyroid hormones play an essential role in human
to T3 conversion and rT3 clearance. Increased
metabolism as they support anabolism, share in
metabolic clearance of T4 in critical illness further
cardiovascular system function (increase myocardial
diverts T4 to form the inactive isomer rT3. Thus, T3
contractility and cardiac output) by secreting
decreases and rT3 increases. Several mechanisms can
triiodothyronine (T3) and thyroxine (T4). Thyroid
contribute to the inhibition of 5`-monodeiodination
stimulating hormone (TSH) which is secreted by the
and therefore to the low serum T3 concentration in
pituitary gland is adjusting serum levels of thyroid
critically ill patients with NTI (5). Some authors have
hormones (1).
reported a relationship between hypothyroxinaemia
Euthyroid sick syndrome (ESS) is described as
and mortality in critically ill patients. Moreover, it has
abnormalities in circulating thyroid hormone levels
been suggested that primary hypothyroidism affects
without pre-existing hypothalamic pituitary or thyroid
respiration by causing abnormalities in the respiratory
gland dysfunction in the setting of non-thyroidal
system. However, the mechanism underlying the need
Illness (NTI). It reverts back to normal after recovery
for mechanical ventilation (MV) in patients with sick
from the NTI (2). ESS is characterized by low
euthyroid syndrome (SES) is still unclear (6).
triiodothyronine (T3), low or normal thyroxine (T4)
and low or normal thyroid stimulating hormone (TSH).
AIM OF THE WORK
Three patterns are described in ESS; Type1 or low T3
This study was conducted to evaluate frequency of
syndrome (low T3 only), type 2 or low T4 syndrome
thyroid dysfunction in Intensive Care Unit patients of
(low T3 and T4) and type 3 or low TSH syndrome (low
Aswan University Hospital and if there is correlation
T3, T4, and TSH) (3). Under normal circumstances
between thyroid dysfunction and possible susciptibility
100% of T4 and 10-20% of T3 are directly secreted by
for mechanical ventilation.
the thyroid gland. 5`deiodinase is an enzyme causes
peripheral monodeiodination of T4 transforming it to
PATIENTS AND METHODS
T3 and that step resulting in 80-90% of T3. This
This is a prospective observational cross-sectional
enzyme also increases the clearance of the inactive
non randomized hospital-based study. The study was
isomer reverses T3 (rT3), which is derived by the
conducted at Internal Medicine Intensive Care Units
action of 5` deiodinase on T4 (4). Critical illness
and Surgical Intensive Care Unit of Aswan University
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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/
)
835
Received:11 /5 /2020
Accepted:20 /6 /2020
c:\work\Jor\vol802_15
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 845-851
Kidney Injury Molecule 1 in Children with Heart Failure
Sahar Abd Elraouf Elsharawy1, Laila Raslan Abd Elaziz1, Naglaa Ali Khalifa2,
Hamdy Ahmed Mohammed Mohey El-Din*1
Departments of 1Pediatric & 2Clinical Pathology, Faculty of Medicine Zagazig University, Sharkia, Egypt
*Corresponding Author: Hamdy Ahmed Mohammed Mohey El-Din, Mobile: 01204404003, Email:
ABSTRACT
Background: Kidney injury molecule-1 (KIM-1) is a novel biomarker that was initially identified and evaluated
in patients with acute kidney injury. It predominantly indicates tubular injury and is an earlier and more sensitive
indicator of acute kidney injury than plasma creatinine. Objective: To evaluate the role of KIM-1 as an early
marker of renal dysfunction in children with heart failure and to assess whether KIM-1 concentration is related
to heart failure severity and cardiac function. Patients and Methods: This case-control study was carried out at
the Cardiology Unit, Outpatient Cardiology Clinic, and Clinical Pathology Unit, Zagazig University Hospitals
during the period from November 2018 to May 2019 included 93 children. Results: KIM-1 was higher in patients
with acute and chronic heart failure as compared with controls also it has positive correlations with LVEDD,
LVESD, and serum creatinine, while it had a negative correlation with GFR. An optimal admission KIM-1 cut
off at >588 ng/ml, with a sensitivity of 85.5%, a specificity of 83.9% for WRF prediction in HF, with an area
under the curve (AUC= 0.948, P>0.001). While the sensitivity of GFR and serum creatinine was 67.7%, 72.6%
respectively and the specificity was 71%, 90.3% respectively with an area under the curve of 0.773 and 0.875
respectively. Conclusions: KIM-1 can be considered as a sensitive diagnostic marker superior to both GFR and
creatinine for early detection of impaired renal function in acute and chronic HF even before GFR is markedly
reduced and even before serum creatinine is significantly affected.
Keywords: Heart failure, Cardiorenal syndrome, Renal dysfunction.
INTRODUCTION
protein, is undetectable in normal kidneys, but it is
Pediatric heart failure may be encountered with
markedly induced in renal injury including acute
or without the presence of structural heart disease and
kidney injury (AKI) and chronic kidney disease
at any age from fetal life to late adolescence. It may
(CKD)(4).
arise from diverse causes. The most common causes
of CHF in infancy are congenital heart diseases.
AIM OF THE WORK
Beyond infancy, myocardial dysfunction of various
This study aimed to evaluate the role of KIM-1
etiologies is an important cause of CHF (1). Children
as an early marker of renal dysfunction in children
with heart failure represented 10% to 33% of all
with heart failure and to assess whether KIM-1
cardiac admissions. Slightly more than half of the
concentration is related to heart failure severity and
pediatric heart failure cases reported in both studies
cardiac function.
were due to congenital heart disease, although the
incidence of heart failure in children with congenital
PATIENTS AND METHODS
heart disease was only 6% to 24%. This reflects the
This case-control study was carried out at the
fact that congenital heart disease is considerably more
Cardiology Unit, Outpatient Cardiology Clinic, and
common than other causes of heart failure. In
Clinical Pathology Unit, Zagazig University
contrast, 65% to 80% of children with
Hospitals during the period from November 2018 to
cardiomyopathies had heart failure, but this
May 2019. The study included 93 children, who were
represents only 5% to 19% of total pediatric heart
randomly selected, were included in this study. Our
failure cases. Most of heart failure cases (58% to
study included (31) cases with acute HF, (31) cases
70%) occurred in the first year of life, with congenital
with chronic HF and control group which included
heart
disease
disproportionately
represented
(31) age and sex-matched apparently healthy
compared to older ages (2). Renal dysfunction is a
children.
common phenomenon in heart failure and is one of
Inclusion Criteria: Age: from 2 months to 12 years.
the most potent prognostic indicators in these
Gender: male and female. Patients diagnosed with
patients. This mutual interaction shares the common
heart failure secondary to CHD. Exclusion Criteria:
name of the cardiorenal syndrome (3).
Age less than 2 months or more than 12 years. Heart
Renal epithelial cell injury is a feature of many
failure due to cardiac causes except for CHD as
acute and chronic renal diseases. Kidney injury
cardiomyopathy. Presence of an underlying lung
molecule-1(KIM-1), a transmembrane tubular
pathology as a cause of heart failure detected by
This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license ht
( tp://creativecommons.org/licenses/by/4.0/
)
845
Received:9 /5 /2020
Accepted:18 /6 /2020
c:\work\Jor\vol802_16
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 852-856
The Value of Estimating Paraoxonase Activity in Nephrotic Children
Saad Ahmed Mansour1, Mayy Abd Alfattah Neemat-Allah1,
Amal Saeed El Shal2, Shaymaa Sherif Abd El Aziz Ibrahim*1
1Pediatrics Department and 2Biochemistry Department, Faculty of Medicine,
Zagazig University, Zagazig, Egypt
*Corresponding author: Shaymaa Sherif Abd El Aziz Ibrahim, Mobile: (+20)01014901316, Email: drshaymaasherif@gmail.com
ABSTRACT
Background: Nephrotic syndrome (NS) is a series of symptoms caused by kidney damage. This involves protein in
the urine, low levels of blood albumin, elevated blood lipids, and high levels of swelling.
Objective: This study aimed to evaluate paraoxonase1 (PON1) activities in children with nephrotic syndrome before
and after treatment and compare it with healthy control individuals.
Patients and Methods: A case control study was carried out at Pediatric Nephrology Unit and Outpatient Nephrology
Clinics of Children Hospital at Zagazig University over a period of fifteen months from August 2017 to November
2018, included 40 children classified into three groups; group1: included 20 child of newly diagnosed nephrotic
syndrome children; Group 2: comprised same nephrotic patients of group 1 in remission stage after one month of daily
divided dose of steroid; group 3 included 20 children apparently healthy and matched with the previous groups in age
and sex (control group).
Results: There was a high significant difference in the lipid profile among the three studied groups. There was a
significant difference in serum PNO1 levels among three studied groups. There was a high significant decrease in serum
PNO1 in group1 than control group. There was no significant difference in PNO1 serum levels between group 2
(remission) and control group.
Conclusion: PON1 activity of newly diagnosed cases is significantly decreased antioxidant ability to prevent lipid
oxidation. Hyperlipidemia with diminished antioxidant potential due to reduced PON1 collectively predisposes NS
patients to the possibility of atherosclerosis.
Keywords: Paraoxonase, Antioxidants, lipid profile; Nephrotic Syndrome.
INTRODUCTION
AIM OF THE WORK
Abnormal lipid metabolism is typical in patients
The present study aims to evaluate PON1 activities
with kidney disease(1). This effect is most pronounced in
in children with nephrotic syndrome before and after
nephrotic syndrome (NS) where there is a marked rise in
treatment and comparing it with healthy control
plasma lipid levels(2).The lipid profile seen in the NS is
individuals. Also to study any correlation exists between
atherogenic and predisposes to premature coronary artery
PON1 activity and lipid profile.
disease (CAD) (3). Paraoxonase1 (PON1) is mainly
synthesized in the liver(4). Human serum PON1 is closely
PATIENTS AND METHODS
associated with apolipoprotein A1 in high density
A case control study was carried out at
lipoprotein (HDL) and has the highest expression in the
Pediatric Nephrology Unit and Outpatient Nephrology
liver and blood. PON1 has been involved in the
Clinics of Children Hospital at Zagazig University over
prevention of low density lipoprotein (LDL) lipid
a period of fifteen months from August 2017 to
peroxidation and also degrades biologically active
November 2018. Forty children were included in this
oxidized lipids in lipoprotein(5). Oxidized LDL formation
report. They were randomly divided into three groups.
in the sub-endothelial space of the arterial wall is a
Group 1: This group comprised 20 children of
crucial initial step in atherosclerosis. There is also an
newly diagnosed nephrotic syndrome (Acute). The cases
inverse relationship between the amount of oxidized lipid
were assessed for the clinical, laboratory parameters at
products and the activity of PON1. PON1 activity is
baseline. Each of our nephrotic patients had NS
decreased in subjects at high risk of developing
characters in the form of generalized edema, proteinuria
atherosclerosis (6).
> 40 mg/m2/h, hypoalbuminemia (serum albumin < 2.5
PON1 plays a vital function in the antioxidant
g/dL) and hypercholesterolemia (serum cholesterol > 200
system. Decreased paraoxonase levels reduces the
mg/dL).The age of patients ranged from 2-10 years
antioxidant activity of high-density lipoprotein and
(median, 6 years), both sexes were presented (65% male
induce glomerulosclerosis. Few studies have investigated
and 35% female). They were treated at Nephrology Unit
paraoxonase activity and antioxidant status in NS(4).
of Pediatric Department of Children Hospital. All
patients were steroid sensitive nephrotic syndrome
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/)
852
Received:10 /5 /2020
Accepted:19 /6 /2020
ACKNOWLEDGEMENT
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 857-864
Thyroid Dysfunction as a Mortality Predictor for ICU Patients
Marwa Ahmed Abdelhameid Ahmed*1, Mohammad Alyamany Kobiesy2,
Mohamed Zein EL-Dein Hafez2, Asmaa Osama Bakr3
1Departments of 1Internal Medicine & 3Clinical Pathology, Faculty of Medicine, Aswan University, Aswan,
2Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
*Corresponding author: Marwa Ahmed Abdelhameid Ahmed, Mobile: (+20)01067854019,
E-Mail: dr_marwaabdelhamed@yahoo.com
ABSTRACT
Background: Patients suffering from critical illness admitted to the Intensive Care Unit (ICU) exhibit alterations
in their thyroid hormone levels. These changes correlate with the outcome and mortality of critically ill patients
treated in ICUs.
Objective: Our study was conducted to determine thyroid dysfunction as a risk predictor for ICU patients.
Patients and Methods: This is a prospective observational cross-sectional non-randomized hospital-based study.
The study was performed at the Internal Medicine Intensive Care Units and Surgical Intensive Care Unit of Aswan
University hospital at the duration between 1-6-2017 to 30-1-2019 for 200 patients.
Results: Regarding TSH, 61.8% sensitivity, 37.1% specificity, 61.3% negative predictive value and 37.6% positive
predictive value. Regarding the FT3, 63.2% sensitivity, 50.8% specificity, 69.2% negative predictive value and
44.0% positive predictive value. Regarding the FT4, 15.0 was the cut off value with 61.8% sensitivity, 50.0%
specificity, 68.1% negative predictive value, and 43.1% positive predictive value. It showed 54.5% Accuracy &
the area under the curve (AUC) was 0.601. From results, FT3 is the most sensitive thyroid function in predicting
prognosis and mortality of critically ill patients in ICU. The increase in the APACHE II score could significantly
predict the increased risk of mortality while a decrease in FT3 and FT4 could significantly increase the risk of
mortality.
Conclusions: FT3 was the strongest predictor of ICU mortality. Further, the combination of FT3 levels and
APACHE-II scores provided for a higher probability for predicting mortality in ICU patients.
Keywords: Thyroid dysfunction, MV, ICU, FT3, APACHE-II
INTRODUCTION
involving 480 critically ill patients admitted to ICU
During any critical illness, a common
showed fT3 levels to be an independent and powerful
phenomenon experienced is the alteration in the
predictor of mortality (9).
levels of thyroid hormones (1). These changes
Some authors have reported a relationship
correlate with the outcome and mortality of critically
between hypothyroxinemia and mortality in critically
ill patients treated in Intensive Care Units (ICUs) (2,
ill patients. More so, it has been suggested that
3). In the 20th century, various studies observed that
primary hypothyroidism affects respiration by
thyroid dysfunction is associated with increased
causing abnormalities in the respiratory system;
morbidity and mortality in ICU-admitted patients (4).
however, the mechanism underlying the need for
Such alterations in thyroid hormone levels during
mechanical ventilation (MV) in patients with SES is
critical illness is described as "euthyroid sick
still unclear (10).
syndrome" or "nonthyroidal illness syndrome (5, 6). It
Subsequent studies confirmed the association
is characterized by low levels of free and total
between NTIS and adverse outcomes in patients with
triiodothyronine (T3) and high levels of reverse T3
sepsis, multiple trauma, acute respiratory distress
(rT3) with variable values of thyroxine (T4) and
syndrome respiratory failure, and mechanically
thyroid-stimulating hormone (TSH) in the low to
ventilated patients, as well as in unselected ICU
normal range.
patients. However, the performance of the thyroid
Various studies were conducted to demonstrate an
hormones to predict adverse outcomes in general ICU
association of thyroid dysfunction in critically ill
patients is unimpressive until now (9).
patients with mortality and morbidity of such
Conflicting results also existed in terms of other
patients. Initial studies showed inconsistent results
indicators, such as total triiodothyronine (TT3) total
with some showing decreased free T3 (fT3) levels in
thyroxin (TT4) and TSH. Most of these studies were
no survivors (7), while others failed to show any such
rather small and just evaluated the prognostic value
association (8). Whether thyroid hormones can
of some but not the complete thyroid hormonal
independently predict mortality in ICU patients
indicators. Until now, which one among the complete
remains a matter of debate. A large prospective trial
thyroid hormonal indicators is best for predicting
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/
)
857
Received:12 /5 /2020
Accepted:22 /6 /2020
INTRODUCTION
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 865-870
Hearing Affection in High Risk Neonates
Abdel-Razek El-sheikh1, Ali Abdel Hamied1, Waleed Mohamed Ibrahim2,
Marwa Mostafa Mohamed El Shanawany*1
Departments of 1Pediatrics & 2Audiology Unit, ENT - Faculty of Medicine, Zagazig University
*Corresponding author: Marwa Mostafa Mohamed El Shanawany, Mobile: (+20) 01020520224,
E-Mail: m.melshanwny019@medicine.zu.edu.eg
ABSTRACT
Background: Hearing impairment in children is a hidden disability. By the time, it is recognized usually at 2:3
years. The child's speech and language ability will be irreversibly affected. Early detection of hearing impairment
and timely intervention can give better consequences.
Objectives: Identification of the most significant risk factors for hearing impairment in high risk neonates
hospitalized at our Neonatal Intensive Care Unit (NICU) and to assess the sensitivity of hearing screening tests.
Patients and methods: This study was carried out on newborns with risk factor of hearing loss admitted to NICU
of Pediatric Department, Zagazig University Hospital from December 2017 to December 2018 using both transient
evoked otoacoustic emissions (TEOAE) and Auditory Brainstem Response (ABR) tests in Audiology Unit,
Zagazig University Hospital. Number of the studied neonates was 58 high risk neonates.
Results: Of the criteria that studied neonates was chosen according to it, exposure to ototoxic medications was the
most common risk factor (82.8%) followed by assisted ventilation > 5 days (77.6%), prematurity (62.1%), LBW
(56.9%), septicemia (50%), perinatal asphyxia (13.8%). There were statistical significant relationship between
auditory brainstem response and ototoxic medications in the studied neonates. Vancomycin and meropenem were
significant risk factors of hearing loss.
Conclusion: Prematurity, Low birth weight, Septicemia, Perinatal asphyxia and Administration of vancomycin
and meropenem were significant risk factors of hearing impairment in our studied neonates by ABR test.
Keywords: Hearing Affection, Neonates, ABR test, Vancomycin, Meropenem.
INTRODUCTION
TEOAE is cheap, quick, simple and reliable, AABR
Hearing is the most vital of all senses in
has the additional advantage of identifying neonates
newborns. Almost all information from surroundings
with auditory neuropathy (4).
newborns get by sound perception (1).
OAEs are used to assess cochlear integrity and
Hearing in the first year of life is critical for
are physiologic measurements of the response of the
development of speech and cognitive functions of the
child whereas beyond this period, neural plasticity
outer hair cells to acoustic stimuli. They serve as a
sets. Hearing loss in very early life has shown
fast objective screening test for normal preneural
multiple deleterious effects on the child related to
cochlear function through the use of probe in the ear
attainment of speech and language. Early screening
canal (4).
and recognition of hearing impairment is the
Auditory brainstem response is an auditory
fundamental step to reduce the negative
evoked potential that originates from the auditory
consequences on a child's psychosocial, scholastic
nerve. It can detect injury on the level of cochlea,
and social-emotional development (2). The severity of
auditory nerve and auditory pathway in the brainstem
these hearing disabilities is generally related to the
(5).
length of time the hearing loss is left untreated. Early
The aim of this work was to identify the most
identification of hearing impairment improves
significant risk factors for hearing impairment in high
prognosis, hence screening programs have been
risk neonates hospitalized at our Neonatal Intensive
widely and strongly advocated (3).
Care Unit (NICU) and to assess the sensitivity of
Until mandatory screening programs are
hearing screening tests.
established universally, many hospitals will continue
to use high risk criteria to screen for hearing loss. The
PATIENTS AND METHODS
screening of infant at risk is selective and considered
This was a cross sectional study carried out on
as first step towards introduction of universal hearing
neonates with one or more risk factors of hearing loss
screening (3).
admitted to NICU of Pediatric Department, Zagazig
Tests used for screening newborns for hearing
University Hospital from December 2017 to
loss include TEOAE and automated auditory
December 2018 using both transient evoked
brainstem response audiometry (AABR). While
otoacoustic emissions (TEOAE) and auditory
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/
)
865
Received:15 /5 /2020
Accepted:25 /6 /2020
c:\work\Jor\vol802_19
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 871-875
Prevalence and Risk Factors of Minimal Hepatic Encephalopathy in
Patients with Compensated Liver Cirrhosis
Marwan N Elgohary*, Kamal Amer**, Mohamed AA Bassiony*
*Gastroenterology and Hepatology Unit, Internal Medicine Department and
**Tropical Medicine Department, Faculty of Medicine, Zagazig University
Corresponding Author: Mohamed Bassiony, Telephone: 00201205664331, E-mail: dr_mbh13303@yahoo.com
ABSTRACT
Background: Minimal hepatic encephalopathy (MHE) is the earliest phase of hepatic encephalopathy. It is associated
with increased risk of falls, impaired work and diminished quality of life.
Subjects and methods: This study included 302 patients with liver cirrhosis, of which 130 patients had Child A
(compensated) liver cirrhosis. All patients were assessed by history taking, clinical examination, routine investigations,
serum ammonia level and abdominal ultrasound for porto-systemic shunt (PSS). MHE was diagnosed in 60 patients
of compensated liver cirrhosis patients using mini-mental state examination (MMSE) and number connection test A
(NCT-A).
Results: Our stud showed that Child A patients were 43% of the study group and MHE was present in 46% of
compensated liver cirrhosis patients. Our results showed a significant association between lower serum albumin,
higher INR, high serum ammonia, presence of PSS in ultrasound examination and MMSE and NCT-A high scores
with the development of MHE. MMSE and NCT A showed significantly good performance in diagnosis of MHE.
Multiple regression analysis showed that high serum ammonia level (53-61) u/dl, large PSS (> 8 mm in diameter),
MMSE score (22-26) and NCT A score (45-56) were the most significant risk factors for MHE.
Conclusion: MHE is a major and prevalent manifestation in compensated liver cirrhosis patients. It is associated with
significant decrease in work and driving abilities and quality of life. Its major risk factors are high serum ammonia,
large PSS and high scores of MMSE and NCT A tests that have a good performance in MHE diagnosis.
Keywords: Minimal hepatic encephalopathy, hepatitis C, cirrhosis, mini-mental state examination, porto-systemic
shunt, number connection test A.
INTRODUCTION
Liver cirrhosis is a major global health burden
cerebral neurotransmitters and fluid homeostasis.
affecting about 2% of the global population. Viral
These covert abnormalities can't be identified by
hepatitis (hepatitis C and B), chronic alcohol abuse and
history or clinical neurological examination. However,
non-alcoholic steatohepatitis (NASH) are the most
they can be elucidated by neuropsychometric and
common causes of liver cirrhosis worldwide. Liver
neurophysiological tests (3).
cirrhosis is the most common indication of liver
MHE can be diagnosed in chronic liver disease
transplantation. Despite healthcare improvements in
patients with or without portosystemic shunt (PSS), and
the last few decades, Egypt still has the highest
also in PSS patients due to portal hypertension without
mortality rate of liver cirrhosis (72%) and 20% of
liver disease (4).
deaths in adult Egyptian males between 45-55 years
MHE has a substantial burden on the psychosocial
were due to liver cirrhosis in 2010 (1).
and medical aspects of the patients. It interferes with
Hepatic encephalopathy is a major clinical feature
and markedly diminishes the patients working ability,
of decompensated liver cirrhosis. It is a
independent survival and quality of life especially for
neuropsychiatric syndrome characterized by mental
patients whose jobs require physical coordination.
state and sleep disorders with or without motor
MHE is associated with impaired cognitive functions
manifestations. Mental state disorders range from mild
such as attention, alertness, orientation and learning
cognitive impairment to deep coma (2).
processes with poor navigation and driving
Minimal hepatic encephalopathy (MHE) is the
performance leading to high incidence of motor vehicle
mildest stage of hepatic encephalopathy that affects 30-
accidents and falls (5).
80% of patients with liver cirrhosis and often
MHE is diagnosed in patients with grade 0 hepatic
undiagnosed and untreated by physicians due to its
encephalopathy according to West Haven criteria if
covert nature. It is characterized by subtle changes in
other neurophysiological/ neuropsychometric tests, as
neuropsychological features, cognitive functions
mini-mental state examination (MMSE), number
particularly in the domains of attention, vigilance and
connection tests, block design, digit symbol, critical
integrative function, changes in cerebral blood flow,
This article is an open access article dis tributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
871
Received:14 /5 /2020
Accepted:24 /6 /2020
c:\work\Jor\vol802_20
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 876-882
Outcome of Minimally Invasive Locked Plate in Management of
Proximal Tibial Fracture
Mohamed Abd Allah El-Soufy, Amr Mohamed Ahmed El-Adawy,
Mohamed Khaled Saleh, Abdel-Rahman Mansour AlKoum*
Department of Orthopedic Surgery - Faculty of medicine, Zagazig University, Egypt
*Corresponding author: Abdel-Rahman Mansour AlKoum, Mobile: (+20)01064104986, Email: abdulrhmanmansour88@gmail.com
ABSTRACT
Background: Proximal tibia being a prime component of knee joint, which is vital for weight bearing and mobility.
Because of its superficial location and vulnerable position, proximal tibia is frequently injured, more frequently in
road traffic accidents (RTA). Open reduction and internal fixation with plate can result in extensive devitalization of
soft tissue leading to wound healing problems. Minimally invasive plate osteosynthesis (MIPO) is a new technique
which is becoming widely accepted for treatment of proximal tibial fractures.
Objective: To evaluate functional and radiological outcome of fixation of proximal tibial fracture by minimal invasive
plate osteosynthesis. Patients and methods: A prospective analysis of 12 patients with proximal tibial fracture. The
right side was affected in 8 patients and left side in 4 patients, all of patients treated by MIPO technique by LCP. The
patients were assed clinically by Rasmussen score post-operatively.
Results: Functional evaluation was performed according to the criteria described by Rasmussen score. 7 cases
(58.33%) had excellent result, 4 patients (33.33%) had good results and 1 patient (8.33%) had fair results. No patient
had poor result. Conclusion: Minimally invasive plate osteosynthesis for proximal tibia fractures achieved good
radiological and functional outcome. There was minimal soft tissue damage and minimal disruption of blood supply
to fracture ends. The fractures treated with pure bridge plating and combined principle of compression and bridge
plating healed rapidly by secondary fracture union.
Keywords: Proximal tibial, Fracture, Minimally invasive plate osteosynthesis (MIPO).
INTRODUCTION
Proximal tibial fractures fall into two broad
vascular supply to bone due to soft tissue and
categories, high energy fractures and low energy
periosteal stripping(5). Conventional plates needed to
fractures (1). Extra-articular proximal tibial fractures
be accurately contoured to achieve good fixation.
account for 5% to 11% of the total number of tibial
Osteoporosis also posed the same problem of
injuries. Intra-articular fractures (tibial plateau)
poor fixation with conventional plates (6). The concept
represent 1% of all fractures and 8% of fractures in
of biological fixation using the plates, called
elderly population. The majority of tibial plateau
minimally invasive plate osteosynthesis (MIPO)
fractures are secondary to high- speed velocity
developed. Hence, this study was conducted to analyze
accidents and fall from a height where fractures result
the duration of union and functional outcome in
from direct axial compression, usually with a valgus
proximal tibial fractures treated with LCP (7, 8).
(more common) or varus moment and indirect shear
forces (2). Extra-articular fractures of the proximal tibia
AIM OF THE WORK
were usually secondary to direct bending forces
This study aimed to evaluate functional and
applied to the metaphysiodiaphyseal region of the
radiological outcome of fixation of proximal tibial
upper leg. Older patients with the osteopenic bone are
fracture by minimally invasive plate osteosynthesis.
more likely to sustain depression type fracture because
their sub-chondral bone is less likely to resist axial
PATIENTS AND METHODS
directed loads (3).
A prospective study of twelve patients, their ages
Surgical treatment of proximal tibial fracture
ranged from 19 years to 65 years old with the mean of
aims to restore congruent articular surfaces of the tibial
39.25 years. The right side was affected in 8 cases and
condyles maintaining the mechanical axis and
the left in 4 cases proximal tibial fractures treated by
restoring ligamentous stability eventually achieving
Locked compression plates at Zagazig University
functional knee joint with a painless and good range of
Hospital and Zliten Teaching Hospital during the
motion (4). The various clinical studies established that
period from September 2018 to July 2019. The
bones beneath a rigid conventional plate is thin and
fractures were classified according to AO
atrophic which make them to be prone for secondary
classification as extra articular fracture type A (eight
displacement due to insufficient buttressing and
patients) and intra-articular fracture type C (four
secondary fractures after removal of the plate. Fracture
patients). One case was open fracture and the other 11
site take longer period to unite due to interruption of
cases were closed fracture. We used locking
compression plate and locking or non-locking screws.
This article is an open acc
ess article distributed under the terms and conditions of the Creative
Commons Attributio
n (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
876
Received:16 /5 /2020
Accepted:26 /6 /2020
Microsoft Word - 21.docx
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 883-884
Delayed Massive Lower Gastrointestinal Bleeding Secondary to Suprapubic
Cystostomy, A Case Report of Very Rare Complication
Bashaeer Abdullh Al Jalal1
College of Medicine, King Faisal University, Al Ahsa, Saudi Arabia
ABSTRACT
Introduction: Suprapubic cystostomy is a common procedure in urology.
Bowel perforation is the most serious and rare complication. This report highlights the first published case
of massive lower gastrointestinal bleeding as a complication secondary to suprapubic cystostomy.
Case presentation: A sixty-seven-year-old patient with benign prostate hyperplasia had a suprapubic catheter
inserted under spinal anesthesia, during concurrent cystoscopy. It was functioning well after insertion. Twelve days
later, he developed massive hematochezia. On examination, he was hemodynamically stable. There was a
demonstrable right lower abdominal tenderness and the digital rectal examination revealed dark red blood. The
suprapubic cystostomy was draining clear urine without leakage. Investigations revealed a hemoglobin 6 g/dL and
normal INR. Two units of packed red blood cells were given. A colonoscopy showed a normal colon with blood
coming from above the ileocecal valve area. Upper endoscopy was normal. A red blood cell scan revealed active
bleeding at the terminal ileum. A computerized tomography scan of the abdomen with IV contrast showed that the
suprapubic catheter had passed into terminal ileum causing active bleeding. Exploratory laparotomy confirmed the
presence of suprapubic catheter passing to the terminal ileum. The suprapubic catheter was removed, the unhealthy
bowel resected, and anastomosis performed with no immediate post-operative complications.
Conclusion: This case determines the importance of keeping careful watch for possible bowel injury after
cystostomy and should be considered a rare complication and cause of lower gastrointestinal bleeding.
Keywords: Suprapubic cystostomy; Lower gastrointestinal bleeding; Rare complication.
INTRODUCTION
insertion. He was observed for one-day post-
Suprapubic cystostomy is a common procedure in
procedure and he was well.
urology. It is implied for acute urinary retention
Twelve days later, he developed massive
which is not treated with urethral catheterization and
hematochezia. On physical examination, the patient
in the long-term management of bladder outflow
was afebrile, his heart rate was 102 per minute, and
obstruction and neuropathic bladders 1.
his blood pressure was 162\62 mmHg. There was a
The suprapubic catheter can be placed either
right lower abdominal tenderness but without
through a punch trocar or by using other safer
guarding. The digital rectal examination showed dark
techniques2. Although the SPC is a safe procedure
red blood. The suprapubic cystostomy was draining
with known complications such as site infection,
clear urine without leakage. Investigations revealed a
bleeding,
catheter
blockade,
malpositioning,
hemoglobin 6 g/dL (normal range 12-15.5 g/dL, it
dislodgment, or bowel injury 2.
reduced from 8 g/dL four days previously) and a
Bowel perforation is rare and the most serious
normal INR. Two units of fresh packed red blood
complication with an incidence rate of 2.4 to 2.7% 1.
cells were given.
Terminal ileum perforation associated with lower
A colonoscopy showed normal colon with
gastrointestinal bleeding has not been reported.
blood coming from above the ileocecal valve area.
We present a case of terminal ileum injury and
delayed severe lower gastrointestinal bleeding
following suprapubic cystostomy.
CASE PRESENTATION
A sixty-seven-year-old patient with benign
prostate hyperplasia had a suprapubic catheter
inserted because of the failure of prostate stent. The
percutaneous suprapubic catheter was inserted under
spinal anesthesia, during concurrent cystoscopy; they
did not note any intravesical pathology. The patient
had no history of gastrointestinal or urological disease
and had not undergone previous abdominal surgery.
The suprapubic cystostomy was functioning well
after
This article is an open acce ss article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
883
Received:18 / 5 /2020
Accepted:28 /6 /2020
c:\work\Jor\vol802_22
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 885-890
Association between Arginine 16 Polymorphism of B2 Adrenergic Receptor and
Bronchial Asthma in Children
Khalid Mohamed Salah1, Heba Gamal Anany1, Nissreen El-Sayed El-Badawy2,
Doaa Taha Ebrahim Taha*1
Departments of 1Pediatrics & 2Microbiology, Faculty of Medicine Zagazig University, Sharkia, Egypt
* Corresponding author: Doaa Taha Ebrahim Taha, Mobile: (+20)01024683929, Email: mosad8rashed@gmail.com
ABSTRACT
Background: Asthma is one of the most prevalent health problems. The relationship between 2AR genotypes and
response to 2AR agonist therapy is controversial. Some studies have found that the Arg-16 genotype is associated
with reduced response to 2AR agonists, whereas others have found that the Gly-16 genotype is associated with
reduced response.
Objective: to detect gene polymorphism and to determine the association between gene polymorphism and bronchial
asthma susceptibility as a risk factor, and to evaluate of the degree of severity of bronchial asthma among cases having
a defect in studied gene and those without defect, and also to assess of drug response to 2 agonists concerning gene
polymorphism.
Methods: This study was carried out at Zagazig university hospitals. 100 Egyptian children with ages ranging from
5 to 12 years were enrolled. They were divided into 2 groups, the asthmatic group included 50 asthmatic children who
were diagnosed according to GINA guidelines (2016), and a control group of 50 age and sex-matched healthy children.
Results: Arg16Gly heterozygous represents 48%, Arg16 homozygous represents 38% and Gly16 homozygous
represents 16% of asthmatic patients, while among the control group Arg16heterozygous represents 38%,
homozygous represents 14% and 48% for Gly16 homozygous. There was no significant difference between Arg16Gly
genotypes and asthma severity. Also, Arg 16 homozygous showed the best response to treatment with inhaled short-
acting beta 2 agonists.
Conclusion: there is an association between beta 2 adrenergic receptor polymorphism and the occurrence of bronchial
asthma and also between this polymorphism and response to treatment. Also that the polymorphism at codon 16 of
the 2 adrenergic receptor gene not a determinant of asthma severity in the Egyptian children.
INTRODUCTION
Asthma is a chronic disease of childhood and
considered to be susceptibility genes for asthma; they
adolescence characterized by reversible airway
had been reported to be associated with functional
obstruction, with or without treatment, resulting from
changes in the 2AR in the respiratory system (4).
an underlying chronic inflammatory process that
An important factor studied in asthma-related
typically involves infiltration of various cell types (1).
research is the beta-2-adrenergic receptor, which is
Asthma is one of the most prevalent chronic childhood
encoded by the ADR2 gene. Different polymorphic
causes of hospitalization among children (2).
loci of this gene have been associated with an asthma
Genetic factors controlling the 2-adrenergic
diagnosis, nocturnal asthma, asthma exacerbations, and
receptor (2AR) function may be a very important
response to beta-2 agonists in asthma treatment (5).
determinant of response to bronchodilator therapy and
Although this gene is the most studied in asthma
thus of severity and duration of asthmatic symptoms (3).
pharmacogenetics, no clear conclusion as regards its
Inhaled selective 2-agonists were the most
functional effects has been reached. Although the Arg/
widely used treatment for the acute relief of asthma
Gly16 polymorphism has been linked to the level of
symptoms. The 2AR mediates the physiologic
lung function, it has not been linked to change in lung
responses of the airways, including broncho-protection
function with either SABAs or LABAs. The
(reduced responsiveness to non-specific contractile
substitution of arginine (Arg) for glycine (Gly) at codon
stimuli), bronchodilatation (improvement in lung
16 of the 2AR gene is responsible for differences in
mechanics),
enhanced
mucociliary
clearance,
response to short-acting beta-2 agonists (6).
suppression of microvascular leakage, inhibition of
Inhaled
2-adrenergic
receptor
agonist
cholinergic neurotransmission and inhibition of
medications are the foundation of therapy for acute
mediator release from basophils and mast cells. A
asthma exacerbation. The 2AR protein is expressed on
number of single-nucleotide polymorphisms (SNPs) in
bronchial smooth muscle cells and mediates
the 2AR gene had been detected in many populations.
physiologic responses including bronchodilation,
The most common SNPs were due to two missense
vasodilatation, and lipolysis (7).
mutations, which occur in the coding region of the
The objectives of this study were to: detect gene
2AR gene. Although these polymorphisms were not
polymorphism and to determine the association
This article is an open access art icle distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
885
Received:17 /5 /2020
Accepted:27 /6 /2020
c:\work\Jor\vol802_23
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 891-898
Influence of Addition of Ondansetron or Ketorolac on Levobupivacaine in
Bier Block for Upper Limb Surgeries
Hossam Eldeen AS Faid, Enas M Ashrey, Sahar Y Osman
Department of Anesthesia, Intensive Care & Pain Management,
Faculty of Medicine for Girls. Al-Azhar University
*Corresponding to: Enas M Ashrey. MD, Department of Anesthesia, Intensive Care and A Management, Faculty of
Medicine for Girls, Al-Azhar University. Cairo, Egypt. Mobile: +2 01005301224, E-mail: drenasenas@yahoo.com
ABSTRACT
Background: Intravenous administration of a local anesthetic into a tourniquet occluded limb, continued to be in
favor due to simplicity and reliability with rapid onset of the technique and decreased systemic toxicity.
Objectives: Our study aimed to compare between the effects of adding ondansetron 8 mg or ketorolac 30 mg to
levobupivacaine 0.125% for IVRA on duration of postoperative analgesia
Patients and methods: 60 adult patients of both sex who are matched with American Society of Anesthetists (ASA,
I - II). Their ages ranged between 2160 years old and scheduled for upper limb surgery under intravenous regional
anesthesia (IVRA). Patients were randomly divided into three equal groups (20 patients each). Group (L):
levobupivacaine (0.125%) + IV saline, (control group). Group (LO): levobupivacaine (0.125%) + IV ondansetron (8
mg/kg). Group (LK): levobupivacaine (0.125%) + IV ketorolac (30mg). All patients received levobupivacaine
(0.125%) diluted with 0.9% normal saline to a total volume of 40 ml.
Results: Onset of sensory and motor block was rapid in ondansetron group than other groups. Duration of offset time
of sensory and motor block was significantly prolonged in ketorolac group (p < 0.0001). Visual analog scale was
significantly lower in ketorolac (p < 0.001) and ondansetron group than in control group. Duration of postoperative
analgesia was longer in ketorolac group and ondansetron group than in control group (p < 0.001). Postoperative total
analgesic consumption in 24h was significantly less in ketorolac group than in ondansetron group and control group
(P < 0.002).
Conclusion: The results of the present study revealed that addition of ondansetron or ketorlac to levobupivacaine for
IVRA improved quality of anesthesia, reduced postoperative analgesic consumption with rapid onset of sensory block
with ondansetron group than with ketorolac group. Moreover, the time to the first analgesic requirement after surgery
was prolonged with ketorolac group than with ondansetron group when compared to the control group.
Keywords: Intravenous regional anesthesia, Levobupivacaine, Ondansetron, Ketorolac.
INTRODUCTION
IVRA, commonly known as (Bier's block),
inflammatory, antiemetic, anesthetic, and analgesic
includes intravenous administration of a local
effects that may have a role in decreasing pain. As, it
anesthetic (LA) into a tourniquet occluded limb that
shares in the pathway of nociception by interfering with
diffuses from the peripheral vascular bed to neural
peripheral effects of serotonin on nociception. Also, it
tissues such as axons and nerve endings (1). It is
binds to opioid mu receptors and acts as a potential
continued to be in favor due to simplicity and reliability
opioid agonist resulting in analgesic effect (6). Also, it
with rapid onset of the technique and decreased
plays a crucial role in pain transmission as it is located
systemic toxicity (2). Ideal IVRA anesthetic should have
in inhibitory interneurons of the pain-modulating
the following criteria: rapid onset with reduced dose of
descending pathways, which impinge to the substantia
local anesthetic and reduced tourniquet pain and
gelatinosa of the dorsal horn that inhibits incoming
prolonged post-operative analgesia. This may be
painful impulses from the primary afferent fiber. This
achieved by the addition of adjuvants to LA (3).
allows the anti-nociceptive action of serotonin at spinal
Levobupivacaine is an amino amide LA drug of
levels (7).
pure S (-)-enantiomer of bupivacaine. It is safer and
Ketorolac, an acetic acid derivative, non-steroidal
superior
than
bupivacaine
regarding
to
anti-inflammatory drug (NSAID) that acts through
pharmacokinetic profile with faster protein binding
inhibition of prostaglandin synthesis. It inhibits action
rate. It acts through reversible blockade of neuronal
of the cyclooxygenase enzymes (COX-1 and COX-2),
sodium channels (4).
which converts arachidonic acid to prostaglandins and
Ondansetron is a serotonin 5-HT3 receptor
thromboxane A2 giving high analgesic and anti-
antagonist of ligand-gated sodium ion (Na+) and
inflammatory effect (8).
potassium ion (K+) channels that found in the central
Study Outcomes: Duration of postoperative
and peripheral nervous system in the chemoreceptor
analgesia is that the primary outcome. Whereas the
trigger one (CTZ), afferent fibers of vagus nerve in GIT
evaluation of hemodynamic parameters, onset and
and central nervous system (CNS) (5). It possesses anti-
offset time of sensory and motor block, visual analogue
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/)
891
Received:19 /5 /2020
Accepted: 29/ 6/2020
ABSTRACT
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 899-906
Albumin and Magnetic Resonance Imaging-Liver Volume to
Identify Hepatitis C-related Cirrhosis and Esophageal Varices
Said Abd Elbaky Gad Shams El Deen
Department of Internal Medicine, Faculty of Medicine, Zagazig University, Sharkia, Egypt
Corresponding author: Said Abd Elbaky Gad Shams El Deen, Mobile: 01227517689, Email: saidabdelbaky12345@gmail.com
ABSTRACT
Background: Liver cirrhosis is the 3rd leading cause of death globally, with increasing mortality rate worldwide portal
hypertension is a frequent consequence in the progress of liver cirrhosis and plays a crucial role in the progression of
the disease. One of the most serious complications of portal hypertension is the development of esophageal varices.
Objective: To evaluate the changes in the liver lobes volume with that of albumin as non-invasive predictors of liver
cirrhosis and esophageal varices. Patients and methods: One hundred cases are chosen and classified into four groups
as 20 healthy as controls, 20 cases HCV without cirrhosis, 40 cases with cirrhosis but without varices, and 20 cirrhotic
cases with varices. All participants undergo magnetic resonance imaging for liver lobes volume, biochemical analysis
of serum albumin. All cirrhotic patients are exposed to upper gastro-intestinal endoscopy to differentiate cirrhotic with
or without varices. Statistical analysis was done to determine the combination of liver lobes volume change together
with albumin changes to predict the severity of cirrhosis and for esophageal varices.
Results: RV, LMV, LLV, and albumin are significantly lower in cases of cirrhosis and LMV/albumin LLV/ALB,
CV/Albumin shows a more significant difference in cirrhotics with varices.
Conclusion: From the results of our study we conclude that MRI liver lobes volume and albumin are good predictors
noninvasive markers of liver cirrhosis.
Keywords: Liver cirrhosis, Serum albumin, MRI.
INTRODUCTION
patients who have large varices (5, 6). Nevertheless,
Liver cirrhosis is defined as the histological
repeated endoscopic examinations are not accepted for
development of regenerative nodules surrounded by
patients and are expensive. As a safe, effective, and
fibrous bands in response to chronic liver injury, which
repeatable noninvasive modality, magnetic resonance
leads to portal hypertension and end-stage liver disease.
imaging (MRI) has increasingly been used to assess
Recent advances in the understanding of the natural
liver diseases (7, 8). Previous studies reported that liver
history and pathophysiology of cirrhosis, and treatment
volume indexes measured on MRI could be used as a
of its complications (1).
method for grading the severity of cirrhosis (9, 10).
Portal hypertension is a frequent complication of
liver cirrhosis, which develops in many patients and
AIM OF THE WORK
plays a role in the development of other complications
The work aimed to evaluate the changes in the liver
of the disease. Portal hypertension results in the
lobes volume with that of albumin as non-invasive
development of esophagogastric varices which oen
predictors of liver cirrhosis and esophageal varices.
bleed; and plays a role in the development of ascites,
hepatorenal syndrome, and hepatic encephalopathy (2).
PATIENTS AND METHODS
Therefore, it is important to follow up on the
Ethical approval:
progress of this disease and determine the stage of
This study had carried out at the internal medicine
cirrhosis. The modified Child-Pugh classification
and radiology departments of Zagazig University after
system has been confirmed as an independent prognostic
approval by the institutional human research review
factor for the survival of cirrhotic patients and can be
committee of our hospital after complete written
utilized to adequately assess liver transplantation
consent from the participants.
candidates (3, 4).
The study included 100 consecutive patients with
The morphology of the liver changes with the
confirmed cirrhosis in the period between February
progress of the Child-Pugh classification. Previous
2018 and April 2019.
studies reported that changes in liver lobe volume were
positively correlated with prognosis and Child-Pugh
Inclusion criteria:
classifications (4).
Diagnosis of liver cirrhosis due to HCV infection
Esophageal varices are one of the major
based on history, examination, imaging finding, and
complications of liver cirrhosis, with a risk of bleeding
histopathological findings, if available according to the
from varices of approximately 25%-35%. Prophylactic
American association of study if liver disease practice
endoscopic variceal ligation can decrease the incidence
guidelines on chronic HCV.
of first variceal bleeding and mortality in cirrhotic
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/)
988
Received:19 /5 /2020
Accepted:29 /6 /2020
c:\work\Jor\vol802_25
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 907-912
Comparative Study between Bonfils Intubation Fiberscopy, Fiberoptic
Bronchoscopy and Direct Laryngoscopy in Difficult Airway Patients
Noha Mohamed Abdelwahab*, Amira Abdelfattah Shaaban, Ruqaya Mohamed Elsayed,
Amira Mohamed Nassar
Department of Anesthesiology and ICU, Faculty of Medicine (Girls), Al-Azhar University, Egypt
*Corresponding author: Noha Mohamed Abdelwahab, Mobile: (+20)1008681422,
E-Mail: khaledhelal80@gmail.com
ABSTRACT
Background: Airway management has progressed since the first orotracheal intubation using a blind digital
technique. The Macintosh laryngoscope has allowed tracheal intubation under direct vision.
Objective: The present study was designed to compare the effect of fiberoptic intubation, bonfils intubation and
direct laryngoscope on the hemodynamics, time taken for intubation, stress response hormones (glucose, cortisol and
C-peptide) in difficult airway patients.
Subjects and Methods: This Prospective, randomized, controlled study included a total of 90 adult patients aged
21-50 years with physical status (ASA) I or II of both sexes undergoing general anesthesia for elective surgical
procedures. Patients were subjected to clinical examination and full investigations and assessment of the patients'
airway by El-Ganzori score. Patients were randomly allocated into three equal groups, 30 patients each: Group A:
direct laryngoscope, Group B: fiberoptic bronchoscope and Group C: bonfils fiberoscope.
Results: Fiberoptic has significant hemodynamic stability after one min of intubation than bonfils and direct
laryngoscope. While bonfils has significant hemodynamic stability after five minute and ten minutes after intubation
and had highly significant short time of intubation than fiberoptic and direct laryngoscope. As regard to number of
attempts, most patients were successfully intubated on the first attempt in group B, while on the second attempt in
groups A, and group C which was statistically non-significant between three groups.
Conclusions: It could be concluded that bonfils has hemodynamic stability after five minute and ten minutes after
intubation and also had the shortest time of intubation than fiberoptic and direct laryngoscope.
Keywords: Fiberoptic bronchoscope, Bonfils, Direct laryngoscope, General anesthesia, Hemodynamic responses
INTRODUCTION
Airway management is a vital skill that is
for intubation, stress response substances (glucose,
relevant to the practice of all medical specialties,
cortisol and C-peptide) in difficult airway patients.
especially anesthesiology, critical care, emergency
medicine
and
surgery.
Inappropriate
airway
PATIENTS AND METHODS
management may result in adverse outcomes (1).
This Prospective, randomized, controlled study
Pre-operative airway assessment to be routinely
included a total of 90 adult patients aged 21-50 years
performed to identify factors leading to difficult
with physical status (ASA) I or II of both sexes assessed
facemask ventilation, supraglottic airway device (SAD)
by El Ganzouri risk index test (EGRI) score of three and
insertion, tracheal intubation and emergency surgical
higher, undergoing general anesthesia for elective
access. This may help to identify potential problems
surgical procedures. Patients were investigated at Al-
before surgery leading to proper planning and
Zahraa University Hospital from September 2016 to
preparation to reduce the risk of complications (2).
March 2019.
Pre-operative sedation should be used with
caution in patients with an anticipated difficult airway
Ethical approval:
(3). Fiberoptic intubation (FOI) is an effective technique
Written informed consent of all the subjects was
for establishing airway access in patients with both
obtained. Approval of the Hospital Ethics Committee
anticipated and unanticipated difficult airways (4).
was obtained.
Bonfils intubation endoscope is a semi-rigid
optical stylet, 40 cm in length, with a fixed anterior
Exclusion Criteria:
curvature of its tip of 40 degrees. Difficult orotracheal
Patients with ASA physical status III or more,
intubations can be safely performed with its use. One
age less than 21years or more than 50 years, patients
major limitation is that it has an immobile tip and cannot
with BMI > 35%.
be used for nasotracheal intubation (5).
Patients were subjected to clinical examination
The present study was designed to compare the
and full investigations and assessment of the patients'
effect of fiberoptic intubation, bonfils intubation and
airway by El-Ganzori score. Patients were randomly
direct laryngoscope on the hemodynamics, time taken
allocated with closed envelope method into three equal
groups, 30 patients each: Group A: direct laryngoscope,
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/)
907
Received:19 /5 /2020
Accepted:29 /6 /2020
c:\work\Jor\vol802_26
retracted
1
c:\work\Jor\vol802_27
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 920-927
Value of Nailfold Capillaroscopy as A Screening Method for Pulmonary
Arterial Hypertension in Patients with Systemic Sclerosis
Rasha M. Hammoda1, Yasmin Abdelrazek Ali 2, Nermeen Samy*1
1Department of Internal Medicine and Rheumatology and 2Department of Cardiology,
of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Nermeen Samy, Mobile: 01223744672, Email: dr.nermeen81@gmail.com
ABSTRACT
Background: Pulmonary arterial hypertension (PAH) represents one of the main clinical pictures of microvascular
damage in systemic sclerosis (SSc).
Objective: To assess the role of nailfold capillaroscopy (NFC) changes as a screening tool for the existence of PAH in
patients with systemic sclerosis.
Patients and methods: Forty SSc patients were studied, included: 20 patients with PAH (diagnosed by transthoracic
echocardiography and confirmed by right heart catheterization) and another 20 without PAH. History taking, clinical
examination, and laboratory investigations including serological biomarkers (anti-centromere and anti-topoisomerase1
antibodies) have been recorded. NFC was performed for all patients according to the standard method.
Results: Scleroderma patients with PAH had significantly a longer disease duration (p=0.002) and higher frequencies
of positive anticentromere and anti-topoisomerase 1 antibodies (p=0.011 and p=0.010 respectively). As regard NFC
picture, SSc patients without PAH had significantly higher frequencies of early scleroderma pattern changes in 73.7%
(p= 0.003), avascular area score 0 in 52.6% (p=0.014) and total NFC score 0 in 57.9% (p=0.022). In contrast, SSc
patients with PAH showed higher frequencies of late scleroderma pattern changes in 50% (p=0.005) with lower
capillary density (p <0.001), increased number of dilated mega-capillaries (p=0.049) together with more advanced
avascular area of score 3 in 47.6% (p=0.007) and total NFC of score 3 in 45% (p=0.003). A significant negative
correlation between mean pulmonary arterial pressure and capillary density (r=-0.57, p<0.001) was reported.
Conclusion: Low capillary density together with wide avascular areas and more severe NFC scores have a clear
association with the presence of PAH.
Keywords: Systemic Sclerosis, Pulmonary Arterial Hypertension, Nailfold capillaroscopy.
INTRODUCTION
Systemic sclerosis (SSc) is a long term complex
hypertension (6). The WHO has subtyped PH into 5
autoimmune illness that still poses a great challenge to
categories: (1) PAH, (2) PH with left-sided heart
clinicians (1). Autoimmunity, skin together with internal
failure, (3) PH due to hypoxic lung illness, and (4) PH
organs fibrosis, and vasculopathy are marked
secondary to chronic thromboembolism (8). Patients
features (2). Scleroderma is more common in women
with scleroderma may develop type 1, 2, or 3 (9). PAH
than men with male:female ratio equals 4-5:1. The
is a common late complication of scleroderma, mainly
average age of disease diagnosis is nearly 50 years (3).
in those with limited cutaneous disease and anti-
The medical disease is classified according to the
centromere antibodies (6). PAH is a lethal and malignant
degree of skin affection into subclasses with diffuse
manifestation of vasculopathy in SSc that causes a
cutaneous involvement (dcSSc) and limited cutaneous
dramatic impact on prognosis; and thus, necessitates an
involvement (lcSSc) (4). Systemic sclerosis is marked by
early screening and management (4). Circulating plasma
early and progressive microvascular distortion which
levels of endothelin1 are elevated in patients with PAH
can lead to fatal organ disorders of SSc, such as
and are raised in their pulmonary tissue; making this
pulmonary arterial hypertension (PAH), scleroderma
vasoconstrictor a potential target for therapeutic
renal crisis, and tissue ischemia linked to organ
intervention (10). Moreover, a high serum endothelin1
dysfunction and fibrosis (5). Egyptian SSc patients are at
level
was
found
in
SSc
with
late
an increased risk of subclinical atherosclerosis and
nailfold videocapillaroscopy (NVC) pattern and
peripheral arterial disease (6) and interstitial lung disease
visceral involvement (11).
(ILD) is a frequent consequence of PAH especially in
Nailfold video capillaroscopy is considered a
dcSSc patients (7). Therefore, improvement of
useful safe non-invasive tool used in evaluation and
vasculopathy in SSc patients is one of the key treatment
follow-up of systemic rheumatic illnesses and
targets (5).
constitutes one of the best assessment tools of
Pulmonary hypertension (PH) is considered one of
microvascular defects in SSc. The capillary changes in
the main causes of mortality in patients with
SSc usually incorporate dilated and giant capillaries,
scleroderma. Scleroderma patients with PH had poorer
capillary hemorrhages, disarrayed capillary loops,
outcome compared to those with idiopathic pulmonary
ramified/bushy
capillaries,
and
capillary
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icle distributed under the terms and conditions of the Creative
Commons Attribution (CC BY -SA) license (http://creativecommons.org/licenses/by/4.0/)
920
Received:19 /5 /2020
Accepted:29 /6 /2020
c:\work\Jor\vol802_28
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 928-935
Pretreatment Renal Biopsy Findings as a Predictor of Post Treatment Renal Function
in Patients with Hepatitis C Virus Associated Nephropathy: A Prospective Study
Marwa K. Khairallah1, Effat A. E. Tony1, Mohamed A. Tohamy1, Mahmoud Essmat2
1Internal Medicine Department, Assuit University Hospital and
2Nephrology Unit, Assuit General Hospital, Assuit, Egypt
*Corresponding author: Marwa K. Khairallah, Institution: Assiut University Hospital, Department of Internal medicine,
EMAIL: marwa.kamal82@hotmail.com, MOBILE: (+20)01097878113
ABSTRACT
Background: Renal histopathological patterns are established predictors of outcomes in many disorders. However, its
role in predicting outcomes in hepatitis C virus (HCV)-associated nephropathy has not been elucidated yet. The preset
study aimed to assess utility of biopsy in predicting post treatment renal functions in HCV-associated nephropathy
patients. Patients and Methods: Prospective study included HCV 30 nephropathy-established patients, recruited from
Nephrology Unit of Internal Medicine Department from September 2016 to September 2017. Ultrasound-guided,
percutaneous, needle biopsy was utilized to obtain the renal samples.
Results: Commonest form of HCV-associated glomerular disease was membranoproliferative (43.3%), followed by
membranous glomerulonephritis (16.7%). Focal segmental glomerulosclerosis (FSGS), crescentic glomerulonephritis
(CGN), and cryoglobulinemic were equally presented in 13.3% of the patients, each. Interstitial fibrosis was found in
(73.3%), tubular atrophy in (70%), glomerular sclerosis in (46.7%), and arteriolosclerosis in (33.3%). Twelve weeks
after new antiviral therapy, patients with moderate tubular atrophy exhibited statistically significant higher reductions
in serum creatinine and urea levels than patients with severe form (-1.13 ±0.45 versus -0.71 ±0.56 mg/dL and -9.98 ±
1.67 versus -4.01±4.02 mg/dL, respectively; p =0.01). No significant difference between both groups was noted
regarding 24-hours urinary protein and e-GFR. Patients with mild and moderate interstitial fibrosis and
arteriolosclerosis exhibited statistically significant higher reductions in serum creatinine and urea levels. Tubular
atrophy and Interstitial fibrosis significantly affect post treatment serum creatinine and urea (p <0.05).
Conclusion: Pretreatment renal histopathology significantly influence post treatment renal functions in HCV
nephropathy patients.
Keywords: Hepatitis C Virus Glomerulopathies; Renal Biopsy; Viral Response; Direct-acting antiviral.
INTRODUCTION
exhibited an increased risk of proteinuria, chronic
Recent decade has witnessed major advances
kidney disease, and need for permanent hemodialysis(8).
regarding controlling hepatitis C virus (HCV) infection.
While the exact pathogenesis of HCV-associated kidney
Nonetheless, recent figures demonstrated that
disease has not been fully elucidated yet, previous
seroprevalence of HCV is still increasing, especially in
reports demonstrated that hepatitis virus binding to
the Eastern Mediterranean and European Regions, with
receptors in mesangial and epithelial cells is a major
an estimated global prevalence of 2.5% (1,2). Egypt has
contributor to proteinuria (9). Other mechanisms include
the highest prevalence rate of HCV worldwide with
development of mixed cryoglobulinemia and
approximately 2 to 6 new cases per 1000 population
overexpression of Toll-like receptors(10). Although
every year (3). Despite being largely asymptomatic in
membranoproliferative glomerulonephritis (MPGN) is
acute stage, chronic HCV is associated with a significant
the commonest renal pathology injury, other patterns
risk of liver-related complications (4). Recently, up to
were
reported
including
glomerulonephritis,
30% of patients with chronic HCV was reported to have
membranous nephropathy, glomerulosclerosis, and
liver cirrhosis, while prevalence of decompensated liver
tubular atrophy(11).
failure is 11%(5); moreover, chronic HCV is documented
Historically, a combination of pegylated-
to be the leading risk factor for hepatocellular carcinoma
interferon and ribavirin were the main therapy for
(HCC)(6). In addition, mortality rates secondary to
chronic HCV with reported low rates of sustained
chronic HCV showed a notable increase from 2006 to
virological response (SVR) (less than 50%) but high
2010(5). Chronic HCV represents a financial burden, in
rates of severe adverse events(12). However, since the
global levels, as well(7).
usage of direct-acting antivirals (DAAs), tremendous
Renal outcomes are common extra hepatic
achievements in treatment and outcomes of chronic
complications of chronic HCV, patients with HCV
HCV had been noticed. DAA medications, with or
This article is an open access art
icle distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-
SA) license (http://creativecommons.org/licenses/by/4.0/)
928
Received: / /2020
Accepted: / /2020
c:\work\Jor\vol802_29
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 936-942
Thyroid Autoantibodies in Egyptian Patients with Autoimmune Rheumatic
Diseases: Relation to Disease Activity and Functional Impairment
Safaa Abd Elsalam Hussein1, Howaida Elsayed Mansour1, Mohammed Salah Hussein2,
Ayat Sami Mohamed Abdel Aziz1, Nermeen Noshy Aziz1
1Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ain Shams University,
2Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Safaa Abd Elsalam Hussein, email: safaa.abdelsalam@gmail.com
ABSTRACT
Background: Autoantibodies against the thyroid seem to be more common in patients with rheumatic diseases
than in the normal population. Their appearance may be linked to an associated autoimmune thyroid disease.
Knowing the degree of association between rheumatic and thyroid diseases may help the clinician to make the
correct decision.
Objectives: The aim of the work was to estimate the prevalence of thyroid autoantibodies among patients with
systemic autoimmune rheumatic diseases with or without thyroid disorders and its association with disease
activity and functional impairment.
Patients and Methods: The current study included 60 patients and 20 healthy controls. Patients were divided
into three groups; systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and systemic sclerosis (SSc).
Clinical and laboratory assessment were done to all patients including routine laboratory investigations and
thyroid function tests (thyroid stimulating hormone [TSH], T3 and T4), and thyroid autoantibodies; anti-
thyroglobulin (TgAb) and anti-thyroperoxidase (TPOAb).
Results: SLE group had significant (P=0.018) lower age than other groups. Antithyroid antibodies and thyroid
disorders were more common in SSc and SLE patients than RA patients and control subjects; however, no
significant difference between studied groups. Presence of autoantibodies with and without thyroid disorders
was not associated with the activity or functional indexes evaluated.
Conclusion: The prevalence of thyroid autoantibodies in SLE and SSc patients was higher than in RA patients.
No link could be established between the presence of thyroid autoantibodies and the results from any of the
instruments used to measure inflammatory activity and functional impairment in these cases of rheumatic
diseases.
Keywords: Thyroid autoantibodies, Autoimmunity, Rheumatic disease, RA, SLE, SSc
INTRODUCTION
thyroid dysfunction and RA has been reported in
Autoimmune thyroid disease (AITD) is a
adults; however, the pathogenic mechanism
term used to describe a group of pathologies that
remains uncertain (5). SLE is an autoimmune disease
has thyroid dysfunction, and an autoimmune
that affects the skin, kidneys, musculoskeletal,
response against this endocrine organ as its
hematologic systems, and it is characterized by the
hallmark (1). However, being a group of
presence of various autoantibodies against self-
autoimmune diseases (ADs) clustered together, the
components,
especially
double-stranded
clinical presentation varies among these diseases;
deoxyribonucleic acid and ribonucleic acid-binding
it can be divided into those that cause
nuclear proteins. Thyroid autoantibodies have been
hypothyroidism, hyperthyroidism, or both (2). The
found more often in patients with SLE than in the
major antigens of thyroid autoantibodies are
general population and even in patients with no
thyroglobulin (Tg), thyroid peroxidase (TPO) and
thyroid disease (6). Progressive systemic sclerosis
thyroid-stimulating hormone receptor (TSH-R) (3).
(SSc) is a connective tissue disease, characterized
Hypothyroidism and rheumatic diseases share
by vascular abnormalities, multiorgan fibrosis and
common clinical findings such as arthralgias,
complex immune system alterations. The
arthritis, myalgias, myopathy and fatigue, which
association of SSc with thyroid fibrosis,
need to be correctly diagnosed to be properly
hypothyroidism and thyroid autoimmunity has
treated. Knowing the degree of association
been reported by several studies in a wide range of
between rheumatic and thyroid diseases may help
variability (7).
the clinician to make the correct decision (4).
The aim of the current study was to
Rheumatoid arthritis is a systemic disease
estimate the prevalence of thyroid autoantibodies
characterized by inflammatory peripheral arthritis.
among patients with systemic rheumatic disease
An association between AITDs with or without
(SLE, RA and SSc) with or without thyroid
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/
)
639
Received:19 /5 /2020
Accepted: 29/ 6/2020
c:\work\Jor\vol802_30
The Egyptian Journal of Hospital Medicine (July 2020) Vol. 80 (2), Page 943-950
Prediction of Acute Kidney Injury in Critically-Ill Pediatric Patients
Admitted to PICU: The Role of Serum Cystatin C And Serum Interleukin-18
Hams Ahmed Attalla1*, Ali Mahmoud Ahmed2
1Department of Pediatrics, Faculty of Medicine, Helwan University, 2Department of Neurology, Faculty of
Medicine, Al-Azhar University, Cairo, Egypt.
*Correspondence to Dr. Hams Ahmed Attalla; Email: hamsattala20002003@yahoo.com.
ABSTRACT
Objectives: We conducted this study to assess the sensitivity and specificity of serum cystatin C (sCysC) and
serum interleukin-18 (IL-18) in comparison with serum creatinine and serum urea for early detection of acute
kidney injury (AKI) in critically-ill pediatric patients admitted to the pediatric intensive care unit (PICU).
Methods: This was an observational case-control study enrolled 61 patients admitted in PICU divided into two
groups (the case group 30 patients with proposed AKI and the control group 31 control individuals). After complete
clinical evaluation, electrolyte profile, including Na and K besides the biomarkers assay of serum creatinine, urea,
sCysC , and IL-18 were measured at the first day of admission and after three days.
Results: Urea and creatinine were increased at admission in only three patients and two patients, respectively,
while it dramatically increased in 25 patients in both urea and creatinine separately on the third day of admission.
sCysC and sIL-18 showed a high diagnostic ability for detecting AKI at admission with AUCs of 0.877 and 0.819
respectively. Supportingnly, sCysC and IL-18 were significantly higher in AKI group compared to the control
group. Conclusions: sCysC and serum IL-18 proved their accuracy in prediction of AKI in patients admitted to
the PICU. Their diagnostic ability was superior to serum creatinine, serum urea, and even urinary IL-18 and CysC.
Keywords: Serum Cystatin C; Serum Interleukin-18; Acute Kidney Injury; PICU.
INTRODUCTION
affected by previous body hydration state and fluid
As an intense and permanent deterioration of the
intake (4). Having serum creatinine, it is not appropriate
kidney functions leads to accumulation of waste
predictor for early changes in renal function as it is
products and metabolic disturbances arrives in
affected by the patient's sex, age, metabolic state,
developing of acute kidney injury (AKI) that had a
dehydration, drugs and muscle bulk. Interestingly,
higher incidence of morbidity and mortality especially
throughout the first three days of neonatal period serum
in critically-ill patients due to sepsis, convulsions and
creatinine reflects the maternal levels rather than the
uremia (1. Of date, the burden of AKI is about 27% of
neonatal levels (2). Moreover, serum creatinine
children admitted to the pediatric intensive care unit
concentration may be stationary in spite of half
(PICU) with a mortality rate approximately 10%,
function of the kidney was lost (5). Thus, serum
whilst neonatal incidence widely varied from 8% to
creatinine may respite diagnosis, management, and
24% with mortality rate two to even five patients every
prohibition of AKI sequel.
ten patients admitted to NICU (2). In spite of the
The limited value of serum creatinine in AKI
prerenal causes, as sepsis, hypovolemia, hypoxia and
brings to light the need for new potential biomarkers
congenital urological abnormalities, were considered
with higher accuracy and ability to detect even
the commonest,(2) AKI may be developed as
subclinical AKI simplifying early diagnosis, evident
exacerbation of chronic kidney disease (CKD) (3).
intervention and assessment of the progression of the
Early diagnosis and proper management of AKI
disease.
is the magnificent purpose as regard as AKI is
Serum interleukin-18 (IL-18) and serum cystatin
reversible if the proper decision was taken at the
C (sCysC) are potential biomarkers, proved their
adequate time. Otherwise, the kidney is a reticence
abilities not only in the early detection of physiological
organ so, deterioration of its functions took time to be
and pathological derangements accompaning AKI but
manifested clinically so that the biomarkers is the key
also the prognosis of the disease (6). Interleukin-18 is
to early detection of renal dysfunction (3).
one of IL-1 pro-inflammatory cytokine family that is
Among the past era, serum creatinine, urea, and
produced in an inactive form inside proximal
urine output were the standard parameters for the
convoluted tubules (PCT) then activated to 18.3 kDa
diagnosis of AKI as monitors of the glomerular
cytokine (7). Furthermore, it was proved that IL-18 has
filtration rate and excretory function of the kidney.
a significant role in the early prediction of renal
However, urine output is of limited value as it is
ischemia and reperfusion injury. It is increased after six
This article is an open access art icle distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-
SA) license (http://creativecommons.org/licenses/by/4.0/)
943
Received:19 /5 /2020
Accepted:29 /6 /2020