c:\work\Jor\vol814_1 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1722-1725

The Effectiveness of Tracheal Decannulation
Criteria: A Prospective Study
Yasmin Aljedaani1, Majed AlMourgi2, Fahad Alshehri3, Mohamed Hatem2
1ENT Department, East Jeddah Hospital, Jeddah, 2Department of Surgery,
College of Medicine, Taif University, Taif, 3Radiology Medical imaging Department,
Medical College, Qassim University, Saudi Arabia
Corresponding author: Majed AlMourgi, e-mail: mourgi@tu.edu.sa

Long-term insertion of the tracheostomy tube may lead patients to have complications such as
tracheal stenosis, leakage, sepsis or aspiration.
Aim of the work: Our study aimed at applying standards for decannulation of the tracheostomy tube depending on
the expertise from prior studies.
Methods: The study included 102 patients who underwent tracheostomy during the study period.
Surgical tracheostomy was done in operating room in 67% of patients and in intensive care unit by
percutaneous dilatational technique in 33% of patients. Decannulation was successful in 97.7% of patients and
discharged from the hospital within 24-48 hours. Decannulation failed in 2.3% of patients.
Conclusion: The decision to perform elective decannulation of the tracheostomy tube can be challenging. However,
we have demonstrated that decannulation based on objective criteria is effective in improving clinical judgment and
weaning safety, with a low failure rate. We did not encounter any mortality or significant adverse events.
Keywords: Tracheostomy, Tracheal decannulation, Criteria.


Tracheostomy is a surgical procedure in which
much safer, and the technical aspects of the procedure
a surgical airway is created in the cervical trachea to
were refined and described in detail by the famous
facilitate airway protection, ventilation and secretion
removal (1). Tracheostomy may be performed
tracheostomy was performed extensively during the
surgically or using a percutaneous approach (1, 2).
polio epidemic in Denmark(10).
Tracheostomy is usually carried out for patients who
A tracheostomy may only be a short-term
have trouble in weaning from mechanical ventilation
requirement for most patients and decannulation
following polytrauma, and those who are unable to
should be carried out when it is no longer required, to
clear excessive secretions following a catastrophic
reduce the incidence of complications(6).
neurological insult (2).It is also performed to bypass an
Decannulation or weaning is the process of
upper airway obstruction(3). A tracheostomy is less
removal of the tracheostomy tube when it is not
commonly required in cases of infectious and
required as the patient has recovered from the
neoplastic disease. Performing a tracheostomy
underlying illness and the indication for its initial
facilitates the transfer of patients from intensive care
insertion no longer exists (11).
to a step-down unit(4).
Patients may be exposed to the possibility of
Historically, the first known descriptions of
late complications, including tracheal stenosis,
tracheostomy are from Egyptian tablets from 3600
leakage, infection or aspiration as a result of
BC.(5) Aretaeus (2nd century AD) and Galen (2nd to
prolonged tracheostomy tube placement (12).
3rd century AD) documented tracheostomy
Decannulation is a basic step in rehabilitation from a
performed by the Greek physician Asklepiades
critical illness. It carries positive psychological
around 100 BC(6). Islamic physicians `contributions to
implications as the ability to speak may enhance
the history of tracheostomy during the medieval era
patient motivation(13). There is no universal agreement
have been recently detailed(7). The first, scientific
regarding the appropriate criteria for tracheostomy
description of successful tracheostomy was by
weaning. There are various decannulation practices
Antonio Musa Brasavola in 1546, who performed the
described in the literature(12-14).
procedure for relief of airway obstruction resulting

from enlarged tonsils(8). From 1546 through to 1833,
around 28 successful tracheostomies have been
The aim of our study was to apply tracheostomy
recorded in the literature; nearly all of them were
tube decannulation criteria based on experience from
performed for relief of upper airway obstruction(8, 9).
previous studies that addressed this vital transition.
In the early 20th century, tracheostomy was made

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Received:4 /7 /2020

Accepted:3 /9 /2020

Full Paper (vol.814 paper# 1)

c:\work\Jor\vol814_2 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1726-1731

Growth Disorders in Children with Type 1 Diabetes in Aswan, Egypt
Magda Farghali Gabri*1, Treza Saad Abdshaheed1, Edrees Hasan Zaki3,
Islam Fathy ElNakeeb2, Hanan Mohammed Aly1
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Aswan University
Department of 3Pediatrics, Faculty of Medicine, Assiut University
*Corresponding author: Magda Farghali Gabri, Mobile: (+20)01063439319,
E-mail: magda.farghly@med.aswu.edu.eg, magdagabri78@gmail.com

Background: Type 1 diabetes mellitus is the most common chronic metabolic disorder in children. Diabetic children
who take proper nutrition and good care attain normal growth status. One sign of poorly controlled diabetes is poor
Objective: This study was conducted to assess the growth parameters (weight, height, and body mass index) in
diabetic children and to study the impact of age at diagnosis, duration of the disease, and disease control on the
growth parameters.
Patients and Methods: This is a cross-sectional study that carried out on diabetic children aged from 6 to 18 years
old in 8 months period. History, examination with stress on anthropometric measurement (weight, height, and body
mass index) together with HbA1c level was done.
Results: Mean HbA1c was (10.85 ± 2.299) %. Patients with HbA1c of more than 9% were 75.5%. There was an
insignificant negative correlation between HbA1c and age and disease duration and a significant negative correlation
between HbA1c and tanner staging, but there was no relation between HbA1c and sex or family history. There was
a significant negative correlation between HbA1c and weight, HbA1c, and body mass index, while there was an
insignificant negative correlation between HbA1c and height. There was an insignificant correlation of weight to
disease duration, while there was a significant positive correlation of height to disease duration.
Conclusion: in this study, most of our patients were uncontrolled diabetic patients. Weight, height, and BMI were
less in uncontrolled patients than controlled patients.
Keywords: Diabetes, Weight, Height, BMI


less in weight comparing to the controlled group, they
Type 1 diabetes mellitus (T1DM) is one of the
gain weight after taking insulin especially during
most common chronic metabolic disorders in children
puberty (9). Diabetic children who take proper nutrition
and adolescents and its incidence is increasing
and good care attain normal growth status (10). One sign
worldwide (1). It is characterized by chronic
of poorly controlled diabetes is poor growth (11).
hyperglycemia and body composition is important in

So we conducted this study to assess the growth
disease control (2). The etiopathology of hyperglycemia
parameters (weight, height, and body mass index
includes a defect in insulin secretion, insulin action, or
(BMI) in diabetic children and to study the impact of
both with resultant of different complications (3).
age at diagnosis, duration of the disease, and disease
Diagnostic criteria by the American Diabetes
control on the growth parameters.
Association (ADA) include the following: A fasting

plasma glucose level 126 mg/dL (7.0 mmol/L), or A
2-hour plasma glucose level 200 mg/dL (11.1
This is a cross-sectional study carried out on
mmol/L) during a 75-g oral glucose tolerance test, or A
diabetic children who attained Endocrinology
random plasma glucose 2 00 mg/dL (11.1 mmol/L) in
Outpatient Clinic at Aswan University Hospital for
a patient with classic symptoms of hyperglycemia or
regular follow up in the duration of study from July
hyperglycemic crisis (4).
2019 to February 2020.

Many complications affect diabetic patients
Inclusion criteria:
including impaired growth, represent a major concern

The age of children between 6 and 18 years old.
despite the advances in treatment (5). Nutrition is the
Exclusion criteria:
main factor in the management of diabetes (6). The other
Children < 6 years or above 18 years old.
cornerstone in the management of type 1 diabetes is
Children who have a duration of disease less than
insulin injection (7).
2 years.
Factors affecting growth in diabetic patients
Children have medical syndromes, and /or other
include gender, age at diagnosis, duration of disease,
chronic diseases.
glycemic control, and puberty status (8). Although most
Complete history taking including child's
diabetic children at the beginning of diagnosis were
gender, age, duration of the disease, and presence of

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Commons Attribution (CC BY-SA) license (

Received:5 /7 /2020

Accepted:4 /9 /2020

Full Paper (vol.814 paper# 2)

c:\work\Jor\vol814_3 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1732-1735

Parathyroid Hormone Profile In Sickle Cell Disease In School Aged Children
Hosny Mohamed Ahmed El-Masry1, Mostafa Abd-Elazeem Hassan1,
Alaa Mohamed Hashem2, Abdullah Arafa Shaban1*
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
*Corresponding author: Abdullah Arafa Shaban, Mobile: (+20) 01007558708, E-Mail: abdullaharafa@gmail.com

Sickle cell disease (SCD) is group of hemoglobinopathies associated with hemolytic anemia and vaso-
occlusive complications. All forms of SCD are inherited in an autosomal recessive fashion. Parathyroid hormone
plays an essential role in calcium and phosphorus homeostasis, which is achieved by its action on target organs
(intestine, bone and kidney), leading to normal bone formation and mineralization and normal physiological
concentration of calcium and phosphorus.
This study aimed to detect the effect of sickle cell disease on parathyroid hormone and consequently on
serum calcium (S.Ca), phosphorus (ph), alkaline phosphatase (alk.Ph) and magnesium (Mg) on patients with sickle
cell anemia.
Subjects and Methods:
Forty children known as sickle cell disease patients, twenty of them were SCD (HbSS) (11
males and 9 females). The other twenty were known SC trait (10 males and 10 females). The ages of the children
ranged from 5 to 15 years old. All were in non-crises state in routine Outpatient Clinic visits, compared to twenty
apparently healthy, age matched and with normal hemoglobin from Atfal Masr Hospital as control. Neither patients
nor control received calcium supplementation before the study.
Results: The results indicated that sickle cell patients and sickle cell trait patients had hypocalcaemic tendency
associated with supernormal parathyroid hormone level and implied impaired calcium absorption from intestine
leading to disturbed calcium metabolism, which might contribute in skeletal changes seen in sickle cell patients.
Conclusion: We found that there was statistically significant decrease in serum Ca levels accompanied with increase
in serum PTH, ph, alk Ph and Mg levels in SCD and Sickle cell trait patients compared to control group.
Keywords: Sickle cell disease, Sickle cell trait, Parathyroid hormone profile, Serum calcium, phosphorus.


Many studies have been made in the
recommended, with all patients who have initial
management of both acute and chronic complications
abnormal screens being retested during the first clinical
of sickle cell disease with a significant improvement in
visit and after 6 months of age to determine the final
the life expectancy of a child born today. In sickle cell
hemoglobin phenotype. In addition, a complete blood
anemia, HbS is commonly as high as 90% of the total
cell count (CBC) and hemoglobin phenotype
hemoglobin while in sickle cell trait, HbS is 50% of
determination is recommended for both parents to
all hemoglobin (1). Hemoglobin S (HbS) is the result of
confirm the diagnosis and to provide an opportunity for
a single base-pair change, thymine for adenine, at the
genetic counseling (3).
sixth codon of the -globin gene. This change encodes
Physiological concentrations of plasma calcium
valine instead of glutamine in the 6th position in the -
and phosphorus are necessary to ensure skeletal
globin molecule (2).
integrity and to maintain vital physiological processes,
In red blood cells, the hemoglobin molecule has
including muscle contraction, coagulation, energy
a highly-specified conformation allowing for the
metabolism, and neuronal excitation. Calcium and
transport of oxygen in the body. In the absence of
phosphorus homeostasis is regulated by both hormonal
globin-chain mutations, hemoglobin molecules do not
and non-hormonal factors. Increased appreciation of
interact with one another. However, the presence of
these complex interactions allows for a deeper
HbS results in a conformational change in the
understanding of the pathophysiology of the clinical
hemoglobin tetramer and in the deoxygenated state.
disorders that occur with disturbance of this delicate
HbS molecules can now interact with each other
balance (4).
forming rigid polymers that give the red blood cell its
When serum levels of calcium fall, the signal is
characteristic "sickled" shape. The lung is the only
transduced through the calcium-sensing receptor, and
organ capable of reversing the polymers, and any
secretion of PTH increases. PTH stimulates activity of
disease of the lung can be expected to compromise the
1-hydroxylase in the kidney, enhancing production of
degree of reversibility (2).
1, 25-dihydroxycholecalciferol (1, 25(OH) 2D3). The
The most commonly used procedures for
increased level of 1, 25(OH) 2D3 induces synthesis of
newborn diagnosis is high-performance liquid
a calcium-binding protein (calbindin-D) in the
chromatography (HPLC). A confirmatory step is
intestinal mucosa resulting in absorption of calcium.

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY- SA) license (
Received:5 /7 /2020

Accepted:4 /9 /2020

Full Paper (vol.814 paper# 3)

c:\work\Jor\vol814_4 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1736-1741
Current Situation of Rhinogenic Headache in-between Sohag University Students
Yousry Othman Abdel-Rahman1, Eslam M. Ali2, Tasneem Mohammed Bakheet3, Mahmoud M. Elbahrawy1
1Department of ENT, Faculty of Medicine, Al-Azhar University, Assiut
Departments of 2ENT and 3Public Health and Community Medicine, Faculty of Medicine, Sohag University
Corresponding author: Mahmoud Mohamed El Bahrawy, Mobile: (+20) 1275754926, E-Mail: bahrawymhmwd71@gmail

Background: Headache is a symptom of pain anywhere in the region of the head or neck, and it can occur as a result of
many conditions whether serious or not.
To detect the rhinogenic headache cases among Sohag University students and to determine their
Patients and methods: Over a period from Oct 2017 to May 2019, 104 patients were complaining of rhinogenic
headache and diagnosed by CT scanning. Data obtained using a structured questionnaire.
Results: Most of the population enrolled in the study (59.6 %) were females, mostly in the first grade (46.2 %),
inhabiting rural and/or slum areas of Sohag (69.2 %). Smoking habit associated with all pneumatization cases and 16.7
% of DNS were male cases. Frontal site of headache predominated, then the nasal\glabellar site. These followed by
periorbital, tempro-parietal, temporal and scalp regions respectively in 32.7, 25, 17.3, 11.5, 7.7 and 5.8 % of the
rhinogenic cases. Compressing and dullness types are predominated in cases of rhinogenic headache without
abnormalities in about 55 %. The associated symptoms with rhinogenic headache cases included malaise, allergic nasal
symptoms like running nose and red eyes, sneezing, nasal itching and bleeding. Congestion and occlusion affected larger
percent (55.8 %), followed by running nose (40.4 %) and postnasal discharge (46.2 %). Diminished sense of smell to a
lesser extent of rhinogenic headache cases. In addition, sore throat, bad mouth odor and chronic cough had been reported
in some cases.
Conclusion: Understanding the preoperative CT scan is substantially important because it is the road map for the sinus
Keywords: Headache-Rhinogenic headache.


University Hospital in Sohag Governorate through the
Rhinogenic headache is a controversial that
period from Sep. 2017 until Aug. 2019.
received an increased attention by most physicians

especially otorhinolaryngologists over the last two
decades as it is a common complaint worldwide among
A clinical observational study over a period of 2
the population. It is a facial pain syndrome occurred
years involved all patients who presented with chronic
secondary to mucosal contact points in the nasal/sinus
headache to ENT Outpatient Clinic at Sohag University
cavities in the absence of sino-nasal inflammatory
Student Hospital. Patients were enrolled in the study if
conditions. It was noticed that it increases with sudden
they were satisfying strict inclusion criteria as follow:
movements of the head, bending forward and on
Complaining of headache rhinogenic in nature.
straining. It starts in the morning, worsen at mid-day and
Pressure-like pain in one specific area of the face or
gets better at night. It has multiple synonyms used
head for example over sinus or behind the eyes
frequently in the literature, which include rhinopathic
(diagnosed by medical history, clinically and by
headache or sinogenic headache (1).
investigations) being the principal or only c/o. Other
We have to differentiate rhinogenic headache from
sino-nasal symptoms were vague or absent. Of long-
sinus headache. The latter is contributed to a viral or
term duration and not responding to medical treatment.
bacterial sinus infection (1). International Classification
In addition, patients accepted to be a participant in the
of Headache Disorders (ICHD) declared strict criteria,
study, with full cooperation. Diagnosis was confirmed
which are used to tell the difference between headache
by CT scan. A total of 104 patients were enrolled in this
types (2). Etiology of rhinogenic headache is a
study. According to a multi-item questionnaire, all cases
multifactorial aspect. Computed tomography show an
were subjected to the following:
excellent anatomical soft tissue and bony details that are
- History taking: For identification data (name, age,
of importance in diagnosis and management.
gender, residence, marital status, special habits, faculty

and phone number). ­ Present history of Headache
(type, location, duration, referral, what aggravates or
This study aimed to determine cases suffering from
even evokes the condition, medication, recurrence after
rhinogenic headache among Sohag patients seeking
medication) and other associated conditions, weather
health services in the ENT Outpatient Clinic of Sohag
nasal or extra-nasal.

This article is an open access article distributed under the terms and conditions of the Creative
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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:6 /7 /2020

Accepted:5 /9 /2020

Full Paper (vol.814 paper# 4)

c:\work\Jor\vol814_5 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1742-1749

Evaluation of Vitamin D in Preterm Neonates and Effects of its Supplementation in
Preterm Neonates with Respiratory Distress Syndrome
Amira Mohammed Mohammed Hamed1, Mona Mohamed Abdelmeguid2,
Ahmed Haggag Ismail1, Aya Eissa Ahmed Othman*1
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine,
Al-Azhar University, Assiut, Egypt
*Corresponding author: Aya Eissa Ahmed Othman, Mobile: (+20) 01090284816, E-Mail: ayaeissa141991@yahoo.com

Prematurity and related problems, especially respiratory distress syndrome, are one of the main
challenges for neonatal medicine. Many studies have shown the relationship between lung development and vitamin
To investigate Vitamin D status and to evaluate the effect of vitamin D supplement as adjuvant therapy in
the management of respiratory distress syndrome (RDS) in preterm infants.
Patients and Methods:
This study included 90 preterm neonates chosen from those at NICU of Minya General
Hospital and Al-Azhar University, Assiut, Egypt. The cases were divided into two main groups; a group with RDS
(case group 66 cases) and a group without RDS (control group =24 cases). The group with RDS was further subdivided
into three subgroups (subgroup I received just traditional therapy and the subgroup II received traditional therapy plus
vitamin D 400 IU/day, while subgroup III received traditional therapy plus vitamin D 800 IU/day).
Results: The RDS group had lower neonatal and maternal vitamin D concentrations than the group without RDS. We
found a strong positive correlation between neonatal and maternal vitamin D levels on the day of delivery. The
subgroups supplemented with vitamin D had a significant improvement in all ABG parameters, lower Downs score,
less hospital stay, less morbidity than the subgroup without vitamin D supplementation.
Conclusion: Administration of vitamin D as adjuvant therapy in cases of RDS was associated with a significant
decrease in severity, rate of complications, and duration of hospital stay in the subgroup received 800 IU/Day
compared to the subgroup received 400 IU/Day.
Keywords: Vitamin D, Preterm neonates, Respiratory distress syndrome

Prematurity is the most important risk factor
levels in the body as well as the development of a
predisposing to neonatal RDS. Preterm birth continues
healthy skeleton (5).
to be an important public health problem globally and
Serum levels of 25-hydroxyvitamin D are
is a leading cause of perinatal death and disability
considered the best circulating biomarker of vitamin D
worldwide (1).
metabolic status and reflect contributions from all
Preterm neonates can have many complications
sources of vitamin D i.e., diet and sun exposure (6).
such as respiratory distress syndrome (RDS),
Maternal and neonatal vitamin D deficiency is
intraventricular hemorrhage, necrotizing enterocolitis,
alarmingly high in Arabs and significantly associated
bronchopulmonary dysplasia, sepsis, persistent ductus
with each other. One study showed that almost 85% of
arteriosus, and retinopathy (2).
Arab pregnant women and 88% of their neonates had
Even in late preterm newborns whose
vitamin D deficiency or insufficiency (7).
gestational ages are between 34-36 weeks, infection,
As pregnancy is a time of tremendous growth
hyperbilirubinemia, feeding difficulties are more
and physiological changes in the developing fetus,
common than in term babies. Kalyoncu et al. (3) have
vitamin D and its metabolites could affect the genetic
reported 2.3% mortality and 11 times more respiratory
signaling of the developing fetus and could minimize
distress syndrome (RDS) compared to term babies.
the risk of certain adverse outcomes through a not fully
Respiratory distress syndrome (RDS) is the
understood mechanism (8).
commonest cause of respiratory failure during the first
Because the placental transfer of vitamin D is
days after birth. In addition to prematurity, other
the major source of vitamin D to the developing fetus,
factors contributing to the development of RDS such
this does mean that a mother deficient in vitamin D is
as maternal diabetes, cesarean delivery without
equal to a fetus deficient in vitamin D. with increased
preceding labor, fetal asphyxia, and being the second
risk of various maternal and fetal adverse effects,
twins (4).
including increased risk of gestational diabetes
Vitamin D is a steroid hormone, responsible
mellitus, preeclampsia, small for gestational age, and
mainly for the maintenance and regulation of calcium
other tissue specific conditions (9). Antenatal

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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:5 / 7/2020

Accepted:4 /9 /2020

Full Paper (vol.814 paper# 5)

c:\work\Jor\vol814_6 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1750-1753

Safety and Efficacy of Direct Acting Antivirals (Sofosbuvir & Daclatasvir) in
treatment of Chronic HCV in HIV-HCV Co-Infected Egyptian Patients
Mahmoud Ezat Hegazy*, Ihab Barsoum Fahim, Mahmoud Ahmed Sharaf Eldin, Saeed Abd Elbaky Gad
Internal Medicine Department, Faculty of Medicine ­Zagazig University, Egypt
*Corresponding author: Mahmoud Ezat Hegazy, Email: Bedomessi12989@gmail.com

Liver-related mortality is considered the most common cause of death in HIV/HCV-co infected
individuals. Accordingly, treatment of HCV infection in HIV/HCV-co infected individuals is a priority to manage
such major health burden.
Objectives: To evaluate the safety and efficacy of treatment of chronic HCV by DDAs in HCV-HIV co-infected
Egyptian patients.
Patients and methods: It is an observational study that included 22 patients; only 18 HCV\HIV co-infected patients
completed the study [14 males (77.8 %) and 4 females (22.8 %)]. Their ages ranged from 21 to 46 years with a mean
age of 32.89 years. Half of them married and 72% of them working. 61% of them are smokers and IV addicts. Patients
were divided into two groups according to HIV PCR. Group I included 12 Patients with HIV PCR > 50 copies/mm
and group II that included 6 patients with HIV PCR < 50 copies \mm.
Results: The rates of a sustained virologic response (SVR) at post-treatment week 12 (SVR 12) were high [17/18
(94.4%)]. The most common adverse events were fatigue (66.7%), headache (50%) and there was a high safety profile
on using direct-acting antivirals (DAAs) and no patient discontinued treatment because of adverse events. No serious
adverse events or mortality was reported. In addition, AST & ALT were significantly decreased at end of treatment
and 12 weeks after treatment. Otherwise there were no significant changes in both hematological and chemistry labs.
Conclusions: Daclatasvir plus sofosbuvir for 12 weeks resulted in a high rate of sustained virologic response in
patients co infected with HIV and HCV with high safety profile after treatment completion.
Keywords: Daclatasvir, sofosbuvir, sustained virologic response, HCV/HIV co infection.


According to United Nations Program on
HIV/AIDS (UNAIDS), there were 8,800 people living
extrapyramidal syndromes marked by ataxia),
with HIV/AIDS in Egypt by the end of 2014 (1).
autoimmune syndromes, complex drug interactions,
With the wide spread of antiretroviral therapy, the
and limited efficacy with SVR rates of 20%­29% in
effect of HIV co-infection on the course of HCV
patients with HCV genotype 1 infection (4) are recorded.
disease is reduced but not eliminated by antiretroviral
The development of pegIFN-free oral regimens of
therapy. On the other hand, liver-related mortality is
direct-acting antivirals (DAAs) greatly improved the
considered the most common cause of death in
efficacy and tolerability of HCV treatment in co-
HIV/HCV-co infected individuals. Accordingly,
infection. The combination of daclatasvir (DCV) +
treatment of HCV infection in HIV/HCV-co infected
sofosbuvir (SOF) without ribavirin (RBV) for 12 weeks
individuals is a priority to manage such major health
showed a high rate of sustained virological response
burden (2).
(SVR) with good tolerability in HIV­HCV-co-infected
Hepatitis C virus treatment can eradicate infection
patients treated with a wide range of cART (5).
achieving sustained virological response (SVR),
The aim of this study is to evaluate the safety and
defined as undetectable HCV ribonucleic acid (RNA)
efficacy of treatment of chronic HCV by DAAs in
in the blood 12 weeks after the completion of HCV
HCV-HIV co-infected Egyptian patients.
treatment. This is strongly associated with reduced risk

of liver-related morbidity and mortality such as
Type of the study: Observational study.
transplantation (3).
Study period: 6 months.
Among HIV/HCV-coinfected patients, HCV
Site of the study: Abbasia Fever Hospital.
treatment in the era of interferon-based regimens was
Sample size: 18 cases
marked by poor tolerability, frequent serious adverse
Inclusion criteria: Age > 18 years. HCV RNA
events like, bone marrow depression and flu-like
positive. HIV infection confirmed by western blot.
symptoms (e.g., fever, chills, headaches, arthralgia, and
Exclusion Criteria: Child C cirrhotic patients,
myalgia). In addition, neuropsychiatric disorders (e.g.,
platelet count < 50000/mm3, patients with HCC,
severe fatigue, irritability and apathy), neurological
pregnancy and uncontrolled diabetes mellitus
side effects (e.g., seizures, paresthesia, confusion,
(HbA1c > 9%).

This article is an open access article distributed under the terms and conditions of the Creative
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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:7 /7 /2020

Accepted:6 /9 /2020

Full Paper (vol.814 paper# 6)

c:\work\Jor\vol814_7 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1754-1766

Effect of Nicotine on the Rat's Tongue and the Possible Protective Role of
Royal Jelly Light and Scanning Electron Microscopic Study
Salwa M. Ouies
Human Anatomy and Embryology Department, Faculty of Medicine, Sohag University
Corresponding author: Salwa M. Ouies, Mobile: (+20)01002073124, E-Mail: salwaouies@yahoo.com

nicotine (NIC) is an active substance in tobacco, the excessive use of tobacco products has been
associated with various lesions in the oral cavity. Royal jelly (RJ) believed by many authors to be an anti-oxidant
that protects different organs. Aim of the work: this study aimed to detect the effect of nicotine on the structure
of the tongue and the possible protective effect of royal jelly. Materials and methods: 30 adult male rats were
equally categorized into 3 groups. Group I: 10 rats used as the control group; Group II: 10 rats received nicotine
sulphate 2 mg/kg subcutaneously daily for 4 weeks; Group III: 10 rats received nicotine as the previous group and
royal jelly (100 mg/kg by intra-gastric tube daily) for 4 weeks. After 24 hrs of the last dose, the animals were
dissected. Tongues were processed for the histological and scanning electron microscopic study.Results: group II
revealed that the lingual dorsal surface was formedof irregularly and destructed papillae. Most of these papillae
were thin with blunted or absent tips. Fungiform papillae showed destruction of their epithelium and ill-defined
pores. Lamina propria showed depletion of the collagen fibers, skeletal muscle fibers revealed separations and
destruction. Group III revealed restoration of the normal appearance at some regions and presence of nicotine
effects at the others within light microscope and apparent restoration of the normal shape as seen within the electron
microscope. Conclusion nicotine has harmful effects on the tongue and the addition of RJ can decrease these
harmful effects, but not prevent it.
Key Words: Nicotine, Royal Jelly, Tongue.

created interference with excessive oxidative cascade
The nicotine, the main component of tobacco,
and production of free radicals(7,8).
stimulates the central nervous system, addicting
Aim of the work: this study aimed to investigate the
firmly and fast. The nicotine changes the metabolism
histological changes in the tongue following nicotine
of proteins and nucleic acids and disorders functioning
toxicity in experimental rats and to assess the possible
of defense-and repair system. The tobacco smoke
protective effects of Royal jelly using light
provides also physical damages because of increases
microscopy (LM) and scanning electron microscopy
temperature inside the mouth and burns tissues
(1).Tobacco use affects the surface epithelium,

resulting in changes in the appearance of the tissues.
The changes may range from an increase in
pigmentation to thickening of the epithelium (White
Nicotine: it was used as a powder and obtained from
lesion) (2).Nicotine has been recognized as capable of
El-Nasr Company for Pharmaceutical Industries,
inducing changes in taste functionality in conditions
of chronic exposure. The mechanisms underlying
Royal jelly: RJ 1000 mg tablet soft gelatin capsules
these sensory alterations, however, are currently
produced by Pharco- Pharmaceuticals, Alexandria,
unknown (3).Royal jelly (RJ) as the most important
beehive product is secreted from the salivary glands of
Animals: thirty adult male Albino rats, aging 4 - 6
worker honeybees and serves as a primary super food
months and weighing 200 - 250 g, obtained from
for the queen and larvae during their first three days of
Assiut Faculty of Medicine. They were housed in
life. The RJ includes several important compounds
Animal Facility at Faculty of Medicine, Sohag
such as sugars, free amino acids, fatty acids, minerals
University, Egypt. All rats were given access for
(e.g., calcium) and vitamins with biological
rodent chow diet and water.
activities(4).Royal jelly was believed to have beneficial

protective effects in the experimental animals with
Ethical approval:
anti-oxidant(5), anti-inflammatory and anti-cancerous
The experiment was performed according to the
properties(6).The RJ regulated the balance between the
"Guide for the Care and Use of Laboratory
pro-oxidative and anti-oxidative effectors and has
Animals" (Institutes of laboratory Animal
antioxidant property; therefore, administration of RJ
Research) (9)and in accordance with the guidelines

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Received:5 /7/2020

Accepted:4 /9 /2020

Full Paper (vol.814 paper# 7)

c:\work\Jor\vol814_8 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1767-1774

Study of Serum Magnesium level and Atherosclerotic Changes in
Patient on Maintenance Hemodialysis
Ahmed Rabie Alarbagy, Yassein Salah Yassein Mohamed, Mai Magdy Saad Zeid,
Heba EL Sayed Kasem Mohamed
Internal Medicine Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt.
*Corresponding author: Mai Magdy Saad Zeid, Mobile: (+20)01022665962, E-mail: dr.mai.zeid@gmail.com
Cardiovascular complications in dialysis patients focused on atherosclerosis. Serum magnesium has a
role in cardiovascular complications in dialysis patients. Objectives: This study aimed to study the correlation between
serum magnesium level and atherosclerotic changes in patients on maintenance hemodialysis.
Patients and methods:
This prospective study included 60 patients with end-stage renal disease patients on
maintenance HD, divided into Group I: (20 patients) with normal serum magnesium level (1.7 -2.8 mg/dl), Group II
20 patients) with low serum magnesium level (< 1.7mg/dl) and Group III (20 patients) with high serum magnesium
level (> 2.8mg/dl.). Serum magnesium and lipid profile and intima-media thickness (IMT) of both common carotid
arteries were measured. Results: Our results showed a significant negative association between level of serum Mg and
IMT complex of both common carotid (P = 0.045) and ischemic heart disease in the studied patients (P = 0.012). The
binary logistic regression for the predictors for IHD and CCA-IMT, we found that serum magnesium not an independent
factor for atherosclerosis but we found that age and DM (P 0.001) followed by cholesterol and triglycerides (P 0.05)
are the most independent factors for CCA-IMT. Also, age (with OR: 95% confidence Interval) (0.145:1.26-1.06) (P
0.001) and triglycerides (1.02:1.05-1.002), (P 0.05) are the independent factors for IHD.
Conclusion: Our study revealed a significant inverse correlation between level of serum Mg and CCA-IMT and IHD
in the studied HD patients. Thus, we suggest that regular screening of HD patients for serum Mg and CIMT with special
consideration to diabetic and old patients is recommended to stratify their CV risk.
Keywords: End stage renal disease, Magnesium, Atherosclerosis, Intima media thickness.


CKD is a worldwide public health issue and has
ultrasound imaging is one of the tools used for the
been identified as a major risk factor for atherosclerotic
diagnosis of atherosclerotic Changes (13). Mg is the second
CVD (1). Cardiovascular diseases affect the morbidity and
most abundant intracellular cation and it plays a key role
mortality of CKD patients in the early stages of the
in a wide range of cellular functions. End-stage renal
disease (2). Thus, CKD can be defined as a pro-atherogenic
disease (ESRD) patients have usually normal serum levels
state (3). The atheroma­promoting CKD factors are
of Mg and sometimes even low serum Mg concentration
dyslipidemia, impaired HDL function and disrupted
reverse cholesterol transport (4). Factors contributing to
hypomagnesaemia may result from different medications,
this atherogenic environment include the presence of
proton-pump inhibitors, aminoglycoside antibiotics and
uremic toxins, persistent inflammation and oxidative
decreased intestinal Mg absorption probably due to a
stress (5).
deficiency of active vitamin D (15).
CKD itself is an independent risk factor for CVD;
Recently it was found that hypomagnesaemia has
both traditional and non-traditional risk factors for CVD
been associated with inflammation and disturbances in
exist in CKD patients (6). Traditional risk factors are found
vascular tone regulation and endothelial function, which
in both the CKD and non-CKD population (7). Non-
traditional risk factors may result from or be worsened by
progression (16). So, the aim of our study was to study the
CKD and negatively influences the cardiovascular system
correlation between serum Magnesium level and
in the CKD population (8). These include oxidative stress,
atherosclerotic changes in patient on maintenance
inflammation, lipids metabolism, calcium and phosphate
(9). In early stages of CKD patients mainly have

endothelial dysfunction, which is a predictor of CVD (10).
There is a common association between CKD and
Our study included 60 patients with ESRD on
alterations in lipoprotein structure and function, as
maintenance HD. They were divided into three main
reduced high-density lipoprotein cholesterol, increased
groups, Group (I): included 20 patients with normal serum
magnesium level (1.7 -2.8 mg/dl), Group (II): included 20
atherogenic lipid particles (11). To diagnose of CVDs,
patients with low serum magnesium level less than 1.7
especially atherosclerotic changes in patients with HD
mg/dl and Group (III): included 20 patients with high
noninvasive tests are necessary (10). IMT can be predict
serum magnesium level more than 2.8 mg/dl. Patients of
survival outcomes in patients with HD (12). B-mode
acute renal failure, chronic liver disease, taking

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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:6 /7 /2020

Accepted:5 /9 /2020

Full Paper (vol.814 paper# 8)

Results The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1775-1779

Coronavirus Anxiety Scale: Content Validity and Reliability of Arabic Version
Samir El Sayed1, Doaa Shokry2, Sarah Gomaa3
1 Department of Psychiatry, 2 Department of Public Health, 3 Department Psychiatry, Faculty of Medicine, Mansoura
University Students' Hospital,Mansoura University, Mansoura, Egypt
*Corresponding author: Samir El Sayed, Mobile: (+20) 01025747441, E-Mail: shinnysky83@gmail.com

Psychiatric manifestations of individuals impacted by the coronavirus pandemic have not been
sufficiently investigated. It is very important to find a short valid and reliable scale for particularly assessing the anxiety
manifestations during coronavirus disease -2019 (COVID-19) pandemic which is suitable in our culture leading to early
intervention and management. Objectives: The current study aimed to validate the Arabic version of corona virus
anxiety scale (CAS) and assess its reliability and translation into Arabic.
Patients and Methods: CAS has been translated into Arabic. Methodological design was used to investigate content
validity index (CVI) reported by eleven expert jurors. The Arabic version was distributed among 700 participants who
completed the scale. Intra class correlation coefficient (inter-rater and intra-rater agreement) and Cronbach's reliability
coefficients were addressed to investigate reliability. Results: The CVI Item for relevance ranged from 0.90 to 1.0 and
for clarity from 0.71 to 1.0. All inter-rater and intra-rater correlation coefficients are positive and significant and ranges
from 0.78 to 0.92 for inter-rater and from 0.88 to 0.96 for intra-rater. The inter-rater and intra-rater correlation
coefficients of the total score were 0.83 and 0.92, respectively. The total Cronbach's of the total scale was 0.92.
Corona virus anxiety scale (CAS) Arabic version based on the results is valid, reliable, stable, and its
translation is convenient to the culture. It can be used for screening of anxiety manifestations concomitant with Covid
19 pandemic.
Keywords: Arabic, Corona Virus Anxiety, Pandemic, Reliability.


On 31 December 2019, a unique viral pneumonia
result in people becoming more anxious, angry, stressed,
emerging in Wuhan, China was declared to the World
agitated, and withdrawn (7).
Health Organization (1). As of 23 March 2020, this novel
Santini et al. (8) said that a crucial risk factor for
coronavirus (COVID-19) speeded across the entire
both anxiety and depression is perceived isolation.
world, infecting more than 294,110 people in 187
Anxiety is considered the most common mental
countries and killing 12,944 individuals (2).
disorders and defined as a persistent feeling of worry,
Xiang et al. (3) noted although there has been a
apprehension fear, or nervousness, also approximately 1
considerable effort to investigate people with the
in 10 people living in the UK suffer from an anxiety
coronavirus infection, assessing the psychiatric status of
related disorder (9). The coronavirus anxiety scale (CAS)
people impacted by this pandemic was not fair enough.
is a 5-item mental health screener implemented to help
Balaratnasingam and Janca (4) highlighted
the health care professionals to find the possible cases of
during the pandemic of infectious diseases, there are
COVID 19-related handicapping anxiety by an efficient
often elaborated high levels of stress and anxiety that
and effective way (10). Asmundson and Taylor (11)
lead to disturbance of the behavioral and psychological
released the terminology of "coronaphobia" which
wellbeing of the individuals.
referred to corona virus anxiety in their emerging
Liu et al. (5) mentioned in a recent, large survey of
research. The data regarding this CAS has been
people highly vulnerable to the coronavirus infection,
presented previously by Lee (10).
including Chinese medical workers, the prevalence rate
The current study aimed to validate the Arabic
of traumatic stress was at an alarming 73.4%, depression
version of corona virus anxiety scale (CAS) and assess
was at 50.7%, generalized anxiety was at 44.7%, and
its reliability and translation into Arabic.
insomnia was at 36.1%.

Previous researches were done during the
infectious outbreak found clear relationship between
This study was conducted in Hayat National
pandemic related anxiety and high stress levels, anxiety,
Hospital, Psychiatry Department, Riyadh, Kingdom of
post-traumatic stress disorder, contamination thoughts,
Saudi Arabia. Data were gathered from 10th of June to
and suicidal ideations (6).
25th of June 2020.
The World Health Organization has declared that
This current methodological (validation) design is
such curfew/social distancing measurements might
a cross sectional study with a longitudinal component for

measuring the reliability and content validity of the

Arabic version of coronavirus anxiety scale (CAS).

This article is an open access article distributed under the terms and conditions of the Creative
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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:6 /7 /2020

Accepted:5 /9 /2020

Full Paper (vol.814 paper# 9)

c:\work\Jor\vol814_10 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1780-1784

The Relationship Between Serum Lead Level and Uremic Pruritus in
End-Stage Renal Disease Patients on Regular Hemodialysis
Essam Eldin Mahmoud Lotfy1, Lamiaa Abd Elwahab Mohammed2, Nafesa Mohammed
Kamal1, Hatem Elmaghawry Mohammed Elsheikh*1
Departments of 1Internal Medicine & Nephrology and 2Clinical Pathology, Faculty of Medicine, Zagazig
University, Sharkia, Egypt
*Corresponding Author: Hatem Elmaghawry Mohammed Elsheikh, Mobile: (+20)01558857795,
Email: hatemelshiekh@gmail.com

Uremic pruritus (UP) is commonly described as a daily or near-daily occurrence of itch that spans
large bilaterally symmetrical surface areas. Blood lead level (BLL) has been noted to be associated with
inflammation and nutritional status in long-term HD patients.
Objective: To evaluate the possible relationship between BLL and UP in chronic HD patients.
Patients and Methods:
This Cross-Sectional Study was carried out in the Hemodialysis Unit in EL Agouza
Hospital from November 2018 to the end of April 2019 and included 100 randomly selected patients with end-
stage who received hemodialysis sessions thrice weekly, four hours /session, for more than 6 months. Dialysate
with standard ionic composition and a bicarbonate-based buffer is used for all patients.
Results: The mean age of the chosen patients were ±SD 48.6 ± 7.1 years and the difference among the groups was
non-significant (p-value 0.116). The study included 42 females (42%) and 58 males (58%). There was no
significant difference among the studied groups (p=0.292) regarding sex. According to Pruritus Onset in our study,
there was a non-statistically significant difference among the studied groups. In our study, there was a statistically
highly significant difference among different groups regarding Serum Lead (µg/dL) (p-value <0.001). In our study,
Serum Lead 14µg/dL is a cut-off value predictor for pruritus in HD patients with a sensitivity of 89.5%, specificity
of 64.2%, and an accuracy of 69%.
Serum Lead is a predictor for the incidence of pruritus in patients with end-stage renal disease
maintained on hemodialysis.
Keywords: Uremic pruritus, Blood lead level, End-Stage Renal Disease.

Uremic pruritus is most commonly described as a
Our study was conducted on ESRD patients in the
daily or near-daily occurrence of itch that spans large
hemodialysis unit at Alagouza hospital in Giza during
bilaterally symmetrical surface areas (1). It is a
the period from November 2018 to the end of April
common and burdensome symptom for patients with
2019 (six months period).
kidney failure, affecting up to 46% of hemodialysis

patients (2). The association between uremia and
Type of study: Cross-sectional Study
pruritus was first reported more than a century ago (3).
Inclusion criteria: Patients age between 16 to 60 years
Patients with severe chronic renal failure may be
old. Patients maintained on Hemodialysis for at least
predisposed to the development of xerosis,
6 months were recruited in this study. Patients receive
hyperpigmentation, uremic roseola, calcinosis cutis,
hemodialysis sessions thrice weekly, four hours for
acquired perforating dermatosis, bullous dermatosis of
each session, Dialysate with standard ionic
hemodialysis, and pruritus (4). Although uremic
composition and the bicarbonate-based buffer is used
pruritus (UP) is a common and annoying symptom for
for all patients, with a low flux polysulphone dialyzer
end-stage renal disease patients on hemodialysis (HD)
F10. The blood flow was usually kept between 250­
and peritoneal dialysis, its pathogenesis is poorly
300 and the dialysate flow were 500 ml/min.
understood (5).
Ultrafiltration was controlled volumetrically in all
Blood lead level (BLL) has been noted to be
hemodialysis machines used in this study. One
associated with inflammation and nutritional status in
hundred patients met the inclusion criteria out of 120
long-term HD patients (6). BLLs in HD patients might
increase the intensity of or have an addictive role of
Exclusion criteria: Any associated primary skin
pruritus caused by other more common risk factors (7).
lesion. Patients age above 60 years old or less than 16
This study aims to evaluate the possible
years old. Patients with malignancies, infectious
relationship between BLL and UP in chronic HD
diseases, pregnancy, and immune diseases. Those who
had been admitted or received surgery within 3 months

of the study. Patients who work as a painter or in

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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:7 /7 /2020

Accepted: 6/ 9/2020

Full Paper (vol.814 paper# 10)

c:\work\Jor\vol814_11 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1785-1788

Mini External Fixator for Management of Fracture Metacarpals and
Phalanges of the Hand
Ahmed Al Saeed Abd Allah*, Khaled IdreesAbd Al Rahman,
Mohammed El Sadek Attia, Ahmed Mohammed Abdel Wahab
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Al Saeed Abd Allah, Mobile: (+20) 10-9300862, E-mail: draaasa@gmail.com


Background: Fractures of metacarpals and phalanges are the most common fractures of the upper extremity.
Objective: The aim of this study was to assess the functional outcomes of management of metacarpal and phalangeal
fractures by mini external fixator.
Patients and Methods: This prospective study included a total of 12 patients with fractures of metacarpals and
phalanges, attending at Orthopedics and Traumatology Departments, Zagazig and Helwan University Hospitals.
This study was conducted between August 2018 and July 2019 and was done to assess the functional outcomes of
metacarpal and phalangeal fractures fixed by mini external fixator.
Results: In this study there was good union time among studied group with average 8.33±2.1 weeks. One case
(8.3%) had pin tract infection and one case (8.3%) had delayed union >12 weeks, malunion founded in 2 cases
(16.7%) and stiffness founded in 3 cases (25%). At the end of the follow up period, two patients (16.7 %) sustained
malunion deformities, one patient (8.35%) had rotational deformity and in another patient (8.35%) had angular
malunion. Regarding active movement score 75% were acceptable results (Excellent and Good) and 25% were not
acceptable results (Fair and Poor). There was significant association between acceptability of outcome and
deformity, as 66.7% of not accepted result had deformity while no one from accepted outcome had deformity.
: Use of mini external fixator is an adequate procedure for unstable phalangeal and metacarpal fractures.
In cases of open fractures, the mini external fixator allows wound inspection and care and avoidance of hardware
application at fracture site.
Metacarpal and Phalangeal Fractures, Mini External Fixator.


The human hand is the most part of the body
geometry, location, deformity and if the wound is
susceptible to a wide range of injuries especially in
closed or opened plus the stability of the fracture (5).
manufacturing, agricultural field and adding to this
Non-operative treatments like elevation, rest,
increased road traffic accidents resulting in high
splinting, cast with or without traction, open reduction
incidence of phalangeal and metacarpal fractures
and internal fixation by k-wire, plates, screws etc.,
particularly mutilating hand injuries, open fractures,
leads to more damage of the already injured soft tissues,
comminuted fractures and intra articular fractures (1).
stiffness of the joints and delay in rehabilitation.
Metacarpal and phalangeal fractures are the
External fixation allows fracture reduction to normal
most common fractures of the upper extremity that
bony length via a rigid external support (6).
account for 10% of total body fractures. The outer parts
The aim of this study was to assess the
of the hand are the most commonly parts to be injured.
functional outcomes of management of metacarpal and
The incidence of metacarpal and phalangeal fractures is
phalangeal fractures by mini external fixator.
most common in males and peaks at the age of 10-40

years when the athletic injury and industrial exposure
is the greatest (2).
This prospective study included a total of 12
The bad thing among these fractures that the
patients with fractures of metacarpals and phalanges,
metacarpal and phalangeal fractures are often neglected
or regarded as trivial injuries (3). Proximal phalanges of
Departments, Zagazig and Helwan University
the fingers are fractured more frequently than the
Hospitals. This study was conducted between August
middle or even distal phalanges. Deformity leads to
2018 and July 2019.
displacement is typical to occur when the proximal
The mini-external fixator was used to fix the
phalanges are fractured (4).
fractures within one week and patients were followed
Treatment with closed procedure has led to bad
up for 12-36 months with an average period of 24
outcomes as the malunion, stiffness and loss of soft
tissues or skin over the injured part. Type of surgery for

fixation depends on several factors that include fracture
Inclusion criteria: Patients aged between 17 and 50

years with unstable fractures of metacarpals or

This article is an open access article distributed under the terms and conditions of the Creative
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SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:7 /7 /2020

Accepted:6 /9 /2020

Full Paper (vol.814 paper# 11)

c:\work\Jor\vol814_12 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1789-1795

Dexamethazone Prophylaxis before Near Total Thyroidectomy to Reduce
Vocal Dysfunction: A Randomized Clinical Trial
Atef Mohamed Abdel Latif, Tamer Youssef Mohamed, Ahmed Elsayed Lotfy,
Ahmed Helmy Mohamed Ahmed*
Endocrine Surgery Unit, Faculty of Medicine, Mansoura University, Egypt
* Corresponding author: Ahmed Helmy Mohamed Ahmed, E-mail: dr.a7med7elmy@gmail.com


Background: Thyroidectomy operation is one of the most common operations around the world. There are different
complications of thyroidectomy including vocal cords dysfunction, hypocalcaemia, pain, bleeding, hematoma,
nausea and vomiting.
This study aimed to study the prophylactic effect of dexamethasone 8 mg/2ml amp, intravenous before
near total thyroidectomy to reduce vocal dysfunction. Also, to study the effect in relation to pain, nausea, vomiting
and hypocalcaemia.
Patients and Methods: This study was conducted in Mansoura University Hospitals, Endocrine Surgery Unit during
the period between July 2018 and June 2019. All patients were admitted from the Outpatient Clinic. All patients were
informed about the surgical procedure in the clinic and a written consent was taken from all patients participating in
the study. Sample size was calculated using G- Power with effect size 0.8 and power of 0.8 where it was 100 patients
(50 patients in each group).
Results: comparing the 2 groups postoperatively, the dexamethasone group had fewer complications as regards
postoperative nausea, vomiting, pain, hypocalcaemia and vocal dysfunction.
Conclusion: From this study, it was shown that dexamethasone 8 mg/2ml IV before near total thyroidectomy has
significant effect regarding reduction of postoperative nausea, pain, vomiting, hypocalcaemia and vocal cords
mobility, which was less affected. In addition, there was no side effects of dexamethasone administration. Therefore,
we advise to give dexamethasone to all patients before thyroid surgery.
Keywords: Dexamethasone, near total thyroidectomy, vocal dysfunction.

corticosteroid, which has significant benefits in
One of the most frequently performed surgical
reduction of pain, nausea and vomiting in
procedures in the world is thyroidectomy. Immediate
postoperative period (5).
complications postoperative include pain, nausea,

vomiting, bleeding, hematoma, and voice change.

Because of post intubation vocal fold edema, neural
The aim was to study the prophylactic effect of
injury, local tissue changes and inflammation may
dexamethasone 8 mg/2ml amp, intravenous before near
occur, which cause voice change (1). Total
total thyroidectomy to reduce vocal dysfunction and to
thyroidectomy and subtotal thyroidectomy are the most
study the effect in relation to pain, nausea, vomiting
common operations for multi nodular goiter in adults.
and hypocalcaemia.
However, near total thyroidectomy is defined as a

postoperative thyroid remnant less than 1 mL and is
supposed to be a similarly effective but safer option
This study was conducted for patients admitted to
than total thyroidectomy (2). Voice change may be
Mansoura University Hospitals, Endocrine Surgery
permanent or transient due to injury to the recurrent
Unit during the period between July 2018 and June
laryngeal nerve, which can cause significant morbidity
2019. All patients were admitted from the Outpatient
for patients and significant voice change may occur in
Clinic. All patients were informed about the surgical
injury of the external branch of the superior laryngeal
procedure in the clinic and a written consent was taken
nerve, intubation trauma, cricothyroid dysfunction,
from all patients participating in the study. Sample size
psychological reaction in the postoperative period,
was calculated using G- power with effect size 0.8 and
edema, and scarring of the strap muscles (3).
power of 0.8 and it was 100 patients. A randomized
Post-operative nausea and vomiting is not only
clinical trial was done where the patients were
uncomfortable for the patient but the repeated times of
randomized into 2 groups, 50 patients in each group:
vomiting may lead to bleeding which can obstruct the

airway and may lead to entry the operating room again.
Group A (study group): Received 8mg/2ml amp
Therefore, the importance of avoiding nausea and
of dexamethasone immediately I.V before
vomiting events are very important even than pain
induction of anesthesia
postoperatively (4). Dexamethasone is a widely used

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-
SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:7 /7 /2020

Accepted: 6/9 /2020

Full Paper (vol.814 paper# 12)

c:\work\Jor\vol814_13 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1796-1803

Role of Metformin in Combination with Trastuzumab and Neoadjuvant
Chemotherapy in Treatment of HER-2 Positive Breast Cancer
Ahmed Said Ahmed Said*1, Hussein Ali Mustafa Abd Al-Mutteleb2, Mohammed Ali Morsy Abdeen3,
Mohammed Abd Al Rahman Hassan3, Soha Abdelrazek Abbas Ahmed1
Departments of 1Clinical Oncology and Nuclear Medicine and
2General Surgery, Faculty of Medicine- Aswan University
Department of 3Clinical Oncology and Nuclear Medicine, Faculty of Medicine- Cairo University
*Corresponding author: Ahmed Said Ahmed Said, Mobile: (+20) 01125408705, E-Mail: ahmedsaidorman@yahoo.com

HER2 overexpression is a good predictive marker of HER2 targeted therapy, which means that HER2
therapy will be very effective in reducing the size of HER2 positive breast cancers. Therefore, the size of HER2
positive breast cancer can easily be reduced in patients who wish to have a breast-conserving operation, and
potentially improves the outcome of patients if pathologic complete response (PCR) can be achieved.
To determine whether metformin use with trastuzumab was associated with improvement in PCR rate
in patients with breast cancer receiving neoadjuvant chemotherapy.
Patients and Methods:
This prospective study was conducted at the Clinical Oncology Department, Aswan
University and Upper Egypt Hospitals in the period between 1/7/2016 and 1/9/2019. This study included 30 patients
divided into 2 groups, test group (metformin group) and standard group (non-metformin group). Histopathology
was confirmed by tissue core biopsy.
All patients in the two groups in our study achieved either pathological complete response or partial
response. No patients developed disease progression or were still stable disease. Among the patients in test group
(metformin group), 12 patients (80%) achieved pathological complete response (PCR) while 3 (20%) patients did
not achieve PCR. However, among the patients in standerd group (non-metformin group) 9 patients (60%) achieved
pathological complete response (PCR) while 6 (40%) patients did not achieve PCR. There was statistically
significant difference between the two groups regarding the response with better PCR in metformin group (p value
is 0.089).
The addition of metformin to tratuzumab in neoadjuvant chemotherapy has a significant impact on
pathological complete response (PCR) in female patients with HER-2 positive breast cancer.
Keywords: Breast Cancer, Metformin, Neoadjuvant Chemotherapy.

together with its well characterized and modest
Preoperative systemic therapy (neoadjuvant) is
toxicity profile, has significantly shortened the clinical
becoming popular nowadays for early-stage or locally
evaluation path of metformin in cancer prevention and
advanced breast cancer. In the last decade,
treatment (4). Accordingly, many clinical studies,
pathological response for neoadjuvant chemotherapy,
including proof-of-principle studies in the prevention
as an indicator for long term clinical benefit in breast
setting and phase 2 trials in the adjuvant and metastatic
cancer, was an evolving chance for more rapid
settings, have been planned and/or are currently under
incorporation of new drugs (1).
way to test the causal nature of the suggested
Metformin, a biguanide derivative that reduces
correlation between metformin and clinical benefit in
insulin levels, has long been a cornerstone in the
cancer (5).
treatment of type 2 diabetes (T2D). There is
To avoid overestimation of the potential effects
compelling evidence to incorporate metformin into the
of metformin in unselected populations of nondiabetic
armamentarium against cancer, particularly breast
BC patients, preoperative translational studies are
cancer (BC). Notwithstanding the limitations of
important to define specific BC subgroups more likely
observational studies, many have consistently
to benefit from metformin-based regimens. The
indicated that metformin can reduce the incidence,
neoadjuvant (preoperative) approach is known to
outcome, and mortality of BC in patients with T2D (2).
maximize the capacity to test the benefits of drug
Moreover, preclinical studies have described a variety
combinations in the context of carefully designed
of molecular mechanisms through which metformin
clinical trials of early BC (5). In this regard, a landmark
indirectly or directly inhibits the growth of BC cells in
retrospective study revealed that patients with T2D
vitro and in vivo (3).
and BC who received metformin and neoadjuvant
The extensive clinical experience accumulated
chemotherapy appeared to have a higher PCR rate than
from patients with T2D prescribed metformin,
did those not receiving metformin, a hypothesis-

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Commons Attribution (CC BY-SA) license (

Received:6 /7 /2020

Accepted:5 /9 /2020

Full Paper (vol.814 paper# 13)

c:\work\Jor\vol814_14 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1804-1809

Posterior Approach to Neurotize Suprascapular Nerve by Spinal Accessory Nerve
Muhammad Hassan Muhammad Abdel-Aal1, Mohammad Reda Ahmad1,
Hassan Rabea Galal Ashour2, Ahmed Mohamed Desoky Hemid*1
Departments of 1Plastic & Reconstructive Surgery and 2Surgical Oncology,
Faculty of Medicine-Zagazig University
*Corresponding author: Ahmed Mohamed Desoky Hemid, Mobile: (+20) 01008308149,

Surgical reconstruction of the shoulder is a high priority in patients with total brachial plexus injuries.
This is not only because functional control of the shoulder is of paramount importance, but also because of the
overall reduced success of reinnervation of muscles below the elbow.
This study aimed to neurotize suprascapular nerve by spinal accessory nerve through posterior approach.
Patients and methods:
This prospective cohort study was conducted in the Department of Plastic and
Reconstructive Surgery, Faculty of Medicine, Zagazig University within the period from November 2018 to July
2019. Twelve patients were included in the present study. All patients were exposed to traumatic brachial plexus
our study showed progressive improvement of shoulder flexion, abduction and external rotation. By the
comparison between pre- and postoperative range of movement. It was recorded that the mean value of shoulder
flexion has significantly elevated from 4.167 ± 4.68 preoperative to be 59.58 ± 8.11 (P < 0.001). The mean value
of shoulder abduction was increased significantly from 4.58 ± 4.50 preoperative to 65.41 ± 8.91 postoperative (P <
0.001). Moreover, the mean value of external rotation was improved significantly from 5.83 ± 5.15 preoperative to
65.42 ± 9.64 postoperative.
That transferring spinal accessory nerve to the suprascapular nerve via the posterior approach for
restoring shoulder abduction and external rotation is an effective and reliable treatment with high success rate in
patients with brachial plexus palsy.
Keywords: Brachial plexus injuries, Spinal accessory nerve, Nerve transfer, Neurotization.


The brachial plexus is the most complex
important branches to the upper trapezius muscle may
peripheral neural unit. It supplies the arm and hand,
be sacrified while attempting to gain a sufficient
allowing expression of the mind through writing, art,
length (4).
athletic endeavor and delicate manipulation of the
Recent clinical series suggest that better results in
environment (1). In most of the brachial plexus
shoulder abduction and external rotation can be
injuries, it is necessary to recover the stability of the
obtained when the XI ­ SSN neurotization is
shoulder as well as its abduction and external rotation
performed using a posterior approach (5).
(2). Although there are many techniques to achieve this
This study aimed to neurotize suprascapular
goal , one of the most used techniques is the nerve
nerve by spinal accessory nerve through posterior
transfer of fascicles of the accessory nerve (XI) to the
supra scapular nerve (SSN), which gives better results

than using nerve grafts from a ruptured C5 root . This
technique can be performed either by an anterior
This prospective cohort study was conducted in
approach or a posterior approach (3).
the Department of Plastic and Reconstructive
The anterior approach is simple and feasible for
Surgery, Faculty of Medicine, Zagazig University
any surgeon used to access the brachial plexus by a
within the period from November 2018 to July 2019.
supraclavicular route. However, many obstacles are
Twelve patients were included in the present study.
encountered in this technique such as tedious
The sample was taken as a comprehensive sample due
dissection of spinal accessory nerve because it lies
to rare presentation of brachial plexus injuries cases
deep in fatty tissue rich in lymphatic and blood
at Zagazig University Hospital about 2/month, so the
vessels. Distal suprascapular nerve injuries may also
sample was 6/12 months.
be missed when plexus exploration and nerve transfer
Inclusion criteria: Age more than 3 months and less
have been performed through anterior approach. Also
than 60 years and less than 9 months from time of
in healed clavicular fractures with exorbitant callus
formation. Thus, suprascapular nerve dissection can
Exclusion criteria: Obstetric brachial plexus injuries
be difficult and risky. Moreover, during anterior
cases. Cases with spinal accessory nerve injury.
exploration of spinal accessory nerve few of its

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:27 /6 /2020

Accepted:25 /8 /2020

Full Paper (vol.814 paper# 14)

Diabetic Foot paper The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1810-1814

Comparative Study between Treatment by Vacuum-Assisted Closure (VAC),
Treatment by Hyperbaric Oxygen Therapy and
Traditional Treatment of Diabetic Foot Infection
Ahmed El-Said Mousa*, Mahmoud Salah Shehata, Mohamed Mohsen Salem
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
* Corresponding author: Ahmed El-Said Mousa Ibrahim, email: dr_wiseman@yahoo.com

: To compare the therapeutic effects of vacuum-assisted closure therapy, hyperbaric oxygen therapy, and
traditional moist dressings in improving the healing process of chronic diabetic foot infection.
Study design: A prospective randomized study.
Patients and Methods: A total of 75 patients, with a chronic diabetic foot infection, were included in this study. After
surgical debridement, all patients were randomly classified into 3 groups, with 25 patients in each group. Group A
were treated by VAC therapy, Group B were treated by HBOT and Group C were treated by traditional moist dressings
respectively. Wounds were evaluated every week for six weeks as regards the size, timing of healthy granulation tissue
formation, local wound complications, and number of debridement sessions.
Results: There was a significant reduction in the wound size in group A with a mean of 70.25 %, B with 62.65 %
compared to group C with 32.46 %. As regards healthy granulation tissue formation onset, it was more rapid in group
A with a mean of 6.5, B with 7 compared to group C with 14 days. As regards the number of debridement sessions
and local wound complications they were significantly less in group A than the other two groups.
Conclusion: Vacuum-assisted closure (VAC) therapy appears to be safe, more effective with less complications than
the other two methods in the treatment of diabetic foot infection, and can be used with HBOT simultaneously if
Keywords: Vacuum-assisted closure, VAC, hyperbaric oxygen therapy, traditional moist dressings, chronic diabetic
foot infection.


The management of diabetic foot ulcers (DFU)
Topical negative pressure application is said to
has become a major public health concern as the
increase local blood flow to the tissues, reduces edema,
incidence of diabetes continues to increase. Diabetes
and decrease bacterial colonization and infection rate.
mellitus is widespread as regard the Egyptian society
It is thought to promote wound healing by accelerating
nowadays, nearly 10.4 % of the Egyptian population
the granulation tissue formation as well as by exerting
has Diabetes mellitus [1].
mechanical effects on the wound. It also provides an
The standard care for diabetic foot ulcers
ideal wound healing environment by keeping a moist
includes; blood glucose level control, treatment of
environment and removes excess wound exudates [6].
infection, adequate and frequent debridement followed
The present study was conducted to compare the
by moist dressings, revascularization in the case of the
efficacy of vacuum-assisted closure therapy,
ischemic limb [2]. Only 30 % of DFUs heal within 12
hyperbaric oxygen therapy, and traditional wound
weeks even after recent advances in traditional moist
dressings in improving the healing process and
dressings and so increases the risk for serious
reducing the complication rate in chronic diabetic foot
complications such as hospitalization, infection, and
the possibility of amputation [3].

Traditional treatment alone may not be enough to
Ethical Considerations:
heal diabetic foot infection and adjunctive methods
This study was carried after obtaining approval
may be necessary. Two different modalities have been
from the local ethical committee of the faculty of
suggested as effective methods; vacuum-assisted
medicine, Cairo, Al-Azhar university, and after fully
closure (VAC) therapy, and hyperbaric oxygen
informed written consent signed by every patient was
therapy (HBOT) [4].
Hyperbaric oxygen therapy involves the

inhalation of 100 % oxygen at pressures 2 or 3 times
greater than atmospheric pressure at sea level. This
A prospective randomized study was carried out in
method is used primarily to aid the healing of diabetic
the diabetic foot department at Raas Al-teen General
foot ulcers and proved to be effective in decreasing
Hospital. A total of 75 patients, with chronic diabetic
major amputation in diabetic patients with resistant
foot ulcers were included in this study. After surgical
foot ulcers [5].
debridement, all patients were randomly classified into

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY- SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:8 /7 /2020

Accepted: 7/9 /2020

Full Paper (vol.814 paper# 15)

c:\work\Jor\vol814_16 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1815-1821

Impact of Phototherapy on Oxidative Stress Indices in
Preterm Neonates with Unconjugated Hyperbilirubinemia
Khaled Hassaan Awad1*, Walid A. Elmorsy2
Departments of 1Pediatric and 2Clinical Pathology, Al-Azhar University, Assiut, Egypt
*Corresponding author: Khaled Hassaan Awad, Mobile: (+20) 01004790309, E-Mail: khaledelenaizy@yahoo.com

: Neonatal jaundice is one of the most common neonatal problems especially in preterm ones. Preterm
babies are treated with different types of phototherapy. Preterm neonates have a weak antioxidant defense mechanism.
Both the hyperbilirubinemia and phototherapy have an impact on this antioxidant defense system.
Objective: In the current study we aimed to assess the effect of hyperbilirubinemia and phototherapy in the
oxidant/antioxidant status of preterm newborns.
Subjects and Methods: Thirty late preterm (35 weeks) neonates with non-hemolytic neonatal jaundice in the 3-9
days of life were involved in the preset study, and received phototherapy. 15 healthy neonates of the same gestational
and postnatal age without jaundice were included as a control. We assessed the total oxidant status (TOS), total
antioxidant capacity (TAC), and oxidative stress index (OSI).
Results: TOS and OSI were significantly higher (P<0.01); TAC level was significantly lower (P<0. 01); in jaundiced
preterm neonates than in control group. Following phototherapy there were significant increase in TOS and OSI (P<0.
01) and decrease in TAC (P<0.001).
Conclusions: Both hyperbilirubinemia and phototherapy induce oxidative stress in preterm neonates.
: preterm neonates with significant hyperbilirubinemia benefits of phototherapy overwhelm the
Keywords: Preterms, oxidants, antioxidants, hyperbilirubinemia, oxidative stress


Most preterm babies less than 35 weeks
antioxidant effects (6). Reactive oxygen products can
gestational age (GA) has hyperbilirubinemia, that
cause many serious neonatal diseases such as
present with jaundice. When these babies left
retinopathy of prematurity, bronchopulmonary
dysplasia, periventricular l
(hyperbilirubinemia) can be symptomatic in the form
eukomalacia, intraventricular hemorrhage,
of neurologic manifestations. Acute bilirubin
sepsis, necrotizing enterocolitis, and hypoxic ischemic
encephalopathy (ABE) is an acute, progressive, and
encephalopathy(7). Nowadays, the effects
mostly reversible with aggressive intervention,
of newborn diseases on the oxidative system have been
investigated by using different oxidative
encephalopathy [CBE]) is the syndrome of chronic,
markers. There are several studies that reported the
post-icteric and permanent neurologic sequelae that is
effects of both hyperbilirubinemia and phototherapy
associated with more serious condition and
used for its treatment on the oxidative balance of
manifestations are usually irreversible (1). Actually,
neonates (8). Some studies conclude that bilirubin has
increase in bilirubin production in preterm neonates
anti-oxidant effects in neonates (9). Whereas, there are
adds to the risk of long-term neurodevelopmental
many clinical studies that demonstrate that bilirubin
impairment (NDI) or mortality due to neurotoxic effect
has prooxidant effects or no effect on oxidative
of bilirubin (2) that can be manifested as the syndrome
balance of neonates (10). Moreover, some clinical trials
of bilirubin-induced neurologic dysfunction (BIND)
reported increased oxidative stress markers following
(3). Additionally, the incidence of neurologic damage
phototherapy (11).
in preterm infants is also low, so the risk-benefit
Oxidative stress most often occurs as a result
spectrum for interventions should include a weight of
of an imbalance between oxidants, antioxidants, and
the risk of overtreatment and the reduction of long-
free radical production (12). Moreover, preterm
term post-icteric sequelae(4).
neonates have an immature antioxidant system which
The increase of the production of
make them more vulnerable to oxidative stress.
endogenous and exogenous reactive oxygen in the
Mildly elevated level of bilirubin may be
human body is regulated by antioxidant defense
associated with less morbidity and related mortality,
systems (5). However; these systems have not
which could be caused by the antioxidant properties of
adequately protective effects on oxidative stress in
bilirubin. Bilirubin regarded as a potentially cytotoxic,
neonates especially in the preterms. Lipid peroxidation
lipid-soluble waste product, is now known to present
and protein oxidation occur as result of insufficient
potent antioxidant criteria preventing the oxidative

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-

SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:8 /7 /2020

Accepted:7 /9 /2020

Full Paper (vol.814 paper# 16)

c:\work\Jor\vol814_17 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1822-1827

Efficacy of Oxytocin Infusion Versus Tranexamic Acid Infusion in Controlling
Blood Loss During Elective Lower Segment Caesarean Section
Nashwa Elsaid Hassan, Nermeen Ahmed Mostafa Elghareeb, Fady Makram Zaki
Department of Obstetrics and Gynecology, Faculty of Medicine-
Ain Shams University
*Corresponding author: Nashwa Elsaid Hassan, E-mail: FadyMakram.fmz@gmail.com.

Caesarean section represents a risk factor for intrapartum and postpartum hemorrhages and a burden of
ongoing anemia. Therefore, methods of controlling blood loss during caesarean section decrease maternal morbidity and
mortality and enhance the quality of mother's life during puerperium.
Objective: to compare efficacy of oxytocin infusion after oxytocin bolus and efficacy of tranexamic acid infusion after
oxytocin bolus in controlling blood loss during elective lower segment caesarean section.
Patients and methods: The study included 138 legally adult pregnant women (18 ­ 38 years old) with singleton
pregnancies at term (37 ­ 42 weeks) who were recruited from Ain Shams University Maternity Hospital where and
booked for primary elective caesarean section. They were randomly divided into three groups. Group (A) was given an
intravenous slow bolus of oxytocin 10 IU over 1 minute and 40 IU oxytocin in 500 l of 0.9% saline solution over 4 hours
after delivery of baby. Group (B) was given an intravenous slow bolus of oxytocin 10 IU over 1 minute and 1 gm
tranexamic acid in 200 ml of 0.9% saline solution over 5 minutes after delivery of baby. Group (C) was given only an
intravenous slow bolus of oxytocin 10 IU over 1 minute after delivery of baby. The three groups would be compared
regarding to gravimetric assessment of "measured" blood loss and mathematical estimation of "calculated" blood loss.
Results: The estimated and calculated blood loses in group (A) were statistically insignificant less than those in group
(B). But those loses in group (C) were statistically significant more than the loses in other groups.
Conclusion: The tranexamic acid infusion after oxytocin bolus is effective as oxytocin infusion after oxytocin bolus in
controlling blood loss during elective lower segment caesarean section. It can help against postpartum hemorrhage with
no considerable side effects.
Keywords: oxytocin, tranexamic acid, postpartum hemorrhage, caesarean section.

eight times the antifibrinolytic activity of an older
Postpartum hemorrhage (PPH) is an obstetrical
analogue, -aminocaproic acid (6). So, TXA has been
emergency. It is a major cause of maternal morbidity,
widely used to reduce blood loss in elective surgery
and one of the top three causes of maternal mortality in
where it reduces blood transfusion by about one-Third
both high and low per capita income countries (1). In the
(7). It was found by Chandrakala and Venkateswarlu (8)
developing world about 1.2%of deliveries are associated
that tranexamic acid significantly reduced bleeding form
with PPH and when PPH occurred about 3% of women
placental delivery to 2 hours post partum in study group
died (2). PPH remains a major cause of both maternal
(given slow IV tranexamic acid 1 gm in 20ml 5%
mortality and morbidity worldwide more so in
dextrose 10 minute before skin incision with oxytocin 20
developing countries with an estimated mortality rate of
units IV Drip after delivery of baby) compared with
140,000 per year or one maternal death every four
control group (given only oxytocin 20 units IV Drip after
minutes. PPH occur in 5% of all deliveries, majorities of
delivery of baby). In the study group total blood loss was
death occur within four hours of delivery indicating that
reduced by 76.8ml as compared with that of the control
it is a consequence of third stage of labour(3).The major
group. There was significant increase in the difference of
four causes for PPH related to four Ts: Tone, Tissue,
postoperative and preoperative value of the Hb % and
Trauma, and Thrombin(4). Their incidences are: 70% for
PCV in the study group compared with the control group.
uterine atony, 20% for genital trauma, 10% for retained

tissue and 1% for coagulation defects (5).
Tranexamic acid is a synthetic analog of the
The study group included 138 pregnant women who
amino acid lysine. It serves as an antifibrinolytic by
admitted at Ain Shams University Maternity Hospital to
reversibly binding four to five lysine receptor sites on
be delivered through elective primary caesarean section.
plasminogen or plasmin. This prevents plasmin from
The study included all legally adult pregnant women (18
binding to and degrading fibrin and preserves the
­ 38 years old), primigravida or multigravida without
framework of 48 fibrin's matrix structure. It has roughly
history of previous caesarean section, at term (37 ­ 42

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-

SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:2 /11 /2018

Accepted:25 /12 /2018

Full Paper (vol.814 paper# 17)

c:\work\Jor\vol814_18 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1828-1834

Histological Structure of Dentate Gyrus in Global Cerebral
Ischemia/Reperfusion Injury and Role of Nitraetes in Protection
Samah Sayed Hassan Elsayed Soliman, Mostafa Mahmoud El-Habiby,
Neveen Mohamed El-Sherif, Marwa Abdel-Samad Al-Gholam
Department of Anatomy and Embryology, Faculty of Medicine, Menoufia University, Menoufia, Egypt.
Corresponding Author: Samah Sayed Hassan Elsayed Soliman, Mobile: (+20) 01205290320,
E-mail: Drsamahsayed91@gmail

Background: Ischemia-reperfusion injury is a hell mark of stroke that happens if blood supply is returned back after
a period of ischemia. However, the benefit from restored blood supply by reperfusion can cause bad effect compared
to permanent occlusion.
Objectives: This study aimed to analyze morphological alterations in dentate gyrus tissue during ischemia and its
effects on histology of cells and to understand mechanisms of brain ischemia-reperfusion injury to develop effective
therapy. Results: Many experiments proved that the mechanisms of ischemia-reperfusion injury include complement
activation, leukocyte infiltration, oxidative stress, platelet adhesion and aggregation and mitochondrial-mediated
mechanisms leading to blood-brain-barrier (BBB) disruption, which leads to brain edema.
Conclusion: In summary, over the past few years there have been significant advancement in our understanding of
molecular and cellular mechanisms of ischemia-reperfusion injury in the brain. The major mechanisms of reperfusion
injury are clear but are still far from being clinically successful. Thus, further investigations on brain reperfusion
injury mechanisms are wanted. Also, role of nitrates in protection for ischemia-reperfusion brain injury.
Keywords: Blood-brain-barrier, Complement, Dentate gyrus, Ischemia, Reperfusion, Mitochondria.


In this review, we discuss pathology, molecular
The goals of this review were to analyze
and cellular mechanisms of brain ischemia-reperfusion
morphological alterations in dentate gyrus tissue
injury, and possible protection of nitrates strategy.
during ischemia and its effects on histology of cells.
According to the World Health Organization (WHO),
This review also summarized and discussed the
15 million suffer from stroke in the world every year
underlying mechanisms responsible for the preventive
(1). Of these, 5 million die and other 5 million are
effects of vasodilators against brain ischemia.
disable. High blood pressure causes more than 12. 7

million strokes injury all over the world.
General appearance and microscopic structure of
Approximately European averages 650,000 die every
brain dentate gyrus:
year from stroke (2). Stroke is the second comes after
The brain dentate gyrus is a cortical area that is a
ischemic heart disease in causes of death, and over a
part of the larger functional cerebral system called the
third of these deaths occur in developing countries.
hippocampal formation, which is a portion of the
Populations in Arab countries have a similar diet and
limbic system (8). The dentate gyrus forms new memory
lifestyle that may increase stroke risk, and affect
episodic. The limbic system includes structures that lie
survival after stroke, as well as other characteristics in
in the border zone between the cortex and diencephalon
comparison with Oriental and Western populations (3).
(9). The limbic structures include limbic lobe (cingulate,
The causes of brain ischemia vary from blood
isthmus and parahippocampal gyrus), hippocampal
clots, sickle cell anemia, congenital heart defect that
formation, amygdaloid nucleus, septal areas,
have a higher predisposition to brain ischemia, plaques
mammillary bodies of the hypothalamus, some
in the arteries, ventricular tachycardia and extremely
thalamic nuclei, habenular nucleus of the epithalamus
low blood pressure. This cause impairment in body
and brainstem structures e.g. autonomic nuclei of the
movement, vision and speaking, which lead to
brainstem, connecting pathways as the fornix, stria
irreversible damage of brain and unconsciousness (4).
terminalis and others. The hippocampal formation
In spite of stroke being a serious life-threatening
consists of hippocampus proper, dentate gyrus,
risk and causing disability, the only effective accepted
subiculum and indusium griseum (9). The hippocampus
treatment is tissue plasminogen activators. However,
is an important component of humans' brains.
the duration limitations of this treatment makes it can
It came from the Greek two words for horse (hippo)
only be given to a small number of patients, 1­2% (5).
and sea monster (campus) and has a C- shaped
Despite decades of intense research, the beneficial
appearance in its coronal section like a sea horse. The
treatment of stroke remains limited (6). In light of this,
hippocampus proper is divided into four distinct fields
we search for effective methods ameliorating cerebral
including CA1, CA2, CA3 and CA4 on the basis of
ischemia-reperfusion injury, which is one of the major
their cellular variances (density, branches of axons,
problems of experimental medicine and biology (7).
dendrites and size) (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/)
Received:8 /7 /2020

Accepted:7 /9 /2020

Full Paper (vol.814 paper# 18)

c:\work\Jor\vol814_19 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1835-1839

Histological Structure of Pancreas in Chronic Pancreatitis and
The Role of Pancreatic Stellate Cells
Ghada Hamed Hasan Romeh, Fatma El-Nabawia Abdel-Hady El-Safty,
Abeer El-Said El-Mehi, Manar Ali Faried
Department of Anatomy and Embryology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
Corresponding Author: Ghada Hamed Hasan Romeh, Mobile: (+20) 1012043009, E-mail: baghdada2012@yahoo.com

Chronic pancreatitis is a progressive inflammatory disease that causes damage and fibrosis of the
parenchyma of pancreas, thus leads to endocrine and exocrine dysfunction.
Objective: The goals of this review were to analyze morphological alterations in pancreatic tissue during chronic
pancreatitis and this analysis addresses the effect of pancreatic stellate cells (PSCs), on chronic pancreatitis, and
collagen fiber deposition.
Results: This review also discussed the different immunohistochemical markers for PSCs. Alpha smooth muscle
actin (-SMA) is an excellent marker for activated PSCs. Transforming growth factor beta (TGF) is an important
profibrogenic cytokine that appears to act by stimulating collagen production by PSCs.
Conclusion: It was concluded that chronic pancreatitis caused a significant and progressive serious effects on the
acinar cells, duct system, and islets of Langerhans in the form of intracellular vacuolations, decreased zymogen
granules, pyknotic nuclei and thickening of the duct wall, and extensive fibrosis. It is hypothesised that during
pancreatic injury, PSCs are activated and proliferated exhibiting positive staining for the cytoskeletal protein -
SMA, and synthesising amounts of extracellular matrix proteins, particularly collagen.
Keywords: Chronic pancreatitis, pancreatic stellate cells, fibrosis.


Chronic pancreatitis is a very progressive
of patients, chronic pancreatitis has been shown to
inflammatory disease altering the pancreas' normal
be hereditary. Almost all patients with cystic
structure and functions. It can be preceded by episodes
fibrosis have established chronic pancreatitis, usually
of acute inflammation in a previously injured
from birth. Cystic fibrosis gene mutations have also
pancreas, or as chronic disease with persistent pain or
been identified in patients with chronic pancreatitis but
malabsorption. It is characterized by an irreversible
in whom there were no other manifestations of cystic
damage to the pancreas as distinct from reversible
fibrosis. Obstruction of the pancreatic duct because of
changes in acute pancreatitis (1). Chronic pancreatitis
either a benign or malignant process may also result in
is the commonest cause of pancreatogenic diabetes
chronic pancreatitis (5). Most of patients with this
followed by pancreatic neoplasia (2). Loss of endocrine
disease have poor quality of life and the management
function by beta-cells in the Langerhans islets is
is still mainly supportive.
considered to be the main causative factor of diabetes

mellitus, although several studies have also suggested
General appearance and microscopic structure of
insulin resistance as a possible additional mechanism
Pancreas is surrounded by a very thin
Among the causes of chronic pancreatitis are
connective tissue capsule that invaginates into the
excessive alcohol intake, autoimmune disorders,
gland to form septa, which serve as scaffolding for
intraductal obstruction, idiopathic pancreatitis,
large blood vessels. Further, these septa divide the
tumors, ischemia, and calcific stones (4).
pancreas into distinctive lobes and lobules (6).
The bulk of the pancreas is composed of pancreatic
factors, genetic predisposition, and progression of the
exocrine cells and their associated ducts. Embedded
disease requires further clarification. Also, recent
within this exocrine tissue are roughly one million
research indicates that smoking may be a high-risk
small clusters of cells called the islets of Langerhans,
factor to develop chronic pancreatitis. In a small group
which are the endocrine pancreatic cells (7) (Fig. 1).

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (

Received:8 /7 /2020

Accepted:7 /9 /2020

Full Paper (vol.814 paper# 19)

8 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1840-1844

Serum Levels of Tumor Necrosis Factor- Like Weak Inducer of Apoptosis
(TWEAK) in Patients With Psoriasis Vulgaris
Amin Mohamed Amer1, Sara Mohammed Saad1, Sally Mahmoud Shalaby1, Mai Ahmed Samir2
1Dermatology and Venerology Department, 2Medical Biochemistry Department,
Faculty of Medicine, Zagazig University, Egypt
Corresponding author: Sara Mohammed Saad, E-Mail: dr.sarasaad87@ yahoo.com

Psoriasis is a chronic, immune-mediated, systemic inflammatory disease that is defined by a
characteristic skin reaction produced when elevated levels of inflammatory cytokines that alter the growth and
differentiation of skin cells. Tumour necrosis factor (TNF)-like weak inducer of apoptosis (TWEAK) has been
implicated in the pathogenesis of variety of inflammatory disorders and autoimmune diseases. However, studies
conducted on the relationship of TWEAK and psoriasis patients are limited.
Objective: We aimed to assess the serum level of TWEAK in psoriatic patients and determine whether levels are
related with clinical variables, such as disease severity and duration.
Patients and Methods: The study was conducted on 30 patients with psoriasis attending Dermatology, Venerology
& Andrology Outpatient Clinic, Faculty of Medicine, Zagazig University Hospitals spanning the period from
January 2019 to March 2019. They were divided into mild, moderate and severe according to Psoriasis Area and
Severity Index (PASI) score, 10 patients in each group. The patients' age ranged from 10 to 60 years old. 10 healthy
subjects with matched age and sex served as control group.
Results: There was non-significant difference between the studied groups regarding age, BMI, sex, family history,
DM and smoking. However, the difference between them was highly significant regarding itching and presence of
stressors. The mean TWEAK levels were significantly higher in psoriasis patients than in control subjects, which
was significantly associated with severity and duration of the disease. There was positive correlation (P < 0.001)
between serum TWEAK levels and severity of psoriasis with highly significant level in severe cases.
Conclusion: The serum TWEAK levels significantly correlated with the clinical state, as represented by the PASI
score. Also, it was found that TWEAK measurement in serum of patients with psoriasis provides a tool for
monitoring disease activity and its use as a marker of disease severity. Thus, they have prognostic significance.

inflammatory mediators from a variety of cell types,
Psoriasis is a common, chronic, relapsing
including endothelial cells and keratinocytes (8).
TWEAK acts through binding to its receptor
characterized by red, scaly papules and plaques, which
expressed on endothelial cells: fibroblast growth
are usually pruritic (1). The disease affects 0.09 -11.4%
factor-inducible 14 (Fn14) (9). This substrate­receptor
of the general population (2). In psoriasis skin cells are
replaced every 3­5 days rather than the usual 28­30
pathological processes. TWEAK promotes the pro-
days (3). These changes are believed to stem from the
inflammatory activities of other cytokines such as
premature maturation of keratinocytes induced by an
TNF-, IL-1, IL-6, and IFN-, which also participate
inflammatory cascade in the dermis involving
in the pathogenesis of psoriasis (10). TWEAK might
dendritic cells, macrophages and T cells (4). These
play a role in IL-17 signal pathways and has been
immune cells move from the dermis to the epidermis
suggested as a potential targeted treatment in
inflammatory diseases (11).
(cytokines). These secreted inflammatory signals are
Only limited evidence has been available about
believed to stimulate keratinocytes to proliferate (5).
the effect of anti-TWEAK treatment in inflammatory
Psoriasis has been considered a T helper type 1
process. Park et al. (12) observed that blockade of Fn14
(Th1)-mediated disease for many years (6). T cells
significantly down regulated IL-17 production related
infiltrating psoriasis skin lesions display a T-
to a variety of inflammatory diseases, including
helper/cytotoxic cell (Th/c) 17 phenotype producing
psoriasis. Although increased TWEAK levels have
the Th/c17 signature cytokines interleukin (IL)-17A,
been evaluated in various inflammatory and
IL-22, and IFN- (7).
autoimmune diseases, limited studies have reported
Tumor necrosis factor (TNF)-like weak inducer
the serum TWEAK levels in small samples of psoriasis
of apoptosis (TWEAK) is a member of the TNF-ligand
patients (13).
superfamily and promotes the expression of pro-

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (

Received:9 /7 /2020

Accepted:8 /9 /2020

Full Paper (vol.814 paper# 20)

c:\work\Jor\vol814_21 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1845-1857
Role of Cardiovascular Magnetic Resonance Imaging in Assessment of
Myocardial Iron Overload in Thalassemic Patients
Wafaa H. Abdallah1, Ayman M. Ibrahim 2, Hanan M. Eissa2, Amgad S. Abdel-Rahman2
1 Department of Radiology, Egyptian Ministry of Health
2Department of Radiology, Faculty of Medicine, Ain Shams University
*Corresponding author: Wafaa Hamed Mohamed Abdallah, Mobile: (+2) 01067474182,
E-mail: wafaahamed83.wh@gmail.com
Thalassemia major anemia patients require repeated blood transfusions, which improves their survival
and quality of life, however it leads to iron overload and cellular damage. Serum ferritin and liver biopsy were used
classically to measure iron overload and to monitor patient response to chelation therapy. Magnetic resonance imaging
(MRI T2*) has proven to be a non-invasive, effective technique in detecting and quantifying iron in the heart and liver
and in adjustment of iron chelation therapy.
Objective: To assess myocardial siderosis among our patients using MRI T2* technique and correlate it with hepatic
iron load and left ventricular ejection fraction (LVEF).
Patients and methods: Our study included 42 cases of monthly transfused patients. Hepatic and myocardial iron
overload were measured by multi-breath-hold MRI T2* technique and a cine view sequence was used to assess left
ventricular function (EF). Results: Myocardial and hepatic iron overload were inter-correlated to each other and
correlated to left ventricular function (LVEF). There was insignificant correlation between cardiac and hepatic T2*
value results (k = 0.014, P > 0.05). However, there was a progressive and significant decline in left ventricular ejection
fraction (r = 0·61, P < 0·001) in patients with low cardiac T2* values (T2* < 20 ms).
Conclusion: MRI T2* technique is a precise, reproducible, and non-invasive technique for measuring tissue iron
concentration and sparing the patients from an invasive biopsy technique. It also benefits in early detection of cardiac
dysfunction and provides a follow up tool helping in chelation therapy adjustment.
Key words: Cardiac MRI, Iron overload, Liver iron concentration, T2*, Thalassemia.

reduction in morbidity and mortality in thalassemia
Frequent blood transfusion is considered to be
patients (9). Patients with T2* values of >20 ms are
the basic treatment for patients with thalassemia major.
regarded as having no cardiac iron load, those with T2*
Despite regular transfusion has lifesaving benefits, it
values between 10 and 20 ms have mild to moderate
can cause further complications, particularly iron
cardiac iron load, and those with T2* values of <10 ms
overload and hemochromatosis (1). Iron accumulation in
are considered to have heavy cardiac iron load (10).
heart can result in cardiac dysfunction, cardiomyopathy
The aim of this study was to evaluate the utility
and heart failure, which is the most common cause of
of MRI T2* technique in assessment of myocardial iron
deaths in these patients (2). The liver is also susceptible
load and to correlate it with hepatic iron load and left
to early iron deposition and liver iron overload, if not
ventricular ejection fraction (LVEF).
diagnosed and properly treated, rapidly develops into

cirrhosis. In order to prevent hemosiderosis, iron has to
be chelated and excreted (3).
Cardiac T2* and liver iron concentration (LIC)
Until recently, liver biopsy was considered the
measurements were performed on 42 thalassemia major
gold standard diagnostic tool to detect iron overload.
patients (18 males and 24 females, mean age 27.9
However, it is invasive and resulting in several
years), in Radiology Department in Ain Shams
complications (4). Serum ferritin was used as a marker
University Hospital, Cairo, Egypt, From January 2018
for iron load as well, but it is not specific as its level can
till June 2019.
be elevated in inflammations such as hepatitis,
Inclusion criteria:
infections and in liver damage (5).
Diagnosis of -thalassemia major based on clinical
The limitations of serum ferritin and liver biopsy
and hematological evaluation.
for estimating organ iron overload make the search for
No age or sex predilection
non-invasive methods, with high accuracy, is necessary
All the patients received repeated blood
for assessing organs iron content (6). The highly
transfusions (15 ml packed RBCs/kg body weight every
sensitive magnetic resonance imaging (MRI) T2*
4-8 week to keep their hemoglobin level at a level of 9-
technique revolutionized thalassemia management,
10 g/dl before each transfusion).
providing a direct assessment of cardiac and hepatic

iron content and evaluating the effectiveness of iron
Exclusion criteria:
chelation therapy (7, 8). This method allowed for early
1. Patients with bad general condition.
diagnosis of liver and heart hemosiderosis and a

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (

Received:8 /7 /2020

Accepted:7 /9 /2020

Full Paper (vol.814 paper# 21)

c:\work\Jor\vol814_22 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1858-1865
Evaluation of Serum Endothelin-1 (ET-1) and Nitric Oxide (NO) Levels in
Unconjugated Hyperbilirubinemic Neonates
Hosny M. A. El-Masry1, Alaaeldin A. Hassan1, Alaa M. Hashim2,
Mohammed Abo-Alwafa Aladawy1, Asmaa Ahmed Alameldin Abdelwahab*1
1Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
*Corresponding author: Asmaa A. Alm El-Dien Abd El-Wahab, Mobile: (+20) 01000541589,
E-Mail: amata2008@yahoo.com

Neonatal hyperbilirubinemia is the most common cause of admission in NICU. Phototherapy is the
golden standerd therapy long time ago, which shows efficacy and safety but its side effects should be studied in
depth. Both endotheline 1 (ET-1) and nitric Oxide (NO) are potent vasoconstrictor and vasodilator respectively and
they are affected by phototherapy.
Objectives: This study aimed to investigate the impact of phototherapy on the level of ET-1 and NO in fullterm
and preterm as well as studying their effect on hemodynamic stability in treated newborns.
Subjects and Methods:
This study included 120 newborn infants who were classified into two groups. 60 patients
(30 term infants and 30 preterm infants < 37 weeks and > 30 weeks) with unconjugated hyperbilirubinemia
indicated for phototherapy and not indicated for exchange transfusion and the onset of jaundice from 2nd to 4th day.
In addition, to 60 apparently healthy newborns as control group with matched age, sex, weight and gestational age.
There was significant increase in both endothelin-1 and nitric oxide in both fullterm and preterm groups
after phototherapy. For fullterm group, ET-1 levels were 53.20 ± 6.17, 55.94 ± 6.30 Pg/ml and 65.42 ± 6.36 Pg/ml
before, 12 hour and 24 hour after phototherapy respectively (p-v alue = 0.048 and 0.013 respectively). Nitric oxide
levels among fullterm group were 54.56 ± 6.95, 59.77 ± 5.03 & 62.23 ± 5.26 umol/L before, 12 hour and 24 hour
after phototherapy respectively (p-value = 0.042 and 0.012 respectively). The means heart rate changes among
fullterm group were 134.50 ± 1.73 and 135.73 ± 3.96 beat/min before and 24 hours after photothearpy (p-value =
Conclusion: There was significant increase in both endothelin-1 and nitric oxide in both fullterm and preterm
groups after treatment with photo-therapy. In addition, a significant increase in mean heart rate and a significant
decrease in mean blood pressure among preterm and fullterm groups befor and after phototherapy and before
phototherapy versus controls.
Keywords: Neonatal hyperbilirubinemia, Phototherapy, Endothelin-1, Nitric Oxide.

heart function by increasing the heart rate and
Neonatal jaundice is defined as yellowish
diminishing the variabilities of heart rate and cardiac
discoloration of the skin, sclera of eyeball, and
output while affecting blood vessel function by
mucous membranes due to deposition of bilirubin in
diminishing the mean arterial blood pressure and
these tissues. Depending upon the cause, jaundice
increasing peripheral blood flow. After phototherapy
may be present at birth or any time during the
treatment, closure of PDA may be affected via
neonatal period. Jaundice due to either indirect
alteration of the fluid homeostasis and cardiovascular
(unconjugated) or direct (conjugated) bilirubin
function (4).
within the first 24 hours of life should be taken
Effect of phototherapy on the autonomic nervous
seriously (1). Phototherapy has remained the standard
system modulatin of heart rate in term neonates are
of care for the treatment of hyperbilirubinemia in
apparent as significant diminution in heart rate
infants for four decades. Efficient phototherapy
variability was documented during phototherapy, a
rapidly reduces serum bilirubin concentration (2) and
phenomenon assumed to be centrally mediated. The
it is generally regarded as a safe method.
reasons for this decrease are yet unknown (5).
The reported side effects have been subjected to
NO has been noted to relax the smooth muscle
extensive and controversial debate and include
and walls of arterioles. The complex endothelial cells
rashes, loose green stools, water loss, oxidative
lining the blood vessels release a puff of NO at each
injury, dehydration and ocular hazards (3). One of the
systole, which gets diffused into the underlying
smooth muscle cell, and thus permits the surge of
phototherapy is "bronze baby syndrome", a greyish-
blood to pass through easily (6).
brown discoloration of the skin that occurs
The pharmacological action of ET-1 is very
exclusively in infants with cholestatic jaundice.
unusual compared with other vasoactive mediators
Phototherapy treatment has been suggested to alter
such as angiotensin-II (ANG-II). It remains the most
This article is an open access article distributed under the terms and conditions of the
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received: 9 /7/2020

Accepted: 8/9 /2020

Full Paper (vol.814 paper# 22)

c:\work\Jor\vol814_23 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1866-1871

Comparative Study between Simple Percutaneous Transluminal Angioplasty and
Drug-Coated Balloons in Chronic Total Occlusion of The Femoro-popliteal Artery
Emad El-dien Ahmed Hussein1, Mohammed Ahmed Mohammed Ismail2,
Ali Mahmoud Mohammed Galal2, Ahmed Khalf Fathy*2
1Department of Vascular Surgery, Faculty of Medicine, Ain Shams University, Cairo,2Department of Vascular
Surgery, Faculty of Medicine, Aswan University, Aswan, Egypt
*Corresponding author: Ahmed Khalf Fathy, Mobile: (+20) 01063454956, E-Mail: dr_a_khalf1986@yahoo.com

Atherosclerotic peripheral artery disease (PAD) affects a growing number of patients in aging
populations. Peripheral artery disease (PAD) accounts for a large proportion of cardiovascular disease (CVD)
prevalence in most world regions.
Objective: This study aims to evaluate and compare the patency, clinical outcome, and limb salvage rates between
the simple percutaneous Transluminal angioplasty and the drug-coated balloons in chronic total occlusion of the
femoropopliteal arterial segment on the short-term course.
Patients and Method: A prospective randomized controlled comparative study was conducted in the vascular
surgery department; Aswan University Hospital during the period from March 2018 to March 2020. In total, 30
patients with a well-established diagnosis of superficial femoral artery (SFA) and/or proximal popliteal lesions
with symptoms of PAD.
Results: The primary patency at 12-month following treatment with DCB was significantly better 100. %, 80.0%,
60.0% at 1, 6, 12 months compared with POBA 86.7 %, 66.7%, 46.7% at 1, 6, 12 months. The rate of clinically-
driven TLR was the same in both groups (26.6%). The use of DCB was safe and did not increase the major adverse
clinical events (death, myocardial infarction, and minor or major amputation) when compared with those seen with
the use of the uncoated balloons).
Conclusion: Use of DCBs is associated with improved vessel patency when compared to POBA in patients with
FPD. There was no difference in clinically driven TLR between DCB and POBA in our study.
Keywords: DCB, Patency, Limb Salvage, TLR, POBA


Endovascular treatment of symptomatic
anti-proliferative drug to reduce both restenosis and
atherosclerotic peripheral arterial disease (PAD) has
the need for reintervention compared with PTA (5).
gained wide-scale acceptance and is now
DCBs are covered with an anti-proliferative
recommended as a primary revascularization strategy
agent, paclitaxel, using urea as an excipient to
in many clinical and anatomical scenarios (1).
facilitate the transfer of paclitaxel to the inner vessel
In the majority of patients with peripheral
surface on balloon inflation. After angioplasty
arterial disease, the femoropopliteal segment is
paclitaxel can persist in the vessel wall for up to 180
days in experimental models (6). The IN.PACT SFA
encourage the endovascular as first-line approach (1).
study evaluated the IN.PACT Admiral DCB with the
The optimal treatment for superficial femoral
area as the excipient of paclitaxel with primary
(SFA) and popliteal arteries remains controversial.
patency of 86.6% at 12 months (7).
Some practical guidelines advise against primary
The ILLUMINATE Pivotal Study assessed
stenting in patients with intermittent claudication,
the Stellarex DCB with paclitaxel and a novel
while others recommend primary stenting in short or
excipient (polyethylene glycol) and showed a patency
intermediate course lesions (2).
rate of 89.5% at 12 months (8).
However, observational studies raised
This study aims to evaluate and compare the
concerns regarding the risk of stent fracture and
patency, clinical outcome, and limb salvage rates
significant restenosis due to the unique mechanical
between the simple percutaneous Transluminal
forces in the superficial femoral (SFA) and popliteal
angioplasty and the drug-coated balloons in chronic
arteries (3).
total occlusion of the femoropopliteal arterial
Although treatment with Percutaneous
segment on the short-term course.
Transluminal Angioplasty (PTA) is effective in

initially restoring blood flow, restenosis from vessel
recoil and neointimal hyperplasia may occur (4).
One approach to this challenge has been the
comparative study was conducted in the Vascular
development of drug-coated balloons (DCB) which
Surgery Department, Aswan University Hospital
combines balloon dilatation with local delivery of an
during the period from March 2018 to March 2020. In
This article is an open access article distributed under the terms and conditions of the
Commons Attribution (CC BY-
SA) license (http://creativecommons.org/licenses/by/4.0/)
Received: 10/7 /2020

Accepted: 9/9 /2020

Full Paper (vol.814 paper# 23)

c:\work\Jor\vol814_24 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1872-1877

Factors Affecting Length of Stay in Pediatric Emergency
Department in Zagazig University Hospital
Mohamed Mosaad Abohashem Ahmed Nassar, Beshir Adhallah Hassan, Hossam Fathi El-Saadany
Department of Pediatrics, Faculty of Medicine - Zagazig University
Corresponding author: Mohamed Mosaad Abohashem Ahmed Nassar, Mobile: (+20) 01000043784,
E-Mail: mmosaad521@gmail.com

Emergency medicine now is recognized as an essential part of public health service. As the services
provided by emergency departments (EDs) increase and the management process becomes more complicated,
patients stay in EDs for longer periods and EDs become more crowded. A number of studies have discussed the
adverse impacts of ED crowding, which include prolonged waiting times, increased complications, and increased
Objective: The aim of this work was to analyze factors affecting length of stay (LOS) in the pediatric ED.
Patients and methods: This Cross-sectional study was conducted in the Pediatric Emergency Unit of Zagazig
University Hospitals, from July 2019 until December 2019. Assuming that rate of admission of children in
Emergency Department is 200 cases/month, so a comprehensive sample of 1200 children was included in the
Results: The age of the studied cases ranged from 1 month to 12 years with mean 3.62 years. Regarding sex,
53.4% were female. In our study, the 43.8% of patients were discharged from the ED in the current study. This
study showed that 71.8% of the studied cases came to hospital from 9 am to 9 pm. There was no statistically
significant difference between length of stay and sex. In the present study, mean value of length of stay (hours)
was low among discharged patients (0.20 ± 0.59) than admitted patients (0.51± 0.58).
Conclusion: We concluded that several factors are associated with high average emergency department LOS.
High LOS may lead to increases in expenditures and may have implications for patient safety, whereas certain
organizational changes, communication improvement, and time management may have a positive effect on it.
Keywords: Length of stay, Pediatric Emergency Department, Zagazig University Hospital.


Emergency department (ED) staff face
who remain in the ED for 8­12 h are 20 % more
unique challenges such as treatment of patients
likely to stay in hospital longer than the national
arriving to the department with dynamic and
average for the relevant admission problem.
unexpected states of illness, dealing with uncertainty
Moreover, this number raised to 50 % if emergency
regarding patient medical histories, and the need for
department LOS was greater than 12h. Another
time-dependent and triage-based decision-making.
study examined one of the direct factors influencing
All of which are often accompanied by high
emergency department LOS known as "access
financial costs to healthcare systems and a pressure
block," when hospital admission remains more than
to be economically efficient (1).
8 h in the emergency department due to a lack of
According to the Institute of Medicine, one
access to appropriate hospital inpatient beds (4).
of the most common weak points of EDs is
The study examined the relationship
crowding, and it is important to understand the
between access block in the ED, defined as the total
causes, effects, and prevention strategies for this.
time exceeding eight hours from a patient's initial
Overcrowding diminishes the capability of the EDs
arrival in the ED to transfer to another department
to manage and provide immediate access and
and inpatient LOS. Results revealed that 7.7 % of
stabilization for patients who have an emergency
11,906 patients experienced access block. In
medical condition (2). In a study analyzing crowding,
addition, the mean LOS was 4.9 days in those who
researchers found three main factors contributing to
experienced access block compared with 4.1 days in
it: input factors reflected sources and aspects of
those who did not. Subgroup analysis showed that
patient inflow, throughput factors reflected
the effect of access block varied across severities of
bottlenecks within the ED, and output factors
illness and diagnosis. For example, the mean LOS
reflected bottlenecks in other parts of the healthcare
was 3.9 days in patients with cardiac diagnosis who
system that can affect the ED (3).
experienced access block compared to 5.6 days in
Excess inpatient LOS was defined as:
cardiac patients who did not experienced access
exceeding the stated benchmark for the relevant
block (4).
diagnosis-related group. They found that compared
The aim of this work was to analyze factors
with patients who stay in the ED for 4­8 h; those
affecting the LOS in the pediatric ED.

This article is an open access article distributed under the terms and conditions of th e Creative
Commons Attribution (CC BY-
SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:11 /7 /2020

Accepted:10 /9 /2020

Full Paper (vol.814 paper# 24)

c:\work\Jor\vol814_25 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1878-1883

Neutrophils-to-Lymphocytes Ratio in Children with Acute Heart Failure
Mohamed Salah Mousa Ibrahim, Azza Ali Khalil, Al-Shaymaa Ahmed Ahmed Ali
Department of Pediatrics, Faculty of Medicine - Zagazig University
Corresponding author: Mohamed Salah Mousa Ibrahim, Mobile: (+20) 01026699717, E-Mail: msmmsm@hotmail.com

Heart failure is a common cause of morbidity and mortality in pediatric patients in the third world.
Heart failure in children occurs due to heart lesions that cause volume overload as in large ventricular septal defect
or due to lesions that causes obstruction to flow as in aortic stenosis.
Objective: This study aimed to evaluate the neutrophils to lymphocytes ratio in children with heart failure & to
investigate if this ratio is helpful in predicting mortality and adverse outcome in those patients.
Patients and methods: Our study was performed over a number of 80 children 40 of them were having CHD with
acute heart failure, 20 of them were congenital heart disease (CHD) without failure and 20 of them were normal.
The was conducted in Pediatric Cardiology Unit and Pediatric ICU, Zagazig University Children Hospitals during
the period from February 2017 till May 2018.
Results: Our present work showed that neutrophils, CRP and NLR were statistically higher in the Heart failure
group compared to cardiac group and control group. While lymphocytes and oxygen saturation (SO2) were
statistically lower in the heart failure group. The echocardiographic findings showed that compared to cardiac
group, the heart failure group was significantly higher regarding PAP and LVEDD but significantly lower
regarding EF and FS.
Conclusion: Elevated NLR seems to be a predictor of short-term mortality in patients with acute heart failure.
Keywords: Neutrophils-to-lymphocytes ratio, Children, Acute heart failure.

relationship between the NLR and in-hospital
Heart failure is a clinical entity where the
mortality in AHF patients has not been assessed (5).
heart does not function to its best level as it does in its

healthy state. Compared with adult patients, where
NLR reflects the balance of the neutrophilia
heart failure resulted from an insult to the
of inflammation and the relative lymphopenia of
myocardium, heart failure in children occurs due to
cortisol-induced stress response. NLR has been
heart lesions that cause volume overload as in large
proposed as a prognostic marker predicting worse
ventricular septal defect or due to lesions that causes
clinical outcomes in cardiovascular diseases
obstruction to flow as in aortic stenosis (1). Acute
including acute heart failure, and acute myocardial
heart failure in children in the developed
infarction (5).
communities is often due to cardiomyopathic causes
The aim of this study was to evaluate the
or palliated congenital heart disease as opposed to
neutrophils to lymphocytes ratio in children with
developing countries where unoperated congenital
heart failure & to investigate if this ratio is helpful in
heart disease and acquired heart disease are the 2 that
predicting mortality and adverse outcome in those
are more prevalent.
Acute heart failure (AHF) is the term used to

describe the rapid onset of or change in symptoms
and signs of heart failure (HF) (3). The prevalence of
The current study was a case-control study
the syndrome is increasing. In addition, AHF is
that was conducted in Pediatric Cardiology Unit and
associated with high mortality and morbidity (4).
Pediatric ICU, Zagazig University Children Hospitals
Therefore, the early identification of patients at high
during the period from February 2017 until May
risk of AHF is important. Many prognostic factors
have been found to be related to AHF in past studies.

Several of these factors are associated with
Ethical approval: The study protocol was
inflammation (3).
approved by Ethics Committee, Faculty of
The neutrophil-to-lymphocyte ratio (NLR) in
Medicine, Zagazig University.
the peripheral blood is reported to be an easily
An informed consent from parents was provided
assessable factor. An increased neutrophil count
after explanation of the nature and the purpose of the
might reflect inflammation, and lymphopenia is an
investigations to the parents prior to participation in
indicator of physiologic stress. Data on the ability of
the study.
the NLR to predict cardiovascular risk in different
This study was conducted on 60 infants and
patient groups have been reported. However, the
children (33 males & 27 females) with congenital
heart disease attending to the Pediatric Cardiology
Unit and the Pediatric ICU, Zagazig University
This article is an open access article distributed under the terms and conditions of the Creative
Attribution (CC BY-SA) license (htt
1878 1878
Received: 10/7 /2020

Accepted: 9/9 /2020

Full Paper (vol.814 paper# 25)

c:\work\Jor\vol814_26 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1884-1889

Excision of Posterior Mediastinal Neurogenic Tumor: Video
Assisted Thoracoscopic versus Thoracotomy
Rezk Zenhom Abogamela and Elkahely Mohamed
Department of Cardiothoracic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt.
Corresponding author: Rezk Zenhom Abogamela, Mobile: (+20)01212401747, E-Mail: rezkzenhom1969@gmail.com

The posterior mediastinal tumors represent different diseases. Most of them are detected incidentally.
Regarding difficult anatomic access for mass in the mediastinum, surgical excision remains the best method for diagnosis
and therapeutic result. Video-assisted thoracic surgery (VATS) is increasingly used for the management of posterior
mediastinal mass. This study aimed at evaluation of the outcomes of VATS compared to conventional thoracotomy in
treatment of posterior mediastinal tumors.
Patients and Methods: A retrospective analysis was performed of 22 patients who underwent surgery for posterior
mediastinal neurogenic tumors at our Department in Security Force Hospital (SFH), Riyadh, KSA from September 2013
to January 2018. Nine tumors were excised via video assisted thoracic surgery (VATS) and 13 tumors via surgical
Results: When compared with the thoracotomy group, patients in the VATS group had a shorter operation time (95±33
min vs. 130±35 min, P=0.023), less blood loss (65±13 mL vs. 180±95 mL, P=0.0005), and shorter time of hospital stay
and discharge (2.5±0.7 days vs. 3.6±0.7 days, P = 0. 0023).
Conclusion: VATS is safer and more effective surgical procedure for excision posterior mediastinal neurogenic tumors
with good outcomes than conventional thoracotomy.
Keywords: Neurogenic tumors, Posterior mediastinum, Thoracotomy, Video assisted thoracoscopy.

The most common posterior mediastinal tumor is
We collected retrospective clinical data of 22
neurogenic tumors. As reported, 95% of thoracic
patients (10 males and 12 females) with neurogenic
neurogenic tumors occur in the posterior mediastinum
tumors of the posterior mediastinum undergoing surgical
are usually asymptomatic. More than 95% of neurogenic
treatment in Security Force Hospital (SFH), Riyadh,
tumors are benign (1). There are different surgical

approaches to mediastinal masses such as median
KSA from September 2013 to January 2018. Age of the
sternotomy, thoracotomy and video assisted thoracic
patients ranged from 16 to 59 years, 13 (59%) patients
surgery (VATS) (2).
underwent thoracotomy and 9 (41%) underwent VATS
VATS become the procedure of choice in the
for removing neurogenic tumors.
treatment and diagnosis of intrathoracic tumors in
Pediatric patients or patients presented by mediastinal
developed countries that previously required sternotomy
neurogenic mass or malignant tumors were excluded
and open thoracotomy (3). It is done by thoracic surgery
from this study.
by insertion of instruments through small chest incisions
Preoperative investigation and evaluation included
under two dimensional video images. The advantage of
computed tomography (CT), in some cases magnetic
VATS includes shortened hospital stay, decease
resonance imaging (MRI), pulmonary function test
postoperative pain, decrease operative complications,
(PFTS), electrocardiography, and routine blood
and less cost (4).
laboratory evaluation.
Major advantage of VATS is in the resection of

posterior mediastinal tumors as the morbidity associated
Ethical approval:
with VATS is minimal as compared to conventional
Approval was obtained from our Institutional
thoracic surgery. However, due to lack of skilled
Review Board of Al-Azhar univeristy before
personnel and decreased facilities, it is not widely
initiation of the study, and written informed consent
practiced in developing countries such as ours (4).
was obtained from all patients to authorize data
So we aimed to compare the outcomes of VATS with
thoracotomy for the removal of posterior mediastinal

neurogenic tumors.

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (

Received:10 /7 /2020

Accepted:9 /9 /2020

Full Paper (vol.814 paper# 26)

c:\work\Jor\vol814_27 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1890-1895

Intravenous Dexamethasone Prolongs the Analgesic Effect of Caudal
Bupivacaine after Hypospadias Repair Surgery
Wesam A. Abo Elwafa, Amr A. Zakaria*, Abdelrahman H. Abdelrahman, Wael A. Mahmoud
Department of Anaesthesia and Intensive Care, Faculty of Medicine, Sohag University
*Corresponding author: Amr A Zakaria, Mobile: (+20) 01004423431, E-Mail: amrsalam381@gmail.com

Dexamethasone has a powerful anti-inflammatory action and has been demonstrated to reduce
morbidity after surgery.
Objective: The aim of this study was to examine the effects of a single i.v. dose of dexamethasone in combination
with caudal block on postoperative analgesia in children.
Patients and methods: Sixty pediatric patients (aged 2-10 years) undergoing hypospadias repair surgery were
included in this prospective, randomized, double-blinded study at Sohag University Hospital. After induction of
general anaesthesia, children received either dexamethasone 0.5 mg kg (maximum 10 mg) (n=30) or the same
volume of saline (n=30) i.v. A caudal anaesthetic block was then performed using 1 ml kg of bupivacaine 0.25%
in all patients.
Results: After surgery, rescue analgesic consumption, pain scores, and adverse effects were evaluated for 24 h.
The time to first administration of acetaminophen (rescue analgesia) was significantly longer in the dexamethasone
group (11.35 ± 2.36 hr vs 8.75 ± 1.33 hr) with a significant value of 0.01. Total amount of the analgesia required
(paracetamol) was significantly lower in dexamethasone plus caudal block group than the caudal block alone (430
mg vs 680 mg) respectively.
Conclusion: Postoperative pain scores were lower in the dexamethasone group and the incidence of adverse effects
was similar in both groups. Intravenous dexamethasone 0.5 mg kg in combination with a caudal block augmented
the intensity and duration of postoperative analgesia without adverse effects in children undergoing hypospadias
repair surgery.
Keywords: Dexamethasone, Bupivacaine, Hypospadias Repair Surgery.

Paracetamol, a low molecular weight phenol
A caudal block is a popular reliable and safe
compound, is another analgesic widely used for
technique for pediatric pain management after
pediatric postoperative pain. Its efficacy depends on the
infraumbilical surgical procedures. It is by far the most
route and dose of administration. Benefits are greater
commonly used regional anesthesia technique. It is a
when it is given through the intravenous route in
good, reliable and easy method to provide perioperative
contrast to oral or rectal forms (9).
analgesia in a variety of pediatric surgery (1, 2). However,
The goal of this study was to evaluate the efficacy
it has the disadvantage of short duration of action and a
of a single dose of intravenous dexamethasone in
significant proportion of patients; despite face moderate
combination with caudal block as regards the
to severe pain as the block resolve (1).
augmentation of the intensity and duration of
Dexamethasone is a corticosteroid hormone with
postoperative analgesia after hypospadias repair
powerful anti-inflammatory as well as analgesic
property. Its administration through epidural route has

been shown to reduce the incidence and severity of post-
operative pain in adults (3) and improved morbidity such
This prospective cohort study design was
as nausea, vomiting, fever and delayed oral intake, in
employed at Sohag University Hospital. 60 ASA status
children (4).
I and II pediatric patients aged 2 to 9 years and
Systemic administration of steroids suppresses
tissue levels of bradykinin and the release of
prospectively enrolled in this study.
neuropeptides from nerve endings. It also inhibits
Children having any contraindication for caudal blocks
synthesis of cyclooxygenase-2 in peripheral tissues and
such as known allergy to local anesthetic agents,
in the central nervous system resulting in a reduction in
prostaglandin production, which contribute to enhanced
disorders, any systemic or local infection, and
nociception in inflamed tissue (5, 6, 7). Dexamethasone
anatomical abnormalities of the spine were excluded
administration through intravenous (IV) route along
from the study. Also, children having other coexisting
with caudal block has been shown to significantly
diseases such as diabetes mellitus, cardiovascular or
reduce severity of pain and rescue analgesic
respiratory problems, history of convulsions,
requirement in the post-operative period (8).
psychiatric disorders, mental retardation and failed
caudal block were excluded from the study.

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Commons Attribution (CC BY-SA) license (

Received:11 /7 /2020

Accepted:10 /9 /2020

Full Paper (vol.814 paper# 27)

c:\work\Jor\vol814_28 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1896-1902

Comparison between Mycophenolate and Cyclophosphamide in
Treatment of Lupus Nephritis
Ayman Abd El Aziz Abd El Rahman, Aldosoky Abd El Aziz Alsaid,
Wael Mohamed Abdelkader Abdelaziz *
Departments of Internal Medicine, Faculty of Medicine, Al-Azhar University, Assiut, Egypt.
*Corresponding author: Wael Mohamed Abdelkader Abdelaziz, Mobile: (+20)01550299959,
E-mail: waelmoh202@gmail.com
Systemic lupus erythematosus is a chronic inflammatory disease that can affect any organ, but very
often injures the kidney. It is more prevalent in women than men across all age groups and populations; the female-
to-male ratio is higher at reproductive age, ranging between 8:1 and 15:1, and is lowest in prepubertal children at
about 4:3. Aim of the Work: To study the effect of intravenous cyclophosphamide versus oral mycophenolate
(MMF) in the treatment of lupus nephritis (LN).
Subjects and Methods: This was a prospective, randomized, comparative study on the efficacy of I.V
cyclophosphamide compared to oral MMF in the induction therapy of LN. In this study 40 patients of systemic lupus
erythematosus with lupus nephritis, were included. All patients were divided randomly into two groups. The first
group included 20 female patients who given Oral Corticosteroid 1mg /kg and intravenous cyclophosphamide 500mg
once every two weeks for 6 months. The second group included 20 patients receiving oral corticosteroid 1mg /kg
and oral mycophenolate 2-3g/day (1200 mg/m2) for 6 months.
Results: - As regard serum creatinine, alb/cr ratio, serum albumin, ESR, Anti DNA, c3, and eGFR there was a highly
significant difference between before/after the treatment in each group, with no significant difference comparing the
two group to each other.
Conclusion: In our study, both MMF and IVC show significant improvement in patients with lupus nephritis with
no superiority of one of them to the other.
Keywords: Mycophenolate; Cyclophosphamide; Lupus Nephritis.


Systemic lupus erythematosus characterizes by
Mycophenolate mofetil (MMF) is widely used
various manifestations, degrees of severity, and phases
in solid organ transplantation and it reduces the rate
of remission and flares [1]. Patients may present with
of acute rejection following renal transplantation [9].
kidney disease, serositis, rashes, cytopenia's, arthritis,

psychiatric, neurological, and other manifestations [2].
Clinically evident lupus nephritis occurs in 35­
This was a prospective, randomized,
75 % of patients with (SLE). The prevalence of kidney
comparative study conducted on 40 female patients
involvement in patients presenting at around 50years of
with lupus nephritis.
age is about 60%, whereas about 80 %of children have
Inclusion criteria
renal involvement during their illness. Lupus nephritis
All patients with a history of systemic lupus
usually occurs within three years after the diagnosis of
erythematosus with lupus nephritis of all stages of
SLE [3-6].
lupus nephritis except stage (I, VI), females only with
It is the most severe manifestation of systemic
age range (15/50) years.
lupus erythematosus. There was no specific treatment
for severe lupus nephritis until 1950. Corticosteroids
Exclusion criteria
were used for LN, between the 1950s and 1970s [7].
Patients with an acute inflammatory process
became the standard of care in induction regimes;
rheumatological diseases), patients who are taking
However, IV CPM was associated with complications
other immunosuppressive therapy, patients with
such as infections, bladder toxicity, and gonadal
malignancies, patients with HCV, HBV, or HIV
problems. To decrease the toxicity, low-dose IV CPM.
infection, and patients who are diagnosed with Lupus
Intravenous CPM (using six biweekly fixed IV doses of
nephritis sage(I, VI)
500 mg IV CPM) and showed equivalent efficacy and
All lupus nephritis patients were divided randomly
less side effects [8].
into two groups:
Mycophenolate mofetil (MMF) is widely used in
The first group included 20 female patients with
solid organ transplantation and it reduces the rate of
lupus nephritis. They were given Oral
acute rejection following renal transplantation [9].
Corticosteroid 1mg /kg and intravenous
IV doses of 500 mg IV CPM) and it showed
cyclophosphamide 500mg once every two weeks
equivalent efficacy and fewer side effects [8].
for 6months

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-

SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:11 /7 /2020

Accepted:10 /9 /2020

Full Paper (vol.814 paper# 28)

c:\work\Jor\vol814_29 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1903-1909
Assist Control Ventilation Versus Synchronized Mode Intermittent
Mandatory Ventilation in Pediatric Intensive Care Unit
Nehad Ahmed Karam Abd El Fatah1, Dalia Abdul Latif Abdul Rahman1, Ibrahim Saleh Farag Agaarib*2
1Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt
2Department of Pediatrics, Faculty of Medicine, Sirte University, Libya
Corresponding author: Ibrahim Saleh Farag Agaarib, Mobile: 00218918939094, E-Mail: newscorpion84@gmail.com

: Ventilator weaning consists of the gradual reduction of ventilatory support and the transfer of
respiratory control and the work of breathing back to the patient, resulting in discontinuation of mechanical ventilation.
: The aim of this study was to compare between assisted controlled (AC) ventilation mode and synchronized
intermittent mandatory ventilation (SIMV) mode for easy weaning in pediatric intensive care unit (PICU).
Subjects and methods: This was non-randomized control trial; 50 patients were selected and divided alternatively
into two equal groups: an AC group (ACG) and an SIMV group (SIMVG). The patients were connected on SIMV or
AC mode according to inclusion and exclusion criteria and follow up of the cases was done regarding ventilator
settings, compliance of the patients, need of sedation, and progress of weaning process.
Results: the results revealed that there wass statistically non-significant difference between the studied groups
regarding progress or weaning interruption. Larger percentage within both groups had progressive uninterrupted
weaning. Conclusion: We found no evidence to support any clear-cut advantage of SIMV or AC in the acute
management of respiratory failure, and we concluded that AC and SIMV could improve and fasten the weaning
process and increase the success rate of weaning.
Keywords: Intermittent, Rate, SIMV, Synchronized, Ventilation, Weaning.


Since its introduction into the modern PICUs,
In this mode, weaning often involves combined
mechanical ventilation has undergone continuous
reduction of all of the above. A spontaneous breathing
evolution. Newer modes of mechanical ventilation have
trial involves allowing the child to breathe spontaneously
on minimal pressure support or through a T-piece
barotrauma/volutrauma. No data exist so far to determine
attached to the ventilatory circuit. Each approach may be
the ventilatory mode that provides the greatest benefit
managed with or without written protocols, or with
with the minimum risk of ventilator induced lung injury.
partial or fully automated ventilator loop algorithms (5).
Each model has precise indication which allows better
Weaning refers to a gradual withdrawal of ventilatory
application on one hand, while avoiding side effects on
support through a stepwise process, rather than
the other (1). The most common ventilator weaning
extubation from full ventilatory support. For some
modes used in weaning children are pressure support
children weaning may take weeks or months, and a few
ventilation, volume support ventilation, synchronized
remain ventilator-dependent (6).
intermittent mandatory ventilation and a spontaneous
In ACV mode, the breaths are patient- or time-triggered,
breathing trial (2). Synchronized intermittent mandatory
flow-limited, and volume-cycled similar to SIMV
ventilation is a combination modes by which patients
mandatory breaths but unlike SIMV, all spontaneous
receive mandatory (set) breaths synchronized with their
breaths are assisted in the same manner. In this mode, the
breathing efforts and according to a pressure- or volume-
volume or pressure delivered in every breath will be the
selected mode. Patients breathe spontaneously with
same, regardless of patient or time triggering (7). Assist
pressure support between ventilator breaths; this results
control ventilation (A/C), is a mode of ventilation where
in patient-ventilator synchrony (3).
every spontaneous inspiratory effort is assisted with a
mechanical breath (8). The aim of this study was to
ventilation (SIMV) has been the conventional mode of
compare between assisted controlled ventilation mode
ventilation in many intensive care units (ICUs) around
and synchronized intermittent mandatory ventilation
the world for decades. In SIMV, the physician sets the
mode for easy weaning in PICU.
respiratory rate, tidal volume and levels of pressure

support (PS), positive end-expiratory pressure (PEEP)

and fractional inspired concentration of oxygen (FiO2).
This study was a non-randomized control trial
Once set, the settings are static, until changed again by
was carried out at PICU, Zagazig University Hospitals,
the operator on the basis of changing monitored
from March 2019 until November 2019.
parameters such as respiratory rate, pulse oximetry
Target population: 50 children in pediatric intensive
(SpO2), end tidal CO2 (PetCO2) or intermittent arterial
care unit.
blood gas (ABG) measurements (4).
Group I (n=25) Patients treated with AC.

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-

SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:11 /7 /2020

Accepted:0 /9 /2020

Full Paper (vol.814 paper# 29)

c:\work\Jor\vol814_30 The Egyptian Journal of Hospital Medicine (October 2020) Vol. 81 (4), Page 1910-1915

Comparative Study between Backdoor and Conventional
Thyroidectomy in Non-Recurrent Goiter
Yasser Aly El ­ Sayed, Tamer Yousef Mohamed, Amr Samir Elsaied, Osama Mohammed Mohammed Mostafa*
Department of General and Endocrine Surgery, Faculty of Medicine ­ Mansoura University
*Corresponding author: Osama Mohammed Mohammed Mostafa, Mobile: (+20) 01011673775,
E-Mail: dr.osama.mans.2020@gmail.com
Thyroidectomy is the most common endocrine surgery. The traditional procedure of thyroidectomy is
through midline splitting of strap musculatures. The Backdoor approach of thyroidectomy is an established method
to explore thyroid and parathyroid lesions. Objective: To evaluate how safe and feasible is the backdoor approach
for thyroidectomy and to compare its results with the conventional thyroidectomy technique.
Patients and methods: This prospective study was conducted at Mansoura University Hospitals. We included 40
cases with benign non-recurrent goiter who were divided into 2 equal groups; group "A" included 20 cases who
underwent the conventional procedure, and group "B" which included the remaining 20 cases who underwent the
backdoor procedure. Results: Regarding the early post-operative period, the backdoor group (group B) experienced
less post-operative pain scores and thus, less need for analgesic requirement (1.67 vs. 3.76 for the other group ­ p =
0.017). One case (5%) in group A was complicated by hematoma and was managed via surgical exploration. Both
groups had the same range of hospital stay after the operation (2 days). Superficial surgical site infection was
diagnosed in one case (5%) in each group. Transient post-operative hypocalcemia was encountered in 5 cases (25%)
in group A and 2 cases (10%) in group B (p = 0.179). Conclusion: Based on our study findings, it was evident that
back door thyroidectomy has more advantages compared to the conventional approach including: Less post-operative
pain as peritracheal fascia is not closed, easy identification of parathyroid glands and recurrent laryngeal nerve and
avoidance of recurrent laryngeal nerve injuries.
Keywords: Backdoor, Conventional Thyroidectomy, Goiter.

7). The respect for the motoricity of cervical strap
The technique of thyroidectomy has evolved over the
muscles is necessary not only because they are
last 200 years. The initial contributions made by
accessory breathing muscles but more importantly
(Kocher). Over the next years, the procedure has been
because of their part in voice pitch control and
safe and with less complication (1). Backdoor
swallowing functions (8, 9, and 10). This study aimed to
thyroidectomy uses the same central neck incision
compare between backdoor and conventional
however reaches thyroid postero-laterally between
thyroidectomy, as regard feasibility and safety, in non-
anterior borders of sternocleidomastoid (SCM) and
recurrent goiters.
strap muscles. It is known as the sternomastoid or
"backdoor" or lateral approach (LA) to thyroid (2).
This prospective randomized control study was
The important structures, which need recognition and
conducted at Endocrine Surgery Unit, Mansoura
preservation during thyroidectomy like parathyroid
University Hospitals. The study group included patients
glands and recurrent laryngeal nerves are postero-
with benign goiters who underwent thyroidectomy
laterally situated in relation to thyroid lobe. LA permits
between July 2016 and July 2018.
an easier access in delivering the gland into operative
Ethical approval: The study was approved by the
field for easier recognition of such structures with less
local Ethics Committee of Mansoura University.
retraction and pulling of strap muscles (3). There are only
Written informed consent was taken from all cases in
some studies about the effectiveness of LA and the
our study after explanation of the aim of the study and
majority of them concluded that LA provided very good
explanation of the complications of each approach.
visualization of these critical structures (2). Division of
The patients were randomized into 2 groups
cervical strap muscles during thyroidectomy is a
according to thyroidectomy technique: Group A
controversial issue. Some surgeons do it routinely to
underwent Conventional Thyroidectomy and Group B
gain adequate exposure of the field. Cervical strap
underwent backdoor thyroidectomy. Randomization
muscles have a role in voice pitch control and
was simple and achieved using the sealed envelope
swallowing functions (4). Some investigators advocate
that strap muscles division has no morbid sequelae and
Inclusion criteria: Simple multinodular goiter, toxic
recommend its liberal use when operating on large,
multinodular goiter and solitary thyroid nodule with
toxic or neoplastic goiters (5). Strap muscles cutting and
expected benign criteria.
reconstitution lead to fibrosis with laryngotracheal
Exclusion criteria: Huge goiters with retrosternal
fixation that impairs vertical mobility together with
extensions, recurrent goiters, malignant goiters, history
strap muscles temporary malfunction with the resulting
deleterious effect on voice and swallowing functions (6,

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) licens e (
Received:12 /7 /2020

Accepted:11 /9 /2020

Full Paper (vol.814 paper# 30)