c:\work\Jor\vol821_1 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 1-5

Intrauterine Device Versus Levonorgestrel As Emergency Contraception.
Observational Study
Ibrahim Saif Elnasr, Mohamed Fahmy, Haitham Hamza, Heba Mahmoud El-Fiqy, Hesham
Ammar
Obstetrics and Gynecology Departments, Faculty of Medicine, Menoufia University, Menoufia
Governrate, Egypt
* Corresponding author: Ibrahim Saif Elnasr, Tel: +201003086747, Email: Ibrahimalisaifelnasr @gmail.com,
ORCID ID; https://orcid.org/0000-0002-5055-228

ABSTRACT
Background:
Emergency contraception (EC) is a method to be used in the case of unprotected sexual intercourse,
failure of a regular contraceptive method and after rape to try to prevent an unintended pregnancy. They include
copper intrauterine devices (IUD) and different types of pills like estrogen-progestin combination pill,
levonorgestrel containing pills (LNG). Objective: This study was conducted to compare the efficacy; satisfaction,
pregnancy rate and side effect of emergency contraception in women who selected either oral levonorgestrel (LNG)
or copper intrauterine device (IUD). Patient and methods: This observational prospective cohort study was
conducted on 200 women enrolled and separated into two groups, IUD group: 100 women used cupper T380A
IUD. LNG group: 100 women using levonorgestrel 1.5 mg divided into two doses each 0.75 mg 12 hours a part.
Satisfaction was assessed using a 5-point Likert scale.
Results: There was significantly higher rate of contraption efficacy in IUD group compared with LNG group
(p<0.05). Significantly higher rates of nausea, vomiting and headache in LNG group (p<0.05) when compared with
IUD group. IUD patients had significantly higher rate of bleeding (p<0.05) and higher rate of satisfaction among
LNG users (p<0.05). Significant association between women satisfaction and efficacy in LNG group (p<0.05) and
significant association between women satisfaction and efficacy in IUD group (p<0.05).
Conclusion:
Emergency IUD has higher efficacy than emergency contraceptive pills (LNG) and has fewer side
effects. However, there is more satisfaction regarding emergency contraceptive pills (ECP) as compared to IUD.
Keywords: Emergency contraception, Emergency IUD, Levonorgestrel, Emergency contraceptive pills,
Intrauterine devices.

INTRODUCTION

Emergency contraception refers to contraceptive
El-Kom City, Menoufia Governorate, Egypt during the
methods that are used to protect against pregnancy
period from May 2017 to May 2018.
occurrence after unprotected intercourse (1).

In fact, a large percentage of pregnancies occur
Ethical approval:
unintended despite the presence of many methods of
The respective approvals of the Review Board
contraception. Unintended pregnancies usually occur
and the Ethics Committee of Faculty of Medicine ,
due to either absence of contraceptives or failure of
Menoufia
University
was
obtained
before
contraceptive method or after rape (2).
proceeding with the study.
Many methods of emergency contraception have

been known but, only six methods have been clinically
used. These are the high dose estrogens, combined
The study protocol and its benefits and
estrogen­progestogens
pills
(Yuzpe
regime),
complications were explained to all participants and all
progestogen only (levonorgestrel) pills, IUCD, danazol
recruited patients completed and signed the "informed
and mifepristone. EC pills that are used nowadays are
consent" form.
marketed in Egypt under brand name contra plan II (two
Inclusion criteria: Multiparous women. Aged 18­ 30
tablets of 0.75 mg levonorgestrel taken together)(3).
years. Unprotected intercourse within 120 h of
This study was conducted to compare the efficacy;
presenting (5 days).
satisfaction, pregnancy rate and side effect of EC in
In our study we excluded Nulliparous women, women
women who selected either oral levonorgestrel (LNG)
with pelvic infection; women over 30 years of age were
or the copper IUD as emergency contraception.
excluded to maximize participant fertility, and other
PATIENTS AND METHODS
contraindications of IUD insertion (abnormal uterine
bleeding, genital cancer, pelvic tuberculosis, AIDS or
This observational prospective cohort study was
high risk for gynecological infections).
conducted in the Obstetrics and Gynecology

Department at Menoufia University Hospital, Shibin

This article is an open access art

icle distributed under the terms and conditions of the Creative
Commons Attribution (CC BY- SA) license (http://creativecommons.org/licenses/by/4.0/)
1
Received: 1/8 /2020

Accepted: 27/9/2020

Full Paper (vol.821 paper# 1)


c:\work\Jor\vol821_2 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 6-10

Prophylactic Use of Tranexamic Acid in Reducing Blood Loss during
Elective Cesarean Section
Ayman A. Soliman, Sayed A. Mahmoud, Ragab M. Dawood, Aliaa A. Fayed, Amira A. Fathey
Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
Corresponding Author: Aliaa Ali Mohamed Fayed, Mobile: (+20)01008106648, E-Mail: aliaafayed3@gmail.com

ABSTRACT
Background:
Primary postpartum hemorrhage (PPH) plays a major role in maternal mortality and morbidity like
severe anemia, blood transfusion requirement, hospital stay and infection. Tranexamic acid is now recommended in
treatment of PPH, yet its prophylactic use before delivery is still not recommended.
Objective:
To assess the efficacy of preoperative administration of Tranexamic acid in decreasing blood loss during
elective cesarean section.
Patients and Methods: The study was conducted at Department of Obstetrics and Gynecology of Menoufia
University Hospitals. It included 100 pregnant females who went through elective cesarean section with age >18 and
< 35 years and singleton alive fetus. They were randomly allocated to two groups: the study group of which women
received 1 gm of tranexamic acid 20 minutes before skin incision and the control group who did not receive
tranexamic acid. The assessment included the following: measurement of blood loss amount and estimation of
postoperative 1st day hemoglobin and hematocrit value.
Results: There was highly statistically significant difference between both groups regarding the amount of blood
loss during cesarean delivery and blood loss 2 hours from end of CS (p 0.001). This was reflected in the percentage
of difference of preoperative and postoperative hemoglobin and hematocrit values, which showed highly significant
statistical difference (p 0.001).
Conclusion:
Tranexamic acid administration before elective cesarean section was effective in decreasing
intraoperative and postoperative bleeding. And in turn reduces the incidence of PPH with no immediate maternal or
neonatal side effects.
Keywords: Cesarean section, Postpartum hemorrhage, Tranexamic acid.

INTRODUCTION
Gynecology, Menoufia University Hospital in the
Cesarean section (CS) is considered one of the
period from March 2019 to March 2020. The study
most common surgeries in the entire world (1). In the
included 100 pregnant women who underwent elective
last three decades, increased cesarean delivery rates has
cesarean section.
been a worldwide concern , witnessed in both
After excluding patients who did not meet
developing and developed conutries. In Egypt, women
inclusion criteria and those who declined to participate,
with less than 3 living children were twice more likely
the patients were randomized into two groups. Group
to go through caesarean birth than women with more
(A) (study group): pregnant women who received 1 gm
parity (2). Primary postpartum hemorrhage (PPH) plays
of tranexamic acid 20 minutes before skin incision and
a major role in maternal mortality and morbidity like
Group (B) (control group): pregnant women who did
severe anemia, blood transfusion requirement, hospital
not receive tranexamic acid. Sealed, consecutively
stay and infection (3), with about 295 000 women died
numbered envelopes containing computer-generated
during childbearing and follwing parturition. About
number (Randomization Generator Version 1.0) were
94% of these deaths took place in settings with poor
opened when the women were recruited. The allocation
resources, with about 65% (two thirds) occurred in the
ratio was 1:1. The Patients were blinded to the groups.
World Health Organization (WHO) African region (4).
A full general examination, including blood
In 2017, WHO recommended that tranexamic
pressure (BP), pulse, height, and weight, was done first.
acid (TXA) should be given in the first 3 hours
Then, body mass index (BMI) was calculated and
following delivery in-patient with established
recorded. Ultrasound was done to ensure viability and
diagnosis of PPH, alongside basic established care for
to determine the gestational age, the presenting part, the
all patients either with PPH delivered vaginally or by
position of the placenta and the amniotic fluid.
cesarean section (5). For this reason, we designed this
Preoperative routine investigation CBC, PT, ABO &
prospective randomized control trial to analyze effect
Rh typing was done.
of prophylactic administration of TXA in decreasing
Preoperative administration of 1 gm of
bleeding during caesarean section.
tranexamic acid [AMOUN company, as 5 mL ampoule

containing 500 mg (100 mg/mL solution) that is, 1 g/10
PATIENTS AND METHODS
mL] intravenously over 10 min at a rate of 1 mL/min,
This prospective randomized clinical study
about 20 min before skin incision in the study group
was carried out in Department of Obstetrics and
with no drug is given to control group. 1 gram of TXA


This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC B
Y-SA) license (http://creativecommons.org/licenses/by/4.0/)
6
Received:3 /10 /2020

Accepted:2 /12 /2020

Full Paper (vol.821 paper# 2)


c:\work\Jor\vol821_3 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 11-20
The Role of Functional MRI in The Evaluation of The Treated Head and
Neck Squamous Cell Carcinoma
Ahmed S. Abdelrahman*, Amgad S. Abdel-Rahman, Mena E.Y. Ekladious
Radiology Department ­ Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Ahmed S. Abdelrahman; Mobile: 01200220999; Email: dr_ahmedsamy@yahoo.com

ABSTRACT
Background:
The diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) map and the
dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) constitute the functional MRI technique with
many oncological applications as it can define tissue microstructure and characterize the post-treatment changes from
a recurrent tumor in treated head and neck squamous cell carcinoma (HNSCC).
Objective: To evaluate the role of the DWI, ADC map and DCE-MRI for characterization of post-treatment changes
and recurrent tumors in patients with treated HNSCC.
Patients and Methods: Forty-five patients with treated HNSCC were included in this study with mean ages of 59 ±
7.5 years. The patients underwent pre and post-contrast head and neck MRI, DWI with ADC map and DCE-MRI,
each study diagnosis was then compared to the patient outcome.
Results: The sensitivity and specificity of the qualitative DWI (DW-MRI) (87.5% and 82.8% respectively) were
higher than the conventional MRI (75% and 75.9% respectively). The ADC cut-off point for the diagnosis of
HNSCC recurrence was 1.095 x10-3 mm2/s with sensitivity and specificity of 87.5%, 86.2% respectively. The DCE-
MRI revealed a significant difference in the type of time intensity curve (TIC) between post-treatment changes and
recurrent lesion (p-value < 0.0001).
Conclusion: The DWI, ADC and the DCE-MRI can be used as a synchronized tool for the differentiation between
post-treatment changes and recurrent tumor in treated HNSCC patients.
Keywords: HNSCC, MRI, DWI, ADC, DCE-MRI.

INTRODUCTION

characterize the physiological properties of the lesion
Head and neck squamous cell carcinoma
including the lesion hypoxia and the angiogenesis (5). It
(HNSCC) is a major medical cause of morbidity and
was validated as a useful technique for differentiating
mortality. The incidence of tumor recurrence after
the benign from the malignant lesions and for
treatment was 15%-50% (1-3).
discrimination between tumor recurrence and the post-
Magnetic resonance imaging (MRI) can
treatment changes in the breast and pelvic masses.
accurately delineate the tumor spread and it is
DWI with apparent diffusion coefficient
considered the investigation of choice for the
(ADC) map measures the differences in water mobility
evaluation of head and neck cancer. However, it
at different tissue microstructures (6). The more cells
exhibited limited results after surgery or radiation
number and nucleus dimensions in the malignant
therapy (4). The surgical treatment distorts the normal
lesions lead to limited water molecules diffusion and,
anatomical structure. It is associated with edema and
consequently to lower ADC values noted in the
fibrosis especially after radiotherapy. This renders
malignant lesion. On the other hand, decreased
accurate differentiation between tumor recurrence and
cellularity and the presence of edema and
the post-treatment changes by the conventional MRI
inflammatory changes in the benign and post-treatment
technique to be difficult (5). Although the recurrent
changes lead to higher ADC values of the necrotic,
tumor demonstrated higher signal intensity in T2-
edematous and fibrotic changes (7).
weighted images (WI) than the benign fibrotic change
The aim of this study was to delineate the
exhibited, yet further studies have demonstrated that
value of the functional MRI including both the DWI,
the non-neoplastic inflammation and edema may also
ADC map and DCE-MRI for differentiating the
demonstrate hyperintense signal in T2 WI (5).
residual/recurrent tumors and the post-treatment
The functional MRI study included the
changes in the treated HNSCC.
diffusion-weighted imaging (DWI) and the dynamic

contrast-enhanced magnetic resonance imaging (DCE-
PATIENTS AND METHODS
MRI), both can delineate the microstructure of
This retrospective study was performed in our
different tissues, which provide a new approach for
institution hospital during the period from February
imaging the neoplastic lesions (5). DCE-MRI can
2018 to September 2020. it included 45 patients with


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/)
11
Received:1 /10 /2020

Accepted: 26/11 /2020

Full Paper (vol.821 paper# 3)


c:\work\Jor\vol821_4 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 21-24
Effect of Laser Acupuncture on Inflammatory Markers and
Chest Expansion in Children with Parapneumonic Effusion
Arwa Gamal Hussieny1, Manal Salah El Dein1, Amera Bahour Gereges2
1Department of Physical Therapy for Growth and Development Disturbance in Children and its Surgery,
Faculty of Physical Therapy, Cairo University
2Consultant of Paediatrics Chest Diseases in El Shekh-Zayed Hospital
*Corresponding author: Arwa Gamal Hussieny, Mobile: (+20) 01063414336, E-Mail: drarwagamal.1992@hotmail.com

ABSTRACT
Background:
Parapneumonic effusion and pleural empyema are the most common complications of community
acquired pneumonia in children. Recently an increase in the incidence and severity of parapneumonic pleural effusion
in paediatric populations has been observed. Objective: To detect the effect of laser acupuncture as a non-invasive
anti-inflammatory treatment procedure on controlling the inflammatory markers and improving chest expansion in
children complaining from parapneumonic effusion following acquired pneumonia.
Patients and methods: Thirty children with parapneumonic effusion as a complication of acquired pneumonia, ranging
in age from 6 to 12 years were selected from El-Abbasia chest diseases hospital. They were randomly assigned into
two groups of equal number (control and study groups 15 patient in each group) Patients in both groups were treated
by selected chest physical therapy program while patients in the study group received an additional laser acupuncture
intervention that was conducted 3 times per week for 2 successive months. Chest expansion and inflammatory markers
were measured before and after the suggested treatment period.
Results: The results showed a statistically significant reduction of C-reactive protein (CRP) a significant increase in
the mean values of chest expansion, while insignificant difference in the mean values of WBCs and Neutrophilia was
recorded. Conclusion: Laser acupuncture therapy is an effective non-invasive physical therapy modality in treating
children with parapneumonic effusion following the acquired pneumonia where it is added to conventional chest
physiotherapy program alone
Keyword: Laser acupuncture, inflammatory markers, chest expansion, parapneumonic effusion.

INTRODUCTION
However, it is more usually because pulmonary
Pediatric
community-acquired
pneumonia
complications to the initial infection have developed.
(PCAP) is defined as the presence of signs and
These may be due to the accumulation of fluid,
symptoms of pneumonia in a previously healthy child
accumulation of air or Atelectasis, leading to pus
due to an infection, which has been acquired outside
formation (empyema) (3).
hospital, it is a leading cause of morbidity and mortality
Parapneumonic effusion is defined as fluid in the
in children worldwide, with streptococcus pneumonia
pleural space in the presence of pneumonia. It is a well-
and mortality rate are significantly higher in developing
known complication of CAP, and it is a common clinical
countries than in the industrialized world (1).
problem that frequently causes dyspnea and abnormal
Community-acquired pneumonia (CAP), the
arterial oxygenation. Infections with Streptococcus
most common serious bacterial infection in childhood, it
pneumonia are the most common cause of this
may be complicated by parapneumonic effusion
complication. The high frequency of pneumonia in
empyema, necrotizing pneumonia, and lung abscess.
children worldwide makes this local complication an
Children with complicated pneumonia require prolonged
important problem. Moreover, an increasing incidence
hospitalization and frequently undergo multiple pleural
of Parapneumonic effusion and Pleural effusion PPE/PE
fluid drainage procedures. Additionally, para-
has been reported since 1990s (4).
pneumonic pleural effusion and empyema are
Pleural effusion causes reduction of chest
considered
different
stages
of
the
same
expansion and leads to lung atelectasis, because the
pathophysiological
process
in
which
pleural
capacity of the thorax is limited and excess fluid causes
inflammation causes fluid to accumulate in the pleural
the lungs to collapse so it is important to emphasize
cavity (2).
expansion of problems areas of the lungs and chest wall
Treatment failure in CAP may be due to
(5).
antibiotic resistance as CAP is the first presentation of an
Physical Therapy management of pleural
underlying condition such as cystic fibrosis, immune-
effusion may include breathing exercises, localized chest
deficiency or congenital thoracic malformation (CTM).
expansion exercises, positioning, chest mobility


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/)
21
Received:20 10/ /2020

Accepted:19 /11 /2020

Full Paper (vol.821 paper# 4)


c:\work\Jor\vol821_5 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 25-31

Peri-Operative Pain Management for Cleft Lip Repair in Children, Bilateral
Infraorbital Nerve Block Versus Combined Intravenous Fentanyl with
Peri-Incisional Infiltration. A Randomized Comparative Study
M Elsonbaty, Mohamed Maher, Ahmed Reda, Khaled Sarhan
Anesthesia Department, Faculty of Medicine, Cairo University
*Corresponding author: M Elsonbaty, Mobile: (+20) 01111110126, Email: jijsonbaty@yahoo.com

ABSTRACT
Background:
The good control of postoperative pain has an important impact on the patient as regards his general
condition, wound healing and hospital stay. Regional nerve blocks and systemic analgesics especially opioids offered
this control but with superiority of the regional block due to avoidance of the side effects of opioids. The assessment
of pain in pediatrics is difficult, as they usually do not have the ability to describe their pain. Pediatric patients
undergoing cleft lip repair can benefit from nerve blocks related to the lip. Different types of analgesia were
described, such as bilateral infraorbital nerve block (IONB), pharmacological analgesics and surgical site infiltration.
Objective: To compare the effect of bilateral infraorbital nerve block with conventional methods (IV fentanyl and
peri-incisional infiltration) as a proper perioperative pain management in children undergoing cleft lip (CL) repair
operation. Patients and Method: Seventy-six children, scheduled for cleft lip repair, were enrolled in this study in
Cairo University Pediatric Hospital (Abu El Reesh). The patients were randomly assigned into two groups: Group
infraorbital nerve block IONB (n=38): received bilateral infraorbital nerve block. Group conventional (n= 38):
received IV fentanyl with surgical site infiltration. Patients in both groups received general anesthesia and our
interventions were performed after induction of anesthesia and before skin incision. Results: This study demonstrated
that the use of bilateral IONB in children undergoing cleft lip repair was accompanied by superior levels of
intraoperative and postoperative analgesia as compared to the use of IV fentanyl with surgical site infiltration in the
same population. This difference was evidenced by significantly less need for postoperative rescue analgesia as well
as lower pain scores up to 24 hours postoperative in the IONB group. Conclusion: This study results indicate that
bilateral ION block is simple, safe and technically easy to perform with good postoperative analgesia.
Keywords: Regional block, Perioperative analgesia, Infraorbital block, Cleft lip.

INTRODUCTION


Cleft lip (CP) is one of the most common
anesthesia techniques are no longer considered as
congenital abnormalities needing surgical treatment in
alternative but instead, as complementary. This is
the early years of life (1). After corrective surgical
especially indicated in pediatrics where regional
procedures, these children subject to intense
anesthesia is performed under general anesthesia. The
postoperative pain. The complications of surgical
combination of the two techniques has dramatically cut
procedure can be airway obstruction and respiratory
down the risks of both procedure (4). Hodges et al. (5)
complications. Giving opioids, needed for intra- and
while reviewing anesthesia for cleft surgeries found that
postoperative analgesia, increases the risk of airway
opioids are better to be avoided, and intraoperative and
obstruction and affects ventilatory control dysfunction.
postoperative analgesia can be achieved by local both
Cleft lip is painful mainly in the first 24­48 h following
infiltration with local anesthetics or by giving nerve
surgery. Morphine is one of the common drugs used for
block. There is a lack of consensus and evidence
postoperative analgesia, and therefore, a minimal 24-h
concerning both techniques of intraoperative and
stay in the recovery room or intensive care unit is often
postoperative analgesia strategies for cleft lip in repair
necessary. Recently there is an increasing awareness
children. Cochrane systematic review about infraorbital
regarding the need for complete wellbeing of the child
nerve block for postoperative analgesia (2016)
after CL repair in the postoperative period and not just a
concluded that: "There was very low-quality evidence
pain free state and decrease the time of postoperative
that infraorbital nerve block either with lignocaine or
stay in hospital (2,3).
bupivacaine may reduce postoperative pain more than
Sedation and other adverse complications
placebo and intravenous analgesia in children
produced by opioids do not help in achieving such a
undergoing cleft lip repair". Further studies with larger
goal. Local anesthesia with nerve block appears to be
samples and standardized observation time and the
the answer in such circumstances. Both regional and
instruments used to measure outcomes were needed (6).
general


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/)
25
Received:15 /11 /2020

Accepted:25 /12 /2020

Full Paper (vol.821 paper# 5)


c:\work\Jor\vol821_6 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 31-36

The Impact of Stria Gravidarum On Quality-of-Life Issues
Mohamed Abdelwahed Gaber1, Aliaa Fathallah Mohamed Elshafie2*
1Dermatology, Andrology and STDs Department, Faculty of Medicine, Menoufia University, Egypt
2Dermatology, Andrology and STDs Department, Tala Central Hospital, Tala, Egypt
*Corresponding authors: Aliaa F.M. Elshafie, Mobile: (+20) 01007641157, E-mail: aliaaelshafie2018@gmail.com

ABSTRACT
Background:
Striae gravidarum is a commonly occurred physiological change among women with pregnancy.
Although these changes are accepted as physiological, the lack of therapeutica and preventive techniques led to
impaired quality of life of women. Objective: To assess the quality-of-life affection as regards emotions, symptoms
and functioning by presence of stria gravidarum in pregnant females. Patients and Methods: This cross sectional
study was carried on three hundred twenty-three pregnant female patients with stria gravidarum over the age of
eighteen years. They were enrolled in the study from the Obstetrics & Gynecology Department, Faculty of Medicine
Menoufia University, Shebin El Kom University Hospital and Local Health Care Centers. This study was conducted
between April 2020 and October 2020. Results: Severe striae gravidarum, score (3-8) was observed in 20.6% of
primiparae cases and 54.9 % of multiparae cases. Mild stria gravidarum, score (1-2) was observed in 79.4 % of
primiparae cases and 45.1 % of multiparae cases. There was significant difference in Dermatology life quality index
(DLQI) mean value between different davey's score scale as (p < 0.001), mild cases with SG had mean value 15.24 ±
1.42 and severe cases. There is significant difference regarding DLQI of pregnant women who did or did not take
preventive steps (p < 0.001). There is significant difference regarding association between Parity and DLQI (p=0.01).
Conclusion: Women suffer from striae should be examined in detail to prevent the development or progression of
striae, particularly in women encountered for the first time or primiparae with severe striae those might be intensely
affected.
Keywords: pregnant females, Quality of life, severity index, Stria Gravidarum, treatment.

INTRODUCTION
besides the changes that occur particularly in abdominal
Stria gravidarum or what is known as stretch
girth (16). Various scoring tools were implemented to
marks is considered a very common dermatological
classify and categorize the severity of the condition as
benign issue in pregnancy that predominantly occur on
regards the physical appearance and the impact on
the skin of the anterior abdominal wall but could appear
psychological quality of life by various prior research
at other sites such as thighs and breasts (1). It influences
groups to help to improve the quality and level of care
the psychological wellbeing and consequently the
giving to those cases (17). Famous examples of those
quality of life (2, 3). Although the underlying cause for
clinically implemented score in research were Davey's
stretch marks is still not fully elucidated, it's a condition
scoring tool implemented in a prior Japanese research
that reduces the quality of beauty in the back mind of
study to assess the gravity of stria gravidarum and the
many females (4, 5). As regards the quality of life after
Skindex 29 tool implemented to evaluate the
occurrence of stria gravidarum, that affects around 90
dermatology specific quality of life (18). Females during
percent of pregnant females during pregnancy is
pregnancy usually were observed by different research
considered a crucial issue to be investigated by
groups to take preventive measures to avoid stria
researchers to aid in analysis of the best management
gravidarum whether or not they occurred denoting its
protocols to enhance the psychological, social and self-
emotional impact and its influence on self-esteem (19, 20).
esteem for many females after finishing their gestational
Therefore, this study aimed to assess the quality-of-life
period (6, 7, 8). It is considered a physical modification of
affection as regards emotions, symptoms and
skin affecting females during pregnancy due to
functioning by presence of stria gravidarum in pregnant
hormonal changes triggered by estrogen, progesterone
females.
and relaxin besides the mechanical challenges that lead

to overstretch of the skin causing collagen breakdown of
PATIENTS AND METHODS
the dermal structure of the skin in a manner that leaves
This cross sectional study was carried on three
atrophic linear marks (9, 10).
hundred twenty-three pregnant female patients with stria
Decreased elastin and fibril content of the skin are
gravidarum over the age of eighteen years. They were
considered to be predisposing factors for those stretch
enrolled in the study from the Obstetrics & Gynecology
marks to occur, that denotes that there is genetic
Department, Faculty of Medicine Menoufia University,
predisposition for the condition as well as the age, race
Shebin El Kom University Hospital and Local Health
and birth weight (11-15). It could occur due to rapid weight
Care Centers. The 323 pregnant women have been
gain during pregnancy, or during second or third
counselled during antenatal care routine visits in third
trimester in different frequencies according to the
gestational trimester. This study was conducted between
clinical condition of the skin and genetic susceptibility
April 2020 and October 2020.


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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
31
Received:25 /10 /2020

Accepted:24 /12 /2020

Full Paper (vol.821 paper# 6)


c:\work\Jor\vol821_7 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 37-39

The Vacuum-Assisted System as A Treatment of Deep Sternal Wound Infections
Following Cardiac Surgery. Cairo University Hospitals Experience
Ahmed S Mahmoud1*, Rafik F B Soliman2, Fouad M Rasekh1
1Department of Cardiothoracic Surgery, Faculty of Medicine, Cairo University,2Department of Cardiothoracic
Surgery, Faculty of Medicine, Menofia University
*Corresponding authors: Ahmed Sayed Hussein, Mobile: (+20) 01090991111, E-mail: drahmed 755@gmail.com

ABSTRACT
Background:
The vacuum-assisted system in wound closure (VAC) is a new modality, which is recently used
widely as a treatment of severely infected wounds. It is a noninvasive way that improves healing of severely infected
wounds that fail to respond to conventional ways of treatment. This type of treatment depends on applying air tight
controlled negative pressure suction directly to the infected wounds. The mechanism of action of this treatment
depends on allowing the growth of healthy granulation tissues of the infected wounds.
Objective: To evaluate the effect of vacuum assisted suction in treatment of deep sternal wound infection after
cardiac surgery.
Patients and Methods: In Cairo University Hospitals, in the period between January 2018 and January 2019, 17
patients (6 men, 11 women) with a median age of 62.5 years (range 50 to 75 years) underwent open heart surgery,
which was complicated by sternal dehiscence and deep sternal wound infection. All those patients were subjected
to the VAC system before any surgical intervention.
Results: All patients involved in this study had complete wound healing without need of any major surgical
intervention (muscle or omental flaps) even without wound debridement. The VAC system was applied for a mean
of 21.5 days (range 15 to 28 days), VAC system was removed when the wound became completely clean with
healthy granulation tissues. After removal of the VAC system, 9 patients (52.9%) were subjected to closure of the
skin and subcutaneous tissues by interrupted stitches while the remaining 8 patients (47.1%) the wound was
completely closed in all layers up to the skin. Duration of hospital stay varied from 22 to 45 days (median 33.5
days). There were no mortalities among all the patients who were involved in this study.
Conclusion: The VAC system is a noninvasive, safe and very effective as a treatment for deep sternal wound
infections following cardiac surgery.
Keywords: Deep sternal wound infections, Vacuum assisted system.

INTRODUCTION
In Cairo University Hospitals, in the period
Deep sternal wound infections after heart
between January 2018 and January 2019, 17 patients
surgery are a major complication and sometimes a life-
(6 men, 11 and women) with a median age of 62.5
threatening
condition,
despite
significant
years (range 50 to 75 years) underwent open heart
improvements in wound care and antibiotic
surgery and complicated by sternal dehiscence and
medications, the incidence of these complications is
deep sternal wound infection, all those patients were
around 4% in the best cardiac centers with a mortality
subjected to the VAC system. All infected patients
rate around 15% (1, 2).
underwent coronary artery bypass surgery (CABG)
Over the past decades, cardiac surgeons have
with use the left internal thoracic artery, the left radial
tried numerous methods of treating deep sternal wound
artery and the greater saphenous vein and no bilateral
infections after heart surgery, ranging from topical
internal mammary artery were used. The preoperative
lavage and wound washing with antibiotics to
patient's characteristics and risk factors were reported
aggressive
surgical
interventions
such
as
in table (1).
reconstructive surgery with pectoral flaps or omental

flaps (3). The idea of VAC was first used in 1996 in the
Table (1): Patient's characteristics and risk factors.
treatment of pressure ulcers in a bedridden patient with
Age (years)
50-75 mean (62.5)
excellent results (4), and since then VAC has become
Female patients
11 (64.7%)
the cornerstone of treating highly contagious wounds
Diabetes
6 (35.2%)
(3, 4). The mechanism of action of the VAC is based on
Body mass index> 35
4 (23.5%)
the expansion of the microcirculation by controlled
Chronic
obstructive
3 (17.6%)
negative pressure on the affected wound, which
pulmonary disease
promotes healthy granulation tissue proliferation (4).
Prolonged
postoperative
2 (11.8%)
Aim of present work was to evaluate the effect
mechanical ventilation
of vacuum assisted suction in treatment of deep sternal
Redo surgery
1 (5.9%)
wound infection after cardiac surgery.
Postoperative reopening
1 (5.9%)

PATIENTS AND METHODS


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37
Received:1 /10 /2020

Accepted:9 /11 /2020

Full Paper (vol.821 paper# 7)


c:\work\Jor\vol821_8 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 40-42

Early Hospital Outcome of Using Both Internal Mammary Arteries in
Cairo University Hospital
Fouad M. Rasekh, Ahmed. S. Mahmoud*
Department of Cardiothoracic Surgery, Faculty of Medicine, Cairo University
*Corresponding authors: Ahmed Sayed Hussein, Mobile: (+20) 01090991111, E-mail: drahmed 755@gmail.com

Abstract
Background:
Long-Using both mammary arteries in coronary artery bypass surgery has a good term results, but it is
not recommended in old patients due to its technical difficulty and increased incidence of sternal wound complications.
Several studies declared that bilateral internal mammary arteries (BIMA) grafting has a great benefit in patients aged
50­60years, but this benefit does not extend to patients aged >60years. This study was designed to analyze the early
hospital results, and experience in preventing sternal wound complications for BIMA grafting in patients 50­60years
old.
Objective: To detect early outcome of using both internal mammary arteries in patients aged 50-60 years in Cairo
University Hospital.
Patients and Methods: Clinical data and echocardiographic and coronary angiography data of 100 patients who
underwent BIMA grafting for coronary artery disease between 2017 and 2019 were analyzed retrospectively to detect
the early hospital results. 100 patients aged 50 to60years. The operation time, aortic clamp time, and cardiopulmonary
bypass time were studied to analyze the operation difficulty. The flow and P.I were studied to analyze the coronary
artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction
(LVEF) were studied to detect heart function.
Results: The operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility
index were recorded. There was no incidence of sternal wound complications or graft occlusion. Furthermore, there
was no significant difference in LVEF post-operation.
Conclusions: Using both mammary arteries in coronary artery bypass surgery is safe and effective for patients 50­
60years old similar to younger patients (<50years).
Keywords: Coronary artery disease, Internal mammary arteries, Cairo University Hospital.

INTRODUCTION

Due to the increase in life expectancy, the
PATIENT AND METHODS
proportion of coronary bypass surgery for elderly
From January 2017 to January 2019, 100 patients with
patients increases (1). Due to the high rate of opening of
coronary artery disease underwent BIMA grafting in
the arterial ducts and its protective effect on the
our hospital.
coronary course of patients (2).
Inclusion criteria: patients with multi vessel disease.
Several studies have shown that the use of both
Exclusion criteria: 1) emergency surgery or patients
breast arteries in coronary artery bypass surgery is
with other critical diseases requiring concurrent
better than a single breast graft in protecting heart
surgery; 2) patients with severe cardiac failure or
function and long-term follow-up after surgery (3, 4).
multiple organ dysfunction before surgery.
However, due to the increased operation time, technical

difficulties, and increased incidence of complications of
Ethical and patients' approval:
sternal wounds, the application of BIMA vaccination is
An approval of the study was obtained from Cairo
not widely used (5). The use of the BIMA vaccination is
University academic and ethical committee. Every
about 6% worldwide and is only recommended for
patient signed an informed written consent for
younger patients (6). Mohammadi et al. (7) reported that
acceptance of the operation.
BIMA vaccination has great benefit in patients aged 50-
Operative methods
59 years.
The surgeries were performed via median
Thus, this study was designed to analyze the
sternotomy. The BIMA and great saphenous vein were
experience of the operation, the graft function during
harvested. In 100 patients the internal mammary artery
surgery, early hospital outcomes, and the experience in
(IMA) was harvested using skeletonization technique
preventing sternal complications of the use of both
(Fig. 1). After the IMA was harvested, heparin was
mammary arteries in coronary artery bypass surgery in
given, and the distal end was cut off. Then, it was
patients 50-60 years old.
wrapped in warm wet gauze for preservation. All of the
Aim of the present work was to detect early
surgeries were performed using heart lung machine and
outcome of using both internal mammary arteries
warm antegrade cardioplegia. The distal and proximal
in patients aged 50-60 years in Cairo University
end were anastomosed before unclamping of the aorta.
Hospital.
The common grafting methods were as follows: the left


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40
Received:1 /10 /2020

Accepted:19 /11 /2020

Full Paper (vol.821 paper# 8)


c:\work\Jor\vol821_9 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 43-47
Reticulocyte Haemoglobin Content and Soluble Transferrin Receptor
Concentration as Markers of Iron Stores in Chronic Kidney Disease in Egyptian Patients
Hassan Abd- Elhady Ahmed1, Yassein Salah Yassein1, Ahmed Ragheb Tawfeek1,
Amira M. Fouad Shehata2, Karim Salah Mahmoud*
Departments of 1Internal Medicine and 2Clinical Pathology, Faculty of Medicine, Menoufia University
* Corresponding author: Karim Salah Mahmoud, Mobile: +20 01098798540, E-mail: kareem_salah2000@yahoo.com

ABSTRACT
Background:
Chronic kidney disease (CKD), also known as chronic renal disease, is progressive loss in kidney function
over a period of months or years. It is an internationally recognized public health problem affecting 5­10% of the world
population.
Objective: To evaluate the role of reticulocyte hemoglobin content and soluble transferrin receptor concentration for
detection of iron deficiency anemia in chronic kidney disease in Egyptian patients compared to conventional markers.
Patients and Methods: This is a cross­sectional study that had been done on 177 Chronic Kidney Disease Egyptian
patients with iron deficiency anemia. Patients had been selected from the Outpatient Clinics and Hemodialysis Unit of the
Internal Medicine Department, Menoufia University Hospital. Subjects had been divided into three groups: group 1
(Hemodialysis group): A number of 49 chronic hemodialysis patients (more than 3 months), group 2 (CKD group): A
number of 88 patients with chronic kidney disease stages 3-5 and group 3 (Controls): Included 40 healthy subjects as a
control group and had been matched with other groups regarding age and gender.
Results: There was statistically significant difference between the studied groups regarding serum iron, serum transferrin
and serum ferritin. There was statistically significant difference between group I, II compared to control regarding total
iron binding capacity (TIBC), Hb, reticulocyte hemoglobin content and serum soluble transferrin receptors (sTfR).
Conclusion: This study concluded that sTfR, and TfR-F index proved to be important tools to determine iron deficiency
anaemia (IDA) in RH anemic patients and TFR index has superior accuracy than sTfR.
Keywords:
Chronic Kidney Disease, Reticulocyte Hemoglobin content, soluble transferrin receptor concentration.

INTRODUCTION
further intravenous (IV) iron should be administrated
Chronic kidney disease (CKD), also known as
until the inflammatory condition has been resolved (4).
chronic renal disease, is progressive loss in kidney

function over a period of months or years. It is an
The hemoglobin content of reticulocyte and soluble
internationally recognized public health problem
transferrin receptor concentration are now considered to
affecting 5­10% of the world population (1).
be the most useful for diagnostic purposes. Moreover, the
Anemia as a frequent complication in chronic
concentration of soluble transferrin receptor confirmed its
kidney disease (CKD). It is often accompanied by various
high diagnostic value in the detection of iron deficiency-
clinical symptoms, such as impaired physical capacity,
based anemia in patients undergoing dialysis for chronic
decreased neurocognitive function, and poor quality of
renal failure at the end-stage compared to conventional
life (2). Causes of anemia in CKD include decreased
serum iron markers (5).
production
of
erythropoietin,
iron
deficiency,
We aimed in this study to evaluate the role of
inflammation, and the accumulation of uremic toxins (3).
reticulocyte hemoglobin content and soluble transferrin
A common clinical problem is distinguishing
receptor concentration for detection of iron deficiency
between functional iron deficiency and inflammatory iron
anemia in chronic kidney disease in Egyptian patients,
block, since the TSAT could be above the 20% and
compared to conventional markers (serum ferritin and
circulating ferritin could be 100 to 700 ng/mL in both
transferrin saturation).
clinical situations. During functional iron deficiency,

ESA treatment induces a decrease in circulating ferritin
PATIENTS AND METHODS
levels, which however remain elevated (generally more
This is a cross­sectional study that had been done
than 100 ng/mL). In contrast, inflammatory process is
on a suitable number of chronic kidney disease Egyptian
characterized by an abrupt increase of serum ferritin
patients with iron deficiency anemia. Patients had been
levels that is associated with a sudden drop in the
selected from the Outpatient Clinics and Hemodialysis
transferrin saturation (TSAT). Measurement of high
Unit of the Internal Medicine Department, Menoufia
sensitivity C-reactive protein (CRP) may be indicated if
University Hospital, Egypt during the period between
occult inflammation is a concern. In this situation, no
2017 ­ 2020.


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43
Received:28 /7 /2020

Accepted:27 /8 /2020

Full Paper (vol.821 paper# 9)


c:\work\Jor\vol821_10 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 48-55

Histopathological Evaluation of Scar Tissue and Adjacent Non-Involved Skin
Rehab Monir Samaka1, Ola Ahmed Bakry2, Nancy Mohammed Fayez3, Iman Seleit2
1Department of Pathology, Faculty of Medicine, Menoufia University, Shebin Elkom, Menoufia Governorate
2Department of Dermatology, Andrology and STDs, Faculty of Medicine, Menoufia University,
Shebin Elkom, Menoufia Governorate
3Department of Dermatology and Andrology, Al Mahala General Hospital, Egyptian Health Ministry
*Corresponding author: Rehab M Samaka, Mobile: +20 01002806239, Email: rehabsamaka@yahoo.com

ABSTRACT
Background
: Previous researches declared that scars are the end outcome of the natural healing and reparative
process as a result of dermal fibrotic scar formation post inflammation. Few studies were conducted to explain the
role of perilesional area in abnormal scar pathogenesis.
Objective: To study the histopathological changes in different types of scars and adjacent apparently non-involved
skin. Hopefully, this insight can set the route for newer therapeutic approaches.
Patients and Methods: This prospective case control study was carried out on 30 participants divided into three
groups. Group1 included ten keloid biopsies, Group2 included ten hypertrophic scar biopsies and Group3 included
ten atrophic scar biopsies. Clinical assessment of scars was done. Skin biopsy specimens were taken from lesional
and perilesional skin and sent to histopathology laboratory.
Results: Increased epidermal thickening was significantly noted in 80% of perilesional specimens of keloid scar and
that was significantly higher than lesional skin, while dermal fibroblasts/myofibroblasts were mildly increased in
80% of specimens and were associated with severe perivascular inflammatory infiltrates in 70% of perilesional
specimens. Myofibroblasts/ fibroblasts and perivascular infiltrate were significantly higher in perilesional than
lesional keloid skin. Epidermal thickening was significantly increased in all perilesional specimens of hypertrophic
scar and was significantly higher than lesional skin. In dermis, hair follicles and sebaceous glands were identified in
100% of perilesional skin. Dermal cellularity was significantly mildly increased in 100% of perilesional specimens
of atrophic and hypertrophic scars and both were significantly higher than normal skin.
Conclusion: Perilesional area is a shadow area and may be a main player in abnormal scar pathogenesis and could
be responsible for progression or regression of scar.
Keywords: Abnormal scars, Atrophic scar, Histopathology, Keloid, Hypertrophic scar, Perilesional area.

INTRODUCTION

Scars are the end outcome of the natural healing
hypertrophic scar reaches a certain size and
and reparative process as a result of dermal fibrotic scar
subsequently stabilizes or regresses (3).
formation post inflammation. They have been
Studies have shown that those with darker
categorized according to clinical and histological
complexions are at a higher risk of keloid scarring as a
appearance
into
various
categories:
keloid,
result of skin trauma and less in those of a Caucasian
hypertrophic, and atrophic scars (1).
background with no reported cases in patients with
This collagen scar tissue alignment is usually of
albinism. Atrophic scars are broadly described as
inferior functional quality to the normal collagen
exhibiting generalized cutaneous atrophy resulting in
randomized alignment. Keloids and hypertrophic scars
loss of cutaneous cells in the epidermis although appear
are caused by cutaneous injury and irritation, including
clinically as a loss of normal dermis. Clinically, atrophic
trauma, insect bite, burn, surgery, vaccination, skin
scars classically appear as depressions of the skin and
piercing, acne, folliculitis, chicken pox, and herpes
commonly occur post acne amongst other causes (4).
zoster infection. Notably, superficial injuries that do
Structure of the skin was histologically changed in
reach the reticular dermis never cause keloidal and
scar tissue. Collagen IV, expressed under the epidermis
hypertrophic scarring (2).
of normal skin, was reduced distinctly in scar tissue.
Keloid is a result of an overgrowth of granulation
Additionally, it was found that keratinocytes in scarring
tissue at the site of a healed skin injury which is then
epidermis were more proliferative than in normal skin.
slowly replaced by collagen type 1. Keloids are firm,
These results indicate that during the skin wound
rubbery lesions or shiny, fibrous nodules, and vary from
healing, altered formation of basement membrane may
pink to red to dark brown in color sometimes
affect the proliferation of keratinocytes, re-epithelial
accompanied by severe itchiness, pain, and changes in
and tissue remodeling, and then result in scar formation
texture. In severe cases, it can affect movement of skin.
(5).
The hypertrophic scar is defined as visible and elevated
Perilesional area is defined as the adjacent
scars that do not spread into surrounding tissues and that
apparently clinically non-involved that removed to
often regress spontaneously. Unlike keloids, the
insure complete excision. The periphery is often thought


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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
48
Received:28 /7 /2020

Accepted:27 /8 /2020

Full Paper (vol.821 paper# 10)


Pediatric airway management The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 56-60

Management of Distal Tibial Intra-Articular Fractures by Using
Ring External Fixators Assisted Arthroscopically
Mohammed Safwat Shalabi, Mohammed Abdel Wahab Ibrahim,
Ashraf Abd Al-Daim Mohamed, Mohammed Osama Mohammed Morsi*
Departments of Orthopaedic Surgery, Faculty of Medicine - Zagazig University
*Corresponding author: Mohammed Osama Mohammed Morsi, Mobile: (+20) 0107682955,
E-Mail: amanymohed77@gmail.com

ABSTRACT
Background:
Tibial pilon fractures are relatively uncommon injuries, representing only 1% of all fractures of the
lower limb and 5% to 10% of those of the tibia. Frequent comminution and the thin soft-tissue envelope in the area
make the treatment of these fractures challenging. The tibial pilon is characterised by a total absence of muscle
coverage and marginal vascularity. Therefore, even moderate trauma often results in extensive soft-tissue damage.
Objective: The aim of this present study was to evaluate the arthroscopic assisted (Ilizarov) ring external fixation of
distal tibial intra articular (pilon) fractures.
Patients and methods: This was a prospective study conducted between February 2012, April 2015 on thirty
patients with closed, and Gustilo Types I & II open fractures of pilon fractures of the distal tibia who were admitted
to Zagazig University Hospitals. During a period of two years, all cases were treated by Ilizarov fixators with or
without limited internal fixation and assessment of intra-articular reduction tibial plafond by arthroscopy.
Results: Nineteen patients had right-sided injury, eleven patients had left sided injury and one patient had bilateral
injury. At the time of injury, the youngest patient was 19 years old and the oldest was 6o years. The results in
relation to pain as distributed according to the fracture. It is noted that the excellent results were with type I & II
fracture, while the fair and poor results were with type II and III fracture.
Conclusion: The present study provided information on the use and the role of ankle arthroscopy in assisting and
evaluation (the value, advantages, techniques of ankle arthroscopy and ring external fixators) of distal tibial intra-
articular reduction after pilon fracture. The study showed that this technique might be a good method to manage the
pilon fractures.
Keywords: Distal tibial intra-articular fractures, Pilon fractures, Arthroscopy.

INTRODUCTION
partially intra-articular; and type C, completely
Two distinct mechanisms are believed to be
intra-articular. Each group is further divided into
responsible for most tibial pilon fractures: low-stress
subgroups that indicate the severity of the
trauma (sports injuries), which is less common and
comminution and the fracture pattern (4).
secondary to rotational forces. The second is high-
The treatment of tibial pilon fractures,
stress trauma (motor vehicle accidents, falls from
particularly high-stress fractures, is complex and often
height and workplace accidents), which is more
difficult. The historically disappointing results of
common
and
produces
axial
transmission
conservative treatment and the first attempts at limited
of the load with the talus pushed onto the distal tibia,
internal fixation led the AO to develop guidelines for
resulting in a multifragmentary implosion of bones and
open reduction and internal fixation. This method has
cartilage structures. The pattern of the fracture with the
produced and still produces good results, particularly
mechanism of injury depends on the position of the
in less severe, low stress fractures, but results are not
foot at the time of trauma. With the foot dorsiflexed,
as good in high-stress injuries. In fractures with severe
compressive forces are placed on the anterior part of
soft-tissue damage and metaphyseal comminution, the
the plafond, whereas with the foot plantar flexed the
introduction of plates and screws through an extensive
forces are directed posteriorly. If the foot is in a neutral
exposure is associated with a high rate of failure and
position, the axial force can also compromise the
severe complications, such as surgical wound
integrity of the articular surface (1). Several
infections, osteomyelitis, and non-union (5).
classification systems have been proposed for tibial
Hybrid external fixation represent a possible
pilon fractures. Rüedi and Allgöwer introduced a
alternative method to provide stable fixation and
classification that divides fractures into three groups
reduce complications. These devices have gained
according to the degree of displacement and
increasing popularity among orthopaedic surgeons
comminution of the articular and metaphyseal
because they provide a stable fracture synthesis that
fragments (2), to which Ovadia and Beals added two
can drastically reduce soft-tissue damage. However, in
fracture variants (3).
some cases, a relatively simple and standardized
Currently, the most widely used classification
method of assembly of the external fixation is balanced
is the AO/OTA classification, which divides fractures
by the need for minimal additional internal fixation to
into three groups: type A, extra-articular; type B,
restore proper joint congruity.
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56

Received:2 /10 /2020

Accepted:20 /11 /2020

Full Paper (vol.821 paper# 11)


c:\work\Jor\vol821_12 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 61-66

The Role of Intermediate Monocytes (CD14+CD16+) in Development and
Diagnosis of Recent Type 1 Diabetes in Children
Mona Kamal Mohamed Abdelghany*1, Mervat Abdallah Hesham1,
Zeinab Ismail Eldarawany1, Naglaa Ali Khalifa2
Departments 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Zagazig University.
*Corresponding author: Mona Kamal Mohamed Abdelghany, Mobile: (+20) 01272036363,
E-mail dr.monakamal2014@gmail.com

Abstract
Background:
Monocytes play an important role in antigen presentation and cytokine production to achieve a
proper immune response and are therefore largely implicated in the development and progression of
autoimmune diseases such as Type 1 diabetes mellitus.
Objectives: To determine the significance of expanded intermediate monocytes as a predictive factor for the
poor residual islet -cell function in children with recent-onset Type 1 diabetes mellitus.
Subjects and methods: This study was a case- control study carried out at Pediatric Endocrinology Outpatient
Clinic and Clinical Pathology Department, Zagazig University Hospital. It included 20 patients with recent
onset T1DM and 20 age and sex matched healthy children as a control group. All studied groups were subjected
to full history taking, thorough clinical examination and laboratory investigations in the form of CBC, fasting
blood glucose, C-peptide and serum HbA1c levels. Cell-surface monocyte phenotypic analysis was performed
after staining with human anti-CD14 and anti-CD16 by flow cytometry.
Results: There were highly significant increase in the ratio of intermediate monocytes and significant increase
in the ratio of classical, non-classical monocytes in T1DM group compared to control group.
Conclusion: The intermediate monocyte population was expanded in pediatric patients with T1DM. As these
cells were shown to have pro-inflammatory activity, they are likely to be implicated in the impaired function
of -cells, with deleterious consequences for the development of T1DM.
Keywords: Children, Type 1 Diabetes Mellitus, Intermediate Monocytes, -cells.


INTRODUCTION
rheumatoid arthritis, heart and coronary artery
Type 1 diabetes mellitus (T1DM) is
disease, and type 2 diabetes (4). In addition,
considered an autoimmune disease in which the
monocytes expand in patients with human
function of pancreatic -cells, which secrete
immunodeficiency virus as they promote
insulin, is impaired and this is due to auto reactive
expansion in memory T cell (5). The marked
immune cell-mediated destruction (insulitis).
expansion in intermediate monocytes in patients
T1DM is also characterized by dysregulation of
with T1DM was demonstrated to produce more
blood glucose level due to impairment of the
tumor necrosis factor-alpha (TNF-). This factor is
pancreatic -cell function leading to increase
an effective inflammatory factor (6). Therefore, this
hemoglobin A1c level (HbA1c) in peripheral blood
factor TNF- has been correlated with the severity
(1).
of T1DM (7). There is evidence that the
There are many studies suggest that the
intermediate monocyte has an antigen-presenting
development of T1DM is associated strongly with
function with a dendritic cell-like feature (7). Upon
different immune cell subsets, which include
antigen
stimulation,
studies
proved
that
monocytes. This increase in the monocyte
intermediate monocytes became the main
population especially the intermediate subgroup
producers of inflammatory factors, like interleukin
has been shown to trigger the destruction of
(IL)-1, IL-6, and TNF- (8). Recent studies
pancreatic -cell (2).
showed that the expansion of intermediate
Monocytes are classified into three
monocytes could trigger the destruction process of
subgroups based on the differential expression
-cell (9, 10).
level of CD14 (a lipopolysaccharide (LPS)
The aim of the study was to determine the
receptor) and CD16 (FcRIII). These subgroups
significance of expanded intermediate monocytes
are classical (CD14++ CD16-), which make about
as a predictive factor for the poor residual islet
85%, intermediate (CD14+CD16+) that is about
-cell function in children with recent-onset Type
5% and non-classical (CD14dim CD16++) that is
1 diabetes mellitus.
about 10% (3). Many studies proved that there is

expansion in Intermediate monocytes subgroup in
SUBJECTS AND METHODS
many inflammatory and autoimmune conditions,
Study design: A case-control study that was
for example chronic kidney disease, active
performed in Pediatric Endocrinology Outpatient

Clinic, Zagazig University Hospital and Clinical


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/)
61

Received:28 /6 /2020

Accepted:27 /8 /2020

Full Paper (vol.821 paper# 12)


c:\work\Jor\vol821_13 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 67-73

Predictive Factors of Difficult Laparoscopic Cholecystectomy
Esmail Tharwat Kamel Awad*, Mohammed Abdel Fattah Abdel Rahim, Ahmed Mohamed Hassan
General Surgery Department, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
*Corresponding author: Esmail Tharwat Kamel Awad, Email: esmailsarwat95@gmail.com, Mobile: +20 01008877548

ABSTRACT
Background:
Laparoscopic cholecystectomy is considered the gold standard treatment of symptomatic cholelithiasis,
preoperative prediction of the difficult surgery is an important aspect of planning laparoscopic surgery.
Objective: The purpose of this prospective study is to evaluate, analyze, and document different predictive factors of
difficult laparoscopic cholecystectomy and whether conversion rate to open surgery and complications can be
minimized during laparoscopic cholecystectomy. Patients and Methods: This is a prospective clinical study done on
100 patients complaining of calcular cholecystitis admitted to having (LC) at the Department of Surgery Faculty of
Medicine Al-Azhar University Hospital in Assiut and Al-Arish General Hospital from May 2018 to January 2020.
Results: Univariate analysis of pre-operative risk factors versus operative data variables showed that male gender was
associated with prolonged operative time. Age above 45 years was associated with prolonged dissection time, GB bed
dissection time. BMI of 30 or more was associated with prolonged GB bed dissection time. Palpable GB was associated
with prolonged operative time, prolonged GB bed dissection time, prolonged GB extraction time, and increased risk for
conversion to open surgery. Distended GB in ultrasound was associated with prolonged operative time. Solitary stone
in GB was associated with prolonged extraction time. Conclusion: Pre-operative factors can help to predict a difficult
LC. This information may be useful to both the patient and the treating surgeon. Prediction of a difficult procedure
would allow the surgeon to discuss the likelihood of conversion with the patient and prepare him/her psychologically
as well as planning their recovery and explaining their absence from work.
Keywords: Laparoscopic Cholecystectomy, Predictive Factors.

INTRODUCTION


Laparoscopic cholecystectomy LC) since its advent in
Medicine Al-Azhar University Hospital in Assiut and
1987(1) has dramatically replaced open cholecystectomy
Al-Arish General Hospital from May 2018 to January
in
the
management
of
cholecystolithiasis(2).
2020.
Laparoscopic cholecystectomy provides a safe and
Surgical procedure (LC) adopted by all surgeons
effective treatment for most patients with symptomatic
corresponded with the American method: The patient is
gallstones(3) and is the treatment of choice for
placed in the supine position, the surgeon stand on the
cholelithiasis. It has now become the most common
left side of the patient. Pneumoperitoneum is created
operation performed by general surgeons(4).
with carbon dioxide gas.
The
advantages
of
laparoscopic
Patients were excluded from the study according to the
cholecystectomy are earlier return to bowel function,
following criteria: Patients with a history of upper
less postoperative pain, cosmetics, shorter length of
abdominal surgery, patients with evidence of
hospital stay, earlier return to full activity, and decreased
concomitant choledocholithiasis or dilated bile ducts,
overall cost (5-7). Conversion to open cholecystectomy is
patient
contraindication
to
laparoscopic
neither a complication nor a failure but an attempt to
cholecystectomy e.g. uncompensated cardiac and
avoid a complication(8). Most previous contraindications
respiratory patient, and pregnancy.
to (LC), such as morbid obesity, previous upper
Information's obtained for every patient admitted at
abdominal surgery, and acute cholecystitis are no longer
least 1 day before elective (LC) for symptomatic
absolute contraindications(9), with the growing
cholelithiasis included: The patient's characteristics:
experience, a selection criterion has become more liberal
gender, age and body habits (BMI), the patient's history:
(10). The levels of difficulties during (LC) can be
jaundice, number of previous acute attacks of
predicted based on certain preoperative clinical,
cholecystitis previous abdominal surgery, and ERCP,
laboratory, or radiological parameters(11).The purpose of
clinical examination: positive Murphy's sign and
this prospective study is to evaluate, analyze, and
palpable gall bladder, preoperative laboratory tests,
document different predictive factors of difficult
serum alkaline phosphatase, AST, ALT, GGT, and
laparoscopic cholecystectomy and whether conversion
routine investigation CBC, PT, PC, INR, RBS, urea,
rate to open surgery and complications can be
creatinine, bilirubin and Hepatitis virus profile, and
minimized during laparoscopic cholecystectomy.
preoperative imaging: (ultrasound of gall bladder and

biliary tree).
PATIENTS AND METHODS
Ethical Considerations:
This is a prospective clinical study done on 100
An approval of the study was obtained from Al-
patients complaining of calcular cholecystitis admitted
Azhar University academic and ethical committee.
to having (LC) at the Department of Surgery Faculty of
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67
Received:2 /10 /2020

Accepted:20 /11 /2020

Full Paper (vol.821 paper# 13)


c:\work\Jor\vol821_14 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 74-79

Effect of Iron Deficiency Anemia on HbA1c Levels in Non-Diabetic Individuals
Ahmed Said Mohamed, Essam Nasr Mohamed, Ayman Fathy Abd El Halim, El Sayed Anany Metwally
Internal Medicine Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt.
Corresponding Author: Ahmed Said Mohamed, Mobile:(+20) 01111134983, Email:mousad1998@yahoo.com

ABSTRACT
Background:
Glycated hemoglobin (HbA1c) is the parameter of choice to evaluate the long term degree of
glycaemic control in patients with diabetes mellitus (DM). Iron Deficiency Anemia is the most common cause of
anemia.
Objective:
We study the effect of iron deficiency anemia on HbA1c levels in non-diabetic individuals.
Patients and Methods:
This was a case-control study in the period from February 2019 to September 2019. Included
90 cases at outpatient Clinic of Internal Medicine Department in Zagazig University Hospitals. The patients were
randomly divided (by alternation) into three groups 30 patients, Group1: who are healthy. Group2: who have iron
deficiency anemia. Group3: who has any type of anemia other than iron deficiency anemia. A detailed history of
clinical examination and biochemical examination was performed including HbA1c.
Results:
The study revealed that there was a highly significant difference between the before and after treatment in
the iron deficiency group as regard HbA1c and there was no significant difference between the studied groups as
regard FBG or PPG. Conclusion: There is a significant relation between HbA1c and iron deficiency anemia while
there is no relation between iron deficiency anemia and Fasting blood sugar or Postprandial sugar, Iron deficiency
anemia elevates HbA1c levels in non-diabetic individuals.
Keywords: Glycated hemoglobin, diabetes mellitus, Iron deficiency anemia.

INTRODUCTION
There are several studies on the role of anemia
Glycated hemoglobin (HbA1c) is the parameter
on the HbA1c levels but their results are conflicting(6).
of choice to evaluate the long term degree of glycaemic
Because of the important role of HbA1c on DM
control in patients with diabetes mellitus (DM)(1).
diagnosis and the high prevalence of anemia worldwide.
It reflects the patient's glycemic status over the
So, this study aimed to investigate the effect of IDA on
previous 3 months. HbA1c is widely used as a screening
HbA1c levels in patients without DM.
test for diabetes mellitus, also, HbA1c 6.5%

(48mmol/mol) is recommended as the cutoff point for
PATIENTS AND METHODS
diagnosing DM(2).
This was a case-control study in the period from
HbA1c is a form of hemoglobin with a glucose
February 2019 to September 2019. included 90 cases at
residue attached to the terminal NH2 group (valine
the Outpatient Clinic of Internal Medicine Department in
residue) of one or both HbA beta chains. Red blood cells
Zagazig University Hospitals. The patients were
are freely permeable to the plasma glucose molecules,
randomly divided (by alternation) into three groups 30
and hemoglobin is practically exposed to the same
patients, Group1: healthy control whose mean age was
glucose concentrations as plasma. Therefore, the levels
48.20 ± 8.58 years with a range of (35.0 ­ 62.0) years, 15
of HbA1c reflect more specifically the glycaemic control
males (50%) and 15 females (50%). Group2: iron
from the past 2 to 3 months, the red blood cells half
deficiency anemia whose mean age was 47.0 ± 7.77
lifetime, preceding the measurement(3).
years with a range of (34.0 ­ 61.0) years, 15 males (50%)
Clinically, HbA1c is used to determine
and 15 females (50%). Group 2: non-iron deficiency
improvement or worsening in glycaemic control by
anemia whose mean age was 49.77 ± 8.88 years with a
comparing HbA1c serial results to determine if the
range of (35.0 ­ 62.0) years, 17 males (56.7%) and 13
patients achieve their HbA1c targets, and recently, it has
females (43.3%).
been also recommended to diagnose DM(2).

Depending on the methodology used to measure
Ethical approval: An approval of the study was
HbA1c, several factors can affect or interfere in the
obtained from Zagazig University academic and
HbA1c results(1).
ethical committee. Every patient signed an informed
Traditionally, some diseases and pathological
written consent for acceptance of the operation.
states, such as anemia and hemoglobinopathies, are

considered potential factors that can significantly alter
Inclusion criteria: Patients without anaemia,
HbA1c results(4).
haemoglobin (Hb) more than 13g/dl (if male) or more
Anemia is a public health problem that affects
than 12g/dl (if female) with serum ferritin above 15
worldwide populations. Its primary cause is iron
g/mL and below 150 g/mL (if female) or below 200
deficiency (ID). Approximately one-third of the patients
g/mL (if male),plus complete blood count within the
with anemia have iron deficiency (IDA)(5).
reference values. Patients with IDA- serum ferritin below
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74
Received:26 /6 /2020

Accepted:25 /8 /2020


Full Paper (vol.821 paper# 14)


c:\work\Jor\vol821_15 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 80-88

Comparative Study between Intrathecal Morphine and Nalbuphine Added to
Hyperbaric Bupivacaine 0.5% in Elective Cesarean Delivery
Khaled Mohammed Hassan, Hamza Aboalam Mahmood, Islam Khaled Moustafa*, Ghada Abd el-Gaber Rezk
Department of Anaesthesia, Intensive Care and Pain Management, Faculty of Medicine, Sohag University, Egypt
*Corresponding Author: Islam Khaled Moustafa, Mobile: 002 01224081113, Email: eslamelmaghraby40@yahoo.com

ABSTRACT
Background:
Many additives have been used to improve spinal anesthesia; morphine and nalbuphine are commonly
used drugs.
Objective: This work aimed to compare intrathecal morphine and different doses of nalbuphine in elective cesarean
section (CS).
Patients and Methods: This double-blinded, randomized controlled study was done on 150 patients, American
Society of Anesthesiologist (ASA) grade I to II undergoing elective CS. Patients underwent spinal anesthesia 3 ml
with 10 mg hyperbaric bupivacaine 0.5 % with the addition of a 1 ml volume (morphine or nalbuphine) according to
the group; Group M: 150 µg morphine, Group N1: 1 mg nalbuphine, and Group N2: 2 mg nalbuphine.
Results:
Intraoperative and postoperative hemodynamics, respiratory rate, SPO2 and Apgar score were insignificantly
different in all groups. Postoperative VAS was significantly decreased in group M and was insignificantly different
between group N1 and group N2. Postoperative BROMAGE was significantly higher in group M. Time of rescue
analgesia was significantly increased in group M and was insignificantly different between group N1 and group N2.
Postoperative nausea and vomiting (PONV) was insignificantly different in all groups, and pruritus was significantly
decreased in group N1.
Conclusions:
As additives to hyperbaric bupivacaine in the spinal block, morphine was superior to nalbuphine in
decreasing VAS and increased time for rescue analgesia by prolonged sensory block. Increasing the dose of nalbuphine
up to 2 mg did not increase the analgesic effect. Nalbuphine is superior to morphine in decreasing pruritus, and both
drugs have similar effects on neonatal APGAR score and hemodynamics
Keywords: Morphine, Nalbuphine, Cesarean Delivery.

INTRODUCTION


Spinal anesthesia (SA) for cesarean section (CS)
common -agonist side effects (PONV, pruritus,
is the most common and the most effective maneuver
urinary retention, unwanted sedation, and respiratory
since it is quick to execute with fast onset and full
depression) with obtaining the advantages of analgesia
relaxation of muscles. Lower rate of blockade failure,
of mu and kappa (7-8).
reduced doses of medications, minimal depression of

neonates, and reduced aspiration pneumonia incidence
SUBJECTS AND METHODS
are additional benefits of SA (1, 2).
This double-blinded, randomized, and controlled
Opioids used intrathecally synergize with local
clinical study was conducted at Sohag University
anesthetics (LA) and potentiate the sensory blockade
Hospital from June 2019 to June 2020. Written consent
(prolonging the postoperative analgesic role) with no
was taken from all patients. 150 patients were included
increase in the sympathetic block. They are usually used
and their ages ranged from 18 to 35 years old with ASA
as additives to LA to potentiate their role, minimize the
grade I to II, and undergoing elective CS.
doses of LA and decrease side effects of LA, and

maintain hemodynamic stability (3).
Ethical approval:
Morphine is the basic reference drug of opioids to
An approval of the study was obtained from Sohag
compare with its kind. It is a phenanthrene derivative
University academic and ethical committee. Every
that opiates prototypically in mu and kappa opioid
patient signed an informed written consent for
receptors (4). Efficient analgesia can be acquired from
acceptance of the operation.
0.1 to 2.5 mg of morphine. Low doses of intrathecal
Aim of the study: comparative study between
morphine are used to minimize adverse effects
intrathecal morphine and nalbuphine and between
(pruritus, postoperative nausea and vomiting (PONV)
different doses of nalbuphine (1 & 2 mg) in elective
and respiratory depression) and to provide effective and
cesarean delivery regarding haemodynamics, block
safe CS analgesia (5).
assessment, postoperative analgesia and analgesic
Nalbuphine, an agonist-antagonist opioid, has the
requirement as primary outcome, side effects and
ability to mitigate symptoms of mu and strengthen the
neonatal assessment as secondary outcome.
effects of kappa. It was manufactured in an effort to
Exclusion criteria: Patient refusal, patient with
generate analgesia without mu agonist's unwanted side
significant neurological, psychiatric, or neuromuscular
effects (6). Many researchers tried combining agonist
disease,
drug
abuse,
alcoholism,
suspected
opioids to reduce both incidence and severity of the
coagulopathy, known allergy to some medications,
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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
80

Received:2 /10 /2020

Accepted:20 /11 /2020


Full Paper (vol.821 paper# 15)


c:\work\Jor\vol821_16 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 89-95

Body Mass Index in Systemic Lupus Erythematosus: Relation to
Disease Activity, Bone Mineral Density And Vitamin D Level
Dalia A. El-Sherbiny1, Mohja A. El-Badawy*2, Amira R. Elmahdi3
1Department of Internal Medicine, Rheumatology, 2Department of Physical Medicine,
Rheumatology, and Rehabilitation, 3Department of Internal Medicine, Allergy and Clinical Immunology,
Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Mohja Ahmed Elbadawy, Mobile: 002 01005048716 ­002 01111434418,
E-mail: mohjaelbadawy@gmail.com

ABSTRACT
Background
: High incidence of obesity has been reported in Systemic Lupus Erythematosus (SLE). However, the
relationship between obesity and SLE is still unclear. Studies reported low vitamin D levels and bone mineral
density (BMD) in SLE patients. Moreover, vitamin D plays a vital role in the pathogenesis and complication of
SLE.
Objective: To investigate the link between increased body mass index (BMI), disease activity, BMD, and vitamin
D level in SLE patients .
Patients and Methods:120 SLE patients were classified according to BMI into three groups, normal BMI (<25
kg/m2), overweight (25­29.9 kg/m2), and obese (>30 kg/m2). Laboratory investigations were done, assessment of
disease activity by the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), measuring the serum
levels of 25-hydroxyvitamin D 25(OH) D were assessed.
Results: 30% were overweight, and 45% were obese. Overweight and Obese patients had lower 25(OH) D levels
and a high prevalence of osteoporosis in comparison to patients with normal BMI. SLEDAI score was positively
correlated to BMI and negatively correlated with 25(OH) D and BMD.
Conclusion: Increased BMI is common in SLE and is independently associated with higher disease activity,
osteoporotic rates, and lower 25 (OH) vitamin D levels. These findings are associated with important clinical
implications, which suggests that weight control may be a potential target for improving SLE outcome.
Keywords: Bone mineral density, Obesity, Systemic Lupus Erythematosus, Vitamin D.

INTRODUCTION

Obesity could modify the chronicity and
on the surface of natural killer cells, antigen-presenting
severity of various autoimmune pathologies, through
cells, and B- and T-lymphocytes (10).
the release of pro-inflammatory cytokines which are
Studies demonstrate low BMD and vitamin D in
incorporated in the onset and progression of diverse
SLE patients. An inverse association was observed
autoimmune diseases, like rheumatoid arthritis,
between SLE disease activity and vitamin D serum
psoriatic arthritis, and multiple sclerosis(1). Studies
level. Moreover, low serum vitamin D levels are
reported a high predominance of obesity in Systemic
combined with poor outcomes in SLE patients
Lupus Erythematosus (SLE) ranges between 29 and 50
including fatigue, cardiovascular diseases, cutaneous,
percent (2).
and renal involvement(11).
Reports noticed that obese SLE patients have
In this study, we aimed to study the association
increased gene and protein expression of various pro-
between increased BMI and disease activity, BMD and
inflammatory cytokines as IL-23 (3), and TNF-, which
vitamin D level in a cohort of SLE patients.
linked to total fat mass (4). Obesity is a state of chronic

low-grade inflammation, associated with altered
PATIENTS AND METHODS
immune function and the release of different
The present cross-sectional study enrolled 120
adipokines such as leptin (5).
adult SLE patients who were divided into three groups
Elevated leptin levels were detected in SLE
according to BMI based on WHO international
patients and could be the connection between both
classification (12). Group I included 30 (25%) SLE
obesity and SLE (6-7). Obesity aggravates the
patients with normal weight (BMI < 25 kg/m2), Group
inflammatory burden of SLE disease, and contributes
II included 36 (30%) SLE patients with overweight
to increased cardiovascular disease risk (8). Obese SLE
(BMI: 25 ­ 29.9 kg/m2) and Group III included 54
patients are presented with higher disease activity,
(45%) patients with obesity (BMI 30 kg/m2). Patients
more depressive symptoms, and fatigue in comparison
were recruited from the Department of Rheumatology
to non-obese SLE patients(9).
and the Department of Physical Medicine,
Vitamin D is recognized as an immune
Rheumatology, and Rehabilitation including the
modulator that regulates innate and adaptive immune
Obesity Unit Clinic from May 2018 to September
response in the presence of vitamin D receptor (VDR)
2018.



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89
Received:1 /10 /2020

Accepted:19 /11 /2020


Full Paper (vol.821 paper# 16)


Chronic Graft-versus-Host Disease: An Immunologic Perspective The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 96-100

Acute Graft-versus-Host Disease: An Immunologic Perspective
Sabry A. Shoeib; Alaa E. Abd El-Hamid; Enas S. Zahran, Noha I.A. El-Mowafy
Department of Internal Medicine, Faculty of Medicine, Menoufia University
Corresponding author: Noha I.A. El-Mowafy, E-mail: nohamowafy933@gmail.com, Mobile:(+20)01016362824

ABSTRACT
Background:
Acute graft-versus-host disease (GVHD) following allogeneic hematopoietic stem cell transplant
(AHscT) is an immune triggered process, leading to profound immune dysregulation and organ dysfunction.
Three phases summarize the development of the immunopathophysiology of acute GVHD: an afferent phase, an
efferent phase and an effector phase. A panel of plasma biomarkers including IL-2-receptor-a, TNF receptor-1,
IL-8, and hepatocyte growth factor has been suggested as a confirmatory tool for the diagnosis of acute GVHD
at the onset of clinical symptoms and to provide prognostic information independent of GVHD severity. Initial
therapy for acute GVHD ranges from a simple observation or a trial of topical corticosteroids for skin GVHD of
stage or , to systemic treatment in patients with grade -V acute GVHD.
Objectives: The aim of this work is to summarize the most recent available data concerning acute graft versus
host disease from biology, immunopathogenesis, diagnosis and therapy.
Material and Methods: We searched the PubMed and Google scholar databases for relevant studies acute
graft-versus-host disease an immunologic perspective.
Conclusion:
Acute graft versus host disease (aGVHD) remains the second leading cause of death following
allogeneic hematopoietic stem cell transplant (AHSCT). Over the last five years, the progress in understanding
the pathophysiology of this immune based-process helped redefine graft versus host reaction and opened new
possibilities for novel preventive and therapeutic approaches.
Keywords: Bone marrow transplantation, Acute versus host disease.


INTRODUCTION

Acute graft-versus-host disease (GVHD)
liver and gastrointestinal tract, occasionally the eyes
following allogeneic hematopoietic stem cell
and oral mucosa. It often presents with skin rash,
transplant (AHscT) is an immune triggered process,
diarrhea, elevated bilirubin, and it is associated with
leading to profound immune dysregulation and organ
recurrent infections. Acute GVHD most commonly
dysfunction. Despite pivotal advances, acute GVHD
occurs 2 to 42 weeks after stem-cell infusion. A
remains the second leading cause of death, after
hyperacute form of GVHD can occur within the first
disease relapse, in patients undergoing AHscT (1).
2 weeks of AHscT, and is usually due to significant
Historically, acute GVHD has been defined as a
HLA mismatch or inadequate GVHD prophylaxis. It
manifestation of rejection occurring in the first 100
can be rapidly fatal (6). A panel of plasma biomarkers
days following AHscT, while chronic GVHD
including IL-2-receptor-a, TNF receptor-1, IL-8, and
referred to signs of rejection occurring after 100
hepatocyte growth factor has been suggested as a
days. However, a clear distinction between the two
confirmatory tool for the diagnosis of acute GVHD at
conditions has been challenged by the recognition of
the onset of clinical symptoms and to provide
signs of acute GVHD and chronic GVHD outside of
prognostic information independent of GVHD
these delineated periods (2). Evolution in clinical
severity (7). There are no standardized preventive
immunology brought more insight into the
measures for acute GVHD. Prophylactic approach is
pathogenesis of GVHD and several components were
based mainly on immunosuppression either by T cell
identified to interplay in the mechanism of GVHD: a
depletion or pharmacologically. Immunosuppression
genetic component favoring the role of HLA
remains the primary pharmacologic strategy to
compatibility in AHscT and immune/biologic
prevent GVHD. The most commonly includes a
component (3). Risk factors for the development of
combination of a calcineurin inhibitor (cyclosporine
acute GVHD, other than the extent of HLA disparity,
(csa) or tacrolimus (TAc)) and a short course of
include increased age of both the recipient and the
methotrexate (MTX) (8). In acute GVHD, treatment
donor, gender disparity, multiparous female donors,
should always be tailored to the severity of the
ineffective GVHD prophylaxis and the intensity of
presentation and targeting the symptoms. Initial
the transplant conditioning regimen and the source of
therapy for acute GVHD ranges from a simple
graft (4). Classically, three phases summarize the
observation or a trial of topical corticosteroids for
development of the immunopathophysiology of acute
skin in GVHD of stage or , to systemic treatment
GVHD: an afferent phase, an efferent phase and an
in patients with grade -V (8). Alternative therapies
effector phase (5). Clinical manifestations of acute
for steroid refractory cases include antithymocyte
GVHD include specific derangements in the skin,
globulin (ATG), cyclosporine alone, mycophenolate


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96
Received:3 /10 /2020

Accepted:29 /11 /2020


Full Paper (vol.821 paper# 17)


c:\work\Jor\vol821_18 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 101-105

The Contribution of Tumor Necrosis Factor- (TNF-) to Pathogenesis of
Childhood Primary Immune Thrombocytopenia: Single Center Study
Mervat Abdallah Hesham1, Asmaa Mohamed Husny Esh2, Ahmed Mokhtar Beshik*3
Departments of 1Pediatric and 2Clinical Pathology Faculty of Medicine, Zagazig University, Egypt.
3 Department of Pediatric, Zliten Teaching Hospital, Libya
*Corresponding author: Ahmed Mokhtar Beshik, Email: ahmedbeshik@gmail.com

ABSTRACT
Background:
Primary immune thrombocytopenia (ITP) is an autoimmune disease mediated by antiplatelet
autoantibodies that cause platelet destruction and suppression of platelet production. Tumor necrosis factor alpha
(TNF-) is a multifunctional cytokine and is involved in the promotion of inflammatory responses. It also plays critical
roles in the pathogenesis of autoimmune diseases. Objective: To assess the level of TNF- in children with primary
ITP and its contribution to pathogenesis of the disease. Patients and Methods: A case control study was conducted
on 21 ITP patients (13 males and 8 females) and twenty age- and sex-matched healthy children as a control group at
the Outpatient Clinic of Hematology Unit of Pediatric Department and Clinical Pathology Department at Zagazig
University Hospitals, Sharkya, Egypt in the period from November 2019 to April 2020. All patients and control were
subjected to full medical history, thorough clinical examination and laboratory investigations in the form of complete
blood picture, PT, PTT, C3, ANA, anti-DNase and serum TNF- by ELISA kit. Results: There was statistically
significant higher serum TNF- in ITP cases than controls with highest level in the newly diagnosed ITP cases
followed by persistent then chronic cases. TNF alpha showed statistically significant negative correlation with
platelets count and disease duration and positive correlation with WBCs and response to treatment. Conclusion:
Significant differences in TNF alpha levels between ITP patients and healthy controls indicates that TNF alpha
disturbances might be involved in the pathogenesis of ITP in pediatric patients.
Keywords: Immune thrombocytopenia, TNF-, bleeding disorders and platelet destruction.

INTRODUCTION


Primary immune thrombocytopenia (ITP) is an
response to infectious agents. It participates also in the
acquired hematological disorder that is developed
pathogenesis of many autoimmune diseases e.g. ITP(7).
secondary to the production of auto-antibodies against
Therefore, the present study aimed to assess the level of
platelets leading to isolated thrombocytopenia
TNF- in children with primary ITP and its contribution
(peripheral platelet count <100,000/ml) in the absence of
to pathogenesis of the disease.
other causes of thrombocytopenia such as drugs,
SUBJECTS AND METHODS
infections, malignancy, or other autoimmune diseases (1).
A case control study carried out at Hematology and
Over the last two decades, several investigators have
Oncology Unit, Pediatric Department, Zagazig
contributed to an improved understanding of the
University Hospital during a period from (November
complex pathophysiology of this condition in an attempt
2019 to April 2020).
to develop an individualized treatment approach for
The sample size was 42 using OPEW EPI at
affected patients (2).
power 80% and C.I 95%. As seaming that the mean ±
Studies have shown that patients with ITP
SD of (TNF-) in acute ITP is 0.16±0.12 versus
exhibit antiplatelet self-reactive T cells and an
0.08±0.05 in control group. The subjects were divided
imbalance in cytokine levels, which suggests loss of
into two groups: Group (A): composed of 21 children
peripheral tolerance (3). Dysfunction of T cells in ITP
diagnosed with ITP (newly diagnosed, persistent and
may be contributed to loss of tolerance, and impairment
chronic) and Group (B): composed of 21 age- and sex-
of the delicate balance of specific cytokine and serum
matched healthy children as a control group.
cytokines may play a role in the pathogenesis of ITP (4).
Ethical approval:
Understanding the role of T-cell subsets will permit a
The present study was conducted in accordance
better control of autoimmunity through manipulation of
with the ethical standards of the Helsinki Declaration
their cytokine network (5). Dysfunction at cellular
of 1964, as revised in 2000, and was approved by
immunities is evaluated by the levels of cytokines, e.g.
ethical committee of Zagazig University . Informed
TNF- and IL-6. Measurement of levels of cytokines
consent was obtained from the study participants.
may help in prediction of the course of ITP(6).
Inclusion and exclusion criteria: Children from 1-18
Tumor necrosis factor-alpha [TNF-] is a
years of both sexes who were diagnosed with primary
pleiotropic
cytokine
produced
primarily
by
ITP (newly diagnosed, persistent and chronic) were
macrophages and T cells, and has a range of
included in the study. While, children below 1 year or
inflammatory and immunomodulatory activity. It is
above 18 years and patients with secondary immune
considered an inflammatory cytokine that is involved in
thrombocytopenia were excluded.
the inflammatory response and protective immune
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101

Received:29 /7 /2020

Accepted:28 /8 /2020


Full Paper (vol.821 paper# 18)


c:\work\Jor\vol821_19 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 106-114
Effect of Direct Acting Anti-Hepatitis C Drugs on the Heart
Mohamed Mahmoud Ahmed1, Muhammad Abdel-Gawad2,
Mahmoud Ahmed Abd elbaset1, Assem Elkady *1
Departments of 1Cardiology and 2Hepatology, Gastroenterology & Infectious
Diseases, Faculty of Medicine, Al-Azhar University, Assiut
*Corresponding author: Assem Abd elraheim Ahmed Abd elraheim, Mobile: (+20) 01125715555,
E-Mail: assemqadi21@gmail.com

ABSTRACT
Background:
The introduction of direct acting antiviral agents (DAAs) for its treatment represents a major advance
in terms of sustained virologic response (SVR) rates and adverse effect profiles; however, few data are available on
cardiac side effect.
Objectives: We aimed to study the effect of DAA on echocardiographic changes.
Patients and Methods: One hundred and fifty (150) patients with HCV were divided into 3 groups according to type
of treatment given: Group 1 included 50 patients received dual therapy (Sofosbuvir plus Daclatasvir), group 2 included
50 patients received triple therapy (Sofosbuvir, Daclatasvir and Ribavirin), and Group 3 included 50 patients received
Qurevo ± Ribavirin. All participants went through a cardiac assessment for detection of development of cardiovascular
changes after 3 months of treatment.
Results: In compare to baseline values, no significant difference regarding echocardiographic findings and the mean
changes in values of QT & QTC interval among all patients' groups. Dual therapy produced a significant lower serum
levels of Albumin (Alb), prothrombin time (PT) and a significant increase in the serum levels of alkaline phosphatase,
hemoglobin. Triple therapy produced significant lower serum levels of ALT, AST, total bilirubin, hemoglobin
concentration, WBCs, RBCs and platelets, while a significant increase was observed in the mean values of the Alb
and alkaline phosphatase. In the third group, there was a significant decrease in serum levels of PT while a significant
increase was observed in serum values of alkaline phosphatase.
Conclusion:
DAAs are safe drugs to use in non-cardiovascular patients and in cardiac patients with caution and
avoidance of some drugs.
Keywords: Anti-Hepatitis C Drugs, HCV, Heart, DAAs, hepatitis C virus, interferon free regimens.


INTRODUCTION

Hepatitis C virus (HCV) is considered one of the
new DAAs, FDA recently announced a change in
major public health problems all over the world (1).
labeling for the hepatitis C antiviral LDV/SOF
Egypt has the highest prevalence of HCV infection in
(Harvoni) and SOF (Sovaldi) after the manufacturers
the world. HCV genotype 4 is the most predominant
reported bradycardia, pacemaker intervention, and even
isolated genotype from 90% of the HCV-infected
death in patients who took the medications along with
patients in Egypt (2).
amiodarone (5).
The main objective of the treatment for chronic HCV
Advances in trans-thoracic echocardiography with
infection is to attain a sustained virologic response
the application of strain analysis and speckle tracking
(SVR), defined as undetectable HCV-RNA, 12 weeks
provide sensitive assessment of cardiac function that
after completing the treatment course. Long-term
may predict clinical outcomes in various heart diseases,
follow-up studies reported by Backus et al. (3), they
including those with HCV infection (6). The aim of the
showed that sustained virologic response reduces risk of
study was to assess cardiac side effects of direct acting
all-cause mortality in patients with hepatitis C.
anti hepatitis C drugs.
The development and improvement of the HCV

treatments were continuing. The use of interferon in the
PATIENTS AND METHODS
treatment proved to cause health issues and
One hundred and fifty (150) patients with chronic
consequently was excluded from the treatment.
hepatitis C virus infection attending to Sohag Center of
However, the use of DAAs has raised some concerns
Cardiac and Digestive system & Al-Azhar Assiut
about the possibilities of cardiac toxicity which could
University Hospital were enrolled in this study. The
result in toxic cardiomyopathy (4).
study was conducted through the period from February
Harvoni is a tablet in which there is combination of
2018 to September 2018. The infection with hepatitis C
two DAA: Ledipasvir (NS5A inhibitor) and Sofosbuvir
virus in the studied cohort was confirmed by the
(NS5B Nucleotide Polymerase Inhibitor). It was
positivity of HCV antibodies using ELISA and further
approved by the FDA (Food and Drug Administration,
confirmed by Real time PCR for quantitative
USA) in October, 2014 for the treatment of naļve and
measurement of the HCV RNA.
treatment-experienced patients suffering from chronic

hepatitis C genotype 1 4, 5 and 6. Most of the patients
Ethical and patients' approval: The study protocol
tolerate this medication very well (3). Concerning, the
was approved by the Institutional Ethics Committee
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106
Received:3 /10 /2020

Accepted:21 /11 /2020


Full Paper (vol.821 paper# 19)


c:\work\Jor\vol821_20 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 115-122

The Relation between Pre-Procedural Increase in
Urinary Albumin Excretion and Changes in Estimated Glomerular
Filtration Rate after Coronary Angiography in Diabetic Patients
Magdy Mohamed El Sharkawy1, Mohamed Abd El Monem1, Ahmed Yehya Ramadan2, Lina Essam Khedr*1
Departments of 1Internal Medicine and 2Cardiology, Faculty of Medicine - Ain Shams University
*Corresponding author: Lina Essam Khedr, Mobile: (+20) 01223421925, E-Mail: linakhedr@med.asu.edu.eg

ABSTRACT
Background:
Contrast-induced nephropathy (CIN), is an acute impairment in renal function, and typically occurs
within 3 days following the exposure to a iodinated contrast medium (CM). It is associated with increased hospital
stay and increased morbidity and mortality. Adult patients with diabetes have a higher risk than the general
population for developing contrast-induced nephropathy.
Objective: To assess the significance of preprocedural microalbuminuria on renal function changes post coronary
angiography.
Patients and methods: The current study included 40 patients all over the age of 18 years, with diabetes mellitus
type 1 or type 2, scheduled for coronary angiography with estimated GFR > 60 ml/min.
Results: incidence of contrast-induced nephropathy in this study was 40 % (n=16) of patients while 60% (n = 24)
did not fit the definition of CIN. There was no statistically significant difference in the age, gender distribution and
use of angiotension converting enzyme inhibitors (ACEIs) or diuretics between the cases who developed and who
did not develop CIN. The mean albumin creatinine ratio (ACR) in the group with no contrast induced nephropathy
was 225.38 ± 209.53 which was statistically significantly lower when compared to the cases with contrast-induced
nephropathy (420.43 ± 348.52) (p = 0.033). The mean HbA1c in no contrast-induced nephropathy group was 7.11
± 0.64 and in contrast induced nephropathy group it was 9.09 ± 0.66, which was significantly higher (P > 0.001).
With univariate regression analysis, ACR, HbA1c and number of vessels affected were shown to be risk factors for
occurrence of CIN after use of contrast, but with multivariate analysis, both ACR and HbA1c were shown to be
risk factors for CIN.
Conclusion: An increase in urinary albumin creatinine ratio in itself maybe be a risk factor for development of
contrast-induced nephropathy in diabetic patients.
Keywords: Urinary albumin excretion, Estimated glomerular filtration rate, Coronary angiography, Diabetic
patients.

INTRODUCTION
included 200 patients (10). Evidence suggests that
Contrast-induced nephropathy (CIN) is an
patients in a pre-diabetic state are also at increased risk
increasingly common cause of iatrogenic acute kidney
of CIN especially if they have CKD. Toprak et al. (11)
injury (AKI) (1) and represents about 12% of the cases
showed that CIN occurred in 20% of patients with
of hospital-acquired AKI (2). Although the risk of renal
CKD and diabetes and in 11.4% of patients with CKD
function impairment associated with radiological
and pre-diabetes, versus 5.5% of patients with CKD
procedures is low (0.6­2.3%) in the general population
but no evidence of diabetes or prediabetes. These
patients with cardiovascular disease are more
findings about the incidence of CIN in diabetic patients
susceptible, with the higher incidence being reported
are inconsistent which might be due to the existence of
after emergency PCI (3, 4).
different phenotypes of diabetic nephropathy (12).
Although the pathophysiology of CIN is poorly
An increase in serum creatinine and, less
understood, intrarenal vasoconstriction, and direct
commonly,
oliguria
are
the
major
clinical
tubular damage are among the predominant factors
manifestations of contrast nephropathy. In a
contributing in the development of CIN (5). Several
prospective study, among approximately 40 patients
groups have documented immediate vasoconstriction
who developed contrast nephropathy, none was
and reduction in renal blood flow occurring after
oliguric (13). The increased creatinine is generally
administration of contrast medium (6). Exposure of
observed within 24 to 48 hours after contrast exposure
renal tissue to high osmotic radiocontrast agents results
and is mild. Creatinine usually starts to decline within
in characteristic histopathologic changes called
three to seven days. Oliguria (if it occurs) occurs
"osmotic nephrosis." (7). Histopathologic features of
immediately after the procedure (13). Other
"osmotic nephrosis" includes focal or diffuse
manifestations of acute kidney injury may be present,
vacuolization of the proximal tubular cells as well as
including
hyperkalemia,
acidosis
and
tubular necrosis (8). Risk factors for developing CIN
hyperphosphatemia (14). The diagnosis of contrast-
include diabetes with chronic kidney disease (CKD) (5,
induced nephropathy is based upon the clinical
9). The overall incidence of CIN in patients with type 2
presentation, including the characteristic rise in serum
diabetes was 21.5% in a study by Sany et al. (10) that
creatinine concentration beginning with the first 24 to
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115
Received: 3/10/2020

Accepted: 21/11/2020


Full Paper (vol.821 paper# 20)


c:\work\Jor\vol821_21 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 123-128

Precipitating Factors for the Development of Diabetic Ketoacidosis in a
Tertiary Care Hospital in Bahrain
Mandeel, Fatema H. 1; Radhi, Husain T. 1; Sarwani, Aysha A. 1; Alsadah, Ahmed H. 2
1, Department of Endocrinology, Salmaniya Medical Complex, Bahrain,
2 Department of Accident and Emergency, Qatif, KSA
*Corresponding author: Fatema Hussain Mandeel, Mobile: +973 33931910, email: dr.mandeel124@gmail.com

ABSTRACT
Background:
Diabetic ketoacidosis is a commonly presenting complication of diabetes occurring commonly in type
1 and occasionally in type 2 DM patients as well, the precipitating factors for which are varied and only a few studies
have explored this.
Objective :
To review the causative factors that lead to the occurrence of DKA among the adult age group of patients
in Bahrain.
Methods:
The study was conducted in a retrospective, descriptive method in Salmaniya Medical Complex, Bahrain.
The age group included consisted of adult patients of age 14 years and onwards, during a period of two years 2017-
2018. Patient demographic data as well as related scientific data during the hospital stay were collected.
Results:
A major precipitating factor was non-compliance (62 patients) with treatment regimen followed by
infectious causes (26 patients). Poor diabetic control also caused a high occurrence of DKA (16 patients), as well as
disruption in insulin supply, lead to DKA in patients on an insulin pump (3 patients). A high readmission rate was
noted in the admission analysis due to repetitively occurring causative factors.
Conclusion:
Preventing the occurrence of precipitating factors of DKA, through patient education and support can
decrease the occurrence of this preventable complication of diabetes, leading to decrease morbidity and mortality
related to DKA.
Keywords:
Diabetes, Diabetic ketoacidosis, Precipitating factors.
Abbreviation,
DM: Diabetes Mellitus;DKA: Diabetic ketoacidosis.

INTRODUCTION
than 14 years old not fulfilling the criteria of DKA
Diabetic ketoacidosis (DKA) is a life-threatening
were ruled out during admission.
complication of diabetes mellitus (DM). It is

commonly associated with type 1 diabetes, but it is not
Statistical analysis:
uncommon in some patients with type 2 diabetes. It
The data collection form included the patient's
resulted from absolute or relative insulin deficiency
age, gender, nationality, type of diabetes,
and it is characterized by hyperglycemia, ketonemia,
comorbidities,
HbA1c,
readmissions,
and
and acidosis¹.
precipitating factors. IBM SPSS 25 and R studio
DKA can be classified into mild, moderate, or
1.1.14 were used to analyze the collected data. The
severe based on the metabolic acidosis severity and
variable relations were investigated with the proper
mental status alteration. The most common precipitant
statistical methods (Chi-square test and A NOVA).
for ketoacidosis was omission/error of insulin

administration followed by acute illness².
Ethical approval:
Although mortality rates had fallen significantly
The study was approved by Secondary Health
over the past 20 years from 7.96% to 0.67%, the
Care Research Sub Committee in Salmaniya
mortality rate is still high in non-hospitalized patients
Medical Complex and an informed written consent
and developing countries³. DKA is a serious but
was taken from each participant in the study.
largely preventable acute complication of diabetes

mellitus. Identifying precipitating factors and increase
RESULTS
awareness will prevent admission and associated
Patient characteristics
mortality and morbidity .
A total of 224 patients were enrolled in the

current study, 58.5% of whom were males while
MATERIAL AND METHODS
41.5% were females. The age group ranged from 14
This was a retrospective and descriptive study
to more than 76 years old.
conducted at a tertiary academic center, Salmaniya
The majority of the patients were Bahraini (80.8%)
Medical Complex, Bahrain. The study was approved
while the rest were from 13 other nationalities (19.1%)
by the secondary health care research committee at the
(Table 1). Nearly two-thirds of them have no co-
study site. Inclusion criteria for study involvement
morbidities while a third has associated comorbidities
were admission to the medical center between 2017
(37.1%).
and 2018 with the diagnosis of DKA. Patients younger


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123
Received: / /2020

Accepted: / /2020


Full Paper (vol.821 paper# 21)


c:\work\Jor\vol821_22 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 129-136

The Prognostic Role of -Catenin Subcellular Localization in
Hepatocellular Carcinoma of Egyptian Patients
Rania Abdallah Abdallah 1, Dalia Refaat Al-Sharaky1, Doha Maher Taie2,
Marwa Said EL Masry 2, Rehab Monir Samaka1
1Pathology Department, Faculty of Medicine, Menoufia University, Shebin El Kom, Menoufia Governorate,
2Pathology Department, National Liver Institute, Menoufia University, Shebin El Kom, Menoufia Governorate, Egypt
Corresponding author: Rehab Monir Samaka, Mobile: (+20) 01002806239, E-Mail rehabsamaka@yahoo.com

ABSTRACT
Background:
Hepatocellular carcinoma (HCC) is one of the most common cancers in Egypt with fatal outcome. The
molecular pathogenesis of this type of cancer is so complex involving interaction of several signaling pathways. Among
those is Wingless (WNT)/-catenin signaling pathway, which is frequently activated in HCC.
Objectives: To investigate the relationship of different localization patterns of -catenin in relation to different
histopathologic parameters in Egyptian HCC cases.
Patients and methods: One hundred and twenty-one (121) HCC specimens were subjected for -catenin evaluation by
immunohistochemistry.
Results: The studied HCC cases showed -catenin membranous expression in 47/121 (38.8%) of cases, while
nucleocytoplasmic localization was observed in 31/121 (25.6%). Most of HCC cases that showed single tumor mass
presentation exhibited negative nucleocytoplasmic expression pattern (79.2%, P=0.02). Membranous pool of -catenin
was associated with adverse prognostic factors like increased positivity among high-grade cases (P=0.04), higher H score
value in cases having lymphovascular invasion, positive lymph node and higher (advanced) TMN stages (P = 0.01, 0.00,
0.00 &0.03 respectively).
Conclusion: HCC cases showed heterogeneous -catenin expression pattern. Membranous -catenin localization was
associated with aggressive prognostic parameters of HCC.
Keywords: -catenin, Subcellular localization, HCC, Immunohistochemistry.

INTRODUCTION

Hepatocellular carcinoma (HCC) represents a
adherence junction complex connecting cadherins with
popular and challenging health problem in Egypt, being
actin cytoskeleton. The activity of this molecule is well
a leading cause of cancer-related morbidity and mortality
organized via several binding proteins affecting its
(1). It is ranked as the fourth common cancer in Egypt and
stability, subcellular localization and transcriptional
the sixth most common cancer worldwide (2).
activity (7).
Several etiologic factors played an important
In this study, we used immunohistochemistry to
role in the pathogenesis of HCC, among them, chronic
investigate the relationship of different localization
hepatitis B virus (HBV) and hepatitis C virus (HCV)
patterns of -catenin in relation to different
infections, which by far were considered as the most
histopathologic parameters in Egyptian HCC cases.
common risk factors for HCC (3). In the same line,

alteration of numerous signaling transduction pathways
PATIENTS AND METHODS
have been documented in HCC (4). The Wingless
This is a retrospective study; included 121 liver
(WNT)/-catenin signaling pathway regulates multiple
tissues (surgical specimens) obtained from Egyptian
cellular processes and is a commonly dysregulated
patients presented by HCC and retrieved from the
pathway in several types of cancers including HCC (5).
archival material of Pathology Department, National
-catenin is a central component of the WNT
Liver Institute, Menoufia University during the period
signaling pathway. Aberrant activation of WNT pathway
between April 2010 and August 2017. All specimens
causing accumulation of -catenin in the cytoplasm and
were collected as a part of the standard clinical
then translocate into the nucleus with subsequent
management of the patients.
activation of different transcription genes thus

contributing to carcinogenesis (6).
Ethical approval:

The study was approved by Institutional Review
In addition to its WNT signaling activity, -
Board (IRB) of the National Liver Institute (NLI) and
catenin at cell membrane functions as a component of
Faculty of Medicine, Menoufia University.




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129
Received:5 /10 /2020

Accepted:23 /11 /2020


Full Paper (vol.821 paper# 22)


c:\work\Jor\vol821_23 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 137-141

Evaluation of the Results of Antiglide Plating of Vertical Medial Malleolus Fractures
Ali El-Alfy1, Ashraf Abd-ELdayem1, Ahmed Mashhour Gaber1,
Ahmed Mohamed Abdelrahman Ben Alashher*2
1Department of Orthopedic Surgery, Faculty of Medicine ­ Zagazig University, Egypt
2Department of Orthopedic Surgery, Faculty of Medicine ­ Tripoli University, Libya.
*Corresponding Author: Ahmed Mohamed Abdelrahman Ben Alashher, Mobile: (+20) 01069067723,
Email: ahmed.alshher@gmail.com

ABSTRACT
Background:
Vertical fractures of the medial malleolus are fixed with cancellous screws placed perpendicular to the
fracture site. It is important to buttress the fracture by placing a screw with a washer at the proximal apex of the
fracture or to use a small tubular plate or T-plate as a buttress. Objective: To assess the radiological and functional
outcomes of open reduction and internal fixation with T-shaped plate (antiglide plate) of vertical shear medial
malleolus fracture.
Patients and Methods: This was clinical trial study included 22 adult patients with vertical shear medial malleolus
fracture who were admitted to Orthopedic Surgery Department, Zagazig University Hospitals in the period from
January 2019 to February 2020. They were treated by internal fixation with T-shaped plate (antiglide plate). In this
study, we used the Biard and Jackson ankle scoring for assessment of result.
Results:
The union duration was 12.1± 2.2 weeks ranged from 9 to 16 weeks, most of the studied group (59.1%) had
healing time ranged from 9 to 12 weeks. No complications and only two patients (9.1%) had superficial infection with
no other complications. Biard and Jackson score was 95.3 ± 4.9 ranged from 76 to 98. Most of the studied group
(68.2%) had excellent outcome, 22.7% of them had good outcome and 9.0% had poor outcome.
Conclusions: Surgical management of vertical shear of medial malleolus fracture give excellent anatomical reduction
and rigid fixation to restore articular congruity, help to facilitate early mobilization and hence to achieve optimal
ankle function.
Keywords: Medial malleolus, Fracture fixation, Fractures.

INTRODUCTION

age ranged from 50 to 65 years. The fourteen (14)
Vertical shear fractures of the medial
patients have isolated vertical medial malloulus
malleolus occur through supination­adduction loading
fracture, which were fixated by small T antiglide plate,
of the talus onto the articular surface of the medial
the other Eight (8) patients had vertical medial
malleolus (1,2). Vertical shear fractures of the medial
malleolus fracture associated with lateral malleolus
malleolus are less common than transverse fractures.
which were fixated one third semi tubular plate then
There are wide varieties of techniques available for
fixation of the vertical medial malleolus fracture by
fixation of these fractures, including various cortical
small T antiglide plate.
screws, cancellous screws, tension bands, and antiglide

plates (3). Fixation of these fractures must be sufficient
Ethical and patients' approval: The study was
to maintain stable reduction of the ankle joint articular
approved by the Institutional Ethics Committee of
surface allowing early range of motion, maintaining
Zagazig University and informed written consents
congruency of the ankle joint, and decreasing the risk
were taken from patients and/or their caregivers. This
of future post-traumatic arthritis to maximize
Work was performed according to the code of Ethics of
functional outcome (4).
the World Medical Association (Declaration of
These fractures are often treated successfully
Helsinki) for studies involving humans.
with buttress or antiglide plates and screws with

neutralization plates (5). This study aimed to assess the
Inclusion criteria: Age above 18 years. Closed / Open
radiological and functional outcomes of open reduction
Gustilo Type I, II.
and internal fixation with T-SHAPED PLATE
Exclusion criteria: Open fracture type III. Patients
(ANTIGLIDE PLATE) OF VERTICAL SHEAR
medically unfit for surgery. Timing of surgery: During
MEDIAL MALLEOLUS FRACTURE.
1st week after injury.

All patients were examined both clinically and
PATIENTS AND METHODS
radiological on admission to the hospital, 12 patients
Clinical data of 22 adult patients with vertical shear
were done operation at same day of admission, and 10
medial malleolus fracture who were admitted to
patients' operations were done after 5 day of admission
Orthopedic Department included 12 males (54.5%) and
due to swelling and ecchymosis. Air way, breathing ,
10 females (45.5%). The mean age of the patients in the
circulation, vital signs and conscious level was
current study was 44.9 ± 14.7 years ranging from 21 to
assessed.
65 years. About half of the studied group (45.4%) had
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137
Received:15 /7 /2020

Accepted:27 /8 /2020


Full Paper (vol.821 paper# 23)


c:\work\Jor\vol821_24 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 142-144

An Uncommon Disease Presenting as a Common One
Emergency Department Practice Challenges in COVID 19 Era
Abdullah Al-Shamrani, Ahmed A. Alsamman, Mohammed A. Hasabalnabi
Prince Sultan Military Medical City (PSMMC)
Corresponding author: Ahmed A. Alsamman, email: aasamman@hotmail.com, Mobile: 0966565575297

ABSTRACT
Background:
doctors working in Emergency Department (ED) face the challenge of persistently applying practice
guidelines and evidence-based medicine. In addition, physicians consider other factors such as bed vacancies,
administrative rules and above all, medicolegal problems. In COVID 19 era, strict infection control precautions rose as
another point of consideration that consume time and effort.
Objective: ED physicians must show flexibility when they follow guidelines, especially during the current pandemic.
Results: the patient presenting with clinical picture suggestive of pneumonia was finally diagnosed with serious
malignancy.
Keywords: Chest mass, Community acquired pneumonia (CAP), COVID 19, Emergency Department (ED).

CASE REPORT

History: a 12 years old girl, previously healthy, was
of aerosol generation abiding with infection control
referred from primary care to ED at Prince Sultan
precautions.
Military Medical City complaining of fever and
The provisional diagnosis was community-acquired
tachypnea. Nine days earlier, the girl sought advice to ED
pneumonia.
complaining of chest pain and headache. Her symptoms

were attributed to myositis because pain was localized
Question 1: the ED doctor faced this decision making
and chest wall was tender on palpation. She was
challenge. Whether to follow national (1) and western (2-4)
discharged on analgesics that relieved her symptoms.
guidelines as regard community acquired pneumonia,
There was no weight loss or night sweats. She didn't have
and treat the girl with oral antibiotics and send her home
any COVID 19 epidemiological risk factors. However,
without any laboratory or radiological investigations
she was put in isolation ward.
except PCR for COVID19 or to admit in ED for further

investigation, initial intravenous antibiotics and possible
Examination: the child was fully conscious and
admission to the ward ?
cooperative but she was obviously tachypneic. Weight
The ED doctor took the second choice and investigations
and height were at 50th percentile. Vital signs showed a
were done.
respiratory rate (RR) of 43/minute, heart rate was 140,

temperature of 39.4°C, normal blood pressure of 111/65
Investigation
, and her pulse oximeter read 97%. On auscultation, she
Laboratory result showed: WBC 8,900 10^9/l, HB
had normal vesicular air entry with no bronchial
9.5 g/dl and PLT. 848,000 10^9/l
breathing or friction rub. Right side showed decreased
PT 19.1 sec, PTT 44 sec, INR 1.4,
air entry. There was no working accessory muscles of
Fibrinogen 7.8 g/L
respiration. Later, after fever had subsided, (RR) was
Ferritin 94; ESR 102 mm/hr C - reactive protein 486
still 43/minute while heart rate decreased to 120.
mg/L
Cardiovascular exam was normal except for tachycardia.
Procalcitonin 0.76 ng/ml. D-Dimer 9.440.000 -
There was no associated lymphadenopathy or
.500 ug/ml
organomegaly. Examination of other systems was
COVID PCR came negative later.
unremarkable. Throat exam was not performed for fear
X- rays (Fig 1 a and b) showed right side opacity

with no rising fluid level to the axilla.


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142
Received:4 /10 /2020

Accepted:22 /11 /2020


Full Paper (vol.821 paper# 24)


c:\work\Jor\vol821_25 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 145-149

Diagnostic Accuracy of MRI in The Evaluation of Patients with
Idiopathic Intracranial Hypertension
Ahmed M. Abdrabou
Radiology department ­ Faculty of Medicine ­ Ain Shams University, Cairo, Egypt

ABSTRACT
Background:
Idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri, is a disease
characterized by elevation of intracranial tension with no apparent cause e.g. space occupying lesion or ventricular
pathway obstruction. Patients usually complain of headache and sometimes burring of vision. It is believed that
impaired drainage of the cerebrospinal fluid (CSF) from the dural venous sinuses and decrease spinal fluid absorption
or increased secretion contribute to the development of IIH. As the optic nerve is covered by meninges and surrounded
by CSF, the elevated pressure is inevitably transmitted to the nerve and can cause damage.
Objective: To assess the accuracy of different MRI findings in the early diagnosis of idiopathic intracranial
hypertension to achieve better prognosis.
Patients and methods: twenty patients and ten controls were enrolled in the study and underwent ophthalmological
tests, lumbar punctures analysis for pressure, MRI study of the brain and orbit with IV contrast administration and MR
venography.
Results: Six signs were analyzed from which intraocular optic nerve protrusion was the most specific (90%) and empty
sella sign was the most sensitive (90%). There was statistically significant correlation between empty sella sign (r=
0.784; p = 0.01) and posterior globe flattening (r= 0.65; p = 0.04) with the idiopathic intracranial hypertension.
Conclusion: MRI findings can be used to suggest idiopathic intracranial hypertension and increasing accuracy can be
made by combining several signs.
Keywords: Optic nerve, CSF, intracranial hypertension, empty sella, pseudotumor cerebri.

INTRODUCTION

PATIENTS AND METHODS
Idiopathic intracranial hypertension (IIH),
The study was a prospective study that was
previously known as pseudotumor cerebri, is a disease
undertaken from March 2015 to June 2017, including
characterized by elevation of intracranial tension with
27 patients confirmed to have IIH and 10 controls. The
no apparent cause e.g. space occupying lesion or

ventricular pathway obstruction (1).
diagnosis of IIH was suspected by papilledema on
Patients usually complain of headache and
ophthalmological examination followed by CT study of
sometimes blurring of vision (2). It is believed that
the brain which revealed no apparent cause. Then, it
impaired drainage of the cerebrospinal fluid (CSF) from
was confirmed by lumbar puncture (LP) which revealed
the dural venous sinuses and decrease spinal fluid
elevated CSF pressure (opening pressure > 250 mg
absorption or increased secretion contribute to the
H2O) while in the control subjects the pressure was <
development of IIH (3).
250 mg H2O. Inclusion criteria included age >18 years,
As the optic nerve is covered by meninges and
no intracranial pathology that may lead to increased
surrounded by CSF, the elevated pressure is inevitably
intracranial tension and patients at the pre-treatment
transmitted to the nerve and can cause damage (1).
stage. Exclusion criteria included patients <18 years of
A combination of CSF hydrodynamic studies
age, patient who started treatment and patients with
together with radiological studies is important to
secondary intracranial hypertension. Seven patients
accomplish the diagnosis (4). Early diagnosis and proper
were excluded from the study; two patients with no
intervention are crucial to relieve the pressure and
lumbar puncture data available and five patients had
preserve the patient's vision (2). Imaging modalities are
contraindications to MRI (4 with claustrophobia and 1
primarily used to exclude causes of secondary
with cochlear implant). Finally, twenty patients and ten
intracranial hypertension e.g. tumors, obstructive
controls were enrolled in the study.
hydrocephalus and dural sinus thrombosis (5).
Following the lumbar puncture, the patients
Recently, many MRI signs are seen in IIH and
underwent MRI of the brain and orbit with IV contrast
being studied in the literature (6).
administration and MR venography. MRI 1.5 Tesla

machine with dedicated head coil (Achieva, Philips

healthcare medical systems, Best, Netherlands) was
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145
Received:5 /10 /2020

Accepted:23 /11 /2020


Full Paper (vol.821 paper# 25)


c:\work\Jor\vol821_26 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 150-155

Organoprotective Effect of Remote Ischemic Preconditioning during Living Donor
Liver Transplantation, A Prospective Randomized Double-Blinded Study
Alrefaey K Alrefaey, Mohammed A Elmorshedi, Usama A Elsayed
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
Address for Correspondence: Alrefaey K. Alrefaey,Email: refa3ey2@yahoo.com , Mobile:00201064203475

ABSTRACT
Background: Ischemia reperfusion injury (IRI) during liver transplantation carries a substantial risk for graft
damage, and other major organ injury. Strategies to minimize IRI in the grafted liver are of paramount importance.
Remote ischemic preconditioning (RIP) is a recently described technique that can offer a liver protective effect
against IRI.
Patients and Methods:
In this prospective randomized study, consent was obtained from 80 couples (donor­
recipient) prepared for liver transplantation (LT). Patients were divided randomly (using closed envelope technique)
into two groups: RIP group (n=35) as RIP procedure was run in the donor non-dominant hand just at the start of
parenchymal transection and control group (n= 35). In all the study cases, the pressure cuff was wrapped around the
recipient arm. In RIP group, four sets of 5 minutes manual pressure cuff elevation to 200 mmHg, separated by 5
minutes of release (Using the non-dominant hand).
Results: No statistically significant difference was found between the biochemical profile (SGPT, CRP, and
bilirubin) of the recipients in both of the study groups. Similarly, post-operative kidney function (Serum creatinine)
was comparable findings in the two studied groups.
Conclusion: RIP in living donor liver transplantation failed to show a protective effect neither on the graft response
to reperfusion injury, nor the on the postoperative kidney functions. Future studies are recommended taking into
consideration histopathological, tissue damage scores.
Keywords: Liver transplantation, Preconditioning, Reperfusion, Organ protection.

INTRODUCTION

Ischemia­reperfusion injury (IRI) is a
transplantation. Early graft functions in the form of
condition where the tissue and organ damage initiated
Liver enzymes (primary variable), serum bilirubin and
during an ischemic episode is accentuated when blood
C-reactive protein in the 1st post-transplant week was
flow and oxygen delivery is resumed. The
considered as an indicator of graft IRI. In addition, the
pathophysiology of IRI involves direct ischemic cell
study investigated the effect of RIP on post-transplant
injuries that trigger a cascade of inflammatory
kidney function, and the occurrence of acute kidney
response (1). The extent of damage extends beyond the
injury (AKI) in liver transplant recipients (secondary
primary affected organ to cause a subsequent remote
variables).
organs dysfunction (2­5). IRI was encountered in a large

variety of clinical situations including stroke,
PATIENTS AND METHODS
myocardial ischemia, limb ischemia, kidney
In this prospective randomized study, consent
transplantation and liver transplantation. In the era of
was obtained from 80 couples (donor­recipient)
the shortage in liver donor and the use of marginal
prepared for liver transplantation (LT). Recruited
grafts, strategies to minimize IRI in the grafted liver
recipients were of either sex, age ranged from 20 to 50
the effect are of paramount importance (1).
years, body mass index (BMI) was 35 kg/m2, and
In ischemic preconditioning (IPC), the
model for end-stage liver disease (MELD) score was
adaptation of the target organ tissues to prolonged
25. Donors were of either sex, age ranged from 18-35
ischemic insult and subsequent reperfusion injury is
years and BMI was 30 kg/m2.
induced through short periods of planned ischemia.
Patients with known peripheral vascular
IPC has been used in many experimental models to
disease, graft to patient-weight ratio (GRWR) was
protect the liver from IRI where results do not only
0.7 gm/100 gm (either by preoperative volumetry or
support its ability to protect the liver against IRI but
direct intraoperative calculation), the need of high dose
also enhances the capacity of liver regeneration (4).
vasopressor infusion before graft reperfusion, post-
Also, in liver surgery, this can be done either by local
reperfusion vascular occlusion, and patients with
application of ischemia (pringle maneuver) or by
postoperative pathological diagnosis of acute rejection
remote organ ischemia (intestine, upper limb or lower
were excluded from the study.
limb (6, 7).
Patients were divided randomly (using closed
In this study, the effect of remote IPC (RIP) of
envelope technique) into two groups: RIP group
the donor upper limb on IRI of the liver graft was
(n=35) as RIP procedure was run in the donor non-
assessed in the setting of living donor liver

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150
Received:5 /10 /2020

Accepted:23 /11 /2020


Full Paper (vol.821 paper# 26)


c:\work\Jor\vol821_27 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 156-163

A Novel Noninvasive Index for Assessment of Liver Fibrosis and Cirrhosis in
Patients with Chronic Hepatitis C Virus Infection
Mohamed Rizk Elmdams, Said Abdel Baky Gad, Mohamed Samy Farouk Gawish*
Internal Medicine Department, Faculty of medicine, Zagazeg University, Egypt
*Corresponding Author: Mohamed Samy Farouk Gawish, Mobile: (+20) 01146768080,
E-mail: mohamed_gawish11@yahoo.com

ABSTRACT
Background:
Liver fibrosis and cirrhosis are major causes of morbidity and mortality in chronic hepatitis C (CHC)
patients.
Objective: To assess a novel non-invasive index in prediction of hepatic fibrosis and cirrhosis in chronic hepatitis
c patients by using red cell distribution width to platelet ratio (RPR).
Patients and Methods: This cross-sectional study was conducted on 84 patients with hepatitis C virus in El Ahrar
Teaching Hospital during the period from May 2019 to October 2019. The patients were classified into 3 groups,
group (I) 26 CHC cases without fibrosis, group (II) 48 CHC cases with fibrosis, and group (III) 10 CHC cases with
cirrhosis. The patients were subjected to history taking, clinical examination, laboratory investigations (CBC, liver
function, kidney function, INR), and imaging modalities.
Results:
There was a higher sensitivity of RPR (83.3%) in detecting fibrotic liver among CHC cases and ability
of 73.4% to negative cases among truly negatives, with higher accuracy of 78.6% than other scores which had high
sensitivity of 75%, 77.1% and 68.8% and specificity of 69.4%, 72.2% and 72.2% of APRI score, FIB4 and AAR
respectively. While, there was a higher sensitivity of RPR (90%) in detecting cirrhotic liver among CHC cases and
ability of 97.4% to detect negative cases among truly negatives, with higher accuracy of 96.4% than other scores,
which had high sensitivity of 90%, 80% and 80% and specificity of 95.9%, 85.9% and 95.5% of APRI score, FIB4
and AAR respectively.
Conclusion:
The progression and prognosis of chronic hepatitis C using a complete blood cell count.
Keywords: Chronic Hepatitis B (CHB), Hepatic Fibrosis, Cirrhosis.

INTRODUCTION

Egypt and other developing countries because of the
Hepatitis C virus (HCV) infects 130­170
cost and unavailability of some tests.
million people worldwide, representing a global
The complete blood count (CBC) is one of the
health problem. Approximately 12­25 % of infected
most frequently ordered laboratory tests in clinical
patients clear the virus spontaneously. However, the

majority of HCV-infected patients remains infected
practice. Standard CBC tests include white blood cell
and may evolve to the chronic phase of the disease,
(WBC), red blood cell (RBC) and platelet counts as
characterizing a silent epidemic. The major
well as their morphological indices. Various studies
complications of HCV infection are the progression to
have evaluated the performance of these
fibrosis, cirrhosis and hepatocellular carcinoma (1).
hematological CBC parameters to predict disease
The assessment of disease progression not
severity and mortality risk. For example, the
only provides useful information for diagnosis and
circulating platelet count has been proposed as a
therapeutic supervision judgment but also for
biomarker of liver fibrosis and cirrhosis (5). An
monitoring disease. Different invasive and non-
elevated red cell distribution width (RDW) has been
invasive methods are applied to diagnose the disease
reported to be associated with mortality and other
from initial to end stage (mild fibrosis to cirrhosis).
severe adverse outcomes in cardiac, renal and
Although, liver biopsy is still considered as gold
infectious diseases, even in the general population (6-9).
standard to identify liver histological stages, an
Other studies have found an association between low
assessment of the disease development based on non-
hemoglobin (Hb) concentrations and mortality (10).
invasive clinical findings is also emerging and this
This study aimed to assess a novel non-invasive index
may replace the need of biopsy in near future (2).
in prediction of hepatic fibrosis and cirrhosis in
Noninvasive methods to measure severity of
chronic hepatitis c patients by using red cell
liver injury are clinically important in Egypt where
distribution width to platelet ratio.
advanced liver disease from HCV is common (3). In

addition, reliability of the biopsy to detect and
PATIENTS AND METHODS
measure hepatic pathology is not ideal, as the
This study included 84 CHC patients aged 48-
pathology is a diffuse process (4). Most of the indices
68 years, which were classified into 3 groups 26 CHC
proposed in various studies would not be practical in
cases without fibrosis, 48 CHC cases with fibrosis and
10 CHC cases with cirrhosis. All patients collected
This article is an open access article distributed under the terms and conditions of the Creative


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156
Received:5 /10 /2020

Accepted:23 /11 /2020


Full Paper (vol.821 paper# 27)


c:\work\Jor\vol821_28 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 164-173

The Adjuvant Protective Effect of Resveratrol on Cisplatin-Induced
Liver Toxicity in Male Albino Rats
Huda I. Abd-Elhafiz 1, Noha M. Issa 2
Departments of 1Clinical Pharmacology and 2Anatomy and Embryology, Faculty of Medicine, Menoufia University
*Corresponding author: Noha Mohey Issa, Mobile: (+20)01005780374, E-mail: drnohaissa@yahoo.com

ABSTRACT
Background
: Cisplatin is antineoplastic drug associated with hepatotoxicity due to oxidative stress. Resveratrol has
antioxidant effect so it could protect the liver cell. Objective: the aim of this work was to investigate the possible
protective effects of resveratrol on hepatotoxicity caused by cisplatin drug in rats. Materials and Methods: forty
male albino rats were randomly divided into four groups: Group I (control group): was maintained throughout the
experiment without any treatment. Group II (resveratrol group) that received resveratrol daily in a dose of 25 mg/kg
intraperitoneally for 21 days. Group III (cisplatin group) that received single intraperitoneal injection of cisplatin in
a dose of 7.5 mg/kg at the 16th day of the experiment. Group IV (protected group) that received resveratrol in a dose
of 25 mg/kg intraperitoneally for 21 days and cisplatin at 16th day of the experiment. Body and liver weight were
estimated, biochemical measurements and histopathological study of the liver tissue were done. Results: showed
significant preservation of the liver function and histological structure. Conclusion: it is concluded that resveratrol
could protect liver against cisplatin side effects.
Keywords: Cisplatin, Liver toxicity, Resveratrol.

INTRODUCTION

Ethical approval:
Cisplatin (cis-diamminedichloroplatinum II, CP)
All animals received appropriate care in
is one of the antineoplastic drugs and of a class of
compliance with the Public Health Service Policy
alkylating agents that are commonly used in the
on use of Laboratory Animals published by the
treatment of many neoplastic disorders like gut,
National Institutes of Health and was approved by
ovarian, cervical, and germ cell tumors (1). Moreover,
the Ethical Committee of the College of Medicine,
cisplatin could discontinue the tumor growth by
Menoufia University, Egypt.
means of cross-linking guanine bases in DNA double

Chemicals:

helix strands directly attacking DNA, so cisplatin can
Cisplatin and Resveratrol were brought from
arrest the base pairing process causing cell death and
(Sigma­Aldrich) company, while Phosphate buffer
apoptosis (2).
was from (Biodiagnostic CO.).
Its cytotoxic destructive effects extended to the

normal cells also, that cause hepatotoxicity,
Induction of cisplatin toxicity:
nephrotoxicity, neurotoxicity, and ototoxicity.
Animals were weighed and divided into four
However, the mechanism of hepatotoxicity is not
groups (n = 10 for each). The treatment procedure
clear, it may be due to interfering with the antioxidant
was planned as:
defense process that causing oxidative stress (3, 4).
Group I (control group): was maintained
Oxidative stress caused by cisplatin is due to
throughout the experiment without any
exhaustion of the antioxidant systems either non-
treatment.
enzymatic or enzymatic like superoxide dismutase
Group II (resveratrol group) that received
and glutathione peroxidase. This leads to
resveratrol daily in a dose of 25 mg/kg
accumulation of free radical, which is the main cause
intraperitoneally for 21 days.
of biological molecules destruction (as lipid and
Group III (cisplatin group) that received single
protein), DNA destruction and overproduction of
intraperitoneal injection of cisplatin in a dose of
inflammatory cytokines (5). Moreover, reactive
7.5 mg/kg at the 16th day of the experiment (8).
oxygen species (ROS) are the main cause of lipid
Group IV (protected group) that received
peroxidation (6). Resveratrol (trans-3, 5, 40-
resveratrol in a dose of 25 mg/kg
trihydroxystilbene) is one of the polyphenols extract
intraperitoneally for 21 days and cisplatin at 16th
which has antioxidant and anti-inflammatory
day of the experiment (on that day resveratrol
properties that could ameliorate the toxic adverse
dose was injected 30 minutes before cisplatin
effects of cisplatin drug on liver (7).
injection). Resveratrol was freshly prepared in


MATERIALS AND METHODS
0.9% normal saline at a concentration of 20 mg
Animals: Forty male albino rats at the same age,
resveratrol/ml, (0.2 ml / rat) (9).
weighing 150-250 gm/each were kept in groups
At the end of the experiment, body weight for each
inside animal cages at room temperature; they were
rat was recorded before they were sacrificed. Venous
fed standard laboratory food and water.
blood samples were collected in heparinized capillary

tubes from the retro-orbital plexus.

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164
Received: 4/10/2020

Accepted: 22/11/2020


Full Paper (vol.821 paper# 28)


c:\work\Jor\vol821_29 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 174-180

Immunohistochemical Expression of Heparanase-2 in Psoriasis
Rehab Monir Samaka 1, Mohammed Abd Elmoneim Shoieb 2, Walaa Adel Abdo*3
Departments 1Pathology and 2 Dermatology, Faculty of Medicine, Menoufia University, Shebin El Kom,
Menoufia Governorate, 3 Dermatology Department, Sammanud Central Hospital, Gharbeya Governorate Egypt.
*Corresponding author: Walaa Adel Abdo, Mobile: (+20)01227287215, E-mail: Walaa_adel9@yahoo.com

ABSTRACT
Background:
Psoriasis is a chronic, inflammatory immune mediated skin disease characterized by dense infiltrates
of immunocytes especially macrophages. Cross talk between immunocytes and keratinocytes is thought to mediate
the disease. Hparanase 2 inhibits activity of Heparanase 1 which is involved in this cross talk by degradation of
heparin sulphate chains in the basement membrane and extra cellular matrix (ECM).
Objective: To assess the of Heparanase2 in psoriasis through its immunohistochemical expression in lesional and
perilesional skin of psoriasis patients.
Patients and Methods: This prospective case control study was carried out on a total number of 60 subjects, they
included 30 patients with chronic plaque psoriasis and 30 age and gender matched apparently normal subjects as
control group. Skin biopsies were taken for immunohistochemical evaluation of Heparanase 2 expression.
Results: Our results showed significant difference between lesional, perilesional and control groups regarding the
status of epidermal Heparanase 2 expression (P = 0.038). All lesional epidermal expression was negative while
perilesional epidermal expression was negative in 24 (80%) cases and positive in 6 (20%) cases, control epidermal
expression was negative in 27 (90%) cases and positive in 3 (10%) cases. There was no significant difference
between the three studied groups regarding dermal Heparanase 2 expression (P = 0.318).
Conclusion: Downregulation of Heparanase 2 could be incriminated in the pathogenesis of psoriasis. Heparanase
2 could have a protective role in skin.
Keywords: Heparanase2, Psoriasis, Downregulation, protective.

INTRODUCTION


Psoriasis is a chronic, inflammatory immune
perilesional skin of psoriasis patients and control
mediated skin disease (1). It is characterized by
skin.
development of erythematous, indurated, scaly,

pruritic skin plaques and its pathogenesis is driven by
PATIENTS AND METHODS
proinflammatory cytokines (2). Psoriasis prevalence is
This is a prospective case control study carried out on
now in increase. It is a serious dermatological disease
a total number of 60 subjects, they included 30
extending beyond the physical symptoms as it exerts
patients with chronic plaque psoriasis attending the
significant, negative impact on patients' quality of
Menoufia skin and andrology outpatient clinic during
life (3).
the period between June 2019 to June 2020 and 30
In psoriasis heparanase acts through facilitation
age and gender matched apparently normal subjects
of pathologic crosstalk between keratinocyte and
as control group.
immunocyte communication circuits through

activation of macrophages and other cells of innate
Ethical approval:
immunity at the site of inflammation following
The study was approved from the ethical
degradation of heparan sulphate in the basement
committee of Faculty of Medicine Menoufia
membrane and extracellular matrix (4).
University and the patients gave an informed
Hparanase 2 retains the capacity to bind
consent.
Skin
biopsies
were
taken
for
heparin/heparin sulphate (HS) and, importantly,
immunohistochemical evaluation of Heparanase 2
exhibits an even higher affinity toward heparin/HS
expression.
than heparanase1, thus competing for HS binding and

inhibiting heparanase1 enzymatic activity. Moreover,
Clinical data:
coimmunoprecipitation studies revealed physical
All study subjects were subjected to the
association between Hparanase2 and heparanase1
following after taking written consent: complete
proteins, providing additional explanation for the
history tacking, complete general examination,
inhibition of heparanase1 enzymatic activity by
dermatological examination with determination of
Hparanase 2 (5).
site, size, number, type, extent, distribution of the
Aim of our study is to assess the role of
lesions, assessment of Psoriasis Area and Severity
Heparanase
2
in
psoriasis
through
its
Index (PASI) score.
immunohistochemical expression in lesional and



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174
Received:5 /10 /2020

Accepted:23 /11 /2020


Full Paper (vol.821 paper# 29)


c:\work\Jor\vol821_30 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (1), Page 181-185

Mean Platelet Volume and Platelet Function in Neonatal Sepsis
Mohamed Hussien Meabed1, Eman Abd-ElAzim Sharaf2,
Rehab Muhammad Abd-Elkareem3, Mohamed Hamdy Abd Elwahab Mahmoud1
Departments of 1Pediatrics and 3Clinical Pathology, Faculty of Medicine ­ Beni-Suef University
Departments of 2Pediatrics, Faculty of Medicine ­ 6 October University
*Corresponding Author: Mohamed Hamdy Abd Elwahab Mahmoud, Phone Number: (+20) 01024683929,
Email: mosad8rashed@gmail.com

ABSTRACT
Background:
Neonatal sepsis is a clinical disorder developed by bacterial blood stream infections in neonates. CBC
indices, such as platelet count, mean platelet volume (MPV), PDW have been used as markers of systemic
inflammation in children and adults.
Objective: To assess MPV and platelets function in neonatal sepsis.
Patients and Methods:
This study was a case control, which included 50 cases and 50 controls. All participants were
subjected to history taking, clinical examination, CBC, C-reactive protein, blood cultures and assessment of mean
platelets volume.
Results:
There was a significant decrease in haemoglobin level, RBCs count, and platelet count. While, there was
significant increase in WBCs count and MPV in the patient group than in the control group. Mean value of platelet
count was statistically significantly lower among cases than in control. MPV was significantly higher in patients than
controls. PDW was statistically significantly lower among cases than in controls. MPV showed significant negative
correlation with gestational age, birth weight and platelet count. While it showed statistically significant positive
correlation with CRP.
Conclusion:
Mean value of platelet count and PDW were statistically significant lower among cases than in
control while MPV was significantly higher in patients than in controls. So, platelet function could be a useful early
diagnostic marker in neonatal sepsis.
Keywords:
Neonatal sepsis, Mean platelet volume, Platelet function.

INTRODUCTION
conditions (5). MPV is a measure of platelet volume. It
It is estimated that four million neonatal deaths
reveals the presence of inflammatory burden and
occur worldwide every year, and approximately one-
disease activity in many diseases (6). This study aimed
third of these are caused by infections. Sepsis continue
to assess platelets' function in neonatal sepsis.
to be one of the main causes of neonatal mortality (1).

Neonatal sepsis is a clinical disorder developed by
PATIENTS AND METHODS
bacterial blood stream infections (BSI) in neonates. It is
This study was a case control study, which included
a dangerous and common disease among infants, which
50 patients with neonatal sepsis. In addition, there was
is associated with high morbidity and mortality (2).
50 age and sex matched healthy neonates who served as
Although blood culture has been considered as
controls. The cases and controls were taken from NICU
the gold standard, this analysis is still too slow and
of Benha Children Hospital during the period from
limited by false negative results. There has been
October 2018 till July 2019.
constant search of an ideal sepsis biomarker that have

high sensitivity, specificity, positive predictive value
Inclusion criteria:
(PPV) and negative predictive value (NPV) (3). The
Neonates with neonatal sepsis: A diagnosis of clinical
most commonly used biomarkers are C-reactive protein
sepsis requires the presence of at least three of the
(CRP) and procalcitonin (PCT), but both have shown
following: bradycardia (<100 beats/min), hypotension,
varied sensitivity, specificity, PPV and NPV in different
hypotonia, seizures, apnea, tachypnea, cyanosis,
studies (4).
respiratory distress, poor skin color and perfusion,
CBC is a simple and routine workup to determine
feeding difficulty, irritability, lethargy and laboratory
infection in neonates. Low white blood cell count,
results showing elevated levels of CRP or IL-6. Patients
absolute neutrophil count, and high immature-to-total
with culture positivity were accepted as proven sepsis.
neutrophil ratio were the most commonly used indices

for detection of infection in neonates. Recently, other
Exclusion criteria:
CBC indices, such as platelet count, MPV and PDW
Undergoing a course of antibiotics prior to
have been used as markers of systemic inflammation in
appropriate blood sampling
children and adults. In neonates, very limited data are
Undergoing surgery in the previous week
available about the usage of platelet indices for
Chromosomal abnormality
diagnosis of neonatal infection or other inflammatory
Lack of informed consent from the parents
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181
Received:6 /10 /2020

Accepted:24 /11 /2020


Full Paper (vol.821 paper# 30)