c:\work\Jor\vol822_1 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 186-189

Early Outcome of Minimally Invasive Versus Median Sternotomy Mitral Valve
Replacement In Patients With Severe Chronic Obstructive Pulmonary Disease
Ahmed S. Mahmoud1, Rafik F B. Solima2, Amira I. Alamaldeen3, Passant M. Hassan4, Fouad M. Rasekh1
Departments of 1Cardiothoracic Surgery, 3Chest Medicine and 4Anesthesia, Faculty Medicine - Cairo University
Department of 2Cardiothoracic Surgery, Faculty Medicine - Menofia University
Corresponding author: Ahmed Sayed Hussein, Mobile: 00201090991111, E-mail: drahmed 755@gmail.com

Minimally invasive valve surgery is considered much more beneficial than routine median sternotomy
in patients undergoing open heart surgery with sever chronic obstructive pulmonary disease (COPD).
Objective: To compare between early outcomes of minimally invasive versus routine median sternotomy in patients
with severe COPD undergoing isolated mitral valve replacement (MVR).
Patients and Methods: 100 patients with severe COPD between October 2016 and September 2019 underwent isolated
MVR. Patients were divided into 2 groups: Group (A): 50 patients underwent surgery via minimally invasive approach
and group (B): 50 patients underwent surgery via median sternotomy. Early postoperative complications, Intensive Care
Unit stay and total hospital stay were compared in both groups.
Results: The mean age was 60 ± 9 years for Group (A) and 61 ± 10 years for Group (B), (P = 0.29). Combined
postoperative complications were significantly lower in Group (A) [8 (16%) versus 12 (24%), P < 0.05]. The median
postoperative mechanical ventilation time was 10 hours in group (A) versus 22 hours in group (B) (P < 0.05). The
median ICU stay in group (A) was 1.5 days versus 3 days in group (B) (P < 0.05). The median length of total hospital
stay was 7 days in group (A) versus 13 days in group (B) (P < 0.05). The overall hospital mortality was 2 patients (4%)
in group (A) versus 1 patient (2%) in group (B) P < 0.05.
Conclusion: Minimally invasive had better early outcome than routine median sternotomy in patients with severe
COPD undergoing MVR and should be considered as a good option in these patients.
Keywords: Minimally invasive, Median sternotomy, Mitral Valve replacement, Chronic obstructive pulmonary disease.


Median sternotomy is considered one of the major

traumas in open heart surgery in addition to
approach and group (B) 50 patients underwent MVR
cardiopulmonary bypass (CPB) (1). Minimally invasive
through routine median sternotomy. All patients of both
as an approach for MVR has many advantages over
groups were diagnosed as severe COPD by the
routine median sternotomy as: less blood loss, less
pulmonologist after pulmonary function test (PFT) and
incidence of reopening, less pain, better respiratory
arterial blood gases after their receiving of intense
function and rapid (1-4). Although minimally invasive
medical treatment for 2 or 3 weeks before surgery to
approach has the previous advantages over median
improve chest condition of patients before surgery as
sternotomy, yet it is technically more difficult and
possible. Once the pulmonologists gave approval to go
requires a good training for use of long instruments used
for surgery, patients were prepared by proper history
in minimally invasive approach and also needs more
CPB time (2-3). Many studies hypothesized that patients
echocardiography, computerized tomography (C.T) of
with severe COPD undergoing open-heart surgery via
chest and diagnostic coronary angiography.
minimally invasive approach will have many benefits
Patients with isolated MVR were selected and patient
over the routine median sternotomy approach (2-4).
was considered severe COPD with forced expiratory
Aim of study was to compare between early outcomes
volume 1 (FEV 1) < 50% in the first minute in PFT, PO2
of minimally invasive versus routine median
< 55, PCO2 > 50 and oxygen saturation < 93% in arterial
sternotomy in patient with sever COPD undergoing
blood gases in room air.
isolated MVR.

Ethical approval and written informed consent:
An approval of the study was obtained from
Through the period between October 2016 and
Cairo University Academic and Ethical Committee.
September 2019, a 100 patients with sever COPD
Every patient signed an informed written consent for
undergoing MVR in Cairo University Hospitals were
acceptance of the operation.
selected and divided into 2 groups; group (A) 50

patients underwent
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ted under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received:4 /10 /2020

Accepted:22 /11 /2020

Full Paper (vol.822 paper# 1)

c:\work\Jor\vol822_2 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 190-192

Early Outcomes of Using Radial Artery in Coronary Artery Bypass
Surgery in Cairo University Hospitals
Fouad M. Rasekh and Ahmed S. Mahmoud
Department of Cardiothoracic Surgery, Faculty Medicine - Cairo University
Corresponding author: Ahmed Sayed Hussein, Mobile: 00201090991111, E-mail: drahmed 755@gmail.com

Using arterial grafts is commonly associated with good outcome. Using left internal mammary artery and
radial artery can achieve complete arterial revascularization of left coronary system by using sequential grafting or multiple
Y Technique.
Objective: We present our experience in using internal mammary artery and radial artery (RA) Y-graft in 100 patients.
Patients and Methods: Between February 2016 and January 2019, 100 patients (aged 45-60 years) with the diagnosis of
multi-vessel disease underwent complete arterial revascularization using left internal mammary artery (LIMA) and RA.
We used the technique of RA (Y) or (T) graft on LIMA to revascularize left coronary system; we did multiple (Y) or (T)
graft or sequential grafts.
Results The operating time was 220±20 minutes in average, the bypass time was (92.5 ± 16.7) minutes, and cross-clamp
time was (70.6 ± 20.6 minutes). LIMA was anastomosed to the left anterior descending coronary artery (LAD) system in
all patients. RA Y-graft was anastomosed to LIMA in all patients. Sequential grating using RA was done in 20 patients.
The mean ICU stay of the patients was (2.2 ± 0.5 days). Mean hours of mechanical ventilation was (14.3 ± 2.9). Four
patients required re-exploration for bleeding. 66 patients needed blood transfusion. 45 patients required inotropes.
Conclusions: RA can be used safely with LIMA to revascularize left coronary territory using sequential grafts or multiple
(Y) grafts. This method allows for complete arterial grafting in multi-vessel disease using only single IMA and RA grafts
with good early results.
Keywords: Radial Artery, Coronary artery bypass surgery, Left internal mammary artery.


Arterial grafting of coronary arteries is a surgical
The RA was anastomosed to branches of circumflex
method to improve long-term results of coronary artery
artery which must have more than 90% stenosis. No
disease (CAD). Using radial artery started since 1970 by
patients had other cardiac disease requiring surgical
Carpentier and coworkers (1).
The aim of coronary artery bypass graft surgery
The patients were 70 men and 30 women, with a
(CABG) is complete revascularization and it is better to
mean age of 52.5±7 (table 1). The risk factors for these
use arterial grafts to reach this goal to avoid the failure
patients are shown in table 2. No patients had chronic
of saphenous vein graft (2,3).
pulmonary obstructive disease. Creatinine of all patients
Due to the lack of enough length of the arterial
was within normal. Left ventricular ejection fraction
grafts, and in order to achieve arterial revascularization,
(LVEF) was within normal (Table 3).
it is a must to do sequential or/and composite grafting
They all underwent total revascularization of left
techniques (4).
coronary territory using LIMA and Radial artery; using
Bilateral internal mammary arteries (IMAs), and
either multiple Y grafts or sequential grafting, as for right
the radial artery (RA) were used as conduits in the
coronary artery saphenous vein graft (SVG) was used.
patients. Sequential grafting using arterial grafts,
All operations were done through sternotomy,
besides, classical Y-graft technique of RA has been used
using heart lung machine and warm antegrade
cardioplegia, skeletonized IMA was harvested routinely

and RA was harvested. LIMA was anastomosed to LAD
in all patients. Sequential anastomoses were performed
Between February 2016 and January 2019, 100
with RA grafts if needed (20 patients).
patients with multi-vessel coronary artery disease
The rest of patients received single or multiple (Y-graft).
underwent total arterial revascularization with left

internal mammary artery (LIMA) and RA.

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

Received: / /2020

Accepted: / /2020

Full Paper (vol.822 paper# 2)

INTRODUCTION The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 193-198

The Role of Helicobacter Pylori Infection in Idiopathic
Thrombocytopenic Purpura in Children
Al Zahraa Elsayed Ahmed, Ashraf Mahmoud Radwan, Heba Latif Rizk*
Department of Pediatric, Faculty of Medicine, Sohag University
*Corresponding author: Heba Latif Rizk, Mobile: (+20) 01283523294, E-Mail: hebalatif90@gmail.com

Many studies had found obvious relation between helicobacter pylori infection and chronic idiopathic
thrombocytopenic purpura; several studies have reported remission of immune thrombocytopenic purpura (ITP) after
eradication of a coexistent Helicobacter pylori infection in adults, data in children are limited.
Objective: To detect the association of H. pylori infection and idiopathic thrombocytopenic purpura in children and
the effect of eradication of the infection on platelet count in these patients.
Patients and methods: This study was conducted on 83 chronic idiopathic thrombocytopenic purpura children with
age range from 3 to 13 years. They were 46 males 37 females. Also the study included 104 healthy individual with
the same range of age. They were 58 males and 46 females as a control group. This was between October 2018 and
September 2019 in the Pediatric Hematology and GIT Clinics or inpatients wards of Pediatric Department.
Results: Clinical benefit occurred in 31 cases of the 83 chronic ITP (cITP) patients screened; nevertheless, we have
a simple, inexpensive, noninvasive screening method; the adverse events of eradication therapy are negligible,
together with an affordable cost, all uncommon attributes among the specific treatments currently available for cITP;
therefore it is worthwhile to test for and treat H. pylori infection.
Our data showed a prevalence of H. pylori infection in cITP pediatrics that was similar to other studies.
We found that successful H. pylori eradication induced platelet response in 37.3% of 83 cases included in our study.
Keywords: H. pylori, Immune thrombocytopenic purpura, Platelet count.

diseases, e.g. idiopathic thrombocytopenic purpura, iron
Immune thrombocytopenic purpura (ITP), also
deficiency anemia, atherosclerosis, and Alzheimer's
known as idiopathic thrombocytopenic purpura, is an
disease (6).
autoimmune bleeding disorder characterized by
Aim of the work was to detect the association of
bleeding due to isolated thrombocytopenia with a
H. pylori infection and idiopathic thrombocytopenic
normal bone marrow in the absence of other causes of
purpura in children and the effect of eradication of the
low platelets (1, 2). It causes a characteristic red or purple
infection on platelet count in these patients.
bruise-like rash and an increased tendency to bleed (3).

The exact mechanism of autoimmunity leading to
ITP is still unclear. Under non-pathological conditions
This study was conducted on 83 chronic idiopathic
the immune system is finely regulated by humoral and
thrombocytopenic purpura children with age range from
cellular components, including primarily regulatory T
3 to 13 years. They were 46 males 37 females. Also the
and B cells (T regs and B regs). Alteration of the balance
study included 104 healthy individual with the same
between these regulatory cells and effectors results in a
range of age. They were 58 males and 46 females as a
breakdown of the immune tolerance causing increased
control group. This was between October 2018 and
platelet clearance and impaired thrombopoiesis.
September 2019 in the Pediatric Hematology and GIT
Similarly to other autoimmune disorders, molecular
Clinics or inpatients wards of Pediatric Department, in
mimicry with bacterial or viral proteins might be one
Sohag University Hospital.
reason for pathogenesis of ITP. In fact, it was reported

a cross-reactivity of anti-platelet autoantibodies with
Inclusion Criteria: The patients were children aged
human immunodeficiency virus, hepatitis C virus and
less than 14 years who were diagnosed with chronic
Helicobacter pylori in secondary ITP (1).
idiopathic thrombocytopenic purpura with no other
Helicobacter pylori (H. pylori), previously known
recognized cause of thrombocytopenia, such as
as Campylobacter pylori, is a gram-negative, helically-
shaped, microaerophilic bacterium usually found in the
myeloproliferative or lymphoproliferative disorders.
stomach (4). Its helical shape (from which the genus
Exclusion Criteria: All children who were diagnosed
name, helicobacter, derives) is thought to have evolved
thrombocytopenic purpura as a part of systemic disease
in order to penetrate the mucoid lining of the stomach
or infection and children with age older than 14 years.
and thereby establish infection and causes mainly
We chose group of children who were diagnosed
chronic gastritis and gastric ulcer (5).
ITP and stopped any treatment they were receiving it
Many investigators have proposed causal
(patient group) and group of children with normal count
associations between H. pylori and a wide range of other
of platelet (control group) then both were investigated

for H. pylori by non-invasive method, which was

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:5 /10 /2020

Accepted:23 /11 /2020

Full Paper (vol.822 paper# 3)

c:\work\Jor\vol822_4 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 199-204
Governance: Governance Indicators in Nursing Faculty, Benha University
Abdel-Rahim S. Shoulah, Sabry A. Salem, Hala A. Abed Hassen, Hoda S. Abd El-Hamid*, Omyma M. Hassen
Department of Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
*Corresponding author: Hoda S. Abd El-Hamid, Mobile: (+20) 01275478932, E-Mail: hoda.saad2018@yahoo.com

Governance is the system through which the organization's work is directed and monitored at the
highest level in order to achieve its objectives and to meet the standards of responsibility, integrity and openness.
To determine the degree of practice of the principles of governance in the of nursing faculty from
viewpoint of its faculty members, administrative staff and students. Subjects and Methods: This descriptive cross
sectional study was conducted to assess the degree of practicing the principles of governance at University College
of Nursing in Benha from the viewpoint of its faculty members, administrative staff and students. Data were collected
using a questionnaire formed of 83 questions to staff member, administrators and students.
Results: This study finding illustrated that 60.0% of staff members, 62.6% of administrators and 59.2% of students
had their knowledge about governance in Benha Faculty of Nursing regarding total items.
Conclusion: There is no statistically significant difference between staff member, administrators and students
regarding their score of knowledge about total transparency, total participation and total rule of law. However
difference between staff member, administrators and students regarding their score of knowledge about total
accountability, total strategic vision and total efficiency and excellence are of statistically significant importance.
Keywords: Governance, Knowledge, Staff member, Administrators, Students, BUH.


staff and students to identify the possible ways to
Good governance plays an important role
develop it.
throughout the world. Recently there has been much

debate about good governance and its role in
development in terms of improving economic
Sample of this descriptive cross sectional study
performance and financial investment (1). Good
was chosen using first: Cluster random sampling to
governance represents one of the most important
choose one student section from each academic year.
requirements to achieve development in all societies,
Second: Stratified random sample of faculty members
especially in developing countries. These countries are
and administrative staff according to the academic
now in a dire need of making some serious reforms in
grade and experience years respectively. Data were
their political, economic, social, and administrative
gathered using a questionnaire formed of 83 questions
structures in order to be able to provide the necessary
to staff member, administrators and students.
services for their citizens and help them fulfill their

aspirations (2).
Governance is a set of mechanisms, procedures,
EpiinfoTM software, Version 3.4.3 is used to calculate
laws, systems and decisions that ensure discipline,
the least required sample size at 0.05 alpha error and
transparency and fairness. Thus, aiming to achieve
80% power of the study and population size. Using the
quality and excellence in performance by activating the
proportion of practicing governance (69.48%) among
management's actions with regard to exploiting the
faculty members obtained from previous study in Gaza.
economic resources available to it, stakeholders and
The least number is 316. After adjusting for 20%
society as a whole (3). The principles of good
dropout a sample size of 400 was suggested.
governance such as participation, rule of law,

transparency, accountability, fairness and efficiency
Tool of data collection:
enable employees to be more effective and transparent
Governance Indicators in Nursing Faculty, Benha
in providing high quality services. It also protects them
University included 2 parts as follow:
from the tendency towards misconduct (4).
Part 1: Personal and work-related data: Gender, sex,
The concept of the governance of education in
type of work, degree, and years of service
terms of universities, colleges and all educational
institutions has recently emerged as a concept to try to
reform university education in all foreign countries,
administrators and students about governance: The
including Arab countries (5).
questionnaires for staff member, administrators and

students are formed of 83 questions. The total score of
them ranged from (1-5), (1) strongly disagree, (2)
To find out the degree of practicing of the principles of
disagree, (3) natural, (4) agree and (5) strongly agree.
governance at Nursing Faculty, Benha University from
After modification the total score of them ranged from
the viewpoint of its faculty members, administrative
(1-3), (1) for strongly disagree and disagree, (2) for

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

Accepted:24 /11 /2020

Full Paper (vol.822 paper# 4)

c:\work\Jor\vol822_5 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 250-211

Genotyping and Severity of Rotavirus Infection among Infants and Children with
Acute Diarrhea
Manar Fathy1, Rania m Amer2, Mohamed A Almalky*1, Sherif El Gebaly1
Departments of 1Pediatrics and 2Microbiology and Immunology, Faculty of Medicine, Zagazig University
*Corresponding author: Mohamed A Almalky, Mobile: (+20) 01144444929, E-Mail: drmohamedalmalkyped@yahoo. com

Rotavirus (RV) belongs to the Reoviridae virus family and the virion comprises of three concentric
protein layers. Worldwide, rotavirus (RV) is the most common cause of severe gastroenteritis (G.E.) among infants
and young children especially in those countries which has not launched a RV vaccination program and approximately
40% of hospitalized patients suffering from gastroenteritis were infected with RV. Objective: To determine the
prevalence of rotavirus infections, genotypes and degree of severity of its acute diarrhea in infants and children
attending the children hospital, at Zagazig University Hospitals. Patients and methods: this study was done on 140
patients admitted to Children Hospital, Zagazig University suffering of gastroenteritis, Vesikari clinical severity score
was done and stool sample was taken from patients, which was tested for RV by dipstick method and positive patients
underwent genotyping by immunochromatography using PCR technique.
Results: Among the studied group 128 patients (91.4%) showed positive results for rotavirus detection by dipstick
analysis of stool, while only 12 patients (8.6%) were negative. The Vesikari score of severity ranged from 9 to 15 with
median of 12 and its mean ± SD was 11.9±1.3. G3 and P8 were the most types in the examined patients.
rotavirus is still the main cause of severe gastroenteritis that requires hospital admission. G3 and P8 are
the most detectable genotypes.
Keywords: Diarrhea, Genotyping, Infants and Children, Rotavirus.


Worldwide, rotavirus (RV) is the most common
proteins, VP7 and VP4 that are used to classify rotavirus
cause of severe gastroenteritis among infants and young
strains into G (glycoprotein) and P (protease sensitive)
children especially in those countries which has not
genotypes, respectively (8). Of the 12 G and 15
launched a RV vaccination program (1). Every child
genotypes known to infect humans, genotypes G1P81,
encounters at least one episode of RV gastroenteritis by
G2Pl4, G3P8, G4P8 and G9P8 cause over 90%of
the age of 5 years. Each year, about 2 million subjects
rotavirus disease worldwide (9).
have to be hospitalized for developing severe RV
The aim of this work was to determine the
gastroenteritis while about 25 million patients seek
prevalence of rotavirus infections, genotypes and
medical help by visiting a physician's office or clinic
degree of severity of its acute diarrhea in infants and
and 111 million cases require care at home (2). While
children attending the Children Hospital, at Zagazig
diarrhea is the second most common cause of fatal
University Hospitals.
childhood illness, about 1.34 million deaths occur

worldwide among children aged less than 5 years due to
RV (3).
This study was a cross-sectional study
Though the incidence of RV infection among
conducted in Pediatric Department, Zagazig University
children in developed and developing countries is
Hospitals, Medical Microbiology and Immunology
similar, outcomes vary widely with 82% of fatalities
Department and in Medical Scientific and Research
estimated to occur in developing countries. Most death
Centre, Faculty of Medicine, Zagazig University
occurs in low- and middle-income countries, such as
Egypt (4). RV can be detected in high concentrations in
For one year surveillance, the data and the stool
the stool of children suffering from gastroenteritis.
samples were gathered from January 2019 to January
Control measures such as improved sanitation is not
2020 (in November, December, January months which
effective in preventing this disease (5).
was the peak of RV). A total of 140 stool specimens
Several studies performed in the Middle East
were collected from admitted patients diagnosed with
showed that approximately 40% of hospitalized patients
acute diarrhea in Pediatric Department, Zagazig
suffering from gastroenteritis were infected with RV (2,
University Hospitals. The stool samples were from the
6). Rotavirus (RV) belongs to the Reoviridae virus
consecutive patients in this study period. Case
family and the virion comprises of three concentric
enrollment was done on the basis of inclusion and
protein layers (7). The outer capsid consists of two
exclusion criteria.
This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received:6 /10 /2020

Accepted:24 /11 /2020

Full Paper (vol.822 paper# 5)

c:\work\Jor\vol822_6 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 221-221

Myocardial Protection with Glucose-Insulin-Potassium Infusion during
Cardiopulmonary Bypass for Coronary Revascularization
Essam Ezzat Abd El-Hakeem1, Ahmed Elsaied Abd Elrahman Aly2,
Osama Salah El Din Mahmoud*2, Ahmad Hamody Hassan2
1Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Assiut University,
2Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Osama Salah El Din Mahmoud, Mobile: (+20) 01001752726,
E-Mail: osamasalah@med.sohag.edu.eg
Sodi-Pallares and colleagues first time introduced use of glucose-insulin and potassium (GIK) solution
for myocardial protection. They used this solution in patients with acute myocardial infarction and concluded that
GIK solution limited electrocardiographic changes in these patients.
Objective: To investigate the effectiveness of the GIK solution regarding myocardial protection evaluated by
postoperative creatine kinase MB (CKMB) and cardiac troponin I levels.
Method: In this prospective, randomized clinical trial, sixty-four patients were assigned into two groups: GIK group,
in which glucose-insulin and potassium infusion were given during surgery, and non-GIK group in which only saline
infusion was given during the procedure.
Results: All CK-MB values were lower in the GIK group than the Non-GIK group in the postoperative period (6,
12 and 24 hours' samples) with statistically significant results. Troponin values were lower in the GIK group versus
the Non-GIK group after 6 and 12 hours with statistical significance (P < 0.001 and 0.022 respectively).
Conclusion: The addition of GIK infusion throughout the operation to standard myocardial protective techniques in
patients undergoing on-pump coronary artery bypass graft (CABG) surgery attenuates myocardial ischemic injury.
CABG, Cardiac Protection, Inotropic support, GIK.


The heart is separated from the circulation during
potassium levels are decreased, whereas the delivery
cardiac surgery with cardiopulmonary bypass (CPB).
of potassium raises its levels inside myocardial cells,
This causes myocardial ischemia, inevitably. In
thus increasing the threshold against ventricular
addition to this ischemic insult, upon reperfusion, an
arrhythmias (3).
extra hit will occur, which may intensify the

magnitude of cardiac dysfunction (1). The loss of high-
Ethical approval:
energy phosphates and disruption of normal
This prospective randomized clinical trial
intracellular calcium homeostasis is central to the
was conducted after approval of the Ethical
pathogenesis of ischemic myocardial injury (2).
Committee board of Sohag University and obtaining
Myocardial ischemia causes extreme release of catech
informed written consent from each patient.
olamines within minutes and induces hormonal and m

etabolic changes, such as a major decrease in insulin
secretion and rise in free fatty acids (FFAs) (3).
Patients aged more than 30 years undergoing
Several techniques have been developed over the
coronary artery bypass grafting (CABG) on
years to reduce and/or modulate the magnitude of this
cardiopulmonary bypass. The study was conducted in
ischemia-reperfusion injury associated with the
the period from January 2019 until January 2020 at
cardiopulmonary bypass episode (1). The early years of
Sohag University Hospital.
myocardial protection studies during CPB largely

focused on the quest for the exact formulation of
Exclusion criteria: Patients who underwent off-pump
solutions to satisfy the optimal demands of
surgery, poorly controlled diabetes mellitus (glucose
cardioplegic solutions (4).
>12 or < 3 mmol/L), patients with preoperative renal
Therapy with glucose-insulin-potassium (GIK) is
dysfunction (creatinine > 1.2 mg/dl), those with a
associated with a decreased level of circulating FFAs
previous stroke, those with severe liver disease (Child-
and facilitates the use of glucose as the main energy
Pugh C stage), emergency CABG surgery and those
source of cardiac myocytes (3, 5).
with concomitant valvular heart diseases or poor
In contrast with FFAs, glucose is less oxygen-
cardiac functions (EF less than 50%).
consuming and has favorable impacts on myocardial
Patients were randomly (using sealed envelopes)
function and integrity of the membrane (3, 6). Besides,
assigned into two equal groups: GIK group in which
insulin activates pathways of intracellular signaling
patients were given GIK solution (50 IU of regular
that promote cell survival and inhibit apoptosis-related
insulin and 50 mEq of potassium were added to 1000
events (7). During ischemia, intracellular
ml of 5% Dextrose solution) at a rate of 100ml/ hour

This article is an open access article distributed under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received:6 /10 /2020

Accepted:24 /11 /2020

Full Paper (vol.822 paper# 6)

c:\work\Jor\vol822_7 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 217-224

COVID-19 Quarantine Measures and Its Impact on Pattern of Life of
School Children
Eman M. Araby*1, Ehab M. Emadeldin2, Hany M. Zakaria3
1Department of Public Health and Community Medicine, Faculty of Medicine, Benha University­ Egypt
2Department of Physical Health Sciences, Faculty of Physical Education, Benha University­ Egypt
3Department of Educational Sciences and Psychological - Faculty of Physical Education - University of Benha ­ Egypt
*Corresponding author: Eman M. Araby, Mobile: (+20) 01017571492, E-Mail: dremanaraby77@gmail.com

Although the physical effects of lockdown due to COVID-19 pandemic have become largely known, the
psychological effects are still unknown. Objective: to investigate physical and psychological impact of quarantine
measures among school children in Egypt. Methodology: This study investigated the impact of lockdown measures on
eating, sleeping, mood and behavior of school children using online survey. Results: Total participants were 1507, aged
between 6 to 14 years, private schools' students represented 60% of responders. 96.4% had changes in sleeping pattern,
77.8% had changes in eating pattern, 21.7% showed worries about general health condition, 70.5% had mood and
behavioral changes especially aggressive behavior and finally, 37.3% had problems in concentration and focusing.
Sociodemographic factors significantly affected sleeping of children during quarantine. Males were more affected
considering bed time, 77.8 % of those returned to bed wetting were girls, the most affected age group was 8 -10 years
old , urban residents and the first ordered child were the most affected. Changes of eating pattern were more common
among females, within the age group 8-10 years, first ordered child of families with sufficient monthly income. Those
having one or both of his/her parents is a health care worker were significantly affected and had more worries about
health. Finally, sex was the only factor affecting behavioral changes (male more than females). Conclusion: COVID-19
has a notable impact on eating, sleeping patterns as well as mood and behavior of the children.
Keywords: COVID-19, Lockdown, Impact, School-children.

parents related to quarantine and has strong impact on
Quarantine means separating and restricting the
their children (7).
movement of people who are potentially exposed to a
The current study aims to investigate physical and
contagious disease to ensure that they do not become
psychological impact of quarantine measures among
infected and to reduce the risk of transmitting the disease
school children in Egypt.
to others (1). COVID-19 quarantine measures like school

terminations and movement restrictions has been used as
a public health strategy to reduce disease transmission and
Data were collected via an online survey using
it has overturned the lives millions globally, disrupted
google forms. The link was shared to IT employee in the
children's routines and support systems and added new
selected schools who in turn disseminated it widely
stressors on parents who may have to go to work (2).
through email, Facebook page of the school, WhatsApp
COVID-19 pandemic and its quarantine measures
and via partnerships. The survey was available from the
have a strong impact on individuals mental health (3-5).
1st to 31st May 2020. The total number of individuals
Separation from loved ones, loss of freedom, uncertainty
participating in the survey during this time frame and
about the health condition and illness can have significant
completed it properly was 1507 participants. Schools
effects; even cases of suicide have been reported. Also
shared in the survey were selected by stratified random
fear and anxiety about a new disease and what could
sampling technique to have a representative sample from
happen can be overwhelming and cause strong emotions
primary and preparatory schools at Qualubyia
among adults and children(6).
Longer durations of quarantine, insufficient data
international schools. The total sharing schools were 10 (3
from public health authorities about purposes of isolate,
preparatory and 7 primary).
increased worry about becoming infected or infecting
Questions included in the survey were adopted and
others, inadequate access to regular medical care,
translated from CDC fact sheet about stressful effects of
restricted social contact with others, dissatisfaction due to
COVID-19 pandemic on children and teens, 2020. We
loss of one's standard daily schedule, financial loss and
asked about sociodemographic status of school children in
shame or dismissal from others are strong stressors on
addition to questions about:

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

Accepted:24/11 /2020

Full Paper (vol.822 paper# 7)

c:\work\Jor\vol822_8 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 225-230
Epidemiology of Central Venous Catheters Infection in Hemodialysis Patients
Said M. Al-Barshomy*1, Neveen G. El-Antony1, Mohammed Sakr1, Rehab H. El Sokary2
Departments of 1Internal Medicine & Nephrology and 2Microbiology, Faculty of Medicine, Zagazig University-Egypt
*Corresponding author: Said M. Al-Barshomy, Mobile: (+20) 01008559101, Email: saidbarshomy@yahoo.com

Vascular access infections in hemodialysis patients increase by 2-3 folds in central venous catheters
compared to arteriovenous fistula or graft. Among these infections exit site infections, tunnel infections and catheter-
related bloodstream infections (CRBSI), are the most common complications. CRBSIs are major risk of hospitalization
as well as mortality in hemodialysis patients.
Objective: To study the epidemiology of central venous catheter related infections (CVC-RI), patterns of microbial
infections and antibiotic sensitivity among our hemodialysis patients.
Patients and methods:
94 ESRD patients on hemodialysis with temporary central venous catheter (CVC) inserted for
more than 48 hours, monitored for the development of CVC related infections (CVC-RI) and divided into two main
groups according to presence of catheter infection; (A) non-infected catheter patients and group (B) infected catheter
Results: The rate of CVC-RI is high in our hemodialysis patients (42.5 %). There was a significant difference between
the two studied groups as regard duration of HD and catheterization duration. Patients with evident catheter infections
had significantly higher total leucocytic count (TLC) and C-reactive protein (CRP) values. There was a significant
positive correlation between CRP with catheter duration and TLC. Staphylococcus aureus was the most prevalent
isolated bacteria. Vancomycin was the most common used antibiotic among infected patients.
Conclusion: CVC-RI rate is high in our hemodialysis patients (42.5 %). Prolonged duration of CVC usage and
diabetes are major risk factors related to infections. Both S. aureus and Gram-negative micro-organisms were the most
common organisms found in our study. Vancomycin and imipenem were the most common effective antibiotics
according to our blood cultures.
Keywords: Hemodialysis catheters, Infection, Renal failure.

Arteriovenous fistula (AVF) is the preferred access for
The number of end-stage renal disease (ESRD)
most HD patients as it provides the best outcomes
patients in need of renal replacement therapy (RRT) has
compared with tunneled cuffed dialysis catheter (TDC)
been increased over the last decades and it is expected
or arteriovenous graft (AVG) (4).
that this increase will continue in the next years.
The risk of infection with catheters is much
Hemodialysis (HD), which is the main modality of
higher than with arteriovenous fistulas (AVF) with a
RRT, requires long-term and effective vascular access
relative risk for bacteremia in patients with HD
(1). Hemodialysis (HD) patients are at a great risk of
catheters almost 10-fold the risk (5). Catheter access has
infection as the process of HD necessitates frequent
been used in 10% of HD patients in China and in 15%
insertion of needles or use of catheters to access the
of HD patients in the US (6).
blood stream. In addition to impaired immunity,
According to Dialysis Outcomes and Practice
increasing their risk for infection, they also require
Patterns Study (DOPPS) Practice Monitor (DPM) data,
frequent hospital admissions and surgery where they
despite a great effort to reduce its use. Landmark-guided
might caught an infection (2).
internal jugular vein (IJV) cannulation still a basic skill,
In patients with ESRD, insertion of large-bore
which every nephrologist and anesthetist is expected to
double-lumen catheters in the central venous system are
acquire. A successful first attempt is required as each
usually necessary till a functioning permanent vascular
attempt increases the chance of complications. Right
access is established. Vascular access in ESRD patients
internal jugular vein (IJV) is a preferable route for
requiring acute hemodialysis remain a great challenge
tunneled hemodialysis catheters, meanwhile both right
despite recent advances in technics of percutaneous
and left external jugular veins are alternative routes in
venous cannulation (3).
case the right IJV isn't suitable for catheter placement (7).
Vascular access (VA) infection is a major issue
NKF-KDOQI (National Kidney Foundation­
in chronic HD patients. Catheter-related infections
Kidney Disease Outcomes Quality Initiative) in its
include local infections, exit site infections, pocket
clinical practice guidelines recommended the right IJV
infections, tunnel infections and bloodstream infections.
as a preferred route for HD catheters, because it is easy
This article is an open access article distributed under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received: 6/10 /2020

Accepted: 24/11/2020

Full Paper (vol.822 paper# 8)

c:\work\Jor\vol822_9 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 231-236

Study of Urinary N-Acetyl-Beta-D-Glucosaminidase as a biomarker of
Diabetic Nephropathy
Amira A. Mahmoud1, Noha M Mostafa2 , Osama Mesbah 2, Omar M Sabry3, Said M. Al-Barshomy*1
Departments of 1Internal Medicine & Nephrology, Faculty of Medicine, Zagazig University, and Theodor Bilharz
Research Institute, 2Nephrology & 3Hematology, Egypt
*Corresponding author: Said M. Al-Barshomy, Mobile: (+20) 01008559101, Email: saidbarshomy@yahoo.com

Diabetic nephropathy (DN) is a major cause of morbidity and mortality in diabetic patients
worldwide. Plenty of tubular damage biomarkers have been discovered. Urinary N-acetyl--D-glucosaminidase
(NAG) is a hydrolytic enzyme that acts on glycosyl compounds. NAG is excreted in abnormally high amounts in
many renal diseases.
Objective: The aim of this work was to study the importance of Urinary N acetyl--D-glucosaminidase level as an
early biomarker for detection of DN and to assess the degree of kidney affection in various stages of DN.
Patients and methods: 100 subjects divided into five groups: Group 1: 20 healthy volunteers (control group),
group 2: 20 pre diabetic persons, group 3: 20 normo-albuminuria diabetic patients, group 4: 20 micro-albuminuria
diabetic patients (ACR 3 -300 mg/mmol) and group 5: 20 macro-albuminuria diabetic patients (ACR 300
All individuals were subjected to full history taking, ECG & echocardiography, abdominal ultrasound, laboratory
investigations (HbA1c, fasting and post prandial blood glucose, lipid profile, oral glucose tolerance test (OGTT),
blood urea, serum creatinine, serum uric acid, e-GFR and urinary NAG.
Results: There was high significant difference between the five groups regarding duration of the disease, fasting
blood sugar, postprandial blood glucose, HbA1c, Serum cholesterol, albumin/creatinine ratio, serum urea and
creatinine, e-GFR and urinary NAG. In addition, there was significant positive correlation between urinary NAG
and albumin/creatinine ratio, blood urea, creatinine, and e-GFR.
Conclusion: The urinary NAG can be used as an early urinary biomarker for early detection and progression of
diabetic nephropathy in type 2 diabetic patients.
Keywords: Diabetes, Nephropathy, Urinary N-Acetyl-Beta-D-glucosaminidase.

hematuria, heavy proteinuria, active urine deposits,
Diabetes mellitus (DM) is a metabolic disorder in
rapid decrease in glomerular filtration rate, absence of
which hyperglycemia is predominant due to an
retinopathy, or resistant hypertension) (1). DN occurs
imbalance in insulin secretion, its effect, or both.
in ~30% of people with type 1 DM and 25-40% of
Chronic hyperglycemia in diabetes is usually
people with type 2 DM (4).
associated with dysfunction, long-term damage, and
Several modifiable and non-modifiable risk
failure of many organs, especially the kidneys, eyes,
factors, such as poor blood sugar control, smoking,
heart, blood vessels, and nerves (1). Diabetic
high blood pressure, hyperlipidemia, urinary albumin
nephropathy (DN) is defined as persistent
excretion, and genetic factors may predict the
albuminuria [albumin excretion rate (AER) > 300
development of diabetic nephropathy in albuminuric
mg/24 hours] in diabetic patient for more than 5 years
patients with type 2 diabetes mellitus (5). Glucose
with concomitant retinopathy, in the absence of other
amplifies the effects of intra-glomerular blood
kidney disease, urinary tract infection (UTI) and heart
pressure by inducing impaired self-regulation in
failure. This process is often accompanied by high
glomerular microcirculation. On the other hand,
blood pressure (2). The K/DOQI diagnosis of diabetic
glomerular capillary hypertension enhances glucose
kidney disease is based on elevated urinary albumin,
transporter-1 (GLUT-1) expression with concomitant
low glomerular filtration rate, or persistence of GFR
intracellular accumulation of glucose, amplifying the
(less than sixty mL/min/1.73 m2) of 3 months or
harmful effects of glucose and its metabolites within
more (3).
the kidney (6).
DN is diagnosed clinically in most individuals, as
Biomarkers play an essential role in early
kidney biopsy will not alter the management of these
detection of DN. Microalbuminuria is the most
patients. However, a kidney biopsy may be required
common. At the same time, microalbuminuria is a
in some diabetics with CKD to determine the
sign of the generalized endothelial dysfunction that
underlying cause and thus referral to a nephrologist
occurs in diabetes, which explains the involvement of
should be considered when there is uncertainty about
the kidneys with impaired brain and cardiovascular
the etiology of the kidney disease (patients with
disease. Over time, it has been suggested that

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

Accepted: 24/11/2020

Full Paper (vol.822 paper# 9)

c:\work\Jor\vol822_10 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 237-240

Study of MICS in Hemodialysis Patients and Its Relation with
Serum Thyroid Hormones
Mohamed Omar Al Sayed Ali*, Mohammed Ali Fahmy El Zanaty, Tamer Mohamed Goda
Department of Internal Medicine, Faculty of Medicine ­ Zagazig University
*Corresponding Author: Mohamed Omar Al Sayed Ali, Mobile: (+20)01002284678,
Email: dr.mohamed2008@gmail.com
Malnutrition-inflammation complex syndrome (MICS) is a frequent and serious problem in patients
undergoing dialysis with estimated prevalence about 18­75%. The etiology is multifactorial. MICS is believed to be
main cause of erythropoietin hyporesponsiveness, low free triiodothyronine (FT3) and increased mortality and
hospitalization among the dialysis patients.
Objective: To determine the prevalence of MICS and identify association between MICS and thyroid hormones.
Patients and Methods: This was cross sectional study, which was conducted on 91 patients admitted at Hemodialysis
Units of Zagazig University Hospitals and Fakous General Hospital. Blood samples had been obtained before the
initiation of the HD session and after an 8 hours fasting, blood measurements included: Serum urea, creatinine, TSH,
T3, FT3 and FT4.
Results: This study showed that, prevalence of MICS was about 56%. There was statistically significant difference
between patients had MICS and patients without MICS regarding age, and duration of hemodialysis. There was no
statistically significant difference between patients had MICS and patients without MICS regarding T3, T4, TSH.
There was statistically significant difference between patients had MICS and patients without MICS regarding serum
Conclusion: This study concluded high prevalence of malnutrition-inflammation complex syndrome on patients on
dialysis. There was no association between MICS and thyroid hormones.
Keywords: Dialysis, Frequency, Malnutrition inflammation complex syndrome, Thyroid hormones.

In CKD, there is an alteration of the metabolism,
Malnutrition is a frequent and serious problem in
distribution, degradation and excretion of thyroid
patients undergoing dialysis with estimated prevalence
hormones; the most commonly observed is a decrease in
about 18­75%. It is referred as "malnutrition-
total triiodothyronine (T3) concentration (5). The
inflammation complex syndrome (MICS) or "energy
etiology of thyroid disorders in CKD is multifactorial
protein wasting syndrome" (1).
and it is not entirely understood. There are a number of
MICS is a condition in which there is a loss of
contributing variables: a decreased activity of
protein reserves and energy resulting from inflammatory
deiodinase, reduction in the excretion of inorganic
and non-inflammatory causes in patients with chronic
iodine, presence of uremic toxins, metabolic acidosis,
kidney disease (CKD) (2).
malnutrition, use of heparin in hemodialysis (HD),
The etiology is multifactorial including diet,
advanced age, infection by hepatitis C virus and drugs
oxidative stress, acidemia, blood loss by hemodialyzers
(amiodarone, steroids, beta-blockers, lithium, rifampin,
and through feces, uremic medium and the effect of
sunitinib, sorafenib, imatinib, among others). Some
anabolic hormones. The possible causes of MICS
studies in CKD patients have found correlations between
include comorbid illnesses, oxidative and carbonyl
low concentrations of T3 with high concentrations of
stress, nutrient loss through dialysis, anorexia and a low
inflammatory markers (highly sensitive C reactive
nutrient intake, uremic toxins, a decreased clearance of
protein [hsCRP], interleukin 6 [IL-6]), malnourishment
the inflammatory cytokines, a volume overload, and
(decrease in serum prealbumin concentration),
dialysis-related factors (3).
endothelial dysfunction, deterioration of cardiac
MICS is believed to be main cause of
function, poor survival and greater mortality from all
causes. Other authors have shown that low serum
triiodothyronine (FT3), a high rate of cardiovascular
concentrations of FT3 are associated with an increase in
atherosclerotic disease, a decreased quality of life, and
mortality, which is explained in part by its underlying
increased mortality and hospitalization among the
association with poor nutritional status and
dialysis patients (4). Low FT3 syndrome is defined as low
inflammation (6).
FT3 with normal thyroid stimulating hormone (TSH)
The study aimed to improve the quality of life and
and normal or slightly reduced free thyroxine (FT4)
to decrease morbidity in hemodialysis patients by
level. This has been correlated with parameters of
focusing on malnutrition-inflammation complex
malnutrition and inflammation (4).
syndrome (MICS) and clarify the relationship between

it and changes in serum thyroid hormones.

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:16 /7 /2020

Accepted:25 /8 /2020

Full Paper (vol.822 paper# 10)

c:\work\Jor\vol822_11 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 241-248

Accuracy of Thyroid Imaging Reporting and Data System in
Evaluation of Thyroid Neoplasm
Tamer Youssef Mohamed, Atef Mohamed Abdel Latif, Ahmed Mahmoud Mohamed Zaki,
Mahmoud Abd El Shahid, Mohammed Mohammed Abd Elfatah Ali*, Ahmed Elsayed Lotfy
Endocrine Surgery Unit, Faculty of Medicine, Mansoura University, Egypt
* Corresponding author: Mohammed Mohammed Abd Elfatah Ali, Mobile: (+20) 01007450402,
E-mail: mohamedmegar6@gmail.com
Background: Several US Thyroid Imaging Reporting and Data Systems (TIRADS) have been proposed for risk
assessment of thyroid nodules. The nodules are usually divided into variant categories based on TIRADS and are
then guided to Fine Needle Aspiration (FNA) Biopsy or follow-up, according to the risk of malignancy.
To assess the specificity, sensitivity and accuracy of TIRADS in diagnosis of thyroid neoplasm
Patients and Methods: This study included 60 patients presented to the General Surgery and Endocrine Surgery
Unite Outpatient Clinic at Mansoura University Hospitals with thyroid disorders. The study was conducted during
the period between 1 November 2018 and the end of March 2020.
All patients were radiologically evaluated using neck ultrasound with TIRADS classification. Fine needle
aspiration was performed and the results of both were compared to the postoperative pathology reports.
Results: the current study evaluated the accuracy of TIRADS (TIRADS 3,4a and 4b) compared to (TIRADS 4c
and 5) with sensitivity 83.3%, specificity 92.9%, PPV 83.3%, NPV 92.9% and accuracy 90.0%.
Conclusion: TIRADS scoring system is of great value in the diagnosis of simple nodular goiter as it gives a
degree of accuracy more than 90% compared to FNAC were the degree of accuracy was 78.3%.
Keywords: TIRADS, Fine needle aspiration, thyroid neoplasm.

based on sonographic characteristics, called the Thyroid
In the general population, the prevalence of thyroid
Imaging Reporting and Data System (TI-RADS) (4).
nodules is growing around the world, especially in
Six major sonographic characteristics were
women. The American Thyroid Association and the
concluded by the authors: solid components, marked
American Association of Clinical Endocrinologists have
hypo-echogenicity, micro-lobulated or irregular margins,
issued separate recommendations for thyroid lesion
micro-calcifications, and taller-than-wide shapes that are
treatment. High-resolution ultrasound is indicated in the
significantly correlated with carcinoma. These thyroid
assessment of thyroid nodules as the first line modality (1). cancer risk stratifications facilitated TIRADS practice (5).
In the prediction of malignancy and the selection of
To date, TI-RADS has been implemented in different
thyroid nodules that should be assessed by fine-needle
studies to assess malignant and benign thyroid nodules
aspiration (FNA), ultrasonography (US) is an important
and to decide if thyroid lesions have good diagnostic
diagnostic process. Well-known suspicious US features
output. While, its clinical use was challenged and
are the presence of marked hypo-echogenicity, micro-
multicenter evidence was required to further improve its
lobulated or irregular margins, micro-calcifications and a
clinical practice practicability. Several studies showed
taller-than-wide shape. It has been reported that a
positive results of TI-RADS in the diagnosis of thyroid
combination of these features could provide better
cancer (6).
diagnostic accuracy than a single feature alone (2).

Several studies have examined the possibility of
malignant nodules using ultrasound-guided biopsy due to
This study included 60 patients presented to the
suspicious ultrasonographic characteristics in order to
General Surgery and Endocrine Surgery Unit Outpatient
prevent overuse of fine needle aspiration cytology
Clinic at Mansoura University Hospitals with thyroid
(FNAC) in multiple benign thyroid nodules. The
disorders. The study was conducted during the period
American College of Radiology has created the Breast
between the 1 November 2018 and the end of March
Imaging Reporting and Data System (BI-RADS) for
breast cancer to classify various groups according to the
All patients were radiologically evaluated using
risk of malignancy (3).
neck ultrasound with TIRADS classification by Professor
Likewise, for thyroid imaging, there was no regular
Mahmoud Abd El-Shahid. Fine needle aspiration was
sonographic reporting method.
performed and the results of both were compared to the
Horvath et al. (4) created a thyroid ultrasonographic
postoperative pathology reports.
system to stratify cancer risk and formed six categories

Ethical approval: Approval of the Ethical Committee,
Faculty of Medicine, Mansoura University was

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Received:22 /7 /2020

Accepted:21 /9 /2020

Full Paper (vol.822 paper# 11)

c:\work\Jor\vol822_12 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 249-255

Prevalence of Pseudoexfoliation Syndrome in Patients with
Sensorineural Hearing Loss
Basma Ebrahim Mohamed*1, Abdalla Mohamed Al Amin Abdalla 1,
Essam Ali Abo El Magd 2, Ahmed Fathy Gabr 1
Departments 1Ophthalmology and 2Otolaryngology, Faculty of Medicine, Aswan University, Aswan, Egypt
* Corresponding author: Basma Ebrahim Mohamed, E-mail: dr.beme2015@ymail.com

Pseudoexfoliation syndrome (PEX) is a complex systemic disorder of the extracellular matrix
primarily affecting the eye and visceral organs. In this age-related disease fibrillar extracellular material is
produced and accumulates in many ocular and extraocular tissues.
Objective: To study the prevalence of pseudoexfoliation syndrome among patients with sensorineural hearing
loss. Patients and Methods: A cross-sectional study, conducted on 50 patients with sensorineural hearing loss
at the departments of Ophthalmology and Otolaryngology of Aswan University Hospital, was performed among
patients aged 50 years and older and both sexes were included while patients with a history of acute ear disease,
head trauma, long term exposure to heavy noise, intake of ototoxic drugs and chronic suppurative otitis media
(cholesteatoma) were excluded.
Results: The prevalence of PEX among SNHL patients was estimated in the current study as 36%. The mean
age was 61 (±7.1) years and ranged from 50 to 77 years old. The majority of participants (35 patients, 70%) were
female. Thirty-three patients (66%) of participants had chronic co-morbidities. Unilateral PEX was represented
by 10 patients (55.6%), while bilateral PEX was represented by 8 patients (44.4%).
Conclusion: This study establishes the reciprocal association between pseudoexfoliation and sensorineural
hearing loss. The main reason for this association remains unclear although the infiltrative nature of PEX can
still explain this concurrence.
Keywords: Pseudoexfoliation Syndrome, Sensorineural hearing loss.


Pseudoexfoliation (PEX) is defined as an age-
Aggregations of pseudoexfoliative material on
related disease, in which abnormal fibrillar
these structures interfere with normal hearing
extracellular material is formed and progressively
threshold levels due to dysfunction of the
accumulates in many ocular and extraocular tissues
mechanoreceptors of the ear by alterations in fine
(1). Recent reports showed that an identical
vibrations induced by sound waves and thereby
fibrillopathy to that seen in PEX and was documented
inhibiting the conversion of the vibration energy to
pathologically in the basement membranes and
bioelectric, resulting in hearing loss (6).
extracellular matrices of extraocular orbital tissues,
As there is increasing evidence that
the skin and visceral organs such as heart, lung, liver,
pseudoexfoliation not only affects ocular anterior
gall bladder, kidney, and cerebral meninges; which
segment structures but may also be a systemic
suggest that PEX is a systemic disease (2).
disease, this study was done to assess the relationship
The incidence and prevalence of PEX vary even
between PEX and sensorineural hearing loss (5).
in different sites of the same population. The
So this work aimed to study the prevalence of
prevalence of PEX is reported to be 5% to 20%
pseudoexfoliation syndrome among patients with
regardless of geographical features. The other
sensorineural hearing loss.
important result of the studies is that the prevalence

of PEX is higher over the age of 50 (3).
Sensorineural hearing loss (SNHL) is related to
This cross-sectional study was conducted at the
pathologies affecting the inner ear, cochlear nerve,
Departments of Ophthalmology and Otolaryngology
and auditory cortex. Congenital autoimmune and
of Aswan University Hospital. The study population
metabolic syndromes, infections, drugs, vascular
included 50 patients with evident sensorineural
disorders, exposure to noise or chemical substances,
hearing loss and the sampling was sequential till
acoustic neuroma, cochlear otosclerosis, Meniere's
completing the sample size.
disease, are among common (4). Some studies, using
Patients with sensorineural hearing loss aged 50
years or older of both sexes were included. On the
sensorineural hearing loss is significantly more
other hand, patients with a history of acute ear disease
common in patients with PEX (5). Moreover, PEX
or head trauma, those with long-term exposure to
material has been found on the tectorial and basilar
heavy noise, patients with a history of intake of
membrane of the organ of Corti of the inner ear.
ototoxic drugs such as aminoglycosides as well as

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:7 /10 /2020

Accepted:25 /11 /2020

Full Paper (vol.822 paper# 12)

c:\work\Jor\vol822_13 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 256-269
The Possible Radio Protective Role of Gum Arabic on
The Kidney Cortex of Adult Male Albino Rats
Heba Ahmed Mohamed Kandeal1, Fatma Ahmed Eid1,
Hemmat Mansour Abdelhafez1, Amr Mahmoud Abd El-Hady2,
1Zoology Department, Faculty of Science, Al-Azhar University, Egypt
2Faculty of Applied Medical Sciences, Misr University for Science and Technology (MUST), Egypt

Aim of the work: the use of ionizing radiation exposure increases, oxidative stress especially for cancer patients.
Therefore, there is a critical need to develop antioxidants that prevent oxidative stress damage. Gum Arabic is an
antioxidant and anti-inflammatory mediator. This study aimed to assess the possible radio protective effect of gum
Arabic (Acacia senegal) against gamma irradiation-induced injury on the rat kidney. Materials and Methods: four
groups of male Albino rats (each of 12 rats) received normal saline (G1), dose 5Gy of gamma irradiation (G2), orally
administered with 25 mg/kg gum Arabic for 3 weeks (G3) and gamma irradiation plus oral gum Arabic administration
for 7 days before and 21 days after irradiation (G4). Results: in the gamma irradiated group, histopathological and
ultrastructural examinations of the rat kidney cortical tissue revealed signs of degeneration to the cortical renal tubules
and glomeruli. In contrast, gum Arabic treatment alleviated most of the damaging effects of gamma radiation.
oral administration of gum Arabic could ameliorate adverse gamma radiation-induced effects that might be
attributed to its antioxidative and free radical scavenging effects.
Keywords: gamma radiation, kidney, gum Arabic, radio protective, rats.


Ionizing radiation (IR) exposure is a worldwide
This study aimed to assess the possible radio protective
(global) problem. Everyone can be exposed to IR under
effect of GA on the kidney of the irradiated adult male
several conditions - at home, at workplaces, as a patient
Albino rats through the use of some histological and
or caregiver in the medical settings and other sources. Its
ultrastructural studies.
medical application for diagnosis and therapy is one of

the increasing activities. Gamma and X-rays are the most
commonly used types of IR in medical the settings (1).
Living cell absorption of IR may lead to some chemical
The gum Arabic powder was obtained from El
and biological cellular damages through direct or
Gomhouria Company, Cairo, Egypt, it was administrated
indirect actions (2).Reactive oxygen species (ROS)
to the rat groups after suspension in distilled water at a
production is one of the most important damaging
dose of 25 mg/kg/day using a gastric tube for
effects of IR and the imbalance between excessive ROS
consecutive 21 days (9).
generation and cellular endogenous antioxidant defense

system production reflects an oxidative stress process
Radiation treatment
(3).Antioxidant treatment is one of the most effective
Whole-body 5-Gy single-dose gamma irradiation
strategies in protecting living cells against radiation
process of rats was performed at the National Center for
exposure damages, where some natural substances
Radiation Research and Technology, Nasr City, Cairo,
obtained from plant sources showed a protective effect
Egypt, using Cesium-137 Gamma cell 40. The dose rate
was 0.62 Gy/min at the time of the experiment.
(4).Applications of natural products are considered as an
Experimental animals
alternative method to ameliorate chronic renal failure
Experimental adult male Albino rats (Wistar
disease (5). Gum Arabic (GA) is a natural polysaccharide,
albino), weighing 160­180 grams at the beginning of the
extracted from the dried discharges of sticky stems and
experiment, were purchased from the Egyptian Holding
branches of Acacia trees, mainly Acacia senegal and
Company for Biological Products and Vaccines,
Acacia seyal trees, with no viscous soluble fiber content
Helwan, Cairo, Egypt. The animals were placed in
(6).GA trees are one of the genus Acacia, subfamily
plastic cages at proper environmental circumstances of
Mimosoideae and family Leguminosae(7).GA was found
light, ventilation, food and water. This experiment was
to be potent in treating patients with chronic renal
performed in accordance with the guidelines set by the
failure. The nephroprotective mechanism is unclear, but
National Institutes of Health (Publication no. 85­23,
may include antioxidant and anti-inflammatory effects(8).
revised 1996).
This article is an open access article distributed under the terms and conditions of the Creative

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Received:9 /10


Accepted:27 /11 /2020

Full Paper (vol.822 paper# 13)

c:\work\Jor\vol822_14 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 270-275

A Comparative Study of External Dacryocystorhinostomy with Stent Versus No
Stent in Acquired Nasolacrimal Duct Obstruction
Alaa Abdulmongy Abdulfattah Sadaka 1, Abdallah Mohammed AlAmin 2,
Nashwa Nasser Mohammed Gad 1
1Department of Ophthalmology, Faculty of Medicine, Aswan University, 2Department of Ophthalmology -
Faculty of Medicine, Al-Azhar University, Egypt
*Corresponding author: Nashwa Nasser Mohammed Gad, Mobile: (+20)01128328641 E-Mail: nashwa.n8n@gmail.com

Epiphora is defiened as decreased tear transfusion or defective tear discharge flow. Blockage of the
NLD (NLDO) prevents the flow of tears from the eye to the nose, leading to symptoms of obstruction.
Dacryocystorhinostomy (DCR) was established as the predominant measure.
Objective: To evaluate the effect of intubation on the outcome of external dacryocystorhinostomy.
Patients and methods: It was a prospective interventional randomized study. The study was carried on 40 eyes
of patients were going to do DCR under general anaethesia. They were divided into 2 groups as follows: Group A
(20 participants) were undergoing external dacryocystorhinostomy with silicone intubation and group B (20
participants) were undergoing external dacryocystorhinostomy without intubation.
At the final follow up of the patients of the two groups for 6 months, there were 4 cases had persistent
epiphora post-operative two cases in group (A) and two cases in group (B). This indicated that there was no
significant difference between the use of intubation or not in cases of acquired NLDO and chronic dacryocystitis.
External dacryocystorhinostomy is still gold standard surgical treatment in primary nasolacrimal duct
obstruction. This study showed that the silicone tube implantation is not necessary in the surgery.
Keywords: Dacryocystorhinostomy, Nasolacrimal duct obstruction (NLDO).

anatomy of the medial cantal and orbital eye muscles,
DCR is among the common eye cosmetic
and restrictions in patients with acute dacryocystitis
surgeries that are used to treat a dried outdue to a
with abscess formation (4).
blocked tear nasal canal (1).
The role of the silicone tube in DCR surgery
Obstruction of the lacrimal nasal canal
remains unclear. Recent studies provide a higher
(NLDO) can be classified as either a primary
level of evidence against intubation in DCR.
acquired nasal lacrimal duct obstruction (PANDO)
Intubation of the tear nasal canal with silicone tubes
when it is an idiopathic obstruction or a secondary
arose largely due to history and anecdote and the
tear duct obstruction (SALDO) when it is secondary
development of DCR surgery rather than relying on
to various etiologies (2). Acquired NLDO may
sound evidence. Based on current evidence, silicone
develop for a variety of causes, including secondary
intubation appears to be unrelated to increased rates
facial trauma, chronic environmental allergies,
of functional and anatomical success in DCR surgery
toxicity from chemotherapy or topical medications,
for patients with uncomplicated primary NLDO
tumors, old sinus diseases, or after nose surgery.
without narrowing of the common canal. In addition,
Dacryocystorhinostomy is a bypass procedure that
this practice increases costs and postoperative visits
creates anastomosis between the lacrimal sac and the
and may aquire additional morbidity (5). This
nasal mucosa through the bone. It can be performed
technique calls for an edge-to-edge anastomosis
through an external skin or nose incision with or
between the lacrimal sac and the nasal mucosa
without endoscopic visualization (3).
(across the flaps) above the bone margins of the
External DCR advantages include high
component bone, thereby building a lined epithelium
predictability and direct visualization of anatomy,
with the exception of minor changes (6).
which is highly relevant to cyst tumors. This
In 1970, ophthalmologists began to favor
technique facilitates an accurate anastomosis
DCR with silicone intubation over DCR without
between the lacrimal sac and the nasal mucosa.
intubation (7). Since its introduction by Gibbs in 1967,
However, the external DCR has some disadvantages,
they have advocated its use and reported an increased
including facial scarring, an imbalance in the
postoperative negative rate due to keeping the nozzle
lacrimal pump resulting from interruptions of the
open (8, 9). However, other studies have reported a

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:7 /10 /2020

Accepted: 25/ 11/2020

Full Paper (vol.822 paper# 14)

c:\work\Jor\vol822_15 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 276-281

The Pattern of Electrolyte Imbalance in Critically Ill Children admitted in
Pediatric Emergency Unit at Sohag University Hospital
Safaa Hussein Ali, Montasar Mohammed Mohammed, Raafat Shawky Youssef
Department of Pediatrics, Faculty of Medicine, Sohag University, Sohag, Egypt
Corresponding author: Raafat Shawky Youssef, Mobile: (+20) 01274794073, E-Mail: raafatyoussef77@yahoo.com

Electrolyte abnormalities are one of the common medical problems that should be addressed
well in hospitalized children. Electrolyte abnormalities could occur due to underlying illness or incorrect
management with fluid input. Electrolyte disorders have a significant impact on patient outcomes; treating
physicians usually pay attention to the underlying medical illness but preventable and manageable electrolyte
disorders are often overlooked.
Objective: To identify the pattern of electrolyte imbalance in critically ill children in the pediatric emergency
unit at Sohag University Hospital.
Patients and methods: We included 150 children aging from one year to 12 years age, presenting with
manifestations suggesting electrolyte imbalance coming to the pediatric emergency unit at Sohag university
hospital, the period from May 2018 to May 2019.
Results: Hypocalcaemia was the most common electrolyte imbalance accounted for (83.33 %) of studied
cases, followed by hypokalemia accounted for 96 (64.00%) of studied cases, then hyponatremia accounted for
54 (36.00%) of studied children, then hypernatremia accounted for 31 (20.67%) of studied children, followed
by hyperkalemia accounted for 23 (15.33%) of studied cases. According to our study, it was found that children
with hypernatremia had an 8.9 times higher risk of dying, AOR 8.92, 95% CI, 2.26:35.24 than children with
normal sodium levels. As regard to our study, we found that children with hyperkalemia had 8 times higher
risk of death than children with normal potassium level (AOR=8.07, 95% CI, 1, 39-47, 00).
Conclusion: Electrolyte abnormalities are common in children admitted to the emergency with an underlying
medical illness and contribute to significant morbidity and mortality. Preventive measures in high-risk patients
and early treatment would decrease morbidity and mortality.
Keywords: Pattern of Electrolyte Imbalance, Critically Ill Children.

Electrolytes imbalances are present in the
Infants and Children have been recognized as
form of excesses (Hyper) or Deficits (Hypo) such as
having more frequent episodes of electrolyte
Sodium imbalance (hypernatremia or hyponatremia),
disturbances than do adults, these disturbances may
alter the delicate homeostasis that is normally
hypokalemia), Calcium imbalance (hypercalcemia or
maintained by the growing and developing human (1).
hypocalcemia), these are the most common types of
Children are more vulnerable to electrolyte
electrolyte disturbances (2, 3).
disturbances than adults due to several characteristics
The most important and common electrolyte
of the young infants that emphasize the importance of
imbalance is Sodium imbalance, sodium plays a
this normally tightly regulated "salt and water"
primary role in terms of body fluid balance and also
balance include: A larger body surface area per unit
has an impact on the functioning of body muscles and
of body mass, promoting the loss of water via the
the central nervous system. The second one is
skin; A larger percentage of total body weight
Potassium imbalance, potassium promotes and
composed of water; A higher metabolic rate,
facilitates electrical impulses that are necessary for
requiring more water for energy dissipation and
muscular contractions and also for the normal
waste product excretion; In the very young infant,
functioning of the brain. The third one is calcium
immaturity of certain discrete renal functions; Rapid
imbalance, calcium is essential for bone health (4).
utilization of body fluids; A much greater likelihood
Electrolyte disturbances are involved in
of many different types of disease processes
many disease processes and are an important part of
manifesting by dehydration or electrolyte imbalance
patient management in medicine. The causes,
severity, treatment, and outcomes of these
Electrolytes are ions that can have either a
disturbances can vastly differ depending on the
negative charge such as, chloride (CL), Hydrogen
implicated electrolyte (5).
phosphate (HPO4), Bicarbonate (HCO3), Sulfate
The major purpose of this study was to study
(SO4), or positive charge such as, Sodium (Na),
the pattern of electrolyte disorders as regards the
Potassium (K), Magnesium (Mg), Calcium (Ca).
diagnosis and management in the Pediatric

Emergency Unit.
This article is an open access article distributed under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:8 /10 /2020

Accepted:26 /11 /2020

Full Paper (vol.822 paper# 15)

c:\work\Jor\vol822_16 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 282-288

Glutathione S- Transferase as a Marker of Acute Kidney Injury in
Pediatric Intensive Care, Zagazig University Children Hospital
Samir M. Zamzam1, Nehad AK Abd Elfatah1, Noha AM Rezk2, Magdi MH Soliman*1
Departments 1Pediatrics and 2Medical Biochemistry, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Magdi Mohamed Hossam El-Din Soliman, Mobile: (+20)1030804508,
Email: magdisoliman.1973@gmail.com

Glutathione S-transferases (GST) are major phase II detoxification enzymes having central roles in
the cellular detoxication of a diverse group of exogenous and endogenous harmful compounds.
The aim of the work was to investigate the role of GST in development of acute kidney injury in
PICU, Zagazig University Children Hospital.
Patients and Methods: A prospective cohort study was conducted on 50 pediatric patients admitted to PICU who
were divided into two groups according to incidence of Acute Kidney Injury (AKI). Patients were subjected to
clinical, laboratory, and plasma & urinary GST evaluation.
Results: AKI developed in 24% of patients. There was no significant relation between presence of AKI and
patient age, gender, weight, height, or clinical outcome. There were significant relations between plasma and
urine GST and presence of AKI. There is statistically non-significant relation between Pediatric Risk, Injury,
Failure, Loss, End-Stage renal disease (pRIFLE) staging and plasma and urine GST. There were statistically
significant negative correlations between each of plasma and urine GST on one side and both heart rate and
estimated creatinine clearance on the other side. Plasma GST can predict presence of AKI at cutoff 30.5, with
AUC 0.964, sensitivity 100%, specificity 84.%, PPV 66.7%, NPV 100% , accuracy 88%. Urinary GST in
prediction of AKI was 12.5, with AUC 0.95, sensitivity 91.7%, specificity 84.2%, with accuracy 86%.
: It could be concluded that AKI had significant incidence in PICU admission. High levels of plasma
and urine GST Pi after admission in PICU are associated with an increased development of AKI and GST Pi is a
valuable tool for early diagnosis of AKI.
Keywords: Kidney injury, Glutathione Transferase.


about the underlying etiology and indicate different
Acute kidney injury (AKI) is defined as the
stages of the pathophysiological processes involved
abrupt loss of kidney function that results in a
in AKI from acute stage to recovery (5).
decline in glomerular filtration rate (GFR), retention
The GST protein family, which is divided
of urea and other nitrogenous waste products, and
into 3 major subclasses alpha ,bi, gamma are
ubiquitous enzymes which have a role in the
electrolytes. The term AKI has largely replaced
detoxification of free radicals .The GST proteins
acute renal failure (ARF), as more clearly defines
family have been purified from a wide variety of
renal dysfunction as a continuum rather than a
human tissues (e.g. kidneys , testes ovaries , small
discrete finding of failed kidney function (1).
intestine, liver and adrenal glands). In renal tubules
If renal function of the patient returns to
contain alpha and pi forms in high amounts thus GST
baseline within 48h, this is called rapid reversal AKI
is a good marker for diagnosis of AKI (6).
while persistent AKI is beyond 48 hrs. If renal
This study was aimed to find and investigate
dysfunction that persists for 7 days is categorized as
the role of GST in development and outcome of acute
Acute Kidney Disease (AKD) and the term Chronic
kidney injury in PICU of Zagazig University
Kidney Disease (CKD) is used for patients with
Children Hospital.
kidney disease persistent after 90 days period (2).

The role of creatinine as a marker of renal
function is not enough, by the fact that its half-life
This prospective, cohort study included a
increases from 4 h to 24­72 h if the glomerular
total of 50 critically ill infants and children, attending
filtration rate (GFR) decreases. Rise of serum
at PICU, Faculty of Medicine, Zagazig University
concentration may take 24­36 h after a definite renal
Children Hospital. This study was conducted between
insult. True decrease in GFR may not be adequately
September 2018 to end of February 2019.
reflected by serum creatinine in cases with sepsis,

liver disease, and/or muscle wasting (3-4).
Approval for doing the research was obtained
Some of new biomarkers e.g. (Cystatin C,
from Pediatrics and Medical Biochemistry
Glutathione S-Transferase, Alkaline phosphatase and
Departments, Zagazig University, after receiving
Angiopoiten 1 and 2) may also provide information
Institutional Review Board (IRB) approval. The

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:12 /7 /202 0

Accepted:21 /8 /2020

Full Paper (vol.822 paper# 16)

Full Paper (vol.822 paper# 17)

c:\work\Jor\vol822_18 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 296-301
Effect of Use of Single Dose of Misoprostol on Blood Loss during Myomectomy
Alaa Elden Fath Alah Alhalaby, Hend Ali Shehl*, Heba Maged Abo Shady, Nabih Ibrahim El khouly
Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
*Corresponding Author: Hend Ali Shehl, Mobile: (+20)01094078963, E-mail: hendshebl3333@gmail

Uterine leiomyomas are the commonest benign tumours in women, which are estrogen-dependent
and grow during the reproductive life. Standard treatment for leiomyoma is hysterectomy or myomectomy according
to women's age and fertility. Prostaglandins and particularly PGE1 as misoprostol have an impact on uterine
contractions and decrease blood loss.
Objective: To evaluate the effect of using a single dose of vaginal misoprostol (400 Microgram) one hour before
abdominal myomectomy on intraoperative blood loss.
Materials and methods: This prospective randomized study was carried out postmenstrual upon 50 women with
symptomatic uterine myoma who attended to Department of Obstetrics and Gynecology, Faculty of Medicine,
Menoufia University during the period from October 2019 until October 2020. All subjects were divided into two
equal groups: Misoprostol group included 25 women administered 400 mg misoprostol vaginally one hour before
operation, and control group included 25 women underwent operation without misoprostol. Outcome variables
included: intraoperative blood loss (ml), postoperative hemoglobin values, postoperative hematocrit values and
operative time.
Results: there was statistically significant difference between the two studied groups according to amount of
intraoperative blood loss (ml) as Misoprostol group showed less blood loss than control group [(308.0 ± 32.66 vs.
404.4 ± 87), with p = 0.001]. In addition, there was statistically significant difference between the two studied
groups regarding operative time as Misoprostol group showed shorter duration than control group [(56.8 ± 3.12 vs.
78.6 ± 10.6), with p=0.001].
Conclusion: A single dose of preoperative vaginal misoprostol is an effective method for reducing blood loss and
operative time during abdominal myomectomy operations.
Keywords: Abdominal myomectomy, Blood loss, Operative time, Uterine leiomyoma, Vaginal misoprostol.


Leiomyomas are the most common benign
It has been shown that misoprostol, a PGE1
tumors in women, which originate from myometrial
analogue, apparently reduces uterine artery blood flow
smooth muscle cells. These tumors are estrogen-
when used in early pregnancies (8).
dependent and grow during the reproductive period.
Misoprostol, which is employed in the induction
Leiomyomas are mostly asymptomatic, but become
of birth and abortus and the treatment and prevention
symptomatic in 20­50 % of affected cases, presenting
of postpartum hemorrhages in obstetrics, may
with menorrhagia, pelvic pain or pressure, or urinary
decrease intraoperative hemorrhage in myomectomies
complaints (1-3).
when hemorrhage constitutes an important problem (9).
The standard approach for treating leiomyomas
This property of misoprostol can facilitate every
is hysterectomy for women who do not want to have
surgical operation on myometrium, limiting blood loss
more children and myomectomy for those who want to
to minimum. In recent years, misoprostol has been
preserve fertility (4, 5).
used for reducing bleeding during myomectomy.
However, hemorrhage was one of the most
Misoprostol (prostaglandin E1 analogue) is used
common complications in cases underwent
widely for cervical ripening, labor induction,
myomectomy. Literature showed that, about 20 % of
postpartum hemorrhage and second trimester
the cases who underwent myomectomy needed blood
terminations. It could increase myometrial contraction
transfusion (6).
and decrease hemorrhage (10).
Because hemorrhage is an important problem in
In a previous study, Celik and Sapmaz (11)
myomectomies, methods have been developed to
reported that a single dose of vaginal misoprostol
reduce hemorrhages. These methods include use of
before myomectomy reduced blood loss and the need
preoperative GnRH agonist, tourniquet methods,
for postoperative blood transfusion in women who
clamping of the bilateral uterine and/or ovarian artery
underwent myomectomy.
and injection of intraoperative vasopressin into the
The aim of the current study was to evaluate the
myometrium (7). As is well known, prostaglandins
effect of using a single dose of vaginal misoprostol
increase myometrial contractions and lead to a
(400 Microgram) one hour before abdominal
reduction in myometrial hemorrhage.
myomectomy on intraoperative blood loss.

This article is an open access article distributed under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received:8 /10 /2020

Accepted:26 /11 /2020

Full Paper (vol.822 paper# 18)

c:\work\Jor\vol822_19 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 302-307

Discrepancy of Glycosylated Haemoglobin and Fructosamine in
Egyptian Patients with Prediabetes and Iron deficiency
Mohammed Ali Gameil¹*, Maha Mahmoud Elshafie¹, Mohammed Ayed Mohammed Rashwan²,
Shaimaa Saber Elashwah³, Tarek Elsayed Abouzid³
Departments of ¹ Internal Medicine (Endocrine Unite), ² Clinical Pathology (Haematology Unite),
³ Clinical Haematology Unite (Oncology centre), Faculty of Medicine, Mansoura University.
*Corresponding Author: Mohammed Ali Gameil, Mobile: 00201099975071, Email: drmaligameil1979@yahoo.com

the controversies concerning the influence of iron deficiency on glycaemic control parameters in
patients with prediabetes prompted us to conduct this research.
Objective: Our aim was to get a delicate estimation of these changes that may alter the management plan in this
clinical situation.
Patients and methods:
a case control study included 197 Egyptian patients with prediabetes; 113 patients with
iron deficiency versus 84 patients without iron deficiency (control group) during the period (May 2019 - October
2019). History, physical examination and laboratory tests of fasting and postprandial plasma glucose (FPG and
PPPG), glycosylated haemoglobin (HBA1c), fructosamine, serum creatinine, ALT, AST, CBC, ferritin, serum iron
and total iron binding capacity (TIBC) were done.
Results: HBA1c was significantly higher in the iron deficiency group than the control group with non-significant
difference between the studied groups regarding FPG and PPPG. HBA1c level was positively correlated with
fructosamine, exclusively in the healthy group indicating the lack of credibility of HBA1c in iron deficient subjects
with prediabetes. HBA1C level was inversely correlated with serum iron level in both study groups. Conclusion:
there is discordance in glycaemic control parameters in patients with prediabetes and iron deficiency. Diagnosis
of deranged glucose homeostasis in patients with co-existent iron deficiency and prediabetes should not be with
HBA1c solely.
Keywords: HBA1c, Iron deficiency anaemia, Prediabetes.


Fasting and post prandial plasma glucose
However, Kim et al. (8) found a non-
(FPG and PPPG) tests are the main tools for diagnosis
significant relationship between iron deficiency and
of deranged glucose homeostasis, however the
HBA1c level in non-diabetic subjects. On the other
American Diabetes Association (ADA) and World
hand, Sinha et al. (9) found a significant lowering of
HBA1c in iron deficient patients.
glycosylated haemoglobin (HBA1c) for diagnosis of
To our knowledge, there is a lack of data
prediabetes and diabetes (1). Blood glucose is the main
concerning blood glucose control parameters
determinant of HBA1c but other factors can affect
alterations in Egyptian patients suffering from
HBA1c status as haemolytic anaemia, haemoglobin
prediabetes with iron deficiency. Our aim was to get a
disorders, pregnancy, malnutrition (iron, vitamin B12
delicate estimation of these changes that may alter the
and folic acid deficiency), race and ethnicity (2).
management plan in this clinical situation.
HBA1c was influenced by disordered erythrocyte turn

over conditions therefore HBA1c level in these
disorders is doubtful (3). Iron deficiency and iron
We conducted this case control study at the
deficiency anaemia (IDA) represent a common global
outpatient department of our university hospital
health challenge. People with iron deficiency are more
during the period from May 2019 to October 2019.
vulnerable to disordered glucose homeostasis and
This study included two groups of patients with
subsequent complications. The precise interrelation
impaired glucose regulation; the case group comprised
between iron deficiency, serum glucose and HBA1c is
113 patients; 41 male (36%) and 72 female (64%) with
still controversial (4).
iron deficiency versus the control group that
In case of iron deficiency, there is persistent
comprised 84 subjects; 34 male (40%) and 50 female
doubt concerning the credibility of HbA1c in
(60%) without iron deficiency.
diagnosis of prediabetes and diabetes (5). Contradictory
Patients were subjected to a detailed medical
data concerning HBA1c measurement in iron
history including age, socioeconomic status, marital
deficiency states were found in the literature (6).
status, smoking, alcohol consumption, exercise,
Madhu et al. (7) reported elevated HBA1c level in
infectious and tropical diseases, hereditary and
patients with iron deficiency with reversible decrease
familial diseases with therapeutic history of previous
after iron therapy.
iron therapy or history of blood transfusion as well as

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:8 /10 /2020

Accepted:26 /11 /2020

Full Paper (vol.822 paper# 19)

Microbial The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 308-315

Outcomes and Indications of Mini Percutaneous Nephrolithotomy in
Zagazig University Hospitals Patients
Safwat Elsayed Abou Hashem, Hazim Mohammed El Galaly,
Ahmed Mohammed Eliwa, Ahmed Ismail Abdel Rahman Kotb*
Department of Urology, Faculty of Medicine, Zagazig University.
*Corresponding author: Ahmed Ismail Abdel Rahman Kotb, Mobile: (+20)01126899392, E-mail kotba2276@gmail.com

PCNL is a well-established treatment option for patients with large and complex renal calculi. In
order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential
renal damage. A modification of the technique of standard PCNL has been developed. This is performed with a
miniature endoscope via a small percutaneous tract (11­20 F) and was named as minimally invasive or mini-
Objectives: To improve medical service for patients attending for Zagazig University Hospital by determining
indications and outcomes of M-PCNL when used as treatment modality for patients with renal stones.
Methods: This prospective cohort study was conducted at Urology Department Zagazig University Hospitals
during the period from March to November 2019. 48 patients from those attending to Urology Outpatient Clinic.
Percentage of improvement of patients M-PCNL was 94%, so sample was calculated to be 32 patients using open
EPI with CI 95%.
Results: 48 patients and percentage of improvement of patients M-PCNL was 94%. Male represented 53.8% of
the studied patients. Mean age was 35.10 years, ranged from 18 to 60 years. Mean body mass index was 39.56
kg/m2, ranged from 18.60 to 63.20 kg/m2. Mean preoperative hemoglobin was 12.56 g/dl, ranged from 11 to 14
g/dl. The most common site of stone was renal pelvis in 44.6% of the studied patients. Mean stone density was
1024.76, ranged from 220 to 1500. Mean stone size was 1.86 mm, ranged from 1.20 to 3-mm. Mean tract diameter
was 16.92 mm, ranged from 14 to 18 mm.
Conclusion: Mini-PCNL was safe and efficacious in treatment of patients with renal stone disease.
Keywords: miniPCNL, Renal stones, Nephrolithiasis, Nephrostomy, Percutaneous.


Nephrolithiasis is a common problem in our
that time was a size 24 French (Fr) or larger.
population (1). When surgical care is required for this
Although standard PCNL (SPCNL) is now routinely
performed with sheath sizes 24­26 Fr or less, the term
procedures are often employed. These include
Mini-PCNL is commonly defined as a tract size less
extracorporeal shock wave lithotripsy (SWL),
than or equal 18 Fr (6).
In this study, we described the equipment,
nephrolithotomy (PCNL). The choice of which
indications, and efficacy of M-PCNL with particular
procedure to perform is based on both patient and
attention to its value over traditional minimally
stone characteristics (2).
invasive stone removal techniques.
The European Association of Urology (EAU)

provides recommendations based on renal stone size
and location. For stones < 2.0 cm, SWL, PCNL, or
URS are options, but for stones > 2.0 cm PCNL is
This prospective cohort study was conducted at
recommended with URS reserved as a second-line
Urology Department, Zagazig University Hospitals
therapy. In the lower pole, both PCNL and URS are
during the period from Mars to November 2019 with
options, even for stones > 1.5 cm, given the limited
patients from those attending to Urology Outpatient
efficacy of SWL in this setting (3). Although effective
for the clearance of large stone burdens, PCNL is
Sample size:
associated with significant morbidity, particularly
Assuming that the number of patients with renal
bleeding requiring a transfusion (4).
stones attending at Zagazig University Hospitals was
In an effort to reduce the morbidity of the
48 patients and percentage of improvement of patients
procedure, miniaturized PCNL techniques were
M-PCNL was 94%, so sample was calculated to be 32
developed. In 1998, Jackman et al. (5) described a
patients using open EPI with CI 95%.
mini-PCNL (MPCNL) procedure. This was defined as
Inclusion criteria: Patients scheduled for PCNL and
any PCNL performed through a sheath too small to
decision of mini-PCNL is made by surgeon.
accommodate a standard rigid nephroscope, which at

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:3 /7 /2020

Accepted:22 /8 /2020

Full Paper (vol.822 paper# 20)

c:\work\Jor\vol822_21 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 316-322

Ultrasonographic Evaluation of Placental Sites and Thickness at
Second Trimester and Its Correlation with Pregnancy Outcome
Ibrahim Mohiy El-Maghraby
Fellow, Obstetrics & Gynecology Department, Shibin El Kom Teaching Hospital, Menoufia, Egypt
Corresponding author: Ibrahim El-Maghraby, Mobile: (+2)0100035 7896, E-mail: ibrahim_mohie@yahoo.com
Adverse fetal outcome has a wide spectrum of perinatal mortality and morbidity as low fetal Apgar
score, admission to NICU, low birth weight, stillbirth & maternal morbidity, and mortality. The use of
ultrasonography of placental sites and thickness is the most effective method to estimate the adverse pregnancy
outcome. Objective: To investigate the relationship between placental sites, diameter, and thickness at the second
trimester with pregnancy outcome. Patients and Methods: the current study was conducted at the Obstetrics &
Gynecology Department in Shibin El Kom Teaching Hospital, on 200 pregnant women with a single fetus presenting
for routine antenatal care in the second trimester, from September 2016 to August 2017. Detailed history, laboratory
investigations, obstetric and ultrasound follow up study was done. Results: The mean age of all patients was
27.54±5.03 years old. Placental sites were associated with placenta previa, placenta abruption, bleeding, FGR, and
preterm delivery. Also, the placental diameter was highly related to placenta previa, placental abruption, bleeding
and positively correlated with age and body mass index. Regarding, the placental thickness, it was highly associated
with macrosomia and negatively correlated with age, and positively correlated with GA.
Conclusion: Placental implantation at the 18th to 24th weeks can be used as being at risk for adverse outcomes. Low
placental implantation sites are associated with higher frequent preterm (labor & deliveries) and lower postpartum
hemorrhage. High lateral placental implantations are associated with lower Apgar scores.
Keywords: Placental site, Pregnancy outcome, Thickness, Second trimester, Ultrasonography.

fetuses at risk of growth restriction, while another study
A detailed ultrasound for fetal anatomy is now
reported that ultrasonographic measurement of
routinely studied on most pregnant in the USA. Also,
placental diameter and thickness is of prognostic value
the evaluation of fetal anatomy, an assessment of the
in identifying the subsequent occurrence of fetal growth
uterus placental implantation site, and its association
restriction (5). This prediction of growth-restricted
with the internal cervical OS is noted (1).
pregnancies from placental size is based on the fact that
Ultrasonography is the preferred technique for placental
diminished placental size precedes fetal growth
localization. If a woman comes for the first time at term,
restriction (6). The aim of this study was to determine the
even then a preliminary ultrasound examination for
utility of two-dimensional (2D) sonographic placental
placental location is mandatory. One of the reasons for
location and measurements in the prediction of adverse
repeating the examination at the beginning of the third
pregnancy outcome.
trimester is to determine the location of the placenta if

it was described as a placenta previa at the mid-
pregnancy examination (2).
This observational cohort study was conducted at
Pregnant women with placenta previa were found
the Obstetrics & Gynecology Department, Shibin El
to had decreased risk of hypertensive disorders as
Kom Teaching Hospital, Menoufia, Egypt on 200
compared with normally implanted placentas (2). While,
pregnant women with a single fetus presenting for
unilateral placental implantations have been associated
routine antenatal care in the second trimester (between
with a higher incidence of preeclampsia, fetal distress in
18 and 24 weeks' gestation) from September 2016 to
labor, abdominal deliveries, and intrauterine growth
August 2017.
retardation (3). The placenta is a fetal organ that provides
Ethical Considerations: All participants were
the physiologic link between a pregnant woman and the
volunteers. All of them signed written informed consent
fetus. The placenta develops from the chorionic villi at
with explaining the aim of the study before the study
the implantation site at about the fifth week of gestation
initiation. Approval was obtained from the ethical
and by the ninth or tenth week, the diffuse granular
committee at the Faculty of Medicine, Menoufia
echotexture of the placenta is apparent at sonography (4).
Inclusion criteria: pregnant women with a single fetus
measurements have exhibited potential utility for
presenting for routine antenatal care in the second
predicting adverse outcomes in certain high-risk
trimester (between 18 and 24 weeks' gestation).
patients, possibly by serving as a marker of normal
All the recruited women underwent ultrasonic
chorionic regression and placental growth (4).
placental localization and measurements and were
Second-trimester placental volumes measured by
followed via regular antenatal care visits in the
three-dimensional ultrasound have been used to identify
outpatients' clinic to record obstetric outcomes.

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:8 /10 /2020

Accepted:26 /11 /2020

Full Paper (vol.822 paper# 21)

c:\work\Jor\vol822_22 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 323-328

Comparative Study between Analgesic Effects of Intrathecal Administration of
Midazolam Versus Tramadol with Bupivacaine for Infra-Umbilical Surgeries
Mohamed Abdel Raheem Mohamed, Hitham Mohamed Ali, Fawzy Abbas Badawy*
Department of Anesthesia and Intensive Care, Faculty of Medicine, Sohag University, Sohag, Egypt.
*Corresponding author: Fawzy Abbas Badawy, Mobile: (+20) 01004862474, E-Mail: fabadawy@gmail.com


Background: The administration of bupivacaine intrathecally as a regional anesthesia is commonly used to provide
anesthesia for lower abdominal surgeries. The motor blockage of bupivacaine provides adequate blockage, which
allows the surgeons to do their work comfortably and also provides effective postoperative analgesia in early
postoperative period. However, adding adjuvants to the local anesthetics to prolong the period of postoperative
analgesia after fading of the spinal anesthesia was tried in many studies. These supplements as regard to postoperative
pain relief are beneficial as they decrease or abolish the need for the administration of analgesics and their associated
Objective: To compare the analgesic effect of intrathecal midazolam versus intrathecal tramadol when added to
bupivacaine during spinal anesthesia after infra-umbilical surgeries.
Patients and methods
: In our study we included 80 patients scheduled for elective surgeries in the lower abdomen
and lower limbs (infra-umbilical surgeries) under spinal anesthesia. They were randomly divided to one of two groups.
Group M received 10 mg of hyperbaric bupivacaine + 2 mg midazolam, and group T received 10 mg of bupivacaine
+ 20 mg of tramadol (total is 3cc in both groups). The comparison was done by using the visual analogue scale (VAS)
for assessing postoperative pain score and recording the duration of postoperative analgesia.
Results: The postoperative analgesia duration was significantly higher in the tramadol group than midazolam group
Conclusion: Addition of 20 mg tramadol to bupivacaine during spinal anesthesia provides longer duration of analgesia
when compared to intrathecal midazolam 2.0 mg.
Keywords: Midazolam, Tramadol, Bupivacaine, Infra-umbilical surgeries.


Spinal anesthesia is the most commonly used
effective postoperative analgesia after a variety of
technique for lower abdominal surgeries as it is easy to
surgical procedures, but with increased risk for
administer and of less cost(1). It also has the advantage
respiratory depression(5).
that profound nerve block can be produced in a large part
But tramadol is a centrally acting analgesic that
of the body by the relatively simple injection of a small
has minimal respiratory depressant effects(6,7), as its
amount of local anesthetic(2), and avoids the risks of
6000-fold decreased affinity for mu-receptors compared
general anesthesia such as aspiration of gastric contents
with morphine(8,9). It also inhibits serotonin and
and difficulty with airway management(3). Bupivacaine
norepinephrine reuptake in the spinal cord and has no
is suitable for procedures lasting up to 90-120 minutes(4),
reported neural toxicity(10). So tramadol has the potential
and is the most commonly used local anesthetic agent for
to provide effective postoperative analgesia with no risk
spinal anesthesia. But it doesn't provide prolonged
postoperative analgesia. So supplements were suggested
to prolong postoperative analgesia. Intrathecal opioid
administration has been demonstrated to provide
the nervous system, including the spinal
aimed to compare the analgesic effect of intrathecal

midazolam versus intrathecal tramadol when added to
cord. Midazolam is a water-soluble benzodiazepine with
bupivacaine during spinal anesthesia after infra-
sedative, amnesic, anxiolytic, muscle relaxant, and
umbilical surgeries.
anticonvulsant properties(11,12).

Midazolam can be given by intrathecal or
epidural injection to provide postoperative analgesia,

and also produce an anti-nociceptive effect. This may be
Ethical approval:
gamma-aminobutyric acid (GABA) mediated. The
This study was performed after approval of Ethical
gamma-aminobutyric acid has been shown to have
Committee of Faculty of Medicine, Sohag University.
analgesic properties. There are many uses for midazolam
Eighty patients aged between 18-70 years with ASA I-II
during the perioperative period including premedication,
who were scheduled for elective infra-umbilical
anesthesia induction, and maintenance of sedation for
surgeries under spinal anesthesia were enrolled in our
diagnostic and therapeutic procedures(13). Our study

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:8 /10 /2020

Accepted: 26/ 11/2020

Full Paper (vol.822 paper# 22)

c:\work\Jor\vol822_23 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 329-334

Role of Renal Parenchymal Thickness and Renal Isotope Scan in
Predicting Outcome After Pyeloplasty in Children with
Ureteropelvic Junction Obstruction (UPJO)
Mohamed Shawkey El-Desoukey, Salem Ahmed Khalil, Emad Abdelhamid Salem, Mohamed Mahmoud Seleem
Department of Urology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Mohamed Shawkey El-Desoukey, Mobile: (+20)01141314881, Email: mohcoldzero11@gmail.com

Pelviureteric junction obstruction (PUJO) is the most common cause of pediatric hydronephrosis.
Objective: To find the relation of renal parenchymal thickness & isotope scan preoperatively & postoperatively in
predicting outcome after pyeloplasty.
Patients and Methods:
This prospective study included, 30 children 18 years, with 1ry unilateral UPJO from
September 2018 to September 2019 were included in the study. Ultrasound abdomen was done on all patients to look
at the size of the kidney, parenchymal thickness & renal echogenicity. DTPA scan was done to measure the GFR, t½
and split function of each kidney & all patients underwent open pyeloplasty. Patients were followed up after the
operation at 1, 3, and 6 months respectively. At each follow-up visit, U/S was performed & renal isotope was done at
the 6th month. The preoperative parameters were compared with the same parameters after surgical repair of the UPJO
at 3rd & 6th months.
Results: In our study, there was an improvement in (83.3%) with a significant change in all parameters at 6th months
postoperatively (P < 0.01) as T ½ significantly decreased while parenchymal thickness, GFR of the affected kidney
& split renal function were significantly increased postoperatively.
Conclusions: This study showed that parenchymal thickness and renal isotope are good predictors for pyeloplasty
Keywords: Pelviureteric junction obstruction, Renal parenchymal thickness, Renal isotope scan.


Ureteropelvic junction obstruction (UPJO) is the
commonest cause of pediatric hydronephrosis
A prospective study was conducted in the
occurring in 1 in 1000-2000 live births [1].
Department of Urology, Outpatient Clinic, Zagazig
UPJO is defined as an obstruction to the flow of
University Hospital from September 2018 to September
urine from the kidney to the proximal ureter that
2019 including a total of 30 children 18 years with 1ry
results in renal damage and symptoms [2]. The Gold
unilateral UPJO.
standard surgical treatment for UPJO is Anderson

Hynes (AH) dismembered pyeloplasty with or without
Ethical Considerations:
surgical reduction of the renal pelvis. However, and
Written informed consent was obtained from the
regardless of the employed technique, the pyeloplasty
patient caregivers to participate in the study. The
should results in a dependent, tension-free,
approval for the study was obtained from the
anastomosis with meticulous attention to the
Urology Departments of Zagazig University
vascularity, which relieves the obstruction and is also
Hospitals after the approval of the Institutional
expected to help in functional improvement [3].
Review Board (IRB). The work was carried out
There are certain parameters to assess the
following the Code of Ethics of the World Medical
postoperative outcomes of pyeloplasty. The ultrasound
Association (Declaration of Helsinki) for studies
parameters are the reduction in the AP diameter of the
involving humans.
pelvis and an increase in parenchymal thickness in a

growing kidney. The definitive evidence of improved
Inclusion criteria were: Children 18 years who did a
function is by doing an isotope renogram in the follow-
pyeloplasty for unilateral 1ry pelviureteric junction
up period, objectively to look for the improvement in
obstruction (UPJO) in which the diagnosis of UPJO was
GFR (glomerular filtration rate) and also the
made using US parameters & renal isotope scan.
radiotracer clearance from the PCS (pelvicalyceal

system) [4].
Exclusion criteria were: Children with renal
This study aimed to find the relation of renal
anomalies associated with UPJO, ureteral anomalies
associated with UPJO, bilateral UPJO, redo
preoperatively & postoperatively in predicting
pyeloplasty, 2ry cause of UPJO, renal impairment (GFR
outcome after pyeloplasty.
10 ml/min), single Kidney, patients who were lost to

follow up.

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

Accepted:26 /8 /2020

Full Paper (vol.822 paper# 23)

Evaluation Of QT Interval In Diabetic Ketoacidosis In Medical Intensive Care Unit The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 335-342

Effect of Progesterone Replacement Therapy on Uteroplacental
Circulation in Treatment of Threatened Abortion
Yousef Abo Elwan Elsayed, Walid Abdallah Mohamed,
Amira Ahmed Said Zolfakar*, Basem Mohamed Hamed
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Amira Ahmed Said Zolfakar, Mobile: (+20)1277433818, E-mail: Zolfakaramira@gmail.com

: Miscarriage is interruption or termination of pregnancy before 20 weeks based upon the day of the
last normal menses or it is the expulsion of the product of conception before the age of medicolegal viability
which is 26th weeks of gestation in Egypt or fetal weight < 500gm or fetal length 25 according to WHO
This study was performed to compare the effect of vaginal micronized progesterone and oral
dydrogesterone on utero-placental circulation in threatened miscarriage.
Patients and Methods: A prospective clinical study in Zagazig University Hospital during the period from
December 2018 to August 2019. Included fifty pregnant cases complaint of first trimester vaginal bleeding and
diagnosed as threatened miscarriage. They were classified into two groups on a randomized basis, the first group
received micronized vaginal progesterone (400 microgram daily) while the second one received dydrogesterone
orally (40 mg at once then 10 mg every 8 hours). Both groups were followed up every two weeks for three visits
by serial transvaginal Doppler ultrasound measurement of pulsatility index, resistance index, and
systolic/diastolic (S/D) ratio of the spiral arteries, uterine arteries & intrachorionic area.
Results: The study demonstrated that vaginal progesterone administration, contrary to oral dydrogesterone
treatment, decreased spiral artery pulsatility and resistive indices. No major changes in the uterine artery blood
flow impedance were observed, only S/D ratio significantly decreased in the dydrogesterone group.
: It could be concluded that vaginally administrated progesterone was nearly as equally effective as oral
dydrogesterone in prevention of miscarriage in pregnant women with threatened abortion with different effects on
the uteroplacental circulation.
Keywords: Progesterone, Dydrogesterone, Threatened abortion, Utero-placental, Miscarriage.

progesterone is associated with injection-site pain and
Threatened miscarriage, which occurs in 20% of
abscesses [6].
all pregnancies, is diagnosed when vaginal bleeding
with or without abdominal pain occurs during the first
bioavailability and is associated with systemic adverse
half of pregnancy. The required prerequisites for
events such as drowsiness, dizziness and headaches [7].
threatened miscarriage are a closed cervix and an
Micronized vaginal progesterone (MVP) is now
intrauterine viable fetus. Unfortunately, nearly half of
preferred over oral and intramuscular progesterone, but
threatened miscarriage end in miscarriage [1]. A suitable
it is associated with its own administration related side
level of progesterone is an important factor that
effects such as vaginal irritation [8].
determines uncomplicated embryo development. Thus,
Dydrogesterone is a retroprogesterone that has
progesterone supplementation can decrease the
been used since the 1960s for the treatment of
miscarriage rate [2]. Progestagens enhance implantation,
conditions associated with progesterone deficiency [9].
affect the cytokine balance, inhibit natural killer cell
Dydrogesterone has a good safety and tolerability
activity at the fetomaternal interface, inhibit the release
profile. It is structurally and pharmacologically similar
of arachidonic acid, prevent myometrial contractility
to natural progesterone has good oral bioavailability
and prevent cervical dilatation [3].
and few side effects. Dydrogesterone has no androgenic
Progesterone can be administered orally,
effects on the fetus, and does not inhibit the formation
intramuscularly, vaginally, and most recently
of progesterone in the placenta [10]. Importantly, oral
subcutaneously, with each route having different
administration of dydrogesterone circumvents the
bioavailability and tolerability profiles [4]. Oral
inconvenience and side effects related to intravaginal or
administration is the easiest route of administration,
intramuscular administration [6].
and generally the most acceptable route for the patient.
Adequate oxygen and nutrient supply are other
Vaginal administration results in higher uterine
important factors that determines proper embryo
concentrations but is often uncomfortable in the
development. Efficient blood transport depends on an
presence of vaginal bleeding, or may be washed out if
adaptive capacity of the uterine vascular system.
bleeding is severe [5]. In contrast, intramuscular
Arterial blood is transported to the uterus by way of the

uterine and ovarian arteries.

This article is an open access article distributed under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received:9 /7 /2020

Accepted:25 /8 /2020

Full Paper (vol.822 paper# 24)

c:\work\Jor\vol822_25 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 343-346

Using Gelfoam Technique to Reduce the Incidence of Seroma Formation after
Modified Radical Mastectomy
Tamer Mohamed Elshahidy*, Mohamed Mahmoud Mokhtar, Mahmoud Abdou Yassin
Department of General Surgery, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Tamer Mohamed Elshahidy, E-mail: shahidytamer@yahoo.com

Breast cancer is the most prevalent cancer in our surgical practice in Egypt. Seroma is one of the most
annoying complications after modified radical mastectomy and axillary clearance. Different modalities have been used
to decrease the incidence of seroma.
Objective: To assess the impact of using gelfoam in decreasing seroma formation following modified radical
Patients and methods: This randomized controlled trial was done on eighty patients operated upon for modified
radical mastectomy between January 2019 and November 2020 in Zagazig University Hospitals. Patients were
randomly allocated into two groups; in each one forty patients. In the first group (group A) we used the gelfoam under
the mastectomy and axillary flaps; in the second group (group B) we did the same surgical technique without using the
Results: We noticed that the incidence of seroma formation among group (A) was 2.5% versus 17.5% in group (B),
with statistically significant difference between both of them (P<0.05).
Conclusion: The use of gelfoam is an effective procedure which reduces the incidence of seroma formation under
mastectomy flaps.
Keywords: Gelfoam, Modified radical mastectomy, Seroma.


Breast cancer is one of the most common cancers in
Aim of the work was to assess the impact of using
Egypt and represents 18.9% of all cancers (32.04 percent
gelfoam in decreasing seroma formation following
in women and 2.2 in men) (1). The most common surgical
modified radical mastectomy.
operation for this cancer is modified radical mastectomy

(2). Many problems commonly occur after this procedure
such as skin flaps necrosis, hematoma, seroma and
This study is a randomized controlled trial
surgical site infection.
performed in Zagazig University Hospital between
Seroma is a clinically apparent serous fluid
January 2019 and November 2020, involving eighty
accumulation at the surgical site (2). It is considered one
patients who had modified radical mastectomy and
of the most common complications that may postpone
axillary clearance. Patients were randomly allocated into
starting adjuvant therapy causing considerable patient
two groups; in each one forty patients. In group (A) we
distress associated with increasing the risk of surgical
used the gelfoam sheets under mastectomy and axillary
site infection (3). The frequency of seroma formation
flaps, in group (B) we did the same surgical technique
ranges from 15 to 18% after breast cancer surgery (4). The
without using the gelfoam.
pathogenesis of its formation is still not completely

elucidated. Seroma can be developed by acute
Inclusion criteria: Female patients with breast cancer
inflammatory exudates generated during the acute stage
stage II, average body weight and normal coagulation
of wound healing in response to surgical trauma (5).
The incidence of seroma was decreased by different
Exclusion criteria: Advanced breast cancer stage
methods, such as suturing the mastectomy flaps to the
III and stage IV, patients who have a problem in blood
pectoralis muscle, immobilization of the ipsilateral arm
clotting, history of long term use of steroids,
in the early postoperative period , also using anti
uncontrolled diabetes or advanced liver disease and
fibrinolytic agents such as tranexamic acid were found to
morbid obese patients.
be useful in minimizing fluid leakage therefore

decreasing seroma formation (6).
In this study, we have evaluated the effect of using
The breast tissue was dissected and removed from
gelfoam under mastectomy flaps to reduce seroma as
medial to lateral. The axillary tail was continuously
the gelfoam is a widely used intraoperatively as gelatin
removed with axillary contents, then cleared from the
compressed sponge for hemostasis. It is an organically
lateral edge latissimus dorsi. Axillary vessels were
degradable agent made of purified swine gelatin thought
identified by retracting pectoralis minor muscle.
to help clot formation (7).
Dissection of axilla with preservation of the

thoracodorsal bundle (nerve and vessels) (Figure 1) and

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:9/10 /2020

Accepted:27 /11 /2020

Full Paper (vol.822 paper# 25)

Immediate and long term results The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 348-353

Comparative Study between Efficacy of Serratus Anterior Muscle Block as
A Regional Analgesia Technique and I.V Morphine Infusion in
Patient with Fracture Ribs
Wesam Abd El-Galil Abu-Elwafa, Islam Ahmed Ragab*,
Abdelrahman Hassan Abdelrahman, Wael Alham Mahmoud
Department of Anaesthesia, ICU & Pain Management, Sohag Faculty of Medicine, Sohag University
*Corresponding author: Wesam Abd El-Galil Abu-Elwafa, Mobile: (+20) 01002005802,
E-Mail: abdelgalilwesam@gmail.com

Rib fractures are very common and are detected in at least 10% of all injured patients, the majority of
which are because of blunt thoracic trauma with road traffic collisions being the main cause. Pain management of the
acutely injured patient with rib fractures can be difficult for even the most experienced emergency physician.
Objective: To evaluate the safety and efficacy of serratus anterior muscle plane block as a regional analgesic
technique performed in patient with fracture ribs.
Patients and Methods: Randomized, controlled study was carried out in Department of Anesthesia and Intensive
Care Unit, Sohag University Hospital. Forty patients with lateral multiple rib fractures were included in this study.
All patients were suffering from excruciating pain and were not responding to conventional analgesics. The patients
were randomly assigned into two groups, 20 patients each. Group A, for whom serratus anterior plane block (SAP)
was done and Group B, for IV morphine infusion.
Results: In Group A, the mean pain score decreased from 9.1 ± 0.7 to 0.6 ± 0.7 after intervention. In group B, the
mean pain score improved from 9.3 ± 0.8 to 1.15 ± 0.8 after IV morphine infusion. Pain scores gradually decreased.
There were no significant difference between the two groups when the other trauma surveys were compared.
Conclusion: Ultrasound guided Serratus Anterior Plane block is an effective technique for providing analgesia in
patients with anterior and lateral rib fractures with fewer risks of complications.
Keywords: Regional analgesia, Serratus anterior muscle block, I.V Morphine infusion.


Rib fractures are very common and are detected in
significant morbidity and mortality of rib fractures,
at least 10% of all injured patients, the majority of which
particularly the development of pneumonia (4). Jadon
are because of blunt thoracic trauma (75%) with road
and Jain (5) concluded that serratus anterior plane block
traffic collisions being the main cause. The remaining
could provide effective analgesia in patients with
(25%) are due to penetrating injuries. Rib fractures are
multiple rib fractures. However, the results need to be
associated with significant morbidity, with patients
further substantiated in randomised controlled studies
frequently requiring admission to the intensive care unit
with larger number of patients comparing the efficacy of
(ICU), and mortality rates as high as (33%)(1).
this block with other regional anaesthetic techniques and
Morphine is a pain medication of the opiate family,
evaluate the efficacy of Serratus Plane Block for
which is found naturally in a number of plants and
thoracic wall blockade if fractures are occurring in
animals. It acts directly on the central nervous system
posterior 1/3 part.
(CNS) to decrease the feeling of pain. It can be taken for

both acute pain and chronic pain. It is frequently used
for pain from myocardial infarction and during labor. It
Evaluate the safety and efficacy of serratus anterior
can be given by mouth, by injection into a muscle, by
muscle block as a regional analgesia technique
injection under the skin, intravenously, injection into the
performed in patient with fracture ribs by the use of
space around the spinal cord, or rectally (2). Esmailian
ultrasound to improve the success rate and accuracy of
et al. (3) showed that morphine has a therapeutic value in
the Serratus anterior block & to prevent potential
relieving the pain of rib fracture. The success rate after
30 minutes drug administration was 58.6%.

Ultrasound-guided serratus anterior plane (SAP)
block is a relatively new technique that provides
This was an interventional, randomized and
analgesia for thoracic wall surgeries by blocking the
controlled study that was carried out in Department of
lateral branches of the intercostal nerves (T2­L2). The
Anesthesia & Intensive Care Unit, Sohag University
procedure has been largely discussed for managing pain
after breast surgery, and new interest has arisen for the

treatment of thoracic trauma, specifically rib fractures.
Ethical and patients' approval: After an approval of
Inadequate pain management of rib fractures causes
the Ethics Committee of Sohag University and
This article is an open access article distributed under the terms and conditions of the Creative

Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)

Received:8 /10 /2020

Accepted:26 /11 /2020

Full Paper (vol.822 paper# 26)

c:\work\Jor\vol822_27 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 354-361

Study of Perinatal Outcome of Severe Late onset Intrauterine Growth
Restriction using Biophysical and Doppler Fetal Parameters
Medhat Essam Eldeen Helmy1, Mohamed Ehab Ali Salit2, Shaimaa Abdel-hamid Hassanein3,
Ahmed Sabry Fouad El-hamouly1, Mohamed ELsibai Anter*1,
Departments of 1Obstetrics & Gynecology, 3Diagnostic Radiology, Faculty of Medicine, Menoufia University.
Department of 2Obstetrics and Gynecology, Faculty of Medicine, Cairo University
*Corresponding author: Mohamed ELsibai Anter, Mobile: (+20) 01009737067,
E-Mail: mohamedsibai681@yahoo.com
Intrauterine growth restriction is one of the most common causes of perinatal morbidity and mortality
worldwide. Strong evidence about the optimum method of surveillance is needed.
Objective: to determine the relationship between biophysical fetal parameters and arterial and venous Doppler
parameters in fetuses with severe intrauterine growth restriction (IUGR).
Patients and Methods: This is a Prospective cohort study was conducted at Menoufia University Hospital during
the period from March 2019 to September 2020. Fourty two IUGR fetuses with elevated Umbilical Artery (UA)
Doppler had follow up with Doppler (UA, middle cerebral artery and ductus venosus) and Biophysical profile
(BPP). Patients were stratified into three groups: G1: abnormal UA alone. G2: brain sparing effect. G3: abnormal
DV Doppler. Our main primary outcome was neonatal intensive care unit (NICU) admission while secondary
outcomes were APGAR score, Birth weight, EFW and stillbirth rate.
Results UAEDV was present in 29 fetuses (69%), Absent/Reversed (AREDV) in 13 (31%). Brain sparing was
observed in 18 fetuses (42.85%). Abnormal DV Doppler was noticed in 5 fetuses (11.9%). The BPP was > 6 in 28
fetuses (66.6%). Abnormal doppler (UA, MCA, DV) and abnormal BPP were significantly associated with
increased NICU admissions, Still birth rates, lower APGAR scores, EFW and Birth weight. Multivariate regression
analysis was performed, and it was found that abnormal MCA was the most associated parameter with NICU
admission. Conclusion: Fetal Doppler (UA, MCA, DV) and BPP are complementary antenatal modalities.
Therefore, pursuit of a combined testing approach has merit.
Keywords: Biophysical profile, Doppler, Fetal monitoring, Growth restriction.


Previous studies clearly show that cardiovascular
undoubtedly is one of the most common causes of
and biophysical responses in IUGR fetuses both relate
perinatal morbidity and mortality worldwide.
to fetal status. To determine which combination of
Historically, IUGR has been defined as fetuses whose
antenatal tests provides the best reflection of fetal status,
estimated fetal weight falls below the 10th percentile for
it is first necessary to assess the relationship between
gestational age (1). Doppler ultrasonography and
test results in these principal modalities (8).
biophysical profile scoring (BPP) are the principal
If deteriorations in both Doppler and biophysical
surveillance tools in pregnancies complicated by
parameters are closely related, then test results should
placental vascular insufficiency and IUGR (2). These
be concordant in the majority of cases.
antenatal testing modalities aim to detect fetal
On the other hand, if deterioration in
compromise by evaluating fetal manifestations of
altered oxygenation and metabolic status (3). As
independently of each other a certain degree of
placental blood flow resistance worsens, changes in
disagreement between the test results is to be expected.
cerebral blood flow resistance are observed in the
It was the aim of this study to determine the distribution
compensated state. Finally, deteriorations in venous
and relationship of Doppler and BPP test results in a
Doppler parameters are observed that reflect alterations
population of IUGR fetuses with placental insufficiency
in cardiac forward function in response to advanced
placental insufficiency (4). Multi-vessel Doppler

examination is able to accurately depict this progression
in IUGR fetuses. Dynamic fetal variables (movement,
Study Setting: This is a Prospective cohort study was
tone, breathing, heart rate reactivity and amniotic fluid
conducted at Obstetrics and Gynecology Department,
volume) utilized for BPP remain normal longer in the
Menoufia University Hospital during the period from
progression of IUGR fetuses (5). With progressive fetal
March 2019 to September 2020.
compromise reduction of global fetal activity is

followed by a decline in fetal heart rate reactivity and
Eligibility criteria: The participants were chosen
fetal breathing movement and amniotic fluid volume (6).
according to appropriate inclusion and exclusion
Finally, fetal tone and movement are lost in response to
criteria. Fourty two patient fulfilled the inclusion
worsening acidemia (7).
criteria. The inclusion criteria was; Normal fetal

This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received: 8/10 /2020

Accepted: 26/11/2020

Full Paper (vol.822 paper# 27)

c:\work\Jor\vol822_28 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 362-368
Ultrasound Guided Serratus Anterior Plane Block versus
Thoracic Epidural Analgesia in Breast Surgery
Ahmed Elsaied Abd-Elrahman Ali1, Sherif Kamal Hafez Arafa2,
Amir Abou Zkry Elsayed2, Mahmoud Fawzy Shehata El Sharkawy*3
1Department of Anesthesia and Intensive Care and Pain Medicine, Faculty of Medicine ­ Sohag University
2Department of Anesthesia and Intensive Care, Faculty of Medicine - Kafr Elsheikh University
3Department of Anesthesia and Intensive Care, Faculty of Medicine - Aswan University
*Corresponding author: Mahmoud Fawzy Shehata, Mobile: (+20) 01011774192, E-Mail: mahmoud83me@gmail.com

Breast Surgery is becoming more and more common. Patients are often middle-aged women and with
high public awareness around issues of breast cancer. The numbers are increasing. Breast surgery is an exceedingly
common procedure and associated with an increased incidence of acute and chronic pain. Regional anesthesia
techniques may improve postoperative analgesia for patients undergoing breast surgery.
Objective: To assess the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) compared with
thoracic epidural analgesia (TEA) for breast surgery. Patients and methods: This is a prospective randomized clinical
study done at Aswan University Hospitals. The present study was conducted on sixty female patients ASA I-II, their
ages ranged from 20-50 years and scheduled for unilateral breast surgery. The patients were allocated randomly into
three groups (n=20 each) according to type of regional anesthesia administrated. Results: There was no significant
difference between the studied groups in age, body weight, height and BMI. VAS pain scores throughout the first 24
hrs postoperative showed that there was highly statistically significant decrease in VAS in immediate till 6 hrs
postoperative in SAPB group (VAS in group C was less than in groups A and B, P-value < 0.001). As regard to side
effects, no complications in the studied groups were recorded such as pneumothorax, vascular puncture, or local
anesthetic toxicity. Conclusion: Serratus anterior plane block maintained hemodynamic stability as compared to TE
and it produced low pain scores and less total morphine consumption in the early postoperative period after unilateral
breast cancer surgery. These advantages, suggest the usefulness of SAPB especially in outpatient surgery.
Keywords: Breast Surgery, SAPB, TEA, VAS pain.

procedural complications. Literature emphasizes the
Although general anesthesia is the conventional
role of chest wall block in this surgical field as
technique used for oncologic breast surgeries and it
innovative and simple reproducible regional anesthesia
produces the desired state of unconsciousness, but it
(RA) techniques, placed in the context of a multimodal
does not eliminate the surgical stress response. It may
approach (5).
also aggravate immunosuppression and may cause
Blanco et al. (6), first described a new block of
undesirable side effects such as postoperative pain,
the thoracic wall serratus plane block under ultrasound
nausea and vomiting after surgery (1). Opioids, are good
guidance. Local anaesthetic (LA) was deposited in the
option to control postoperative pain, however, these
serratus anterior plane (SAP). The lateral cutaneous
drugs are associated with many side effects such as
branches of the intercostal nerves, before dividing into
nausea, vomiting, pruritus, sedation, respiratory
anterior and posterior branches are blocked as they pass
depression, delayed channeling, hypotension, urinary
through this plane to supply sensation to the anterolateral
retention, as well as immunosuppressive effects and pro-
chest wall. This novel technique become popular
metastatic rule (2). The use of regional blocks can not
analgesic alternative to multiple puncture intercostals
only help to minimize pain, but also improves the
block, epidural and paravertebral block in breast surgery
pulmonary function and reduce narcotic requirement
given decreased incidence of adverse events and has the
during the perioperative period (3).
advantage of simultaneous blockade of multiple
Thoracic epidural analgesia is the gold standard
dermatomes. It is easy to do and decreases rate of local
technique after breast surgery but the adequacy of
anesthetic absorption (7). The effectiveness based on our
thoracic and axillary blockade during lymph node
understanding that the brachial plexus nerves are the
dissection is still a problem (4).
main component of this painful surgery (8).
Currently, thoracic epidural anesthesia (TEA)
The aim of this study was to assess the efficacy
and thoracic paravertebral block (TPVB) represent the
and safety of ultrasound-guided serratus anterior plane
main techniques to manage postoperative analgesia in
block (SAPB) compared with thoracic epidural
breast surgery. However, although these techniques
analgesia (TEA) for breast surgery.
allow excellent control of pain, they are not always easy

to perform and their clinical effectiveness is limited by
the presence of several contraindications, as well as the
This is a prospective randomized clinical study
possible occurrence of systemic side effects or
done at Aswan University Hospitals.
This article is an open access article distributed under the terms and conditions of the
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:9 /10 /2020

Accepted:27 /11 /2020

Full Paper (vol.822 paper# 28)

c:\work\Jor\vol822_29 The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 369-378

Association of Receptor Activator of Nuclear Factor-B Ligand (RANKL) and
Osteoprotegerin with Secondary Hypogonadism in Egyptian Females with
Beta-Thalassemia Major
Nearmeen M. Rashad1*, Amira M. El-Helaly2, Ahmed M. Radwan3, Neveen F. Ibrahim1
Departments 1 Internal Medicine, 2Clinical Pathology and 3Obstetrics & Gynecology,
Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Nearmeen M. Rashad, Tel.: +20 1224248642,
E-mail: nrashad78@yahoo.com & n.rashad@zu.edu.eg.

Thalassemia is the most common cause of chronic hemolytic anemia and is correlated with significant
morbidity and mortality. Osteoprotegerin (OPG) is an tumor necrosis factor receptor superfamily glycoprotein that
acts as a decoy receptor for the receptor activator of nuclear factor kappa B ligand (RANKL), exerting an
antiresorptive bone effect and also play critical roles in hypogonadism associated osteoporosis.
Objective: To explore the serum levels of RANKL and OPG in adult Egyptian females with Beta-Thalassemia Major
(BTM) and to detect their relations with female hypogonadism
Patients and Methods: a prospective cross-sectional controlled study enrolled 50 control females and 45 women
with BTM. We measured OPG and RANKL by ELISA, Bone mineral density (BMD) of the lumbar spine and femoral
neck was measured by dual-energy X-ray absorptiometry
Results: Among 45 patients with BTM, 27 patients had hypogonadotropic hypogonadism, and they had significantly
higher values of serum RANKL (8.3±1.8pmol/l) compared to BTM without hypogonadism (5.9±1.01) and controls
(5.5±1.11). Regarding serum OPG, there were no non-significant differences between the studied groups. Linear
regression analysis test revealed that serum RANKL levels were independently correlated with BMD femur and
spine, while serum OPG levels were independently correlated with BMD spine and LH. The sensitivities and the
specificities of serum RANKL levels by ROC tests to discriminate against BTM patients with hypogonadism were
91.1% and 96%.
Conclusions: Serum RANK levels elevated in BTM patients particularly hypogonadism groups. The diagnostic
power of serum RANKL was highly significant thus, it could be used as a biological marker of hypogonadism in
Keywords: Beta-Thalassemia Major, RANKL, OPG, hypogonadism, BMD.

thalassemias but also in the general population and is
Accumulating studies have reported that the
characterized by high bone turnover (6). stromal cell
survival rate of patients with Thalassemia has
and osteoblast derived cytokines are under the
increased significantly and this could be due to
control of sex hormones(7,8), Bone resorption is reliant
treatment with transfusion programs and chelating
on receptor activator of the nuclear factor kappa B
therapy, osteoporosis represents an important cause of
(NFB) ligand (RANKL), a tumor necrosis factor
morbidity in adult patients who display increased
(TNF) family member that is produced by osteoblasts,
fracture risk (1). Thalassemia is a group of genetic
osteocytes, bone marrow stromal cells, and T-cells
disorders characterized by quantitative defects in
among others (9).
globin chain synthesis with the subsequent absence of
Osteoprotegerin (OPG) is a multifunctional
Hb production leading to a variable degree of
cytokine involved in the regulation of cell survival and
microcytic anemia(2).
differentiation of several cell lineages and apoptosis in
Beta-thalassemia major (BTM) is inherited in
normal and malignant cells and it binds RANKL and
an autosomal recessive disorder. Beta-thalassemia is
represents a decoy receptor even for TNF-related
the most common genetically inherited hemoglobin
apoptosis-inducing ligand (10). There are many
disorder in Egypt with a carrier rate varying from 5.3
evolving studies about the biological effects of the
to >9% (3).
OPG/RANKL system on various metabolic bone
diseases but still, the pathogenesis of bone disease in
complication associated with Beta-thalassemia's and
thalassemia has remained completely unknown. Thus,
the etiology is multifactorial (a hormonal deficiency,
the objective of the current study was to explore the
bone marrow expansion, increased iron stores,
serum levels of RANKL and OPG in adult Egyptian
desferrioxamine toxicity, and calcium and vitamin D
females with Beta-Thalassemia Major (BTM) and to
deficiency (4) and hypogonadism (5).
detect their relations with female hypogonadism.
Hypogonadism is a well documented cause

of osteoporosis and osteopenia not only in
This article is an open access article distributed under the terms and conditions of the

Cre ative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
Received:9 /10 /2020

Accepted:27 /11 /2020

Full Paper (vol.822 paper# 29)


The Egyptian Journal of Hospital Medicine (January 2021) Vol. 82 (2), Page 379-385

Novel Biomarker Serum Calprotectin for Early Diagnosis of Diabetic
Peripheral Neuropathy in Type 2 Diabetes Patients
Farid Fawzy Abd El-hafez1 , Ayman Abd-Elrahman Mohamed Nsr-Allah1, Ahmed Kamal Abd Eljalil
Mohamed 2, Azza Moustafa Ahmed3, Amira Ahmed Mahmoud*1
Departments of 1Internal Medicine & Endocrinology and 3Clinical Pathology,
Faculty of Medicine, Zagazig University, Egypt
Department 2Internal Medicine, Shbeen El Kom Teaching Hospital, Ministry of health
*Corresponding author: Amira Ahmed Mahmoud, Mobile: 00201007257223, E-mail: amiraahmed923@gmail.com

Calprotectin was identified as an endogenous activator of Toll-like receptor 4 (TLR4) and as receptor
for advanced glycation end product (RAGE). Elevated plasma levels of calprotectin have been reported in a variety
of chronic inflammatory conditions. Elevated calprotectin levels have been reported to predict microvascular
alterations in type 2 diabetes (T2DM) patients.
Objective: To make an up to date review of serum level of calprotectin as a predictor for early diagnosis of peripheral
neuropathy in type 2 diabetes patients.
Patients and methods: A total number of 90 subjects were included in the study after fulfillment of the inclusion
and exclusion criteria. Calprotectin was measured for all the 90 subjects.
Results: Serum calprotectin levels were significantly higher in group III "diabetics with neuropathy" compared to
group II "diabetics without neuropathy "and group I "healthy controls".
Conclusion: High levels of calprotectin were detected in type 2 diabetic patients with peripheral neuropathy.
Keywords: Calprotectin, Diabetes mellitus, Neuroinflammation, Peripheral neuropathy.

The inflammatory Myeloid-related protein
Diabetes mellitus remains as one of the most
complex Calprotectin, also known as MRP8/14, is a
challenging healthcare problems in the 21st century,
heterodimer comprised of two intracellular calcium-
and its prevalence is higher in developing countries.
binding proteins, S100A8 (MRP8) and S100A9
While for year 2030, 170% increase is expected for
(MRP14), predominantly expressed in activated human
developing countries, 42% increase expected for
neutrophils, monocytes and macrophages. Calprotectin
developed countries (1). Diabetes mellitus is a chronic
is actively secreted during the stress response of
endocrine illness, which occurs when the pancreas does
phagocytes (7) and was found to be associated with
not secrete enough insulin, or when the body cannot
inflammation more than 20 years ago(8). Calprotectin
efficiently use the insulin (2).
was identified as an endogenous activator of Toll-like
receptor 4 (TLR4) and as receptor for advanced
microvascular complication of type 2 diabetes is
glycation end products (RAGE) (9). Calprotectin is
diabetic neuropathy with the prevalence of 50-60%.
believed to function both as an intracellular
Neuropathy may cause decreased nerve functions and
differentiation marker for phagocytes and as an
nerve blood perfusion with persistent nerve damage.
extracellular protein complex (a damage-associated
Diabetic peripheral neuropathy increases development
of foot ulceration risk, and increases developmental
molecular pattern (DAMP) molecule) (10). Elevated
risk of necrosis, which may cause lower extremity
plasma levels of Calprotectin have been reported in a
amputations. Diabetic peripheral neuropathy has
variety of chronic inflammatory conditions, including
significant contributions in morbidity and mortality in
rheumatoid arthritis, allograft rejection, inflammatory
diabetic patients (3, 4).
bowel disease, and cancer lung diseases (11). Elevated
Although it is predicted that hyperglycemia is
Calprotectin levels have been reported to predict
an important pathophysiological factor in development
microvascular alterations in type 2 diabetic (T2DM)
of diabetic neuropathy, the related mechanisms have
patients (12).
not been much clarified. Opinions suggesting that

inflammatory processes may play a role in
pathogenesis of diabetic neuropathy are increasing. In
A total number of 90 subjects were included in the
previous studies, it has been shown that peripheral
study after fulfillment of the inclusion and exclusion
neuropathy was associated with increased levels of
criteria. This study was conducted from March 2019 to
proinflammatory immune mediators in patients with
December 2019 in Endocrinology Clinic, Zagazig
University Hospital and Endocrinology Clinic of
type 2 diabetes (5, 6).
Shbeen El Kom Teaching Hospital. This was a case-

control study where the patients were classified into

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

Received:11 /7 /2020

Accepted:23 /8 /2020

Full Paper (vol.822 paper# 30)