c:\work\Jor\vol851_1 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85, Page 2671-2677

Diagnostic Utility of Thoracic Ultrasound in Assessment of
Volume Status of Haemodialysis Patients
Al-zahraa A. El-saadawi1, Taghreed S. Farag1, Eman Sobh1,
Sawsan B. El-sawy1, Hanaa Mohammed Eid El Sayed*2
Departments of 1Chest Diseases and 2Internal Medicine, Faculty of Medicine for Girls,
Al-Azhar University, Cairo, Egypt.
*Corresponding author: Hanaa Mohammed Eid El Sayed, Mobile: (+20) 01006566308, E-Mail: hana_sozy@yahoo.com


ABSTRACT
Background:
Optimizing volume status of hemodialysis patients is an important clinical challenge because volume
expansion is a critical deadly complication of chronic kidney disease. The use of thoracic ultrasound to detect cases of
volume overload and depletion has gained great attention by several studies that are because of its advantage as a
rapid, available, non-invasive and free of radiation imaging method.
Aim: To evaluate the usefulness of thoracic ultrasound for the assessment of extravascular lung water and
intravascular volume in hemodialysis patients.
Patients and Methods: This prospective observational study was conducted on 30 patients on regular hemodialysis.
Assessment of extravascular lung water (EVLW) by number of B ­lines, and intravascular volume by measurement of
inferior vena cava (IVC) diameter and collapsibility index, was done pre- and post-dialysis.
Results: There was statistically highly significant reduction in number of B-lines and highly significant decrease of
IVC minimum and maximum diameters post-dialysis (P value < 0.001). There was also highly significant increase in
IVC collapse index following hemodialysis (P value < 0.001).
Conclusion: Lung ultrasound is a useful method for the assessment of both EVLW and intravascular volume. EVLW
as represented by B-lines number was highly significantly reduced post-hemodialysis. Intravascular volume assessed
by IVC ultrasound was improved by 53% following hemodialysis.
Keywords: Volume status, B-lines, IVC diameter.


INTRODUCTION

Chronic kidney disease (CKD) is defined as
PATIENTS AND METHODS
kidney damage or a glomerular filtration rate (GFR) of
This was a prospective observational study that
less than 60 ml/min/1.73 m2 for more than three
included 30 patients from Al-Zahraa University
months. CKD is a term that refers to any degree of
Hospital through the period from January 2018 to
renal dysfunction, whether mild, moderate, or severe
August 2018. Patients were maintained on regular
(1). Dialysis and chronic kidney disease can influence a
hemodialysis three times per week, four hours per
variety of bodily systems, including the cardiovascular,
setting with standard bicarbonate dialysis by using
respiratory, and musculoskeletal systems (2).
semisynthetic membranes.
Pulmonary complications that have been

reported in CKD patients include pulmonary edema,
Inclusion criteria:
pleural effusion, pulmonary hypertension, respiratory
Patients with end stage renal disease on regular
infections, pulmonary fibrosis and hypoxemia (3).
dialysis more than 18 years old were included.
Fluid overflow is a frequent consequence of

Exclusion criteria:
kidney illness in patients on hemodialysis with end-
Patients with all causes of alveolo-interstitial
stage renal disease (ESRD). Fluid overload is difficult
syndrome either acute or chronic conditions such as
to identify since standard clinical indicators are
congestive heart failure, Acute Respiratory.
sometimes subjective or difficult to interpret in the
Distress Syndrome (ARDS) and lung fibrosis,
presence of kidney disease (4).
even if they are on regular hemodialysis, were
The use of lung ultrasound to evaluate fluid
excluded from the study as in these conditions B-lines
status in haemodialysis patients is a straightforward,
will be present on thoracic ultrasonography but they
noninvasive, readily available, and cheap technique. It
are not due to volume overload and are not affected by
can determine the amount of EVLW by determining
hydration status.
the number of B-lines and the distance between them

(5).
All patients were subjected to the following:
The presence of three or more B-lines in a
1. Obtaining of a medical history, including co-
longitudinal plane between two ribs defines a positive
morbidities, the date of initiation of haemodialysis,
area, and the presence of two or more positive regions
and the degree of dyspnea on the modified
bilaterally defines a positive exam (6).
Medical Research Council scale.


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


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2671
Received: 2/5/2021

Accepted: 29/6/2021



Full Paper (vol.851 paper# 1)


c:\work\Jor\vol851_2 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85, Page 2678-2687

Laparoscopic Inguinal Hernia Repair; Sohag Experience
Mahmoud S. Abol Kher, Ahmed Abdel Kahaar Aldardeer,
Osama Abdullah AbdulRaheem, Ayman M. A. Ali, Alaa A. Redwan
Department of Surgery, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Mahmoud S. Abol Kher, Mobile: (+20) 01010674328, E-Mail: msa201040201040@gmail.com

ABSTRACT
Background:
Laparoscopic inguinal hernia repair is widely adopted and well accepted in many centers.
Objective: We aimed with this study to evaluate the technique regarding its advantages and disadvantages
in Sohag University Hospital.
Patients and Methods: This was a prospective observational study included 50 patients suffering from
inguinal hernia admitted electively to Sohag University Hospital between September 2019 and April 2020.
Patients were enrolled for laparoscopic Trans Abdominal Pre Peritoneal (TAPP) repair. Patients were
evaluated regarding demographic criteria, clinical picture, operative, and postoperative course after an
outpatient follow-up period of 6 months.
Results: The mean operative time in minutes ±SD was (125±12.5) for the early 10 patients while it was
(69.8± 24) for the last 25 patients. Intraoperative complications were encountered in two cases of visceral
injury and one case of bleeding arising from the inferior epigastric artery that was managed
laparoscopically without surgical sequelae. The duration of hospital stay ranged from 24-48 hours.
Postoperative complications were encountered in 3 patients whom had surgical emphysema which
resolved conservatively. Patients returned to full activities in 7.14 ± 0.96 days and returned to their work
in 14 ±2.5 days. On follow-up, recurrence was not encountered allover the period of 6 months
postoperatively.
Conclusion: TAPP repair for inguinal hernias is justified as a feasible, reproducible, and safe technique
with rapid recovery and early return to work as well as comparable morbidities to other techniques. It is
recommended as the procedure of choice in elective groin hernia repair especially in bilateral cases, with
short learning curve requiring little facilities in the center.
Keywords: Inguinal hernia, Laparoscopic surgery, .

INTRODUCTION
Inguinal hernia is a prevalent condition
Today, laparoscopic TAPP hernioplasty is
worldwide with an incidence of 5%-7%. The
accepted as a method that is routinely performed
repair of inguinal hernias is one of the most
in bilateral and recurrent hernia cases as well as
commonly
performed
general
surgical
in primary unilateral hernia cases(6). Moreover,
procedures(1). Approximately 20 million inguinal
the posterior approach can be much more reliable
hernia repairs are performed worldwide every
for patients with recurrent hernias, in which the
year, which constitutes a significant cost and
mesh will be fixed to the unchanged muscular-
morbidity burden on the health authorities
aponeurotic tissues of the inguinal area(7). The
worldwide. For several decades, the mainstay of
high
cost
of
the
procedure
cannot
be
treatment was an "open" repair, using a
underestimated but this cost can be offset by less-
prosthetic mesh with reduced risk of recurrence
easily quantified benefits such as earlier return to
when compared to an open suture repair(2).
work(8).
In
the
early
90s,
minimally
invasive
Opponents of laparoscopic inguinal hernia
approaches
were
introduced.
Since
then,
repair claim that recurrence rates which are a key
laparoscopic repair has become increasingly
outcome in hernia surgery are somewhat still
utilised(3).
Unlike
operations
such
as
encountered, and usually require re-operation(9-
cholecystectomy, the laparoscopic technique has
10). and serious intraoperative complications(11)
not superseded open operations in terms of
have
been
found
following
laparoscopic
numbers being undertaken(4). Advocates of the
operations, some of which have been attributed to
laparoscopic repair describe reduced incision
the
early
implementation(9)
or
lack
of
size, reduced postoperative pain and more rapid
standardisation
of
laparoscopic
techniques(12).
recovery, with similar complication rates when
These re-operations are also associated with
compared to open repairs(5).
worse outcomes than the primary repair(13). Add
The
transabdominal
preperitoneal
(TAPP)
to this laparoscopic repair demands significant
laparoscopic approach also enables intraoperative
expertise to achieve outcomes comparable with
assessment of the contralateral side for detection
those of open repair(14).
and repair of defects missed preoperatively.


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2678
Received: 5/5/202
1

Accepted: 1/7/2021



Full Paper (vol.851 paper# 2)


c:\work\Jor\vol851_3 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85, Page 2688-2694

Evaluation of CHA2DS2-VASc Score as a Predictor of Platelet Reactivity in Acute
Myocardial Infarction Patients Treated by Percutaneous Coronary Intervention
1Ghada Selim, 1Ahmed Tamara, 2Lobna Refaat, 3Mohamed Awadein, 4Ahmed Elbarbary
1Cardiology Department, Faculty of Medicine, Ain Shams University,Egypt,
2Clinical Pathology Department, 3Internal Medicine Department and
4Cardilogy Department, Faculty of Medicine, Misr University for Science and Technology (MUST), Egypt
*Corresponding author: Ghada Selim, Mobile: (+20)01277691115

ABSTRACT
Background:
The CHA2DS2-VASC score was evaluated as a risk stratification tool used in predicting outcomes in clinical
settings other than preventing stroke in patients with atrial fibrillation (AF). But, its use in coronary artery disease
patients who recently had percutaneous coronary intervention (PCI) was not thoroughly studied.
Aim of work: determining the availability of using CHA2DS2-VASc score as an effective and simple platelet reactivity
predictor in acute myocardial infarction (AMI) patients managed with percutaneous coronary intervention.
Subjects and methods: Our prospective study included 180 consecutive acute myocardial infarction patients who were
submitted to percutaneous coronary intervention and were hospitalized within twelve hours of symptoms onset. They were
categorized, according to their CHA2DS2-VASc risk scores, into two groups: low-risk (0­1 score) and high-risk (2­9 score).
Following PCI, using light transmittance aggregometry, platelet reactivity was determined utilizing adenosine diphosphate
(ADP)-induced platelet aggregation.
Results: We found a significant difference between high and low CHA2DS2-VASc score groups regarding sex, BMI,
hyperlipidemia, ST-elevation, statins use, and the number of diseased vessels. As regards mean platelet ADP-induced
aggregation reactivity, a significant correlation between reduced mean platelet ADP-induced aggregation reactivity and low
CHA2DS2-VASc score was detected in comparison to the high score (42.53 ± 16.21 and 50.67 ± 18.1, respectively, and P
= 0.002).
Conclusion: The CHA2DS2VASc score may be a significant independent platelet reactivity predictor in acute myocardial
infarction patients managed with PCI, and thus it can be utilized in assessing the acute stent thrombosis risk in acute
myocardial infarction (AMI) patients after PCI.
Keywords: Acute myocardial infarction, CHA2DS2-VASc score, Platelet functions testing.

INTRODUCTION
(VED), as assessed by brachial flow-mediated dilation
CHA2DS2-VASc Score is the most frequently used
(bFMD) and brachial-ankle pulse wave velocity (baPWV).
method in atrial fibrillation for predicting thromboembolic
Cardiovascular disorders, for example, myocardial
risk. CHA2DS2 is an acronym for (Congestive heart
infarction and ischemic stroke were found to be
failure, hypertension, advanced age (> 65 = 1 point, > 75 =
pathophysiologically accompanied by VED as measured
2 points), diabetes, and stroke/transient ischemic attack
by bFMD or elevated baPWV. In general, platelet
history (2 points). VASc refers to vascular disease
aggregation and adhesion are induced by VED, as well as
(peripheral arterial disease, aortic atheroma, and prior
fibrin synthesis, both of which are necessary for systemic
myocardial infarction), and this scoring system also
hypercoagulability4. A significant association between
includes a gender component (female sex). Each risk factor
VED and risk factors for cardiovascular disorders, such as
is worth one point, with the exception of age > 75 and
diabetes or heart failure (all of which are CHA2DS2-VASc
stroke/TIA, which are worth two points1.
score elements) was detected. VED was shown to be a
ACI is the leading mortality cause in millions of
critical point of vulnerability for coronary plaque and other
lives annually in the developed countries. Non-ST segment
cardiovascular problems such as vascular remodeling 5.
elevation myocardial infarction (NSTEMI) and ST-
The preceding sequential linkages may suggest a
segment elevation myocardial infarction (STEMI) are the
relation between the adverse CV disorders and the
two types of acute myocardial infarction. Reperfusion of
CHA2DS2-VASc score. Among patients treated with
the heart is the key in the treatment of myocardial
P2Y12 inhibitors, platelet function testing (PFT) was
infarction. The earlier the treatment, the better is the
extensively used in ACS to predict myocardial infarction,
prognosis 2. In acute coronary syndrome (ACS)
stent thrombosis, and bleeding events after PCI.
patients, most of the CHA2DS2-VASc score items
Low platelet reactivity (LPR) and high platelet reactivity
independently predicted poor cardiovascular outcomes 3.
(HPR) patients had an increased risk of bleeding and
The CHA2DS2-VASc score was shown to be
ischemic events, respectively. Whereas, those with optimal
significantly related to vascular endothelial dysfunction
platelet reactivity (OPR) had a decreased ischemic and

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2688
Received: 5 /5 /2021

Accepted:1 /7 /2021



Full Paper (vol.851 paper# 3)


c:\work\Jor\vol851_4 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85, Page 2695-2700

Vitamin D Pattern in Patients with Systemic Lupus
Erythematosus with and without Nephritis
Hayat Mahmoud Mahmoud1, Yasser Abdalmonem Elhendy1,
Ghada Elsaid Amr2, Rasha Abdulhamid Eisay Elzwawy1, Nafesa M. Kamal1
Departments of 1Internal Medicine and 2Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

ABSTRACT
Background:
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease where chronic inflammation and
organ damage is observed due to various suspected causes e.g. inadequate levels of vitamin D (a steroid hormone with
immunomodulatory effects).
Objective: To assess vitamin D (VD) levels in serum of patients with lupus nephritis (LN) in comparison with patients
with extra-renal lupus and healthy controls, and to assess the relation between VD levels and the various clinical and
laboratory disease parameters.
Patients and Methods: This was a case-control study that was held in Zagazig University Hospitals between June 2019
and July 2020. The study included 40 patients admitted with systemic lupus erythematosus (SLE) with and without
lupus nephritis (LN), and 20 age-matched healthy subjects. Laboratory investigations such as complete blood count,
electrolytes, PTH, acute phase reactant, complements, Ads DNA and 25(OH) D levels of the subjects were measured.
Results: Patients with SLE with lupus nephritis were significantly lower regarding vitamin D with no significant
difference between patients with SLE without LN and control group.
Conclusions: Our study revealed a high frequency of Vit D deficiency and insufficiency among patients with SLE with
LN compared to SLE without LN and healthy controls.
Keywords:
Systemic lupus erythematosus, Lupus nephritis, Vitamin D.


INTRODUCTION

VD is a lipo-soluble vitamin that plays a key role
60 individuals, 40 of them were patients admitted
in calcium and phosphorus metabolism and bone
with SLE with and without LN.
mineralization. The main source of VD in our body

comes from the conversion of 7-dehydro-cholesterol
Ethical consent:
into preVD3 in the skin, while smaller amounts of VD
An approval of the study was obtained from
come from dietary sources (1).
Zagazig
University Academic
and
Ethical
However, it had been reported that several
Committee Board (ZU-IRB#5839-29.12.2019). Every
immune cells express VD receptors (VDRs) on their
patient signed an informed written consent for
surfaces (2) and many immune cells synthesize the 1-
acceptance of the study. This work has been carried
hydroxylase enzyme responsible for synthesis of the
out in accordance with The Code of Ethics of the
active form of VD in the microenvironment of lymph
World Medical Association (Declaration of Helsinki)
tissues. These findings indicate that VD is involved in
for studies involving humans.
the immune modulation (3).

SLE is an autoimmune disorder that affects
Inclusion criteria:
multiple organ systems including the skin, kidneys, and
Age > 18 years and of either sex. All patients were
brain (4). Clinical features are highly variable, ranging
diagnosed according to revised American college of
from skin and joint involvement to organ involvement
Rheumatology (ACR) classification criteria for SLE
and life-threatening complications (5). LN is one of the
(The new 2019 EULAR/ACR classification criteria for
most serious consequences of SLE and is one of the
SLE). The criteria for LN (11) include persistent
major factors predicting poor outcome, or End-Stage
proteinuria > 0.5 grams/day, renal biopsy class II, III,
Renal Disease (ESRD) 10 years after onset of LN (6).
IV or V. The study included also healthy matched
Renal involvement can interfere with 1-hydroxylation
controls.
that is essential to make active form of VD (7).

Low serum VD is prevalent in SLE patients,
Exclusion criteria:
ranging from 16% (8) to 95% (9) and can be attributed to
Patients with SLE without overlapping with other
several factors such as photosensitivity, sunscreen
inflammatory arthritis or other connective tissue
application, renal damage, chronic glucocorticoids or
disease. Underlying chronic kidney disease other than
anti-malarial therapy (10).
LN. Malignancy or suspected malignancy and those on

VD therapy. Patients with serious chronic illness
PATIENTS AND METHODS
including advanced difficult to be controlled chronic
A case-control study that was conducted in
obstructive pulmonary disease, inflammatory bowel
Nephrology Outpatients Clinic of Internal Medicine
disease, inflammatory arthritis, connective tissue
Department from June 2019 to July 2020.

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2695
Received: 6/5/2021

Accepted: 2/7/2021



Full Paper (vol.851 paper# 4)


c:\work\Jor\vol851_5 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85, Page 2701-2703
Endometriosis of the Iliacus and Psoas Muscle: Case Report
Yasir Mohammed Shukri Alwan*1, Joud Mohammed Shukri Alwan2, Mohammed Khalid Al Hebshi3
1Department of Orthopedic, National Guard Hospital, Jeddah, Saudi Arabia
2Department of Orthopedic, Umm Al-Qura University, Makkah, Saudi Arabia
3Department of Orthopedic, King Abdulaziz University Jeddah, Saudi Arabia
*Corresponding author: Yasir Mohammed Shukri Alwan, Mobile: 00966564947766, E-Mail: yasser.s.alwan@hotmail.com

ABSTRACT
Background:
Endometriosis is a prevalent benign, inflammatory, estrogen-dependent disease that affects between 1%
to 11.5% of women. Deep endometriosis is one of the three types of endometriosis. Described as "deeply infiltrating
endometriosis" or "adenomyosis externa," and it is characterized histopathologically as endometrial glands and stroma
penetrating adjacent fibromuscular tissue, obliterating and substituting connective tissue septa. Objective: The present
work aimed to report a case of endometriotic of the iliacus muscle and psoas muscle. Mention the place and time of the
study. Conclusion: Deep endometriosis is rare to infiltrate the retropsoas area (iliacus, iliopsoas) and the diagnosis can
be difficult, therefore a comprehensive patient assessment is necessary for adequate treatment. The use of appropriate
imaging techniques, such as MRI and CT scans, is essential to show the lesions.
Keywords: Endometriosis, Iliacus muscle, Psoas muscle.

INTRODUCTION


Endometriosis is a condition in which the
pain in the hip movement bilaterally. On palpation, there
endometrial glands and stromal tissue are found outside
was an abdominal tenderness with guarding abdomen,
of the uterus, primarily in the pelvic cavity. It's a chronic,
localized tenderness at the right trochanteric area,
estrogen-dependent inflammatory disease that affects
localized tenderness at the lumbar area of the spine and
women during their reproductive years and is linked to
paraspinus muscle. Distal neurovascular was examined
pelvic discomfort and infertility (1, 2).
and it was intact.
It is classified into 4 stages according to the
Laboratory investigations and radiological studies
American Society for Reproductive Medicine. Peritoneal
were done. Laboratory results were unremarkable while
and ovarian endometriosis are the more common types,
the X-ray pelvis showed no clear fracture with mild
whereas deep infiltrating endometriosis refers to lesion
degenerative changes. Ultrasound, CT, and MRI pelvis
invasion 5mm. Endometriotic lesions may be located
were done and compared to the previous studies that
in the uterosacral ligaments, rectouterine pouch, vaginal
were done in 2014 outside the hospital. They showed that
vault, rectum, or colon. They can also invade the bladder
the patient had endometriosis with a lesion at the retro
wall and ureter. Endometriosis has been found in other
iliopsoas location suggestive of atypical location of
areas of the body including scar endometriosis
endometriosis involving the iliacus muscle and femoral
(abdominal and perineal incision) and rare distant
nerve.
endometriosis, such as in the lungs, pleura, groin,
A CT-guided biopsy from the right iliac mass was
diaphragm, sciatic nerve, outer ear, and scalp (1, 2).
done and examined histopathologically as well as

microbiologically.
Histopathological
examination
CASE REPORT
showed pelvic endometriosis while the microbiological
A
44-years-old
female,
married,
regularly
examination was unremarkable.
menstruating Saudi patient, was presented to the
The final diagnosis was endometriosis with
gynecology outpatient clinic at National Guard Hospital,
metastases to the right iliacus muscle as well as iliopsoas
Jeddah, Saudi Arabia suffering from right-side hip pain
muscle invasion. Gynecology consultation was done to
in 2014.
evaluate the endometriosis and to rule out any
After taking a full detailed history with serial
malignancy. Pap and cervical smears as well as
examination and investigation. She was diagnosed with
endometrial biopsy were done and showed no
endometriosis and treated with laparoscopic surgery
malignancy cell.
outside the country. After the surgery, she is continued to
follow with the gynecology team for 3 years. In 2017 the
Declaration of patient consent:
patient had an episode of low back pain with bilateral hip
Approval of the study was obtained from National
pain and right trochanteric hip pain, associated with loss
Guard Hospital (Jeddah, Saudi Arabia) academic
of weight and loss of appetite, and irregular menstrual
and ethical committee. The patient and her relatives
cycle.
were informed that the case was taken as a case report for
On examination, the patient was conscious, alert,
publishing and she was accepted. This work has been
oriented, and vital signs were within normal parameters.
carried out following .
Normal gait without any assistive device. The range of
The Code of Ethics of the World Medical Association
motion of the hip and lower extremity was intact with
(Declaration of Helsinki) for studies involving
humans.


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2701
Received: 7/5/2021

Accepted: 3/7/2021



Full Paper (vol.851 paper# 5)


A Prospective Study of the Association between Arterial Blood Gases Disturbances, Serum Lactate Level and the Prognosis of Acutely Poisoned Patient in Ain-Shams Poison Control Center The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2704-2712

A Prospective Study of the Association between Arterial Blood Gases
Disturbances, Serum Lactate Level and the Prognosis of
Acutely Poisoned Patient in Ain-Shams Poison Control Center
Maha A. Hilal1, Mona Elkotp Moussa2, Alaa Mohamed Abd Elgwad*1, Reda M. Elsayed1
1Department of Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Sohag University, Sohag, Egypt.
2Department of Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
*Corresponding author: Alaa Mohamed Abd Elgwad, Mobile: (+20) 01095929540, E-Mail: Alaa.abdelgwad18@yahoo.com

ABSTRACT
Background:
Analysis of blood gases and acid-base status is an essential tool in assessment of ill patients in the
emergency setting. However, the role of acid-base disturbance on survival of acutely poisoned patients has not been
thoroughly investigated.
Objective: To evaluate the role of arterial blood gases (ABG) and serum lactate level for early detection of the
severity of toxicity and prediction of death in acutely poisoned patients.
Patients and methods: The current study is a prospective study that was done on 100 of acutely poisoned patients by
drugs and toxins with acid base disturbances effect. They were admitted to Ain-Shams Poison Control Center, during
the period from January 2019 to the end of December 2019.
Results: Results of the current study revealed that 47.8% of dead patients suffered from metabolic acidosis and
respiratory acidosis, 30.4% of them, were with metabolic acidosis, 13% of them were with respiratory acidosis, and
8.7% of them, were with metabolic acidosis and respiratory alkalosis. According to ROC curve analysis serum lactate
level can be used as a predictor of mortality as serum lactate level with cut off 1.45 had sensitivity of 91.3%,
specificity 29.8% and NPV 93.6% with excellent diagnostic characteristic ( accuracy rate 84.6%).
Conclusion: The study concluded that ABG and serum lactate level can be used as simple predictor tools of the
severity of toxicity and prediction of death in acutely poisoned patients.
Keywords: Arterial blood gases disturbances, Serum lactate, Acutely poisoned.

INTRODUCTION

Analysis of blood gases and acid-base status is
elevated lactate concentration accompanied by a
an essential tool in assessment of ill patients in the
decrease in blood pH (5, 6).
emergency setting (1).
Elevated concentrations of serum lactate occur
Lactate is a metabolic byproduct of anaerobic
in conditions that cause tissue hypoxia/hypoperfusion
metabolism and therefore is produced by most tissues in
(type A) as well as other pathophysiologic conditions
the human body. Lactate is rapidly cleared by the liver
(type B) not related to tissue hypoxia (2).
with some additional clearance by the kidneys under
The present study aimed to evaluate the role of
normal conditions. Elevated concentrations of serum
Arterial blood gases (ABG) and serum lactate level for
lactate occur in conditions that cause tissue
early detection of the severity of toxicity and prediction
hypoxia/hypoperfusion (type A) as well as other
of death in acutely poisoned patients.
pathophysiologic conditions (type B) not related to

tissue hypoxia (2).
PATIENTS AND METHODS
Blood lactate levels have been used as a
This prospective study was conducted on 100 of
prognostic factor in critically ill patients. Lactate has
acutely poisoned patients by drugs and toxins with acid
also been studied for the prognosis of patients with
base disturbances effect. They were admitted to Ain-
poisoning from metformin, acetaminophen, beta
Shams Poison Control Center, during the period from
blockers, carbon monoxide, cyanide and paraquat (3).
January 2019 to the end of December 2019.
Regardless of the etiology of elevated serum lactate

concentration, it is a useful prognostic indicator in a
Inclusion criteria:
variety of clinical circumstances. However, there are
Acute toxicity with toxins that cause ABG
conflicting data about the utility of lactate specifically
disturbances effect like opioids, sedatives, pesticides,
in the setting of acute drug overdose, which leaves the
alcohols, stimulants, barbiturates, antidepressant,
prognostic indicator utility of lactate an open question
metformin,
acetaminophen,
theophylline,
(4).
antipsychotics, antiepileptics ... etc. The type of toxin
Under anaerobic conditions, lactate is an end
was determined according to the history given by the
product of glycolysis and feeds into the Cori cycle as a
patient him/herself if he/she is conscious on admission
substrate for gluconeogenesis. Hyperlactatemia is an
and from clinical signs and investigations. If the patient
elevated lactate concentration, and lactic acidosis is an
is unconscious, the history was taken from the relatives.





This article is an open access article distributed under the terms and conditions of the Creative
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2704
Received: 6/5/2021


Accepted: 2/7/2021




Full Paper (vol.851 paper# 6)


Microbial 1The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2713-2717

Efficacy and Safety of Topical 2% Glycopyrrolate in the
Treatment of Facial Hyperhidrosis
Eman Abd Elgawad Nofal, Shrook Abd Elshafy Khashaba, Somya Salem Elsayed Hasan*
Dermatology, Venereology and Andrology Department, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Somya Salem Elsayed Hasan, Mobile: (+20)01119680224, E-mail: salemsomya@gmail.com

ABSTRACT
Background:
Facial hyperhidrosis is a frequent complaint characterized by excessive sweating which usually affects
the forehead bilaterally but can also involve other regions of the face such as the scalp, nose, chin and less frequently
cheeks. The topical application of 2% glycopyrrolate is safe, efficacious, well tolerated and convenient method in the
treatment of facial hyperhidrosis. Objective: The aim of this study was to evaluate the clinical efficacy, safety and
tolerability of topical 2% glycopyrrolate in the treatment of facial hyperhidrosis.
Patients Methods: This clinical trial was conducted in the Outpatient Clinics of Dermatology, Venereology and
Andrology Department, Faculty of Medicine, Zagazig University Hospitals. Twelve patients suffering from primary
facial hyperhidrosis were included in this study. They were treated by topical glycopyrrolate gel 2%. Each patient
applied the test product to the area affected in their faces once a day for 9 days. Response to treatment was evaluated
by starch iodine test. Patient's satisfaction level and adverse effects were also evaluated. Follow up evaluation was
done for detection of any recurrence.
Results:
9 patients (75%) showed complete response and 2 patients (16.7%) showed partial response. Only one
patient showed no response to topical glycopyrrolate 2% after 10 days of treatment. The improvement was lost in 8
patients (66.7%) on the 3rd day of stoppage of treatment and on the next day of stoppage of treatment among 3
patients (25%).
Conclusion: Topical glycopyrrolate 2% is safe, efficacious, well tolerated and convenient method in the treatment of
facial hyperhidrosis with minimal, transient and well-tolerated side effects.
Keywords: Glycopyrrolate, Facial hyperhidrosis.

INTRODUCTION

anticholinergic drugs but unfortunately, high doses are
Hyperhidrosis is a disorder characterized by
often required with possible side effects such as
excessive sweating. It is a common health problem
insomnia, altered mental status, seizures, palpitation
affecting about 3% of the population. Patients with
and urine retention. Topical antiperspirants as topical
hyperhidrosis usually have low self-esteem and
20% aluminum chloride could be attempted in the
frequently withdraw from the social arena. They can
treatment of facial hyperhidrosis with possible local
have secondary effects such as damp, cold hands,
irritation and contact dermatitis. Surgical management
dehydration and skin infections secondary to
can be used for the treatment of facial hyperhidrosis.
maceration. Hyperhidrosis is classified according to
The principle behind it is disruption of nerve impulses
cause into primary or secondary and can be
from sympathetic nervous ganglia (predominantly T2-
categorized based on the source of the neural impulses
T3) to the eccrine sweat glands (4).
that drive it into cortical (emotional), hypothalamic,
Glycopyrrolate is an anticholinergic agent that
medullary, spinal cord and local axon reflex (1).
blocks acetylcholine receptors lowering gastric,
Facial hyperhidrosis is a frequent complaint, which
bronchial, lacrimal and other body secretions. The
usually affects the forehead bilaterally but can also
topical application of 2% glycopyrrolate appears to be
involve other regions of the face such as the scalp,
safe, efficacious, well tolerated and convenient in the
nose, chin and less frequently cheeks. It can be either
treatment of facial hyperhidrosis with few secondary
focal affecting only the face and scalp or part of a
effects such as slight headache, dry mouth or
generalized hyperhidrosis involving several body sites
odynophagia(5).
of skin. It could be primary or secondary to other

causes such as infection, endocrine disturbance or
PATIENTS AND METHODS
neoplasm (2). Primary facial hyperhidrosis is
This clinical trial was conducted in the Outpatient
characterized by sudomotor dysregulation stimulated
Clinics of Dermatology, Venereology and Andrology
by triggers such as heat and stress. The possibility
Department, Faculty of Medicine, Zagazig University
exists that the cause of primary facial hyperhidrosis
Hospitals during the period from June 2020 to
could be excessive stimulation of the sweat glands by
February 2021.
an overactive sympathetic system or by overreaction of
Twelve patients suffering from primary facial
the glands to a normal amount of acetylcholine (3).
hyperhidrosis were included in this study. They were
There are many available treatments for facial
treated by topical glycopyrrolate gel 2%.
hyperhidrosis including systemic treatment 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/)
2713
Received: 6/5/2021


Accepted: 2/7/2021




Full Paper (vol.851 paper# 7)


c:\work\Jor\vol851_8 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2718-2724

Wound Complications in Obese Patients after Gynecologic
Oncology Surgeries, an Intervention Study
Hussein Mohammed Abdeldaim, Taha Abdelfattah Ahmed,
Esraa Gomaa Mustafa Alsyied*, Mohammed Mustafa Zaitoun
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt
*Correspondence to: Esraa Gomaa Mustafa Alsyied, Mobile: (+20)1068973935, E-mail: Gomaae975@gmail.com


ABSTRACT
Background:
Obesity is one of the comorbid conditions which can affect the operative and postoperative outcome
of patients undergoing surgery.
Objective: The aim of the current work was to assess the impact of using specific protocol suggested by author included
(saline wash, suture material, subcutaneous drain and binder) on wound complications after major gynecologic
Oncology surgeries in obese patients.
Patients and Methods: This study was an intervention prospective study which included 86 women undergoing surgical
gynecologic procedures via a vertical abdominal incision performed at Obstetrics and Gynecology Department, Faculty
of Medicine, Zagazig University Hospital during the period from April 2020 to October 2020. All patients were
subjected to detailed history taking, Clinical examination including general, abdominal and pelvic examination. Surgical
Protocol for skin closure was applied.
Results: There was a significant difference between study group and control group regarding wound complications
(P=0.001). Fever was found in 23.2% in study group and 34.8% in control group, seroma was found in 100% in study
group and 80% in control group and wound dehiscence, wound infection and wound hematoma respectively were found
in 100% in study group and 60% in control group.
Conclusion:
It could be concluded that using this specific protocol (saline wash, suture material (Polydioxanone
Suture), subcutaneous drain and binder) may decrease the incidence of wound complications in obese women
undergoing a gynecologic procedure via a vertical abdominal incision.
Keywords: Wound Complications, Obese Patients, Oncology Surgeries, saline wash

INTRODUCTION

abscess and peritonitis. The etiology may be related to
Obesity is comorbid conditions which can affect
type of surgery, diabetes mellitus, (DM) poor technique,
the operative and postoperative outcome of patients
obesity, or disorders of immune system. (8).
undergoing surgery (1).
Seroma can be due to subcutaneous potential space
It is better expressed by body mass index (BMI).
or inadequate drainage. This may lead to wound
BMI is calculated from weight and height. Body mass
infection (9).
index of less than 18.5 is underweight, 18.5 to 24.9 is
Wound dehiscence, in particular, leads to
normal, 25 to 29.9 is overweight and more than 30 is
incisional hernia. Risk factors for the development of
obesity (2).
wound dehiscence and hernia include chronic
The distribution of body fat between visceral and
pulmonary disease, ascites, jaundice, anemia, obesity,
non-visceral compartments and within different
coughing, type of surgery, wound infection and closure
subcutaneous areas is important clinically. Both the
technique. Incisional hernias can occur after any type of
central and peripheral types of obesity are associated
abdominal wall incision, but midline incisions are more
with surgical complications (3,4).
prone to have this complication (10).
The Gynecologic Oncology surgeries may be open
Perioperative risk factors are age, hypertension,
or laparoscopic and elective or emergency. Possible
diabetes mellitus, heart diseases, renal failure, cirrhosis,
complications of these surgeries may be local or
pulmonary disease, endocrine disorders, smoking,
systemic (5).
obesity, and coagulopathy. These disorders need to be
The local complications include hemorrhage,
controlled before the surgery (11).
infection, damage to internal organs, formation of
The operative problems associated with obesity are
adhesions, bowel obstruction, seroma, wound
difficulty in exposure and closure, bleeding, prolonged
dehiscence, hernia (6).
operative time, visceral damage, wound infection,
The systemic complications are like chest
dehiscence, incisional hernia (12).
infection, septicemia, deep venous thrombosis,
The aim of this study was to assess the impact of
nosocomial infections, ischemic heart disease and some
using specific protocol (suggested by author) as (saline
procedure related complication (7).
wash, suture material, subcutaneous drain and binder)
Infectious complications of these surgeries range
on wound complications after major gynecologic
from skin and soft tissue infection to intra-abdominal
Oncology surgeries in obese patients.





This article is an open access article distributed under the terms and conditions of the Creative
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2718
Received: 7/5/2021

Accepted: 3/7/2021



Full Paper (vol.851 paper# 8)


c:\work\Jor\vol851_9 1The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2725-2729

Evaluation of Ochratoxins in Lactating Mothers and its Transfer to
Their Exclusively Breast-Fed Infants through Breast milk
Mahmoud Mohamed Mohamed El-Sayed Mousa1, Alaa Zidan Ibrahim1, Mohamed Osman Hafez1, Doaa
Metwaly Abd Elmonem2
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Mahmoud Mohamed Mohamed El-sayed Mousa,
Mobile: (+20)01141033445, Email: mahmoudmousa.mr@gmail.com

ABSTRACT
Background:
Ochratoxin A (OTA) is a well-known widely-spread mycotoxin all over the world that constitutes a real
human threat. Its presence in human milk has previously been reported in different countries.
Objective: This study aimed to detect the presence of OTA in both mothers' milk, sera, and infants' sera and compare
the results with a previous study done in Egypt.
Patients and Methods: Forty-eight healthy breast-lactating mothers and their infants who were exclusively breast-fed
for at least 4 months were included. All of them were subjected to a thorough laboratory evaluation including
determination of OTA concentration by (ELISA) Enzyme-Linked Immunosorbent Assay. Results: Fifteen mothers
(31.3%) and their infants had been contaminated with OTA. The analysis showed that all infants of affected mothers
had OTA in their sera. Conclusion: Multivariate logistic regression analysis showed that there was a significant
correlation between OTA levels in mothers' sera, milk, and their infants' sera.
Keywords: Human milk, Kidney functions, Lactation, Ochratoxin A- urinary NGAl.

INTRODUCTION

Ochratoxin A (OTA) is a well-known widely-
2. Fecal Excretion and EnteroHepatic Circulation.
spread mycotoxin all over the world(1). Ochratoxins (A,
3. Excretion through Breast Milk: There is a direct
B, and C) are secondary metabolites of Penicillium and
relationship between the ingestion of OTA and its
Aspergillus microfungi of which the most hazardous
concentration in the milk(10). In a human study, it was
type is Ochratoxin A that causes harmful effects in
observed that the highest OTA level was found in breast
humans and animals(2). OTA was first found in the
milk during the first few days after delivery(11). Its
Balkan region; however, it can be detected practically
presence may be associated with the chronic tubulo-
in all territories, it is accumulated in animal feed and
interstitial kidney disease called Balkan Endemic
human food due to the favorable weather conditions and
Nephropathy (BEN) (12).
microclimate, and/or to improper storage of food
BEN is a chronic progressive disease with a period
components(2).
of 6­10 years leading to irreversible renal failure. Due
Ochratoxin A occurs in wheat, fruits, oilseeds, and
to its high heat stability, complete removal of OTA from
animal feed resulting in its presence in milk, meat, and
food is practically impossible although several
even in eggs(1). Therefore, many drinks (e.g., wine, beer,
approaches exist for reducing OTA contamination(13).
coffee, tea, milk, etc.) Bellver Soto, et al.(3) and Flores-
After the absorption of OTA from the gastrointestinal
Flores et al.(4)), as well as common meals (bakery, meat,
tract, it binds primarily to albumin with high affinity,
and dairy products) El Khoury et al.(5) contain more or
which results in its very long half-life (from a few days
fewer amounts of OTA. Furthermore, recent studies
to one month, depending on species).
also highlighted its presence in herbal medicines Shim
Although glomerular filtration of OTA is strongly
et al.(6) food coloring agents, spices Ostry et al.(7), and
limited due to its albumin binding, the small filtrated
even in bottled water Mat et al. (8). The wide occurrence
and secreted fraction is partially reabsorbed, which
of OTA and its high thermal stability makes the
might help the accumulation of the toxin in the kidney
eradication of OTA from the food chain very difficult.
tubule cells. OTA toxicity is strongly correlated with the

occurrence of BEN Castegnaro et al. (9); however, its
Excretion:
mechanism of action is very complex Hadjeba-
1. Renal Excretion: In vivo studies verify that the toxin
Medjdoub et al.(14). It is thought to be carcinogenic,
can be reabsorbed from practically any part of the
teratogenic, hepatotoxic, neurotoxic, and immunotoxic,
nephron both by active transport and by passive
based on in vitro and on animal studies(5).
diffusion in a pHdependent fashion(9).
IARC (International Agency for Research on
Excretion of OTA is primarily done through tubular
Cancer) categorizes OTA as a member of the 2B
secretion. The tubular reabsorption of the toxin might
subgroup which means that, based on animal studies,
be considered to be partially responsible for the
OTA is a potential human carcinogen(15). The NCI/NTP
intracellular accumulation of OTA(1).
(National Cancer Institute/National Toxicological

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/)
2725
Received: 8 /5 /2021

Accepted: 4 /7 /2021



Full Paper (vol.851 paper# 9)


c:\work\Jor\vol851_10 1The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2730-2733

Insulin Glargine versus Neutral Protamine Hagedorn Insulin in Young and
Preschool Children with Type 1 Diabetes Mellitus
Khadiga Eltonbary*1, Manal Abd Alaziz 2, Assad Abolela 1, Eman M Sherif 1
Departments of 1Paediatrics and 2Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
*Corresponding author: Khadiga Yehia Eltonbary, Phone: 00201010477244, Email: khadigadoc@yahoo.com

ABSTRACT
Background:
Diabetic patients need to maintain tight glycemic control to avoid long term complications. Children need
to achieve tight control without the risk of hypoglycemic excursions.
Objective:
To assess the safety and efficacy of insulin glargine as a basal insulin in type 1 diabetic children aged 3
to 8 years old in comparison to neutral protamine Hagedorn (NPH) insulin as regards the key parameters of diabetes
management and low-grade inflammation.
Patients and Methods: Fifty children aged 3-8 years old with type 1 diabetes mellitus following in pediatric diabetes
clinic, Ain Shams University Hospital were enrolled in this study. They were randomized into two groups, group A:
shifted from NPH insulin to basal-bolus regimen using insulin glargine once a day and group B: kept on using NPH
insulin two to three times a day. Both used regular insulin or rapid acting analogues at mealtime.
Results: At six months, weight gain was significantly higher among group B patients 0.6 kg (±0.14 SD) vs 0.38 kg,
mean fasting blood sugar was lower in group A, 109.1(+17) mg/dl versus 125.3(+20) mg/dl in group B. HbA1C showed
significant improvement in both groups with tight control, however group A was better with a mean of 6.7(+0.5)%
versus 7.4(+0.7) and still with significantly less hypoglycemic excursions. Hs-CRP as a marker of inflammation showed
significant drop with better overall control independent of the basal insulin used.
Conclusion: Insulin glargine as once daily basal insulin is safe in achieving good glycemic control in young and
preschool children with less hypoglycemic excursions.
Keywords: Insulin Glargine, Neutral Protamine Hagedorn insulin, Type 1 diabetes mellitus.

INTRODUCTION

Diabetic patients should maintain tight glycemic
families. With multiple daily injections and NPH, good
control, with a hemoglobin A1c (HbA1C) concentration
glycemic control can be achieved however severe
of 7.0 percent or less, to lower the risk of long-term
hypoglycemia is still a risk(5).
consequences such as cardiovascular mortality,
Studies have shown that administering insulin
retinopathy, and nephropathy(1).
glargine instead of NPH improves glycemic control and
NPH (Neutral Protamine Hagedorn) insulin is an
reduces hypoglycemic episodes, particularly nocturnal
insoluble intermediate-acting insulin. N is for neutral, P
episodes, which are prevalent in children(6). The highly
for protamine (a protein), and H stands for Hans
sensitive C-reactive protein (Hs-CRP) is a marker of
Hagedorn, the scientist who created it. Insulin glargine
low-grade inflammatory state that characterizes the
is an insulin analogue with a lower solubility at
early stages of atherosclerosis. Inflammatory markers in
physiological pH than natural insulin, allowing for a
diabetes type 2 and metabolic syndrome in adults are
longer absorption time after subcutaneous injection and
well studied, but less is known about the inflammatory
a consistent 24-hour basal insulin supply(2).
process in diabetes type 1, particularly in children(7).
A normal-growing child with type 1 diabetes
The purpose of this study was to assess the safety
needs about 0.7-1 IU of insulin per kg of body weight
and efficacy of insulin glargine as a basal insulin
per day after the end of the remission phase.
therapy in type 1 diabetic children aged 3 to 8 years
Approximately 30-40% of this is to be administered as
old in comparison to NPH insulin as regards the impact
basal insulin(3).
on key parameters of diabetes management and low
Before introduction of long-acting analogues and
grade inflammation.
to initiate multiple daily injections, the use of NPH

insulin was recommended to tailor the dose to the
PATIENTS AND METHODS
circadian variation of insulin requirement. The basal
The study was performed at the Pediatric Diabetes
dose of intermediate-action NPH insulin is frequently
Clinic, Ain Shams University Hospital. Fifty children
divided into two to three injection intervals to match the
aged 3-8 years old with type 1 diabetes mellitus (DM)
basal insulin need at different times(4). For children
were randomly enrolled in this study.
younger than eight years, especially those younger than

six, it is hard to detect hypoglycemia, their activity is
They were randomized into two groups: Group A:
unpredictable, and they have many dietary
Shifted to basal-bolus regimen using insulin glargine
discrepancies, and so it is a serious concern of their
once a day and regular insulin or rapid acting analogues

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/)
2730
Received: 5/5/2021

Accepted: 1/7/2021



Full Paper (vol.851 paper# 10)


c:\work\Jor\vol851_11 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2734-2740

Management of Deep Median Sternotomy Wound Infection after Open Heart Surgery
Nour El-Din Noaman Gwely, Sameh Mostafa Amer, Ahmad Abdel Aleem ElDerie*, Mohamed Mohamed Zaki
Zahran
Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
*Corresponding author: Ahmad AbdelAleem ElDerie, Mobile: (+20) 01093668612, E-Mail: doctorzahran@gmail.com


ABSTRACT

Background: Deep sternal wound infection (DSWI) is a rare but potentially devastating complication of median
sternotomy performed in cardiac surgery. The incidence of DSWI is reported to be between 0.2% and 3%. Identifying
high-risk patients and strategies to optimize risk factors plays an important role in reducing the incidence of DSWI.
Objective: This retrospective prospective study was designed to evaluate the management of deep median sternotomy
wound infection after open heart surgery as regard the risk factors, rate and the outcome of its surgical treatment in
Cardiothoracic Surgery Department, Mansoura University Hospital.
Patients and methods: This retrospective prospective observational study was conducted in Cardiothoracic Surgery
Department at Mansoura University Hospitals from January 2016 to December 2019. The data were obtained from 24
retrospective patient and 7 prospective patients. 31 patients had DSWI and treated surgically, the incidence was 2.9%.
Results: We found that 16 (51.6%) patients were males and 15 (48.4 %) were females. The mean age was 58.23±7.898
(year), minimal age was 40 year and the maximal was 71 years. The mean BMI was 32.18 ±5.364. 14 (45.16%) of
patients had diabetes mellitus (D.M). 18 (58.06%) patients were hypertensive. 10 (32.3%) patients were smokers. 51.6%
of patients had coronary artery bypass graft (CABG). The most common causative organism was MRSA in 35% of
patients.
Conclusion: Using of vacuum and pectoral flap in DSWI management is more effective with better healing, higher
success rate and less mortality.
Keywords: Deep sternal wound infection, Open Heart Surgery.


INTRODUCTION
wound infection (DSWI), management is complex and
Median sternotomy is currently the standard
may need an interdisciplinary team including
incision for surgery of the heart and great vessels.
microbiologists,
infectious
disease
specialists,
However, patients still suffer from its complications (1).
cardiothoracic and plastic surgeons. There is a progress
Deep median sternotomy wound infection is a severe
in deep sternal wound infection management in the last
complication despite the progress in its prevention and
50 years. Deep median sternotomy wound infection
management (2).
treatment must be individualized based on the depth of
Deep median sternotomy wound infection
the infection, the organisms that are cultured, and the
diagnosis needs one of the following to be present: (1)
patient's clinical status (7).
positive cultures taken from mediastinal tissue or fluid.
If DSWI is suspected, cultures should be taken
(2) Presence of mediastinitis (during surgery or on
as early as possible followed by administration of
histopathological examination) (3) one of the following
empirical intravenous broad-spectrum antibiotics
clinical findings: Fever more than 38°C, sternal instability,
against the most likely causative organism, debridement
or chest pain with one of the following findings: Purulent
of all devitalized and necrotic tissue, drainage of all
discharge from mediastinum, positive culture from blood,
infected spaces, after sternal debridement, primary or
or mediastinal widening in radiology (3).
delayed wound closure can be done (8). Reconstruction
Risk factors for deep median sternotomy wound
using pectoralis major, omentum, rectus abdominis, or
infection include patient comorbidities, intraoperative and
latissimus dorsi muscle flaps can be used. Negative
postoperative factors (3). Patient comorbidities such as
pressure wound therapy can also be used and it is
obesity, smoking, chronic obstructive pulmonary disease
recommended (9).
(COPD), diabetes, steroid use. Intraoperative factors such
This retrospective prospective study was
as poor sternal wire fixation or paramedian sternotomy,
designed to evaluate the management of deep median
bilateral internal mammary artery harvesting for coronary
sternotomy wound infection after open heart surgery as
artery bypass graft (CABG) and bone wax use.
regard the risk factors, rate and the outcome of its
Postoperative factors including re-exploration and
surgical treatment in Cardiothoracic Surgery
prolonged positive pressure ventilation, tracheostomy (4).
Department, Mansoura University Hospital.
The most common causative microorganisms

blamed for deep sternal wound infection are considered
PATIENTS AND METHODS
to be Staphylococcus aureus and Coagulase-negative
This retrospective prospective observational
staphylococci (5). Studies show that there is a relation
study was conducted in Cardiothoracic Surgery
between etiology and causative organism (6). Deep sternal
Department at Mansoura University Hospitals from
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2734
Received: 6/5/2021

Accepted: 2/7/2021



Full Paper (vol.851 paper# 11)


c:\work\Jor\vol851_12 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2741-2743

Paravertebral Block and Thoracotomy: Review Article
Ahmed Elsaied AbdElrahman1, Omima Emad Eldin Mohamed*1,
Ayman Mohamed Abd Elghaffar2, Ahmed Talaat Mohamed, Asmaa Saad Eldin Farghaly1,
Wael Alham Mahmoud1
Departments of Anesthesia, I.C.U. and Pain Management and
2Cardiothoracic Surgery, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Omima Emad Eldin Mahran, Mobile: (+20) 01093181802, E-Mail: omimaemad2008@yahoo.com

ABSTRACT
Background:
First described paravertebral block (PVB) to provide abdominal analgesia in 1905. This technique has
been modified for rib fracturing, flail chest, hepatic-biliary operations, open cholecystectomy, inguinal hernia repair,
breast tumors operations and thoracotomies. PVB was shown to be as successful as thoracic epidural analgesia with less
minimal complications in recent systematic reviews and meta-analyses.
Objective: To evaluate the effect of paravertebral block and Thoracotomy to the other technique in issues analgesia,
complications.
Conclusion: Paravertebral block is a very useful regional anaesthetic technique for surgeries, Paravertebral block was
shown to be as successful as thoracic epidural analgesia with less minimal complications.
Keywords: Paravertebral block, Thoracotomy.

INTRODUCTION
needle is placed 2.5 cm lateral to the upper edge of the
Hugo Sellheim first described paravertebral
spinous process perpendicular to all planes and
block (PVB) to provide abdominal analgesia in 1905.
progressed until it came into contact with the transverse
Along with Arthur Lawen, Hugo Sellheim are
process (TP) planes.
merited as being the first to administer local anesthetic
After that, a needle is retracted to the skin,
(LA) into the paravertebral (PV) space in order to
rotated 15 degrees, and progressed without resistance to
identify the intra-thoracic and intra-abdominal organs'
the upper costotransverse ligament. To stop pleural
innervation (1).
puncture, the needle is progressed one centimeter

(maximum 1.5 centimeters) beyond the point where the
Indications: Indications for TPVBs are illustrated in
TP was touched.
table 1 (2).
To reduce the chance of local anaesthetic
Table (1): Common indications for TPV (2)
injection through a dural sleeve, the anesthetist should

Surgical
Non-
prevent medial angulation of the needle. It's also a good
surgical
idea to stop lateral angulation because the PV area is
Acute
Chest area
Abdomen area

smaller laterally, putting the anesthetist at risk of pleural
Breast
Inguinal
Rib
puncture (6, 7).
Lung
hernia repair
fractures

Cardiovascular Renal
Ultrasound Guidance Technique:
Esophagus
Cholecystectomy
The application of ultrasound (US) guidelines
Spine
Gynecological
in the thoracic PVB has made it easier to determine the
(open)
needle injection locations, needle tip position, and depth
Chronic

Post-operational pain
Post-
to the TP and pleura. The traditional loss-of-resistance
herpetic
neuralgia
approach is used when the TP has been reached under
US guidance.
Role in Thoracotomy:
The US probe is positioned 2.5 cm from the
PVB was shown to be as successful as thoracic
midline in a longitudinal parasagittal plane to visualize
epidural analgesia (TEA), which is the traditional local
the TP. The US probe is positioned 2.5 cm from the
technique, in recent systematic reviews and meta-
midline in a longitudinal parasagittal plane to visualize
analyses with less minimal complications (3-5).
the TP. A "thumbprint symbol" is what this is known as.

The parietal pleura can be seen as a sharp hyperechoic
Techniques:
line about 1 cm extending to the TP on either side
Conventional Technique:
(Figure (1) (7).
To access the PV region, traditional strategies
represented a loss-of-resistance. A small-gauge Tuohy


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/)
2741
Received:8 /5 /2021

Accepted:4 /7 /2021



Full Paper (vol.851 paper# 12)


c:\work\Jor\vol851_13 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2744-2750

Incidence Rate, Risk Factors and Outcome of Premature Rupture of
Membranes (PROM) at Zagazig University Hospitals
Ali El-Shabrawy Ali, Wael Sabry Nossair, Randa Mohamed Reda Abdel Maaboud, Safaa Abdelsalam Ibrahem
Department, Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt.
Corresponding Author: Randa Mohamed Reda Abdel Maaboud, Mobile: (+20) 01126749855,
Email: randamohamed007@gmail.com

Abstract
Background: Premature rupture of membranes (PROM) is a common pregnancy complication and is associated with
significant risks of fetal and neonatal morbidity and mortality.
Objective: This study aimed to measure the incidence rate of preterm premature rupture of membranes (PPROM)
among pregnant women attending Zagazig University Hospital, and to identify the risk factors associated with PROM
and fetal/neonatal outcomes.
Methods: This cross-sectional study was conducted at Zagazig University Hospitals. It included 69 women with PROM.
The study was conducted from July 2019 to January 2020. All patients were subjected to detailed history taking, general
examination and laboratory investigations.
Results: There were 46 mother gave birth of healthy babies with good Apgar score (66.7%), 15 with babies needed O2
incubators (21.7%) and 8 with babies that were put on ventilators (11.6%). There were 68 mothers with no bad outcomes
and 1 with chorioamnionitis. The risk factors of the cases showed that there were 15 with no risk factor (21.7%), 8 with
previous PROM (11.6%), 6 with multi pregnancy (8.7%), 12 with antepartum (17.4%), 16 with infections (23.2%) and
12 with chronic diseases (17.4%).
Conclusions: we concluded that younger, illiterate parturient women were found to be provoking factors to increased
PPROM. Such hazards may affect both maternal and neonatal outcome such as infection, maternal distress, fetal distress,
increase operative delivery, as well as need for neonatal intensive care unit care in more than 50% of the neonates.
Key words: Premature rupture of membranes, Abortion, Risk Factors.

INTRODUCTION
prostaglandins and metalloproteases are released.
Premature rupture of the membranes (PROM) is
Prostaglandins stimulate uterine contractions, and
usually defined as rupture of membranes at any time
metalloproteases cause cervical ripening, and ultimately
before the onset of uterine contractions. PROM which
cause the rupture of membrane (1).
occurs prior to 37 weeks of gestation is referred as
The risk factors for PROM include maternal ones,
preterm premature rupture of membranes (PPROM),
including the history of PROM in previous pregnancies
whereas PROM, which occurs after 37 weeks of
(the risk of recurrence of 16% to 32% in comparison
gestation, is referred as term premature rupture of
with the risk of 4% in non-complicated term
membranes. The latent period is defined as the duration
pregnancies), vaginal bleeding before delivery, long-
from rupture of the membranes until the onset of true
term use of steroids, vascular collagen disorders such as
labor (1).
EhlersDanlos syndrome, systemic lupus erythematosus,
The prevalence of PROM varies in different
abdominal trauma, preterm labor history, cigarette
countries and populations, and many factors affect its
smoking, drug abuse, anemia, low BMI (under 19.8
occurrence. Therefore, its etiology is complex and
kg/m2), food deficiencies including ascorbic acid and
multifactorial. Two-thirds of PROM cases occur
copper, low socioeconomic status, history of
spontaneously or for unknown reasons. However, other
hypertension, abortion, cesarean section, black
cases are due to structural defects in the membrane due
race/ethnicity, access to hospital care services, marital
to deficiency of collagen content in the membrane,
status, parity, history of preterm labor and exposure to
protrusion of the membrane due to isthmus-cervical
diethylstilbestrol in the uterus. Other risk factors in this
incompetence and activation of catabolic enzymes such
group are related to pregnancy complications such as
as collagenase. The fetal membranes weaken due to
gestational diabetes or overt diabetes, maternal weight
enzymatic degeneration in inflammatory or infectious
gain, invasive procedures such as cerclage and
processes, mechanical stresses, and secretion of
amniocentesis (3).
proteolytic enzymes from cervicovaginal flora or
PPROM is associated with a prenatal morbidity
infection of amniotic fluids (2). One of the main causes
and mortality rate in more than 20%, and the outcomes
of the PROM occurrence is infection (often bacterial
are primarily dependent on the gestational age at
infection) that stimulates the release of proinflammatory
delivery. The key for reducing the adverse effects of
cytokines from decidua and amniotic membranes.
PPROM is to make a prompt diagnosis, admission and
Therefore, many bioactive materials, such as
start antibiotic coverage (4). The aim of the present study

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2744
Received: 9 /5 /2021

Accepted: 5 /7 /2021

Full Paper (vol.851 paper# 13)


Measurement of Serum Lipid Level in Children with Congenital Heart Diseases The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2751-2757

Evaluation of Biochemical Bone Markers in Children with
Nephrotic Syndrome with Correlation to Its Severity
Sahbaa Fehr Mohamed Hafez1, Dina Mohamed Shokry1,
Mansour Khamees Faraj*1, Samar Mahmoud Abd Elhalim2
Departments of 1Pediatrics and 2Medical Biochemistry, Faculty of Medicine ­ Zagazig University, Egypt.
*Corresponding author: Mansour Khamees Faraj, Mobile: (+20)01097046456, E-mail: manskhamis.21.10.1987@gmail.com

ABSTRACT
Background:
Vitamin D is a vital component of bone metabolism and calcium homeostasis, and its deficiency is known
to cause rickets, osteomalacia and hypocalcemia.
Objective: The aim of this study was to evaluate vitamin D level in patients with nephrotic syndrome and its relation to
calcium.
Patients and methods: This study was a case-control study carried out at Pediatric Nephrology Unit Pediatric
Department, Faculty of Medicine, Zagazig University Hospitals from June 2020 to December 2020. It included 108
patients divided into 2 groups; each group included 54 patients.1st group was patients with nephrotic syndrome and 2nd
group was healthy children as control group. A detailed history and clinical examination including anthropometry was
taken for cases of Nephrotic syndrome admitted to the hospital. The patients underwent the following investigations:
serum albumin, serum cholesterol, C3, C4, alkaline phosphatase, total calcium, ionized calcium, 25(OH) vitamin D,
CBC, renal function test, urine analysis urine albumin/creatinine ratio, 24hr urine protein and X-ray bone.
Results:
There was statistically significant relation between vitamin D level and steroid response where steroid-resistant
patient had lower vitamin level followed by steroid-dependent then steroid-sensitive patients. There was non-significant
correlation between vitamin D and occurrence of relapse.
Conclusion: Vitamin D and calcium supplementation should be considered in nephrotic patients.
Keywords:
Nephrotic syndrome (NS), Vitamin D, Biochemical bone markers.

INTRODUCTION

associated with multiple systemic effects including
The most frequent glomerular disease in children
elevated blood pressure, metabolic syndrome,
is idiopathic nephrotic syndrome, which involves
cardiovascular disease, anemia, and impaired immune
histological abnormalities of the kidney including
system regulation (5).
minimal changes, focal segmental glomerulosclerosis
The loss of both 25(OH)D and its binding protein
and diffuse mesangial proliferation (1). Nephrotic
(DBP) in urine is responsible for the low levels of 25-
Syndrome (NS) often has a relapsing course and usually
hydroxycholecalciferol [25(OH)D] documented in NS
responds to steroids (2). Nephrotic syndrome (NS) is a
patients during a relapse. However, these low levels do
clinical entity characterized by massive loss of urinary
not reflect steady state of body stores since most
protein
(primarily
albuminuria)
leading
to
relapses are short-lasting (6).
hypoproteinemia resulting in edema. Nephrotic
The evidence on vitamin D levels during remission
syndrome patients frequently have abnormalities in
of NS remains mixed but since vitamin D deficiency
calcium metabolism that manifest as hypocalcemia.
may contribute to osteoporosis in NS, early detection
Hypocalcemia
is
initially
attributed
to
and treatment is in order (1). This study aimed to evaluate
hypoalbuminemia but it may also relate to a low level
vitamin D level in patients with nephrotic syndrome and
of ionized calcium (3).
its relation to calcium.
If the serum ionized calcium level declines below

normal, clinical symptoms like neuromuscular
PATIENTS AND METHODS
irritability including tetany as manifested by chovstek's
The study was conducted in Pediatric Nephrology
sign or Trousseau's sign. Patients with nephrotic
Unit, Pediatric Department, Faculty of Medicine, Zagazig
syndrome (NS) lose 25-hydroxyvitamin D3 (25OHD3)
University Hospitals from June 2020 to December 2020.
in the urine and have low blood levels of this metabolite
This study enrolled 54 patients with nephrotic syndrome
(4). Abnormal vitamin D metabolism in idiopathic NS is
and 54 healthy control subjects.
multifactorial, with contributions from losses of both

vitamin D binding protein and 25(OH)D in the urine.
Ethical approval:
The urinary losses of vitamin D binding protein may be
Written informed consent was obtained from all
secondary to proteinuria, overwhelming the proximal
participants' parents and the study was approved by
tubule reabsorption via megalin and cubilin pathways.
the Research Ethical Committee of Faculty of
Deficiency in 25(OH)D may lead to hypocalcemia,
Medicine, Zagazig University.
hyperparathyroidism, and diminished bone mineral
The work has been carried out in accordance
density/content. Vitamin D deficiency has also been
with the Code of Ethics of the World Medical

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2751

Received:8 /5 /2021

Accepted: 4 /7 /2021

Full Paper (vol.851 paper# 14)


c:\work\Jor\vol851_15 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2758-2766
Validity of Vital Signs, Coma Scales and Modified APACHE Score in
Prediction of Prognosis and Outcome of Acutely Poisoned Patients
Meray M. Shokry Zaghary*, Rania A. Radwan, Reda M. Elsayed
Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Sohag University, Sohag, Egypt.
*Corresponding author: Meray M. Shokry Zaghary, Mobile: (+20) 01228121497, E-Mail: meraymedhat@med.sohag.edu.eg

ABSTRACT

Introduction: Acute toxicity management is a major medical problem in the whole world as poisoning is one of the
most common causes for coming to hospital emergency departments. Early diagnosis and treatment in emergency
department and ICU are critical for the poisoned patient to reduce hospital morbidity and mortality.
Objective:
Evaluation of the validity of coma scaling systems as Glasgow coma scale (GCS), Reed scale, poisoning
severity score (PSS), modified acute physiology and chronic health evaluation (APACHE) score (MAS) and vital
signs as predictors of clinical course and outcome of acutely poisoned patients.
Patients and Methods:
This retrospective study was carried out on 100 acutely intoxicated patients. They were
selected from patients attended Sohag University Hospitals with age more than 18 years old who were in need for
intermediate or intensive care unit. The study was conducted during the period from March 2018 to the end of
February 2021. Results: this study revealed that 62% of the patients were in the age group 18-30 years old and 63%
were females. The majority of them intoxicated by oral route (91%) and most of them were suicidal (68%). For the
outcome, 75% of patients had been survived and 25% of patients died. PSS, Reed, MAS and GCS as coma scaling
scores at admission showed significant difference between survivors and non-survivors of these patients. Systole and
diastole as parameters of vital signs also showed significant difference between survivors and non-survivors. While,
pulse, temperature and respiratory rate showed non-significant difference between survivors and non-survivors.
Conclusion: The study concluded that PSS, Reed scale, MAS, GCS, diastole and systole respectively are valid
prognostic tools for the outcome in acutely poisoned patients.
Keywords: Acute poisoning, Validity of vital signs, Validity of coma scales, Prognosis of acute poisoning.

INTRODUCTION
Examples of these factors demographic and
Acute toxicity management is a major medical
socioeconomic data of the patient, literacy rate, the age
problem in the whole world as poisoning is one of the
and comorbidities of the patient (6, 7). Due to shortage of
most common causes for coming to hospital emergency
ICU beds, we need rapid decision and simple non-
departments (1). Early diagnosis and rapid treatment in
invasive tests for triaging patients in acute
emergency department and ICU are critical for the
intoxications. This retrospective study designed for
poisoned patient to reduce hospital morbidity and
evaluation of the validity of different coma scaling
mortality (2). There are many clinical factors that can
systems as GCS, Reed scale, PSS and modified
affect the prognosis and outcome of the poisoned
APACHE score as well as vital signs as simple
patients and affect decision of admission to ICU, for
predictors of clinical course and outcome of acutely
example type of toxic agent, delay in time to come to
poisoned patients.
hospital and multiorgan failure that need immediate

advanced life support which can lead to high mortality
PATIENTS AND METHODS
(3). Also, one of these factors is vital signs
This study was a retrospective one conducted over
measurement. It represents the critical first step for any
three years from March 2018 to February 2021 on
clinical assessment as it reflects the degree of
acutely intoxicated patients. 100 acutely intoxicated
derangement that is occurring. So, as soon as possible
patients were selected from patients attended Sohag
detection of any abnormality in the vital signs typically
University Hospitals who fulfilled the study inclusion
correlates with rapid detection of changes in the
criteria.
cardiopulmonary state of the patient as well as up-
Inclusion criteria: Age equal or more than18 years,
gradation of the level of intervention if needed (4).
acutely poisoned patients who were admitted the
Additionally, there are many scoring systems
hospital either in the intermediate department or ICU.
used to assist to predict cases liable to death. These
Exclusion criteria: Patients less than 18 years old,
scoring systems include GCS, APACHE II score,
patients with history of any disease or condition that
simplified acute physiology score SAPS II. Also, the
may alter vital signs results, and patients presented with
modified APACHE II system, which was used to assess
traumatic coma and pathological or metabolic causes.
critical cases in ICU (5). However, the diagnosis and
management are influenced by multiple factors, which
Tools of the study:
make the pattern of poisoning is very challenge.
1- A prepared sheet containing the demographic
information of each patient such as sex, age, the type

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2758
Received: 9 /5 /202
1

Accepted:5 /7 /2021


Full Paper (vol.851 paper# 15)


c:\work\Jor\vol851_16 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2767-2771

Differences in Lateral Core Muscles' Endurance Measurementsb
Adolescents with And Without Flexible Flat-Feet
Mona T. Abd El Ghafar1*, Khalid A. Olama2, Marwa M. I. Ismaeel 2
1Department of Physiotherapy, Zagazig Al-Ahrar Teaching Hospital, Zagazig, Egypt.
2Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt.
*Corresponding author: Mona T. Abd El Ghafar, Mobile: (+20)01200332565, E-mail: ptmonamony@gmail.com

ABSTRACT
Background:
Flexible flatfeet are a common deformity that affects youngsters and persists throughout their lives, and
it is considered to be a contributing factor in many lower limb accidents and low back discomfort. Core muscles function
as trunk stabilisers, and any disruption or weakening in these muscles puts a person at risk for low back discomfort and
lower limb injury.
Objective: We aimed to compare the core muscles' endurance between adolescents with and without flexible flatfeet.
Patients and Methods: Thirty participants with bilateral flexible flatfeet (study group) were compared with thirty
healthy participants (control group). Navicular drop test (NDT) was used to evaluate the medial longitudinal arch.
Modified back extensors, modified flexion and lateral muscles' endurance tests were used to evaluate the endurance of
the core muscles.
Results: There was no significant difference found in the trunk lateral muscles for left bridge (p = 0.38) and right bridge
(p = 0.70) endurance time between both groups.
Conclusion: There is no significant difference in the endurance of the lateral core muscles between adolescents with
and without flexible flatfeet at the selected age in the early adolescent stage.
Keywords: Core muscles, Endurance, Flexible flatfeet, Adolescents.

INTRODUCTION

The presence of a depressed medial longitudinal
Flat feet result in more proximal lower limb
arch, with or without rear foot eversion, in youngsters is
dysfunctions, which impact lumbopelvic hip stability
characterised as flexible flatfoot (also known as pes
(core stability) and hence contribute to a variety of
planus or planovalgus) (1). It is one of the most common
lower limb injuries affecting the lower back, hip, knee,
causes for seeking an orthopaedic opinion (2). Flexible
lower leg, ankle, and foot (13).
flatfoot is a common childhood deformity characterised
The aim of the current study was to compare
by a collapsed medial arch, forefoot abduction, internal
between lateral core muscles' endurance concerning
rotation, plantar flexion of the talus, and calcaneal
adolescents with and without flexible flatfeet.
eversion (3).

The core has been referred to as the lumbo pelvic-
PATIENTS AND METHODS
hip complex (4) and core training has highlighted
Thirty adolescents were diagnosed by a physician
benefits for athletes (5), general health (6, 7), and patients
as flexible flatfeet and thirty adolescents free from any
with low back pain (8). Core measurement is frequently
type of deformities participated in this study. They were
split into three categories: core endurance, core
selected from the governmental Egyptian schools at Al-
stability, and core strength (9). The most critical core
Sharqi Governorate according to inclusion criteria.
qualities for ensuring spine stability for force
Their ages ranged from 10 to 12 years.
production and injury avoidance are core stability,
They were assigned into two groups (A and B)
strength, and endurance.
with equality in number and gender distribution.
Core endurance is defined as the ability to maintain
Group A included adolescents with flexible
a position or perform multiple repetitions (10). Core
flatfeet. Group B included adolescents with normal feet.
stability is described as "the stabilising system's ability
Participants of group (A), on visual assessment, had a
to keep the intervertebral neutral zones within
normal medial longitudinal arch (MLA) in sitting and
physiological limits" (9). While, core strength refers to
had a ten mm difference or more on the NDT for both
the ability as the ability of the musculature to produce
feet, all participants on group (A) had flexible flatfeet
force through contractile force and intra-abdominal
according to Hubscher maneuver or Jack's test, which
pressure (11).
is used to differentiate between flexible and rigid flat
A later study discovered that those who performed
feet.
poorly on the Biering-Sorenson muscular endurance
Participants of group (B) had less than 10 mm
test were three times more likely to suffer from low back
difference on the NDT for both feet and followed the
pain (LBP) than those who performed better (12).
normal growth indices concerning weight and height.


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


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2767
Received:9 /5 /2021

Accepted:5 /7 /2021

Full Paper (vol.851 paper# 16)


c:\work\Jor\vol851_17 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2772-2776

Suprascapular Nerve Entrapment by Labral Cyst Associated with
Labral Lesion: A Case Report
Jihad Abdullah Bandah, Khalil Awad AlMalki, Salman Ahmed
Department of Orthopedic Surgery, King Abdullah Medical City Specialist Hospital, Mecca, Saudi Arabia
*Corresponding author: Jihad Bandah, Mobile: 966500174875, E-Mail: jab-12@hotmail.com

ABSTRACT
Background:
The suprascapular nerve is a mixed motor and sensory nerve originating from the brachial plexus. It
passes between the suprascapular notch and superior transverse scapular ligament into the posterior surface of the
scapula, which dominates the supra- and infraspinatus muscles. Suprascapular nerve entrapment is an uncommon but
significant cause of shoulder pain.
Objective: We report a 30-year-old man who had a complaint of right shoulder pain and external rotation weakness
that lasted for 4 years which was diagnosed as labral lesion associated with suprascapular nerve entrapment.
Conclusion: Patient underwent surgical repair of labral lesion with debridement of the cyst. Follow-up for 12
months postoperatively showed that patient shoulder pain improved significantly and external rotation improved (45-
50°).
Keywords:
Labral cyst, Labral lesion, SLAP, Suprascapular nerve entrapment.

INTRODUCTION

Suprascapular nerve entrapment can be a
radiate to the neck, arm, or upper chest wall.
consequence of direct trauma (1-3), anterior dislocation
Entrapment syndrome is diagnosed on the basis of the
or fractures of the scapula and overhead sports
clinical
history,
physical
examination
and
activities (3). Direct compression of the nerve can
electromyography(8).
occur by progressive compressive masses of

suprascapular notch or spinoglenoid notch as a
CASE REPORT
consequence of malignant tumors (1,4,5), hematomas or
A 30-years-old male known to have hypertension
ganglion cysts (1, 2, 6).
presented with a 4-year history of right shoulder pain
Suprascapular nerve compression is a rare cause
and decreased range of motion. Four years back, he
of shoulder pain. Shoulder pain is among the most
threw a heavy object and had his 1st shoulder
common musculoskeletal complaints in the general
dislocation. His last shoulder dislocation was 1 years
population. Often, it is due to rotator cuff pathologies
ago. Patient was managed conservatively for right
such as tendonitis and/or tears, labral pathologies such
shoulder pain with non-steroidal anti-inflammatory
as superior labral anterior to posterior (SLAP) lesions
drugs, and physiotherapy and these techniques
or instability, capsular pathologies such as adhesive
provided no benefits. After then, he visited our
capsulitis, or articular pathologies such as
Department of Orthopedic, King Abdullah Medical
acromioclavicular or glenohumeral arthritis. On rare
City Specialist Hospital.
occasions, suprascapular nerve compression may be
Physical examination showed painful arc limited
the cause of such shoulder pain or weakness. Because
to 160° of right shoulder active flexion, 90° of right
of its rarity, this condition is unfortunately often not
shoulder abduction and external rotation of 10-20°.
diagnosed until a magnetic resonance imaging (MRI)
Weak right infraspinatus muscle (power: 3/5).
scan is performed on the patient who fails to respond
O'Brien's test for SLAP lesion was positive. External
to therapy (7).
rotation lag sign was positive in right shoulder plain
Suprascapular nerve entrapment is characterized by
radiographs of right shoulder were unremarkable
deep, diffuse posterolateral shoulder pain, which may
(Figures 1-2).


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/)
2772
Received: 10 /5 /2021



Accepted: 6 /7 /2021


Full Paper (vol.851 paper# 17)


c:\work\Jor\vol851_18 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2777-2784

Vitamin D Receptor FokI Gene Polymorphism in Rheumatoid Arthritis Patients
Lamiaa Abdel Wahaab Mohammed1, Ahmed Mohammed Baraka1, Ghada S. Nageeb2, Fatma Mohammed
Mohammed Alsayed*1, Ahmed Mokhtar Ahmed1, Ahmad Sallam Soliman1, Mahmoud Amer3
Departments of 1Clinical Pathology, 2Rheumatology, and Rehabilitation, and 3Internal Medicine,
Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Fatma Mohammed Mohammed, Mobile: (+20) 01151234898, E-Mail: dr.mosad@yahoo.com

ABSTRACT
Background:
Rheumatoid arthritis (RA) is a chronic, systemic, destructive joint disease. Vitamin D initiates biological
responses via binding to the vitamin D receptor (VDR), which is a member of the steroid hormone receptor superfamily
located on chromosome 12 (12q12-q14) that regulates gene expression in a ligand-dependent manner. The receptor
(VDR) is active in almost all tissues that are necessary for the effects of vitamin D.
Objective:
The present work aimed to detect vitamin D receptor FokI gene polymorphism in rheumatoid arthritis
patients, to assess its role as a risk factor of the disease.
Patients and Methods:
A case-control study was conducted on 44 subjects (22 RA patients and 22 apparently normal
volunteers age and sex-matched with patients) at the Clinical Pathology, Rheumatology and Rehabilitation Departments,
Faculty of Medicine, Zagazig University.
Results: Serum vitamin D level was found to be significantly lower among RA patients compared to healthy controls.
There was a significant difference between the studied groups regarding VDR FOK1 gene polymorphism and its alleles.
There was a non-significant difference between the different genotypes regarding age, however, the difference between
them was significant regarding sex as it was noticed that FF and ff homozygous genotypes were found only in females
compared to their male counterparts while Ff heterozygous genotype was found equally among both males and females.
Conclusion:
Vitamin D receptor gene FokI polymorphism could be considered as genetic risk markers of RA
susceptibility, associated with vitamin D level deficiency which was found to be significantly lower among FF genotype
compared to other genotypes. Having FF and Ff genotypes have almost a higher risk than having ff genotype to be RA
patient.
Keywords:
Rheumatoid arthritis, vitamin D receptor, FokI gene polymorphism.

INTRODUCTION

identification and treatment of the disease. About 60% of
Rheumatoid arthritis (RA) is a chronic, systemic,
RA risk is thought to be genetic. (5).
destructive joint disease. It occurs most frequently in
Vitamin D, as an immunoregulatory hormone, is
middle-aged women, and about 0.5 to 1.0% of the
central to the control of bone and calcium homeostasis.
population suffers from the disease in the industrialized
The previous meta-analysis showed that low vitamin D
world. It is characterized by the presence of
intake was associated with an elevated risk of RA
autoantibodies including rheumatoid factor (RF) and anti-
development (6). Greater intake of vitamin D was
citrullinated peptide antibodies (ACPA). Rheumatoid
associated with a lower risk of RA, as well as a significant
patients have an increased risk of morbidity and mortality
clinical improvement was strongly correlated with the
(1).
immunomodulating potential in vitamin D-treated RA
Rheumatoid arthritis is the most common
patients (7).
autoimmune disease worldwide and is an important
Vitamin D initiates biological responses via binding
public health concern, associating with early death and
to the vitamin D receptor (VDR) (8), which is a member of
systemic complications (2).
the steroid hormone receptor superfamily located on
The characteristic of RA is muscular weakness
chromosome 12 (12q12-q14) that regulates gene
around the affected joints, and symmetric joint
expression in a ligand-dependent manner (9). VDR is
inflammation, stiffness, and pain. It is the most severe
active in almost all tissues that are necessary for the
form of arthritis (3).
effects of vitamin D. Several genetic variations have been
Smoking, diabetes mellitus, citrullination, and
identified in the VDR gene. Among which, TaqI
genetic variability were shown to be involved in the
(rs731236 in exon 9), BsmI (rs1544410 in intron 8), ApaI
immune pathogenesis of RA and might contribute to its
(rs7975232 in intron 8) at the 3'-end, and FokI
prevalence (4).
(rs2228570 in exon 2) at the 5'-end of this gene were the
Although major progress has been made in treating
most studied (10).
RA, many patients still experience premature work
Although several studies reported the role of VDR
disability and co-morbidities. Therefore, there is an
polymorphisms in RA risk, the results remain
urgent need to explore new risk factors in helping early
inconclusive. This may due to the non-equilibrium
distribution of RA incidences and VDR polymorphisms.

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2777
Received:9 /5 /2021


Accepted: 5 /7 /2021

Full Paper (vol.851 paper# 18)


c:\work\Jor\vol851_19 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2785-2787

Acute Pyogenic Sacroiliitis: Brucellosis and Early Diagnosis
Moyassar Matoog Karami 1, Dhafer Saad Al-Mufarrh 2
1 King Khalid National Guard Hospital, Jeddah - Kingdom of Saudi Arabia,
2 King Abdullah International Medical Research Center, Western region, Jeddah - Kingdom of Saudi Arabia
Corresponding author:Moyassar M Karami,email: drkaramimo@gmail.com,mobile:00966566873344

ABSTRACT

Acute pyogenic sacroiliitis is an uncommon condition caused by multiple infectious agents, and a few cases are
reported to be caused by brucella species. We present the case of a 20-years-old woman who developed afebrile low back
pain of sudden onset, few weeks after the ingestion of unpasteurized milk. Thorough physical examinations with provocative
tests were done. Suspected acute sacroiliitis and the brucella etiology were addressed by serological tests completed by
multiple imaging. The rapidly favorable response to the antimicrobial therapy was further supportive for the diagnosis.
Keywords: Acute, Pyogenic, Brucella, Sacroiliitis, Brucellosis.

INTRODUCTION
assays are warranted to address the diagnosis at a timely
Sacroiliitis is defined as the inflammation of the
manner, in addition to radiological imaging (6­8).
sacroiliac joint, and can have an acute or chronic

presentation. Chronic presentation refers commonly to
CASE PRESENTATION
ankylosing spondylitis, but can also be caused by other
A 20-years-old female having iron-deficiency
rheumatic
inflammatory
and
non-inflammatory
anemia presented to our emergency department with a 4-
conditions. However, acute sacroiliitis is rare and is more
day complaint of low back pain of sudden onset. She was
likely underlaid by infectious or neoplastic processes (1, 2).
transported on a wheelchair and reported no preceding
The sacroiliac joint is stabilized by two strong ligaments,
history of trauma. The pain was described as severe,
the anterior and posterior sacroiliac ligaments. The
radiating to the left gluteal area with no associated
anterior complex is bordered by a thin capsule that allows
numbness. The patient denied any history of fever or
joint effusion to diffuse anteriorly into the psoas muscle.
chills, and reported a history of raw milk ingestion.
Moreover, due to the adjacent lumbosacral plexus, mainly
On examination, the patient was unable to stand or
L4-L5 nerves, patients can present with severe pain due
walk. Her vitals were within normal ranges. Low back
to nerve irritations. In acute sacroiliitis, pain can be
examination revealed localized tenderness in the lumbar
severe, causing inability to bear weight or walk, and its
spine region and left sacroiliac joint. The hip range of
topography commonly involves the buttock area in 94%
motion was limited and Faber provocative test was
of the cases, radiating to lower extremities or groin area
positive. Lower limb neurological examination showed
in 50% and 14% of the cases respectively (2, 3).
intact motor and sensory function bilaterally.
A thorough physical examination with provocative
Laboratory investigations showed elevated C-
tests is required to diagnose acute sacroiliitis. Early
reactive protein (CRP = 147 mg/L) and erythrocyte
diagnoses can be challenging, and wide differentials can
sedimentation rate (ESR = 65 mm/hr). Serological testing
be considered including hip pathology, intervertebral disk
showed elevated brucella specific antibodies including
injury, gluteal muscle injury, psoas muscle collection or
IgM (unit) and IgG (unit/ml). Imaging including
an abdominal etiology (3).
ultrasonography of the hip was carried out showing no
Infectious or pyogenic sacroiliitis, the most common
fluid collection or joint effusion. Radiographs of pelvis
cause of acute sacroiliitis, occurs in young adults with
and spine showed normal osseous appearance. An urgent
fulgurant onset, causing disability (4, 5).
lumbosacral magnetic reasoning imaging (MRI) revealed
Biologically, high inflammatory markers and
edematous changes and increased signal intensity at the
leukocytosis are the hallmark of the infectious etiology,
left sacroiliac joint, along with trace of fluid at the left
which may be completed by further tests to identify the
sacroiliac joint. In addition, edematous changes were
causing organism (2, 4). Although, staphylococcus aureus
noted in the left obturator internus and iliac muscle, and a
is the most prevalent organism, pyogenic sacroiliitis has
juxta-articular collection was evidenced superior to the
often been reported as one of the manifestations of
left sacroiliac joint (Figure 1).
brucellosis, in which case serological tests, polymerase
A multidisciplinary team was constituted to evaluate
chain reaction (PCR) and enzyme-linked immunosorbent
and co-manage the patient. The team involved infectious




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2785
Received:8 /5 /2021

Accepted:4 /7 /2021

Full Paper (vol.851 paper# 19)


c:\work\Jor\vol851_20 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2788-2793

Prognostic Impact of Flow Cytometric Measurement of G Protein­Coupled
Receptor 56 (GPR56) in Acute Myeloid Leukemia
Hanaa M. Sayed Afifi(1), Mai A. Rashad(1), Haitham M. Abdelbary(2), Rasha A. El-Gamal(1)
Departments of (1) Clinical Pathology and (2) Internal Medicine and Bone Marrow Transplantation,
Faculty of Medicine, Ain Shams University, Egypt
Corresponding author: Rasha A. El-Gamal; Mobile: 01145405005; Email: rashaelgamal@med.asu.edu.eg

ABSTRACT
Background: A variety of factors influence the prognosis of acute myeloid leukemia (AML), and leukemic stem cells
(LSCs) are one key prognostic factor that predicts poor prognosis over the course of the disease. G protein­coupled
receptor 56 (GPR56) was presented as a new human LSC marker in AML patients. The engraftment potential of GPR56+
cells selected from AML specimens helps the spread of leukemia in mice, which supports the concept of using it as an
LSC marker. Aim of the Work: The objective of this study was to use flow cytometry to investigate GPR56 expression
in newly diagnosed AML patients. The results of GPR56 expression were linked to the patients' clinical outcomes.
Subjects and methods: Forty AML patients and 20 healthy control subjects were evaluated for GPR56 expression on
myeloblasts. At the end of induction treatment, bone marrow aspirates were obtained for assessment of morphological
remission and minimal residual disease analysis. Results: GPR56 levels were significantly higher in control subjects
than in AML patients. AML patients who failed to achieve complete remission were more likely to show high levels of
GPR56. However, a relationship to long term follow up data was not evident in our results. Conclusion: Despite the
lack of a direct prognostic influence of GPR56 on patient outcome or a relationship to prognostic cytogenetic subgroups,
the association of GPR56 with a poor prognostic marker, early response to therapy, can be regarded an evidence of the
speculated bad prognostic impact of GPR56.
Keywords: Acute myeloid leukemia; Complete remission; Flow cytometry; G protein-coupled receptor 56; prognosis.

INTRODUCTION
Adherence, migration, and mobilization of HSC in BM
Acute myeloid leukemia (AML) is a diverse
niches are influenced by the small GTPases, while
disease that is distinguished by unregulated
GPR56 modulates RhoA signaling implicated in
proliferation of leukemic myeloblasts, which interferes
cellular adhesion (9).
with the formation of normal blood cells. AML is the
In a study by Pabst and coworkers, GPR56+ cells
most prevalent acute leukemia in adults, and its
were found to have an engraftment capability in both the
incidence continues to increase with age (1). Relapse
CD34+ and CD34- fractions sorted from specific AML
remains a common sequel in AML, as the 5-year
samples, and they played an important role in leukemia
survival of 30­45% has been reported, which differs
growth in mice. Hence, the authors have proposed GPR56
according to age. Recognition of AML prognostic
to define a new LSC compartment that is distinct from the
factors have become increasingly important for the
CD34+CD38- LSC phenotype (10).
choice of the appropriate therapy (2,3).
Stemming from this speculated prospect of GPR56
A variety of factors influence the prognosis of
in AML, the objective of this study was to use flow
AML, and leukemic stem cells (LSCs) are one key
cytometry to investigate GPR56 expression in newly
prognostic determinant that can predict disease relapse
diagnosed AML patients. The results of GPR56 expression
(4,5). LSCs have been shown to be located in the CD34+
are to be linked to the patients' clinical outcomes as well as
CD38- compartment (6), and various markers have been
other relevant laboratory data.
described to identify LSCs particularly anti-CD44,

anti-CD33, and anti-CD123 (7).
PATIENTS AND METHODS
The surface G protein­coupled receptor 56
This study involved 40 patients with newly
(GPR56) was presented as a new human LSC marker
diagnosed AML, all of them were evaluated and
in AML patients. GPR56 is one of the adhesion family
treated at Hematology-Oncology Department, Ain
members that belongs to the G protein­coupled
Shams University Hospitals, during the period from
receptors (GPCR) superfamily and has been connected
November 2016 to July 2017. In addition, 20 non-
to human brain developmental abnormalities (8).
leukemic patients in whom bone marrow (BM)
Overexpression of GPR56 in cancer cells has been
aspirates were obtained as a part of their diagnostic
shown to inhibit tumour development and metastasis in
work up were included as healthy control group.
melanoma cell lines, while GPR56 is involved in

tumour cell adhesion in glioma cells (9). Although the
Ethical approval
role of GPR56 in hematopoietic stem cells (HSCs) is
All patients and controls gave verbal
uncertain, it was discovered in a family of LSC-related
informed consents. The work was approved by Ain
genes that are linked to a dismal AML prognosis.
Shams University's Local Research Ethical

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2788
Received: / /2021


Accepted: / /2021

Full Paper (vol.851 paper# 20)


c:\work\Jor\vol851_21 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2794-2799

Effect of Intermittent Pneumatic Compression in Combination with
Kinesiotape on Post Mastectomy Lymphedema
Hayam A. Diab*1, Haidy N. Asham1, Nancy H. Aboelnour1, Hagar A. Alagizy2
1Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt.
2Department of Oncology and Nuclear Medicine, Faculty of Medicine, Menoufia University, Egypt.
*Corresponding author: Hayam A. Diab, Mobile: (+20) 01092710752, E-Mail: haiamdiab519@gmail.com

ABSTRACT
Background:
Lymphedema caused by breast cancer is one of the side effects of therapy. It is defined as arm edema in
breast cancer patients caused by surgery or radiation therapy interrupting the flow of the axillary lymphatic system,
resulting in fluid accumulation in the subcutaneous tissue of the arm, decreased tissue distensibility around the joints,
and increased weight of the extremity.
Objective: This study was conducted to detect the effect of combination of intermittent pneumatic compression and
kinesiotape on post mastectomy lymphedema.
Patients and methods: Thirty females diagnosed with post mastectomy lymphedema were assigned randomly into two
equal groups. Group A (Study group) received intermittent pneumatic compression (IPC) with kinesiotape (KT) in
addition to complete decongestive therapy (manual lymphatic drainage-compression bandage-medical exercises-skin
care) three times per week for 4 weeks. While, Group B (Control group) received only complete decongestive therapy
3 times per week for 4 weeks. Assessment of lymphedema and shoulder range of motion (flexion-abduction-external
rotation) were done by tape measurement and goniometer respectively before and after 4 weeks.
Results: There was no significant difference in lymphedema size and shoulder range of motion (ROM) between groups
pre-treatment (p > 0.05). Comparison between groups post treatment revealed a significant decrease in lymphedema
size and a significant increase in shoulder ROM of the study group compared with that of the control group (p >0.05).
Conclusion: The results suggested that IPC in combination with KT was an effective method in post mastectomy
lymphedema more than complete decongestive therapy only.
Keywords: Intermittent pneumatic compression, Kinesiotape, Post mastectomy lymphedema.

INTRODUCTION
in the affected body part, which induces constant
Mastectomy is the surgical removal of the
swelling and obstructs the flow of fluid (5). The most
cancerous portion of the breast tissue (malignant tumor)
well-known causes of lymphedema are radiotherapy
as well as a margin of normal tissue surrounding it
and lymph node dissection in patients with breast
before normal margins are found (i.e., no cancer cells
cancer. Large axillary disease, obesity, and positive
are found at the edges of the tissue removed (1).
axillary lymph nodes are also risk factors for
Modified radical mastectomy is one of the main
lymphedema (6). Upper limb lymphedema is the most
methods of clinical treatment for breast cancer, in which
common cause of morbidity after mastectomies with
the purpose to thoroughly eliminating breast cancer is
axillary lymph node removal. This condition is
achieved by removing the lesions and adjacent tissues
characterized by the abnormal accumulation of fluids
of breast cancer. Modified radical mastectomy can be
and proteins in the intercellular space, chronic
classified into 2 types: type1 is Patey's operation, in
inflammation, and edema (7). Lymphedema is classified
which the pectoralis major is preserved; another type is
as either primary or secondary. Primary lymphedema is
Auchincloss's operation, in which the pectoralis major
caused by error in lymphatic growth and is idiopathic.
and pectoralis minor are retained. In the latter, the
Secondary lymphedema develops after an injury to the
axillary lymph nodes can also be thoroughly dissected
lymphatic system, which is usually established (8).
while preserving the pectoralis major and pectoralis
Intermittent pneumatic compression (IPC) is a
minor (2). At present, modified radical mastectomy is
noninvasive procedure that has been shown to be
usually applied to patients with stage I and II breast
beneficial in clinical practice. IPC is also commonly
cancer, especially in patients with lesions distributed in
used in the treatment of extremity edema as well as
the lateral breast and patients with axillary lymph node
venous thromboembolism prevention in patients with a
metastases, However, in modified radical mastectomy,
high risk of bleeding and venous ulcers (9). IPC is a
all breast tissues must be removed (3).
multi-chambers, sequential inflation, gradient inflation
Breast cancer related lymphedema (BCRL) is one
pressure, time of inflation sufficient for translocation of
of the most commonly reported complications of
tissue fluid to proximal region, no deflation of distal
treatment for the estimated 2 million breast cancer cases
chambers to prevent fluid back-flow and venous stasis
worldwide annually with an incidence of 17% (4).
in the superficial limb system (10). Pneumatic
Lymphedema is the accumulation of protein-rich fluid
compression therapy has been used extensively to aid in

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

2794
Received:10 /5 /2021

Accepted:6 /7 /2021

Full Paper (vol.851 paper# 21)


c:\work\Jor\vol851_22 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2800-2803

Hemangioendothelioma Lumbar Spine and Ribs: Case Report
Eissa Mubarak*, Mahdi Basi, Mohammed Al Sobaie
Department of Orthopedic Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
Corresponding author: Eissa Mubarak, Mobile: 00966599109901, E-Mail: Tiger_1346@hotmail.com

ABSTRACT
Background:
Spine hemangioendothelioma is a rare low-grade vascular neoplasm that is characterized as intermediate
between benign hemangioma and high-grade angiosarcoma, affecting 1 in 1,000,000 people worldwide. It has been
described throughout the body with lung, liver, skin, bone and spine being the most frequent sites.
Case presentation: A 31-year-old male, complained of mid and lower back pain for 2 years, which was on and off. 5
months ago pain increased after lifting heavy object, which affected his walking and sitting. No weight loss or night
sweating. He came to Dr. Solaiman Fakeeh Hospital as second opinion regarding the Lumbar 1 (L1) tumor. The patient
was diagnosed with pseudomyogenic hemangioendothelioma according to radiological images and histopathology
report in other center.
Conclusion:
Through our experience in this case in the management of spine hemangioendothelioma tumor resection
should be attempted whenever possible. Given the propensity of these lesions to recur, intralesional or subtotal resection
should be followed by radiotherapy.
Keywords: Hemangioendothelioma, Spine, Radiotherapy.

INTRODUCTION
sitting and daily activities. No numbness, no weight loss
Spine hemangioendothelioma is a very rare
or night sweating and no constitutional symptoms.
neoplasm that has been described to have histological

features between hemangioma and high-grade
Physical exam:
angiosarcoma (1).
Normal gait.
Weiss et al. (2) described it first in 1982 as a
Average height and weight.
vascular neoplasm of both bone and soft tissue (2). It is
In brace (thoracolumbar brace).
commonly seen in soft tissues but can also be located in
Previous incision of open biopsy.
other organs such as lung, pleura, spleen, heart, liver,
Mid and lower back tenderness.
and bone (3, 4). Primary hemangioendothelioma of the
Decreased trunk flexion, extension and
bone is rare, and it represents only 1% of all malignant
twisting due to severe pain.
tumors of the bone (3). These tumors can be
Right T12 distribution sharp pain.
asymptomatic and discovered as an incidental finding.
No neurological deficit.
However, local pain is the most common presentation

of spine hemangioendothelioma (5).
Intact sensation and motor 5/5 in all

limbs.
CASE PRESENTATION
Reflexes were normal.
A 31-years-old male, non-smoker, unknown to
No urinary or bladder issues.
have any medical illness, complained of mid and lower

back pain for 2 years, which was on and off. 5 months
Drug allergy: No known drug allergy.
ago pain increased after lifting heavy object. Pain
Clinical Warning: No clinical warning.
continued by the same intensity, intermediate, altered
PMH: Unknown.
his sleep and increased with turning, twisting, bending
PSH: Open biopsy of lumbar spine (L1).
and standing from sitting that affected his mobilization,

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2800
Received: 11/5/2021

Accepted: 7/7/2021

Full Paper (vol.851 paper# 22)


c:\work\Jor\vol851_23 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2804-2808

Role of Adding Phytoestrogen to Clomiphene Citrate in Improving
Endometrial Thickness in Woman with Unexplained Infertility
Ali El-Shabrawy Ali, Sherin Attia Shazley, Waleed Abd - Allah Abd Al-Salam,
Marwa Yahia Ramadan Metwali*
Department of Obstetrics & Gynecology, Faculty of Medicine ­ Zagazig University, Egypt.
*Corresponding author: Marwa Yahia Ramadan, Mobile: (+20) 01091677724, E-Mail: marwayahia120@gmail.com

ABSTRACT
Background:
Unexplained infertility is failure to conceive after 1 year in couples with normal semen samples and no
abnormality found during an infertility work-up. Clomiphene citrate (CC) induces ovulation.
Objective: The aim was to evaluate the effect of follicular phase oral phytoestrogens (PES) in patients with unexplained
infertility, managed by clomiphene ovulation induction, triggered by HCG injection and timed intercourse, in terms of
pregnancy rate, follicular maturation and endometrial thickness.
Patients and Methods: This study included 56 infertile patients seeking for pregnancy. Clomiphene was given orally
at a dose of one tablet twice per day (tablet 50 mg), from day 3 to day 7 for all patients (group I and group II), while
phytoestrogens were given at a dose of two tablets one shot per day (tablet 20 mg), from day 1 to day 12 only for group
I, followed by HCG injection on attaining mature follicle(s) by trans-vaginal US scan with diameter 18 mm in both
group. The study was conducted in Department of Obstetrics and Gynecology, Zagazig University Hospitals.
Results: The number of days till HCG injection were significantly lower in group I (13.8 ± 1.8 days) than in group II
(14.9 ± 2.1 days), which indicates a better ovulation. As for the endometrial thickness, it was significantly higher in
group I than in group II. The number of ovulatory follicle(s) as single, two or three showed no significant difference
between the studied groups.
Conclusion: Adding PES to CC induced cycles, improved the endometrial thickness, promoted follicular maturation in
a shorter time and also, improved pregnancy rates.
Keywords: Phytoestrogen, Clomiphene citrate, Endometrial thickness, Infertility.

INTRODUCTION


Unexplained infertility is defined as failure to
The study aimed to evaluate the effect of follicular
conceive after 1 year in couples with normal semen
phase oral phytoestrogens in patients with unexplained
samples and no abnormality found during an infertility
infertility, managed by clomiphene citrate ovulation
work-up (1).
induction, triggered by HCG injection and timed
Clomiphene citrate (CC) is most commonly used
intercourse, in terms of endometrial thickness, follicular
as a first-line treatment of unexplained infertility (2). It
maturation and pregnancy rate.
is an estrogen analogue that was first used in induction

of ovulation in 1961, and clinically approved in the
PATIENTS AND METHODS
United States in 1967. Clomiphene exerts both estrogen
This was a controlled clinical trial conducted on
agonist effects and antagonist effects (3). Also, CC is
fifty six (56) unexplained infertile patients seeking for
successful in ovulation induction in 80% of cases,
pregnancy to evaluate the effect of follicular phase oral
however the cumulative pregnancy rates reaches 30-
phytoestrogens in patients with unexplained infertility,
40% only after its use for a few cycles. The discrepancy
managed by clomiphene citrate. Ovulation induction
between ovulation and cumulative pregnancy rates is
was triggered by HCG injection and timed intercourse.
due to the anti-estrogenic effects of CC on both
Fifty six (56) unexplained infertile women seeking for
endometrial lining and the quality of cervical mucus (3).
pregnancy were divided into two groups: The 1st group
Phytoestrogens (PES) are natural compounds with
(study group) included twenty eight (28) women
estrogenic activity that occur in many plants and fungi.
receiving CC in the form of clomid 50 mg tablet (Sanofi
The effects of different PES on estrogen-sensitive
Aventis, France) at a dose of 100 mg/day in two divided
genes, their uterotropic activity and their selective
doses, starting from day 3 to day 7 of the cycle plus
affinity to estrogenic receptor subtypes, have been
phytoestrogens (black cohosh/cimicifugae racemosa) in
investigated and characterized in numerous studies. The
the form of Klimadynon uno tablet 20 mg (Bionorica,
affinity of PES for estrogen receptors is 20­30 folds
Germany) at a dose of 2 tablet/day in single dose 40 mg.
higher than that for alpha-estrogen receptor (4).
Choriomon 5000 I.U. ampoule (Ibsa, Switzerland) at a
In general, phytoestrogens such as soy isoflavones
dose of two ampoules i.m. one shot for attaining mature
have been thought to have predominant affinity to
follicle(s) by trans-vaginal US scan with diameter 18
estrogen receptor beta (ER ) (5).
mm for triggering ovulation.


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/)
2804
Received: 10 /5 /2021


Accepted:6 /7 /2021

Full Paper (vol.851 paper# 23)


c:\work\Jor\vol851_24 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2809-2815

Treatment Options and Outcome of Premature Rupture of Membranes at
Zagazig University Hospitals
Ali El-Shabrawy Ali, Hend Salah Abdo, Amira Ehmida Elsayed Elawady*, Ahmed Ismaeil Mohammed
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt.
*Correspondence to: Amira Ehmida Elsayed Elawady, Mobile: (+20)01091804893, E-mail: amiraelawady253@gmail.com

ABSTRACT
Background:
PROM "premature rupture of membrane" is defined as a spontaneous leakage of amniotic fluid from the
amniotic sac before onset of labor.
Objecitve: The aim of this work was to verify better management and improve outcome of PROM cases. Patients and
Methods: A prospective cohort study was conducted at High Risk Pregnancy Room, Emergency Hospital Obstetrics
and Gynecology Department, Faculty of Medicine, Zagazig University. It included 80 women with PROM. The study
was between August 2019 and March 2020. All patients were subjected to detailed history taking, general, obstetric
examination, and laboratory Investigations.
Results: The gestational age at labor was 35.6 weeks compared to gestational age at PROM, which was 34.3 weeks; the
difference was statistically significant, mean increase of gestational age was 1.27 weeks. The incidence of postpartum
complication was 1.25% of mothers in the form of chorioamnionitis.
Conclusions
: that conservative procedures like antibiotics, corticosteroids, tocolytics and magnesium sulphate could
prolong latency period, improves the fetomaternal outcome and decreases the need for incubators.
Keywords: Abortion, Premature Rupture of Membranes, Risk Factors.

INTRODUCTION


A premature rupture of membranes (PROM) is
whether to make the diagnosis of PROM from the
defined as a spontaneous leakage of amniotic fluid
woman's complaint(3).
before onset of labor. Preterm PROM occurs after 28
The causes of PROM are unclear. But
weeks of gestational age and before 37 weeks. Term
PROM/PPROM is more likely to happen in women
PROM occurs after 37 completed weeks of gestational
who: Had prior PPROM, had prior preterm labor and
age including postterm cases occurring after 40 weeks.
delivery, have an infection in the vagina or uterus
Differentiating between PROM and PPROM has mainly
(chorioamnionitis, group B streptococcus, bacterial
got therapeutic consequence, as it enables to decide on
vaginosis, urinary tract infections), have bleeding from
appropriate intervention prolonging pregnancy or
the vagina, smoking, have poor nutrition, have had
initiating birth. Preterm PROM and term PROM can be
previous cervical surgery, including cone biopsies
divided into early PROM: less than 12 hours has passed
or cerclage, have had overstretching of the uterus and
since the rupture of fetal membrane and prolonged
amniotic sac, which sometimes occurs with multiple
PROM: 12 or more hours has passed since the rupture
fetuses or too much amniotic fluid (hydramnios) (4).
of fetal membranes(1).
For treatment of these cases, delivery if there is
Premature rupture of membrane (PROM),
fetal compromise, infection, or gestational age 34
which is a spontaneous rupture of membrane is a normal
weeks, otherwise, the woman's activity is limited to
component of labor and delivery. Preterm PROM
modified bed rest, antibiotics and corticosteroids should
complicates 3-8% of pregnancies and leads to one third
be given(5).
of preterm deliveries. It increases the risk of prematurity
Intravenous magnesium sulfate should be
and leads to other perinatal and neonatal complications
considered in pregnancies > 32 weeks, use of tocolytics
with 1-2% risk of fetal death(2).
is controversial(6). PROM management requires
Rupture of the fetal membranes can occur when
balancing risk of infection when delivery is delayed
the cervix is either closed or dilated. Sometimes, it can
with risks due to fetal immaturity when delivery is
occur in a very early pregnancy (before twenty-eight
immediate. So, the aim of this study was to verify better
weeks this leads to inevitable abortion). Risk factors
management and improve outcome of PROM cases.
highly
associated
with
PROM:
Infection,

malpresentation of the fetus, multiple pregnancy, excess
PATIENTS AND METHODS
amniotic fluid, cervical incompetence, and trauma to the
This study was carried out at High Risk Pregnancy
abdomen. When there is a rupture in the fetal
Room, Emergency Hospital Obstetrics and Gynecology
membranes, the woman notices a painless sudden
Department, Faculty of Medicine, Zagazig University.
leakage of fluid from her vagina, which is usually
All patients were asked to fill the questionnaire,
excess and watery. However, when the amount of
physical examination was done and sterile Cusco
amniotic fluid in the sac is minimal, the leaking fluid
speculum was conducted.
may only wet her underwear, and you may be unsure


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2809
Received:10 /5 /2021


Accepted: 6 /7 /2021

Full Paper (vol.851 paper# 24)


ACE inhibitors (ACEIs) improve insulin resistance and The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2816-2822

A Study of The Cardio-Protective Effect of Pioglitazone on Isoprenaline- Induced
Myocardial Infarction in Male Albino Rats
Ahmed M. M. El-Sherbiny, Ali Abd El-Salam Ahmed Attia,
Sherif Motawie Abd Elfadeel, Mohammad Sabry Ibrahim Hassan*
Department of Pharmacology, Faculty of Medicine, Al-Azhar University (Assiut), Egypt
*Corresponding author: Mohammad Sabry Ibrahim, Mobile: (+20) 01099433484,
E-Mail: mohammadsabry.el.8.372@azhar.edu.eg

ABSTRACT
Background:
Isoprenaline (ISO) in large doses induces morphological and functional alterations in the heart leading
to myocardial necrosis. It also produces excessive free radicals resulting from oxidative metabolism of catecholamine.
There are increasing evidences that cardiotoxicity of ISO occurs because of generation of free radicals and oxidative
stress.
Objective: To investigate the protective effect of pioglitazone on the outcome of isoprenaline (ISO) induced
myocardial infarct-like lesions in rats.
Materials and methods: 50 male Wistar albino rats (150-200gm) were selected for this study. The rats were divided
into five groups each consisted of 10 rats. This study was conducted at Department of Pharmacology, Faculty of
Medicine, Al-Azhar University (Assiut).
Results: Results showed that pretreatment with pioglitazone significantly decreased the activity of LDH, CK, TNF
alpha, IL 6 and the levels of CTnI in serum of ISO-induced rats. Our results showed that pretreatment with
pioglitazone significantly (p<0.01) decreased the level of MDA compared with ISO alone-induced rats.
Conclusion: Pioglitazone has a valuable protective role against myocardial infarction through its action as peroxisome
proliferator activated receptor gamma (PPAR-) agonist.
Keywords: Pioglitazone, Isoprenaline, Myocardial infarction, Male albino rats.

INTRODUCTION
PPAR- plays an important role in regulation
Despite great efforts during the last decades,
of adipocyte differentiation and insulin resistance. In
cardiovascular diseases (CVDs) remain the major
addition, recent large clinical studies have
cause of death worldwide, increasing their prevalence
demonstrated that a Peroxisome PPAR- agonist had
every year (1). Myocardial infarction (MI) is a
beneficial effects not only on glycemic control but also
cardiovascular disease that occurs when the blood
in preventing atherosclerotic disease (8). Increasing
supply to a part of the heart is interrupted, causing
evidence has demonstrated that PPAR- plays
death to the heart tissue. It is a complex phenomenon
important roles in the immune system, since PPAR- is
affecting the mechanical, electrical, structural, and
expressed in inflammatory cells such as macrophages,
biochemical properties of the heart (2). Rates of death
T cells, B cells, and dendritic cells (9).
from ischemic heart disease have declined in most high
Pioglitazone is a thiazolidinedione with PPAR-
income countries, although cardiovascular disease still
agonist activity. It was proved that treatment with
accounted for 1 in 3 of all deaths in the USA in 2013
pioglitazone therapy resulted in a significantly greater
(3). Ischemic heart disease is becoming a more common
reduction in blood glucose level. It can improve
cause of death in the developing world. For example in
hypertriglyceridemia and hypercholesterolemia (10).
India, ischemic heart disease had become the leading
Additionally, it plays an important role in suppression
cause of death by 2004 accounting for 1.46 million
of inflammation in intestinal ischemia as a PPAR-
deaths (14% of total deaths) and deaths due to
agonist. Pioglitazone (10 mg/kg) is effective in
ischemic heart disease were expected to double during
reducing ventricular arrhythmias, creatine kinase-MB
2005­2015 (4).
release and restoring energy production (11).
ISO, a adrenergic agonist, has been reported
Bisphenol, A diglycidyl ether (BADGE), is a
to induce infarct-like lesions in rats and other animal
synthetic substance used in the production of
species (5). It has been shown to exhibit many
polycarbonate and industrial plastics. Competition-
metabolic and morphological aberrations in the heart
radioligand-binding studies showed this compound to
tissue of experimental animals similar to those seen in
be a ligand for PPAR- with micromolar affinity.
humans with myocardial infarction (6). Injected
BADGE has been reported to act as PPAR-
isoprenaline undergoes auto-oxidation resulting in the
antagonists (12).
generation of free radicals that stimulate lipid
The aim of the present study was to evaluate
peroxidation, which causes destruction and damage to
the protective effects of pioglitazone on cardiac marker
the myocardial cell membrane. Inflammation is a key
enzymes [creatine kinase (CK) and lactate
process involved in mediating myocardial tissue
dehydrogenase (LDH)], troponin-I, inflammatory
damage through the release of proteolytic enzymes (7).
markers (IL-6 and TNF-alpha) and antioxidant

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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
2816

Received: 13 /5 /2021



Accepted:9 /7 /2021

Full Paper (vol.851 paper# 25)


c:\work\Jor\vol851_26 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2823-2827

Efficacy of Lactoferrin in Prevention of Premature Rupture of Membrane
Ali El-Shabrawy Ali, Manar Abdelhafeez Fathi*, Ahmed Ismail Mohammed
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding Author: Manar Abdelhafeez Fathi, Mobile: (+20)01002770634, Email: malikamahmoud21@gmail.com

ABSTRACT
Background:
Prematurity is a leading cause of maternal and neonatal mortality and morbidity, complicating up to 10%
of all pregnancies. Mortality and morbidities, including respiratory distress syndrome (RDS), intraventricular
hemorrhage (IVH), necrotizing enterocolitis (NEC) and sepsis, are inversely associated with gestational age at birth.
Objective: This study aimed to decrease the morbidities and mortalities resulting from premature rupture of membrane
(PROM).
Patients and Methods: This was a cohort study, which was conducted at Obstetrics and Gynecology Department,
Faculty of Medicine, Zagazig University Hospital. Patients were divided into two groups; Group A: 24 patients received
100 mg of recombinant human lactoferrin (RHLF) twice a day before meals. Group B: 24 patients received placebo
medicine. All patients were subjected to detailed history taking, general examination. Obstetric transvaginal ultrasound
had been performed to evaluate cervical length and funneling.
Results: Mode of delivery in group (A) in 14 women (58.3%) was normal vaginal delivery (NVD) and in 10 (41.7%)
was cesarean section (CS) while in group (B) 11 women (45.8%) was NVD and in 13 (54.2%) was CS. There was no
statistically significant difference between groups where P=0.564. Lactoferrin had sensitivity of 62.5 with specificity
56.2 and positive and negative predictive value of 41.7 and 75 respectively, while the area under curve was 0.594 with
p value of 0.222.
Conclusion: Supplementation with lactoferrin may be an option to reduce the risk of premature rupture of membrane.
Keywords: Lactoferrin, Premature, PROM.


INTRODUCTION
Lactoferrin (Lf) is an approximately 80-kDa iron-
Premature rupture of membrane (PROM) refers to
binding glycoprotein, belonging to the transferrin
the disruption of fetal membranes before the beginning
family, with well-known bacteriostatic and bactericidal
of labor, resulting in spontaneous leakage of amniotic
properties, that plays a significant role in iron
fluid. PROM, which occurs prior to 37 weeks of
homeostasis. Lf is produced and stored in specific
gestation, is defined as preterm PROM while PROM
(secondary) neutrophil granules and released during
that occurs after 37 weeks gestation is defined as term
neutrophil activation and degranulation(8).
PROM(1). PROM occurs in approximately 5%­10% of
It has been detected in secretory fluids, such as
all pregnancies, of which approximately 80% occur at
milk, tears, saliva, vaginal secretion, seminal fluid, and
term(2). There are numerous risk factors for PROM, such
amniotic fluid. Therefore, it is considered an important
as intrauterine infection at early gestational age, lower
component of host defense against microbial
socioeconomic status of pregnant women, inadequate
infection(9). The aim of the present study was to decrease
prenatal care and inadequate nutrition during
the morbidities and mortalities resulting from PROM.
pregnancy, sexually transmitted infections, vaginal

bleeding, and smoking during pregnancy(3).
PATIANT AND METHODS:
PROM is linked to significant maternal and fetal
A cohort study was conducted at Obstetrics and
morbidity and mortality. It has been shown to be the
Gynecology Department, Faculty of Medicine, Zagazig
cause of 18%­20% and 21.4% of prenatal mortalities
University Hospital from August 2020 to June 2021.
and morbidity respectively(4). Complications of PROM

for the fetus and newborn consist of prematurity, fetal
Inclusion criteria: Age from 20-40. Gestational age
distress, cord compression, deformation and altered
before 37 weeks with preterm premature rupture of
pulmonary development leading to pulmonary
membrane confirmed by ultrasound and clinical
hypoplasia and pulmonary hypertension, necrotizing
examination. Single pregnancy. Viable fetus.
enterocolitis (NEC) and neurologic disorder(5).

Infectious morbidities in mother, fetus and newborn
Exclusion criteria: Twin pregnancy. ROM after 37
have been related to both PROM and prolonged rupture
weeks. Comorbidity.
of membranes(6).

Patients had been divided into two groups; Group
Maternal complications include intra-amniotic
A: Patients received 100 mg of recombinant human
infection, which occurs in 13%­60% of women with
lactoferrin (rhLf) twice a day before meals. Group B:
PROM,
placental
abruption,
and
postpartum
patients received placebo medicine. At enrollment, and
endometritis(7).
after 10 and 30 days of treatment, obstetric transvaginal


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2823
Received:10 /5 /2021


Accepted: 6/7 /2021

Full Paper (vol.851 paper# 26)


c:\work\Jor\vol851_27 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2828-2835

Laparoscopic Ventral Hernia Repair: Comparative Study between Closure of
Hernia Defect and Non-Closure (Tension Free Repair)
Ahmed Mustafa Azmy Mahmoud*, Yasser Ali El-Sayed, Hamed El Sayed Horya,
Tamer Youssef Mohammed, Mohamed Elghandor
Department of General and Endocrine Surgery, Mansoura University, Faculty of Medicine, Egypt.
*Corresponding author: Ahmed Mustafa Azmy Mahmoud, Mobile: (+20) 01091414520, E-Mail: azmyy55555@gmail.com

ABSTRACT

Background: Any protrusion through the anterior abdominal wall with the exception of hernia through the inguino-
femoral region is defined as ventral hernia. Incisional hernia and primary defects in the abdominal fascia, which can
cause umbilical hernia, epigastric hernia, para-umbilical hernia and spigelian hernia are grouped under the definition of
ventral hernia.
Objective: To evaluate the recurrence rate of laparoscopic ventral hernia repair with closure and non-closure of the
hernia defect in non-complicated ventral hernia cases.
Patients and Methods: This prospective randomized study was conducted from March, 2015 till December, 2019 in
General Surgery Department, Mansoura University Hospital. It involved 50 patients with ventral hernia, who were
classified randomly into 2 groups by computer generated sampling technique after retrieval of the calculated sample
size according to inclusion and exclusion criteria.
Results: The mean age of the non-closure group and of the closure group was 39.96 ± 6.52 and 39.84 ± 7.48 years
respectively. The males were 36.0% and females were 64.0% in non-closure group, while in the closure group males
were 24.0%, and the females were 76.0%. The mean BMI in the non-closure group was 31.44 ± 3.76 kg/m2, while in
the closure group was 30.88 ± 3.70 kg/m2. In the non-closure group, the most common hernia sites were epigastric
(60.0%), followed by umbilical (40.0%) while in the closure group, the most common hernia sites were umbilical
(96.0%).
Conclusion: Laparoscopic ventral hernia repair is a safe and feasible technique. The great advance in abdominal
laparoscopic surgery and advance in the equipments and instruments as well as individual skills make closure of the
hernia defect represents a good alternative to conventional laparoscopic ventral hernia repair (LVHR) with mesh only.
Keywords: Laparoscopic ventral hernia repair, Closure and non-closure of hernia defect, Tension free repair.

INTRODUCTION
infection, and recurrent hernia. These complications can
Any protrusion through abdominal wall with the
often be discovered at clinical assessment (5).
exception of hernia through the inguino-femoral region
Presenting symptoms may include abdominal
is defined as ventral hernia (1). A ventral hernia arises
pain, distention, and vomiting. Physical examination
through fascial defects in the anterior abdominal wall.
may reveal a tender, firm abdominal wall swelling.
These defects can be classified as spontaneous
Imaging studies are mandatory when the clinical
(primary) or acquired (secondary) or by their site on the
manifestations are misleading or uncertain or
abdominal wall. Spontaneous hernias just as epigastric
preoperative assessment of the hernia is needed (6).
hernia arises from the xyphoid process to the umbilicus,
The main challenges in hernia management lie
umbilical hernia arises at the umbilicus, and hypogastric
in deciding the surgical approach and type of repair
hernias are unusual spontaneous hernias that occur
procedure to do: laparoscopic or open surgery;
below the umbilicus in the midline. Acquired hernias
anatomical or mesh repair and type of mesh to use, and
commonly occur after surgical incisions and are in
where to place the mesh to guarantee the strongest
consequence termed incisional hernias (2). Incisional
possible repair with the least probability of recurrence
hernia is a projection, beneath the skin, of
(7). The treatment of ventral hernia is operative repair.
intraabdominal viscera through a post-operative defect
These techniques include primary closure of the defect
in the anterior abdominal wall (3).
by suture, open repair of the hernia using a prosthetic
Umbilical hernias in adults are acquired, rather
mesh, and laparoscopic hernioplasty (8).
than congenital, and occur usually in females more than
Tension-free mesh repair has been approved as
males with a 3 to 1 ratio. Umbilical hernias are
the standard surgical technique for the majority of
associated with increased intra-abdominal pressure due
ventral hernias, nevertheless of defect size, and is most
to obesity, ascites, pregnancy, and abdominal distension
frequently used. The main types of mesh with different
(4). The most frequent complications of ventral hernia
basic components are used: polypropylene mesh, the
are bowel obstruction, incarceration, strangulation, in
polyester mesh and expanded polytetrafluoroethylene
addition to common complications associated with
(PTFE) mesh. Polypropylene mesh (proline) is most
hernia repair such as seroma formation, wound
commonly used and consists of an inert, non-absorbable
monofilament that exhibits rapid incorporation into the

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2828
Received:13 /5 /2021


Accepted: 9 /7 /2021

Full Paper (vol.851 paper# 27)


c:\work\Jor\vol851_28 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2836-2839

Trans-Scaphoid Perilunate Fracture Dislocation with Ipsilateral
Terrible Triad Injury of The Elbow: Case report
Al-Talyoni Raghib*, Al-Otaibi Mohammed, Al-Beladi Reyadh
Department Orthopedic Surgery, King Abdulaziz Hospital, Jeddah, Saudi Arabia
*Corresponding author: Al-Talyoni Raghib, Mobile: 00966594422448, E-Mail: raghib-kt@hotmail.com

ABSTRACT
Background:
Complex elbow dislocations are injuries in which there is a significant risk of long-term disability. The
combination of elbow dislocation with both radial head and coronoid process fracture is particularly challenging to treat
and, as such, has been termed terrible triad injury (TTI) of the elbow. TTI is typically caused by high-energy falls onto an
outstretched hand.
Case report: A-48-years-old male patient, not known to have any medical illnesses, presented to Emergency Department
Orthopedic, King Fahad General Hospital, complaining of right elbow, forearm and wrist pain and deformities after history
of fall down directly to his right hyperflexed wrist and extended elbow that resulted in elbow dislocation and ipsilateral
transscaphoid perilunate fracture dislocation.
Management: Patient was shifted to operation room for open reduction internal fixation. We started with elbow through
posterior elbow approach, coronoid reduced that was fixed by two interfragmentry screws. Then for olecranon fracture,
through same posterior incision, ulnar nerve was identified and protected and fracture was reduced and fixed with
anatomical plate. Elbow stability was checked where it was stable. Then, distal radius open reduction through dorsal
approach and internal fixation with LC-DCP was achieved. Additionally, through dorsal approach, lunate dislocation
and scaphoid fracture were reduced and fixed with 6 k-wires and spaning external fixator applied from radius to 2nd
metacarpal to maintain reduction.
Conclusion: In case of right terrible triad injury of the elbow with ipsilateral trans-scaphoid perilunate fracture dislocation,
only urgent surgical treatment of both elbow and wrist may achieve good results.
Keywords: Trans-scaphoid perilunate fracture dislocation, Ipsilateral terrible triad injury of the elbow.


INTRODUCTION

CASE REPORT
The term "floating forearm" refers to a rare
A-48-years-old male patient, not known to have any
condition in which concurrent elbow and wrist
medical illnesses, presented to Emergency Department
dislocations occur (1, 2).
Orthopedic, King Fahad General Hospital. He was

complaining of right elbow, forearm and wrist pain and
When elbow dislocation is associated with radial
deformities after history of fall down directly to his right
head and coronoid apophysis fractures, the diagnosis of
hyperflexed wrist and extended elbow that resulted in
"terrible triad injury" is made. This association is even
elbow dislocation and ipsilateral transscaphoid
rarer, and we found only one case reported in the
perilunate
fracture
dislocation.
On
physical
literature. Among the various types of injuries associated
examination, patient was fully conscious, oriented and
with elbow trauma, the occurrence of TTI is rare. Injury
vitally stable, while local examination of right upper
accounts for only 8­11% of dislocations of the elbow
extremity revealed sever swelling of the elbow and wrist
joint and 3.4-10% of all radial head fractures, such
with obvious deformity, sever tenderness and restricted
complex elbow fracture dislocations occur as a result of
range of movement, otherwise distal neurovascular
high-energy trauma, such as falling from a height onto an
examination was intact. Radiological assessment
outstretched hand (3).
showed: right terrible triad injury of the elbow with

ipsilateral trans-scaphoid perilunate fracture dislocation

(Figure 1).

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


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2836

Received:13 /5 /2021


Accepted:9 /7 /2021

Full Paper (vol.851 paper# 28)


c:\work\Jor\vol851_29 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2840-2844

Effect of Lymphatic Pump on Inflammatory Markers and Chest Expansion in
Children with Community-Acquired Pneumonia
Manal Salah El Dein1, Saher Nour El Dein2, Asmaa Hassan*1
1Department of Physical Therapy for Growth and Development Disturbance in Children and its Surgery,
Faculty of Medicine, Cairo, University, Egypt.
2Department of Genetics, Faculty of Medicine, Ain Shams, University, Egypt
*Corresponding author: Asmaa Hassan, Mobile: (+20) 01157755155, E-Mail: mamasemsem99@yahoo.com

ABSTRACT
Background:
Community-acquired pneumonia (CAP) is the most common serious bacterial infectious disease in
childhood. It is a leading cause of morbidity and mortality in children younger than the age of 5 years. Pneumonia is an
invasion of the lower respiratory tract, that may result in an inflammation, injury or death of the surrounding epithelium
and alveoli by a migration of inflammatory cells to the site of infection.
Objective: The purpose of this study was to detect the effect of Lymphatic pump as a physical therapy modality on
controlling the inflammatory process and improving chest expansion in children complaining of CAP
Patients and methods: Thirty inpatient children with diagnosis of CAP ranging in age from 6 to 12 years were selected
from El-Abbasia Chest Diseases Hospital. They were randomly assigned into two groups of equal number (control and
study groups). Patients in both groups were treated by conventional chest physical therapy program while patients in
the study group received an additional intermittent pneumatic compression, sessions were conducted three times per
week till discharge. Inflammatory markers and chest expansion were measured before and after the suggested treatment
period. Results: show a statistically significant improvement of c-reactive protein (CRP) and chest expansion while
insignificant difference of WBCs count, absolute neutrophils, and lactate dehydrogenase (LDH) was recorded.
Conclusion: It could be concluded that intermittent Pneumatic compression is an effective physical therapy modality in
treating children with community acquired pneumonia.
Keywords: Community acquired pneumonia, Inflammatory markers, chest physiotherapy, Intermittent Pneumatic
compression.

INTRODUCTION
diaphragmatic breathing that may be done to increase air
Pneumonia is an inflammatory condition of the
entry, chest expansion, and to loosen secretions (7).
lung affecting primarily the microscopic air sacs
Lymphatic pump technique (LPT) enhances the
(alveoli) (1). It is usually caused by infection with viruses
flow of lymph fluid through the lymphatic system (8). It
or bacteria and less commonly other microorganisms and
is used to treat infection and oedema and might be an
autoimmune diseases (2). Pneumonia is a common illness
effective adjuvant therapy in patients with pneumonia.
affecting approximately 450 million people per year and
LPT enhances the uptake of lymph into the lymphatic
occurring in all parts of the world. It is a major cause of
system and increases lymph flow and leukocyte output,
death among all age groups resulting in 4 million deaths
LPT may enhance innate immunity(9), which collects
(7% of the world's total death) yearly (3).
fluid, immune cells, antigens, pathogens and proteins
The presentation of pneumonia includes fever,
from the tissue interstitial space and delivers them to
cough and pleuritic chest pain. Focal chest signs in child
regional lymph nodes(10).
with pneumonia includes: decreased chest expansion,
Intermittent pneumatic compression (IPC) is a
dullness on percussion, decreased entry of air, bronchial
form of Lymphatic pump therapeutic technique that
breathing, and crackles (4). WBCs and CRP are a good
force fluids such as blood and lymph, out of the
diagnostic markers. WBCs are elevated in a direct
pressurized area. After a short time the pressure is
proportional manner with severity of pneumonia as
reduced, allowing increased blood flow back into the
during
infection,
pro-inflammatory
cytokines,
limb(11). IPC has been proved to be successful, easy and
chemokines are released from injured tissue to enter
inexpensive method (12).
blood and lymph. Leukocytes utilize this inflammatory
The aim of the current work was to detect the effect of
tissue gradient to detect sites of infection and
Lymphatic pump as a physical therapy modality on
inflammation in the body and directly kill pathogens and
controlling the inflammatory process and improving
continue to release inflammatory mediators (5, 6).
chest expansion in children complaining of CAP.
Conventional physical therapy modalities that

may be used to treat chest problems may include
PATIENTS AND METHODS
modified postural drainage that allows gravity to drain
This randomized controlled study (RCT) included a
secretions from specific segments of the lungs. Shaking,
total of 34 children of both sexes suffering from
percussion and vibration that may mobilize secretions.
pneumonia with age ranged from 6 to 12 years, attending
Coughing and huffing techniques that may be used to
at El Abbasia Chest Disease Hospital. This study was
expectorate secretions and breathing exercises like
conducted between December 3, 2019, to December 12,

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

2840
Received:11 /5 /2021


Accepted:7 / 7/2021

Full Paper (vol.851 paper# 29)


c:\work\Jor\vol851_30 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2845-2851

Serum Leptin and Adiponectin in Obese and Non-Obese
Patients with Acne Vulgaris
Manar Sallam*1, Magdy Abd El-mageed Al Sohafy1, Dalia Shaalan Abdel Salam2, Doaa Ali Elsakka1
Departments of 1Dermatology, Andrology & STDs and 2Medical Biochemistry,
Faculty of Medicine, Mansoura University, Egypt
*Corresponding author: Manar Sallam, Mobile: (+20)1002220953, E-Mail: manar.sallam@hotmail.com

ABSTRACT
Background:
Adipokines are demonstrated to be associated with multiple cutaneous diseases. Leptin is mainly
produced by the adipocytes that stem from the obese gene. In addition, it was reported that, secretion of leptin is a
response to increased lipid uptake, thus, it might be regarded as a link between improper diet and the development of
inflammatory acne.
Objective: The aim of the current work was to estimate serum leptin and adiponectin in both obese and non-obese
patients with acne vulgaris and to evaluate adiponectin/leptin ratio (A/L) rates as a biomarker of insulin resistance and
hence their role in pathogenesis of acne vulgaris in correlation with body weight and disease severity.
Patients and methods: This prospective case-controlled study included a total of 60 patients with acne vulgaris,
attending at the Dermatology, Andrology & STD Outpatient Clinic, Mansoura University Hospitals. Forty healthy
subjects matched with the patients in age, sex were included. This study was conducted between April 2019 to January
2020.
Results: Cases with acne vulgaris demonstrated significant increase in serum leptin level as well as significant decrease
in serum adiponectin level compared to controls. No significant correlation was reported between both serum leptin and
adiponectin levels and disease severity. Leptin could be used as reliable predictor in terms of the differentiation between
cases of acne vulgaris and controls with high sensitivity, specificity and accuracy. Adiponectin could be used as reliable
predictor in terms of the differentiation between cases of acne vulgaris and controls with high sensitivity, specificity and
accuracy.
Conclusion: Acne vulgaris was associated with significant elevation in leptin level, significant reduction in adiponectin
level and significant decrease in A/L ratio. Thus, leptin, adiponectin and insulin resistance may be pathogenic cofactors
contributing to the development of the disease and could be used as reliable predictors for development of acne vulgaris
but not for severity of disease.
Keywords: Serum leptin and Adiponectin, Obese and Non-Obese, Acne Vulgaris.

INTRODUCTION

which suggests that the leptin signaling may be involved
Acne vulgaris is an inflammatory disease of the
in the pro-inflammatory regulation of sebaceous lipid
pilosebaceous unit. The pathogenesis of acne is
metabolism. Given the fact that secretion of leptin is a
multifactorial, and adipokines secreted from the
response to increased lipid uptake, leptin might be
sebaceous gland are considered novel factors affecting
regarded as a link between improper diet and the
acne inflammation. Several studies have investigated
development of inflammatory acne (6).
the association between serum levels of various
Adiponectin is an adipocyte-derived hormone
adipokines and acne vulgaris in patients; however, the
that plays a role in insulin function and energy
results have been inconsistent (1, 2).
homeostasis. Early studies indicated that adiponectin
Adipokines are small molecular weight
has an anti-inflammatory effect on endothelial cells by
biologically active proteins primarily produced by
inhibiting the following: nuclear factor B activation (7).
adipocytes, however many members are expressed and
The adiponectin/leptin ratio (A/L) has been
secreted also by non-adipocyte cells (3). The roles of
suggested as a marker of adipose tissue dysfunction.
adipokines in regulating inflammatory responses in
This emerging biomarker correlates negatively with
adipose tissues and systemic organs become evident
BMI. Moreover, it is strongly associated with surrogate
during the development of obesity and in response to
measures of insulin resistance such as the homeostatic
infection or systemic inflammation. An increasing
model assessment (HOMA), the hyperinsulinemic-
number of studies have identified the relationship
euglycemic clamp and the quantitative insulin
between various adipokines and multiple cutaneous
sensitivity check index (QUICKI) in different cohorts.
diseases (4, 5).
Furthermore, it has been stated that the
Leptin is mainly produced by the adipocytes
adiponectin/leptin ratio correlates with insulin
that stem from the obese gene. The function of leptin in
resistance better than adiponectin or leptin alone, or
the sebocyte is to form lipid droplets within the cell.
HOMA even in subjects with hyperglycemia (8).
Moreover, leptin can activate the STAT-3 and NF-B
Obesity is characterized by a generalized
pathways and induce pro-inflammatory enzyme and
change in the levels of circulating adipokines due to
cytokine (IL-6 and IL-8) secretion in human sebocytes,
abnormal accumulation and dysfunction of adipose

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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
2845

Received: 11 /5 /2021


Accepted: 7 /7 /2021

Full Paper (vol.851 paper# 30)


c:\work\Jor\vol851_31 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2852-2856

Minimally Invasive Lumbar Discectomy Versus Conventional Discectomy for
Symptomatic Lumbar Disc Herniation
Essam Aldin Gaber Saleh1, Tarek Rageh2, Mohamed Hamed1,
Ahmed Said Fahim Mansour1, Alaa Mohamed Badawy Alhayes*1
Departments of 1Neurosurgery and 2General Surgery, Faculty of Medicine, Menoufia University, Egypt
*Corresponding Author: Alaa Mohamed Badawy Alhayes, Mobile: (+20) 01129813441,
Email: magdymohamedalaa@gmail.com

ABSTRACT
Background:
Lumbar disc herniation is a localized displacement of disc material beyond the normal margins of the
intervertebral disc space and is the most common cause of sciatica. Lumbar microdiscectomy (MD) and open discectomy
(OD) are commonly performed surgical procedures for patients with lumbar disc herniation.
Objective: The aim of the current work was to compare the benefits and harms of minimally invasive discectomy (MID)
versus MD/OD for management of lumbar intervertebral discopathy.
Patients and Methods: This cross-sectional study was conducted at Menoufia university hospitals & Al-Haram
Specialized Hospital including 36 Patients (with single or double level disc prolapse (L4-L5 or L5-S1) who underwent
discectomy using microscopic/or conventional discectomy.
Results: In group (1): 75% of the patients had good pain improvement (60 ­ 90%) and the rest had moderate
improvement (40 ­ 60 %). In group (1) only 30% experienced intermittent pain while the rest have no pain. While in
group (2) about 50% had an intermittent pain. There is no significant difference. In group (1) the mean days of hospital
stay was (6.10 + 1.6) while in Group (2) the mean days of hospital stay was (1.60 + 0.12). The group (2) has significant
short hospital stay length than group (1).
Conclusion: It could be concluded that endoscopic approach was associated with similar postoperative pain
improvement and frequency and lower operating time, blood loss and hospital stay in comparison to open approaches.
We believe that both techniques are safe, and both can be used to lumber disk surgery, but microscopic technique is
preferred for its better outcomes.
Keywords: Minimally invasive lumbar discectomy- conventional discectomy- lumbar disc herniation.

INTRODUCTION

Lumbar disc herniation is a localized displacement
Low back pain is one of the most common
of disc material beyond the normal margins of the
reasons for people to seek medical help; its prevalence
intervertebral disc space and is the most common cause
ranges from 60­90% (1). Lumbago is a general term
of sciatica, affecting 1% to 5% of the population
referring for low back pain while Sciatica is a name
annually (7).
given to pain in the area of distribution of the sciatic
First-line treatments for sciatica are nonsurgical and
nerve (L4 to S3) which is commonly felt in the buttock
may consist of physical therapy, pharmacologic
and over the poster lateral aspects of the leg (2).
therapy, and/or epidural steroid injection. Acute sciatica
The most common cause of sciatica is lumbar disc
symptoms subside in most patients independent of
herniation which may result from acute traumatic injury
treatment. For symptoms that are resistant to initial
or from preceding degenerative changes within the
conservative treatments, continued conservative care or
lumbar disc (3). The degenerative disc disease (DDD)
lumbar discectomy to remove the offending herniated
occurs even in asymptomatic patients, but for about
disc material may be considered (8).
10% of the population it results in permanent chronic
Lumbar microdiscectomy (MD) and open-
pain and disability (4).
discectomy (OD) are commonly performed surgical
The lifetime prevalence of a lumbar disc herniation
procedures for patients with lumbar disc herniation.
is approximately 2%. The natural history of sciatica
Mixter et al. were the first to describe pitfalls of
secondary to lumbar disc herniation is spontaneous
laminectomies and later in 1978 Caspar and Williams
improvement in the majority of cases. Among patients
initially reported the technique of lumbar MD, which
with radiculopathy secondary to lumbar herniation,
slightly contributes to a relatively smaller incision, less
approximately 10-25% (0.5 of the population)
soft tissue damage, therefore reduced postoperative
experience persistent symptoms (5).
pain, early discharge from hospital and return to work
Virchow first described traumatic lumbar vertebral
compared to OD (9).
disc disease in 1857 contributors from physicians
The aim of the current work was to compare the
striving to understand back pain and sciatica have
benefits and harms of MID versus MD/OD for
encouraged the development of new surgical
management of lumbar intervertebral discopathy.
intervention as well as conservative modalities for

treatment of herniated lumbar disc (6).
PATIENTS AND METHODS

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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
2852

Received: 2/5/2021

Accepted: 28/6/2021

Full Paper (vol.851 paper# 31)


c:\work\Jor\vol851_32 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2857-2862

Radiofrequency Coblation versus Surface Bipolar Cautarization for the
Treatment of Inferior Turbinate Hypertrophy
Abdel-Zaher El-Sayed Tantawy, Ahmed Soliman Ramadan,
Sara Mielod Youssef Moamar*, Ashraf El-Hussieny Oda Basha
Department of Otorhinolaryngology, Faculty of Medicine Zagazig University, Egypt.
*Corresponding Author: Sara Mielod Youssef Moamar, Mobile: +218925624278, Email: boost.balm83@yahoo.com

ABSTRACT
Background:
Nasal obstruction is the foremost complaint of a large number of patients in otolaryngologic practice most
commonly caused by inferior turbinate hypertrophy. Objective: This study aimed to compare surface bipolar
electrocautery with radiofrequency coblation in the treatment of inferior turbinate hypertrophy.
Patients and Methods: This clinical trial study was conducted at ENT Department, Faculty of Medicine, Zagazig
University Hospitals in the period from May 2020 to Jul 2021, included 34 patients with nasal obstruction due to
hypertrophied inferior turbinates (HIT) resistant to medical treatment for a period not less than six weeks. The first
group included 17 patients with HIT treated by bipolar cauterization and second group include 17 patients with HIT
treated by radiofrequency coblation. Results: This study showed that nasal obstruction showed significant improvement
in both groups postoperatively. There was no significant deference between both regarding nasal obstruction although
there was improvement in objective evaluation. In addition, there was no crustation observed in nasal mucosa among
patient. The discharge and crustation were significantly associated with bipolar group.
Conclusions: Both techniques have proven to be equally effective. In both the groups, radiofrequency is considered to
be more accurate. Bipolar electrocautery and radiofrequency volumetric tissue reduction are equally effective in
improving both the subjective and objective nasal obstruction.
Keywords: Bipolar electrocautery, Nasal obstruction, Radiofrequency, Turbinate hypertrophy.

INTRODUCTION
surface mucosa, thereby maintaining the physiologic
One of the major causes of nasal obstruction is
role of the turbinates in creating turbulent airflow,
inferior turbinate hypertrophy (ITH). ITH is commonly
airway resistance, warming and humidifying inspired
associated with chronic allergic or vasomotor rhinitis(1).
air. As a result, there has been a trend toward the
These conditions are traditionally treated conservatively
intramural or submucosal surgical modalities(2).
with
topical
corticosteroids,
antihistamines,
Surface bipolar cautery has been the method of
decongestants, and immunotherapy. However, medical
choice for many surgeons. This is due to the low cost,
therapy is frequently ineffective in relieving nasal
ease of use, and ability to perform under local anesthesia.
obstruction and has the added risk of progressive
The relatively novel technique of RF coblation offers
consumption leading to iatrogenic effects such as rhinitis
similar benefits but may have the added benefit of
medicamentosa(2).
For
these
reasons, surgical
improved mucosal preservation and tolerance by the
intervention is commonly employed in the treatment of
patient(6). This study aimed to compare surface bipolar
chronic nasal obstruction secondary to ITH. A myriad of
electrocautery with radiofrequency coblation in the
surgical options exists to include partial or total
treatment of inferior turbinate hypertrophy as regards to
turbinectomy, laser-assisted turbinoplasty, submucosal
objective and subjective improvement in nasal
resection, electrocautery, cryotherapy, corticosteroid
obstruction, rate and type of complications, experience
injection,
turbinate
outfracture,
radiofrequency
during the procedure, and rate of recovery.
volumetric tissue reduction, and most recently,

radiofrequency
coblation(3).
The
severity
of
PATIENTS AND METHODS
complications, vary with increasing degrees of
This study included 34 patients (divided into 2
invasiveness and range from minor bleeding to
groups; 17 patients each) with nasal obstruction due to
significant hemorrhage, synechia, crusting, foul odor,
hypertrophied inferior turbinates resistant to medical
pain, hyposmia, and chronic dryness. There have been
treatment for a period not less than six weeks. Our study
many studies comparing the various surgical
included 10 males and 24 females with mean age of 28.7
techniques(4).
years (range 18-50 years). The study work was done in
Many procedures have been described for the
Otorhinolaryngology Department in Zagazig University
surgical management of inferior turbinate hypertrophy.
Hospitals in the period from May 2020 to Jul 2021.
Coblation is a relatively new technology that used

radiofrequency energy to ablate hypertrophied tissues.
Ethical approval:
The standard method of using this technology has been
Written informed consent was obtained from all
shown to be effective(5). The proposed benefit of the
participants. The study was approved by the
radiofrequency (RF) technique is the maintenance of the
Research Ethical Committee of Faculty of Medicine,

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2857
Received:12 /5 /2021

Accepted: 8 /7 /2021

Full Paper (vol.851 paper# 32)


c:\work\Jor\vol851_33 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2863-2869

Role of Venous Lactate in Predicting Outcomes in Patients with
Acute Upper Gastro-Intestinal Bleeding
Nahla El-Sayed El-Gammal1, Alaa Magdy Mohamed EL Arini*1,
Nahla Ibrahim El-Attar2, Ahmed Attia Abdel-Moaty1, Soha Alhwary1
Departments of Tropical Medicine and Clinical Pathology, Faculty of Medicine ­ Zagazig University, Egypt
*Corresponding Author: Alaa Magdy Mohamed EL Arini, Mobile: (+20) 01129813441,
Email: magdymohamedalaa@gmail.com

ABSTRACT


Background: Several risk scores were clinically assessed for risk stratification of patients with UGIB including
Glascow­Blatchford score (GBS) and Rockall score pre and post endoscopy. Many studies tried to detect value of lactate
as a predictor of mortality but its role in association with other systems is not well defined.
Objective:
To deduct the role of lactate and other scoring systems in assessment of outcomes of UGIB.
Patients and Methods:
We conducted a prospective cohort study of patients admitted to ICU of Tropical Medicine
Department, Zagazig University Hospitals through the period from December 2019 to March 2020 with a charted
diagnosis of upper gastrointestinal bleeding (UGIB).
Results:
Regarding performance of GBS, Rockall score and lactate among the studied group, cutoff point of GBS was
equal or less than 10.5 can be used as a predictor for recovery with sensitivity of 63.6%, specificity 100%. Cut off of
Pre Rockall score was less than or equal to 4.5 can be used as a predictor for recovery with sensitivity of 60.6%,
specificity of 80%. As regards venous lactate, cutoff point was equal to or less than 1.85 can be used as a predictor for
recovery with sensitivity of 75.8% and specificity of 100%. Regarding lactate clearance, the cutoff point of equal to or
more than 18.8% can be used as a predictor for active bleeding with sensitivity of 63.2% and specificity of 42%.
Conclusion:
Elevated venous lactate in association with GBS, Rockall scoring systems were found as independent
predictor factors for ICU admission, transfusion, endoscopy, length of hospital stay and mortality in patients with acute
UGIB.
Keywords:
Lactate-Prediction, Outcomes, Acute Upper Gastro, Intestinal Bleeding.

INTRODUCTION


Acute upper gastrointestinal bleeding (AUGIB) is a
PATIENTS AND METHODS
common emergency condition that ranges in severity
A prospective cohort study was performed
from mild symptoms that do not require any
including patients >18 years old who presented to
interventions, to a life-threatening presentations with
intensive care unit of Tropical Medicine Department,
hemorrhagic shock that require emergency endoscopy
Zagazig University Hospitals in between November
or surgery. It has been estimated to account for up to
2019 and March 2020. Patient's demographic
20,000 deaths annually in the United States (1, 2). Several
information, medical history, and clinical and
well-validated risk stratification tools have been
laboratory data were collected. Patient characteristics
developed specifically for UGIB. The most commonly
included age, gender and comorbidities. Other clinical
used being the GBS, Rockall, and AIM65 scores. These
and laboratory variables included history of prior GIB,
scoring systems are based on clinical, laboratory, and
history of alcohol abuse, history of smoking, use of non-
endoscopic findings (3, 4). Emergent endoscopy and
steroidal anti-inflammatory drugs (NSAID), use of
endoscopic findings are often unavailable at the time of
aspirin, use of anticoagulant, presentation with syncope,
initial assessment. Therefore, risk-scoring systems
bright red blood per rectum, melena, abdominal pain,
based on clinical and laboratory parameters may be
hematemesis, altered mental status, ascites, initial heart
more useful to a clinician at the time of initial
rate and systolic blood pressure, initial hemoglobin,
assessment (5).
platelet count, prothrombin time as international
Venous lactate is predictive of the severity of illness
normalized ratio(INR), creatinine, and venous lactate.
and risk of mortality in patients with sepsis. Also, it was
The range of normal venous lactate was defined as
found that serum lactate and its serial change (lactate
normal 0.5-2.0 mmol/L. Accordingly the venous lactate
clearance) have been suggested as possible predictor of
was predefined as normal (0.5 -2 mmol/liter) or elevated
patient outcome in several critical care conditions (6, 7),
(> 2.0 mmol/L). Intensive care unit (ICU) admissions,
but little is known about the role of lactate measurement
upper endoscopy, packed red blood cell (PRBC)
in the triage of patients with acute UGIB (8). The aim of
transfusion (transfusion of at least a unit of PRBC) were
the present study was to deduct the role of lactate and
assessed as outcomes (categorical outcome variables).
other scoring systems in assessment of outcomes of
Two groups were also compared for any difference in
UGIB.



This article is an open access article distributed under the terms and conditions of the Creative
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2863

Received:14 /5 /2021

Accepted:10 /7 /2021

Full Paper (vol.851 paper# 33)


c:\work\Jor\vol851_34 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2870-2878
Perception of Online Learning among Undergraduate Students at Suez Canal
Medical School during the COVID-19 Pandemic: A Cross-Sectional Study
Noha M Abu Bakr Elsaid1, Hadeer El Nagar1, Doaa Kamal*2, Mariam Yousef Bayoumi3, Monica George
Kamel3, Ahmed Adel Abuzeid3, Sara Abdelrahman Elewa3, Menna Mohamed Hussein3, Hussein Nasser
Hussein3, Ahmed Mohamed Saed Elshahidy3, Jawad Abdelnasser Saleh3
1Department of Public Health, Community, Occupational and Environmental Medicine,
2Department of Medical Education, 3Fifth Year Medical Student,
Faculty of Medicine, Suez Canal University, Egypt.
*Corresponding author: Doaa Kamal, Mobile: (+20) 01222486807,
E-mail: doaa_kamal@med.suez.edu.eg, dr_doaa84@yahoo.com

ABSTRACT
Background:
Many adaptations to medical education have been made in response to the new emergent COVID-19
pandemic and its enormous global effects including the teaching and learning strategies to assure the educational
process's safety and advancement. Accordingly, it was necessary to implement new online instructional approaches
at the Faculty of Medicine, Suez Canal University in Egypt.
Objective: To assess online learning advantages and disadvantages as perceived by medical students in addition to
their preference regarding online vs face-to-face learning,
Subjects and methods: This study was conducted as a cross-sectional study that included 340 students who filled an
online survey consisting of 16 questions and was conducted on the Google Forms platform. Target population: years
1, 2 and 3 undergraduate medical students at Faculty of Medicine, Suez Canal University who experienced online
learning during the COVID-19 pandemic.
Results: The mean age of students was 19.57±1.02, ranged from 17 to 23 years, 61% of them were females. About
63.8% of students had no previous experience with online learning. The main perceived advantages were the ability
to stay home (63.8%), comfortable surrounding (52.1%) and access to online materials (47.1%), while the main
perceived disadvantages were technical problems (67.6%), lack of interaction with patients (58.8%), and reduced
interaction with teachers (48.5%). Most of the students found face-to-face learning is superior to online learning in
improving the knowledge (p=0.005), clinical skills (p<0.001) and social competence (p<0.001). Though 77% of them
rated online learning as enjoyable.
Conclusion: Most of our participants preferred traditional face-to-face learning over the online learning. Stakeholders
should take the required steps to improve learning by reducing the disadvantages and increasing advantages of online
learning as perceived by students during this study.
Keywords: COVID-19, Egypt, Online Learning, Perception.

INTRODUCTION
need for teacher and learners to be physically present
The use of a wide range of technologies such
or working at the same time. Various novel online
as the internet, email, chat, new groups and texts, audio
venues provide useful learning spaces for students and
and video conferencing transmitted across electronic
tutors who might find it difficult to meet together in real
networks to transfer education is referred as online
time (3).
learning. It enables students to study at their own speed
Among the success factors of online learning
and at their own convenience. It usually necessitates
is the used delivery technology improves learning. It
meticulous planning and a significant investment of
has been recognized that specialized delivery
time and money (1).
technology can provide efficient and timely access to
Online
distance
learning
enabled
learning material. However, researches claim that used
educators/tutors to overcome some of the limitations of
technologies are only vehicles that deliver instructions,
face-to-face
teaching
by
allowing
easier
and do not themselves improve student achievement,
communication and interaction between tutors and
they suggest that the used instructional strategies and
students. Besides the ability to provide immediate
content influence student learning more than the type
educational support and feedback gives, online
of technology used to deliver instruction (4).
learning has many logistical, instructional and financial
Online learning encourages learners to be self-
advantages over face-to-face teaching (2).
directed learners and to improve their own skills of
Many educators may find online learning a
self-organization in addition to skills in technology (5).
useful tool to scaffold learning, through providing a
At institutional level; online learning can also
common set of learning resources and experiences as
potentially sustain educational programs that have been
well as through enabling group discussion without the
struggling for many reasons in an on-campus version
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2870
Received:14 /5 /2021


Accepted:10 /7 /2021

Full Paper (vol.851 paper# 34)


c:\work\Jor\vol851_35 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2879-2883

Assessment of Serum Magnesium Concentration in Patients with Knee Osteoarthritis
Amira Abdel-Aziz*, Amir Abdel-Rahman, Amany Salama, Mohammed Hossam Eldeen Zaghloul
Department of Rheumatology and Rehabilitation, Faculty of Medicine, Mansoura University, Egypt.
*Corresponding author: Amira Abdel-Aziz, Mobile: (+20) 01221490420, E-Mail: ameraabdelaziz1989@gmail.com

ABSTRACT
Background:
Magnesium, which is an essential trace element in bone metabolism, has been paid to great attention in
recent years due to its osteogenic effect and critical role in bone mineralization process.
Objective: Detection of the association between serum Mg concentration and clinical and radio-graphical findings in
patients with knee OA and in apparently healthy controls.
Subjects and method:
A cross-sectional study conducted on 100 female patients with primary knee osteoarthritis
(OA) diagnosed according to the American College of Rheumatology (ACR) clinical and radiological classification
criteria for knee OA. In addition, 100 apparently healthy volunteers with no features of OA matched for age and sex
worked as control group. All the study populations underwent bilateral weight bearing anteroposterior x-ray of the
knee which was assessed according to the Kellgren and Lawrence (KL) grading system. The Western Ontario and
McMaster Universities Arthritis Index (WOMAC) and Visual Analogue Scale (VAS) were used to assess pain severity
and functional limitation. Blood samples had been collected for assessing serum Mg concentration by colorimetric
method.
Results: The mean serum Mg level in the OA group was 1.97 ± 0.17 mg/dl and the mean level of Mg in the control
group was 2.09 ± 0.15 mg/dl with high statistically significant difference between the two groups (p < 0.001).
Conclusion:
Serum Mg concentration may have an inverse relationship with radiographic knee OA. Therefore, high
level of Mg could possibly exert a protective role in the control of knee OA and can be used in its management.
Keywords: Knee osteoarthritis, KOA, Magnesium, Mg, forgotten mineral.

INTRODUCTION
sensitization (7). Low magnesium has been associated
Osteoarthritis is a type of degenerative
with elevated serum levels of C-reactive protein (8). Mg
disorder of the joints characterized by a combination of
also decreases the prevalence of metabolic syndrome
degenerative, inflammatory and reparative process that
and DM, which were reported to be risk factors for OA
can result in defect in articular cartilage, change in
progression (9).
subchondral bone and synovial inflammation (1).
Finally, despite its importance, Mg is referred
In
the
ACR
Clinical/Radiographic
to by some as the "orphan" or "forgotten" cation.
classification criteria, the presence of knee pain with at
Increasing the awareness on Mg may focus greater
least one of the following three items along with
clinical attention to its important role in health and
osteophyte in knee X-ray can classify the knee OA: Age
disease (5). The aim of this study was to find out the
> 50 years old, morning stiffness < 30 minutes, crepitus
association between serum Mg concentration and
on knee motion (2). With further increase in prevalence
clinical and radiographical findings in patients with
of knee OA, there is an increasing rate of knee
knee OA and in apparently healthy controls.
arthroplasty performed, which is currently the only

effective treatment for the late phase of OA. Diagnosis
PATIENTS AND METHOD
of early osteoarthritis can significantly improve the
This is a cross-sectional study, which was done on
quality of life, save cost and decrease incidence of
100 female patients with primary knee osteoarthritis and
disability and morbidity related to OA. These facts have
100 controls age and sex matched. Patients were
made identification of effective conservative and
selected from the Department of Rheumatology and
preventive measures for knee OA a high priority (3).
Rehabilitation in Mansoura University Hospital (from
Magnesium (Mg) as an essential trace element
January 2018 ­ January 2019). They were diagnosed
in bone metabolism has been paid to great attention in
according to American College of Rheumatology
recent years according to its osteogenic effect and
clinical and radiological classification criteria for knee
critical role in bone mineralization process (4). Serum
OA.
magnesium measurement is the most available and

commonly employed test to assess magnesium state (5).
Inclusion Criteria: 50 years old or above, female
The normal serum magnesium concentration is 0.75 to
gender, normal renal function, and bilateral weight
0.95 mmol/L, and a level of less than 0.75 mmol/L is
bearing anteroposterior radiography of the knee.
considered Mg depletion (6). There are several
Exclusion Criteria: Younger than 50 years old, male
mechanisms by which low magnesium intake may
gender, and radiographic evidence of non-osteoarthritis
contribute to OA pain, including proinflammatory
joint disease (e.g., chondromalacia patella and
effects of magnesium deficiency, and its role in pain
rheumatoid arthritis), and renal abnormalities.

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2879
Received:14 /5 /2021

Accepted:10 /7 /2021

Full Paper (vol.851 paper# 35)


c:\work\Jor\vol851_36 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2884-2889

Serum Elafin Level as a Potential Marker of Psoriasis Severity
Dina Mostafa Abdelraheem Elghetany*1, Mohamed Khaled Galal Selim1,
Ziyad Mohamed Essam El-Din Tawhid2 Ahmed Abdel Khabir Ahmed Ibrahim1
Departments of 1Dermatology, Andrology& STDs and
2Clinical Pathology, Faculty of Medicine - Mansoura University, Egypt
*Corresponding author: Dina Mostafa Abdelraheem, Mobile: (+20) 01142014528, E-Mail: dinamelghetany@gmail.com

ABSTRACT
Background:
Elafin is barely detectable in normal skin and is strongly expressed in inflamed skin. It is highly expressed
in epidermis, sputum, and urine of psoriatic patients but is not specific for psoriasis.
Objective: To estimate the serum level of elafin in psoriasis cases and its correlation with the severity of psoriasis.
Patients and methods: This was a case-control study carried out on 45 patients with different clinical types of psoriasis
who were newly diagnosed or stopped systemic treatment for at least 3 months before the study. They were recruited
from the Outpatient Clinic of Dermatology Department, Mansoura University Hospital. In addition 45 normal healthy
subjects with matched age and sex were selected to act as a control group.
Results: The mean onset, duration and psoriasis area severity index (PASI) were 37 ± 9.43, 8.37 ± 8.07 and 23.28 ±
14.53 respectively.
Psoriasis group was associated with a significant increase in serum elafin level compared to the
control group. Cases with severe psoriasis demonstrated the highest serum elafin level followed by moderate psoriasis
and lastly mild psoriasis. ESR, CRP and elafin could be used as reliable biomarkers in terms of the differentiation among
psoriasis and the control group with high accuracy, sensitivity and specificity. Elafin level was demonstrated to be
significantly correlated with PASI, ESR and CRP.
Conclusion: Elafin level demonstrated significant elevation among psoriatic cases and correlated positively with the
disease severity (as revealed by PASI score). Thus, it could be used as a promising predictor for psoriasis diagnosis,
which could impact the therapeutic lines in the future.
Keywords:
Serum elafin level, CRP, ESR, PASI, Psoriasis.

INTRODUCTION
pathogenic microorganisms and modifying host
Psoriasis is a chronic, hyperproliferative
inflammatory responses (7).
inflammatory skin disease with a genetic background,
Elafin is one of natural AMPs (8). It is a serine
with characteristic erythematous squamous plaques that
protease inhibitor produced by epithelial and immune
have specific silver scaly appearance. Its percentage in
cells with anti-inflammatory properties (9). Elafin's
the general population is 1-3 % (1). Diagnosis of
functions are not only restricted to its protease inhibitor
psoriasis is informed by examination of the skin. The
action but also extend to involve other molecular
classic symptoms of psoriasis vulgaris are highly visible
properties, influencing cellular proliferation and
chronic erythematous plaques covered by silvery white
inflammation (10).
scales, forming on the elbows, knees, scalp, umbilicus
Interleukin 1 beta and TNF alpha are released
and lumbar area (2). Additional types of psoriasis
by neutrophils in skin disorders with extensive dermal
comprise approximately 10% of cases. They include
neutrophil infiltration (as psoriasis), causing over-
pustular, inverse, napkin, guttate, oral, and seborrheic-
expression of elafin, which acts as a protective agent
like forms (3). Pustular psoriasis (PP) is a group of
against damage of the epidermis by neutrophil elastase
inflammatory skin conditions characterized by
(11). The aim of this work was to estimate serum level of
infiltration of neutrophil granulocytes in the epidermis
elafin in psoriasis cases and its correlation with the
to such an extent that clinically visible sterile pustules
severity of psoriasis.
develop (4). Psoriasis causes functional impairment and

emotional distress to patients. The impact of the disease
PATIENTS AND METHODS
can result in restrictions to social and recreational
This is a case control study carried out on 45
activities and productive life, in addition to possible
patients with different clinical types of psoriasis. They
harm to these patients' affective and sexual
were recruited from the outpatient clinic of
relationships (5).
Dermatology department of Mansoura University
The psoriasis area severity index (PASI), which
Hospital, from August 2018 to August 2019. In addition
is used for clinical evaluation, is the most cited and most
45 normal healthy subjects with matched age and sex
often used tool due to its high degree of reliability,
were selected to act as a control group.
applicability and reproducibility (6).
The subjects were subdivided into two groups:
Lesional skin in psoriasis is characterized by
Group A (patient group): includes 45 patients with
the excessive production of antimicrobial peptides
different clinical types of psoriasis, and Group B
(AMPs), which are known for their role in killing

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y/4.0/)

2884

Received:15 /5 /2021

Accepted:11 /7 /2021

Full Paper (vol.851 paper# 36)


c:\work\Jor\vol851_37 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2890-2896

Serum Homocysteine Level as A Marker of Erectile Dysfunction
Mohammed Hussein Mahmoud Elmogy, Ashraf Elsaid Abd Elfattah Elsaid*,
Ahmed Fathy Ahmed State, Ahmed Shawki Hasan
Departments of 1Dermatology, Andrology & STDs and 2Clinical Pathology,
Faculty of Medicine - Mansoura University, Egypt.
*Corresponding author: Ashraf Elsaid Abd Elfattah Elsaid, Mobile: (+20) 01006342361, E-Mail: ashraf_elsaid@mans.edu.eg

ABSTRACT
Background:
The Fourth International Consultation on Sexual Medicine defined erectile dysfunction (ED) as a
consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction homocysteine
(Hcy) is a toxic, nonproteogenic sulfur-containing amino acid synthesized from dietary methionine in the liver and is
metabolized either via trans-sulfuration or remethylation pathway.
Objective:
To investigate serum Hcy levels in ED patients as compared to those in healthy controls, and to explore its
correlation with severity of ED.
Patients and methods: This study consisted of 30 ED-affected men and 50 age-matched controls who were free from
ED. All participants were recruited from the Andrology Outpatient Clinic of Mansoura University Hospital, between
October 2019 and September 2020.
Results: Serum Hcy was significantly higher in ED cases compared to controls (P < 0.001). The mean of serum Hcy in
cases was 24.17 ± 11.502 µmol/L versus 8.43 ± 9.076 µmol /L in controls. 23 out of 30 ED cases (76.66 %) had
hyperhomocysteinemia (> 15 mol/L). On the other hand, 6 out of 50 controls (12 %) had elevated level of Hcy.
Elevation of Hcy levels was associated with an increased risk of ED, and that a cut-off value of 8.28 µmol/L was able
to detect ED patients with a corresponding sensitivity and specificity of 90.0% and 78% respectively.
Conclusion: Elevated Hcy is associated with ED and may represent an important risk factor and play a pathophysiologic
role in ED. Hence, Hcy-lowering agents, such as folic acid and vitamin B12, seem reasonable choices for the prevention
and management of this condition.
Keywords: Homocysteine, Erectile dysfunction.

INTRODUCTION
a common primary cause of ED, but rather a marker of
Erectile dysfunction (ED) is a major health
endothelial oxidant stress that is a major mediator of this
problem that becomes increasingly prevalent with age,
disorder. Hcy can cause cellular injury via oxidative
and seriously affects the quality of life and self-esteem
damage (9), which is a major mechanism responsible for
of patients and their partners (1). A wide range of
vascular dysfunction in hyperhomocysteinemic
disorders are associated with increased concentrations
animals' model that is made by genetic or dietary means
of Hcy.
(10), and in humans with massive elevation of Hcy as
The proposed mechanisms of the association
seen in homocysteinuria(11).
include angiotoxicity, neurotoxicity, and inhibition of
Severe forms of hyperhomocysteinemia are
collagen cross-linking (2). Elevated serum Hcy has been
commonly due to major genetic mutations of the
linked to impaired endothelial function and occlusive
enzymes implicated in the Hcy metabolism (e.g.,
vascular disease (3). ED and cardiovascular disease share
MTHFR polymorphisms), whereas slightly elevated
the same principal risk factors considered to induce
Hcy values are more frequently caused by vitamin
vascular endothelial damage (4). Hyperhomocysteinemia
deficiencies and environmental factors (12). Several
could also be involved in the pathogenesis of ED, and
studies suggest Hcy may be an independent risk factor
there is a growing body of evidence supporting the close
for ED (6, 7). The aim of the present study was to
correlation between hyperhomocysteinemia and ED (5).
investigate serum Hcy levels in ED patients as
Increased Hcy could inhibit NOS, probably influencing
compared to those in healthy controls, and to explore its
the production of NO, and the development of ED (4).
correlation with severity of ED.
Meanwhile, hyperhomocysteinemia was shown to be a

risk factor for ED and endothelial dysfunction in rat
SUBJECTS AND METHODS
models (6). It was assumed that Hcy might be a risk
This prospective case-control study was
factor for ED in men (6, 7, 8). However, the role of Hcy in
conducted in the Outpatient Clinic of Dermatology,
the development of ED is still putative, and it is not clear
Andrology, and STDs Department (Andrology Unit),
whether Hcy actually plays a causal role in ED with
Mansoura University Hospital, between October 2019
which it is associated, or rather a marker of some other
and September 2020.
underlying mechanism. Data suggests that Hcy is a
Cases group included 30 men with ED who
marker for the presence of pathological oxidant stress
consecutively attend the Andrology Outpatient Clinic.
(7). Thus, it is possible that hyperhomocysteinemia is not
A control group of 50 age-matched healthy men with

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2890
Received: 17/5/2021

Accepted: 13/7/2021

Full Paper (vol.851 paper# 37)


c:\work\Jor\vol851_38 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2897-2902

Relation between Complicated Allergic Fungal Rhinosinusitis and the
Mycological Profile of the Isolated Fungal Species
Awatef Mahmoud Ahmed1*, Ibrahim Rezk Mohamed1,
Abeer Sheneef Mohamed2, Mohammed Abdel-Kader Ahmed1, Ahmed Ismail1
Departments of 1Otorhinolaryngology and 2Microbiology and Immunology,
Faculty of Medicine, Sohag University, Sohag, Egypt
*Corresponding Author: Awatef Mahmoud Ahmed, Email: awafef.ahmed@med.sohag.edu.eg

ABSTRACT
Background:
Allergic fungal sinusitis is a non-invasive pansinusitis that occurs in young immunocompetent
individuals, with a strong history of atopy and elevated levels of total immunoglobulin E and peripheral eosinophilia.
Objective:
The main target of the study was to know the relation between complicated allergic fungal sinusitis and the
mycologic profile of the causative fungal species, as regards the genus and species of the isolated fungus, its antifungal
susceptibility and its ability to produce destructive extracellular metabolic products and toxic agents.
Patients and Methods: Our cross sectional research included 50 individuals diagnosed with complicated allergic fungal
rhinosinusitis who attended to the ENT outpatient clinic. All the studied patients were evaluated by full history, complete
ENT examination, radiological evaluation, laboratory investigations and endoscopic sinus surgery.
Results: Aspergillus spp., particularly Aspergillus fumigatus and Aspergillus flavus, are the most often identified agents
in allergic fungal rhinosinusitis. A multifaceted strategy to treat allergic fungal rhinosinusitis is necessary; surgery is the
primary treatment for allergic fungal sinusitis. Corticosteroid treatment in its entirety is presently the gold standard of
medical management, whereas alternative pharmacological treatments such as antifungals, antimicrobials, leukotriene
modulators, and immunotherapy are reserved for those who are insufficiently responsive..
Conclusions: The most frequent kind of fungal rhinosinusitis is allergic fungal rhinosinusitis. It is found in immune-
competent youth who have a history of allergic rhinitis and/or asthma. Allergic fungal rhinosinusitis has a relatively slow
and indolent clinical course, but results in the growth of bone walls, resulting in their thinning or weakening and final
erosion.
Keywords: Allergic sinusitis, Aspergillus, Fungal Species, Mycological Profile.

INTRODUCTION

Fungal sinusitis is a prevalent infection that has
mucin acquired surgically, the presence of fungal
raised considerably in incidence over the last 30 years.
hyphae in allergic mucin or a positive fungal culture in
This tendency might be related to the greater usage of
correctly collected sinus material in an otherwise typical
immunosuppressive drugs in the modern era, as well as
patient, no histopathologic evidence of mucosal fungal
improved public awareness (1).
invasion, granulomata, mucosal necrosis, or giant cells
The clinical, radiologic, and histologic aspects of
must be eliminated, as well as other fungal
the host-pathogen interaction can be used to classify
rhinosinusitis disorders (3).
fungal illness of the nose and paranasal sinuses. The
Species of Aspergillus especially Aspergillus
majority of widely recognized categorization methods
Niger, Flavus and Fumigatus Diagnostic criteria for
categorize fungal rhinosinusitis as invasive or
allergic fungal sinusitis include the following: Sinusitis
noninvasive based purely on histopathologic evidence
is confirmed radiographically, with serpiginous areas of
of fungus penetration of host tissue. Acute fulminant
heightened attention in affected sinuses seen on
invasive fungal sinusitis, granulomatous invasive
computed tomography (CT). Atypical allergic mucin
fungal sinusitis (GIFS), and chronic invasive fungal
obtained surgically, the presence of fungal hyphae in
sinusitis are all types of invasive fungal sinusitis (CIFS).
allergic mucin, or the presence of a positive fungal
Saprophytic fungal infection (SFI), sinus fungal ball,
culture in properly collected sinus material in an
and allergic fungal rhinosinusitis are all examples of
otherwise typical patient. No histopathologic evidence
noninvasive fungal sinusitis (2).
of fungal invasion, granulomata, mucosal necrosis, or
Allergic fungal sinusitis is a non-invasive
large cells, as well as other fungal rhinosinusitis
pansinusitis that often affects young immunocompetent
diseases, must be excluded (4).
people with a significantly strong history of atopy and
Complications of allergic fungal sinusitis include
increased total immunoglobulin E and peripheral
orbital medial wall erosion seen on imaging,
eosinophilia (1). The following characteristics constitute
ophthalmoplegia, epiphora, diplopia, proptosis, orbital
the diagnostic criteria for allergic fungal sinusitis:
abscesses and also visual loss in rare cases. The
Sinusitis verified radiographically, with computed
proximity of important neurovascular structures
tomography (CT) indications of serpiginous regions of
including the internal carotid artery, cranial nerves,
increased attention in afflicted sinuses, Atypical allergic
cavernous sinus, dura mater, and cerebral lobes puts any

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2897

Received:15 /7 /2021

Accepted:11 /5 /2021

Full Paper (vol.851 paper# 38)


c:\work\Jor\vol851_39 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2903-2906

Reduction and Fixation of Unstable Slipped Capital
Femoral Epiphysis: A Case Report
Abdulhamid Talal Alghamdi
Department of Orthopedic Surgery, Al Noor Specialist Hospital, Makkah, Saudi Arabia
Corresponding author: Abdulhamid Talal Alghamdi, Mobile: +966500323870, E-Mail: dr.atghamdi@hotmail.com

ABSTRACT
Background:
Slipped capital femoral epiphysis, is a common condition of the proximal femoral physis that leads
to slippage of the epiphysis relative to the metaphysis. Diagnosis can be confirmed with radiographs of the hip.
Treatment is usually percutaneous screw fixation.
Objective: To study the outcome and complications of closed reduction and internal fixation by percutaneous screw
fixation in unstable slipped capital femoral epiphysis.
Patient and methods: Our case report is 11 years old obese male patient with history of progressive right hip pain
for 10 days prior to presentation to the hospital. BMI was 36.1 kg/m2. Patient presented with right hip pain and
inability to bear weight, radiological evaluation confirmed right hip unstable slipped capital femoral epiphysis that
required emergency in situ fixation
Result: close follow up of the patient to 6 months, patient regain full functional activity, he achieved a complete
range of motion of the right hip with good outcomes and with no complications. The goal in such injuries is to
achieve a stable hip joint with gradual rehabilitation to reach a good functional outcome
Conclusion: Slipped capital femoral epiphysis occurs in adolescent age group, more affecting male and obese
patient, and they are idiopathic in the majority of cases. The goal of treatment in such patients is to achieve a stable
hip joint with gradual rehabilitation to reach the optimal functional outcomes
Keywords: Slipped capital femoral epiphysis, Adolescent hip problem, Klein's line.

INTRODUCTION

Slipped capital femoral epiphysis (SCFE) is
CASE REPORT
defined as a posterior and inferior slippage of the
11 years old obese male patient not known to
proximal femoral epiphysis (femoral head) on the
have any medical or surgical past history, came to the
metaphysis (femoral neck), occurring through the
hospital with a complaint of severe pain on weight
epiphyseal growth plate during the early adolescent
bearing of the right hip after sustaining a very
growth spurt (1).
minimal fall about one week ago, that classifies the
SCFE has been found to affect children aged 9
slip as unstable. The patient gave a history of mild
to 16 years in the United States at a rate of 10.80 cases
right hip pain for approximately 4 month, making the
per 100,000 children (2). In a retrospective review,
presentation taken a form of acute on top of chronic.
investigators found that 81.1% of children with SCFE
He didn't report left hip pain, he denied any radiation
had a BMI above the 95th percentile (i.e. clinically
exposure, family history was insignificant.
obese) compared to only 41.3% of controls (P <
Physical exam revealed a well-developed, well-
0.0001) (3).
nourished child, 158 cm height and weighed 90 kg,
The obesity had the effect of increasing the
The resultant BMI was 36.1 kg/m2a. slight antalgic
weight and cause shearing force across the growth
lean to the left, on supine examination, leg length
plate of proximal femoral physis leading to
discrepancy noted with right leg was short by about 2
progressive slippage of femoral head posterior and
cm and externally rotated. The right hip joint ROM
inferior in direction to weight-bearing force (3).
was restricted and very painful in passive flexion and
This case report presents the initial assessment,
internal rotation.
diagnosis, efficacy of the closed reduction and screw
Patient had positive Drehmann sign (obligatory
fixation method and post-operative follow up,
external rotation while passive flexion applied on the
reporting complications if found in patient with a
hip), positive FABER-Patrick's test (Flexion,
SCFE. Therefore, this study aimed to evaluate the
Abduction and External Rotation of the hip produce
efficacy of the used fixation and treatment methods.
pain or restriction of motion). Supine leg length

testing using Allis' sign revealed no gross anatomical

leg length discrepancy.



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2903
Received: 17/5/2021

Accepted: 13/7/2021

Full Paper (vol.851 paper# 39)


c:\work\Jor\vol851_40 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2907-2911

Manual Hyperinflation, A Novel Technique in Physiotherapy of
Pediatric Post Cardiac Surgery Patients
Eman Abdel-Wahab Abdel-Mageed Mohamed*1, Naglaa Ahmed Zaky Aly1,
Tamer Mohamed El-Saeed1, Mohammed Abdel-Gayed Ibrahim2
1Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
2Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Eman Abdel-Wahab Abdel-Mageed Mohamed, Mobile: (+20) 01141716119,
E-Mail: amdabdelmageed@gmail.com

ABSTRACT
Background
: Physiotherapy plays an important role in Pediatric Intensive Care Unit (PICU) after cardiac surgery, and
addition of manual hyperinflation (MHI) to physiotherapy program may help early weaning from mechanical ventilation
and decrease length of stay in PICU.
Objective: To measure the effect of MHI on ventilation period and ICU stay days in pediatric post cardiac surgery
patients.
Patients and methods: Thirty patients from both sexes were selected from PICU at Academic Institute for Heart
Surgery, Ain Shams University. Their ages ranged from 6 to 36 months.
Results: There was a significant decrease in PaCO2 post treatment compared with that pre-treatment in the study and
control groups (p>0.05). There was a significant increase in PaO2 post treatment compared with that pre-treatment in
the study and control groups (p>0.001). Comparison between groups post treatment revealed a significant increase in
PaO2 and a significant decrease in PaCO2 of the study group compared with that of the control group (p>0.01). There
was a significant decrease in ventilation days and ICU stay days of the study group.
Conclusion:
Based on this study, it could be concluded that manual hyperinflation improves arterial oxygenation and
reduces length of stay in PICU.
Keywords: Arterial Blood Gases, Cardiac Surgery, Manual Hyperinflation, Pediatric Intensive Care Unit.

INTRODUCTION

expand the lungs and release secretions, and in most
Patients with congenital heart disease are at risk
centers this technique is also commonly used for
of difficulty in movement, cognition, language,
critically ill infants and children (5).
breathing, and feeding after heart surgery.
Research in the field of pediatric post cardiac
Rehabilitation treatment can even reduce complications
surgery in ICU is deficient. New horizons for
and length of stay (LOS) during PICU and
physiotherapy are opening and new evidence based
hospitalization. The purpose is to reduce morbidity and
guidelines should be created for treatment plans to
mortality through acute postoperative time in children
follow, which will transform physiotherapy from an art
after surgery, and describe rehabilitation program.
to a science.
However, there is little information about the type of
Decreasing the number of ICU stay days has a
acute postoperative treatment that children require (1).
social dimension by decreasing the burden of long term
For a variety of reasons, mechanically ventilated
sequelae thereby improving the whole health care
patients are at risk of secretion retention. Tracheal
system throughout. So this study was conducted to
intubation will disturb the mucociliary escalator and
evaluate and decrease morbidity and mortality in
make the patient vulnerable to infection, thereby
pediatrics after cardiac surgery.
increasing the volume and viscosity of the mucus. The
The aim of this study was to investigate effect of
relative immobility of mechanically ventilated patients
manual hyperinflation on arterial blood gases in
in bed can cause atelectasis, changes in coughing
children after cardiac surgery.
production, and stagnant secretions (2). Respiratory

physical therapy intervention is routinely used in the
PATIENTS AND METHODS
treatment of ventilated children in the pediatric
Thirty patients from both sexes were selected from
intensive care unit to prevent mucus retention and
PICU at Academic Institute for Heart Surgery, Ain
pulmonary complications, enhance oxygenation, and
Shams University. Their ages ranged from 6 to 36
re-expand the collapsed lobes (3).
months.
Physical therapists have been using manual
Children were divided randomly into 2 groups of equal
hyperinflation for many years to mobilize excess lung
number, Group A: (Control group, fifteen subjects)
secretions, re-inflate the area of atelectasis, and improve
received traditional chest physiotherapy only (postural
oxygenation (4). Physical therapists working in the
drainage, positioning, passive movement, manual
intensive care unit often use manual hyperinflation
intervention (percussion and vibration) and suction)
techniques in combination with other interventions to
twice/day for 15 minutes each session till discharge

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2907

Received: 3 /5 /2021

Accepted:29 /6 /2021

Full Paper (vol.851 paper# 40)


c:\work\Jor\vol851_41 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2912-2919

Effect of Educational Training Program on Research Activities among First Grade
Medical Students at Zagazig University
Abd El-Lateef S. Ali, Sohair A. Hagag, Alaa S. Nouh*, Hanaa A. Nofal
Department of Public Health and community medicine, Faculty of Medicine, Zagazig University,Egypt
*Corresponding author: Alaa Nouh, Mobil: (+20)01097748986, Email: nouh.alaa@yahoo.com
ABSTRACT
Background:
One of the most important measures of scientific progress in any country in the present days is the research
situation. Medical students should be equipped with ample skills and knowledge about conducting research to become
an efficient researcher. Objective: This study aimed to upgrade scientific research among medical students of Faculty
of Medicine, Zagazig University to assess the effect of educational training program on knowledge, attitude and skills
of research. Patients and Methods: A randomized-controlled trial (an interventional study) was conducted among 110
first grade medical students. The sample was divided randomly into 2 groups: Intervention group included 55 students
received the educational training program and control group that included 55 students. This study done on 3 phases: In
the pre-intervention phase: knowledge, attitude and skills of research were assessed among all studied sample. Then the
intervention group underwent the educational training program. Lastly in the post-intervention phase; knowledge,
attitude and skills of research were assessed among both groups. Results: There was statistically significant difference
of knowledge, attitude and skills of research between intervention group and control group at post-intervention phase
(P<0.05). Also, there was statistically significant difference of knowledge, attitude and skills in intervention group pre-
and post-intervention (P < 0.05). Conclusion: The educational training program was effective in improving levels of
knowledge, attitude and skills of research among the first grade medical students.
Keywords: Research skills, Training program, Medical students.

INTRODUCTION
educational training program and control group (55
Research is a systematic process to achieve new
students). Assuming that knowledge score in
knowledge, science or invention by using of standard
intervention group is 70 ± 22 and in control group 60 ±
methods (1). One of the most important measures of
12 with confidence level 95% and power of test 80.0%
scientific progress in any country in the present days is
. The sample size was calculated to be 110 students by
the research situation. Therefore, the importance of
using Epi program.
conducting scientific and accurate research has
The students included in the study were selected
increased in most countries, both developed and
by simple random sample. Then, they were classified
developing. This trend may be due to the desire to
randomly into intervention group and control group.
resolve the health care problems in their communities,
1st phase: knowledge, attitude and skills of research
to establish independence from other countries or to
were assessed in both groups.002
compete with them (2).
2nd phase (Education session phase): Education
Research training is a vital constituent of
procedures were implemented to establish objectives of
medical education, so becoming a consumer of research
the study It is done by :
should be a goal for all medical students and graduates
- A brochure that was distributed as handout to students
(3). The level of knowledge has also been found to be
of intervention group.
poor among these students. However, after receiving
- Lectures (power point presentation): contain research
training on research a significant improvement in
definition & process, study designs and research
knowledge and a desirable change in attitude has been
methodology and guidelines for protocol and papers
observed (4). To become an efficient researcher, one has
writing.
to be equipped with ample skills and knowledge about
- Training on searching skills: Students were trained
the research methodology (5). This study aimed to
online on how to find medical websites, how to write
upgrade scientific research among medical students of
the query and number of key words, specification
Faculty of Medicine, Zagazig University to assess the
and narrowing of research topics.
effect of educational training program on knowledge,
3rd phase (post-test phase): Reassessment of
attitude and skills of research.
Knowledge and attitude after one month from giving the

educational message. Reassessment of skills by check
PATIENTS AND METHODS
list for the online searching skills and using web for
Randomized-controlled trial ( an interventional
finding information.
study) was conducted at Faculty of Medicine, Zagazig
Tools of study: Data of the study were collected
University from April 2019 till October 2020 among
through out the following tools:
first grade medical students, Faculty of Medicine
Tool I: Structured questionnaire used to collect personal
Zagazig University. The sample was divided into 2
data such as sex, type of school, educational level and
groups: Intervention group (55 students) received the
work of parents



This article is an open access article distributed under the terms and conditions of the Creative
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2912

Received: 17/5/2021

Accepted: 13/7 /2021

Full Paper (vol.851 paper# 41)


c:\work\Jor\vol851_42 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2920-2924

Outcomes of Interfragmentary Mini Screws for Fixation of
Metacarpals and Phalanges Fractures
Abdelrahman Ibrahim Noureldin*, Alaa Mostafa Elngehy,
Waleed Mohamed Nafea, Mohamed Adel Abdelrazek
Department of Orthopaedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Abdelrahman I. Noureldin, Mobile: (+20)01008695648, Email: abdulrhmanour@gmail.com

ABSTRACT
Background:
Hand fractures represent a considerable burden upon society in terms of medical costs and reduced
workplace productivity. Fractures of the metacarpals and phalanges are the most common fractures of the upper
extremity. Outcome of conservative treatment in displaced, irreducible, unstable and rotational fractures is poor.
Objective: To assess the outcome of fixation of oblique and spiral fractures of phalanges and metacarpals of the hand
by interfragmentary mini screws and to evaluate the rate of complications. Patients and methods: A study included 18
patients with oblique and spiral fractures, 6 metacarpals and 12 phalangeal fractures. Patients were managed by open
reduction and internal fixation using mini Interfragmentary screws with lag technique at Zagazig University Hospital
and Zagazig General Hospital. Results: Four weeks postoperative, the mean total active motion (TAM) score was 83.22
± 13.26. Early range of motion assessment revealed one (5.6%) poor, two (11.1%) fair, five (27.8%) good and ten
(55.6%) excellent results. The end results by measuring grip strength of affected hand for metacarpals was excellent in
two patients (40%), good in two patients (40%) and fair in one patients (20%). The mean grip strength for metacarpals
was 85.8 ± 7.5. While the grip strength of affected hand for phalanges was excellent in eight patients (61.5%), good in
four patients (30.7%) and fair in one patients (7.7%). The mean grip strength for phalanges was 90.07 ± 7.3.
Conclusion:
Inter-fragmentary mini lag screws fixation represents an effective method for managing such rotationally
unstable fractures as oblique and spiral hand fractures. Younger patients with hand fractures revealed better results of
range of motion and hand function.
Keywords: Mini screws, Spiral hand fractures, TAM score, Metacarpal fractures.

INTRODUCTION
patterns amenable to non-operative treatment. While, in
Hand fractures represent a major burden to society
those patients who are requiring surgical fixation,
in terms of medical costs and low productivity of the
treatment options are variable and include: closed or
workplace (1). Approximately, 70% of all metacarpal and
open reduction and fixation with percutaneous pinning,
phalangeal fractures occur between the age of eleven and
extra-
or
intra-osseous
wiring,
lag
screws,
45 years (2). Additionally, when the hand has multiple
intramedullary devices, plates or external fixation (7, 8).
fractures that each might be stable in isolation, the
The current study aimed to evaluate the outcome
collective may necessitate operative fixation, as is
of fixation of oblique and spiral fractures of metacarpals
sometimes the case for metacarpal shaft fractures (3).
and phalanges of the hand by Inter-fragmentary mini
Many hand fractures that require surgical treatment are
screws and to assess the rate of complications, in
amenable to minimally invasive techniques for several
particular related to joints stiffness and bone healing.
reasons. First, the subcutaneous location of bones lends

them to the placement of percutaneous fixation. Second,
PATIENTS AND METHODS
the deforming forces exerted by the forearm and hand
This study included 18 patients with oblique and
musculature are relatively modest, so rigid fixation with
spiral fractures, 6 metacarpals and 12 phalangeal
plates and screws is less necessary than in other parts of
fractures. Patients were managed by open reduction and
the body where forces are greater (4). Open reduction and
internal fixation using mini interfragmentary screws
internal fixation with lag screws are technically
with lag technique at Zagazig University Hospital and
demanding but provides inter-fragmentary compression.
Zagazig General Hospital.
It avoids the risk of soft tissue dissection (5). The main
Inclusion criteria: Skeletally mature patients with spiral
advantages of these implants are the added stability
displaced metacarpals or phalanges (8 patients), oblique
provided by fracture compression and the resultant or
displaced metacarpals or phalanges (10 patients), closed
independent neutralization of bending, rotational and
fractures (17 patients), open fractures with minimal
shear forces acting upon the fracture site. These features
tissue laceration (one patient). All patients had recent
help to ensure timely fracture healing and to allow earlier
fracture within 2 weeks of trauma.
and more intensive digital rehabilitation (6).
Exclusion criteria: Patients with a non-displaced
Optimal treatment for metacarpal and phalangeal
fractures, comminuted fractures, fractures associated
fractures remains to be debated. Closed reduction and
with tendon injuries and significant neurovascular
immobilization or functional bracing is reported, but
injuries, high grade open fractures and fire arm injuries.
requires careful selection of patients with fracture

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2920
Received:18 /5 /2021

Accepted:14 /7 /2021

Full Paper (vol.851 paper# 42)


c:\work\Jor\vol851_43 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2925-2929

Different Patterns of Juvenile Idiopathic Arthritis in Zagazig University Hospitals
Mohamed Abd-Elkader Almalky, Ehab Mahmoud Rasheed,
Mohamed Attia Mortada, Khairia Mohamed Ayyad*
Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Khairia Mohamed Ayyad, Mobile: (+20) 01008695648, E-mail: ayyad Khairia@gmail.com

ABSTRACT
Background:
Pediatric rheumatic diseases can cause considerable disease burden to children and their families. They
are associated with the potential for physical disability, diminished quality of life and significant direct and indirect
costs. Objective: We aimed to describe the clinical spectrum and the frequencies and different patterns of Juvenile
idiopathic arthritis (JIA) in children in Zagazig University Hospitals.
Patients and methods:
A cross-sectional study included 68 cases with Juvenile idiopathic arthritis < 16 years. The
study was conducted over two years from December 2017 to December 2019. Investigations as complete blood count,
C reactive protein, antinuclear antibody (ANA), rheumatoid factor (RF), complement C3 & C4, creatine phosphokinase,
and EMG. Management and treatment plans were achieved and data about the results were collected.
Results:
Most of patients diagnosed with rheumatological diseases were females. Oligoarticular JIA was the commonest
subtype of JIA in our study followed by polyarticular then systemic onset type. NSAIDs was the commonest drug used
by JIA patients followed by methotrexate then corticosteroids.
Conclusion:
Early diagnosis and effective management of these children is essential so that they can lead a normal or
near normal life especially in patients with rheumatological diseases with chronic morbidity as JIA.
Keywords: Juvenile idiopathic arthritis, Pediatric rheumatic diseases.

INTRODUCTION
cases diagnosed with Juvenile idiopathic arthritis either
Rheumatic diseases include many types such as,
inpatient or outpatient <16 years. The study was
juvenile idiopathic arthritis, juvenile systemic lupus
conducted over two years from December 2017 to
erythematosus, juvenile dermatomyositis, mixed
December 2019.
connective tissue disease, Kawasaki disease, juvenile

scleroderma and fibromyalgia (1). Juvenile idiopathic
Data were collected from all patients as follows:
arthritis (JIA), also known as juvenile rheumatoid
1- Full history taking and duration of symptoms.
arthritis, is the most common chronic systemic
2- Full clinical examination including the skin, mucous
inflammatory disease in children below 16 years old of
membrane, cardiopulmonary auscultation and
unknown etiology. It causes persistent joint pain,
assessment of enlarged organs and glands. After
swelling and stiffness. Some children may experience
performing the complete general examination,
symptoms for only a few months, while others have
examination of the joints was done. Examination of
symptoms for the rest of their lives (2).
the joint finally confirms the diagnostic impression
Pediatric rheumatic diseases (PRDs) are any of a
suggested by the medical history (presence of arthritis
variety of disorders marked by inflammation,
or other finding and the type whether oligoarthritis or
degeneration, or metabolic derangement of the
polyarthritis) (5).
connective tissue structures especially the joints and
3- Investigations as complete blood count.C- reactive
related structures in children. Approximately 1 in 1000
protein, antinuclear antibody (ANA) profile,
children suffers from childhood rheumatic diseases (3).
rheumatoid factor (RF), anti-cyclic citrullinated
Although they share many common symptoms, like pain,
peptide antibodies, complement C3 & C4, creatine
joint swelling, redness and warmth, they are distinct and
phosphokinase and EMG.
each has its own special concerns and symptoms. Some
4-Treatment:
Corticosteroids,
nonsteroidal
anti-
pediatric rheumatic diseases affect the musculoskeletal
inflammatory drugs include aspirin, ibuprofen,
system, but joint symptoms may be minor or nonexistent
acetaminophen, disease-modifying antirheumatic
component. Pediatric rheumatic diseases can involve the
drugs (DMARDS) including hydroxychloroquine,
eyes, skin, muscles and gastrointestinal tract as well (4).
penicillamine,
sulfasalazine,
methotrexate,
We aimed to describe the clinical spectrum and
immunosuppressant drugs like cyclophosphamide,
the frequencies and different patterns of Juvenile
antidepressants like imipramine and new drugs such
idiopathic arthritis (JIA) in children in Zagazig
as tumor necrosis factor (TNF) blockers etanercept,
University Hospitals.
adalimumab and infliximab.


PATIENTS AND METHOD
Ethical approval:

This study was a cross-sectional study carried
An approval of the study was obtained from
out in Pediatrics and Rheumatology Departments of
Zagazig
University
Academic
and
Ethical
Zagazig University Hospitals. The study included 68
Committee. Every patient signed an informed written

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2925

Received:18 /5 /2021

Accepted:14 /7 /2021

Full Paper (vol.851 paper# 43)


Microbial The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2930-2936

Management of Metaphyseal Tibial Fractures by Expert Tibial Nail System
Elsayed Abdelmoaty Elsherbiny, Ahmed Mohammed Abdelwahab,
Mohamed Ismail Abd El Rhman Kotb, Ahmed Mohammed Mousa*
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Ahmed Mohammed Mousa, Mobile: (+20)1283612715, E-mail: ahmedmousa_201017@yahoo.com

ABSTRACT
Background:
Metaphyseal tibial fractures contain distal and proximal metaphyseal fractures which account for (3-
11%) and (5-11%) of total tibial fractures, respectively. Numerous treatment options exist for treating metaphyseal
tibial fractures. Objectives: The aim of the current work was to assess the clinical and radiological functional
outcomes of expert tibial intramedullary nail in treatment of metaphyseal tibial fractures in adult.
Patients and Methods: This prospective study included a total of 12 patients who had metaphyseal tibial fractures,
attending at Zagazig University Hospital and Damietta Specialized Hospital. Patients were operated by closed
reduction and internal fixation with expert interlocking tibial nail and followed up for average 6 months from
November 2019 to December 2020. Results: All patients underwent full history taking, Clinical examination and
Radiographic views were taken for other skeletal injuries if suspected. 2 patients (16.7%) has proximal tibial fracture,
1 (8.3%) of them had excellent final result and 1 (8.3%) had good final result. 2 patients (16.7%) had segmental tibial
fracture,1(8.3%) of them had excellent final result and 1 (8.3%) had fair final result. 8 (66.7%) patients had distal
tibial fractures, 6 (50%) had excellent final result, 1 (8.3%) had good final result,1 (8.3%) had poor final result.
Conclusion: It could be concluded that intramedullary fixation with expert interlocking tibial nail is a safe and
effective method for the treatment of metaphyseal tibial fractures. Multiple reduction aids as percutaneous clamps,
blocking screws/wires help in obtaining and maintaining reduction. The nail design allows the distal or proximal
segment to be controlled through placement of multiple locking screws within a small distance from the articular
surface. The alignment can be well maintained despite the short metaphyseal segment. Expert nail showed excellent
and good results in more than 83% in this study.
Keywords: Anteroposterior, Expert Tibial Nail, Intramedullary, Minimally Invasive Plate Osteosynthesis, Total Knee
Arthroplasty

INTRODUCTION


Rising incidence of high velocity trauma due to
screws like soft tissue damage , wound infection and
motor vehicle accidents usually results in fractures of
delayed weight bearing it also overcomes the
long bones. The tibia is the most commonly fractured
malreduction complications related to conventional
long bone in the body due to its location, structural
intramedullary nails when used in metaphyseal tibial
anatomy and sparse anteromedial soft tissue coverage (1).
fractures as procurvatum and flexion deformity which
Tendency towards operative management of tibial
occur when used in proximal metaphyseal fractures (6,7).
fractures is in vogue to reduce the complications
The aim of the current work was to assess the
associated with conservative treatment. Various
clinical and radiological functional outcomes of expert
operative methods like open reduction and plating,
tibial intramedullary nail in treatment of metaphyseal
intramedullary nailing and external fixation have their
tibial fractures in adult.
own indications, advantages and disadvantages (2,3,4).

Intramedullary nailing (IMN) has numerous
PATIENTS AND METHODS
advantages for fracture fixation, including its potential
This prospective study included a total of 12
for minimally invasive exposure, biologically friendly
patients (8 males and 4 females) aged from 18- 60 years
implant insertion, longer implant to span more complex
who had metaphyseal tibial fractures, attending at
fractures and load sharing fixation to allow earlier
Zagazig University Hospital and Damietta Specialized
weight
bearing.
The
major
advancement
in
Hospital. Patients were operated by closed reduction and
intramedullary nailing of metaphyseal tibial fractures
internal fixation with expert interlocking tibial nail and
was the introduction of modern implants like Expert
followed up for average 6 months from November 2019
Tibial Nail System (ETNS) (5).
to December 2020.
The Expert Tibial Nail System (ETNS) was

introduced worldwide in 2005. In addition to the
Ethical Consideration:
standard static and dynamic locking options, the (ETNS)
An approval of the study was obtained from
has multi-directional locking options in the distal and
Zagazig
University
Academic
and
Ethical
proximal part of the nail which enable the surgeons to
Committee. Every patient signed an informed written
use it in management of metaphyseal tibial fractures
consent for acceptance of the operation. This work
with less complications related to ORIF by plate and
has been carried out in accordance with The Code of



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2930

Received:16 /5 /2021


Accepted:12 /7 /2021

Full Paper (vol.851 paper# 44)


c:\work\Jor\vol851_45 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2937-2940

Prevention of Postpartum Hemorrhage after Vaginal Delivery
Using Tranexamic Acid
Moustafa Mohamed Ali*, Wael Hussien El-Bromboly, Walid Mohamed Elnagar,
Mohamed Fathy Abou Hashem
Obstetrics & Gynecology Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Moustafa M. Ali, Mobile: (+20)01010970217, Email: moustafa_ali19@gmail.com

ABSTRACT
Background:
The postpartum hemorrhage is still remaining a leading cause of maternal mortality, especially in
developing countries.
Objective: We aimed to determine the efficacy of using tranexamic acid in vaginal delivery to avoid postpartum
hemorrhage and to reduce blood loss and hospital stay.
Patients and methods: A prospective-randomized clinical trial study was conducted on 92 pregnant women that were
prepared for vaginal delivery. They were divided into two groups. Group (A) included 46 pregnant women that received
1 gm of tranexamic acid (TXA group) in the third stage of labour and group (B) included 46 pregnant women that
received 10 IU of oxytocin (Non-TXA group) after delivery of the baby. Estimation of blood loss was done. Hemoglobin
(Hb) and hematocrit (HCT) values were checked before and 24 hours after vaginal delivery as well as other basic
laboratory investigations.
Results: In our study, there was no significant difference regarding Hb at pre- but at post-, there was significant decrease
in Non-TXA group. There was no significant difference regarding HCT at pre- but at post-, there was significant
decrease in Non-TXA group. Blood loss was significantly lower at TXA group.
Conclusion: Use of tranexamic acid would help to reduce blood loss during delivery. It is a cheap and readily available
drug. The use of TXA decreases need of uterotonics and hence decreases morbidity and mortality.
Keywords: Postpartum hemorrhage, Vaginal delivery, Tranexamic acid.

INTRODUCTION

Pregnancy and delivery are considered as
We aimed to determine the efficacy of using
normal physiological phenomena in women.
tranexamic acid in vaginal delivery to avoid postpartum
Approximately, 10% of deliveries are considered as
hemorrhage and to reduce blood loss and hospital stay.
high risk. Vaginal delivery may result in major obstetric

hemorrhage, hysterectomy, admission to an intensive
PATIENTS AND METHOD
care unit and maternal death. Medications, such as

This prospective-randomized clinical trial
oxytocin, misoprostol, prostaglandin F2alpha, and
study was conducted at Obstetrics and Gynecology
methyl ergonovine have been used to control bleeding
Department at Zagazig University Hospitals during the
after vaginal delivery (1). But, still the postpartum
period from March 2020 to December 2020. A total of
hemorrhage is a leading cause of maternal mortality,
92 women that fulfilled the inclusion criteria were
especially in developing countries (2).
enrolled in the study. The patients were randomized into
The hematocrit falls by 10% and blood
2 groups using a computer-generated randomization list
transfusion is required in 6% of women undergoing
(using medcalc© version 13(medcalc@ software,
Cesarean delivery compared to 4% of women who have
mariakirke, Ostend, Belgium). Group (A) (TXA
a vaginal birth (3).
group) included 46 pregnant females that received 1 gm
Tranexamic acid (TXA) is a synthetic
of tranexamic acid (Kapron, Amon, Egypt) in 100 ml of
derivative of the amino acid lysine, which is an anti
lactated Ringer's solution by slow intravenous infusion
fibrinolytic that reversibly inhibits the activation of
over 5 minutes in the third stage of labour and after
plasminogen. Thus inhibiting fibrinolysis and reducing
delivery of the baby, 10 IU of oxytocin (sytocinon,
bleeding. Tranexemic acid may enhance effectiveness
Novartis, Egypt) in 500 ml lactated Ringer's solution
of the patient's own haemostatic mechanism (4).
were given. Group (B) (Non-TXA group) included 46
Tranexamic acid is widely used in the field of obstetric.
pregnant females that received 10 IU of oxytocin in 500
Both antepartum and postpartum hemorrhage are being
ml lactated Ringer's solution after delivery of the baby.
treated by TXA extensively. Although tranexamic acid
The solution was prepared by an anesthetist who was
crosses the placenta, no mutagenic activity or harmful
not involved in patient management or assessment.
effects of tranexamic acid on the fetus have been

reported and animal reproduction studies have shown
Inclusion criteria: Full-term pregnant women
no teratogenic affects. Tranexamic acid has been well
(gestational age > 37 weeks) with singleton pregnancy
tolerated and has not been associated with a prejudicial
being delivered vaginally, multiple pregnancy,
effect on the delivery of healthy children (5).
macrosomia and polyhydramnios.

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2937

Received:18 /5 /2021

Accepted:14 /7 /2021

Full Paper (vol.851 paper# 45)


c:\work\Jor\vol851_46 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2941-2944

Diagnostic Value of Ultrasound-Guided Pleural Biopsy in
Patients with Recurrent Pleural Effusion
Mohamed Azzam1, Tarek Mohsen1, Sally Fouad Tadros2, Hesham Zayed Saleh1
Departments of 1Cardiothoracic Surgery and 2Radiology, Kasr Al Ainy Faculty of Medicine, Cairo University, Egypt
*Corresponding author: Mohamed Azzam, E-mail: dr.mohamed.ezzazzam@gmail.com

ABSTRACT
Background:
Establishing a definite diagnosis in cases of pleural effusion is sometimes challenging. Adding
ultrasound-guided tru-cut biopsy at the time of obtaining pleural fluid for analysis may increase the diagnostic yield in
such cases.
Objective: The aim of the current work was to assess the diagnostic yield and the safety of percutaneous ultrasound
guided tru-cut needle biopsy in patients with recurrent undiagnosed pleural effusion.
Patients and Methods: A retrospective observational study including 45 patients with recurrent undiagnosed pleural
effusion who underwent ultrasound-guided tru-cut needle biopsy in the period between January 2019 and October 2020.
Results: By using ultrasound-guided needle biopsy, we were able to reach a final histopathological diagnosis in 40
patients with a diagnostic yield of 88.8%. Only 5 cases remained undiagnosed (11.1%). Mesothelioma was found in 13
cases (28.9%) and bronchogenic carcinoma in 7 cases (15.5%). Post-procedural complications included 1 case of
pneumothorax (2.2%) and 1 case of hemothorax (2.2%) all resolving with the small caliber chest drain that was inserted
at the conclusion of the procedure.
Conclusion
: It could be concluded that ultrasound-guided needle biopsy is a safe procedure that can be useful in
establishing a diagnosis in patients with recurrent pleural effusion. Its high diagnostic yield, while being simpler and
cheaper than CT guided biopsy or thoracoscopy, makes it a suitable option in our clinical settings. More studies are
needed to validate our findings.
Keywords: Pleural effusion, Tru-cut needle biopsy, Ultrasound

INTRODUCTION

make ultrasound-guided biopsies more suitable for our
Establishing a diagnosis in cases of pleural
clinical settings.
effusion is sometimes difficult. In many cases no
The objective of the current study was to assess the
definite diagnosis is reached even after complete
diagnostic yield and the safety of percutaneous
investigations (1). Obtaining pleural tissue, especially in
ultrasound-guided needle biopsy in patients with
the presence of pleural thickening or masses may help
recurrent pleural effusion.
establishing a diagnosis. The classical alternatives

usually used to obtain biopsy material are either CT-
PATIENTS AND METHODS
guided biopsy or thoracoscopy (1, 2, 3).
This retrospective observational study included a
Over the past years, ultrasound assessment has
total of 45 successive patients presented with recurrent
gained grounds as a useful bedside tool guiding
pleural effusion as evidenced by recent radiologic
thoracocentesis and placement of chest drains (4).
examination, attending at Cardiothoracic Surgery
Moreover, Ultrasound can also delineate pleural masses
Department of Cairo University Hospitals. This study
as well as lung tumors involving or abutting the pleura
was conducted between January 2019 and October
(5, 6). Extending the use of ultrasound to guide cutting-
2020.
needle biopsies from such lesions would offer many
During the study period 48 consecutive patients
potential advantages over CT-guided techniques or
remained undiagnosed despite previous pleural fluid
thoracoscopy. With the lighter more mobile modern
chemical and cytological examination. Three patients
ultrasound units, such procedures can be arranged and
were excluded; one of them due to features of pleural
performed in a much easier and faster way by the
aspirate compatible with empyema, one due to
pulmonologist or thoracic surgeon. Advantages over CT
transudative pattern on previous pleural aspirate and the
guidance also include real-time imaging allowing
last one was excluded due to severe emphysema. The
compensation for breathing motion thus increasing the
remaining 45 patients were included in the study.
safety margin of the procedure while minimizing
All patients underwent CT chest with contrast
patient's exposure to ionizing radiation. Previous
prior to the procedure to gain proper delineation of the
studies comparing the ultrasound to CT-guidance
target lesions if any and the surrounding anatomy.
showed ultrasound to be at least equivalent to CT for
Platelet counts, international normalized ratio (INR)
needle biopsies of suitable chest lesions (6-8). Other
and activated partial thromboplastin time (aPTT) were
authors found ultrasound guidance to result in a higher
obtained to ensure the absence of coagulopathy prior to
likelihood of a diagnostic sample (9). Such advantages
the procedure.
Ethical Consideration:

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2941

Received: 16/5/2021

Accepted: 12/7/2021

Full Paper (vol.851 paper# 46)


c:\work\Jor\vol851_47 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2945-2950

Short Term Assessment of Surgical Treatment of Lisfranc Fracture Dislocation
Sameh Mohamed Holyl, Elsayed Abdelmoty Mohammed,
Alaeddin Mohamed Hadida*, Ahmed Hatem Farhan Imam
Department of Orthopedic, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Alaeddin Mohamed Hadida, Mobile: (+20)1012109449, E-mail: alaeddinhadida@gmail.com

ABSTRACT
Background:
Lisfranc fractures are rare injuries, with reported incidence of 0.2% of all fractures and 1/55,000 per year
incidence in the population. These are reported to occur 2­4 times more commonly in men, and the peak incidence is in
the third decade of life.
Objective: This study was aimed to assess the functional outcome of using open reduction and internal fixation in
management of ligamentous Lisfranc injuries.
Patients and Methods: This prospective operative study was conducted on 18 patients with Displaced Lisfranc injury
admitted to the Orthopedic Surgery Department, Faculty of Medicine, Zagazig University, during the period from
February 2021 to August 2021. The diagnosis was made by medical history taking, clinical examination and radiological
assessment.
Results: The mean operation time was 140.0±27.43 minutes with minimum 90 and maximum 200 minutes and mean
hospital stay was 4.38±1.33 with minimum 3 and maximum 8 days. The mean healing time 8.38±2.45 with minimum 6
and maximum 16 weeks. The most prevalent complication was infection (22.2%), Transient numbness (5.6%), Delay
healing (5.6%), Loss reduction (5.6%) and overall complicated cases were 5 cases 27.8%.
Conclusion
: It could be concluded that anatomical reduction of Lisfranc injury can be achieved by open reduction and
internal fixation with the Kirschner wires (K-wires) and Cannulated Screws.
Keywords: Lisfranc, Midfoot, Open reduction, Internal fixation.

INTRODUCTION

metatarsal bases. The notch sign, in which a small notch
Lisfranc injury refers strictly to an injury in which
appears in the lateral aspect of the medial cuneiform,
one or more of the metatarsals are displaced with respect
might also be seen (7).
to the tarsus (1). Lisfranc injuries are infrequent, at
Conservative
treatment
includes
midfoot
approximately 0.2% of all fractures, although in 20% of
stabilization and movement restriction. For Lisfranc
cases they are not diagnosed or are diagnosed late (2).
injuries without displacement on weight bearing
However, early, and accurate diagnosis of these
radiographs, the use of cast immobilization for 6 to 12
injuries are fundamental requirements for their
weeks is common. Modern surgical treatments include
appropriate treatment and to prevent long-term
closed reduction and immobilization, closed reduction
sequelae. Men are two to four times more likely to suffer
and percutaneous pinning, and open reduction with
a Lisfranc joint injury, possibly because they participate
percutaneous pinning or screw fixation (8).
more frequently in high-speed activities. These injuries
This study was performed to assess the functional
are common in the third decade of life. The majority
outcome of using open reduction and internal fixation in
(87.5%) are closed injuries and are becoming more
management of ligamentous Lisfranc injuries.
frequent in athletes, in whom it is common to see subtle

Lisfranc injuries (3). These are injuries that have
PATIENTS AND METHODS
occurred in sports such as soccer, gymnastics and
This prospective operative study included a total of
running (4).
18 patients with displaced Lisfranc injury admitted to
Lisfranc injuries, which disrupt the strong midfoot
the Department of Orthopedic, Faculty of Medicine,
ligaments supporting the arch, require immediate
Zagazig University, during the period from February
surgical intervention to prevent complications such as
2021 to August 202. Patients were 4 males and 14
compartment syndrome and amputation. On clinical
females, aged 39-70 years and the mean age was
examination, patients can present with edema, point
56.77±8.17 years.
tenderness, and decreased function (5). The dorsal

drawer test of the medial column will elicit a "clunk"
Ethical Consideration:
compared with the contralateral side, and the passive
Written informed consent was obtained from
midfoot pronation abduction test will yield positive
all participants and the study was approved by the
results (6).
Research Ethical Committee, Faculty of Medicine,
On radiographic evaluation, Lisfranc injuries
Zagazig University (ZU-IRB). The work has been
commonly show an increased asymmetric joint space at
carried out in accordance with The Code of Ethics of
the naviculocuneiform joint and first and second

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2945
Received:17 /5 /2021

Accepted:13 /7 /2021

Full Paper (vol.851 paper# 47)


c:\work\Jor\vol851_48 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2951-2955

Efficacy of Distal Intracoronary Epinephrine and Glycoprotein IIb/IIIa
Inhibitors in the Treatment of No-reflow during Percutaneous
Coronary Intervention; a Pilot Project.
1Mahmoud Tantawy, 1Ahmed Elbarbary, 2Ahmed Tamara, 2Ghada Selim
1Cardiology Department, Faculty of Medicine, Misr University for Science and Technology (MUST),
2Cardiology Department, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Mahmoud Tantawy, Mobile: (+20) 0121865587

ABSTRACT
Background:
No-reflow is considered a major percutaneous coronary intervention complication, especially in primary PCI.
A variety of medications have been studied for no-reflow treatment, including intracoronary nitrates, verapamil, adenosine,
glycoprotein IIb/IIIa inhibitors, and epinephrine. Glycoprotein IIb/IIIa inhibitors and epinephrine are the two most
promising agents for the treatment of no-reflow.
Aim of work: evaluating epinephrine and glycoprotein IIb/IIIa inhibitors efficacy in treating no-reflow through local distal
intracoronary injection in comparison to traditional intracoronary administration in the guiding catheter.
Subjects and methods: 30 patients undergoing PCI complicated by no-reflow phenomenon. Patients were randomized to
either group I where they were treated by local distal intracoronary injection of GP IIb/IIIa inhibitor and epinephrine or to
group II where they received the same medications via the traditional intracoronary injection. Primary outcomes were TIMI
flow, corrected TIMI frame count and TMPG, and major adverse cardiac events within 48 hours was the secondary outcome.
Results: Group I had significantly superior angiographic outcomes than group II. As regards TIMI II-III flow, 86.7% of
patients achieved it in versus 53.3% in group II, CTFC was 8.2versus 9.9, and in group I, 80% of patients achieved TMPG
II-III, compared to 46.7 % in group II. MACE was insignificantly different between both groups. Diabetes mellitus was
found to be the only predictor to be negatively associated with TIMI flow.
Conclusion: Distal coronary artery local injection of a combination of GP IIb/IIIa inhibitors and epinephrine achieved
superior angiographic outcomes in the treatment of refractory no-reflow in comparison with traditional intracoronary
administration of the same medications.
Keywords: No-reflow, Intracoronary epinephrine, GP IIb/IIIa inhibitors.

INTRODUCTION
with or without verapamil had shown superior results than
The No-reflow phenomenon is considered one of the
traditional IC injection of the same medications.
nightmares in the catheter laboratory. It is known as
As the intracoronary (IC) usage of GP IIb/IIIa
inadequate myocardial perfusion without an apparent
inhibitors and epinephrine are considered effective agents
mechanical cause, like a coronary dissection of significant
in the treatment of persistent no-reflow (8), local distal
obstruction. Primary percutaneous coronary intervention
intracoronary injection of both medications may get more
(PCI) is more likely to result in no-reflow than elective
benefits.
PCI. Different mechanisms contribute to the no-reflow

phenomenon,
including
distal
microembolization,
AIM OF WORK: assessing epinephrine and glycoprotein
reperfusion injury, endothelial dysfunction, microvascular
IIb/IIIa inhibitors efficacy in treating no-reflow through
spasm, and myocardial edema (1(.
local distal intracoronary injection in comparison to
Multiple medications have been studied in the
traditional intracoronary administration in the guiding
treatment of no-reflow. Some of them have shown benefits
catheter.
like nitrates (1,2), calcium channel blockers (3), adenosine (4),

glycoprotein IIb/IIIa inhibitors5, and epinephrine (6-8). Most
SUBJECTS AND METHODS
of these drugs were partially effective in the treatment of
The present study included 30 documented coronary
no-reflow but have shown variable results across different
artery disease patients who underwent either rescue or
studies, and there is still a limited success rate in the
primary PCI complicated by no-reflow.
treatment of refractory no-reflow (6).

A meta-analysis (7) has shown that intralesional
Ethical approval:
injection of GP IIb/IIIa has better outcomes in preventing
MUST university Ethical Committee Board
no-reflow than intracoronary (IC) injection as it gives
approved the study. Each patient enrolled in the study
better contact with the thrombus burden. A single study (3)
signed an informed consent form.This work has been
concluded that the usage of distal injection of epinephrine
carried out in accordance with The Code of Ethics of

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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
2951
Received:15 /5 /2021

Accepted:11 /7 /2021

Full Paper (vol.851 paper# 48)


c:\work\Jor\vol851_49 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2956-2962

Correlation between Nonsynonymous A803G Polymorphism of
N-acetyltransferase 2 Gene and Impaired Glucose Homeostasis in
Egyptian Obese Children and Adolescents
Asmaa AbdElkhalek Hussein*1, Ashgan Abd Allah Alghobashy1, Nermin Raafat Abd Elfattah2
Department of 1Pediatrics and 2Medical Biochemistry, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Asmaa AbdElkhalek Hussein, Mobile: (+20) 01022086110, Email: asmaahussein93@gmail.com

ABSTRACT
Background:
Two thirds of the world's populations live in countries where obesity-related illness is a significant cause
of death. There is a considerable increase in adult obesity and there is good evidence that more children are also
becoming obese especially over the last 30 years period.
Objective: To assess A803G polymorphism in the NAT2 gene in Egyptian obese children and adolescents and to detect
the relation between this gene mutation and development of impaired glucose homeostasis in them.
Patients and methods:
100 children and Adolescents were investigated in the study. They were divided into 2 groups
according to their HbA1c: 50diagnosed as pre-diabetic obese were enrolled as group (1) and 50 diagnosed as non-
diabetic obese were enrolled as group (2). Results: correlation between HbA1c and HOMAIR showed that HbA1c was
statistically significantly positively correlated with weight, waist circumference, systolic and diastolic blood pressures,
HOMAIR, total cholesterol and LDL. While, HbA1c was statistically significantly negatively correlated with HDL and
BMI-SDS, with no statistically significant correlations with other variables among Group 1. HOMA-IR was statistically
significantly positively correlated with weight, waist circumference and systolic and diastolic blood pressures. While,
HOMAIR was statistically significantly negatively correlated with BMI-SDS among Group 1. HbA1c was statistically
significantly positively correlated with weight and waist with no statistically significant correlation with other variables
among Group 2.
Conclusion:
Egyptian obese children and adolescents who are carrying NAT2 A803 allele might be at a high risk of
developing impaired glucose homeostasis and consequent increased future risk to develop diabetes mellitus type 2.
Keywords: Glucose homeostasis, NAT2 A803G, BMI-SDS.

INTRODUCTION

Overweight and obesity are serious public
Egyptian obese children and adolescents and to detect
health problems that are caused by energy imbalance
the relation between this gene mutation and
between calories consumed and energy gained. Obesity
development of impaired glucose homeostasis in them.
are caused by many interrelated factors as dietary

behaviour,
physical
inactivity,
family
socio-
PATIENTS AND METHODS
demographic characteristics, environmental factors, and
A comparative cross-sectional study was carried
genetic factors (1). Childhood obesity and its related
out in the Pediatric Endocrinology Unit Outpatient
complications such as impaired glucose tolerance
Clinic, Pediatric Department, Zagazig University
(IGT), type 2 diabetes (T2D), and nonalcoholic fatty
Children's Hospital and the Microbiology and
liver disease have been constantly increasing during the
Immunology Department in collaboration with Zagazig
last decades with a strong impact on children's well-
Scientific and Medical Research Center Faculty of
being (2). Genetic analysis is a powerful tool to identify
Medicine, Zagazig University, Egypt. The study was
metabolic risk loci, and alleles that contribute to IR and
conducted in the period from December 2019 to
T2D risk (3).
December 2020.
The strongest association for a nonsynonymous
100 children and adolescents were investigated in
SNP in NAT2 [rs1208 (803A>G, K268R)] with the
the study then divided into 2 groups according to their
ancestral "A" allele (frequency 0.57) associated with a
HbA1c: 50 diagnosed as pre-diabetic obese were
greater degree of IR in analyses are adjusted for age,
enrolled as group 1 and 50 diagnosed as non-diabetic
gender, and BMI in a large adult population. The same
obese were enrolled as group 2. The mean age was 9.4
ancestral "A" allele at rs1208 was associated with IR-
± 4.2 years. 62 males and 38 females were included in
related traits, including increased fasting glucose,
both cases and controls.
hemoglobin A1c, total and LDL cholesterol,
Inclusion criteria: Children and adolescents with age
triglycerides, and coronary artery disease (4).
ranging from 5 to 18 years. BMI of cases was greater
The NAT2 A803 allele seems to play a role in
than 2 SD above the WHO Growth Reference Median.
worsening the destiny of obese children carrying it,
Patients do not have T1DM. Patients do not have
predisposing them to impaired glucose homeostasis and
secondary forms of obesity.
then to a possible future T2D (5). This study aimed to
Exclusion criteria: Patients outside age group, patients
asses A803G polymorphism in the NAT2 gene in
that their parents refuse to share in the study, patients

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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
2956
Received:20 /5 /2021

Accepted:16 /7 /2021

Full Paper (vol.851 paper# 49)


c:\work\Jor\vol851_50 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2963-2967

Asthmatic Versus Non-Allergic Children in Relation to
The Presence of Cow Milk Allergy
Hadeel I. Enany*1, M. H. M. Ebrahim1, E. M. Rasheed1, Eman M. Elbehedy2, Shereen A. Baioumy 2
Department of 1Pediatric and 2Microbiology and Immunology, Faculty of medicine, Zagazig University, Egypt
*Corresponding author: Hadeel Ibrahim Enany, Mobile: (+20)01021067578, Email: hadeelibraheem2016@gmail.com

ABSTRACT
Background:
Cow's milk allergy is among the most frequent food allergies in young children and one of the risk factors
of asthma.
Objective: The study aimed to assess the role of Cow's milk allergy (CMA) to induce asthma and to study the effect
cow milk protein on asthmatic and non-allergic children to prevent occurrence of asthma among children.
Patients and methods: A case-control study that was carried out in Pulmonology Unit of Pediatric Department, Faculty
of Medicine, Zagazig University Hospital. The patients were investigated at Medical Community and Immunology
Department. The study included 154 child divided equally into two groups. Group A included patients with bronchial
asthma and group B (control) included age- and sex-matched healthy individuals. Iinvestigations: complete blood
picture, renal and liver function tests, skin prick test, total immunoglobulin (IgE) was done for all participants.
Results: There was high statistically significant difference between the two studied groups as regards skin pick test.
There was statistically significant increase in the levels of both total and specific Ig E in allergic group compared to
control group. There was high significant increase in the severity recorded in respiratory function test in allergic group
compared to control group. There was non-significant difference between the two groups regarding GIT manifestation.
There was high statistically significant difference between the two groups regarding skin and respiratory manifestations.
Conclusion: CMA can exacerbate the symptoms in children with asthma. Therefore, it is worth considering a possible
role of food allergy in asthma in young children, particularly when asthma is not adequately controlled in spite of proper
routine management.
Keywords: Asthma, Non-allergic children, Cow milk allergy.

Therefore, the aim of the present study was to
INTRODUCTION
assess the role of cow milk (CM) to induce asthma and
The food allergy and asthma are the most
to study the effect of cow milk protein allergy on
common chronic conditions in childhood. The
asthmatic and non-allergic children to prevent
prevalence of asthma and allergic diseases like allergic
occurrence of asthma among children.
rhinitis in childhood has shown an increasing trend in

several industrialized countries since the second half of
PATIENTS AND METHODS
the twentieth century (1). Cow's milk allergy (CMA) is
A case-control study that was carried out in
defined as an adverse clinical reaction to ingested cow's
Pulmonology Unit of Pediatric Department, and
milk proteins based on an immunologically mediated
investigated at Medical Community and Immunology
adverse reaction to the provoking proteins at doses
Department, Zagazig University Hospital. The study
which are tolerated by healthy persons (2).
included 154 participants divided into 2 groups. Group
A key component in the pathology is chronic
A, 77 patients with bronchial asthma and group B, 77
inflammation and various factors such as viruses,
healthy control group.
allergens and exercise. These factors are also

responsible for hyper-responsiveness, inflammation
Ethical consent:
together with hyper-reactivity associated with airway

An approval of the study was obtained from
obstruction. Asthma can present with symptoms such as
Zagazig
University Academic
and
Ethical
recurrent episodes of wheezing, coughing, shortness of
Committee. Every patient signed an informed
breath, and chest tightness. In addition to medical
written consent for acceptance of the study. This
history, methods to establish asthma diagnosis include
work has been carried out in accordance with the
physical examination, evaluation of lung function,
Code of Ethics of the World Medical Association
atopy,
airway
inflammation,
bronchial
(Declaration of Helsinki) for studies involving
hyperresponsiveness and exclusion of alternative
humans.
diagnosis. In young children, the asthma diagnosis is

particularly challenging due to difficulties in applying
Inclusion criteria: Patients with asthma that were
objective lung function measurements. Thus, in infants
diagnosed on the basis of symptoms and physical
and preschool-aged children, the diagnosis is often
examination of respiratory systems. Both males and
based on medical history and symptoms (3).
females of age from 6 to 12 y.



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2963
Received:20 /5 /2021

Accepted:16 /7 /2021

Full Paper (vol.851 paper# 50)


c:\work\Jor\vol851_51 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2968-2972

Efficacy of Skin Needling Device versus Placebo in Treatment of Melasma
Najla Abubakr Taher*, Manal Mohamed El-Sayed and Hagar Awad Bessar
Dermatology, Venereology and Andrology Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding authors: Najla Abubakr Taher, Mobile: (+20)0116043631, Email: najlaabubakr1985@gmail.com

ABSTRACT
Background
: Melasma is a common acquired condition of symmetric hyperpigmentation, which typically happening
on the face with higher prevalence in females and darker skin types. Multiple causes as light exposure, hormonal changes
and family history have been implicated in the melasma pathogenesis.
Objective: To assess the efficacy of microneedling with dermapen in the treatment of melasma compared to placebo.
Patients and methods: The study comprised 17 patients with melasma. They were collected from Dermatology
Outpatient Clinics of Zagazig University Hospital. Each patient had five sessions for treatment of facial melasma in
split face manner with two weeks interval between the sessions. Right side: each patient was applied with microneedling
(dermapen) while, left side was with placebo. A modified MASI (melasma area and severity index) scoring system was
assessed. Results: There was a significant difference in mMASI score between baseline and after sessions in right side
(Dermapen) (p<0.001*), while no significant change between baseline and after sessions in left side (placebo). Physician
global assessment in right side (Dermapen) showed a significantly lowered mean physician global assessment than left
side (placebo) (p<0.001*). According to the pattern of melasma either (malar or centrofacial), there was a significant
decrease in mMASI score among right side (Dermapen) compared to placebo. Regarding the clinical pattern of melasma
either epidermal or mixed melasma, there was no statistical significant difference between the right side (Dermapen) and left
side (placebo).
Conclusion:
Microneedling technique alone using dermapen provides significant lightening effect with a satisfactory
results compared to placebo.
Keywords:
Dermapen, Melasma, Needling device.

INTRODUCTION
increased prevalence with pregnancy, oral contraceptive
Melasma, formerly known as chloasma, is an
use and other hormonal therapies (8,9). Extra-facial
acquired pigmentary condition, occurring most
melasma is also associated with a peri-menopausal state
commonly on the face with a three predominant facial
(10).
patterns: centrofacial, malar, and mandibular. This
On dermoscopic examination, a pronounced
disorder, which is more prevalent in females and darker
hyperpigmentation is found in the pseudo-rete ridges of
skin types, is predominantly attributed to ultraviolet
the skin. Using a Wood's lamp, the hyperpigmentation
exposure and hormonal influences (1). The centrofacial
can be accentuated when the pigment is epidermal (11).
pattern affects the forehead, nose, and upper lip,
However, this accentuation may be seen with dermal or
excluding the philtrum, cheeks, and chin. The malar
mixed melasma (12).
pattern is restricted to the malar cheeks on the face,
Melasma has not been consistently associated
while mandibular melasma is present on the jawline and
with other clinical conditions. In a case control study,
chin and occur in older individuals and related to severe
melasma was shown to be associated with an increased
photodamage (2,3).
number of lentigines and nevi (13). Endocrinological
Various epidemiologic studies have estimated the
conditions such as thyroid disease are also not
prevalence of melasma in the general population at 1%
associated with melasma when compared to the general
and in higher-risk populations at 9­50% (4, 5). These
population (14).
wide ranges are secondary to variations in prevalence
This study aimed to assess the efficacy of
among darker skin types, different ethnic heritages. As
microneedling with dermapen in the treatment of
such, the true prevalence across the entire population is
melasma compared with placebo.
unknown. The average age ranging being between 20

and 30 years (6).
PATIENTS AND METHODS
The etiology of melasma is multifactorial as
A clinical trial that carried out at outpatient clinic
ultraviolet (UV) light has been shown in clinical and
of Dermatology, Venereology and Andrology
laboratory studies to trigger and exacerbate the
Department, Zagazig University Hospitals during the
condition through inducing reactive oxygen species
period from November 2019 to April 2020. It included
(ROS) by activating inducible nitric oxide and
18 patients, their ages ranged from 18-60 years old.
promoting melanogenesis (7). Hormonal influences play
Inclusion criteria: Patients with melasma of more than
a significant role in the pathogenesis of melasma by the
18 years of age, who were not on any medications for
melasma since at least 2 weeks for topical therapy, 1

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2968
Received:19 /5 /2021

Accepted:15 /7 /2021

Full Paper (vol.851 paper# 51)


c:\work\Jor\vol851_52 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2973-2978

Transposition versus Decompression Alone for Ulnar Nerve
Entrapment in Cubital Tunnel
Randa Abd Eldayem A. Said*, Magdy El-Sayed Rashed,
Hosni Hassan Salama and Ibrahim Metwally Abdel Fattah
Department of Neurosurgery, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Randa Abd Eldayem Said, Mobile: (+2)01092320958, Email: randaabdeldayem91@gmail.com

ABSTRACT
Background:
Cubital tunnel syndrome is the most common form of ulnar nerve entrapment (UNE).
Objective:
The aim of the present study was to evaluate patient-reported and surgeon-evaluated outcome of ulnar
nerve entrapment in cubital tunnel decompression versus transposition.
Patients and methods: The study was conducted on 18 ulnar nerve entrapment patients 9 cases underwent simple
decompression operation and 9 cases underwent transposition operation. All cases were subjected to electrodiagnostic
tests. Post-operative outcomes were assessed and graded, based on patient-reported and surgeon-evaluated outcome,
into four groups: cured, improved, unchanged or exacerbated.
Results: Our study showed that 88.9% of the decompression group showed full motor power (FMP) postoperatively
while this was shown in 44.4% of transposition group with significant difference (P < 0.05) between the two groups.
All patients of both groups showed postoperative improved sensory manifestations. There was highly significant
difference (p < 0.05) between the two studied groups regarding postoperative nerve conduction velocity (NCV) as it
was higher in decompression group than transposition group . while there was no significant difference between them
regarding nerve thickness by ultrasound.
Conclusion: Simple decompression is associated with less operative time, less amount of blood loss, smaller wound,
less exposure to nerve, less need to affect elbow joint except in large deformation than surgical treatment with
transposition.
Keywords: Transposition, Decompression, Carpal tunnel syndrome, Ulnar nerve entrapment.

INTRODUCTION
during surgery, then perform a medial epicondylectomy
Cubital tunnel syndrome is the second most
(5). Anterior transposition surgical procedures can be
common upper extremity entrapment neuropathy
grouped into 3 classes, depending on the location of the
following carpal tunnel syndrome. Symptoms progress
transposed ulnar nerve: subcutaneous anterior
of cubital tunnel from mild intermittent numbness
transposition, submuscular anterior transposition, and
induced with elbow flexion to constant anesthesia. Pain
intramuscular anterior transposition (6).
and tenderness over the medial epicondyle and cubital
Persistent symptoms may be related to an
tunnel may be present with flexion and extension of the
incomplete release of structures affecting the ulnar
elbow. Weakness of ulnar nerve-innervated intrinsic
nerve or to intraneural pathology, while recurrence after
hand muscles can also be seen at this time. Weakness
primary surgery may be due to perineural scarring and
starts with clumsiness and loss of dexterity of the hand,
adhesions. Predictors of recurrence are female gender,
with progression to weakness of grip and pinch
age < 50 years, concomitant carpal tunnel syndrome
(Froment's sign) (1, 2).
(CTS), clinically mild ulnar nerve entrapment (i.e.,
The elbow flexion test is performed with both
McGowan stage I) and previous elbow fracture or
elbows maximally flexed and wrists in full extension for
dislocation (7). Ulnar nerve entrapment is usually treated
three minutes, while the pressure provocative test is
with ulnar nerve transposition, achieving satisfactory
done by applying pressure for 60 seconds over the ulnar
results in 73-82% of patients. The main improvement is
nerve just proximal to the cubital tunnel with the elbow
reduction of pain whereas return of sensibility and
flexed at 20ŗ and forearm is supinated. These tests are
motor function are more unpredictable (8).
positive if symptoms of pain, numbness, and paresthesia
The aim of the present study was to evaluate
occur in the ulnar nerve distribution (3).
patient-reported and surgeon-evaluated outcome of
Many surgical procedures are advocated for the
ulnar nerve entrapment in cubital tunnel decompression
treatment of cubital tunnel syndrome, including simple
versus transposition.

decompression, anterior transposition (subcutaneous,

submuscular,
intramuscular),
and
medial
PATIENTS AND METHODS
epicondylectomy (4).
This study was anon-randomized case-control
Surgical treatment of patients with cubital tunnel
study that was conducted at Neurosurgery Department,
syndrome is governed by the following principles:
Zagazig University Hospitals on 18 surgically-treated
release all possible sites of compression; preserve the
ulnar nerve entrapment patients. 9 cases were treated by
vascularity of the ulnar nerve at the elbow, allow early
simple decompression and 9 cases were treated by
mobilization of the elbow, and if the nerve subluxates
transposition. This study was done for a year. Patients

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2973

Received:20/5 /2021

Accepted:16/7 /2021

Full Paper (vol.851 paper# 52)


c:\work\Jor\vol851_53 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2979-2984

Short-Term Outcome in Patients with Acute Kidney Injury at
Sohag University Hospital
Ali Taha Ali, Amal Khalifa Ahmed, Noher Mohamad Abass, Milad Sayed Saeed*
Department of Internal Medicine, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Milad Sayed Saeed, Mobile: (+20) 01224847421, E-Mail: miladsayed2@gmail.com

ABSTRACT
Background:
Acute kidney injury (AKI) is a common clinical situation with serious complications with long-term
and short-term negative consequences as regards morbidity and mortality.
Objective: To determine the short-term outcome of AKI among those patients and to evaluate the relationship
between patient characteristics and the outcome of AKI.
Patients and methods: A prospective study that was conducted on 70 Patients diagnosed with AKI using the Kidney
Disease­Improving Global Outcomes (KDIGO) criteria based on serum creatinine (increase in serum creatinine by
0.3 mg/dL within 48h or increase in serum creatinine to 1.5 times baseline), which is known or presumed to have
occurred within the prior 7 days. They were admitted to Internal Medicine Department, Sohag University Hospital
from December 2019 to May 2020. Results: There was statistically significant relationship between patient age,
history of diabetes, established chronic kidney disease (CKD) and AKI outcomes. Also there was statistically
significant relation between AKI outcome and increased s. creatinine level, elevated white blood cells count,
decreased hemoglobin level and increased serum potassium level. As regards the staging of AKI, We found
statistically significant relationship between AKI outcomes and staging of studied population as stage 3 had worse
outcomes. Also we found statistically significant relationship between AKI outcome and ultrasound grading of
echogenicity of studied population as increased echogenicity had worse outcome than normal kidneys.
Conclusions:
Our study concluded that mortality and morbidity in patients with AKI were increased in advanced age,
diabetics, CKD patients, patients with anemia, leucocytosis hyperkalemia and increased serum creatinine.
Keywords: Acute kidney injury, Chronic kidney disease, Sohag University Hospital.

INTRODUCTION
of renal damages caused by AKI. For effective planning
Acute kidney injury (AKI) is one of the most
regarding reduction of mortalities resulting from AKI
important causes of mortality in hospitalized patients
there is a need for sufficient data regarding the
and with aging of the population, the number of those
epidemiologic pattern of this disease in our country (7).
affected with it has increased (1). Epidemiology of AKI
This study aimed to determine the etiology, short-term
is determined by variation in climate, ethnicity, culture,
outcome and the predictors of AKI among patients
socioeconomic, and development status. Therefore, the
admitted to Sohag University Hospital and to evaluate
epidemiology of AKI differs from country to country,
the relationship between patient characteristics and the
and from center to center within the same country (2).
outcome of AKI.
The causes of AKI are different based on various

geographical regions and there is a significant
PATIENTS AND METHODS
difference in its prevalence between developing and
A prospective study was conducted on 70 patients
developed countries (3). The main AKI causes are
diagnosed with AKI using the Kidney Disease ­
ischemia, sepsis, and nephrotoxic drugs. AKI is
Improving Global Outcomes (KDIGO) criteria based on
frequently encountered in the community in smaller
serum creatinine (increase in serum creatinine by 0.3
urban areas distant from large cities and in rural zones
mg/dL within 48h or increase in serum creatinine to
secondary to diarrhea, tropical infectious diseases,
1.5 times baseline), which is known or presumed to
animal venoms, use of native medicines, and poor
have occurred within the prior 7 days. They were
obstetric care among previously healthy young
admitted to Internal Medicine Department, Sohag
individuals (4). Furthermore, the delayed presentation of
University Hospital between December 2019 and May
AKI patients to health care facilities, lack of resources,
2020.
late recognition of the disease and absence of reliable

statistical data regarding the incidence of AKI all add to
Staging of AKI was based on serum creatinine:
the magnitude of the problem in developing
Stage I: 1.5 to 1.9 times base-line or 0.3 mg/dL
countries (5). Failure to detect and treat timely and/or
increase, stage II: 2.0 to 2.9 times baseline, and stage
adequately usually leads to significant untoward
III: 3.0 times baseline or increase in serum creatinine to
consequences. It is associated with a high morbidity
4.0 mg/dL or initiation of renal replacement therapy.
and permanent loss of kidney function (6).

All stages of AKI are associated with significantly
Exclusion criteria: Patients with kidney transplant,
high short- and long-term mortality. However, early
patients below 18 years, and patients with other end
detection and treatment leads to partial or total reversal
organ damage.

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2979

Received:21/5 /2021


Accepted:17/7 /2021

Full Paper (vol.851 paper# 53)


c:\work\Jor\vol851_54 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2985-2989

Trapezium Fracture: Case Report
Mohammed Aljuhani*, Eyad Alakkas, Mohammed Alamri, Ahmed Alnajrani
Department of Orthopedic Surgery, East Jeddah Hospital, Jeddah, Saudi Arabia
*Corresponding author: Mohammed Abdulwahab Aljuhani, Mobile: +966548557799, E-Mail: mohaljh@hotmail.com

ABSTRACT
Background:
Trapezium fractures are extremely uncommon, accounting for only 4% of all hand injuries. Trapezium
fractures are a very infrequent kind of carpal bone injury. They can happen alone or in conjunction with another carpal
bone lesion.
Cases report: A 19-years old female right hand dominant with no medical conditions presented to the Emergency
Department at East Jeddah Hospital as a case of motor vehicle accident (MVA). She was sitting in the back chair
where she put her both hands in hyperextension over the seat in front to protect her during the injury. She came
complaining of left hand pain and swelling.
Conclusion: We report this case of trapezium fracture, which is a rare injury with our management done by using
open reduction and Herbert's screws fixation. The patient got successful early mobilization. We achieved good
clinical and functional outcomes as well as satisfaction.
Keywords: Trapezium fracture, Hand pain, Hand swelling.

INTRODUCTION
- She presented to the Emergency Department at East
Trapezium fractures are very rare and can lead to a
Jeddah Hospital as a case of motor vehicle accident
significant deficit of hand function if missed. Isolated
(MVA). She was sitting in the back chair where she
fractures of the trapezium account for 3­5% of all carpal
put her both hands in hyperextension over the seat in
fractures (1, 2). However, they should not be missed
front to protect her during the injury. She came
because inadequate treatment of trapezium fractures can
complaining from left-hand pain and swelling.
lead to permanent impairment based on the substantial
- After a primary and secondary survey and clearance
forces experienced at the trapeziometacarpal (TMC)
from other specialties, our examination was localized
joint in pinch and grip (3, 4).
to the left hand. There was swelling and no signs of
The trapezium forms a double-saddle articulation
open fracture with tenderness at the base of the left
with the base of the thumb metacarpal allowing motion
thumb.
in
two
planes--both
flexion/extension
and
- X-ray revealed trapezium fracture in the body vertical
abduction/adduction. The volar "beak" ligament from the
intra-articular type so we proceeded for CT scan for
metacarpal to the trapezium is a key structure in
preoperative planning.
maintaining joint stability and resisting dorsal radial
subluxation during a key pinch. The trapezium body
- Dorsoradial skin incision on the base of thumb about 3
articulates with the carpal bones. The trapezial ridge is a
cm has been used for reduction and fixation that was
volar structure that serves as a radial attachment for the
completed by 2 Herbert' screws. Then, post operative
transverse carpal ligament (5).
slab was made.
Trapezium fractures include body and ridge
- Patient was discharged and follow up at the clinic after
fractures. Fractures of the trapezial ridge can result from
2 weeks where sutures and slab were removed with
a direct blow or from an avulsion injury. Pain in the
the advice of protected weight lifting and early range
thenar area following a wrist injury should alert surgeons
of motion to avoid stiffness. After that regular follow
to the possibility of a scaphoid fracture, but trapezial
up to assess union and alignment that showed good
fractures can occur, albeit more rarely (6).
healing signs up to full healing in 2 months with a

good range of motion.
CASE REPORT
- The last visit after 1.5 years, the patient was satisfied
A 19-years old female right-hand dominant with no
doing her daily activity with a full range of motion of
medical conditions.
the thumb and index with no complaint of pain except
with lifting heavy objects sometimes.



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2985
Received: 22/5/20 21

Accepted: 18/7/2021


Full Paper (vol.851 paper# 54)


c:\work\Jor\vol851_55 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2990-2994

Evaluation of Anterior Knee Pain by Magnetic Resonance Imaging
Rehab Arafa Mohamed*, Moanes Mohamed Arafa Enaba,
Engy Fathy Tantawy, Riham Amir Kamal
Radiodiagnosis Department, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Rehab Arafa Mohamed, Mobile: (+20) 01063473920, Email: Rehabarafa11@gmail.com

ABSTRACT
Background:
Anterior knee pain (AKP) is the commonest cause of knee complaints. It represented about 25% of all
adult knee problems and its non-specific complaint has multiple causes and risk factors.
Objective: This study aims to evaluate the role of magnetic resonance imaging (MRI) in diagnosing different diseases
that cause pain in the front of the knee.
Patients and methods: A cross sectional study of forty eight patients with history of anterior knee pain. All patients
were referred from the outpatient clinic of orthopedic surgery, Zagazig University Hospitals. This work was performed
at the MRI unit of Radiodiagnosis Department, Zagazig University Hospitals.
Results: The mean age of the studied group was 37.35±13.78 years. Visual Analog Scale (VAS) was (4.62±1.16) with
more than half (56.2%) of cases having right sided pain. Most presenting symptoms was isolated anterior knee pain
(62.5%). The frequency distribution of all MRI findings in all patients showed that 58.3% of the studied group had
patellar tilt, 33.3% had patellar chondromalacia or patellofemoral instability, and 20.8% of cases had patellofemoral
osteoarthritis.
Conclusion: MRI is proven to be the technique of choice in differentiation between various knee pathologies that cause
AKP in different age groups due to its safety. Also, MRI has the ability to detect the different grades of some knee
pathologies as trochlear dysplasia, chondromalacia patella or factors that may predispose to them.
Keywords: Anterior knee pain, Chondromalacia patella and trochlear dysplasia, MRI.

INTRODUCTION

Anterior knee pain (AKP) is a very common
makes it insensitive in evaluation of periarticular
knee complaint affecting adults and young individuals.
ligaments and insertions, joint capsule and menisci.
It was recorded that about a quarter of attendants to
Furthermore,
accurate
TT-TG
distance
sports injury clinics suffer from AKP (1). This pain can
measurements need special image protocol techniques,
be acute or chronic and increases by physical activity
patient position and overlay of images requiring
such as climbing up and down the stairs, squatting or
specific software capabilities and a high dose of
kneeling (2). Since the anterior part of the knee contains
ionizing radiation (7, 8). Therefore, the aim of the present
multiple structures such as cartilage, subchondral bone,
study was to evaluate the role of magnetic resonance
synovial plica, patellar fat pads, retinacula, capsule and
imaging in diagnosing different diseases that cause pain
tendons, any of these structures can be affected alone
in the front of the knee.
or together to cause AKP (3).

The majority of the cases with AKP can be
PATIENTS AND METHODS
improved with conservative treatment using
This study included 48 patients (26 males and 22
medications and physical therapy. Nevertheless, the
females) with history of anterior knee pain. Their ages
most difficult challenge is to localize the exact origin of
ranged from 12 to 60 years (average age 37 years). The
AKP only by physical examination (4). Imaging options
period of study was 6 months. All patients were referred
for anterior knee pain include X-ray, CT, and MRI. X-
from the outpatient clinic of orthopedic surgery, Zagazig
ray is usually the first modality used to evaluate AKP
University Hospitals. This work was performed at the
due to its wide availability, rapidity, and low cost. X-
MRI unit of Radiodiagnosis Department, Zagazig
rays can be used to detect various disorders of the knee
University Hospitals.
such as fractures, osteoarthritic degenerative changes,

and joint effusions (5).
Inclusion criteria: Any patient with a pain at the
Nevertheless, it is quite limited because it
anterior knee. All age groups were included.
cannot detect the pathology in soft tissues and cartilage,

and has the added risk of exposure to radiation. This
Exclusion criteria: Patients with contraindication to
means it may not be suitable for all patients, especially
MRI examination e.g. implanted pacemaker, ocular
pregnant women and children (6). CT can also be used
implants, aneurysmal clips, and any orthopedic device
to accurately detect bony pathologies and measure the
incompatible with MRI. Patients with isolated pain in
TT-TG distance, which is important in the detection of
other
compartments
(posterior
or
lateral
patellofemoral instability. The main limitation of CT is
compartments).
the low soft tissue contrast, which

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2990
Received:19/5 /2021

Accepted:15/7 /2021

Full Paper (vol.851 paper# 55)


c:\work\Jor\vol851_56 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2995-2998

Cutis Verticis Gyrata and Quality of Life: Clinical Report of 13 Cases
Alzaid Mohammed*1, Reygagne Pascal2, Assouly Philippe2, Matard Bruno2
1Department of Dermatology, University Hospital of Nice, France,
2Department of Dermatology - Sabouraud Center, Saint-Louis University Hospital, Paris, France
*Corresponding author: Reygagne Pascal, Mobile: +33142493939, E-Mail: p.reygagne@centresabouraud.fr


ABSTRACT
Background: The quality of life of patients with Cutis Verticis Gyrata (CVG) has not been previously investigated
in the literature.
Objective: Description of features and evaluation of quality of life of CVG patients.
Materials and methods: We employed a mixed methods study. We retrospectively collected data from the clinical
database from 2012 to 2020. We selected 17 clinically diagnosed CVG patients and prospectively evaluated the
quality of life of these CVG patients.
Results: Out of 13 patients, 11 patients were in between the 14-47 age group. The majority of them were male (77%),
Caucasian (54%), had no significant family history (92.3%), and had the age of onset below < 30 years (69.2%). The
majority of the patients had a secondary form of CVG (54%) followed by a primary essential form of CVG (46.1%).
The CVG had a small effect on the majority of patient's quality of life (77%), and a majority of patients were not
taking any treatment (69.2%)
Conclusion: In our study, the CVG was shown to have a small effect on the patient's quality of life.
Keywords: Acromegaly, Cutis verticis gyrata, DLQI, Quality of life, Skin diseases.

INTRODUCTION
Cutis Verticis Gyrata (CVG) is a rare benign
onset, type of CVG, risk factors, complications,
cutaneous disorder characterized by the scalp's
presence of depression or anxiety, treatment, and
convoluted folds and deep furrows that mimic cerebral
disease course. The information on Dermatology Life
sulci and gyri(1). The primary essential CVG is not
Quality Index was collected from the patient.
linked to any other diseases, whereas the primary non-

essential form is linked to mental deficiency,
Ethical consideration
neurological
diseases,
and
ophthalmological
An approval of the study was obtained from
disorders(2). Secondary CVG can be caused by many
Sabouraud Center ­ Saint Louis University
factors, including inflammatory dermatoses, systemic
Hospital, (Paris, France) Academic and Ethical
diseases, infiltrates, and cutaneous neoplasms(3).
committee. The aim of the study was clearly
Clinical, pathological, and radiological features
explained to the 13 patients, and written informed
of cutis verticis gyrata patients were reported in many
consent was collected from them.This work has
studies(2-6). As far as we know, patients' quality of life
been carried out in accordance with The Code of
with CVG has not been previously investigated in the
Ethics of the World Medical Association
literature.
(Declaration of Helsinki) for studies involving
Dermatology Life Quality Index (DLQI) scale
humans.
helps measure how much the skin disease has affected

patients' lives suffering from dermatological disorders
Statistical analysis

(7).
The collected data were coded, processed and
So, we aimed to evaluate the patient's quality of
analyzed using the SPSS (Statistical Package for the
life of different forms of cutis verticis gyrata using the
Social Sciences) version 22 for Windows® (IBM
Dermatology Life Quality Index (DLQI) scale.
SPSS Inc, Chicago, IL, USA).


PATIENTS AND METHODS
RESULTS
A mixed-methods study was carried out using
As shown in table (1), 11 patients were in
a clinical database in Sabouraud Center ­ Saint Louis
between the 14-47 age group. The majority of them
University Hospital, Paris. We found 17 clinically
were male (77%), Caucasian (54%), had no
diagnosed CVG cases from 120000 patients in the
significant family history (92.3%), and had the age of
database as it is a rare disease. Out of 17 patients, we
onset below < 30 years (69.2%). The majority of the
were unable to reach four patients.
patients had a secondary form of CVG (54%)
So, we presented 13 cases of CVG. The
followed by a primary essential form of CVG
following information was collected from the patient's
(46.1%), had no complications (69.2%), and no
case sheet: age, gender, ethnicity, family history, age of
depression or anxiety (69.2%).


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2995
Received:1/7 /2021

Accepted:14/8 /2021

Full Paper (vol.851 paper# 56)


RELATIONSHIP BETWEEN SLEEP DISORDERED BREATHING AND PRO-INFLAMMATORY MARKERS IN ACUTE ISCHEMIC STROKE The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 2999-3006

Role of Activin A as A Novel Marker for Diagnosis and Evaluation of
Nonalchoholic Fatty Liver Disease
Ahmed Samir Abohalima, Samir Yousry Barsoum Atalla,
Amal Shawky Mohamed Bakir, Ramy Samir Ghait
Internal Medicine, Gastroenterology and Hepatology Department,
Faculty of Medicine, Ain Shams University, Egypt
*Corresponding Author: Ahmed Samir Abo Halima, Phone No.: (+2) 01111194743, E-mail: dr.abohalima@hotmail.com

ABSTRACT
Background:
Nonalcoholic fatty liver disease (NAFLD) is a disease gaining increasing interest worldwide. It
ranges from simple nonalcoholic steatosis to nonalcoholic steatohepatitis (NASH), which is characterized by
steatosis, inflammation and fibrosis, and may lead to liver cirrhosis and hepatocellular carcinoma.
Objectives: To study the role of activin A, a member of the transforming growth factor (TGF) superfamily, in
diagnosis and evaluation of non-alcoholic fatty liver disease (NAFLD).
Patients and Methods: This study is a comparative case-control study. This study was carried out at Outpatient
Clinics of Internal Medicine Department of Ain Shams University. The study included 90 patients that were divided
into 3 groups. Group 1 that included 35 patients with NAS (steatosis) with exclusion criteria of intake of hepatotoxic
drugs, group 2 that included 35 patients with fatty liver and elevated liver enzymes (NASH) and group 3 that
included 20 patients as a control group.
Results: There was a high statistical significant difference between the studied groups as regards ALT, AST, total
and direct bilirubin, plts count, activin A, and Albumin. There was a high statistical significant difference between
the studied groups as regards APRI score and FIB-4. There was high correlation between activin A and BMI, APRI
score, FIB-4 and liver size with high significance (p < 0.001). Using activin A, it was shown that above 858.5, it
can discriminate between NAFLD and non-NAFLD with level of sensitivity 100% and specificity 100%.
Conclusion: Serum activin A showed a trend towards progressive level increase from controls, to steatosis and
NASH patients.
Keywords: Activin A, Non-alcoholic fatty liver disease.


INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is
triggering of hepatocyte injury and hepatic fibrosis in
becoming one of the most frequent causes of impaired
NASH are still largely unknown. Little is known, in
liver function, with an estimated incidence of over 20%
particular, regarding the mediators that may cause an
in the Western world (1). NAFLD is a spectrum of
extensive hepatic fibrogenic response in certain people
disease that ranges from simple steatosis (fat
with NAFLD, leading to advanced NASH.
accumulation) of the liver to non-alcoholic
Activin A is a member of the transforming
steatohepatitis (NASH) with inflammation and fibrosis,
growth factor (TGF)-b superfamily (7) and was first
followed by extensive fibrosis and NASH-associated
identified as a follicle-stimulating hormone inducer (8).
cirrhosis in the most advanced forms of NASH. While
Studies have also suggested that activin A may have a
NASH implies a risk of progressive liver disease (2),
role in the development of a variety of liver diseases,
simple steatosis may be regarded as a risk factor (3).
including acute liver damage, chronic viral hepatitis,
NAFLD is characterised by triglyceride buildup in
and some hepatic cancers (9). We established that activin
hepatocytes, necrosis, and apoptosis of these cells, as
A has a role in NAFLD (10). The aim of the present study
well as inflammatory and fibrogenic reactions in the
was to study the role of activin A, a member of the
liver, which can progress to cirrhosis.
transforming growth factor (TGF) superfamily, in
In NASH, the two-hit model highlights the key
diagnosis and evaluation of non-alcoholic fatty liver
early metabolic processes that contribute to fat buildup
disease (NAFLD).
and, eventually, hepatic necrosis and inflammation (4).

According to the two-hit model, identifying variables
PATIENTS AND METHODS
that cause hepatic fat accumulation as well as mediators
Study design: This study is a comparative case control
that facilitate the hepatic shift from basic steatosis to
study.
NASH is critical. NAFLD is commonly linked to the
Setting: This study was carried out at Outpatient
metabolic syndrome, which includes obesity,
Clinics of Internal Medicine Department of Ain Shams
dyslipidemia, and insulin resistance (IR) (5). Though
University.
these factors, as well as inflammation and oxidative
Time of the study: from November 2019 till May 2020.
stress (6), may predispose to NAFLD development, the
Target population: Group 1 included 35 patients with
mechanisms that underlie hepatic fat accumulation and
NAS (steatosis) with exclusion criteria of intake of


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2999
Received:19/5 /2021

Accepted:15/7 /2021

Full Paper (vol.851 paper# 57)


c:\work\Jor\vol851_58 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3007-3011
Assessment of Complicated Anterior Abdominal Wall Hernia by
Ultrasonography and Colour Doppler
Yara Ibrahim Abdel Hamid*, Enas Mohamed Khattab, Ahmed Abdel Azim Isamail, Sameh Saber Baioumy
Department of Radiodiagnosis, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Yara I. Abdel Hamid, Mobile: (+20) 01158925343, Email: dryara100@yahoo.com

ABSTRACT
Background:
A hernia is defined as a protrusion from a structure through the normally tissues containing it, either a
focal or diffuse defects in the tissues with many types including: inguinal, femoral, umbilical and paraumbilical,
epigastric and incisional hernias. Objective: This study aimed to evaluate anterior abdominal wall hernia using
ultrasound and color Doppler. Patients and methods: An interventions study included (48) patients who were referred
from the Surgery Department, Zagazig University Hospitals for sonographic evaluation of the abdominal wall and the
abdomen when their clinical presentations were suggestive of abdominal wall hernia obstruction, either progressed or
not progressed to bowl obstruction, when their physical examinations were inconclusive or when surgeons believed it
was important to determine the contents of a suspected hernia preoperatively. Results: The mean age of the studied
patients was 47.5 ± 21.88 years old, with a range from 3 months to 66 years old, less than ½ of the studied patients were
males (41.7%) and 58.3 % were females. About 100% of the studied hernias were irreducible containing omentum,
while hernias were containing bowel in 95.8% of cases, 41.7 % of cases contained free fluid in hernia sac, 47.8% of the
studied patients had absent bowel peristalsis. Comparing the ultrasound finding with the operative data revealed that
ultrasound had 100% sensitivity, while accuracy in diagnosis of peristalsis, bowel irreducibility, bowel thickness ranged
from 93.4% to 98.8%. Conclusion: High-resolution ultrasonography (US) is an efficient tool for detecting the presence
of abdominal wall hernias and accurately detecting the content, and the possible associated complications.
Keywords:
Abdominal hernia, Doppler, Sonographic evaluation, Ultrasonography

INTRODUCTION

Imaging studies are required when the clinical
A hernia is the protrusion of a structure through
manifestation is misleading or inconclusive or
the tissues normally containing it, either through a focal
preoperative assessment of the hernia. Moreover, early
defect in the tissue or stretching of the tissue (1).
diagnosis of hernia complications is feasible using
Predisposing factors for hernia are developmental
ultrasound examination, potentially improving patient
anomalies, chronic cough, obesity, ascites, previous
outcome by preserving bowel viability. Ultrasound give
surgery, trauma, pregnancy, impaired wound healing,
information on the herniated organs, the presence of
and aging (2). The most common hernias are the inguinal
peritoneal fluid, the presence or absence of color
hernias. Inguinal hernias are further divided into the
Doppler signals in the hernial contents and the presence
more common indirect inguinal hernia. There are cases
or absence of peristalsis in the herniated bowel loop may
in which the hernia may contain both direct and indirect
be detected (1).
hernia simultaneously; pantaloon hernia (3).
Therefore, the present study aimed to evaluate of
Femoral hernias is a rare hernia that is more
anterior abdominal wall hernia using ultrasound and
common in women, possibly because of pregnancy (4).
color Doppler.
Umbilical and paraumbilical hernias involve protrusion

of intra-abdominal contents through a weakness at the
PATIENTS AND METHODS
site of passage of the umbilical cord through
An interventions study included (48) patients of
the abdominal wall (5). Epigastric hernia occurs in the
28 females and 20 males, with an age range from 3
midline above the umbilicus till the xiphisternum.
month to 66 years old. These cases were referred from
Diastasis of the rectus abdominis muscle often
the Surgery Department, Zagazig University Hospitals
predisposes to epigastric hernias and fatty hernia of the
for sonographic evaluation of the abdominal wall and the
linea alba (6).
abdomen when their clinical presentations were
Incisional hernia is an important type of hernia
suggestive of abdominal wall hernia obstruction, either
that is located at the scar from previous surgery as a
progressed or not progressed to bowl obstruction, when
delayed complication of abdominal surgery (4).
their physical examinations were inconclusive or when
The most common complications of abdominal wall
surgeons believed it was important to determine the
hernias are bowel obstruction secondary to the hernia,
contents of a suspected hernia preoperatively.
incarceration, and strangulation. These complications can
This study included a patient clinically
often be detected at clinical evaluation. Presenting
presented with acute inguinal lump with suspected
symptoms may include abdominal pain, vomiting, and
obstructed abdominal wall inguinal hernia and some
distention. Physical examination may reveal a firm, tender
cases were referred for sonography due to vomiting and
abdominal wall mass (7).
abdominal pain of unobvious cause. This work was



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3007
Received: 19/5/2021

Accepted: 15/ /2021

Full Paper (vol.851 paper# 58)


c:\work\Jor\vol851_59 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3012-3017

Study Of RET/PTC1 Translocation in Differentiated Thyroid Cancer
Ahmed Elshazli*, Tamer Youssef, Atef Mohamed Abd El-Latif,
Mohamed Saleh El-Hagar, Mostafa Mammdouh Sofan
Department of Endocrine Surgery Unit, Faculty of Medicine, Mansoura University, Egypt
* Corresponding author: Ahmed Elshazli, Mobile: 01064003707, E-mail: ahmedelshazli87@gmail.com

ABSTRACT
Background: Thyroid cancer is a very common malignancy of endocrine system with increasing incidence rate over
the previous two decades. Most thyroid cancers are well-differentiated papillary carcinomas or follicular carcinomas.
Several risk factors have been attributed to the development of thyroid carcinomas such as exposure to ionizing
radiations, iodine uptake, and Hashimoto's thyroiditis. In addition to environmental factors, genetic factors are
involved in thyroid cancer. RET/PTC translocation plays a role in pathogenesis of differentiated thyroid carcinoma.
The most common rearrangement types are RET/PTC1 and RET/PTC3, which are found mainly in papillary thyroid
carcinoma.
Objective:
To study the association between RET/PTC translocations and differentiated thyroid carcinoma, its
clinical implications and the role RET/PTC translocations in tumor genesis and aggressiveness.
Patients and Methods: This prospective study was conducted on 100 patients with provisional diagnosis of nodular
goiter underwent thyroidectomy. Detection of RET/PTC1 translocation was studied in our patients within thyroid
nodules. After full history taking, examination and investigation for 100 patients, who underwent thyroidectomy
postoperative pathology and were 25 malignant 75 benign cases. Specimens from this 100 cases were subjected to
RET/PTC1 translocation testing.
Results: The incidence of RET/PTC1 gene translocation was 8 case of 25 cases of malignant cases (32%), and
three cases of 75 benign cases (4%).
Conclusion: RET/PTC1, RET/PTC3 translocation plays an important role in the pathogenesis of differentiated
thyroid cancer. The RET/PTC1, RET/PTC3 translocations were significantly associated with differentiated thyroid
cancer especially papillary variants.
Keywords: RET/PTC translocation, Thyroid Cancer, Total thyroidectomy.

INTRODUCTION
Among
all
RET/PTC
rearrangements,
Thyroid nodules are a very common clinical
RET/PTC1, and RET/PTC3 are in general the most
finding; the prevalence of palpable nodules ranges from
frequent. RET/PTC3 is much more prevalent in
4 to 7 % in general population. Although only less than
irradiated PTC especially in those with solid variants
5% of palpable nodules are malignant lesions, thyroid
(4).
cancers are the most frequent endocrine malignancy
This research aimed to study the association
accounting for about 5­10% of thyroid nodules (1).
between RET/PTC translocations and differentiated
About 95% of malignant lesions are derived from
thyroid carcinoma, its clinical implications and the
thyroid follicular cells and are distinguished into well
role RET/PTC translocations in tumor genesis and
differentiated, either papillary (PTC) or follicular (FTC)
aggressiveness.
histotype, and anaplastic thyroid carcinoma (2).

PATIENT AND METHODS
Over the last several years, significant progress
This prospective case series study was
has been made in understanding the genetic
conducted during the time between September 2017
mechanisms of thyroid cancer and in the development
and September 2020 in Mansoura Endocrine Surgery
of molecular tests for cancer diagnosis in thyroid
Unit, Mansoura University Hospital. The study included
nodules. RET/PTC translocation plays a role in
100 cases with provisional diagnosis of nodular goiter
pathogenesis of differentiated thyroid carcinoma. The
who underwent thyroidectomy.
most common rearrangement types are RET/PTC1 and
The study included patients with nodular goiter
RET/PTC3 which are found mainly in papillary thyroid
either multinodular goiter (MNG) or solitary thyroid
carcinoma (3).
nodule (STN), as assessed by clinical examination,
A lot has been discovered between the
ultrasonography or computed tomography and
relationship of RET/PTC rearrangements and PTC
recurrent goiter.
clinical pathological, a n d epidemiological features.
Patients who had thyrotoxic goiter and
Although present also in non-irradiated cases,
undifferentiated carcinoma were excluded from the
RET/PTC rearrangements are related to radiation
study, also patients having psychiatric disease, were
exposure and are more frequent in patients with radio
excluded as well.
induced PTC.





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3012
Received: 22/5 /2021

Accepted: 18/7 /2021

Full Paper (vol.851 paper# 59)


c:\work\Jor\vol851_60 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3018-3025

Effect of Tranexamic Acid in Patients with Traumatic Brain Injury
Yasser Ibrahim Fathey, Hadeer Hussein Ghoneim, Noha Abd-Allah Afify,
Alaa Eldin Abdel Samie Aiad
Department of Anesthesiology, Intensive Care and Pain Management,
Faculty of Medicine ­ Menoufia University, Egypt.
*Corresponding author: Hadeer Hussein Ghoneim, E-Mail: hadeerhussein15@gmail.com


ABSTRACT
Background:
Traumatic brain injury (TBI) is a leading cause of death and disability. Intracranial hemorrhage
secondary to TBI is associated with a high risk of coagulopathy and progress of intracranial hemorrhage (ICH).
The hemostatic drug tranexamic acid (TXA) with anti-fibrinolytic activity is usually used in patients with trauma
to reduce hematoma size. It has been considered a possible therapy to improve the clinical outcome in patients
with TBI.
Objective: To evaluate the effect of tranexamic acid on the volume of intracranial bleeding in patients with TBI
admitted to Critical Care Unit at Menoufia University Hospital.
Patients and methods: A prospective randomized placebo-controlled double blinded study in the Critical Care
Unit, Menoufia University hospitals, through one year from January 2020 to January 2021. The study was carried
out on 40 patients with TBI with Glasgow Coma Scale (GCS) of 4 to 12. They had a computerized tomography
(CT) brain scan within 8 hours of injury and in whom there was no indication for immediate surgical intervention.
We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1
g over 8 hours) or matching placebo.
Results: There was statistically significant reduction in the volume of ICH after 48 hours (p = 0.021) in TXA
group than in placebo group. While in placebo group, there was high statistically significant increase in volume of
ICH after 48 hours compared to on admission. Moreover, TXA reduced the need of blood transfusion, surgical
intervention and the incidence of complications with no evidence of increased risk of thromboembolic events.
Conclusion: TXA may reduce the volume of ICH in patients with TBI with no evidence of increased risk of
thromboembolic events.
Keywords: Tranexamic acid, Traumatic brain injury.

INTRODUCTION

Trauma is a time-sensitive condition. During
be commonly used in surgery to reduce blood loss (5).
the first hours of trauma management, early
TXA also has an excellent safety profile and has
assessment, resuscitation, and definitive care are very
been shown to be cost-effective. Because of the
important to decrease disability and mortality (1).
mechanistic potential for TXA to decrease secondary
Traumatic brain injury (TBI) is a major cause of
brain injury, it has been considered as a possible
death and disability worldwide, especially in children
therapy to clinically improve outcomes in patients
and young adults and represents a major social,
with TBI by reducing systemic blood loss and
economic, and health problem (2). Traumatic brain
hypotension (6). The aim of this work was to evaluate
injury (TBI) is commonly accompanied by
the effect of tranexamic acid on volume changes of
intracranial bleeding, which occurs in 25% to 45%,
intracranial bleeding in patients with TBI.
3% to 12% and 0.2% of severe, moderate, and mild

TBI cases respectively (3). In patients with TBI,
PATIENTS AND METHODS
repeated CT scanning has found that intracranial
This was a prospective randomized placebo-
bleeds can develop or expand in the 24 hours after
controlled double blinded study that was carried out
injury and that larger bleeds have a worse prognosis.
on 40 patients with TBI. They were admitted at
Delayed enlargement of traumatic intraparenchymal
Menoufia University Hospital through one year from
contusions and hematomas is the most common cause
January 2020 to January 2021. According to a sealed
of clinical deterioration and death in patients who had
envelope random allocation, patients were
a lucid interval after TBI (4).
randomized into two groups: tranexamic group and
Tranexamic acid (TXA) is a potent anti-
placebo group (20 patients each).
fibrinolytic agent that exerts its effect by blocking

lysine-binding sites on plasminogen molecules and
Inclusion Criteria:
has the potential to enhance the effectiveness of the
Adult patients (>16-year-old) with TBI with
patient's
own
hemostatic
mechanisms.
Glasgow Coma Scale (GCS) score of 4-12 who had a
Consequently, clot breakdown is inhibited, and
CT brain scan performed within eight hours of injury.
excessive or recurrent bleeding is reduced. TXA may


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3018
Received:20/5 /2021

Accepted:16/7 /2021

Full Paper (vol.851 paper# 60)


c:\work\Jor\vol851_61 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3026-3030

Percutaneous Pinning for Recent Lower Tibial Epiphyseal Injury in Pediatric
ElSayed ElEtewy Soudy, Mohsen Fawzy Omar, Mohamed Ismail Abd El Rhman Kotb,
Mahmoud ElSayed ElSayed Abbas
Orthopedic Surgery Department, Faculty of Medicine, Zagazig University, Egypt.
Corresponding author: Mahmoud ElSayed ElSayed Abbas, Mobile: (+20)01273539354,
E-mail: mahmoudabbas11121@gmail.com

ABSTRACT
Background:
Physeal fractures of long bones are common injuries treated by orthopedists. Distal tibial physeal fractures
account for 11% of all physeal injuries. Objectives: The aim of the work is evaluation of the clinical and radiological
outcome of lower tibial epiphyseal injury managed by percutaneous pinning.
Patients and Methods: This was a prospective randomized study carried out on 12 cases with distal tibial epiphyseal
injuries admitted to Zagazig University with follow up period up to six months. The youngest patient was 8 years old,
while the oldest was 16 years old, with an average of 12 years; the high incidence was in the age group 10-15 years.
Results: Overall results obtained from 12 cases were satisfactory in 11 cases (91.66%) and unsatisfactory in 1 cases
(8.37%). More satisfactory results in this work were in the age group 10-15 years. However, age did not affect the results
significantly. Cases with closed injury showed more satisfactory results (100%) than those with open injury, the
difference was statistically highly significant. All cases in this study were presented within the first 48 hours from onset
of trauma. 8 cases were immobilized for 8 weeks and 4 cases for 6 weeks. The difference was statistically insignificant.
2 cases were managed by open reduction and internal fixation and the difference was statistically insignificant.
Conclusion:
The percutaneous pinning for lower tibial epiphyseal injury showed good reduction of fracture, satisfactory
functional outcome and less complications. The technique provided speed recovery, secure fixation and avoiding
prolonged cast immobilization and conservative treatment.
Keywords: Anteroposterior, Extracellular matrix, Kirschner wire, Percutaneous, Salter-Harris type I, II, III, IV, V,
Tibial.


INTRODUCTION
the leg or foot, although uncommon, can be associated
Physeal fractures of long bones are common injuries
with physeal fractures of the distal tibia and fibula(4).
treated by orthopedists. Distal radius fracture are the
The decision to treat pediatric ankle fractures is
most common long bone physeal fractures closely
based on the fracture type, amount of displacement and
followed by distal tibial physeal fractures(1). These
the ability to restore and maintain the alignment of the
injuries account for 11% of all physeal injuries and carry
physis and the congruity of the ankle joint. If a
a significant risk of growth disturbances such as
satisfactory closed reduction can be achieved and
premature physeal closure, angular deformity and leg
maintained internal fixation is unnecessary. However if
length discrepancy. The incidence of premature physeal
closed reduction is unsuccessful, open reduction with
closure has been reported to be between 2-5 %. The
skeletal fixation is warranted. If the fracture
mechanism of injury was categorized according to the
displacement was still more than 2 mm after reduction,
Lauge-Hansen classification and Diaz and Tachdjian
open reduction and internal fixation (ORIF) is
classification of ankle fractures. The most common
performed. A long-leg, non­weight-bearing cast is
mechanism of injury was supination-external rotation
applied for 4 weeks postoperatively and is changed into
(66%), followed by pronation-abduction (30%),
a short-leg, weight-bearing cast for 2 weeks. If the K-
pronation-external rotation (3%) and axial crush (1%)(1-
wire (KW) is used for internal fixation, it is removed 6
3). The Salter-Harris classification system is simple and
weeks postoperatively. If a screw is used for fixation, it
reproducible, and it remains the most widely used system
is removed 2 to 6 months postoperatively(5,6).
for children's ankle fractures(2).
This study aimed to evaluation of the clinical and
The physical exam of the injured ankle should
radiological outcome of lower tibial epiphyseal injury
include a thorough visual inspection and palpation
managed by percutaneous pinning.
around the entire ankle. Identifying lacerations, blisters

or evidence of an open wound is paramount and may
PATIENTS AND METHODS
alter the treatment plan. Vascular exam should include
This was a prospective randomized study carried out
palpation of the dorsalis pedis, anterior and posterior
on 12 cases with distal tibial epiphyseal injuries, (8 males
tibial arteries. If excessive swelling impedes palpation of
60% and 4 patients were females 40%) aged (8 - 16)
the pulses, Doppler exam of the arteries should be
years old and the mean age was 12 years, the high
performed, combined with careful sensory and motor
incidence was in the age group 10-15 years. Car accident
exam of the nerves of the foot (superficial and deep
was the commonest cause of injury; it was encountered
peroneal, tibial and sural). Compartment syndrome of
in 58.33% of cases. The right side was affected in 8 cases



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3026
Received:22/5 /2021

Accepted:18/7 /2021

Full Paper (vol.851 paper# 61)


c:\work\Jor\vol851_62 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3031-3036

Effect of Cognitive Behavioural Therapy in Treatment of
Chronic Non-Specific Low Back Pain
Mohamed Yehia Elabd*1, Enas Fawzy Youssef1, Mohamed Ezzat Mohamed1, Ahmed Samir Mohamed2
1Department of Physical Therapy for Musculoskeletal Disorders and its Surgery,
Faculty of Physical Therapy, Cairo University, Egypt
2Department of Physical Therapy for Musculoskeletal Disorders and its Surgery,
Faculty of Physical Therapy, South Valley University, Egypt
*Correspondence: Mohamed Yehia Elabd, Mobile: (+20)01097726515, Email: yehiamohamed83@gmail.com

ABSTRACT
Background:
Low-back pain is a major health and economical problem that affects populations around the world.
Chronic low-back pain, in particular, is a major cause of medical expenses, work absenteeism, and disability.
Objective:
To explore the effect of adding cognitive-behavioral therapy to physical therapy interventions in patients
with chronic non-specific back pain. Patients and methods: 20 male and female patients between 25 and 40 years old
diagnosed as chronic non-specific back pain with central sensitization and fear avoidance behaviors symptoms
participated in this study. Patients were randomly assigned into two groups. The first group was treated by cognitive
behavioral therapy (graded exposure and graded activity) in addition to physiotherapy the second group was treated by
physical therapy interventions which was given only 3 times/week for 4 consecutive weeks.
Results: Descriptive statistics was used to identify each variable's mean and standard deviation. A paired t-test was
used to compare characteristics of patients between both groups. Pre-treatment results showed no significant difference
in both measured variables of Oswestry, and pain in both groups (P > 0.05). On the other hand, post-treatment results
showed a significant decrease in the Oswestry, and pain only in group A (the study group).
Conclusion: Adding graded exposure and graded activity as an operant cognitive behavioural therapy approach to
physical therapy program is more beneficial than physical therapy program alone. More data and follow up needed for
this study.
Keywords: Cognitive behavioral therapy, Graded exposure, Graded activity.

INTRODUCTION

It's found that 70% to 85% of all adults suffer from
dynamic tactile allodynia, pressure hyperalgesia and
low back pain affecting them in their life (1). About 42%
pain hypersensitivity that is felt by humans producing
to 75% of patients have persistent back pain after twelve
pain hypersensitivity and secondary changes in brain
months, which affects most of costs in healthcare and
activity would be seen by imaging techniques or
disability system. So, chronic low back pain stills a
electrophysiological studies (8).
burden health problem worldwide (2).
Chronic low back pain management is categorized
Most of 85% of low back pain patients are
into different strategies like exercise, medication, and
categorized into non-specific chronic low back pain. It's
behavioral therapy. The primary hypothesis underlying
referred to as a non-recognizable, unknown specific
a behavioral therapy method is that pain and its current
pathology such as, spinal canal stenosis, radicular pain,
disability are not only affected by recent
cauda equina syndrome, radiculopathy compression
pathophysiology but also by social factors and
fracture, spondyloarthropathy and malignancy (3). There
psychological problems. Chronic low back pain is not a
is a strong evidence that non-specific chronic back pain
physical problem only but also is affected by the
affects many other aspects of body reactions e.g.
patients' behaviors and belief, illness behaviors and
psychological (pain-related fear, feeling distress and
psychologic stress (9).
negative beliefs), social (stress of life), lifestyle factors
A review including cognitive behavioral therapy
(poor sleep and lack of activity), behavioral responses to
for chronic low back pain, which includes thirty
pain (avoidance of protective behaviors) and guarding
randomized-control trials revealed that behavioral
leading to distress and disability and cycle of pain (4, 5, 6).
treatments have no difference in intermediate and long-
Understanding of chronic pain disorders has been
term effects on pain or disability status. There were few
greatly taken into consideration. Over the past decades,
or no changes between behavioral therapy and group
it became obvious that most of chronic muscle and
exercise in improving pain and distress results over the
skeletal pain is characterized by continuous changing of
inter-mediate to long-term although in comparison there
central nervous system process. In other word, the
was only low evidence in results. So, more researches
response of neurons to input from uni-modal and
are needed (10).
polymodal receptors is increased, which results in what
The purpose of this study was to investigate the
is called pathophysiological state that is called central
effect of cognitive behavioral therapy in treatment of
sensitization (7). Central sensitization is defined as
chronic non-specific low back pain.



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/)
3031
Received:22/5 /2021

Accepted:18/7 /2021

Full Paper (vol.851 paper# 62)


c:\work\Jor\vol851_63 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3038-3043

Study of buffered 50% glycolic acid and 0.5% salicylic acid solution in acne vulgaris
Rewan Hossam Abdel-Maged Mohamed*, Mohamed Hamed Khater, Elsayed Mohamed Galal Elsayed Khater
Departemnt of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
*Corresponding author: Rewan Hossam Abdel-Maged Mohamed, Mobile: (+20)01002344830, E-mail:
rewanhossam91@gmail.com

ABSTRACT:
Background:
Acne vulgaris is an inflammatory disorder of the pilosebaceous unit, which runs a chronic course and it
is self-limiting. Glycolic Acid (GA) peels need to be neutralized to have their action stopped. Neutralizing agents for
alpha hydroxy acid (AHA) peels are basic solutions, such as ammonium salts, sodium bicarbonate, sodium hydroxide,
or water. Buffered glycolic acid has been clinically proven to dilute the concentrated effect of acids when applied
topically. Glycolic acid peels have anti-inflammatory, keratolytic, and antioxidant effects. GA targets the corneosome
by enhancing breakdown and decreasing cohesiveness, causing desquamation. Objective: To assess buffered 50% GA
(pH 3.0) and 0.5% salicylic acid (SA) solution in treatment of acne vulgaris. Patients and methods: A dermatological
examination had been done for 24 participants. Acne severity was assessed as mild, moderate, and severe according to
Global Acne Grading System (GAGS). For every case, treatment by buffered 50% GA and 0.5% SA solution was tested
and evaluated. Results: After treatment with buffered 50% glycolic acid and 0.5% salicylic acid, 54.2% of acne lesion
showed excellent improvement, 25.0% showed good improvement, 16.7% of acne lesion showed moderate
improvement and 4.1% showed poor improvement. Conclusion: Buffered glycolic acid 50% and salicylic acid in
treatment of mild to moderate degree acne vulgaris is very effective with few adverse effects.
Keywords:
Acne Vulgaris, Glycolic, Salicylic.

INTRODUCTION
the proper moment can lead to dermal wound and
Acne vulgaris is an inflammatory disorder of the
scarring (3).
pilosebaceous unit, which runs a chronic course and it
Buffered glycolic acid has been clinically
is self-limiting. Acne vulgaris is triggered by
proven to dilute the concentrated effect of acids when
Cutibacterium acnes in adolescence, under the influence
applied topically. For example, a buffered glycolic
of normal circulating dehydroepiandrosterone (DHEA).
solution at 10% with a pH of 5.4 yields a 1.7% active
It is a very common skin disorder which can present
contact versus the 3% of 10% free glycolic acid -
with inflammatory and non-inflammatory lesions
significantly lowering the benefit to the skin. Buffered
chiefly on the face but can also occur on the upper arms,
glycolic acid provides good, immediate exfoliation
trunk, and back (1).
result with the added benefit of secondary results not
The etiopathogenesis of acne vulgaris involves a
found with other AHA solutions: (4) Antibacterial
complex interaction between the main factors such as:
effect (as good as or better than salicylic acid). Opens
Genetic
predisposition;
androgenic
hormone
pathways for deeper penetration of other treatment
stimulation leading to an increase in sebaceous
layers.
Non-drying
results
without
TEWL
secretion; alteration of the lipid composition; follicular
(transepidermal water loss). Stimulates cell turnover
hyper-keratinization; bacterial colonization mainly by
and cell growth. Improves micro-vascular blood flow
Cutibacterium acnes (C. acnes) and periglandular
Glycolic acid peels have anti-inflammatory,
dermal inflammation. Currently, inflammation is
keratolytic, and antioxidant effects. GA targets the
considered a key component and can be detected on
corneosome by enhancing breakdown and decreasing
histopathological
and
immune
histochemical
cohesiveness, causing desquamation. The intensity of
examination in apparently non-inflammatory acneic
peel is determined by the concentration of the acid, the
lesions such as comedones and even in perilesional
vehicle used to carry it, the amount of acid applied, and
areas, without lesions (subclinical) (2).
the technique used (5).
GA peels need to be neutralized to have their
The hydroxy acids (HAs) were initially
action stopped. Neutralizing agents for AHA peels are
described by Yu and Van Scott (6) when they discovered
basic solutions, such as ammonium salts, sodium
that HA with a hydroxyl group at the or position
bicarbonate, sodium hydroxide, or water. The most
applied on the skin would lead to an improvement of
used is a 10­15% sodium bicarbonate solution, and as
hyperkeratosis. They found that keratinization was
it produces carbon dioxide in the process of
affected, causing a thinning of the stratum corneum. The
neutralizing the acid, bubbling is seen on the surface
use of HAs in cosmetics happened years later, with the
of the skin, which is important as it assures the
observation that they would also improve the clinical
physician that they have neutralized the acid. After
aspect and texture of photodamaged skin (7).
that, the patient should wash his or her face with a large
The HAs are classified as organic carboxylic
amount of cool water. Failing to neutralize the peel at
acids as they are composed of carbon and hydrogen



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/)
3037
Received:23/5 /2021

Accepted:19/7 /2021

Full Paper (vol.851 paper# 63)


c:\work\Jor\vol851_64 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3043-3053

Effect of Mulligan Technique on Subacromial Impingement
Syndrome: A Systematic Review
Mohamed Abdellatif Hassan1*, Enas Fawzy Elanni2, Karima Abdelaty Hassan2, Karim Ghuiba2
1 Department of Physiotherapy, Misr International Hospital, Giza, Egypt
2 Department of Physical Therapy for Musculoskeletal Disorders and Its Surgery,
Faculty of Physical Therapy, Cairo University, Egypt.
*Corresponding author: Mohamed Abdellatif Hassan, Mobile: (+20) 01111028319, E-Mail: elmezaien@yahoo.com

ABSTRACT
Background:
Subacromial impingement syndrome (SIS) is considered the most prevailing cause of shoulder pain. Although
Mulligan's technique may be useful in treating shoulder impingement, its significance in areas of range of movement
(ROM), pain, and function is still debated.
Objective:
To systematically review and summarize the best evidence on treating subacromial impingement syndrome
using mobilization with movement.
Patients and Methods: Databases Cochrane Library Web search, PEDro and PubMed were searched for RCTs published
in English language from inception to September 2019, updated later to 7th of July 2021. Reference lists of relevant
publications were also screened. Two reviewers separately identified relevant papers based on the inclusion criteria. The
identified papers by both authors were obtained in full text. To evaluate methodological quality and risk of bias, the
Cochrane risk of bias tool was used. We used the random-effects model in all analyses for meta-analyses.
Results: A total of 11 RCTs with a total number of 358 adults with subacromial shoulder pain were included. They examined
the effect of mobilization with movement (MWM) combined with exercise with or without taping against rotator cuff
strengthening, ROM exercises, isometric strengthening, shoulder joint mobilization, and sham techniques. Meta-analysis
was done comparing MWM against exercise and found a significant difference in VAS and a non-significant difference in
SPADI.
Conclusion: Shoulder mobilization with movement combined with a supervised exercise program (ROM, and functional
limitations) has a better impact on pain than exercise alone or sham in short-term with similar improvement to exercise in
the long-term.
Keywords:
Shoulder impingement, Mobilization with movement, Mulligan.

INTRODUCTION
reduction of pain can be accelerated in the short-term by
Shoulder impingement contributes to 44­60% of
adding of mobilizations to exercises. Mobilization with
all disorders causing shoulder pain, makes it the most
movement (MWM) is a manual therapy technique used for
familiar cause of shoulder pain (1). Shoulder impingement
musculoskeletal pain management. The therapist applies a
syndrome can be caused by several factors include
sustained glide to a painful or stiff joint while the patient
weakness of the rotator cuff muscles, morphology of the
performs a concurrent active movement (10). Mulligan (10)
acromion, muscle imbalance, laxity or tightness of the joint
advocated that MWM is clinically useful when a single
capsule, dysfunctional glenohumeral and scapulothoracic
application exhibits a measurable pain and range of
kinematics, degeneration and the tendons or bursa
movement improvement in joint.
inflammation(2).
Subacromial
impingement
is
A recent systematic review Stathopoulos et al.
distinguished by painful shoulder, elevation or overhead
studied the effect of mulligan's technique on peripheral
activities of the arm aggravate pain in adults. It has a huge
joints, concluded that MOM for shoulder adhesive
impact on socioeconomic status due to individual's
capsulitis and hip pain produced not only a statistically
working ability limitation(3, 4).
significant but also, a clinically significant ROM increase
Various physical therapy interventions, which
in all movement directions. On the contrary, a therapeutic
include thermotherapy, electrotherapy, therapeutic
benefit regarding ROM for shoulder impingement
exercise therapy, and manual physical therapy are used to
syndrome, shoulder dysfunction / pain, tight hamstring,
treat impingement of the shoulder (5). Therapeutic exercises
knee arthritis, and chronic instability of the ankle could not
generally have a positive effect in restoring shoulder
be obviously settled (11).
mobility and retraining muscle imbalance in SIS (6, 7, 8).
The strength of evidence concerned with the
Exercise therapy was described by Haik et al. (9) as the first
clinical efficacy of Mulligan MOM is not clear. The
choice to improve function, range of movement and pain
purpose of this study was systematically reviewing the best
and range of motion in treatment of shoulder. The
evidence on the effectiveness of using Mulligan



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/)
3043
Received: 23/5/2021

Accepted: 19/7 /2021

Full Paper (vol.851 paper# 64)


c:\work\Jor\vol851_65 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3054-3060

Vitamin D Level in Patients with COVID-19 and Its Relationship with
Severity of The Clinical Course
Nearmeen M. Rashad*, Yassmin E. Abdelhamid, Neveen G. Mekhael, George E. Shaker
Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
*Corresponding author: Nearmeen M. Rashad, Mobile: (+20) 01224248642,
E-mail: nrashad78@yahoo.com and n.rashad@zu.edu.eg.

ABSTRACT
Background:
Coronavirus disease 2019 (COVID-19) has killed millions of individuals and has led to the largest
economic contraction since the Great Depression. The antiviral effects of vitamin D can hinder viral replication directly,
and also be effective in an anti-inflammatory and immunomodulatory way.
Objective: This study aimed to estimate the serum levels of free 25 hydroxycholecalciferol (25(OH)-D) in patients with
COVID-19 infection in correlation to clinical manifestations and severity in multicenter tertiary-care hospitals, Egypt.
Subject and Methods: This cross-sectional study included 150 confirmed patients with COVID-19 by using RT-PCR
for detection of the viral RNA. The COVID-19 patients were classified into four groups of mild (n=40) moderate (n=40),
severe (n=40), and critical (n=30) based on disease severity. Serum concentrations of 25(OH)-D were tested using
enzyme-linked immunosorbent assay (ELISA).
Results According to the current study results, all included patients (n=150) had a low level of serum levels of 25(OH)-
D (11.46±4.47) in COVID -19 patients compared to normal levels. Interestingly, the levels of serum 25(OH)-D were
significantly low in severe (9.5±2.71) and critical (6.26±2.58) groups compared to mild (16.37±2.62) and moderate
(12.3±2.62) groups. Also, there was a significant positive correlation between serum 25(OH)-D levels and hemoglobin,
platelets, albumin, and SPO2 values. On the other hand, there was a significant negative correlation between serum
25(OH)-D levels and LDH, C reactive protein, D dimer, and ferritin levels.
Conclusions: Patients with COVID-19 in particular patients with severe and critical COVID -19 had a significantly low
level of serum 25(OH)-D compared to mild and moderate cases, in addition, PSO2 and D dimer were independently
correlated with serum 25(OH)-D, thus low serum 25(OH)-D level could be a predictor of severe and critical COVID -
19.
Keywords
: COVID-19, COVID-19 in multicenter tertiary-care hospitals, Critical, Egypt, Serum 25(OH)-D.


INTRODUCTION


Mounting evidence showed that coronavirus
with increased production of anti-inflammatory
disease 2019 (COVID-19) has rapidly spread
cytokines such as IL-10 (9).
worldwide and caused more than 1 billion infections
There is a lot of evidence that raised the
and 2 million deaths (1).
antiviral effects of vitamin D, as vitamin D can prevent
The pathophysiology of COVID-19 has not yet
viral replication directly, and also be effective in an anti-
been fully discovered. However, the direct viral toxicity
inflammatory and immunomodulatory way (10). It seems
(2), endothelial cell damage and dysregulation of the
that SARS-CoV-2 primarily uses the immune evasion
immune response are widely believed to contribute to
process during infection, which is followed by hyper
the pathogenesis of COVID-19 (3, 4). Growing evidence
reaction and cytokine storm in some patients (11), as a
highlights the link of 25 hydroxycholecalciferol
known pathogenic process of acute respiratory disease
(25(OH)-D) and immunity. There have been
syndrome (ARDS) development (12).
tremendous advances over the last 2 decades in
SARS-CoV-2 uses angiotensin-converting
understanding the processes that regulate the immune
enzyme 2 as the host receptor to enter into alveolar and
system. Numerous previous studies concluded that
intestinal epithelial cells (13). Subsequent dysregulation
vitamin D plays an important part in the innate
of the renin-angiotensin system may lead to excess
antimicrobial response as it inhibits B cell proliferation
cytokine production resulting in prospective fatal
and blocks B cell differentiation and immunoglobulin
ARDS (14).
secretion (5, 6).
The SARS-CoV-2 infection has killed millions
Furthermore, vitamin D suppresses T cell
of individuals and has led to the largest economic
proliferation and results in a shift from a Th1 to a Th2
contraction since the Great Depression. Therefore,
phenotype. Additionally, it affects T cell maturation
therapies are required to treat severe COVID-19 and to
with a skewing away from the inflammatory Th17
prevent its complications. Thus, the present study aimed
phenotype (7) and facilitates the induction of T
to estimate the serum levels of free 25
regulatory cells (8). These effects result in decreased
hydroxycholecalciferol (25(OH)-D) in patients with
production of inflammatory cytokines (IL-17, IL-21)
COVID-19 infection in correlation to clinical



This article is an open access article distributed under the terms and conditions of the Creative
Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
3054
Received:24/5 /2021

Accepted:20/7 /2021

Full Paper (vol.851 paper# 65)


c:\work\Jor\vol851_66 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3061-3071

Effect of Implementing an Educational Program on Parental Knowledge and
Practice About Febrile Convulsion
Fatma Ahmed El-Esrigy, Taghreed Mohamed Farahat, Eglal Al Sayed Mohamad Othman*
Department Family Medicine, Faculty of Medicine, Menoufia University, Egypt
*Corresponding author: Eglal Al Sayed Mohamad Othman, Mobile: (+20) 01002535222, E-Mail: eglalothman20@gmail.com

ABSTRACT
Background:
Febrile convulsion (FC) in under five children is a common presentation in family medicine and pediatric
clinics. Lack of parental knowledge regarding FC leads to anxiety and fear and improper management.
Objective:
To improve parental knowledge and practice regarding febrile convulsions through implementing health
educational program.
Patients and methods: A quasi experiment, one group pre/post-test study enrolled 300 parents 21-50 years old attended
two family health facilities, Menoufia Governorate, Egypt, with their children (aged from birth to six years old). Data
were collected through a predesigned questionnaire that included personal and socio-economic status, family history of
febrile convulsions or epilepsy, questions about parental beliefs regarding causes of febrile convulsions, knowledge
about febrile convulsions and recommended and non-recommended practices for febrile convulsion. Health educational
program was implemented and parent's knowledge and practice about febrile convulsions was assessed before and after
educational program.
Results: Among 300 participants aged from 21-50 years old with a mean age of 31.57 ± 6.98 years, majority of them
(85%) and (62%) had unsatisfactory knowledge and appropriate knowledge about home management of FC
respectively. There was a statistically significant improvement in the perceptions of the participants regards to the causes
of febrile convulsions pre- and post- intervention. There was a statistically significant improvement in the level of
knowledge, practice and home management of convulsions before and after education. The mean level of knowledge
and practice was statistically significantly higher after intervention.
Conclusion: There was significant improvement of parental perception, knowledge and practice regarding FC in
preschool children after educational program.
Keywords: Convulsions, Febrile, Practice, Parents, Preschool children.

INTRODUCTION
febrile convulsions. Risk factors, such as having family
Febrile seizure or febrile convulsion is "a
members who had febrile convulsions will put a child at
seizure in association with a febrile illness, in the
a higher risk for having them. (3) A neonatal nursery
absence of a central nervous system infection or acute
stay of >30 days, developmental delay, or attendance of
electrolyte imbalance in children older than one month
day care nursery (3).
of age without prior afebrile convulsion". It is common
Although
the
occurrence
of
febrile
in young children (3% - 4% of children below six years
convulsions in childhood is quite common and is
of age), and is one of the common causes of pediatric
generally considered a benign condition with a good
hospital admissions (1). The recurrence possibility of
prognosis, it can be extremely frightening, emotionally
febrile convulsions is 30%. The only relevant short-
traumatic, and anxiety provoking when witnessed by
term adverse outcome is new febrile convulsion. Death
parents. Parents are shocked to see their children
caused by febrile convulsion itself or by the treatment is
experience a seizure and consider it to be life
almost nonexistent. Adverse outcome may be more
threatening. The daily life of some parents is negatively
related to an underlying preexisting cerebral condition
affected by FC, with parents frequently waking at night
than to the febrile convulsion itself (2).
to follow their children's temperature (4). Parental
Pathophysiology of FC remains unclear. It is
anxiety and apprehension are related to inadequate
suggested that FC is an age-dependent response of the
knowledge of fever and febrile convulsions. Parents
immature brain to fever; there is an enhanced neuronal
may lack the knowledge or preparedness to offer first
excitability. Febrile convulsions generally happen when
aid to a child who is having a convulsion (5).
the child has an illness, but many times, they occur
The best approach for FC should involve
before the parent may realize that the child is sick. That
establishment of a good communication with parents
is because they usually take place on the first day of an
and should improve their responses to convulsions at
illness. There are several different causes for febrile
home. It is of particular importance that the families are
convulsions; (1) A fever that occurs after
relieved of their concerns and are capable of intervening
immunizations, especially the MMR (mumps measles
optimally with the disease (6). Accordingly,
rubella) immunization, (2) A fever resulting from a
understanding and improving parental knowledge,
virus or a bacterial infection can also cause febrile
attitudes, concerns and practices (KACP) toward FC are
convulsions. Roseola is the most common cause of
essential. Therefore, a quick assessment tool 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/)
3061
Received: 23/5/2021

Accepted: 19/7/2021

Full Paper (vol.851 paper# 66)


c:\work\Jor\vol851_67 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3072-3074

Prolonged Fever: Case Report
Basma Nabil Zahid*, Ashwaq Durzi Alruwaili, Muath Saleh AlMubarak,
Nuha Saad Alhammad, Alanoud Musead Alhalwan, Maram Marzouq Alotaiby,
Samiha Mohammed Aljetaily, Layla Bidah Algahtani, Fatema Ahmed Abdulkarim
Department of Pediatrics, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
*Corresponding author: Basma Nabil Zahid, Mobile: 9660564174000, E-Mail: Bzahid92@gmail.com

ABSTRACT
Background:
Sarcoidosis is a granulomatous disease with unknown cause that can vary from an asymptomatic
condition. Almost half of the patients with sarcoidosis have no symptoms.
Case report: 8 year-old female, referred from Abha Hospital as a case of prolonged fever. The fever was low grade,
lasted for months, mostly at night, and was associated with fatigue and no weight gain. Systemic review showed
abdominal distension, history of knee pain, mouth ulcers and temporary rash on feet.
Conclusion: Sarcoidosis is a disease that mostly affects the lung, but sometimes it is outside the lung, as in our cases.
Doctors should pay attention to this so that the wrong diagnosis does not lead to complications or death of the patient.
Keywords: Prolonged fever, Sarcoidosis.

INTRODUCTION

Sarcoidosis is an idiopathic multisystem
was referred her to our hospital (Children's Specialized
granulomatous disease that affects patients of all races
Hospital, King Fahad Medical City).
and ethnic groups however predilection for women and

African Americans is apparent. Extrapulmonary
History of Presenting Illness:
manifestations of sarcoidosis occur in up to 50% of
Fever:
cases. The most common sites of extrapulmonary
· Low grade (at home: 38oC).
involvement are the skin, eyes, liver, and
· Occurred mostly at night.
reticuloendothelial system followed by renal, cardiac,
· Progressed later on and lasted full days.
and neurological involvement (1-6). Only 8% of patients
· Responded to antipyretics temporarily.
present with isolated extrapulmonary disease in the
· Associated with lethargy and decreased
absence of pulmonary involvement with the most
activity.
common presentation in this group being isolated
· Lasted a total of 7-8 months.
cutaneous sarcoidosis (4, 6).
Past Medical and Surgical History:
Our case being presented is a unique
· At 6 months of age: had BCG abscess
manifestation of nonpulmonary sarcoidosis with
(required drainage) with axillary lymph node
abdominal
distension
with
hepatomegaly
on
enlargement.
examination, and palpable cervical lymph nodes.
· Not on any medications.

· No similar complaints before.
CASE REPORT
· Was admitted in Abha Hospital for 9 days then
8 year-old female, referred from Abha Hospital as a
discharged.
case of prolonged fever. The fever was low grade, lasted
· Not known to have allergies.
for months, mostly at night, and was associated with
· No surgical history.
fatigue and no weight gain. She had abdominal
· Vaccinations were up to date.
distension with hepatomegaly on examination, and
Family History:
palpable cervical lymph nodes, history of knee pain but
· Mother and father are healthy
no current swelling, history of mouth ulcers and history
· Siblings are healthy
of temporary rash on feet. Family history was
· Maternal uncle had lymphoma at 12 years,
significant for lymphoma in the maternal uncle.
treated with chemotherapy
She was admitted for total of 9 days and treated with
· No history of sibling deaths
antibiotics. She improved but then fever recurred. Bone
· No history of congenital or metabolic diseases
marrow biopsy was done: was reported as
in the family
unremarkable. She was followed up in OPD: suspected

to have familial Mediterranean fever. Colchicine was
Investigations:
prescribed for around 2 months, with which the fever
CT of the chest abdomen and pelvis showed:
improved. Yet, her ESR remained elevated, so an
Enlarged lymphadenopathy throughout the
alternative diagnosis was suspected, and therefore she
body, the largest in the neck is seen at the lower cervical

region on the left side approximately measuring 0 7 cm,



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/)
3072
Received:24/5 /2021

Accepted:20/7 /2021

Full Paper (vol.851 paper# 67)


c:\work\Jor\vol851_68 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3075-3079

Minimal Invasive Aortic Valve Replacement by Upper Ministernotomy Approach in
Comparison to The Conventional Full Median Sternotomy Approach
Hosam Fouad Fawzy, Khaled Abdel All, Mohsen Saber, Ayman Abdelmotelb
Department of Cardiothoracic Surgery, Faculty of medicine, Sohag University (Sohag), Egypt
*Corresponding author: Ayman Abdelmotelb, Mobile: (+20)01029454892, E-Mail: aymanabdelmotelb86@gmail.com
ABSTRACT
Background:
Minimal invasive cardiac surgery has gained more popularity nowadays in field of cardiac surgery due
to the rapid progress in equipments and techniques in this field. Ministernotomy technique for aortic valve replacement
is one of the most common minimal invasive cardiac surgery techniques.
Objective: Our study aimed to evaluate the advantages and disadvantages of using minimal invasive upper
ministernotmy approach versus conventional full median sternotomy approach for aortic valve replacement.
Patients and methods: The study include 60 aortic valve replacement patients done from 2017 to 2019 in Sohag
University Hospitals, Egypt and Hero Heart Institute, India. 30 patients by using conventional full sternotomy approach
(group A), and 30 patients by using upper ministernotomy approach with central cannulation (Group B). Operative and
post-operative data were compared. Results: Total operation time, ventilation time, ICU stay and total hospital stay,
were significantly longer in conventional group (group A). Total bypass and cross clamp time were significantly longer
in ministernotomy group (group B). Post-operative wound infection was significantly higher in conventional group
(group A). Wound cosmoses post-operatively was better in ministernotmy group as regards patient opinion. Post-
operative echocardiography showed no significant difference in post-operative pericardial effusion between both
groups. Post-operative pain as well as early morbidity were significantly less in ministernotomy group (Group B). No
mortality occurred in both groups. Conclusion: Upper ministernotomy is safe approach for aortic valve replacement
and show advantages over conventional full sternotomy in form of shorter operative time, shorter hospital and ICU stay,
better wound cosmetics, less post-operative bleeding and less post-operative pain.
Keywords: Cardiac surgery, Ministernotomy, Aortic valve replacement.

INTRODUCTION

parasternal incisions, Gundry et al. (6) first showed
Modern cardiac surgery that has been based on
encouraging valve surgery results with a low surgical
cardiopulmonary bypass (CPB), myocardial protection
mortality (1 to 3%). This study aimed to evaluate the
and median sternotomy. The median sternotomy incision
advantages and disadvantages of using upper
provides simultaneous access to all cardiac valves and
ministernomy approach versus conventional full median
coronary arteries. Good exposure has been a necessity for
sternotomy approach for aortic valve replacement.
the extensive corrections needed to treat for complex
PATIENTS AND METHODS
heart disease of most patients requiring cardiac operations
This study was designed to be a prospective, non-
(1). The aims of less invasive procedures are to maintain
randomized controlled one. It was conducted in the
the effectiveness of the operation, decrease patient
Department of Cardiothoracic Surgery at Sohag
suffering, minimize cost, improve patient recovery,
University Hospitals in Egypt and Hero DMC Heart
shorten intensive care and hospital stay and cosmetic for
Institute in India for a period of two years from 2017 to
the patient. These potential benefits encourage
2019. Sixty patients that were undergoing aortic valve
application of minimally invasive cardiac valve surgery
replacement were included in the study: 30 patients were
with further refinement of techniques; the minimally
assigned to group (I) which was the conventional aortic
invasive approach can be applied to many cardiac surgical
valve replacement (median sternotomy) group. The other
procedures (2). Direct-vision minimally invasive valve
30 patients were assigned to group (II) which was
surgery and (minimal access valve operations) were based
minimally invasive (upper mini-sternotomy) aortic valve
on modifications of previous incisions, and nearly all
replacement group.
were done under direct vision.
In 1996, the first minimally invasive aortic
Inclusion criteria: All patients were above 18 years old
operations were done (3). A minimally invasive procedure
of both genders with indications for isolated aortic valve
for performing repair or replacement of the aortic valve
replacement surgery.
simplifies the technique and reduce surgical trauma (4).In
Exclusion criteria: General criteria (bad renal function,
early 1996, working in Malaysia, the Stanford group
hepatic impairment). Cardiac condition (Patient with
performed the first four minimally invasive mitral valve
other cardiac disease: ischemic heart disease, mitral valve
replacements using end aortic balloon occlusion (Port-
disease, aneurysm of the ascending aorta, poor ejection
access) with cardioplegia (5). Surgeons found also that
fraction (less than 40), pecuts excavatum, patient with
minimal access incisions provided adequate exposure of
history of pericarditis and patient with previous valve
the aortic and mitral valves. Using ministernal or
replacement).



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3075
Received:25/5 /2021

Accepted:21/7 /2021

Full Paper (vol.851 paper# 68)


c:\work\Jor\vol851_69 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3080-3086
Laparoscopic Repair of Perforated Peptic Ulcer: Simple Closure Versus Omentopexy
Ahmed M. Salah El-Din*, Mohamed Yousef Batikhe, Mohamed M. Ali, Alaa A. Redwan
General Surgery Department, Sohag Faculty of Medicine, Sohag University, Egypt.
*Corresponding author: Ahmed M. Salah El-Din, Mobile: (+20) 01001329315

ABSTRACT
Background:
Laparoscopic repair of perforated peptic ulcer (PPU) has become an accepted way of management.
Omentopexy was the main method of repair for decades.
Objective: The goal of the present study was to evaluate whether laparoscopic simple repair of PPU is as safe as
omentopexy.
Patients and Methods: This prospective study included 50 patients who were diagnosed with perforated peptic ulcers
and underwent laparoscopic repair of perforated peptic ulcers at our institute from September 2019 to September
2020. They were divided into two groups: Omentopexy (group A) (n=20) and repair with simple closure only (group
B) (n=30). Patients' age, sex, pulse, blood pressure, respiratory rate, Boey score, perforation size, operation time,
leakage, wound infection, and length of hospital stay were evaluated. The data were compared by Mann-Whitney U
test and the Pearson's chi-square test.
Results: No patients died nor leaked. After matching, the simple closure and omentopexy groups had similarity in
age, gender, pulse rate, respiratory rate, Boey score, perforation size and wound infection. There were statistically
significant differences in systolic blood pressure (P = 0.002), operating time (136.40 ± 10.45 versus 106.83 ± 6.89
minutes; P < 0.0001), and length of hospital stay (7.20 ± 1.32 versus 5.67 ± 0.55; P < 0.0001).
Conclusion: Laparoscopic repair of a perforated peptic ulcer without an omental patch is a safe option and shortens
the operating time.
Keywords: Laparoscopic repair, Perforated peptic ulcer, Simple closure, Modified Cellan-Jones omentopexy.

INTRODUCTION

shorten the operating time? A review of the literature
The incidence of perforation in peptic ulcer
revealed a few studies that have reported on the safety
disease is 2­10% (1). While treatment of
of simple closure and compared its outcomes versus
gastroduodenal perforations remains surgical. the
those of omental patches (9-11). In our study, we aimed
number of patients presenting with this problem has
to compare the outcomes of laparoscopic repair of
declined over the past decade due to improved medical
perforated peptic ulcers using an omental patch with
management of peptic ulcer disease (2). Closure of a
that of simple closure without an omental patch.
perforated duodenal ulcer using an omental pedicle

was first reported by Cellan-Jones in 1929 (3). In 1937,
PATIENTS AND METHODS
Graham described 51 cases treated with free omental
This
was
a
single-center
prospective
patch closure in essentially the same fashion (4).
comparative study. All patients were diagnosed in our
Mouret et al. (5) first described laparoscopic
tertiary hospital with a perforated peptic ulcer from
intervention for perforated duodenal ulcers in 1990. A
September 2019 to September 2020, who underwent
number of studies have demonstrated that laparoscopic
laparoscopic surgery. For the prevention of selection
surgery for patients with a perforated peptic ulcer is
bias of patients who did or did not undergo the
superior to conventional open repair, and is safe and
laparoscopic method, patients with shock, generalized
feasible in terms of early outcomes, including pain and
peritonitis, previous upper-abdominal surgery, non
wound infection (6). Patients with risk factors for
juxtapyloric gastric ulcers, perforations > 12 mm, and
increased mortality at presentation should not be
concomitant ulcer bleeding or gastric outlet obstruction
considered for laparoscopic intervention. These
were excluded.
include individuals who present in shock, who have
Preoperative data like age, sex, and Boey score
delayed presentation > 24 h and who have a major
were recorded. The Boey scoring system is known
medical illness, or are > 70 years old (7).
worldwide for stratification of high-risk patients with
A published systematic review of laparoscopic
perforated peptic ulcers. Thirty patients underwent
versus open perforated peptic ulcer repair, proposes
simple closure whereas the other twenty patients
that laparoscopic approach should be the first
underwent repair using an omental pedicle
treatment of choice. In most institutions, the standard
(omentopexy). Consultant surgeons who are well
laparoscopic repair for PPU is closure with an omental
experienced in advanced laparoscopy did all surgical
patch (8). Adding an omental patch requires technical
procedures. Under general anesthesia, patients were
skill and is time consuming. However, is it safe to
placed in a 15- to 20-degree reverse Trendelenburg
repair the perforation without an omental patch to
position. The surgeon and assistant stood at the
patient's left side (with an assistant on the other side).

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3080

Received: 25 /5/2021

Accepted: 21/7/2021


Full Paper (vol.851 paper# 69)


c:\work\Jor\vol851_70 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3087-3091

The Utility of Serum Procalcitonin Measurement in the Diagnosis of
Spontaneous Bacterial Peritonitis in Liver Cirrhosis patients
Khaled H. Abd-Almaged, Inas E. Mohamed , Eslam S. Mohamed ,
Sabry E. Abd El Rahman, Ayman G. A. Dawod*
Internal Medicine, Hepatogastroenterology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
*Corresponding author: Ayman G. A. Dawod, Mobile: (+20) 01226714803, E-mail: ayman.gamil@med.asu.edu.eg.

Abstract
Background:
Ascites in cirrhosis has a poor prognosis, with mortality rates of around 40% at one year and 50% at two
years. It is also associated with other complications, such as spontaneous bacterial peritonitis (SBP), which can lead to
hepatorenal syndrome (HRS) in 30% of patients. Diagnostic paracentesis is the gold standard for diagnosing SBP. Serum
biomarkers such as procalcitonin (PCT) have recently received a lot of attention for the early detection of SBP.
Objective: To determine the usefulness of measuring serum procalcitonin levels in patients with liver cirrhosis and
ascites for the diagnosis of spontaneous bacterial peritonitis.
Patients and methods: A cross-sectional case-control study that was conducted on ninety (90) patients diagnosed with
liver cirrhosis. They were divided into three groups: Group (A) included 30 cirrhotic patients with ascites diagnosed as
spontaneous bacterial peritonitis, Group (B) included 30 cirrhotic patients with ascites but without spontaneous bacterial
peritonitis, and Group (C) included 30 cirrhotic patients without ascites as a control group.
Results: Serum procalcitonin levels in SBP patients were significantly higher than in sterile ascites and cirrhotic patients
without ascites with a P value of 0.001. It had a better cutoff value of 0.315 ng/ml, sensitivity of 87% and specificity of
97% than serum CRP that had a cutoff value of 16 mg/L, sensitivity of 76% and specificity of 90% in cirrhotic patients
for predicting ascitic fluid infection.
Conclusion: In cirrhotic patients, serum procalcitonin levels appear to provide a satisfactory diagnostic accuracy in the
diagnosis of spontaneous bacterial peritonitis, with a suggested cut-off value of 0.315 ng/ml. Further studies are needed
to determine the widespread use of serum PCT as a predictor of SBP clinically.
Keywords: liver cirrhosis, Ascites, Procalcitonin, Spontaneous bacterial peritonitis (SBP).

INTRODUCTION

Cirrhosis of the liver is a leading cause of morbidity
In healthy individuals, procalcitonin (PCT) is a
and mortality. Cirrhosis results from distortion of
calcitonin precursor naturally produced by thyroid C-
hepatic architecture characterized by diffuse nodular
cells. If infection is not present, the extra-thyroidal
regeneration, fibrosis, and collapse of liver structures.
expression of the PCT gene, which is present in the
This distortion leads to portal hypertension because of
liver, lung, kidney, adrenal tissue, monocytes,
increased resistance to portal blood flow (1). In cirrhosis,
granulocytes, testis, prostate gland, and small intestine,
portal hypertension and splanchnic vasodilation result
is suppressed and falls below the detection limit for
mainly from increased production of nitric oxide, which
clinical assays. Whereas, microbial illness, particularly
is the main pathophysiological mechanism of ascites (2).
bacterial infection, stimulates PCT gene expression
One of the complications that can occur in ascitic
with blood PCT levels rising 4 hours after the onset of
patients is SBP, which can result in HRS in 30% of
systemic infection and peaking between 8 and 24 hours
cases (3).
(7).
In hospitalised patients with liver disease, early
The aim of this study was to determine the
diagnosis of SBP is essential. Due to the lack of
usefulness of measuring serum procalcitonin levels in
symptoms in the early stages of SBP, that represents a
patients with liver cirrhosis and ascites for the diagnosis
problem for clinicians (4). Currently, most guidelines
of spontaneous bacterial peritonitis.
indicate that all patients with ascites admitted to the

hospital undergo a diagnostic paracentesis, regardless of
PATIENTS AND METHODS
clinical
suspicion.
A
count
of
ascites
This cross-sectional case-control study that was
polymorphonuclear cells (PMN) greater than 250
conducted at Ain Shams University Hospitals from
cells/mm3 confirms the diagnosis (5). During the
2016 to 2018. The study included ninety cirrhotic
paracentesis procedure, problems may occur, such as
patients. They were divided into three groups: Group
the introduction of pathogenic microorganisms into the
(A) included 30 cirrhotic patients with ascites who had
ascites along with the needle. As a result, the
spontaneous bacterial peritonitis proved by ascitic fluid
availability of blood samples for routine examination is
examination, group (B) included 30 cirrhotic patients
easier and more secure than using ascitic fluid. As a
with ascites but no spontaneous bacterial peritonitis
result, serum biomarker assessment has recently
proved by ascitic fluid examination and group (C)
attracted a lot of attention for early identification of SBP
included 30 cirrhotic patients without ascites as a
(6).
control group.

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3087
Received:25/5 /2021

Accepted:21/7 /2021

Full Paper (vol.851 paper# 70)


c:\work\Jor\vol851_71 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3092-3097

Accuracy of Optic Nerve Sheath Diameter Measurement as a Predictor of
Intracranial Pressure in Traumatic Brain Injury
Sanaa Magdi Mohamed Mahmoud*1, Samir Mohamed Attia2,
Mohamed Ali El Adalany3, Mohamed El Saeed Ahmed4
Departments of 1Emergency Medicine, 2Vascular Surgery, 3Diagnostic Radiology and 4Critical Care Medicine,
Faculty of Medicine ­ Mansoura University,Egypt
*Corresponding author: Sanaa Magdi Mohamed, Mobile: (+20) 01092382446, E-Mail: dr.idol96@gmail.com

ABSTRACT
Background:
Ultrasound assessment of optic nerve sheath diameter (ONSD) has been used as a promising tool to aid
in the diagnosis of elevated intracranial pressure (ICP). Optic nerve sheath is contiguous with the dura matter
surrounding the brain and contains cerebrospinal fluid, which allows transmission of pressure from the cranium.
Objective: To determine the diagnostic accuracy of measurement of ONSD by using ocular ultrasonography to detect
elevated ICP in patients with TBI in Emergency Department.
Patients and methods: This prospective cross-sectional observational study that was carried out on 99 patients
presented and admitted to Mansoura University Emergency Hospital with traumatic brain injury (TBI) over a year from
June 2020 to June 2021.
Results: The clinical features of raised ICP had low specificity (38%), positive predictive value (PPV) (61.7%), and
accuracy (69%) for diagnosis of raised ICP with high significant statistical difference (62% vs 100%) towards group 2.
The ONSD were much higher (P <0.01) in group 2 (6.493 ± 0.586 mm) than group 1 (3.93 ± 0.976 mm). The cutoff
value of binocular mean ONSD for diagnosing raised ICP was > 5 mm with sensitivity of 100 %, specificity of 96%,
and accuracy of 99%. The optimal cutoff value to predict mortality rate was >6.8 mm with modest sensitivity and
accuracy. While the optimal value to predict unfavorable Glasgow Outcome Scale (GOS) was >6.05 mm with high
sensitivity and accuracy.
Conclusion:
ONSD measurement via bedside ocular ultrasound is a useful, non-invasive method for early diagnosis of
elevated ICP in adult patients with TBI in the Emergency Department.
Keywords:
Intracranial Pressure, Optic Nerve Sheath Diameter Measurement, Traumatic Brain Injury

INTRODUCTION

Traumatic brain injury (TBI) is defined as brain
always easy to perform even in expert hands (4).
damage resulting from external mechanical force
Ultrasonography has become an indispensable
leading to physical, cognitive, emotional and behavioral
component of the emergency department as a result of
symptoms and outcome can range from complete
being an easy-to-learn, bedside, fast, noninvasive, and
recovery to permanent disability or death. TBI is a
reproducible method. Use of the focused assessment
major cause of morbidity and mortality worldwide,
with sonography in trauma (FAST) examination has
mainly in children and young adults (1). Timely
already gained wide acceptance as an adjunct in
diagnosis of post-traumatic elevated ICP can allow for
evaluating patients with major trauma to the chest and
early momentary procedures and definitive treatment in
abdomen. However, the role of ultrasonography in
the neurologically compromised patient and is
assessing ICP remains unclear (5).
associated with improved outcomes. Invasive ICP
The optic nerve is a tubular structure surrounded
monitoring is the gold standard for demonstrating ICP
by the same meningeal layers as the brain with its
increase but can lead to complications as hemorrhage,
intraorbital segment is evaluable sonographically. It
infection, malposition and device malfunction. Also, it
appears as a hypoechoic linear structure located inside
is not always available in many healthcare facilities (2).
the optic nerve sheath. Between the optic nerve and the
Hence, noninvasive methods have been
sheath is situated the subarachnoid space which
developed for detection of elevated ICP. CT is
experiences the same pressure change as the intracranial
considered as the noninvasive method of choice in this
compartment. Thus, the use of bedside ocular
concern, but several limitations for its use exist as
ultrasonography in measuring optic nerve sheath
transport of critically ill patient, excessive radiation
diameter (ONSD) may be a useful method for detecting
hazards exposure, being time-consuming and high cost,
raised ICP (5).
which has urged researchers to find other alternatives (3).
The objectives of the current study are to
Fundoscopy allows detection of papilledema which may
determine the diagnostic accuracy of measurement of
take hours to days to develop after sustained elevation
ONSD by using ocular ultrasonography to detect
of CSF pressure, which stands for increased ICP.
elevated ICP in patients with TBI in Emergency
Transcranial Doppler pulsatility index has been shown
Department (ED). Also, to determine the prognostic
to reflect decreases in cerebral perfusion pressure due to
value of ONSD measurement by ultrasonography for
increases in ICP. However, both maneuvers are not
outcome.

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3092
Received:24/5 /2021

Accepted:20/7 /2021

Full Paper (vol.851 paper# 71)


c:\work\Jor\vol851_72 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3098-3103

Effect of Narrow Band ­UVB Phototherapy on Circulating T-Regulatory cells and
Serum IL-17 Level in Egyptian Patients with Non-Segmental Vitiligo
Magdy Abdel Mageed El Sohafy1, Bothaina Mahrous Ghanem1, Shereen Salah Mitwally2,
Ahmed Fathy State1, Rasha Abdelgawad Mohammed Elshawaf1
Departments of 1Dermatology, Andrology & STDs and 2Clinical Pathology,
Faculty of Medicine - Mansoura University
*Corresponding author: Rasha Abdelgawad Mohammed Elshawaf, Mobile: (+20) 01003694969,
E-Mail: dermadrrasha@yahoo.com

ABSTRACT
Background:
Vitiligo is an acquired chronic depigmenting disorder of the skin, characterized by the development of
milky white macules and patches resulting from a selective loss of epidermal melanocytes. There are various theories
about its pathogenesis and the etiology is multifactorial associating genetic and environmental factors together with
metabolic and immune alterations.
Objective: To demonstrate the role of circulating T regulatory cells (Treg) (specifically CD4+, CD4+25+, CD4+25+FoxP3)
and serum level of IL-17 in pathogenesis of non-segmental vitiligo (NSV) in Egyptian patients.
Patients and methods: This case-control study was carried out on eighty subjects in the period from January 2018 to
March 2020, attending Dermatology, Andrology & STDs Outpatient Clinic of Mansoura University Hospital. Subjects
were classified into two groups: Group (1): patients group included forty patients suffering from NSV (vitiligo patients
group). Group (2): control group included forty persons who were selected from hospital workers with no personal or
family history of vitiligo or systemic autoimmune diseases in their first-degree relatives.
Results: After NBU-VB treatment, there was a highly statistically significant increase in CD4+%, CD4+25+% and
CD4+25+FoxP3% expression with a mean of 12.1 ± 4 versus 10 ± 3.2, 3.5 ± 1.1 versus 3.2 ± 1 and 1.8 ± 0.6 versus 1.1
± 0.3 when compared to before treatment levels respectively. Also, a highly statistically significant decrease in IL-17
level with the mean of 14.3 ± 4.1 versus 19.9 ± 6 pg/mL when compared to before treatment levels. There was a highly
statistically significant positive correlation between CD4+25+% expression and CD4+% expression in vitiligo group
before and after treatment. Conclusion: Lower CD4+%, CD4+25+% and CD4+25+FoxP3% expression and elevated
serum levels of IL-17 positively were correlated with disease severity.
Keywords:
Narrow band­UVB phototherapy, T-regulatory cells, Serum IL-17 level, Non-segmental vitiligo.

INTRODUCTION

of active patients than in stable patients. Significant
Vitiligo is an acquired chronic depigmenting
defects in the immunosuppressive function of CD4+
disorder of the skin, characterized by the development of
CD25+ Tregs in patients with vitiligo on CD4+ CD25- T
milky white macules and patches resulting from a
cells or CD8+ T cells have been shown by in vitro assays
selective loss of epidermal melanocytes (1). It was
with TCR stimulation (7).
recently described as basal melanocyte detachment (2).
IL-17
is
significantly
correlated
with
The exact etiology of vitiligo is unknown. It is frequently
autoimmune diseases as vitiligo and may be an integral
associated with multiple autoimmune diseases. There are
factor in its progression and severity. It has been
various theories about its pathogenesis. The etiology is
demonstrated that elevated expression of the
multifactorial, associating genetic and environmental
proinflammatory cytokine IL-17, either in peripheral
factors together with metabolic and immune alterations.
blood or in tissues contributes to the pathogenesis of
Abnormalities leading to impaired melanocyte
vitiligo (8).
regeneration and/or proliferation suggest a primary
Narrow-band Ultraviolet B (NB-UVB, 310­312
defect of melanocytes (3). The immune hypothesis is
nm) is considered the first choice treatment for inducing
supported by several factors, including the association
repigmentation in generalized vitiligo. Its therapeutic
with autoimmune conditions, organ-specific antibodies,
effect involves a combination of action in cell cycle
antibodies against antigens in melanocytes and the
kinetics, alterations in cytokine expression, effect on
participation of immune cells (4). The imbalance between
melanocytes and immunomodulation (9). For the
melanocytes reactive CD8+ cytotoxic T cells and Tregs
treatment of vitiligo, NB-UVB has been shown to be
has been suspected as a potential pathogenesis of
superior to PUVA with respect to rates of
vitiligo. Many studies have addressed the role of Tregs
repigmentation, particularly for unstable extensive
in vitiligo (5).
vitiligo, and in achieving more cosmetically acceptable
The serum level of TGF- is significantly lower
even repigmentation (10).
in patients with vitiligo than in controls, suggesting the
The aim of this study was to demonstrate the role
dysfunction of Tregs in vitiligo. The number of
of circulating T regulatory cells (Treg) (specifically
circulating Tregs is lower in patients with vitiligo than in
CD4+, CD4+25+, CD4+25+ FoxP3) and serum level of IL-
controls (6). Furthermore, the frequency and counts of
17 in peripheral blood of Egyptian patients with non-
Treg were significantly decreased in the peripheral blood
segmental vitiligo.

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3098
Received: 26/6/2021

Accepted: 22/7/2021

Full Paper (vol.851 paper# 72)


c:\work\Jor\vol851_73 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3104-3108

Prevalence of Hepatitis C Virus IgG and Cytomegalovirus IgG in
Serum of Type 2 Diabetes Mellitus Patients
Neveen George El-Antouny 1, Rana Mostafa Yousef *1, Rehab Ahmed Rabie2, Heba Shafeak Abdelkhalik 1
Departments of 1Internal Medicine and 2Medical Microbiology and Immunology,
Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Rana Mostafa Yousef, mobile: (+20)01064380457, Email: rolaali335@gmail.com

ABSTRACT
Background:
There are several organized factors which influence the development of diabetes among HCV-infected
patients like age, sex, and family history of diabetes. Patients with diabetes mellitus type 2 (T2DM) have higher risk to
be infected with hepatic viruses, as hepatitis B or C virus.
Objective: This study aimed to notice the prevalence of HCV and cytomegalovirus in patients with type 2 diabetes
mellitus.
Patients and methods: A case-control study included 95 patients with T2DM and 95 apparently healthy individuals.
We evaluated the seroprevalence of two viral antibodies including (CMV IgG, HCV IgG) beside Hepatitis B surface
antigen (HBsAg) in patients with T2DM in comparison to the control group.
Results: There was a significant increase in HCVAb (IgG) positive patients in diabetic group compared to control group.
There was a significant association between HCVAb (IgG) with systolic blood pressure (mmHg), diastolic blood
pressure (mmHg), mean arterial blood pressure (mmHg), WBCs, platelets and ALT. There was a significant association
between CMV IgG with age, systolic blood pressure, and mean arterial blood pressure. There was a significant
association between HBV Ag with ALT, AST.
Conclusion:
Seropositive of anti-HCV and CMV IgG were presented in higher rate on T2DM patients than control.
This confirmed a strong association between HCV, and cytomegalovirus among T2DM patients.
Keywords: CMV, HBsAg, HCV, T2DM.

INTRODUCTION
Egypt has the highest HCV prevalence in the
Type 2 diabetes is characterized by a combination
world and the highest prevalence of HCV (67 %), which
of peripheral insulin resistance and inadequate insulin
reflects a national-level epidemic. HCV infection and its
secretion by pancreatic beta cells. Insulin resistance has
complications are among the leading public-health
been attributed to elevated levels of free fatty acids and
challenges in Egypt (7). Several studies reported that
pro-inflammatory cytokines in plasma. It also leads to
HCV infection may also contribute to the development
decreased glucose transport into muscle cells, elevated
of diabetes, and higher prevalence of type 2 diabetes
hepatic glucose production, and increased breakdown of
mellitus has been observed in the developed world (2%
fat (1). The etiology of DM is still enigmatic. Complex
to 9.4%) in patients with HCV infection than in those
interaction of genetic, metabolic, and environmental
with other forms of chronic hepatitis (8).
factors contributes to type 2 DM development (2).
The aim of the current study was to notice the
Cytomegalovirus (CMV) is a herpes viral genus
prevalence of HCV and cytomegalovirus in patients
of the Herpesviruses group which is prevalent
with type 2 diabetes mellitus.
worldwide with an estimated seroprevalence nearly of

45% in the general population. In humans it is
PATIENTS AND METHODS
commonly known as Human CMV or Human
A case-control study included 95 patients with
Herpesvirus 5 (HHV-5) (3).
T2DM and 95 apparently healthy individuals. This
Human CMV may infect several organs/and is
study was done at Internal Medicine Department and
transmitted through infected body secretions; saliva,
Microbiology
Department,
Zagazig
University
cervical fluid, semen, urine, breast milk, blood and
Hospitals.
organ allografts (4). Control of CMV and its

complications and reduction of its transmission are in
Ethical considerations:
the interest of public health (5). The seroprevalence of
The study was approved by the Zagazig
selected viruses was studied in a group of
University Institution Review Board (IRB). Official
predominantly Hispanic patients with type 2 diabetes
permission from study setting department was
and controls without diabetes. They indicated an up to
taken and an informed written consent was obtained
12 times greater odds of having type 2 diabetes for
from all patients before they joined the study. This
persons previously exposed to CMV. Since accelerated
work has been carried out in accordance with The
atherosclerosis is also associated with diabetes and
Code of Ethics of the World Medical Association
CMV, past CMV infection may be a common factor that
(Declaration of Helsinki) for studies involving
links atherosclerosis and diabetes (6).
humans.



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


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3104

Received: 25/5/2021

Accepted: 21/7/2021

Full Paper (vol.851 paper# 73)


c:\work\Jor\vol851_74 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3109-3115

Myths and Facts About Breast Feeding in Primary Health Care
Center in Sohag, Egypt
Abdel M. Megaied Bioumy, Mohammed Abo-Alwafa Aladawy, Wafaa Adel Shehata*
Department of Pediatrics and Neonatology, Faculty of Medicine, Al-Azhar University (Assiut), Egypt
*Corresponding author: Wafaa Adel Shehata, Mobile: (+20) 01119966826, E-Mail: m_adel_20102020@yahoo.com

ABSTRACT

Background: Environment influences infant feeding decisions of mothers, which have influence on growth,
development, health and nutrition of infants and children.
Objectives: To assess the maternal knowledge and practices towards breast-feeding among mothers in Sohag. To
correlate breast-feeding practices with maternal education, parity, mode of delivery, socioeconomic status and
employment.
Patients and methods: This cross-sectional study included 500 mothers of infants attending some primary health
centers from 1st January to 30th November 2020. Data were collected using a self-administered standardized
questionnaire.
Results: Information present in this questionnaire were taken from 500 mothers, their information was founded to be
taken from what friends (33%), media (10%) and primitives (57%). 52% of mothers knew that breast feeding was used
as contraceptives. 63% of mothers agreed that babies breast fed naturally were healthier than those who breast feed
artificially. 67%of mothers agreed that breast milk is useful but not satisfy the nutritional needs to sustain optimal
growth beyond 6 months not due to decrease quality of breast milk but increased demand. Breast-feeding is related to
educational level, parity, and socioeconomic status, in which (58%) and (80) of mothers had moderate educational
level and moderate socioeconomic level respectively. Despite 61% of mothers disagree with the concept that they
should stop nursing after only one year. Only 20% of them agreed to give bottle-feeding as complementary.
Conclusion: It is really an encouraging observation that majority of the mothers had good knowledge and a positive
attitude towards breast-feeding. Majority of the mothers fed the baby colostrum. Late initiation of breast-feeding has
implications for health education programs and neonatal feeding strategies.
Keywords:
Breast feeding; Knowledge; Practices; Colostrum; Duration of breast feeding, Bottle-feeding.

INTRODUCTION

residence and child's characteristics including birth
Breast-feeding called nursing means introduction
weight, method of delivery, birth order, and the use of
of breast milk to infant. Breast-feeding provides optimal
pacifier (4). Breast-feeding practices are influenced by
and complete nutrition for newborn babies and the health
demographic, social, cultural and psychological factors
risks associated with infant formula feeding are
(5).
increasingly documented (1).
The World Health Organization (WHO) recommends
During infancy, breast-feeding protects against
exclusive breast-feeding for six months. The estimated
infectious disease, by the time, breast-feeding is
reduction of infant mortality by promoting exclusive
associated with several benefits such as C.V.S, IQ, and
breast-feeding is 13%. Non-exclusive breast-feeding
atopy (2).
rather than exclusive breast-feeding can increase the risk
It is known that breast-feeding rates vary by
of dying due to diarrhea and pneumonia among 0­5
demographic and socioeconomic factors that affect its
month old infants by more than two-fold (4).
initiation and duration. Studies showed that
Despite awareness of advantages of breast-
characteristics such as increasing maternal age,
feeding, its rates often fall short of recommended
education, income and being a non-smoker are
practice. Importance of exclusive breast-feeding (EBF)
associated with elevated rates of breast-feeding (3).
is well established particularly in poor environments
The first two years of life are serious for a child's
where early introduction of other milk is of particular
growth and development. Any damage caused by
concern because of the risk of pathogens, contamination
nutritional deficiencies during this period could lead to
and over dilution of milk leading to increased risks of
impaired
cognitive
development,
compromised
morbidity and undernutrition. However, the rates of
educational
achievement
and
low
economic
early initiation, exclusive breast-feeding and timing of
productivity. Various factors such as sub-optimal breast-
complementary feeds are far from desirable (6).
feeding and complementary feeding practices have been
This study aimed to assess the knowledge,
identified.
practices towards breast-feeding and to find these
These are influenced by maternal characteristics
factors, which influence the breast-feeding among
such as age, marital status, occupation, education level,
mothers in Sohag. Information about breast-feeding
antenatal, maternity health care, health education and
practices in the rural population will be useful for
media exposure, socio-economic status and area of
interventional programs.


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3109
Received: 22 /7 /2020


Accepted: 2 1/9 /2020

Full Paper (vol.851 paper# 74)


c:\work\Jor\vol851_75 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3116-3118

Laser Palatoplasty versus Laser Palatoplasty and Laser Turbinectomy for
Snoring and Mild Obstructive Sleep Apnea
Nasser Naguib Nasr, Sherif Mohammad Askar, Loay Mohamed Farid*, Ali Awad
Department of Otorhinolaryngology, Faculty of Medicine Zagazig University, Egypt.
*Corresponding Author: Loay Mohamed Farid, Mobile: (+20)01148696583, Email: loayamir93@gmail.com

ABSTRACT
Background:
Patients with obstructive sleep apnea (OSA) have both anatomic and physiologic dysfunction of the upper
airway during sleep resulting in repeated airway obstruction and varying degrees of hypoxemia. In patients with
obstructive sleep apnea suffering from both snoring and nasal obstruction, nasal surgery relieves snoring and improves
apnea/hypopnea index (AHI), lowest O2 saturation (LOS), epworth sleepness scale (ESS) and snoring severity scale
(SSS) by different proportions.
Objective
: To compare AHI, SSS, and ESS in laser palatoplasty and combined laser palatoplasty and laser
turbinoplasty.
Patients and Methods
: All patients underwent surgery had snoring and mild OSA symptoms, aged between 20 and 60
years with continuous positive airway pressure (CPAP) refusal, failure or non-compliance, classified according to type
of surgical intervention into: group A 14 patients were treated with laser palatoplasty and laser turbinoplasty. Group B:
14 patients were treated with laser palatoplasty only. Pre and postoperative sleep study, Epworth sleepiness scale, and
snoring score were reported and compared.
Results
: As regard AHI there was no significant difference between 2 groups at pre or post, according to ESS (epworth
sleepness scale) there was no significant difference between 2 groups pre and post. Regarding SSS the preoperative
snoring score was reported to be significantly more in patients who had associated nasal obstruction (group A). But after
surgery, the difference in postoperative values was nonsignificant reflecting the value of performing nasal surgery in
this group of patients. Conclusion: Combined nasal and palatal surgery is more effective for snoring and mild OSA than
palatal surgery only.
Keywords: Mild obstructive sleep apnea, Nose, Palatal surgery.

INTRODUCTION
The study included twenty eight adult patients who
More than one third of all people snore regularly.
had snoring and mild OSA symptoms, aged between 20
Snoring is a common accompaniment of obstructive
and 60 years with CPAP refusal, failure or non-
sleep apnea (OSA) and is often disruptive for the bed
compliance, body mass index (BMI) 35, being fit for
partner (1). Laser-assisted uvulopalatoplasty (LAUP)
general anesthesia, with anterior posterior retropalatal
technique constituted first choice surgical treatment (2).
collapse, Friedman tonsillar size grade 0 and 1 with or
However, it is only able to improve the condition in 50%
without nasal obstruction due to inferior turbinate
of all obstructive sleep apnea syndrome (OSAS)
hypertrophy.
patients. Friedman et al. (3) reported a 41% success rate
Patients were divided into two equal groups: Group
with this technique.
A: was treated with laser palatoplasty and laser
Laser turbinoplasty is a simple and well-tolerated
turbinoplasty, and Group B: was treated with laser
treatment for nasal obstruction. It appears to be a safe
palatoplasty.
and effective adjunct surgical procedure for snorer with
We excluded patients with age < 20 and > 60 year,
nasal obstruction on an outpatient basis(4). The nasal
body mass index (BMI) >35, moderate or severe OSA,
valve is the narrowest part of the upper airway. Because
deviated nasal septum, hypopharyngeal collapse with
the upper airway accounts for two-thirds of the entire
prominent tongue base, concentric and transverse
airway that extends down to the alveoli, simple widening
retropalatal collapse and Friedman tonsillar size grade
of the nasal valve and the entire nasal passage would
2,3 and 4.
significantly contribute to a decrease in negative
After
detailed
history
taking
flexible
pressure at inspiration during sleep and contribute to
nasoendoscopy
during
Muller
maneuver,
improve OSA(5).
polysomnography, and drug induced sleep endoscopy
This study aimed to compare AHI, SSS, ESS
was performed for all patients. Moreover, all patients had
(epworth sleepness scale) in laser palatoplasty and
subjective analysis with the Epworth Sleepiness Scale
combined laser palatoplasty and laser turbinoplasty.
(ESS) as a measure of daytime somnolence.

Six months after surgery, all patients underwent
PATIENT AND METHODS
nasopharyngolaryngoscopy as part of the standard
The present study is a comparative prospective
postsurgical protocol using the Muller maneuver. A
study. It was conducted over the period from April 2020
postoperative sleep study, ESS (epworth sleepness
to May 2021 in Otorhinolaryngology Head and Neck
scale), snoring score were also performed and assessed.
Surgery Department, Zagazig University Hospitals.



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3116
Received: 26/5/2021

Accepted: 22/7/2021

Full Paper (vol.851 paper# 75)


c:\work\Jor\vol851_76 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3119-3124

Comparative Study between Scrotal and Inguinal Approach for Repair of
Communicating Hydrocele in Children
Abduo A. Arnous, Ibrahim M. ElSayaad, Ahmed M. Kamel*
Department of General and Pediatric Surgery, Faculty of Medicine, Al-Azhar University (Damietta), Egypt.
*Corresponding Author: Ahmed Magdi Kamel, Mobile: (+20)01023366778, E-mail: dr.a.magdi1990@gmail.com

ABSTRACT
Background:
The inguinal method is utilized for treating hydrocele in the pediatric populace. While, investigations on
scrotal orchiopexy have declared herniation or hydrocele repairing via the same scrotal cut as a portion of an orchiopexy
operation, there are a few researches investigating the treatments of separated communication hydrocele via a scrotal
incision.
Objective: To compare between scrotal and inguinal surgery for repair of communicating hydrocele in kids with
assessment of surgical period, intraoperative complications, hospitalization, and postoperative complication.
Patients and methods:
This work was an interventional research accomplished in Department of Surgery, Al-Azhar
University Hospital, New Damietta. 40 cases of ages from 1 year to 18 years were scheduled for communicating
hydrocele repair; they were randomized into 2 groups: Group-A (scrotal approach) that included 20-cases and group-B
(inguinal approach), which included 20-cases. This study was performed on systematic random sampling from April
2020 until October 2020.
Results:
A highly significant change was found among studied groups regarding surgical period. In addition, a highly
significant change was found between the two groups regarding postoperative hospitalization. There was significant
change between both groups as regards overall satisfaction, while there was insignificant difference between groups as
regards early post-operative complications.
Conclusion: The scrotal method for treating the children communicating hydrocele can be another procedure in
qualified centers. The key benefits of this method were cosmesis and reduced surgical period. Nevertheless, the
commonest early complication was temporal scrotal edema. This procedure delivers a simple method to the anatomical
structure included in scrotal and groin pathologic characteristics with no disruptions of the inguinal duct integrity.
Keywords: Scrotal approach, Post-operative, Hydrocele, Inguinal.

INTRODUCTION
PATIENTS AND METHODS
The inguinal method for treating children's
This work was an interventional research achieved
inguinoscrotal pathologies is the suggested typical
in Department of Surgery, Al-Azhar University
surgery. This operative method comprises release of the
Hospital, New Damietta. 40 cases of ages from 1 year
spermatic cord from the connected tissues, tissues
to 18 years were scheduled for communicating
separation, and high ligation of the patent processes
hydrocele repair. This study was performed on
vaginalis (PPV). It is significant to avoid vas and
Systematic random sampling from April 2020 till
vessels injury at highly ligation of the PPV. Then, the
October 2020. They were randomized into 2 groups:
testicle was immobile to the scrotum with no tensions
Group-A (scrotal approach) that included 20-cases and
(1).
group-B (inguinal approach), which included 20-cases.
Inguinal explorations with subsequent scrotal

incisions are also the gold standard for treating palpable
Inclusion criteria: Failures of the hydrocele to
un-descended testes, but the single scrotal cut technique
spontaneous resolution after one year of follow up,
has gained popularity among pediatric surgeons in the
inability to obviously inspect testis, pain or discomfort
last 20 years (2).
and cosmesis.
Two major anxieties with the scrotal method are

that PPV cannot be sufficiently ligated and proximal
Exclusion criteria: Patients younger than 1 year, small
attachment cannot be detached. Lately, scrotal incisions
atrophic testes or solitary testes and connotation of
orchiopexy has effectively been achieved on definite
hydroceles with revealing pathologies (e.g. torsions or
un-descended testis both with and without PPV (3).
tumors).
Furthermore, the scrotal method was utilized to modify

other pathologies of PPV like inguinal herniation and
Methods:
hydrocele (1).
1. Clinical assessment: Complete history taking
The aim of the present study was to compare
including age, sex, residency, time of onset and
between scrotal and inguinal surgery for repair of
complications.
communicating hydrocele in kids with assessment of
2. Clinical examination: Vital signs to roll out
surgical
period,
intraoperative
complications,
haemodynamic stability of blood pressure, pulse,
hospitalization, and postoperative complications.
temperature and respiratory rate. Associated injuries:

head, chest, abdomen, pelvis, neck, back and limbs.

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3119
Received:26/5 /2021

Accepted:22/7 /2021

Full Paper (vol.851 paper# 76)


c:\work\Jor\vol851_77 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3125-3129

Induction of Labor Using Vaginal Misoprostol Alone or Combined with
Intracervical Foley Catheter
Zaineb Abdusalam Aregeb*, Wael Albromboly, Azza Abdelmageid Abdelhameid,
Khaled Fathy Helal, Mohammed Samir Badr
Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Zaineb A. Aregeb, Mobile: (+2): 01115118269, Email: gyni84cology@gmail.com

ABSTRACT
Background:
Induction of labor is a common intervention in obstetric practice, which is a procedure used to stimulate
uterine contractions during pregnancy to accomplish delivery prior to the onset of spontaneous labor.
Objective: The aim of the present study was to select the best method for induction of labor.
Patients and methods
: This study was conducted on 72 pregnant women for induction of labor in Maternity Hospital,
Faculty of Medicine, Zagazig University Hospitals. Pregnant women were divided into: group (A): 36 patients who
underwent induction of labor by intra-vaginal misoprostol and group (B): 36 patients who underwent induction of labor
by intravaginal misoprostol combined with intracervical Foley catheter. All patients were subjected to full history taking,
proper examination. Primary and secondary outcomes were estimated for all the studied patients.
Results:
Between the studied groups, there was statistically non-significant difference regarding parity, gestational age
or birth weight. There was statistically significant difference between the studied groups regarding number of
misoprostol doses, induction of active stage and induction of delivery time, occurrence of complications and occurrence
of dystocia, tachysystole and vomiting.
Conclusion: This comparative study showed that the use of Foley's with vaginal misoprostol results in a shorter
induction to delivery time compared with vaginal misoprostol alone.
Keywords: Foley Catheter, Labor Induction, Misoprostol.

INTRODUCTION

Induction of labor is a common intervention in
should be emphasized with respect to adverse maternal-
obstetric practice, which is a procedure used to
neonatal outcome (5).
stimulate uterine contractions during pregnancy to
The use of Foley's catheter as a mechanical
accomplish delivery prior to the onset of spontaneous
method for labor induction has been recommended in
labor (1). Successful labor induction leads to a vaginal
many developing countries. The reports from different
birth. A health care provider might recommend labor
countries have mentioned excellent results with the use
induction for various reasons, primarily when there's
of Foley's catheter either alone or in combination with
concern for a mother's health or a baby's health as labor
prostaglandins (6). Although the exact mode of action of
induction carries various risks, including infection and
Foley's catheter is not fully understood. Yet it has been
the need for a Cesarean section. Sometimes the benefits
postulated that the catheter stimulates various
of labor induction outweigh the risks (2).
unspecified regions of the uterus, elevates its
Prostaglandins are frequently used for labor
excitability and causes regular uterine contractions (7).
induction in pregnant women. The presence of cervical
Therefore, the aim of the present study was to select the
immaturity indicates the use of prostaglandin
best method for induction of labor.
compounds, frequently followed by oxytocin infusion,

prostaglandins are received orally or applied locally to
PATIENTS AND METHODS
the cervix or the vagina, to promote both cervical
This study was conducted on 72 pregnant women
ripening and myometrial contractility (3). Various
for induction of labor in Maternity Hospital, Faculty of
prostaglandins preparations including misoprostol
Medicine, Zagazig University Hospitals. This study was
vaginal tablets, dinoprostone vaginal gel and vaginal
conducted in the period from October 2020 to April
insert are commercially available to be used in labor
2021.
induction. Misoprostol is a synthetic prostaglandin El

analogue and has been reported to be a considerably safe
Inclusion Criteria:
and efficacious cervical ripener. It's inexpensive, easy
Pregnant woman with valid indication for
to administer, stable at room temperature, does not
induction of labor. Gestational age 37 weeks
require refrigeration (4). In spite of different doses and
(calculated from reliable menstrual dates and/or late
routes of administration (sublingual, oral, vaginal),
first trimester or early second trimester ultrasound).
ideal dosage and mode of administration still remain to
Age: 18-40 years old. Vertex presentation with intact
be controversial. Potential complications such as uterine
fetal membranes. Normal fetal non-stress test. Modified
rupture, tachysystole and uterine hyperstimulation
Bishop Score 5. Cervical dilation less than or equal to

2cm.

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3125

Received:27/5 /2021

Accepted:23/7 /2021

Full Paper (vol.851 paper# 77)


c:\work\Jor\vol851_78 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3130-3133

Outcome of Bilateral Segmental Internal Anal Sphincterotomy for
Treatment of Chronic Anal Fissure
Hesham Bahlul Marzogi*, Samir Ibrahim Mohammad, Mohamed Farouk Amin and
Ashraf Abdel Monem Elsayed
Department of General Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Hesham B. Marzogi, Mobile: (+2)1220634986, Email: albahlolhesham@gmail.com

ABSTRACT
Background:
Chronic anal fissures are harder to treat, and surgery may be the best option. The goal of surgery is to
help the anal sphincter muscles relax which reduces pain and spasms, allowing the fissure to heal.
Objective: The aim of the present study was to assess the improving outcome of patients of chronic anal fissure.
Patients and methods:
This study included 18 patients with chronic anal fissure admitted at Department of General
Surgery, Faculty of Medicine, Zagazig University. All patients were subjected to full history taking, proper local
examination and baseline investigations. Anorectal manometry was performed for all patients preoperatively and
bilateral segmental internal sphincterotomy was done for all patients.
Results:
The present study showed that 88.9% had constipation, 100.0% had pain and 77.8% had bleeding defecation.
Duration was distributed as 7.55 ±2.68 with minimum 4 and maximum 14 months and the majority were between 6-12
months. Complete healing was distributed as 5.16 ±1.09 with maximum 8 weeks. Visual Analogue Scale (VAS)
significantly decreased from pre to 1st 24 hours tell the end of follow up. Incontinence score significantly decreased
from pre to 1st week tell the end of follow up.
Conclusion: It could be concluded that bilateral segmental internal sphincterotomy takes some extra time for the
procedure and significantly a good procedure in treatment of chronic anal fissures in terms of early pain relief, reduction
of resting anal pressure and complete healing rate in 5 weeks. The risks of incontinence and recurrence of fissure are
negligible with superior patients' satisfaction.
Keywords: Anal Fissure, Anal Incontinence; Anal Sphincterotomy; VAS.

INTRODUCTION

internal sphincterotomy performed through the floor of
Anal fissure can occur at any age, but are usually
the fissure. The healing rate associated with anal fissure
seen in younger and middle-aged adults. Both genders
treated by lateral internal sphincterotomy in most series
are affected equally. The anal fissures are most
is reported as greater than 98% (5).
commonly seen in the posterior midline, although 10-
This study was aimed to evaluate feasibility of
20% in women and 1-10% in men are located in the
bilateral segmental internal anal sphincterotomy in
anterior midline (1). The exact cause of anal fissures is
treatment of chronic anal fissure.
unknown but many factors appear likely, such as the

passage of large, hard stools, which may be the initiating
PATIENTS AND METHODS
factor; inappropriate diet; previous anal surgery;
This clinical trial study included a total of 18
childbirth and laxative abuse (2).
patients with chronic anal fissure, attending at
Many fissures heal spontaneously, often in two or
Department of General Surgery, Zagazig University
three weeks. These are usually superficial lesions which
Hospitals.
have a relatively short history of pain. By contrast,

really chronic fissures are most resistant to any form of
Inclusion criteria: Patients with a primary chronic anal
conservative treatment, and though there may be
fissure of more than 6-week duration with classical
temporary abatements of symptoms, the trouble tends to
symptoms of a chronic anal fissure in age above 18
recur frequently. Therefore anal fissures are treated
years who unresponsive to medical treatment with
either conservatively or surgically (3).
recurrence of symptoms after initial short-term relief.
The principle of surgical treatment for chronic

anal fissures is to decrease internal sphincter tone and
Exclusion criteria: Patients with chronic inflammatory
hence increase the blood flow with subsequent tissue
bowel diseases, tuberculosis, positive HIV, pregnancy
healing. The lateral internal sphincterotomy is the first-
and anorectal tumors. Patients with previous anorectal
line surgical option for all fissures associated with
surgery. Patients unfit for anesthesia or surgery.
hypertrophy and hypertonicity of the internal anal

sphincter (4).
All patients were subjected to complete history
Lateral internal sphincterotomy has shown to
taking including demographic data (age, sex, symptoms
have advantages over other forms of surgical
with their duration and position of fissures). Proper
treatments, such as anal dilatation and mid-posterior
limited local examination, symptoms with their duration


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3130

Received:27/5 /2021

Accepted:23/7 /2021

Full Paper (vol.851 paper# 78)


c:\work\Jor\vol851_79 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3134-3137

Dual Energy CT Impact on Determination of Chemical Composition for Urolithiasis
Maamar Ahmed Hasan*, Khaled Ahmed Lakouz, Mohamed Zakaria Alazzazy and Nesma Adel Hamed
Radiodiagnosis Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Maamar A. Hasan, Mobile: (+20)1279520645, Email: moamerahmadhasan@gmail.com

ABSTRACT
Background:
The urinary tract stone disease is a common problem. Dual energy CT with advanced post processing
techniques gives anatomical information as size, site of the stone as well as its chemical composition which alter the
clinical management.
Objective: This study was aimed at studying the role of dual energy computed tomography in characterization of renal
stones.
Patients and methods: This study was carried out at the private radiology center throughout the period from January
2020 to January 2021 included 48 patients with renal stones. In this study, renal stones were more common in men (66.7
%) than in women (30.3%). The age of our selected patients ranged from 24 to 55 years with a mean of 42 years. The
most affected age group was from 24-44 years (24 cases) represented 50% of the cases.
Results: The average age of the studied group was (42.1±7.6), the most common presentation symptoms was loin pain
(75.0%) followed by hematuria (18.8 %) then nausea& vomiting (4.2%) and fever (2.0%).Dual energy CT had 88.9%
ability to truly detect uric from non-uric acid stones with (97.9%) accuracy, (100.0%) ability to exclude non uric stones
(specificity), (100.0%) predictive value positive and (97.5%) predictive value negative with (50.0%) prevalence and
(35.0%) likelihood positive ratio.
Conclusion: It could be concluded that dual energy CT has been shown to be effective for characterizing chemical
composition of the urinary stones, dual energy CT not well established enough to be used in clinical practice, but it
will replace helical non contrast CT as the standard imaging modality for urinary calculi.
Keywords: Urolithiasis, Dual energy CT, Chemical Composition of stones

INTRODUCTION


The renal stone disease is a common clinical
two materials with similar attenuation values on SECT
problem representing about 10­14% of the population.
but different chemical composition can be distinguished
There are different chemical compounds forming renal
from one another by analyzing their energy dependent
stones; they are about sixteen in number, most of these
changes in attenuation (5).
are rare. The most common chemical composition that
Previously, most researches focused only on
form stones are calcium oxalate (70%), calcium
distinguishing uric acid from non-uric acid. recently, it
phosphate (20%), uric acid (8%) and cystine (2%) (1).
was reported that in addition to reliably differentiation
Unenhanced helical CT is the preferred method
uric acid stones from calciferous stones , calcium
for evaluation patients with suspected urinary calculi, it
oxalate and calcium phosphate stones could be
provides information about the presence, size and
marginally differentiated (6). Dual energy CT has been
location of stone, as well as the presence of associated
reported as having a near 100% sensitivity and
complication (2).
specificity for characterizing renal stone composition
Dual energy CT with advanced post processing
when stone size is at least 3 mm (7).
technique improves characterization of renal stone
It is likely that dual energy CT will replace
chemical composition beyond that achieved with single
conventional SECT as the standard imaging method for
energy CT (SECT) acquisition with basic attenuation
urinary calculi, as it provides the same anatomical
assessment (3).
information as well as stone composition without
Because many patients harboring urinary calculi
increasing patient radiation exposure (8).
will ultimately require some form of intervention, here
Therefore, this study was aimed at studying the
it is great importance in further developing the
role of dual energy computed tomography in
capability of CT to predict stone composition, a reliable
characterization of renal stones.
determination of the type of the stone that is presence

will allow the clinician to better satisfy treatment option
PATIENTS AND METHODS
for the patient, such as stones composed of uric acid,
This study was carried out at the private
may be treated medically and may not require surgery
radiology center throughout the period from January
(4).
2020 to January 2021. Our study included 48 patients
Any given material will have different
(32 male and 16 female) with known renal stones. The
attenuation values when imaged at low and high peak
patients aged from 24 to 55 years.
kilo voltage (KVP) result in a predictable change in

attenuation when imaged by two known x ray energy,

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3134

Received: 27 /5 /2021


Accepted: 23 /7 /2021

Full Paper (vol.851 paper# 79)


c:\work\Jor\vol851_80 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3138-3143

Serratus Anterior Plane Block as a Regional Analgesia Technique for Post
Thoracotomy and Thoracoscopy Pain: Review Article
Fawzy Abbas Badawy, Abd El-Rahman Hasan Abd El-Rahman, Salah Ahmed Mohamed, Asmaa Saad-Eldeen
Farghaly Gad-Allah*, Omima Emad Eldin Mohamed, Khaled Abdelfattah Mohamed Abdelfattah
Department of Anaesthesiology, ICU and Pain Management, Faculty of Medicine, Sohag University, Egypt.
*Corresponding author: Asmaa Saad-Eldeen Farghaly Gad-Allah, Mobile: (+20)01020283823,
E-mail: asmaasaad@med.sohag.edu.eg

ABSTRACT
Background:
Chest wall surgeries are accompanied by severe postoperative pain. Inadequate relief of this pain may
lead to both pulmonary complications as lung atelectasis and infection and chronic post thoracotomy pain syndrome.
Regional analgesic modalities are important portion of the multimodal therapeutic approach suggested for the
management of post thoracotomy pain.
Objective: To evaluate serratus anterior plane block as a regional analgesia technique for post thoracotomy and
thoracoscopy pain.
Recent Findings: Serratus anterior plane block (SAPB), a regional analgesic modality developed by Blanco et al. in
2013, has shown good analgesic effect after thoracotomy and thoracoscopy in many case reports and clinical trials. In
such block, a local anesthetic is injected in the fascial plane deep or superficial to the serratus anterior muscle leading
to block of lateral cutaneous branches of the intercostal nerves. This provides a sensory block of T2­T9 dermatomes.
Conclusion: Serratus anterior plane block as a fascial plane block can be a preferred regional analgesia technique for
both post-operative pain management with procedures involving anterolateral chest wall as thoracotomy, thoracoscopy
and breast surgery and in cases of multiple rib fractures. This is owing to its easy technique, effective pain relief and
potentially better side effects profile compared to other regional modalities and systemic opioids.
Keywords: Serratus anterior plane block, Post thoracotomy pain.

INTRODUCTION
include
acetaminophen,
Non-steroidal
anti-
Thoracotomy and thoracoscopy are associated
inflammatory drugs, N-methyl-D-aspartate (NMDA)
with acute severe pain, inadequate relief of which will
antagonists, Gabapentin, Glucocorticoids and Opioids
immediately affect pulmonary function and patient
(4).
comfort. In addition, it will lead to longer term pain
Intraoperative regional analgesia: Thoracic epidural
(post thoracotomy pain syndrome) that interferes with
analgesia was considered by many studies as the gold
patient's returning to his regular activities for extended
standard, as it was more effective when compared to
time (1, 2). Pleural irritation, costovertebral joints
many other regional analgesic modalities used for post
dislocation, intercostal nerves injury and retraction and
thoracotomy pain treatment. Though, associated risks
resection or fracture of ribs are involved factors in
with the use of epidural analgesia are becoming more
evolving such severe pain (3). Providing analgesia for
obvious
than
previously
thought,
including
thoracic surgery can be challenging for a variety of
hypotension, urinary retention, technique failure,
reasons as thoracic surgery patients are often elderly
muscle weakness and other epidural related
and/or frail with multiple comorbidities (1).
complications (6, 7). Thoracic paravertebral block
For thoracic surgery, enhanced recovery after
analgesia can be used as a unilateral block of both
surgery (ERAS) guidelines (4) advised a multimodal
somatic and sympathetic nerves and is suitable in
approach for post thoracotomy acute pain management
unilateral thoracic procedures with equivalent
including:
analgesic effect, better side effects profile and
Cognitive behavioral modalities to relief anxiety as
probably less respiratory complications compared to
guided imagery, intraoperative positive suggestions,
thoracic epidural analgesia (6, 8). Other regional
limiting noise and playing music during anesthetic
analgesia techniques were tried aiming easier access
induction and other relaxation techniques can reduce
and fewer complications, like intercostal nerve blocks
anxiety. Patient education and providing proper
and intrapleural block and showed better analgesic
information also have important rule in experiencing
effect than placebo (6, 9, 10), while others like erector
less pain (5).
spinae plane block still evolving (11). In 2013, Blanco
Multimodal systemic analgesia by using synergistic
et al. (12) presented serratus anterior plane block
effects of different analgesic types aiming to avoid or
(SAPB), a new feasible and safer ultrasound guided
minimize opioids use to avoid opioids related side
technique for thoracic wall nerve block, as an
effects that may interfere with achieving ERAS targets
alternative to the standard regional analgesic
like postoperative nausea/vomiting control, quick
techniques as thoracic epidural and paravertebral
resuming of oral diet and early mobilization. These
block.



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3138
Received: 28 /5 /2 021

Accepted: 24 /7 /2021

Full Paper (vol.851 paper# 80)


c:\work\Jor\vol851_81 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3144-3147

Effectiveness of Angioplasty in Treatment of Diabetic Foot Patients with
Infragenicular Multiple Stenosis or Occlusion: A Prospective Study
Ali Mahmoud Mohamed Galal*, Mohamed Ahmed Mohamed Ismail, Abdel Hady Mohamed Hussein
Vascular Surgery Department, Faculty of Medicine, Aswan University, Egypt
*Corresponding author: Ali M. M. Galal, Mobile: (+20)1001816078, E-Mail: a_mando76@yahoo.com

ABSTRACT
Backgound:
Diabetic foot is one of the most serious and debilitating consequences of diabetes, and it is described as an
ulcerated foot in a diabetic patient with neuropathy and/or peripheral artery disease of the lower limb. Diabetic foot
ulceration affects 4­10% of diabetic patients, with the condition affecting older patients more frequently.
Objectives: In this study, we aimed to assess the effectiveness of angioplasty in the treatment of diabetic foot patients
with infragenicular multiple stenosis or occlusion.
Patients and Methods: We performed a prospective cohort investigation that recruited diabetic patient with
infragenicular critical limb ischemia (CLI) with or without supragenicular lesion at Vascular Surgery Department in
Aswan University Hospital through the period from January 2019 to June 2020. 20 patients were included if they were
older than 18 years old, diabetic, had diabetic foot, and had confirmed diagnosis of CLI.
Results: Seventeen patients (85%) had immediate success, they remained patent after one month. After three and six
months, 14 patients (70%) and 13 (65%) remained patent, respectively (p >0.05). With regard to limb salvage by the
end of six months, 15 patients (75%) had limb salvage in the form of rest pain relief in 3/4 patients (75%), minor ulcer
healing in 10/10 patients (100%), and healing of tissue after debridement or minor amputation 2/6 patients (33.3%). The
remaining five patients had non-salvaged limbs. As regarding amputations, three patients (15%) underwent major
amputation. A total of four patients (20%) had complications.
Conclusion: In conclusion, infragenicular angioplasty exhibited efficacy in CLI management in diabetic patients, with
an acceptable patency rate and safety profile.
Keywords: Diabetes, Diabetic Foot, Infragenicular Angioplasty, Limb Ischemia.


INTRODUCTION

Diabetic foot ulcers are common complications
A large meta-analysis of 52 studies
of diabetes mellitus (DM), affecting more than 15% of
demonstrated the efficacy of angioplasty in managing
all diabetic patients during their lifetime (1). It was
infrapopliteal atherosclerotic lesions, with an overall
estimated that about 15 ­ 20% of patients with such
success rate of 91.1% (10). In this study, we aimed to
conditions would need an amputation (2,3). The most
assess the effectiveness of angioplasty in the treatment
significant risk factor for foot ulcers is peripheral sensory
of diabetic foot patients with infragenicular multiple
neuropathy, which is accompanied by peripheral
stenosis or occlusion.
vascular disease (PVD) (3). PVD affects the arterial tree

at all levels, but atheroma seems to prefer some
MATERIAL AND METHODS
locations, such as bifurcations where hemodynamic
We
performed
a
prospective
cohort
shear stress is low or flow separation occurs (4). The
investigation that recruited diabetic patient with
infragenicular arteries are often involved in patients with
infragenicular CLI with or without supragenicular lesion
diabetes, resulting in multiple stenosis or occlusion (5).
at Vascular Surgery Department in Aswan University
Patients with critical limb ischemia (CLI) are becoming
Hospital through the period from January 2019 to June
older and sicker with the more complex distal disease.
2020. 20 patients were included if they were older than
Revascularization is mandatory for patients with
18 years old, diabetic, had diabetic foot, and had
evident peripheral ischemia because sufficient blood
confirmed diagnosis of CLI. We included patients with
flow is essential for the healing of injuries and the
type B the Trans-Atlantic Inter-Society Consensus
resolution of the underlying infection (6).
Document (TASC), defined as "multiple stenosis each
A surgical bypass is a popular form of treatment
equal or less than 5 cm in length with total length less
of ischemic limbs, which has recorded good long-term
than 10 cm, or single occlusion equal or less than 10 cm
findings (7). In cases of multiple occlusions,
in length 5 cm in the target tibial artery with occlusion or
revascularization is required at each stage to restore
stenosis similar or worse in severity in the other tibial
blood flow and raise the likelihood of limb regeneration
arteries".
(8). In combination with surgical bypass on the distal
The diagnosis of diabetic foot was based on
extremity, transluminal angioplasty of iliac arteries can
clinical presentation and supporting imaging modalities
be performed, and effectiveness has been demonstrated
(11). While the CLI was defined as Rutherford category of
in diabetic patients. Transluminal angioplasty is also an
equal or more than four (12). Patients were excluded if
ideal alternative for single stenotic injuries (9).
they had extensive lower limb infections, full-thickness

gangrene, primary vascular etiology, and/or mental or

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3144
Received:28 /5 /2021

Accepted:24/ 7/2021

Full Paper (vol.851 paper# 81)


c:\work\Jor\vol851_82 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3148-3151

Is Copper Intra Uterine Contraceptive Device-Induced Menorrhagia Correlated with
Changes in Transvaginal Ultrasound Findings before and after Insertion?
Youssef Abo Elwan El Sayed, Hala Elsayed Mohamed Mowafy,
Hend Salah Abdo Saleh, Mahmoud Hassan Mohamed Ahmed Salem*
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Mahmoud Hassan Mohamed, Mobile: (+20) 01001752425, E-mail: sanhoty41@gmail.com


ABSTRACT

Background: Many women all around the world use the Cu T 380A for contraception as it is cheap and effective way
for contraception. Menorrhagia is the most common cause of removal of the intra uterine contraceptive device (IUCD)
and it is a very annoying side effect for IUCD users. Finding a way to avoid such a complaint is important to find a
proper way for contraception.
Objective: To prove the correlation between the Cu IUCD-induced menorrhagia and the findings of the transvaginal
Doppler ultrasound.
Patients and Method: It was a prospective cross-sectional study and it was conducted on eighty four women who were
referred to the family planning clinic of Zagazig University Hospital and Zagazig General Hospital for Cu T-380A IUCD
insertion. The study was conducted in the period from 1/1/2019 to 30/7/2019. Then, all specimen had been classified
into 2 groups: Group 1 (n =37): with menorrhagia, and group 2 (n = 47) without menorrhagia.
Results: Uterine artery pulsatility index (PI) and resistance index (RI) after one month of insertion were significantly
lower than at time of insertion among women with IUCD-induced menorrhagia. Endometrial thickness after one month
of insertion was significantly higher than at time of insertion among women with IUCD-induced menorrhagia. PI and
RI at time of insertion were significantly lower in women with IUD-induced menorrhagia than in those using IUD with
normal menstrual bleeding. Uterine artery PI 1.99 and RI 0.82 have been associated with menorrhagia at time of
insertion.
Conclusions: The transvaginal Doppler ultrasound is very helpful in prediction of menorrhagia among IUCD users.
Keywords:
Pulsatility index, Resistance index, Endometrial thickness, Cu IUCD, Transvaginal Doppler ultrasound.

INTRODUCTION

More than fourteen percent of women around the
correlation between the copper T intra uterine
world use the intrauterine device for contraception (1).
contraceptive device-induced menorrhagia and the
The IUCD is more effective than other contraceptives
change in findings of transvaginal ultrasound Doppler
and it's a long standing and reversible way of
before and after one month of insertion.
contraception (2).

The Pearl Index was introduced at the beginning
PATIENTS AND METHOD
of the 20th century as the first measure to describe the
It was a prospective cross-sectional study, which
effectiveness of a contraceptive method. The Pearl
was conducted on 84 women from 1/1/2019 to
Index is defined as the number of pregnancies per 100
30/7/2019. They had been classified into two groups
woman-years of a contraceptive method's use. It still
according to presence or absence of menorrhagia:
meets the essential criteria of an index, i.e. easy
Group (1) included thirty seven cases with complaint of
calculation, approximation of real probability and
menorrhagia and group (2), which included forty seven
prediction accuracy. Since the mid-1960s, objections to
cases without complaint of menorrhagia.
the Pearl Index have been raised, mainly because it does
Site of study: Obstetrics and Gynecology
not reflect the duration of use of the contraceptive
Department and Family Planning Clinic, Zagazig
method (3).
University Hospitals and Zagazig General Hospital,
The levonorgestrel and copper T380A T have
Egypt.
remarkably low pregnancy rates that may be less than

0.2 per hundred women per year. Twelve-year data on
Ethical approval:
the CU T380A showed a cumulative pregnancy rate of
The study was approved by Institutional
only 1.9 per one hundred women (4). The Cu IUCD
Review Board (IRB) and by the Ethical Committee,
increases amount of blood flow during the
Faculty of Medicine, Zagazig University. All
woman's menstrual periods. On average, the
corresponding documents were declared for ethical
menstrual blood loss increases by 20­50% after
and research approval by the Council of Obstetrics
insertion of a Cu T IUCD. Increased menstrual
and Gynecology Department, Zagazig University.
discomfort is the most common medical reason for the
Informed verbal and written consents were obtained
IUCD removal (5).
from all women included in the study. This work has
The aim of the present study was to assess the
been carried out in accordance with The Code of

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3148
Received:28/5 /2021

Accepted:24/7 /2021

Full Paper (vol.851 paper# 82)


c:\work\Jor\vol851_83 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3152-3156

Retrospective Statistical Study of Thermal injury Patients in
Al-Azhar University Hospitals
Esam Said M. Amer*1, Mohammed Abdelrahman Aglan1,
Ahmed Ezzat Abdelaziz2, Ahmed Elsyeed M. Abd-Rabo2
Departments of 1Forensic Medicine and Clinical Toxicology and
2Public Health and Industrial Medicine, Al-Azhar Faculty of Medicine, Egypt
*Corresponding author: Esam Said M. Amer, Email: dresam777@gmail.com
ABSTRACT
Background: Thermal injuries are one of the leading causes of disability and death, particularly in low and middle
income countries, yet its epidemiology in Egypt is under- reported. Thermal trauma is a significant health problem that
has physical, psychological, and economic repercussions on affected patients.
Objective:
Our aim was to analyze the epidemiological and clinical features of thermal injury patients.
Patients and methods: This retrospective study was done on one hundred patients with thermal injuries admitted to
Al-Azhar University Hospitals. Data were collected from patient's files.
Results:
The highest incidence of thermal injuries was seen in 3rd and 4th decade age group (65 cases) while the lowest
incidence was those < 10 years (5 cases). Fire predominates in both genders (more than 50%) followed by hot liquids.
Electrical injures represented the lowest cause. The most commonly injured part was upper limbs. Thermal injury
covering less than 10% of total body surface area (TBSA) represented 28% of studied cases, while 40% of studied cases
had injury covering 10-20% of TBSA and those with 21-30% injury of TBSA were 25% of cases. Majority of cases had
thermal injuries of third degree (62 cases). Eighteen cases died; 8 cases died early from dehydration and shock, 6 cases
from infection and 4 cases from surgical interventions.
Conclusion: Thermal injuries are public health problem accounting for a substantial proportion of all trauma admissions
at Al-Hussein Hospital. These injuries and deaths are preventable, provided a community-specific preventive program
is implemented with a strong educational component.
Keywords: Al-Azhar University Hospitals, Thermal injuries.

INTRODUCTION
PATIENTS AND METHODS
Thermal injury is, caused by heat, cold, electricity,
Our study is a retrospective statistical study included
chemicals, friction, or radiation to the skin or other
one hundred cases who were hospitalized due to thermal
tissues. These thermal injuries are the most severe form
injuries. This study was based on analysis of data in
of trauma that has afflicted humanity since ancient time
medical files in Al-Azhar University hospitals.
(1). Heat, cold and electricity are some of the `physical
Epidemiological and clinical analysis of the collected data
agents' that can cause non-kinetic injuries to the body.
was done as regards age, gender, cause of thermal
Energy is transferred from a physical or chemical source
injuries, site and degree, complications and cause of
into living tissues, which causes disruption of their
death.
normal metabolic processes and commonly leads to
Ethical approval:
irreversible changes that end in tissue death (2).
An approval of the study was obtained from Al-Azhar
Burns are a major cause of injury worldwide. The
University Academic and Ethical Committee. Every
World Health Organization estimates that the lifetime
patient signed an informed written consent for acceptance
incidence of severe burns is 1% and that more than
of the study. This work has been carried out in accordance
300,000 people die annually from fire-related burns
with The Code of Ethics of the World Medical
worldwide. In addition, the prevalence of burns is
Association (Declaration of Helsinki) for studies
significantly higher in developing countries than in
involving humans.
developed ones. Due to damage to the skin and other
Statistical analysis:
organs, burns can lead to open wounds, disability, death,
The collected data were coded, processed and analyzed
major economic consequences, severe emotional and
using the SPSS (Statistical Package for Social Sciences)
psychological complications, and economic burden (3).
version 22 for Windows® (IBM SPSS Inc, Chicago, IL,
Damage to the tissues arising from the application of
USA). Data were tested for normal distribution using the
heat is commonly encountered in forensic pathology,
Shapiro Walk test. Qualitative data were represented as
which may have serious criminal aspects (4).
frequencies and relative percentages. Chi square test (2)
The aim of the present study was to study clinical
was used to calculate difference between two or more
and epidemiology of thermal injury cases in Al-Azhar
groups of qualitative variables. Quantitative data were
University Hospitals, e.g. age, gender and etiology of
expressed as mean ± SD (Standard deviation).
thermal injuries, to find out the degree, sites, and percent
Independent samples t-test was used to compare between
of injuries, complications and cause of mortality.
two independent groups of normally distributed variables

(parametric data). P value 0.05 was considered

significant.

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3152
Received: 29/5/2021

Accepted: 25/7/2021

Full Paper (vol.851 paper# 83)


c:\work\Jor\vol851_84 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3157-3165

Predictive Value of CD229, CD319 and c-Maf Overexpression for
Treatment Response in Multiple Myeloma Patients
Huda F Ebian1, Mai Abdelwahab*2, Samah S Elbasateeny2, Shimaa Abdelmoneem3, Heba E Abd Elrahman1
Departments of 1Clinical Pathology, 2Pathology and 3Internal Medicine,
Hematology Unit, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Mai Abdelwahab, Mobile: (+20) 01003149432, E-Mail: Maiabdelwahab@ymail.com

ABSTRACT
Background
: Ly-9 (CD229) and SLAMF7 (CD319) are more stable markers that could be used to replace the less stable
conventional markers CD138 and CD38 in multiple myeloma (MM) patient follow-up. In those patients, the correlation
between these markers and the histopathologic marker c-Maf has not been well investigated.
Objective
: To assess the predictive value of CD229, CD319, and c-MAF overexpression on outcome of treatment in
MM patients.
Patients and Methods: 61 newly diagnosed multiple myeloma patients were involved in this prospective study. Flow
cytometric analysis of bone marrow (BM) samples for CD229 PE, CD319 PE, CD138 PerCP and CD38FITC as well as
BM biopsy immunohistochemically were analyzed for c-Maf expression
Results: CD229 and CD319 were highly expressed in (93.95%) and (95.6%) of MM patients respectively. c-Maf was
positive in (29.5%) of patients. In MM patients with high expression of CD229 and CD319 as well as those with c-Maf
positivity showed high serum Ca++, 2M, CD138 and CD38. CD229 was significantly correlated with CD319, CD38,
CD138, 2M and serum Ca (p-values were< 0.001,0.01, 0.01, 0.009, and 0.02 respectively). Patients with
overexpression of CD 229, CD319 and c-Maf were more refractory to treatment (p-values were <0.001,<0.001 and
<0.001 respectively).
Conclusion: We detected that both CD229 and CD319 were significantly overexpressed on MM cells and correlated
significantly with CD138 and CD38, suggesting their use as alternative markers for MM diagnosis as well as follow-
up. Patients with CD229,CD319, and c-Maf overexpression were associated with a significant poor response to therapy.
Keywords: CD229, CD319, c-Maf, MM, SLAMF7.


INTRODUCTION

prognosis. To rule out other cells contaminating PC
Multiple myeloma (MM) is a malignant
gating, MFC uses a combination of high to moderate co-
neoplasm of plasma cells that accumulate in bone
expression of CD38 and CD138 with weak and/or
marrow, and lead to destruction of bone then bone
negative CD45 to identify MM cells in BM (4).
marrow failure. The primary work up for diagnosis
In relapsed or resistant cases CD138 is lost in
should include a complete history, physical examination
varying degrees, while CD38 expression is reduced.
and the following basic blood studies: CBC with
Moreover, CD138 has a poorer stability at low
differential and platelet counts; serum creatinine; blood
temperatures, necessitating the addition of a new stable
urea nitrogen (BUN); serum electrolytes and calcium;
and reliable marker in the FC panel of MM (5).
albumin; 2-microglobulin and lactate dehydrogenase
T-lymphocyte surface antigen Ly-9 (CD229)
(LDH). Increased creatinine and BUN indicate
and SLAM family member 7, which is a protein
decreased renal functions, while LDH levels help to
encoded by the SLAMF7 (CD319) are members of the
evaluate tumor cell burden in cases of lymphoma-like
signaling lymphocyte activating molecule (SLAM) that
or plasmablastic myeloma(1).
have been found on the surface of malignant PCs in
Multiple myeloma (MM) is a hematological
varying degrees(5,6).
malignancy, which is characterized by aberrant plasma
Despite this variable expression of these markers
cells (PC) clonal proliferation in the bone marrow (BM)
on MM cells, they are effective gating indicators in FC
or, less commonly, in extramedullary lesions.
for accurate diagnosis, and they have been studied as
Monoclonal proteins (IgG,
IgA,
IgD,
IgE
probable therapeutic targets for MM. CD319
immunoglobulin) and/or monoclonal immunoglobulin
knockdown may affect the development of MM(7).
free light chains (FLC) are produced by cells of MM(2).
The protooncogene c-Maf is an avian retrovirus
The existence of 10% or more clonal plasma
cellular homolog transforming gene linked to (14;16)
cells on BM examination or a biopsy-proven
translocation. By boosting integrin 7 adherence to BM
plasmacytoma, in addition to one of the following, is
stroma, it promotes cell cycle progression and vascular
required for diagnosis: renal failure, hypercalcemia,
endothelial growth factor production, and it may play a
anemia, or lytic bone lesions (3).
role in MM pathogenesis (8,9).
Multiparametric flowcytometry (MFC) is a
Overexpression of c-Maf may have a prognostic
reliable method for MM diagnosis, classification, and
significance in the survival of MM. The clinical

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3157
Received: 29/5/2021

Accepted: 25/7/2021

Full Paper (vol.851 paper# 84)


c:\work\Jor\vol851_85 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3166-3172

Functional Outcome After Arthroscopic Capsular Release in
Management of the Shoulder Adhesive Capsulitis
Elias Emhemed Yousef Alazabi*, Adel Mohammad Salama,
Mohmed A. Abdel Salam, Hany Mohamed Abd Elfattah Bakr
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Elias Emhemed Yousef Alazabi, Mobile: (+20)01145521737, Email: eliasalazabi1979@gmail.com

ABSTRACT
Background:
When adhesive capsulitis develops, it causes shoulder pain and limits ranges of motion in the 2 passive
and active ways. Following an arthroscopic release of the frozen shoulder, the pain intensity and frequency were found
to be significantly reduced.
Objective: This work was performed to assess the clinical findings after use of arthroscopic capsular release in
management of shoulder adhesive capsulitis that had not responded to at least six months of conservative treatment
prior and to study how much is the regaining of functions of shoulder after the operation.
Patients and methods:
A total of 18 Egyptian patients with frozen shoulder recruited and treated by arthroscopic
capsular release. Preoperative evaluation was done and 1 week, 6 weeks, 12 weeks, and 24 weeks of follow-up after
surgery. We used Constant score for assessment of shoulder functions and pain.
Results: All of internal rotation, external rotation, abduction, forward flexion, and range of motion significantly
increased from pre- to last follow up as follows 3.66 ± 1.2, 3.77 ± 1.25, 4.77 ± 1.21, 4.88 ± 1.40, and 17.11 ± 3.83 pre-
operative versus 8.44 ± 1.46, 8.33 ± 1.41, 8.55 ± 1.14, 9.0 ± 1.57, and 31.88 ± 7.52 respectively in last post-operative
follow up. Strength of abduction significantly increased from 13.33 ± 1.71 preoperative to 20.50 ± 3.01 in last follow
up postoperative. Pain Constant score significantly increased from 5.94 ± 1.43 to 13.44 ± 2.66. Total shoulder Constant
score significantly increased from 48.16 ± 6.31to 84.50 ± 11.96.
Conclusion: Shoulder adhesive capsulitis that has not well responded to conservative treatment can be successfully
treated with arthroscopic surgery.
Keywords: Adhesive capsulitis of shoulder, Arthroscopic capsular release.

INTRODUCTION
analgesics, steroid injections into the affected joint
"Frozen shoulder" or adhesive capsulitis affects the
itself as well as the physical therapy. They may reduce
2 passive and active ranges of motion made by
pain, but they have not been shown to speed up the
shoulders (1). Adhesive capsulitis has been linked to
healing process (6).
systemic disorders such as cardiovascular diseases,
Anesthesia manipulation, open release, and
tuberculosis,
diabetes,
hypothyroidism,
arthroscopic release are some of the surgical options for
hyperthyroidism, hypoadrenalism, hyperlipidemia, and
adhesive capsulitis treatment. Pain and range of motion
Parkinson's disease. In addition, there are traumatic
can be improved by arthroscopic release of the rotator
causes such as post-shoulder surgery, Rotator cuff tear,
interval, tight middle glenohumeral ligament (MGHL),
calcified tendinitis, and so forth (2). Adhesive capsulitis
and tight intra-articular structures. To complicate the
usually progresses through three distinct stages of
procedure is the possibility of iatrogenic shoulder
clinical development. There is a pain and restriction of
instability (7). Seven years after arthroscopic release of
shoulder movement in the first stage (freezing stage).
frozen shoulder, pain intensity and frequency were
The pain tends to be worse at night. All glenohumeral
reduced and shoulder range of motion improved (range,
movements has been significantly decreased,
5-13 years). More than a year after capsular release for
particularly, external rotation, occurs during the second
adhesive capsulitis, several other studies have shown
stage (Frozen stage). Spontaneous improvement in
positive results. Nevertheless, a capsular release can
mobility occurs in the last stage. In the meantime,
cause iatrogenic instability (8, 9).
though, limited range of motion and pain could be
We aimed in this work to assess the clinical findings
prolonged (5).
after use of arthroscopic capsular release in
In Orthopedic Outpatient Clinics, adhesive
management of shoulder adhesive capsulitis that had
capsulitis affects 2 to 4 percent of patients. In women,
not responded to at least six months of conservative
this condition is more common in middle age, peaking
treatment prior and to study how much is the regaining
at 55 years of age (ranging from 45 to 60 years) (3).
of the functions of shoulder after the operation.
Controlling the pain and restoring or improving

shoulder range of motion are the primary goals in
PATIENTS AND METHODS
managing this condition. Management is based on
This was a prospective study that had been
physical therapy combined with home exercise
conducted on 18 patients with frozen shoulder who
programs (4). Other non-operative treatments include
admitted to Zagazig University in the Orthopedic
medications such as anti-inflammatory drugs and
Department, in the duration between February 2021 and

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3166
Received: 08/05/2021


Accepted: 10/09/2021

Full Paper (vol.851 paper# 85)


c:\work\Jor\vol851_86 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3173-3178

Irritable Bowel Syndrome in Patients with Chronic Viral Hepatitis
Asmaa Naser Mohammad, Mena Monir Roshdy*, Safaa Khalaf Abd Allah
Tropical Medicine and Gastroenterology Department, Sohag University, Sohag, Egypt
*Corresponding Author: Mena Monir Roshdy, Mobile: (+20) 01008094103, Email: mena.monir.1992@gmail.com

ABSTRACT
Background:
Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by
abdominal pain or discomfort, in association with altered bowel habit. Hepatitis B virus (HBV) and hepatitis C virus
(HCV) infections are two communicable diseases in which there have been increases in related morbidity and mortality
over the past 20 years.
Objective: Our study aimed to investigate a possible association between IBS as one of psychosomatic disorders and
chronic viral hepatitis and to follow up the improvement of patients' condition after management.
Patients and Methods: A prospective case-control study included 481 consecutive patients attending the outpatient
clinic and were all applied to IBS questionnaire. They were divided into three groups: HCV cases (n = 246), HBV cases
(n = 183) and co-infection cases (n = 52), in addition to normal control cases (n = 145).
Results: Prevalence of IBS was 17.24% in normal individuals who were included as control group. The highest
prevalence of IBS was seen among HCV cases (45.53%), followed by cases with combined HCV and HBV infection
(30.77%), then cases with isolated HBV (24.59%). There was a significant relation between IBS and chronic hepatitis
which means that IBS prevalence was higher among chronic hepatitis cases. The improvement of IBS symptoms was
significantly better among HBV cases who received antiviral treatment but that wasn't the same among HCV cases who
received antiviral treatment.
Conclusions: There is a significant relation between IBS and chronic hepatitis, as IBS prevalence was higher among
chronic hepatitis cases than general population. Young adult patients with chronic HCV with a previous history of
psychiatric symptoms are more likely to have IBS.
Keywords: Chronic Viral Hepatitis, Irritable Bowel Syndrome, Psychosomatic disorders.

INTRODUCTION
to follow up the improvement of patients' condition
Irritable bowel syndrome is one of the most
after management of chronic viral hepatitis.
common syndromes seen by gastroenterologists and

primary care providers with a prevalence rate of 10­
PATIENTS AND METHODS
15% in industrialized countries (1). Despite its relatively
This is a prospective case-control study included
high prevalence rate, only about 10­30% of afflicted
481 consecutive adults with chronic viral hepatitis
individuals seek medical care (2).
attending the outpatient clinic of the Tropical Medicine
Patients with IBS often report altered bowel
and Gastroenterology Department, Sohag Faculty of
movements, such as diarrhea, constipation, alternating
Medicine.
diarrhea and constipation, or predominantly normal

bowel movements with occasional diarrhea or
Ethical approval:
constipation. The Bristol stool scale can help patients to
We got acceptance of Ethical Committee at Sohag
identify which type of stool is most frequently observed
Faculty of Medicine. Patients were informed about
in their bowel movements (3).
the survey by the doctors and were asked for
Irritable bowel syndrome is a multifactorial
voluntary participation in the study and they signed
condition in which gastrointestinal (GI) motor and
informed written consent before starting the study
sensory dysfunction and psychological traits may
with respect to patients' confidentiality. This work
contribute in combination with a series of
has been carried out in accordance with The Code of
environmental factors such as acute GI infections and
Ethics of the World Medical Association
food intolerance. There also may be a background
(Declaration of Helsinki) for studies involving
genetic predisposition (4).
humans.
Patients with Chronic hepatitis usually have

different abdominal complaints. Abdominal pain or
The patients were divided into three groups: HCV
discomfort is frequently seen in clinical practice in
cases (133 females and 113 males), HBV cases (86
patients with chronic hepatitis without organic lesion,
females and 97 males) and Co-infection cases (30
the functional origin of abdominal complaints is
females and 22 males). In addition to 145 normal
claimed in many patients (5).
individuals were included as a control group. All
We aim to investigate the possible association
patients and control group were subjected to IBS
between irritable bowel syndrome (IBS) as one of
questionnaire.
psychosomatic disorders and chronic viral hepatitis and

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3173

Received: 29/5/2021

Accepted: 25/7/2021

Full Paper (vol.851 paper# 86)


c:\work\Jor\vol851_87 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3179-3184

Bypass Surgery versus Endovascular Therapy for Lower Limb Ischemia Due to
Infragenicular Lesions
Abraheem Mohammed Khoujah, Khaled Safwat Fahmi,
Ayman Abd Elhamid Salem and Mohammed Ahmed Effat
General Surgery Department, Faculty of medicine, Zagazig University, Egypt
*Corresponding author: Abraheem M. Khoujah, Mobile: (+20)01102916469, Email: ebrakhoja@gmail.com

ABSTRACT
Background:
Endovascular and open surgical revascularization are delivered to patients by a variety of vascular
specialists. Critical limb ischemia (CLI) is compounded by the fact that there is limited high quality data guiding vascular
specialists on the optimal treatment approach.
Objective: The aim of the present study was to assess the better management of patients with critical lower limb
ischemia.
Patients and methods: This study included 24 participants diagnosed with critical lower limb ischemia (CLI) due to
Infragenicular lesions. They were allocated into two groups: group (1), which include 12 patients undergoing the
endovascular therapy (EVT) and group (2) that include 12 patients undergoing the bypass surgical therapy. All patients
were subjected to radiological evaluation including X-ray foot, arterial Duplex U-S on affected limb, CT angiography
on lower limb arteries and the saphenous vein. The patients followed an appropriate risk factor modification program.
Results: There was no significant difference between the studied groups regards Rutherford classifications (p > 0.05).
There was a statistically significant increase in frequency of amputation among EVT group versus bypass group (p =
0.04). Furthermore, there was a statistically significant increase in frequency of thrombosis among EVT group versus
bypass group (p = 0.03). On the other hand, there was no statistically significant difference between the studied groups
that underwent different surgical techniques regarding complications. Kaplan Meier curve showed cumulative survival
from major amputation following infrapopliteal angioplasty and bypass treatment over the study period.
Conclusion: Endovascular intervention is considered a safe and efficient technique in the treatment of critical limb
ischemia. The technique has many advantages over open surgical procedures, being tolerable, easy, safe, and effective
with general anesthesia avoidance and has low mortality and morbidity.
Keywords: Endovascular Therapy, Bypass Surgery, Lower Limb Ischemia.

INTRODUCTION
became equivalent to those of bypass surgery (3).
Among known peripheral limb ischemia (PAD)
Application of EVT for the first treatment has been
patients, prevalence of critical limb ischemia (CLI) may
shown to be appropriate, although there are some
be as high as 11%. In fact, 5-10% of asymptomatic PAD
exceptions. Regarding EVT for PAD with lesions
patients or those with claudication will progress to CLI
mainly below the knee, the long-term patency rate is
over a period of 5 years. The rate of limb loss is as high
still low, and which of EVT or bypass surgery should be
as 40% in this group of patients. According to a German
performed for the first treatment is the most
registry involving 40,000 PAD patients, two-thirds of
controversial issue. CLI frequently extends over many
those belonging to CLI had their limb amputated within
regions, and lesions are present in below-the-knee
4 years after diagnosis. In Bangladesh, most of the PAD
arteries in many cases (4).
patients present in advanced stages of CLI with features
The current study aimed to assess the better
of tissue loss (1).
management of patients with critical lower limb
The decision to recommend surgical or
ischemia. To compare the efficacy and durability of a
endovascular revascularization for CLI patients varies
bypass-first vs endovascular-first strategy for
substantially among providers. The United Kingdom
revascularization in patients with CLI due to
multicenter bypass versus angioplasty in severe
infrageniculate arterial disease.
ischemia of the leg (SIL) trial remains the only

randomized controlled trial (RCT) to compare a bypass-
PATIENTS AND METHODS
first with an endovascular-first revascularization
The randomized controlled trails study was
strategy for infrainguinal arterial occlusive disease.
conducted in Outpatient Clinic in the Vascular Surgery
However, this study did not specifically address the
Department at Zagazig University Hospitals during the
effectiveness of treatment for the infrageniculate
period from June 2020 to July 2021. The study included
arteries (2). For the aortoiliac and femoropopliteal
24 participants diagnosed with CLI due to
arterial
areas,
the
therapeutic
infragenicular lesions with mean age of 69.01 ± 7.11
results of lower limb enodovascular therapy (EVT)
years (range, 55-75 years). Regarding sex majority were
including long-term outcomes have improved and



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3179
Received: 29 /5 /2021


Accepted: 25 /7 /2021

Full Paper (vol.851 paper# 87)


c:\work\Jor\vol851_88 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3185-3193

Role of Magnetic Resonance Imaging in Evaluation of Post Traumatic Ankle Joint
Hayam A. Abdellatif, Alshaimaa A. Turky*, Elsayed E. Elsayed
Department of Radiodiagnosis and Interventional Radiology,
Faculty of Medicine, Menoufia University, Menoufia, Egypt.
*Correspondence to: Alshaimaa A. Turky, Mobile: +20 1093738144; E-mail: alshaimaa.turky@gmail.com

ABSTRACT
Background:
The ankle joint injuries are common emergency and account for about 10% of all visits to emergency
departments. This is usually due to a sprain related to sports, walking, fall, or road traffic accident. Ankle joint has a
complex three-dimensional anatomy, so MRI is considered the modality of the choice in evaluating patients with ankle
problems. MRI provides precise information about soft tissue, skeletal and extra-skeletal lesions.
Objectives: To evaluate the role of magnetic resonance imaging (MRI) in the detection of abnormalities and injuries
associated with post traumatic ankle joint.
Patients and methods:
A descriptive cross-sectional study was conducted from July 2019 to April 2021. Sixty patients
with post-traumatic ankle joint complaints underwent MRI examination during this period. All patients performed MRI
examination in the Radiology Department, Menoufia University Hospital after signing informed consent.
Results: Out of 60 patients, nine (16%) were diagnosed with ligamentous injuries, 29 (48.3%) were diagnosed with
tendon injuries and 35 (58.3%) were diagnosed with bone injuries. Nine (15%) were fractures, one (1.7%) was bone
necrosis and 34 (56.7%) were bone contusions. 55 (91.7%) had joint effusion and 11 (18.3%) had sinus tarsi syndrome.
Conclusion:
MRI is the modality of choice in evaluating ankle injuries because of its high soft tissue contrast resolution
and multi-planar capabilities. It is an ideal modality for global evaluation of the osseous and soft tissue structures of the
ankle.
Keywords: Ankle joint, MRI, Traumatic Injuries.

INTRODUCTION


The Ankle joint injuries are common and
of this region may explain the less popularity of MRI of
make up approximately 10% of all emergency
the ankle (2).
department visits. They are frequent in men aged 12 to
MRI can provide precise information about
24 years. However, women older than 30 years have
cartilage, tendon, ligament, bone marrow, joint
higher rates. This is usually due to a sprain related to
effusion, skeletal and extra-skeletal masses. It has
sports, walking, falling, or road traffic accident (1). The
superiority in soft tissues over any other modality; this
increased sports activities these days have increased the
makes it a useful tool for surgeons to diagnose and to
number and type of sports-related injuries (2). About
make treatment plans (7).
10,000 people are suffering from an ankle injury every
Future improvements in MRI technique may
day in the United States with most of these being
help the surgeon to limit the extent of dissection by
sprains (3). A sprain can be defined as disruptions of the
localization of the area of interest and MRI may then be
ligaments of the joint, but there are other associations as
used to monitor healing or response to treatment. MRI
bone fractures, avulsion, and contusions can be
is not a replacement of plain radiography but is a
present. It usually happens due to the inversion of the
valuable adjunct (8).
ankle, but eversion can also cause ankle injury (4).

This injury is often taken for granted due to
The aim of this work was to evaluate the role of MRI
its frequency and most patients are treated with
in the detection of abnormalities and injuries associated
conservative management successfully, but about 30%
with post traumatic ankle joint.
of the patients with ankle sprains remain with chronic

lateral ankle instability and residual pain, which
PATIENTS AND METHODS
requires a surgical procedure (5).
This study was conducted at the MRI Unit,
Ankle joint has a complex three-dimensional
Department of Radiodiagnosis and Interventional
anatomy, so magnetic resonance imaging (MRI) is
Radiology, Menoufia University in the period from July
considered the modality of the choice in evaluating
2019 to April 2021. The study included 60 patients with
patients with ankle problems due to its multiplanar
post traumatic ankle symptoms referred from the
capabilities, excellent soft-tissue contrast, bone marrow
orthopedic department. They included 31 males and 29
imaging capability, non-invasiveness, and lack of
females with age distribution from 4 to 73 years, with a
ionizing radiation (6). Plain radiographs are still the
mean age of 34.6 years.
initial and most valuable imaging study of any patient

with a musculoskeletal injury. Lack of familiarity of
Inclusion criteria: Our study included any patient with
radiologists with local pathology and complex anatomy
ankle pain following traumatic insult, with no age or sex

predilection.

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3185

Received:1/6 /2021

Accepted:27/7 /2021

Full Paper (vol.851 paper# 88)


c:\work\Jor\vol851_89 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3194-3197

Higher Energy Endovenous Laser Ablation Impact on Varicose Veins
Mohamed Saad Alaribi*, Osama Hasan Gharib, Wael Mohamed El Shimy and Waleed Abdelbadee Sorour
General Surgery Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohamed Saad Alaribi, Mobile: (+2): 01016506301, Email: aloribimohamed@yahoo.com

ABSTRACT
Background:
Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure
when standing. Endovenous laser therapy (EVLT) is a popular surgical treatment for varicose veins.
Objective: The aim of the present study was to assess the higher energy endovenous laser occlusion rate in treatment
of varicose veins.
Patients and methods: This clinical trial study included 18 patients with lower limb varicose veins presented to the
outpatient clinic of the Zagazig University Hospital. All patients were assessed clinically to identify symptoms and signs
related to venous diseases and duplex ultrasonography was performed. Patients were instructed to remove all dressings
after one week, to shower and then to apply class II full length compression hosiery for 3 months.
Results: the mean age of patient's was 35.58±5.93 and BMI ranged from 18.5 to 32, with a mean of 26.11 ± 2.84. 27.7%
have family history in the first degree relative. The operative time ranged from 35 minutes to 70 minutes, with a mean
of 55 minutes. Regarding hospital stay, all patients undergoing GSV were discharged at the same day of the intervention.
Conclusion: Endovenous laser treatment of varicose veins in the great saphenous vein with the 1470 nm diode laser is
safe and highly effective. Our study suggests that improved outcomes are associated with higher energy EVLA of
varicose veins, 95% of cases were successfully treated.
Keywords: Diode Laser, Endovenous Laser Ablation, Varicose Veins.

INTRODUCTION
results at energies higher than this and many providers
Varicose veins are veins that have become
now use 80-100 J/cm. Despite this, 100% success
enlarged and tortuous. The term commonly refers to the
remains an elusive goal. The reluctance to increase
veins on the leg, although varicose veins can occur
energy delivery further is most likely due to concerns
elsewhere. Veins have leaflet valves to prevent blood
that this may result in increased morbidity and
from flowing backwards (retrograde flow) (1). Venous
complications from the procedure. There is however, no
hypertension caused by incompetent valves in the
evidence that this is the case, when EVLT is performed
superficial veins is by far the most common cause of this
using tumescent anesthetic solution (2).
condition. It is expected that approximately 25% of
Therefore, this study aimed to assess the higher
women and 15% of men have lower extremity superficial
energy endovenous laser occlusion rate in treatment of
venous insufficiency (2). Great Saphenous Vein (GSV)
varicose veins. Also to demonstrate the outcome after
reflux is the most common underlying cause of
EVLA of GSV or small saphenous vein with a 1470 nm
significant varicose veins. When the GSV reflux is the
diode laser.
principal underlying problem, treatment should involve

eliminating this source of reflux with ablation of any
PATIENTS AND METHODS
associated incompetent venous segment (3).
This clinical trial study included 18 patients with
Although surgical treatment of varicose veins is
lower limb varicose veins presented to the outpatient
the traditional one, it has a 30­60% recurrence rate (4).
clinic of the Zagazig University Hospital.
Endovenous laser therapy (EVLT) is a popular treatment
Inclusion criteria: Patients with varicose vein in age
for varicose veins (5). It was firstly introduced in 1998 by
from 25 to 58 years. Patients with primary, symptomatic,
Spanish phlebologist, Carlos Bone. Diode lasers are
varicose veins, patients with saphenofemoral junction
most commonly used for EVLA (6). EVLA is performed
(SFJ) incompetence or saphenopopliteal junction
with a laser fiber introduced into the lumen of the
incompetence.
incompetent superficial vein. By applying different
Exclusion criteria: Patients with tortuous GSV, deep
wavelengths, different chromophores are used (7). Laser
venous incompetence on duplex, non-palpable distal
devices with higher wavelengths (1320 nm, 1470 nm)
pulsation and inability to ambulate. Inability to give
are targeting water and act specifically on the vessel
informed consent to trial participation.
wall. Lower wavelengths (810 nm, 940 nm, and 980 nm)

used at the earlier stage of the technical evolution have
Ethical approval:
an indirect heat effect on the venous wall by generating
The study was approved by the Ethical
vapor bubbles (8).
Committee of Zagazig Faculty of Medicine. An
Commonly energy deliveries of around 20-60
informed consent was obtained from all patients in
J/cm or equivalent influence calculations have been
this research. Every patient received an explanation
used, but the current best evidence points to improved
for the purpose of the study. All given data were used



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3194
Received:29/5 /2021

Accepted:25/7 /2021

Full Paper (vol.851 paper# 89)


c:\work\Jor\vol851_90 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3198-3201

Intralesional Injection of Purified Protein Derivative in the
Treatment of Viral Warts: A Pilot Study
Nagwa Diab, Hend Atef*, Eman Salah
Dermatology, Venereology and Andrology Department, Faculty of Medicine, Zagazig University,Egypt
*Corresponding Author: Hend Atef, Email: hendatef135@gmail.com

ABSTRACT
Background:
Human papilloma virus (HPV) could contribute to warts and prevalence of warts is estimated to be from
7 to 10 percent of population. Immunity system could recognize bacterial, fungal as well as viral antigens. Researchers
got benefit of this through development of antigen immunotherapy intralesional management. Purified protein derivative
(PPD) is an intralesional immune-treatment for warts that has shown promising results.
Objective: To determine whether intralesional PPD is effective and safe in common warts management.
Patients and methods: The study involved twenty patients. History taking, general exam, and complete dermatological
exam were performed on each patient to determine the type and number of warts, as well as the size and location of each
wart in every patient. Without any pre-sensitization, all patients were then given PPD injection of 0.1 ml into the largest
wart every two weeks for a maximum of six treatment sessions, or until the wart was completely cleared. The
effectiveness of the treatment was determined by the size and number of warts. PPD injections were also evaluated for
patient satisfaction and side effects. There was a follow-up evaluation for wart recurrence six months after the end of
the treatment.
Results: After 1/3 sessions, the mean of wart size reduction was 11.25 ± 14.67 whereas after 2/3 sessions the mean was
29.80 ± 28.72. After all sessions, the wart size reduction ranged from 0 ­ 100 with a mean of 55.55 ± 42.65. 35% of
patients had complete wart clearance, 20% had a moderate response, and 40% had an inadequate response, 5% showed
marked response.
Conclusion: Common warts can be treated with intralesional immunotherapy using PPD, which is a safe, effective, and
tolerable treatment modality.
Keywords: Human papilloma virus, Wart, PPD, Immunotherapy.

INTRODUCTION
Immunity system could recognize bacterial, fungal
Human papilloma virus (HPV) infection can cause
as well as viral antigens.
warts on the skin and mucous membranes. It affects
Researchers got benefit of this through development
about 7­10% of the population (1). It is presented in
of antigen immunotherapy intralesional management. As
different clinical forms including common wart (Verruca
a result of the delayed-type hypersensitivity reaction, the
vulgaris), wart on the sole of the foot, plantar wart
immune system is better able to recognise, clear, and
(Verruca plantaris), flat wart (Verruca plana) and genital
prevent HPV infection in both treated and untreated
wart (Condyloma acuminate). On the hands of children
lesions and thus to prevent recurrence (5). Functional host
and young adults, common warts are hyperkeratotic
immunity is very important for successful intralesional
papillomas that can occur anywhere on the skin or
antigen immunotherapy (6).
mucous membrane surface (2).
There has been promising efficacy in the treatment
Warts have been treated with a variety of
of warts using a purified protein derivative (PPD). As an
destructive and immunotherapeutic methods. Some of
extract of Mycobacterium tuberculosis, PPD can be used
the destructive therapies include the use of medical
to test for tuberculin protein, either through previous
agents such as trichloroacetic acid, salicylic acid, and
vaccination or exposure to the environment. Immunity is
formaldehyde or the surgical use of cryosurgery, surgical
stimulated by PPD injection in an unspecific manner by
excision, and electrocautery or laser ablation. All of
activation of cytokines and natural killer cells as well as
these treatments have the potential to cause
T lymphocytes. Regardless of the HPV serotype, it is
dyspigmentation and/or scarring, as well as recurrences.
effective against all types of warts, including verruca
They can also be used to treat multiple warts and facial
vulgaris, verruca plana, and planter warts (7).
warts to a limited extent. Diphencyprone is an example
In addition to its efficacy and safety profile, this
of a contact sensitizer and imiquimod is an example of
therapeutic approach has the following main advantages:
an immunomodulatory agent (3).
low cost, simple and easy application and only one wart
Virus-induced cell-mediated immunity (CMI) has
per application (8). In addition, there are no side effects
been shown to cause warts to spontaneously regress. In
such as scarring, pigmentary changes, and movement
recent years intralesional immunotherapy using antigens
restrictions (9). The aim of this work was to determine
like tuberculin, mumps, and candidin have gained good
whether intralesional PPD is effective and safe in
popularity (4).
common warts management.




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3198
Received:18/7 /2021

Accepted:11/9 /2021

Full Paper (vol.851 paper# 90)


c:\work\Jor\vol851_91 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3203-3209

The Correlation Between Gestational Sac Volume and Embryonic
Volume in Prediction of Pregnancy Outcomes
Marwa Zakaria Zakaria Elfaiomy, Ehsan Mohamed Raghib Refaie,
Mostafa Hassan Nawwar, Sara Abdelaziz Ebada Mohamed
Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Egypt
*Corresponding author: Marwa Zakaria Zakaria Elfaiomy, Mobile: (+20)1012574251, E-Mail: marwaelfaiomy@gmail.com

ABSTRACT


Background: Accurate estimation of gestational (GA) is the basis of vital decisions in pregnancy and hence its
importance in obstetric management. Crown rump length (CRL) has been proved to be a reliable parameter for the
estimation of pregnancy age especially from 7 to 10 weeks. Additionally, it was demonstrated that, the gestational sac
volume (GSV), embryonic volume (EV), CRL are important parameters for the early diagnosis of growth disorders.
Objective:
The aim of the current work was to assess the correlation of pregnancy outcome with gestational sac volume
in relation to embryonic volume at )710) weeks of gestation.
Patients and methods: This was a prospective observational cross-sectional study carried out on 100 pregnant women
with singleton pregnancy that belonging to7-10 week of pregnancy attending a routine antenatal checkup at Outpatient
Clinic Of Obstetrics and Gynecology Department, Mansoura University Hospital.
Results: Caesarean section (CS) was the most frequent mode of delivery among the studied cases. The average GSV,
EV and CRL were higher among females with higher gestational age. EV and GSV were demonstrated to be significant
predictors of CRL. CRL=1.55+0.02*GSV+0.08*EV. GSV was displayed to be a significant predictor of fetal birth
weight. Fetal birth weight=2.94+0.008*GSV.
Conclusion: It could be concluded that the GSV and EV reference intervals established in the present study can be
used as normal parameters in future studies assessing cases at risk for adverse pregnancy outcomes.
Keywords: Gestational sac volume, Embryonic volume, Pregnancy outcomes

INTRODUCTION

first trimester, may predict adverse pregnancy
Sonography is an excellent modality for first
outcome (4).
trimester pregnancy evaluation and in determining the

progress of pregnancy and predicting prognosis. The
The aim of the present study was to assess the
3D volumetric methodology is more accurate than 2D
correlation of patient's pregnancy outcome (maternal
US and reliable for clinical evaluations, but it is not a
and fetal) with gestational sac volume in relation to
substitute for 2D US and both methods should be used
embryonic volume at )710) weeks of gestation.
together to get accurate and efficient ultrasound

diagnosis (1).
PATIENTS AND METHODS
First trimester of pregnancy is defined as 12
This prospective observational cross-sectional
weeks after the last menstrual period in a woman
study included a total of 100 pregnant women with
during her reproductive life. This period is exposed to
singleton pregnancy that belonging to7-10 week of
a lot of complications associated with human
pregnancy, attending for a routine antenatal checkup in
formation, development, and growth. However, First
Outpatient Clinic, Obstetrics and Gynecology
trimester ultrasonography aims to establish viability,
Department, Mansoura University Hospital.
pregnancy dating, detect multiple pregnancy, observe

uterine
adnexal
structures,
measure
nuchal
Inclusion criteria: The women of singleton pregnancy
translucency and evaluate limited fetal gross anomaly
with a live embryo < 35years old who will give
and predict an abnormal fetal outcome not only in the
informed consent, without other medical disorders, and
presence of a live embryo but also before visualization
gestational age between (7-10) weeks and no history of
of the embryo itself that can be used to identify a
vaginal bleeding in the index pregnancy.
subgroup of embryo at high risk of embryonic demise

or subsequent diagnosis of fetal anomaly that requires
Exclusion criteria:
close monitoring (2).
Pregnancy from stimulated ovulation, an uncertain
First trimester prediction of IUGR,
last menstrual period date, irregular menstrual cycles,
preeclampsia, birth weight, aneuploidy miscarriage,
multiple pregnancies. Cases without embryonic heart
complications
in
multiple
pregnancies
and
rate,
anembryonic
pregnancy,
subchorionic
homozygous thalassemia is a challenging and an
hemorrhage, uterine malformations, and women who
emerging field in obstetrical sonography (3).
has medical disorders or used any abortive or
Gestational sac is closely related to amniotic fluid
teratogenic drug.
volume that may reflect uteroplacental functions in the
All cases were subjected to:

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3203

Received: 30/5/2021

Accepted: 26/7/2021

Full Paper (vol.851 paper# 91)


c:\work\Jor\vol851_92 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3209-3215

Comparison between Endoscopic Microdebrider Adenoidectomy and
Conventional Curettage Method
Atef Taha El-Bahrawy, Khaled Abd-Elshakour Mohammed,
Ahmed Muftah Emhemmed Yadam*, Mohammed Elsayed Abdel Bary
Department of Otorhinolaryngology, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding Author: Ahmed Muftah Emhemmed Yadam, Email:ahmedyadim82@gmail.com

ABSTRACT
Background:
Adenoidectomy is a surgical removal of hypertrophic nasopharyngeal lymphoid tissue forming a part of
the Waldeyer's ring. Adenoid hypertrophy causes nasal obstruction and airway problems such as snoring, obstructive
sleep apnea, recurrent sinusitis, and/or Eustachian tube dysfunction. These complications frequently lead to a need for
adenoidectomy. Objective: To compare between cold curettage and endoscopic assisted powered technique as regard
operative time, blood loss, postoperative complications.
Patients and Methods: This prospective study included 18 patients, both genders, all suffering from hypertrophied
adenoid tissue, presented clinically with mouth breathing, snoring, bilateral nasal obstruction and/or discharge and
evidenced radiologically with plain X-ray film lateral view to the nasopharynx. All cases presented to ENT Department
Zagazag University, during the period from July 2019 to July 2021, seeking for management of their problem. Patients
were divided into two groups (9 patients each); Group I: In which patients were undergone conventional adenoidectomy
with adenoid curette. Group II: Patients were undergone endoscopic assisted powered adenoidectomy.
Results: Conventional curettage method of adenoidectomy group was associated with more operative bleeding than
endoscopic assisted powered adenoidectomy group, but there was no significant difference. Nasal packing of
conventional curettage method of adenoidectomy group was distributed as following; one patient (11.1%) required mild
packing, 3 patients (33.3%) required moderate packing. While in endoscopic assisted powered adenoidectomy group,
one (11.1%) required moderate packing.
Conclusions: Endoscope assisted powered adenoidectomy needs to be acknowledged as a safe alternative to
conventional adenoidectomy.
Keywords: Conventional adenoidectomy, Curettage, Powered adenoidectomy.

INTRODUCTION

Nasopharyngeal tonsil becomes evident by six
electro cautery, laser, or a combination of these
months to one year of life, increases rapidly in size
instruments. One can instead use a transnasal approach
during the first 6 to 8 years of life and generally atrophies
with an adenoid punch cutting and biting forceps, or
by adolescence(1). To determine the necessity for
electrocautery, in conjunction with transnasal telescopic
adenoidectomy the physician typically relies on physical
visualization. A combined transoral and transnasal
examination and history. However physical examination
approach can also be used(3).
provides little information about size of adenoid,
One of the newest adenoidectomy techniques is
although enlarged tonsils may be proved easily. Several
endoscopic transnasal adenoidectomy utilizing a
radiological techniques have been proposed to favour the
powered microdebrider. This instrument uses a powered
decision for adenoidectomy(2).
rotating blade within a suction device so that it debrides
During the last 20 years, we have observed
only loose soft tissue which can be aspirated into the
higher prevalence of sleep disordered breathing in
device. This powered instrumentation, which was
children. Adenotonsillar enlargement leading to partial
originally used to shave cartilage in arthroscopic surgery,
or complete obstruction of nasopharynx/oropharynx
has been popularized recently for use in nasal
account for majority of these cases. Consequently
polypectomy and endoscopic sinus surgery(4).
adenoidectomy performed in children has increased
This study aimed to compare between cold
significantly. Adenoidectomy can be performed as an
curettage and endoscopic assisted powered technique as
isolated procedure or along with tonsillectomy.
regard operative time, blood loss, and postoperative
Adenoidectomy is conventionally performed using the
complications.
curettage method with an adenoid curette. This is blind

procedure and was described since 1885(1).
PATIENTS AND METHODS
There are many different adenoidectomy
This is a prospective study, which included 18
methods. The conventional adenoidectomy is performed
patients,
both genders,
all
suffering
from
with the transoral approach and can be accomplished
hypertrophied adenoid tissue, presented clinically with
with an adenoid curette, adenotome, St. Clair-Thompson
mouth breathing, snoring, bilateral nasal obstruction
forceps, adenoid punch, electrocautery curette, suction
and/or discharge and evidenced radiologically with



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3209
Received:30/5 /2021

Accepted:26/7 /2021

Full Paper (vol.851 paper# 92)


c:\work\Jor\vol851_93 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3216-3221

Assessment of Post-Operative Infection of Acetabular Fracture Fixation:
Meta-Analysis
Sami Khalifa M Elkammushi, Abdelsalam Mohamad Hefny,
Tarek Abd ELSamad EL-Hewala, Ahmed Mashhour Gaber
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
Corresponding Author: Sami Khalifa M Elkammushi, Email: alkamoshysami@gmail.com

ABSTRACT
Background: Acetabular fractures is a break in the socket portion of the "ball and socket" hip joint. The operative
treatment often necessitates extensive surgical exposure. Surgical site infection (SSI) an unfortunate and troublesome
complication after surgery, usually leading to increased morbidity, mortality
Objective: The aim of the current work was to investigate the risk factors of SSI after acetabular fracture surgery and to
perform a meta-analysis of all the case-controlled trials (CCTs) to determine whether there were any significant
differences in the average operation time, intraoperative blood loss, fracture end reset satisfaction rate, early/late
complication rates, and the approach during operation and BMI.
Patients and methods: This Meta-analysis is a quantitative, formal, epidemiological study design used to
systematically assess previous research studies to investigate the risk factors of SSI after acetabular fracture surgery and
to perform a meta-analysis of all the case-controlled trials (CCTs) in the last ten years to determine whether there were
any significant differences in the average operation time, intraoperative blood loss, fracture end and the Harris hip score
(HHS) good function rate.
Results: Pooled prevalence of SSI was 6.71% among all studies and it was a significant rate like all studies as they
were significant impacted rates in comparison to base (Zero). Majority among all studies were Staphylococcus species
including Methicillin Resistant Staphylococcus aureus (MRSA), followed by Enterococcus faecalis. Operation time
was significantly higher among cases of SSI at all studies and at pooled analysis. Regard pooled analysis diabetes
mellitus (DM) considered as significant risk factor with Pooled OR 2.31 (1.1-8.63).
Conclusion: The collected data from the included studies showed that operative time, injury severity score and DM are
all risk factors after operation. Also, most common organism among all studies were Staphylococcus species including
Methicillin Resistant Staphylococcus aureus (MRSA), followed by Enterococcus faecalis. Finally, in all studies we
founded hypertension and smoking are not risk factors of the post-operative infection.
Keywords: Acetabular Fracture Fixation, Surgical site infection (SSI).

INTRODUCTION
preservation of the hip and less posttraumatic OA (4).
Surgical site infection (SSI) is defined as an
Since that time, operative treatment of displaced
infection at the site of operation that occurs within 30
acetabular fractures has been the treatment of choice.
days after the procedure or within 1 year if a foreign
However, it is associated with postoperative
body was implanted during the operation (1). The SSI is
complications, such as infection and nerve palsy as
an unfortunate and troublesome complication after
(sciatic nerve) (5).
surgery, usually leading to increased morbidity,
The treatment of patients with acetabular fractures
mortality, length of hospital stays, and health-care costs
is challenging. Surgical treatment of acetabular fractures
(2).
was established. In the last 30 years, open anatomical
A great variety of risk factors for SSI after
reduction of the articular surface with a rigid internal
orthopedic surgery are reported, including patient
fixation became the standard management for these
related (e.g., increased age, diabetes mellitus, obesity,
fractures (6).
previous surgical infection, poor nutrition), injury-
The operative treatment often necessitates
related (e.g., open fracture grade) and surgery-related
extensive surgical exposure, long operative time, and
(e.g., operation duration, surgical site classification,
high blood loss. Post-operative SSI after the acetabular
excessive blood loss, and antibiotic prophylaxis) factors
fracture surgical procedure is fortunately uncommon.
(3).
Still, the results from an infection are devastating,
Acetabular fracture is a break in the socket portion
limiting the patient's physical performance substantially
of the "ball and socket" hip joint. Historically, they were
and dramatically impairing life quality (7).
treated conservatively, which often involved prolonged
Suzuki et al. (8) reported 326 patients who
immobilization and a high incidence of post-traumatic
underwent acetabular fracture surgery in which SSI
osteoarthritis (OA). In 1964, Judet et al. were the first
developed in 17 patients, including 10 deep infections
to advocate open anatomical reduction and internal
and seven superficial infections. The univariate analysis
fixation of these fractures. They found that operatively
showed that the Injury Severity Score (ISS), intensive
treated displaced acetabular fractures resulted in better
care unit (ICU) stays, amount of packed red blood cells

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3216
Received:19/7 /2021

Accepted:10/9 /2021

Full Paper (vol.851 paper# 93)


c:\work\Jor\vol851_94 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3222-3227

The effect of interdialytic weight gain on pulmonary artery pressure and lung
congestion in prevalent hemodialysis patients
Magdy M. El Sharkawy1, Ahmed M. Samy El Shimy2,
Ali E. Abdel Rahman3, Ahmed M. Shebl Draz4, Lina Essam Khedr*1
Departments of 1Internal Medicine & Nephrology and 2Radio Diagnosis,
Faculty of Medicine, Ain Shams University, Egypt
Departments of 3Radiology and 4Nephrology, Nasser Institute Hospital, Egypt
*Corresponding author: Lina Essam Khedr, Mobile: (+20)1223421925, Email: linakhedr@med.asu.edu.eg

ABSTRACT
Background:
Patients with end stage renal disease on regular hemodialysis (HD) commonly present with volume
overload. This has been found to be associated with increased incidence of pulmonary hypertension (PH) and chronic
lung congestion.
Objective: The aim of the study was to determine the effect of interdialytic weight gain (IDWG) on pulmonary artery
pressure by echocardiography and lung congestion by lung ultrasound.
Patients and Methods: This observational cross-sectional study was conducted on 60 patients on regular haemodialysis
at Nasser Institute Hospital, Cairo. Patients were divided into 2 groups: Group (I) 30 patients with IDWG < 3.5% of
their dry weight, and Group (II) 30 patients with IDWG > 3.5 % of their dry weight.
Results: Patients with increased IDWG > 3.5% (group 2) had pre-HD higher pulmonary artery pressure (PAP) than
those with IDWG < 3.5% (group 1) and patients with IDWG > 3.5% had more change in their PAP post HD session
than those with IDWG < 3.5% but no significant difference between the change after the HD session in both groups.
There is a significant relation between HD duration, anemia, and hypercalcemia with PH. Patients with more increased
IDWG > 3.5 % (group 2) had higher pulmonary congestion than those with IDWG < 3.5% (group 1) and patients with
IDWG < 3.5% had more change in their lung congestion level after the HD session than those with IDWG > 3.5% but
no statistical significance between the change in both groups.
Conclusion:
Increase in IDWG% over 3.5% significantly affects lung congestion and pulmonary hypertension in
dialysis patients.
Keywords: Pulmonary Hypertension, pulmonary congestion, Haemodialysis, Interdialytic weight gain.

INTRODUCTION

hypertension using echocardiography (Echo) and lung
Pulmonary hypertension (PH) is a recognized
congestion using lung ultrasound (LUS).
cardiovascular complication for patients with end stage

renal
disease (ESRD)
on
hemodialysis
(1).
PATIENTS AND METHODS
Echocardiography is a non-invasive, vastly available
This comparative cross-sectional study included a
and inexpensive tool for screening for PH and
total of 60 patients on regular haemodialysis, at Nasser
monitoring its progression (2).
Institute Hospital, Cairo.
The prevalence of pulmonary hypertension in
Patients were divided into 2 groups: Group (I) 30
hemodialysis patients is high and differs in different
patients with IDWG < 3.5% of their dry weight, and
studies from 17% to 49.53% depending on the method
Group (II) 30 patients with IDWG > 3.5 % of their dry
of dialysis and the presence of other cardiovascular
weight. Comparison between the two groups was done
comorbidities (3).
to detect statistically the effect of IDWG and
Lung congestion is a common problem in ESRD
ultrafiltration on PAP and lung congestion.
patients on dialysis. Before hemodialysis (HD), nearly
A standardized questionnaire used to collect
60% of ESRD patients show moderate to severe lung
demographic data and data regarding the kidney disease
congestion which was decreased but not completely
and HD including aetiology of ESRD, date of onset of
abolished by ultrafiltration process during dialysis, and
haemodialysis therapy and HD access. Laboratory data
nearly one third to one fourth of those patients had some
including haemoglobin, calcium, phosphorus, urea and
degree of lung congestion post hemodialysis (4). Marini
virology were also collected.
reported in 2017 that lung ultrasound can be used as a
Pulmonary artery pressure was measured by echo
reliable method of evaluation of lung congestion
and patients classified according to PAP into mild (25-
through assessment of B-lines (5). A B-line score was
30 mmHg) moderate (30-44 mmHg) and severe (>45
calculated and categorized as minimal (0-5 B-lines
mmHg) pulmonary hypertension. Lung congestion in
present), mild (6-13), moderate (14-30) and severe (>30
all patients was measured by lung ultrasound and
B) pulmonary congestion (6).
patients classified into minimal (0-5 B lines) mild (6-
The aim of the current work was to determine the effect
13) moderate (14-30) and severe (>30) lung congestion.
of interdialytic weight gain (IDWG) on pulmonary
ESRD patients' age 18 years old had been on regular
haemodialysis 3 times per week > 6 months at Nasser

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3222
Received:6/6 /2021

Accepted:2/8 /2021

Full Paper (vol.851 paper# 94)


c:\work\Jor\vol851_95 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3228-3235

Value of Regulatory T Cell in Hepatocellular Carcinoma Patients
Seham Mahrous Zaki Nasr1, Afifi Fahmy Afifi Ahmed2,
Neveen Emam-Eldein1, Maher Borai Mohammad*1
Departments of 1Clinical Pathology, 2Internal Medicine, Faculty of Medicine - Zagazig University, Egypt
*Corresponding author: Maher Borai Mohammad, Mobile: (+20) 01116441130, E-Mail: maherborai@yahoo.com

ABSTRACT
Background:
Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, representing the
second leading cause of cancer-related death worldwide. It is the 2nd leading cause of cancer death in men and the sixth
among women.
Objectives: To investigate the role of CD4+, CD25+, FOXp3+Regulatory T cells (Tregs) in patients with HCC and
their correlation with the prognosis.
Patients and Methods:
The study was conducted on 25 patients with hepatocellular carcinoma. Detection of regulatory
T cells by flow cytometry using CD4, CD25 and FOXp3 before and after intervention.
Results:
CD4 significantly increased but CD4/CD25, Foxp3, AFP, ALT and AST significantly decreased. Patients with
high numbers of FOXp3+ cells and those with higher FOXp3+ Tregs /CD4+ T cell ratio had poorer overall survival
rates.
Conclusion: Tregs seem to be a promising prognostic factor in patients with HCC and a high Tregs level has been
reported to be correlated with poor outcomes in a number of publications.
Keywords: HCC, CD4, FOXP3, CD25.

INTRODUCTION

Hepatocellular carcinoma (HCC) is the most
Hospital, in the period from March 2018 to September
common primary malignancy of the liver. World Health
2018. Twenty five subjects with HCC were included in
Organization (WHO) considers HCC as the second
this study. HCC was diagnosed on the basis of the
leading cause of cancer deaths (1, 2, and 3). HCC patients
results of alpha fetoprotein (AFP) determination and
have an established background of chronic liver disease
liver radiology techniques. The choice of patients based
and cirrhosis, hepatitis B virus (HBV) and hepatitis C
on the Barcelona Clinic Liver Cancer (BCLC) staging
virus (HCV) infections, alcoholic liver disease, and
classification. All patients were at stage A (early stage).
nonalcoholic
steatohepatitis
(3,
4).
Aberrant
They were 7 females and 18 males with the age ranged
transformation of tumour cells and evolution of
from (40-76) in whom Treg detection was performed
microenvironment are contributed to disease
before and after the intervention.
progression (5).

The immune cells, in particular, regulatory T cells
Ethical approval:
(Tregs), a subgroup of CD4+ T-helper cells, constitute
An approval of the study was obtained from
a critical component in modulating local immune
Zagazig University academic and ethical committee.
microenvironment and facilitates the evasion of tumor
Every patient signed an informed written consent
cell clearance by CD8+ cytotoxic lymphocytes (CTLs)
for acceptance of the operation. This work has been
(6, 7, 8).
carried out in accordance with The Code of Ethics of
The transcription factor, forkhead box P3 (Foxp3),
the World Medical Association (Declaration of
provides a biomarker for Tregs' detection, in addition to
Helsinki) for studies involving humans.
GITR+; LAG3+ and CD127low. Tregs mediate
Inclusion Criteria: Age > 18 years, and hepatocellular
immunosuppression by secreting TGF-1 and IL-10.
carcinoma patients.
The number of FOXp3+Tregs is markedly increased in
Exclusion
Criteria:
Patient's
refusal,
other
both peripheral blood and tumor of HCC patients, which
malignancy, chemotherapy, and liver tumors other than
is linked to uncontrolled tumor growth and progression
HCC.
(9, 10).

The aim of the present study was to investigate the
All patients included in this study were subjected to
role of CD4+, CD25+, FOXp3+Regulatory T-cells in
the following:
patients with HCC and their correlation with the
A- Routine laboratory investigations: after complete
prognosis.
history taking, full clinical examination and

abdominal ultrasonography, the following were
SUBJECT AND METHODS
done:
This cohort study was carried out at Clinical
1- Measurement of T. bilirubin, D. bilirubin, total
Pathology Department and Advanced Hepato-
protein, S. albumin, ALT, AST, GGT and alkaline
Pancreatico-Biliary Centre in Zagazig University



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3228
Received: 2 /6 /2021

Accepted:28 /7 /2021

Full Paper (vol.851 paper# 95)


c:\work\Jor\vol851_96 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3236-3243

Value of Glypican-3 as a Diagnostic and Prognostic Biomarker for
Hepatocellular Carcinoma before and after Treatment. A Prospective Study
Amira Isaac*, Hanan Mahmoud Mohamed Badawy, Inas Elkhedr Mohamed, Al Saeed Ezzat Ibrahim
Department of Internal Medicine, Gastroenterology and Hepatology Unit,
Faculty of Medicine, Ain Shams University, Egypt.
*Corresponding Author: Amira Isaac Samaan, Phone No.: (+2) 01222216927, E-mail: dr.amira@med.asu.edu.eg

ABSTRACT
Background:
Hepatocellular carcinoma is a highly prevalent tumor globally and the world's second leading cause of cancer-
related deaths. Glypican-3, a heparan sulfate proteoglycan expressed on the surface of HCC cells, has emerged as a new
molecule with a strong link to occurrence and progression of HCC. Objective: This study was done to determine the role
of Glypican-3 in diagnosis of HCC and its prognostic value following different treatment modalities. Patients and methods:
The study included thirty patients with liver cirrhosis and HCC on top, and thirty patients with liver cirrhosis without HCC.
Standard laboratory investigations, abdominal ultrasound and triphasic computed tomography were done for all patients.
Serum alpha fetoprotein and Glypican-3 were measured in all patients before and one month after different treatment
modalities. Results: Glypican-3 was significantly higher in HCC group (2.28 ± 0.97) in comparison to cirrhosis group (0.56
± 0.31) with P-value <0.001. Glypican-3 level was higher in larger sized lesions with p value 0.023, one month after
treatment with different modalities, Glypican-3 declined significantly (from 2.28 ± 0.97 to 1.44 ± 0.93) with p value <0.001.
At a cutoff point of > 1.1 ng/ml Glypican-3 has 93.3% sensitivity, 96.67% specificity, 96.6% PPV and 93.5% NPV for
detection of HCC. Conclusion: Glypican-3 can be a valuable diagnostic marker for HCC diagnosis and prognosis after
various treatment modalities and may be complementary to alpha fetoprotein increasing overall sensitivity of HCC
detection.
Keywords: Glypican-3, Hepatocellular carcinoma.

INTRODUCTION
following liver transplantation have demonstrated its
The most frequent type of liver cancer is
sensitivity and specificity (6).
hepatocellular carcinoma (HCC). In the United States, the

incidence of HCC has increased by 80% in the last two
The Aim of this work was to determine the role of
decades. This was also seen in several developed
Glypican 3 in HCC diagnosis and its prognostic value
countries (1). In Egypt, the burden of HCC is growing,
following different treatment modalities.

with the incidence rate doubling in the last ten years. The
PATIENTS AND METHODS
high frequency of hepatitis C virus (HCV) in Egypt is
This study was conducted on 60 patients including
implicated for the high incidence of HCC (2).
30 patients with liver cirrhosis and HCC on top, HCC was
Although Egyptian HCC patients are diagnosed
diagnosed based on development of characteristic
according to international guidelines, there are few
vascular enhancement in triphasic abdominal CT scan
Egyptian reports on HCC relapse and survival. In
according to 2011 AASLD guidelines (7), and 30 patients
comparison to other countries, both basic and clinical
with liver cirrhosis with no evidence of HCC based on
HCC research is still scarce in Egypt (3). Alpha-fetoprotein
absence of any hepatic focal lesions by triphasic CT. The
(AFP) is the commonest marker for detection of HCC,
patients were recruited from hepatology outpatient clinics
with false negative rate of 40% when used alone for early-
of Ain Shams University Hospitals and Ahmed Maher
stage HCC. Its value may still be normal in 15% to 30%
teaching hospital, during the period From February 2019
of patients, even those with late-stage HCC (4).
to December 2020.
Glypican-3 (GPC3) is a glycosyl-phosphatidyl

inositol anchored cell surface heparan sulphate
All patients underwent:
proteoglycan that belongs to the glypican family. Because
Detailed history taking, thorough clinical
GPC3 is not seen in healthy liver tissue and increases
examination, laboratory investigation including complete
significantly in patients with HCC, it has been discovered
blood count, full hepatic profile, serum creatinine,
as a useful tumor marker for HCC detection (5). Several
assessment of Barcelona clinic liver cancer (BCLC)
studies on the utility of serum GPC3 as a marker for the
staging.
initial diagnosis of HCC and detection of recurrence
Determination of serum AFP level was assayed
using human AFP EIA kit lot, Sweden, and serum GPC3
levels was measured using ELISA kit (INTRON)



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3236
Received: 1/6 /2021

Accepted: 27/7 /2021

Full Paper (vol.851 paper# 96)


c:\work\Jor\vol851_97 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3244-3246

Quadriceps Muscle Strain among Athletes: Case report
Ahmad Atiq Alharbi*, Dareen Ibrahim Rednah
Department Orthopedic Surgery, My Clinic Mohammadiya Hospital, Jeddah, Saudi Arabia
*Corresponding author: Ahmad Atiq Alharbi, Mobile: +966555071126, E-Mail: Alrehaily.ahmad@gmail.com

Abstract
Background:
In this case report we present a case of both vastus lateralis and intermedialis sprain in basketball athlete
young male who presented to the clinic with loss of knee motion, anterior knee pain and tense anterior thigh.
Case report: We present a young male in his early twenties, who was engaged in recreational sports activities regularly
and practice basketball as professional player. He sustained a direct blow to his right thigh by direct trauma while
playing basketball, and then suddenly experienced severe pain with minor tingling sensation. No other injuries were
noted at the time. Later, he developed anterior knee pain and significant loss of knee motion and by the end of the
day his anterior thigh became tense with very severe pain.
Conclusion: The quadriceps injury among athletes is common as combined injury of the two heads of quadriceps and
very rare as an isolated one head of quadriceps and the best treatment of such injury is to prevent it.
Keywords: Quadriceps muscle strain, Lateralis muscle, Athletes.
INTRODUCTION

The vastus lateralis muscle is located on the
The range of motion of the knee was around 0-80
lateral side of the thigh. This muscle is the largest of the
degrees. Knee motion with hip extended was
quadriceps which includes: rectus femoris, vastus
significantly compromised but with flexion of the hip
intermedius, and vastus medialis. Together, the
motion of the knee was improved mildly. Hip and ankle
quadriceps acts on the knee and hip to promote
motion were normal, distal pulses were palpable with
movement as well as strength and stability. They
good capillary refill and no neurological deficits were
provide power for and absorb the impact of daily
noted.
activities such as walking, running, and jumping (1).
His injured leg was mild colder than the other leg,

which increased the suspicion of hematoma anterior
CASE REPORT
thigh that compromised one of the blood supplies to
We present a young male in his early twenties,
lower extremity. Urgent Arterial and venous Doppler
who engages in recreational sports activities regularly
study were done that showed good flow with no
and practice basketball as professional player
significant stenosis, however thick heterogeneous
attending at My Clinic, Mohammadiya Hospital. He
anterior thigh muscles were seen.
sustained a direct blow to his right thigh by direct
Plain radiographs showed degenerative changes
trauma while playing basketball, and then suddenly
of both hips joints, no other osseous or soft tissue
experienced severe pain with minor tingling sensation.
findings were noted; an MRI was the next step. The
No other injuries were noted at the time. Later, he
MRI report stated that the Vastus Lateralis and
developed anterior knee pain and significant loss of
Intermedialis muscles were severely strained with
knee motion. By the end of the day his anterior thigh
evident intramuscular hematoma.
became tense with very severe pain.
Our initial step in managing the patient condition
Upon examining the patient in the office, he was
included close monitoring of the patient for
mildly distressed because of the pain, his vitals were
compartment syndrome with elevation, ice and pain
unremarkable. Locally there was a moderate swelling
medication improved the swelling and the motion. We
over the anterior aspect of the thigh with some
started for aggressive quad muscle strengthening and
redness, tender on palpitation with a noticeable
hamstring strengthening protocol. After 14 session of
depression over distal portion of his thigh, which gave
physiotherapy, the motion of the patient returned to
us false impression of quadriceps tendon partial
normal base and the strength of the muscle was much
rupture found lateral to be 2nd to hematoma collection
improved.
proximally.
This article is an open access article distributed under the terms and conditions of the Creative

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/4.0/
)

3244
Received: 2 /6 /2021



Accepted: 28 /7 /2021

Full Paper (vol.851 paper# 97)


c:\work\Jor\vol851_98 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3247-3250
The Regulatory Role of CD26 And Its Expression in
Chronic Lymphocytic Leukemia and B-Cell Non-Hodgkin Lymphoma
Dalia Ibrahim 1 and Abeer Farouk 2
1Department of Physiology Suez Canal University, 2Clinical Pathology, Ain Shams University
Corresponding author: Dalia Ibrahim, Mobile: (+20) 01003580845

ABSTRACT

Background: Chronic lymphocytic leukemia (CLL) is a monoclonal disorder characterized by uncontrolled
proliferation of mature B lymphocytes. CD26 is a multi-functional type II cell surface glycoprotein, which is expressed
mainly by T lymphocyte and it has a regulatory role in progression and also in migration and metastasis of tumour.
Objective: The aim of the work was to assess the regulatory role and expression of CD26 in patients with B-CLL and
B-cell non-Hodgkin lymphoma (B-NHL) and the relation to disease staging and progression.
Methods: This study was conducted on 6 patients with B-CLL and 5 patients with NHL who were attending at National
Cancer Institute. We detected functional role and specificity of CD26 by flow cytometry during the period from
December 2019 to March 2020. The ages of patients ranged from 42 to 79 years old. Besides, 5 healthy individuals
worked as control group. Results: A significant difference was found as regards expression of CD26 in CLL cases in
comparison to control cases (p.0001). Also there was a significant difference between the NHL group and control group
in expression of CD26 (p.0001). But no significant difference was detected between the NHL groups and CLL groups
in expression of CD26 (p.052). Conclusion: This study confirmed that CD26 expression in CLL and NHL is variable
and didn't correlate with other prognostic factors. In addition, there was no significant difference between the NHL
groups and CLL groups in expression of CD26.
Keywords: CD26, Chronic lymphocytic leukemia, B-cell non-Hodgkin lymphoma.


INTRODUCTION

Chronic lymphocytic leukemia (CLL) is a
METHODS
monoclonal disorder characterized by uncontrolled
This study was done on 6 patients with B-CLL and
proliferation of mature B lymphocytes with a distinct
5 patients with NHL who were attending at National
morphological and immunological pattern (1). CLL is
Cancer Institute. We detect functional role and
due to the accumulation of monoclonal B-cells, this
specificity of CD26 by flowcytometry, during the period
accumulation is due inhibition of apoptosis rather than
from December 2019 to March 2020. Their ages ranged
cell proliferation (2).
from 42 to 79 years old. 5 healthy individuals worked as
CD26 is a type II cell surface glycoprotein, which
control group.
is expressed by T lymphocytes and natural killer cells. It

has a regulatory role in progression of neoplasm as a
Ethical approval:
result of its ability to bind extracellular matrix proteins
The study was approved by the Ethics Board of Al-
(3). B-CLL undergoes a slowly progressive clinical
Azhar University and an informed written consent
course and others enter advanced phase (4). We must
was taken from each participant in the study. This
identify molecular parameters to detect high risk patients
work has been carried out in accordance with the
(5). A large number of factors help predict the outcome of
Code of Ethics of the World Medical Association
the patients with B-CLL. These include clinical stage,
(Declaration of Helsinki) for studies involving
cell morphology, and cytogenic abnormalities (6).
humans.


Typical feature of CLL (called Gumprecht
All patients and controls were subjected to the following
phenomenon) is presence of basket cells on the smears,
except for (4) was done for patients only:
reflecting fragility and distortion during preparation of
1. Full history and clinical examination for the
the smear on the glass slide (7).
presence of lymphadenopathy, splenomegaly or

hepatomegaly.
Atypical CLL is about 15% (8). Active disease is defined
2. Abdominoplevic ultrasound for lymphadenopathy
by The National Cancer Institute Working Group (NCI-
and /or organomeglay
WG). The guide lines include: - progressive marrow
3. Laboratory investigations including:
failure, splenomegaly, progressive lymphadenopathy
o Complete blood count (CBC)
(>10 cm in longest diameter), lymphocytosis with an
o Leishman-stained peripheral blood (PB)
increase of > 50% over a 2-month period, and anemia
smears.
and/or thrombocytopenia (10).
4. Leishman stained bone marrow (BM) aspiration
- Additionally, one of the following must be present:
smears were examined for lymphocyte percentage
weight loss of 10% within the previous 6 months,
and morphology (12).
fatigue, fevers of > 38.0 oC for 2 weeks (11).
5. Detection of CD26 by flow cytometry.

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


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3247
Received: 3 /6 /2021

Accepted:29/7 /2021

Full Paper (vol.851 paper# 98)


Computerized tomographic study of the normal dimensions of the anterior horn of lateral ventricle in adults The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3251-3255

Epidemiological and Clinico-Pathological Characteristics of Bladder Cancer at
Clinical Oncology Department, Zagazig University: Retrospective Analysis
Osama Abdel Fattah*1,Yousra Dorgham1, Mohammed Abdelgawad1, Ibrahim Nasr2
Departments of 1Clinical Oncology and 2Nuclear Medicine,
Faculty of Medicine, Zagazig University, Sharkia, Egypt.
*Correspondence to: Osama Abdel Fattah ElSayed Attiya, Mobile: (+20)1004600539, E-mail: osama866@hotmail.com


ABSTRACT
Background:
Bladder cancer is the ninth most common cancer worldwide, with an estimated 430 000 new cases
in 2012. Transitional Cell Carcinoma (TCC) represents 90% to 95% of malignant bladder tumors.
Objective:
This retrospective observational study was done to analyze age, gender, histological characteristics in
patients with bladder cancer.
Patients and Methods:
The whole number of UBC cases diagnosed, treated at the Clinical Oncology
Department, Zagazig University Hospital, Sharkia, Egypt from 2013 to 2018 was found in 328 cases; 270 males
(82.3%) and 58 females (17.7%). Major clinic-pathological parameters were systematically collected from records
and investigated in this study.
Results:
In the present study, the age of the patients ranged between 26 to 92 years, more than half of cases
(69.2%) were >60 years. 73.2% of cases live in Rural areas and only 26.8% were Urban. In our study, 86.6%
don't have Bilharziasis and only presented at 13.4%. More than half of them were smokers (63.7%). Our study
showed that 78.3% of cases were of the urothelial type of carcinoma. Our study showed that 60% of tumors were
less than 3cm, 34.8% were from 3-5cm, 5.2% were more than 5 cm. As regard the tumor grade, 52.7 were of
grade III, 27.7% were of grade II, 19.5% were grade I, 98.2% had no CIS, 95.1% had no LVI, 84.5% had lamina
propria invasion, 66.4% had muscle invasion, 80.75 had no extravesical extension.
Conclusion:
Bladder cancer occurs most commonly in the elderly with male predominance. Hematuria was the
most common complaint of patients with bladder cancer.
Keywords: Epidemiological, Clinico-Pathological Characteristics, Bladder Cancer.

INTRODUCTION
immortality, inducing angiogenesis, and activating
Bladder cancer is the ninth most common cancer
invasion and metastasis. Cancers arising in the
throughout the world and is considerably more
urothelial tract display a wide spectrum of variant
common in developed than developing countries.
morphologies. Tumors composed of purely variant
Bladder cancer is the fourth most common cancer in
histologies tend to have worse survival. The neoplastic
men and the fifth most commonly diagnosed cancer in
changes in the urothelium of the bladder are a
the United States. In 2006, approximately 44,690 men
multistep phenomenon involving the activation of
and 16,730 women will be newly diagnosed with
oncogenes, and inactivation or loss of tumor
bladder cancer in the United States(1).
suppressor genes(3).

This retrospective observational study was done
In Egypt, it is the most prevalent cancer in men
to analyze age, gender, histological characteristics in
(16%) and the second most common cancer in women
patients with bladder cancer.
(12%), producing more than7900 deaths annually,

which is strikingly higher than most other parts of the
PATIENTS AND METHODS
world(2).
This was a retrospective study on urinary
BC is pathologically classified into two groups:
bladder cancer patients treated at Clinical Oncology
non-muscle-invasive BC (NMIBC) and muscle-
Department, Zagazig University Hospital between
invasive BC (MIBC). Approximately 50% to 80% of
2013 to 2018. Medical records of 328 patients, who
bladder cancer patients are characterized with NMIBC
were referred to our Clinical Oncology Department
which can be treated by removing the tumor by
after proved diagnosis with Urinary Bladder cancer,
transurethral approaches. Unfortunately, NMIBC may
underwent TURBT, laboratory, and radiological
recur, and approximately 25% of cases progress to
examination after complaints of hematuria or dysuria.
MIBC which is the main cause of death(3).

Cancer acquires a set of functional biological
Data collection:
capabilities during its multistep development including
Via histopathological reports, staging and metastatic
sustaining proliferative signaling, evading growth
workup including TURBT, CT abdomen and pelvis,
suppressors, resisting cell death, enabling replicative
pelvi-abdominal U/S, and isotope bone scan.





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3251
Received:4/6 /20
21

Accepted:30/7 /2021

Full Paper (vol.851 paper# 99)


Measurement of Serum Lipid Level in Children with Congenital Heart Diseases The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3256-3259

Diagnostic Value of Procalcitonin in Well-appearing Febrile Children
Hesham Samy Abdelhamid1, Ahmed Mohamed Gaballah*2,
Ahmed Mohamed Ali Elghannam1, Heba Gamal Anany1
Department of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine ­ Zagazig University, Egypt
*Correspondence to: Ahmed Mohamed Ali Elghannam, Mobile: (+20) 01207954328, E-mail: elGhannam4444@gmail.com

ABSTRACT
Background:
Occult bacteremia (OB) means bacteremia without an obvious focus of infection. About 30 % of febrile
children, three months to three years old have occult bacteremia, many children with occult bacteremia may appear
relatively well. If occult bacteremia is neglected and not treated, it may be localized resulting in meningitis, pneumonia,
cellulitis or septic arthritis. Objective: This study aimed to evaluate the estimation of serum procalcitonin (PCT) in
determination of genuine bacterial contamination specifically intrusive bacterial disease in well-seeming febrile cases.
Subjects and methods: This cross-sectional study, which was conducted at Pediatrics Department of Zagazig
University Hospitals from April 2016 to October 2016. This study was conducted on 37 cases with fever without source
(FWS). All patients were subjected to detailed history taking, general examination and laboratory investigations
included serum procalcitonin (PCT), complete blood picture (CBC), C-reactive protein (CRP) and blood culture.
Results:
There was significant increase in WBCs among positive culture group than negative culture group. There was
statistically significant increase in procalcitonin (PCT) among positive culture group than negative culture group. There
were statistically significant positive correlation between PCT & CRP and PCT & TLC.
Conclusion: PCT shows the highest sensitivity and specificity for detection of cases compared to other parameters of
infection.
Keywords:
Occult bacteremia (OB), Procalcitonin (PCT), fever without source (FWS).

INTRODUCTION


Occult bacteremia (OB) means bacteremia without
bacterial contamination specifically intrusive bacterial
an obvious focus of infection. About 30 % of febrile
disease in well-seeming febrile cases.
children, three months to three years old have occult

bacteremia, many children with occult bacteremia may
PATIENTS AND METHODS
appear relatively well. If occult bacteremia is neglected
This cross-sectional study carried out from April
and not treated, it may be localized resulting in
2016 to October 2018 in Pediatrics Department,
meningitis, pneumonia, cellulitis or septic arthritis (1).
Zagazig University Hospitals. The study included 37
Procalcitonin (PCT), which is the key precursor of
children with fever without source (FWS).
calcitonin, has been reported to be a specific marker of

bacterial infection, its cellular origin and its metabolic
Ethical approval:
pathway is not known. PCT had been demonstrated to be
Written informed consent was obtained from
released into the blood 3-6 hours after endotoxin
every participant's parents and the study was
injections into humans, thus the molecule seems to be
approved by the Research Ethical Committee of
closely dependent on the cytokine response against
Faculty of Medicine, Zagazig University. The work
micro-organism (2). Procalcitonin, a propeptid of
has been carried out in accordance with The Code of
calcitonin devoid of hormonal activity, had been
Ethics of the World Medical Association
measured in various systemic inflammatory response
(Declaration of Helsinki) for studies involving
syndromes including severe infections, burns and heat
humans.
stroke. Plasma concentration of procalcitonin are very

low in healthy individuals (< 0.1ug /L) and increase up to
Sample Measure: Confidence Interval: 95%, Power:
1700 fold in respond to bacterial endotoxins. PCT had
80%. As the total number of well appearing febrile
been described recently as a marker of infection that can
children attending to Pediatric Department, Zagazig
help in the early diagnosis of bacterial neonatal infection
University Hospitals is 360 cases per six months and
and contributes to the differentiation of bacterial versus
predictive positive value of procalcitonin in prediction
viral meningitis in children (3).
of serious bacterial infections is 70 %. So, sample size
It is found that the magnitude of the increase in
calculated to be 37 cases.
procalcitonin concentration in systemic viral and

localized bacterial infections is much smaller than that
Inclusion criteria: Any youngster who had well-
after systemic infections with bacteremia. Procalcitonin
showing up with fever without core interest.
concentration decreases with antibiotic therapy (4). This
Exclusion criteria: Cases in which the physical
study aimed to evaluate the estimation of serum
examination performed on landing in the PED enabled
procalcitonin (PCT) in determination of genuine
the source of the fever to be recognized. Cases named

not well showing up on entry to the PED; cases at first

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3256
Received: 5 /6 /2021

Accepted: 1 /8 /2021

Full Paper (vol.851 paper# 100)


c:\work\Jor\vol851_101 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3260-3264

Evaluation of Flush Endovenous Laser Ablation of the Great Saphenous
Vein up to the Saphenofemoral Junction
Ayman Abdelhamed Salem, Ashraf Goda Farag, Mohammed Ahmed Effat, Najla Mohammed Ali*
Department of General Surgery, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding Author: Najla Mohammed Ali, Mobile: (+20)01223315448, Email: drnajlamohammedali@gmail.com

ABSTRACT
Background:
Varicose vein disease is one of the most common health problems faced by vascular surgeons worldwide
affecting up to 23% of the adult population. The majority of patients with primary varicose veins have great saphenous
vein (GSV) insufficiency.
Objective:
To determine the feasibility and safety of flush Endovenous laser ablation (EVLA) of the patients with Great
saphenous vein (GSV) up to the saphenofemoral junction.
Patients and Methods:
A prospective study was conducted in the Vascular Surgery Department, Faculty of Medicine,
Zagazig University from January to June 2021 including 18 cases. All patients were subjected to detailed history taking,
clinical examination, the clinical severity of venous disease was established using CEAP [Clinical, etiological,
anatomical & pathological] and VCSS, the effect of disease-specific quality of life was determined using the CIVIQ,
Laboratory Investigations and duplex ultrasonography performed for all patients.
Results
: The operative time ranged from 20 minutes to 40 minutes, with a mean of 30 minutes. Regarding hospital stay,
all patients were discharged on the same day of the intervention. Return to normal activity ranged from 7 to 9 days, with
a mean of 7.33 +/- 1.46. as regard complications; only Ecchymosis in 2 limbs (7%), Temporary numbness at the leg in
3 limbs (11%), and incomplete occlusion in one patient (4 %).
Conclusion: The use of a high wavelength (1470nm) with a modified fiber tip with tumescent solution has a crucial
role in achieving the best results and minimizing the adverse effects. This allows homogenous destruction of the vein
wall exclusively.
Keywords: Varicose vein, Endovenous laser ablation, Great saphenous vein.

INTRODUCTION
stump interacting with junctional tributaries at a regular
The varicose vein is considered one of the most
source of reflux (between 8% and 31%)(8).
common presentations at the vascular clinics; it affects
In EVLA, the most common scenario is the
both sex and different age groups, with an incidence of
propagation of incompetence from the saphenofemoral
up to 40% of the population(1).
junction (SFJ) down the anterior accessory saphenous
Traditionally, varicose veins were treated with
vein. Not only the GSV but also all SFJ tributaries were
Trendelenburg and stripping for many decades. Since
connected during HL/S, specifically to reduce
the start of the 90 in 20 century, new techniques were
recurrence. The GSV is normally ablated up to 1 to 2
introduced with subsequent refinement and advances in
cm distal to the confluence of the GSV and common
technology as endovenous laser ablation (EVLA) and
femoral vein (CFV) during EVLA, leaving a GSV
radiofrequency ablation (RFA) (2,3).
stump
to
mitigate
potential
thrombotic
Patients with varicose veins may complain of
complications(3,9).
unsightly appearance, aching, heaviness, pruritus, and
The development of such a postoperative
early fatigue of the affected leg. These symptoms
thrombus is called endovenous heat-induced
worsen with prolonged standing and sitting and are
thrombosis (EHIT) at the end of the ablated GSV and is
relieved by elevation of the leg above the level of the
indeed a well-recognized complication following
heart. Also, mild edema is often present. More severe
endovenous thermal ablation procedures(10,11).
signs include thrombophlebitis, hyperpigmentation,
Compared to first-generation front-firing fibers,
lipodermatosclerosis, ulceration, and bleeding(4).
technological advances, such as the production of
The desired consequence of varicose vein therapy
radially emitting fibers, could reduce the risk of EHIT
is relief from persistent varicose veins. However,
during flush EVLA (fEVLA)(11). This study is aimed to
current literature indicates that both high ligation and
determine the feasibility and safety of flush Endovenous
stripping (HL/S) and endovenous laser ablation
laser ablation (EVLA) of patients with Great saphenous
(EVLA) has a similar high long-term (>5 years)
vein (GSV) up to the saphenofemoral junction.
varicose vein recurrence rate(5,6).

In approximately one-third of patients, long-term
PATIENTS AND METHODS
recurrence (> 5 years) after EVLA of the great
A prospective study was conducted in the Vascular
saphenous vein (GSV) has been documented in
Surgery Department, Faculty of Medicine, Zagazig
practice(7). However, compared to HL/S, where new
University, Sharkia, Egypt from January to June 2021
visualization tends to be an inept proximal saphenous



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3260
Received: 4 /6 /2021


Accepted: 30 /7 /2021

Full Paper (vol.851 paper# 101)


c:\work\Jor\vol851_102 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3265-3267

Outcomes of Excision of Parasagittal Meningiomas
Ahmed Saro*, Momen Mohamed Elma'mon
Department of Neurosurgery, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Ahmed Saro, Mobile: +201003911767, E-mail: ahmedsaro33@yahoo.com

ABSTRACT
Background:
Meningiomas that have any relation to the superior sagittal sinus are called parasagittal meningiomas.
They have an insidious onset and grow gradually and can reach a large size without any manifestations. The surgical
management of these tumors is still controversial whether to excise the tumor completely with risks of cerebral infarction
and massive brain edema or to excise it gradually with lifting some tumor remains with the risk of tumor recurrence.
Objective:
To report our experience with the surgically managed parasagittal meningiomas with analysis of factors that
influence the patients' outcome and reporting the complications including tumor recurrence.
Patient and method: A retrospective study was applied on 27 patients (17 females and 10 males) with parasagittal
meningiomas in Sohag District between September 2015 and September 2018 with a mean age of 53.5 ± 2 years.
Preoperative and postoperative data were collected and analyzed.
Results: Out of 27 patients, in 14 of them the sinus was patent, in 9 the sinus was partially occluded, and 4 patients had
complete sinus occlusion. The sinus was ligated and excised with the tumor in 11 patients, of those eleven patients, four
had venous infarction and three had postoperative massive brain edema. The second group included 16 patients at which,
residuals of tumors were left behind with the sinus. Remote follow-up of this group show recurrence in 3 patients.
Conclusion: The outcome of radical resection is favorable whenever possible as the main limiting factor for achieving
gross total resection is sinus involvement. However complete excision is crucial to prevent recurrence and many factors
share in the success of the surgery. However, the sinus invaded meningiomas should be cautiously managed to prevent
postoperative hemodynamic complications.
Keywords: Brain edema, Magnetic resonance venography (MRV), Meningiomas, Superior sagittal sinus (sss), Total
excision.

INTRODUCTION

The management of parasagittal meningioma is
venography). MRV is important to evaluate the degree
still a highly controversial issue. The few series reported
of sinus patency and to detect the draining cortical
that there is no agreement about the best option of
veins. Microsurgical resection was done for them.
treatment. While some authors believe that sinus
All the preoperative clinical data, WHO
invasion is an absolute contraindication for the total
grading, and postoperative complications were gathered
excision (1), other authors see this invasion as a good
and analyzed. Follow-up was done for all patients for
chance for complete excision especially if the sinus
about three years (mean follow-up was 2.8 years).
obstruction is complete due to the high collateral

circulation(2). On the other hand, many authors
Ethical considerations:
considered the subtotal excision is better due to
The study protocol was approved by the
avoidance of major venous complications as venous
Local Ethical Committee of Sohag Faculty of
infarction and massive brain edema with the risk of
Medicine, under the number 3317/2009. Every
recurrence(3). The ideal management is to achieve total
patient signed an informed written consent for
tumor excision without venous complications(4).
acceptance of the operation. This work has been
The aim of the present study was to present our
carried out in accordance with The Code of Ethics of
experience with the different options of treatment of
the World Medical Association (Declaration of
parasagittal meningiomas and report different
Helsinki) for studies involving humans.
complications that occurred in our cases.


Statistical analysis
PATIENT AND METHOD
Data were analyzed using the statistical package for
Study type: A retrospective study.
the social sciences (IBM-SPSS), version 25 (IBM-
Study design: The study was done in the Neurosurgery
Corporation,
Chicago,
USA;
August
2017).
Department, Sohag Faculty of Medicine between
Quantitative data were expressed as mean and standard
September 2015 and September 2018. It included 27
deviation (SD), while qualitative data were expressed as
patients.
number and percentage.
The majority of patients were females (63%)

while males constituted 37%, with ages ranging from 41
RESULTS
to 67 years old.
The demographic and clinical manifestations
All patients were subjected to preoperative CT
are showin in table 1. Headache, contralateral
brain, MRI brain, and MRV (magnetic resonance

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3265
Received: 1 /6 /2021

Accepted:27 /7 /2021

Full Paper (vol.851 paper# 102)


Apelin and tumour necrosis Factor alpha in obese frail elderly The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3268-3273

Remodifying Omentopexy Technique Used With Laparoscopic Sleeve
Gastrectomy: Does It Change Any Outcome?
Abdelrhman Mohammad Amin Sarhan, Gamal Mohammad Osman Hassan,
Tamer Mohamed Mahmoud Elshahidy, Aghnayah Mohammed Abrahem Aghnayah*
Department of General Surgery, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Aghnayah Mohammed Abrahem Aghnayah, Mobile: (+20)01065359115,
Email: aghnaya1985@gmail.com

ABSTRACT
Background:
Gastric obstructions (LSG) leaks and staple line bleeding are reported after laparoscopic sleeve
gastrectomy. There is no ideal method or technique to avoid these mishaps. modified omentopexy (OP) added to LSG
to determine if there is any effect on gastric leaks and other complications. The aim of this study was the assessment
of safety & feasibility of the omentopexy technique in Laparoscopic sleeve gastrectomy.
Objective:
This study aimed to assess the safety & feasibility of the omentopexy technique in Laparoscopic sleeve
gastrectomy.
Patients and Methods: This prospective randomized controlled clinical trial study was conducted in the Zagazig
University hospital including 32 patients with morbid obesity who were admitted to the General Surgery Department,
for intervention surgery with laparoscopic sleeve gastrectomy during the period from July 2020 to July 2021. Patients
underwent a standardized preoperative assessment, including a complete history, physical examination, and
psychological evaluation.
Results: There was a highly statistically significant decrease in mean weight and BMI at six months postoperative
compared to pre-operative Laparoscopic sleeve gastrectomy with and without omental fixation group.
Conclusion:
Omentopexy may not change the outcome for a laparoscopic sleeve gastrectomy in terms of
gastrointestinal symptoms or weight loss results although it is associated with longer operative time. However, it may
serve as an extra guard against leakage, bleeding, vomiting, and gastroesophageal reflux disease, manifested by the
decreased incidence of these complications with that technique. Laparoscopic sleeve gastrectomy with omentopexy
can be a feasible procedure for decreasing morbidity and gastric leak rate.
Keywords: Bariatric surgery, Laparoscopic sleeve gastrectomy, Omentopexy.

INTRODUCTION
PATIENTS AND METHODS
LSG is the preferred and most commonly
This Prospective Randomized controlled
performed bariatric operation in the USA. The fear of
clinical trial study was conducted in Zagazig university
staple line leaks associated with LSG remains high.
hospital including 32 patients with morbid obese who
This is eluded to the fact that LSG creates an elevated
were admitted to the General Surgery Department of
intraluminal pressure secondary to partial or complete
Zagazig University Hospital, for intervention surgery
closed-loop conditions within the functional pyloric
with laparoscopic sleeve Gastrectomy during the
and lower esophageal sphincters (1).
period from July 2020 to July 2021.
Laparoscopic sleeve gastrectomy (LSG) has

been increasingly performed as a primary and sole
Ethical Considerations:
weight-loss operation for morbidly obese patients. It
Written informed consent was obtained
has grown in popularity and become the dominant
from all participants and the study was approved
bariatric procedure during recent years by maintaining
by the research ethics committee of the Faculty of
gastrointestinal continuity and being a relatively easy
Medicine, Zagazig University. The work has been
procedure (2).
carried out following the Code of Ethics of the
Routine omentopexy in Laparoscopic sleeve
World Medical Association (Declaration of
gastrectomy proved to show remarkable efficacy in
Helsinki) for studies involving humans.
reducing postoperative leakage and bleeding rates in

comparison with Laparoscopic sleeve gastrectomy
Inclusion criteria:
with no omentopexy. This decreases patient morbidity
Obese patients with body mass index >40kg/m2, or
and mortality (3).
BMI>35kg/m2,
with
associated
co-morbidity
This study aimed to assess the safety and
(hypertension, diabetes mellitus, and hyperlipidemia),
feasibility of the omentopexy technique in
failure of medical and conservative modality, and fit
Laparoscopic sleeve gastrectomy.
for surgery.





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3268

Received: 15/8/2021


Accepted: 15/9/2021

Full Paper (vol.851 paper# 103)


c:\work\Jor\vol851_104 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3274-3278

Transcutaneous Electric Diaphragmatic Stimulation versus Pilates Method on
Lung Functions Post Bariatric Surgery
Mohamed Maher El Keblawy1, Asem F. Moustafa2, Nessrien A. Abd Elrashid1, Alaa A.F.A Elnadar*1
1Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
2Department of Surgery Menoufia University, Faculty of Medicine, Menoufia, Egypt
*Corresponding author: Alaa Ali Fathi Ali Elnadar, Mobile: (+20) 01060089494, E-Mail: dralaaali3@gmail.com

ABSTRACT
Background: Bariatric surgeries could alter pulmonary function because of usage of anesthesia as well actual surgical
maneuver leading to reduction of residual functional capacity (RFC), precocious closure of small airways and more
probability for hypoxemia as well as higher tendency for atelectasis.
Purpose: To evaluate transcutaneous electric diaphragmatic stimulation versus pilates method on lung functions post
bariatric surgery.
Subject and Methods: Thirty patients aged 25-40 years old with body mass index (BMI) ranging from 35- 60 kg/m2
underwent sleeve gastrectomy were selected from Outclinics at Menouf General Hospital. They were randomly allocated
into two equal groups: Group (A) included 15 participants that received conventional chest physiotherapy plus
transcutaneous electric diaphragmatic stimulation as well as medical treatment. While, group (B) included 15 participants
that received their conventional chest physiotherapy program, pilates method and medical treatment. Response of lung
volumes pre- and post-treatment was recorded.
Results: There was a significant increase of VC and FVC post-treatment in group A & B compared to pre-treatment values
(p > 0.001). Furthermore, increase of VC and FVC in group A (12.08% & 12.87% respectively) also group B (45.19% &
52.19% respectively).
Conclusion: conventional chest physiotherapy in addition to pilates method promote maintenance of pulmonary function.
Therefore, it can serve as a preventive character following bariatric surgeries.
Keywords: Bariatric surgery, Electric stimulation, Physiotherapy, Pilates, Respiratory muscle strength, Spirometry.

INTRODUCTION

Obesity is considered a chronic disorder with
determining responses to different electrode placement,
complicated etiologies that require variety of treatment
equipment type, stimuli types, also its parameters, as well
options (1). Most of managing pillars were dietetic and
various pulmonary function parameters(7). Despite rare
physical activity programs plus medicines. Up to date,
clinical trials had examined, electrical stimulation based
standard obesity management reported inadequate
on expert unanimity lack, plus technical usage problems.
outcomes clinically, which present actual need for new
However, diaphragmatic electrical stimulation might be
approaches such as bariatric surgery (2). Unless, anesthetic
quick and safe especially in healthy individuals to increase
usage throughout bariatric surgeries could affect
diaphragmatic strength (8). The aim of the study was to
pulmonary function, leading to reduction of residual
evaluate
transcutaneous
electric
diaphragmatic
functional capacity, premature closure of small airways
stimulation versus pilates method on lung functions post
and more probability for hypoxemia as well as higher
bariatric surgeries.
tendency for atelectasis (3). Therefore, obese who already

have respiratory abnormalities become worse due to
PATIENTS AND METHODS
bariatric surgeries, which alter mechanics of respiratory
Thirty participants aged 25- 40 years old of both
muscle? Such complications explained a result of intra-
genders, with a BMI of 35- 60 kg/m2 underwent
operative handling, anesthesia, in addition to pain (4). Main
gastrectomy surgery were selected randomly from
accepted explanation was the diaphragm's reflected
Outclinics at Menouf General Hospital, then allocated into
inhibition that initiated diaphragmatic paresis then
two equal groups: Group (A): Fifteen patients underwent
restricted pulmonary conduct (5).
sleeve gastrectomy surgery received traditional chest
Respiratory therapy was recommended in bariatric
physiotherapy
(diaphragmatic
respiratory,
deep
surgeries for both prophylaxis also management
inhalation, also respiratory exercises associated with
throughout recovery phase. Respiratory therapy was
shoulder flexion and extension of the upper extremities,
addressed for maintaining as well quickly reorganizing
assisted cough, circulatory exercises, and early
lung function and respiratory musculatures strength (6).
ambulation), plus transcutaneous electric diaphragmatic
Electrotherapy was advised in pulmonary clinical trials on
stimulation in addition to their medical treatment.
healthy humans. Besides, animal trials that aim for

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

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

3274
Received: 5 /6 /2021

Accepted: 1 /8 /2021

Full Paper (vol.851 paper# 104)


c:\work\Jor\vol851_105 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3279-3283

Transcutaneous Electrical Nerve Stimulation versus Laser on
Shoulder Functional Performance in Living Liver Donors
Ahmed NM Ahmed*1, Eman M Othman2, Hossam EM Soliman2, Walid AI Abouelnaga1
1Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
2 National Liver Institute, Menoufia University, Menoufia, Egypt
*Corresponding author: Ahmed NM Ahmed, Mobile: (+20) 01066428968 E-Mail: drahmednabil771@gmail.com

ABSTRACT
Background:
In living donor liver transplantation (LDLT), reported donors` mortality and morbidity were highly
correlated with surgeon skills. Therefore, liver transplantation has become a distinct maneuver. In addition, minor liver
surgeries complications include shoulder pain, pruritus, urinary retention, as well as major morbidity such as central venous
catheter-induced thrombosis of brachial and/or subclavian vein, neuropraxia, foot drop also prolonged post-dural puncture
headache.
Objective: to compare effectiveness of transcutaneous electrical nerve stimulation (TENS) versus low level laser therapy
(LLLT) on pain and functional performance of liver donors' suffering from shoulder pain.
Patients and Methods: Thirty donors of both genders with ages ranging from 20 to 40 years old were selected from the
Physical Therapy Outpatient Clinic of National Liver Institute, Menoufia University. They were randomly allocated into
two equal groups: Group A included 15 donor patients who received 30 minutes TENS, 3 times per week, plus conventional
physical therapy exercise program for 12 sessions along 4 weeks and group B that included 15 donor who received fifteen
minutes LLLT 3 times per week plus conventional physical therapy exercise program for 12 sessions along 4 weeks.
Results: A significant improvement of VAS values post-treatment in both groups, also a significant SST benefits, plus
improvement in shoulder flexion and abduction post-treatment compared to pre-values (p > 0.001) unless group A values
that were superior to those of group B.
Conclusion: It could be concluded that both TENS as well LASER were effective in shoulder functional performance in
donor` painful shoulders, but TENS was more effective.
Keywords: Living donor liver transplantation, Shoulder pain, TENS, LLLT.

INTRODUCTION

(LLLT) has been determined as effective physical
Liver has been classified as an internal organ interacts
modality for gaining analgesia also accelerates healing of
with all human` systems, so that individuals received or
numerous clinical disorders such as painful shoulders,
donated liver graft faces huge physiological changes (1).
which is explained based on biostimulation with light
Postoperative donors faces shoulder pain, foot drop also
energy enhancing homeostasis level. LLLT is used in
compartment syndrome, which might be explained due to
acute, chronic painful and inflammatory affections by
intraoperative malpositioning. That is why must ensure
very weak (1-10 mW) irradiation in special wavelength of
that proper positioning is whole surgical team obligation
904 nm (6).
including the anesthesiologist (2). Commonly, liver
The aim of the present study was to compare
donors` shoulder pain determined as an important
effectiveness of transcutaneous electrical nerve
musculoskeletal
complication
that
requires
stimulation (TENS) versus low level laser therapy
multidisciplinary management including self-advice,
(LLLT) on pain and functional performance of liver
analgesics and relative rest, as well access to
donors' suffering from shoulder pain.
physiotherapy
(3).
Donors'
painful
shoulders`

physiotherapy protocols includes various modalities
PATIENTS AND METHODS
including cryotherapy, electrotherapy and mobilizing
Thirty liver donors' participants of both genders
techniques in addition to therapeutic exercise training.
whose ages were 20- 40 years old. They were randomly
Clinically, usual electrotherapy applications were
selected from Physical Therapy Outpatient Clinic of
ultrasound therapy, transcutaneous electrical nerve
National Liver Institute, Menoufia University. Then, they
stimulation (TENS) as well as laser for painful donors`
were allocated into two equal groups. Liver donors`
shoulders (4). In addition, TENS is non-invasive, analgesic
participants that were suffering from unilateral painful
technique that is claimed to have an effect. Worldwide
shoulder, had assigned their informed consent, if free of
TENS usage for various musculoskeletal painful
study exclusion criteria, which included cardiac and
disorders throughout health care is considered a common
pulmonary disorders, diabetes mellitus or other
managing modality (5). Besides, low level laser therapy



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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
3279
Received: 5 /6 /2021

Accepted: 1 /8 /2021

Full Paper (vol.851 paper# 105)


c:\work\Jor\vol851_106 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3284-3290

Diffusion Tensor Imaging (DTI) and Fractional Anisotropy (FA) for
Arcuate Fasciculus in Predicting Post-Stroke Aphasia Outcome
Hwaida Mahmoud Mokhtar *, Heba Mohamed Sawahel
Radiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
*Corresponding Author: Hwaida Mahmoud Mokhtar, Telephone: +201066823901, Email: hwaidamahmoudhm18@gmail.com

ABSTRACT
Background:
In certain regions of the brain, aphasia arises from a lack of understanding and regulating language
following damage. About 35­40 percent of the people receiving hospitalization after stroke are identified with aphasia.
The recently developed imaging methods for the analysis of the impact of brain lesion sites and sizes on aphasia are the
Diffusion Tensor Imaging (DTI) and Fractional Anisotropy (FA). In order to reflect micro-structural integrity DTI may
give data on the damage level of the white matter of the brain and subcortical neural structure.
Objective: We examined the relationship between arcuate fasciculus (AF) and the prognosis of aphasia outcome after
ischemic stroke utilizing DTI, and FA.
Patients and Methods: In this study, which included 34 patients with post stroke aphasia, we investigated DTI and FA
of arcuate fasciculus in predicting post-stroke aphasia outcome.
Results: There was no significant association between the sex and Aphasia Handicap Scale (AHS) (P>0.05), while the
age was significantly correlate with AHS (P<0.05). The vascular risk factors (hypertension, diabetes mellitus, smoking,
dyslipidemia) were associated with poor aphasia outcome. In our study, we found that lesion size had significant effect
on aphasia outcome. Also, the site of ischemic infarction site was important factor in determining aphasia outcome. In
the Broca and Wernicke regions, AHS was greater than in the cortical injury, and in the insula and cortical injuries (1.92
± 1.26) were the least common in patients.
Conclusion: The site and the size of ischemic infarction significantly predicted s aphasia outcome, also the extent and
mechanism of AF injury, which can be detected in DTI and FA, stood as a significant indicator on aphasia severity for
patients with ischemic stroke.
Keywords: AF, AHS, Aphasia, DTI, FA, Stroke.

INTRODUCTION
(4). The AF is one of the most significant bundles of
The most frequent debilitating effects of stroke
subcortical neurons involved in language function; it
were aphasia. At the beginning of the stroke, it is
also connects the Broca and Wernicke regions of the
impossible to anticipate which patient exhibit significant
brain. Many investigations have been conducted to
language recovery and who have limited recovery or
compare the clinical characteristics of aphasia with AF
perhaps lifelong impairment (1). In adults, aphasia which
damage (5).
occurs as a result of stroke, represents 20% to 40% of
DTI studies have shown variations in the
symptoms in patients with acute stroke symptoms.
asymmetry of fibre counts in AF of patients suffering
Injury-relative variables such as the location, the lesion
ischemic stroke with and without aphasia. Patients who
size and aphasia type may affect aphasia. Recovery may
did not exhibit a left AF in DT tractography six months
be affected by various variables such as age, sex,
after their strokes suffered severer aphasia more than
manhood and environment (2).
other patients (6). The aim of this study was to examine
Many studies have shown a significant link
the relationship between AF and the prognosis of aphasia
between the location of a lesion in the arcuate fasciculus
outcome after ischemic stroke utilizing DTI, and FA.
(AF), the integrity of right hemisphere white matter

pathways, and the result of identifying and speech
PATIENTS AND METHODS
fluency in post stroke aphasia (3). Newly developed
This was a cohort prospective study included 34
methods such as diffusion tensor imaging (DTI), voxel-
patients during a 12-month period.
based lesion symptom mapping, and functional magnetic
Inclusion criteria: Patients presented with acute
resonance imaging (MRI) have been utilized to
ischemic stroke (diagnosed by brain MRI or computed
investigate the impact of brain lesion sites and sizes on
tomography (CT), aged less than 80 years. Their native
aphasia. DTI may offer useful information about the
language was Arabic.
extent of injury and white matter structure by using water
The exclusion criteria consisted of patients with
molecules diffusion inside the tissue to create pictures.
lesion did not affect AF like brainstem or cerebellar
By analyzing DT pictures, you may get several values
lesion, patients with traumatic brain lesions, a previous
like fractional anisotropy (FA), axial diffusivity, radial
history of other neurological, psychiatric, or speech
diffusivity, and mean diffusivity. It is now feasible to see
disorders which affected the language task.
white matter bundles via analytical tools. Because it
All included patients were subjected to the following,
represents microstructural integrity, FA is now one of the
history taking including the personal history and
best indicators for assessing subcortical brain structures

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3284
Received: 3 /6 /2021

Accepted: 1 /8 /2021

Full Paper (vol.851 paper# 106)


The Role of Interleukin 4 and Interleukin 6 in the Pathogenesis and Prognosis of Childhood Primary Immune Thrombocytopenia The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3291-3296
Prevalence, Prognosis, and Outcome in Egyptian Children with Primary
Immune Thrombocytopenia: A Single-Center Experience
Mohamed Refaat Beshir, Marwa Zakaria Mohamed,
Asmaa Mohamed Hosny Esh, Ridha Mohammed Tayib*
Pediatrics Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt
* Corresponding author: Ridha Mohammed Tayib, Mobile : (+20)01065359115, E-mail: priority1953@gmail.com

ABSTRACT
Background:
Idiopathic (immune) thrombocytopenic purpura (ITP) is a heterogeneous clinical disorder characterized
by immune-mediated platelet destruction. ITP is usually a benign, self-limiting disease in children.
Objective: To assess prevalence, prognosis, and outcome of Egyptian children with primary immune
thrombocytopenia.
Patients and Methods: This cross-sectional study was carried on 80 children (1-13 years) with primary ITP who
presented to the Pediatric Hematology Unit and outpatient clinic of Zagazig University Hospitals, during the period
from April 2020 to June 2021. Patients were divided into two groups; Group (1): included 20 healthy matched
subjects (control), Group (2): included 60 patients with primary ITP. The group was subdivided into 3 subgroups,
Subgroup (2A) included 20 patients with newly diagnosed ITP, Subgroup (2B) included 20 patients with persistent
ITP, and Subgroup (2C) included 20 patients with chronic ITP.
Results: There were significant differences between the studied groups in age, sex, and weight. There was a
statistically significant association between prognosis and general characteristics of the studied ITP patients.
Conclusion: primary ITP in children is a nonthreatening and self-limited disease, usually lasting less than one year,
and chronic form has different prognostic parameters. The use of these parameters can early distinguish children who
are expected to have short and uneventful disease duration, to minimize their exposure to pharmaceutical intervention.
Keywords: Immune thrombocytopenic purpura, Cytokines, Thrombopoietin, Reticulated platelets.

INTRODUCTION

Immune thrombocytopenic purpura (ITP) is an
According
to
the
standardization
of
acquired autoimmune disorder characterized by an
terminology, definitions and outcome criteria in ITP in
isolated low platelet count in which platelets are
children is divided into newly diagnosed (duration < 3
destroyed mainly in the reticuloendothelial system.
months, 50% of the cases), persistent (3­12 months,
The disorder is defined as primary ITP in the absence
25% of the cases), and chronic (>12 months, 25% of
of other causes or disorders that may be associated
the cases) type. The older time limit of 6 months to
with thrombocytopenia (1).
define chronicity is no longer in use (5).
The pathogenesis of ITP is relatively
Immune thrombocytopenia (ITP) in children is
complicated, the definite pathogenesis and cause
a disorder with a favorable prognosis characterized by
remain unclear up to the present. More recent evidence
increased platelet destruction and decreased platelet
suggests that multiple mechanisms contribute to
number. It may be triggered by viral infection or
thrombocytopenia in ITP patients. Increasing studies
immunization(1). Newly diagnosed ITP in children is
have found that T-cell subsets, regulatory B cells
usually a short self-limiting disorder without any late
(Bregs), dendritic cells, myeloid-derived suppressor
sequelae; in most cases, ITP lasts for several weeks or
cells (MDSCs), and natural killer (NK) cells are all
months, although in 5% to 30% of affected children,
involved in the pathogenesis of ITP(2).
the condition becomes chronic. Chronic ITP (cITP) is
The true incidence of ITP is unknown, as those
associated with a high risk of bleeding, such as
with a more mild form of the disease may never come
cerebral hemorrhage, and often requires the restriction
to medical attention. However, there are published data
of physical activities (6).
on the reported incidence and prevalence of ITP in
This study aimed to assess the prevalence,
different parts of the world without substantial
prognosis, and outcome of Egyptian children with
differences (3).
primary immune thrombocytopenia.
ITP presents as a primary form characterized

by isolated thrombocytopenia (platelet count <
PATIENTS AND METHODS
100×109/L) in the absence of other causes or disorders
This cross-sectional study was carried on 80
that may be associated with thrombocytopenia, or a
children (1- 13 years) with primary ITP who presented
secondary form in which immune thrombocytopenia
to the Pediatric Department, Zagazig University
develops in association with another disorder that is
Hospitals, during the period from April 2020 to June
usually immune or infectious (4).
2021.


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


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3291
Received: 7 /6 /2021


Accepted: 3 /8 /2021


Full Paper (vol.851 paper# 107)


c:\work\Jor\vol851_108 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3297-3300

Myocardial Protection Using Custodiol versus Cold Blood
Cardioplegia in Patients Undergoing Triple Valve Surgery
Mohamed Azzam*1, Alaa Omar1, Sherif M Abass2, Hesham Zayed Saleh1
Departments of 1Cardiothoracic Surgery and 2Anesthesia and ICU and Pain Management, Kasr Al Ainy
Faculty of Medicine, Cairo University, Egypt.
*Corresponding author: Mohamed Azzam, E-mail: dr.mohamed.ezzazzam@gmail.com

ABSTRACT
Background:
The use of Custodiol cardioplegia solution may be tempting in cases undergoing long open-heart surgical
procedures, given its single dose administration, which offers myocardial protection for a long period.
Objective: The aim of the current study is to report our initial experience with the use of Custodial cardioplegia in
patients undergoing triple valve surgery, and comparing it with our routinely used cold blood cardioplegia.
Patients and Methods: A retrospective observational study including 79 consecutive patients who underwent first-time
triple valve surgery in the period between April 2018 and May 2020. Patients were divided into two groups. Group (A)
included 31 patients where Custodiol cardioplegia was used, and Group (B) included 48 patients where cold blood
cardioplegia was used. The primary endpoint was in-hospital mortality. Secondary endpoints included postoperative
levels of CK-Mb, the need for inotropes and the incidence of ventricular fibrillation on aortic declamping.
Results: Apart from a higher incidence of ventricular fibrillation on aortic declamping, there was no statistically
significant difference between groups in any of the endpoints examined.
Conclusion: Custodiol cardioplegia is a safe option for myocardial protection in patients undergoing triple valve
surgery. The added cost and the concerns about its efficacy in patients with impaired ventricular function reported by
other authors should be borne in mind while considering its use.
Keywords: Cardioplegia, Custodiol, Valve surgery.

INTRODUCTION

PATIENTS AND METHODS
During open-heart surgery, the adequacy of
This retrospective observational study included a
myocardial protection achieved by cardioplegic
total of 79 consecutive patients who underwent first-
solution is one of the major determinants of operative
time triple valve surgery at the Cardiothoracic Surgery
outcomes (1). Over the past decades, various
Department of Cairo University Hospitals in the period
cardioplegic solutions have been tried to optimize
between April 2018 and May 2020.
myocardial protection during cardiac arrest, with the
During this period, a total of 86 patients underwent
aim of minimizing myocardial damage hence
triple valve surgery involving the mitral, aortic and
improving results (2-5). Among those, custom-made
tricuspid valves. Three patients were excluded due to
blood cardioplegia proved a highly effective alternative
incomplete files, two patients were excluded due to
(6), and continues to be the most commonly used
associated coronary bypass grafting during the surgery
cardioplegic solution in our practice. With a more
and two more patients were excluded on account of redo
physiological composition and the added advantage of
surgery. The remaining 79 patients were included in the
oxygen carrying capacity, blood cardioplegia has been
study and their individual files were reviewed to extract
claimed to be associated with improved outcomes (7).
clinical, operative and outcome data.
Bretschneider et al. initially described Custodiol

back in the seventies, as an intracellular crystalloid
Ethical Consideration:
cardioplegia, with a low sodium and calcium content (3).
The study was approved by the local Ethical
It is an attractive option for surgeons especially in long
Committee of Cairo University.
surgeries, as it can be administered in a single dose,
Written consent was obtained from all patients
which is claimed to offer myocardial preservation for up
prior to the procedures. This work has been carried
to three hours (8). This allows the performance of long
out in accordance with the code of Ethics of the
procedures without interruption.
World Medical Association (Declaration of Helsinki)
Studies comparing blood cardioplegia to Custodiol
for studies involving humans.
often revealed variable results, largely because of the

heterogeneity of patient populations studied and the
Study Groups:
outcome variables reported (9-11).
Depending on the type of cardioplegia solution used
The aim of the current study was to report our
intraoperatively, patients were divided into two groups.
initial experience with the use of Custodiol cardioplegia
Group (A) included 31 patients where Custodiol
in patients undergoing triple valve surgery, and
cardioplegia was used, and Group (B) included 48
comparing it to the more commonly used cold blood
patients where cold blood cardioplegia was used.
cardioplegia.



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/)
3297
Received: 3/6/2021

Accepted: 23/7/2021

Full Paper (vol.851 paper# 108)


c:\work\Jor\vol851_109 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3301-3305

Ankle Rocking Training and Functional Abilities in Children with Cerebral Palsy
Amira M. Eltohamy1, Mahmoud A. Mahran2, Mohamed I. Elassal1, Ahmed H. Kamel*1
1Department of Physical Therapy for Pediatric Disorders and its Surgery, Faculty of Physical Therapy, Cairo
University, Egypt. 2Department of Orthopedic Surgery, Pediatric Orthopedics and Limb Reconstruction Surgery Unit,
Ain Shams University, Egypt.
*Corresponding author: Ahmed H. Kamel, Mobile: (+20) 01113203945, E-Mail: ahmedhany191991@gmail.com@gmail.com

ABSTRACT
Background:
Children with a physical disability are known to be at higher risk of an inactive life style. The hip, knee,
and ankle joints have different roles depending on the phase of walking and running. They must work together to
produce and absorb forces to allow efficient movement through the stance phase. In walking there are three rockers: the
heel rocker, the ankle rocker, and the forefoot rocker.
Objective: The aim of the study was to investigate the effect of ankle rocking training on the development of gross
motor functional abilities in children with cerebral palsy.
Patients and methods: Thirty children diagnosed as spastic cerebral palsy according to gross motor classification
system, (Grade II & III GMFCs) were selected from the Outpatient Clinic, Faculty of Physical Therapy, Cairo
University. The children' ages ranged from three to six years old from both sexes. This was a cross-sectional study
where the selected cerebral palsied children were divided into two groups (control group and study group). The control
group received traditional gait training and standing program, while the study group received the same traditional gait
training and standing program in addition to gait training using ankle rocker device. Both groups received treatment
program 3 times/week for three consecutive months for one hour per session.
Results: It was revealed that there was a significance difference within each single group (the pre- and post-treatment)
and between both groups.
Conclusion: According to the current study results, there was a highly significant difference within the study group pre-
and post-treatment and between groups in favour of the study group because of ankle rocking training.
Keywords: Cerebral Palsy, Ankle Rockers, Rocking training, Hand-held Dynamometer, Foot Posture Index-6,
Functional Abilities.

INTRODUCTION
A cross-sectional study that included thirty children
Cerebral palsy (CP) is a neurological disorder
from both sexs diagnosed as spastic cerebral palsy. They
caused by abnormalities in the developing brain of
were selected from the outpatient clinic of the Faculty of
infants and children. CP leads to an impairment of
Physical Therapy, Cairo University. The study was
muscle coordination in the body and movement control
conducted through the period from September 2020 and
(1). Cerebral palsy (CP) is the most common childhood
March 2021. They were classified as GMFCs II and III.
motor disability and often results in debilitating walking
They were assigned into two groups: Study group and
abnormalities, such as flexed-knee and stiff-knee gait (2).
control group respectively, after fulfilling the inclusion
The ability to maintain and control the body center of
criteria. Functional abilities, muscle power and foot
mass within the base of support to prevent falls and
posture were assessed for both groups before and after
complete desired movements, is known as postural
performing traditional physiotherapy programs with and
stability. The control of postural stability involves a
without using rocker instrument.
system of intricately associated neuromuscular
Inclusion criteria: Patients' age ranged from 3 to 6
mechanisms of a high degree of complexity, which is
years old. The diagnosis of these children was
maintained by proprioceptive, vestibular and visual
established according to gross motor classification
feedback. Three basic coordination patterns of standing:
system (Grade II & III GMFCs).
ankle strategy, hip strategy, and stepping strategy have
Exclusion criteria: Botox injection in the last 6 months.
been described in both adults and children (3).
Surgical procedures in the last 12 months.
In walking there are three rockers: the heel rocker,
Musculoskeletal contractures. Visual or other sensory-
the ankle rocker, and the forefoot rocker. While foot
input impairments.
position at initial contact in running has been extensively

studied, little research has framed foot and ankle motion
Ethical approval:
in running in context of the foot rockers even though at
The whole procedure was explained for every parent.
slow running speeds, 80 to 90% of runners' heel strike
Each parent signed informed consent before
and exhibit all three rockers (4).
beginning of the study to insure complete
The aim of the study was to investigate the effect of
satisfaction. The Ethical Committee of Faculty of
ankle rocking training on the development of gross
Physical Therapy, Cairo University approved this
motor functional abilities in children with cerebral palsy.
study. This work has been carried out in accordance
PATIENTS AND METHODS
with The Code of Ethics of the World Medical

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

3301
Received:4/6 /2021

Accepted:5/8 /2021

Full Paper (vol.851 paper# 109)


c:\work\Jor\vol851_110 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3306-3312

Effect of Coronavirus Disease 2019 Pandemic on Mental Health among
Health Care Workers and Others
Mona Ahmed Elawady, Marwa Salah El-Dien Abd-Elraouf*
Public Health Department, Faculty of Medicine, Benha University, Qalyubia, Egypt.
*Corresponding author: Marwa Salah El-Dien Abd-Elraouf, Mobile: (+20) 01065063533, E-mail: marwad24@yahoo.com

ABSTRACT
Background
: A pandemic of Coronavirus 2019 (COVID-19)may endanger the mental well-being of health care
workers.
Objective: This is to stipulate some mental issues faced by health care workers at the time of COV-SARS.
Patients and Method: A cross-sectional study was conducted upon 5745 participants from the Qalyubiya Governorate
(7 centers). Online self-administered questionnaire (Fear of Coronavirus-19 Scale (7 Qs scale) and The Hospital Anxiety
and Depression Scale (HADS) (14 items of two subscales: anxiety and depression)) was utilized. Propensity score
matching was performed to minimize bias between health care workers (1740) and non-healthcare workers.
Results
: After performing propensity score matching, 1740 participants were included for comparison between health
care workers and non-healthcare workers. Health care workers expressed more fear, anxiety, and depression scores.
Increasing hours of watching media is a predictor of fear, anxiety, and depression among health care workers ((95%CI:
0.555-1.4, p<.001), (0.77-1.22, p<.001) and (0.45-0.85, p<.001) respectively) and ((1.44-2.2, p<.001), (0.94-1.49,
p<.001) respectively) among non-healthcare workers.
Conclusions:
HCW showed mental disorders scores more than non-healthcare workers. Among health care workers,
females, the age group from 26 to 30 years, and more than 4h of watching media about COVID-19 had significantly
higher mental scores. Non-married health care workers showed a higher fear score. Among non-healthcare workers,
married and low educated levels expressed lower scores.
Keywords: COVID-19, Mental health-Propensity score matching, Pandemic.

INTRODUCTION
specific features like its mode of transmission, rapidity of
In late 2019 COVID-19 was at first rumored by
spread, and lack of definitive treatment protocols or
China and had unfolded to thirteen countries by January
vaccines all are responsible for the mental state issues (8).
24, 2020 (1). Its impacts haven't nonetheless been
Although extensive restrictions, like the prohibition
determined, as the observations and testing results are
of national and international travel that reflects a
square measure dynamical quickly. Among the rife
replacement variety of quarantine area units effective in
symptoms of this sickness, cough, fever, shortness of
controlling and managing the disease, they need negative
breath, and sometimes diarrhea. Older men with medical
psychological impacts on individuals. Anxiety
co-morbidities square measure a lot of doubtless to urge
concerning food shortages is additional wide. Moreover,
infected, with worse outcomes(2). Severe cases will result
spreading rumors has negative psychological impacts (9).
in internal organ injury, respiratory failure, acute
Psychiatric morbidities are found to vary from
respiratory distress syndrome (ARDS), and death (3).
anxiety, depression, panic attacks, somatic symptoms,
COVID-19 epidemic is thought of as a general
posttraumatic stress disorder, delirium, psychosis, and
health crisis that has caused challenges for mental
even suicidality (10). Past tragedies have shown that the
resilience and has been the most important natural event
psychological state implications will last longer and have
since the severe acute respiratory syndrome (SARS)
a bigger prevalence than the epidemic itself which the
outbreak in 2003 (4).
psychosocial and economic impacts are determinable if
The planet has witnessed several widespread
we tend to take into account their resonance in numerous
outbreaks of acute respiratory illnesses. For instance,
contexts. (11). Therefore, psychiatric interventions are
SARS as a communicable infectious disease spread in
essential throughout infectious disease outbreaks with a
2003; however, it had been mostly managed by
high mortality rate (12).
quarantine measures. However, the results of quarantine
COV-SARS pandemic might endanger the mental
haven't been investigated (5). The implications of the
well-being of the healthcare workers, inflicting
disease outbreaks touching all aspects of humans' lives
depression, anxiety, insomnia, or distress. A sustained
have continued (6).
rise in cases, excessive employment, inevitable media
Mental health is one of the largest issues that have to
coverage,
and
inadequate
personal
protecting
be self-addressed currently, and post-pandemic as this
instrumentality and medications were among the varied
crisis has generated tremendous stress publicly (7).
factors for the deterioration of the psychological state.
The advent of COV-SARS has confused, modified
HCW aren't solely petrified of obtaining infected however
people's living conditions, as well as commutation
additionally upset concerning contaminating their
restrictions, the worry of disease transmission, and
families, friends, and colleagues with the virus(13).
closure of schools and businesses (5). In addition to

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3306
Received: 9 /6 /2021

Accepted: 5 / 8/2021

Full Paper (vol.851 paper# 110)


ABSTRACT The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3313-3318

The Use of Neutrophil Gelatinase Associated Lipocalin (NGAL) As A Novel Marker in
Early Diagnosis of Hepatorenal Syndrome in Advanced Cirrhotic Patients
Ahmed Samir Abo Halima, Nevine Ibrahim Musa, Amr Ahmed Okasha, Ahmed Samir Allam*
Department of Internal Medicine, Gastroenterology, Faculty of Medicine, Ain Shams University
*Corresponding author: Ahmed Samir Allam, Mobile: 01001701223,
Email: ahm82allam@gmail.com

ABSTRACT
Background:
Acute kidney injury (AKI) in cirrhosis, including hepatorenal syndrome (HRS), is a common and
serious complication in cirrhotic patients, leading to significant morbidity and mortality.
Objective:
To predict value of serum and urinary NGAL as an early predictor of hepatorenal syndrome in cirrhotic
patients.
Patients and Methods: This study was a prospective clinical trial conducted at Kafr El Sheikh Liver Institution. The
study included 60 participants with cirrhosis Child C on Child-Pugh score, each one was investigated for both Urinary
and Plasma NGAL level.
Results: Group I had urinary NGAL ranged from 12 - 120, with a mean value of 61.45 ± 36.17. While group II A,
ranged from 211-493 with a mean value of 379 ± 72.825 and in group II B, ranged from 306-732 with a mean value of
438.05 ± 111.26. There was statistical difference between studied groups, p value <0.001. It was found that urinary
NGAL is not only good predictor for early renal affection, but also it can differentiate between HRS and non HRS
AKI due to the marked difference readings of its level in groups with renal impairment.
Conclusion: Urinary NGAL shows noticeable differences between degree of elevation with different causes of AKI,
so it somehow could be a trusted diagnostic tool to diagnose HRS.
Keywords:
Acute kidney injury, HRS, NGAL.

INTRODUCTION


In individuals with liver cirrhosis, kidney
months. According to the previous criteria for AKI and
impairment is a complicated and prevalent occurrence.
CKD, acute chronic kidney disease appears as an
Acute kidney damage (AKI) is a significant
overlap of AKI with pre-existing chronic renal disease
consequence of decompensated liver cirrhosis, with
(4).
high morbidity and death rates. Despite some hopeful
The members of the ADQI group met in
findings from new therapies (1), AKI remains a major
Vicenza (Italy) in May 2002 to develop a new set of
complication of decompensated liver cirrhosis with
diagnostic and classification criteria for AKI: the
high morbidity and mortality rates. Prerenal azotemia
RIFLE classification (published in May 2004). This
(PRA), hepatorenal syndrome (HRS), and acute tubular
approach divides patients into three severity categories
necrosis (ATN) are among the most common causes of
(Risk, Injury, and Failure) and two outcome categories
AKI in hospitalised patients with liver cirrhosis, with
(Loss of kidney function and end-stage renal disease)
prevalence rates of about 68 percent, 25 percent, and 33
based on changes in blood creatinine, glomerular
percent, respectively. According to studies, about 1% of
filtration rate, or urine output (5).
cirrhotic individuals with azotemia develop progressive
The Acute Kidney Injury Network (AKIN)
parenchymal renal disease as a result of hepatic viral
group established a new set of AKI criteria called the
infections, immunological, or metabolic problems
AKIN classification during a conference in Amsterdam
(chronic glomerulonephritis, IgA nephropathy, diabetic
in September 2005 (Published in March 2007). This
nephropathy) (1, 2).
enhanced the categorization method, which was based
Members of the Acute Dialysis Quality
only on changes in serum creatinine (two measurements
Initiative (ADQI) and the International Ascites Club
within 48 hours) and urine output and consisted of three
(IAC) collaborated in 2011 to establish a new set of
levels of severity (5).
diagnostic criteria for better evaluating kidney
The failure of both categorization methods to
impairment in liver cirrhosis (3). The term AKI refers to
offer any information on the etiology of renal
a rapid loss in renal function, as evidenced by a rise in
impairment in liver cirrhosis is a frequent flaw. Existing
serum creatinine levels of more than 50% from baseline
evidence does not support the AKIN classification's
in less than 48 hours, or an upward trend in serum
advantage over standard risk prediction criteria in
creatinine levels of 26.4 mol/ L (0.3 mg/dL) in less
patients with liver cirrhosis and renal failure (6).
than 48 hours. Using the Modification of Diet in Renal
Fagunds et al.(7) note that the combination of the AKIN
Disease 6 (MDRD6) formula, chronic kidney disease
classification and conventional criteria for renal
(CKD) is defined as an estimated glomerular filtration
impairment may provide a better risk assessment in
rate (eGFR) of less than 60 ml/minute for more than 3
patients with cirrhosis, compared to the AKIN criteria

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3313
Received: 3 /6 /2
021

Accepted:29 /7 /2021


Full Paper (vol.851 paper# 111)


Introduction: The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3219-3323

Cardiovascular Disease in Chronic Kidney Disease: Review Article
Abdulrhman Al Abdulqader
Department of Internal Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
Corresponding author: Abdulrhman Al Abdulqader, Mobile: +966555917740, E-Mail: alabdulqader@kfu.edu.sa

ABSTRACT
Background:
Since the first description of the association between chronic kidney disease and heart disease, many
epidemiological studies have confirmed and extended this finding. As chronic kidney disease progresses, kidney-
specific risk factors for cardiovascular events and disease come into play. As a result, the risk for cardiovascular
disease is notably increased in individuals with chronic kidney disease.
Objective: To study the relationship between importance of CVD in determining of CKD patients.
Conclusion: Cardiovascular disease is frequently underdiagnosed and undertreated in patients with chronic kidney
disease. This group of patients should, therefore, be acknowledged as having high cardiovascular risk that needs
particular medical attention at an individual level.
Keywords: Cardiovascular Disease, Chronic Kidney Disease.

INTRODUCTION
mg/day (albumin in urine), while on assessing non-
Chronic kidney disease (CKD) is an
diabetic CKD patients, we use a range of proteinuria >
independent risk factor for the development of coronary
300 mg/day or urinary protein/creatinine ratio > 200
artery disease, and for more severe coronary heart
mg. Proteinuria is either considered to be due to renal
disease (CHD). CKD is also associated with adverse
damage or a systemic endothelial dysfunction marker.
outcomes in those with existing cardiovascular disease
Proteinuria accompanied cardiovascular disease and
(1). This includes increased mortality after an acute
mortality, in general population, even at values
coronary syndrome, after percutaneous coronary
regarded as normal. The presence of reduced eGFR,
intervention (PCI) with or without stenting, and after
associated with micro- or macro-albuminuria, were
coronary artery bypass. In addition, patients with CKD
shown within several studies to be independent
are more likely to present with atypical symptoms,
predictors of mortality, either in diabetics, or in non-
which may delay diagnosis and adversely affect
diabetics as reported (5, 6).
outcomes (2).
GFR and CVD:

Fink et al. (3), reported that cardiovascular
GFR decline was proved to be an independent
disease (CVD), as it is well known, was the leading
risk factor for cardiovascular morbidity and mortality,
cause of death in chronic kidney disease (CKD). They
wither proteinuria is present or not. Kottgen et al. (7), in
also stated that risk factors associated with CVD fully
their study including more than one million subjects
exists within CKD patients. These include accelerated
above 18 years, found that eGFR decline affected
atherosclerosis, left ventricular hypertrophy (LVH) and
cardiac and vascular system state of patients leading to
dilatation, systolic dysfunction, and high left ventricular
cardiovascular events such as CAD, heart failure,
filling pressure. They deduced that cardiac disorders
stroke, peripheral vascular disease and death, as
and renal diseases affect each other through direct and
reported within ARIC study (Atherosclerosis Risk in
indirect complex mechanisms. According to Keith et
Community Study).
al. (4), the high mortality rates occurring among patients
Cardiovascular Injury in CKD:
having CKD stage 5 and stage 5 D, are mainly due to
Pathogenetic
mechanisms
leading
to
cardiovascular disorders co-existing with chronic
cardiovascular damage in renal disease were reported
kidney disease and end-stage renal stage.
that more than a dozen of pathways were recognized

including
Renin-Angiotensin-Aldosterone
System
Proteinuria/Albuminuria and CVD:
(RAAS) hyperactivity, osmotic sodium retention
The presence of a protein quantity in urine
volume
overload,
endothelial
dysfunction,
exceeding normal range is called (proteinuria), and
dyslipidemia, coagulopathy, inflammation and anemia.
when this protein consists mainly of albumin, it is
The following pathogenetic mechanisms were added to
called (albuminuria). We can detect proteinuria by urine
the previous list: sympathetic hyperactivity, cardiotonic
dipstick testing in a semi-quantitative way, by
steroids, nonosmotic sodium retention, and catalytic or
measuring protein/creatinine ratio (UPCR) or urinary
labile iron. Also sympathetic hyperactivity within CKD
albumin/creatinine ratio (UACR), or by quantifying
caused progression of renal damage and also
protein in collected 24 hours urine using laboratory
cardiovascular morbidity. Treatment of over activity of
methods. In diabetic nephropathy patients, we use
sympathetic nervous system could be an option to
micro-albuminuria in the range of 30-300 mg/day
decrease deleterious effects of sympathetic nervous
(albumin in urine) and overt albuminuria as > 300
system in cases of chronic kidney disease (8).

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3219

Received:8 /6 /2021


Accepted:4 /8 /2021


Full Paper (vol.851 paper# 112)


c:\work\Jor\vol851_113 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3224-3328

Vertical Axillary Incision for Treatment of Breast Outer Quadrants Tumors
Taha Abd El-wahab Baiomy, Nawel El Sayed Hussein Abd El Hamid Matar,
Aisha Ahmad Ashtaiwe*, Joseph Rizk Israel
Onco-Surgery Unit, Department of Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Aisha Ahmad Ashtaiwe, Mobile : 00218910477032, Email: aishaahmad8519@gmail.com


ABSTRACT
Background:
Breast cancer is the second most common cancer among women, with an estimated 3.5 million survivors
as of 2015. There is continuous annual improvement of the overall survival of breast cancer patients, with 5-year overall
survival estimates increasing from 84.6% to 90.9% over the previous two decades.
Objective:
The aim of the current work was to improve aesthetic satisfaction and oncological outcome of patients with
breast outer quadrant tumors.
Patients and Methods:
This interventional study included a total of 18 cases with early breast cancer at upper and
lower-outer quadrants of breast, attending at Onco-Surgery Unit, General Surgery Department, Faculty of Medicine,
Zagazig University. This study was conducted between December 2020 to May 2021. All patients were subjected to
demographic data taking, complete clinical examination, and investigations including imaging, biopsies, and
histopathology.
Results: The Histopathological type of tumor, all of them had Invasive ductal carcinoma. Most of the tumors were (ER)
and (PR) Positive with HER2/neo Negative. The mean duration of operation was 86.94±10.45 (range 70­105) minute
and the mean blood loss was 286±12.34 (range 250-315) milliliter and all patients had no intraoperative complication.
Conclusions: It could be concluded that the vertical axillary incision is a safe and effective approach for the management
of tumors of the outer quadrant of the breast; and cosmetically appropriate maneuver for these tumors.
Keywords: Breast Conserving Surgery (BCS), Breast cancer, Quadrant tumors.

INTRODUCTION
PATIENTS AND METHODS
Breast cancer is the most common cancer among
This interventional study included a total of
women. There is continuous annual improvement of the
18 cases with early breast cancer at upper and lower-
overall survival of breast cancer patients, with 5- year
outer quadrants of breast, attending at Onco-Surgery
overall survival estimates increasing from 84.6% to
Unit, General Surgery Department, Faculty of
90.9% over the previous two decades (1).
Medicine, Zagazig University. This study was
The outer quadrant of the breast is the most
conducted between December 2020 to May 2021.
common for breast cancer quadrant and axillary

extension of the breast (2).
Ethical Consideration:
Breast Conserving Surgery (BCS) is nowadays the
Written informed consent was obtained from
standard surgical approach for the treatment of most
all participants and the study was approved by the
cases of early breast cancer. During the last decades, the
Research Ethical Committee, Faculty of Medicine,
trend of breast conserving surgery has shifted from
Zagazig University. The work has been carried out
quadrantectomy , to large excision, to lumpectomy with
in accordance with The Code of Ethics of the World
the intent to minimize the excision volume in order to
Medical Association (Declaration of Helsinki) for
reduce breast shape deformaties, asymmetry, and scar
studies involving humans.
length (3).

The possibility of carrying out this conservative
Inclusion criteria:
treatment will depend, on one hand, the tumor volume
Patients with early breast cancer at upper and lower-
compared to that of the breast (tumor volume / breast
outer quadrants of breast provided that tumor pathology
volume ratio), and on the other hand, tumor location (4).
is invasive ductal carcinoma, less than 5 cm in the
The possible distortion of breast shape and the
biggest diameter and the skin overlying it is not
following poor cosmetic result led surgeons to develop
involved.
different surgical techniques in order to overcome the

aesthetic discomfort for the patient(5).
Exclusion criteria:
We performed this study to evaluate vertical
Patients not eligible to breast conservative
axillary incision as an option for improving aesthetic
treatment. Patients presenting with advanced malignant
satisfaction and oncological outcome in the
that is (More than 5 cm in diameter and the skin
management of breast outer upper and lower quadrant
overlying it is involved). Patients refuse to have breast
tumors.
conservative treatment.





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3224
Received: 6 /6 /2021

Accepted: 2 /8 /2021


Full Paper (vol.851 paper# 113)


c:\work\Jor\vol851_114 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3229-3334

Assessment of The Role Annexin A1 in Pediatric with Bronchial Asthma at
Zagazig University Hospitals
Hassan El-Banna Khedr1, Mohammed Sanad Nagiub1,
Ayman Abd El Rahman Allam2, Basma Abd El Hamid El-Said1
Departments of 1Pediatrics and 2Microbiology & Immunology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author Name: Basma Abd El Hamid El-Said, Mobile : (+20)1024683929, Email: mosad8rashed@gmail.com

ABSTRACT


Background: Childhood asthma is a chronic inflammatory disorder of the airways in children characterized by
interaction between many cells of the innate and adaptive immune systems that interact with epithelial cells to cause
bronchial hyper-reactivity. Annexin A1 (ANXA1) is a glucocorticoid-induced protein with multiple functions in the
regulation of inflammatory cell activation. ANXA1 has anti-inflammatory effects by stimulating inflammatory cell
programmed cell death and prohibiting eicosanoid synthesis.
Objectives: The aim of the current work was to evaluate Annexin A1 levels in the blood of asthmatic patients and to
evaluate the relationship between Annexin A1 levels and clinical profiles in asthma.
Patients and Methods:
This case-control study included a total of 100 children, 80 of them were asthmatic and 20 were
apparently healthy children, attending at Pediatric Department, Zagazig University Hospitals.
Results:
There is a statistically significant higher annexin A1 among cases than control group (3.3ng/ml & 2.6 ng/ml,
respectively). There was a statistically significant difference between severity of bronchial asthma and serum Annexin
A1 (higher annexin A1 values with increased severity of the disease). There was a statistically significant negative
correlation between serum annexin A1 & FEV1, FVC and PEF (r=-0.27, p=0.01, r=-0.31, p=0.00 and r=-0.22,
p=0.05 respectively). Serum IgE had statistically significant positive correlation with serum annexin A1 among studied
cases (r=0.254 p=0.023). ROC was done to detect a cutoff point, at which trying to detect asthma cases. We found that
at a level of 2.65 we can diagnose asthmatic cases with sensitivity 70 %, specificity 65% with total accuracy 69%.
Conclusion: It could be concluded that serum annexin A1 can be considered as a possible biomarker for diagnosis,
grading of asthma severity.
Keywords: Assessment, Annexin A1 levels, Pediatric, Bronchial Asthma.

INTRODUCTION


Childhood asthma is a chronic inflammatory
ANXA1 differ based on intra- versus extracellular
disorder of the airways in children (1), characterized by
localization (5).
interaction between many cells of the innate and
ANXA1 has anti-inflammatory effects by
adaptive immune systems that interact with epithelial
stimulating inflammatory cell programmed cell death
cells to cause bronchial hyper-reactivity. Within the
and prohibiting eicosanoid synthesis.
past few years, it has emerged as the most common
Lee et al. (6) identified the role of ANXA1 in
incommunicable respiratory disease affecting children
bronchial asthma. They suggested that ANXA1 may be
worldwide (2)
a potential marker and therapeutic target for asthma.
It manifests as recurrent attacks of wheezing,
They found that plasma ANXA1 levels were increased
breathlessness, chest tightness, and coughing,
in asthmatic patients.
particularly at night and in the early morning. These
The reduced levels of lipoxin A4 (LXA4) and
attacks are usually associated with variable airflow
ANXA1 were reported in wheezy infants (7). In addition,
obstruction that is often reversible either spontaneously
Ng et al. (8) have shown that ANXA1 is associated with
or with treatment. Childhood asthma prevalence
asthma development.
worldwide is rising dramatically making it regarded as
The aim of this work was to improve methods of
a major healthcare problem in children (3).
diagnosis of patients with bronchial asthma.
The prevalence and morbidity of childhood asthma
The aim of the current work was to evaluate
have been rising evidently during recent decades
Annexin A1 levels in the blood of asthmatic patients
throughout the world (4).
and to evaluate the relationship between Annexin A1
Annexin A1 (ANXA1) is a glucocorticoid-
levels and clinical profiles in asthma.
induced protein with multiple functions in the

regulation of inflammatory cell activation. ANXA1 is a
PATIENTS AND METHODS
37 kDa protein that has been reported to have anti-
This case-control study included a total of 100
phospholipase activity following glucocorticoid
children, 80 of them were asthmatic and 20 were
induction and possesses a wide range of physiological
apparently healthy children, attending at Pediatric
and pathological functions. The biological effects of
Department, Zagazig University Hospitals. This study


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3229
Received: 6 /6 /2021

Accepted: 2 /8 /2021


Full Paper (vol.851 paper# 114)


c:\work\Jor\vol851_115 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3235-3340

Direct-Acting Antiviral Therapy Effect on Extrahepatic Rheumatic
Manifestations in Egyptian Chronic Hepatitis C (HCV) Patients
Mahmoud Mahmoud Yousif, Abd-Elazeim Mohammad Elhefny, Reem Abd-Elmoneim habeeb,
Maryam Ahmed Abdelrahman, Rasha Nabil Thabet*
Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Rasha Nabil Thabet, Mobile: (+20)1223248583, E-mail: dr_rashanabil@hotmail.com

ABSTRACT
Background:
Hepatitis C virus infection is an important cause of many rheumatic diseases, especially cryoglobulinemic
vasculitis, fibromyalgia, arthralgia and Sicca Syndrome. Direct acting antivirals are found to be highly effective for the
treatment of chronic Hepatitis C virus infection.
Objective: The aim of this study was to evaluate the clinical and serological course of extrahepatic rheumatic
manifestations in chronic hepatitis C Egyptian patients after treatment with new direct-acting antivirals.
Patients and Methods: This study was carried out on 60 Egyptian patients with chronic hepatitis C with one or more
of the HCV- related rheumatic manifestations treated with sofosbuvir (400 mg daily) plus daclatasvir (60 mg daily) as
a direct-acting antivirals for 3 months. All patients were subjected to clinical and serological course of extrahepatic
rheumatic manifestations evaluation.
Results: show that among the 60 patients, 21 patients (35.0%) met the criteria of mixed cryoglobulinemia syndrome
(MC), 19 patients (31.7%) were complaining of arthralgia, 17 patients (28.3%) were complaining of fibromyalgia and
3 patients (5.0%) were complaining of Purpura without other criteria of mixed cryoglobulinemia syndrome. Complete
clinical response was achieved in a significant number of patients with mixed cryoglobulinemia syndrome (MCS), the
results also show significant clinical improvement in patients with fibromyalgia, arthralgia and purpura. Significant
reduction but not complete normalization in auto-antibodies at short term follow-up was observed.
Conclusion: It could be concluded that sustained virologic response correlates with clinical and immunological
improvement in most patients with extrahepatic rheumatic manifestations among the studied group of chronic hepatitis
C Egyptian populations.
Keywords:
Rheumatic manifestations, Hepatitis C, Direct-acting anti-viral.

INTRODUCTION

Since 2013, several new direct-acting antivirals
Hepatitis C virus (HCV) is infecting about 200
(DAAs) have been confirmed by the United States, such
million people world-wide. It's main cause of morbidity
new DAAs are extremely effective for the therapy of
and mortality (1). HCV can arouse and support a clonal
chronic HCV infection and are well tolerated with lesser
B-cell expansion because of its lymphotropic nature that
side-effects (8).
causes numerous autoimmune/lymphoproliferative
The treatment of extra-hepatic rheumatic
disturbances (2).
troubles includes: etiological treatments with anti-viral
HCV-related extrahepatic manifestations (EHM), range
agents aiming to removal of HCV, pathogenetic and
from benign mixed cryoglobulinemia to frank
symptomatic approaches (2). DAA therapies are strongly
lymphomas, have been reported (3). HCV infection is,
considered in the initial management of HCV mixed
also, known cause of much rheumatic illnesses, as
cryoglobulinemia syndrome (9). Combined/sequential
HCV-related cryoglobulinemic vasculitis, among
therapies with anti-viral and the anti-CD20 mono-clonal
others (4).
anti-body (Rituximab) represent a real refinement in the
The most prevalent HCV-related rheumatic
treatment of most severe manifestations of HCV-related
manifestations are fibromyalgia which is reported in
MC (10).
57% of chronic hepatitis C (CHC) patients (5), arthralgia
The aim of this study was to evaluate the
which is reported in 23% of CHC patients, Sicca
clinical and serological course of extra-hepatic
Syndrome which is reported in 11% of CHC patients (6),
rheumatic manifestations in chronic hepatitis C
and vasculitis which is reported in 5% of CHC patients
Egyptian patients after treatment with new direct-acting
and represented with purpura and weakness (2).
anti-viral.
Auto-anti-bodies are generally utilized in the

diagnosis of rheumatic illnesses pending chronic HCV
PATIENTS AND METHODS
infection. Levels of cryoglobulins, rheumatoid-factor
This study included a total of 60 Egyptian patients
(RF), and anti SSA/SSB antibodies are increased
with chronic hepatitis C with one or more of the HCV-
(79%) as well as several other autoantibodies, anti-
related rheumatic manifestations treated with
nuclear antibodies (ANA) (63%), cANCA ( 64%),
sofosbuvir (400 mg daily) plus daclatasvir (60 mg daily)
anti- Cardiolipin (62%), anti-DNA ( 25%) (7).
as a direct-acting anti-viral for 3 months. Patients

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3235
Received: 7 / 6/2021

Accepted: 3 /8 /2021


Full Paper (vol.851 paper# 115)


c:\work\Jor\vol851_116 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3341-3346

Correlation between both Child Pugh Score and Spontaneous Bacterial
Peritonitis with Plasma D-Dimer Level in Cirrhotic Patients
Mohamed Abdelmonem Ali*1, Ehab Fawzy Abdelaziz1, Noha Abdelhalim Mohammed2, Amr Samir Ebrahim1
Departments 1Internal Medicine and 2Medical Biochemistry, Faculty of Medicine, Zagazig University Zagazig, Egypt.
*Corresponding Author: Mohamed Abdelmonem Ali, Email: drmonem14@yahoo.com

ABSTRACT
Background: Cirrhosis is a chronic liver disease in which diffuse destruction and regeneration of hepatic parenchymal
cells have occurred. D-dimer is regarded as a diagnostic marker for Portal vein thrombosis in liver cirrhosis.
Objective: To correlate plasma D-dimer levels as a hemostatic parameter with Child Turcotte Pugh (CTP) score of post
hepatitis cirrhosis patients and occurrence of spontaneous bacterial peritonitis (SBP).
Patients and methods: This was a case-control study that included 84 patients with hepatitis C-related cirrhosis who
were admitted to Al-Ahrar Teaching Hospital in the period from November 2020 to June 2021. 28 apparently healthy
subjects were included as control group.
Results: There was a significantly higher level of D-dimer in each cirrhotic group; child A, child B and child C with
median of 1.05 mg/l, 2 mg/l and 3 mg/l respectively compared to healthy control group with a median of 0.09 mg/l. The
best cutoff of D dimer in prediction of Child C was 2.45 mg/l with area under curve of 0.986, sensitivity of 96.4%,
specificity of 94%, positive predictive value (PPV) of 84.4%, negative predictive value of 98.8 % and accuracy of 94.6%
(p < 0.001). There was a statistically significant association between SBP and D dimer, which was significantly higher
among those with SBP.
Conclusion: D-dimer was correlated with esophageal varices grades and degree of ascites. D-dimer could be a marker
for severity of liver disease in patients with post hepatitis c cirrhosis as indicated by Child' score.
Keywords: D-dimer, Child Pugh Score, Spontaneous bacterial peritonitis.

INTRODUCTION
The enzymatic breakdown of cross-linked
Liver cirrhosis is the last frequent
fibrin produces a persistent and quantifiable
pathological route of liver damage caused by a range of
characteristic known as D-Dimer. D-Dimer estimation
chronic liver disorders (1). Cirrhosis is caused by a
has previously been used to diagnose diseases such as
variety of factors, including drinking, chronic hepatitis
deep vein thrombosis and pulmonary embolism.
C virus infection, and nonalcoholic fatty liver disease
Because chronic liver illness is linked to hemostasis
(NAFLD) (2). Egypt has the highest prevalence rate of
problems, it's conceivable that it's linked to clot lysis
hepatitis C virus infection in the world (3).
problems as well. Estimation of D-Dimer might give
Though, the causes of liver cirrhosis are
some insight into potential fibrinolytic pathway
diverse, several clinical features are similar to all cases
derangements (7).
of liver cirrhosis, such as hepatocyte degradation and
We aimed in this work to correlate plasma
necrosis, liver parenchyma replacement by fibrotic
D-dimer levels as a hemostatic parameter with Child
tissues and regenerative nodules, and liver function
Turcotte Pugh (CTP) score of post hepatitis cirrhosis
loss. Fibrosis is a key pathogenic step in the progression
patients and occurrence of SBP.
of all chronic liver disorders to cirrhosis (4). Liver

cirrhosis is a serious hepatic parenchymal disease with
PATIENTS AND METHODS
life-threatening consequences. Synthetic functions are
This is a case-control study that included 84
severely reduced in patients with decompensated liver
patients with hepatitis C-related cirrhosis with varying
cirrhosis. The liver produces many of the proteins
degrees of severity who were admitted to Al-Ahrar
involved in the coagulation process. As a result, many
Teaching Hospital. 28 apparently healthy subjects were
people think that decompensated liver cirrhosis is a
also included as control group. The studied hepatitis C
precursor to hemorrhagic coagulopathy. Coagulation is
patients were randomly categorized according to CTP
now recognised as a complicated process including
score into: Group (1) that included 28 patients class A
interactions between procoagulation, anticoagulation,
CTP score, Group (2) that included 28 patients class B
and the fibrinolytic system (5).
CTP score and Group (3) that included 28 patients
Child-Torrcot-Pugh score (CTP score)
class C CTP score. Group (4) (Control group) included
involves total bilirubin, albumin, International
28 apparently healthy subjects.
Normalized Ratio (INR) or prothrombin time, hepatic

encephalopathy and ascites. It is very frequently used
Inclusion Criteria: Patients with hepatitis C-related
scoring system for judging the prognosis of cirrhosis of
cirrhosis with varying degrees of severity aged above
liver. Every measure is scored 1-3 points and 3 indicates
18 years from both sexes were included in the study.
very intense imbalance (6).


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3341
Received: 8/8/2021

Accepted: 15/9/2021


Full Paper (vol.851 paper# 116)


Introduction and aim of the work The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3347-3353

Dexmedetomidine Versus Fentanyl in Caudal Block for Postoperative
Pain Relief in Pediatric Surgery
Fouad Ibrahim Soliman, Abdel-hady Ahmed Helmy Abdel-hady
Department of Anesthesia & ICU, Faculty of Medicine, Sohag University, Egypt.
*Corresponding author: Fouad Ibrahim Soliman, Mobile: (+20)01113815186,
E-Mail: fouadsoliman1977@gmail.com @gmail.com

ABSTRACT
Background:
Caudal block is one of the most common regional anesthetic techniques used in children. It is considered
safe and simple procedure but its main disadvantage is its relatively short duration of action even with use of long acting
agents such as bupivacaine. Fentanyl is most common additive to local anesthetics to caudal block, but it has undesirable
side effects. Dexmedetomidine is 2 adrenergic receptor agonist which prolongs the duration of analgesia when added
to caudal bupivacaine.
Objective: This work aimed to compare the postoperative analgesic and any side effects of addition of either
dexmedetomidine or fentanyl to bupivacaine in pediatric patients undergoing lower abdominal and lower limb surgeries.
Patients and methods: This interventional randomized-controlled study was carried out in Department of Anesthesia
and Intensive Care, Sohag University Hospital. Sixty patients aged from 2 to 6 years who were going to do a lower
abdominal surgery were included in the study.
Results: As regards sedation score, dexmetedomidine showed more sedation than that of fentanyl where there was a
significant difference between both groups at ½ hour and 1 hour (P value 0.008 and 0.016 respectively) and number of
children sedated in group D (23) was more than that of group F (8) at 1 hour.
Conclusion: Adding dexmetedomidine to bupivacaine in caudal block is longer in duration of postoperative analgesia
and showed more sedation time than that of fentanyl with more stability in haemodynamics.
Keywords: Dexmedetomidine, Fentanyl, Caudal block analgesia, Pediatric surgery.

INTRODUCTION
solution for prolonged analgesia postoperatively (5).
Pain is an unpleasant subjective sensation, which can
Caudal analgesia could reduce the amount of inhaled and
only be experienced and not expressed, especially in
intravenous anesthetic administrative, attenuate the stress
children (1). Acute pain management for surgical patients
response to surgery, facilitate rapid and smooth recovery
intraoperatively and post operatively is important for the
and provide good immediate postoperative analgesia. In
patient comfort. It leads to an improved perioperative
order to decrease intra- and post-operative analgesic
experience and reduction in pulmonary complications (2).
requirements after single shout caudal blockade, various
This result in reduced hospital costs due to short hospital
additives, such as opioids and non-opioids drugs were
stay especially in ambulatory surgical patient (3, 4).
used (6).
The concept of postoperative pain relief and its
Thus, addition of various drugs to local anesthetics
utilization in children has improved dramatically over the
has been used to prolong the pain-free period (7).
recent years. Till date, many methods have evolved for
This work aims to compare the post-operative
providing postoperative pain relief in pediatric
analgesic and any side effects of dexmedetomidine and
population, nonetheless having some side effects, which
fentanyl in adding one of them to bupivacaine in pediatric
prohibit their use in children (1).
patients undergoing lower abdominal and lower limb
Caudal block is one of the most popular regional
surgeries.
techniques in pediatrics and is commonly used for

procedures below umbilicus including urogenital, rectal,
PATIENT AND METHODS
inguinal and lower extremities surgery. Single shot caudal
This interventional randomized-controlled study
epidural blockade is one of the most widespread
was conducted in Department of Anesthesia and
techniques providing intra- and pos-toperative analgesia
Intensive Care, Sohag university hospital. Sixty
in pediatric patients (5). Pediatric caudal blocks were
patients aged from 2 to 6 years who were going to do
performed after the induction of general anesthesia. This
a lower abdominal surgery were included in the study.
technique (block) is useful adjunct during general

anesthesia and for providing postoperative analgesia. The
Ethical approval:
quality and level of caudal blockade is dependent on the
An approval of the study was obtained from
dose, volume and concentration of the injected drug. One
Sohag
University
Academic
and
Ethical
of the major limitations of single injection technique is the
Committee. Informed written consents were
relatively short duration of post-operative analgesia. So,
obtained from parents of all children participants
addition of different adjunct drugs to the local anesthetic
before recruitment in the study after explaining the

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3347
Received: 10/6/2021

Accepted: 6/8/2021


Full Paper (vol.851 paper# 117)


c:\work\Jor\vol851_118 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3354-3358

Endoloop Versus Endostapler Techniques in Appendicular Stump Closure during
Laparoscopic Appendectomy: A Prospective Randomized Trial
Hamada Rashad Mohamed Abdelkader*
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Egypt.
Consultant General Surgery, General Surgery Department, King Khaled Hospital, Hail, KSA.
*Corresponding author: Hamada Rashad Mohamed Abdelkader, Mobile: (+20)01003902869, E-Mail: dr_7mada79@yahoo.com

ABSTRACT
Background:
There has been an ongoing debate regarding the ideal method of appendicular stump closure during
laparoscopic appendectomy. Objective: We conducted this study to compare endoloops and endostaplers as stump
closure methods regarding postoperative infectious complications. Patients and methods: This prospective study
included 110 patients diagnosed with appendicitis and scheduled for laparoscopic appendectomy. According to the
stump closure method, they were divided into Group A or the endoloops group and Group B or the endostapler group.
All cases received the same standard perioperative care. Preoperative, intraoperative, and postoperative data were
collected, and the incidence of postoperative intraabdominal abscess was our primary outcome.
Results: Both groups showed statistically comparable findings regarding most of the demographic, clinical, and
laboratory variables. Complicated appendicitis was detected in 29.09% and 36.36% of patients in groups A and B,
respectively. Operative time was also comparable between the two groups (50 and 55 minutes, respectively). An
intraabdominal abscess was detected in only one patient in group A (1.82%). Wound infection was encountered in two
patients in each group (3.64%). The incidence of infectious postoperative complications was statistically comparable
between the two groups. No need for reoperations and no port-site hernias were detected in our study.
Conclusion: Both endoloops and endostaplers have comparable intraoperative and postoperative outcomes. The
surgeon should use the method he is more experienced with and according to the available facilities.
Keywords: Endoloops, Endostaplers, Intraabdominal abscess, Laparoscopic appendectomy.

INTRODUCTION
endoloops require more manipulation of the

Acute
appendicitis
is
the
commonest
appendicular stump and carry a slippage risk, especially
intraabdominal surgical emergency, and appendectomy
in patients with complicated appendicitis, when the
is one of the most performed procedures in the field of
appendicular base is inflamed and friable (11, 15).
general surgery (1, 2). Currently, laparoscopic

As there was no consensus about the ideal
appendectomy is considered the gold standard
method for stump closure, we conducted the current
management option for the management of this disease.
study to compare endoloops and endostaplers as stump
This is due to the known advantages of laparoscopy over
closure methods regarding postoperative infectious
laparotomy, including faster recovery, less postoperative
complications.
pain, better cosmoses, shorter hospitalization period,

earlier return to work (3, 4). Furthermore, laparoscopy
PATIENTS AND METHODS
allows better exploration of the whole abdomen and

The current prospective study was conducted at
pelvis, making it easier to detect and manage any
King Khaled Hospital in Hail, KSA, during the period
associated disease (4, 5). There is an ongoing debate
between January 2019 and December 2020.
about the ideal method used for appendicular stump

Power Analysis and Sample Size software
closure, especially some surgeons believe that the
program (PASS) version 15.0.5 for Windows was used
method of closure is strongly related to postoperative
to calculate the sample size. We used the data published
infectious complications (6). Nevertheless, this topic
by van Rossem et al. (6) with the incidence of the
lacks substantial evidence, and the existing researches
postoperative
intraabdominal
abscess
following
handling this topic yielded conflicting results (7, 8).
laparoscopic appendectomy for acute uncomplicated and

Both endoloops and endostaplers are frequently
complicated appendicitis as the primary outcome. The
used for appendicular stump closure during the
null hypothesis was considered the presence of statically
laparoscopic procedure (9, 10). Some surgeons prefer to
significant superiority of the endostapler group
use endostaplers to ensure proper and safe sealing of the
compared to the endoloop group. According to van
stump. However, others prefer the endoloops because of
Rossem et al. (6), the incidence of postoperative
their safety, feasibility, and low economic cost (11-13).
intraabdominal abscess in complicated cases was 11.7%

Despite the previous advantages, both of these
in the endoloop group and 9.6% in the endostapler group.
two closure techniques have their drawbacks. The
A non-inferiority margin of 25% was set as the target
endostaplers have a high cost, and it requires the
difference between both study groups. A sample size of
insertion of a 12-mm trocar for its entry. In addition,
50 patients in each group was needed to achieve 80%
leaving metallic clips on the stump could be a risk for
power in the proposed study using a one-sided Z test,
adhesive bowel obstruction (1, 14). On the other hand,
with a significance of 5%. Five percent drop-out patients

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3354
Received: 8 /6 /2021

Accepted: 4 /8 /2021


Full Paper (vol.851 paper# 118)


c:\work\Jor\vol851_119 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3359-3363
Impact of Sugarless Chewing gum Versus Peppermint on First Bowel
Movement after Cesarean Section: Randomized Controlled Trial
Ahmed Adel Tharwat, Marwa Elsayed Muhammed Gomaa,
Nermeen Ahmed Mostafa Elghareeb
Department of Obstetrics and Gynaecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Marwa Elsayed Muhammed Gomaa, Mobile: 01069258555,
Email: mezosaad2012@hotmail.com

ABSTRACT
Background:
Cesarean delivery (CD) became one of the commonest major surgical operations performed daily
worldwide. Postoperative ileus (POI), Cesarean section (CS), is the most critical form of intestinal dysfunction that leads
to absolute constipation and oral intake intolerance. It is mainly a result of a non-mechanical injury that disturbs the
normal gastrointestinal tract motor activity. Objective: To assess which is more effective sugarless chewing gum or
peppermint on first bowel movement after cesarean section. Patients and Methods: A randomized controlled study
was conducted at Ain shams University Maternity Hospital in the period between (June to August 2021). The study
included 300 full-term pregnant ladies after elective cesarean section under spinal anesthesia, aged 20-40, BMI 30and
Hb 10. The patients had been randomly allocated to two groups: Group A received 200 ml of warm water with 2
packets of peppermint without sugar 2 hours after the surgery. Group B chewed sugarless chewing gum for 15 minutes
2 hours after the surgery. Results: Statistical analysis of current results showed that time to regain of GIT motility (4.4
± 1.5 versus 2.8 ± 0.9 hours) and passage of flatus (8.3 ± 2.0 versus 7.1 ± 1.8 hours) were significantly longer among
peppermint than gum group. Conclusion: Both peppermint and sugarless gum are effective nonpharmacological options
for enhancement of post-cesarean section motility. The gum was more effective in shortening of time to regain GIT
motility and passage of flatus with higher women's acceptance. No side effects were noted except slight heartburn,
nausea, and vomiting with peppermint of no significant importance.
Keywords: Sugarless chewing gum, Peppermint, Bowel movement.


INTRODUCTION
It appears that peppermint oil may have several
Physiologic postoperative ileus is generally a
mechanisms of action including smooth muscle
benign condition that resolves without serious sequelae.
relaxation (via calcium channel blockade or direct
However, when ileus is prolonged, it leads to patient
enteric nervous system effects); visceral sensitivity
discomfort,
dissatisfaction,
and
prolonged
modulation (via transient receptor potential cation
hospitalization and it must be differentiated from
channels); anti-microbial effects; anti-inflammatory
mechanical bowel obstruction or other postoperative
activity; modulation of psychosocial distress.
complications (1). However, this belief has been
Peppermint oil has been found to affect esophageal,
challenged; the duration of postoperative gastrointestinal
gastric, small bowel, gallbladder, and colonic
dysmotility appears to be shorter than previously
physiology. It has been used to facilitate the completion
thought. Generally, gastric and small intestinal activity
of
colonoscopy
and
endoscopic
retrograde
appears to return within hours of surgery, and colonic
cholangiopancreatography. Placebo-controlled studies
activity returns by postoperative day 2 or 3 (2).
support its use in irritable bowel syndrome, functional
Although the most affected parts of the intestine
dyspepsia, childhood functional abdominal pain, and
are those that have been manipulated during the surgery,
postoperative nausea (5).
there is experimental evidence that inflammation of the

intestinal muscle extends from manipulated areas to
PATIENTS AND METHODS
nonmanipulated parts of the intestinal tract. When the
This cross-sectional study was conducted at Ain
expected time extends beyond what is acceptable, the
shams University Maternity Hospital in the period
patient is diagnosed as having a "prolonged" or
between June and August 2021. The study included full-
"pathologic" postoperative ileus, provided there are no
term pregnant ladies aged 20 to 40 years, BMI 30, Hb
signs of mechanical intestinal obstruction (3).
10, undergoing elective cesarean section under spinal
Chewing gum has been tested to accelerate the
anesthesia.
recovery from postoperative ileus for over a decade. This

intervention is effective in the postoperative period of
Exclusion Criteria:
gastrointestinal surgery and some studies are showing
Women who had any medical disorder or had a
that it can also be effective after a CS.
previous history of bowel surgery or chronic
Most of the studies that tested chewing gum to
gastrointestinal problems (chronic constipation, peptic
enhance post-cesarean recovery of bowel function used
ulcer, and irritable bowel syndrome) or had
between three to 12 pieces of gum per day and chewing
intraoperative or immediate post-operative major
times ranging from 15 to 60 minutes per session (4).
complications or added any antiemetic/ prokinetic/
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3359
Received: 10/6/2021

Accepted: 6/8/2021


Full Paper (vol.851 paper# 119)


c:\work\Jor\vol851_120 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3364-3369
The Role of Diagnostic Hysterolaparoscopy in the Evaluation of
Infertility in Tertiary Care Centers
Ali El-shabrawy Ali, Sherin Attia Shazly Essa, Ahmed Metwally Mohmoud Al Ktway,
Remma Mahmoud Ali Soulah
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt
*Correspondence to: Remma Mahmoud Ali Soulah, Mobile: (+20) 01002132769, E-mail: soulah81@gmail.com

ABSTRACT
Background:
Female infertility constitutes one of the commonest problems in gynecological practice. Infertility is
defined as failure to achieve pregnancy during one year of frequent unprotected intercourse.
Objective: This study aimed to evaluate the role of the combined laparoscopy and hysteroscopy in the diagnosis and
treatment of infertile female.
Patients and methods: This retrospective study was conducted at Gynecologic Endoscopic Unit, Zagazig University
Hospital during the period from December 2020 to May 2021. Two hundred infertile women were included in this
study. They were divided by the following percent 1:1 primary to secondary infertile cases. Group : 50% patients with
primary infertility and group II included 50% patients with secondary infertility. Women aged 20-40 years with normal
hormone profile without male factor infertility were included.
Results:
The frequency of women with arcuate uterus is significantly increased in group than in group II. Regarding
frequency of women with arcuate uterus, bicornuate and very small uterine cavity were significantly increased in group
than in group II and the frequency of women with intrauterine synechia and bilateral narrow corneal end were
significantly higher in group II than in group .
Conclusions
: laparoscopy and hysteroscopy play very important role as diagnostic and therapeutic tools in the infertile
women. Combined diagnostic simultaneous laparoscopy and hysteroscopy should be performed in all infertile patients
before the treatment.
Keywords: Hysteroscopy; infertility; laparoscopy.

INTRODUCTION

Combined laparoscopy and hysteroscopy is
Infertility is defined in specific terms as failure to
considered the gold standard for evaluation of causes of
conceive after one year of unprotected regular
infertility; as the advantages of combined hysteroscopy
intercourse. A broader view of infertility includes, not
and laparoscopic approach is proper assessment of the
being able to carry a pregnancy to term and have a baby
distal tubes and ovaries, peritoneal cavity, and the
(1). Infertility affects about 10% - 15% of couples of
elimination of tubal spasm as a factor of infertility,
childbearing ages. A malfunction in the fallopian tubes
absence of radiation, more precise application of
is responsible for 40-50% of cases, while uterine
instruments and confirmation of achievement of tubal
problems are estimated at about 15% of cases and other
patency during the procedure (5).
factors include an ovulation defect of 20-30% of cases.
The aim of this study was to evaluate the role of
Laparoscopic findings showed endometriosis in
the combined laparoscopy and hysteroscopy in the
majority of primary infertility and polycystic ovarian
diagnosis and treatment of infertile female.
syndrome (PCOS) in majority of secondary infertility

patients along with other pathologies (2).
PATIENTS AND METHODS
Laparoscopic surgery, is a minimally invasive
This retrospective study was conducted at
surgery (MIS), band aid surgery, or keyhole surgery, is
Gynecologic Endoscopic Unit, Zagazig University
a modern surgical technique in which operations in the
Hospital during the period from December 2020 to May
abdomen are performed through small incisions
2021. It included two hundred infertile women aged
(usually 0.5­1.5cm) as opposed to the larger incisions
between 20 and 40 years old. who were divided into
needed in laparotomy. Keyhole surgery displays
two groups: Group , 50% patients with primary
images on TV monitors to magnify the surgical
infertility and group II that included 50% patients with
elements. Laparoscopic surgery includes operations
secondary infertility.
within the abdominal or pelvic cavities. It belongs to

the broader field of endoscopy (3).
Inclusion criteria: All fulfilled the following criteria:
Hysteroscopy is a well-established diagnostic and
Primary or secondary infertility of more than 1 year
operative technique. Hysteroscopy procedures are
duration. Primary infertility patients were those who
highly appreciated mainly for their minimal
had never conceived before, while secondary infertile
invasiveness, suitability for office gynecology, cost
patients had at least one prior conception, irrespective
effectiveness and safety (4).
of the outcome. Ultrasonic folliculometry was
suggestive of ovulation.



This article is an open access article distributed under the terms and conditions of the Creative
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3364
Received: 11 /6 /2021


Accepted: 7 /8 /2021



Full Paper (vol.851 paper# 120)


c:\work\Jor\vol851_121 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3370-3374

Effect of Plyometric Exercise on Shoulder Internal Rotation after
Overuse Injuries in Adolescent
Mahmoud Megahed Bagago*, Khaled Ahmed Olama, Mohamed Ismail Elassal
Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
*Corresponding author: Mahmoud Megahed Bagago, Mobile: (+20) 01092193365, E-Mail: mahmoudalibagago@gmail.com


ABSTRACT
Background:
Shoulder overuse injuries represent a common complaint among adolescents. Overuse injuries usually
occur as a result of muscles weakness and imbalance between shoulder external (ER) and internal rotation (IR). Muscle
tendon units may have elevated risk of overuse injuries in the actively growing child because as the bone lengthens, the
muscle-tendons have to stretch to keep up. This relative tightness and related poor flexibility place young athletes at
increased risk of muscle-tendon strains, avulsion injuries, and muscle tears.
Objective: The aim of this study was to determine the effect of plyometric exercise on shoulder internal rotation for
adolescent after overuse injuries.
Patients and methods: A total 30 adolescents boy children were enrolled in this study, their age ranged between 15 to
18 years old. The shoulder internal rotation was evaluated by using universal goniometer. The pain intensity was
evaluated by using Wong Backer Faces pain scale (WBFS).
Results: All children were graded as 4 "hurts little" by WBFS. There was a significant decrease in glenohumeral internal
rotation deficit (GIRD) and increase shoulder internal rotation post treatment compared with that pretreatment in the
group A and B (p > 0.001).
Conclusion: According to results we concluded that there was significant improvement in shoulder internal rotation
and decrease in GIRD for adolescents' shoulders after overuse injuries.
Keywords: Internal rotation, Glenohumeral internal rotation deficit, Overuse injuries, Plyometrics exercise.

INTRODUCTION

Overuse injury is a broad term used to describe an
weakness, or glenohumeral internal-rotation deficit,
injury caused by repeated micro-trauma, rather than
resulting in internal impingement or labral injury (or
a specific or single injury event [1].
both) [6].
Muscle tendon units may have elevated risk of
GIRD is a reduction in the IR angle of the throwing
overuse injuries in the actively growing child because
shoulder in comparison to the non-throwing shoulder
as the bone lengthens, the muscle-tendons have to
and considered a primary factor in the development of
stretch to keep up. This relative tightness and related
shoulder injuries [7].
poor flexibility place young athletes at increased risk of
Strength balance between agonist and antagonist
muscle-tendon strains, avulsion injuries, and muscle
muscles around the scapula and shoulder provides
tears [2].
dynamic glenohumeral joint stabilization, which is
Although little research has identified causative
needed for optimum performance in overhead sports [8].
factors for overuse injuries in children and adolescents,
Plyometric exercises are a quick, powerful
these injuries may be caused by training errors,
movement using a pre-stretch or counter movement,
improper technique, excessive sports training,
which involves the stretch shortening cycle. The
inadequate rest, muscle weakness and imbalances [3].
purpose of plyometric exercises is to increase the power
Overuse injuries in the pediatric population represent a
of subsequent movements by using both the natural and
significant health care concern. Some reports and
elastic components of muscle, and tendon and the
clinical observations indicate that 50% of pediatric
stretch reflex [9].
patients present to sports medicine clinics for chronic
The aim of this study was to determine the effect
injuries [4].
of plyometric exercise on shoulder internal rotation for
Given the incomplete development of their
adolescents after overuse injuries.
musculoskeletal systems, adolescents may be more

susceptible to sports injuries than adult athletes. Sport-
PATIENTS AND METHODS
specific adaptations at the glenohumeral joint could
This study included thirty male adolescents; their
occur during adolescence because athletes begin
age ranged from 15 to 18 years old, were selected from
participating in high-performance sports in early
el Menshawy General Hospital Tanta City. Those
childhood [5].
meeting the criteria of inclusion were divided
Shoulder injuries in overhead athletes are commonly
according the type of intervention into two groups
due to repetitive use, muscle fatigue, may be related to
(group A and B).
scapular dyskinesia rotator cuff injury and

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3370
Received: 8 /6 /2021

Accepted: 4 /8 /2021


Full Paper (vol.851 paper# 121)


c:\work\Jor\vol851_122 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3375-3379

Incidence of Hepatocellular Carcinoma in Patient with
Elevated Alpha Fetoprotein before DAAS
Ahmed Mohamed Mansour Abd El Shafi, Abd El Wehab Fathi Ali, Mohammed Fakhery Mohamed Morsey
Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine,
Al-Azhar University (Assiut), Egypt.
*Corresponding author: Ahmed Mohamed Mansour Abd El Shafi, Mobile: (+20) 01002159714,
E-Mail: ahmedserag932@yahoo.com

ABSTRACT
Background:
Management of chronic infection with hepatitis C virus (HCV) with direct acting antivirals (DAAs)
agents achieves high virological response. Recently, there is a matter of controversy about occurrence of hepatocellular
carcinoma (HCC) following those agents. Objective: This study aimed to evaluate the efficacy of alpha fetoprotein
(AFP) in development of HCC following DAAs therapy. Patients and methods: two hundred patients with chronic
HCV infection who were eligible for DAAs therapy were recruited. Those patients were followed up for one year
following therapy to detect development of HCC. Patients were grouped into either with normal AFP (100 patients) or
high AFP (100 patients). Results: Majority (84%) of patients were males with overall mean age of 43.87±12.76 years.
There were no significant differences between both groups of patients as regard baseline data. With exception of 4% of
patients, all of them reached the sustained virological response (SVR). Frequency of HCC detection was higher among
those patients with high AFP (9 (9%) vs 1 (1%); P< 0.001). We found that liver cirrhosis; FIB-4, APRI and AFP were
predictors for HCC. AFP had the best diagnostic accuracy for prediction of HCC following DAAs
Conclusion: Patients who received DAAs for HCV infection should be regularly screened for development of HCC.
Keywords: Hepatocellular carcinoma, Alpha fetoprotein, Direct acting antivirals.

INTRODUCTION

pregnancy or inability to use effective contraception,
Progression to liver cirrhosis and development
inadequately controlled diabetes mellitus (glycosylated
of hepatocellular carcinoma (HCC) are the major
hemoglobin more than 9 %), and/or patient's refusal
complications of hepatitis C virus (HCV) infection.
Those enrolled patients were subdivided based
Pathophysiological mechanism to develop HCC and its
on baseline level of alpha fetoprotein into (5): One
progression till metastasis is considered a complex
hundred patients with normal AFP (< 10 ng/ml), and one
process. This process required long term interaction
hundred patients with high AFP ( 10 ng/ml).
between the viral components and defense mechanism of
Complete history taking and clinical assessment
the host (1). Sofosbuvir (SOF) is one of the new direct
were done. The following data were gathered; age, sex,
acting antivirals (DAAs) that could be used with other
body mass index, previous interferon therapy for HCV
agents belong to DAAs and produce high safety profile
infection, residence, and comorbidities as diabetes
and efficacy. Its tolerability and efficacy was proofed
mellitus, hypertension, ischemic heart disease and
whatever age, sex, HCV genotype and stage of hepatic
chronic kidney disease.
fibrosis (2).

Alpha-fetoprotein (AFP) is released form
Laboratory tests and serum biomarkers:
gestational sac in the early embryonic life then liver
The investigations that were ordered are
synthesize it later on. Its high level in cirrhotic patients
complete blood picture, liver function tests, kidney
carries a risk for HCC (3). This work was conducted to
function tests including blood urea and serum creation.
assess the predictive value of baseline AFP in prediction
Also, baseline AFP was assessed in all patients. Different
of HCC following DAAs therapy.
markers of fibrosis were assessed at baseline during

follow up; the AST to platelet ratio index (APRI) score
PATIENTS AND METHODS
and
Fibrosis-4
(FIB-4)
score.
Abdominal

A cross sectional study was conducted in period
ultrasonography was performed in all patients at baseline
between 2020 and 2021 at Outpatients Clinics, Al-Azhar
and SVR24 for the detection of focal lesions and hepatic
University Hospitals. Based on previously reported HCC
decompensation. Screening for HCC development
following DAAs therapy that was 2.69% (4) with
occurred every three months till one year after end of
considering 3% alpha error and 95% confidence interval,
therapy by abdominal ultrasound. Any suspected lesion
a minimum of 112 patients receiving DAAs were
during follow up, a dynamic imaging either computed
required.
tomography and/or magnetic resonance image would be
Two hundreds patients with HCV infection who
done.
were eligible for direct acting antivirals (DAAs) were

enrolled. Any patient with one or more of the following
Ethical consideration:

criteria was excluded; patients aged <18 years, platelet
Approval of the study was obtained from the
count less than 5000 /mm3, extra hepatic malignancy,
Research Ethics Committees in Faculty of Medicine,

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3375
Received: 9 /6 /2021

Accepted: 5 /8 /2021


Full Paper (vol.851 paper# 122)


Measurement of Serum Lipid Level in Children with Congenital Heart Diseases The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3380-3384

Urinary Uric Acid/Creatinine Ratio as A diagnostic Marker for Perinatal Asphyxia
Esraa Ali Mohammed Ali Yousef*1, Lotfy Mohammed Elsayed1,
Ali Abd EL-Hameed Abdo1, Noha Abd El-Halim Mohamed2, Mohammed M. Shehab1
Departments of 1Pediatrics and 2Biochemistry, Faculty of Medicine ­ Zagazig University, Egypt.
*Corresponding author: Esraa Ali Mohammed Ali Yousef, Mobile: (+20)01030071306, E-mail: tebmisr1@gmail.com

ABSTRACT
Background:
Brain injury that occurs during the perinatal period is one of the most commonly recognized causes of
severe long-term neurological deficits in children often referred to as cerebral palsy (CP) that affects approximately 2-
3 per 1000 school-aged children.
Objectives: The aim of this study was to detect the validity of urinary uric acid/creatinine ratio (UUA/Cr) in the
identification of perinatal asphyxia and its role in grading asphyxia according to severity of hypoxic ischemic
encephalopathy.
Patients and methods: This prospective study was carried out at Neonatology Unit or delivered at Gynecology
Department of Zagazig University Hospitals during the period from July 2020 to July 2021. The study included 48
newborns with hypoxic ischemic encephalopathy (HIE). They were divided into two groups each group included (24)
patients. Group I included 24 babies with perinatal asphyxia. Group II included 24 healthy babies (with gestational ages
and weights matched to cases) as control group. The primary outcome was determining the values of UUA/Cr in
newborns with hypoxic ischemic encephalopathy and its relation with different stages of HIE.
Results:
UUA/Cr was significantly higher in cases as compared to control and was significantly higher in preterm babies
when compared to full-term ones (this was applied for both cases and control). Moreover, significant difference in
UA/Cr ratio in comparing the mild, moderate and severe groups of HIE.
Conclusion:
We found that UA/Cr ratio level was increased in the asphyxiated newborns in comparison to normal
healthy newborns.
Keywords:
Apgar score, Hypoxic ischemic encephalopathy, Brain injury, Urinary uric acid/ creatinine ratio.

INTRODUCTION

PATIENTS AND METHODS
Perinatal asphyxia is still one of the significant
This study was carried out on 48 neonates admitted to
causes of mortality and long-term morbidity in spite of
Neonatology Unit or delivered at Gynecology Department
major advances in perinatal medicine. Failure to initiate
of Zagazig University Hospitals during the period from July
or sustain respiration after birth" has been defined as
2020 to July 2021.
criteria for the diagnosis of asphyxia by WHO. Perinatal

asphyxia results in hypoxic injury to various organs
Ethical approval:
including kidneys, lungs and liver but the most serious
Written informed consent was obtained from all
effects are seen on the central nervous system (1).
participants' parents and the study was approved by
Anyway, asphyxia is considered one of the most
the Research Ethical Committee, Faculty of
preventable causes of morbidity and mortality so many
Medicine, Zagazig University. The work has been
asphyxiated babies might profit from appropriate and
carried out in accordance with The Code of Ethics of
timely treatment and resuscitation when asphyxia is
the World Medical Association (Declaration of
properly diagnosed (2).
Helsinki) for studies involving humans.
It has been established that an Apgar score at 5

minutes is a better tool than 1 minute score for the
Inclusion criteria: Apgar score at 1 and 5 minutes 3.
assessment of newborn. However, the Apgar score is an
Umbilical cord arterial pH < 7.2. Umbilical cord arterial
expression of the infant's physiological conditions and
base deficit > 10 mEq/L. Postnatal clinical
includes subjective components (3). The limitations of
manifestations of CNS insult (e.g. seizures, lethargy,
Apgar score have prompted researchers to explore into
coma, abnormal tone and reflexes).
other molecular markers of organ damage. Studies

suggest role of UUA/Cr in asphyxiated babies. Oxygen
Exclusion criteria:
deficiency increases the level of hypoxanthines and uric
Cases of oliguria [urine output below 0.5
acid due to degradation of purines, which are important
ml/kg/hour (estimated after the 2nd day) or abnormal
sources of free radicals, which cause hypoxic brain
renal functions (serum creatinine level above 1.25
injury (4).
mg/dl)]. These neonates were excluded to avoid
This study aimed to detect the validity of UUA/Cr
misleading uric acid levels. Neonates who started oral
in the identification of perinatal asphyxia and its role in
milk feeding to avoid protein diet effect on increased
grading asphyxia according to severity of hypoxic
uric acid excretion level. Cases with congenital
ischemic encephalopathy.
anomalies.


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3380
Received: / /2021


Accepted: / /2021


Full Paper (vol.851 paper# 123)


c:\work\Jor\vol851_124 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3385-3390

Renal Resistive Index as An Indicator of Atherosclerotic Changes and
Renal Damage in Hypertension and Its Role in Therapeutic Intervention
Ahmed Elshimy*1, Ghada El Shimy2, Tari George Michael3,
Amgad S. Abdel-Rahman1, Mohamed M. Abd El Aziz1
Departments of 1Radiology and 3Internal Medicine, Ain Shams University, Cairo, Egypt.
2Endocrine Division, Augusta University, Georgia, USA.
*Corresponding author: Ahmed Elshimy, Mobile: (+20) 01001294030, E-Mail: ahmedchimi@hotmail.com

ABSTRACT

Background: Renal resistive index (RRI) was suggested as an indicator of renal atherosclerotic changes in hypertensive
patients with possible prognostic role in treatment.
Objectives: This study aimed to assess RRI in hypertensive subjects, its relation to other predictors of target organ
damage and prognostic usefulness in management, specifically, with different antihypertensive drugs.
Patients and methods:
The study included 100 newly diagnosed hypertensive adult subjects, who underwent abdominal
ultrasound with Doppler to assess RRI, which was correlated with their clinical parameters including estimated
glomerular filtration rate (eGFR) and other subclinical atherosclerosis markers as carotid intima-media thickness (IMT)
and aortic knob width (AKW) calculated from chest radiograph. Another 50 non hypertensive subjects were assessed
for their RRI as a control group. In addition, some of hypertensive patients were followed up one year after starting
treatment was done and effects of different antihypertensive agents on their RRI were compared.
Results:
The mean baseline RRI in hypertensive patients (0.71 ± 0.04) was significantly higher compared to control
group (0.60 ± 0.02) and was positively significantly correlated with their clinical parameters (age, systolic, diastolic,
pulse pressure and eGFR) and with their atherosclerotic parameters (IMT and AKW). In addition, ACE/ARBs treatment
was associated with significant decrease of RRI compared to other drugs [beta blocker (BB) and calcium channel blocker
(CCB)], indicating their more renal protective effect.
Conclusion:
Assessment of RRI in patients with primary hypertension not only reflecting intrarenal perfusion changes,
but it indicates systemic atherosclerotic changes, so it can be useful as prognostic parameter in addition to its possible
therapeutic implications.
Keywords: Renal resistive index, Atherosclerosis, Hypertension.

INTRODUCTION
years in assessment of many kidney diseases as chronic
Hypertension is a major health problem in all
allograft rejection of the kidney (3), stenosis of the renal
countries, affecting approximately 1 billion individuals
artery (4,5), detection of obstructive renal disease and
worldwide. In Egypt, prevalence of hypertension was
progress of chronic kidney disorders (6). It was also used
estimated to be 26.3% among adult subjects and
as a prognostic indicator of outcome in critical patients
increases with age, to reach around 50% of Egyptians
(7, 8). Renal RI was suggested to reflect atherosclerotic
over 60 years. It is considered a major risk factor for
changes secondary to hypertension either on the reno-
occurrence of cardio-vascular events, in addition to
vascular or systemic circulation. So, it was proposed to
subsequent renal and cerebro-vascular complications (1,
be used as a parameter of renal injury in hypertensive
2).
patients that may be affected by different
Aortic knob width (AKW) represents a
antihypertensive medications (9, 10).
measurement of the aortic arch and upper part of the
Accordingly, this study aimed to evaluate the
descending aorta assessed in X-ray of the chest. Many
RRI changes in adult Egyptian hypertensive subjects
studies of hypertensive patients showed intimate
with no other risk factors of renal vascular disease, its
relation between AKW and cardiovascular diseases (3, 4).
relation to other target organ damage predictors and its
As AKW was found to be increased with age and
prognostic usefulness in the diagnosis and management
atherosclerosis, so it was suggested to be a major
of these patients, specifically, the impact of different
predictor of organ damage occurring in hypertension (5).
therapeutic agents of hypertension on it.
Increase of intima-media thickness (IMT) of

the carotid artery is the first structural change occurring
PATIENTS AND METHODS
in atherosclerosis and so it is considered as another
One hundred patients 35 years old, newly
marker of target organ damage, which usually develops
diagnosed with essential hypertension attending
slowly and gradually, in different velocity resulting in
Outpatient Internal Medicine Clinic, Ain Shams
many problems (6).
University Hospital during the period from March to
On the other hand, the renal resistive index
December 2020 were included in this study.
(RRI) assessed by Doppler ultrasound was used for
Hypertension was considered when blood pressure

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3385
Received: 11/6/2021

Accepted: 7/8/2021


Full Paper (vol.851 paper# 124)


Diabetes Mellitus Type 1 In Children The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3391-3395

Relation between Mir-196a2 and Mir-146a Polymorphisms and
Susceptibility to DM1 in Egyptian Children
Hanaa Abdulfatah Mostafa1, Ashgan Abdalla Alghobashy1, Heba Fouad Pasha2, Yaser Mukhtar Alati*1
Departments of 1Pediatrics and 2Medical Biochemistry, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Yaser Mukhtar Alati, Mobile: (+20)01018454325, E- mail: yaseralati01018@gmail.com

ABSTRACT
Background:
MicroRNAs (miRNAs) are small non-coding RNA molecules that control the post-transcriptional gene
expression. They play a pivotal role in the regulation of important physiological processes. Variations in miRNA
genes coding for mature miRNA sequences have been implicated in several diseases, however, its role in type 1
diabetes mellitus (T1DM) is still underestimated. Objective: To investigate the association of miR-196a2
(rs11614913) and miR-146a (rs2910164) polymorphisms with T1DM in Egyptian children and adolescents.
Patients and Methods: A case-control study was done on 100 Egyptian children diagnosed with T1DM and
additionally, 100 healthy age- and sex-matched subjects non-diabetic (control group) in the Department of Pediatrics
and Endocrine and Metabolism Unit, Zagazig University Children Hospital from March 2021 to August 2021.
Random blood sugar (RBS), glycosylated hemoglobin (HbA1c) and laboratory assessment for lipid profile were done
for all patients.
Results: There was no significant difference between CC, CT and TT genotype in age, BMI, sex, onset, and disease
duration, HbA1c, TC, LDL or HDL. There was a significant increasing in TG level in TT genotype compared to other
genotypes. There was no significant differences between different genotypes in any of the studied parameters.
Conclusion: The present study demonstrated that variants rs11614913 T/C and rs2910164 G/C were linked with the
risk of T1DM. The data suggested that rs11614913 T/C and rs2910164 G/C could be considered as novel risk factors
in the pathogenesis of T1DM in the Egyptian population.
Keywords: MIR146A, MIR196A2, miRNAs, T1DM.

INTRODUCTION
upregulated 9-fold in cells transfected with miR-
Type 1 diabetes mellitus (T1DM) results from
196a2-C allele but increased only by 4.5-fold with
a cellular mediated autoimmune destruction of
miR-196a2-T allele. Other reporter demonstrated that
pancreatic -cells, leaving patients insulin-dependent
increased expression of miR-196a2 was associated
for life. The triggering of autoimmunity against -cells
with the C allele (6).
arises from a multifaceted interaction between multiple
Currently, different case control studies have
genetic and environmental risk factors (1).
put the spotlight on miR-196a2 also in various human
miRNAs are key regulators of gene expression
diseases regarding its role in developmental control,
and, like other genes, their coding sequences are
regulation of immune response and regulation of cell
subject to genetic variation. Polymorphisms in miRNA
differentiation and migration. Jameel et al. (3) study
genes can have marked effects on miRNA
found that miR-196a2 polymorphism was associated
functionality at all levels, including miRNA
with diabetes disease. The study of Assmann et al. (7)
transcription, maturation and target specificity and,
indicates that miR-146a rs2910164 polymorphisms are
consequently, they may contribute to T1DM
associated with protection for T1DM in Brazilian
pathogenesis (2). Recent studies have reported that
populations. These associations are biological
miRNAs are critical posttranscriptional regulators of
plausible considering the involvement of miR-146a in
30­50% of human gene expression and thus they may
immunity and inflammation, which are key players in
contribute in different pathological conditions. The
T1DM pathogenesis.
SNPs in the sequences of miRNAs genes are relatively
The aim of this study was to investigate the
rare and highly conserved, which indicates the
association of miR-196a2 (rs11614913) and miR-146a
functional importance of these SNPs. The miR-196a2
(rs2910164) polymorphisms with T1DM in Egyptian
rs11614913 C > T polymorphism is located on
children and adolescents.
chromosome 12 (12q13.13) (3).

To date, miR-196a gene polymorphism of
PATIENTS AND METHODS
rs11614913 is one of the most investigated SNPs in
A case-control study design was conducted on
case control studies concerning cancer and cardiac
100 Egyptian children diagnosed with T1DM aged
diseases but no previous study has reported its
from 3 to 18 years and 100 healthy age- and sex-
association with T1DM (4). The association of miR-
matched subjects were selected as non-diabetic group
196a rs11614913 with the previous diseases could be
(controls) recruited from the Department of Pediatrics
explained by findings reported by Hoffman and his
and Endocrine and Metabolism Unit, Zagazig
colleagues (5) that miR-196a2 expression was
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3391
Received:10/6 /2021

Accepted:6/8 /2021


Full Paper (vol.851 paper# 125)


c:\work\Jor\vol851_126 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3396-3401

Serum Interleukin-15 in Egyptian Vitiligo Patients
Aliaa Mohamed Eladl, Mohamed Khalid Galal, Yousra Ibrahim El-tantawy, Mohamed Hussein Elmogy
Department of Dermatology, Andrology & STDs, Faculty of Medicine, Mansoura University, Egypt
*Corresponding author: Aliaa Mohamed Eladl, Mobile: (+20) 01027244597, E-Mail: aliaaeladl@icloud.com

ABSTRACT


Background: Vitiligo is a multifactorial acquired depigmenting skin disorder with poorly understood etiology. It is
characterized by white macules and patches due to loss of functioning epidermal melanocytes. The most widely accepted
hypothesis is the autoimmune-mediated melanocyte destruction through the interplay between cellular immunity,
humoral immunity, and cytokine action. Peri-lesional vitiligo skin biopsies revealed CD8+ cytotoxic T (cT) cell
infiltration proposing a cytotoxic attack against melanocytes. It has been hypothesized that IL-15 might play a role in
this autoimmune disease; thus, inhibiting IL-15 activity might be a breaking new therapeutic strategy in the treatment
of vitiligo.
Objective:
The current study was conducted to assess the serum level of IL-15 in patients with non-segmental vitiligo,
and to correlate its levels with disease duration, extent, and activity.
Patients and methods: The present study was a case-control study conducted on three groups of subjects attending the
Dermatology Outpatient Clinic in Mansoura University Hospitals: 30 patients suffering from active non-segmental
vitiligo, 30 patients with stable non-segmental vitiligo, and 30 age- and sex-matched healthy controls.
Results:
Healthy controls and vitiligo cases demonstrated insignificant differences in terms of the demographic
characteristics as well as the risk factors. IL-15 level demonstrated insignificant correlation with the gender, smoking,
stress, and clinical type in both vitiligo groups. Higher IL-15 level was suggested to be independent risk predictor for
vitiligo occurrence and severity but not activity.
Conclusion: It could be concluded that, vitiligo cases were associated with a significant elevation in IL-15 level.
Keywords:
Vitiligo Extent Score, Cytotoxic T, Radioimmunoassay, Superoxide dismutase, Enzyme-linked
immunosorbent assay

INTRODUCTION


Vitiligo is an acquired depigmenting skin disorder
Interlukin-15 is a pleiotropic cytokine that plays an
that affects 0.5­1% of the population worldwide and
important role in both the innate and adaptive immune
characterized by white macules and patches due to loss
system and was found to be a critical factor for the
of functioning epidermal melanocytes (1). Vitiligo has
development & proliferation of CD8+ memory T cells
been classified into segmental vitiligo, non-segmental
(11, 12). The aim of this study was to assess the serum
vitiligo (Acrofacial, Mucosal > 1 site, Generalized,
level of IL-15 in patients with non-segmental vitiligo;
Universal, Mixed), and undetermined / unclassified
and to correlate its levels with disease duration, extent,
vitiligo (Focal, Mucosal, <1 site) (2). Vitiligo is a
and activity.
multifactorial disease with poorly understood etiology.

There are three major hypotheses for the pathogenesis
PATIENTS AND METHODS
of vitiligo; autoimmune, neural and biochemical
This case-control study included a total of 60
(autocytotoxic) hypothesis (3, 4). Today the autoimmune
patients suffering from vitiligo and 30 age-matched
pathogenesis of the disease has become a rapidly
healthy controls, attending at Dermatology Outpatient
evolving field of research. An autoimmune etiology is
Clinic, Mansoura University Hospitals.
supported by the frequent association of vitiligo with
The included subjects were divided into three
autoimmune diseases and presence of autoantibodies
groups; Group 1 consisted of 30 patients suffering from
and autoreactive T cells against melanocyte antigens (5,
active non-segmental vitiligo (active vitiligo means
6).
patients reporting worsening of already existent lesions
Many of the functions of immune cells are
as well as the development of new lesions during the
mediated through cytokines, and several studies have
previous 3 months), Group 2 consisted of 30 patients
analyzed the presence of these molecules in vitiligo
with stable non-segmental vitiligo, and Group 3
patients (7, 8). Cytokines, which are pivotal in
(control) consisted of 30 age-matched healthy controls
maintaining immune homeostasis, are crucial in vitiligo
of both genders without previous, or current, or any
pathogenesis; and several studies indicate that there is
family history for vitiligo nor autoimmune diseases.
an imbalance between pro- and anti-inflammatory

cytokines in the skin and serum of vitiligo patients (9).
Inclusion criteria
One of these cytokines, interlukin-15 (IL-15), is a
Patients with active and stable non-segmental
proinflammatory cytokine and its expression is
vitiligo receiving no treatment for vitiligo in the past 1
upregulated under inflammatory conditions (10).
month.

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


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3396
Received: 12/6 /2021

Accepted: 8 /8 /2021


Full Paper (vol.851 paper# 126)


c:\work\Jor\vol851_127 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3402-3406

Effect of Phototherapy on Serum Calcium and Magnesium Levels in Neonates
Receiving Phototherapy for Neonatal Jaundice
Hibatallah A. Elshenawi1, Rania E. Abdelatty1, Eman R. Abdelgawad2, Ismail A. Ramadan1
Departments 1Pediatrics and 2Clinical Pathology, Benha Faculty of Medicine, Benha University, Benha, Egypt
*Correspondence author: Hibatallah A. Elshenawi, Mobile: (+20) 01126576769,
E-mail: heba.elshenawi@gmail.com

ABSTRACT
Background:
Neonatal hyperbilirubinemia is one of the most common newborn entities. Phototherapy has been the
therapy of choice for neonates suffering from indirect hyperbilirubinemia. One of the consequences of phototherapy is
hypocalcaemia and hypomagnesaemia. Phototherapy leads to inhibition of pineal gland by transcranial illumination
resulting in a decline in melatonin level, which leads to increased calcium absorption by bones.
Patients and Methods: This study was conducted on 50 full-term jaundiced neonates (23 males & 27 females) received
phototherapy for treatment of neonatal indirect hyperbilirubinemia. Cases were selected from those admitted to NICU
of Benha University Hospital. Serum calcium, serum magnesium were measured in their blood samples before
phototherapy and after 48 hours and at the end of phototherapy.
Results: In our study hypocalcemia was assessed as a complication of phototherapy in newborns managed for neonatal
hyperbilirubinemia as mean calcium was 8.63 ± 1.54 mg/dl pre-phototherapy and was 8.22 ± 1.64 mg/dl post-
phototherapy. The difference was as statistically significant (p < 0.001). Calcium level was lower after phototherapy.
Pre-phototherapy, 12 (24.0%) showed hypocalcemia (< 8 mg/dl) and 38 (76.0%) showed normal calcium (> 8 md/dl).
Post-phototherapy, 19 (38.0%) showed hypocalcemia (< 8 mg/dl) and 31 (62.0%) showed normal calcium (> 8 md/dl).
The difference was as statistically significant (p = 0.039). Hypocalcemia was higher after phototherapy. Whereas, mean
Mg was 2.25 ± 0.32 mg/dl pre-phototherapy and was 2.03 ± 0.38 mg/dl post-phototherapy. The difference was as
statistically significant (p < 0.001). Mg level was lower after phototherapy. Pre-phototherapy, 11 (22.0 %) showed hypo
and 39 (78.0 %) showed normal. Post-phototherapy, 17 (34.0 %) showed hypo and 33 (66.0 %) showed normal. The
difference was as statistically non-significant (p = 0.238).
Conclusion: Hypocalcemia is a common complication of phototherapy whereas hypomagnesaemia cannot be
considered as a complication of phototherapy.
Keywords: Phototherapy, Hyperbilirubinemia, Calcium, Magnesium.


INTRODUCTION

Hyperbilirubinemia is the most common
hypocalcemic effect and increases bone uptake of
abnormal physical finding in the first week of life and is
calcium and induces hypocalcemia (6).
observed in approximately 60% of term infants and 80%
Magnesium plays a role in protecting the neural
of preterm infants (1). Kernicterus is a devastating and
system against hypoxia and neurotoxic effects of
disabling neurologic disorder characterized by the
bilirubin, through blocking N-methyl-D-aspartate
following clinical tetrad: choreoathetoid cerebral palsy,
receptor) NMDA receptor. Magnesium ion is one of the
high-frequency sensorineural hearing loss, palsy of
most important complex antagonist regulators of
vertical gaze, and dental enamel hypoplasia.
bilirubin molecule/ionic canal/NMDA receptor in
Kernicterus is a pathologic diagnosis, describing the
humans. Bilirubin leads to hyperactivity of the NMDA
yellow discoloration of the deep nuclei of the brain (2).
receptor and exerts neurotoxic effects through binding
Phototherapy has been the therapy of choice for
to NMDA, which has a key role in synaptic physiologic
neonates suffering from indirect hyperbilirubinemia. It
functions and memory (7).
reduces the plasma levels of unconjugated bilirubin,
The signs of disorder in magnesium and
preventing kernicterus and decreasing the need for
calcium are, to some extent, similar. In the recent years,
exchange transfusion (3). Phototherapy has some
limited research showed that phototherapy should be
complications such as insensible water loss, mutation
considered as a risk factor for hypocalcemia (8).
and DNA strand break, hyperthermia, tremors, retinal
Hypocalcemia is defined as total serum calcium
damage, bronze baby syndrome, and affection of
concentration of < 7 mg/dl (1.75 mmol/L) in preterm
maternal-infant interaction (4). One of the complications
and serum calcium < 8 mg/dl (2 mmol/L) in term
of phototherapy in neonates includes hypocalcemia and
neonates. It can cause serious complications like
hypomagnesaemia (5). The mechanism of hypocalcemic
neuromuscular irritability; myoclonic jerks, jitteriness,
effect of phototherapy was reported by inhibition of
convulsion, cyanosis, apnea and laryngospasm.
pineal gland via transcranial illumination, resulting in
Moreover, cardiac manifestations like tachycardia,
decline of melatonin secretion, which blocks the effect
heart failure, prolonged QT interval and decreased
of cortisol on bone calcium. Cortisol has a direct
contractibility are also seen due to hypocalcemia (9).

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


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3402
Received: 12 /6 /2021

Accepted: 8 /8 /2021


Full Paper (vol.851 paper# 127)


Predictors of quality of life among adolescents and young adults with a bleeding disorder The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3407-3412

Impact of Hemophilia on Health-Related Quality of Life in Pediatric Population
Osama Rushdy Elsafy1, Mervat Atfy Mohammed1,
Nelly Raafat Abdelfatah2, Ishtaiwi Elbahlul Ishtaiwi*1
Departments 1Pediatrics and 2Psychiatry, Faculty of Medicine ­ Zagazig University, Egypt.
*Corresponding author: Ishtaiwi Elbahlul Ishtaiwi, (+20)01065359115, E-mail: priority11n@yahoo.com

ABSTRACT
Background:
The health-related quality of life (HRQoL) of patients with hemophilia is negatively affected by both
the disease and treatment. Recurrent bleeding and resulting complications such as joint and muscle damage, and pain
and disability, can significantly affect patients' HRQoL.
Objective: This study aimed to improve the current status of health related quality of life (HR-QOL) in pediatric
population with hemophilia using an Arabic version of (EQ-5D-5L and EuroQoL Egypt) questionnaire.
Patients and Methods: This study was carried out during outpatient visits in the Department of Pediatrics
Hematology and Oncology Unit at Zagazig University Children Hospital on 48 cases ranged from 4-16 years during
the period from January 2021 to July 2021. Patients were divided equally into 2 groups; group I included 24 children
from (4 to 10 years) had hemophilia A and Group II 24 children from (11 to 16 years) had hemophilia B.
Results: In our study, it was found that most frequent manifestation in younger patients were hemarthrosis (70.8%)
followed by epistaxis (62.5%) and bleeding after circumcision (60.4%), while in older patients, most frequent
manifestation were hemarthrosis (87.5%) followed by bleeding after circumcision (75%), which reflects bad quality of
life in older age group (10-16 years), which was attributed to frequent bleeding events and its complication.
Conclusions: Subscale impairments, severity of hemophilia, barriers to hemophilia care, presence of support groups
are factors that significantly affect and predict the QOL of Egyptian children with hemophilia. Addressing these
concerns may amplify their understanding of the disease and further improve their quality of life.
Keywords: Chronic pain, Hemophilia, Pain management, Patient adherence, Prophylaxis.

INTRODUCTION

Hemophilia A and B are inherited bleeding
care. In the case of hemophilia, the factors which stand
disorders due to a deficiency of coagulation factors.
out are: restrictions to physical activities, the concern
Bleeding episodes are the main consequence of
about hemorrhages that may be life-threatening, the
hemophilia. Chronic arthropathy caused by repeated
development of arthropathy, the need for orthopedic
joint bleeding can lead to joint pain, reduction in joint
procedures and infectious diseases, vectorized by
range of motion, and permanent joint damage and
blood or hemoderivatives (3).
disability. Moreover, internal bleeding in some parts of
This study aimed to improve the current status
the body, such as the brain, throat, and abdomen, can
of health related quality of life (HR-QOL) in pediatric
be life-threatening and cause disability in the absence
population with hemophilia using an Arabic version of
of prompt treatment. Clinical conditions and disease
(EQ-5D-5L and EuroQoL Egypt) questionnaire.
progression of hemophilia can be evaluated by

performing joint examination and/or monitoring
PATIENTS AND METHODS
bleeding frequency and severity. However, these
This study was carried out during outpatient
objective clinical measurements limit the functional
visits in the Department of Pediatrics Hematology and
status assessment of hemophilia patients (1).
Oncology Unit at Zagazig University Children
The assessment of health-related quality of life
Hospital on 48 cases ranged from 4-16 years during
(HRQoL) in hemophilia as a patient-reported outcome
the period from January 2021 to July 2021. Patients
provides direct information about hemophilia patients'
were divided equally into 2 groups: Group I: included
general well-being as well as the effects of hemophilia
24 children from (4 to 10 years) had hemophilia A,
and treatment outcomes. The generic assessment of
and group II: 24 children from (11 to 16 years) had
HRQoL in hemophilia started in 1990. Subsequently,
hemophilia B.
both generic and disease-specific instruments have

been used to assess the HRQoL of hemophilia patients.
Ethical considerations:
The EQ-5D Questionnaire is generic HRQoL
Written informed consent was obtained
instruments (2).
from all children's' parents or their relatives and
The quality of life related to the health
the study was approved by the Research Ethical
(QOLRH) may be influenced by factors such as the
Committee of Faculty of Medicine, Zagazig
disease and its treatment, the manner in which the
University (International review board IRB#:6752-
person copes with his/her problem and the access to
30-1-2021).


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3407
Received: 12 /6 /2021

Accepted: 8 /8 /2021



Full Paper (vol.851 paper# 128)


c:\work\Jor\vol851_129 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3413-3414
Intralesional Platelet-Rich Plasma in the Treatment of
Oral Lichen Planus: Review Article
Asmaa El-sayed Attia El-sayed, Soheir Mohammed Ghoneimy,
Mohamed Ibrahim El-Ghareeb, Kamal Ahmed El-Kasheshy
Dermatology, Venereology and Andrology Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Asmaa El-sayed Attia El-sayed, Email: asmaaelhefnawy11@yahoo.com.com

ABSTRACT
Background:
a lingering disease of inflammatory type called oral lichen planus (OLP) affects the oral mucosa. It can
be presented at one of the following forms: ulcerative, erosive, hyperkeratotic and reticular form. Patients usually feel
discomfort, burning sensation, pain and changes of the life quality. Mostly it affects women of middle ages and to a
lesser extent affects children. There are many therapeutic modalities in treatment of OLP but mostly no effective
results are obtained and patient satisfaction is poor and recurrence occurred. Intralesional platelet-rich plasma is used
to treat erosive dermatological lesion, it depends on its high concentration of growth factors that prompt healing.
Objective: To study the effect of intralesional platelet-rich plasma in the treatment of oral lichen planus.
Conclusion: Intralesional platelet-rich plasma is a good and safe modality for treatment of oral lichen planus.
Keywords: Oral lichen planus, Platelet rich plasma, Intralesional.

INTRODUCTION
components beside the other previous mentioned
Middle- aged adults are the most common
growth factors (8).
population who suffer from lichen planus subtype that
When the injured part of the body being injected
affects mucosa, which is called oral lichen planus
with PRP, healing occurs through release process of
(OLP) (1).
platelet activation through the previous factors within
Pain is the most frequent symptom affects OLP
the platelet themselves. Vitronectin, Fibronectin and
patients, in addition to other manifestations that
Fibrin are 3 protein components of PRP, which play
include hyperkeratotic plaques, erythema of mucosa,
important role in epithelial migration as they act like
ulcerations and erosions. The reticular type may be
cell adhesion molecules and act as connective tissue
asymptomatic (2).
matrix (9).
OLP may have immunologic background in the

form of immune response-mediated, autoimmune
Preparation
response, and nonspecific mechanisms (3).
PRP approaches varies greatly in terms of sample
Treatment aims at relieving symptoms, decreasing
collection, rotation force, and centrifugation details
risk of scaring from erosive lesions, decrease rate of
like quantities and duration, in addition to quantities
recurrence and risk for malignant transformation (4).
and types of platelet activators. The outcomes and

quality of preparation is affected by some factors like
Intralesional platelet-rich plasma:
the time interval between activation of PRP and
Platelet-rich plasma (PRP) is defined as plasma
application (10).
that is condensed and contains high concentration of

platelet-derived growth factors (PDGF) (5). PRP have
PRP is collected by one of 2 common methods:
an autologous function, hence to promote healing of
1) Conventional: Because the ingredients and
any damaged part of the body through its direct
equipment are all obtained separately, this
injection. Theoretically, lower percentage of
procedure is similar to typical laboratory methods
complications or side effects tend to occur because it
for blood collection and processing (11).
belongs to the same personnel own blood (6).
2) Device or prepackaged Kits: Some firms provide
Several growth factors are released, which
kits with specially constructed containers and
facilitate the therapeutic function of PRP. These
modified centrifuges with preset timings suited for
growth factors include: Keratinocyte growth factor
extracting PRP from whole blood. It results in
(KGF), platelet-derived growth factor AB (PDGF-
greater
platelet
counts
than
conventional
AB), vascular endothelial growth factor (VEGF),
approaches (12).
insulin-like growth factor 1 and 2 (ILGF),
The next step in preparing PRP is centrifugation;
transforming growth factor 1 (TGF 1), epithelial
several centrifugation procedures have been described.
growth factor (EGF), fibroblast growth factor (FGF),
These approaches can be categorized into 2 main
and connective tissue growth factor (CTGF) (7).
ways: Single centrifugation and double centrifugation,
Interleukin 8 (IL-8) chemokine facilitates circulation,
which are two methods of separation (13).
blood flow and angiogenesis, which is one of PRP
Pérez et al. did a ten minutes initial centrifugation
at 723 rpm, then the second for ten minutes at 1445

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


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3413
Received: 12/8/2021


Accepted: 19/9/2021


Full Paper (vol.851 paper# 129)


c:\work\Jor\vol851_130 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3415-3419

Evaluation of Laparoscopic Versus Open Repair for Inguinal Hernias
Islam Mohammed Mohammed Ibrahim, Mohammed Farouk Amin,
Mohammed Murajia Ali*, Mohamed Abdallah Zaitoun
Department of General Surgery, Faculty of Medicine - Zagazig University, Egypt.
*Corresponding Author: Mohammed Murajia Ali, Mobile: (+20)01068162892, Email: mohmedmrg92@gmail.com

ABSTRACT
Background:
The inguinal hernia is a protrusion of abdominal contents into the inguinal canal through an abdominal
wall defect, and the risk of inguinal hernia increases with age. Currently, inguinal hernia repair with a mesh is the mostly
common method through surgical procedure.
Objective: To compare the outcome of laparoscopic versus open repair for inguinal hernias.
Patients and Methods:
This prospective comparative study conducted at General Surgery Department, Faculty of
Medicine, Zagazig University at the period between January 2021 till July 2021, between open technique (preperitoneal
approach, conventional Lichtenstein repair) versus laparoscopic transabdominal preperitoneal (TAPP) and totally
extraperitoneal (TEP) mesh repair of inguinal hernia. 24 patients were randomized into 2 groups by the closed envelop
method, 12 patients underwent open repair operation and 12 patients underwent laparoscopic repair operation. The
clinical diagnosis of inguinal hernia was based on symptoms and signs elicited during clinical assessment.
Results: we found that mean duration of operation in laparoscopic group was longer than open group with significant
difference, as regard length of hospital stay there was significant differences between two groups. Return to daily activity
(Days) was early among laparoscopic inguinal hernia repair group with mean 1.67±0.49 and range from 1 to 2 days
versus 4.58±1.5 with range from 3 to 7 days in open repair for inguinal hernia group, the difference was highly
statistically significant. Conclusions: Laparoscopic surgical techniques for inguinal hernia repair (TAPP and TEP) can
be carried out with a very low rate of predominantly harmless complications and with an acceptable duration of
operation.
Keywords: Inguinal hernia, Laparoscopy, Open repair.

INTRODUCTION

Hernia is the abnormal exit of an organ or fatty
We performed this study to compare the outcome of
tissue, such as the bowel, through the wall of the cavity
laparoscopic versus open repair for inguinal hernias.
in which it normally resides. Repair of inguinal hernia is

one of the common surgical procedures done worldwide.
PATIENTS AND METHODS
Irrespective of country, race or socioeconomic status
This prospective comparative study conducted at
hernia constitutes a major health-care. The definitive
General Surgery Department, Faculty of Medicine,
treatment of all hernias, regardless of their origin or type,
Zagazig
University
between
open
technique
is surgical repair with approximately 20 million repairs
(preperitoneal approach, conventional Lichtenstein
done worldwide annually(1).
repair) versus laparoscopic (TAPP and TEP) mesh repair
The lack of consensus in the literature as to the
of inguinal hernia. This study was conducted on 24
optimum repair technique or prosthetic mesh to insure a
patients. The selected patients were randomized into 2
long term durable result is also surprising(2). The wide
groups by the closed envelop method.
use of mesh in the groin hernia repair has gained more
Group A: 12 patients underwent open technique by
popularity and has almost replaced the suture repairs
conventional Lichtenstein.
such as Shouldice or Maloney repair. There is, however,
Group B: 12 patients underwent laparoscopic operation:
a very large debate on relative merits of laparoscopic
6 patients by TAPP and 6 patients by TEP.
mesh placement by using two to three small abdominal

incisions compared with placement of mesh by using an
Ethical considerations:
open approach through a standard groin incision(3).
Written informed consent was obtained from all
Open inguinal hernia repair (OH) remains the
participants and the study was approved by the
standard approach to inguinal hernias since its initial
Research Ethical Committee of Faculty of Medicine,
description over 50 years ago(4).
Zagazig University. The work has been carried out in
Laparoscopic inguinal hernia repair (LH) has now
accordance with The Code of Ethics of the World
become routinely employed. Advantages of LH as
Medical Association (Declaration of Helsinki) for
reported by retrospective studies include better cosmesis,
studies involving humans.
shorter length of stay (LOS), faster recovery, and greater

ability to visualize and repair a contralateral hernia but
We considered the following inclusion criteria Age
still it is not being commonly performed due to need for
above 18 years. All patients of both sex. Patients with a
general anesthesia and long learning curve(5).
diagnosis of inguinal hernia, either bilateral or unilateral.


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3415
Received: 13 /6 /2021


Accepted: 9 /8 /2021


Full Paper (vol.851 paper# 130)


Safety and efficiency of Mini-Sternotomy versus Standard in open Heart surgery for Aortic Valve Replacement The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3420-3424

Safety and Efficiency of Mini-Sternotomy versus Standard Sternotomy in
Open Heart Surgery for Aortic Valve Replacement
Essam Saad Abdelwahed, Ahmed Mohamed Amin Bakry, Ahmed Elwan Mohamed and Ahmed Alhammali
Amir Abdulsalam
Department of Cardiothoracic Surgery, Faculty of Medicine - Zagazig University, Egypt.
*Corresponding Author: Ahmed Alhammali Amir Adulsalam, Mobile: 01552266507, Email: dr.aalhammali@gmail.com
ABSTRACT
Background:
For decades, the traditional median sternotomy has been the access of choice in aortic valve surgery;
however, numerous researchers have worked to develop less invasive procedures, and the partial upper mini-
sternotomy is the most prevalent minimally invasive procedure. Objective: To compare outcomes, in patients who
undergo mini-sternotomy, and patients who undergo standard sternotomy, in aortic valve replacement operations.
Patients and Methods:
This randomized controlled clinical trial study included fifty patients who were admitted to
the Zagazig University Hospital, Cardiothoracic Surgery Department in the period between January 2021 to August
2021, Patients were split into two groups, each with 25 patients: Group "A" had aortic valve surgery by mini-
sternotomy, while Group "B" got aortic valve surgery via traditional surgery. Aortic valve surgery was performed via
a conventional median sternotomy in Group "B." An ECG was performed to see whether there was any ischemia
present, as well as laboratory tests and a chest x-ray. Results: In the present research, there was a significant
difference in postoperative outcomes between the mini-sternotomy and complete sternotomy groups in terms of
mechanical ventilation and hospital stay. Inotropic support and reopening were not substantially different across
groups; however, infection and blood transfusion were strongly linked with the complete group, and neither group had
any mortality. Conclusions: Minimally invasive aortic valve replacement, is a safe and effective procedure and is
performed with comparable morbidity and mortality to conventional aortic valve replacement (AVR). Minimally
invasive aortic valve replacement (MIAVR) results in improved ventilator function, fewer wound infections, shorter
hospital stays, and a higher percentage of patients released home early.
Keywords: Mini Sternotomy, Full Sternotomy, Aortic Valve Replacement.

INTRODUCTION
This work has been carried out in accordance with The
The majority of patients with severe aortic valve
Code of Ethics of the World Medical Association
stenosis are elderly individuals with several
(Declaration of Helsinki) for studies involving humans
comorbidities, resulting in a greater surgical risk profile
(IRB#6628/30-12-2020).
and associated morbidity and mortality risks (1,2).
Inclusion criteria: Age > 16. Patients who are
Harken et al. published the first report on aortic valve
candidates for isolated aortic valve replacement, either
replacement in 1960, and it has since become the
aortic valve stenosis or aortic valve regurgitation, or
second most common cardiac surgical operation,
both.
beyond coronary artery bypass surgery (3). In an attempt
Exclusion criteria: Patients suffering from severe
to avoid the dangers of a full sternotomy, minimally
coronary artery disease. Renal failure sufferers. Patients
invasive aortic valve replacement became popular in
experiencing cardiogenic shock or cardiopulmonary
the 1990s and was found to be related with less
resuscitation prior to surgery. Patients who have had a
postoperative discomfort, blood loss, pulmonary issues,
redo or combination valve surgery. Patients with
wound complications, and a shorter hospital stay (4,5).
abnormalities of the chest or vertebral walls. When
aortic root dilatation is required in patients with a small
PATIENTS AND METHODS
Fifty patients with aortic valve disease who
aortic annulus. Infectious endocarditis.
needed aortic valve surgery were chosen nonrandomly.
Technique:
The research was carried out in the Cardiothoracic
For all patients, the intraoperative anesthetic
Department of Zagazig University Hospital.
approach was the same: a 20-gauge non-dominant
Twenty-five patients had standard sternotomy for aortic
radial artery cannula was placed utilizing local
valve surgery, whereas the other twenty-five patients
anesthesia. The first blood sample was taken from the
underwent mini-sternotomy J shape to the third right
arterial line for preoperative baseline activated clotting
intercostal space with aortic and single venous
time (ACT) analysis, and the second was taken for
cannulation.
preoperative baseline arterial blood gas (ABG) analysis.
Two grey peripheral venous cannulas were used for
Ethical considerations:
An approval of the study was obtained from Zagazig
monitoring, followed by Fentanyl 5-10 mic/kg and
University Academic and Ethical Committee. Every
Rocuronium (Esmeron) 0.6-1.2 mg/kg as a loading
patient signed an informed written consent for
dosage and 0.1-0.2 mg/kg as a maintenance dose for
acceptance of the operation and sharing in this study.
endotracheal intubation and a propofol hypnotic dose of
1-2.5 mg/kg augmented hypnotic dosage. The trachea

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3420
Received: 3/8/2021


Accepted: 15/9/2021


Full Paper (vol.851 paper# 131)


c:\work\Jor\vol851_132 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3425-3430

Revision of Total Hip Replacement with Acetabular Deficiency
Malak Nader Yousef Ragheb*, Khaled Mohamed Hassan,
Ashraf Abl-Eldayem Mohamed, Ahmed El-Sayed El-Malt

Department of Orthopedic Surgery, Faculty of Medicine - Zagazig University
*Corresponding authors: Malak Nader Yousef Ragheb, Mobile: (+02) 01228085576, Email: dr_malak_josef@yahoo.com

ABSTRACT
Background:
The paradigm of revision surgery has been evolving constantly. There is a wide range of surgical options
for successful reconstruction.
Objective: This study aimed to evaluate the
results of reconstruction techniques in acetabular deficiency.
Patients and methods: A prospective interventional design included patients with acetabular deficiency who were
admitted to Orthopedic Department at Zagazig University Hospitals. We had 10 patients with acetabular deficiency
(Three were classified as Paprosky IIIA; one of them was AAOS IIB and two were AAOS III, Two were classified as
Paprosky IIIB and AAOS III, Two were classified as Paprosky IIA and AAOS IIA; one was Paprosoky IIB and AAOS
IIB and Two patients were classified as Paprosky IIC; one of them was AAOS IIB and the other was AAOS III). The
evaluation and follow up of patients depended mainly on the Harris hip score, which evaluates the patient clinically
preoperatively and postoperatively.
Results: All the patients reached full weight bearing between 7 and 9 weeks after surgery. Revision total hip
replacement (THR) was the treatment of choice for patients with severe groin pain and apparent acetabular deficiency.
Restoration of the normal center of rotation was essential for the joint biomechanics and survival of the prosthesis.
Conclusion: There was no method of reconstruction of acetabulum superior to another method; each method had
specific indication, which differs according to the percentage of acetabular coverage and bone stock. Patients with mild
to moderate acetabular deficiency (Paprosky I, IIA and IIB) were managed by using acetabular augmentation graft or
small acetabular component with medialization.
Keywords: Hip replacement, Paprosky, Acetabular deficiency.

INTRODUCTION

Total hip replacement (THR) is an increasingly
impaction of bone graft and cemented hemispherical
performed common surgery. In spite of the fact that most
cups (6, 7).
patients have acceptable joint stability, about 17% of
Revision of acetabular component is a challenging
these surgeries fail and require surgical correction and
problem when bone stock is severely deficient (8).
revision. Cases that need revision for total hip may have
Reconstruction of this discontinuity has high morbidity
isolated acetabular bone defect (12.7%), isolated
and failure rates (9). There are many classifications for
proximal femur bone defect (13.2%), combined
assessment of acetabular bone loss such as Paprosky
acetabular and femoral bone defect (41.1%), isolated
classification (10), AAOS "American Academy of
prosthetic head and liner revision due to component
Orthopedic Surgery" classification (11) and Saleh
failure (12.6%), arthrotomy and removal without
classification (12).
revision (10.9%) and not otherwise specified revision in
These classifications aim to choose the proper
9.5% of cases (1).
management or to compare different results but often
The common causes of revision after primary total
have poor inter- and intra-observer correlation (13, 14).
hip replacement include instability of the joint (35%),
Reviewing and evaluating the current techniques and
aseptic loosening (30%), osteolysis and polyethylene
guide-lines is essential to decrease the need to perform a
prosthesis wear (12%), infection (12%), recurrent
second revision after this surgery (15). This study aimed
dislocation (9%) and periprosthetic fracture (2%) (2). Old
to evaluate the results of reconstruction techniques in
prostheses such as ceramic biomaterials and
acetabular deficiency.
polyethylene formulations cause acetabular wear so they

were modified during the first decade of the 2000s by
PATIENTS AND METHODS
introducing thermally stable prostheses with less friction
A prospective interventional design included
with the acetabulum (3).
ten patients with acetabular deficiency who were
Mostly in cases of acetabular component revision
admitted to Orthopedic Department at Zagazig
in total hip replacement (THR) there will be variable
University Hospitals.
degrees of bone loss. Minimal defects with an intact

labrum acetabulare are not usually symptomatic. Most of
Inclusion criteria:
these cases can be managed with an uncemented
Patients with primary THR in age > 18 years old
hemispherical cup (4, 5). Very satisfying results have also
of both gender. Post-traumatic fracture acetabulum.
been recorded for acetabular component revision with
Healed infectious disease.


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3425
Received: 14 /6 /2021


Accepted: 10 /8 /2021


Full Paper (vol.851 paper# 132)


c:\work\Jor\vol851_133 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3431-3435

Frequency and Clinical Features of Over-Expressed HER2 in
Egyptian Breast Cancer Women Patients
Elham Ahmed Mohmmed*1, Shimaa Shawki Ramadan2,
Abeer Salah EL-Saiid3, Wafaa Ghoneim Shousha2
1Department of Central Labs, National Nutrition Institute, Cairo, Egypt.
2Department of Biochemistry, Faculty of Science, Helwan University, Cairo, Egypt.
3Department of Clinical and Chemical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt.
*Corresponding author: Elham Ahmed Mohmmed, Mobile: (+20)01112690163,
E-Mail: elham.ahmed.mohammed21@science.helwan.edu.eg

ABSTRACT
Background:
Overexpression of human epidermal receptor protein-2 (HER2) is correlated to a poor prognosis in breast
cancer (BC) patients who respond well to anti-HER2 therapy.
Objective: Therapeutic procedures for treating HER2-positive breast cancer (BC) patient address HER2 protein.
According to reports, the expression of HER2 oncogene and its relationship to clinicopathological factors in BC patients
is yet unknown.
Patients and methods: The present study involved 50 patients who were diagnosed histologically with invasive primary
breast carcinoma. The PR, ER, and HER2 immunohistochemistry testing was conducted on the formalin fixed paraffin-
embedded blocks of patient's breast tissue. The relationship between HER2 status and clinicopathologic diagnostic
characteristics was investigated using analysis of variance and the Chi-Square Test.
Results: Invasive lobular carcinoma (ILC) was the most common histological type, accounting for 86% of cases. The
highest percentage of patients was grade II (66.7 %), tumour size (2-5) cm accounted for 73.3 % of cases, and lymph
node metastases were present in 84 %. The majority of the individuals were diagnosed at stage II (66.7 %). The majority
of patients had moderate Nottingham prognosis index (66.7 %). 60 % and 33.3 % of women tested positive for the
estrogen and progesterone receptors, respectively. 53.3 % of the women tested positive for HER2. Histological type (p =
0.049*) and histopathology grade (p = 0.002**) were both significantly associated with HER2 overexpression.
Conclusion: HER2 positive expression could produce further evidence about the inadequate diagnosis of BC and could
be utilized for pre-choice of BC patients with HER2-overexpressing who demonstrated resistance to hormonal treatment.
Keywords: Clinical features, Over-expressed HER2, Breast cancer.

INTRODUCTION

Breast cancer (BC) is the most often diagnosed
treatment. BC has a wide range of clinical, pathological,
cancer in Egyptian women and the second leading cause
and molecular characteristics, all of which have various
of death. BC incidence rates are increasing in virtually
prognostic and therapeutic implications. The status of
every area. In Egypt, BC ranks first among female
progesterone receptors (PR), estrogen receptors (ER),
malignancies, accounting for 22,038 (16.4 percent) of all
and human epidermal receptor protein-2 (HER2) is now
cancers and 9,148 (10.3%) of all cancer-related fatalities
routinely assessed to guide BC management and
(1). BC incidence had grown by more than 23% in the last
prognosis, as these hormone receptors have been
six years (from 1.7 million new patients in 2012 to 2.1
demonstrated to have a significant impact on the clinical
million in 2018) (2). Despite high survival rates in many
outcomes (7).
wealthy countries, Egypt's 5-years survival rate has
HER2 is a transmembrane tyrosine kinase receptor
remained low, ranging from 28 % to 68%, according to
protein that is encoded by the HER2/neu proto-oncogene
many studies (3).
on chromosome 17q. It regulates cell proliferation,
Despite the fact that the illness is prevalent all over
differentiation, and survival, as well as death.
the world, it has a wide range of incidence, mortality, and
Overexpression can result in a 40-100-fold increase in
survival rates, which might be due to a number of
protein expression (8). Abnormalities of HER-2 have
variables such as population structure, lifestyle, genetic
been found in roughly 15-20% of BC (9). The discovery
factors, and environment (4).
of new anti-HER2 targeted treatments for management
Only 2% of surveyed Egyptian women had any
of BC has resulted from a better knowledge of the
form of clinical screening (mammogram, ultrasound, or
underlying mechanisms of HER2 overexpression in the
clinical breast examination [CBE]) and only 6%
occurrence of the BC (10). Anti-HER2 targeted therapy
conducted breast self-examination, according to a study
have a significant response rate in HER2 positive
by the Egyptian Ministry of Health (5).
patients. Thus, the overexpression or amplification of
BC is a heterogeneous disease that is caused by a
HER2 has prognostic and therapeutic significance
variety of variables (6). We urgently need to strengthen
estimating around 50-75% of response rate to hormonal
BC control procedures by raising knowledge about the
therapy. The immunohistochemical evaluation of HER2
need of early cancer detection, screening, and proper
in combination with ER and PR is a common clinical

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3431
Received: 15 /6 /2021


Accepted: 11 /8 /2021


Full Paper (vol.851 paper# 133)


Microbial The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3436-3440

Calcaneal Lateral Column Lengthening Osteotomy for
Symptomatic Flexible Flatfoot
Emad Elsayed Mohamed Abdelhadi, El Sayed El Etewy Soudy, Ashraf Abd ELDayem Mohammed,
Ahmed Hesham Lotfy*, Ahmed Mohammed Nahla
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Ahmed Hesham Lotfy, Mobile: (+2) 01027140067, Email: dr_ zh90@yahoo.com

ABSTRACT
Background:
Existing methods of foot type classification based on foot morphology could be put into one of the 4
categories, including visual non-quantitative inspection, anthropometric values, footprint parameters and radiographic
evaluation. Objective: The aim of the present study was to evaluate the clinical and functional outcome after calcaneal
lateral column lengthening osteotomy in patients with symptomatic flexible flatfoot.
Patient and Methods:
This is clinical trial (pre-post intervention) included 18 patient with symptomatic flexible
flatfoot who were admitted to Zagazig Orthopedic Department, with mean follow up period of 13.6±2.7 months.
Results:
Age was 9.05±1.89 with minimum 6 and maximum 13 years, and as regard sex distribution male were
majority with 66.7%. There was significant improvement regarding talocalcaneal angle at anterior view from pre to 3, 6
and 12 months as it decreased from 46.94±5.19 to 29.66±2.86 at 3 months to 26.55±3.45 at 6 months and to 24.55±3.97
at 12 months. There was significant improvement regarding talocalcaneal angle at lateral view from pre to 3 months
and also to 6 and 12 months. Conclusion: The advantages of calcaneal lengthening osteotomy are as follows: it is
technically easy to be applied, has a low risk of neurovascular injury and low loss of blood. In addition, it allows other
procedures to be applied in the future contrary to arthrodesis. If arthrodesis is required later in these feet, it will be far
easier to do because of the corrected alignment of the foot.
Keywords: Calcaneal Lateral Column, Flexible Flatfoot, Osteotomy.

INTRODUCTION
if the foot is not weight bearing (5).
Flatfoot is a complex disorder, with diverse
Surgical treatment is indicated for older children
symptoms and degrees of deformity and disability.
with symptomatic flexible flatfeet in which there are
There are several types of flatfoot, all of which have
interference in daily life physical activities (6). Among
partial or total loss of normal arches of foot. Other
the various surgical treatments, calcaneal lateral column
characteristics present in most types include toe drift, in
lengthening osteotomy is widely used for the flexible
which the toes and front part of the foot pointed
flatfoot treatment. Evans conceived the technique in
outward. The heel tilts toward the outside and the ankle
1959, but it was published only in 1975. He believed
appears to turn in. A tight tendon Achilles, which
that the lateral column of the valgus flatfoot was shorter
causes the heel to lift off the ground earlier when
than the medial column. Thus, the purpose of the
walking and may make the problem worse and
surgery is to equalize the length of the lateral and
hammertoes, may develop as a result of a flatfoot.
medial columns, which leads to the correction of the
About 30% of people have a flatfoot. For every person
forefoot abduction and, consequently, of the
who has a flatfoot, one in ten probably has symptoms
talonavicular subluxation (7). Initially, Evans used
from it. Despite being a frequent affection, the flexible
autologous tibial graft, without implants to achieve
valgus flatfoot does not show objective diagnostic
correction. Mosca modified the technique by
criteria (1).
performing a more obliquely oriented calcaneal
Most children are born with flatfoot, but the
osteotomy, not in parallel to the calcaneocuboid joint.
medial plantar arch mainly develops between two and
Mosca used a tricortical graft, obtained from the iliac
six years of age (2). However, some individuals do not
crest and fixed with Steinmann pins. Currently, the
show any spontaneous correction. The therapeutic
allogenic bone graft is widely used for calcaneal lateral
approach of symptomatic flatfoot in children may be
column lengthening, with good results in terms of graft
conservative with prescription of analgesics, anti-
healing (8).
inflammatories, physiotherapy and orthoses (3).
The aim of the present study was to evaluate the
However, there is no scientific evidence that these
clinical and functional outcome after calceneal lateral
measures act to correct the deformity (4). There are two
column lengthening osteotomy in patients with
major types of flatfeet as follows: flexible flatfeet (FFF)
symptomatic flexible flatfoot.
and rigid flatfeet. FFF begins in childhood and

continued into adulthood and usually affects both feet.
PATIENTS AND METHODS
It is the most common type. The term flexible is defined
The comprehensive sample size was 18 cases.
as a medial longitudinal arch of the foot that collapses
Assuming that the rate of administration of patient with
in various degrees when standing and returns to normal

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


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3436
Received: 14 /6 /2021



Accepted: 10 /8 /2021


Full Paper (vol.851 paper# 134)


c:\work\Jor\vol851_135 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3441-3444

Association between using of Mirena and Changes on Female Sexual Function
Tarek Mohamed El behedy, Hussein Mohamed Abdeldayem,
Mohamed Ramadan Ali, Mayson Mohammed Saleh Elhawat
Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Mayson M. Elhawat, Mobile: (+2)01153140119, Email: sona.hawat@gmail.com

ABSTRACT
Background:
Mirena prevents pregnancy for up to five years after insertion. It is one of several hormonal intrauterine
device (IUD) with Food and Drug Administration approval. Like the progestogen-related mental side effects, is still a
rather unexplored scientific field?
Objective: the present study aimed to assess the perception effects of mirena intrauterine contraceptives (IUC) and the
actual sexual functioning, weight gain and mood changes level.
Patients and Methods:
this study included 46 women, using an intrauterine contraceptive method. The study was
conducted in Obstetrics and Gynecology Department, Zagazig University Hospitals. All patients who enrolled in the
study were subjected to full history taking, clinical examinations, and estimation of female sexual function index and
BMI. Main outcomes was estimated including desire, orgasmic function, lubrication and vulvovaginal symptoms, sexual
satisfaction and mood changes.
Results: About 19.6% of the studied group had no pain during insertion, 36.9% had mild pain, 36.9% had moderate
pain and 6.6% had high pain. Mean pain score was 4 ± 1.8 with range from 0 to 8. Most frequent complication among
the studied group were vulvovaginitis (52.2%) followed by abdominal and pelvic pain (37%). Only 6.5% had heavy
menstrual bleeding and no cases had uterine perforation during insertion.
Conclusion:
Using of mirena IUD type is not associated with changes related to sexuality of women, quality of life and
body weight gain.
Keywords:
Mirena intrauterine contraceptives, Weight gain, Menstrual bleeding.

INTRODUCTION
study was conducted in Obstetrics and Gynecology
The intrauterine device (IUD) is one of the most
Department, Zagazig University Hospitals.
popular contraceptive methods, especially for long-term

reversible contraception, as it can be easily fitted and
Inclusion criteria: The study included young women
removed (1). Mirena is a hormonal IUD that can provide
aged from 18 ­ 40 years currently using mirena as
long-term birth control (contraception). It prevents
intrauterine contraceptive (IUC). Ongoing intrauterine
pregnancy for up to five years after insertion. It is one
contraceptive use was the only inclusion criterion.
of several hormonal IUDs with Food and Drug
Exclusion criteria: Ingestion of any hormonal
Administration approval (2). Mirena offers effective
treatment, pregnancy, pelvic inflammatory disease and
long-term contraception. It can be used in
genital tumors.
premenopausal women of all ages, including teenagers
All patients who enrolled in the study were
(3, 4).
subjected to the following: history taking, demographic
The levonorgestrel-intrauterine system, (Lng-
characteristics, duration about hormonal contraceptives
IUS) offers excellent contraceptive efficacy and a range
uses, education status, family status, obstetric history
of non-contraceptive benefits such as a significant
and complete clinical examination. Female sexual
reduction in mean menstrual blood loss, reduced
function index (FSFI) was evaluated using the Turkish
endometriosis-associated pain, and reduced fibroid
version of the FSFI (5). BMI was calculated using the
associated blood loss (2). The most commonly used and
Healthy Weight Guide BMI calculator.
most studied Lng-IUS contains 52 mg levonorgestrel

(Mirena®, Bayer AG). It involves a low systemic
Questionnaire Setting: All respondents answered a
release of levonorgestrel and is therefore, on a
three-part validated questionnaire. All questions except
theoretical basis, believed to be a good option for
for height and weight were multiple choice with boxes
women with previously reported systemic progestogen
to tick and extra space for comments on the questions
associated side effects (4).
about side effects. Questions had a short
The aim of this study was to assess the effects of mirena
multidimensional scale for assessing sexual function in
intrauterine contraceptives (IUC), the actual sexual
women acceding to Rosen et al. (5), and the McCoy
functioning, weight gain, mood changes level.
female sexuality questionnaire (MFSQ) (6), weight gain

and mood changes.
PATIENTS AND METHODS
Outcome Measure: including desire, orgasmic
A cross-sectional analysis study included 46
function, lubrication and vulvovaginal symptoms, and
women using an intrauterine contraceptive method. The
relationship and sexual satisfaction. Weight gain and
body composition. Detection of mood changes as

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3441
Received: 17 /6 /2021


Accepted: 13 /8 /2021


Full Paper (vol.851 paper# 135)


c:\work\Jor\vol851_136 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3445-3449

Association between Depression and Risk Factors as Obesity and
Type 2 Diabetes Mellitus
Ahmed A. Zaghlol 1, Khaled M. Hadhoud1, Amira Fouad2,
Ahmed Mohamed Eldernawi*1, Mohamed R. Herzalla1
Departments of 1Internal Medicine and 2Psychiatry, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding author: Ahmed Mohamed Eldernawi, Email: docahmed1989@gmail.com

ABSTRACT
Background:
the prevalence of mood and anxiety disorders is higher among persons living with diabetes compared to
those without diabetes. Numerous studies have demonstrated that both obesity and metabolic disorders are associated
with depression. This study aimed to confirm the association between depression and risk factors as obesity and type 2
diabetes mellitus. Subjects and methods: This comparative cross-sectional study was carried out on 90 adults
attending to the Diabetes outpatient clinic in Internal Medicine Department, Faculty of Medicine, Zagazig University
Hospitals. They were divided into three groups, 30 patients with type 2 diabetes mellitus with normal body mass index
(BMI), 30 obese non-diabetic individuals and 30 obese type 2 diabetic patients. Full medical history, clinical
examination, laboratory investigation and assessment of depression were performed.
Result: Age was 51.60±14.28, 42.26±12.21 and 51.93±9.89 respectively and Group B it was significantly younger
than other two groups with no significant difference between them. No significant difference was found between
groups regarding disease duration or diabetes mellitus (DM) treatment and also complication but regarding
comorbidity Group C was significantly associated with comorbidity. Group A was significantly lower regarding Beck
Depression Inventory and overall depression was significantly associated with group B and Group C as it was 30.0%
and 46.7% respectively. Grade and overall depression were significantly associated with BMI >35 group.
Conclusion: Type 2 diabetes mellitus and morbid obesity (BMI > 35) were associated with high prevalence of
depression. It is evident that several modifiable and non-modifiable risk factors play an important role in the
pathogenesis of diabetes and depression among population.
Keywords: Depression, Diabetes mellitus, Metabolic diseases, Obesity.

INTRODUCTION

Diabetes mellitus is a chronic-degenerative
`diabesity', highlighting the fact that the majority of
disease, characterized by high levels of blood glucose.
individuals with diabetes are overweight or obese (5).
It has been estimated that diabetes mellitus type 2
Patients with diabetes mellitus type 2, often
affects about 246 million people in the world;
present a careless attitude towards their disease,
nevertheless, incidence varies among countries. The
resulting in metabolic decompensation, with high and
International Diabetes Federation has anticipated an
low glycemic levels which could trigger mood
increase of 366 million people by 2030, giving a total
alterations. Diabetes mellitus 2 is also associated with
of 552 million people with diabetes type 2 in the world
a higher risk of comorbid depression compared with
(1). The prevalence of type 2 diabetes is increasing
the general population. It has been suggested that
around the world, affecting approximately 422 million
diabetes type 2 could be conditioned by depression,
people in 2014 (2).
anxiety or anguish; nevertheless, the reason for this
In Egypt, the incidence of diabetes among
association is not clear (6).
adults between the ages of 20 and 79 is around 15.56
This study aimed to confirm association between
percent, with an annual diabetes-related death of
depression and risk factors as obesity and type 2
86,478. The International Diabetes Federation (IDF)
diabetes mellitus.
estimated 7.5 million people with diabetes in 2013 and

about 2.2 million people with pre-diabetes in Egypt (3).
PATIENTS AND METHODS
The association between type 2 diabetes and
This is comparative cross sectional study, which
depression is bidirectional with depression increasing
was carried out on 90 adults attending to the Diabetes
the risk of type 2 diabetes and type 2 diabetes
outpatient clinic in Internal Medicine Department,
increasing the risk of depression (4).
Faculty of Medicine, Zagazig University Hospitals,
Obesity is known to be the main risk factor for a
from April 2021 to July 2021. They were divided into
number
of
non-communicable
diseases
like
Three Groups, 30 patients with type 2 Diabetes Mellitus
cardiovascular disease and type 2 diabetes. Besides, it
with normal BMI, 30 obese non-diabetic individuals
causes diverse psychological problems or various
and 30 obese type 2 Diabetic patients.
physical disabilities. Type 2 diabetes is most strongly
Inclusion criteria: Age: adults (aged 18 years and
associated with obesity, and the prevalence of obesity-
over), sex: both male and female, and obese
related diabetes is expected to double to 300 million by
Individuals, type 2 diabetes patients with normal BMI
2025. This close relationship also led to the connotation

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3445
Received: 14 /6 /2021


Accepted: 10 /8 /2021


Full Paper (vol.851 paper# 136)


c:\work\Jor\vol851_137 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3450-3453

Structure Cardiac Lesion in Transient Tachypnea of the Newborn
Zaziyah Abdullah Almuqaddim*, Azza Ibrahem Eldesouky,
Ehab Mahmoud Rasheed, Alshaymaa Ahmed Ali
Pediatrics Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Zaziyah A. Almuqaddim, Mobile: (+2)01101508383, Email: alaiebm@gmail.com

ABSTRACT
Background:
Transient tachypnea of the newborn (TTN) is one of the commonest causes of respiratory distress in
newborns in late preterm and term infants. TTN occurs due to delay in clearance of fetal alveolar fluid after birth.
Objective: The aim of our study was to detect cardiac changes in neonates with TTN and correlating the presence of
cardiac changes to the severity of the condition.
Patients and methods: Twenty-five neonates were included in this study (15 males and 10 females) with a mean
gestational age of 37.76 ± 0.72 weeks and a mean weight of 3.10 ± 0.33 Kg. All cases were subjected to full history and
clinical examination and detailed maternal history, laboratory and radiological investigations. Echocardiography was
done in all cases as a diagnostic noninvasive tool to assess the cardiac changes in neonates with TTN.
Results: About 32% of TTN cases were associated with pulmonary hypertension. 25% showed mild persistent
pulmonary hypertension (PPHT), 12.5% showed moderated PPHT and 62.5% showed sever PPHT. The present results
showed 13 patients required nasal support, 9 patients required continuous positive airway pressure (CPAP) and 3
patients required advanced respiratory support in the form of mechanical ventilation (SIMV). There was a significant
relation between elective cesarean section and occurrence of pulmonary hypertension. 24 neonates included in this study
survived and one died. None of our patients developed neonatal sepsis.
Conclusion: Echocardiography represents an important non-invasive tool for assessment of cardiac changes and
determination of the severity of the condition in neonates suffering from TTN.
Keywords: Transient tachypnea, Echocardiography, Cardiac changes.

INTRODUCTION
echocardiography varied by at least 10 mmHg when
Transient tachypnea of the newborn (TTN) is a
compared to the catheter-measured values more than
benign, self-limited condition that can present in infants
50% of the time (5).
of any gestational age shortly after birth. It is caused by
The aim of our study was to detect cardiac
a delay in the clearance of fetal lung fluid after birth,
changes in neonates with TTN and correlating the
which leads to ineffective gas exchange, respiratory
presence of cardiac changes to the severity of the
distress, and tachypnea (1).
condition.
The Risk factors for TTN include birth by cesarean

section with or without labor, male gender, positive
PATIENTS AND METHODS
family history of asthma (especially in mother). A
This prospective observational study was
significant decrease in respiratory morbidity can be
conducted on 25 neonates suffering from TTN admitted
achieved if elective cesarean section is performed after
to the NICU of Zagazig University Obstetrics &
39 weeks of gestation (2).
Gynecology Teaching Hospital. They were studied after
TTN may be associated with persistent
an informed consent obtained from the parents.
pulmonary hypertension (PPHN). For example, with

elective cesarean section newborns with TTN who have
Inclusion Criteria:
low oxygen concentration may be given high
Neonate 37 weeks gestational age admitted in the
concentrations of inspired oxygen (about 100%) by
first 3 days of life with the suspected diagnosis of
mask or nasal cannula without positive pressure. The
TTN.
formation of reactive oxygen species from the high
Respiratory rate > 60/min starting within the first 6 h
alveolar oxygen concentration can lead to increased
of birth with tachypnea persisting for at least 6 h,
pulmonary vascular reactivity leading to PPHN (3). The
with or without other signs like retractions, grunting,
degree of PPHN can range from mild hypoxemia with
nasal flaring, and need for supplemental oxygen.
mild respiratory distress to severe hypoxemia and
Well-expanded lungs with or without increased fluid
cardiopulmonary dysfunction that needs intensive care
in lungs on chest radiograph.
support (4).

Echo estimates of right ventricular (RV) pressure
Exclusion criteria:
have limitations when compared directly with cardiac
Clinical or radiological features of congenital heart
catheterization.
A
study
that
compared
disease
echocardiographic estimates of RV pressure in
Neonates with chromosomal abnormalities.
comparison to direct measurement with right heart
Neonates with congenital anomalies.
catheterization found that the absolute values by

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3450
Received: 17 /6 /2021


Accepted: 13 /8 /2021


Full Paper (vol.851 paper# 137)


c:\work\Jor\vol851_138 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3454-3461
Assessment of Knowledge of Primary Health Care Providers about
Routine Care of Type 2 Diabetic Patients in Primary Health Care Units in
Zagazig District, Sharqia Governorate
Amany Mahmoud Oraby Mohammed*1, Gehan Abdel Qader Ibrahim2, Hanaa Salah Said1
Departments of 1Family Medicine and 2Internal Medicine, Faculty of Medicine ­ Zagazig University, Egypt.
*Corresponding author: Amany Mahmoud Oraby Mohammed, Mobile: (+20)01019520580,
Email: amanyoraby20@yahoo.com

ABSTRACT
Background:
Diabetes mellitus is a major and growing health problem in Egypt. Despite considerable advances in
diagnosis and management of diabetes, there is a large gap between ideal treatment goals and actual outcomes. Lack of
up-to-date knowledge, wrong attitudes and malpractice among healthcare workers regarding diabetes control may play
an important role in failure to achieve therapeutic goals.
Objective: This study aimed to reduce complications and improve outcome of type 2 diabetic patients attending family
medicine units & centers through assessing the knowledge of healthcare providers about routine care of type 2 diabetes
mellitus.
Patients and Methods: This cross-sectional study was carried out on 102 doctors (family physicians & general
practitioners) from Family Health Centers & Units in Zagazig Health District, Sharqia Governorate. Data were collected
through a questionnaire, which assess doctors' knowledge about type 2 diabetes mellitus. Data was collected and
analyzed. Bar charts for knowledge were done.
Results:
This study showed that 66.7% of doctors had good knowledge about routine care of type 2 diabetic patients.
Conclusion: The doctors were good in communication skills with patients, describing medications, emphasizing on
blood sugar control.
Keywords:
Healthcare provider, practical performance, Type 2 diabetes.

INTRODUCTION
into 17 major cities according to Sharkia.gov.eg, 2018).
Diabetes mellitus care is complex and requires
The study was conducted in the family health centers
patients to take an active role in the management of their
and units (accredited and not accredited), which affiliate
disease. Currently, adequate and continuing medical
to Zagazig health district.
care aiming at preventing acute complications,

diminishing risk of long-term complications as well as
Inclusion criteria were; Primary health care providers
patient self-management education are considered
(general practitioner or family physician) who are
standard in the care for type 2 diabetes patients (1).
working in primary health care units in Zagazig district.
The management of DM largely depends on the
The data were collected by using American Diabetes
patient's ability to do self-care in their daily lives, and
Association up to date recommendations for routine
therefore, patient education is always considered an
care of type 2 DM in 2018, a structured questionnaire
essential element of DM management. Studies have
was used to assess physicians' knowledge and checklist
shown that patients, who are knowledgeable about the
to assess their practice.
DM self-care, have better long-term glycemic control (2).

Knowledge about glycemic control can help the
Operational Design:
people to understand the risk of diabetes and motivate
Fieldwork started at the beginning of March 2019,
them to seek proper treatment and care and to keep the
and completed by the end of March 2021 by attending
disease under control (3).This study aimed to reduce
the health facilities 3 days/ week. The visits to each
complications and improve outcome of type 2 diabetic
selected center was done at different days in order to
patients attending family medicine units & centers
ensure complete week coverage.
through assessing the knowledge of healthcare
The observation was done after taking permission
providers about routine care of type 2 diabetic patients
from doctors without clearing the actual aim of the visit
attending family health centers & units.
(assess doctors performance) to avoid their trials to

improve his/her performance during observation. It
PATIENTS AND METHODS
wasn't ethically and should not happen but many authors
This cross-sectional study was carried out on 102
do this for the same reasons provided taking permission
doctors (family physicians & general practitioners)
from higher authorities (4).
from Family Health Centers & Units in Zagazig Health
The researcher start to fill the items of personal
District, Sharqia Governorate from March 2019 to
data & knowledge by asking doctors then fill the rest of
March 2021. They were selected randomly to represent
the sheet away from them with putting in consideration
Sharqia Governorate (which administratively divided
that the researcher in the field cannot rely on their

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Commons Attribution (CC BY-SA) license (http://creativecommons.org/licenses/by/4.0/)
3454
Received: 16 /6 /2021


Accepted: 12 /8 /2021


Full Paper (vol.851 paper# 138)


c:\work\Jor\vol851_139 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3462-3466

Assessment of Immunoglobulin E in Asthmatic Pediatric Patients
Aeshah Mohamed Saeid*1, Mohamed Sanad Naguib1, Amal Fawzy Abdelmajid2, Yousif Mohamed Yousif1
Departments of 1Pediatrics and 2Medical Biochemistry, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Aeshah Mohamed Saeid, Email: aisha.mohamed.25.9.82@gmail.com

ABSTRACT
Background
: Recurrent reversible symptoms of hyperresponsiveness of bronchi and obstruction of air flow occur in
bronchial asthma which is a chronic airway disease with pathologic inflammation. Objective: To assess the IgE level
among asthmatic patients in children.
Patients and Methods: our research was conducted on 116 children (87 asthmatic cases and 29 non-asthmatic healthy
age and sex matched as control group). This were recruited from Pediatric Department and Outpatient Clinic at Zagazig
University Hospital. The cases were subdivided to three groups according to the GINA guide line. They were assessed
for the pulmonary functions with assessment of IgE.
Results: In terms of IgE levels, statistically significant differences were found between the four groups tested with all
asthmatic groups were significantly higher than control group (p < 0.001). Well controlled group had higher values of
FEV1% and FVC% with statistically significant difference between asthmatic patients groups. Sensitivity; specificity,
PVP and PVN of IgE level were 100.0%, 96.6%, 98.9% and 100% respectively.
Conclusion
: IgE level can be considered a good predictor for severity of bronchial asthma.
Keywords: Bronchial asthma, Immunoglobulin E (IgE).

A case-control study conducted on 116 individuals
INTRODUCTION
at Pulmonology & Allergy Unit in Pediatric Hospital and
Asthma is a diverse illness defined by persistent
Biochemistry Department divided in to 4 groups: A: 29
airway inflammation. Cough, chest tightness, shortness
non-asthmatic participant. B: 29 well controlled
of breath and wheezes are the main respiratory symptoms
asthmatic patient. C: 29 partially controlled asthmatic
of bronchial asthma, which differs in severity, with
patient. D: 29 uncontrolled asthmatic patients.
diminished expiratory airflow. Airway inflammation is
Classification of asthmatic children occurred according
linked to airway hyperreactivity, also known as bronchial
to the level of asthma control into three groups:
hyperresponsiveness (BHR), which is described as the
controlled, partially controlled or uncontrolled according
airways' natural inclination to constriction due to various
to GINA recommendation at 2008 considering the
stimuli (like irritants and environmental allergens) (1).
following items (7): Daytime symptom, limitation of
According to family and twin research, genetics has
activation, nocturnal symptom, need for relievers,
a major influence in the development of asthma and
pulmonary function test, and exacerbation.
allergies, most likely via multiple genes of moderate

impact (i.e., genes linked with relative e risks in the range
Ethical approval:
of 1.2­2) (2). Asthma in humans may be initiated due to
Research Ethics Committee of Zagazig University's
oxidative stress processes, which contributed due to gene
Faculty of Medicine approved the study after all
polymorphism (3).
participants' parents gave written informed consent (ZU-
Estimation of the total IgE level supports the
IRB#6175/14-6-2020). Work was done in accordance
existence of atopy. Atopy, or the tendency to create
with the Declaration of Helsinki, the ethical code of the
excessive amounts of immunoglobulin (Ig) E antibodies
world medical association for human studies.
in response to allergens, is almost always found in

children with asthma (4). Asthma patients often have more
Inclusion criteria: Children from both sexes with
sensitive airways, making them more sensitive to
bronchial asthma aged from 5-15 years after taking
allergens, irritants, exercise, cold air, and virus infection
approval from their parents.
(5).
Exclusion criteria: Children with chronic pulmonary
A child's serum IgE concentration varies with age
disease, children suffering from liver, kidney and heart
and is typically less than 10 IU/mL in the first year of life
disease and parents' refusal of participation.
for the majority of infants. According to many population
All patients were subjected to full history taking,
researches, prevalence of asthma/BHR and total serum
general and local chest examination.
IgE levels are linked, regardless of particular allergy

reactivity or allergy symptoms to commonly allergenic
Laboratory investigations:
substances (6).
Routine complete blood count, C-reactive protein,
We aimed at this study to assess the IgE level
liver function tests, kidney function tests, IgE level
among asthmatic patients in children.
assessment, and pulmonary function tests.

We used spirometry to assess lung function and

volume versus time. It is a simple and quick technique
PATIENTS AND METHODS
to carry out: Patients were instructed to take a deep

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3462
Received: 11/8/2021

Accepted: 22/9/2021


Full Paper (vol.851 paper# 139)


c:\work\Jor\vol851_140 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3467-3473

Serum CCL20 Level in Patients with Vitiligo
Amany Saleh Khalil, Fawzia Amin Saafan, Marwa Zohdy Moubarak, Shimaa Mohsen Elbeah*
Department of Dermatology and Department of Biochemistry*, Faculty of medicine, Mansoura University, Egypt
Corresponding author: Amany Saleh Yoseif Khalil, Mobile: (+20)1016137400. E-Mail: asykh1988@gmail.com

ABSTRACT
Background:
Vitiligo is a chronic, acquired depigmenting cutaneous disorder due to damage of melanocytes in
genetically susceptible persons. The existence of vitiligo is mediated by the autoimmune dysfunction of cases. CCL20 was
expressed at low levels in normal human skin, because both CCL20 and CCR6 were significantly up-regulated within
chronic inflammatory cutaneous disorders.CCL20 interacts with its receptor CCR6 to recruit IL-17A-forming cells into
skin.
Objective: This study was aimed to assess relationship between serum level of CCL20 in cases with vitiligo and its
correlation to disease severity and activity
Patients and methods: This case-control study included a total of fifty cases with vitiligo and 30 matched age and sex
control attending at the outpatient clinic of Dermatology, Mansoura University Hospital.
Results: CCL20 levels were considerably greater within vitiligo cases when compared to controls. CCL20 levels were
found to be considerably higher in active vitiligo cases in comparison to stable vitiligo cases.
Conclusion: It could be concluded that the serum level of CCL20 was demonstrated to be correlated positively with
vitiligo-affected patients. Additionally, it seems to have a positive association with disease activity but not with disorder
duration so CCL20 could be a candidate as a biomarker to evaluate the activity of vitiligo as well as it is a good predictor
of vitiligo and discriminates patients from control.
Keywords: vitiligo, CCL20, melanocytes, VETF, skin.

INTRODUCTION

Vitiligo is a chronic, acquired depigmenting
The aim of the current study was to assess
cutaneous disorder due to selective damage of
relationship between serum level of CCL20 within
melanocytes in genetically susceptible cases. It shows
cases with vitiligo and its correlation to disease severity
well-circumscribed, milky-white depigmented macules
and activity
(1). overall incidence is nearly 1%, with 80% of patients

happening below 30 years influencing both sexes
PATIENTS AND METHODS
similarly (2).
This case-control study included a total of 50 cases
Vitiligo is a melanocyte-specific damage
with vitiligo and 30 age and sex matched control
disease having complex pathogenesis. Although
attending at the Dermatology Outpatient Clinic,
autoimmunity causing a melanocyte-specific response
Mansoura University Hospital. This study was
with adaptive immunity is currently considered as the
conducted between May 2019 till December 2020.
main pathway, this theory alone does not explain the

pathogenesis as a whole. Intrinsic defects within
Inclusion criteria:
melanocytes
including
oxidative
stress,
Age: from 20 to 70 years, both sexes with generalized,
melanocytorrhagy, neural mechanisms, adhesion
Focal, Acrofacial, and Mucosal vitiligo
defects, and inflammasomes are the other different

mechanisms proposed to be involved in vitiligo lesions
Exclusion criteria: cases with history of autoimmune
(3). It is assumed that incidence of vitiligo is related to
disorder that can affect IL17 level hence affect CCL20
autoimmune dysfunction of cases (4, 5).
level e.g. Thyroiditis and Psoriasis, Diabetes mellitus,
The psychological, social and financial burdens
Pernicious anemia, Atopic dermatitis, Inflammatory
of vitiligo are great. Vitiligo affects about 100 million
skin disorders with autoimmune background, Pregnant
people universal. People in poor countries tolerate the
cases and those who on systemic treatment for 6 months
impact, because of possibility for inappropriate
before the study.
diagnosis of the disease, poor reach to effective

managements, and stigmatization and discrimination (6).
This study was carried out on two groups:
The most commonly used treatment of vitiligo are local
Group A (patient group): included 50 patients with
steroids and ultraviolet light (7).
vitiligo subdivided into 25 active vitiligo and 25 stable
CCL20 was expressed at low to very low levels
vitiligo.
within normal cutaneous tissue, as both CCL20 and

CCR6 were markedly upregulated within chronic
Group B (control group): included 30 healthy persons
inflammatory cutaneous diseases(8) . CCL20 reacts with
who match the patients in the same age and sex.
its receptor CCR6 to recruit IL-17A-forming cells into

skin (9).

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3467

Received:15 /6 /2021

Accepted: 11 /8 /2021


Full Paper (vol.851 paper# 140)


Screening and Prevalence of Internal Hemorrhoids in Patients Undergoing Flexible Colonoscopy The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3474-3477

Screening and Prevalence of Internal Hemorrhoids in
Patients Undergoing Flexible Colonoscopy
Samir Abdel Azim Morsy Afifi, Waleed Younus Abu Aeshah*,
Ayman Fathy Elsayed Mohammed, Ayman Magd Eldin Mohammad Sadek
Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Waleed Younus Abu Aeshah, Mobile: (+20)01030866527, Email: walidabuaishay@gmail.com

ABSTRACT

Background: Hemorrhoids are swollen veins of the hemorrhoidal plexus that are normally present in the anal canal.
Clinically detectable if the supporting connective tissue is compromised. In this study, we focused on the effectiveness
and importance of colonoscopy for studying the prevalence of internal hemorrhoids.
Objective: The study aimed to evaluate the prevalence of internal hemorrhoids in patients undergoing colonoscopy for
different indications.
Patients and Methods: This cross-sectional study was conducted in the Elective Gastrointestinal Endoscopy Unit,
Internal Medicine Department, Faculty of Medicine, Zagazig University. The study was conducted through the period
from March 2021 to Augustus 2021, and including 300 consecutive Egyptian patients who underwent a flexible
colonoscopy for different reasons.
Results: In the present study, we revealed that hemorrhoids increasing with aging. The diagnostic results were internal
hemorrhoids (38.3%), colonic ulcers (11%), inflammatory lesions (7.3%) and mass (7%), diverticular disease (6%),
polyps (5.7%), and vascular malformations (1.3%). The complaints of the patients were lower GI bleeding (41.7%).
Chronic diarrhea (17.7%), abdominal pain (14.7%), and chronic constipation (13.3%) in the subsequent levels. Also,
chronic anemia (6.7%), follow-up colon polyp (5.3%), one patient had weight loss (0.3%) and one patient had anal
pain (0.3%).
Conclusions: We can conclude a wide prevalence of internal hemorrhoids in patients who underwent colonoscopy for
various reasons. Besides, retroflexed colonoscopy can contribute to the study of the prevalence of internal
hemorrhoids because it can diagnose even asymptomatic hemorrhoids. In addition, colonoscopy was found to be
extremely safe and no complication was detected.
Keywords: Colonoscopy, Prevalence, Internal hemorrhoids.


INTRODUCTION

Hemorrhoid is a common benign anorectal
prevalence of hemorrhoidal disease is less in
disease in which are swollen veins present in the anal
underdeveloped countries (6).
canal and become clinically detectable when the
However, there has been a noticeable increase in
connective tissue that supports the anorectal region is
the incidence of hemorrhoids in recent years (2).
damaged (1). The symptoms of Huntington's disease

(HD) vary depending on the location and type of HD.
PATIENTS AND METHODS
Lower gastrointestinal (GI) bleeding is the main
This Cross-sectional study was conducted in the
clinical symptom (2).
Elective Gastrointestinal Endoscopy Unit, Internal
The diagnosis of hemorrhoids is made clinically
Medicine Department, Faculty of Medicine, Zagazig
through a careful digital examination. Anoscopy is
University from March 2021 to Augustus 2021.
performed paying particular attention to the known
300 consecutive Egyptian patients who underwent
position of hemorrhoidal disease (3).
a flexible colonoscopy were enrolled in this study for
There is limited data about the incidence, gender,
different reasons.
and age distribution of internal hemorrhoids in the
Inclusion criteria:
population especially those undergoing elective
Age from 18 to 75 years old. All patients
colonoscopy for different indications. Colonoscopy has
underwent a flexible colonoscopy for different reasons
an important role in the diagnosis of many anorectal
as lower GI bleeding, screening and surveillance of
diseases especially internal hemorrhoids (4).
colorectal polyps, cancers and inflammatory bowel
Worldwide, the prevalence of symptomatic
diseases, acute and chronic diarrhea, abnormal
hemorrhoids is estimated at 4.4% in the general
radiological examinations, isolated unexplained
population, there has been a paucity of study
abdominal pain, chronic constipation, and preoperative
researches on the epidemiology of hemorrhoids, and
localization of colonic lesions.
prevalence is not well-documented (5).
Hemorrhoids are not selective for age or sex.
Exclusion criteria:
However, age is known to be a risk factor, and the
Grade IV internal hemorrhoids in Goligher's

classification. Age < 18 and > 75. Contraindications

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


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3474
Received: 18 /6 /2021



Accepted: 14 /8 /2021


Full Paper (vol.851 paper# 141)


c:\work\Jor\vol851_142 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3448-3453

Adding Ketamine to Xylocaine and Epinephrine in Local Infiltration for
Rhinoplasty, Postoperative Analgesia and Side Effects
Sameh Ghareeb and Ahmed Sonbul
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
*Corresponding author: Sameh Ghareeb, Mobile: (+20)105589289,E-Mail:sameh926@yahoo.com



ABSTRACT
Background
: Rhinoplasty is considered a surgical technique used to repair various nose deformities. This is one of the
most challenging procedures in face aestheticsurgery. It is performed under general anesthetic, and often particular areas
of the nose are infiltrated with 2% xylocaine and epinephrine to induce vasoconstriction, reduce surgical bleeding, and
provide analgesia.
Objectives: The aim of the work was to determine the effect of combining ketamine with xylocaine and epinephrine in
local infiltration.
Patients and methods: This prospective randomized study included a total of 44 cases distributed into two equal groups
(22 each); the xylocaine - epinephrine (XE) group where the local infiltrationwas done by xylocaine and epinephrine.
The second group xylocaine ­ epinephrine - ketamine (K) group includes the remaining patients in whom the local
infiltration was done by xylocaine, epinephrine andketamine.Heart rate, blood pressure, visual analogue score (VAS),
and morphine consumption were recorded.
Results: When group K was compared to group XE at 1, 2 hours post-operatively, the VAS was substantially lower.In
group K the period for the initial request for analgesia (3.30±1.04h) was longer than in group XE (2.14±0.94h).A
statistically significant reduction of the morphine requirement was seen in group K (7.0±3.3 mg), in comparison to
group XE (10.0±3.19 mg) during the first post-surgical 24 hours.
Conclusion: It could be concluded that adding ketamine to xylocaine-epinephrine local infiltration for rhinoplasty
lowered post-operative pain ratings, delayed the initial request for analgesia, and decreased overall analgesic intake in
the first 24 hours post-operatively without causing severe adverse effects.
Keywords: Rhinoplasty,xylocaine, epinephrine, ketamine,local infiltration.

INTRODUCTION
PATIENTS AND METHODS
Rhinoplasty is a surgical technique that may be
This prospective randomized study included a total
used to address a range of nasal deformities. It is one of
of 44 cases subjected for rhinoplasty, attending at
the most difficult operations in the field of face cosmetic
Mansoura UniversityHospitals. This study was
surgery (1).
conducted betweenDecember 2020 and June 2021.
Combining general and local infiltration


anesthesia prior to the initial incision lowers the need
Ethical Consideration:
for postoperative analgesics following rhinoplasty. Few
This study was ethically approved by Mansoura
studies in the scientific literature investigate the effect
University's Faculty of Medicine's Institutional
of various local anesthetics and adjuvants on
Research
Board
(IRB)
(Code
Number:
postoperative analgesia after rhinoplasty. Xylocaine 2%
R.21.04.1308), Written informed consent of all the
with epinephrine is the most often used local anesthetic
subjects was obtained. This work has been carried
in rhinoplasty(2, 3).
out in accordance with The Code of Ethics of the
Ketamine is a popular intravenous anesthetic in
World Medical Association (Declaration of Helsinki)
dose of 1-2mg/kg. Smaller dose can be used for
for studies involving humans.
sedation(4). Ketamine inhibits NMDA receptors, which

are involved in central transmission, regulation, and
Inclusion criteria: Any patient age < 21 years, ASA I
sensitization of acute and chronic pain states.
and II subjected for rhinoplasty.
Additionally, research has identified NMDA receptors
Exclusion criteria: patient refusal, age>21,history of
in the epidermis, muscles, and knee joints and shown
hypertension,coronary
artery
disease,psychiatric
that they are involved in the sensory transmission of
disorders,sensitivity to any of the drugs used and local
noxious signals(5).
skin infection.
Ketamine had been used successfully in many

regional blocks topotentiate local anesthetic (LA)
Patients were randomly distributed into two equal
effect(6).
groups (22 each) using closed envelope method, in
The aim of the current work was to determine
accordance with the medicines used:
the effect of combining ketamine with xylocaine and
Xylocaine ­ epinephrine(XE) group (n=22): patients
epinephrine in local infiltration.
received local infiltration composed of6ml xylocaine

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


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3448
Received: 15 /6 /2021


Accepted: 11 /8 /2021


Full Paper (vol.851 paper# 142)


c:\work\Jor\vol851_143 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3454-3458

Association between Vitamin D Receptor Gene Polymorphisms with
Immune Thrombocytopenic Purpura in Children
Rafik Abdoelgader Salem1, Mohamed Ahmed Badr1, Tamer Hassan Mustafa1,
Wafaa Abdelatief Emam 2, Hala Mossad2
Departments of 1Pediatric and 2Medical Biochemistry and Molecular Biology,
Faculty of Medicine, Zagazig University, Egypt
Corresponding author: Rafik Abdoelgader Salem, Mobile: (+2)0100847142, Email: rafikkhpiza@gmail.com

ABSTRACT
Background:
Vitamin D receptor (VDR) gene polymorphisms have been demonstrated in the development of
autoimmune diseases. Also, vitamin D deficiency has been linked with the development of autoimmune diseases.
Immune thrombocytopenia purpura (ITP) is developed secondary to the production of autoantibodies against platelets
leading to isolated thrombocytopenia. Objective: This study aimed to evaluate the association between VDR gene
polymorphism and susceptibility to ITP in children as well as other prognostic factors. Patients and Methods: A case-
control study included 60 subjects and conducted at Hematology Unit of Pediatric Department and Clinical Pathology
Department at Zagazig University Hospital. Children were divided into: case group included 30 children with primary
ITP and the control group included 30 matched healthy children 15. All the included subjects were subjected to the
following: history taking, physical examination, laboratory investigations. Results: There was no statistical significance
difference between the studied groups regarding age or sex. Platelets count between the studied groups ranged from 6
to 38 x103/mm3 with mean 16.63±7.89 and median 17 x103/mm3. There was no statistical significant relation between
VDR BsmI gene polymorphism and sex, frequency of upper respiratory tract infection (URTI), purpura and ecchymosis;
but there was a statistical significant increase in frequency of wet bleeding among BB genotype compared to other
genotypes. There was no relation between VDR BsmI analysis and line of treatment among the studied cases group.
Conclusion: VDR BsmI polymorphism can be used as a risk marker for ITP susceptibility in children. There was an
association of VDR BsmI genotype frequency in ITP patients with no effect on platelet count or bleeding severity.
Keywords: Thrombocytopenia, Purpura VDR Bsmi, Vitamin D Receptor.

INTRODUCTION


Vitamin D is a steroid hormone precursor that
adaptive immunity, and regulating the inflammatory
undergoes chemical conversion in the liver and kidney:
cascade, vitamin D has a significant influence on the
the first reaction produces 25-hydroxyvitamin D, an
host's immune system (7).
objective indicator of vitamin D status, and the second
In recent years 1,25 [OH]2D3 has been
produces
the
main
bioactive
form,
1,25-
rediscovered as an immune modulator. Lassandro et al.
dihydroxyvitamin D (1). Vitamin D receptor
(8) suggested that vitamin D deficiency does not represent
polymorphisms are associated with the incidence and
a chronicity factor for ITP. So, further studies are needed
severity of certain autoimmune diseases (2). The
to understand the role of vitamin D in ITP pathogenesis.
mechanism by which VDR polymorphism affects
The current study aimed to evaluate the
autoimmunity is not yet clear, although activation of the
association between VDR gene polymorphism and
receptor contributes to immune responses via regulation
susceptibility to ITP in children as well as other
of the T-helper (Th)1/Th2 cytokine balance and reduces
prognostic factors.
production of Th2 cytokines (3).

The immune thrombocytopenia purpura (ITP) in
PATIENTS AND METHODS
children is one of the most common benign hematologic
A case-control study included 60 subjected and
disorders. Isolated, immune-mediated thrombocytopenia
conducted at Hematology Unit of Pediatric Department
is characteristic of it (4). The etiology of
and Clinical Pathology Department at Zagazig
thrombocytopenic purpura in the immune system is
University Hospital during a period from December
unclear but is likely due to genetic or acquired factors (5).
2020 to the end of May 2021.
Most
frequently
acquired
factors
are

immunological problems such as cross-reactive
Inclusion criteria: Children with primary ITP, both
antibodies to platelet membrane glycoproteins
sexes, and age between 1 - 15 years.
developed during viral infections such as rubella,

varicella, mumps, cytomegalovirus, and Epstein­Barr
Exclusion criteria: Children with other causes of
viruses (6). These viral infections can trigger an
thrombocytopenia, children < 1 year and > 15 years, and
autoimmune process leading to a loss of peripheral
children with recent manifestations of active infection,
tolerance, and the production of self-reactive antibodies
or secondary causes of ITP.
that destroy platelets. By modulating both innate and


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3454
Received: 17 /6 /2021


Accepted: 13 /8 /2021


Full Paper (vol.851 paper# 143)


Laparoscopic Hiatal Hernia Repair with or without Fundoplication The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3459-3464

Laparoscopic Hiatal Hernia Repair with or without Fundoplication.
Is There Any Difference?
Abdelrahman Mohamed Amin Sarhan, Muhammad Ali Baghdadi, Mohammed Mahmoud Mokhtar
Mohammed, Anas Abdelhmed Yousef Abdelhmed*.
Department of General Surgery, Zagazig University hospitals, Zagazig, Egypt.
*Correspondence to: Anas Abdelhmed Yousef Abdelhmed, E-mail: priority1953@gmail.com

ABSTRACT

Background: A hiatal hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the
diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or
laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other
symptoms may include swallowing trouble and chest pains.
Objectives:
This study aimed to compare laparoscopic hiatal hernia repair (HHR) cruroplasty (the effect of hernia
reduction and only repair of diaphragmatic crura) versus HHR with concomitant fundoplication in terms of relative
frequency and severity of symptoms before laparoscopic antireflux surgery, and DeMeester scores (DMS), relative
symptom improvement, patients' satisfaction, and complications after antireflux surgery.
Patients and methods:
This prospective randomized study was conducted in GIT Unit of General Surgery
Department, Faculty of Medicine, Zagazig University, on 18 patients with hiatal hernia underwent laparoscopic hiatal
hernia repair. They were divided into two equal groups; 1st group was laparoscopic hiatal hernia repair (HHR) without
fundoplication and 2nd group was with Nissen Fundoplication (HHR ­ LNF).
Results: We found that there was complete absence of hernia among HHE-LNF group (0.0 %) versus 2 patients (22.2
%) had persistent hernia after HHR group with no significance difference between both groups pre- and post-
operatively. There was not a statistically significance difference between the two studied groups regarding success rate
with 100.0% versus 77.8% among HHR_LNF and HHR respectively.
Conclusion: Laparoscopic hiatal hernia repair with Nissen Fundoplication had better short-term outcome than without
Nissen fundoplication.
Keywords: Hiatal hernia, Gastroesophageal reflux disease, Laryngopharyngeal reflux.

INTRODUCTION

component of laparoscopic antireflux surgery
Hiatal hernia is a common disorder. It is
performed for medication-refractory GERD (6).
characterized by a protrusion of any abdominal
In addition, fundoplication is thought to support
structure other than the esophagus into the thoracic
the anchoring of the cardia below the diaphragm,
cavity through a widening of the hiatus of the
thereby reducing the risk of recurrence. For all these
diaphragm (1). Greater than 95% of hiatal hernias are
reasons, routine addition of fundoplication is commonly
Type I. Types II ­ IV hernias as a group are referred to
recommended (7). Even more important, there is a risk
as paraesophageal hernias (PEH), and are differentiated
of fundoplication-related complications and side
from Type I hernias by relative preservation of
effects. The frequency of gas-bloating symptoms after
posterolateral phrenoesophageal attachments around the
fundoplication are reported to be up to 58%, and in
gastro-esophageal junction. Of the paraesophageal
about 20% of patients, new symptoms occur
hernias, more than 90% are Type III, and the least
postoperatively. Therefore, intended improvement of
common is Type II (2).
GERD represents a trade-off against the risk of
The history of antireflux surgery over the last 48
fundoplication related side effects (8).
years has shown that reduction of the hiatal hernia in
The question arises as to whether routine addition
conjunction with diaphragmatic crural approximation is
of a fundoplication is reasonable. Therefore, the aim of
at best a transient antireflux deterrent and that an
this study is to compare laparoscopic HHR (the effect
additional procedure needs to be performed (3).
of hernia reduction and only repair of diaphragmatic
Ultimately, a fundoplication is performed either
crura) with HHR with concomitant fundoplication in
through the chest (Belsey Mark IV) or through the
terms of relative frequency and severity of symptoms
abdomen involving varying degrees of encirclement of
before laparoscopic antireflux surgery, and DeMeester
the distal esophagus by the fundoplication.
scores (DMS), relative symptom improvement,
Laparoscopic hiatal hernia repair (HHR) has been
patients' satisfaction and complications after antireflux
shown to provide good short- and long-term results in
surgery.
gastroesophageal reflux disease (GERD) (4) and may

reduce
the
laparoscopic
antireflux
surgery
PATIENTS AND METHODS
complications (5). Fundoplication is also an important
This prospective randomized study was conducted
in GIT Unit of General Surgery Department, Faculty of

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3459

Received: 18 /6 /2021


Accepted: 14 /8 /2021


Full Paper (vol.851 paper# 144)


c:\work\Jor\vol851_145 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3465-3468

Mortality Rates in Patients with Charcot's Foot: Review of Literatures
Amany Mohammed *, Hanan Gawish, Ahmed Albehairy
Department of Endocrinology, Faculty of medicine-Mansoura University, Egypt.
*Corresponding author: Amany Mohammed, Mobile: (+20) 01274776734, E-Mail: amanymera3@gmail.com

ABSTRACT
Background:
Diabetes mellitus (DM) is considered a frequent metabolic disorder and its prevalence in adults has been
increasing in the last years. Charcot neuroarthropathy is considered a main etiology of morbidity among diabetic cases
with subsequent joint destruction, which ends ultimately in deformity. The mortality in cases with Charcot foot was more
than expected. However, there were no differences among cases with Charcot and cases with uncomplicated neuropathic
ulcers.
Objective: This study aimed to investigate the mortality rate in patients with Charcot's foot.
Material and methods: A PubMed search was done with the key words "Charcot foot, Diabetes, Mortality, CKD, IHD"
We could trace about 1000 papers on the subject. Electronic database was systematically searched for literature discussing
the Epidemiology, Pathogenesis, Clinical features, and Investigations, Management and Prognosis of Charcot
neuroarthropathy. We applied no restrictions on publication date. Article eligibility was assessed independently by all
authors. Reasons for exclusion of articles based on title or abstract were (1) nonoriginal data (e.g., editorials, guidelines,
and comments), (2) nonclinical articles (e.g., technical or animal studies), (3) case reports, and (4) articles not written in
English language. All authors independently chose the most relevant papers with regard to target topics resulting in the
identification of 25 "most pertinent" articles.
Results: Diabetic cases with Charcot foot were more susceptible for mortality compared to Charcot foot free ones. The
actual mechanism of such association was unknown, however it could be explained by the fact that cases with foot ulcers
were at a high possibility for PVD and macrovascular diseases development compared to cases with CA with a subsequent
higher mortality rates. Another possible mechanism is the existence of ulceration which raises the possibility of infections,
with a subsequent increase in the possibility of complications which may ultimately end in death
Conclusion: Physicians should take into consideration, ACN in all cases complaining from warm red joint together with
neuropathy. The backbone of diagnosis is still clinical however MRI and isotope bone scanning could be considered also
as early diagnostic modalities. Very early management could possibly prevent limb-threatening deformity so encourage
investigations and management is of great importance.
Keywords: Diabetes, Charcot foot, Mortality, CKD, IHD.

INTRODUCTION
events culminating in bone and joint destructions, which
Diabetes mellitus is a disease of improper control
ultimately ends in deformity development (4).
of blood levels of glucose. It could be classified into
It is considered a devastating adverse event
several classifications, such as type I, type II, gestational
affecting diabetic cases as well as peripheral neuropathy
diabetes mellitus, neonatal diabetes and steroids-induced
(PN). It is considered as progressive and destructive state
DM (1). Worldwide, the number of diabetic cases is
featured by acute fractures, dislocations and joint
increased by about four folds in the past three decades,
destructions in the neuropathic foot. Rapid diagnosis and
and DM is considered the 9th main etiology of death.
treatment of acute Charcot neuroarthropathy (ACN) is thus
Approximately 1 out of 11 adults have DM, 90% of whom
essential to evade the abrupt development of permanent
have T2DM (2) . The rising number of diabetic cases was
feet deformation as well as its accompanying adverse
demonstrated to be associated with an increase in co-
events (5).
morbidities
which
involve
microvascular
and
The acute reaction is occasionally misdiagnosed
macrovascular adverse events (3).
and a lot of cases present late with deformity. Although

when the diagnosis is taken into consideration at an initial
Charcot neuroarthropathy
phase, no conclusive criteria could establish Charcot
Charcot neuroarthropathy (CN) is identified for
neuroarthropathy development and a higher degree of
over 130 years and yet it is still a main etiology of
suspicion is of great importance for any diabetic patients
morbidity for diabetic cases and a continuing challenge for
with a swollen warm foot (6).
specialists. The primary etiology is believed to be traumas

in a neuropathic foot that was demonstrated to be
Epidemiology:
accompanied by complicated sequences of pathologic
Till now, there are no epidemiologic researches in
the context of CN. The recorded prevalence CN is about

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3465

Received: 20 /6 /2021

Accepted: 16 /8 /2021


Full Paper (vol.851 paper# 145)


c:\work\Jor\vol851_146 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3469-3472

Correlation between Pulmonary Artery Hypertension Caused by
Acyanotic CHD with Left to Right Shunt and Increased Level of Endothelin-1
Abdulkarim Abdulsalam Alfaqi*, Mohamed Osman Hafez, Besheer Abdallah Hassan, Hanan Samir Ahmed
Pediatric Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding authors: Abdulkarim A. Alfaqi, Mobile: (+2)01143870952, Email: kareamalfaqey@gmail.com

ABSTRACT
Background:
Pulmonary hypertension is defined as a resting mean pulmonary artery pressure (mPAP) of 25 mmHg or
above. PAH is a frequent complication of congenital heart disease (CHD), particularly in patients with left-to-right
(systemic-to-pulmonary) shunts.
Objective: The present study aimed to investigate changes in the blood level of endothelin-1 (ET-1) in patients of PAH
complicated by acyanotic CHD and to detect possible correlation with different hemodynamic parameters.
Patient and methods: 48 children were recruited in Pediatric Cardiology Unit, Pediatrics Department in Zagazig
University Hospitals after obtaining the required permissions and informed consent from the their caregivers. They were
divided into Group (A), which included 24 children with acyanotic CHD with left to right shunt with PAH and Group
B included 24 children with acyanotic CHD with left to right shunt but no PAH. All children were subjected to clinical
and radiological examination, echocardiography and measurement of endothelin-1 level as well as correlation between
the studied parameters were performed.
Results: the present results showed that Group A was significantly associated with previous need of hospital admission
and insignificantly associated with ICU need. Endothelin-1 was significantly negatively correlated with weight and
oxygen saturation (SPO2) but significantly positively correlated with systolic blood pressure (SBP), heart rate (HR),
respiratory rate (RR) and pulmonary blood pressure. Significant area under the curve (AUC) with cutoff value >1.55
with sensitivity 85.05 and specificity 91.1%.
Conclusion: Pulmonary hypertension (PAH) complicated by CHD can be predicted by estimation of endothelin-1 (ET-
1) as an indicator of endothelial injury.
Keywords: CHD, Echocardiography, ET-1, PAH.

INTRODUCTION

PATIENTS AND METHODS
Cyanotic heart defects are called such because
A case-control study included 48 children who
they result in cyanosis, a bluish-grey discoloration of the
were presented to Pediatric Cardiology Unit, Pediatrics
skin due to a lack of oxygen in the body. Such defects
Department in Zagazig University Hospitals for the first
include persistent truncus arteriosus, total anomalous
time. They were divided into Group (A), which included
pulmonary venous connection, tetralogy of Fallot,
24 children with acyanotic CHD with left to right shunt
transposition of the great vessels, and tricuspid atresia (1).
with PAH and Group B included 24 children with
Sometimes, congenital heart disease (CHD)
acyanotic CHD with left to right shunt but no PAH.
improves without treatment. Most of the time CHD is

serious and requires surgery and/or medications.
Inclusion criteria: Patients with acyanotic congenital
Medications include diuretics, which aid the body in
heart diseases with left to right shunt who were
eliminating water, salts, and digoxin for strengthening
diagnosed by echocardiography aged from one month
the contraction of the heart. This slows the heartbeat and
to 12 years of both gender.
removes some fluid from tissues (2).

Pulmonary hypertension is a group of conditions
Exclusion criteria:
with multiple causes rather than a single one.
Patients complicated by acute infection and
Pathogenesis and management differ among entities (3).
inflammation and patients complicated by coronary

heart disease, cardiomyopathy, high blood pressure and
Cardiac defects resulting in left-to-right shunting
other heart diseases. Patients diseased by respiratory
cause pulmonary hypertension (PAH) because the
system diseases, hepatic diseases, chronic renal failure,
increased pulmonary blood flow induces increases in
cerebrovascular diseases, tumors and autoimmune
shear stress and circumferential stretch. These
diseases.
haemodynamic forces within the pulmonary vessels

induce endothelial dysfunction (4).
Operational design:
Therefore, this study aimed to investigate
All participants were subjected to careful history
changes in the blood level of ET-1 in patients of PAH
taking, thorough clinical examination, plain X-ray chest
complicated by acyanotic CHD and to detect possible
postero-anterior
view,
echocardiography
and
correlation with different hemodynamic parameters.
measurement of endothelin-1 level.





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3469
Received: 16 /6 /2021


Accepted: 12 /8 /2021


Full Paper (vol.851 paper# 146)


c:\work\Jor\vol851_147 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3473-3477

Effect of Low FODMAP Diet and Aerobic Exercise on
Irritable Bowel Syndrome Post Abdominal Surgeries
Mohamed Mahmoud Khalaf1, Samar Mahmoud Sharaf*1, Eid Rizk El Gammal2, Khadra Mohamed Ali1
1Department of Burn and Surgery, Faculty of Physical Therapy, Cairo University, Egypt.
2Department of Oncosurgery, Faculty of Medicine, Al-Azhar University, Egypt.
*Corresponding author: Samar Mahmoud Sharaf, Mobile: (+20) 01004140023,
E-Mail: samarsharaf1993@gmail.com

ABSTRACT
Background:
Irritable bowel syndrome (IBS) is a functional gastrointestinal syndrome with an expanding worldwide
incidence. Low FODMAP diet is a recently developed dietary strategy consists of limiting foods that are high
fermentable, which might induce or aggravate IBS symptoms. Aerobic exercise is beneficial in reducing the risk of all
types of gastrointestinal symptoms.
Objective: Investigate the effect of low FODMAP diet and aerobic exercise on irritable bowel syndrome post abdominal
surgeries.
Patients and methods: Forty five female and male patients participated in this study. They were divided into three
equal groups, group (A) received low FODMAP diet group (B) received aerobic exercise (walking on treadmill 25-40
minutes 3 times per week) group (C) received both low FODMAP diet and aerobic exercise. Evaluation was done pre-
and post- 12 weeks of treatment by IBS Severity Scoring System (IBS-SSS) and IBS Quality of Life (IBS-QOL).
Results: There was significant reduction in post-treatment values of IBS-SSS and IBS-QOL in comparison to pre-
treatment values in the three groups, Post-treatment comparison between three groups showed significant difference in
IBS-SSS and IBS-QOL, which revealed a significant reduction in IBS-SSS and IBS- QOL of group C compared to that
of group A and group B.
Conclusion: combining low FODMAP diet and aerobic exercise had a greater effect on irritable bowel syndrome
through reducing IBS symptoms and improving quality of life.
Keywords: Irritable bowel syndrome, Low FODMAP diet, Aerobic exercise, Post abdominal surgeries.

INTRODUCTION
diet and aerobic exercise on irritable bowel syndrome
Irritable bowel syndrome (IBS) is the
post abdominal surgeries.
commonest gastrointestinal condition, accounting for

up to 50% of gastroenterology consultations each
PATIENTS AND METHODS
year(1). It is characterized by recurrent abdominal pain
This study was conducted in Al-Tahrir general
and abnormal evacuation (2). IBS is most prevalent
Hospital to investigate the effect of low FODMAP diet
between the ages of 20 and 40, with a considerable
and aerobic exercise on irritable bowel syndrome post-
female predominance (3). It has been noted that people
abdominal surgeries.
with IBS have a disproportionately high incidence of
Forty five patients were divided equally into three
abdominal and pelvic surgeries (4). The low FODMAPs
groups: Group (A) included 10 females and 5 males and
diet limits foods that are high fermentable oligo-, di-,
received low FODMAP diet, group (B) that included 11
and monosaccharides, as well as polyols. The low-
females and 4 males and received aerobic exercise, and
FODMAP diet is a 2-phased intervention, with strict
group (C) that included 11 females and 4 males and
reduction of all dietary FODMAPs followed by
received low FODMAP diet and aerobic exercise.
reintroduction of specific FODMAPs according to

tolerance (5). FODMAPs are inadequately absorbed and
Ethical approval:
quickly fermented by gut bacteria, causing gas
This study which was approved by the Ethical
generation, bloating and pain (6). As a result, lowering
Committee of the Faculty of Physical Therapy,
FODMAPs in the diet may be a treatment option for IBS
Cairo University. The experimental protocol was
(7). Exercise is a way to alleviate constipation, distension
explained in details for every patient before starting
and for maintaining proper bowel function and reducing
the initial assessment. Approval from all patients
stresses (8). Physical activity improves colonic transit
was formally obtained by signing a consent form.
time, gas transit, and bloating by stimulating
This work has been carried out in accordance with
gastrointestinal motility (9). Finally, exercise is
The Code of Ethics of the World Medical
becoming more widely accepted as a safer and effective
Association (Declaration of Helsinki) for studies
treatment for a variety of diseases, such as depression
involving humans.
and irritable bowel syndrome (10). So, this study was

conducted to investigate the effect of low FODMAP
Inclusion criteria: Age ranged between 25-40 years,
body mass index not exceeding 32, patients who

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3473
Received: 60/6/2021

Accepted: 16/8/2021


Full Paper (vol.851 paper# 147)


c:\work\Jor\vol851_148 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3478-3482

Management of Preterm Infants with Respiratory Distress Syndrome
Using Non-Invasive High Frequency Ventilation versus Nasal Continuous
Positive Airway Pressure
Baha Elhadi Masoud Ettrmal*, Hisham Sami Abd Alhamid, Hosam Fathi Elsaadany
Pediatrics Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Baha E. Ettrmal, Mobile: (+2):010281440 97, Email: bahabon2006@gmail.com

ABSTRACT
Background:
Preterm infants have a risk of the respiratory distress syndrome (RDS). Helpful effects of high-frequency
ventilators have been shown within management of RDS as well as the use of these ventilators as the initial mode of
support or as a rescue treatment once failure of standard mechanical ventilation.
Objective: This study aimed to compare between the nasal high-frequency oscillatory ventilation (nHFOV) and nasal
continuous positive airway pressure (NCPAP) in the treatment of preterm infants with RDS in.
Patients and methods: A study included 62 neonates with respiratory distress syndrome and was conducted at neonatal
intensive care unit, Pediatrics Department, Zagazig University Hospital. Cases were divided into; group (A) was
managed with non-invasive high frequency nasal ventilation and group (B) was managed with nasal continuous positive
airway pressure. All cases were subjected to full medical history, clinical assessment, laboratory investigations and
Silverman Score for respiratory distress grading.
Results:
There was statistically non-significant difference between the studied groups regarding occurrence of nasal
injury, oxygen supply after study and need for use of surfactant. There was statistically non-significant difference
between the studied groups regarding x ray findings before or by the end of the study. There was statistically significant
relation between gestational age groups and need for surfactant in NHFV group.
Conclusion: Noninvasive high frequency ventilation (NHFV) represent a better primary non-invasive mode than
NCPAP in treatment of preterm infants with RDS.
Keywords: CPAP, Neonates, NHFV, RDS.

INTRODUCTION

that applies an oscillating pressure wave type to the
Preterm birth is the leading reason behind
airways using a nasal interface "nasal prong or face mask",
newborn death worldwide. Preterm infants have a risk
This mode has been shown to facilitate carbon dioxide
of the respiratory distress syndrome (RDS), which is
expiration, however very little is understood regarding its
one among the foremost common morbidities in
use in neonates (6).
preterm infants. The introduction of endotracheal
The current study aimed to compare between the
ventilation has improved the survival rate among
nHFOV and NCPAP in the treatment of RDS in preterm
preterm infants however it is related to an increased risk
infants regarding efficacy, safety, reducing the need for
of complications such as bronchopulmonary dysplasia
intubation and avoiding the complication of mechanical
(1).
ventilation.
In the past few decades, nasal ventilation has been

used to manage and improve respiratory complications in
PATIENTS AND METHODS
patients with respiratory distress syndrome (RDS) (2).
This comparative non blind randomized clinical
Nasal continuous positive airway pressure (NCPAP) is
trial included 62 neonates with respiratory distress
the utilization of positive pressure to the airways of
syndrome.
spontaneously breathing newborn during the respiratory
This study was conducted at neonatal intensive
cycle (3).
care unit, Pediatrics Department Zagazig University
The helpful effects of high-frequency ventilators
Hospital.
have been shown within management of RDS as well as

the use of these ventilators as the initial mode of support
Inclusion criteria:
or as a rescue treatment once failure of standard
Preterm infant with a gestational age between 30
mechanical ventilation (4).
to 36 weeks and 6 days. Preterm infants with a good
Sufficient recruitment of lung volume has the major
weight for the gestational age. Preterm infants with
part of protecting and preserving lung architecture in
spontaneous breathing.
addition potentiating surfactant therapy (5).
Preterm infants with respiratory distress syndrome,
Nasal high-frequency oscillatory ventilation
including all grades "Mild, moderate, severe" with signs
(nHFOV) is effective and superior to nasal intermittent
and symptoms such as grunting, intercostals, subcostal
positive pressure ventilation regarding lung carbon
retraction and cyanosis. Preterm infants with respiratory
dioxide elimination during a model using newborn
distress syndrome suggestive by chest X-rays.
manikins. The nHFOV is a non-invasive ventilation mode


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/)
3478

Received: 16 /6 /2021


Accepted: 12 /8 /2021


Full Paper (vol.851 paper# 148)


c:\work\Jor\vol851_149 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3483-3486

Role of Interleukin 33 in Immune Response Process of Vitiligo Disease
Ibrahim El-Gharib El- Ganiny 1, Sahar Mohamed Al-Mokadem 1,
Naglaa Ali Khalifa 2, Mariam Nasr Gado*1, Marwa Mohamed Fathi 1
Departments of 1Dermatology, Venereology & Andrology and
2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Mariam Nasr Gado, Email: mariamnasr6311@gmail.com

ABSTRACT
Background:
When melanocytes cease to operate, vitiligo develops. It is a skin and mucosa depigmentation condition.
Any area of the body can develop well-circumscribed white macules or patches in this disease. Approximately 1-2
percent of the population is affected by Vitiligo. Suppression of tumorigenicity 2 (ST2), a newly discovered member of
the interleukin-1 (IL-1) family, acts as a receptor for the IL-1 receptor-like 1 protein (also known as IL-1RL1) while
also acting as a ligand for the interleukin-1 receptor-like 1 protein (also known as IL-1RL1) and suppressing
tumorigenicity 2.
Objective:
To study Interleukin 33 (IL-33) in generalized and localized vitiligo patients and to assess their relationship
with disease activity.
Conclusion: Vitiligo could be associated with increased serum levels of IL-33, which could help as predictor marker of
disease activity in vitiligo.
Key words: Vitiligo, Interleukin 33 (IL-33).

INTRODUCTION

Skin depigmenting disorder (Vitiligo) is caused by a
of involvement might range from small (localized
loss of functioning epidermal melanocytes in the
disease) to extensive (systemic disease) (generalized
affected area, resulting in milky-white macules on the
disease) (3).
skin. It is an acquired, common, and complex illness (1).
Non-segmental vitiligo (NSV) and segmental
Epidemiology:
vitiligo (SV) are the two primary kinds of vitiligo,
Only 0.5 percent of the world's people are stricken
according to the Vitiligo Global Issues Consensus
by this disease. There are no evident differences in
Conference (VGICC), which was convened in
incidence rates based on phototype or race for either
Bordeaux in 2011 and described them as follows (3):
sex. A study has shown that women are more inclined

to seek therapy (2).
Table (1): Classification of vitiligo (3)
Type
Subtype
Quality of life:
Generalized
Vitiligo is a debilitating autoimmune disease, not
Acrofacial
merely a skin problem. Psychological damage can result
Non-segmental
Mucosal(>1 mucosal site),
when this disfiguring disease affects the face or other
Vitiligo
Universal
visible parts of the body (3).

Mixed (associated with
Clinical presentation:
segmental vitiligo)
Vitiligo is characterized by lightening of the skin
Rare varient
and hair follicles. As a result, the number and size of
Unisegmental
and
white symmetrical macules and patches grow with time.
Segmental vitiligo
multisegmental
Vitiligo first appears in sun-exposed areas in fair-
Undetermined

skinned patients as a result of untouched skin darkening.
/unclassified
Disease can start for a variety of reasons, such as severe

sunburn or pregnancy. It can also start for reasons
1. Non-segmental vitiligo (NSV):
including traumatic cutaneous injury or high levels of
They range in size from a few millimeters in
psychological stress. Patients may experience the
diameter to several centimeters in diameter, and they
Koebner phenomenon, which is characterized by the
affect both sides of the body, with a propensity to be
appearance of new vitiligo lesions in places that have
evenly distributed. It might be all-encompassing,
been subjected to injury or trauma (4).
acrofacial, universal, mucosal, or a combination of
Classification of vitiligo:
these types of treatments (associated with SV).
The clinical manifestations of vitiligo can be
Hypochromic vitiligo/vitiligo minor is a rare form of
characterized as segmental or non-segmental based on
NSV, as is vitiligo punctate (3).
the morphology of the clinical involvement. It can also

be defined as either progressive or stable depending on
Generalized common vitiligo: There are many
how active the disease is at any given time. The extent
other types of vitiligo, but this is by far the most
This article is an open access article distributed under the terms and conditions of the Creative

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


3483
Received: 11/8/2021

Accepted: 19/9/2021


Full Paper (vol.851 paper# 149)


c:\work\Jor\vol851_150 The Egyptian Journal of Hospital Medicine (October 2021) Vol. 85 (1), Page 3487-3490

Assessment of the Complications and Associated Findings by
Conventional MRI in Post-Operative ACL Reconstruction
Amina Shaker Ahmed*, Amal M. Hassan, Enass M. Khattab, Muhammed M. Elfawal
Radiodiagnosis Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Amina Shaker Ahmed, Email: Dr.aminashaker@yahoo.com

ABSTRACT

Background: The anterior cruciate ligament (ACL) runs from the femur to the tibia in the knee joint and is a thick
band of connective tissue that may be exposed to tears. Accurate MR imaging evaluation of these patients requires
an understanding of the usual postoperative MR imaging appearance of postoperative ACL graft and any
abnormalities.
Objective: To assess the complications and associated findings by conventional MRI in post-operative ACL
reconstruction.
Patients and methods: This study included 27 symptomatic patients (23 males and 4 females). The study was
carried out at the Radiology Department at Zagazig University Hospitals. They were assessed by conventional
MRI after the ACL operations.
Results: The mean age of the studied patients was 29.26 ± 7.79 years old. Most of the studied patients were males
(85.2 %). 14.8% of the studied patients had anterior tibial translation, graft impingement in 2/27 (7.4 %) of patients
and anteriorly displaced tibial hardware was found in 3/27 (11.1 %) of the studied patients. 18.5% of the studied
patients had joint effusion. PCL buckling and bone marrow edema were found in 7.4% of the studied patients and
PHMM degeneration was found in 11.1% of the studied patients.
Conclusion: In order to properly evaluate the post-operative knee, particularly in patients who had cruciate
ligament repair, magnetic resonance imaging (MRI) of the knee is required.
Keywords: ACL reconstruction, Conventional MRI.

INTRODUCTION

conditions by analysis of all the characteristics and
Anterior cruciate ligament reconstruction is one of
traits directly or indirectly associated with ACL
the most common orthopedic procedures performed
reconstruction (1).
worldwide (1).
T2-weighted MR scans reveal ACL graft
The incidence of anterior cruciate ligament injuries
disruption, including the absence of complete graft
especially in athletes has rapidly increased over the last
fibers and an increase in signal intensity similar to that
decades. Rupture of ACL compromises the stability of
of fluid at the graft's expected location (4).
the knee in individuals who are active, resulting in
Intact fibers remain in the graft despite partial tears,
chronic instability and recurrent episodes of giving
which show up as areas of elevated signal intensity in
way. This injury presents a challenge for surgeons. The
the graft (4). Accurate MR imaging evaluation of
outcome is better in patients treated by surgical
patients who had an ACL transplant requires an
reconstruction of ACL than those managed
understanding of the typical postoperative MR imaging
conservatively (2). The most common procedure is
appearance and abnormalities (4).
anterior cruciate ligament reconstruction (3). In addition

to an increase in the number of patients undergoing
PATIENTS AND METHODS
ACL surgery, an increase in the number of patients who
The research for this topic was done in the Radiology
require imaging following surgery because of failure to
Department, Faculty of Medicine, Zagazig University
improve, recurrent symptoms or new damage is a result
Hospitals, after obtaining institutional review board
of this increase in ACL surgery (3).
approval and informed consent from patients or
Post-operatively, MRI is useful because it can
relatives before study, including 27 patients.
identify a variety of characteristics and scenarios that
Inclusion criteria: Patient who underwent anterior
could indicate prospective difficulties to clinicians in a
cruciate ligament reconstruction more than six months
non-invasive method. Surgical results could be
at time of examination.
compromised, and failure of the ACL reconstruction
Exclusion criteria: Patient with contraindication for
could be predicted if graft signal and integrity, accurate
MRI examination (Patients with implanted pacemaker
tunnel placement, tunnel widening, and fixation device
and other cardiological devices incompatible with MRI,
or donor site difficulties are present. The worst
patients with ocular implants and patients with
outcomes or a higher failure probability are connected
aneurysmal clips) and arthritis.
with a number of knee anatomical characteristics. This
All patients meeting the inclusion criteria were
article serves as a practical guide for the doctor who
subjected to:
wishes to use MRI to assess the patient's recovery from
Demographic data including patients' name, age, sex
ACL surgery, examine for normal or pathologic
and occupation.

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/)

3487
Received: 13/8/2021
Accepted: 21/9/2021


Full Paper (vol.851 paper# 150)