c:\work\Jor\vol871_1 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 973-978

Safety and Efficacy of Sofosbuvir Based Regimens in the Treatment of
HCV Recurrence Post Liver Transplantation
Mohamed Ali Abbasy*, Mohamed Ahmed Afifi, Eman Abd El-Sameea Mahmoud,
Tary Abd El-Hamid Salman, Eman Ahmed Rewisha,
OmKolsoum Mohamed Al Haddad, Talaat Zakareya Ibrahim
Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Egypt
*Corresponding author: Mohamed Ali Abbasy, Mobile: (+20)1002415060,
E-mail: mohamed.abbasy@liver.menofia.edu.eg

ABSTRACT
Background:
Hepatitis C virus (HCV) recurrence after liver transplantation (LT) is universal and associated with an
accelerated disease course. Second-generation direct-acting antivirals dramatically improve viral clearance. Their use in
the Egyptian population in the post-transplant setting needs further evaluation.
Objectives: To evaluate the safety and efficacy of sofosbuvir-based regimens in the treatment of HCV recurrence after
LT in the Egyptian population.
Patients and methods: Sixty patients with HCV recurrence after LT were included. Twenty patients received sofosbuvir
(SOF) in combination with ribavirin (RBV) for 24 weeks, 21 patients received SOF and simeprevir (SIM) for 12 weeks
and 19 patients received SOF and daclatasvir (DCV) with or without RBV for 12 or 24 weeks according to the stage of
liver fibrosis and eligibility for ribavirin. Treatment response and adverse events were analyzed.
Results: The mean age was 52.5±7.9 years. Most of patients were males (91.7%). Sustained virological response at week
12 after treatment (SVR12) was achieved in all patients who received SIM/SOF and SOF/DCV±RBV regimens and in
85% of patients who received SOF/RBV regimen. The most common reported adverse events were fatigue, anemia and
hyperbilirubinemia. Fatigue was reported in 75% of patients in SOF/RBV group and in 85.7% of patients in SIM/SOF
group. Anemia was reported in 15, 4.8 and 10.5% of patients in SOF/RBV, SIM/SOF and SOF/DCV±RBV groups
respectively, whereas hyperbilirubinemia was documented in 10% of patients in SOF/SIM group and in 9.5% of patients
in SIM/SOF group.
Conclusion: Sofosbuvir-based combinations are safe and effective in the treatment of recurrent HCV after LT,
especially when combined with another directly acting antiviral.
Keywords: DAAs, Daclatasvir, Recurrent HCV after liver transplantation, Simeprevir, Sofosbuvir.

INTRODUCTION
recurrence post LT with an all-oral regimen for short
Chronic hepatitis C virus (HCV) infection and its
duration, with few adverse effects and high cure rates (7).
related complications are among the most common

indications for liver transplantation worldwide (1). HCV
The current study aimed to evaluate the safety and
viraemic prevalence was estimated to be 7.3% in Egypt.
efficacy of sofosbuvir-based regimens in the treatment
Because of such a high prevalence, HCV is considered
of HCV recurrence after liver transplantation in the
the leading cause of liver transplantation in Egypt (2).
Egyptian population.
Hepatitis
C
virus
recurrence after liver

transplantation (LT) is universal and associated with a
PATIENTS AND METHODS
relatively progressive disease course; graft fibrosis,
The current study was conducted on patients who
cirrhosis and decompensated liver disease (3,4).
received living donor liver transplantation for HCV-
Unfortunately,
HCV
recurrence
post
liver
related decompensated liver cirrhosis at the National
transplantation significantly affects patient survival,
Liver Institute, Menoufia University, Egypt, and who
with an estimated survival rate of less than 10% at 3
developed recurrent HCV infection after the transplant.
years (5). Accelerated advances in direct-acting antivirals
Recurrent HCV infection was defined as positivity of
(DAAs) in the last few years have increased the success
serum HCV RNA after liver transplantation.
rate of HCV eradication considerably and significantly
Pediatric and young adult recipients below 18 years
improved the outcome of hepatitis C therapy with a
were ruled out. From December 2014 to September
positive impact on both graft and patient survival (6).
2017, sixty eligible patients were enrolled and started on
Recent studies have shown that LT recipients can be
sofosbuvir (SOF)-based antiviral medications regardless
safely and effectively treated with DAA combination
of their pre-transplant treatment status, whether
therapies. These agents offered treatment of HCV
treatment naļve or experienced. At least 3 months should
have elapsed after liver transplantation to start treatment.
973
Received: 10/12/2021
Accepted: 28/01/2022

Full Paper (vol.871 paper# 1)


c:\work\Jor\vol871_2 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 979-992
Diagnostic Approach of Mycosis Fungoides and Unusual Benign Mimickers
Fatma EL-Zahraa Salah El-Deen Yassin*1, Reham Ezz Eldawla2, Sheren Farrag Mahmoud Ahmed1
Departments of 1Pathology and 2Dermatology, Venereology, and Andrology,
Faculty of Medicine, Sohag University, Sohag, Egypt
*Corresponding author: Fatma El-Zahraa Salah El-Deen Yassin, Mobile: (+20)01007970144,
Email: fatmafm2002@yahoo.com
ABSTRACT
Background:
Diagnosis of mycosis fungoides (MF) and its mimickers is a major diagnostic challenge in era of
Dermatopathology. Objective: To draw a diagnostic stepwise approach to minimize this challenge focusing on the
benign (unusual) mimickers of infectious etiology.
Patients/methods: This retrospective study included 94 paraffin blocks of patients with clinical suspicious of MF or
its mimickers, during the period from Jan 2019-July 2021. The hematoxylin and eosin (H&E) stained sections and
their associated clinical presentations were reviewed. Ancillary studies were performed upon the preliminary clinical
diagnosis of each case. Deeper serial sections with selected special stains were done for benign mimickers. Primary
(CD3/CD4/CD7/CD68) and secondary (CD20/CD8/CD30) panels of immunohistochemistry (IHC) markers were
performed for most of the cases.
Results: A wide spectrum of MF mimickers was identified, our cases were categorized into 3 groups: the first is
classic MF (24) and its variants (5), the second is benign mimickers [subgrouped into infectious (31) & non infectious
(21)] and the third is heterogeneous group; (other lymphomas/parapsoriasis) (13). A suggested stepwise diagnostic
approach with selected IHC panels characterizes each group.
Conclusion:
A constellation of diagnostic clinical data, diagnostic histopathological clues and the suggested stepwise
approach minimize the misdiagnosis of classic MF and conclusively identify the infectious mimickers.
Keywords: Histopathology, Mycosis Fungoides, Mimickers.

INTRODUCTION
The straightforward clinical diagnosis is usually
Cutaneous lymphoproliferative lesions are a
associated with typical histopathological features of
common diagnostic challenge; they include typical
the same lesion. However, the ambiguous clinical
versus atypical infiltrates. Mycosis fungoides (MF) is
presentation is reflected histopatholgically and creates
the most common diagnosis for atypical infiltrate. The
diagnostic
challenges.
Mycosis
fungoides
is
international classification of cutaneous lymphoma
characterized by indolent progression through three
published by World Health Organization (WHO) new
stages: patch, plaque and tumor, characteristic
variants of MF: folliculotropic and granulomatous MF
progression of histopathological features through
(1, 2).
different stages was illustrated in (Figure 1).


Figure (1): MF stages with progression of histopathological features, direction of the arrows from the minimum
to the maximum.





979
Received: 20/09/2021
Accepted: 17/11/2021

Full Paper (vol.871 paper# 2)


c:\work\Jor\vol871_3 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 993-999

Impact of Body Mass Index (BMI) on Serum Interleukin 4 level in
Adult Bronchial Asthma Subjects
Eman El-Sayed Ahmed*, Maged Mohamed Refaat,
Sara Mostafa Mohamed Ahmed, Osama Mohamed Abdel Latif
Department of Internal Medicine, Allergy and Immunology Unit,
Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Eman El-Sayed Ahmed, Mobile: (+20)1005189047,
Email: dr.eman_khalil@med.asu.edu.eg, emelwal@gmail.com

ABSTRACT
Background:
Overweight and obesity are in reported observational studies consistently associated with increased
prevalence of asthma. Recently adipose tissue is considered as a source of inflammatory cytokines. Interleukin 4 (IL-4)
mediates important pro-inflammatory functions in asthma, including induction of isotype rearrangement of IgE.
Objective: The aim of the work was to assess IL4 in relation to Body Mass Index (BMI) in allergic asthmatic patients.
Patients and Methods: 100 allergic asthmatic patients were enrolled in the study and classified according to BMI. All
participants were subjected to routine laboratory investigations, serum IL4, skin prick test and pulmonary function tests.
Results: IL-4 was significantly higher in overweight, obese and massive obesity patients [560 (440-720) pg/ml, 560
(410 -730) pg/ml, 830 (445 -1095 pg/ml respectively] in comparison to non-obese asthmatic patients [160 (80-280)
pg/ml] (p<0.001). This difference in serum IL-4 level was strongly correlated to BMI (r=0.74) and body weight (r=0.69)
(p<0.001). Simple linear regression analysis revealed a strong relation between serum IL4 and BMI ( = 0.705, p <
0.001). Conclusion: It could be concluded that there is a strong association between the inflammatory cytokine IL4 and
BMI among obese allergic asthmatic patients, this may suggest a state of ongoing subclinical inflammatory state in the
obese-asthma phenotype.
Keywords:
Interleukin 4, Obese, BMI, Allergic asthma

INTRODUCTION

and T helper type 2 (Th2) leading to signaling cytokine
Asthma is a worldwide major health problem, that
release (8).
affects all ages, genders, and ethnicities. Prevalence has
Airway hyperresponsiveness (AHR) is a hallmark
been steadily increasing alongside that of allergy, as
of asthma. IL-4 and IL-13 induce hyper-responsiveness
modern lifestyles are adopted and communities become
of the airway smooth muscle in isolated human small
more urbanized, a trend that is predicted to continue
airways and was found to be glucocorticoid-insensitive
over the next two decades (1).
(9).Many studies have reported that obesity-related
Overweight and obesity may affect the lungs
asthma in children is more often non-atopic; yet some
through a mechanical effect on lung function or through
studies have reported that obesity in itself is associated
inflammation that may predispose to asthma (2). It is
with atopy (10, 11). To our knowledge, studies
likely that other factors associated with overweight and
investigating obesity associated asthma in adults are
obesity such as dyslipidemia and increased mast cell
few. So, this study was conducted to determine the
activity, also implicated in the pathogenesis of asthma
relation between serum interleukin 4 (IL-4) level and
and decreased lung function (3, 4). This" obese asthma
body mass index (BMI) in adult atopic asthmatic
syndrome" was found to be complex and multifactorial.
patients.
The inflammatory response associated with

obesity is originated in the adipose tissue cells (5).
PATIENTS AND METHODS
Adipose tissue consists of mature adipocytes and
This comparative cross-sectional study included a
stromal-vascular cells, which play a role in obesity
total of 100 asthmatic adults, attending at Allergy
associated inflammation, including: leukocytes,
Outpatient Clinics in Ain Shams University Hospitals.
macrophages, fibroblasts, endothelial cells, and pre-

adipocytes (6).
The included subjects were divided into two groups;
Asthma is a complex genetic disorder that has
Group 1 (non-obese asthmatics) consisted of 50
been associated with IL-4 gene in promoter
asthmatic patients with BMI<25 and Group 2
polymorphism and proteins involved in IL-4 (7). IL-4
(overweight/ obese /massive obesity asthmatics)
mediates important pro-inflammatory functions in
consisted of 50 asthmatic patients with BMI25.
asthma, including induction of isotype rearrangement of

IgE, expression of VCAM-1 molecules (vascular cell
Inclusion criteria: Allergic asthmatic patients
adhesion molecule 1), promoting eosinophilic
according to Global Initiative for Asthma (GINA)
transmigration through endothelium, mucus secretion
criteria (12), Atopic patients were defined as having
positive SPT or high specific IgE, or having a history of





993
Received: 29/10/2021
Accepted: 05/01/2022

Full Paper (vol.871 paper# 3)


c:\work\Jor\vol871_4 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1000-1005

Weaning from Mechanical Ventilation: Review Article
Abdelhady Noor Eldeen Osman Elew, Abd Alrahman Hassan Abd Alrahman,
Hala Mahmoud Hashim El Khayat, Fawzy Abbas Badawy
Department of Anastasia and ICU, Faculty of Medicine, Sohag University, Sohag, Egypt
Corresponding author: Abdelhady Noor Eldeen Osman, Mobile: (+20) 01065259465, E-Mail: boodynor84@gmail.com
ABSTRACT
Background:
Weaning from mechanical ventilation can be defined as the process of abruptly or gradually withdrawing
ventilatory support. Recommendations for weaning practice would be based on the findings of multiple well-designed
randomized trials conducted over the past decade. In comparison to more progressive removal of ventilatory aid, quick
extubation following successful spontaneous breathing trials expedites weaning and minimizes the time of mechanical
ventilation (MV). More recently, pressure support ventilation and bi-level positive airway pressure modes have become
available. Modern ventilators are increasingly sensitive, allowing easy patient triggering of supported breaths, modes
such as tube compensation, and measurement of numerous respiratory parameters. Developments in weaning techniques
have paralleled these improvements in ventilator functionality.
Objective: In this review article, the initially required criteria to start and the weaning methods from mechanical
ventilation. Methods: These databases were searched for articles published in English in 3 databases [PubMed ­ Google
scholar- science direct] and Boolean operators (AND, OR, NOT) had been used such as [Weaning AND Mechanical
Ventilation OR Intensive Care Unit] and in peer-reviewed articles between 1992 and 2021. Documents in a language
apart from English have been excluded as sources for interpretation were not found. Papers apart from main scientific
studies had been excluded: documents unavailable as total written text, conversation, conference abstract papers, and
dissertations. Conclusion: All cases that received ventilatory assistance should be evaluated daily for weaning
suitability. This may include satisfying several preconditions and then undergoing an SBT. If weaning is ineffective,
either PSV or daily spontaneous breathing spells of increasing length should be tried.
Keywords:
Weaning, Mechanical Ventilation, Intensive Care Unit.

INTRODUCTION
initiated only when the underlying illness state that
Weaning from mechanical ventilation (MV)
necessitated MV has been significantly improved or
could be described as the process of suddenly or
rectified to the point of being capable of sustaining
regularly removing ventilator support. Weaning from
spontaneous breathing. The inadequate resolution,
MV often implies 2 separate but closely linked views of
however, does not preclude effective weaning.
care, elimination of MV of any artificial airway (1). The
Additionally, weaning needs an adequate gas exchange
primary challenge is identifying whether a case is
(defined by the majority of studies as an increase in the
prepared to restart ventilatory support. Several studies
arterial oxygen tension/fractional inspired oxygen ratio
have mentioned that a direct technique for evaluating
> 200), an intact sensorium, suitable muscular and
the ability to preserve spontaneous breathing is by
neurological function, and stable cardiovascular
initiating a trial of unaided breathing. Once a case can
function. A normal hemoglobin (Hb) level enhances
sustain breath spontaneously, a 2nd judgment should be
oxygen transport to body cells, and a standard level of
created about whether the artificial airway could be
blood electrolyte and a status of good nutrition further
withdrawn. This choice is determined based on the
reduce the risk of fatigue of respiratory muscle during
case's mental state, methods of protection for the
the weaning phase (5).
airways, coughing ability, and secretions feature.
Weaning Parameters:
Extubation is an acceptable operation if the case has an
Timing of weaning is crucial. So, it is critical to
adequate sensorium, complete airway protection
have accurate parameters that could be used to evaluate
devices, and no severe discharges (2).
the weaning trial's success. Clinical judgment has been
Weaning failure is defined as the inability of
incorporated into this section, as well as objective
spontaneous breathing trial (SBT) to work or the need
indicators to assist in the decision-making process (1).
for reintubation within 48 hours of extubation. SBT
Accurate indicators would avoid unnecessary
failure is defined by two types of indicators: 1) objective
prolongation of MV by assisting in the early
indicators
such
as
tachypnoea,
tachycardia,
identification of weanable individuals (6).
hypertension, hypotension, hypoxemia or acidosis, and
Furthermore, markers can be utilized to detect
arrhythmia; and 2) subjective indicators such as distress
particular physiological anomalies linked with weaning
or agitation, depressed mental state, diaphoresis, and
failures. At the moment, neither a single predictor nor a
signs of increased effort (3). SBT failure is typically
collection of predictors possesses the needed
accompanied by cardiovascular disease or an inability
dependability. Weaning parameters may be classed as
of the respiratory pump to sustain breathing demand.
those that assess the following indices: oxygenation
Failure to extubate might be due to the same underlying
indices, respiratory muscle strength, endurance,
cause, additionally, upper airway blockage or copious
respiratory drive, and effort of breathing, as well as
discharges (4). Weaning procedures are frequently
composite indices (Fig.1) (7).
1000
Received: 30/09/2021
Accepted: 28/11/2021

Full Paper (vol.871 paper# 4)


c:\work\Jor\vol871_5 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1006-1009

Diaphragmatic Ultrasound: Review Article
Abdelhady Noor Eldeen Osman Elew, Abd Alrahman Hassan Abd Alrahman,
Hala Mahmoud Hashim El Khayat, Fawzy Abbas Badawy
Department of Anastasia and ICU, Faculty of Medicine, Sohag University, Sohag, Egypt
Corresponding author: Abdelhady Noor Eldeen Osman, Mobile: (+20) 01065259465, E-Mail: boodynor84@gmail.com

ABSTRACT
Background:
Mechanical ventilation (MV) is required for most cases introduced the intensive care unit (ICU) as a
portion of their process of care. However, either MV or the chronic illness can result in diaphragm dysfunction, an
incident that may contribute to the incapability of MV separation to be done. Prolonged use of the ventilator significantly
increases health-care expenses and subject morbidity and mortality. However, muscle disease symptoms and
manifestations are frequently difficult to evaluate in a bedridden state ICU case due to complicating variables. A typical
evaluation of diaphragm function lacks, non-invasive, time preservative, easy-to-perform bedside equipment or needs
subject involvement. Lately, the utilization of ultrasound (US) has elevated a lot of interest as a simple, non-invasive
approach for the assessment of diaphragmatic contractile activity. Objective: This narrative review aimed to briefly
describe the common methods of diaphragmatic function assessment using ultrasound techniques. Methods: These
databases were searched for articles published in English in 4 databases [PubMed - Egyptian Knowledge Bank - Google
scholar- Science direct] and Boolean operators (AND, OR, NOT) had been used such as [Diaphragmatic AND
Ultrasound OR Diaphragm function] and in peer-reviewed articles between 1985 and 2021. Conclusion: Diaphragmatic
ultrasonography has been widely investigated and is still being explored as a predictor of effective mechanical
ventilation weaning. Due to the substantial heterogeneity in research design and population, it remains difficult to draw
general generalizations from individual studies. Even worse, terminology such as a failed breathing trial or unsuccessful
extubation has not been defined across research, making comparisons of outcome measures unfeasible.
Keywords: Diaphragmatic, Ultrasound, Diaphragm function.

INTRODUCTION
Table (1): Diaphragmatic ultrasound (US).
The diaphragm is the main muscle of respiration,
Advantages
acting continuously and uninterruptedly to sustain the
Safety
- Cases should not be exposed to ionizing
task of breathing. Diaphragmatic dysfunction can occur
radiation (5).
secondary to numerous pathological conditions and is
- Noninvasive
usually underdiagnosed in clinical practice because of
Feasibility
- Done in less than 15 minutes, and in
its nonspecific presentation. Although several
some cases about 5 minutes (5).
techniques have been used in evaluating the
- There is no requirement for the subject to
diaphragmatic function, the diagnosis of diaphragmatic
be transported for bedside evaluation.
dysfunction is still problematic. Diaphragmatic
- Multiple repeats are possible.
ultrasound has gained importance because of its many
Availability - Ultrasonography needs only basic,
advantages, including the fact that it is noninvasive,
typically readily available tools.
does not expose patients to radiation, is widely
Accuracy
- Extreme temporal resolution (5, 6) great
available, provides immediate results, is highly
replicability, and excellent accuracy (1, 4).
accurate, and is repeatable at the bedside. More recently
- Outperforms fluoroscopy in the diagnosis
lung and diaphragm ultrasound methods have been
of diaphragmatic disorder (7).
introduced, assessing pulmonary airway patterns and
- Has interobserver acceptance and high
diaphragm function (1).
interobserver, for thickness (1) and
Several parameters measured through diaphragm
diaphragmatic excursion (6).
ultrasound have been proposed for the same purpose.
Disadvantages
These include diaphragm thickness, diaphragm
Availability - It is not available in all facilities.
movement or excursion during the respiratory cycle,
- On-staff doctors versed in the method are
and diaphragm thickening or thickening fraction (2-3).
required.
Technical aspects:
Accuracy
- Visualizing the left hemidiaphragm
The diaphragmatic ultrasound is a valuable
might be a problem, especially in fat
approach for evaluating the diaphragm's function and
people (8).
anatomy, exactly diaphragmatic expansion, and
- Diaphragmatic excursion is dependent on
the patients' maximum voluntary
thickness. Table 1 explains certain features of this
inspiratory activity, which is regulated by
method. The tools required for diaphragmatic
case position (9).
ultrasound are straight forward and readily accessible in
- Diaphragmatic excursion is influenced by
most medicinal establishments. The ultrasound system
components and pressure of the abdomen,
must be provided with a convex transducer operating at
both of that act as a constraint on
2.5-5.0 MHz and a linear transducer operating at 7.5-
diaphragmatic displacement (10).
10.0 MHz (2-4).
1006
Received: 26/09/2021
Accepted: 24/11/2021

Full Paper (vol.871 paper# 5)


List of Abbreviations The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1010-1016

Patterns and Outcomes of Patients with Penetrating Head Injury
Samir Mohamed Attia1, Mostafa Mahmoud Nabeeh2,
Mohamed El Said Ahmed3, Moataz Samy Abdelghafar Yousef4
1Department of Vascular Surgery, 2Department of Neurosurgery, 4Department of Emergency Medicine and
Traumatology, Faculty of Medicine, Mansoura University, Egypt
3Department of Critical Care Medicine, Emergency Hospital, Mansoura University, Egypt
*Corresponding author: Moataz Samy Abdelghafar, Mobile: (+20) 01028866777, E-Mail: dr.moatazsamy@gmail.com

ABSTRACT
Background:
Penetrating head injuries, whether low or high velocity, are dreadful casualties associated with a high
incidence of morbidity and mortality. Immediate radiological examination is mandatory to determine the extent of
head penetration, location of the penetrating foreign body and need for surgical intervention.
Objectives: This study aimed to evaluate the incidence of penetrating head injuries among polytraumatized patients
and to follow up and determine the different outcomes of patients with penetrating head injuries.
Patients and methods: This was a prospective observational descriptive study included 63 traumatic patients with
penetrating head injury who were recruited over 1 year duration starting from November 2019 to October 2020 in
Mansoura University Emergency Hospital and El-Sheikh Zayed Specialized Hospital, Egypt.
Results: The mean age in the non-survived group was statistically significantly higher as compared to the survived
group. The percentage of missiles (firearm) injuries in the non-survived group was statistically significantly higher as
compared to the survived group. The Glasgow Coma Scale (GCS) on admission was statistically significantly lower
in the non-survivor group as compared to the survivor group. The percentage of cases with unreactive pupils in the
non-survivor group was statistically significantly higher as compared to the survival group. The incidence of
subarachnoid hemorrhage, intracerebral hemorrhage and brain laceration was statistically significantly higher in the
non-survivors group as compared with survivors group. The length of hospital stay and length of ICU stay were
statistically significantly longer in the non-survivors.
Conclusion:
Early stabilization of patients with suspected head trauma. All patients with head trauma should undergo
brain CT for early assessment of degree of brain affection.
Keywords:
Trauma, CT, Penetrating head injuries, ICU.

INTRODUCTION
the acute phase. The most commonly used indicators are
Trauma-related mortality accounts for 9% of
the GCS score, the pupillary light reflex reaction and CT
deaths in all age groups and most cases involve blunt
scan findings. In addition, missile track and mechanism
injuries. Multiple traumas are the main cause of
of injury also play a significant role in mortality
emergency admission, accounting for approximately
prediction from TBI (7).
16% of global medical expense (1). Traumatic Brain
The highest-velocity injuries tend to have the
Injury (TBI) is the leading cause of death in all age
worst associated damage. In a study, among 314
group. In various series, the mortality estimated to be
individuals who suffered penetrating cranial injuries
about 20­30%. According to severity, the head injuries
caused by gunshot wounds, found that 73% succumbed
are 80% mild, 10% are moderate and 10% are severe (2).
to their injuries at the scene of the incident, and a further
Penetrating brain injury (PBI) includes all traumatic
19% ultimately died later. Thus, indicating a total
brain injuries, which are not the result of a blunt
mortality rate of 92%. Perforating injuries have an even
mechanism. Although less prevalent than closed head
worse prognosis (8). People with penetrating head
trauma, PBI carries a worse prognosis (3).
trauma may have complications such as acute
In civilian populations, PBIs are mostly caused
respiratory
distress
syndrome,
disseminated
by high velocity objects, which result in more complex
intravascular coagulation, and neurogenic pulmonary
injuries and high mortality. PBI caused by non-missile,
edema. Up to 50% of patients with penetrating brain
low-velocity objects represent a rare pathology among
injuries get late-onset post-traumatic epilepsy (9).
civilians, with better outcome because of more localized
The aim of the current study was to evaluate the
primary injury, and is usually caused by violence,
incidence of penetrating head injuries among
accidents, or even suicide attempts (4). The current
polytraumatized patients and to follow up and
increase in firearm-related violence and subsequent
determine the different outcomes of patients with
increase in penetrating head injury remains main
penetrating head injuries.
concern to neurosurgeons in particular and to the

community as a whole (5).
PATIENT AND METHODS
The patterns of intracranial injury in penetrating
This was a prospective observational
TBI are not fully characterized, since only 59­70% of
descriptive study included 63 traumatic patients with
patients arriving alive to the hospital are evaluated with
penetrating head injury who were recruited over 1 year
a head computed tomography (CT) scan (6). Several
duration starting from November 2019 to October 2020
prognostic factors are used to predict TBI mortality in
1010
Received: 24/09/2021
Accepted: 22/11/2021

Full Paper (vol.871 paper# 6)


c:\work\Jor\vol871_7 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1017-1023
Incidental Thyroid Nodules on the COVID-19 Positive CT Chest
Ahmed S. Abdelrahman*, Mena E.Y. Ekladious, Mona A. Nagi
Department of Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Ahmed S. Abdelrahman; Mobile: 01200220999; Email: dr_ahmedsamy@yahoo.com


ABSTRACT
Background:
The recent widespread of COVID-19 led to a marked increase in the number of CT chest examinations.
This led to frequent encounters of associated incidental findings as thyroid nodules. Thyroid imaging reporting and
data system (TI-RADS) using variable ultrasound feature-allowed systematic reproducible approach for diagnosis and
management of thyroid nodules.
Objective: This study aimed to detect the prevalence of incidental thyroid nodules in CT chest for COVID-19 cases as
well as the percentage of malignant nodules among them and the concordance of TI-RADS classification with fine-
needle aspiration cytology (FNAC) results.
Patients and methods: This retrospective study included 895 patients with CT findings of COVID-19 pneumonia.
203 patients were excluded due to absent PCR confirmation of COVID-19, lack of ultrasound confirmation of thyroid
nodules or lack of FNAC results, so our study included 692 patients with confirmed COVID-19 pneumonia.
Results: A solitary thyroid nodule was discovered in 134 CT chest scans of 692 patients with confirmed COVID-19
pulmonary pneumonia, with a 19.4% incidence. These patients underwent ultrasound evaluation for the thyroid
nodule. The nodules with TI-RADS 1-3 score were considered benign yet those with 4-5 score were classified as
malignant. The results of the FNAC were compared to the thyroid TI-RADS classification, with nodules classified as
Bethesda II-III being benign and those classified as Bethesda IV to VI being malignant.
Conclusion: Incidental thyroid nodule discovered during CT chest examination is an important finding and should be
investigated and categorized using the TI-RADS system as even though the incidence of malignancy is not high, early
diagnosis of thyroid malignancy can have a huge effect on the patient outcome.
Keywords: COVID-19, thyroid nodule, CT, US, TI-RADS.

INTRODUCTION

The coronavirus disease 2019 (COVID-19) is
However, this created another debate about
a rapidly spreading infection across the globe with 5-
whether further investigation for incidental findings is
15 % of the affected patients developing severe
of clinical value or is it a waste of resources on further
respiratory illness (1-4).

CT chest is a safe and rapid examination for
investigation of findings that are mostly benign and
diagnosing patients with suspected infection as it
unrelated to the patient complaint (14-16).
allows assessment of the degree of lung affection
The aim of our study was to detect the
especially with the development of CT severity score,
prevalence of incidental thyroid nodules in patients
which allow assessment of the extent of lung
performing CT chest for assessment of COVID-19
involvement (5-8).
pneumonia and the percentage of malignant thyroid
The huge number of patients performing
nodules discovered by further investigation of this
computed tomography (CT) chest examination had led
incidental finding.
to the frequent encountering of incidental findings, one


of which is incidental thyroid nodules. Incidental
PATIENTS AND METHODS
thyroid nodule is considered common findings in the
Between September 2020 and November
cross-sectional imaging of the neck constituting about
2021, 895 patients with CT findings of intermediate to
16 to 18 % (9-10).
a high probability of COVID-19 pneumonia (CO-
The American thyroid association stated that
RADS 3, 4 and 5) were included in this retrospective
all incidental thyroid nodules should undergo further
study. A negative RT-PCR confirmation resulted in the
workup by ultrasound as there are no definite features
exclusion of 73 patients.
in CT that can differentiate benign from malignant
69 patients were excluded because the
lesions (11-12).
ultrasound (US) confirmation of the thyroid nodule
The thyroid imaging and reporting data system
was missed (36 patients with known nodular thyroid
(TI-RADS) is based upon specific ultrasound (US)
disease and 33 patients who couldn't be assessed by
features including size, shape, composition, margins,
the US). 61 patients were also excluded because the
echogenicity and calcification. It aims to standardize
FNAC result was unavailable, so our study included
the classification of thyroid nodules and limit fine
692 patients with confirmed COVID-19 pneumonia
needle aspiration cytology (FNAC) (13).
(Figure 1).




1017
Received: 24/09/2021
Accepted: 22/11/2021

Full Paper (vol.871 paper# 7)


c:\work\Jor\vol871_8 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1023-1026

Surgical Procedures for Prevention of Frey's Syndrome after
Parotidectomy Surgery: Review Article
Mahmoud Ahmed El Said Megahed*, Sherif Mohammad Askar,
Abdel Raof Said Mohamed, Ali Mohammad Awad
Department of Otorhinolaryngology, Zagazig University Hospital, Egypt.
*Corresponding author: Mahmoud Ahmed El Said Megahed, Email: mahmoudmegahed313@gmail.com

ABSTRACT
Background:
Treatment options for benign and malignant parotid gland neoplasms include superficial and whole
parotidectomy, however patients often suffer from facial contour deformation in the preauricular and retromandibular
regions, as well as Frey's syndrome. Preauricular flushing and sweating following parotid surgery has been noted as a
possible side effect. Once thought to be extremely rare, it has been found to occur anywhere from 4% to 62% in post-
parotidectomy patients within the first six to 18 months following surgery. These outcomes have been attempted to be
avoided by the use of certain intraoperative procedures. Dermal-fat-free grafts, fascia lata grafts as well as superficial
flaps of the musculoaponeurotic system, vascularized fat grafts, temporoparietal fascia flaps, as well as implants of
polytetrafluoroethylene are a few of the other options available.
Objective: To evaluate aesthetic and functional outcomes after the use of either superiorly based sternocleidomastoid
muscle flap or free abdominal fat after parotidectomy.
Methods: The databases were searched for articles published in English in 4 data bases; PubMed, Google scholar,
Egyptian Knowledge Bank and Science direct. Boolean operators (AND, OR, NOT) had been used such as [Frey's
Syndrome AND Parotidectomy Surgery OR Prevention of Frey's Syndrome] and in peer-reviewed articles between
January 2001 and October 2020.
Conclusion: Superiorly based Sternocleidomastoid muscle flap improves facial deformity following either superficial
or total parotidectomy by lowering the occurence of Frey's syndrome objectively as well as subjectively compared to
risks of postoperative complications at the donor site associated with free abdominal fat reconstruction, which has a
high incidence of partially fat absorption or liquefaction.
Keywords: Parotidectomy, Frey's syndrome.

INTRODUCTION

Parotidectomy-related
complications
include
subcutaneous arteries. Eating and mastication
paralysis of fascial nerve, salivary fistula, as well as
stimulates skin glands and veins because of this aberrant
Frey's syndrome, infection and masseteric depression, in
communication (4).
addition to return of the tumour in the area where it was

removed. Complications following surgery on the parotid
Surgical procedures for prevention of Frey's
gland can have negative impacts affecting one's life
syndrome:
quality and may be disfiguring (1).
To prevent Frey's syndrome and depression in the
Lucie Frey originally reported the auriculotemporal
masseteric zone, there have been a variety of methods.
syndrome, now known as Frey's syndrome, in 1923.
In order to prevent Frey's syndrome, there are these
Preauricular flushing and sweating following parotid
techniques that separate the skin from the parotid bed
surgery has been noted as a possible side effect. It has
and transplant tissue (autogenous or alloplastic) to the
been found to occur in 4% to 62% of post-
site of the parotidectomy (4). Allografts and autologous
parotidectomy patients within the first six to 18 months
tissue are just two of the materials that can be used to
following surgery. These outcomes have been
fill in soft tissue gaps left by cosmetic surgery (like
attempted to be prevented using a variety of
collagen, hyaluronic acid and alloderm) (5). The
intraoperative procedures. Dermal-fat-free grafts, fascia
nasolabial flap, the palatal pedicled flap, the buccal fat
lata grafts, superficial flaps of the musculoaponeurotic
pad, the temporalis muscle, and the fascia flap are
system, vascularized fat grafts, temporoparietal fascia
among the local flaps that have been employed. The
flaps, as well as implants of polytetrafluoroethylene are
nasolabial flap and the buccal fat pad are two of the most
a few of the other options available (2).
commonly used regional flaps in cosmetic surgery. The
Frey's syndrome has a wide range of prevalence. 23
flap's movement is limited by the volume and form of
percent of patients self-reported Frey's syndrome while
the material it can hold; this is a major drawback.
62 percent of cases were found to have positive Minor's
Reconstruction of small soft tissue abnormalities with
iodine starch tests (3). After a gustatory stimulus, there
pedicled flaps is not frequently employed (5).
are clinical signs such as sweat, flushing, and heat of the
In a study by Hegazy et al. (6) the traditional
preauricular and temporal regions. When a branch of the
approach (Group 1) and a modified technique were both
auriculotemporal
nerve
is
injured,
abnormal
used to perform superficial parotidectomy for benign
regeneration of cut postganglionic parasympathetic
parotid neoplasms (Group 2). Both groups' results were
fibres develops between the otic ganglia and the
compared. The prevalence of Frey's syndrome was
1023
Received: 28/09/2021
Accepted: 26/11/2021

Full Paper (vol.871 paper# 8)


c:\work\Jor\vol871_9 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1027-1033

Short Term Evolution of Left Ventricular Diastolic Function Following
Primary Percutaneous Coronary Intervention
Ahmed Khaled Muhammed Talaat*, Mahmoud Diaa El-Menshawy,
Ahmed Mohammed El-Zaiat, Ibtesam El-Dosouky
Department of Cardiology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Khaled Muhammed Talaat, Email: ahmadtalaat.at@gmail.com
ABSTRACT
Background
: It is well established fact that acute coronary occlusion leads to diastolic dysfunction, followed by systolic
dysfunction when myonecrosis occurs. It is also proven that primary percutaneous coronary intervention (PPCI) is an
excellent therapy for ST elevation myocardial infarction (STEMI) to improve outcomes. However there is a paucity of
information on efficacy of PPCI in improving diastolic function. Evaluation of the role of PPCI in improving diastolic
dysfunction is required. Objective: To evaluate diastolic dysfunction recovery following successful PCI in STEMI
patients according to the occluded artery including Left Anterior Descending (LAD) group and Non-LAD group
including Left Circumflex Artery (LCX) and Right Coronary Artery (RCA).
Patients and methods: The study included sixty one patients who were presented to emergency room with STEMI and
underwent primary PCI. Echocardiographic evaluation was performed within 24 h of PPCI and then on 3 months after
PPCI. We evaluated the prevalence of diastolic dysfunction after PPCI and its recovery during 3 months.
Results
: There was a significant difference between grading of degree of diastolic dysfunction before PCI and after 3-
months follow up with significant improvement after PCI. Conclusion: We concluded that primary PCI improves
diastolic dysfunction in patients with anterior wall STEMI over a period of 3 months.
Keywords: Diastolic dysfunction, Primary percutaneous coronary intervention, ST elevation myocardial infarction.

INTRODUCTION

(PPCI) (6). Although LV (left ventricle) systolic function
An acute ST-elevation myocardial infarction
is a well-known prognostic factor in patients with AMI,
(STEMI) is an event in which transmural myocardial
a growing body of evidence indicates that left
ischemia results in myocardial injury or necrosis.
ventricular diastolic dysfunction (LVDD), as assessed
Although the incidence of STEMI has decreased over
by Doppler echocardiography, is also an important
the past decade, it remains a common and morbid
predictor of patient outcomes after AMI (7). A normal
diagnosis (1). It is a life-threatening situation, rapid and
LV filling pattern illustrating cardiac diastolic function
correct decision making for life saving of patients in
was seen in only one third of patients in the acute phase
emergency room is very important (2).
of MI, and an abnormal pattern usually indicated
MI damages the regional myocardium that
patients having higher risk of developing permanent
undergoes ischemia and necrosis, resulting in
heart failure (8).Two-dimensional echocardiography (2D
impairment of both systolic and diastolic functions of
Echo) is the technique of choice to assess and monitor
the heart. Ischemia of myocardial cells, interstitial
remodeling after AMI, enabling a precise definition of
edema, and regional wall motion abnormalities
magnitude and timing of the process. In addition,
resulting from MI affect active and passive relaxation of
Doppler echocardiography has provided evidence that
ventricles. Left ventricular (LV) function and
serial changes in diastolic filling pattern may parallel
myocardial infarct size both serve as the main
the evolutionary changes in LV dimensions after AMI
determinants of patients' outcome after MI (3).
(9). Previous studies on primary PCI showed that
Currently, the primary strategy for treating MI is
coronary
reperfusion
caused
an
immediate
based on pharmacological thrombolytic or percutaneous
improvement in diastolic function by increasing LV
coronary intervention (PCI) reperfusion therapy. PCI
compliance and in systolic function by increasing apical
has progressed from balloon angioplasty to drug-eluting
contractility in STEMI patients (10).
stents and now bioabsorbable stents. Now it is a very
On the other hand, Chen and colleagues (11)
powerful tool to preserve ischemic myocardium and
concluded that STEMI patients receiving early
reduce mortality as the sooner the ischemic
myocardial reperfusion had no better diastolic functions
myocardium gets reperfused by PCI, the better the
compared with late re-perfused patients within the acute
patient's LV function recovers (4).
phase.
Acute myocardial infarction (AMI) is a leading
The aim of the present study was to evaluate
cause of heart failure, despite significant treatment
diastolic dysfunction recovery following successful PCI
advancements in recent years. Development of new
in STEMI patients according to the occluded artery
onset heart failure in patients with AMI is a poor
including Left Anterior Descending (LAD) group and
prognostic sign with higher in hospital mortality (5). A
Non-LAD group including Left Circumflex Artery
number of studies have indicated that both mortality and
(LCX) and Right Coronary Artery (RCA).
morbidity rates can be reduced in ST elevation
PATIENT AND METHODS
myocardial infarction (STEMI) patients who receive
The study was done in Cardiology Department,
timely primary percutaneous coronary intervention
Zagazig University Hospitals and National Heart
1028
Received: 24/09/2021
Accepted: 22/11/2021

Full Paper (vol.871 paper# 9)


c:\work\Jor\vol871_10 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1035-1038

The CT Chest Findings in Follow-up COVID-19 Patients: Review Article
Yasser Abdelkarim Amin
Department of Diagnostic Radiology, Faculty of Medicine, Sohag University, Sohag, Egypt
Corresponding author: Yasser Abdelkarim Amin, Mobile: (+20) 01501607424,
Email: yasserrad476@gmail.com. ORCID ID: 0000-0002-2174-3351

ABSTRACT

Background: Coronavirus disease 2019 (COVID-19) may benefit from a chest CT scan for diagnosis, identification of
sequelae, and prognosis. Ground-glass opacities, vascular enlargement, bilateral abnormalities, lower lobe involvement,
and posterior inclination have all been found on chest CT in more than 70% of RT-PCR test­proven COVID-19 cases.
In more than one-third of patients who survived severe coronavirus illness 2019 pneumonia, a six-month follow-up CT
revealed fibrotic-like alterations in the lung. COVID-19 survivors exhibited continued improvement on chest CT
following a year of follow-up after discharge. Residual lesions, on the other hand, could be seen and linked with lung
volume metrics. Early diagnosis of post-COVID-19 pulmonary fibrosis cases may allow for the prevention or at least
modification of this disabling consequence.
Objective: Highlight chest CT imaging for the symptomatic COVID-19 patient after three months and the radiologist
should be aware of the pulmonary sequelae changes at imaging.
Methods: These databases were searched for articles published in English in 3 databases (PubMed ­ Google scholar-
science direct) and Boolean operators (AND, OR, NOT) had been used such as (Chest CT AND COVID-19 Patients
OR CT chest findings) and in peer-reviewed articles between February 2020 and December 2021. Documents in a
language apart from English have been excluded as sources for interpretation were not found. Papers apart from main
scientific studies had been excluded: documents unavailable as total written text, conversation, conference abstract
papers, and dissertations.
Conclusion: Chest CT imaging plays an important role in diagnosis and follow-up patients in COVID-19 disease.
Keywords: CT Chest, COVID-19 Patients.

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is a highly
The severity of the underlying infection, age,
contagious disease that causes severe respiratory
gender, and body mass index all influence the likelihood
distress syndrome. It was originally detected in Wuhan,
of developing long COVID or post-COVID syndrome.
China, in late 2019 and has since expanded worldwide.
The real-time polymerase chain reaction is the
The World Health Organization designated the
gold standard for verifying COVID-19 (RT-PCR). In
coronavirus pandemic of 2019 an international public
the diagnosis, care, and follow-up of patients with
health emergency on March 11, 2020 (1). COVID-19 has
COVID-19 pneumonia, radiologic imaging, particularly
a wide spectrum of symptoms, ranging from
thin slice CT, plays a significant role. Chest CT can
asymptomatic infection to fulminant respiratory failure.
detect early stages of infection and allow patients to be
Patients with COVID-19 infection have a varied
isolated sooner the sensitivity of CT in the diagnosis of
recovery rate. Although the majority will heal
COVID-19 has been reported to be 60­98%, with a
completely, others will suffer from sequelae long after
specificity of 25­56% (5).
they have recovered from the acute infection (2).
In the current outbreak, computed tomography
Long COVID is defined as persistent symptoms
(CT) can be a valuable supplement to RT-PCR for
after 4 weeks, while post-COVID syndrome is defined
detecting COVID-19 pneumonia, the extent of
as symptoms that continue longer than 12 weeks,
pneumonia involvement by CT findings can help to
according to British Medical Journal guidelines (3).
evaluate the severity of COVID-19 pneumonia (5).
Imaging by CT plays a crucial role in the diagnosis

of COVID-19 pneumonia. The CT findings vary
CT findings:
depending on the stage of the disease and the severity of
At the initial stage, the most prevalent finding on
the condition. Peripheral and bilateral ground-glass
chest CT in patients with COVID-19 pneumonia is
opacities (GGOs) are the most common CT findings
ground-glass opacities (GGO), which is usually
during the early stages of COVID-19 pneumonia,
described as patchy, peripheral, bilateral, and subpleural
followed by consolidation that gradually disappears in
(6).
survivors as the disease progresses (4).
1035
Received: 26/9/2021
Accepted: 24/11/2021

Full Paper (vol.871 paper# 10)


Measurement of Serum Lipid Level in Children with Congenital Heart Diseases The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1038-1044

Low Weight Gain as Risk Factor for Retinopathy of
Prematurity in Preterm Infant
Ayman Mohammed Lotfy1, Ehab Abd Elmenem Al Banna2,
Omayma Bashir Abuzayd*2, Alaa Elsayed Nafea2
Departments of 1Ophthalmology and 2Neonatology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Omayma Bashir Masoud Abuzayd, Moble: (+20)01017169201, E-mail: omaymabozaid@gmail.com

ABSTRACT
Background:
Low weight gain during the first month of life in preterm infants might be an important contributory
factor for the occurrence of retinopathy of prematurity (ROP).
Objective: Our study aimed to determine the effect of low weight gain on the incidence of ROP in premature infants.
Patients and methods: This prospective, one-year cohort study was conducted in the Neonatology Department, in
collaborate with the Ophthalmology Department in the Faculty of Medicine, Zagazig University. The study included 72
preterm neonates.
Results: Out of the 72 screened infants, (41.7%) cases had ROP, among whom (35.7%) had stage I, (24.5%) had stage
II (39.8%) had aggressive ROP stage III zone II, 60% had a threshold and (33.3%) with plus disease. There were
statistically significant relations between ROP development and weight loss (p<0.001), (OR, 4.5; 95% CI 0.37-54.15),
prolonged duration of admission, (p<0.005), prolonged duration of oxygen therapy (p<0.002), respiratory distress
syndrome (RDs), (p<0.001), pneumonia (p<0.013), bronchopulmonary dyspepsia (BPD) (p<0.005), sepsis (p<0.001),
anemia (p<0.001), intraventricular hemorrhage (IVH) (p<0.005).
Conclusion: Our study results suggest that low weight gain or weight loss in the first month of life may predict pre
threshold ROP that requires treatment. It can help identify babies with poor periods after birth who are most at risk, also
O2 therapy, and its duration, RDs, pneumonia, sepsis, BPD, anemia, and IVH were found to be the most significant risk
factors for ROP development in premature babies.
Keywords: Postnatal Growth Restricted, Prematurity, Retinopathy of prematurity

INTRODUCTION

connection between the avascular and vascularized
The optimal growth after birth is important not
retina as stages. Stage I It's a faint demarcation line,
only for survival but also for improving the long term
Stage II It's an elevated ridge, Stage III is extraretinal
outcomes of preterm infants. Despite recent
fibrovascular tissue, Stage IV is sub-total retinal
improvements in the neonatal care of preterm infants,
detachment, and Stage V is total retinal detachment(9).
postnatal growth restriction is still prevalent among
Treatment of ROP is depending on its severity;
preterm infants during their stay in NICU (1). A new
some of them have side effects of their own, (7). The
study found that an improved neonatal nutritional
laser therapy could be for advanced ROP, but needs
supply after birth is associated with good growth during
general anesthesia, which may be risky for premature
early postnatal life. So, an adequate supply of nutrients
infants (10).
must be provided to achieve optimal weight gain and
As regard medications, injection of anti-vascular,
prevent growth restriction (2). Early improvement in
endothelial growth factor prevents overgrowth of retinal
weight gain is an important parameter of neonatal
blood vessels as intravitreal injection of bevacizumab
nutritional status, and low postnatal weight has been
and ranibizumab (11).
associated with the incidence of aggressive ROP (3).
The aim of the present study was to determine the effect
Small gestational age and low weight at birth are the
of low weight gain on the incidence of ROP in
most important factors for the development of ROP.
premature infants.
Other factors associated with the present of ROP

include RDs, sepsis, anemia, thrombocytopenia, poor
PATIENTS AND METHODS:
weight gain, and the infant's overall health (4).
This prospective one-year cohort study was conducted
There is an estimated 15 million neonate born
in NICU Pediatric Department, in Collaborate with of
prematurely every year worldwide. Declines in infantile
Ophthalmology Department in the Faculty of Medicine;
mortality and increased survival of premature infants
Zagazig University. It included 72 preterm neonates.
contribute to increased incidence of ROP (5).

Retinopathy of prematurity is also called Terry's
Inclusion criteria; preterm infants with gestational age
Syndrome (6). ROP disease affecting preterm infants is
at birth between 27-36 weeks
caused by abnormal growth of retinal blood vessels (7).
Exclusion criteria; Full-term infant, and preterm infant
When a baby is born preterm, the retinal blood vessels
whose relative refused to participate in the study.
can grow abnormally, most ROP resolves
All preterm infants were subjected to details medical
spontaneously, but when ROP is severe, it can cause
history with a focus on demographic data [gender,
damage to the retina, and may cause blindness (8).
mode of delivery; Caesarean section (CS), normal
Ophthalmoscope can describe the retinal findings at the
vaginal delivery (NVD), admission status: inborn /out
1039
Received: 30/09/2021
Accepted: 28/11/2021

Full Paper (vol.871 paper# 11)


Burnout The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1046-1055

Prevalence and Causes of Burnout among Physicians in Arar City, KSA
Anfal Marzouq Alanazi1, Khulud Awad Altarfawi1, Rawan Deham Aledeilah1,
Anwar Matar Alsulobi1, Hisham Nasef Mohammed Meshref2
1Family Medicine, Saudi Board Family Medicine, 2 Family Medicine, Badanha Primary health care center, Arar, Saudi Arabia
Corresponding author: Anfal Marzouq Alanazi,Email: Toop-1991@hotmail.com,Mobile: 9660533034571

ABSTRACT
Background
: Since burnout is a common condition, and its prevalence is expected to increase with time, lack of
knowledge about such problem could impede early diagnosis and may lead to delays in seeking appropriate care.
Objective:
to estimate the prevalence and factors associated with burnout among physicians in Saudi Arabia.
Methodology:
A cross-sectional study was conducted during the period from 1 June to 30 November 2021 on a sample
of physicians in health care centers in Arar city. All data were collected, tabulated, and statistically analyzed using SPSS
23.0 for windows.
Results: Of all 303 participants, 51.5% were males and 48.5% were females. 33.7% of study sample aged between 20-
30 years old. Most (91.7%) of them were working 6-10 hours per day. Only 1% of participants were working 3 days a
week, 5.6% 4 days a week and 64.4% 5 days a week. Only 8.9% of our study participants felt emotionally exhausted
because of work every day, 17.2% several times a week and 14.9% once a week. As for burnout, 9.2%, 11.9%, 11.6%,
13.9%, 14.5%, 21.1%, and 17.8% felt burned out every day, several times a week, once a week, several times a month,
at least once a month, at least few times a year, and never respectively. 23.4% planned to quit their current job.
Conclusion: Physicians in Saudi Arabia suffer from burnout and emotional exhaustion within reported ranges in
previous literature. Actions must be taken to avoid exhaustion, stress, and emphasize pliability.
Keywords: Arar City, Burnout, Physicians, Prevalence, Saudi Arabia.


INTRODUCTION


Burnout is defined as a response to the chronic
of US physicians have experienced burnout at certain
stressors that are prevalent in the workplace. It is
points throughout their careers [4].
characterized by feelings of emotional exhaustion and
In a study conducted in Al Ahsa, Saudi Arabia,
cynicism that leads to inefficacy and lack of
it was found a substantial level of burnout amongst
accomplishment [1]. Healthcare workers, particularly
doctor of medicine occupying the primary health care
physicians, are exposed to high levels of physical and
centers. The proportion of contributors who counted
psychological distress at their work. Many researches
high score in emotional exhaustion was 47.3%, near
showed that physicians and other health care
50% scored high depersonalization, besides 59.7% had
professionals experience high rates of burnout, their
diminished personal accomplishment. Approximately
roles leaving them exhausted, overworked, or
25% scored high burnout in all three dimensions; high
detached, which is the causes and signs of burnout
emotional exhaustion, high depersonalization and low
syndrome [2].
personal accomplishment [6].
Maslach et al., reported that, burnout has three
Another study was designed to investigate the
interrelated dimensions: emotional exhaustion,
frequency of job satisfaction, burnout and ethics
depersonalization,
and
low
personal
among physicians across specialties with varied levels
accomplishment. Emotional exhaustion usually results
of experience and seniority, in hospitals in Makkah,
from prolonged exposure to stress, and it manifests
Saudi Arabia. A high level of burnout was found among
through the loss of enthusiasm for work, feeling not
physicians (51%) and the level of burnout was
helpful, trapped, and defeated [3]. Many causes make
significantly higher among physicians willing to
physicians risky for burnout. Their job demands like
change their specialty compared to those willing to
workload, bad working conditions, lack of management
repeat it (50% vs. 24%, p-value 0.02) [7].
support, limited vacation, and public system related
Elbarazi et al. (2017) conducted a systematic
frustration caused burnout symptoms among
review to guess the occurrence of burnout in Arab
physicians [4]. Also, physicians are exposed to
medical professionals. Then looked at the individual
emotional and social demands at work, while
and occupational influences accompanying this
interacting with patients, which is overloading them
burnout. This review showed moderate-to-high
and resultantly they develop symptoms of chronic
estimates of self-reported burnout among health care
stress and burnout [4].
professionals in Arab countries. This was similar to the
Moreover, burnout syndrome may increase the
prevalence in the developed western countries that do
risk of medical errors and decrease job satisfaction,
not speak Arabic [8].
which incites early retirement or detachment from the
Cape Town survey done by Rossouw et al.,
job [5].
found that 76% of physicians experienced symptoms
It was indicated a high prevalence of burnout
of chronic stress and burnout [9]. Another research,
among practicing physicians and have shown one-third
published in JAMA Surgery, reported nearly 7,000
1046
Received: 30/09/2021
Accepted: 28/11/2021

Full Paper (vol.871 paper# 12)


c:\work\Jor\vol871_13 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1056-1062

A Comparative Study between Esophagogastroduodenoscopy and Non-Invasive
Testing for Diagnosis of Helicobacter Pylori Infection in Hemodialysis Patients
Saddam A.A. Hassan*1, Ahmed E. Mansour1,
Mohammed E. Abdelrazek2, Eman M. Araby3, Mohamed E. Ibrahim1
1Internal Medicine and Nephrology Department, 3Public Health and Community Medicine, Faculty of Medicine,
Benha University, 2Internal Medicine and Nephrology Unit, Maadi Military Hospital, Egypt
*Corresponding author: Saddam A.A. Hassan, Mobile: (+20) 01008950489, E-mail: saddam.ahmed@fmed.bu.edu.eg

ABSTRACT
Background:
Worldwide, data are conflicting on the prevalence of Helicobacter pylori (Hp) infection in Hemodialysis
(HD) population. In Egypt, the data on this population are rather limited.
Objectives: The aim of this cross-sectional study was to screen HD patients with Gastrointestinal (GI) symptoms for
the prevalence of Hp infection using non-invasive serological testing for Immunoglobulin G (IgG) antibody and then to
compare the screening data with the confirmatory esophagogastroduodenoscopy (EGD) findings.
Patients and Methods: From January 2020 to June 2021, the sera of one hundred patients with GI complaints were
screened for IgG antibody against Hp, among them fifty patients underwent EGD as per indication. Univariate and
multivariate analysis were performed to compare serological versus invasive testing performance for Hp infection.
Results: In the present study, (60%) of the screened study population demonstrated a positive IgG against Hp, whereas
the EGD findings confirmed Hp infection in (50%) of the fifty patients who underwent a confirmatory EGD. In
comparison to EDG findings, IgG Antibody sensitivity and specificity for diagnosis of Hp infection was 65.5 % and
52.4 % respectively.
Conclusion:
Among the one hundred HD patients screened for IgG against Hp, we found a seroprevalence of 60%;
however, the performance characteristics of IgG antibody were limited. Further studies are warranted to explore these
findings.
Keywords: End Stage Renal Disease, Esophagogastroduodenoscopy, Helicobacter pylori, Hemodialysis, IgG.

INTRODUCTION
population in Egypt are rather limited despite the high
Worldwide, Helicobacter pylori (Hp) is estimated
prevalence of Hp in the general population in Egypt (6,7).
to be the most prevalent chronic bacterial disease
Gastrointestinal (GI) disorders are the most
affecting almost 50% of the world's population. Hp
prevalent chronic problem in End Stage Renal Disease
infection accounts for a host of gastric disorders
(ESRD) patients, ranking second in frequency only to
including malignancy and has been implicated in a
renal failure itself. GI disorders affect 70 to 80% of
growing list of extra-gastric disorders (1).
patients on Hemodialysis (HD) (8); yet, little is known
The increased recognition of the systemic effects of
about the impact of Hp infection on this multifactorial
Hp (2) has revived the interest to study the epidemiology
disorder(9).
of Hp infection in patients with Chronic Kidney Disease
Hence, the primary aim of the present cross-
(CKD) especially after studies implicating an increased
sectional study was to prospectively assess the
risk of CKD in patients infected with Hp (3).
prevalence of Hp infection among HD patients using
Unfortunately, data are still conflicting regarding
both screening and confirmatory tests. Initially, ELISA-
the association between Hp infection and kidney
based screening for IgG antibodies in the sera of HD
diseases. Whilst some population-based studies have
patients was performed. Then, the performance of
linked Hp to increased risk of renal disorders and CKD
serological non-invasive testing for Hp was compared
progression (3). Contrarian meta-analysis studies have
to the confirmatory EGD findings.
demonstrated a lower incidence of Hp infection in

PATIENTS AND METHODS
Hemodialysis (HD) population (4,5).
One hundred patients on maintenance
In Egypt, the prevalence of Hp in the general
Hemodialysis (HD) were enrolled in this prospective
population varies according to the used test, serological
multicenter cross-sectional study. End Stage Renal
screening reported a prevalence of 70 % to 90 % among
Disease (ESRD) was defined as eGFR < 15 ml/min/1.73
adults tested for serum IgG for Hp (6). Whilst another
m2 and/or the need for renal replacement therapy for
study using Enzyme-Linked Immunosorbent Assay
more than 3 months (10). The patients were selected
(ELISA) to detect Hp Stool Antigen (HpSA) test among
based on the presence of Gastrointestinal (GI)
1120 Egyptian patients reported a prevalence of 52% (7).
symptoms including: (nausea, vomiting, dyspepsia,
This high prevalence in previous studies was attributed
dysphagia, abdominal pain, chest pain, and hiccough).
to poor socioeconomic and sanitary conditions in
All the study population who reported GI
addition to dietary, lifestyle, and age factors.
symptoms (n=100) underwent an initial serological
Epidemiological data are critical to guide the
screening test using Enzyme-Linked Immunosorbent
choice of the proper test (invasive versus non-invasive)
Assay (ELISA) technique to detect serum
for this prevalent problem in view of limited resources.
Immunoglobulin G (IgG) for Helicobacter Pylori (Hp),
Unfortunately, data about Hp infection in HD
the test was labelled positive at a cutoff > 10 U/ml. This
1056
Received: 27/09/2021
Accepted: 25/11/2021

Full Paper (vol.871 paper# 13)


c:\work\Jor\vol871_14 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1063-1066
Newborn Hearing Screening at Qena University Hospital
Mohamed Wael M. Moustafa1, Hager Saleh M. Ali*1, Heba M. Qubaisy2, Abeer A. M. Ali1
Departments of 1Audiovestibular Medicine and 2Pediatric Medicine,
Qena Faculty of Medicine, South Valley University.
*Corresponding author: Hager Saleh M. Ali, Mobile: (+20)1062820512, E-Mail: hagersaleh82@gmail.com

ABSTRACT
Background:
Permanent hearing loss is one of the most common congenital disorders, with an estimated incidence of
one to three per thousand live births far exceeding the combined incidence of conditions for which newborns are
routinely screened. Objective: The aim of this study was to estimate the incidence of hearing loss in newborn at Qena
University Hospital, for early diagnosis, early intervention and good prognosis.
Patients and Methods:
This cross-sectional study was conducted at Qena University Hospital and 100 neonates were
examined. The study was conducted in a duration of 6 months.
Results:
There was statistically significant relationship between the presence of risk factors such as prematurity,
hyperbilirubinemia, hydrocephalus, respiratory distress syndrome, and amplitude of frequencies in both ears, there was
no correlation between amplitudes of frequencies in both ears and age, heart rate, respiratory rate, incubation period or
temperature. Conclusion: It could be concluded that otoacoustic Emission (OAE) is a reliable test for newborn hearing
screening. Although all the 200 ears passed the screening test at Qena University Hospital, this does not guarantee a low
prevalence of hearing loss but due to the limited number of cases and short duration of the study.
Keywords:
Newborn, Hearing Screening

INTRODUCTION

in newborn at Qena University Hospital, for early
Newborn hearing screening (NHS) is a strategy
diagnosis, early intervention and good prognosis.
that enables us to identify congenital deafness and

hearing loss. Over the past two decades, screening
PATIENTS AND METHODS

neonates for hearing deficit has become the standard of
This cross-sectional study included a total of 100
care in many countries all over the world. The major
neonates, attending at Qena University Hospital. This
objective of NHS is to identify children with all kinds
study was conducted for 6 months.
and degrees of hearing impairment, both bilateral and
Inclusion criteria: Neonates at Qena university hospital.
unilateral and to lower the age at the time of diagnosis
Exclusion criteria: All Patients > 1 month of age.
for early hearing amplification, to maximize their
linguistic competence and literacy development (1).
All neonates were subjected to:
Hearing loss in infancy has been shown in
History: Personal history (age, sex, residency and socio-
numerous studies to be permanent, affecting not only the
economic state of the parents), present history (Fever,
development of speech and language but also the
tachypnea,
dyspnea,
yellowish
discoloration,
cognitive, intellectual, cultural, and social development
convulsion), past history (previous admission in NICU),
of children (2). The international statistic is reported two
prenatal history (Full term, preterm, type of delivery,
to six per 1000 live birth suffering from hearing loss. In
type of medication, History of maternal disease, anoxia,
the United States, three per 1000 live birth are born with
convulsion, jaundice), nutritional history (breast feeding,
permanent hearing loss (3). Due to the negative impact of
artificial formula), developmental history, vaccination
hearing loss on child development, the World Health
and family history (family history of hearing loss,
Organization recommends the Newborn Hearing
Consanguinity)
Screening (NHS) programs (4).
Physical examination: General examination: Skin:
The objective of the NHS is the early detection of
Color: pink, jaundice, pallor, and plethora, head and
hearing loss in those individuals who are very likely to
neck: Assessment of head and neck, extremities:
be affected, referring them to rehabilitation (5).
abnormal palmar creases, and talipes and back and spine:
Hearing screening at a young age is critical for a
spinal defect, Scoliosis.
child's future development. Newborn hearing screening
Vital signs: Hyperthermia>38 or hypothermia <36°
can detect infants with mild to moderate bilateral or
rectal, tachycardia (infant heart rate >160 beats per
unilateral hearing loss. These youngsters have previously
minute and tachypnea (infants' respiratory rate >60
been identified as having speech or educational issues
breaths per minute.
later in childhood. In addition, children with hearing loss
who are discovered early have a better chance of gaining
Instruments: - In this study we used one type of
language skills than children who are diagnosed later.
newborn
hearing
screening
methods:
Evoked
Only children diagnosed with hearing loss early in life
Otoacoustic Emissions (EOAEs). (Interacoustics Titan).
and fitted with hearing aids before the age of six months
This method is safe and comfortable.
have a better chance of growing properly (6). The aim of
Trans evoked otoacoustic emission (TEOAE440): -
this study was to estimate the incidence of hearing loss
From .5KHZ to 5.5 KHZ. measuring the amplitude of the
frequencies, As well as the wave reproducibility offering
1063
Received: 28/09/2021
Accepted: 26/11/2021

Full Paper (vol.871 paper# 14)


c:\work\Jor\vol871_15 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1067-1071

Study of Serum Uric Acid in Relation to Diabetic Neuropathy in
Type 2 Diabetic Patients
Mohamed M. Awad1, Ahmed Lotfy Elsayed1, Walaa samy2, Farid Fawzy1
Departments of 1Internal Medicine and 2Medical Biochemistry,
Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Lotfy Elsayed, Email: ahmed.abdelkareem@medicine.zu.edu.eg

ABSTRACT
Background:
Diabetic peripheral neuropathy (DPN) considered a potential complication correlated with diabetes type
1 and type 2 (T2DM).
Objective: The present study was aimed for better control of T2DM complications such as diabetic DPN and to assess
the relationship between serum uric acid (SUA) level and DPN.
Patients and Methods: This cross-sectional study was carried out in Internal Medicine Outpatient Clinics, Zagazig
University Hospital and El Ahrar Teaching Hospital. The study included 50 patients; aged between 42 and 78 years,
divided into two groups, diabetic group without neuropathy (DM) and diabetic group with peripheral neuropathy.
Results: The findings revealed that there was a statistically insignificant difference between DM, and DPN groups and
gender, age, weight, height, BMI. There was a significant difference between the two studied groups and duration of
diabetes and SUA. There was a statistically insignificant difference between DM and DPN groups and type of
medication, systolic BP, diastolic BP, Hemoglobin A1c, and fasting blood glucose.
Conclusion:
It could be concluded that elevated SUA level increased the chance of developing peripheral neuropathy
in a person with type 2 diabetes (T2DM). Many animal experiments and large-scale clinical observations and
experiments are needed to confirm this observation.
Keywords:
Diabetes Mellitus, neuropathy, Serum uric acid.


INTRODUCTION

PATIENTS AND METHODS
Diabetes mellitus type 2 (T2DM) incidence was
This cross-sectional study included a total of 50
expected to reach 7090 cases in every 100,000 by the
Type 2 diabetic patients, aged from 42 to 78 years,
next decade. Regarding the gender, both males and
attending at Internal Medicine Outpatient Clinics,
females were with equal incidences while the mean age
Zagazig University Hospitals and El Ahrar Teaching
of T2DM was around 55 years. DM comes in the ninth
Hospital.
place in the highest cause of mortality (1).
The included subjects were divided into two
Egypt comes ninth in the leading countries of
groups; Group A (Diabetic group without neuropathy)
T2DM incidences, the prevalence of T2DM grows fast
consisted of 25 patients, 13 males and 12 females and
during the past two decades caused by risk factors
their average age was (58.04±6.49) ranged from 49-70
especially obesity (2).
years and Group B (Diabetic group with peripheral
Uric acid considered a metabolic product of
neuropathy) consisted of 25 patients, 11 males and 14
degradation of purines (guanine & adenine), and
females and their average age was (58.84 ± 8.56) ranged
nucleic acids, formed in intestines, liver, and
from 42-75 years.
endothelium (3). Reference uric acid levels are 3.4-7.0
All the cases with the following criteria were
mg/dL (male) and 2.4-6.0 mg/dL (female) (4).
enrolled in the study; Type 2 diabetic patient more than
Recent reports found that studies revealed that
18 years, Gender both male and female, patients newly
inflammation and oxidative stress could be causative
diagnosed with microvascular complications such as
agents of insulin resistance. Insulin resistance was
nephropathy, and controlled group type 2 diabetic
induced by SUA that promotes oxidative stress and
patient without microvascular complications.
elevates reactive oxygen species (ROS) level (5).
The patients with following criteria were
Some implications for the improvement of novel
excluded from the study; pregnant and lactating female
treatments for diabetic peripheral neuropathy can be
patients, causes of retinopathy or nephropathy other
provided from the identification of the associations of
than diabetes mellitus, exclusion of any drug that affects
diabetic peripheral neuropathy (DPN) with modifiable
serum uric acid level, and lymphoproliferative,
risk factors. In addition, recognizing risk factors of
myeloproliferative, and haematological disorder.
diabetic peripheral neuropathy is also necessary for
All cases were subjected to full history taking
screening and prevention of diabetic neuropathy (5, 6).
(age, sex, time since diagnosis of diabetes, and type of
This present study was aimed for better control of
medication),
general
examination,
laboratory
type 2 diabetes complications such as diabetic
investigation (FBG, HbA1c, Serum uric acid).
neuropathy and to investigate relationship between

SUA and DPN.



1067
Received: 29/09/2021
Accepted: 27/11/2021

Full Paper (vol.871 paper# 15)


c:\work\Jor\vol871_16 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1072-1077

Assessment of Aerosolized Colistin and Gentamicin in
Mechanically Ventilated Patients
Aya Mohamed Mohamed Abdel Dayem, Kareem Mohamed Elhamy Matter,
Haitham Salah Eldeen Mohamed*
Department of Chest diseases and Tuberculosis, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Haitham Salah Eldeen Mohamed, Mobile: (+20)1273008111, E-Mail: haysamsalah40@yahoo.com

ABSTRACT
Background:
Ineffective parental antibiotic use in management of Ventilator associated pneumonia (VAP) open the
window for using inhaled antibiotic formula to achieve higher local concentration of antibiotics and subsequently good
recovery response. Objectives: This work was aimed to evaluate the aerosolized antibiotics (Colistin and Gentamicin)
efficacy in improving the mechanically ventilated patient as adjunctive to intravenous systemic antibiotics.
Patients and Methods: This randomized control (RCT) trial study included a total of thirty mechanically ventilated
patients, attending at Respiratory Intensive Care Unit (RICU), Chest Diseases Department, Faculty of Medicine, Ain
Shams University Hospitals. They were classified equally into three groups; Group I: involved 10 patients who received
aerosolized Colistin along with systematic antibiotics (SA), group II: involved 10 patients who received aerosolized
Gentamicin along with SA and group III (Control): involved 10 patients who received only SA.
Results: The incidence of VAP was 10%; in group I no cases had VAP, while in group II and controls, just (20 %) and
(10 %) of cases had VAP respectively, with insignificant association of VAP with particular group, (P= 0.3). Clinically;
only group I showed significant lower degree of temperature in comparison with controls, (P= 0.01). The mean days of
MV and ICU in each group were (6.8±2.15; 8.9±3.11, 5.9±2.23; 7.2±2.7, 5.1±1.1; 6.1±1.85) respectively, with
insignificant difference between the treatment groups. Finally, the survival rate in group I was 90 %, and was slightly
lower in group II and control group; 60 % and 50 % respectively, with insignificant association of survival status in
particular group.
Conclusion: It could be concluded that the empirical treatment by aerosolized Colistin was more effective as an
adjunctive therapy to SA for VAP protection than aerosolized Gentamicin, it had rapid resolution of respiratory infection
signs, and subsequently the MV days, ICU stays and cost but had no effect on mortality.
Keywords:
Ventilator associated pneumonia (VAP), Aerosolized Colistin and Gentamicin

INTRODUCTION

increases toxicity. Because nebulized antibiotic
Respiratory tract infection leads to a major rate of
treatment directly targets the airways and lung tissue,
morbidity and mortality in critically ill patients,
local concentrations are raised and enhance the
especially those on mechanical ventilation (MV) (1).
effectiveness and reducing the toxicity (10, 11).
Ventilator-associated
pneumonia
(VAP)
Many studies have been conducted to investigate
occurred within 48 - 72 hours after endotracheal
the value of inhaled antimicrobial treatment for the
intubation (2). It is considered as the most common
prevention of VAP (12, 13), as well as an adjuvant to SA
hospital-acquired infection among surgical intensive
for the management of existing VAP (14, 15).
care unit (ICU) patients (1). The reported incidence of
The current work was designed to assess the
VAP is 8 ­28% (3). Also, it is frequently linked to
value of aerosolized antibiotics Colistin and Gentamicin
prolonged MV and ICU stays, as well as significant
in improving the mechanically ventilated patient as
health costs and mortality (1).
adjunctive to intravenous systemic antibiotics.
Pathogens
as
pseudomonas
species,

acinetobacter, and methicillin-resistant staphylococcus
SUBJECTS AND METHODS
aureus that can't successfully eradicated by systemic
This randomized control (RCT) trial study included
antibiotic (SA) (1, 4), alone lead to pneumonia in MV
a total of thirty mechanically ventilated patients,
patients, cystic fibrosis or bronchiectasis (5, 6).
attending at Respiratory Intensive Care Unit (RICU),
Current antibiotics for respiratory infection in
Chest Diseases Department, Faculty of Medicine, Ain
MV patients are usually limited by multidrug resistant
Shams University Hospitals. This study was conducted
Gram-negative bacteria (MDR-GNB) such as
between September 2017 to February 2018.
pseudomonas aeruginosa. In addition, eradication of

those aggressive bacteria from the airways looks difficult
The patients were randomly allocated into three groups:
after antibiotic treatment (7).
Group I: 10 individuals received aerosolized Colistin
Outcome is often suboptimal, even with
along with systematic antibiotics (SA).
antibiotic-susceptible bacterial pneumonia, medical
Group II: 10 individuals received aerosolized
response rates of less than 60% are possible (8). The issue
Gentamicin along with SA.
becomes very difficult when bacteria with a minimum
Group III (Control): 10 individuals received only
inhibitory concentration (MIC) near to the resistance
SA.
breakpoint are present (9). Increasing the SA dosage

1072
Received: 28/09/2021
Accepted: 26/11/2021

Full Paper (vol.871 paper# 16)


c:\work\Jor\vol871_17 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1078-1082

Comparative Study between Umbilical Cord Drainage, Cord Clamping and
Intraumbilical Vein Oxytocin Injection in Management of Third Stage of Labour
Azza Abdelmageed Abdelhameed, Mohamed Abdallah El-Bakry Lashin,
Aya Emad Mohamed Khalifa*, Abdelrazik Elsayed Abdelrazik
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Aya Emad Mohamed Khalifa, Mobile: (+20)01092148279, E-mail: ayakhalifa91@hotmail.com

ABSTRACT
Background:
Postpartum hemorrhage is the major cause of maternal mortality globally. So, the active management
during the third stage of labor is recommended as a preventive measure. Active management includes measures that
reduce duration and blood loss which occurs in this stage. The aim of this work was to compare between umbilical
cord drainage, cord clamping and intraumbilical vein oxytocin injection in management of third stage of labour to reduce
the incidence of postpartum hemorrhage and retained placenta. Patients and Methods: This is comparative clinical trial
study which was conducted in Obstetrics and Gynecology Department ­ Zagazig University Hospitals and Zagazig
General Hospital in the period from 1 January 2020 to 30 November 2020. Which included 90 women who were
admitted at term pregnancy being in active phase of labour with Singleton pregnancy, Full term, no Medical disorders
with pregnancy, and in whom fetal anomalies ruled out. Results: In this study we found that both group I and had
statistically significant shorter third stage duration and less blood loss than patients of group . Mean ±SD was 7.73 ±
3.11 for group and 4.73 ± 1.8 for group and 9.9 ± 3.69 for group with highly significant difference P-value<0.001.
The third stage of labor was significantly shorter in group 1 and 2 as compared to group 3. Conclusions. The use of
intra umbilical vein injection of oxytocin and placental cord drainage significantly reduced the duration of the third
stage of labor and blood loss.
Key words: Postpartum hemorrhage, Normal Labor, Labour, Oxytocin.

INTRODUCTION


Normal labour includes 4 stages: the first stage
The third stage of labor is generally managed
begins with the onset of labour and end with full
using two different approaches: active and
cervical dilatation followed by the 2nd stage of labour
physiological or expectant management. The active
including the interval between full cervical dilatation
management involves administration of oxytocic drugs,
and delivery of the fetus then the 3rd stage of labour
clamping and cutting the cord as well as controlled cord
which is the duration from the birth of fetus to the
traction. The physiological or expectant mainly
delivery of placenta, umbilical cord and fetal
involves maternal effort assisted by gravity or putting
membranes. The 4th stage of labor is hour or two after
the baby to the breast without using artificial oxytocin
delivery when the tone of the uterus is re-established as
or early clamping or cord traction(6). The aim of this
the uterus contracts again, expelling any remaining
study was to compare between umbilical cord drainage,
contents. These contractions are hastened by
cord clamping and intraumbilical vein oxytocin
breastfeeding, which stimulates production of oxytocin.
injection in management of third stage of labour to
The puerperium follows delivery and concludes with
reduce the incidence of postpartum hemorrhage and
the resolution of the physiologic changes of pregnancy
retained placenta.
usually by 6 weeks postpartum in which the

reproductive system returns to the nonpregnant state
PATIENTS AND METHODS
and ovulation may resume(1).
The current study was performed at Obstetrics and
The duration of the third stage of labor is 5-15 min
Gynecology Department ­ Zagazig University Hospitals
however, in 2-5% of cases, placenta retention occurs
and Zagazig General Hospital., in the period from 1
and if immediate treatment is not undertaken, these
January 2020 to 30 November 2020.
women are at risk of hemorrhage(2).

The major complications of the 3rd stage of labor are:
Ethical consent:
Hemorrhage, retained placenta, uterine inversion(3).
Written informed consent was obtained from all
Postpartum hemorrhage (PPH) is a leading cause
participants and the study was accepted by the Research
of maternal death in low-income countries and the
Ethics Committee of the Faculty of Medicine, Zagazig
primary cause of approximately one of every four
University. Study has been carried out on experiments
maternal deaths worldwide(4).
involving human subjects in compliance with the Code
Numerous factors lead to increase incidence of
of Ethics of the World Medical Association
postpartum hemorrhage like prolonged labour.
(Declaration Helsinki).
Multifetal gestation, large baby, anemia, eclampsia and

operative vaginal delivary. However, two third of PPH
Sample size:
occur in women with no known risk factors hence all
The sample size is 90 patients in active labour
pregnant women at risk for this catastrophic event(5).
planed for vaginal delivery divided into 3 groups (30 in
1078
Received: 28/9/2021
Accepted: 26/11/2021

Full Paper (vol.871 paper# 17)


c:\work\Jor\vol871_18 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1083-1087

Use of Intravenous Oxytocin versus Intrauterine Misoprostol in
Prevention of Postpartum Hemorrhage
Mohamed Abdallah El-Bakry Lashin, Asma Amsadef Youns Bader*,
Manal Abdelwahed Abdelmageed, Khaled Fathy Helal
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University
*Corresponding author: Asma Amsadef Youns Bader, Email: asmaamsadef@gmail.com

ABSTRACT

Background: Postpartum hemorrhage (PPH) is considered the most common cause of mortality in cesarean section
(CS), and vaginal deliveries and to intercept the uterine bleeding and atony in CS there is need for oxytocin. Objective:
This study aimed to reduce the incidence of primary postpartum hemorrhage after cesarean section (CS) by using either
intravenous oxytocin or intrauterine misoprostol. Patients and methods: This study was conducted on 76 cases full
term pregnant female patients with no risk factors for postpartum hemorrhage. They were admitted for elective caesarean
section at Zagazig University Hospital. They were divided into two groups regarding the protocol of treatment, oxytocin
group (A) was given oxytocin 10 IU in 250 ml of normal saline solution intravenous over 10 minutes directly after
delivery of the fetus. Group (B) included 38 cases that were administered 400 mcg misoprostol intrauterine after delivery
of placenta. Results: There was statistically significant variation between the groups of the present study concerning
blood loss with higher blood loss either intraoperative, postoperative and overall blood loss in intrauterine misoprostol
group than in intravenous oxytocin group. There was a significant difference between the two studied groups concerning
side effects of drugs with higher shivering among intrauterine misoprostol group, while headache, and vomiting were
reported in the group of oxytocin. Conclusion: Intravenous oxytocin infusion considered more potential than
intrauterine misoprostol in blood loss reduction in CS.
Keywords: Cesarean section, Oxytocin, Hemorrhage, Postpartum.

INTRODUCTION

Assessment using ultrasonography was offered to cases
Postpartum hemorrhage (PPH) is considered
for delivery date expectation, and for cases with special
significant cause of mortality in cesarean section (CS),
emphasis on placental localization.
and vaginal deliveries. Recently, CS is comply used in

developing and also developed countries (1).
Inclusion criteria:
For interception of the uterine bleeding and atony
Acceptance to participate in the study, had no
in CS there is need for oxytocin. Despite, the potential
hypersensitivity or contraindications to prostaglandins,
effect of extra uterotonics that are required in 10-40 %
un-complicated pregnancy, gestational age of 37-40
of cases to confirm the wellness of uterine contraction
completed weeks, had no history of coagulopathy,
(2), among prostaglandin E1, misoprostol comes with
elective cesarean sections (indications for elective
less side effects and preferred uterotonic characteristics.
sections were previous history of Cesarean delivery),
The route of administration includes intrauterine, rectal,
contracted pelvis, and abnormal presentation.
buccal, oral, and sublingual. In cases of incomplete or

missed miscarriage, misoprostol is recommended for
Exclusion criteria:
pregnancy termination (3). Misoprostol possesses many
Women with anemia, abnormal placenta,
advantages like its stability at room temperature, and
history of complications at previous pregnancy
being inexpensive, these characteristics make
especially PPH, hypertensive cases, previous or current
misoprostol the first choice in developed countries for
history of cardiac, renal, and hepatic disorders,
the management, and prevention of PPH (4). Misoprostol
emergency cesarean sections and multiple pregnancy,
has a significant role in cervical ripening induction
macrosomic baby, or polyhydramnios.
before procedures resulting in reduced pain caused by
Group (A): 38 cases administered IV infusion
instruments' transcervical passage (5).
of 10 IU oxytocin diluted in 250 ml of normal saline
The present study aimed to investigate the efficacy
after fetus delivery. Group (B): 38 cases administered
and safety of either intravenous oxytocin or intrauterine
400 mcg misoprostol intrauterine after delivery of
misoprostol in reduction of the incidence of primary
placenta.
PPH after CS.
In case of the uterus still atonic after the trial

intervention, extra IV oxytocin was administered by
PATIENTS AND METHODS
anesthetist or obstetrician.
The present study was an open randomized clinical
All cases were subjected to full history taking
trial that conducted at Zagazig University Hospital. 76
to exclude any heart, liver, or kidney problems, obstetric
pregnant females were recruited for this study at term
history, history of chronic diseases, history of blood
(37-40 weeks) gestation scheduled for elective CS. All
transfusion, and general examination (abdominal
Clinical assessments were applied on all cases including
examination,
laboratory
investigation,
and
full history taking and physical examination.
ultrasonography).
1083
Received: 30/09/2021
Accepted: 28/11/2021

Full Paper (vol.871 paper# 18)


c:\work\Jor\vol871_19 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1088-1091

Cardiac Arrhythmia Mechanisms in COVID-19: Review Article
Hany Abdellatif Mohamed, Mohamed Hossam El-Shaer,
Mohammad Mustafa Al-Daydamony, Moataz Ali Hassan
Department of Cardiology, Facutly of Meidicne, Zagazig University Hospital, Egypt
*Corresponding author: Hany Abdellatif Mohamed, E-Mail: hanyabdellatif35@gmail.com

ABSTRACT
Background
: The World Health Organization has declared SARS-CoV-2 a public health emergency and pandemic
because of its fast spread [COVID-19 (coronavirus disease 2019)]. Cardiogenic shock and arrhythmias such as acute
coronary syndrome and myocarditis have been documented in the scientific literature. Heart arrhythmias in COVID-19-
infected patients have been the subject of several recent articles in the scientific literature. It was also shown to be linked
to an increased mortality risk. Atrial fibrillation, atrial flutter, ventricular tachycardia, and ventricular fibrillation have
all been recorded in the literature so far. Unexpectedly, a study found that 7 % of patients who didn't require intensive
care unit treatment experienced arrhythmias, but 44 % of patients who required to be hospitalized in ICU. Repletion of
electrolytes, withdrawal of drugs that cause arrhythmia, volume status management, or suppression of catecholamine
surges in COVID-19 are some of the treatment options for arrhythmias.
Objective: This study aimed to evaluate the potential mechanisms of cardiac arrhythmias especially of supraventricular
tachycardia in COVID-19.
Methods: The databases were searched for articles published in English in 4 data bases. PubMed, Google scholar,
science direct and Boolean operators (AND OR NOT) had been used such as cardiac arrhythmia mechanisms, Covid-
19 OR SARS-CoV-2 and in peer-reviewed articles between March 2005 and October 2021.
Conclusion: The pathophysiology of COVID-19 can be divided into a series of different ways. Metabolic imbalances,
acidosis, and hypoxia are all possibilities as causes. Additional research suggests neurohormonal and catecholaminergic
stress may have a significant influence.
Keywords: Cardiac arrythmia, COVID-19.

INTRODUCTION


SARS-CoV-2, a newly discovered coronavirus in
248 of 301 patients admitted to the ICU with
2019, is to blame for the current outbreak of Coronavirus
COVID-19 infection were studied in another study.
disease. In December of that year, Wuhan in Hubei
Thirty-seven of them (14.9%) were newly diagnosed
Province, China, found the virus (1).
with AF (NOAF). It took an average of 10.0 (5.0-17.0)
COVID-19-related inflammation has been
days from the time that COVID-19 infection symptoms
linked to a significant incidence of supraventricular
began to develop until NOAF appeared. As a general
arrhythmias, particularly in patients with COVID-19-
rule, patients who were admitted to intensive care units
associated systemic inflammation (2). Patients with
were admitted for a median time of 3.0 (0.0-10.0) days
COVID-19 have a higher or lower incidence of
before they developed NOAF (6).
arrhythmias and illness of the conduction system,
A lack of knowledge about the pathophysiology
depending on the population. Atrial fibrillation can
of COVID-19-related AF has led some researchers to
begin anywhere from a few days to a week after
propose a variety of mechanisms, including a decrease
contracting the virus, according to several case reports.
in the availability of the angiotensin-converting enzyme
However, it can take much longer in other cases (3).
2 (ACE2) receptor, surge in pro-inflammatory
There were 19 COVID-19 patients who
signalling that results in inflammation, damage to viral
developed atrial tachyarrhythmias that were not present
endothelium cells, and aberrant electrolyte and acid-
on entry, all of whom were admitted to the MICU
base balance during the acute phase, due to a CD147-
(27.5% of MICU patients). In 12 of these patients, atrial
sialic acid spike protein interaction . Atrial fibrillation
fibrillation was found, whereas in six patients, it was
and other supraventricular tachyarrhythmias are more
found to be atrial flutter (4). Individuals admitted to
frequently linked to sympathetic nervous system
critical care units with COVID-19 who had atrial
activity than ventricular tachyarrhythmias. Thus,
tachyarrhythmias were frequently followed by
COVID-19 individuals are more likely to have
hemodynamic worsening, according to the results of
supraventricular tachyarrhythmias because of their
one recent research (5).
increased sympathetic activity (7).
1088
Received: 30/09/2021
Accepted: 28/11/2021

Full Paper (vol.871 paper# 19)


c:\work\Jor\vol871_20 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1092-1096

Breastfeeding and Its Relation with Autism Spectrum Disorder in Children
Hanin Raja Aloufi1, Felwah Faris Alotaibi1, Linah Zuhair Zamzami1, Raneem Maher Almadani1
1Family Medicine Department, King Fahad Medical Hospital
Corresponding author: Hanin Raja Aloufi, Email: aloufi.hanin99@gmail.com, Mobile: 00966552777383

ABSTRACT
Background:
The causation of autism spectrum disorder (ASD) is uncertain, in spite of the fact that the influence of
genetic and environment related influences for sure to play a principal function in the series of action. Study objectives:
to investigate the strength of association between autism and maternal breastfeeding in affected children. Subjects and
Methods:
A community-based case control study was carried out in Riyadh, Saudi Arabia, during the period from 1
August to 31 September, 2021. A convenience sample of 102 autism child from different areas of Saudi Arabia and 100
matched control child were included in the study. A predesigned questionnaire was filled only by the parents of autistic
children and normal children. Results: the majority (59.8%) of the mothers of autistic children and 62% of the mothers
of the control children were early breastfed (P value <0.05). Child bottle-feeding was found in 78.4% of the autistic
children and 74% of the control (P value >0.05). The number of autistic children who were never breastfed was
significantly higher than non-autistic children. Most (64.7%) of our studied autistic children were females. Conclusion:
The majority of the mothers of autistic children were early breastfed but they took breast feeding for less than 6 months.
The majority of autistic children received colostrum during 1st two weeks after birth, but less than half were exclusively
breastfed, and only small number had completed duration of breastfeeding. Pregnant mothers should be educated about
the importance of breastfeeding for prevention of ASD.
Key words: Autism spectrum disorder, Breastfeeding, Children

INTRODUCTION

Autism is a common condition in infants and
a result of changes in Diagnostic and Statistical Manual
children with an assessed prevalence reaching between
of Mental Disorders (DSM) diagnostic criteria and
20.0 and 116.1 per 10 000 people [1,2]. Autism was
younger age of diagnosis, an increase in risk factors
primarily pronounced in 1943, as a multifaceted
cannot be neglected [11,12]. Also some previous studies
developmental condition categorized by plain
ensure a male preponderance, as they reported that
deficiency in mutual communal communication and
autism disturbs males than females [9,10,13]. This
interactions and by a pattern of repetitive or stereotyped
indicative prejudice on the way to men might be the
behavior and individuals diagnosed with autism
consequence of a nonexistence of cognizance of women
typically have problems of the presence of repetitive
with autism [11]. In addition, some researchers suggest
and restricted patterns of behaviors [3]. Autism is
the possibility of a female-specific protective effect on
associated with substantial lifetime healthcare cost,
autism [12].
alongside multiple social, academic, and occupational
Evidence suggests that the nutritional status of
adversities [4].
the newborn, particularly the duration of breastfeeding,
Autism is a behaviorally definite condition, but
plays a key role in the pathogenesis of autism spectrum
it is caused by a number of several known and unknown
disorder. Several studies have reported contradictory
biologically based brain dysfunctions that disturb the
results regarding the link between autism and
development of brain's capacity to handle information,
breastfeeding. They investigated the association
and recently researches suggests that cases with ASD do
between ASD and breastfeeding initiation and duration
not respond to emotional signals in human social
in the Early Development Research Study, a
communications because they may not pay attention to
community-based case-control study at six sites in the
the social cues that others typically notice and it's
United States [13]. In another previous study done in
usually hard for others to understand the body language
Lebanon, they reported a rising in autism prevalence
of children with ASD [5].
whereas breastfeeding is declining [14].
The neurobiological etiology of autism was
Ghozy et al. [15] performed and reported a
thought to include, at least partially, an imbalance of
systematic review, dose-response analysis, and meta-
some factors like dopamine, glutamate, and
analysis to systematically review the findings of studies
acetylcholine [6]. Some recent studies have suggested
on the relationship between autism spectrum disorders
that the early-life environmental factors like: maternal
and breastfeeding patterns and to meta-analyze related
metabolic syndromes during pregnancy, exposures to
studies. 58 "Continued breastfeeding increases risk of
viral and bacterial infections, air pollution, exposure to
autism spectrum disorder and 76" exclusively
various medications and nutritional deficiency can play
breastfeeding increases risk, breastfeeding for 6 months
a significant role in the risk of autism [7].
reduced risk 54%, breastfeeding for 12-24 months
The prevalence of ASD has a noticeable increase
reduced risk of autism spectrum most significantly
in the past two decades [8]. The current prevalence of
associated obstacle [15].
ASD in the latest large-scale surveys is about 1%-2%
Soke et al. conducted [13] a community-based
[9,10]. In spite of the increase in prevalence is partially as
case-control study in six sites in the Unites States to
1092
Received: 29/9/2021
Accepted: 27/11/2021

Full Paper (vol.871 paper# 20)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1097-1105

Correlation between Cognitive Dysfunction and Serum Magnesium, Calcium and
Phosphorus Level in the Elderly Egyptian Patients in Zagazig University Hospitals
Amal Abdelnaby Mohamed*, Hassaan M. M. M, Atef G. Hussien, Ahmed S. Allam
Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Amal Abdelnaby Mohamed, Email: alkmarrda31@gmail.com
ABSTRACT
Background
: Many elderly neurological disorders are associated with phosphate, magnesium, and calcium deficiency.
Objective: To assess the correlation between cognitive dysfunction and serum magnesium, calcium and phosphorus
level in the elderly Egyptian patients. Patients and Methods: From July 2021 to October 2021, at Zagazig University
Hospitals inpatient and outpatient clinics of Internal Medicine Department, our case control trial was conducted on 94
elderly patients with and without impaired cognitive function, they were divided into two equal groups (47 each group).
All patients underwent a laboratory investigation to assess serum levels of magnesium, calcium, and phosphorus.
Assessment of cognitive function was done through answering a series of questions and/or performing simple tasks.
Results: There was highly statistically significant correlation between the two studied groups (normal and abnormal
cognitive functions) and serum calcium, magnesium, and phosphorus levels (P <0.001 for the 3 correlations), there was
statistically significant correlation between Mg2+ and Montreal Cognitive Assessment (MoCA) test, Mini mental state
examination and Recall Mini-COG test in abnormal group, there was statistically significant correlation between P3+
and age in abnormal cognitive functions group, MoCA test, Mini mental state examination and Recall Mini-COG test
in abnormal group. Conclusion: Calcium and magnesium are associated with cognitive improvement in elderly, but in
contrast, higher level of phosphorus facilitates cognitive decline. We concluded that age, magnesium and phosphorus
were independent variable for cognitive impairment.
Keywords: Calcium, Cognitive Dysfunction, Magnesium, Phosphorus.

INTRODUCTION
functions, including energy storage, bone and muscle
Elderly individuals with cognitive abnormalities face
development, hormone balancing, and the metabolism of
a range of challenges, including decreased quality of life,
brain cells. Phosphorus levels in patients with chronic
repeated hospitalization, and a requirement for in-home
kidney disease are disrupted, which leads to dementia.
nursing care (1). Many age-related central nervous system
Increased serum phosphorus levels were found to be
(CNS) disorders can be traced back to nutritional
associated with a significant increase in the risk of
deficiencies. Neurocognitive capabilities in the elderly
cognitive impairment in a cross-sectional investigation of
are influenced by a number of factors, including
422 chronic renal disease patients who lived in the
nutrition. Magnesium, calcium, and phosphorus-rich
community (6).
foods, nuts, and seafood are quite beneficial. Due to a
The aim of the present study was to assess the
decrease in the amount of vegetables consumed, the
correlation between cognitive dysfunction and serum
levels of these macronutrients in the serum have
magnesium, calcium and phosphorus level in the elderly
decreased (2).
Egyptian patients.
Many enzymatic functions rely on magnesium,

which is one of the most abundant cations in the bodily
PATIENTS AND METHODS
fluid. A lack of magnesium in one's diet increases the risk
From July 2021 to October 2021, at Zagazig
of neuronal toxicity. Magnesium is required for
University Hospitals inpatient and outpatient clinics of
appropriate CNS function. Numerous essential
Internal Medicine Department, our case control trial was
processes, including as tone modulation, RNA, DNA,
conducted on 94 elderly patients with and without
protein synthesis, membrane integrity and fluidity rely on
impaired cognitive function, they were divided into two
magnesium. Magnesium's bioenergetic and metabolic
equal groups (47 each group): Group 1: Patients with
activities are critical to brain function (3).
symptoms, signs of impaired cognitive function, and
Low levels of serum magnesium, a nutritional status
Group 2: healthy elderly with no symptoms, signs of
marker, increase the risk of cardiovascular disease and
impaired cognitive function. Zagazig University's
diabetes mellitus, both of which are associated with
Biochemistry Department handled the technical aspects.
cognitive decline (2). Increased stool and urine loss,
Ethical considerations:
decreased nutrition and the inability of the intestines to
When all participants completed informed
absorb magnesium are all factors that contribute to
permission papers and submitted them to the
magnesium shortage in the elderly. Osteoporosis in older
research ethics committee at Zagazig University, the
women can cause magnesium metabolism to be disrupted
study was permitted (ZU-IRB#6965). Ethics
between bone and blood (4).
guidelines for human experimentation were adhered
Many elderly neurological disorders are caused in
to in line with the Helsinki Declaration of the World
part by low levels of calcium, magnesium, as well as
Medical Association.
phosphorus (5). Phosphorus is widely available in human
Inclusion Criteria: Age: 65 years, sex: both sex
brains and is necessary for a wide range of physiological
female and male,
1097
Received: 29/9/2021
Accepted: 27/11/2021

Full Paper (vol.871 paper# 21)


COVID-19 in HSCT & hematological disorders patients The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1106-1115

Comparative study between COVID-19 Outcomes for Patients on
Chronic Immunosuppressive Drugs, Patients on Active chemotherapy and
Non- Immunosuppressed Patients: A Single-Center Egyptian Experience
Ibtesam M. Khalifa, Mohamed M. Moussa, Inas Abdel Moaty Mohamed
Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Corresponding Author: Inas Abdel Moaty Mohamed, Mobile: (+20)1111379921, E-mail: inasabdelmoaty@med.asu.edu.eg

ABSTRACT
Background:
Patients with hematological disorders especially those who underwent bone marrow transplantation are
known for having some degree of immune system derangement and cytokine signaling instability as well as patients
who were diagnosed with active malignancy and needed chemotherapy.
Objective: The study aimed to compare the outcome between patients infected with COVID 19 who use immune
suppression (either acute or chronic immune suppression) to fight COVID infection and how our different bodies and
immune systems can handle it versus the normal population.
Patients and Methods:
This study was a cross-sectional study in December 2020 conducted on 96 subjects who caught
COVID-19 infection, the subjects were categorized into three groups: Group 1: consists of 32 patients who underwent
BMT (patients on chronic immunosuppressive drugs), Group 2: consists of 32 patients with hematological diseases
(patients on chemotherapy or acute immunosuppressive drugs), and Group 3: control group (non- immunosuppressed
patients) consists of 32 patients with patients had symptomatic COVID-19 infections requiring hospital admission.
Results: We found improved overall survival in group 1 with 4 out of the total 32 patients succumbed to their deaths, 2
of the 4 patients were in the peri-engraftment period with the statistically significant improved OS when compared to
patients in group 2 with a P-value of 0.038.
Conclusion: Acute immune suppression is done by chemotherapy worsen the outcome of COVID-19 infection, while
chronic immunosuppression had the best outcome in COVID-19 patients even better than the normal population due to
loss of immune cell signaling and absent cytokines storm that might occur.
Keywords: HSCT, COVID-19, Hematological malignancies

INTRODUCTION


Hematopoietic stem cell transplantation had a
Aim of the work was to determine the prevalence and
rapid increase over the last decades. It is an established
outcomes in a population who had HSCT and was
therapy for many hematological disorders. HSCT had
infected by COVID 19 versus normal population and
many possible serious complications. One of those
patients who had hematological disorders (mainly
complications is prolonged immunosuppression,
malignancies) and correlate mortality rate among each
Coronavirus disease 2019 (COVID-19) is caused by the
group with other clinical and laboratory parameters.
novel SARS-CoV-2 virus and has been declared a

pandemic on the 9th of March by the WHO (1). Severe
PATIENTS AND METHODS
COVID-19 infection characterized by acute respiratory
This study was a cross-sectional study in
distress syndrome (ARDS), secondary bacterial
December 2020 conducted on 96 subjects who caught
pneumonia, thrombotic complications, myocarditis, and
COVID-19 infection in Ain Shams University Hospitals
gastrointestinal involvement is more prevalent in those
Hematology and bone marrow transplant unit and
with comorbidities such as hypertension, diabetes, and
inpatient COVID-19 unit; the subjects were categorized
old age (2).
as follows:
Patients with cancer have at least a two-times

higher risk of COVID-19- associated intensive care unit
Group 1: consists of 32 patients who underwent BMT
admission, invasive ventilation, and death compared
(patients on chronic immunosuppressive drugs).
with the general population. Hematopoietic stem-cell
Group 2: consists of 32 patients with hematological
transplantation (HSCT) recipients might be an
diseases (patients on chemotherapy or acute
especially vulnerable group due to nascent immune
immunosuppressive drugs).
systems or organ impairment from treatment-related
Group 3: control group (non- immunosuppressed
toxicities, specifically concerning infection-related and
patients) consists of 32 patients with patients who had
respiratory complications. To date, data on outcomes of
symptomatic COVID-19 infections requiring hospital
HSCT recipients with COVID-19 are limited to small
admission with no antecedent hematological disorders.
case series and single-center experiences. Better
Methods:
characterization of HSCT patients infected with SARS-
COVID-19 19 infection was confirmed by a
CoV-2 is needed. Here we describe the clinical
positive real-time PCR assay of a specimen collected
characteristics, treatment patterns, and factors
from a nasopharyngeal swab, After diagnosis; all
associated with outcomes of HSCT recipients who
included patients received the protocol of therapy
developed COVID-19 (3).
1106
Received: 01/10/2021
Accepted: 29/11/2021

Full Paper (vol.871 paper# 22)


c:\work\Jor\vol871_23 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1116-1124

Comparative Study on The Hepato-Protective Effect of
Carvedilol and Nebivolol in Carbon Tetrachloride-Induced Liver Fibrosis in
Normotensive and Hypertensive Albino Rats
Ali Foli Abd El-salam*, Ahmed M. M. El-Sherbiny, Ali A. El-Salam A. Attia,
Ramadan Hassan Ibrahim Thabet, Sherief Motwie Abdelfadeel
Department of Pharmacology, Faculty of Medicine, Al-Azhar University (Assiut), Egypt
*Corresponding author: Ali Foli Abd El-salam, Mobile: (+20) 01015151344, E-Mail: alifoli361987@yahoo.com

ABSTRACT
Background:
Liver fibrosis is one of the main complications of chronic liver disease and is the main reason for increased
mortality in affected patients. Fibrosis is characterized by excess deposition of extracellular matrix components
including different collagens and non-collagenous proteins such as laminin, fibronectin and undulin.
Objective:
This study aimed to: (1) Evaluate the possible hepatoprotective effect of nebivolol and carvidelol on carbon
tetrachloride (CCl4)-induced liver fibrosis. (2) Compare between hepatoprotective effect of nebivolol and carvidelol on
CCl4-induced liver fibrosis on normotensive and hypertensive rats.
Materials and Methods:
This study was conducted on 110 male albino rats. Animals were obtained from the animal
house of Faculty of Medicine, Assiut University. Their weight ranged between 160-200 grams each at the beginning of
the experiment. Rats were housed in 11 groups with 10 rats each in clean capacious macrolane cages under standard
laboratory conditions including good aerated room with suitable temperature (25 ± 5°C) and maintained at good light.
Standard rodent food and water were available ad libitium.
Results:
Subcutaneous injection of CCl4 for 8 weeks caused hepatic pathological damage and significantly increased
the levels of serum AST, ALT, ALP, hepatic malondialdehyde and hydroxyproline content. Moreover, it decreased the
activities of superoxide dismutase and glutathione. Treatment with silymarin, carvedilol and nebivolol decreased
significantly the AST, ALT, and ALP levels in plasma, MDA and hydroxyproline in liver tissues, and increased the
activities of SOD and glutathione in liver tissue.
Conclusion:
The biochemical and histopathological changes induced by administration of CCl4 were improved under
the effect of the used drugs in variable degrees. The most efficient drug was silymarin followed by carvedilol then
nebivolol.
Keywords: Hypertensive albino rats, Carbon tetrachloride, Liver fibrosis, Silymarin, Carvedilol, Nebivolol.

INTRODUCTION
carcinoma (HCC), leading to increased morbidity and
In Egypt, hepatic fibrosis and subsequently
mortality (4).
cirrhosis are believed to be a national problem. The
Among all reasons inducing liver injury and
Egyptian liver has been struggling with many causative
fibrosis, toxic reagents are one that cannot be ignored.
agents leading to its damage; of which, both hepatitis C-
The causes of drug-induced liver injury are
infection and bilharzial-infection that are believed to be
multifactorial, including toxic effects caused by reactive
the two most outstanding causes of liver
metabolites, reactive oxygen species, inflammatory
fibrosis/cirrhosis. The liver has metabolic, excretory
reactions, and imbalances between cellular damage and
and synthetic functions (1). A fibrotic/cirrhotic liver fails
protective responses, which will lead to inflammation,
to perform such important physiological functions
oxidative stress induction and fibrosis in the liver (5).
essential for human body. Up to date, patients suffering
This study aimed to: (1) Evaluate the possible
from hepatic fibrosis/cirrhosis are treated in such a way
hepatoprotective effect of nebivolol and carvidelol on
to compensate such impaired hepatic functions;
CCl4-induced liver fibrosis. (2) Compare between
treatment of complications; without receiving actual
hepatoprotective effect of nebivolol and carvidelol on
antifibrotic agents (2).
CCl4-induced liver fibrosis on normotensive and
Search for new, effective and safe antifibrotic
hypertensive rats. (3) Search for possible mechanisms
agents is still in progress. Oxidative stress, resulting
of hepatoprotective effect of nebivolol and carvidelol.
from an imbalance in generation of free radicals and

antioxidant defense molecules, affects biological
MATERIALS AND METHODS
macromolecules causing their structural alterations that
1-Experimental Animals:
lead to cell damage and its death (3). Oxidative stress is
This study was conducted on 110 male albino rats.
considered to be a major factor in pathogenesis of a
Animals were obtained from the animal house of
variety of liver diseases. In this regard, reduction of
Faculty of Medicine, Assiut University. Their weight
oxidative stress may be a good target for prevention and
ranged between 160-200 grams each at the beginning of
treatment of hepatic fibrosis. Liver fibrosis is an
the experiment. Rats were housed in 11 groups with 10
important public health concern which can progress to
rats each in clean capacious macrolane cages under
cirrhosis, portal hypertension, and hepatocellular
standard laboratory conditions including good aerated
1116
Received: 03/10/2021
Accepted: 01/12/2021

Full Paper (vol.871 paper# 23)


c:\work\Jor\vol871_24 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1125-1130

Association between Reciprocal Changes and Syntax Score in
Patients with ST-Segment Elevation Myocardial Infarction
Mohamed Wafaie Abol-eineen, Waleed Salem Elawady,
Ahmed Husayn Mohammed Abu Hallalah, Ismail Mohamed Ibrahim
Department of Cardiology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Husayn Mohammed Abu Hallalah, Email: ahmedabuhalala@gmail.com

ABSTRACT
Background
: The reciprocal change is a surrogate marker of the severity of myocardial infarction (MI). Patients
exhibiting this reciprocal change tend to have a larger infarction, poorer left ventricular systolic function, higher
incidence of proximal left anterior descending artery (LAD) lesions, multivessel diseases, and worse prognosis.
Objective: This study aimed to find the association between reciprocal ST segment changes and syntax score in
patients undergoing primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction
(STEMI).
Patients and methods: The study included sixty patients who were presented to Emergency Room with STEMI and
underwent primary PCI. Echocardiographic evaluation was performed within 24 h of PPCI. We assessed the severity
of coronary artery disease (CAD) using syntax and gensini scores.
Results
: There was significant difference regarding gensini score and syntax score that was higher in with reciprocal
change group than without reciprocal change group.
Conclusion: We concluded that there is an association between reciprocal ST segment changes and syntax score in
patients undergoing primary PCI for ST elevation myocardial infarction.
Keywords: STEMI, ECG, Reciprocal changes.

INTRODUCTION

with respect to the number, location, complexity, and
Acute myocardial infarction (AMI) is one of the
functional impact of angiographically obstructive
leading causes of morbidity and mortality throughout
lesions. SS is measured to define the coronary artery
the world (1). Acute transmural myocardial infarction
complexity and allows prospective risk stratification
induces ST-segment elevation, enlargement of the R
of patients undergoing PCI (6).
wave, and widening of the QRS complex in
Since admission of ST segment changes in
electrocardiogram (ECG) leads, which are directly
inferior derivations in acute MI occurring secondary
related to the ischemic region (2).
to a combination of benign electrical phenomena and
Moreover, leads not related to the ischemic area
myocardial ischemia, we attempted to find the
can show concurrent reciprocal ST-segment
association between these reciprocal changes and
depression. Numerous studies aimed to determine the
anatomical complexity (which will be assessed by
clinical implications of reciprocal change on ECG.
syntax score). Therefore, our study aimed to
However, the clinical significance of reciprocal
investigate whether reciprocal change in ST-
change on ECG such as ST-segment depression
segments is related to markers of CAD severity, as
remote from the infarct site remains controversial, as
assessed by syntax score in patients undergoing
reflected in a more extensive infarct size or the benign
primary percutaneous coronary intervention (PCI) for
mirror phenomenon (3).
ST-segment
elevation
myocardial
infarction
The reciprocal change is a surrogate marker of the
(STEMI).
severity of the disease. Patients exhibiting this

reciprocal change tend to have a larger infarction,
PATIENT AND METHODS
poorer left ventricular systolic function, higher
This Cross-sectional observational study was
incidence of proximal left anterior descending artery
conducted on 60 patients with ST elevation
(LAD) lesions, multivessel diseases, and worse
myocardial infarction and underwent primary PCI in
prognosis. Patients in the previously mentioned ECG
Cardiology Department, Faculty of Medicine,
studies usually receive conservative or thrombolytic
Zagazig University during the period from May 2021
therapy, followed by coronary intervention. At
to November 2021. Patients were classified according
present, patients with STEMI usually receive primary
to the presence or absence of reciprocal ECG changes
PCI (4).
into two groups: group (I): 30 patients with reciprocal
Patients with acute STEMI who undergo
change and group (II): 30 patients without reciprocal
immediate invasive intervention, the prognostic
change.
significance of reciprocal ECG changes is not clear

(5).
Inclusion criteria: Patients presented with ST
The syntax score (SS) is an anatomic scoring
elevation myocardial infarction who were eligible for
system based on the coronary angiogram that
primary PCI. STEMI was defined as symptoms of
quantitatively characterizes the coronary vasculature
ischemia associated with ST-segment elevation in
1125
Received: 02/10/2021
Accepted: 30/11/2021

Full Paper (vol.871 paper# 24)


c:\work\Jor\vol871_25 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1131-1136

Assess The Quality of Life and Epidemiological Aspect of Pediatric with
Sickle Cell Disease at Zagazig University Hospital
Mohamed Ahmad Badr1, Mervat Atfy Mohammed1,
Nelly Raaft Abdel Fattah2, Marwa Gouda Abd El Hamied Ahmed*1
Departments of 1Pediatrics and 2Psychiatry, Faculty of Medicine ­ Zagazig University, Sharkia, Egypt
*Corresponding author: Marwa Gouda Abd El Hamied Ahmed, Email: merogood728@gmail.com

ABSTRACT
Background:
Sickle cell disease is considered one of the most common inherited diseases in the world. Quality of life
is a broad multidimensional concept that usually includes subjective evaluations of both positive and negative aspects
of life. Objective: To assess the quality of life and epidemiological aspect of pediatrics with sickle cell disease at
Zagazig University Hospital. Patients and Methods: A cross-sectional study was conducted in the Outpatient Clinic
and Pediatric Hematological Department in Zagazig University Hospital including 30 children with sickle cell anemia.
We used two tools, the first was: Structure interview questionnaire sheets, and the second: was the Pediatric Quality of
Life Inventory that was used to assess children's quality of life.
Results:
The mean age of SCD patients is 10.65±3.41years.Our study showed that males (66.7%). In our study, we used
the WHOQOL-BREF criteria for measuring QOL in SCD and found that children with SCD scored positive 76.7% in
physical activity, 50% in emotional aspect, 63.3% in the social aspect, 46.4% in school aspect, and the total QOL
assessment is 63.3%. Concerning the school achievements of children with SCD, the results of this study revealed that
53.3% of students didn't pay attention in class and 66.7% of the children forget things. There were statistically significant
differences in all school health subitems.
Conclusion: It was concluded that sickle cell disease is a chronic disease that had a negative impact on QOL that
includes physical, emotional, social, and school functioning. Our results reflected that all aspects of QOL were affected
especially school functioning.
Keywords: Sickle cell disease; Quality of life; Epidemiology.

INTRODUCTION:
to18 years. B- free from any associated diseases. We
Sickle cell disease (SCD) is a group of blood
used two tools, the first was: Structure interview
disorders typically inherited. The most common type is
questionnaire sheets, and the second: was the Pediatric
known as sickle cell anemia (SCA). It results in an
Quality of Life Inventory that was used to assess
abnormality in the oxygen-carrying protein hemoglobin
children's quality of life.
found in cells. This leads to a rigid, sickle-like shape

under certain circumstances. Problems in sickle cell
Tools of data collection: Two tools were used to
disease typically begin around 5 to 6 months of age (1).
collect the necessary data for this study.
Several health problems may develop, such as
Tool I: Structure interview questionnaire sheets.
attacks of pain ("sickle cell crisis"), anemia, swelling in
It was included the demographic data of children;
the hands and feet, bacterial infections, and stroke.
age, gender, level of education, birth order, and
Long-term pain may develop as people get older. The
residence. Parents demographic data; age, level of
average life expectancy in the developed world is 40 to
education, occupation, and income. The children's
60 years (2).
clinical data comprised the onset, duration, and type of
Sickle cell disease occurs when a person inherits
treatment of sickle cell diseases such as blood
two abnormal copies of the hemoglobin gene, one from
transfusion: frequency and side effect of blood
each parent. This gene occurs in chromosome11.
transfusion, and compliance with chelating therapy.
Several subtypes exist, depending on the exact mutation

in each hemoglobin gene (3).
Tool II: Pediatric Quality of Life Inventory TM
Quality of life is a broad multidimensional concept
Version 4.0 by Varni et al. (5)
that usually includes subjective evaluations of both
The Ped QLTM Measurement model is a modular
positive and negative aspects of life (4).
approach to measure health-related quality of life in
The study aimed to assess the quality of life and
healthy children and adolescents and those with acute
epidemiological aspect of pediatrics with sickle cell
and chronic health conditions. The Peds QL
disease at Zagazig University Hospital.
measurement model integrates seamlessly both generic

core scales and disease-specific modules into one
PATIENTS AND METHODS
measurement system.
This study was a cross-sectional study conducted in

outpatient Clinic and Pediatric Hematological
This form includes (A) Report for young children (age
Department in Zagazig University Hospital Including
5-7). (B) Parent Report for young Children (age5-7).
30 children with sickle cell anemia and their parents
who fulfill the following criteria, A- age ranges from 5
1131
Received: 03/10/2021
Accepted: 01/12/2021

Full Paper (vol.871 paper# 25)


c:\work\Jor\vol871_26 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1137-1139

Comparison between Oxytocin Bolus Versus Bolus Plus Infusion in
Prevention of Postpartum Hemorrhage During Elective Cesarean Section
Ahmed El-Sayed Selim1, Walid Abdallah Abdelsalam2, Amr Kamel El-fayomy2, Anwar Ezzat Ismail2
1 Obstetrics and Gynecology Department, Al-Ahrar Teaching Hospital, Ash Sharqia,
2 Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Ash Sharqia, Egypt
Corresponding author: Ahmed El-Sayed Selim,Phone: +2: 01027770287, Email: Ahmedward10@gmail.com

ABSTRACT
Background:
The risk of postpartum hemorrhage, anemia, blood transfusions, hysterectomy, and even maternal
mortality increases with a caesarean section. Hemorrhage control during and after Caesarean operation helps to reduce
maternal mortality and morbidity. In most situations, uterine atony is linked to fatal obstetric hemorrhage. After a vaginal
birth, oxytocin is commonly administered to reduce postpartum bleeding. Its usefulness in caesarean sections is still
debatable.
Objectives: This study aimed to evaluate the effectiveness of ten IU Intravenous oxytocin bolus in comparison with ten
IU oxytocin bolus plus thirty IU oxytocin infusion on postpartum hemorrhage during elective cesarean section.
Material and Method: At Maternity Hospital in Zagazig University Hospital. This study included 180 singleton
pregnant women admitted for elective cesarean section in two groups. Patients in group A: received ten IU oxytocin
intravenous bolus over one min and infusion of thirty IU oxytocin in 500 ml of 0.9 saline over four hours. While patients
in group B: received ten IU oxytocin intravenous bolus over 1min and 500 ml of 0.9 saline over four hours.
Results: We found that there was an insignificant difference in both groups according to the amount of blood loss. In
Group (A) 10 (11.1%) patients needed blood transfusion while in Group (B) 11 (12.2%) patients needed blood
transfusion, and this difference was insignificant P=0.6.
Conclusion: After a caesarean delivery, an oxytocin infusion lowers the requirement for additional uterotonic drugs but
has little effect on the overall incidence of significant obstetric haemorrhage.
Keywords: Obstetric, Caesarian section, Postpartum, Hemorrhage, Oxytocin.

INTRODUCTION

METHODS
Cesarean section has been one of the most
Study design and sample
common surgeries performed on women in the previous
This randomized control double center trial was
four decades (1). Cesarean section is now the preferred
carried out at Maternity Hospital in Zagazig University
method of delivery in many countries, accounting for
Hospital through the period from March 2020 to Nov
almost 25% of all births (2). Cesarean section increases
2020. The study included 180 pregnant women who
the risk of postpartum hemorrhage, anemia, blood
were scheduled for an elective caesarean section.
transfusion, hysterectomy, and even maternal death (3).
Women having a bleeding condition or anticoagulant
Hemorrhage control during and after Caesarean
therapy, placenta previa or abruption, known fibroid or
section reduces maternal mortality and morbidity. In the
chorioamnionitis, and women older than 40 or younger
majority of instances, uterine atony is linked to fatal
than 20 years old were excluded from the study.
obstetric hemorrhage (4). After a vaginal birth, oxytocin

is commonly administered to reduce postpartum
Procedures:
bleeding. Its usefulness in caesarean sections is still
We divided patients into two groups: group A for
debatable (5).
patients with odds number and group B for patients with
When oxytocin bolus is used regularly, an extra
even number.
oxytocin infusion is frequently given in the event of
Patients in group A (bolus and infusion): received
bleeding. Some obstetricians give an extra oxytocin
ten IU oxytocin intravenous bolus over one min and
injection in high-risk scenarios (6). Intravenous oxytocin
infusion of thirty IU oxytocin in 500 ml of 0.9 saline
infusion maintains uterine contractility. However, it has
over four hours. While patients in group B (bolus only):
a very short half-life (4-10 min). So, the potential effect
received ten IU oxytocin intravenous bolus over one
of intravenous oxytocin infusion is during the surgery
min and 500 ml of 0.9 saline's over four hours.
and immediate postpartum period (7). Despite research
A comprehensive medical and obstetric history,
comparing the use of a bolus vs an oxytocin infusion
a general, abdominal, and local examination, a
during a caesarean operation, there is inadequate
transabdominal ultrasound to determine viability,
evidence to recommend IV oxytocin bolus with infusion
placental position, presenting portion, and gestational
over IV oxytocin bolus alone. We aimed to evaluate the
age, as well as a stander pre-operative evaluation were
effectiveness of ten IU Intravenous oxytocin bolus in
all given to each participant.
comparison with ten IU oxytocin bolus plus thirty IU
Before spinal anaesthesia, all patients received a
oxytocin infusion on postpartum hemorrhage during
500 mL intravenous bolus of normal saline via an
elective cesarean section.
intravenous bolus. Both groups underwent a normal

caesarian section.
1137
Received: 2/10/2021
Accepted: 30/11/2021

Full Paper (vol.871 paper# 26)


c:\work\Jor\vol871_27 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1140-1145

Study of Insulin Resistance in Patients with Hypothyroidism as a
Risk Factor of Diabetes Mellitus
Amira Ahmed Mahmoud1, Hoda Gouda Baker1,
Nouralhoda Fathi Adala*1, Azza Moustafa Ahmed2, Nermin Saad Ghanem1
Departments of 1 Internal Medicine and 2Clinical Pathology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Nouralhoda Fathi Adala, Email: softlive87@gmail.com

ABSTRACT
Background:
Thyroid disease is considered frequent in the population. Regarding diabetes mellitus (DM),
hypothyroidism and subclinical hypothyroidism are considered common, and risk factors for DM development.
Objective: This work aimed to early prediction of diabetes mellitus among hypothyroidism patients and to correlate the
serum FT3, FT4, and TSH with insulin resistance indexes and plasma insulin in cases with patients sub- and clinical
hypothyroidism.
Patients and methods: At the Endocrine out-patient clinic at the Internal Medicine Department, Faculty of Medicine,
Zagazig University Hospitals a total of 162 adult participants, 54 cases of overt hypothyroidism, and 54 patients with
subclinical hypothyroidism (SCH) were studied in this case-control study. The cases were aliquoted into three groups:
Group (A): 54 subjects euthyroid (control), Group (B): 54 cases with SCH, and Group (C): 54 cases with Overt
hypothyroidism.
Results: The results showed that FT3 was significantly negatively correlated with cholesterol, HDL, FBG, and HbA1C.
FT4 was significantly negatively correlated with TPO antibody and HbA1C but significantly positively correlated with
cholesterol. TSH was significantly negatively correlated with TAG but significantly positively correlated with TPO
antibody and regard FBG, F.INS and HOMA_IR were significantly high among sub- and clinical hypothyroidism groups
than the control group.
Conclusion: The current study concluded a significant correlation between thyroid hormones and IR (HOMA-IR). The
evaluation of IR is crucial in clinical events, and for the settlement of insulin sensitivity. To predict type2 DM in
hypothyroid patients.
Keywords: Hypothyroidism, Diabetes, Insulin, FT3, FT4, TSH.

INTRODUCTION

dyslipidemia had a significant role in atherosclerosis
The thyroid gland secretes hormones that are
(8,9).
potential metabolic agents in controlling lipid and
This work aimed to early prediction of diabetes
carbohydrate metabolism and energy homeostasis (1).
mellitus among hypothyroidism patients and to
Hyper and hypothyroidism cause altered metabolic
correlate the serum FT3, FT4, and TSH with insulin
rate that affects lipid profile, body weight, and insulin
resistance indexes in cases with patients sub- and
resistance (2).
clinical hypothyroidism.
Insulin resistance is considered significantly

strongly associated with obesity, metabolic syndrome,
PATIENTS AND METHODS
and DM (3). The thyroid axis is considered an example
At the Endocrine out-patient clinic at the Internal
of the endocrine loop of feedback. To aid in thyroid
Medicine Department, Faculty of Medicine, Zagazig
hormone synthesis and secretion, hypothalamic
University Hospitals a total of 162 adult participants, 54
Thyrotropin Releasing Hormone (TRH) may act as a
cases of overt hypothyroidism, and 54 patients with
regulator of the thyroid-hypothalamus-pituitary-thyroid
subclinical hypothyroidism (SCH) were studied in this
axis (4).
case-control study from March 2021 to October 2021,
The reduced T3, and T4 levels and elevated TSH
and another group of 54 euthyroid individuals was
were correlated with hypothyroidism, resulting in
enrolled as a control group. The patients were divided
increased lipoproteins and plasma lipids, and higher
into three groups: Group (A): 54 subjects euthyroid
body weight. It has been reported that hypothyroidism
(control), Group (B): 54 cases with SCH, and Group
causes an increased lipid profile (2,5).
(C): 54 cases with Overt hypothyroidism.
The hypothyroidism hallmarks include decreased

glucose absorption, decreased hepatic output of
Ethical consent:
glucose, gluconeogenesis, and decreased glucose
Approval of the study was obtained from
disposal (6). Dyslipidemia causes oxidative stress and
Zagazig University academic and ethical committee.
insulin resistance by vice vicious cycle (1,7).
Every patient signed informed written consent for
Insulin resistance, oxidative stress, hypertension,
the acceptance of the operation. This work has been
dyslipidemia, and coagulation defects were promoted
carried out following The Code of Ethics of the
by thyroid disease. Thyroid disease associated with
World Medical Association (Declaration of Helsinki)
for studies involving humans.

1140
Received: 01/10/2021
Accepted: 29/11/2021

Full Paper (vol.871 paper# 27)


c:\work\Jor\vol871_28 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1146-1152

Comparative Study on Effect of Fenofibrate and Simvastatin in
Streptozotocin Induced Diabetic Albino Rats
Ahmed Atef Ahmed Ahmed*, Ahmed M. M. El-Sherbiny,
Ali Abd El-Salam Ahmed, Ramadan Hassan Ibrahim
Department of Pharmacology, Faculty of Medicine, Al-Azhar University (Assiut), Egypt
*Corresponding author: Ahmed Atef Ahmed Ahmed, Mobile: (+20) 01097911000, E-Mail: ahmedatef11086@gmail.com

ABSTRACT
Background:
Diabetes mellitus is one of the most common diseases in the world and number of patients with this
disease increases every day. This disease with long time leads to harmful effects and has many complications as increase
in blood pressure, disturbance in kidney functions and increase in blood lipids. It is, therefore, important to search for
drugs which prevent harmful effects that result from diabetes mellitus. Objective: To study the effect of pioglitazone,
fenofibrate and simvastatin treatment on diabetic albino rats. Materials and methods: A total number of 80 male albino
rats weighing 150­200 g were obtained from Animal House, Assiut University (Assiut, Egypt) was used. They were
housed at ordinary room temperature, exposed to natural daily light-dark cycles, fed with standard laboratory diet pellets
and were given tap water. The standard diet was obtained from Animal Experimental Central.
Results:
Serum superoxide dismutase (SOD) increased significantly in diabetic rats treated with pioglitazone and
diabetic rats treated with fenofibrate or simvastatin. Combination therapy of pioglitazone and simvastatin or fenofibrate
have no synergistic effect on serum SOD. Serum glutathione (GSH) increased significantly in the diabetic rats treated
with pioglitazone and the diabetic rats treated with fenofibrate or simvastatin. Combination therapy of pioglitazone and
simvastatin or fenofibrate have no synergistic effect on serum GSH.
Conclusion:
The present study showed that treatment with fenofibrate or simvastatin did not increase body weight or
lower blood glucose level of the diabetic albino rats significantly, but they improved significantly blood pressure, lipid
profile, and serum level of antioxidants (GSH and SOD).
Keywords: Diabetic albino rats, Fenofibrate, Simvastatin, Streptozotocin.

INTRODUCTION
which increases lipolysis and elimination of
Nowadays diabetes has become an alarming to
triglyceride-rich particles from plasma (6). Simvastatin
the public health globally and day by day its prevalence
is 3-hydroxy-3-methylglutaryl coenzyme A reductase
is getting severe. Recent statistics showed that 4% of the
inhibitor. Simvastatin reduces cholesterol level and
world population are affected by diabetes and this
prevent coronary heart disease (7)
matter is very alarming because this percentage will
Treatment with combination therapy has an effect
raise to 5.4 % in 2025. By 2030, this disease may
on reviving ß-cells and restoring the fluctuation in
become the 7th leading cause of death (1). Diabetes is a
glucose level and cholesterol biosynthetic pathway. At
chronic disease that is responsible for long-term tissue
present, various types of drugs such as biguanides,
damage and complications such as liver and kidney
thiozolidinediones, and sulfonylureas are used to treat
dysfunctions. It is often, associated with serious
diabetes. To control diabetes with cardiovascular
diseases life organ damage (2). Diabetes mellitus is
disease (CVD) and other complications, monotherapy
associated with a marked increase in the risk of coronary
of these drugs are not enough (8). As a result,
heart disease (CHD) or stroke (by a factor of two to
combination therapy has become very popular for
three compared with non-diabetic patients) and
controlling glucose level (9) and inhibiting cholesterol
cardiovascular disease (CVD), which account for the
level (3).
majority of deaths among patients with diabetes (3).
The aim of the present study was to evaluate the
Persistent hyperglycemia in diabetes provokes
effect of fenofibrate and simvastatin in diabetic albino
excessive production of reactive oxygen species (ROS)
rats regarding these parameters: body weight, random
and inflammation, which play a key role in diabetic
blood glucose, lipid profile, blood pressure, detection of
cardiomyopathy (4). Hyperglycemia induces glucose
the antioxidant activity of both drugs plus pioglitazone.
auto-oxidation and surplus generation of reactive

oxygen species (ROS). Hyperlipidemia can also
MATERIALS AND METHODS
increase reactive oxygen species (ROS) production
Experimental animals: A total number of 80 male
through stimulating nicotinamide adenine dinucleotide
albino rats weighing 150­200 g were obtained from
phosphate (NADPH) oxidases and inducing leakage of
Animal House, Assiut University (Assiut, Egypt). They
the mitochondrial electron transport chain (5).
were housed at ordinary room temperature, exposed to
Fenofibrate is fibric acid linked to an isopropyl
natural daily light-dark cycles, fed with standard
ester. It lowers lipid levels by activating peroxisome
laboratory diet pellets and were given tap water. The
proliferator activated receptor alpha (PPAR). PPAR
standard diet was obtained from Animal Experimental
activates lipoprotein lipase and reduces apoprotein CIII,
Central.
1146
Received: 2/10/2021
Accepted: 30/11/2021

Full Paper (vol.871 paper# 28)


c:\work\Jor\vol871_29 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1153-1156

Role of Acitretin in Management of Multiple Warts: Review Article
Mohanad Abdelslam Omar, Ahmad Nofal, Waleed Mohamed Al Balat
Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohanad Abdelslam Omar, E-Mail: mohannadh1989@gmail.com

ABSTRACT
Background:
Human papillomavirus infection (HPV) is the primary cause of cutaneous viral warts. Plantar warts, flat
warts, filiform warts, periungual warts, anogenital warts, oral warts, and pulmonary papillomas are just a few of the
many types of warts that can be found on different parts of the body. Warts can be treated using cryotherapy,
electrocautery, and lasers, which are all local destructive techniques. It is not realistic to use these therapies for several
lesions since they may be unpleasant or cause scarring or dyspigmentation or recurrence. Psoriasis and other
keratinization disorders have been widely treated using acitretin is aromatic systemic 2nd generation retinoid with
immunomodulatory, antiproliferative, and anti-differentiative characteristics. With acitretin, patients with many
recalcitrant warts have reported good results with doses of 0.5 mg/kg each day.
Objective: To evaluate the potential role of acitretin in management of multiple warts.
Methods: The databases were searched for articles published in English in 3 data bases [PubMed ­ Google scholar-
Science direct] and Boolean operators (AND, OR, NOT) had been used such as acitretin and multiple warts OR HPV
and in peer-reviewed articles between January 2006 and November 2021.
Conclusion: Several recent studies showed that acitretin shows great clinical success in treating of widespread as well
as persistent warts, whether it is used alone or in conjunction with other therapies.
Keywords: Acitretin, Multiple warts.

INTRODUCTION

which are precursors to vitamin A. It's here that beta-
HPVs infect stratified epithelium and cause long-
carotene is converted into retinal and absorbed. In the
term infections. These infections can persist because
presence of light, the oxidation of one beta-carotene
papillomaviruses have evolved ways to resist both the
molecule creates two retinal molecules. Vitamin A
innate and adaptive immune systems' impacts during the
deficiency has been linked to skin hyperkeratosis,
earliest phases of infection (1).
mucous membrane squamous metaplasia, and
HPV causes warts, which are visible signs of
precancerous lesions in animals, according to research
infection on the skin. Depending on the epithelium
(3).
surface and the HPV type that caused the infection,
Three synthetic generations of retinoids are
warts can take on a variety of shapes and sizes. HPV
currently available. 1st generation retinoids involve
infection can cause a variety of symptoms, including
alitretinoin (9-cis RA), tretinoin (all-trans RA) as well
plantar warts (Verruca plantaris), genital tract warts
as isotretinoin (13-cis-retinoic acid). 2nd generation
(Condyloma acuminata) , common warts (Verruca
involve acitretin as well as etretinate. 3rd generation
vulgaris) and flat or plane warts (Verruca plana) (2).
involve bexarotene, tazarotene as well as adapalene.
By direct or indirect touch, warts can be
Etretinate and acitretin, two aromatic retinoids
transmitted from one person to another. Skin that has
discovered by Bolag in 1972, were the first of their
been macerated and has come into touch with rough
kind. Etretinate's retinoic acid metabolite, acitretin, is
surfaces, such as those found in swimming pools and
known as retinoic acid. Acitretin, on the other hand, is
laundry rooms, increases the risk of infection through
relatively water-soluble and accumulates in adipose
the environment (2).
tissue in low concentrations (4). To treat psoriasis,

acitretin has been approved by the FDA for use in
Role of acitretin in management of multiple warts:
combination dermatologists frequently prescribe UVB
Retinoids are a class of medications that include
or UVA radiation to treat severe plaque-type psoriasis.
acitretin. Vitamin A-like retinoids include both natural
Cyclosporine and biologics are sometimes used in
and synthetic substances. During embryonic
tandem with this treatment. It works well when
development, vitamin A aids in immune system
administered alone, and it's the only systemic retinoid
regulation and has an impact on cellular growth,
approved by the FDA to treat the disease (4).
differentiation, and proliferation. Additionally,
Off-label use of acitretin in dermatology has been
retinoids have immunologic anti-inflammatory
documented. Acitretin has been used as a chemo-
effects, apoptosis-inducing properties, and anti-tumor
preventative strategy for non-melanoma skin
benefits (3).
malignancies in patients with solid organ
Vitamin A raffinates include retinol (an alcohol),
transplantation. Pityriasis rubra pilaris (PRP), Darier
retinal (an aldehyde), and retinoic acid (a retinoic acid
disease, and ichthyoses such as lamellar ichthyosis
derivative). Vitamin A cannot be synthesized by the
have all been treated with acitretin. Lichen planus,
body, thus it must be obtained from food sources like
Grover disease, and lupus erythematosus are other
milk as well as eggs. Plants produce carotenoids,
conditions for which acitretin is used (5).
1153
Received: 09/11/2021
Accepted: 20/12/2021

Full Paper (vol.871 paper# 29)


c:\work\Jor\vol871_30 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1157-1160

An Insight of Use of Topical Adapalene in Management of
Post Acne Scars: Review Article
Wessal Mohamed Hamed, Enayat Mohamed Atwa, Amin Mohamed Amer
Department of Dermatology, Venereology & Andrology, Zagazig University Hospital, Egypt
*Corresponding author: Wessal Mohamed Hamed, E-Mail: W199199m@gmail.com

ABSTRACT
Background:
This inflammatory condition affects the pilosebaceous unit, causing comedones, inflammatory papules,
and pustules to appear on the face, chest, and back. Propionibacterium acnes and inflammation surrounding the
pilosebaceous unit, aberrant keratinization, and increased sebum production all play a role in acne's pathophysiology.
Scarring from acne and acne can lead to low self-esteem and feelings of embarrassment, all of which have a negative
impact on one's overall wellbeing.
Objective: To see if topical adapalene can help with post-acne scar treatment.
Methods: The databases were searched for articles published in English in 4 data bases [PubMed ­ Google scholar-
Egyptian Knowledge Bank - Science direct] and Boolean operators (AND, OR, NOT) had been used such as topical
adapalene and post acne scars OR acne scar treatment and in peer-reviewed articles between January 2000 and March
2021. Documents in a language apart from English have been excluded as sources for interpretation was not found.
Papers apart from main scientific studies had been excluded (documents unavailable as total written text, conversation,
conference abstract papers and dissertations).
Results:
Anti-acne retinoid adapalene (ADP) was licensed by the FDA in 1996 for use in treating acne. It improves
the appearance of the skin of the face by reducing facial lesions. Acne lesions, both inflammatory and non-
inflammatory, respond well to adapalene gel treatment. In terms of adverse effects, the medicine is completely safe
and does not cause burning or dryness.
Conclusion:
It is possible that adapalene, which has been shown to be effective in the therapy of photoaging-related
skin damage, could have a similar effect on the treatment of atrophic acne scars.
Keywords: Topical adapalene, Post acne scars.

INTRODUCTION


Adolescent acne affects 95­100 percent of 16­17-
success. Adapalene offers a superior benefit-to-risk ratio
years-old males and 83­85 percent of 16­17-years-old
than other retinoids when administered properly (5).
females, and it remains into adulthood in roughly 12­14
The aim of the review was too check whether topical
percent of instances (1). Pilosebaceous glands are most
adapalene can help with post-acne scar treatment.
prevalent on the face, chest and back, where the
Adapalene: FDA approved Adapalene (ADP) in
prevalence of acne is 92, 45 and 61% respectively. When
1996 for acne therapy (brand name Differin, Galderma)
active acne heals, scarring occurs. This can be produced
with less side effects than tretinoin (commercial name
by any type of acne, from papules, pustules and
Retin A) (6).
comedones to the more severe nodulocystic variety (2).
Hair follicle development and maintenance was
There are two types of acne scarring: Atrophic and
improved, while melanogenesis was inhibited, both of
hypertrophic. Scar types such as boxcar, icepick, and
which were helpful in the therapy of photoaging. For the
rolling atrophic acne scars influence the therapy options
most part, ADP's anti-proliferative impact has been
available (3).
inadequately characterized, and its mechanism of action
Many recent evidence-based guidelines for acne
has not been thoroughly investigated thus far. Some
have recognized that retinoids play a significant role in
cancers may benefit from ADP's anti-proliferative
this prevalent illness, including those from the AAD and
properties. In addition to topical ADP and other APIs,
the S3 guidelines from the European Dermatology
innovative treatment combinations with orally given
Forum (EDF) (4).
APIs were also described with favorable results. New
Topical treatment for acne using third-generation
ADP analogues with therapeutic promise are still a
retinoid, adapalene, has shown good clinical
problem to design (7).
1157
Received: 10/11/2021
Accepted: 24/12/2021

Full Paper (vol.871 paper# 30)


c:\work\Jor\vol871_31 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1162-1164

An Insight of Oxybutynin in Hyperhidrosis:
Mechanism of Action and Efficacy; Review Article
Mai Ali Othman*, Samia Ali Ebrahim, Basma Magdy Elkholy
Department of Dermatology, Venereology and Andrology, Zagazig University Hospital, Sharkia, Egypt
*Corresponding author: Mai Ali Othman, E-Mail: am2337097@gmail.com

ABSTRACT
Background:
For those with hyperhidrosis, the condition can cause psychological and social distress. Moreover,
hyperhidrosis in certain sites as the palms can cause significant physical and occupational disability. Aluminum
chloride, iontophoresis, sympathectomy botulinum toxin injections as well as oxybutynin have all been examined in
the therapy of hyperhidrosis. As of yet, the perfect modality has not been discovered. In the absence of unambiguous
data supporting one way over the other, selecting between multiple methods remains a clinical problem. In 1988,
oxybutynin was linked to hyperhidrosis as an antimuscarinic medication. Individuals with primary severe
hyperhidrosis or elderly patients who aren't eligible for surgery are increasingly turning to this medicine as an initial
or alternate treatment.
Objective: Assessment of hyperhidrosis treatment effectiveness by oxybutynin and overview of its mechanism.
Methods: The databases were searched for articles published in English in 4 databases. PubMed, Google scholar,
science direct, and Boolean operators (and or not) had been used such as oxybutynin chloride, hyperhidrosis, or
hyperhidrosis treatment and in peer-reviewed articles between January 2005 and August 2021.
Conclusion: Oxybutynin chloride has been effectively used in the treatment of hyperhidrosis at different sites. It
acts by inhibiting the muscarinic action of acetylcholine. Despite its satisfactory results, the treatment is associated
with multiple side effects due to its anticholinergic action in the form of dry mouth, urinary retention, constipation,
and headache. In addition, the majority of patients are unable to take it because of the lengthy daily administration
schedule.
Keywords: Oxybutynin chloride, Hyperhidrosis.

INTRODUCTION

Oxybutynin Chloride:
Excessive sweating can be caused by
In the treatment of hyperhidrosis, oxybutynin, an
hyperhidrosis, a condition of the eccrine glands that
anticholinergic medication, has emerged as an
results in unusually high sweating. An underlying illness
important option. It works for both localized and
such as an infectious, endocrine, or neurologic disorder
generalized hyperhidrosis, and patients of all ages,
can cause generalized hyperhidrosis. Idiopathic
genders, and weights respond well to it. However,
(primary) hyperhidrosis occurs in healthy individuals. It
adverse effects can be severe enough in some patients
usually affects the palms, armpits, soles, or sometimes
that they must discontinue treatment. We should be
the face. Hyperhidrosis affects roughly 3% of the general
looking forward to the development of an optimum
population, primarily those aged 25 to 64 (1).
protocol of administration with gradually rising dosage
Focal hyperhidrosis may affect as many as 2.8%
and data on long-term compliance to evaluate the long-
of the US population, according to current estimates.
term tolerance of the treatment (5).
Most typically, it strikes adults between the ages of 25
Oxybutynin, commonly known as Ditropan XL, is
and 64, but it can strike anyone, even as early as
an anticholinergic medicine approved by the FDA in
childhood. A hereditary propensity is found in 30­50
1975 for the treatment of overactive bladder
percent of those who have a family member who is sick
symptoms. It has been extensively tested and proven to
(2).
be safe and effective ever since. Patients with OAB can
The condition known as hyperhidrosis
enjoy a better quality of life because of this medication.
describes excessive sweating that isn't caused by heat
As a first-line treatment for OAB, it is frequently
or exertion. A lot of sweat can seep through your
prescribed (6).
clothes or drip off your hands. Additionally, this form

of excessive perspiration might create social anxiety
Indication:
and discomfort (3):
Urinary incontinence and frequency can be
Prescription-strength
antiperspirants
are
alleviated with the use of oxybutynin, which is
frequently the first step in treating hyperhidrosis. Try
approved for the treatment of an overactive bladder.
alternate drugs and therapy if antiperspirants don't
Oxybutynin can also be used to treat the symptoms of
work. Some doctors recommend surgery to remove
detrusor muscle overactivity, which has been linked to
sweat glands or disconnect nerves that cause an
a neurological disorder, in children aged 6 and up.
overproduction of sweat in extreme cases of
There are many conditions in which oxybutynin is used
hyperhidrosis (4).
to treat urinary problems, including spina bifida. The

off-label use of oxybutynin for the relief of ureteral

1161
Received: 3/10/2021
Accepted: 1/12/2021

Full Paper (vol.871 paper# 31)


c:\work\Jor\vol871_32 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1164-1172

Quadratus Lumborum Block for Analgesia after Cesarean Section with
Spinal Anesthesia: A Randomized Controlled Study
*Mohamed Mohamed Tawfik, Mohamed Osama Helal,
Abdelaziz Abdelmotaleb Motawea, Hazem Elsayed Moawad
Department of Anesthesia and Surgical Critical Care, Mansoura University Hospitals, Mansoura, Egypt
*Corresponding author: Mohamed Mohamed Tawfik, Mobile: 01001183400, E-Mail: m2tawfik@mans.edu.eg

ABSTRACT
Background:
Quadratus lumborum block (QLB) was introduced to provide postoperative analgesia.
Objective: This randomized controlled, double-blind study aimed to evaluate bilateral posterior QLB for analgesia after
cesarean section (CS) using spinal anesthesia without intrathecal morphine.
Methods: One hundred ASA-II women with singleton, full-term pregnancy undergoing CS using spinal anesthesia were
randomized into 2 groups (Quadratus Lumborum and Control; 50 subjects each). After completing CS, bilateral posterior
QLB (20 mL bupivacaine 0.25% on each side) was performed in Quadratus Lumborum group, and bilateral sham procedure
was performed in Control group.
Results:
The median (range) of pain score at rest at 6 h was 2 (1-6) in Quadratus Lumborum group and 5 (2-8) in Control
group; median difference (95% CI) was -3 (-3.000007 to -2.99995); P <0.00001. Pain score at rest at 12 h and pain scores
on movement at 6 and 12 h were lower in Quadratus Lumborum group. No significant differences in pain scores at rest and
pain scores on movement at 24 h were detected between the groups. The number of subjects requesting morphine was
smaller, time to the first request of morphine was longer, and total morphine dose was smaller in Quadratus Lumborum
group. Patient satisfaction was greater in Quadratus Lumborum group. No significant differences in the incidence of pruritus
and nausea/vomiting were detected between the groups.
Conclusions: QLB provides adequate postoperative analgesia after CS using spinal anesthesia without intrathecal
morphine.
Keywords:
Analgesia; Cesarean Section; Quadratus Lumborum Block.

INTRODUCTION

PATIENTS AND METHODS
Adequate analgesia after cesarean section (CS)
The study was conducted from May 2, 2020 to April
increases women satisfaction and improves maternal
1, 2021.
outcomes(1), and is usually accomplished with multimodal

analgesic regimens including neuraxial opioids. Various
Ethical considerations:
local/regional techniques can be utilized for post-CS
The study was approved by the Ethics Board of the
analgesia including intraperitoneal local anesthetic
Mansoura Faculty, and an informed written consent
instillation, wound infiltration, transversus abdominis
was taken from each participant in the study. The
plane (TAP) block, and quadratus lumborum block
study has been executed according to The Code of
(QLB)(2).
Ethics of the World Medical Association (Declaration
The QLB is a block of the fascial plane that
of Helsinki) for studies involving humans.
involves injecting local anesthetic adjacent to the
Patients:
quadratus lumborum (QL) muscle to anesthetize the

thoracolumbar nerves, and includes 3 types: lateral (QLB
Inclusion criteria were ASA-II women, 37 weeks of
type I), posterior (QLB type II), and transmuscular (QLB
gestation, singleton pregnancy, presenting for CS
type III) approaches(3-5), all of them were successfully
utilizing spinal anesthesia. Exclusion criteria included
utilized for post-CS analgesia. The QLB improves post-
women less than 19 years old, with body mass index
CS analgesia in the absence of spinal morphine, but the
(BMI) 40 kg/m2, weight less than 60 kg, height less than
proper approach after CS is yet to be determined(6-11).
150 cm, contraindications to spinal anesthesia, active
This study aimed to examine the efficacy of
labor, recent administration of opioid, hypersensitivity to
ultrasonography-guided posterior approach of the QLB
any utilized drug, or significant cardiovascular, hepatic,
(QLB type II) to provide analgesia after CS performed
or renal pathologies.
with spinal anesthesia without intrathecal morphine. The
The study participants (100 subjects) were
hypothesis was that bilateral QLB would decrease the
randomized into 2 groups (QL and Control; 50 subjects in
pain scores at rest and pain scores on movement and the
each group) utilizing the permuted block randomization
total morphine requirement compared to sham procedure.
method (block size = 4). The codes denoting patients`

group were hidden in sequentially numbered, sealed,
1164
Received: 4/10/2021
Accepted: 2/12/2021

Full Paper (vol.871 paper# 32)


c:\work\Jor\vol871_33 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1173-1176

Role of HPV Vaccines in Multiple Recalcitrant Warts Treatment: Review Article
Esam Alfetori Abdulsalam*, Ahmad Nofal, Mohamed Ibrahim El-Ghareeb
Department of Dermatology, Venereology and Andrology, Zagazig University Hospital, Egypt.
*Corresponding author: Esam Alfetori Abdulsalam, E-Mail: alwershefanye1980@gmail.com

ABSTRACT
Background
: When warts appear on the skin, they can cause substantial pain and embarrassment since they are
caused by human papillomavirus. Cryotherapy, laser vaporisation and surgical excision are some of the current
techniques for treatment of skin cancer There are a number of ways to address these issues, but some of them are
more invasive and may result in scarring. A huge number of warts makes local methods impractical for patients.
Combining a targeted strategy with an increase of the host immune system has proven successful in treating various
lesions. To evaluate the numerous vaccine antigens which was intralesionally injected for tratment of anogenital
warts as well as , a comprehensive literature review was conducted. These non-specific intralesional
immunotherapies include Candida albicans, mumps, and rubella; Trichophyton; and tuberculin antigens such as
pure protein derivative, Mycobacterium w vaccine, and Bacillus Calmette-Guerin. Warts, particularly refractory
and anogenital warts, can be treated safely, effectively, and comfortably using intralesional vaccine injection.
Bivalent and guadrivalent HPV vaccines are currently available for primary prevention of HPV infection, which
includes both types 16 and 18. There has been a dramatic reduction in the incidence of cervical neoplasia as well as
genital warts due to HPV vaccines; however, they do not target genotypes that are specific to other skin locations.
Objective: To evaluate the potential role of role of HPV vaccines in multiple recalcitrant warts treatment.
Conclusion: Several previous studies have demonstrated that recent studies and case reports have shown promising
efficacy of HPV vaccines in the treatment of warts.
Keywords: HPV Vaccines, Multiple Recalcitrant Warts.

INTRODUCTION

Treatment] and in peer-reviewed articles between
HPV is the virus that causes warts, which are
January 2001 and January 2020; a 19-year date range
harmless skin and mucosal growths. Prevalent warts,
was selected, and no language limitations, and filtered
Genital Warts, Flat Warts, and Deep Palmoplantar
in selected data basis for the last 19 years, however, the
Wraths are the most common HPV-infected clinical
range of time interval for researches is wide as there's
presentations (myrmecia) . More uncommon HPV-
scarcity of data on the particular reviewed, accurate
related
conditions
include
epidermodysplasia
and depth in the retrieved literature. Documents in a
verruciformis and localised epithelial hyperplasia (1).
language apart from English have been excluded as
Cutaneous viral warts are a prevalent skin
sources for interpretation was not found. Papers apart
ailment that affects nearly everyone at some point in
from main scientific studies had been excluded:
their lives in some shape or form (2).
documents unavailable as total written text,
Between 7% and 13% of children and
conversation, conference abstract papers and
adolescents and between 25% and 34% of adults
dissertations.
between the ages of 25 and 34 have cutaneous viral

warts (3).
HPV Vaccines:
Verrucae vulgaris (common warts) and verrucae
This virus is responsible for many dangerous
plantaris (plantar warts) are the most frequent forms of
disorders, including cancer of the female reproductive
wart. Despite the fact that cutaneous warts have a
tract and squamous cell carcinomas of the head and
benign course, they are a substantial source of physical
neck in adults and children. The goal of developing a
and mental discomfort (4).
preventive HPV vaccination is to eliminate the risk of

female sexually transmitted cancer in women (5).
Methods:
Vaccination of women between the ages of 9 and
A search strategy has been performed to
26 was suggested by the Advisory Committee on
determine the related literature. Initially, the objective
Immunization Practices (ACIP) back in 2007 (6). FDA
of review was identified: To evaluate the potential role
and ACIP approved Cervarix, a vaccine that protects
of role of HPV vaccines in multiple recalcitrant warts
against both HPV 16 and 18 strains, in 2009 (7).
treatment. Relevant keywords included: HPV
In October 2009, the FDA approved the use of a
Vaccines, and Multiple Recalcitrant Warts, more
quadrivalent HPV vaccine for boys aged 9 to 26 years,
synonymous key words had been used.
while the ACIP advised vaccination in 2010 for males
These databases were searched for articles
(8). Over 100 countries have granted vaccination
published in English in 3 data bases [PubMed ­ Google
approval for HPV since 2006. HPV vaccination has
scholar- science direct] and Boolean operators (AND,
been incorporated in immunisation regimens in more
OR, NOT) had been used such as [HPV Vaccines
than 40 nations as of 2012 (9).
AND Multiple Recalcitrant Warts OR Warts
1173
Received: 11/11/2021
Accepted: 23/12/2021

Full Paper (vol.871 paper# 33)


c:\work\Jor\vol871_34 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1177-1185

Perception and Attitudes of School Teachers about The Preparation of Their Schools for
Dealing with Type 1 Diabetic Male Students in Al-Madinah City, Saudi Arabia
Abdulrahman Hassan Issa
Family Medicine Department, Primary Health Care, Al-Madinah City, Saudi Arabia
Email: Da7my1988@gmail.com, Mobile: 00966564700005

ABSTRACT
Background:
teachers should have the knowledge regarding their school's preparations for such complications especially
if their school has students with type 1 diabetes mellitus (T1DM) mellitus.
Aim: To assess the perception and attitudes of school teachers about the preparation of their school for dealing with type 1
diabetic students in Al-Madinah City, Saudi Arabia. Methodology: A cross-sectional descriptive study was held on 425
Saudi, male teachers working at governmental schools. Cluster sample method was followed. Data were entered and
analyzed using SPSS program. Results: Most (80.9%) of participants knew that DM is a chronic disease. Only 34.4% knew
the normal blood sugar level in children. 48.2% knew that the level of sugar in the blood is important to determine the dose
of treatment to be taken. Only 3.1% of teachers reported that the school provide a nurse. 4.5% thought that the nursing room
is equipped with essential supplies for emergency and life support. Also, only 4.5% reported that the school have glucagon
in the first aid kit. 42.4% were willing to receive training by professionals regarding school measures with children with
T1DM. 31.3% were willing to help a student with T1DM.
Conclusion: There is a lack of perception and attitudes among teachers in dealing with diabetic emergency situation in
schools and also there is a lack of knowledge regarding the equipment that the school has for dealing with diabetes.
Key words: Al-Madinah; Perception; Saudi Arabia: School teachers; TI DM.


INTRODUCTION

Diabetes mellitus type 1 (T1DM) is one of the
teachers know everything about diabetes and its specific
diseases that need frequently monitoring as well as close-
management, but it is reasonable to assume that they know
up management to avoid its complications. Strict lifestyle
the basic concept such as signs as well as symptoms of both
modifications such as proper diet control, regular exercise,
hyperglycemia and hypoglycemia when they occurred.
and daily insulin injections are required to achieve proper
Moreover, teachers should have the knowledge regarding
glycemic control and thus better outcomes. According to
their school's preparations for such complications
the American Diabetic Association, diabetes mellitus type
especially if their school have students with T1DM
1 is a common disease in children and adolescents, and
mellitus. The Canadian Pediatric Society has released in
approximately 50%-60% of those with T1DM reported to
2015 the recommendation in managing diabetes type 1 in
be under the age of 16 at presentation (1). A study was
school to educate school teachers about the principle and
released in 2011 by Habeb et al., regarding the incidence
basics of managing those patients and had recommends a
of diabetes mellitus type 1 in Al-Madinah, Saudi Arabia
minimum standard for supervision and care to support
between 2004 and 2009 and it concluded that Al-Madinah
DM1 students in schools (5).
City had the highest reported incidence of DM type 1 in
However, a recent study conducted in 2018 in Spain
the Middle East and North Africa Region (2).
(6), showed that 43.2% of teachers had students with type 1
In Saudi Arabia, 35,000 children and adolescents
DM, but only 0.8% had received specific training of
suffer from T1DM, which makes it the 8th and 5th rank
diabetes. The study revealed the gap of information among
regarding the prevalence and incidence, respectively (3).
school teachers about diabetes type 1, which can result in
However, one of the most common complications of
major complications of diabetes such as hypoglycemia.
diabetes mellitus type 1 is hypoglycemia, which is defined
A study reported the incidence rate of diabetes
as a low blood glucose level <70 mg/dL. A study
mellitus type 1 in Al-Madinah City, Saudi Arabia (7)
conducted in Jeddah, Saudi Arabia, regarding the
between 2004 and 2009, there was a significant increase in
prevalence of type 1 DM in this region, found among 228
the incidence of DM type 1; children between 0 to 4 years
children who were included in the study, 157 children
had an incidence of 17.1 per 100,000. On the other hand,
(68.9%) had hypoglycemic attacks per year, which is
children between 5 to 9 and 10 to 12 the incidence rates
considered high percentage (4). Diabetic school students
were 30,0 and 46.5 per 100,000, respectively.
spend most of their time in school away from their
A study conducted in 2018 in Italy (8) to assess the
parents, so the head principal and school teachers must
knowledge of school teachers on T1DM mellitus. A total
have the basic perception, attitudes on how to react in a
number of 292 teachers were included in the study who
situation when a complication such as hypoglycemic attack
completed their questionnaire to assess their knowledge of
happen and have the proper equipment's in the center to
DM type 1. However, the study concluded that there was a
use them when required. It's unreasonable to assume that
poor sensitivity of the school about diabetes and very
1177
Received: 4/10/2021
Accepted: 2/12/2021

Full Paper (vol.871 paper# 34)


Introduction The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1186-1192

Incidence of Carotid Atherosclerosis in Ischemic Stroke
Detected by Duplex Ultrasound
Asmaa Abd Al-Aziz Saad*1, Samir Mohamed Attia2, Mohamed Said Gomaa3, Hesham Khairy Ismael4
Departments of 1Emergency Medicine, 2Vascular Surgery, 3Neurology and
4Critical Care Medicine, Faculty of Medicine, Mansoura University
*Corresponding author: Asmaa Abd Al-Aziz Saad, Mobile: (+20) 01092980099, E-Mail: smsmsaaad27@gmail.com

ABSTRACT
Background:
Carotid artery atherosclerosis is one of crucial pathogenetic factors of cerebrovascular disease, such
ischemic stroke. The degree of artery stenosis has been regarded as one of the most effective criteria to assess carotid
atherosclerotic severity. Color Doppler ultrasound (CDUS) acts as an easy and noninvasive technique to research the
characterization of carotid atherosclerotic lesion through echogenicity, which is referred to as the reflectance of the
ultrasound signal.
Objective: To evaluate the incidence of extracranial carotid atherosclerosis in patients presenting with ischemic
stroke using the noninvasive CDUS.
Patients and methods:
This was a cohort prospective observational clinical study conducted on a total of 80 patients
with ischemic stroke, divided into two groups (no atherosclerosis n=12 and atherosclerotic cases=73). The study was
conducted at Mansoura University Emergency Hospital through one year period from December 2018 to December
2019.
Results: A statistically significant higher median right carotid artery intimal medial thickness among atherosclerotic than
non-atherosclerotic group. A statistically significant higher median right carotid artery intimal medial thickness was
detected among atherosclerotic than non-atherosclerotic group with median thickness was 0.82 and 0.515, respectively.
Median plaque index was 4 ranging from 1.6 to 5.9 and incidence of left carotid artery stenosis was 78.1%.
Conclusion: Multiple risk factors like age, sex and high mean arterial blood pressure are strongly associated with carotid
artery atherosclerosis, so we suggest that high risk patients should be screened by Doppler ultrasonography in order to
plan out medical and surgical intervention for primary and secondary prevention of ischemic stroke.
Keywords: Carotid atherosclerosis, Ischemic stroke, Duplex ultrasound.

INTRODUCTION
Carotid duplex ultrasound (CDUS) is an
Atherosclerosis is the major cause of
imaging method that has been widely used to detect
cerebrovascular diseases. Reduction in the risk factor
and measure carotid plaques (CP) and carotid intima-
burden can decrease the risk of cerebrovascular events
media thickness (cIMT), which are arterial markers
and
atherosclerosis
progression.
Initially,
integral to the development of atherosclerosis
atherosclerosis is asymptomatic disease that may
independently associated with future cerebrovascular
progress silently for decades before clinical
events (stroke). These two arterial markers are
manifestations that generally appear in middle and late
correlated; however, they show differing patterns of
adulthood. Therefore, an early identification of
association with risk factors and different predictive
subclinical atherosclerosis and interventions may
value for CVD (4). CDUS is a noninvasive imaging
prevent or delay the onset of CVD (1).
modality that can safely and accurately estimate
Stroke is the major cause of long-term disability
subclinical atherosclerotic carotid stenosis to improve
in adults, and the second leading cause of death
cardiovascular risk assessment. However, the cost-
worldwide. Thirty-day mortality rate of ischemic
effectiveness of using CDUS to screen for
stroke has been estimated at around 15% in high-
atherosclerotic carotid stenosis has long been debated.
income countries. Stroke carries a major morbidity
CDUS
is
not
recommended
for
screening
concern in terms of quality of life, health care
asymptomatic individuals in the general adult
maintenance and cost. More than 80% of strokes are
population. Symptomatic individuals or adults with
ischemic, with the rest being hemorrhagic (2).
high risk factors for carotid atherosclerotic disease are
Atherosclerotic carotid stenosis of the
recommended to undergo CDUS screening (5).
extracranial carotid artery accounts for 15% to 20% of
The purpose of this study was to evaluate the
ischemic strokes. Asymptomatic carotid artery stenosis
incidence of extracranial carotid atherosclerosis in
is very commonly encountered in daily clinical
patients presenting with ischemic stroke using the
practice. Its prevalence ranges from 0.1 to 7.5% in the
noninvasive carotid duplex ultrasound (CDUS).
general population and is highest in older men. Carotid

disease can become symptomatic because of plaque
PATIENTS AND METHODS
thrombosis, atheroembolism or, less commonly, a
This was a cohort prospective observational
hemodynamic mechanism and it represents a
clinical study conducted on a total of 80 patients with
significant proportion of anterior circulation strokes (3).
ischemic stroke, divided into two groups (no
atherosclerosis n=12 and atherosclerotic cases=73).
1186
Received: 09/11/2021
Accepted: 20/12/2021

Full Paper (vol.871 paper# 35)


c:\work\Jor\vol871_36 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1193-1203

Effect of Adding Metformin to The Combined Androgen Deprivation Therapy as
Frontline Treatment in Metastatic Hormone-Sensitive Prostate Cancer Patients
Hagar A. Alagizy, Hassan M. Metwaly, Mohamed A. Shehata,
Suzan A. Alhassanin, Rasha A. Abdel Moneum, Amira E. El dosouky
Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
*Corresponding author: Hagar Alagizy, Mobile: (+20)01017843828, E-mail: hagar76@hotmail.com

ABSTRACT

Background: Lack of physical activity and high body mass index (BMI) is linked to the aggressiveness of prostate
cancer due to alteration of circulating levels of metabolic and sex hormones with reduced glucose uptake that led to the
development of insulin resistance.
Objective: evaluate the effect of adding metformin to the combined androgen-deprivation therapy (ADT) in metastatic
cancer prostate patients.
Patients and methods: Patients were included if having a diagnosis of Stage IV prostatic adenocarcinoma, No prior
use of ADT, chemotherapy, and no prior use of metformin or other diabetes mellitus treatment. Both study groups
received Combined ADT in the form of bilateral orchiectomy or luteinizing hormone-releasing hormone (LHRH)
agonists; Goserelin 3.6 mg subcutaneous q28 days with Bicalutamide 50 mg PO daily. In the Trial arm, Metformin was
administered as metformin 1000 mg/twice daily. Patients were monitored monthly for compliance, safety. Prostatic
specific antigen (PSA) level, random blood glucose, body weight, and drug-related side effects were evaluated every 3
months Disease progression was evaluated every 6 months.
Results: the addition of metformin to (ADT) in our study showed improvement of progression-free survival 39 months
vs 30 months, PSA response at 9 months, and radiological response at 9 months were factors correlating with better
PFS. There was an improvement in the quality-of-life assessment.
Conclusion: metformin should be considered as an effective agent to be used in combination with standard treatments
for prostate cancer. The present study showed that Metformin use was associated with improved PFS and OS.
Keywords: Hormone-sensitive metastatic prostate cancer, Androgen deprivation therapy, Metformin.


INTRODUCTION


The country-specific data source of Egypt for the

period (2006-2015) documented that prostate cancer
Metformin exerts direct effects as a metabolic
ranks fourth most common cancer in males after cancer
homeostasis regulator and indirect effects as an anti-
liver, bladder, lung, and it represents 7.2% and is
proliferative and anti-carcinogenic agent. Considering
responsible for 2.5% of cancer-related mortality of all
the potential association between metabolic syndrome
malignant tumors in men (1).
and prostate cancer development and progression,
Treatment of metastatic prostate cancer can be
metformin may be considered an adjuvant agent in
divided into 2 categories, treatment of metastatic
combination with other therapies (5).
hormone-sensitive prostate cancer (mHSPC) and
The study aimed to evaluate the addition of
treatment of metastatic castrate-resistant prostate cancer
metformin on response rate, time to progression of
(mCRPC), when cancer has progressed on ADT (2).
PSA, progression-free survival, toxicity of the drug,
Obesity, lack of physical activity, and high body
overall survival, and the quality of life of the patients.
mass index (BMI) are linked to the aggressiveness of

prostate cancer and worse outcome due to alteration of
PATIENTS AND METHODS
circulating levels of metabolic and sex steroid hormones
This is a phase II prospective double-arm case-
with reduced glucose uptake led to the development of
control study to evaluate the effect of adding metformin
insulin resistance resulting in chronically elevated
to the combined androgen-deprivation therapy (ADT)
blood levels of insulin (3).
in metastatic cancer prostate patients treated at the
Serum glucose is controlled by insulin, the high
clinical oncology department, Menoufia University.
level of circulating insulin decreases the production of

insulin-like growth factor (IGF-1)-binding proteins,
Inclusion criteria:
The IGF system regulates many important cellular
Histological diagnosis of prostatic adenocarcinoma,
processes critical for normal prostate growth and
Stage IV disease, with WHO P.S 2. No prior use of
development, such as proliferation, differentiation, and
ADT, chemotherapy, and no prior use of metformin or
cellular metabolism; Increased serum concentration of
other diabetes mellitus treatment.
IGF-1 was correlated to a higher risk of prostate cancer

(4).

1193
Received: 08/10/2021
Accepted: 06/12/2021

Full Paper (vol.871 paper# 36)


c:\work\Jor\vol871_37 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1204-1207

Emerging Role of Dapsone in the Management of Acne Vulgaris: Review Article
Gehad Nabil Mohamed*, Khaled Mohamed Gharib, Mai Ahmed Samir
Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Gehad Nabil Mohamed, E-Mail: gehadnabil6244@gmai.com


ABSTRACT
Background
: Skin illness Acne Vulgaris (AV) is characterized by excessive sebum production, follicular
hyperkeratinization, and long-term pilosebaceous unit irritation. Acne can persist into adulthood in 12-14% of instances,
resulting in deformity and chronic scarring that can have psychological and social consequences. Acne scars, feelings
of negative effects on psychology, isolation from society, and depression can all be long-term repercussions of the
condition. In a small percentage of patients with nodulocystic acne, the anti-inflammatory drug Dapsone, developed in
the 1950s, was found to be beneficial. However, the risk of systemic side effects has limited the use of dapsone in
clinical practice. Topical dapsone gel was licensed for acne treatment following two double-blind, randomized trials
that established its therapeutic efficacy.
Objective: Summarize the role that Dapsone plays in the treatment of Acne Vulgaris.
Methods: The databases were searched for articles published in English in 3 databases [PubMed ­ Google scholar-
science direct] and Boolean operators (AND, OR, NOT) had been used such as [Management of Acne Vulgaris AND
Dapsone OR Acne Vulgaris] and in peer-reviewed articles between March 2001 and April 2020.
Conclusion: Acne vulgaris can be effectively treated with topical Dapsone, according to clinical trials.
Keywords: Dapsone, Acne Vulgaris.

INTRODUCTION

chemicals, were found. Dapsone, a sulfone that shares
Chronic inflammation of the pilosebaceous unit
chemical similarities with sulfonamides, was first tested
and excessive sebum production mediated by hormones
in mice in 1937 and found to be effective in treating
are the hallmarks of acne vulgaris, a common skin
artificially produced streptococcal infections (6).
disorder (1).
Dapsone was found to be more hazardous than
AV is most common in adolescents, however, it
sulfonamides in animal studies, resulting in anemia and
can afflict people of any age range. An estimated 85
methemoglobinemia, as well as a wide range of other
percent of persons aged 12 to 25 suffer from AV, and
side effects, such as septic shock (7).
15 to 20 percent of those with acne have moderate to
In animal studies in 1941, Dapsone was discovered
severe cases. Acne vulgaris affects people of all
to be effective against leprosy as well as tuberculosis (8).
socioeconomic backgrounds, ethnicities, and genders
The oral formulation for the treatment of leprosy was
due to the production of androgens and the
introduced in 1949. Dermatitis herpetiformis sufferers
commencement of face sebum production during
received sulfones the following year, based on the false
adolescence (2).
notion that the ailment was infected (9).
Puberty is the time when most cases of AV occur,
This original conclusion was supported by further
however it can afflict people of any age in varying
research once the patients' symptoms had significantly
degrees. A study of the global burden of disease found
improved. The noninfectious inflammatory, bullous,
that AV affects roughly 86% of people aged 12 to 25
and auto-immune diseases, including dermatitis
years, and acne affects 15% to 20% of the same young
herpetiformis, can now be treated with dapsone, thanks
people. Androgens are produced, and facial sebum
to FDA approval (10).
production begins throughout adolescence. This helps
Dapsone was the subject of a randomized, double-
explain why acne vulgaris affects so many people, no
blind, placebo-controlled experiment in the treatment of
matter what their socioeconomic situation, country, or
acne, 9 out of 23 patients saw significant improvement,
gender may be (3).
however, the other 9 exhibited no improvement (11).
Adolescence and early adulthood are the most
Later, a study was conducted (12), although the
typical times for men to get acne, although women are
benefits of dapsone were classified as minimal, a
more likely to get it later in life (4).
comparison was made between it and 13-cis-retinoic

acid (isotretinoin). Isotretinoin, which was introduced in
Acne Vulgaris Treatment with Dapsone:
the 1980s, has superseded almost all prior therapies for
In dermatology, the antibacterial agent Dapsone is
severe acne.
commonly used for inflammatory dermatoses because
Acne fulminans with erythema nodosum, a
of its anti-inflammatory properties. Using a new topical
particularly severe and unusual form of acne, may
form of the drug, acne vulgaris has been successfully
benefit from dapsone treatment, even if some research
treated (5).
suggests the drug's efficacy in treating acne fulminans
Dapsone was first synthesized in 1908 by German
may be limited when administered alone. Dapsone's
dye industry experts, but it wasn't until the 1930s that its
potential negative effects have limited its usage as an
therapeutic potential was fully realized when
oral acne treatment (13).
sulfonamides, a new class of sulfur-containing

1204
Received: 8/10/2021
Accepted: 6/12/2021

Full Paper (vol.871 paper# 37)


c:\work\Jor\vol871_38 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1208-1215

Quality Of Life in Female Patients with Systemic Sclerosis
Nagwa Ahmad Sherby, Amany Mohyeldin Sediq,
Amr Aldesouky Omar Alsharawy*, Marwa Ahmed Hany Hammad
Departments of 1Rheumatology and Rehabilitation,
2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Amr Aldesouky Omar Alsharawy, Email: amrboing@gmail.com

ABSTRACT
Background:
Autoimmune diseases, such as systemic sclerosis (SSc), affect the entire body. As the most noticeable
aspect of the disease. SSc is characterized by a gradual fibrosis process that results in organ failure and significant
damage to many organs such as the skin and joints. It is one of the most common causes of organ malfunction, disability,
and even death.
Objective: This study aimed to analyse the quality of life in Egyptian female SSc patients and their associated risk
variables.
Patients and Methods: During the course of this cross-sectional study, 21 patients from the Rheumatology and
Rehabilitation Department of the Faculty of Medicine, Zagazig University Hospitals, were surveyed. The Systemic
Sclerosis Quality of Life Questionnaire (SScQoL) and the modified Rodnan skin score (mRSS) were used to evaluate
SSc patients' quality of life and disease activity (SAQ).
Results:
There was statistically significant relation between studied SSC patients' quality of life (SScQoL) and
deformity (p=0.022), muscle wasting (p=0.027), dyspnea (p=0.023) and nausea and vomiting (p=0.038). Also, there
was a statistically significant relation between SScQoL high score and type of medication especially cyclophosphamide
and biologic treatment. There was a statistically significant higher Systemic Sclerosis Quality of life Score of Systemic
Sclerosis patients and positive anti scleroderma. There was statistically significant and direct correlation between
SScQol score and scleroderma assessment questionnaire (SAQ).
Conclusion:
Patients with SSc have plenty of other symptoms that point to a lowered quality of life. In our studied
population, nausea, vomiting, dyspnea, deformity and muscle wasting were the most prominent features.
Keywords: SSC, SScQoL, SAQ, QoL.

INTRODUCTION
Systemic sclerosis is incurable and has no
Autoimmune diseases, such as systemic
therapy options. Patients' well-being can be improved
sclerosis (SSc), affect the entire body. As the most
by reducing symptoms and disabilities, reducing
noticeable aspect of the disease. SSc is characterized by
tolerance to treatment, or reducing risks associated with
a gradual fibrosis process that results in organ failure
co-morbid conditions and their concomitant diseases (6).
and significant damage to many organs such as the skin
Our study's goal was to assess the health and
and joints. A female to male ratio of 4:1 to 1:1 is
well-being of Egyptian female SSc patients, as well as
common, with the proportion varying with age and
any and all potential risk factors.
ethnicity (1). SSc is a multifaceted disease that is

associated with significant morbidity and death. SSc
PATIENTS AND METHODS
patients' health-related quality of life (HRQoL) suffers
21 patients from the Rheumatology and
greatly compared to the general population and patients
Rehabilitation Department of the Faculty of Medicine,
with other rheumatic diseases or chronic disorders
Zagazig University Hospitals were included in a cross-
because of the disease's severe and systemic nature (2).
sectional study. Women with SSc were identified by the
Because of its long-term and multisystem nature, SSc
American College of Rheumatology's (ACR) criteria
has a significant impact on patient's capacity to
for SSc who were at least 18 years old.
participate in both professional and social activities. In
Exclusion criteria: Patients with other rheumatologic
addition, the costs of treating these diseases and the
diseases, malignancy, endocrinal disease, infectious
resulting loss of productivity could have a significant
diseases (hepatitis or Tuberculosis) and patients who
financial impact (3).
were exposed to any chemical agents or organ solvents
Patients with SSc are frequently plagued by
as silica.
pain, which impairs their ability to do daily tasks and

has a negative impact on their overall health and well-
Ethical approval:
being. Joint pain is the most common cause of
Zagazig University's Faculty of Medicine's
discomfort. Finger ulcers, joint contractures, synovitis,
Institutional Review Board ("IRB") gave its
gastrointestinal problems, and Raynaud's phenomenon
approval for this study. Every patient signed an
are among the other causes of pain (4). In addition to
informed written consent for acceptance of the
physical, psychological, and social aspects, fatigue is a
study. This work has been carried out in accordance
prevalent concern in persons with arthritis, and it can be
with The Code of Ethics of the World Medical
a substantial cause of pain and disability in those with
Association (Declaration of Helsinki) for studies
SSc (5).
involving humans.
1208
Received: 7/10/2021
Accepted: 5/12/2021

Full Paper (vol.871 paper# 38)


c:\work\Jor\vol871_39 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1216-1225

Expression of Tumor infiltrating Lymphocytes (Tils),
Forkhead Box P3 (FOXP3) and Cyclooxygenase-2 (COX2) in
Breast Cancer Patient's Tumor Tissue, A Single Institute Study
Hagar. A. Alagizy*1, Hayam Abdel-Samie Aiad2, Moshira Mohamed Abdel-Wahed2,
Mahmoud Abdelsattar Elshenawy1, Heba Gaber Abou-Sheishai2 , Hala Said El-Rebey2
Departments of 1Clinical Oncology & Nuclear Medicine and 2Pathology,
Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
*Corresponding author: Hagar Alagizy, Mobile: (+20)01017843828, E-mail: hagar76@hotmail.com

ABSTRACT
Background:
Breast cancer (BC) is the most common cancer worldwide and is the main cause of cancer related death
in women. Forkhead boxp3 (FOXP3) is a transcription factor that plays an important role in the development and
function of immune regulatory T cells (Tregs). A strong relation between the COX-2/PGE2 pathway and FOXP3-
positive Tregs has been proposed.
Objective: We implemented this study to evaluate the prognostic significance of FOXP3 and COX-2 expression and
relation with overall survival in BC patients.
Patients and Methods: This study was conducted on archival cases of 66 BC patients. Tumor infiltrating lymphocytes
was evaluated in H&E slides whether peri-tumoral or intra-tumoral and were classified as absent, low, moderate, and
high infiltration. Sections from each case were stained for FOXP3 and Cyclo-oxygenase 2(COX2). Expression of
FOXP3 was assessed in malignant epithelial tissues and in tumor infiltrating lymphocytes (intra-tumoral and peri-
tumoral). Expression of COX-2 was assigned in tumor epithelial cells and correlated with overall survival.
Results: Higher FOXP3 H. scores in epithelial cells were associated with younger age, low grade tumors, non-triple
negative group. Higher FOXP3 H. scores in peri-tumoral lymphocytes were significantly associated with young age.
Higher H. scores of COX2 expression was associated with PR negative cases. OS was improved in patients with high
infiltration by peri-tumoral infiltrating lymphocytes and high FOXP3 positive intra-tumoral lymphocytes scores.
Conclusions: Dense TILs as well as high FOXP3 expression are considered as good prognostic factors. On the other
hand, COX2 might be considered to have poor prognostic role.
Keywords: Tumor Infiltrating Lymphocytes, FOXP3, COX2, Immunohistochemical Expression, Breast Cancer.
INTRODUCTION
inflammatory stimuli. Furthermore, COX-2 is broadly
Breast cancer (BC) is the most diagnosed cancer
expressed and strongly linked to a bad prognosis in a
worldwide and is the main cause of death due to cancer
range of malignant tumors. Therefore, COX-2 may have
in women in the less developed countries of the world (1).
a strong prognostic role in cancer patients (8).
In Egypt, breast cancer ranks as the first
An intimate relationship between the COX-
malignancy affecting females, contributing 30% of all
2/PGE2 pathway and FOXP3-positive Tregs has been
female cancers (2).
proposed (9).
Additionally, it accounts for 15.4% of cancers in
Furthermore, reduction of FOXP3 protein levels
both sexes (3).
was obtained using both non-selective COX and COX-2
Forkhead boxp3 (FOXP3) is a transcription factor
selective inhibitors in a lot of tumors (10).
that plays an important role in the development and
We implemented this study to evaluate the
function of immune regulatory T cells (Tregs) (4).
prognostic significance of FOXP3 and COX-2expression
Increased Tregs activity is a supposed crucial
in breast cancer patients and correlate their expression
mechanism of immune evasion by tumors and a wealthy
with the clinicopathological data.
milieu of molecules capable of increasing the number of

FOXP3+ Tregs has been identified in the tumor
PATIENTS AND METHODS:
microenvironment. This increase in FOXP3+ Tregs by
This retrospective study was conducted on archival
tumor cells appears to be a powerful hindrance to
cases of 66 Egyptian BC patients. Cases were diagnosed
attempts at cancer immunotherapy (5).
in the Pathology Department, Faculty of Medicine,
The prognostic significance of FOXP3+ tumor-
Menoufia University during the period between January
infiltrating lymphocytes (TILs) in BC has been a site of
2010 and March 2015.
debate. Some studies reported that FOXP3+ T-cell
Eligible patients were adult females with a known
infiltration is associated with poor clinical outcomes (6),
diagnosis of breast invasive ductal carcinoma, of no
whereas others found no significant prognostic role for
special type (IDC, no special type) with available
FOXP3+ infiltration in BC (7).
paraffin-embedded blocks of mastectomy specimens for
Cyclooxygenase-2 (COX-2) is one of the two
serial cutting and examination, available clinical,
isoforms of COX which is usually unexpressed in most
survival, and follow up data and available estrogen
normal tissues but induced rapidly by mitogenic and
receptor (ER), progesterone receptor (PR) and human
1216
Received: 8/10/2021
Accepted: 6/12/2021

Full Paper (vol.871 paper# 39)


c:\work\Jor\vol871_40 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1226-1235
Programmed Cell Death Ligand 1(PD-L1) Expression in
Molecular Subtypes of Breast Cancer
Fatma El-Zahraa Salah El-Deen Yassin1*, Cherry Gamal Gaballa Shehata2,
Eman Muhammad Salah EL-Deen1
1Department of Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
2Department of Pathology, Sohag Oncology Center, Sohag, Egypt
*Corresponding author: Fatma El-Zahraa Salah El-Deen Yassin, Mobile: (+20)01007970144,
Email: fatmafm2002@yahoo.com

ABSTRACT

Background: Tumor infiltrating lymphocytes and programmed cell death ligand 1 (PD-L1) are un- classic prognostic
indicators for breast cancer, they are major players in the immune response. Binding of Programmed cell death protein
(PD-1) with PD-L1 plays an important role in the immune suppression and the process of tumor escape.
Objective:
To evaluate the expression of PD-L 1 in mammary invasive duct carcinoma and its correlation with
molecular subtypes and other histopathological parameters.
Patients and methods: Fifty paraffin blocks were included. Histopathological examination of H&E and PD-L1
immunostained sections were done. Scores of PD-L1expression: intra tumoral and in the tumor infiltrating
lymphocytes (TILs) were evaluated. Molecular subtypes and other classic prognostic parameters were assessed
(Tumor size, grade, stage, lympho vascular invasion (LVI) and in situ component).
Results: PD-L1 expression in TILs was more frequent than intra tumoral expression in various molecular subtypes.
However, intra tumoral PD-L1 expression was associated with increasing tumor size, grade, the high level of TILs,
LVI and molecular subtypes with special trend in Triple Negative Breast Cancer (TNBC) subtype. TNBC achieved the
highest relative ratio of positive PD-L1 expression in both: intra tumoral and in TILs.
Conclusion: PD-L1 expression was more pronounced in TILs (immune cells) as compared with tumoral cells in all
molecular subtypes of breast cancer with maximum ratio in TNBC. These results provide a promising future of PD-L1
as a target therapeutic option.
Keywords: TILs, PD-L1, TNBC.

INTRODUCTION
Patients and specimens:
Breast cancer accounts for 25% of all
Fifty formalin-fixed paraffin embedded tissue
malignancy and for 16.67 % of all cancer deaths,
blocks of 50 cases of mammary duct carcinoma were
occupying the first rank for incidence and mortality in
collected from the archives of the Pathology
most of the countries (1).
Department, Sohag University Hospital and Sohag
Molecular alterations are known to affect cancer
Oncology Center during the period (January-December
occurrence and metastasis, which has led to the
2020). Tumor samples included total, subtotal
development of hormonal therapy that targets the
mastectomy and excisional specimens.
estrogen receptor (ER), progesterone receptor (PR), or

human epidermal growth factor receptor type 2 (HER-
Ethical Approval:
2). However, up to 20% of patients with breast cancer
Ethical approval was obtained from the
experience disease progression and death, which
Institutional Research Ethical Committee. Data
highlights the need for more effective therapy (2).
about patients' age, tumor size, ER, PR, HER-2/neu
Programmed cell death ligand 1 (PD-L1, also known
and Ki-67 status were obtained from clinical
as B7-H1) that was discovered in a variety of epithelial
reports.
cancers is believed to mediate local immune evasion

by binding to programmed cell death 1 (PD-1), its co-
Histopathological evaluation:
stimulatory receptor on T cells, to induce saturation of
Four micrometer (4µm)-thick tissue sections
activated anti-tumor T cells (3).
were prepared from the tissue blocks and stained with
PD-1 and PD-L1 have been shown to be promising
hematoxylin and eosin stains. The tumors were
targets for the treatment of different tumor types. Anti-
reviewed for tumor histological type according to the
PD-1 therapies were effective for breast cancer, and
WHO classification (5), graded and staged
particularly triple negative breast cancer (TNBC) (4).
pathologically
(p)
according
to
WHO
Aim of the work was to evaluate the expression of PD-
recommendations (5).
L1 in invasive duct carcinoma of the breast and its
Tumor infiltrating lymphocytes (TILs) were
correlation with molecular subtypes and other
assessed according to the international TIL Working
histopathological parameters.
Group Consensus guidelines 2014(6). They were
1226
Received: 07/11/2021
Accepted: 07/1/2022

Full Paper (vol.871 paper# 40)


Faculty of Medicine The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1236-1240

Relationship of Diabetes Mellitus (DM) and
Ischemic Heart Disease: Review Article
Mohamed Ibrahim Mustafa Al Awadi, Mohamed Samy Mohamed Abd El Aziz,
Abdulrahman Faraj Ali Alhuwayj*, Ibtesam Ibrahim El Dosouky
Department of Cardiology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Abdulrahman Faraj Ali Alhuwayj, Mobile: (+20)01005157826, E-Mail: dr.erhoma85@gmail.com

ABSTRACT
Background:
Diabetes mellitus (DM) is one the strongest risk factors for cardiovascular disease and, in particular, for
ischemic heart disease (IHD). The pathophysiology of myocardial ischemia in diabetic patients is complex and not
fully understood. Some diabetic patients have mainly coronary stenosis obstructing blood flow to the myocardium and
others present with coronary microvascular disease with an absence of plaques in the epicardial vessels.
Objective: This review article aimed to study diabetes mellitus in order to reduce the high morbidity and mortality
due to cardiovascular disease in diabetic patients.
Methods:
These databases were searched for articles published in English in 3 data bases [PubMed ­ Google scholar-
science direct] and Boolean operators (AND, OR, NOT) had been used such as diabetes mellitus and ischemic heart
disease or coronary artery disease and in peer-reviewed articles between July 1998 and April 2021. A 23-year date
range was selected without language limitations, and filtered in selected data basis for the last 23 years. Documents in
a language apart from English have been excluded as sources for interpretation. Papers apart from main scientific
studies had been excluded (documents unavailable as total written text, conversation, conference abstract papers and
dissertations).
Conclusion: Diabetes mellitus, a simultaneously endocrine and metabolic disease, is an especially aggressive process
leading to vascular lesions. In order to reduce the high morbidity and mortality due to cardiovascular disease in
diabetic patients the goals of prevention must be maximal on non-diabetic persons who already have ischemic heart
disease.
Keywords: Diabetes mellitus, Ischemic heart disease, CAD, CVD.

INTRODUCTION
into four different etiological categories: type 1, type 2,
Diabetes mellitus (DM) affects 180 million
"other specific types", and "gestational DM". Type 1
patients worldwide. It is present in up to 25% to 30%
DM (T1DM) is due to T-cell­mediated autoimmune
of all patients undergoing percutaneous coronary
destruction of pancreatic-cells that leads to insulin
intervention (PCI) (1). Diabetes mellitus (DM) is
deficiency; T1DM occurs mostly in young people,
associated with increased cardiovascular risk and
generally up to 30 years of age. Type 2 DM (T2DM) is
mortality, and has long been recognized as an
characterized by both insulin resistance and failure of
independent risk factor for cardiovascular disease
pancreatic-cells. Other specific types of DM are due to
(CVD) and is also an independent predictor of adverse
either single genetic mutations, to other pathological
clinical outcomes after PCI (2). Diabetes mellitus is
diseases of the pancreas, or to drugs. Gestational
regarded as a coronary heart disease risk equivalent
diabetes develops during pregnancy (6).
and an important factor when planning for treatment
Insulin resistance also plays a critical role in
strategies for coronary artery disease as well as
the pathogenesis of type II DM. Hyperinsulinemia is
evaluating clinical outcomes after PCI (3). DM
closely related to the metabolic syndrome, which
markedly
impaired
myocardial
microvascular
includes insulin resistance, arterial hypertension and
perfusion, which is regarded a clinically significant
obesity, and is accompanied by a high risk of coronary
predictive marker of plaque progression in coronary
artery disease (CAD). The change in the concentration
artery disease (CAD) (4).
of plasma lipids in type II DM is a predictor of CAD.

It was established that in persons with high blood
Relationship effect between diabetes mellitus and
glucose level in the blood on an empty stomach and
coronary artery disease patients:
after a load significantly higher cardiovascular
Epidemiological data suggest a reliable
morbidity and mortality rate was noted (7).
relationship between the level of glycosylated
Asymptomatic hyperglycemia, especially in women, is
hemoglobin (HbA1c) and the risk of cardiovascular
an important risk factor for the development of CAD
morbidity and mortality. With an increase in the level
(8).
of HbA1c by 1%, the risk of cardiovascular morbidity
The effect of hyperinsulinemia and insulin
increases by 10% (5).
resistance on the development of atherosclerosis is
DM is a complex and heterogeneous chronic
associated with the impact on blood coagulation
metabolic disease caused by elevated levels of blood
processes. Hypercoagulation and depression of
glucose. DM has a great impact worldwide that will
fibrinolysis are noted, which can contribute to
probably increase in the next decades. DM is classified
intracoronary thrombosis. In patients with DM type II,
1236
Received: 10/10/2021
Accepted: 8/12/2021

Full Paper (vol.871 paper# 41)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1241-1247

Value of Low Dose Short Hypofractionated Palliative Radiation
Therapy in the Management of Bladder Cancer
Sara F. Mahmoud*, Mohammad A. Mazrouh, Mostafa M. Toam, Heba M. Abd-Elhamed
Clinical Oncology & Nuclear Medicine Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Sara Fawzy Mahmoud, Email: Drelenany@gmail.com

ABSTRACT
Background:
In locally advanced and metastatic urinary bladder carcinoma, palliative radiation therapy aims to palliate
symptoms with acceptable toxicity.
Objective: Evaluation of the role of low dose short hypofractionated radiotherapy in improving symptoms of bladder
cancer indefinitely, as long as it does not cause unacceptable toxicity.
Patients and Methods:
From July 2018 to July 2020, 24 patients with advanced bladder cancer were included in a trial
at Zagazig University Hospitals' Clinical Oncology & Nuclear Medicine Department. All patients received a total dose
of 21Gy of conformal radiation (7 Gy/fraction in 3 fractions, a fraction every other day over one week).
Results: There was statistically significant improvement in haematuria symptoms among the studied patients. Also,
there were no statistically significant changes in bowel frequency symptoms, diarrhea symptoms and bleeding
symptoms. There were no significant changes in symptoms at 3-month assessment compared to end of treatment
assessment while there was increase in percent of patients with symptomatic improvements especially in haematuria,
dysuria and nocturia symptoms.
Conclusion:
Low dose hypofractionated radiation therapy protocol showed effective palliation of urinary symptoms
with an acceptable toxicity.
Keywords: Hypofractionated radiotherapy, Bladder symptoms, Bowel symptoms, Bladder cancer.

INTRODUCTION

Bladder cancer is one of the most frequent cancers
We wanted to check if low dosage, short
in developed countries, with the largest incidence
hypofractionated radiation could improve symptoms of
occurring between 70 and 75 years of age (1).
bladder cancer for as long as possible, with no
After prostate cancer, it is the second most frequent
undesirable side effects.
urogenital malignancy. When it comes to cancer

mortality, it is the 8th most common cause of death in the
PATIENTS AND METHODS
United States for both men and women (2).
This prospective cohort study was conducted
In the United States, it is responsible for 3% of all
through the period from July 2018 to July 2020 at the
cancer fatalities in men and 2.5% of all malignancy-
Clinical Oncology and Nuclear Medicine Department of
related deaths (3). Urothelial carcinomas in Egypt are
Zagazig University Hospital in Egypt. This research
more commonly diagnosed in urban areas as the control
included 24 patients with locally advanced or metastatic
of schistosomiasis in the rural areas led to a drop in
bladder cancer who were unfit for any type of radical
squamous cell carcinoma incidence (4).
treatment.
At time of diagnosis, about 25% of patients

presented with muscle-invasive cancer bladder. About
Inclusion criteria:
10%-15% of the remaining 75% who initially presented
Pathologically, they were verified as muscle-
with early disease will progress to muscle invasive one
invasive cancer of the bladder causing local symptoms, a
(5). Many of the 25 percent of patients who may be
normal haematological profile, an expected life span of
identified with a deadly muscle-invasive disease will be
at least three months, and no concurrent or planned use
unable to endure the aggressive treatment because of
of cytotoxic chemotherapy were the criteria for this
their comorbid conditions. In some cases, the disease has
clinical research, with either: (1) T3 and T4a tumors are
progressed to the point where curative treatment is no
appropriate for radical treatment, but the patient's age or
longer possible. The majority of individuals with this
general medical state prevents him or her from receiving
disease suffer from bothersome symptoms like dysuria
it, or (2) Treatment options are limited due to the stage of
and hematuria, which necessitate treatment for the length
the tumor's development (T4b, N1, and M1).
of the patient's life (6).

As long as possible, palliative care should strive to
Exclusion Criteria:
alleviate the patient's symptoms, but it should not cause
Patients fit for radical treatment, previous
unacceptable toxicities (7). As a result, hypofractionated
cystectomy, and decompensated liver failure (ascites).
radiotherapy is used to treat the symptoms of advanced

and metastatic bladder cancer that have spread locally.
Ethical approval:
Only the tumor and bladder will be treated with a dose of
All participants signed informed permission
21 Gy in three segments using this approach, not the
papers and submitted them to the Research Ethics
entire pelvis (8).
Committee, Zagazig University. The study was
1241
Received: 10/10/2021
Accepted: 8/12/2021

Full Paper (vol.871 paper# 42)


c:\work\Jor\vol871_43 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1248-1254

The Effect of Different Levels of Positive End Expiratory Pressure on Oxygenation and
Hemodynamics During Laparoscopic Cholecystectomy in Obese Patients
Asmaa Samy Abd Elkreem Elsheikh, Hassan Mohmed Ali Maguid,
Maha Ibrahim El- Desouky, Salwa Hassan Waly
Department of Anesthesia, Surgical intensive care and pain management,
Faculty of Medicine Zagazig University, Egypt
*Corresponding author: Asmaa Samy Abd Elkreem Elsheikh, Email: names_109@hotmail.com

ABSTRACT
Background:
Obesity represents a major health problem. There are multiple strategies to reduce perioperative
respiratory complications, and one of these strategies is the use of intraoperative recruitment maneuvers (RM), with the
addition of positive end expiratory pressure (PEEP).
Objectives: This study was aimed to compare the effect of using different levels of positive end expiratory pressure on
oxygenation and hemodynamics and to determine the optimal PEEP level that provide the maximum beneficial effect
on oxygenation with minimal effect on hemodynamics during laparoscopic cholecystectomy in obese patients.
Patients and Methods: This study was carried out at Zagazig University Hospitals where fifty-six male and female
patients scheduled for laparoscopic cholecystectomy aged from 21 to 60 years, ASA physical status grade II and body
mass index (BMI) 30-34 kg/m2. Patients were classified into four groups (14 each), underwent history taking, general
examination, and laboratory investigations. Results: Regarding changes in heart rate and mean arterial pressure (MAP)
at different intervals within and between the four studied groups, there was statistically significant difference between
the four groups regarding heart rate and MAP after induction Ti, T1 (20 min), T2 (40 min) and T3 (60 min) with the
least reported heart rate and MAP was significantly found in group 9 (PEEP9) in relation to the other groups.
Conclusions:
It could be concluded that PEEP 7 H2O is the optimal PEEP level with maximum beneficial effect on
oxygenation without affecting hemodynamics during laparoscopic cholecystectomy in obese patients.
Keywords: PEEP, EELV, Laparoscopic, Obese, FRC.

INTRODUCTION

than nonobese patients to develop atelectasis that
World Health Organization (WHO) defined
resolves more slowly (6). This is because of a marked
obesity as a Body Mass Index (BMI) above 30 kg/m2.
impairment of the respiratory mechanics promoting
The characteristic physiological changes induced by
airway closure with reduction of the oxygenation index
obesity such as decreased Functional Residual Capacity
(Pao2/PAo2) to a greater extent than in healthy-weight
(FRC), increased demand for oxygen, decreased lung
subjects (3).
compliance, and altered ventilation perfusion ratio
There are different intra-operative ventilation
make these patients prone to perioperative
strategies in these patients to re-inflate the collapsed
complications like atelectasis, hypoxia and hypercapnia
lungs and optimize the oxygenation. These strategies
(1). The decrease in FRC can lead to ventilation at low
include the application of Positive End Expiratory
lung volume, which in turn can lead to peripheral
Pressure (PEEP) or Recruitment Maneuvers (RM) in the
airway collapse, when the airways closing volume
form of application of positive airway pressure to re-
exceeds the end-expiratory lung volume (EELV) (2).
inflate the collapsed lung tissue (7). Positive end-
Postoperative lung atelectasis develops with both
expiratory pressure (PEEP) can counterbalance the
intravenous (IV) and inhaled anesthesia and whether the
decrease in EELV, thereby preventing atelectasis during
patient is breathing spontaneously or is paralyzed and
the intraoperative period, improving pulmonary
ventilated mechanically (3). The adverse effects of
mechanics and decreasing pulmonary shunt (8).
atelectasis persist into the postoperative period and can
In the present study, we have aimed to compare
affect patient recovery (4).
the effect of using different levels of positive end-
Laparoscopic surgery is usually performed by
expiratory pressure on oxygenation and hemodynamics
intraabdominal insufflation of carbon dioxide; this
and to determine the optimal PEEP level that provide
insufflation leads to an increase in intraabdominal
the maximum beneficial effect on oxygenation with
pressure. The increase in intraabdominal pressure could
minimal effect on hemodynamics during laparoscopic
induce shift of the diaphragm cranially and compression
cholecystectomy in obese patients.
of basal lung regions. Thus, the increase in

intraabdominal pressure could accentuate the effects of
PATIENTS AND METHODS
atelectasis already predisposed to by general anesthesia,
This prospective randomized comparative
and therefore laparoscopic surgeries are associated with
clinical trial included a total of 56 male and female
a frequent incidence of lung atelectasis (5). During
patients scheduled for laparoscopic cholecystectomy,
general anesthesia, as well as during the immediate
attending at anesthesia, surgical intensive care and pain
postoperative period, obese patients are more likely
1248
Received: 09/11/2021
Accepted: 20/12/2021

Full Paper (vol.871 paper# 43)


c:\work\Jor\vol871_44 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1255-1262

The Association of Expression Patterns of Lncrna Taurine Upregulated
Gene 1 (Tug1) with Progression and Severity of Diabetic Kidney Disease
Nearmeen M. Rashad*1, Marwa H.S. Hussien2, Ahmed M. Salah1
1Internal Medicine and 2Medical Biochemistry Departments, Faculty of Medicine, Zagazig University, Zagazig, Egypt
*Corresponding author: Nearmeen M. Rashad, Mobile: (+20)1224248642, E-mail: nrashad78@yahoo.com

ABSTRACT
Background:
Diabetic kidney disease (DKD) has become the leading cause of the end-stage renal disease (ESRD) and
it is one of the most devastating complications of type 2 diabetes mellitus (T2DM). Its pathogenesis encompasses
multiple dysregulated epigenetic mechanisms. Long non-coding RNAs (lncRNAs) have an important function in various
diseases. However, their roles in DKD remain mainly unknown.
Objective:
The present study was performed to explore the relative expression level of lncRNA taurine upregulated
gene 1 (lncRNA Tug1) in Egyptian patients with T2DM and CKD and to investigate its associations with the progression
of CKD.
Patients and methods: This cross-sectional-controlled study included a total of 50 patients with T2DM and 50 age and
sex-matched controls, attending at Internal Medicine, Faculty of Medicine, Zagazig University Hospitals. Quantitative
real-time reverse-transcription PCR (qRT-PCR) was used to detect the expression levels of lncRNA TUG1
Results: patients with T2DM had statistically significantly lower values of the relative expression level of lncRNA
Tug1 compared to the control group (1.313±0.72, vs 2.354±0.97, P 0.001). Interestingly, patients with
macroalbuminuria (0.48±0.311) had statistically significant lower values of the relative expression level of lncRNA
Tug1compared to patients with microalbuminuria (1.42±0.49) and patients with normoalbuminuric (1.86±0.636), P
0.01. In patients with DKD among studied variables, serum creatinine and UACR were the main independent
parameters associated with the relative expression of lncRNA Tug1.
Conclusion: It could be concluded that circulatory lncRNA Tug1 expression level is downregulated in patients with
T2DM in a particular patient with macroalbuminuria. Thus, circulatory lncRNA Tug1 relative expression level may
have a reno-protective role.
Keywords: DKD, lncRNA Tug1, qRT-PCR, T2DM, Macroalbuminuria

Introduction:

coding function. Recent studies have identified the
Diabetes mellitus is a major public health
regulatory role of lncRNA in several gene expression
problem; and its prevalence will be more than 600
processes, including nuclear importation, alternative
million by 2045 (1). Diabetic kidney disease (DKD) is a
splicing, DNA methylation, mRNA decay, as well as
microvascular complication and progresses gradually
other
transcriptional,
post-transcriptional
and
over many years in approximately 30­40% of
epigenetic regulatory roles. The lncRNA taurine
individuals with T2D Mellitus. Approximately 45% of
upregulated gene 1 (TUG1), located on chromosome
cases with ESRD result from DKD which is now the
22q12,
regulates
podocyte
health
and
main cause of chronic kidney disease (CKD) worldwide
glomerulosclerosis by altering the expression of
and the leading cause of end-stage renal disease (ESRD)
peroxisome
proliferator-activated
receptor

in addition, the presence of CKD is the single strongest
Coactivator 1 (PGC1A) (4).
predictor of mortality for persons with diabetes (2).
Although recent studies were conducted to
Interesting studies investigated the pathological
explore the pathogenic mechanism of dysregulated
mechanisms of DKD, and they detected glomerular
lncRNA, only limited examples of lncRNAs have been
hypertrophy,
mesangial
matrix
growth,
studied in DKD (5). Thus, we aimed in the current study
glomerulosclerosis,
tubular
atrophy,
and
to investigate the relative expression level of lncRNA
tubulointerstitial fibrosis. Moreover, podocyte loss and
TUG1 in Egyptian patients with T2DM and CKD and
epithelial dysfunction play important roles in DKD
to investigate its associations with the progression of
pathogenesis with further progression associated with
CKD.
inflammation but the exact molecular mechanisms

responsible for DKD are not fully known.
PATIENTS AND METHODS
Accumulating
evidence
has
indicated
that
This cross-sectional-controlled study included a
Hyperglycemia,
oxidative
stress,
and
renal
total of 50 patients with T2DM and 50 age and sex-
hemodynamic changes are important forms of
matched controls, attending at Internal Medicine,
metabolic stress capable of modifying epigenetic
Faculty of Medicine, Zagazig University Hospitals.
processes (3).

Long noncoding RNAs (lncRNAs) are a class of
The design of the study is shown in figure (1).
transcripts longer than 200 nucleotides without protein-
1255
Received: 5/10/2021
Accepted: 3/12/2021

Full Paper (vol.871 paper# 44)


c:\work\Jor\vol871_45 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1263-1269

Predictors of Recurrence of Spontaneous Bacterial Peritonitis in
Cirrhotic Ascitic Patients
Mahmoud Saif-Al-Islam1, Usama M. Abdelaal*2,
Salwa Mohammed1, Mohamed Malak2, Asmaa Naser Mohammad1
Departments of 1Tropical Medicine and Gastroenterology and
2Internal Medicine, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Usama M. Abdelaal, Mobile: (+20)1065962094,
E-mail: osamelaal74@yahoo.com, ORCID: 0000-0001-9998-668

ABSTRACT
Background:
Spontaneous bacterial peritonitis (SBP) is widely common infection in cirrhosis. Deferral in diagnosis
and treatment exposes the patients to a high risk of complications and death. Recurrence of SBP occurs in many patients
however there is insufficient regional and no local data on factors responsible for its recurrence.
Objectives:
The aim of the current work was to know the predictors of recurrence of SBP in cirrhotic ascitic patients
and to evaluate the impact of some scores as predictors.
Patients and methods:
The study was done in Tropical Medicine and Gastroenterology Department, Sohag University
Hospital. All patients with liver cirrhosis, ascites and SBP were subjected to complete clinical, ultrasonographic and
laboratory evaluation. The patients were followed up for one year after management of the 1st episode and categorized
into 2 groups according to absence or presence of recurrence of SBP.
Results: Hundred patients with SBP were included. Univariate analysis showed that hematemesis, abdominal pain,
multiple paracentesis, urinary tract infection, prolonged use of PPI, low serum sodium, high serum bilirubin and high
MELD score were significant variables responsible for recurrence. Multivariate analysis showed that multiple
paracentesis, urinary tract infection and low serum sodium were the highly risk factors for recurrence.
Conclusions: It could be concluded that multiple paracentesis, urinary tract infection and low serum sodium were the
highly independent risk factors for recurrence of SBP.
Keywords: Liver cirrhosis, Ascites, Spontaneous Bacterial Peritonitis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is one of
advanced liver disease; but they less accurate in the
the most widely recognized and life-threatening
prediction of SBP recurrence (8).
complications of liver cirrhosis which is characterized
Another available score is AIMS65 score
by infection of ascitic fluid without clear simultaneous
which consists of: albumin level <3.0 g/dL,
intra-abdominal wellspring of infection (1). It happens
international normalized ratio (INR>1.5), altered
in 10-30% of cirrhotic ascitic patients with 30-50% in-
mental status, systolic blood pressure 90 mmHg, and
hospital mortality rate. There is 10% likelihood of
age >65 years (9).
acquiring SBP in patients with terminal hepatic disease
The aim of the current work was to know the predictors of
with ascites over a period of one year with chance of
recurrence of SBP in cirrhotic ascitic patients and to
SBP recurrence around 70% per year (2).
evaluate the impact of Child-Pugh grade, MELD score
Altered host immunity and translocation of
and AIMS65 score in prediction of recurrence of SBP.
the microorganisms from the gut to the extra intestinal

sites are believed to be the reason for SBP (3).
PATIENTS AND METHODS
Universally published information shows that raised
This study included a total of hundred patients (61
serum bilirubin, higher serum creatinine, presence of
males and 39 females) with SBP, attending at Tropical
hyponatremia and the utilizationof proton pump
Medicine and Gastroenterology Department, Sohag
inhibitors (PPI) are the risk factors related to
University Hospitals. This study was conducted
development of SBP (4). However, there is lackingdata
between September 2017 to September 2019.
on factors responsible for SBP repeat. Long-term

prophylaxis with antibiotics like
quinolones
All patients were subjected to complete history
(Norfloxacin, 400 mg per day orally) has decreased the
taking, thorough clinical examination, abdominal
rate of recurrence. However, emergence of quinolone
ultrasonography and laboratory investigations including
resistant organisms has lowered its use (5). Improvement
complete blood count (CBC), serum creatinine, serum
in patients' management, including higher index of
electrolytes, liver profile, anti-hepatitis C virus (Anti-
suspicion, clarity of diagnostic properties, safer and
HCV) antibodies, hepatitis B surface antigen (HBsAg),
better antibiotics use, resulted in favorable prognosis
and ascitic fluid study.
and decreased in-hospital mortality (6, 7). Available
Diagnosis of liver cirrhosis was established by
scores, for example Child-Pugh and model of end-stage
clinical, ultrasonographic and laboratory findings. Based
liver disease (MELD) scores have been previously
on the results of ascitic fluid study, patients were
show favorable predictive accuracy in patients with
diagnosed as SBP if polymorphonuclear leucocytes
1263
Received: 5/10/2021
Accepted: 3/12/2021

Full Paper (vol.871 paper# 45)


c:\work\Jor\vol871_46 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1270-1275

Cyanoacrylate Glue Versus Suture for Mesh Fixation in Open Inguinal Hernioplasty
Mahmoud Abdou Yassin**, Othman Mohammed Mohammed Ahmed Ghonaim*,
Wessam Mohammed Amr**, Elsayed Ibrahim Hassan Elhendawy**
*General Surgery Department, Al Ahrar Zagazig Teaching Hospital, Egypt.
** Department of General Surgery, Zagazig University Hospital, Egypt.
Corresponding Author: Othman Mohammed Mohammed Ahmed Ghonaim,
Phone: +201007005353,E-mail: osmanghonaim@gmail.com

ABSTRACT
Background:
In general surgery, the most common technique is inguinal hernia repair. A mesh prosthesis is implanted
ventral to the transversalis fascia in the Lichtenstein repair. After the introduction of tension-free surgical repair with
the use of prosthetic mesh, patients' comfort was reported to be significantly improved over that acquired by traditional,
tension-producing procedures. The use of cyanoacrylate (CA) to secure the mesh may result in better results and reduce
tension on the pubis, muscles, and nerves.
Objectives: Our study aimed to clarify the efficacy and complications of cyanoacrylate glue and nonabsorbable sutures
for mesh fixation in Lichtenstein hernia repair techniques.
Matrials and Method:
Prospective observational study for 6 months at General Surgery Department, Zagazig
University Hospitals. 24 patients were divided into two groups. Group A undergoes hernioplasty using glue for mesh
fixation and group B using sutures fixation. Patients were followed for 6 months for post-operative pain, recurrence,
and complication.
Results:
In our analysis the mean age of glue group was 50 ± 7 years, while in the sutures group it was 49.3 ± 6.7 years.
Mean operation time in the glue group was 41.2 ± 5.1 min, while in the sutures group it was 47.6 ± 4.9 min with
statistically significantly higher mean operation time in the sutures group. There was no substantial difference between
the two groups after a considerable period of follow-up.
Conclusion: Histoacryl glue appears to be a promising alternative for mesh attachment in Lichtenstein inguinal hernia
repair. According to our data, it showed replication of tissue integration and mechanical behavior of sutures while
requiring less time to do. It's also associated with a decrease in persistent inguinal pain.
Keywords: Histoacryl glue, Inguinal hernia, Lichtenstein repair, mesh fixation, cyanoacrylate.

INTRODUCTION
a foreign-body reaction, or an inflammatory response
In general surgery, the most common operation
triggered by the maneuvers and biomaterials 5. The use
is inguinal hernia repair. In the Lichtenstein repair, a
of cyanoacrylate (CA) to secure the mesh may result in
mesh prosthesis is inserted ventral to the transversalis
better results and reduce tension on the pubis, muscles,
fascia. Non-mesh methods such as Shouldice and
and nerves 6.
Bassini repairs, on the other hand, use a continuous non-
Our study aimed to clarify the efficacy and
absorbable suture to reconstruct muscle layers and
complications
of
cyanoacrylate
glue
and
strengthen the inguinal floor 1.
nonabsorbable sutures for mesh fixation in
In adult men, surgical correction of an inguinal
Lichtenstein hernia repair techniques.
hernia is a common treatment. However, postoperative

pain and incapacity are common. After the introduction
PATIENTS AND METHODS
of tension-free surgical repair with the use of prosthetic
A Prospective Observational study for 6
mesh, patients' comfort was found to be significantly
months at General Surgery Department, Zagazig
improved over that acquired by traditional, tension-
University Hospitals. Twenty-Four cases that fulfilled
producing procedures 2.
the inclusion and exclusion criteria were included in the
The best surgical method for inguinal hernia
study. Male patients aged between 20 and 60 years were
repair is still up for debate. To achieve tension-free
scheduled for elective virgine inguinal hernia repair.
healing, most procedures involve reinforcing of the
Patients were anynomusly divided into two groups:
inguinal floor with a synthetic or organic material 3. In

a multicenter RCT, the fibrin sealant was found to have
Group A (an odd number): They underwent mesh
a lower incidence of postoperative neuralgia than suture
fixation with glue.
or staple fixation, with no difference in the rate of

recurrence 4.
Group B (even number): They underwent mesh
Following typical hernia repair methods,
fixation with sutures.
postoperative groin discomfort might include neuralgia,
All patients were subjected to the following: Full
chronic inguinal pain of varying degrees, and
history taking, clinical examination, and routine
paresthesia. Although they are not related, their genesis
preoperative preparation
could be linked to the use of sutures, which could create


1270
Received: 5/10/2021
Accepted: 3/12/2021

Full Paper (vol.871 paper# 46)


c:\work\Jor\vol871_47 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1276-1280

Mid Regional Proadrenomedullin as a Diagnostic Marker in
Pediatric Heart Failure
Samir Mohammed Faried Zamzam1, Soad Abd ElSalam Shedeed1,
Alsalihah Majeed Mohammed*1, Naglaa Ali Khalifa2
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Alsalihah Majeed Mohammed, Mobile: (+20)01003236037, Email: fn131586@gmail.com


ABSTRACT
Background
: Heart failure remains an essential reason of morbidity and mortality in children. The measurement of
various biomarkers might be worthy incentive in the diagnosis.
Objective: We studied the plasma level of MR-proADM as a promising novel diagnostic cardiac biomarker in pediatric
patients with congestive heart failure and its relation to different clinical, laboratory and echocardiographic variables,
aiming to promote their health through achieving good control of their cardiac symptoms and improving their quality of
life.
Patients and methods: The present study included 80 subjects in the pediatric age from (6 months ­ 16 years). They
were classified into two comparative groups: case group included 40 pediatric patients, well diagnosed as having
congestive heart failure and control group included 40 apparently healthy pediatric subjects.
Results
: There was an increase in MR-proADM level among cases group compared to control group and the difference
was highly statistically significant.
Conclusion: We concluded that there was a high diagnostic value of measuring plasma level of MR-proADM at
admission, regarding the diagnosis in the setting of pediatric congestive heart failure.
Keywords: Heart failure, MR-proADM, On-admission plasma levels.

INTRODUCTION


Heart failure (HF) is defined as a complex clinical
kidney failure increase natriuretic peptide levels, while
disorder presented with ventricular dysfunction,
obesity is associated with lower levels. These situations
insufficient peripheral blood flow and neuroendocrine
can give values in a gray area that requires particularly
activation (1). The spectrum of causes of heart failure is
careful analysis. The investigation of new biomarkers
wide in pediatric patients noticing that congenital heart
that can complement natriuretic peptides has been the
diseases (CHDs) represent the most common etiology.
subject of considerable attention. Adrenomedullin
However, the clinical presentation of heart failure in
(ADM) is a 52 amino-acid peptide that belongs to the
infants and small children shows some peculiarities (2).
calcitonin family. Initially isolated from the adrenal
Comprehensive analysis of medical history,
gland, has diverse physiological and pathophysiological
symptoms, biochemical tests and results of
functions in the cardiovascular system. It is produced in
echocardiography are the corner stones for accurate
many organs and tissues including the vasculature. ADM
diagnosis of heart failure. Circulating biomarkers may
has numerous actions, including vasodilation,
play a very important role in the diagnosis and
natriuretic, antiapoptosis and stimulation of nitric oxide
management of patients presenting with heart failure and
(NO) production. It might play a protective role in
that allows better prognosis of the cases (3).
various cardiovascular pathologies (7).
The cardiovascular system is regulated by various
In HF, as a consequence of pressure/volume
neurohumoral components, including the autonomic
overload and ventricular wall stretching, the ADM gene
nervous system, renin­angiotensin­aldosterone system
is upregulated in cardiac myocytes.
and various neuropeptide hormones (4).
The resulting high ADM levels appear to have a
Novel biomarkers typically reflect different
protective effect in the myocardium, as they lead to a
components of the complex HF pathophysiology such as
decrease in preload and after load. Some studies suggest
fibrotic remodeling, myocardial stretch or inflammation,
that ADM additionally inhibits cell growth and
and their complementary use has been shown to greatly
hypertrophy; it has also been associated with reductions
enhance their prognostic and diagnostic power (5).
in remodeling and fibrosis. Clinical use of ADM was
Natriuretic peptides, especially B-type natriuretic
limited for some time because of the in vitro instability
peptide (BNP) and its precursor N-terminal pro-B-type
of this biomarker: its half-life is short and it is quickly
natriuretic peptide (NT-proBNP), are currently used in
removed from the circulation. This problem was solved
clinical practice and their measurement is recommended
by the use of mid regional proadrenomedullin (MR-
by the European Society of Cardiology (ESC) guidelines
proADM), a stable fragment of pro-ADM whose
for the diagnosis and assessment of HF (6).
concentrations reflect those of ADM (8).
Despite their important role in HF, natriuretic
We studied the plasma level of MR-proADM as a
peptides show some limitations. They are elevated in
promising novel diagnostic cardiac biomarker in
other conditions as well as HF, such as valvular heart
pediatric patients with congestive heart failure and its
disease,
pulmonary
hypertension,
pulmonary
relation to different clinical, laboratory and
thromboembolism, atrial fibrillation and sepsis. Age and
echocardiographic variables, aiming to promote their
1276
Received: 9/10/2021
Accepted: 7/12/2021

Full Paper (vol.871 paper# 47)


c:\work\Jor\vol871_48 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1281-1287

Evaluation of Percutaneous Pinning of Fractures of the
Surgical Neck of the Humerus in Children and Adolescents
Mohammed Abdulmajed Adgyeas, Adel Mohammad Salama,
Mohamed Hamed Fahmy, Sameh Mohamed Holyl
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohammed Abdulmajed Adgyeas, E-Mail: mohammedadgyeas@gmail.com

ABSTRACT
Background:
Open or closed reduction with Kirschner wires, screws, and flexible nails has been documented for the
treatment of displaced proximal humeral fractures, however percutaneous K-wire fixation is the most widely utilized
procedure.
Objective: This study aimed to evaluate short-term clinical and radiographic results of percutaneous pinning of surgical
neck-humerus fractures in children and adolescents using k-wire.
Patients and Methods: Our study was done on 18 patients with fractures of the surgical neck of the humerus at Zagazig
University Hospital treated by percutaneous pinning using k-wire. The humerus fractures were followed up clinically
and radiologically for 6 months. Neer and Horwitz classification was used to classify fractures. Constant-Murley
shoulder scoring system were used to evaluate results.
Results: According to Constant-Murley scoring system the result obtained were excellent in 14 patient (77.78%) and
good only in 4 cases (22.22%). Concerning the complications of the current study, 11 cases had no complication
(61.11%), 3 cases had stiffness (16.67%) and 4 cases had superficial infection (22.22%). 4 cases of superficial infection
were treated with antibiotics and daily dressing. K-wires were not required to be removed early. All of them achieved
excellent results. 3 cases of stiffness were completed by physiotherapy, 2 of which yielded good results and 1 of which
yielded excellent results.
Conclusion: Fractures of the surgical neck in children and adolescents can be successfully treated with percutaneous k-
wires technique, which provides stability after reduction of fractures. Early and adequate physiotherapy program gives
better results regarding the range of motion.
Keywords: Percutaneous pinning, Surgical neck of the humerus.

INTRODUCTION

research and reports advocate surgical intervention, as
There is a low incidence of pediatric proximal
the likelihood of remodeling is lowered (9).
humerus fractures. Only approximately 3 percent to 7
Open or closed reduction Percutaneous K-wires
percent of all bone fractures are physeal, and this form of
fixation is the most often used procedure for treating
fracture is more common in boys than in girls 1:3,
displaced proximal humeral fractures, however screws,
peaking at age ten to fourteen (1). Children with fractures
and flexible nails has been reported as an alternative (10).
of the proximal humerus have a great deal of remodeling
It was the goal of this work to assess the union rate,
potential due to the fact that about 80% of the growth in
deformity, shoulder range of motion, return to previous
arm's length occurs at the physis of the proximal
daily activities, and infections and other complications
humerus (2). Children under the age of 11 have a better
associated with percutaneous pinning of surgical neck-
remodeling potential than older children, so non-surgical
humerus in children and adolescents using k-wires.
treatment is likely to produce outstanding results

depending on the patient's age (3).
PATIENTS AND METHODS
Rotator-cuff muscles are responsible for proximal
This study was conducted in the period between July
segment displacement in abduction and external rotation,
2021 and January 2022 in Orthopedic Surgery
while pectoralis major/deltoid muscles are responsible
Department, Zagazig University Hospitals.
for distal segment displacement in adduction, forward

movement, and shortening (4).
Ethical approval:
Salter­Harris
(5)
and
Neer­Horowitz
(6)
Zagazig University's Research Ethics Council
classifications are commonly used to classify proximal
approved the study as long as all participants signed
humerus fractures based on the extent of physeal injury
informed consent forms and submitted them to ZU-
and displacement, respectively (7).
IRB#7045. We adhered to the Helsinki Declaration,
In general proximal humerus fractures in children
which is the ethical norm for human testing
are often treated with conservative methods, regardless
established by the World Medical Association.
of the severity of the angulation, displacement,

translation or rotation of the fractures, despite the fact
Inclusion criteria: Age to be above 8 and below 16
that severely displaced fractures are associated with
years, growth cartilage visible on standard radiographs
malunion and shortening especially in older children (8).
and displaced fractures of the surgical neck-humerus.
In children above the age of 11 and adolescents with
Exclusion criteria: Dislocated or pathological
substantial displacement or angulated fractures, several
fractures, neglected cases, associated neurovascular
1281
Received: 11/10/2021
Accepted: 09/12/2021

Full Paper (vol.871 paper# 48)


c:\work\Jor\vol871_49 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1288-1292

Matrix Metalloproteinase 2 as a New Marker for Diagnosis of
Chronic Kidney Disease
Ahmed Salah Amin Alallam1, Ahmed Saad Abdelhalim Mohamed*2, Mohamed Mohamed Mohamed
Hassaan1, Ola Badr Metwally3, Lamiaa Raafat Elsayed Abdelghany4, Osama Mosbah Abdelaziem5
Department of 1Internal Medicine, Faculty of Medicine, Zagazig University, Egypt
Departments of 2Nephrology, 3Clinical Pathology, 4Radiology and
5Internal Medicine and Nephrology, Theodor Bilharz Research Institute, Egypt
*Corresponding author: Ahmed Saad Abdelhalim Mohamed, Mobile: (+20) 01011640511, E-Mail: justme7700cr@gmail.com

ABSTRACT
Background:
Chronic kidney disease (CKD) is highly prevalent, irreversible, progressive decrease in renal function.
Matrix metalloproteinases (MMPs) have an important role in tissue remodelling by regulating cell death, morphogenesis
and wound healing activity. Objective: The aim was to assess the diagnostic value of matrix metalloproteinase 2 as a
new marker in chronic kidney disease.
Patients and Methods: this study was conducted on (108) individuals who were divided into 3 groups of matching age
and sex. Group I (Control group): 36 healthy individuals with normal kidney functions. Group II (CKD group): (stage
1-4) 36 subjects with eGFR between 15-89 ml/min/1.73m2. Group III (ESRD group): 36 subjects who were under
regular hemodialysis for more than 3 months.
Results: There was statistically non-significant difference between the studied groups regarding serum cholesterol.
There was statistically significant difference between the studied groups regarding MMP-2. On comparing each two
individual groups using Tukey post hoc test for MMP-2, the difference was significant between each two individual
groups (MMP-2 was lower in Group I followed by Group II then Group III). The best cutoff of MMP2 in diagnosis of
ESRD was 0.69615 to <0.78155 with area under curve 0.766, sensitivity 77.8%, specificity 63.9%, positive predictive
value (PPV) 68.3%, negative predictive value (NPV) 74.2% and accuracy 70.8%.
Conclusion: There was significantly increased levels of MMP-2 in CKD with more increase in ESRD patients. MMP-
2 could be used as a marker in diagnosis of CKD.
Keywords:
Chronic Kidney Disease, Matrix Metalloproteinase 2, New Marker.

INTRODUCTION

Chronic kidney disease (CKD) is defined as kidney
Ethical considerations:
damage or glomerular filtration rate (GFR) <60
The study was approved by the Ethics Board of
mL/min/1.73 m2 for 3 months or more, irrespective of
Zagazig University and an informed written
cause. GFR can be estimated from calibrated serum
consent was taken from each participant in the
creatinine (s. Cr) and estimating equations, such as the
study. This work has been carried out in accordance
Modification of Diet in Renal Disease (MDRD) Study
with The Code of Ethics of the World Medical
equation or the Cockcroft-Gault formula (1).
Association (Declaration of Helsinki) for studies
Matrix metalloproteinases (MMPs) are proteolytic
involving humans.
enzymes that act on extracellular matrix protein

components such as collagens, gelatins, elastins,
Population of the study:
laminins, fibronectins, and integrins. They are
This study included 108 subjects with matched age
synthesized as zymogens and are activated to functional
groups and of both sexes. Participants were classified
forms on autoproteolysis or by other proteases (2).
into three groups: Group I (Control group): 36
MMP2 or gelatinase A is the second member of
healthy individuals with normal kidney functions,
MMPs family. Its first two substrates were discovered
Group II (CKD group) (stage 2-4): 36 subjects with
within the components of the extracellular matrix. It
eGFR between 15-89 ml/min/1.73m2, and Group III
was proved that MMP2 overexpression in most if not all
(ESRD group): 36 subjects who were under regular
tumors were considered a hallmark of cancer
hemodialysis for more than 3 months.
aggressiveness (3).

The aim was to assess the diagnostic value of matrix
Inclusion Criteria: Age: more than 30 years, CKD or
metalloproteinase 2 as a new marker in chronic kidney
ESRD with more than 3 months duration of expanded
disease.
hemodialysis (HDx), sex: males and females, and

patient consent to enter the study.
PATIENTS AND METHODS

A case control study was conducted at Internal
Exclusion Criteria: Patients were excluded if they have
Medicine Department, Zagazig University Hospitals
acute severe infection, malignancies, severe cardiac
and Theodor Bilharz Research Institute from March
insufficiency, liver diseases, or acute cerebrovascular
2021 to September 2021. Demographic information was
accidents, and pregnant females.
collected.

1288
Received: 9/10/2021
Accepted: 7/12/2021

Full Paper (vol.871 paper# 49)


c:\work\Jor\vol871_50 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1293-1296

Impact of NQO1 C609T Polymorphism on The Outcome of Childhood Acute
Lymphoblastic Leukemia from Zagazig University Hospital; Egypt
Mohamed Eissa1, Amal Ahmed Zidan2, Ola Aly Hossein2, Alaa A. Omran2
1Pathology Department, College of Medicine, King Khalid University, Abha, KSA and Clinical Pathology
Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
*Corresponding author: Mohamed Eissa, Mobile: 00966599151626, E-Mail: eissa20002000@yahoo.com

ABSTRACT

Background: The NAD (P) H: quinone oxidoreductase (NQO1) C609T polymorphism has been widely thought to be
associated with the risk of acute leukemia.
Objective:
This case-control study aimed to assess the impact of NQO1 C609T gene polymorphism in childhood acute
lymphoblastic leukemia (ALL).
Patients and Method: The study was carried out on one hundred de novo ALL children and one hundred apparently
healthy children. Routine genotyping of NQO1C609T gene polymorphism by PCR-RFLP was done for all subjects.
Results: No statistically significant difference was observed between the patient group and control group as regards
wild and polymorphic genotypes. However, there was a significant difference between ALL patients with wild and
polymorphic genotypes regarding their immunophenotyping diagnosis (P=0.02) and FAB classification (P=0.01). There
was also a significant difference between ALL patients with wild and polymorphic genotypes regarding their response
to treatment. The complete remission in the wild genotype (CC) was 69.2% while in polymorphic genotypes (TT & CT)
was 29.4% (P<0.05).
Conclusion: The polymorphic genotype forms of the NQO1 C609T (CT and TT) are associated with decreased response
to treatment.
Keywords: NQO1, TT, CT, ALL, genotypes.

INTRODUCTION
developed world (7). However, the results in adults ALL
Acute lymphoblastic leukaemia (ALL) is the most
are away from those in children; the long-term disease-
common childhood cancer, accounting for nearly 25%
free survival rates of 30 to 40 percent have been
of all cancers in children and 76 percent of all leukemias
acquired with the use of chemotherapy, as compared to
in children under the age of 15, with a peak between the
45 to 75 percent with the use of allogeneic
ages of 2 and 5 years and falling rates in later childhood,
transplantation (8).
adolescence, and young adulthood (1).
So, allogeneic stem cell transplantation is
Childhood
leukaemia,
like
other
human
considered, a better curative line in certain very-high-
malignancies, is thought to be caused by a combination
risk pediatric patients with low five-year event-free
of environmental stressors and inherited genetic
survival (EFS), such as those with BCR-ABL+ ALL or
predisposition that affects genomic stability and
those with a poor response to induction chemotherapy
Deoxyribonucleic Acid (DNA) repair (2). A range of
(9).NAD (P) H: quinone Oxidoreductase 1 (NQO1) is an
inherited genetic variants, such as those influencing
enzyme utilizes reduced pyridine nucleotide cofactors
enzymes involved in carcinogen metabolism and
Nicotinamide Adenine Dinucleotide (NADH) or
detoxification and those impacting immune response
Nicontinamide Adenine Dinucleotide Phosphate
modulation, may potentially contribute indirectly to the
(NADPH) to catalyze the direct two-electron reduction
risk of leukaemia (3).
of a broad range of quinones (10). Polymorphisms of
To categorize leukemias into numerous particular
NQO1 gene could be influential for patient response to
subtypes, the current World Health Organization
induction therapy and for treatment outcome in
(WHO) classification systems included morphologic
hematological malignancies (11).
characteristics, immunophenotype, molecular genetics,
This case-control study was conducted to assess
and clinical data (4).
the impact of NQO1 C609T gene polymorphisms on the
Acute lymphoblastic leukemia is subdivided into
outcome of childhood acute lymphoblastic leukemia.
distinctive subtypes by the presence or absence of

specific recurrent genetic abnormalities; t (9:22), MLL
PATIENTS AND METHODS
rearrangement, t (12:21), hyperdiploidy, hypodiploidy
This study was carried out in the Clinical and
and t (1:19) (5). Genomic analysis has a significant
Chemical Pathology Department and Pediatric
impact on the diagnosis and treatment of ALL patients.
Department, Zagazig University Hospitals, Egypt. One
Some genetic changes, such as treatment sensitivity and
hundred newly diagnosed pediatric ALL patients from
survival result, were enough to influence overall cancer
oncology unit of pediatrics department were included in
behaviour (6).
this study in addition to one hundred apparently
The five-year event-free survival (EFS) of pediatric
matched healthy children. The patients were 50 males
ALL is currently approaches 90 percent in the
1293
Received: 9/10/2021
Accepted: 7/12/2021

Full Paper (vol.871 paper# 50)


c:\work\Jor\vol871_51 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1297-1302
Study The Association between Serum Osteoprotegerin and
Diabetic Kidney Disease
Mohamed A. Elbana*1, Nagwa S. Said1, Ahmed M. Baraka2, Mayada M. Mousa1
Departments of 1Internal Medicine and 2Clinical Pathology, Zagazig University, Sharkia, Egypt
*Corresponding author: Mohamed A. Elbana, E-Mail: elbana73@gmail.com

ABSTRACT
Background:
Osteoprotegerin (OPG) was first found as being an inhibitor of bone resorption; however, research on
OPG in type 2 diabetes mellitus patients and its relationship to albuminuria in Diabetic Kidney Disease (DKD) has been
insufficient.
Objectives
: Study the association between serum osteoprotegerin and diabetic kidney disease in type 2 diabetic patients.
Patients and methods:
The study recruited 45 participants who all had diabetes. Group 1 comprised 15 type 2 diabetic
patients with albuminuria that ranged from normal to mildly elevated. The second group consisted of 15 type 2 diabetic
patients with mildly elevated albuminuria. Group 3 consisted of 15 type 2 diabetic patients with an extremely high
albuminuria level. In all participants, the following was carried out: history taking; clinical examination, including height
and weight; ophthalmoscopy; kidney ultrasound; and evaluation of fasting blood glucose; glycosylated hemoglobin; lipid
profile; serum creatinine and urea; urinary ACR; and serum osteoprotegerin levels.
Results
: Our study showed statistically positive correlation between osteoprotegerin and degree of albuminuria in type
2 diabetic patients. We found that the best cutoff of serum OPG was 1.652 in prediction of severely increased
albuminuria. Conclusion: A biomarker known as OPG may be effective in identifying diabetics with type 2 who are at
high risk of developing severe albuminuria.
Keywords: Albuminuria, Diabetes, Osteoprotegerin (OPG).

INTRODUCTION
Ahrar Teaching Hospital's Nephrology Clinic from
Twenty to forty percent of patients with diabetes
January 2021 to December 2021, the research was
have diabetic kidney damage, which normally arises
conducted. There were 45 individuals with type 2
after a 10-year period of diabetes, but may already be
diabetes in our study, divided into three groups of 15
present at diagnosis in those with type 2 diabetes (1). Type
each: The first group included six men and nine women,
1 and type 2 diabetics who have chronic kidney disease
all of whom had normal to modestly elevated
(CKD) are at significantly higher risk of cardiovascular
albuminuria (albuminuria less than 30 mg/g creatinine).
disease and incurring significantly higher medical
There were 15 patients in the second group, all
expenses. It is the primary cause of end-stage renal
of whom had moderately elevated albuminuria (30­299
disease (ESRD) worldwide, necessitating dialysis or
mg/g creatinine) with type 2 diabetes. Group 3 included
kidney transplantation. Cardiovascular disease, kidney
15 diabetic patients (8 male and 7 female) with severely
disease progression, and mortality are all linked to an
increased albuminuria (300 mg/g creatinine). End stage
individual's level of albuminuria. A more thorough
renal disease, neoplasms and infections were not allowed
approach to CKD staging is recommended by Kidney
to participate in the trial. Patients having a history of type
Disease: Improving Global Outcomes (KDIGO), which
1 diabetes mellitus and congestive heart failure were not
includes albuminuria at all expected glomerular filtration
allowed to participate in the study.
rate (eGFR) levels (2).
All participants had their medical histories
There has been evidence that the immune
reviewed, their physical examinations, including their
system's release of OPG acts as a decoy receptor for the
BMI, their systolic and diastolic blood pressures, their
nuclear factor kB receptor activator and TNF-related
hemoglobin levels, their fasting blood glucose levels,
apoptosis inducing ligand, respectively (3).
their hemoglobin A1c levels, their lipid profiles, their
Serum OPG levels were found to be significantly
levels of calcium and phosphorus, their levels of
correlated with insulin resistance, suggesting that OPG is
parathyroid hormone (PTH), their levels of creatinine
a causative factor in the development of type 2 diabetes.
and urea, their eGFR using the modification of diet in
Diabetes mellitus can be prevented or delayed by
renal disease (MDRD) equation, their levels of urinary
blocking the OPG/RANK/RANKL system, which has
albumin creatinine, serum OPG.
recently been developing. Diabetes mellitus is associated

with hepatic insulin resistance (4).
Sampling:
The aim of the work was to study the association
Blood samples: A total of 6 ml of venous blood was
between serum osteoprotegerin and diabetic kidney
obtained and divided as follows under strict aseptic
disease in type 2 diabetic patients.
conditions following overnight fasting: 1 ml of whole

blood was added to an EDTA-containing sterile tube for
PATIENTS AND METHODS
the determination of HbA1c and a total of five milliliters
Within Zagazig University Hospitals' Internal
of whole blood were allowed to clot at a temperature of
Medicine Endocrinology and Diabetes Clinic and Al-
37 degrees Celsius. Centrifugation was used to separate
1297
Received: 12/10/2021
Accepted: 10/12/2021

Full Paper (vol.871 paper# 51)


c:\work\Jor\vol871_52 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1303-1306
Comparison between Surgical Offloading and Mechanical
Offloading in Treatment of Planter Diabetic Foot Ulcer
Wesam Amr*, Hatem Mohammed Abdel Monaem Farg,
Omar Mohamed Assaed Abdo Abady, Mahmoud Abdo Yassin
Department of General Surgery, Zagazig University Hospitals, Zagazig, Egypt
*Correspondence to: Wesam Mohammed Ali Amr, Mobile: (+20) 01115263035,
E-mail: wesam_amr@yahoo.com, ORCIDhttps://orcid.org/0000-0002-4475-7844

ABSTRACT
Background:
Diabetes is a systemic disease that affects all body systems and is a major cause of death. Foot problems
are a source of major patient suffering and societal costs. Foot ulcers are the most prevalent problem, with a yearly
incidence of around 2-4% in developed countries and likely even higher in developing countries.
Objective: This study aimed to evaluate the clinical outcome of both surgical and non-surgical methods of offloading in
the treatment of neuropathic non-ischaemic plantar pressure ulcers.
Materials and methods: This prospective non-randomized comparative study was conducted on 30 patients who
presented at the Outpatient Clinic of the Department of General Surgery at Zagazig University Hospital and Department
of Vascular and Endovascular Surgery, National Institute of Diabetes and Endocrinology (NIDE). The study was
conducted through the period from July 2019 till September 2019. All of them had an offloading method; 15 surgical, 15
non-surgical (walkers or shoes). They had followed up for six months.
Results: Successful rate for ulcers healing were 86.7% and 88% for surgical vs. non-surgical methods respectively.
Conclusion: Offloading is very important and effective in treatment of pressure unhealed plantar ulcers. Every patient
should receive his tailored method of offloading. Surgical offloading is a faster way.
Keywords: Diabetes, Peripheral neuropathy, Diabetic foot, Pressure ulcer, Plantar, Offloading.

INTRODUCTION
deformities related to motor neuropathy, minor foot
Diabetes is a global and a systemic disease that
trauma, and peripheral arterial disease (9, 10).
affects all body systems and is a major cause of death. It
This study aimed to evaluate the clinical outcome of
is estimated that 415 million people were diagnosed with
both surgical and non-surgical methods of offloading in
diabetes in 2015. It is expected to rise up to 642 million
the treatment of neuropathic non-ischaemic plantar
by 2040 (1). DM is an increasing problem in both
pressure ulcers.
developed and developing nations. The majority of

persons with DM have type 2 DM with only 5% to 10%
PATIENTS AND METHODS
of patients diagnosed with type 1 DM. About 50% of
This study was conducted as a "Prospective non-
people with DM are unaware of their disease. Early DM
randomized comparative study" that included 30 cases
detection and treatment can improve overall quality of
who presented to the Outpatient Clinic of the Department
life (QOL) and increase the life expectancy of persons
of General Surgery, Zagazig University Hospital and
with DM (2). Diabetes mellitus is the seventh leading
Department of Vascular and Endovascular Surgery,
cause of death in the United States. Diabetes mellitus is
National Institute of Diabetes and Endocrinology
the leading cause of kidney failure, non-traumatic lower
(NIDE). It was conducted through the period from July
extremity amputations, and new cases of blindness in
2019 till September 2019. All of them had an offloading
adult Americans (3).
method; 15 surgical, 15 non-surgical (walkers or shoes).
Diabetic foot ulcers (DFU) are often preventable,
The first case had enrolled in the study in July 2019, the
and treatment is frequently suboptimal. Foot problems
last case in September 2019. They were followed up for
complicating diabetes are a source of major patient
six months. Data analysis and interpretation had done in
suffering and societal costs. The frequency and severity
March 2020.
of foot problems varies from region to region largely due

to differences in socio-economic conditions, type of
Ethical approval:
footwear, and standards of foot care. DFU is a major
Written informed consent was obtained from
source of morbidity and one of the leading causes of
every participant and the study was approved by The
hospitalization representing about 20% of hospital
Research Ethical Committee, Faculty of Medicine,
admissions among patients with DM (4, 5). The incidence
Zagazig University. The work has been carried out in
of diabetic foot ulcers in diabetics is 25% and 50% and
accordance with The Code of Ethics of the World
20% of them will proceed to amputations throughout
Medical Association (Declaration of Helsinki) for
their life time. 70% of these patients will have recurrent
studies involving humans.
lesions within 5 years (6, 7). Yearly 2% - 6.8% of diabetic

patients suffer from foot ulcerations (8). The most
Inclusion criteria:
important factors underlying the development of foot
Diabetic patients with plantar ulcers (possibly
ulcers are peripheral sensory neuropathy, foot
pressure related) that failed to heal after 6 months with at
1303
Received: 13/10/2021
Accepted: 11/12/2021

Full Paper (vol.871 paper# 52)


Introduction The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1307-1316

Keratometric and Visual Outcome post Corneal Cross-Linking in
Keratoconus Patients
Samiha M. Kamel Abo Al Majd*, Adel M. Abd El Wahab Khalil**,
Mona El Sayed Ali Hassan**, Safia Dawod Hamd Al Abedi***
Department of Ophthalmology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt (Deceased)*
Department of Ophthalmology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt**
Department of Ophthalmology, Faculty of Medicine Garyounis University-Benghazi-Libya***
Corresponding author: Mona Elsayed Aly Hassan, Mobile: (+20)1061152678, -
E mail: Mirna.farid_fr@hotmail.com

ABSTRACT
Background
: Keratoconus is a bilateral, primary, progressive, non-inflammatory, and non-symmetric corneal ectasia
induced declined visual acuity in young adults. It leads to continued myopia and irregular astigmatism, causing a
reduction in best-corrected visual acuity (BCVA) and visual quality. Corneal Collagen Cross-linking (CXL) has
progressively become a preferable cure tool and the frontline of therapy for keratoconus and other corneal ectatic
illnesses. It creates a crossed bridge between the collagen fibrils (cross-linking), thus strengthening the Cornea.
Aim of the Work: This work purposes to assess the efficacy of CXL on eyes with keratoconus as regards uncorrected
visual acuity (UCVA), best-corrected visual acuity (BCVA) keratometric readings.
Patients and Methods: This non-randomized, prospective, interventional study included twenty eyes of eighteen
patients with mild and moderate degree keratoconus. All patients were subjected to complete ocular examination and
Pentacam examination. CXL was done under surface anesthesia. Changes in UCVA, BCVA, and keratometric
readings that follow CXL were evaluated.
Results:
Mean + SD of UCVA, BCVA, SE, KI, K2. Preoperatively for the 20 eyes were 0.25±0.18, 0.51± 0.21,
7.95±4.66, 46.93D±2.35, 51.90D±3.55 respectively. At the end of the follow-up period (Three months post-
operatively), they were 0.28+0.20, 0.59+0.21, -7.73+4.10, 46.75+2.23, 51.75+3.63, respectively. No serious
complications were reported in this study. Only two eyes (10%) showed mild corneal haze. They persisted until the
study was finished. Two eyes (10%) showed delayed re-epithelization up to one week.
Conclusion: The CXL is an effective and safe technique for treating mild to moderate keratoconus, regarding
stabilizing the condition and improving the visual outcome, regardless of the keratometric changes.
Keywords:
Keratoconus, Corneal collagen cross-linking, Keratometric readings, Pentacam, Visual acuity.

INTRODUCTION

Keratoconus is a progressive, bilateral,
new treatment efficacious in restricting the
asymmetric, and non-inflammatory ectasia. This
progression of keratoconus, leading to corneal
disease is caused by continuing biomechanical
strengthening (5).
instability of the Cornea, resulting in irregular
Patients of keratoconus may report that their
astigmatism and progressive myopia, eventually
eyes itch and have allergies, and they frequently rub
induced a reduction in best-corrected visual acuity
their eyes with greater force than normal and a
(BCVA) and visual quality(1). Keratoconus typically
decrease in visual acuity. They every so often
presents at puberty and progresses until the third
complain of visual discomfort similar to those with
and fourth decades of life. It progress more rapidly
uncorrected astigmatism. Due to the distortion, they
in young, although it can occur or progress at any
may report glare or halos around lights, particularly
age with various rates (2).
at night, ghost images, monocular diplopia, and
The aetiology of Keratoconus is probably
multiple images. There are many areas of the Cornea
multifactorial (genetic and environmental) (3). Most
having different refracting powers producing various
genetic researches approve of an autosomal
confusing photos (6). One of the first clues that
dominant inheritance paradigm (2). Most cases of
something is wrong is the change in the patient's
keratoconus are sporadic, with family history
refraction (7).
demonstrated in about 6 to 10 % (4).
Keratoconus is divided into advanced, moderate,
The available options for managing
and mild (8):
keratoconus are glasses, corneal collagen cross-
In mild keratoconus, there may be oblique
linking (CXL), contact lenses, epikeratoplasty, and
astigmatism
and
moderate-to-high
myopia.
intrastromal corneal ring segments corneal
Diagnosis can be validated with computer-assisted
transplantation. Not until 1999 where CXL was
videokeratography, which may disclosed low
introduced were corneal ectasia's underlying
corneal steepening (almost 80% of keratoconus
pathogenic mechanisms addressed. Using UVA
cases), central corneal astigmatic steepening (about
light of 370 nm wavelength and the photosensitizer
15% of keratoconus cases), or even bilateral
riboflavin, CXL has been defined as an innovative
temporal steepening (extremely rare) (9).
1307
Received: 1/7/2021
Accepted: 30/8/2021

Full Paper (vol.871 paper# 53)


c:\work\Jor\vol871_54 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1317-1321
Differences in Manual Dexterity between Dominant and
Non-Dominant Side in Typically Developing Children
Salma A. Abd El Hameed*, Elham E. Salem, Marwa M. I. Ismaeel
Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
*Corresponding author: Salma A. Abd El Hameed, Mobile: (+20)01099866600, E-mail: drsalmaashraf1111@gmail.com

ABSTRACT
Background:
Manual dexterity is the ability to manipulate objects using the hands and fingers, which requires
coordination between muscular, skeletal, and neurological systems, which start to develop during childhood.
Objective: We aimed to assess differences of gross manual dexterity and fine manual dexterity between dominant and
non-dominant hand in typically developing children whose age between 8 to 10 years.
Subjects and Methods: Thirty typically developing children of both sexes participated in this study. Box and Blocks
Test was used to assess gross manual hand dexterity and Nine Hole Peg Test was used to assess fine manual hand
dexterity.
Results: There was no significant difference found between the dominant and non-dominant side in Box and Blocks
Test (p = 0.11), but it showed a significant difference between the dominant and non-dominant side in Nine Hole Peg
Test (p = 0.02) measures.
Conclusion: There was no significant difference in gross manual dexterity measured by Box and Blocks Test but there
was significant difference in fine manual dexterity measured by Nine Hole Peg Test between the dominant and non-
dominant hand in children at selected age group between 8 to 10 years.
Keywords: Manual dexterity, Box and Blocks Test, Nine Hole Peg Test, Typically Developing Children.

INTRODUCTION
dexterity; these facets make the test a valuable and
Manual dexterity is the ability to manipulate
suitable test for very young children to compare
objects through coordination of the hands and fingers
atypically developing children with age related peers,
and is a key indicator of motor function. It combines
and to assess the efficacy of the intervention (10).
elements of cognitive acuity, tactile sensation, muscle
The Nine Hole Peg Test (NHPT) is a component
strength, and force control. Manual dexterity can be
of the National Institutes of Health (NIH) Toolbox for
quantified as the time to complete a pegboard test, such
the Assessment of Neurological and Behavioral
as the grooved pegboard test or the nine-hole peg test
Function, which provides a set of assessment tools that
(1).
can be used across the lifespan (3-85 years). Norms of
Primary school activities involve manual
the NHPT that can be used to determine the presence of
dexterity to an even higher degree (2). In primary school,
impairments in dexterity across this age span have been
30­60% of time is dedicated to learning writing and
established as part of the NIH Toolbox Norming Project
other manipulative tasks (3). Therefore, the main goal
(11).
during the preschool and elementary school periods
We aimed to investigate manual dexterity through
should be to facilitate the development of a wide range
measuring box and blocks test and Nine Hole Peg Test
of manual activities. Yakimishyn and Magill-Evans (4)
in typically developed children and compare between
maintain that the preschool period is especially
dominant and non-dominant mesures.
important for the formation of the fundamental

SUBJECTS AND METHODS
manipulative abilities required in elementary school.
Subjects:
They encourage teachers to monitor the development of
Thirty typically developing children of both sexes
manual dexterity during exercises involving various
free from any type of deformities participated in this
implements (4, 5).
study. They were selected from the governmental
Manual dexterity in childhood is primarily
Egyptian schools at Cairo Governorate according to
considered a product of neuro-motor systems and a
inclusive criteria. Their age ranged from 8 to 10 years.
hallmark of a child's broader motor competence. While
All participants were able to follow the verbal and
early childhood is a key period for the development of
visual commands and free from any medical disease.
manual dexterity (6), recent studies demonstrate that
The exclusion criteria included history of surgery,
manual dexterity undergoes continued refinement
congenital deformity in upper extremities or trunk,
across the primary school years (7) and stabilizes in
injury to the upper extremities or back in the previous 6
adolescence (8). Where the development of manual
months, neuromuscular damage of the spine and upper
dexterity is delayed or impaired during this period (e.g.,
extremities.
in children with developmental coordination disorder),

poor manual dexterity has been associated with
Materials:
increased anxiety, poor self-esteem and academic
Informed consent form, Box and Block Test, Nine-
difficulties (9).
Hole Peg Test. Box and Blocks testing form was used
The Box and Block Test is a simple test that can
to record the number of blocks transported in one
be administered quickly to assess gross manual
minute by the dominant and non-dominant side for each
1317
Received: 12/10/2021
Accepted: 10/12/2021

Full Paper (vol.871 paper# 54)


c:\work\Jor\vol871_55 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1322-1327

Role of Leptin as A Risk Factor and Prognostic Marker in Patients with
Acute Coronary Syndrome
Sameh Attia, Bandar Abdulla, Khaled Saeed
Department of Cardiology, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Sameh Attia, Mobile: (+20) 01141991996, E-Mail: drsamehattia201@hotmail.co.uk

ABSTRACT
Background:
Leptin is a bioactive substance secreted by adipose tissue and exerts pleiotropic actions on glucose
metabolism. It may promote atherosclerosis and increase cardiovascular events.
Objective: The aim of this study was to determine the role of leptin as a risk factor in non-obese patients presented with
acute coronary syndrome and its relation to midterm prognosis.
Patients and Methods: The study included 60 non-obese patients who were presented to Coronary Care Unit (CCU)
of Ain Shams University Hospital with acute coronary syndrome (ACS). Patients were classified into 3 Groups. Group
A was composed of 30 patients presented with ST-segment elevation myocardial infarction (STEMI), Group B included
15 patients presented with non-ST segment elevation myocardial infarction (NSTEMI) and Group C included 15 patients
presented with unstable angina. The study also included control group composed of 20 healthy non-obese subjects who
gave no history of chest pain or symptoms suggestive of coronary artery disease (CAD).
Results: Mean serum leptin level in all patients was significantly higher compared to control group. As regards
complications; mean serum leptin level was higher in patients with adverse outcome compared to other patients.
Conclusion: The concentration of leptin is positively correlated with ACS. The mean value of serum leptin in all patients
was significantly higher compared to control. The study suggests that leptin is a significant cardiovascular risk factor
for ACS independent of traditional cardiovascular risk factors. Serum leptin may be a useful marker in risk stratification
of ACS.
Keywords: Acute coronary syndrome, Adipocytokines, Atherosclerosis, Leptin.

INTRODUCTION

The aim of this study was to determine the role of
Acute coronary syndrome (ACS) comprises a set
leptin as a risk factor in non-obese patients presented
of life-threatening health conditions affecting the heart.
with acute coronary syndrome and its relation to
This encompasses myocardial infarction and unstable
midterm prognosis.
angina (UA) (1). ACS can be caused by a variety of risk

factors, including a family history of heart attack or
PATIENTS AND METHODS
unstable angina, cigarette smoking, hyperlipidemia,
Our study included 60 non-obese patients (based on
hypertension, diabetes mellitus, obesity, a sedentary
body mass index (BMI) < 30 kg/m2 and waist
lifestyle, stress, and several non-traditional factors
circumference (WC) <102 cm) who were admitted to
particularly inflammatory markers and markers of
coronary care unit because of acute coronary syndrome
atherosclerotic burden, which have recently emerged as
excluding obese patients (based on BMI 30 kg/m2 and
a result of advances made in the understanding of
WC > 102 cm).
atherosclerosis pathophysiology (2).
Patients with a history of acute myocardial infarction
Now, it is well-established that adipose tissue
in the previous six months and those with atrial
appears to be a hormonally active endocrine organ that
fibrillation and previous coronary artery bypass graft
produces several biologically active substances that
also were excluded from the study in addition to those
regulate and correlate with insulin sensitivity, vascular
with a history of malignancies or renal failure.
function, and atherosclerotic disease, collectively

known as the "adipocytokines" (3). Two major
Patients were divided into 3 groups: Group A:
adipocytokines, leptin and adiponectin are assumed to
Included 30 patients presented with STEMI, Group B:
play important roles in the regulation of metabolic
Included 15 patients presented with NSTEMI, and
homeostasis and the development of atherosclerotic
Group C: Included 15 patients presented with unstable
diseases (4).
angina. The study also included a control group
Leptin shows angiogenic activity, increases
composed of twenty healthy non-obese volunteers who
oxidative stress in endothelial cells, promotes vascular
gave no history of chest pain or symptoms suggestive of
smooth muscle cell migration and proliferation,
CAD.
stimulates platelet aggregation and atherothrombosis,
All patients were subjected to full history taking
decreases arterial distensibility, and contributes to
including determination of risk factors of CAD as a
obesity-associated hypertension. These factors correlate
history of diabetes mellitus, hyperlipidemia, systemic
negatively with vascular health and are strongly
hypertension, and cigarette smoking.
involved in the pathophysiology of atherosclerosis and
BMI was calculated using the formula: body
the development of ACS (5).
weight divided by height squared (weight/height²
(kg/m²)). Weight was measured (in Kilogram) using a
1322
Received: 13/10/2021
Accepted: 11/12/2021

Full Paper (vol.871 paper# 55)


c:\work\Jor\vol871_56 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1328-1335

Urinary Ferritin Creatinine Ratio as a Potential Biomarker for Lupus Nephritis
Usama Ragab1, Yasser Abd El-Monem El-Hendy1, Ghada El-Sayed Amr2,
Esraa Sameh Ibrahim Awadallah*3, Ahmed Abdulsaboor2, Ahmed Noaman1
Departments of 1Internal Medicine, 2Clinical Pathology and
3Nephrology, Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Esraa Sameh Ibrahim Awadallah, Mobile: (+20)01117788260, Email: dr-esraasameh@yahoo.com

ABSTRACT
Background:
Systemic lupus erythematosus (SLE) can affect multiple systems and major organs, among which lupus
nephritis (LN), which is a common major organ manifestation and a main cause of the morbidity and mortality of the
disease. In this regard, LN affects 40­ 80% of SLE patients and result in chronic kidney disease, which sequentially
increases the morbidity and mortality in SLE patients.
Objective: The aim of this study was to evaluate the value of urinary ferritin/creatinine ratio (UFCR) in diagnosis and
evaluation of lupus nephritis.
Patients and Methods: This study was conducted in the Internal Medicine Department, Zagazig University Hospitals.
The study included 36 patients complaining of SLE diagnosed according to the American College of Rheumatology
(ACR) revised criteria for the classification of SLE. Patients were divided into two equal groups; group (I) included 18
SLE patients without LN (17 of them were females and one was male) with a mean age of 32.33 ± 6.47 years, and group
(II) included 18 SLE patients with LN (18 of them were females) with a mean age of 29.28 ± 6.56 years. They were
compared to 18 healthy control participants (16 of them were females and two were males) with mean age of 32.28 ±
6.03years. Urinary ferritin creatinine ratio (UFCR) was measured for all of them.
Results: There was a statistical significance increase in urinary ferritin among LN group compared to other groups.
UFCR was significantly higher in the LN group than control group. There was a statistically significance positive
correlation between UFCR and SLEDAI score, serum ferritin, blood urea and serum creatinine among LN group.
Conclusion: UFCR level can be considered as a potential biomarker for the kidney injury in LN, and it is significantly
increased in LN patients.
Keywords: Urinary ferritin creatinine ratio, Biomarker, Lupus nephritis.

INTRODUCTION
The aim of this study was to evaluate the value of
Systemic lupus erythematosus (SLE) is a chronic
urinary ferritin/creatinine ratio (UFCR) in diagnosis and
autoimmune disease with unknown etiology, which can
evaluation of lupus nephritis.
be characterized by producing various autoantibodies

against self-antigens (autoantigens) (1). SLE can affect
PATIENTS AND METHODS
multiple systems and major organs, among which lupus
This retrospective case-control study was carried
nephritis (LN) is a common major organ manifestation
out in Internal Medicine Department, Faculty of
and a main cause of the morbidity and mortality of the
Medicine, Zagazig University Hospitals between
disease (2). In this regard, LN affects 40­ 80% of SLE
February 2021 and August 2021.
patients, and an immunosuppressive treatment for LN

may have an adverse effect on kidney and result in
Study population: This study was conducted on 54
chronic kidney disease, which sequentially increases the
participants including both females and males and their
morbidity and mortality in SLE patients (1). Therefore,
ages ranged from 18-45 years old. Thirty six
an involvement of renal disease activity is one of the
participants were diagnosed to have SLE and fulfilled at
most important prognostic factors for patients with
least four of 11 American College of Rheumatology
SLE, and the diagnosis of SLE patients with LN has an
(ACR) revised criteria for SLE. We divided them into
important clinical implication in guiding the treatment
three groups. Group I included 18 SLE patients without
of SLE in clinical settings (3).
LN (17 were females and 1 was male). They were
Urinary biomarkers are easily obtained and
admitted to due lupus flares with arthritis, proteinuria <
probably are best at reflecting the current renal status,
0.5 g/day, no hematuria or urinary casts sediment and
as they specifically represent local inflammatory
all of them had a normal kidney function (serum
activity (4). In recent years, ferritin has gained increasing
creatinine <1.1 mg/dl in female or < 1.2 mg/dl in male)
attention in the studies of autoimmune diseases.
with estimated GFR > 90 ml/min/1.73 m2. Group II
Elevated serum ferritin levels were well established as
included 18 SLE patients with LN (18 were females
an acute-phase reactant in antiphospholipid syndrome
with no males) and all had evident clinical nephritis
(APS), rheumatoid arthritis (RA) and adult onset Still's
(proteinuria > 0.5 g/day and some patients had elevated
disease (AOSD). There were several studies that
serum creatinine level > 1.1 mg/dl in female and > 1.2
reported elevated levels of serum ferritin in SLE
mg/dl in males). Group III included 18 apparently
patients, but few studies have investigated the clinical
healthy control population, which were age- and sex-
significance of urinary ferritin in SLE and LN (5).
matched with patients' groups.
1328
Received: 15/10/2021
Accepted: 13/12/2021

Full Paper (vol.871 paper# 56)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1336-1341

The Diagnostic Role of Procalcitonin in Bacterial Pneumonia in
Patients with Heart Failure
Asmaa Khalid Edris1, Omar F. Tawfik2
Departments of 1Chest and 2Cardiology Diseases, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding Author: Asmaa Khalid Edris, Email: music-inmyheart@hotmail.com


ABSTRACT
Background:
Recently, procalcitonin (PCT) has been identified as a useful biomarker to identify heart failure with
bacterial pneumonia in clinical trials.
Objective:
This study aimed to assess the role of procalcitonin in diagnosis of bacterial pneumonia in patients with
congestive heart failure.
Patients and methods: The study was conducted in Chest Department, Cardiology Department and Cardiology
Outpatient Clinic, Zagazig University Hospitals as a case control study. This study included sixty participants who were
classified into 3 groups. Group 1 included 20 chronic stable heart failure patients, Group 2 comprised 20 diagnosed
bacterial community-acquired pneumonia on top of chronic heart failure patients. Group 3 consisted of 20 healthy
individuals as control group. All participants were subjected to full medical history, clinical examination, chest
radiography, CT scan of the chest, ECG, echocardiography, microbiological investigations, general investigations (TLC,
ESR, CRP, electrolytes, LFT, KFT, random and fasting blood sugar levels) and specific laboratory investigations (serum
PCT level).
Results: Procalcitonin levels differed significantly among the groups studied. There was a substantial difference
between the groups when comparing them pairwise. The best cut-off of PCT in diagnosis of bacterial pneumonia in
CHF patients was 0.555 ng/ml with area under curve of 0.994, sensitivity of 95%, specificity of 97.5%, positive
predictive value (PPV) of 95%, negative predictive value of 97.5% and accuracy of 96.7% (p < 0.001).
Conclusion:
Procalcitonin measurement is useful in differentiating bacterial pneumonia in patients with heart failure
from heart failure patients without pneumonia, hoping for better patient care.
Keywords: Procalcitonin, Heart failure, Pneumonia.

INTRODUCTION

There are several respiratory tract infections, like
discovered in recent years. Viral, bacterial and
community-acquired pneumonia (CAP), as well as
nonspecific inflammatory diseases are all associated with
bronchitis that necessitate antibiotic therapy and
high levels (5).
contribute to the rise in antibiotic multi-resistant
During a bacterial infection, the level of
infections. Clinical criteria (like fever, dyspnea as well as
procalcitonin, a precursor peptide to the calcitonin
cough) and chest radiography are the primary diagnostic
hormone, rises dramatically. As a result, new research
tools for respiratory infections. However, despite the fact
suggests that PCT can be used to guide antibiotic therapy
that PCR and culture procedures have low sensitivity and
in patients with heart failure by identifying those with
hence cannot rule out bacterial infection, various research
concurrent bacterial infections (6).
and interventional trials have found that PCT is effective
We aimed at this study to assess the role of procalcitonin
in patients with respiratory infections (1). Pneumonia
in diagnosis of bacterial pneumonia in patients with
continues to be a primary cause of health issues and death
chronic heart failure.
worldwide, with its high mortality rate and widespread

prevalence making it a substantial contributor to the use
PATIENTS AND METHODS
of antibiotics. (2).
From November 2020 to April 2021, in Chest
Emergency medicine is plagued by acute
Department, Cardiology Department and Cardiology
dyspnea, which is associated with a high fatality rate.
Outpatient Clinic, Zagazig University Hospitals, our
Dyspnea can have a variety of underlying reasons, the
case-control trial was conducted. Sixty participants were
most common of which are cardiac or pulmonary causes.
classified into:
It's vital to rule out acute heart failure (AHF) as a
Group (A): Included 20 cases with chronic stable
possibility in these people (3). The non-specific chest X-
heart failure, which is a clinical disease characterized by
ray abnormalities in cardiogenic pulmonary edema make
an impaired ability to fill or eject blood from the
it challenging to diagnose pneumonia in patients with
ventricles. Myocardial structural and functional
acute heart failure. Misdiagnosis has the side effect of
abnormalities can induce chronic heart failure (7).
delayed treatment, which could lead to worse
Group (B): Included 20 cases with definite
consequences (4).
diagnosis of bacterial community-acquired pneumonia
Pneumonia has been successfully diagnosed with
on top of chronic heart failure, which is defined as an
the help of procalcitonin (PCT), a promising biomarker
acute lung infection affecting the alveoli (8).
1336
Received: 15/10/2021
Accepted: 13/12/2021

Full Paper (vol.871 paper# 57)


c:\work\Jor\vol871_58 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1342-1347

Evaluation of Paediatric Postoperative Pain Management among Nursing Staff
Working in Tertiary University Hospitals: A multicentre Cross-sectional Study
Mostafa S. Elawady*, Hani I. Taman, Hosam I. El Said Saber
Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Mansoura University, Egypt
Corresponding author: Mostafa Elawady, Mobile: (+20)01004062862, E-Mail: sasaelawady@gmail.com.

ABSTRACT
Background:
Poor postoperative pain management represents unpleasant experience which occurs in patients following
surgical procedure. Recently, there have been increasing efforts to improve the perioperative pain management of
children. Objective: To evaluate the paediatric postoperative pain management practice as well as identification of
paediatric postoperative pain management influencing factors. Patients and methods: This cross-sectional study was
conducted in Mansoura University Children Hospital, Mansoura University Emergency Hospital (ICU units). Each
hospital serves a wide range of young patient's ages from one day up to 16 years old. All nurses who were involved in
paediatric postoperative pain management were subjected to a specific questionnaire which assess different items that
may affect the postoperative pain management practice. Results: Forty-seven participants have completed this study.
The availability of pain assessment tool, level of knowledge, pain assessment, use comfort measures and considering
pain management as a major priority were higher among the studied nursing staff. Meanwhile, participants who paid
more attention for pain assessment and recording were lower. Good pain management practice was higher in female,
married participants and among bachelor's, technical institute of nursing graduates and secondary nursing school
graduated staff. The availability of pain assessment tool, morphine stock, knowledge, pain assessment, management and
handover were associated with higher good pain practice among the studied nurse group. Conclusion: Nursing
graduation level, marital status, knowledge, training and familiarity with pain assessment, and management tools,
effective communication and pain management handover are fundamental factors that significantly improve the
paediatric postoperative pain services.
Keywords:
Nurses, Paediatric, Pain management, Postoperative, Tertiary hospitals.

INTRODUCTION

Adequate pain treatment is not something that can
According to many research, inadequate
be taken for granted. Despite the fact that the
paediatric postoperative pain treatment is caused by a
Declaration of Montreal (September 2010) declares that
lack of nurse training and their attitude toward pain
"access to pain management is a fundamental right," it
management (11, 12).
is estimated that 80% of the world's population is
The main aim of this study was to evaluate the
afflicted by inadequate pain management, which is a
postoperative pain management services for paediatric
severe problem in more than 150 nations (1,2).
patients among nurses working in Mansoura University
Pain is a sensory and emotional experience that is
Hospitals' Surgical Departments. The secondary aim
unpleasant and is caused by real or prospective tissue
was to identify the factors, which affect the level of
damage (3). Postoperative pain is a significant
practices towards paediatric postoperative pain
consequence that affects people after undergoing
management among nurses working in Mansoura
surgery. In both industrialised and developing nations,
University Children and Emergency Hospitals.
it is linked to higher morbidity and death (4,5).

One of the responsibilities of nursing personnel,
PATIENTS AND METHODS
who are always at the bedside of their patients, is to
This cross-sectional study was conducted in
assess pain (6).
Mansoura University Children Hospital, Mansoura
Efforts to enhance the perioperative pain
University Emergency Hospital (ICU units). Each
treatment of children have been improving for many
hospital serves a wide range of young patient's ages
years, however a significant percentage of children still
between one day and 16 years old.
experience perioperative discomfort (7,8).

The practice of paediatric anaesthesia varies
Ethical considerations:
considerably across countries, including the provision
All participants completed informed written
of postoperative analgesia, as evidenced by the results
consent before being recruited in this study. An
of the recent Anaesthesia Practice In Children
approval from Institutional Review Board (IRB-
Observational Trial (APRICOT) (9).
MFM) of Mansoura University, Faculty of Medicine
The reasons are multifactorial but may reflect
with code number (R/16.12.32, March 2017) was
differences in knowledge, infrastructure, organization,
obtained.
Ethics
guidelines
for
human
and health care economics among different countries.
experimentation were adhered to in line with the
However, even in more affluent settings, paediatric
Helsinki Declaration of the World Medical
postoperative pain management is highly variable and
Association.
is still suboptimal in many centres (10).

1342
Received: 14/10/2021
Accepted: 12/12/2021

Full Paper (vol.871 paper# 58)


c:\work\Jor\vol871_59 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1348-1353

Talipes Equinovarus surgical Management after Failure of
Ponseti Technique in Children
Mohsen Mohamed Abdou Mar'e`i, Reda El-Kady,
Sameh Mohamed Holyl, Lamin Abdel-Salam Mohamed Ismail*
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Lamin Abdel-Salam Mohamed Ismail, E-Mail: tweaary@gmail.com

ABSTRACT
Background
: Conservative approaches as Ponseti Technique in managing Talipes Equinovarus could lead to various
serious consequences, surgical treatment could if necessary.
Objective: The aim of the work was to assess the functional and radiological outcome of surgically treated clubfeet after
failure of Ponseti technique in children.
Patients and Methods
: Twelve clubfeet in twelve patients were undergoing posterior medial release in this prospective
study at the Orthopedic Department, Zagazig University Hospitals during the period from November 2020 to the end of
August 2021 and followed up in out-patients clinics, follow-up period from three to six months. The selected cases were
thoroughly examined clinically and radiologically pre- and postoperative.
Results:
All postoperative cases were plantigrade; with no poor results were noticed. most cases (81.25%) were with
excellent to good results while the remaining (18.75%) were fair with plantigrade foot. Lateral talocalcaneal angle was
12.75±4.65° before surgery; and changed after posterior medial release 40.83±4.37°. The increase was significant
(P<0.001). Anteroposterior talo-first metatarsal angle was also with significant change from pre to after posterior medial
release (P<0.001). As regard complications, there were intraoperative bleeding (two patients) as well as postoperative
infections (one patient) and plaster sores and dermatitis (four patients).
Conclusion:
It could be concluded that in failed Ponseti technique there is adhesion under the skin of the distal tibia and
there is adhesion and fibrosis around the incision of the tendon Achilles certain point should be fulfilled to obtain complete
reduction and anatomical restoration of the foot after failed Ponseti.
Keywords
: Ponseti Technique, Talipes Equinovarus, Surgical

INTRODUCTION

conservative measures. Bad outcomes are influenced by a
Idiopathic Talipes cause Clubfoot, also known as
variety of factors (8, 9).
Equinovarus, is a fibroproliferative condition of the
More than 70% of patients were born with a severe
musculoskeletal system. Its cause is currently a mystery.
deformity (grade III or IV), making non-surgical treatment
There is a 1 in 1000 chance of having a baby with this birth
less effective. Dimeglio score at birth is a prognostic factor
condition (1).
for surgery, as Goldstein et al. established recently (7).
Many theories have been put up to explain the
A study by Dunkley et al. found that repeat casting
pathological changes seen in clubfeet, but the exact cause
was ineffective, with 86% of patients relapsing following
is still unknown (2). The equinus, varus, adductus, and
the failure of the PM (10). McKay et al. conducted research
cavus abnormalities are all present in this three-
and found that repeat casting and bracing for late relapses
dimensional deformity. A pain-free, functional plantigrade
failed in 94% among patients (11). The authors of Richards
foot is the goal of all treatment, regardless of its nature.
et al. report that certain patients, despite repeated tries, do
Surgeons used to prefer surgical treatment, which has been
not react favorably to conservative treatments. As a result,
shown to be effective in the short term (3). Many
if surgery is required, it should not be avoided (6).
abnormalities can be corrected without surgery by utilizing
The goal of this work was to assess the functional and
a combination of conservative methods such as massage,
radiological outcome of surgically treated clubfeet after
stretching, manipulation, and immobilization. Surgical
failure of Ponseti technique in children.
procedures such as posteromedial release (PMR) or

complete subtalar release may be required if various
PATIENTS AND METHODS
manipulation protocols are unable to address the
This prospective study included a total of twelve
abnormalities fully (4).
patients with twelve clubfeet, attending at Orthopedic
For the past two decades, conservative treatment for
Department, Zagazig University Hospitals and
clubfoot has been the primary option. With similar success,
undergoing posterior medial release. This study was
the Ponseti method (PM) and the French functional
conducted between November 2020 to the end of August
approach (FFM) have been much disputed (5). Also, both
2021.
PM and FFM have early relapse rates of 37 and 29 percent,

respectively (6). In order to deal with more severe
Ethical Consideration:
malformations, further therapy may be necessary (7).
Zagazig University's research ethics council
Some malformations, even when treated by highly
approved the study as long as all participants signed
skilled and specialized teams, remain resistant to
informed consent forms and submitted them to ZU-
1348
Received: 12/10/2021
Accepted: 10/12/2021

Full Paper (vol.871 paper# 59)


c:\work\Jor\vol871_60 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1354-1361

Study of Soluble Intercellular Adhesion Molecule-1 in Patients with Sepsis in Medical
Intensive Care Unit, Zagazig University Hospitals and its Relation to the Clinical Outcome
Usama Ahmed Khalil1, Hanem Magdy Abdel Nour1, Hossam Hassan Abdel-hamed*2, Islam Mohamed Salem2
Departments of 1Internal Medicine and 2Biochemistry, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Hossam Hassan Abdel-hamed, Mobile: (+20)1026760275, Email: doc.h.hassan2030@gmail.com

ABSTRACT
Background:
Intercellular Adhesion Molecule-1 (ICAM- 1), which mediates cell-cell adhesion to the extracellular
matrix, may be released in cascades throughout sepsis, causing serious damage to vascular endothelial cells. Numerous
investigations have demonstrated that it is elevated in individuals with sepsis. Thus, ICAM-1 may be a useful biomarker
in predicting and diagnosing sepsis.
Objectives: The aim of the current work was to measure serum sICAM-1 level in septic ICU patients to determine the
association between serum sICAM-1 and inflammatory response of sepsis, clinical severity and mortality.
Patients and Methods:
A Cohort study was conducted on 40 critically ill patients with sepsis and admitted to the
intensive care unit in the Internal Medicine Hospital, Zagazig University Hospitals. Results: There was a high
significant increase of SICAM-1 level in septic patients with MOF group compared to patients without MOF (p=0.003).
A significant increase of serum ICAM-1 level in the non-survivors group compared to the survivor's group (p<0.001).
Serum ICAM-1 had a significant positive correlation with age, APACHE II, SOFA score, TLC, ESR, CRP, urea and
creatinine. There was no correlation between serum ICAM-1 with each sex, AST and ALT. Using multivariate
regression analysis, it was found that serum sICAM-1 level is an independent factor for predicting the severity. Serum
ICAM-1level at 232.4 ng/ml had a sensitivity of 100%, specificity of 100%, 100% NPV and 100% PPV in detecting the
clinical Outcome of septic patients in ICU. Conclusions: It could be concluded that the increased serum level of sICAM-
1 in septic ICU patients is associated with inflammatory response and organ damage and may predict their clinical
Outcome during their admissions in ICU.
Keywords:
Soluble Intercellular Adhesion Molecule-1, Patients with Sepsis, Medical Intensive Care unit, Clinical
Outcome

INTRODUCTION

such as proinflammatory cytokines, cellular stresses,
Sepsis is a global health problem caused by
hormones and virus infection [3].
infection with high morbidity and mortality and is the
Circulating soluble ICAM-1 (sICAM-1) is
most common cause of death in critically ill patients of
cleaved and released from membrane-boundICAM-1,
intensive care units (ICU). Severe sepsis is
and measurement of blood sICAM-1 levels can estimate
characterized by systemic inflammatory response
ICAM-1 expression in the tissue. Circulating sICAM-1
syndrome (SIRS) and is often complicated with septic
level are increased in many diseases, such as coronary
shock (refractory hypotension) and multiple organ
heart disease, systemic lupus erythematosus,
dysfunction syndromes (MODS), thereby determining
obstructive sleep apnea syndrome, atherosclerosis,
the Outcome of severe sepsis. Both proinflammatory
idiopathic pulmonary fibrosis, colorectal and lung
and anti-inflammatory pathways are activated in severe
cancers [4].
sepsis, and their imbalance can determine the
Circulating sICAM-1 is up-regulated in neonatal
probability of septic shock and MODS. Therefore, new
sepsis and associated with disease severity and systemic
biomarkers are highly needed in the early phase of
inflammation. However, the relationship between
sepsis to aid the diagnosis and stratification of severe
circulating sICAM-1 and adult sepsis is complex and in
sepsis patients [1].
whether sICAM-1 concentration is associated with
Sepsis has three stages started by stage I as
severity and mortality of severe sepsis is not well
Systemic Inflammatory Response Syndrome (SIRS)
established [5].
and then stage II as severe sepsis and multiple organ
This study was aimed to measure serum sICAM-
dysfunction (MODS) and complicated by septic shock
1 level in ICU septic patients to determine the
and death as stage III. In Egypt, the incidence rate of
association between serum sICAM-1 and inflammatory
severe sepsis & septic shock in a study was (30.53%)
response of sepsis, clinical severity and mortality and to
with (47.13%) mortality. A gram-positive infection was
find out if sICAM-1 levels can serve as a prognostic
evident in about one-third of the studied septic cases [2].
biomarker for severe sepsis in septic patients in ICU.
Intercellular adhesion molecule 1 (ICAM-1) is a

glycoprotein member of the immunoglobulin
PATIENTS AND METHODS
superfamily and acts as one adhesion molecule that
This Cohort (follow up) clinical study was
stimulates leukocyte adhesion and transmigration
conducted to explore role of serum sICAM-1 levels as
across the endothelium. ICAM-1 is constitutively
a prognostic biomarker for patients with sepsis. The
expressed on endothelium and its expression can be
study included a total of 40 patients at Internal
significantly up-regulated by a variety of mediators,
Medicine Intensive Care Units, Zagazig University
Hospitals.
1354
Received: 20/10/2021
Accepted: 23/12/2021

Full Paper (vol.871 paper# 60)


c:\work\Jor\vol871_61 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1362-1369

Von Willebrand Factor; a New Non-Invasive Marker for Assessment of
Liver Fibrosis in Infants and Children
Fawzy Mohamed Abdelrazek1, Ahmad Kamal Mansour1,
Tarek El Sayed Barakat1, Nashwa Khairat Abousamra2
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Mansoura University, Egypt
*Corresponding author: Fawzy Mohamed Abdelrazek, Mobile: (+20)1553628520, Email: fawzimohamed3031991@gmail.com

ABSTRACT
Background:
Von Willebrand Factor (vWF) is a multimeric adhesive protein to which platelets stick. It is
physiologically released by activated endothelial cells during primary hemostasis. High Shear stress induced by
hyperdynamic (splanchnic) circulation in advanced hepatic fibrosis as well as endotoxinemia caused by bacterial
translocation may contribute to the increased levels of vWF releasing from that activated endothelium.
Objective:
The aim of the current work was to assess the stage of fibrosis changes in children with CLD noninvasively
by measuring the levels of serum Vwf Ag.
Patients and Methods:
This was an observational case control study conducted on sample of 40 infants and children
up to 18 years divided into two equal groups of 20 cases (fibrotic) attending hepatic clinic at Mansoura University
Children' Hospital and another 20 healthy matched controls. The diagnosis of fibrosis was previously verified by clinical,
biochemical, ultrasonographic criteria and biopsy.
Results:
There was highly statistically significant increase in vWF value in the cases compared to the controls (167.1
47.8 Vs 112.9 36.1 IU/dL) (P<0.001). vWF Ag values demonstrated insignificant differences concerning etiology of
liver disease, presence or absence of ascites and hepatosplenomegaly (P>0.05). Values of vWF Ag were demonstrated
to be significantly increases in cases with severe fibrosis as well as cases with varices (P<0.05). There were highly
statistically significant correlations between vWF Ag level and both fibrosis stage and Child Score among the studied
patients (P0.001).
Conclusion:
It could be concluded Willebrand factor antigen level was positively correlated with liver function tests as
well as varices and could be used as a significant predictor to severity of liver fibrosis and / or cirrhosis in children and
infants with chronic liver disease.
Keywords: Von Willebrand Factor, Liver fibrosis, Infants and Children.

INTRODUCTION

fundamental component of the increased hepatic
Liver fibrosis is the formation of scar tissue in
vascular tone of fibrotic livers (7).
response to parenchymal injury secondary to chronic
Von Willebrand factor (vWF), released from
liver disease, e.g. chronic infection and inflammation. It
activated endothelium in very high molecular weight
distorts the normal liver parenchyma (1). The continuous
forms, is an adhesive protein to which platelets stick.
and progressive replacement of hepatocytes by
Thus, it represents an indicator of endothelial cell
extracellular matrix and fibrous tissue leads to liver
activation and plays a crucial role in high shear stress
cirrhosis (2).
depending on primary hemostasis (8).
Cirrhosis is a diffuse pathophysiological state
Currently, liver biopsy is considered as the gold
of the liver considered to be the final stage of hepatic
standard method for stratification of hepatic fibrosis.
fibrosis, characterized by chronic necroinflammatory
However, liver biopsy is an invasive procedure and has
and fibrogenetic processes, with subsequent conversion
limitations of sampling error and variability of
of normal liver architecture into structurally abnormal
histologic interpretation. Further, it is not feasible in a
nodules, dense fibrotic septa, concomitant parenchymal
routine clinical setting to monitor liver fibrosis with
exhaustion and collapse of the liver tissue (3).
repeated liver biopsy (9).
Complications of fibrosis include jaundice,
Recently, many studies conducted on adults
ascites, portal hypertension, gastrointestinal variceal
have reported the role of elevated vWF-Ag level as a
bleeding, and hepatic encephalopathy, whose presence
prognostic marker in chronic liver disease and it might
is indicative of decompensated disease (4).
be a key player in establishing liver fibrosis and
Portal hypertension is a serious consequence of
cirrhosis (10).
cirrhosis that may result in life-threatening
Additionally, Other studies have reported
complications with increased morbidity and mortality
increase of vWF-Ag level with higher Child­Pugh
(5). Portal hypertension often results in endothelial
Score (CPS) which is considered the most widely used
dysfunction owing to the increased intrahepatic
assessment tool for liver function and has been
pressure, accompanied by changes in the hemostatic
incorporated into algorithms for the management of
system including decrease in platelet levels and activity
patients with chronic liver disease (11).
(6). The endothelium plays a crucial role in many
The aim of work was to investigate whether von
vascular diseases and endothelial dysfunction is a
Willebrand factor antigen level is related to severity of
1362
Received: 11/10/2021
Accepted: 9/12/2021

Full Paper (vol.871 paper# 61)


Manuscript template The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1370-1375

Clinical Outcome of Covid-19 Patients with
Pre-Existing Diabetes Mellitus at King Abdulaziz University Hospital
Amani Alhozali, Yousef Khedher, Rahaf Qari *, Ruaa Nughays
Department of Medicine, King Abdul-Aziz University Jeddah-Saudi Arabia
Address for correspondence: Rahaf Qari, Mobile: +966568666236,
Address: Jeddah, Saudi Arabia 22254, Telephone: +966568666236, Email: rahafqari@gmail.com

ABSTRACT

Aims:
To investigate the clinical outcome of patients with confirmed COVID-19 who had diabetes mellitus as a
comorbidity at King Abdulaziz University Hospital, Jeddah.

Methods
: Retrospective study conducted at an academic tertiary hospital, included 147 adults with a confirmed diagnosis
of diabetes mellitus, and a confirmed diagnosis of COVID-19. The data included: age, gender, body mass index (BMI),
HbA1c level, medications, co-morbidities, length of hospital stay, the clinical outcome of the patients, and complications
related to COVID-19 during the hospital stay. Data were analyzed using Stata version 16.

Results: 54% had HbA1c levels >9%. With regard to other health problems, 73% reported having health problems. 31%
and 18% required ICU admission and intubation respectively. Median length of hospital stay was 12 days. Regarding
clinical outcomes, the majority recovered without complications (78%), while 9% recovered with complications and 13%
died.

Conclusions
: The difference in outcomes based on HbA1c levels was not statistically significant, therefore there was
no difference in other clinical parameters based on the different levels of HbA1c. Further, large studies should be
conducted to determine the relationships between diabetes, antidiabetic medications, and COVID-related morbidity and
mortality.

Keywords:
Covid19, Diabetes, King Abdulaziz University Hospital, Sars-cov2, Saudi Arabia.


INTRODUCTION

disease, had worse clinical outcomes and prognosis than
In December 2019, the novel coronavirus that causes
those without these comorbidities [6,7].
severe respiratory distress syndrome 2 (SARS-CoV-2)
In the United States, a study showed that
appeared in Wuhan, China, and subsequently led to the
hospitalized COVID-19 patients with uncontrolled
historic, and currently ongoing, pandemic that has caused
diabetes had a longer length of stay and higher mortality
a global crisis [1,2].
rate than those without diabetes [8].
SARS-CoV-2 binds to angiotensin-converting
Other studies have also identified diabetes mellitus
enzyme 2 receptor via a protein called glycoprotein S; ten
as a risk factor in COVID-19 patients to develop adverse
to twenty times more aggressive than previous SARS
overall clinical outcomes in the form of greater need for
coronaviruses. As this receptor is present in multiple vital
hospitalization, especially in those with higher HbA1c
organs, COVID-19 is associated with end-organ failure of
levels, increased length of stay during hospitalization,
numerous organs and related mortality [3].
occurrence of acute respiratory distress syndrome, and
As of August 13, 2021, there were a total of 205
death [8-11].
million confirmed cases of COVID-19 and 4 million
Similarly, in Saudi Arabia, a study conducted at
resulting deaths globally according to the WHO
King Salman Bin Abdul-Aziz Hospital in Al Riyadh
dashboard [4]. Saudi Arabia, a country with a population
found that diabetes mellitus is a common comorbidity
of 33.2 million citizens [5] in the Middle East, has
among hospitalized patients with COVID-19[12]. Another
recorded 537,374 confirmed cases and 8388 deaths
study conducted at Prince Sultan Military Medical City,
(mortality rate, 1.56%) [4].
Riyadh, also found diabetes mellitus to be the most
Several published studies have shown that COVID-
commonly associated disease in admitted patients with
19 patients with comorbidities, such as diabetes mellitus,
COVID-19[13].
hypertension, cardiovascular diseases, and chronic lung


1370
Received: 29/9/2021
Accepted: 27/11/2021

Full Paper (vol.871 paper# 62)


c:\work\Jor\vol871_63 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1376-1382

Efficacy and Safety of Denosumab Versus Zoledronic acid in
Suppressing Bone Metastases of Breast Cancer
Adel G. Gabr¹, Shaimaa A. Badawy¹, Ashraf Z. Abdalla¹, Eman M. Zaki2, Abdallah H. Mohammed¹
1Department of Medical Oncology and Hematological Malignancies,
South Egypt Cancer Institute, Assiut University, Egypt
2Department of Oncologic Pathology, South Egypt Cancer Institute, Assiut University, Egypt
*Corresponding author: Shaimaa A. Badawy, Mobile: (+20) 01004801121, E-Mail: shimaaali2481988@gmail.com

ABSTRACT
Background:
60% of patients with metastatic breast cancer will eventually develop bone metastases during course of
disease, bone targeting agents either bisphosphonates or denosumab, through different mechanisms of action, these
bone-specific agents block osteoclast function and reduce the risk of skeletal-related events.
Objectives: This study aimed to compare monoclonal antibody against receptor activator of nuclear factor _ B (RANK)
ligand (denosumab), with zoledronic acid in response, toxicity related to treatment and progression skeletal-related
events free survival in boney metastatic breast cancer.
Patients and Methods: Patients were assigned to receive either subcutaneous denosumab for six months or intravenous
zoledronic acid for six months. The primary end point was difference in response and toxicity between bone targeting
agents. The secondary end point was comparing skeletal progression survival analysis and the response in both.
Results: Denosumab was not superior to zoledronic acid in delaying skeletal progression survival (log rank test P value:
0.119). Disease progression and rates of adverse events were similar between groups. An excess of renal toxicity
occurred with zoledronic acid (P value 0.004), while hypocalcemia occurred more frequently with denosumab (P value
0.004).
Conclusions: Denosumab was similar to zoledronic acid in delaying skeletal progression survival in bone metastatic
breast cancer (BMBC) and was generally well tolerated. With the convenience of a subcutaneous injection and no
requirement for renal monitoring, denosumab represents a potential treatment option for patients with bone metastases.
While due to severe hypocalcemia with denosumab, zoledronic acid represent a good treatment option for metastatic
patients.
Keywords: Breast cancer, Zoledronic acid, Denosumab.

INTRODUCTION
management of patients with bone metastasis (10).
Breast cancer is the most prevalent malignancy and
Bisphosphonates have a dual role in decreasing bone
the foremost cause of cancer related death in women
resorption by exerting an apoptotic effect on osteoclasts
worldwide (1). Also is the most common malignancy in
and increasing mineralization by inhibiting osteoclast
women in the United States and is second only to lung
activity (11), Zoledronic acid (ZOL) is a nitrogen-
cancer as a cause of death. The American Cancer
containing bisphosphonate and potent osteoclast
Society has estimated that 279,100 Americans will be
inhibitor. The administration of these agents may reduce
diagnosed with breast cancer and 42,690 die of disease
the risk of SREs and skeletal morbidity rate (12). Either
in the united states in 2020 (2).
intravenous or oral administration of bisphosphonates
Despite the achievements in the management of this
significantly reduced the absolute risk of SREs by 14%
tumor, breast cancer remains an incurable disease when
(RR 0.86, 95% CI 0.78­0.95) when compared to
it is diagnosed, or it has progressed, towards advanced
placebo (13). Denosumab is a fully human monoclonal
stages (3). Metastatic breast cancer (MBC) is estimated
antibody, targets the receptor activator of nuclear factor-
that at least 154.000 people in U.S have metastatic
kappa B (RANK) ligand. This drug inhibits the
breast cancer (4). The median overall survival (OS) of
RANKL/RANK signaling mediated bone resorption,
patients with MBC ranges from 2 to 3 years, with a 27%
suppressing bone turnover and leading to the reduction
overall 5-year relative survival rate (5). The most
of SRE risk (14).
common sites of distant metastasis include bones, lungs,
The objective of our prospective study was to
liver, and brain (6). Bone metastases are common in
evaluate zoledronic acid in comparison to denosumab in
advanced breast cancer; bone is affected in more than
skeletal related events (SREs) progression free survival
70% of patients with MBC (7). Bone metastases not only
in bone metastatic breast cancer and also in toxicity.
considerably reduce the OS but also the health-related

quality of life due to pain, fatigue, and skeletal-related
PATIENTS AND METHODS
events (SREs) (8).
81 female breast cancer patients with radiological
Several therapeutic strategies to specifically target
evidence of newly diagnosed bone metastases were
this condition (e.g., bone-modifying agents) are
admitted to our Medical Oncology Department, South
available (9). Bisphosphonates and RANK/RANKL
Egypt Cancer Institute, Assiut University. Eligible
inhibitors represent the foremost agents for the clinical
criteria of patients were age 18 years with
1376
Received: 16/10/2021
Accepted: 14/12/2021

Full Paper (vol.871 paper# 63)


c:\work\Jor\vol871_64 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1383-1387

Intraocular Pressure, Axial Length and Anterior Chamber Depth
Changes after Scleral Buckling
Ahmad Y. Soliman, Mohammed M. Abdulkadir, Wael O. Elhaig, Ahmad S. Khalil
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmad Y. Soliman, Mobile: (+20) 01092616853, E-Mail: a7medyeh7ya17@gmail.com

ABSTRACT
Background:
A rhegmatogenous retinal detachment (RD) involves pathologic separation of the neural retina from the
pigment epithelium because of a hole or break in the retina. Rhegmatogenous RD leads to the loss of visual function
and requires prompt surgical therapy.
Objective: Study of the axial length (AL) and anterior chamber depth (ACD) following scleral buckling (SB) for
rhegmatogenous retinal detachments (RRD), may help to isolate the preoperative susceptible cases for intraocular
pressure (IOP) variations, explain cause of postoperative IOP changes and find a way to optimize postoperative
management of these changes.
Patients and Methods: The study was a prospective cohort of 28 patients for whom SB surgery was operated at the
Department of Ophthalmology, Zagazig University, Egypt between April 2019 and October 2019. The patients were
divided into two groups depending on the extent of scleral buckle used. Group one (encircling group) included patients
with RRD indicated for encircling (360) scleral buckle. Group two (segmental group) included patients with RRD
indicated for segmental circumferential (less than 360) scleral buckle.
Results: After placement of encircling buckles at 1 month, IOP (in mmHg) increased from 14 ± 1.18 to 27.64±4.77,
ACD (in mm) decreased from 3.66±0.41 to 3.40±0.44 and AL (in mm) increased from 25.56±3.52 to 26.04±0.44 while
after placement of segmental buckles, IOP increased from 14 ± 1.24 to 15.79 ± 2.69, ACD decreased from 3.69±0.28 to
3.63±0.26 and AL increased from 25.56±1.30 to 25.65±1.27 at 1 month.
Conclusion: The study revealed that scleral buckling (either encircling or segmental circumferential) induced increase
in AL and decrease in ACD.
Keywords: ACD, Axial length, Index terms, Rhegmatogenous retinal detachment, Scleral buckling.

INTRODUCTION
axial length of 0.99 mm and an average myopic shift of
Rhegmatogenous retinal detachment (RRD) occurs
2.75 diopters(9).
when a break in the retina leads to fluid accumulation
Goezinne et al.(8) measured the anterior chamber
with a separation of the neurosensory retina from the
depth and axial length of the eye globe after encircling
underlying retinal pigment epithelium (1). This is the
scleral buckles using anterior segment-optical
most common type of retinal detachment(2). RRD is
coherence tomography and IOL Master and reported
regarded as an ocular emergency that needs immediate
that the anterior chamber depth remained decreased and
treatment(3). Techniques for the surgical management of
the axial length remained enlarged after scleral buckling
RRD include pneumatic retinopexy, scleral buckling,
for almost 1 year. This was also confirmed by Kim et
pars plana vitrectomy, alone or in combination(4).
al. (10) who found alteration in the shape of the eye by
Scleral buckle(SB) surgery is an established, safe,
changing axial length and anterior chamber depth
successful and the procedure of choice in
following scleral buckling using anterior segment-
uncomplicated RRD especially in young, phakic,
optical coherence tomography and IOL Master. These
myopic patients(5,6) with inferior breaks as it saves the
changes in anterior chamber depth occurred mainly in
crystalline lens in comparison to the high incidence of
the early postoperative period chiefly in the first
cataract developing after pars plana vitrectomy(7).
postoperative week.
Advantages of this technique are better postoperative
Kawana et al. (9) by means of ultrasound
best corrected visual acuity, low morbidity, slight
biomicroscopy, evaluated the ciliary body thickness and
reaction to intraocular inflammation and lack of serious
anterior chamber depth after scleral buckling
intraoperative and postoperative complications. These
procedures, confirming the existence of subclinical
advantages occur due to the minimally invasive and
ciliary edema for at least 1 month postoperatively that
extraocular nature of this procedure(8).
may induce changes in anterior chamber angle.
Scleral buckling causes refractive changes and
Kornmann and Gedde(11) showed IOP elevation
change in the axial length of the globe depending on
following scleral buckling in about 1.4 to 4.4% of cases.
many variables chiefly the type of buckle, the height of
These elevations may be attributed to impaired venous
the buckling effect and the circumferential extent of the
drainage through the vortex veins by the scleral buckle,
buckle. Radial scleral buckles do not induce significant
leading to congestion and swelling of the ciliary body.
refractive changes even when the buckling effect
As the ciliary body swells, it rotates anteriorly and shifts
extents anteriorly to the ora serrate. On the contrary,
the lens-iris diaphragm forward. These morphological
encircling scleral buckles cause an average increase in
changes have been demonstrated experimentally and
1383
Received: 15/10/2021
Accepted: 13/12/2021

Full Paper (vol.871 paper# 64)


c:\work\Jor\vol871_65 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1388-1394

The Diagnostic Potential of Telomerase Level in Malignant Ascites
Manal Sabry1, Naglaa Raafat AbdRaboh*2
1Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2Department of Medical Biochemistry and Molecular Biology,
Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Naglaa Raafat AbdRaboh, Mobile: (+20)01026494744, E-mail: naglaoda@hotmail.com

ABSTRACT
Background:
The differentiation of the non-malignant ascites (NMA), and malignancy-related ascites (MA) in early
phases, with subsequent appropriate management remains a considerable clinical challenge.
Objective: This study aimed to investigate the possible diagnostic value of the level of telomerase enzyme in ascitic
fluid in discrimination between MA and NMA.
Patients and Methods
: The study included 117 patients, divided into two groups: 45 (38.5%) in group I with NMA as
a control group and 72 (61.5%) in group II with MA. Group II was subdivided into group IIa including patients with
primary hepatocellular carcinoma, and IIb that included patients with other non-hepatic malignancies. All patients
were subjected to complete history taking, cytological examination, and biochemical analysis of the level of
telomerase enzyme in ascitic fluid in comparison to cytological examination of ascetic fluid and the serum level of
some specific traditional tumor markers (CA19.9, CEA, CA125, and alpha fetoprotein).
Results:
In the malignant group, telomerase level was higher than cut off value (1.2 ng/ml) in (34/40) 85.0% of
group IIa, and (25/32) 78.1% in group IIb, while it was high in (14/45) 31.1% of control group. Cytological
examination was positive in (6/40) 15.0 % of group IIa and (12/32) 37.5% of group IIb. Moreover, in group IIa,
telomerase at cut off level of 5.25 ng/ml and serum alpha-fetoprotein (AFP) at level of 210.8 ng/ml demonstrated
a sensitivity of 88.4%, 77.1%, and a specificity of 67.7%, 77.3%, respectively.
Conclusion:
The level of telomerase enzyme could be a useful tool in evaluating the diagnostic performance of
cytological examination especially if used in combination with another more specific tumor marker and may provide a
better differentiation between MA and NMA.
Keywords: Malignant ascites, Telomerase level, Hepatocellular carcinoma, Tumor markers, Cytological examination.

INTRODUCTION
peritoneal diseases, and hypoalbuminemia, in addition
Telomeres are specialized DNA structures located
to miscellaneous disorders. In the Western world, liver
at the end of chromosomes. They are essential for
cirrhosis is the most common cause of ascites (75%),
stabilizing chromosomes by protecting them from end-
followed by malignancy (10%), heart failure (3%),
to-end fusion and DNA degradation (1). Telomerase is a
tuberculosis (2%), and pancreatitis (1%) (7). Malignant
ribonucleoprotein complex containing a telomerase
ascites is an initial diagnostic feature in about 50% of
RNA component (TR), and a catalytic protein with
patients with cancer in organs of pelvic and abdominal
telomere-specific
reverse
transcriptase
activity
cavities that is associated with significant morbidity (8).
(TERT). TERT which synthesizes de novo telomere
This could be found in many malignancies as adrenal,
sequences by using TR as a template, is the rate-
bladder,
cervical,
colorectal,
endometrial,
limiting component of the telomerase complex (2).
hepatobiliary,
gastric,
lymphoma,
melanoma,
It adds DNA sequence repeats ("TTAGGG" in all
mesothelioma, neuroendocrine, ovarian, pancreatic,
vertebrates) to the 3' end of DNA strands in the
and renal tumors (9, 10), mostly it is a poor prognostic
telomere regions at the ends of eukaryotic
sign.
chromosomes that contain non-coding DNA, hindering
The differentiation between malignancy-related
the loss and damage of important DNA from
ascites (MA) and non-malignant ascites (NMA) is
chromosomal ends whenever the chromosome is
important in therapeutic and prognostic terms,
copied. Critical shortening of telomeres occurs during
considering that optimum management should be able
progressive cell division leading to dysfunctional
to maximize patient's comfort and quality of life (11).
telomeres, provoke DNA damage responses that result
Management options for malignant ascites include,
in cellular senescence. Telomerase is suggested to play
diuretic therapy, therapeutic paracentesis, and
an important role in development and survival of
peritoneo-venous shunts. Oncological interventions
tumors, as it has a detectable activity in large majority
could be helpful in ovarian carcinoma, lymphoma, as
(~90%) of cancer cells, at which telomere length is
well as hormonal therapy in hormone-sensitive
maintained by telomerase enzyme. This is mostly
malignancies (6).
achieved through upregulation of human TERT gene
Cytological analysis is considered a well-
(hTERT) that encodes telomerase (3-5).
established golden diagnostic standard of malignancy
Ascites is pathological accumulation of fluid in
in ascites (12, 13). Clearly, positive cytology is highly
the peritoneal cavity that is caused by a wide variety of
indicative for peritoneal carcinomatosis. However, the
benign and malignant causes (6). Ascites can be
sensitivity of cytology is variable, ranging between 60-
classified by the underlying pathophysiological
83%, and it could be as high as 97% if three samples
mechanism that includes portal hypertension,
from separate paracentesis are analyzed (14). But, many
1388
Received: 16/10/2021
Accepted: 14/12/2021

Full Paper (vol.871 paper# 65)


c:\work\Jor\vol871_66 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1395-1399

Safe Surgical Approach to Laparoscopic Cholecystectomy:
Posterior Wall Left Cholecystectomy
Esra Diēi¹, Rifat Peksöz*¹, Mehmet lhan Yildirgan¹, Mesud Fakirullaholu³,
Yavuz Albayrak¹, Fatma Kesmez Can², Sabri Selēuk Atamanalp¹
Department of ¹General Surgery and ²Infectious Diseases and
Clinical Microbiology, Atatürk University Faculty of Medicine, Erzurum/Turkey
³Department of General Surgery, Erzurum City Hospital, Erzurum/ Turkey
*Corresponding author: Rifat Peksöz, Mobile: (+90) 04423447562, E-mail: rifat-peksoz@hotmail.com

ABSTRACT
Background:
Laparoscopic Cholecystectomy (LC) is one of the most common surgical procedures. This surgery can
be difficult and risky for various reasons. Leaving the posterior wall of the gallbladder (GB) may be a safe option.
Objectives: This study aimed to discuss the results of patients who underwent LC with or without leaving the posterior
wall of the gallbladder left in situ.
Patients and methods: Data of 105 patients who underwent consecutive laparoscopic cholecystectomy between 2017-
2021 were analyzed retrospectively. The patients were divided into groups according to whether the posterior wall of
the GB was left in situ and the severity of the sac. The results of 52 patients who underwent standard LC in group 1, 14
patients with normal cholelithiasis and posterior wall left in group 2, 13 patients with elective infection risk and posterior
wall left in group 3, and 26 patients with acute cholecystitis and posterior wall left in group 4, were compared.
Results:
White blood cell (WBC), C-reactive protein (CRP) values of group (3, 4) were statistically higher than the
other two groups (p<0.05). There was no statistically significant difference between the groups in terms of postoperative
fever, pulse, bile and gallbladder wall cultures, and trocar site infection rates.
Conclusion:
Standard LC surgery can be performed in uncomplicated cholelithiasis cases. However, in difficult
gallbladder cases, leaving the posterior wall of the GB can provide a safe operation. The postoperative results of this
patient group were not different from the uncomplicated group.
Keywords: Critical view of safety, Difficult cholecystectomy, Gallbladder, Laparoscopy

INTRODUCTION

laboratory parameters, vital signs, bile fluid culture
Laparoscopic Cholecystectomy (LC) is one of the most
results, and complications, and to discuss them in light
common surgical procedures ¹. Although considered
of the literature.
technically easy, it can have serious consequences when

complications occur in patients with `'difficult
PATIENTS and METHODS
gallbladder'' and biliary tract variation. For this reason,
Patients with indications for elective or emergency
The Society of American Gastrointestinal and
cholecystectomy who underwent LC between 2017 and
Endoscopic Surgeons (SAGES) has created a `'Safe
2021 in Atatürk University General Surgery Clinic,
Cholecystectomy Task Force'' to establish a universal
were analyzed retrospectively.
culture of safety and reduce biliary injuries ². The
Patients were divided into 4 groups.
classical anatomy of the biliary tract is present in only
Group 1- 52 patients who underwent elective
30-50% of individuals, and the high rate of abnormal
standard LC (without leaving the posterior wall of the
anatomical variation can make the surgical procedure
GB)
even more dangerous ³. Causes of difficult gallbladder
Group 2- 14 elective, risk-free patients who
include obesity, adhesions, acute or chronic
underwent LC by leaving the posterior wall
inflammation, hydropic gallbladder (GB), and liver
Group 3- 13 Patients at risk of elective infection
cirrhosis . In patients with advanced cirrhosis and
who underwent LC by leaving the posterior wall
severe portal hypertension, the presence of portal
(patients with biliary colic attacks within 30 days before
cavernoma,
adhesions,
and
neovascularization
the procedure, Common bile duct stones, Jaundice,
complicates the dissection of Calot's triangle and
Non-functioning gall bladder)
gallbladder hilum or control of liver bed bleeding . In
Group 4- 26 Patients with acute cholecystitis who
these cases, the risk of serious complications arises, and
underwent LC by leaving the posterior wall.
the rate of conversion to open surgery increases.
The study included 105 patients. All patients had
Therefore, in patients with anatomical variation,
gallstones. The disease was diagnosed with the imaging
advanced cirrhosis, severe portal hypertension, and
methods of ultrasonography (US) and/or magnetic
difficult gallbladder, LCs performed by leaving the
resonance cholangiopancreatography (MRCP). Patients
posterior wall in situ may be safer than the standard
who underwent LC were included in the study
technique.
consecutively. All operations were performed by
This study aimed to evaluate the effectiveness of the
experienced surgeons under general anesthesia. No
classical LC and the modified LC technique in which
patients' gallbladder was opened and no posterior wall
the posterior wall is left in situ by comparing the
was left to increase the number of patients in the study.
1395
Received: 19/10/2021
Accepted: 17/12/2021

Full Paper (vol.871 paper# 66)


c:\work\Jor\vol871_67 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1400-1406

Anthropometric Measures as Predictors of Non-Alcoholic
Fatty Liver Disease in Adult Asymptomatic Egyptians
Moustafa Abd El Hamid Ali*1, Ghada Moustafa Galal1,
Mustafa Adel Ahmed Younis2, Amr Mohammed Zaghloul1
1Tropical Medicine and Gastroenterology Department, Faculty of Medicine, Sohag University, Egypt
2Department of Clinical Pathology, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Moustafa Abd El Hamid Ali, Mobile: (+20) 01004348810, E-Mail: m_metwally88@yahoo.com

ABSTRACT
Background:
Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease involving about 25% of the
world's population. Several studies investigated the role of the different anthropometric measures in NAFLD diagnosis.
Objective: This study aimed to evaluate the diagnostic performance of the different anthropometric measures as non-
invasive predictors for the presence of steatosis in a series of NAFLD patients.
Patients and methods:
A cross-sectional study was conducted in a series of adult asymptomatic subjects. NAFLD was
diagnosed in 100 cases by ultrasonography for whom controlled attenuation parameters (CAP) examination was done.
Body mass index (BMI), waist circumference (WCir), waist to height ratio (WHtR), lipid accumulation product (LAP)
were measured. Also, subcutaneous and preperitoneal fat were measured using abdominal ultrasound. Roc curve analysis
was used to detect the optimal cutoff of different models that predict steatosis.
Results:
BMI, WCir, WHtR, LAP, subcutaneous and preperitoneal fat had good diagnostic performance for predicting
hepatic steatosis (AUROC for LAP=1 and approaching 1 in all other anthropometric measures).
Conclusion: The clinical anthropometric measures are easy applicable and non-costly promising tools for the prediction
of NAFLD in Egyptian patients.
Keywords:
NAFLD, Steatosis, Anthropometric, BMI.

INTRODUCTION

anthropometric measures as non-invasive predictors for
Nonalcoholic fatty liver disease (NAFLD) is
the presence of steatosis in a series of NAFLD patients.
the most common chronic liver disease worldwide

affecting about 25% of the general population (1).
PATIENTS AND METHODS
NAFLD represents a spectrum of histological findings
This study was a hospital-based cross-
that range from simple increase of intrahepatic lipid
sectional, nested case­control study. Participants were
content (steatosis, non-alcoholic fatty liver, NAFL) to
selected by simple random sampling from
an inflammatory progressive disease known as non-
asymptomatic adults aged 18-75 years accompanying
alcoholic steatohepatitis (NASH). NASH could result in
patients attending to either the Tropical Medicine and
fibrosis, cirrhosis, and subsequently hepatocellular
Gastroenterology Outpatient Clinic or the Inpatient
carcinoma (HCC) (2). The increased NAFLD prevalence
Section of the Department, Sohag University Hospital.
globally is the result of the rising rates of obesity and
Another group of 50 subjects with no sonographic
diabetes (3). The majority of patients with NAFLD are
evidence for fatty liver were randomly selected as
suffering from obesity (4). Owing to this strong positive
controls.
association between obesity and NAFLD, it can be

expected that the prevalence of NAFLD will increase
Exclusion criteria:
with the rising rates of obesity (5).
Participants aged < 18 years or > 75 years. Those
Although liver biopsy is the gold standard for
with a diagnosis of liver diseases other than NAFLD or
diagnosing fatty liver disease and assessment of its
any end-stage liver diseases, including viral hepatitis,
severity, it has several limitations such as the invasive
drug-induced liver injury, autoimmune liver disease,
nature and the risk of complications including pain,
Wilson's disease, primary biliary cholangitis or any
bleeding and infection (6). It is also susceptible to
other CLD that might coexist with NAFLD. We also
sampling errors and assesses only a small fraction
excluded participants with alcohol consumption of 30
(1/50,000th) of the liver parenchyma (7).
g/day in men or 20 g/day in women. All included
A positive correlation was found between
individuals were subjected to a thorough medical
NAFLD and Body mass index (BMI) and waist
history and clinical examination.
circumference (WCir) which are the most commonly

used
indicators
of
obesity(8).
Other
clinical
The following anthropometric measures were
anthropometric measures including waist-to-height ratio
calculated:
(WHtR) and lipid accumulation product (LAP) were
BMI was calculated using the following formula:
found to be more sensitive and specific for
BMI = weight (kg)/ height (m2) (10). WCir was
discriminating visceral fat compared to the classic
measured as described by WHO (11) at a level
measure as WCir and BMI (9). In this study, we aimed to
midway between the lower rib margin and iliac crest
determine the diagnostic performance of the different
with the tape all around the body. WHtR was
1400
Received: 18/10/2021
Accepted: 16/12/2021

Full Paper (vol.871 paper# 67)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1407-1413

Study of Nutritional Status among End Stage Renal Disease Patients on
Regular Hemodialysis in Zagazig University Hospitals
Mohamed Ahmed EL Maghawry, Yasser A. El-hendy,
Ahmed M Salah, Mohamed El Nokrashy Saad*, Usama Ragab
Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Mohamed El Nokrashy Saad Zaghlool, Email: mohamedelnokrashy99@gmail.com

ABSTRACT

Background: The frequency of malnutrition among hemodialysis (HD) cases differs widely depending on the study
participants and assessment methods.
Objective: This study aimed to estimation of the prevalence of malnutrition among hemodialysis adult patients in
Zagazig University Hospitals by using different methods.
Patients and Methods: At Zagazig University Hospitals, Nephrology Unit, Internal Medicine Department, we
conducted our study on 95 patients with end-stage renal disease (ESRD) on regular hemodialysis. All patients underwent
a thorough history-taking as well as laboratory investigations.
Results: Mini-nutritional assessment had a statistically significant relationship with gender, body mass index (BMI),
and dialysis duration. The mini-nutritional assessment (MNA) score, hemoglobin, hematocrit, serum iron, serum
calcium, serum albumin, and high-density lipoprotein (HDL) cholesterol had a statistically significant positive
correlation. Low-density lipoprotein (LDL) cholesterol is negatively correlated with the mini-nutritional assessment
score. The correlation between Subjective Global Assessment (SGA) and BMI was statistically significant. Among
factors significantly correlated to MNA score, only BMI (unstandardized =0.978, 0<0.001) and serum albumin
unstandardized =1.625, p=0.004) significantly independently correlated with it.
Conclusion: Chronic kidney disease patients who receive hemodialysis on a regular basis are more likely to suffer from
malnutrition. Malnutrition becomes more common as people get older and their kidney function deteriorates. The MNA
and SGA Score, when used as regular screening tools, revealed a significant risk of malnutrition and can be used during
the treatment course and rehabilitation of ESRD patients.
Keywords: End-stage renal disease, Malnutrition, Hemodialysis.

INTRODUCTION
proteolysis occurs when blood amino acid levels rapidly
Malnutrition is a condition in which the body's
decline at the outset of hemodialysis. Long-term muscle
tissues are deficient in essential macronutrients or
loss may be the result of this catabolic process. It has
specific micronutrients. There is an increased risk of both
been demonstrated that feeding dialysis patients through
mortality and morbidity in patients with end-stage renal
regular meals, special liquid feeding, or parenteral
disease (ESRD) who are on hemodialysis (HD) (1).
medication can reverse this catabolic condition and
Patients with HD are at risk for malnutrition because of a
should be used as frequently as feasible to achieve this
variety of factors. More than half of the malnutrition in
goal (6). We performed the current study to find out how
hemodialysis patients is caused by anorexia and changed
common malnutrition is among adult hemodialysis
taste sensations in addition to a variety of other
patients by employing a variety of assessment methods.
conditions, such as intercurrent sickness or hyper-

catabolism and diminished anabolism (2). An estimated
PATIENTS AND METHODS
16 to 62% of HD patients are malnourished, depending
From January 2021 to July 2021, at Zagazig
on the study participants and diagnostic methods used (3).
University Hospitals, Nephrology Unit of Internal
Early identification of malnutrition is critical for
Medicine Department, our cross-sectional trial was
providing enough nutritional support, managing the
conducted on 95 patients with end-stage renal disease on
illness effectively, and preventing the negative clinical
regular hemodialysis. All received three weekly HD
outcomes associated with it (4). Patients on hemodialysis
sessions, each of 4 hours-duration. Zagazig University's
who are protein­energy malnourished and have wasting
Clinical Pathology Department handled the technical
are more likely to die. Hemodialysis patients' nutritional
aspects.
status cannot be accurately assessed by a single

measurement (5). For the following reasons, protein
Ethical approval:
requirements during hemodialysis appear to be
When all participants completed informed
insufficient. Dialysis treatment causes nutrients to be lost
permission papers and submitted them to the
through the dialysis filter (glucose, amino acids, vitamins
Research Ethics Committee at Zagazig University,
and trace elements. Dialysis itself is a catabolic process
the study was permitted (ZU-IRB#6983). Ethics
that causes the breakdown of protein (heparin role,
guidelines for human experimentation were adhered
albumin fragmentation, as well as pro-inflammatory
to in line with the Helsinki Declaration of the World
cytokines release). To maintain acceptable plasma and
Medical Association.
cellular amino acid concentrations, for example, muscle

1407
Received: 17/10/2021
Accepted: 15/12/2021

Full Paper (vol.871 paper# 68)


c:\work\Jor\vol871_69 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1414-1417

Retrospective Study of Radiological Diagnosis of
Intra-Cranial Complication of Sinusitis
Magdy Abd Allah Sayed El Ahl, Ahmed Abdel Aziz Elsayed Elsammak,
Nora Yousef Elharam, Ahmed Ibrahim Elsayed
Department of Otorhinolaryngology, Faculty of Medicine Zagazig University, Egypt.
*Corresponding Author: Nora Yousef Elharam, Mobile: (+20)01090398488, Email:ywsfnwr626@gmail.com



ABSTRACT
Background:
Intracranial involvement in complicated sinusitis is a rare but potentially fatal process. This study aimed
to assess the role of radiological diagnosis in assessment and timing of surgical intervention in sinusitis patients
complicated with intracranial complications. Patients and Methods: This retrospective cross sectional study was
conducted in ENT and Radiology Departments, Faculty of Medicine, Zagazig University on 24 cases with sinusitis
complicated with intracranial complications. Results: Included 12 patients had cavernous sinus thrombosis 50% of them
were males with mean age of 65.4 years. They were presented with facial pain, facial edema, fever, proptosis, nasal
obstruction and headache. 2 male patients had lateral sinus thrombosis with mean age of 61.4 years, they were presented
with headache. 2 patients had meningitis, one male and other female with mean age of 41 years. They were presented
with convulsion, fever and headache. CT of paranasal sinuses (PNS) showed sphenoidal sinusitis with mucosal
thickening. CT Brain was irrelevant. MRI brain showed leptomeningeal enhancement, distention of subarachnoid space
and widening of interhemispheric fissure. All patients underwent surgical debridement of diseased tissues with
anticoagulant therapy. One patient died (50%). Conclusions: Both CT scan and MRI of the sinuses are mandatory in
any patient presenting with features suggestive of intracranial complicated sinusitis.
Keywords: Paranasal sinusitis, Orbital involvement, Radiological.


INTRODUCTION
Sinusitis can be caused by a virus, bacteria, or
Complications of paranasal sinusitis are
fungus (invasive fungal sinusitis) that swells and blocks
comparatively rare in the antibiotic era; however, a
the sinuses. A few specific causes include the common
significant proportion of patients (5­40%) can be
cold, nasal and seasonal allergies, including allergies to
affected by sinusitis, mostly due to the delayed
mold, polyps (growths), a deviated septum; the septum
diagnosis of the disease(1). Among paranasal sinuses,
is the line of cartilage that divides your nose, a deviated
frontal sinusitis is the most common predisposing
septum means that it isn't straight, so that it is closer to
pathology leading to brain abscess where the frontal
the nasal passage on one side of the nose, causing a
lobe is mostly affected because of its proximal location.
blockage, and a weak immune system from illness or
Parietal abscess can be found in patients suffering from
medications(6).
sphenoid sinusitis, and temporal lobe abscess is very
This study aimed to assess the role of radiological
rare. Sinusitis is presumed to be the underlying cause of
diagnosis in assessment and timing of surgical
10% of all intracranial abscesses. Patients in the
intervention in sinusitis patients complicated with
adolescent age group get frequently affected by
intracranial complications.
unwanted complications(2). Orbital involvement is the

most common complication of sinusitis (accounting for
PATIENTS AND METHODS
80% of all complications) because of its close
This retrospective cross sectional study was
anatomical relationship to the paranasal sinuses. If
conducted in ENT and Radiology Departments, Faculty
intraorbital complications are not treated in time, they
of Medicine, Zagazig University on 24 cases with
can progress to life-threatening complications such as
sinusitis complicated with intracranial complications.
optic neuritis, cavernous sinus thrombophlebitis or
Inclusion criteria: Gender: male and female. Patients
intracranial complications(3,4) .
with
sinusitis
complicated
with
intracranial
Based upon the anatomical sites and the degree of
complications.
involvement, the patient can have various presentations
Exclusion criteria: Postoperative intracranial infections.
in complicated sinusitis. Along with a proper history
Post-traumatic intracranial infections.
and clinical examination, extensive radiological
Each patient's data set was thoroughly evaluated for
evaluation (computed tomography [CT] scan/magnetic
age, gender, occupation, residence, nasal symptoms
resonance imaging [MRI] of the paranasal sinus and
such as nasal obstruction, mucous-purulent rhinitis,
brain) is always mandated in patients with suspected
impairment in olfaction or anosmia or hyposmia, crust
complications. Conservative treatment is offered as the
formation, epistaxis, discharge, facial pain, headache,
first line of treatment for all complicated sinusitis.
fever, facial fullness or edema, nausea and vomiting.
Endoscopic/open surgical drainage is warranted in
History of ocular manifestations such as; decreased
progressive disease which does not respond to medical
visual acuity, diplopia, proptosis, ophthalmoplegia,
treatment(5).
exophthalmos and swelling of the eyelids, neurological
1414
Received: 16/10/2021
Accepted: 14/12/2021

Full Paper (vol.871 paper# 69)


c:\work\Jor\vol871_70 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1418-1420

Relation between Alkaline Phosphatase and Cardiovascular Disease: Review Article
Omar Adel Abdelkader El-Ghazaly*, Sherif E. H. A, Hussien E.M, El-Kot M. A.
Department of Cardiology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Omar Adel Abdelkader El-Ghazaly, E-Mail: dr.omarelghazali@gmail.com

ABSTRACT
Background:
In human tissues, alkaline phosphatase (ALP) is a membrane-bound glycoprotein with the highest activity
reported in kidneys, bone as well as in liver. In recent years, it has emerged as a risk factor for cardiovascular disease.
ALP has been linked to increased vascular inflammation as well as calcification in both laboratory and clinical trials.
Blood ALP activity has been associated with an increased risk of death or significant adverse cardiovascular events
such as stroke, myocardial infarction, coronary revascularization, coronary slow flow phenomenon, and peripheral
artery disease in epidemiological studies. Patients with chronic renal disease may benefit from medication therapy aimed
at improving bone AP, according to new research.
Objective: This review article aimed to evaluate the Potential relationship between cardiovascular disease and alkaline
phosphatase.
Methods:
The databases were searched for articles published in English in 3 data bases [PubMed, Google scholar and
science direct] and Boolean operators (AND, OR, NOT) had been used such as [alkaline phosphatase AND
cardiovascular disease OR CVD] and in peer-reviewed articles between June 2005 and October 2021.
Conclusion:
Diagnosis of cardiovascular disease (CVD) is not based on ALP measurement. According to recent
research, heart disease and CVD-related death are both more likely in people with higher levels of AP activity.
Keywords: Alkaline phosphatase, Cardiovascular disease.

absence of non-ossifying cartilage, was reported to
INTRODUCTION
liberate phosphate by Robison in 1923. Robison and
As a plasma membrane-anchored enzyme,
Soames later termed the enzyme found in bone
alkaline phosphatases can be found in a wide range of
"monophosphoric esterase. Elevated AP levels have
organisms, from bacteria to humans. Catalyzing the
been linked to cardiovascular disease (CVD) and
hydrolysis and transphosphorylation reactions, the
mortality in population-based research, according to
enzymes can be applied to a wide range of substrate
epidemiological evidence. In patients who had suffered
phosphate monoesters and acceptors (1). The
an acute myocardial infarction, Tonelli and colleagues
biochemical characterisation of AP and the postulation
(3) looked at the correlation between AP and
of its physiological role were greatly aided by a series of
cardiovascular disease risk. A stronger connection was
experiments conducted by Robison and Kay (2) in the
shown between AP and death as the concentration of
1920s. Hexosephosphoric ester hydrolyzed in the
phosphate increased (3).
presence of rabbit and rat bone extracts, but not in the

Structure and function:


Figure (1): The L/B/K ALP protein structure is depicted in a ribbon diagram (1).
1418
Received: 19/10/2021
Accepted: 17/12/2021

Full Paper (vol.871 paper# 70)


c:\work\Jor\vol871_71 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1421-1426

Laparoscopic Totally Extra-Peritoneal (TEP) Versus
Transabdominal Pre-Peritoneal (TAPP) Inguinal Hernioplasty
Ahmed Masaud A. Tyur*, Yasser A. Orban, Ahmed M. Sallam, Abdelrahman A. Sarhan
Department of General Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Ahmed Masaud A Tyur, Email: ahmed.tuoor@yahoo.com
ABSTRACT
Background:
The totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair are the most prominent
laparoscopic techniques for the repair of inguinal hernia.
Objective: The current study aimed to reduce postoperative complications including recurrence rate, wound infection,
and nerve injury.
Patients and methods: The study was a prospective comparative between TEP versus TAPP inguinal hernioplasty. The
study included 60 patients who were presented in the outpatient clinic at Zagazig Hospitals University and followed up
at our clinics. The cases were aliquoted randomly into 2 groups, group (I): 30 cases subjected to TAPP hernioplasty,
and group (II): 30 cases subjected to TEP hernioplasty.
Results: The present findings showed remarkable increase in scrotal swelling frequency in TEP group than TAPP group,
and also a significant elevation in subcutaneous emphysema frequency in TAPP group than TEP group, while
concerning the operative complication there was not any remarkable difference between the groups. The current results
revealed that during follow-up (6 months), there was not any reported recurrent cases.
Conclusion: TEP showed increased safety and potential peritoneal repair. On the other side, TAPP revealed easier
learning curve and fine visualization. Both techniques are effective in inguinal hernia management and were
associated with 0% recurrence. However, due to short follow up duration, and small sample size, longer-term studies
are also recommended.
Keywords: Inguinal Hernioplasty, TAPP, TEP, Totally extraperitoneal, Transabdominal preperitoneal.

INTRODUCTION
PATIENTS AND METHODS
Groin hernias are organ abnormal protrusion
The study was a prospective cohort study between
through a weak area in the lower abdomen. The groin is
laparoscopic TEP versus TAPP repair of inguinal
the area between the abdomen and thigh, including
hernioplasty. The study included 60 male patients that
femoral, indirect, and direct hernias (1). Among the
were presented in the outpatient clinic of Liver, GIT and
general surgeries, the repair of inguinal hernia is
Laparoscopic Surgery Unit at Zagazig Hospitals
considered common worldwide, the diagnosis depends
University during the period between January (2021)
on the physical examination and history, also is
and January (2022) and were followed up at our clinics.
distinguished by bulge appearance. Laparoscopic repair
The cases with following criteria were subjected to
with mesh, open primary repair, and open tension-free
the study; male cases more than 18 years old, patients
repair with mesh are considered the most frequent
with unilateral or bilateral inguinal hernia, and cases
treatment (2).
with comorbidities but fit for laparoscopic surgery.
Inguinal hernia represented 97% of groin hernia,
The exclusion criteria included; cases with
while femoral hernia represented 3%. Concerning
complicated inguinal hernia such as irreducibility,
gender, the males possessed 90.2%, while females
obstruction,
recurrent
inguinal
hernia,
and
possessed 9.8% of inguinal hernia, while femoral hernia
strangulation, patients unfit for surgery, huge
was female-predominant. The hernia risk factors
inguinoscrotal hernia, and patients with inguinal hernia
included external, and patient related factors. Inguinal
associated with more than grade II varicocele by U/S.
hernia elevated incidences were correlated with male
The cases were allocated randomly into 2 groups,
gender, hiatal hernia, Caucasian race, older age, and
group (I): 30 cases underwent TAPP hernioplasty, and
lower body mass index (BMI) (3).
group (II): 30 cases underwent TEP hernioplasty.
Transabdominal preperitoneal (TAPP) repair

includes laparoscopic assessment of peritoneal cavity
Preoperative evaluation:
and inguinal areas, also a mesh is placed against
The evaluation included preoperative clinical
inguinal wall to reduce the sac of hernia (4). The totally
history
taking,
clinical
examination (general
extraperitoneal repair (TEP) helps in hernia sac
examination, vital signs, abdominal examination, and
reduction and dissection, myopectineal orifices
chest examination), and local examination of the hernia
evaluation, and mesh placement without abdominal
site to detect its type and size and to exclude any
cavity entering (5).
complicated hernias (such as incarcerated, irreducible,
The aim of the current study was to reduce
or huge hernias).
postoperative complications including recurrence rate,
Investigations were requested for all patients,
wound infection, and nerve injury.
including: Laboratory tests including kidney and liver

function tests, complete blood picture, fasting blood

sugar levels and hepatitis markers, coagulation profile,

1421
Received: 17/10/2021
Accepted: 15/12/2021

Full Paper (vol.871 paper# 71)


c:\work\Jor\vol871_72 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1427-1435

Non-Diabetic Kidney Disease in Type 2 Diabetic Patients: Assiut University Experience
Mohammad A Sobh1 , Ahmed A. Obiedallah2 , Asmaa Nady Sayed*3 ,
Walaa H Ibrahim1 , Essam M. Abdel Aziz1 , Wesam Ismail4
1 Department of Internal Medicine, Nephrology Unit,2 Department of Internal Medicine,
Cardiology and Critical care Unit, Faculty of Medicine, Assiut University Hospital, Assiut,
3 Department of Internal Medicine, Nephrology Unit, Umm Al Qusur Assiut University Hospital, Assiut,
4 Department of Pathology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
*Corresponding Author: Asmaa Nady Sayed, Mobile: (+2) 01006854221 / (+2) 01550131140,
E-mail: Dr_Asmaa_Nady@yahoo.com

ABSTRACT
Background
: Diabetic kidney disease (DKD) is regarded as the leading reason for inducing end-stage renal disease (ESRD),
representing (34.7%) of hemodialysis patients in Egypt.
Also, the prevalence of non diabetic kidney disease (NDKD) is high in type 2 diabetes mellitus (T2DM). Consequently,
renal biopsy is considered the gold standard for determining NDKD in T2DM.
This study investigated the potential reasons for triggering kidney disease in T2DM cases with atypical presentations of
DKD. Patients and Methods: The present study was conducted in the Department of Internal Medicine, Nephrology Unit,
Assiut University Hospital, Egypt, during the interval from January 2016 to May 2020. We recruited 60 patients with T2DM
and investigated for the atypical presentation of DKD in this study.
Subjects underwent laboratory investigations, examination, detailed history, special investigations when indicated, fundus
examination, and renal biopsy. Results: The current study showed that the NDKD either alone or coexisting with DKD,
representing 81.7% of the studied patients. Subjects were categorized into three groups according to the findings of biopsy
DKD, NDKD, and coexisting DKD with NDKD; the frequencies were 11 (18.30 %), 32 (53.30 %), and 17 (28.30 %),
respectively. Amyloidosis is the most common renal disease, followed by acute tubular injury.
Conclusion: This study demonstrated that NDKD is prevalent in T2DM, and renal biopsy is considered the gold standard
for diagnosing renal pathology in diabetic patients.
Keywords: Diabetic kidney disease, Renal biopsy, Non Diabetic Kidney disease.
Abbreviations: Diabetic kidney disease (DKD), end-stage renal disease (ESRD), non diabetic kidney disease (NDKD), type 2 diabetes
mellitus (T2DM), glomerular filtration rate (GFR), the renin-angiotensin-aldosterone system (RAAS), focal segmental
glomerulosclerosis (FSGS), estimated glomerular filtration rate (eGFR), modified diet in renal disease (MDRD), antinuclear antibody
test (ANA), anti-double stranded deoxyribonucleic acid (AntiDs-DNA), antineutrophil cytoplasmic antibodies test (ANCA), hepatitis
B surface antigen (HBsAg), hemoglobin A1C (HbA1C), blood pressure (BP), masson's trichrome stains (MT), immunoperoxidase (IP),
leucocyte chemotactic factor type 2 (LECT2), amyloid light-chain (AL), amyloid A (AA), the global sclerosis score (GS), advanced
glycation end products (AGEs), renal reactive amyloidosis (RAAA), acute kidney injury (AKI), diabetes mellitus (DM), diastolic blood
pressure (DBP), systolic blood pressure (SBP), periodic acid­Schiff (PAS), eosin and hematoxylin (H&E), standard deviation (SD),
hypertension (HTN), mean arterial pressure (MAP), Immunohistochemistry (IHC).

INTRODUCTION


DKD is regarded as the primary reason for inducing
3. Renal biopsy is considered the standard gold method to
ESRD, representing (34.7%) of hemodialysis cases in
diagnose kidney disease in T2DM 4.
Egypt 1. The guidelines of KDOQI in 2007 defined DKD
Several groups found that the most frequent NDKD
involvement as the existence of microalbuminuria or
diagnoses in diabetes patients' renal biopsies are focal
macroalbuminuria, along with diabetic retinopathy in
segmental glomerulosclerosis (FSGS), membranous
both kinds of diabetes mellitus (DM) 2. On the contrary,
nephropathy, and IgA nephropathy 5.
the properties that indicate the existence of NDKD were
In our study, we aimed at determining the potential
summarized as: a rapid decline in renal function, non-
reasons for inducing kidney disease in T2DM cases.
existence of diabetic retinopathy, rapid elevation in

nephrotic syndrome or proteinuria, active urinary
PATIENTS AND METHODS
sediment, refractory hypertension, symptoms or signs of
Patients:
systemic disease, as well as decreased glomerular
The current prospective cross-sectional study was
filtration rate (GFR) for more than 30% within 2­3
conducted in the Department of Internal Medicine,
months following the blockade of the renin-angiotensin-
Nephrology Unit, Assiut University Hospital, Egypt,
aldosterone system (RAAS) 2.
during the interval from January 2016 to May 2020. We
In contrast, NDKD pervasiveness is increased in
recruited 60 patients with T2DM and investigated for the
T2DM, and thus it is crucial to identify NDKD in T2DM
atypical presentation of DKD.
1427
Received: 14/10/2021
Accepted: 12/12/2021

Full Paper (vol.871 paper# 72)


c:\work\Jor\vol871_73 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1436-1441

Polycystic Ovary Syndrome Phenotypes among Infertile Women in
Zagazig University Hospitals
Amal Mohamed Al Anwar, Mohamed Lotfy Mohamed El Sayed,
Ameerah Mohammed Alsheebani Salim*, Hoda Sibai Abd Al Salam
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ameerah Mohammed Alsheebani Salim, Email: Amiramh545@gmail.com

ABSTRACT
Background:
Little studies have been performed to study the different Polycystic Ovary Syndrome (PCOS) phenotypes
among infertile women.
Objective: Evaluation the phenotypes of polycystic ovary syndrome among infertile women in Zagazig University
Hospitals.
Patients and methods: This study was conducted, as cross-sectional study on 48 infertile women attending Cytogenetic
Unit and Ultrasound Unit at Zagazig University Hospital, who were diagnosed with PCOS. They were evaluated by
ultrasonography. They were assigned into four phenotypes; A, B, C, and D, on basis of Rotterdam criteria.
Results:
The primary infertility was more common among phenotype A, while secondary infertility was more common
among phenotypes B and D but without statistical significance difference. There was no statistically significant
difference between different types of PCO in prolactin, FSH, free testosterone and cortisol but there was a statistically
significant increase in LH among type D in comparison to other types, there was a statistically significant increase in
total testosterone among type A in comparison to other types and there was a statistically significant decrease in 17 -
OHP among type D in comparison to other types. There was a statistically significant increase in antral follicle count
on right side among type A in comparison to other types and there was a statistically significant increase in antral follicle
count on left side among type A and D in comparison to other types.
Conclusion: The study suggests that phenotypic group A is the most prevalent phenotype of PCOS.
Keywords: Infertility, Phenotypes, Polycystic Ovary Syndrome.

INTRODUCTION


As
a
metabolic
and
reproductive
criteria that include both hyperandrogenism (HA) and
endocrinopathy, polycystic ovarian syndrome (PCOS)
oligo-anovulation (OA), according to a 2018
is quite common. It is common for young women with
international PCOS guideline (7).
PCOS to suffer from infertility, menstrual irregularities,
The clinical manifestations of PCOS include
and persistent anovulation due to their condition.
infertility, hyperandrogenism, oligo ovulation or
PCOS-afflicted women have a 10-fold increased risk of
anovulation, and other metabolic problems. There was
infertility, which affects up to 40% of the population (1).
a statistically significant difference between the infertile
Fertility is reduced because of the endocrine, metabolic,
women with PCOS and the infertile women who had
and gynecological problems associated with PCOS,
normal ovaries in terms of the frequency of
which affect the ovary's ability to function (2).
menstruation, oligomenorrhea, hirsutism and serum
As a result, the frequency of PCOS can vary
testosterone levels (8).
greatly from place to place and population to
So finally, in 2012, National Institutes of Health
population. A person's race and ethnicity play a role in
(NIH) consensus panel proposed the phenotypic
whether or not they are diagnosed with PCOS.
approach to classify PCOS (9) into: (1) Phenotype A
According to the Rotterdam criteria, PCOS and PCO
(full-blown syndrome PCOS: PCO+OD+ HA)
have a global prevalence of 5-10% and 17-22%,
involving polycystic ovaries (PCO), ovulatory
respectively. There are few research in Africa on the
dysfunction (OD), in addition to HA (biochemical or
prevalence of PCOS, with estimates ranging from 16
clinical), (2) Phenotype B (non-PCO PCOS: OD+HA)
percent to 32 percent from various institutions (3).
involves ovulatory dysfunction (OD) and HA. (3)
Polycystic ovaries (PCO) are characterized by antral
Phenotype C (ovulatory PCOS: PCO+ HA) involves
follicles that have been unable to mature. PCOS is
PCO and HA. (4) Phenotype D (non-hyperandrogenic
thought to be the root cause of anovulatory infertility in
PCOS: PCO+OD) involves PCO and OD.
as many as 75% of women with the condition. A quarter
These four phenotypes are still to be established
of women with PCO go on to develop PCOS symptoms,
as a broad range of the same illness, which is known as
making it the most common form of PCOS (4,5).
PCOS. PCOS phenotypes have not been studied
PCOS is associated with insulin resistance and
thoroughly enough (10).
obesity, but neither of these symptoms is listed in the
Aim of the work was to evaluation of polycystic
diagnostic criteria, thus they should be employed for
ovary syndrome phenotypes in Zagazig University
this reason (6). Diagnosing polycystic ovarian syndrome
Hospitals among infertile women.
is a difficult task. Adolescents with polycystic ovaries

(PCOS) should be diagnosed using updated Rotterdam
PATIENTS AND METHODS
1436
Received: 17/10/2021
Accepted: 15/12/2021

Full Paper (vol.871 paper# 73)


c:\work\Jor\vol871_74 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1442-1448

The Association Between COVID-19 Pfizer Vaccine and
The Reported Post-Vaccination Menstrual Changesi Citizen and
Resident Women in KSA: Results of Riyadh Survey Study
Ezat A. Mersal1, 2, Ahmed A. Morsi3, Alaa M. Hassanein2,4, Aryaf Alshammri5,
Abeer Alshammari5, Nourah Alkahmous5, Fatimah Alhuwayji5, Riham G Elfawal6,7
1Biochemistry Department, Faculty of Science, Assiut University, Assiut, Egypt
2Department of Basic Medical Sciences, Vision College of Medicine, Riyadh, KSA
3Histology and Cell Biology Department, Faculty of Medicine, Fayoum University, Fayoum, Egypt
4Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
5Students at Vision College of Medicine, Riyadh, KSA
6Clinical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
7Department of Clinical Sciences, Vision College of Medicine, Riyadh, KSA
Corresponding author: Dr Ahmed A. Morsi, Email: aaa21@fayoum.edu.eg, ahmed_saqr4@yahoo.com, ORCID: 0000-0001-7911-0795

ABSTRACT
Background:
Pfizer vaccine has been approved for use in Saudi Arabia. Although the vaccine efficacy has been
frequently addressed, little knowledge is available regarding the real-world post-vaccination menstrual disturbances.
Objective: The aim was to evaluate the possible association between Pfizer vaccine and the post-vaccination menstrual
irregularities among Saudi citizen and resident women.
Subjects and methods: A self-administered validated questionnaire was used to obtain the data. It was distributed all
over Riyadh City, KSA through social media and 731 females responded to the survey. Results: Overall, 50.9% of the
participants reported a menstrual change after vaccination, in particular, those who received the 2 doses. There was a
significant and positive correlation between the number of doses and the experience of menstrual changes being
associated with the 2 dosed women. In details, 60.5% mentioned a menstrual delay, 30.4% reported early onset, and 9.1%
mentioned a menstrual change other than in the date. 43.3% reported a decrease in the amount of menstrual flow, 34.9 %
mentioned an increase. 62.4% declared an increase in the severity of pain while 11% reported a decrease. Interestingly,
only 60.8% of the respondents mentioned the persistence of the menstrual changes each following cycle. However, the
changes were positively correlated with the age and negatively associated with the marital status being less in married.
Conclusion: It was concluded that the post-vaccination menstrual changes might be related to the age, marital status, and
those receiving 2 doses and these changes could be related to the immune response frequently associated with vaccines.
Keywords: COVID19 immunization, Cross-sectional study, Fertile females, Menstrual irregularities, Side effects,
Vaccine reactogenicity

INTRODUCTION
the most widely used RNA vaccine. It was proven to
The outbreak of the 2019-novel coronavirus
induce both cellular and humoral immunities with better
(SARS-CoV-2) that causes severe respiratory infection
response than BNT162b1. Severe allergic reactions
(COVID-19) has been declared a pandemic by the World
including anaphylaxis have been recorded to be the only
Health Organization (WHO) (1). WHO first learned about
contraindication (6,7). The second vaccine developed by
this new virus on December 31, 2019, after case reports
RNA technology is mRNA-1273. It is an LNP-
of viral pneumonia in Wuhan, People's Republic of
encapsulated mRNA vaccine with no safety concerns
China (2). Clinical research and tests have demonstrated
were raised, aside from temporal local and systemic
that licensed vaccines are effective in controlling the
reactions (8).
disease. However, the current vaccines should be
Recently, COVID-19 vaccines have been
evaluated against the emerging variants of SARS-CoV-2
distributed on a wide scale worldwide. Despite their
(3). There are a variety of vaccines that have been
protective efficacy has been frequently addressed, little
approved for use; Pfizer-BioNTech, AstraZeneca, and
data is available regarding the real-world post-
Moderna (4). In Kingdom of Saudi Arabia, the Saudi
vaccination experiences outside the clinical trial
Food and Drug Authority (SFDA) has announced the
conditions, in particular Pfizer mRNA vaccine on
approval of the registration of Pfizer-BioNTech COVID-
females' menstruation. So, the current study strived to
19 Vaccine since December 10, 2020 (5).
investigate whether the Pfizer vaccine is associated with
The
Pfizer-BioNTech
COVID-19
vaccine,
post-vaccination menstrual changes in a sample of 16-40
BNT162b2, is a lipid nanoparticle (LNP) that
years citizen and resident women in Riyadh city, using a
encapsulates nucleoside-modified mRNA that encodes
cross-sectional survey-based study. Precise information
the SARS-CoV-2 full-length spike (S) protein, and it is
about the expectation after vaccination will help us
1442
Received: 21/10/2021
Accepted: 19/12/2021

Full Paper (vol.871 paper# 74)


c:\work\Jor\vol871_75 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1449-1455

Study of Video Assisted Laryngoscope versus Conventional Macintosh Laryngoscope
for Management of Predicted Difficult Airway in Minor Elective Surgeries
Ahmed Mosallem Mohammed, Amal Essam Abdel-Fatah*,
Howaida Kamal Abdul Latif, Manal Salah El-Din Farmawy
Anesthesia, Intensive Care and Pain Management Department, Faculty of Medicine, Zagazig University, Egypt
Corresponding Author: Amal Essam Abdel-Fatah, E-Mail: essamarafa11@gmail.com

ABSTRACT
Background
: Video laryngoscopy can manage predicted difficult airway as ordinary Macintosh laryngoscopy rather
it does not require a line of sight to do the procedure.
Objective: The aim of this randomized clinical trial was to compare between video assisted laryngoscope and
conventional Macintosh laryngoscope in management of predicted difficult airway.
Patients and Methods: Our study included sixty-six patients with predicted difficult airway prepared for elective
minor surgery under general anesthesia. Patients were divided randomly into two equal groups; Group V: The video
laryngoscope was used. Group M: a Macintosh laryngoscope was used. Laryngoscopic and intubation time were
recorded as well as number of intubations attempts and failure rate. Additionally, Heart rate (HR) and oxygen
saturation were recorded at different time intervals (baseline value, before intubation, at laryngoscopic time and at
intubation time). Also, complications during intubation were recorded as hypoxemia <90 %, dental trauma and lip,
gum and oral trauma.
Results: Video laryngoscope group was significantly longer regard laryngoscopy time and intubation time
comparing to direct Macintosh group. Patients of direct Macintosh group had higher HR during laryngoscopy time
and during intubation time. Oxygen saturation during intubation time was significantly lower among direct
Macintosh group. Video laryngoscope group was significantly associated with less attempts, but failure rate was
significantly higher among direct Macintosh group compared to video laryngoscope group.
Conclusion: Using video assisted laryngoscope in anticipated difficult intubated patients improves the quality of
tracheal intubation and gives the best glottic view, but with longer laryngoscopic and intubation time.
Keywords: Video Assisted Laryngoscope, Conventional Macintosh, Difficult Airway management.

INTRODUCTION


The most critical stage in administering general
base of the tongue, which reduces the risk of triggering
anesthesia is intubation of the patient's airway. It keeps
a stress reaction and injuring local tissue. Aside from
the airways open, ensures the safety of the procedure,
reducing neck movements, this laryngoscope creates
and guards against aspiration damage to the lungs(1).
less cervical movement compared to a standard
When numerous attempts, multiple operators, multiple
Macintosh laryngoscope. Several of the blades have a
devices, significant lifting effort, or external laryngeal
characteristic
shape.
An
oropharyngeal
and
manipulation are required to intubate the trachea, it is
hypopharyngeal anatomy-like curvature allows for a
considered a difficult procedure (2). To insert a flexible
more expansive view (8).
polyvinyl chloride tube into the trachea, direct
The aim of this study was to compare video-
laryngoscopy requires a series of operations, such as
assisted laryngoscopy and the standard Macintosh
elongating the head and opening the mouth, dislocating
laryngoscope regarding glottic view, time of intubation,
and compressing the tongue, and elevating the mandible
number of intubation attempts and failure rate.
forward (3).

Poor glottic exposure may necessitate more efforts
PATIENTS AND METHODS
and be more time consuming, as well as posing a risk of
Sixty-six patients undergoing minor elective
problems (4). Attempts to ventilate a patient with a
surgery, at operating theatres, Faculty of Medicine,
difficult airway, such as intubation, on multiple trials
Zagazig University Hospitals.
may increase the risk of tissue trauma, hemorrhage, and

mucosal edema (cannot ventilate, cannot intubate
Ethical considerations:
situation), There is a direct correlation between the
Zagazig University's Research Ethics
number of laryngoscopic attempts and the rate of
Council approved the study (ZU-IRB#6837) as long
complications (5).
as all participants signed informed consent forms
Similar to the standard Macintosh approach, a
and submitted them. We adhered to the Helsinki
video assisted laryngoscope has been reported that it
Declaration, which is the ethical form for human
does not rely on a line-of-sight. Using a camera placed
testing established by the World Medical
in the blade's underside, the picture is collected and
Association.
relayed to a monitor, allowing for verifiable glottic

exposure and video capture (6, 7). Using a video aided
Inclusion criteria:
laryngoscope necessitates less force (5-14 N) on the
Both genders patients aged more than 21 years who
1449
Received: 18/10/2021
Accepted: 16/12/2021

Full Paper (vol.871 paper# 75)


Subclinical impairment of left ventricular function in diabetic obese and non-obese patients: a study based on two dimensional The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1456-1463

Angiographic Parameters in Diagnosis of Microvascular Dysfunction in
Patients with Heart Failure with Preserved Ejection Fraction
Mohammed I. El-Awady, Tamer M. Moustafa, Ahmed H. E. Soliman*, Moataz Elsanan
Department of Cardiology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Hassan Soliman, E-Mail: ahmed_soliman903@yahoo.com

ABSTRACT
Background:
Heart failure with preserved ejection fraction (HFpEF) is a health care problem of epidemic proportions,
currently accounting for roughly 3 million patients in the United States alone.
Objective: To study, using validated angiography indices, coronary blood flow and myocardial perfusion of the
microcirculation to assess whether there is greater microvascular disease (MVD) in patients with microvascular angina
and HFpEF compared to those who do not have.
Patients and methods: This retrospective study took place in El-Mahalla Cardiac Center on 160 patients with stable
angina undergoing coronary angiography and echocardiography. All patients were subjected to complete history taking,
full clinical examination, echocardiography, coronary angiography and angiography indices. Our patients were divided
into two categories: 80 patients with HFpEF and 80 without HFpEF.
Results:
There were statistically significant differences between the studied groups. We found lower myocardial blush
grades (MBG) in three coronary arteries in HFpEF than non-HFpEF patients, with good statistical significance regarding
MBG left anterior descending (LAD) and MBG left circumflex (LCX). Also, there was statistically significant difference
between the studied groups regarding total MBG value. Between thrombosis in myocardial infarction frame count (TFC)
and MBG, there was a good correlation. The best cutoff of total TFC in diagnosis in diagnosis of HFpEF was 98.55
with sensitivity of 92.5% and specificity of 73.8%. Also, the best cutoff of total MBG in diagnosis in diagnosis of
HFpEF was 6.55 with sensitivity of 80% and specificity of 87.5%.
Conclusion: The HFpEF population has a greater involvement of microcirculation than patients without HFpEF.
Keywords: Angiography, Coronary microvascular dysfunction, Heart failure with preserved ejection fraction.

INTRODUCTION
It causes substantial mortality and morbidity and
A growing body of evidence has underscored the
represents a major disease and socioeconomic burden.
importance of coronary microvascular dysfunction
CHF is a systemic syndrome involving the heart,
(CMD), which manifests as the structural and functional
vasculature, kidneys, and other organs, but it develops
abnormalities of coronary microvasculature, in a variety
primarily as a result of diverse acquired and/or genetic
of cardiovascular diseases (1). The prevalence of CMD
structural and functional abnormalities of the heart.
is higher than ever thought in many clinical settings, and
Forty percent to 50% of CHF patients have a form of
its presence is associated with worse clinical outcomes,
heart failure in which left ventricular (LV) systolic
especially when accompanied by myocardial ischemia
function, as assessed by ejection fraction (EF) at rest, is
or nonsignificant coronary artery disease (CAD) (2).
relatively well preserved. This type of heart failure has
Heart failure is a complex medical syndrome that
come to be termed heart failure with preserved EF
comes about from any structural or functional
(HFpEF). The outcome of patients with HFpEF is on
impairment of ventricular filling or ejection of blood.
average slightly better than for those with reduced EF
Strangeities of contracting and diastolic dyswork
(HFrEF), but they still have substantial morbidity and
coexist, irrespective of ejection fraction (EF). EF is
mortality, e.g. 23% mortality over 3 years in a large
considered precious in classification of patients with
meta-analysis (5).
heart failure since of differing sick person
Furthermore, the prevalence of HFpEF relative to
demographics, comorbid status, fate and response to
HFrEF is rising. Although many trials have had limited
therapies and since most medical trials selected persons
power, treatments used for patients with HFrEF (e.g.
based on EF. EF values are dependent on the shaping
inhibitors of the renin-angiotensin-aldosterone system,
technique used, method of analysis and operator. Since
adrenergic blockers, biventricular pacemakers, and
other techniques may indicate strangeities in
implantable defibrillators) have not been shown to
contracting work among patients with a preserved EF,
reduce mortality in HFpEF. Current treatment is thus
it is suggested to use the terms preserved or small
focused on comorbidities (6).
ejection fraction over preserved or reduced contracting
More recently, additional mechanisms have been
work (3).
discovered that are unrelated to diastolic function. Some
Chronic heart failure (CHF) affects nearly 6
studies shifts emphasis from LV afterload excess to
million people in the United States and similar
coronary microvascular inflammation. This shift is
proportions in other industrialized countries. The
supported by a favorable Laplace relationship in
prevalence is projected to rise substantially over the
concentric LV hypertrophy and by all cardiac chambers
next 15 years, particularly in the >65 age group (4).
showing similar remodeling and dysfunction.
Myocardial remodeling in HFpEF differs from heart
1456
Received: 18/10/2021
Accepted: 16/12/2021

Full Paper (vol.871 paper# 76)


c:\work\Jor\vol871_77 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1464-1466

Could Ascitic Fluid Lactoferrin Help in Diagnosis of
Spontaneous Bacterial Peritonitis? Review Article
Mohamed Ahmed Ahmed Abdel wahed*1, Tarik Ibrahim Ali Zaher2,
Ahmed Mokhtar Ahmed Ebrahim3, Ahmed Abou El khair Ahmed Badawy2
Department of 1Tropical Medicine, Police Academy Hospitals, Cairo, Egypt
Departments of 2Tropical Medicine and 3Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohamed Ahmed Ahmed Abdel wahed, Email: mohamedabwahed90@gmail.com


ABSTRACT
Background:
When an ascitic fluid is infected with bacteria, it's known as spontaneous bacterial peritonitis (SBP).
Polymorphonuclear leukocyte (PMN) count of at least 250 cells/mm3 is required for diagnosis of SBP despite the
positive results of bacterial culture in the ascitic fluid. The number of PMNs in the ascitic fluid is counted after bringing
it to the laboratory. True-negative results can be produced by the lysis of PMNs in the laboratory. The operator is
responsible for manually counting the PMN in the ascitic fluid, which can cause a delay in the diagnosis. Proteins that
bind iron, such as lactoferrin, are detected in both human mucosal secretions and PMN-specific granules. Lactoferrin
concentration in faeces has been shown to be very sensitive and specific for the identification of intestinal inflammation
in previous research.
Objective:
Diagnosis of spontaneous bacterial peritonitis could be improved by using ascitic fluid lactoferrin.
Methods: PubMed, Google scholar and Science direct were searched using the following keywords: Ascitic fluid
lactoferrin, spontaneous bacterial peritonitis and polymorphonuclear leukocytes. The authors also screened references
from the relevant literature, including all the identified studies and reviews, only the most recent or complete study was
included.
Conclusion: A biomarker for the existence of PMNs and the detection of SBP in cirrhotic individuals would be
lactoferrin in the ascitic fluid.
Keywords: Ascitic fluid lactoferrin, Spontaneous bacterial peritonitis.

INTRODUCTION

fluid lactoferrin, spontaneous bacterial peritonitis, more
Peritonitis caused by a bacterial infection of the
synonymous key words had been used.
fluid within the abdomen is known as spontaneous
These databases were searched for articles
bacterial peritonitis (SBP) (1). In individuals with
published in English in 3 data bases; PubMed ­ Google
cirrhosis, spontaneous bacterial peritonitis is a well-
scholar and Science direct and Boolean operators
known and worrisome consequence. Child-Pugh class C
(AND, OR, NOT) had been used such as Ascitic fluid
cirrhosis patients account for 70% of cases of
lactoferrin AND spontaneous bacterial peritonitis OR
spontaneous bacterial peritonitis in patients with the
polymorphonuclear leukocyte as well as in peer-
disease. When this occurs in these people, it is connected
reviewed articles between February 2003 and October
with a bad long-term outcome. At significant risk of
2021; a 18-year date range was selected, and no
death is the cirrhotic patient who develops spontaneous
language limitations, and filtered in selected data basis
bacteriophageal peritonitis after septic shock (2).
for the last 18 years. Documents in a language apart
As much as 18% of people with ascites may be
from English have been excluded as sources for
affected. In the last two decades, this number has
interpretation. Papers apart from main scientific studies
increased from 8%, most likely as a result of heightened
had been excluded e.g. documents unavailable as total
awareness of spontaneous bacterial peritonitis and
written text, conversation, conference abstract papers
lowering diagnostic paracentesis thresholds (3).
and dissertations.
The aimed of review was to diagnose spontaneous

bacterial peritonitis, which could be improved by using
Lactoferrin:
ascitic fluid lactoferrin.
Lactoferrin is a component of the human immune

system. It has antibacterial properties (bactericide and
Methods:
fungicide) as well as an innate defensive mechanism,
A search strategy has been performed to
primarily at mucosal surfaces. Lactoferrin, in particular,
determine the related literature. Initially, the objective
has antibacterial properties for newborns. Heparin,
of review was identified: Diagnosis of spontaneous
polysaccharides, and DNA/RNA are among the ligands
bacterial peritonitis could be improved by using ascitic
that lactoferrin interacts with, and the complexes they
fluid lactoferrin. Relevant keywords included: Ascitic
form reveal some of the biological tasks lactoferrin
serves (4).

1464
Received: 23/10/2021
Accepted: 21/12/2021

Full Paper (vol.871 paper# 77)


c:\work\Jor\vol871_78 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1467-1471

Impaction of Delay of Diagnosis of Ankylosing Spondylitis
Patients on Structural Changes
Ghada S. Nageeb1, Lamiaa Abd El Wahab mohammad2,
Hiedy Ahmed Maher Sayed*3, Mohamed Atia Mortada1
Departments of 1Rheumatology and Rehabilitation and
2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
Department of 3Rheumatology and Rehabilitation, Nasser Institute for Research and Treatment, Egypt
*Corresponding author: Hiedy Ahmed Maher, Email: dr.haidyselim@gmail.com

ABSTRACT
Background:
Ankylosing spondylitis (AS) is an inflammatory condition with prolonged pain that results in loss of
function. Diagnosis delay in the past had little effect on the prognosis of AS because of the lack of an appropriate
treatment options. It is now possible to reduce the advancement of AS in patients who have had it for a shorter time
since biological treatment is highly effective, early diagnosis in AS has become increasingly critical.
Objective: The aim of the work was to determine the relation between delay of treatment for ankylosing spondylitis
patients and structural changes by Bath ankylosing spondylitis radiology index (BASRI) as well as Modified Stoke
Ankylosing Spondylitis Spinal Score (mSASSS).
Patients and Methods: At Zagazig University Hospitals, the Department of Rheumatology and Rehabilitation, the
Faculty of Medicine, 42 patients with Ankylosing spondylitis were studied using the modified criteria of New York for
Ankylosing spondylitis. Data were recorded from taking complete history, local as well as general examination and
laboratory investigations involved; complete blood picture, kidney function tests, CRP, ESR and complete urine
analysis. The radiological progression was assessed by mSASSS, and BASRI.
Results: The present results showed that mean patients age at disease onset and at diagnosis were 23.9, and 35.14
respectively, the mean of diagnosis delay was 7.66 years. There is a significant positive association between period of
delay of patients to intake proper treatment and BASRI, and mSASSS (p<0.05).
Conclusion:
It could be concluded that diagnosis delay of AS is associated with more structural damage detected by
mSASSS and BASRI that reflects the importance of early diagnosis.
Keywords: Bath ankylosing spondylitis radiology index, Modified Stoke Ankylosing Spondylitis Spinal Score,
Ankylosing Spondylitis

INTRODUCTION

Rheumatology and Rehabilitation, the Faculty of
Among inflammatory rheumatic disorders,
Medicine, Zagazig University Hospitals. The patients
ankylosing spondylitis (AS) shows the longest
were studied using the modified criteria of New York
diagnosis delay which is the time between symptom
for Ankylosing spondylitis.
onset to a definitive diagnosis as ankylosing spondylitis
The following diseases were excluded: Overlap
patient. This delay has a significant effect on patient
syndrome and mixed connective tissue disease,
outcomes and well-being (1).
inflammatory bowel disease, reactive arthritis, psoriatic
Diagnostic delay in AS was reported a decade ago
arthritis, malignancies (solid and myeloproliferative),
to be between five and ten years. Diagnostic delay
Parathyroid affection, and previous history of fractures
varies according to peripheral arthritis, educational
as well as patients younger than 18 years.
level, extra articular manifestation, sex in addition to
Data were recorded from taking complete history,
family history, as well as Human Leukocyte Antigen
local as well as general examination and laboratory
B27 (HLA-B27) status (2).
investigations involved; complete blood picture (CBC),
Due to the lack of a viable treatment strategy for
kidney function tests, CRP, ESR and complete urine
AS in the past, this lag period in diagnosis had little
analysis.
impact on the disease's outcome (3). The disease
The radiological progression was assessed by
progression of people with shorter disease duration can
mSASSS, and BASRI.
now be decelerated by managing the early stages of AS
The mSASSS scoring system depends on the
(4). It has become increasingly critical to diagnose AS
radiographic assessment of the chronic structural
early because of the availability of highly effective
changes. The mSASSS ranging between 0 and 72 by the
treatments, such as biological treatment (5).
sum of lumbar and cervical of the 24 vertebral edges
The current study was aimed to assess impaction
evaluated by radiographs of lateral vertebral view.
of delay of diagnosis of ankylosing spondylitis patients
Anteroposterior and lateral lumbar radiographs, as
on structural changes by mSASSS and BASRI.
well as lateral cervical radiographs, are used to calculate

the Bath Ankylosing Spondylitis Radiology Index for
PATIENTS AND METHODS
the spine. Lower T12 to upper S1 is a reference point
This study included a total of 42 patients with
for the lumbar spine, A combination of lateral and
Ankylosing spondylitis, attending at the Department of
anteroposterior radiographs is analyzed, with points
1467
Received: 20/10/2021
Accepted: 18/12/2021

Full Paper (vol.871 paper# 78)


c:\work\Jor\vol871_79 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1472-1476

Assessment of Medial Open Wedge High Tibial Osteotomy in
Management of Medial Compartment Osteoarthritis of The Knee
Adel Abd-Elazeem Ahmed, Khaled Edris Abdel-Rahman,
Mohamed Reda Khairy*, Ahmed Mohammed Abd-Elwahab
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohamed Reda Khairy, E-Mail: reda199020.aa@gmail.com

ABSTRACT
Background
: Osteoarthritis of the medial compartment of the knee in young, active individuals with intact range of
motion is commonly treated with medial open wedge high tibia osteotomy (MOWHTO).
Objective: The aim of the work was to use medial open wedge high tibial osteotomy to treat patients with medial
compartment osteoarthritis and varus deformity improves their surgical outcomes.
Patients and Methods: Twelve patients with varus deformity were treated by using MOWHTO performed in the
period between 2020 and 2021 at Zagazig University Hospitals and El-Sahel Teaching Hospital. The age of the
patients was ranged from 17 to 42 years. Eight males and four females completed the follow up period. Eight
osteotomies were fixed using Puddu plate while the other four were fixed using Tomofix plate. Three osteotomies
were performed with using bone graft while the others without using bone graft.
Results: The time of union ranged from 9 to 24 weeks with a mean of 12.3 weeks. The mean period of pain relief
among study subjects was eight months. All patients had full range of motion postoperatively except two who
developed limited ROM due to pain after surgery and they restore full range of motion four months after surgery with
physiotherapy.
Conclusion: It could be concluded that for patients with medial compartment osteoarthritis 2ry to genu varus,
MOWHTO is a good treatment as it restores the mechanical axis, relieves pain, improves motion and about 5 degrees
valgus position is reached and thus redistribution of the load from medial compartment of the knee to lateral
compartment.
Keywords: High tibial osteotomy, Genu varus deformity, Medial compartment knee osteoarthritis

INTRODUCTION

open wedge high tibial osteotomy as a surgical therapy
Regarding the treatment of medial compartment
option.
knee OA with varus deformity in young, active

individuals, high tibial osteotomy (HTO) has been
PATIENTS AND METHODS
commonly used (1). By shifting the center of gravity
This study was conducted at Department of
slightly to the outside of the knee joint, the weight-
Orthopedic Surgery, Zagazig University Hospitals
bearing axis shifts away from the medial compartment
and El-Sahel Teaching Hospital, in the period between
(2).
2020 and 2021. Twelve medial opening wedge high
Medial compartment knee OA symptoms can be
tibial osteotomies were performed on twelve patients.
alleviated with HTO because it realigns the lower leg
Seven of them were left while the other five were right
so that weight is distributed more evenly between the
patients with medial compartment osteoarthritis of the
medial and lateral joints (3). Using an HTO with a
knee with Varus malalignment less than 20°.
medial opening wedge preserves bone mass, ensures a

consistent correction, and protects the lateral knee
Ethical Consideration:
components including the proximal tibiofibular joint
An approval of the study was obtained from
and the common peroneal nerve (4).
Zagazig University Academic and Ethical
The hinge must be preserved and maintained if the
Committee (ZU-IRB#6056). Every patient signed an
osteotomy is to heal properly and remain stable. It is
informed written consent for acceptance of the
possible that secondary correction may be lost if the
operation. This work has been carried out in
hinge is weakened (5, 6, 7).
accordance with The Code of Ethics of the World
For medial open wedge HTO, a wide range of
Medical Association (Declaration of Helsinki) for
fixation techniques have been designed and tested.
studies involving humans.
Because of the plate's instant post-operative stability,

patients were able to be mobilised right away, and the
Inclusion criteria: Medial Compartment arthritis,
technique's initial success helped to popularize it
varus alignment across the knee. (Less than 20°), and
among active, youthful patients hoping to delay or
young, active patients (<55 years old).
avoid arthroscopic resurfacing or replacement surgery

(8, 9).
Exclusion criteria: Combined medial and
For those with medial compartment osteoarthritis and
lateral osteoarthritis, patients older than 55 years,
varus deformity, this study was aimed to use medial
1472
Received: 20/10/2021
Accepted: 18/12/2021

Full Paper (vol.871 paper# 79)


c:\work\Jor\vol871_80 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1477-1482

Prevalence of Anti-erythropoietin Antibody in Prevalent Hemodialysis
Patients Receiving Erythropoietin Hormone
Eman I. Sarhan1, Shaimaa Z. Abdelmegied*1, Asmaa M. Mahmoud2, Hussein S. Hussein1
1Nephrology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2Nephrology Department, Suez Canal Authority Hospital, Port Tawfik, Suez, Egypt
*Corresponding author: Shaimaa Z. Abdelmegied, Email: shaimaazaki@med.asu.edu.eg; nanajettan@gmail.com

ABSTRACT
Background:
Anti-erythropoietin (EPO) antibodies against a recombinant form of Erythropoietin were associated with
pure red cell aplasia. These antibodies probably cross-react with endogenous EPO causing severe anemia.
Objective:
This study was done to estimate the prevalence of anti-EPO antibody in prevalent hemodialysis patients and
its relation to anemia and EPO resistance.
Patients and Methods:
This is cross-sectional study included 90 End-Stage Renal Disease (ESRD) patients who were
on recombinant human erythropoietin for > 6 months with hemoglobin< 11 g/dL. Serum anti-EPO antibody was
measured for all Patients that were divided into 2 groups: anti-EPO antibody positive and anti-EPO antibody negative.
Results: The prevalence of anti-EPO antibodies was 45.6% (41 patients). 58.5% (24 patients) received EPO treatment
by S.C route. Anti-EPO antibody-positive patients Showed lower hemoglobin level, serum iron, and Transferrin
saturation with mean ±SD values 8.60±0.99 g/dl, 52.91±16.30 mcg/dl, 22.62±8.27 % respectively also lower MCHC
with median (IQR)29.7 (2.50) g/dl. On comparing it with antibody-negative patients (N=49) there were significant
differences with p values (< 0.0001), (0.038), (0.034), (0.002) respectively. These patients received higher EPO doses
with high erythropoietin resistance index with median (IQR) values 8000 (4000) IU/week, 10.79 (8.495) respectively.
The anti-EPO antibody was negatively correlated with hemoglobin {r-0.661, p value 0.0001} and positively correlated
with EPO doses, iron doses, and erythropoietin resistance index {r 0.309, p value 0.011, r 0.266, p value 0.003, r 0.417,
p value 0.0001} respectively.
Conclusions:
It could be concluded that anti-EPO antibodies are commonly present in prevalent hemodialysis patients
and were associated with resistant anemia and higher doses of EPO therapy.
Keywords: Anti-erythropoietin, Antibody, Hemodialysis.

INTRODUCTION

of25% in erythropoietin dose or <1 g/dL gain in
Anemia is one of the most frequent early
hemoglobin levels after 2­4 weeks of treatment[6].
complications of chronic kidney disease (CKD)[1]. It is
One of the causes of resistance to treatment with
associated with worse quality of life, reduced exercise
rHuEPO in dialysis patients is anti-erythropoietin
capacity, decreased mental agility, and increased
antibodies although it is well tolerated by most patients,
prevalence of hospitalization and mortality [2].
a small number produce antibodies that can neutralize
The main cause is erythropoietin (EPO)
both endogenous EPO and recombinant proteins [7].
deficiency due to impaired kidney function. However,
Most cases of antibody production have been associated
other causes should be considered when the severity of
with the formulation of EPOetin alfa when administered
anemia is inconsistent with the decrease in renal
subcutaneously [8].
function. Treatment of anemia in CKD patients usually
In some cases, the anti-erythropoietin (anti-EPO)
involves the use of recombinant human erythropoietin
antibody production can lead to the development of
(rHuEPO). The main cause of rHuEPO treatment failure
serious PRCA (pure red cell aplasia) and transfusion-
is the loss or low iron availability [3].
dependent anemia[9]. Recent studies have shown that
The prevalence of iron deficiency is very
anti-EPO antibody-mediated PRCA is rare but has an
common in CKD, affecting as many as 50% of patients
important adverse effect in patients with CKD who take
[4]. Multiple other factors have been identified that may
rHuEPO[10].
further exacerbate anemia developing in patients with
This study was done to estimate the prevalence of
impaired renal function. Some of these factors may be
anti- EPO antibody in prevalent hemodialysis patients
important for the development of anemia (e.g.,
and its relation to anemia and EPO resistance.
inflammatory processes or tumors), while the meaning

of others is only coincidental (e.g., folic acid or drugs),
PATIENTS AND METHODS:
or more or less hypothetical (e.g. uremic inhibitors of
This cross-sectional study included a total of 90
erythropoiesis) [5].
ESRD patients, from Suez Insurance Hospital and Ain
There is no consensus about the definition for
Shams University Hospital hemodialysis units.
rHuEPO resistance. It is defined as persistent anemia
Patients were on HD, receiving 3 sessions per week,
(hemoglobin<10­12 g/dL) or the necessity of very high
each session four hours using bicarbonate dialysate and
doses of EPOetin alfa (300 IU/kg/week subcutaneously
heparin as an anticoagulant. Patients were on
or 450 IU/kg/week intravenously. The evaluation of
recombinant human erythropoietin (rHuEPO) > 6
resistance is recommended if there is an increase
months and their hemoglobin< 11 g /dL.
1477
Received: 20/10/2021
Accepted: 18/12/2021

Full Paper (vol.871 paper# 80)


c:\work\Jor\vol871_81 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1483-1485

An Overview of Survival Rate in Pediatric ICU Following
Cardiac Arrest: Review Article
Dalia A. Abdelrahman, Nehad Ahmed Karam, Ahmed Mohammed Ezz El-Din*
Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Mohammed Ezz El-Din, Email: real7276@gmail.com

ABSTRACT
Background:
Cardiac arrest can be described as the absence of central pulses, unresponsiveness, and apnea as clinical
manifestations indicating the termination of functional mechanical heart activity. There is no way to tell for sure how
common out-of-hospital cardiac arrests happen in children, but the estimated rate is 9 for every 100,000 person/years.
Whereas, the rate in intensive care units is 0.94 for every 100 admissions. In order to maintain optimal blood pressure,
cardiac output and systemic perfusion, fluids and vasoactive, inotropic and inodilator medications should be titrated as
needed, such as norepinephrine, dobutamine and milrinone. Even while mechanical circulatory support helps patients
who aren't going into cardiac arrest, it hasn't been linked to better clinical outcomes, and it's not suggested whether it
can be used routinely in patients who have already gone into cardiac arrest.
Objective: Survival in pediatric critical care units after cardiac arrest is little understood, making it imperative that
additional research should be conducted in this area in order to better the treatment given to those who have experienced
a cardiac arrest. Methods: The databases were searched for articles published in English in 3 data bases PubMed, Google
scholar and science direct as well as Boolean operators (AND, OR, NOT) had been used such as survival rate in pediatric
ICU and cardiac arrest OR cardiopulmonary resuscitation (CPR) in pediatric and in peer-reviewed articles between April
2009 and June 2021.
Conclusion:
The survival rates of infants and young children are higher than those of older children, and this variation in
survival is mediated by the varying rates of bystander CPR or automated external defibrillators (AED) use. Children with
Out-of-Hospital cardiac arrest had a better survival rate.
Keywords: Pediatric, Survival, Cardiac arrest.

INTRODUCTION
conditions. Therefore, the results could have been
Cardiovascular arrest is defined as the absence of
impacted by this. The survival advantage in in-hospital
functional mechanical activity of the heart, as well as
cardiac arrest among children of different ages persists
apnea, unresponsiveness, and absence of central pulses.
even after correcting for all possible confounding pre-
Blood supply to vital organs such as the brain, kidneys,
arrest, arrest, and resuscitation variables, as demonstrated
and heart muscle has been restricted, resulting in a lack
by Meaney et al. (5).
of oxygen. Having a cardiac arrest is one of the most
Preexisting conditions, past neurological state, and
devastating situations a person can face in his lifetime.
previous therapy:
Healthy youngsters and individuals with underlying
Only hematologic and oncologic disorders were
medical issues can both experience it (1).
found to be significant mortality risk factors in the
The frequency of pediatric cardiac arrests in hospitals in
multivariate analysis of numerous patients with
the United States is unknown, however CPR is provided
preexisting conditions. Other researchers have also come
to 5,000 to 10,000 children annually, according to
to the same conclusion. As stated by other writers, pre-
estimates (2). Accounting for 0.77% of all children
arrest neurological status was normal in most patients,
admitted to the hospital, averaging 0.77 children per 1000
and it did not have any bearing on survival (6).
hospitalizations every year (3).
This review article aimed to investigate the survival in
Definition of cardiac arrest characteristics:
pediatric critical care units after cardiac arrest, which is
Arrest Causes:
little understood, making it imperative that additional
According to previous research, pulmonary and heart
research be conducted in this area in order to improve the
disorders were the most common causes of cardiac arrest.
treatment given to those who have experienced a cardiac
Sepsis was also a common cause of cardiac arrest in our
arrest.
study, which was considerably more common than
earlier studies. A study of adults found that sepsis was
Causes of arrest in pediatric ICU:
more likely in nations with a lower HDI. In cardiac arrest,
Age and sex:
sepsis was one of the worst prognostic factors. This
A research has shown that the number of male
shows the need of adopting measures to identify and treat
cardiac arrest victims was higher than the number of
sepsis as soon as possible (7).
female victims. There was a reduced mortality rate for
children under the age of 10, as has been reported by
Rhythm:
some writers. In the multivariate analysis, gender, age,
In contrast to previous, recent studies in children,
and weight were not revealed to be significant risk
which found that bradycardia was more common,
variables (4). Infants and children are more likely to have
asystole was the most commonly observed first heart
cardiac arrest due to respiratory or oncohematologic
rhythm. This shows that many cardiac arrests' patients
1483
Received: 19/10/2021
Accepted: 17/12/2021

Full Paper (vol.871 paper# 81)


c:\work\Jor\vol871_82 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1486-1490

Assessment of Atrial Fibrillation in Patients with Pacemaker Implantation
Mohamed Mortada Mahmoud*, Ahmed Shafie Ammar,
Islam Abd El-Moneem Elsherbiny, Ibtesam Ibrahim El-dosouky
Cardiology Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohamed Mortada, Mobile: (+2):01069373714, Email: boredman28@gmail.com

ABSTRACT
Background:
Atrial fibrillation (AF) is the commonest sustained disorder of cardiac rhythm. Permanent pacemaker
(PPM)-detected atrial high-rate episodes (AHREs) of even 5-minute duration may identify patients at increased risk for
death.
Objective: This study aimed to investigate the association of echocardiographic and clinical parameter with the
occurrence of AHREs in patients with a dual-chamber pacemaker.
Patients and methods: this retrospective study included 208 patients. It was conducted in the Cardiology Department,
Faculty of Medicine, Zagazig University Hospitals. The patients were classified according to development of AF into 2
groups: Group (A) involved 77 patients with AF and group (B) involved 131 patients without AF.
Results: The mean age of the studied cases was 61.67 ± 8.13 years and 53.4% were females. Mean SBP was 122.6 ±
16.8 mmHg while mean DBS was 76.9 ± 10.14 mmHg. There was a high statistically significant increase in LA volume
index, E/é and a high statistically significant decrease in SV index and EF among AF group compared to non AF group.
Conclusion:
In our opinions patients with CIED detected AHREs need oral anticoagulation to prevent thromboembolic
events and decrease burden of ischemic stroke.
Keywords:
Pacemaker implantation, Atrial fibrillation, Echocardiography.

INTRODUCTION
with the occurrence of AHREs in patients with a dual-
Atrial fibrillation (AF) is the most common
chamber pacemaker.
arrhythmia encountered in clinical practice and is

associated with high morbidity and mortality (1). Some
PATIENTS AND METHODS
patients suffering from AF might have mild symptoms
Our retrospective study (record-based) was
or short duration (caused by missed diagnosis) or the
performed in the Cardiology Department, Faculty of
episodes only occur at night/during sleep, which results
Medicine, Zagazig University Hospitals. The patients
in a significant underestimation of the incidence of AF
were classified according to development of AF into 2
(2). Current dual-chamber permanent pacemakers
groups: Group (A) involved 77 patients with AF and
(PPMs) are capable of detecting and storing atrial high-
group (B) that involved 131 patients without AF.
rate episodes (AHREs), which have been shown to be
Inclusion criteria: Patients with previous history of
a reliable surrogate of atrial tachyarrhythmias,
cardiac implantable.
especially for AF (3, 4). Moreover, prior studies have
Exclusion criteria: Patients without follow-up
verified the risk factors associated with AF, i.e., age,
data/echocardiographic findings (including poor-
congestive heart failure, sinus node dysfunction, and
quality images) before the implantation during sinus
higher ventricular pacing ratio (5).
rhythm. Patients who had undergone cardiac surgery.
Subclinical atrial tachyarrhythmias occur

frequently in patients with pacemakers. These
Ethical Consideration:
arrhythmias have been reported to be associated with an
The study was approved by the Local Ethical
increased risk of thromboembolism (6). Symptoms of
Committee of Zagazig University. Written consent
atrial fibrillation (AF) are variable, and approximately
was obtained from every patient prior to the
20% of patients with persistent AF are asymptomatic (7).
procedures. This study has been carried out in
Asymptomatic AF is correlated with thromboembolic
accordance with the code of Ethics of The World
risks and the 1-year mortality rate was found to be
Medical Association (Declaration of Helsinki) for
higher in asymptomatic AF patients (8).
studies involving humans.
Cardiac implantable electronic devices (CIED)
Basic demographic information including age,
have been developed, and most dual-chamber
gender was recorded. Full general and local
pacemakers have specific algorithms to detect atrial
examination with special emphasis on Systolic blood
high-rate episodes (AHREs) (9). Increased left
pressure, diastolic blood pressure and pulse pressure
ventricular (LV) stiffness estimated by LV diastolic
are measured in standard conditions. Laboratory tests
wall strain (DWS) has been reported to be a strong
included, serum creatinine, blood urea, uric acid, CRP
determinant of AF prevalence in structurally normal
and complete blood count (CBC).
patients (10).
Echocardiographic data:
The present study aimed to investigate the
All patients had been subjected to transthoracic
association of echocardiographic and clinical parameter
echocardiography (TTE) during 12-month follow up
period after permanent pacemaker implantation.
1486
Received: 22/10/2021
Accepted: 20/12/2021

Full Paper (vol.871 paper# 82)


c:\work\Jor\vol871_83 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1491-1496
Assessment of Facet Joint Block in Treatment of Persistent
Lower Back Pain in Patients with and without Modic Changes
Abduladim Mohamed Habibi1, Ahmed Ehsan Alawamry1,
Mohamed Reda Abdulaziz1, Ashraf Elsayed Ahmed2, Adel Saad Ismaeil1
Departments of 1Neurosurgery and 2Anesthesia and Pain Medicine, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Abduladim M. Habibi, Mobile: (+20) 010876543789, Email: dr.habibi20@gmail.com

ABSTRACT
Background:
Lumbar facet joints have been implicated as the source of chronic pain in 15% to 45% of patients with
chronic low back pain. Lumbar facet joint block (FJB) has been described in the alleviation of chronic low back pain of
facet joint origin. Objective: To determine the difference of outcome in lower back pain (LBP) patients with and without
Modic changes treated with therapeutic imaging-guided lumbar facet joint injections and the role of those techniques in
the future of accurate diagnosis and proper management for such patients.
Patients and methods: This study included 12 patients complaining of persisting LBP, 6 of them had Modic changes
and 6 cases without, confirmed by lumbar spine MRI at Neurosurgery Department, Zagazig University Hospital. They
were managed by lumbar facet joint block. They were followed up at 6 and 12 weeks after procedure for Visual
Analogue Scale (VAS) as well as Oswestry Disability Index (ODI).
Results: There was statistically non-significant relation between the studied groups regarding ODI pre or 6 weeks post-
injection. While there was statistically significant difference between groups regarding ODI 12 weeks postoperatively,
there was significant change in ODI over times. There was statistically non-significant relation between the studied
groups regarding VAS pre or 6 weeks post-injection. While there was statistically significant difference between groups
regarding VAS 12 weeks postoperatively. Conclusion: The effectiveness of therapeutic lumbar facet joint injections is
not altered by the presence or absence of Modic. There were no reported significant differences between study groups
for the primary outcome at 6 weeks post-injection.
Keywords: Facet Joint Block, Modic Changes, Persistent Lower Back Pain.

INTRODUCTION

The prevalence of low back pain (LBP) presented
PATIENTS AND METHODS
with an annual increase of 11.6% (1). The widely held
This study was carried out in Neurosurgery
belief that most of the episodes of low back pain are
Department, Zagazig University Hospital. We included
short-lived, with 80% to 90% of these attacks resolving
in this study 12 cases with persistent lower back pain
in about 6 weeks (2,3).
(LBP) who were managed by lumbar facet joint block,
Multiple structures in the lumbar spine including
6 of them had Modic changes while other 6 didn't have.
discs, facet joints, and sacroiliac joints have been

considered the major sources of pain in the low back
Inclusion criteria: Patients with LBP more than 6
and/or lower extremities (4). Lumbar facet joints have
months with or without sciatic pain.
been implicated as the source of chronic pain in 21% to

41% (with an overall prevalence of 31%) in a
Exclusion criteria: Patients with active infections:
heterogenous population with chronic low back pain
sepsis, osteomyelitis, discitis and epidural or skin
utilizing controlled comparative local anesthetic blocks
abscess, cold abscess, cellulitis or any kind of skin
with 80% pain relief and the ability to perform
infection in the site of injection. Age less than 18 years
previously painful movements as the criterion
and above 70 years. Recent trauma or surgery like
standard(5-7).
surgical fusions, acute traumatic Schmorl's nodes,
Based on the responses to controlled diagnostic
pregnancy and anticoagulant therapy. Presence of
blocks, false-positive rates of 17% to 19% have been
surgical pathology like spinal meningioma or tumors,
established with an overall false-positive rate of 30%
spine fracture, spondylolisthesis and deformity, huge
(8,9). Level I or II-1 evidence for the diagnostic accuracy
disc herniation compressing of neural structures, neural
of controlled facet joint nerve blocks is based on the
canal stenosis, synovial cyst.
United States Preventive Services Task Force

(USPSTF) criteria (10). In addition, there is a strong
Clinical assessment:
evidence for the diagnostic accuracy of lumbar facet
Complete clinical picture was taken before intervention
joint blocks in evaluating low back pain (11).
as personal history: (name, age, sex, occupational,
We aimed in this work to determine the
special habitat, handiness ...etc.), complaint of the
difference of outcome in LBP patients with and without
patient, present history and past history. General
Modic changes treated with therapeutic imaging-guided
physical condition and examination to assess clinical
lumbar facet joint injections and the role of those
situation and grade of pain and disability during daily
techniques in the future of accurate diagnosis and proper
activity by using Visual Analogue Scale (VAS) and
management for such patients.
Oswestry Disability Index (ODI) before procedure were
1491
Received: 21/10/2021
Accepted: 19/12/2021

Full Paper (vol.871 paper# 83)


c:\work\Jor\vol871_84 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1497-1500

Colonoscopic Findings among Patients with Lower Gastrointestinal
Tract Bleeding Admitted to Intensive Care Unit
Monkez Motieh Yousif, Mahmoud Abdo Ashour, Fayroz Othman Selim, Ahmed Naser Elsayed
Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Naser Elsayed, Mobile: (+2) 01065954395, Email: moamerahmadhasan@gmail.com

ABSTRACT
Background:
Acute lower gastrointestinal bleeding (LGIB) is an alarming indication and common disease with annual
admission of 0.15% with mortality rate of 5-10%. LGIB is caused by neoplastic and non-neoplastic lesions.
Objective: The aim of the present study was to evaluate frequency of patients admitted to Medical Intensive Care Unit
(MICU) of Zagazig University Hospitals (ZUH) with lower gastrointestinal tract bleeding.
Patients and methods: A prospective cohort study included 266 subjects and carried out at in Intensive Care Unit,
Faculty of Medicine, Zagazig University. All studied population were subjected to full history taking, general
examination, laboratory investigation and colonoscopy examination.
Results: Age of the studied cases ranged from 18 to 75 years with mean 46.24 years and more than half of them were
males (53.3%). The most frequent presentation among the studied cases was hematochezia (95%). Colonoscopic
findings among the study population (n=257) showed that 5.8% had diverticular disease, 32.3% had inflammatory
alteration and 2.3% had solitary ulcer.
Conclusion: Acute LGITB is a common and challenging problem in MICU of ZUH with ulcerative colitis, bleeding
piles, and malignancy as the major underlying causes. Colonoscopy represents the most important diagnostic modality.
Keywords: Colonoscopic Findings, ICU, Gastrointestinal Tract Bleeding.

INTRODUCTION
cost effective procedure. It is the investigation of choice
Gastrointestinal (GI) bleeding from the colon is
in LGIB and helps in early diagnosis of colorectal
a common reason for hospitalization and is becoming
carcinoma (6). Therefore, this study aimed to evaluate
more common in the elderly. While most cases will
prevalence and frequency of patients admitted to
cease spontaneously, patients with ongoing bleeding or
Medical Intensive Care Unit of Zagazig University
major stigmata of hemorrhage require urgent diagnosis
Hospitals with lower gastrointestinal tract bleeding.
and intervention to achieve definitive hemostasis (1).

Acute lower gastrointestinal bleeding (LGIB) is
PATIENTS AND METHODS
a common acute medical and surgical emergency. In
This observational cohort prospective study
contrast to upper gastrointestinal bleeding (UGIB),
included patients admitted to Medical Intensive Care
which has several published guidelines, is well
Unit (MICU) of Internal Medicine Department with
researched and has seen improvements in clinical
suspected acute lower gastrointestinal bleeding
outcomes, LGIB has not been a focus for clinical or
(LGITB).
scientific investigation (2). Although LGIB is common
Inclusion criteria: Patients admitted to MICU with
condition, there are limited studies documenting its
suspected LGITB who were having active bleeding per
incidence. A population-based study in ten hospitals in
rectum in the form of hematochezia or melena of
Spain compared patients discharged with hospital codes
suspected lower gastrointestinal origin, and adults 18
consistent with GI complications over ten years. It was
years of both sexes.
found that in comparison to the upper GI tract, where
Exclusion criteria: Presence of hematemesis and
the incidence of complications fell from 87/100,000 to
refusal to participate in the study.
47/100,000 over ten years, the incidence of
Ethical Approval:
complications in the lower GI tract increased from
The study protocol was approved by the
20/100,000 to 33/100,000 (3).
Institution Review Board (IRB) of the Faculty of
Studies of hospital registries have shown that
Medicine of Zagazig University. All procedures were
patients that develop LGIB tend to be elderly, with a
conducted according to the ethical principles
mean age of 63 to 69 years. Comorbid illness is
expressed in the Declaration of Helsinki and
common, 78% of admitted patients have >1 comorbid
informed written consent was obtained from
condition, 33% have 2. Aspirin for secondary
patients or close relatives.
prevention is used in 20-33%, clopidogrel in 3.2% and
warfarin in 6% patients. There are no published data on
Methodology:
the number of patients admitted with LGIB who are
A total number of 266 patients who met the
receiving a direct oral anticoagulant (DOAC) (4).
inclusion and exclusion criteria were enrolled in the
Population-based database studies suggest an increased
study. All patients were subjected to full history taking
risk of developing LGIB with aspirin or long-term oral
and thorough physical examination with emphasis on
non-steroidal anti-inflammatory drug (NSAID) use (5).
the following: Color, amount, frequency, and duration
For accurate diagnosis of various colorectal
of bleeding and questioning about any symptoms that
lesions, colonoscopy is gold standard, convenient and
may suggest a specific source of lower gastrointestinal
Received:22/10/2021 accepted:20/12 2021

1497


Full Paper (vol.871 paper# 84)


c:\work\Jor\vol871_85 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1501-1505

Staphylococcus Aureus Colonization in Atopic Dermatitis Patients
Attending Zagazig University Hospitals
Rehab A. Rabie1, Alaa M. Badr1, Fathia Khattab2, Laila M. Alkady1
Departments of 1Medical Microbiology and Immunology and 2Dermatology,
Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
*Corresponding author: Alaa M. Badr, Mobile: (+20)010287765449, Email: alalaabadrmicrobiologist@gmail.com

ABSTRACT
Background: Atopic dermatitis (AD) is a very common persistent skin disorder at which skin colonization by bacteria
increases. Staphylococcus aureus can be found on the skin as a human commensal or as a causal agent in a variety of
skin and soft tissue infections.
Objective: This study focused on detecting staph aureus colonization on AD lesions and if it influenced the severity of
the disease.
Patients and Methods: Swabs from skin lesions of 108 atopic dermatitis patients were collected and subjected for
bacterial isolation, identification, and antibiotic susceptibility testing.
Results: Among 108 AD patients, Fifty percent of patients had mild AD disease, 37% had moderate disease, and 13%
had severe disease. Staph aureus colonization in AD patients was 61.1%. There were no significant differences between
positive and negative staph aureus culture groups regarding age (P-value 0.57), sex (P-value 0.38), and the most
prominent lesion location (P-value 0.08). There was no significant difference in the severity of AD between positive
and negative staph aureus culture groups (P-value 0.09). Methicillin-resistant Staph Aureus was detected phenotypically
by cefoxitin (30 µg) disc in 84.8% of isolates.
Conclusion: Staphylococcus aureus colonization was detected with a high percentage among atopic dermatitis patients
with an extremely higher incidence in severe forms of atopic dermatitis than mild forms. However, this couldn't be
proved statistically.
Keywords: Atopic dermatitis, Colonization, MRSA, Staphylococcus aureus.

INTRODUCTION


Atopic dermatitis (AD) is a very widespread
PATIENTS AND METHODS
persistent skin disease, which affects individuals having
This cross-sectional study was conducted in the
an atopic tendency together with bronchial asthma,
Microbiology and Immunology Department, and
allergic rhinitis, and food allergies. Atopic dermatitis
Dermatology, Venereology, and Andrology Department,
patients complain usually about itchy skin, especially at
Faculty of Medicine, Zagazig University, Egypt. One
night which is the predominant symptom, dry skin,
hundred and eight patients complaining of atopic
eczema lesions in flexural areas, and recurrent skin
dermatitis lesions were recruited from the Dermatology
infections (1).
outpatient clinic in Zagazig University Hospitals
The pathophysiology of atopic dermatitis (AD)
without any limitations for age, or sex during the period
is complicated, including elements of barrier
from December 2019 to June 2021. Patients with a
malfunction, changes in cell-mediated immune
medical history of topical antibiotic application, or
responses, and environmental variables. During AD
suffering from another skin disease than atopic
flares, skin colonization by bacteria increases with
dermatitis were excluded.
increased density on acutely inflamed AD lesions more
Personal history was acquired from all included
than 1000-fold higher than on non-lesional AD skin.
patients. The severity of AD was assessed with the
The improvement of atopic dermatitis clinically is
SCORAD index to mild, moderate, and severe
related to the reduction in bacterial colonization using
according to the extent of the lesion, swelling, redness,
antibiotics and antiseptics (2).
crusting, skin thickening, scratch marks, dryness,
Staphylococcus aureus is gram-positive
itching, and sleeplessness.
bacteria that can be found on the skin as a human
Samples were collected from open or inflamed
commensal or as a causal agent in a variety of skin and
skin lesions using sterile cotton swabs. Bacterial
soft tissue infections. Staph aureus can be found in the
isolation was done on nutrient, blood, mannitol salt
nasal cavity, skin, perineum, and pharynx in healthy
agar, also on MacConkey's and sabouraud dextrose agar
people, with the anterior nares being the most prevalent
to exclude infection by other organisms. Staph aureus
location of carriage (3).
identification was confirmed by colonial morphology,
The carriage rate of staph aureus on the skin
gram-stained films, and conventional biochemical
varies from five to thirty percent, relying on the body
reactions.
site or if the person is a persistent nasal carrier (4).
The disc diffusion method was used to test the
This study was designed to investigate whether
antimicrobial susceptibility using /the following
staph aureus could be a skin colonizer that influences
antibiotic discs: penicillin (10 units), cotrimoxazole
severity in atopic dermatitis patients attending Zagazig
(1.25/23.75 µg), clindamycin (2 µg), azithromycin (15
University Outpatient clinics.
µg), doxycycline (30 µg), linezolid (30 µg),
1501
Received: 22/10/2021
Accepted: 20/12/2021

Full Paper (vol.871 paper# 85)


c:\work\Jor\vol871_86 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1506-1510

Role of Ultrasound-Guided Spinal Anesthesia for Elder Patients
Going Through Surgeries of Lower Limb: Review Article
Hadeer Mustafa Abd Elfatah, Zeinab Ibrahim El-Hossary,
Ekram Fawzy Sayouh, Manal Salah-ElDin Farmawy
Department of Anesthesia, Surgical Intensive Care, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Hadeer Mustafa Abd Elfatah, E-Mail: hadeeeermustafa@gmail.com

ABSTRACT
Background:
Patients above the age of 65 have an increased risk of adverse effects from anesthesia up to death. For
elderly people with a variety of medical conditions, spinal anesthesia is the preferable method of anesthesia. After
surgery, spinal anesthesia provides excellent postoperative pain control and reduces the perioperative opioid use, which
minimizes opioid adverse effects. Spinal anesthetic is traditionally administered with the use of palpation of specific
anatomical landmarks. Ultrasonography (US) has brought a revolutionary improvement in anesthesiology. Using
ultrasound prior to neuraxial blocks can increase the success rate on the first attempt, minimize the number of attempts,
and enhance both clinical as well as technical consequences. Subarachnoid space depth measurement can be performed
using ultrasound to locate the spine's midline and intervertebral level as well as guides the correct needle insertion
location and needle insertion angle. Objective: This study aimed to determine the role of ultrasound-guided spinal
anesthesia in geriatric persons receiving lower limb surgery.
Methods:
PubMed, Google scholar and Science direct were searched using the following keywords: Spinal anesthesia,
ultrasound guided and elderly. The authors also screened references from the relevant literature, including all the
identified studies and reviews, only the most recent or complete study was included. Documents in a language apart
from English have been excluded as sources for interpretation. Papers apart from main scientific studies had been
excluded (documents unavailable as total written text, conversation, conference abstract papers and dissertations).
Conclusion: There are numerous researches and evidence-based guidelines supporting the use of US neuraxial blocks
that are safer and more convenient especially in elderly patient with age-related spinal changes.
Keywords: Spinal anesthesia, Ultrasound guided, Elderly.

INTRODUCTION
This review aimed to identify the advantage of
For lower-limb procedures, spinal anesthesia provides
ultrasound-guided spinal anesthesia in elderly patients
dense motor and sensory block, postoperative analgesia
during lower limb surgeries.
and eliminates risk of general anesthesia e.g. minimizes

postoperative nausea and vomiting, lowers the chance of
Ultrasound and Spinal Anesthesia
developing a chest infection, lessens the effects of general
The
fundamentals
of
ultrasonography
are
anesthesia on hangovers, and lessens the chance of
summarized as follows:
cognitive impairment in elderly patients following surgery
When an ultrasound transducer transmits and
(1). However spinal anesthesia in elderly may be associated
receives sound waves at frequencies ranging from 2­15
with technical difficulties due to age-related changes in
MHz (human hearing functions at 1­20 kHz), images can
spinal anatomy such as spinal arthrosis that causes
be captured. Nowadays, the majority of transducers
narrowing of interspinous and interlaminar spaces,
employ artificial polycrystalline ferroelectric ceramics
ossification of ligaments, and hypertrophy of facet joints
such as PZT, which are made from lead zirconate titanate
represent a major changes that create abnormalities in their
(PZT), where piezoelectric characteristics can be found.
anatomies (1). It's four times more common for the elderly
The crystal contracts as well as expands depending on the
to need surgery compared to the general population.
voltage polarity. It causes a sequence of pressure sound
Patients above the age of 65 have an increased risk of
waves to occur. At the time of return of sound waves, it
adverse effects from anesthesia up to death. For elderly
squeezes and strains the crystal, causing shift of voltage
people with a variety of medical conditions, spinal
over the surface of the object that provides, the detecting
anesthesia is the preferable method of anesthesia (2).
signal is intensified (7).
Ultrasonography (US) has brought a revolutionary
When it comes to sound propagation in tissue, the
improvement in anesthesiology. Neuraxial US was first
densities and compressibility influence its speed. In order
described in by Cork et al. (3) where they used ultrasound
for a US beam to be reflected at the interface between two
prior to neuraxial blocks and concluded that the success
different structures, it must have the right angle and the
rate can be improved, the number of attempts can be
right acoustic impedance.
reduced, and the clinical and technical outcomes can be
Grey US image is made up of a matrix of picture
improved (4).
elements or pixels that reflect off of these interface
Epidural space depth and optimum needle insertion
reflections. There will be more of the US beam transferred
point can all be determined by US (5). Reduced procedure-
to deeper structures when there are slight changes in
related complications and enhanced patient satisfaction
acoustic impedance. There is greater reflection when the
with the use of ultrasound analgesia were proved by
acoustic impedance of different tissues differs
Perlase et al. (6).
significantly, making the deeper-seated tissues harder to
1506
Received: 23/10/2021
Accepted: 21/12/2021

Full Paper (vol.871 paper# 86)


c:\work\Jor\vol871_87 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1511-1516

Phenotypic Methods of Detection of Antibiotic Resistance in
Gram Positive Bacteria in Sohag University Hospital
Laila Mohamed Yousif, Ashraf Khodeary Mohamed,
Ahmed Mohamed Nor El-Deen, Reham El-Sayed Mohamed*
Department of Clinical Pathology, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Reham El-Sayed Mohamed, Mobile: (+20) 01013757753, E-Mail: remohelmy1992@gmail.com

ABSTRACT

Background: Antimicrobial resistance (AMR) is the ability of a pathogenic microbe to develop a resistance to the
effects of an antimicrobial medication. AMR is one of the most concerning issues in medicine today, impacting
morbidity, mortality and socioeconomic factors.
Objective:
To determine the prevalence and the phenotypic methods of detection of antibiotic sensitivity of gram-
positive bacteria in clinical isolates collected from inpatients at the Sohag University Hospital during one year.
Patients and methods:
Fresh samples (blood, urine, sputum, pus and cerebrospinal fluid) were collected of 69 patients
and cultured on nutrient agar, blood and MacConkey agar, at 37°C and incubated for 24 ­ 48 hours. The pH was adjusted
to 7.4 and all media were sterilized by autoclaving at 121°C for 20 minutes. VITEK2 Compact identification kits was
used to confirm the identification of the isolates and for antibiotic susceptibility test
Results: S. aureus were isolated in (43.48%) of isolated organisms and 31.88 % of the cases (n=22) were distributed
between other staphylococcus species. S. pneumoniae in 10 cases (14.49%) and 10.15% of the cases (n=7) were
distributed between other streptococcus species. All S. aureus isolates were resistant to penicillin but all S. aureus
isolates were sensitive to quinupristin/dalfopristin, vancomycin, tigecycline, nitrofurantoin, rifampicin, and
trimethoprim/sulfamethoxazole. S. pneumonia showed high rate of resistance to benzylpenicillin (100%) and oxacillin
(100%) but the association trimethoprim/sulphamethoxazole showed moderate rate of resistance (50%) to S. pneumonia
Conclusion:
The prevalence of antibiotic resistance to gram positive bacteria continues to increase and is associated
with significant mortality. The most prevalent organisms within gram positive bacteria were staphylococcus aureus
followed by S. pneumoniae.
Keywords: Antibiotic Resistance, Antimicrobial Resistance, Gram Positive Bacteria.

INTRODUCTION

Antimicrobial
resistance
occurs
manufacture
(5).
Antibiotics
increase selective
when microbes evolve mechanisms that protect them
pressure in bacterial populations, causing vulnerable
from the effects of antimicrobials (1). The term antibiotic
bacteria to die; this increases the percentage of resistant
resistance is a subset of anti-microbial resistance
bacteria, which continue growing. Even at very low
(AMR), as it applies to bacteria that become resistant
levels of antibiotics, resistant bacteria can have a growth
to antibiotics. Resistant microbes are more difficult to
advantage and grow faster than vulnerable bacteria
treat, requiring higher doses, or alternative medications
(6). With resistance to antibiotics becoming more
that may prove more toxic. These approaches may also
common there is a greater need for alternative
be more expensive. Microbes resistant to multiple
treatments. Calls for new antibiotic therapies have been
antimicrobials are called multidrug-resistant (MDR) (2).
issued, but new drug development is becoming rare (7).
Fungi evolve antifungal resistance. Viruses
There are public calls for global collective action
evolve
antiviral
resistance.
Protozoa
evolve
to address the threat that includes proposals
antiprotozoal resistance, and bacteria evolve antibiotic
for international
treaties on
antimicrobial
resistance. Those bacteria that are considered
resistance. Worldwide antibiotic resistance is not
extensively drug resistant (XDR) or totally drug-
completely identified, but poorer countries with weaker
resistant
(TDR)
are
sometimes
called
healthcare systems are more affected (8).
"superbugs"(3). Resistance in bacteria can arise
The WHO defines antimicrobial resistance as a
naturally, by genetic mutation, or by one species
microorganism's resistance to an antimicrobial drug that
acquiring resistance from another. Resistance can
was once able to treat an infection by that
appear spontaneously because of random mutations.
microorganism (9). A person cannot become resistant to
However, extended use of antimicrobials appears to
antibiotics. Resistance is a property of the microbe, not
encourage selection for mutations which can render
a person or other organism infected by a microbe (10).
antimicrobials ineffective (4).
Antibiotic resistance is a subset of antimicrobial
Rising drug resistance is caused mainly by the
resistance. This more specified resistance is linked to
use of antimicrobials in humans and other animals, and
pathogenic bacteria and thus broken down into two
the spread of resistant strains between the two. Growing
further subsets, microbiological and clinical. Resistance
resistance has also been linked to the dumping of
linked microbiologically is the most common and
inadequately treated effluents from the pharmaceutical
occurs from genes, mutated or inherited, that allow the
industry, especially in countries where bulk drugs are
bacteria to resist the mechanism associated with certain
1511
Received: 24/10/2021
Accepted: 22/12/2021

Full Paper (vol.871 paper# 87)


c:\work\Jor\vol871_88 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1517-1522

Genetic Polymorphisms of Monocyte Chemotactic Protein-1 and Risk of
Spontaneous Bacterial Peritonitis in Post Hepatitis C Cirrhotic Patients
Rashed Mohammed Hassen1, Sahar Abdelshafy Elnemr1, Heba Fouad Pasha2,
Akram Said Ali Khafagy1, Ahmed S. Mohammed1
Departments of 1Tropical Medicine and 2Medical Biochemistry, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Akram Said Ali Khafagy, Email: khafagyakram790@gmail.com

ABSTRACT

Background: Monocyte chemotactic protein-1 (MCP-1) is efficient chemokine for activated lymphocytes,
macrophages as well as monocytes during infections, which directly or indirectly affects neutrophil infiltration.
Objective: This study aimed to determine whether genetic variants of the MCP-1 are associated with spontaneous
bacterial peritonitis (SBP) in individuals with post hepatitis C.
Patients and methods: Sixty patients with post-hepatitis C virus liver cirrhosis and ascites were included in the study.
They were divided into two groups: 30 patients with SBP in Group I & 30 patients who had not been diagnosed with
SBP in group II. Thirty healthy participants were included in the control group. PCR-RFLP was used to detect the MCP-
1gene polymorphism, and all patients had their medical histories, physical examinations, and laboratory tests completed,
including ascitic sample analysis.
Results: According to MCP-1 2518 genotypes, there was a statistically significant difference in alleles and MCP-1 2518
between the groups analyzed (p0.001 & p=.003 respectively). Both SBP and non-SBP groups studied showed
statistically significant differences in MCP-1 2518 genotypes and alleles (p=0.037& p= .038 respectively). Moreover,
SBP and control groups had significantly different MCP-1 2518 genotypes and alleles, (p0.001 & p=.003 respectively).
Ascitic individuals with AG genotype had a 5.24-fold increased chance of developing SBP, compared to those with the
GG genotype (COR=0.46). Ascitic patients who carry the G allele are less likely to develop SBP (COR=0.45).
Conclusion: Patients with spontaneous bacterial peritonitis have statistically significant difference in MCP-1 2518
genetic polymorphism and AG genotype increases risk of SBP while G allele significantly decreased risk of it.
Keywords: Spontaneous bacterial peritonitis, Hepatitis C virus, Genetic polymorphisms, Monocyte chemotactic
protein-1.

INTRODUCTION
acid protein with a molecular mass of 13 kDa that is
Cirrhosis is the last stage of various chronic
found on human chromosome 17 (chr.17, q11.2). The
hepatic disorders, and it is marked by fibrosis,
distal regulatory region's transcriptional activity and
morphological conversion from normal hepatic
monocyte MCP-1 production are both affected by the
architecture to structural aberrant nodules, and a
MCP-1 polymorphism -2518 G/A (rs 1024611). Since
disruption of normal liver vasculature. Compensated
MCP-1 production by monocytes is affected by this
and decompensated cirrhosis are the two clinical forms.
polymorphism. Monocytes from people with the -2518
Signs of decompensation include jaundice, ascites,
G allele generated more MCP-1 than those from A/A
variceal bleeding, spontaneous peritonitis, and hepatic
homozygous people. According to the results, cells
encephalopathy (1). More than a quarter of people with
from G/A homozygotes at -2518 produced significantly
decompensated cirrhosis are at risk of acquiring
more MCP-1 than did G/G heterozygotes, which
bacterial peritonitis, an infection that can be fatal if left
suggests that the G allele's activity is dose-dependent (5).
untreated. A neutrophil ascites counts more than
The aim of the work was to determine whether
250/mm3 is indicative of the condition. In this regard, it
genetic variants of the MCP-1 are associated with
is critical to understand how macrophages and
spontaneous bacterial peritonitis (SBP) in individuals
monocytes infiltrate cirrhotic patients' ascites and
with post hepatitis C.
become activated (2).

Monocyte chemotactic protein-1 is efficient
PATIENTS AND METHODS
chemokine for activated lymphocytes, macrophages as
At the Tropical Medicine Department at Zagazig
well as monocytes during infections, which directly or
University Hospitals, we conducted this case-control
indirectly affects neutrophil infiltration (3).
study from July 2021 to December 2021. Sixty patients
MCP-1 levels were shown to be higher in
with post-hepatitis C virus liver cirrhosis and ascites
cirrhotic patients' ascites than in healthy controls in
were included in the study. They were divided into two
some investigations. It was also found that during SBP,
groups: Group I included 30 patients with SBP & group
MCP-1 levels in the ascites were much greater, showing
II that included 30 patients who had not been diagnosed
that this strong chemokine is involved in the formation
with SBP. Thirty healthy participants were included as
and progression of SBP (4). MCP-1 is a powerful
control group.
mononuclear phagocyte activator. MCP-1 is a 76-amino

1517
Received: 24/10/2021
Accepted: 22/12/2021

Full Paper (vol.871 paper# 88)


c:\work\Jor\vol871_89 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1523-1528

Predictive value of Neutrophil-Gelatinase-Associated Lipocalin on the
Severity of coronary artery diseases and development of Contrast-Induced
Nephropathy after Percutaneous Coronary Interventions
Mohamed Ibraheem M. Al Awady, Aly Mohamed Abd Alrahman Saad,
Waleed Salim El awady, Mohamed Shafik Shafik Aboleneen*
Department of Cardiology, Faculty of Medicine Zagazig University, Egypt
*Corresponding Author: Mohamed Shafik Shafik Aboleneen, Mobile: 01014795652, Email: mohamedshafeak@yahoo.com

ABSTRACT
Background:
Contrast-induced acute kidney injury (CI-AKI) is a common complication among patients undergoing
percutaneous coronary intervention (PCI). Neutrophil gelatinase associated lipocalin (NGAL) is a glycoprotein stored
in granules of mature neutrophils released by renal tubular cells following acute tubular damage.
Objective: This study aimed to assess the role of neutrophil gelatinase associated lipocalin (NGAL) as a novel
noninvasive biomarker in prediction of contrast-induced nephropathy (CIN) and the severity of coronary artery disease
(CAD). Patients and Methods: This study was conducted as an observational Cross-sectional study included 50
patients who were admitted to the catheterization laboratory at Zagazig University Cardiovascular Department for PCI
from the period of 2014-2020. Patients were divided into two groups: Group A (nephropathy group) included patients
who developed impairment of kidney function and group B (non-nephropathy) group. All patients were subjected to
demographic data taking, full general (BP, Pulse, etc.) and local examination. ECG analysis, laboratory investigation,
echocardiographic examination (According to ASE 2015) and coronary angiography.
Results:
The difference between the two groups regarding post-PCI serum creatinine, pre-PCI NGAL and post-PCI
NGAL was statistically significant. ROC curve was constructed for estimating the validity of post-PCI NGAL as a
predictor for contrast-induced nephropathy and it was found that at cut-off value of 131 g/l was 92% for sensitivity
and 76% for specificity with AUC of 0.92 by ROC analysis
Conclusions: We concluded that among ischemic heart disease patients who underwent PCI, baseline NGAL levels
identified patients at high risk for the development of CI-AKI. Also we found that pre-coronary angio NGAL can predict
the severity of CAD.
Keywords: Contrast-induced acute kidney injury, Neutrophil gelatinase-associated lipocalin, Contrast-induced
nephropathy.

INTRODUCTION
Deterioration of renal function resulting in acute
Despite the revolution in therapeutic approaches,
kidney injury (AKI) is a significant complication
coronary heart disease (CHD) remain one of the prime
associated with adverse outcomes in patients with ACS
causes of death. According to the global burden of
undergoing primary percutaneous coronary intervention
disease analysis, the highest mortality rate was attached
(PCI). Many risk factors have been suggested to play an
to CHD. However, 80% of the global cases of CHD are
important role in the development of CI-AKI. The
diagnosed in low-income countries. Among CHDs,
change of serum creatinine level was well-documented
acute coronary syndrome (ACS), including ST-segment
as a risk factor for CI-AKI. However, serum creatinine
elevation myocardial infarction (STEMI), non­ ST-
level does not elevate until glomerular filtration rate
segment elevation myocardial infarction (NSTEMI), and
(GFR) has decreased by at least 50%. Thus, assessment
unstable angina (UA), make up a significant proportion
of renal dysfunction according to serum creatinine is not
of clinical manifestations of CHD (1).
reliable (4).
Interventional procedures requiring contrast
Neutrophil gelatinase-associated lipocalin (NGAL)
media administration are increasingly prevalent in
is a glycoprotein stored in granules of mature neutrophils
contemporary practice. Yet, a common complication
and is found to be released by renal tubular cells
arising from these procedures is rapid, though often
following acute tubular damage (5). In the present study,
temporary, declines in kidney function in the ensuing
we aimed to assess the role of neutrophil gelatinase
days. The pathophysiology underlying this clinical
associated lipocalin (NGAL) as a novel non-invasive
manifestation is complex and multifactorial, but a clear
biomarker in prediction of contrast-induced nephropathy
role has been related to the nephrotoxic and
(CIN) and the severity of coronary artery disease (CAD).
hemodynamic effects of iodinated contrast media, which

result in increased oxidative stress and cell injury (2).
PATIENTS AND METHODS
Among patients undergoing percutaneous coronary
This observational cross-sectional study included 50
interventions (PCI), the incidence of contrast-associated
patients who were admitted to the catheterization
acute kidney injury (CA-AKI) have been reported
laboratory at Zagazig University Cardiovascular
between 3.3% and 14.5%, according to the definition
Department for PCI through the period from 2014 to
used (3).
2020.

1523
Received: 25/10/2021
Accepted: 23/12/2021

Full Paper (vol.871 paper# 89)


c:\work\Jor\vol871_90 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1529-1535

Recognition of COVID-19 Pneumonia in Patients Performing
Different Interventional Radiological Procedures of The Chest
Emad H. Abdeldayem, Mai M. K. Barakat*, Ahmed S. Abdelrahman
Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Mai M. K. Barakat, Mobile: (+20) 01006294780, E-mail: mai_mokhtar85@yahoo.com

ABSTRACT

Background: Coronavirus disease 2019 (COVID-19) was declared a global pandemic by the World Health
Organization on March 11, 2020. Many individuals remain completely asymptomatic and can transmit the infection to
the general population. The high rate of false-negative results of reverse transcription-polymerase chain reaction (RT-
PCR), particularly early in the course of the disease process, requires other tools to diagnose COVID-19 infection, with
an important role of radiological imaging. Interventional radiology in many instances continues to provide frontline care
during this pandemic and can overcome the unique challenges of safety while providing adequate and efficient high-
quality patient care.
Objective: The aim of our study was to focus upon the detection of typical imaging features of COVID-19 infection for
asymptomatic patients, performing the different interventional radiological procedures of the chest to avoid the spread
of infection and thus influence better detection and further management.
Patients and methods: In this cross-sectional study, we have 382 patients, coming for different interventional
radiological procedures of the chest from May 2020 till 30 October 2021.
Results: 35 (9.1%) patients had computed tomography (CT) features of COVID-19 pneumonia using CORADS
classification. RT-PCR testing was performed in 28 cases while 7 patients showed negative results; four cases repeated
the RT-PCR test and three of them became positive. The other 3 cases refused to repeat RT-PCR and were only isolated
and carefully monitored.
Conclusion: The radiology staff including interventional radiologists should be aware of the accidental discovery of
imaging features of COVD-19 infection, before proceeding with the interventional procedure. CT chest is an important
tool for detection of COVID-19 detection, even in asymptomatic patients.
Keywords: COVID-19 pneumonia, CT chest, Radiological procedures.


INTRODUCTION

In many cases, interventional radiology is still
Coronavirus disease 2019 (COVID-19) is an
providing frontline care throughout the pandemic, and
infectious illness caused by the coronavirus 2 (Severe
it has proven to be capable of overcoming the specific
acute respiratory syndrome (SARS)-CoV-2) that causes
problems of safety while delivering appropriate and
severe acute respiratory syndrome [1, 2]. Most people
efficient high-quality patient care [12].
develop symptoms four to five days after being exposed
The aim of our study was to focus upon the
to COVID-19, but the virus can take up to two weeks to
detection of typical imaging features of COVID-19
incubate [3].
infection for asymptomatic patients, performing the
The clinical signs range from moderate to severe,
different interventional radiological procedures of the
with the majority of infected people experiencing minor
chest to avoid the spread of infection and thus influence
symptoms. Pneumonia is the most dangerous and
better detection and further management.
prevalent symptom of infection, and it is characterised

by fever, expectoration, dyspnea, and bilateral chest
PATIENTS AND METHODS
infiltrates on imaging. Upper respiratory problems, loss
This cross-sectional study adherent to STROBE
of smell or taste, and diarrhea are some of the less
guidelines was done from the first of May 2020 till 30
common symptoms [4, 5].
October 2021. We have included 382 asymptomatic
Many people, on the other hand, are entirely
patients referred for the different interventional
asymptomatic and can spread the virus to the wider
radiological procedures of the chest.
public [6].
223 patients were presented with suspicious
Because of the high probability of false-negative
pulmonary nodule, mass, or cavity lesion. 78 patients
RT-PCR findings, especially early in the disease phase,
were presented with mediastinal mass including
alternative methods are needed to detect COVID-19
enlarged mediastinal lymph nodes. 25 patients were
infection, with radiological imaging playing a key role
presented with a hilar or para-hilar lesion. 21 patients
[7]. On chest radiographs and CT exams, several typical
were requested for CT-guided taping of pleural effusion
imaging features of COVID-19 have been documented
and sampling from pleural thickening. 13 patients were
[8-11].
referred for ablation of a solitary pulmonary nodule in
1529
Received: 07/11/2021
Accepted: 28/12/2021

Full Paper (vol.871 paper# 90)


c:\work\Jor\vol871_91 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1536-1539

Erythropoietin's Influence on Renal Anemia Treatment: Review Article
Doaa Yousef Mohamed, Ahmed Mohamed Taha Farag*, Sahbaa Fahr Mohamed
Department of Pediartics, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ahmed Mohamed Taha Farag, E-Mail: ahmedtaha7522@gmail.com

ABSTRACT
Background
: The main chain of erythropoietin (EPO) consists of 193 amino acids and it has a molecular weight of
34000 Dalton (Da). EPO is a hormone-like molecule that is secreted primarily by renal interstitial cells, with the liver
contributing the remaining 10%. Renal tubular or glomerular injury can restrict EPO production and create renal tissue
hypoxia, which can then lead to an increase in the production of EPO in the serum. EPO is a humeral factor that enhances
red blood cell production by increasing bone marrow cell proliferation and differentiation. Blood flow into peripheral
blood arteries can also be boosted by EPO's ability to differentiate stem cells into red blood cells. After being activated
by its receptors, to create adult hemoglobin, erythroid cells need to be differentiated and proliferated. EPO aids in the
differentiation and proliferation of these cells.
Objective: To determine if erythropoietin could be useful in the treatment of renal anemia.
Methods: The databases were searched for articles published in English in 3 data bases [PubMed ­ Google scholar-
Egyptian knowledge bank] and Boolean operators (and, or, not) had been used such as [Erythropoietin and Renal
Anemia OR EPO] and in peer-reviewed articles between July 2002 and May 2021.
Conclusion: Renal anemia patients who receive EPO treatment can have considerable improvements in oxygen levels,
immunological function, and so on; An iron overload or blood infection can be prevented by using EPO in transfusions.
Keywords: Erythropoietin, Renal Anemia.

INTRODUCTION


It's common for youngsters with renal illness to
Erythropoietin's main chain has a molecular
suffer from anemia. When the glomerular filtration rate
weight of 34000 Da and is composed of 193 amino acids.
drops below 60 mL/min per 1.73 m2, hemoglobin levels
Renal interstitial cells are the primary source of EPO, with
drop as well, and this is particularly prominent in adults.
the liver accounting for the remaining 10%. Damage to the
The association between GFR and anemia is less evident
renal tubules or glomeruli can result in renal tissue
in children. For both adults and children, erythropoietin
ischemia and hypoxia, which can prevent the generation
and iron therapy has made it possible to forego routine
of EPO and increase the amount of EPO produced in the
blood transfusions in order to maintain a patient's
bloodstream. EPO enters the body's metabolic pathway as
hemoglobin level. Numerous research in adults and
soon as it is created. An abnormality in the hemoglobin
comparatively few in children have shown that higher
and hemoglobin pressure feedback regulation, prolonged
hemoglobin levels are linked to greater quality of life,
rise in serum EPO levels leads to kidney damage in the
cognitive function, exercise ability, and cardiovascular
human body (4).
health (1).
EPO can increase bone marrow cell proliferation
More than 170 years ago, Richard Bright first
and differentiation, and it is a humeral factor that
connected anemia to chronic kidney disease (CKD).
promotes red blood cell production. Red blood cell
Nearly all patients with CKD stage 5 develop anemia as
development and blood flow into peripheral blood
their kidney disease progresses. Having anemia as a result
arteries can also be facilitated by EPO, which is a growth
of chronic renal disease increases one's risk of
factor for stem cells. EPO can increase bone marrow cell
cardiovascular illness, in-patient stays in the hospital,
proliferation and differentiation, and it is a humeral
mental decline, and even death (2).
factor that promotes red blood cell production. Red blood
A
normocytic,
normochromic,
and
cell development and blood flow into peripheral blood
hypoproliferative anemia is common in people with
arteries can also be facilitated by EPO, which is a growth
kidney disease. A lack of erythropoietin in individuals
factor for stem cells (5).
with chronic kidney disease (CKD) has been attributed to

the discovery in the 1950s of a circulating factor that
Effects of Erythropoietin and Other Substances
stimulates erythropoiesis and the kidney as the primary
Taken Together:
source of erythropoietin. Development of immunologic
Iron sucrose:

assays for quantifying circulating EPO levels in the late
The clinic offers two main therapy options: oral iron
1970s and early 1980s was made possible by EPO
supplements and intravenous iron supplements.
purification and cloning. EPO levels are considered
Individuals with uremia and digestive tract iron release
abnormally low in anemia of CKD, despite the fact that
and iron malabsorption issues generally fail to achieve
anemic individuals with normal kidney function had EPO
EPO therapy needs when delivered orally using the
levels 10­100 times higher than those with CKD. Assays
reticuloendothelial
system.
Intravenous
iron
like this one measure all immunogenic EPO fragments,
supplementation can bypass the reticuloendothelial
which don't all correlate with biological activity (3).
1536
Received: 25/10/2021
Accepted: 23/12/2021

Full Paper (vol.871 paper# 91)


c:\work\Jor\vol871_92 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1540-1544
HELLP Syndrome after Caesarean Section: Review Article
Ahmed Elsaied Abdel Rahman, Hamza Abu Alam Mahmoud,
Ghada Abdel Gaber Rezq, Mohammed Samir Ismail, Al shymaa Mahmoud Ahmed*
Department of Anesthesia & Intensive Care, Faculty of Medicine ­ Sohag University, Egypt
*Corresponding author: Al shymaa Mahmoud Ahmed, Mobile: (+20) 01067796177, E-Mail: dr. alshimaaagag@gmail.com

ABSTRACT
Background:
HELLP occurs in 0.5%­0.9% of all pregnancies. About 30% of the cases happen within 48 hours after
delivery. Women with postpartum HELLP syndrome have significantly higher incidences of complications. Because of
the absence of classical signs of preeclampsia, it can confuse physicians and lead to delay in diagnosis. Therefore, it is
associated with serious maternal and baby morbidity.
Objective: We aimed in this review to highlight on HELLP syndrome after cesarean delivery due to its extreme risk to
the mother and baby after birth.
Methods: These databases were searched for articles published in English in 4 data bases: PubMed ­ Google scholar-
The Egyptian knowledge bank and Science direct. Also, Boolean operators (AND, OR, NOT) had been used such as
[HELLP Syndrome AND Caesarean section OR preeclampsia] and in peer-reviewed articles between March 1994 and
August 2021. A 27-year date range was selected, no language limitations, and filtered in selected data basis for the last
27 years. Documents in a language apart from English have been excluded as sources for interpretation. Papers apart
from main scientific studies had been excluded (documents unavailable as total written text, conversation, conference
abstract papers and dissertations).
Conclusion: The HELLP syndrome usually occurs with preeclampsia, so timely and early diagnosis of HELLP is
important. Additionally, early treatment is important to prevent potentially fatal complications, especially in patients
with poor health status.
Keywords: HELLP syndrome, Caesarean section, Pregnant.

INTRODUCTION
HELLP is an acronym that refers to a syndrome
that 35% of the variance in susceptibility to PE were
characterized by hemolysis, elevated liver enzymes, and
attributed to maternal inheritance, and 20% to fetal
a low platelet count (1). It occurs in 0.5%­0.9% of all
genetic effects with similar contribution of maternal and
pregnancies. About 70% of the cases happen before
paternal inheritance (3).
delivery and within 48 hours after delivery. Although,
Risk factors:
there are no differences in laboratory findings between
Elevated body mass index, metabolic disorders, as
HELLP syndrome before and after delivery, women
well as antiphospholipid syndrome, significantly
with postpartum HELLP syndrome have significantly
increase the risk of HELLP syndrome in all female
higher incidences of complications, such as pulmonary
patients. Females who had or are related to a female
edema, renal failure, disseminated intravascular
with previous HELLP syndrome complications tend to
coagulation, and subcapsular liver haematoma (2).
be at a higher risk in all their subsequent pregnancies (4).
The clinical triad of hypertension, proteinuria, and
The risk of HELLP syndrome is not conclusively
oedema is a well-recognized syndrome of the second
associated with a specific genetic variation, but likely a
half of pregnancy known as preeclampsia, although its
combination of genetic variations, such as FAS gene,
etiology remains uncertain (1). Patients' cases that were
VEGF gene, glucocorticoid receptor gene and the toll-
variants of severe preeclampsia-eclampsia with atypical
like receptor gene, increases the risk (1).
signs and symptoms or very complicated courses of this
disease process have been reported since the end of the
Classification:
19th century. Many of these descriptions of pregnancies
A classification system has been developed in
complicated by an uncharacteristic presentation of
Mississippi based on the lowest observed maternal
preeclampsia are representative of the condition now
platelet count as a primary, easily measured indicator of
identified as HELLP syndrome (2).
disease severity, with class I HELLP syndrome
We aimed in this review to highlight on HELLP
referring to a maternal platelet count of < 50,000/l,
syndrome after cesarean delivery due to its extreme risk
class II to a platelet count > 50,000 to < 100,000/l and
to the mother and baby after birth.
class III to a platelet count > 100,000 to < 150,000/l,

with haemolysis and raised liver enzymes levels (2).
Epidemiology and inheritance:
Pregnant patients who develop class I HELLP
Inheritance: Sisters and children of a woman who
syndrome have the highest incidence of perinatal
has sustained HELLP have increased risks of HELLP.
morbidity and mortality and the most protracted
A woman who has sustained HELLP has a high risk of
postpartum recovery periods. Tennessee classification
developing HELLP (14­24%) and PE (22­28%) in
system is based on the partial or complete expression of
subsequent
pregnancies,
suggesting
related
HELLP syndrome (5).
pathogenetic mechanisms. A population study indicated
1540
Received: 26/10/2021
Accepted: 24/12/2021

Full Paper (vol.871 paper# 92)


c:\work\Jor\vol871_93 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1545-1548

Association of Cytokines in Preeclampsia: Review Article
Ahmed Elsaied Abdel Rahman1, Hamza Abu Alam Mahmoud1,
Ghada Abdel Gaber Rezq1, Mohammed Samir Ismail2, Al Shymaa Mahmoud Ahmed*1
Departments of 1Anesthesia & Intensive Care and
2Obstetrics & Gynecology, Faculty of Medicine ­ Sohag University, Egypt
*Corresponding author: Al shymaa Mahmoud Ahmed, Mobile: (+20) 01067796177, E-Mail: dr. alshimaaagag@gmail.com

ABSTRACT
Background:
Preeclampsia (PE) is an important, common, and dangerous complication of pregnancy that causes
maternal and perinatal illness and is responsible for a high proportion of maternal and infant deaths. PE is associated
with increased blood pressure and proteinuria, with a whole host of other potentially serious complications in the mother
and fetus. The maternal syndrome in PE is primarily that of generalized dysfunction of the maternal endothelium, and
this generalized endothelial dysfunction appears to be part of an exaggerated systemic inflammatory response that
involves maternal leukocytes and proinflammatory cytokines.
Objective: This review aimed to study the role of cytokines in preeclampsia.
Methods: The databases were searched for articles published in English in 3 data bases: PubMed, Google scholar and
science direct. Also, Boolean operators (and, or, not) had been used such as cytokines and preeclampsia OR cytokines
and pregnancy and in peer-reviewed articles between June 1991 and April 2021.
Conclusion:
Cytokines can be used as biomarkers for the prediction and better clinical management of preeclampsia in
the initial stages. The balanced ratio of pro- and anti-inflammatory cytokines is essential to regulate the maternal
inflammation system throughout pregnancy.
Keywords: Cytokines, Preeclampsia, Pregnancy.

INTRODUCTION
PE: An Inflammatory State:
Substantial evidence has accrued over the years
Preeclampsia is associated with chronic immune
supporting roles for cytokines in the pathogenesis of
activation that results in elevated levels of inflammatory
preeclampsia (PE) at the early placental stage and in the
cytokines released by proinflammatory helper T-cell
later systemic stage as well. Cytokines play critical,
subsets. The proinflammatory cytokines tumor necrosis
essential roles in signaling between cells of the immune
factor (TNF-), interleukin (IL) 6, and IL-17 are
system, with a prolific range of regulatory activities
typically secreted by activated TH1 and TH17 cells to
including the recruitment, activation, stimulation,
instigate a cytotoxic and inflammatory immune response
killing, and suppression of immune and non-immune
to foreign pathogens or injury. During PE, these
cells. Interestingly, research in the last two decades has
cytokines are significantly increased in the maternal
shown that cytokines are also involved in several events
circulation and the placenta, resulting in chronic
in pregnancy such as ovulation, implantation,
systemic and local placental inflammation, which
placentation, and parturition (1).
contributes to the pathophysiologic complications that
Cytokines like granulocyte-macrophage colony-
manifest during PE (3).
stimulating factor (GM-CSF), colony-stimulating factor-
The increased TNF- and IL-6 in the vasculature
1, IL-3, and IL-10 contribute to the success of pregnancy,
contribute to increased endothelial expression of
while cytokines such as TNF- and IFN- have been
adhesion molecules and permeability, resulting in
shown to have harmful effects on pregnancy. IL-2, TNF-
endothelial dysfunction during PE. Expression of
, and IFN- are characteristic of T helper 1 (Th1)-type
adhesion molecules in the vasculature promotes
immunity and induce several cell-mediated cytotoxic
leukocyte rolling and extravasation, leading to increased
and inflammatory reactions. Th2-type cells, on the other
endothelial permeability. Studies have demonstrated that
hand, secrete the Th2 cytokines IL-4, IL-5, IL-6, and IL-
TNF- signaling results in endothelial cell activation,
10 are associated with help for humeral immunity. Th2-
decreased nitric oxide synthase (NOS) messenger RNA
type immunity is associated with a normal pregnancy,
(mRNA), and increased production of preproendothelin
whereas a strong Th1 reactivity is associated with
1 (PPE-1) mRNA. Decreased nitric oxide (NO)
pregnancy complications such as recurrent spontaneous
bioavailability results in a loss of vasodilator ability of
miscarriage, preterm delivery, and premature rupture of
endothelial cells and leads to endothelial dysfunction and
fetal membranes. In addition, being classified as Th1 and
the development of hypertension and IUGR in
Th2 cytokines, cytokines can also be classified as pro-
PE. Preproendothelin 1 is the precursor to the potent
and anti-inflammatory. Cytokines such as IL-1, IL-2, IL-
vasoconstrictor endothelin 1 (ET-1), which has been
8, TNF-, and IFN-, which are proinflammatory.
shown to be increased in the circulation of preeclamptic
Increased levels of such proinflammatory cytokines are
women. Furthermore, PPE-1 mRNA expression is
associated with pregnancy complications such as
increased in the endothelial cells of women with PE
preterm delivery and intrauterine growth retardation (2).
compared
to
women
with
normal

pregnancies. Interleukin 6 has also been shown to
1545
Received: 27/10/2021
Accepted: 25/12/2021

Full Paper (vol.871 paper# 93)


c:\work\Jor\vol871_94 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1549-1552
Lipid Profile of Children and Adolescents with Hemophilia at
Zagazig University Hospitals
Mervat A. Hesham1, Samah Mohamed Abdalla Alshiri1, Saffaa M Elalawi2, Mahmoud Abdelazeem*1
Departments of 1Pediatric and 2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding Author: Mahmoud Abdelazeem, Email: abdelazeemmahmoud29@yahoo.com

ABSTRACT
Background:
The increased management of hemophilia has led to an increase in age-related problems in this population.
These patients have high rates of cardiovascular risk factors, such as high blood pressure, hypercholesterolemia, and
diabetes, which may have an impact on their overall health and healthcare costs.
Objectives: To investigate hemophilia patients for lipid profile changes and its clinical impacts.
Subjects and methods: this case-control study was conducted in Hematology Unit and Outpatients' Hematology Clinic of
Pediatric Department at Zagazig University Hospitals over 6-month period. This study was conducted on 153 subject
divided into 87 patients with clinical and laboratory diagnosis of hemophilia (65 hemophilia A and 22 hemophilia B) and
66 age and sex matched healthy children as a control group. All the studied groups were subjected to full medical history,
thorough clinical examination and laboratory investigations such as complete lipid profile, fasting blood glucose and
hemoglobin A1C.
Results: Overweight was reported in 19.5% of hemophilia patients and obesity in 14.9%. High blood pressure, increase
lipid profile (hypercholesterolemia, high LDL, hypertriglyceridemia) and high blood sugar were shown to be more
significantly higher in the cases compared to the control group.
Conclusion: Findings from our study revealed hyperlipidemia among people with hemophilia (PwH). Hyperlipidemia,
being overweight or obese, and their implications must be prevented and managed early in healthcare for the hemophilia
population if it is to improve overall health.
Keywords: Hemophilia, Hypertension, Lipid profile, Obesity, Risk factor.

INTRODUCTION
diseases (6). Comorbidities that affect hemophilia care,
For people with hemophilia A or B, a lack of clotting
such as obesity and overweight, may be better addressed
factors VIII or IX causes a lifelong bleeding disease.
with advancements in treatment (7).
Bleeding can occur with or without trauma in many
Atherosclerosis in both children and adults has been
coagulopathies, and treatment requires therapeutic or
linked in several studies to plasma cholesterol levels(8).
preventative replacement of the deficient clotting factor (1).
Thus assessing changes in lipid profile levels in
The more severe the hemophilia, the more likely it is that
hemophilic patients is useful in children who requires
a person will experience a bleed. Severe hemophilia can
lifelong therapy (9).
result in spontaneous bleeding, abnormal bruising or
Aim of the work was to investigate hemophilia
bleeding, and re-bleeding following invasive procedures
patients for lipid profile changes and its clinical impacts.
(all of these are examples of severe hemophilia) (2).

Joints are the site of approximately 60% of all
PATIENTS AND METHODS
bleeding events. It is most frequent to have bleeding in one
This is a case control study conducted during the
of the following joints: knees. But it can happen in any of
period from July 2021 to January 2022, at Pediatric
the other ones: ankles, shoulders, and wrists (3). Risk
Hematology ­ Oncology Units (Pediatric Hospital) and
factors for mortality and morbidity in hemophilia patients
Pediatric Hematology Outpatient Clinic at Zagazig
include diabetes mellitus (DM), hypertension (HT),
University Hospitals, on 153 subject divided into 87
obesity, as well as family history of cardiovascular disease
Patients with clinical and laboratory diagnosis of
(CVD) (4).
hemophilia (65 hemophilia A and 22 hemophilia B) and
Arthritis, functional disability, and chronic joint
66 age and sex matched healthy children as a control
discomfort are all symptoms of hemophilia. As a result,
group.
obesity is a health problem for people with hemophilia
Patients with age <6 and >18 year, with bleeding disorders
(PwH) and a factor exacerbating cardiac, metabolic, and
rather than hemophilia, with genetic or systemic causes for
joint health for those who are already predisposed to
dyslipidemia or patients whose relative refused to
obesity (5). An increase in chronic pain and decreased joint
participate in the study were excluded from the study.
range of motion are all linked to PwH being overweight.

A patient's overall health, including their anxiety and
All participants of the study were subjected to:
distress as a result of their long-term sickness, may be
A) Complete history taking; with stress on age of
affected by the burden of obesity and hemophilia-related
diagnosis, inability to move the damaged joint or the
1549
Received: 25/10/2021
Accepted: 23/12/2021

Full Paper (vol.871 paper# 94)


c:\work\Jor\vol871_95 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1553-1560

Metabolic Syndrome Predictors among Shift Workers of Zagazig
Central Railway Station: A Case-Control Study
Samah S. Sheta*, Reem A. Abbas, Dina Abd El Wehab
Department of Community, Environmental and Occupational Medicine,
Faculty of Medicine, Zagazig University, Zagazig, Egypt
*Corresponding author: Samah S. Sheta, Mobile: (+20)01143500624, Email: shtasmah@gmail.com

ABSTRACT
Background:
Metabolic syndrome (MetS) describes a number of metabolic disorders involving blood glucose
abnormalities, elevated blood pressure, triglycerides levels, decreased high-density lipoprotein and increased abdominal
obesity which are associated with risk of developing type 2 diabetes mellitus and cardiovascular abnormalities with
more mortality. MetS globally has been attributed to alterations in lifestyle, like eating patterns and sedentary life.
Objectives: 1- To compare metabolic syndrome prevalence between shift and day workers. 2- To clarify associated risk
factors for metabolic syndrome. 3- To study impacts of metabolic syndrome affection on workplace accidents,
absenteeism, and workers engagement. Materials and methods: This cross-sectional study was conducted between
shift and day workers at Zagazig Railway Station with a sample size of 244 (122 shift workers (exposed group) and 122
day workers. Data were collected by using 1- structured interview questionnaire including relevant socio-demographic,
occupational characteristics, certain past and family histories data of concern, questions to assess risk factors of
metabolic syndrome and questions to assess some consequences of metabolic syndrome. 2- Anthropometric
measurements and laboratory investigations to assess parameters of MetS. Results: Studied shift workers had significant
prevalence of metabolic syndrome (51.6% vs. 36.1% in day workers), fasting blood glucose, larger waist circumference
and triglyceride levels compared to day workers. The prevalence of poor sleep quality complaint was significantly higher
among shift workers compared to the day workers. Shift workers showed significant incidence of workplace accidents
in addition to decreased work engagement compared to day workers.
Conclusion:
Shift work constitutes an occupational risk for MetS development, which has its special health and work
consequences.
Keywords: Shift work, Metabolic syndrome, Risk factors, Sleep quality, Workplace accidents.

INTRODUCTION
increase of the risk for coronary heart disease, a two or
The Railway is an important industry where large
threefold increased risk for future ischemic heart attack
numbers of human resources are involved in rotational
and a greater risk for diabetes mellitus (7).
task (1). According to Egyptian National Railways

MATERIALS AND METHODS
(ENR), there is a large number of employees about
Study design: Comparative cross-sectional study.
86,000 working in railway sector, it transports about one
Sample size: The expected frequency of metabolic
million passengers and provides 1,300 daily services (2).
syndrome among shift workers was (37.1%) compared
There is increasing concern over shift work side
to (20.8%) among day workers as estimated from a
effects on health. Shift work disrupts normal biological
previous study (8), taking into account power of the test
rhythms and has been associated with multiple health
(80%) and confidence interval (CI) of 95%. The sample
problems (3). Much evidence showed that shift work is
size was calculated to be 244 (122 exposed group (night
related to cardiovascular diseases and diabetes mellitus
shift) and 122 comparable group (day shift). Simple
type 2. Some studies showed that hypertension and
random sample method was used for selection of
diabetes type 2 were associated with the metabolic
workers groups.
syndrome (Mets) (4).
Multiple studies have demonstrated that shift
Study setting: Zagazig Railway Station. The
workers are at an increased risk for metabolic
questionnaires were distributed at the different work
syndrome, which leads to an increased risk for "the
spots and Zagazig Railway and local clinic was used for
metabolic trifecta" of cardiovascular disease, stroke,
clinical examination and blood sampling.
and type 2 diabetes. Metabolic syndrome (Mets)
Subjects:
describes a group of metabolic disorders including
· Exposed group (Shift workers): the working
blood glucose changes, increased blood pressure,
schedule of the studied shift work group was as
reduced high-density lipoprotein, high triglycerides,
follows: (12 hours) work followed by (24 hours)
and abdominal obesity, which are associated with
rest.
increased risk of developing type 2 diabetes mellitus
· Comparative group (Day workers): have fixed
and cardiovascular disease, as well as increased death
morning shift.
rates (5).
Inclusion criteria: Male workers, age 18 to 60, have no
Recent findings clarified that short sleep time can
other Job and work for at least two years in Zagazig
elicit a physiological and psychological stress response.
Railway Station.
Gut microbial showed altered and biases of intestinal
Exclusion criteria: Subjects working for less than two
microbial generations in circadian disrupted mice and
years. - Subjects who were in a leave at the time of the
jet lagged humans (6). MetS induces an almost two-fold
1553
Received: 26/10/2021
Accepted: 24/12/2021

Full Paper (vol.871 paper# 95)


c:\work\Jor\vol871_96 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1561-1568

Evaluation of Outcomes of Bipolar Hemiarthroplasty in
Unstable Intertrochanteric Fractures in among Elder Patients
Mohamed Abdullah El-Soufy, Waleed Mohmed Nafea,
Mare Altahir Saed Almahrouq, Mohamed Hussein ElSayed Ibrahim
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mare Altahir Saed Almahrouq, E-Mail: mare.a.mahrouq@gmail.com

ABSTRACT
Background
: Early postoperative ambulation following hemiarthroplasty for elderly patients with unstable
intertrochanteric femur fractures is possible with the use of bipolar prosthesis.
Objective: to evaluate the safety and efficacy of a new surgical treatment for unstable intertrochanteric fractures in
elderly patients treated with bipolar hemiarthroplasty.
Patients and Methods: Our study was done on 18 patients that experienced primary cemented bipolar hemiarthroplasty
for fixation of unstable intertrochanteric fractures at Zagazig University Hospital. Patients were followed up clinically
and radiologically for 6 months. Clinical evaluation was done using Harris hip score.
Results: The standard cemented bipolar hemiarthroplasty represented (61.1%) and cemented bipolar hemiarthroplasty
with calcar replacement (38.9%) of line of treatment. Most of the studied group (41.2%) had excellent Harris hip score
(HHS) followed by (35.3%) had good score then fair (17.6%) and lastly poor score (5.9%), with mean HHS of 83.23.
Conclusion: When treating older patients with unstable intertrochanteric fractures, primary bipolar hemiarthroplasty is
a better option than open reduction and internal fixation.
Keywords: Bipolar Hemiarthroplasty, Elderly, Unstable Intertrochanteric Fractures.

INTRODUCTION

therefore avoiding the postoperative problems that arise
Intertrochanteric fractures (IT) are among the most
from immobilization or implant failure (5).
common types of fractures seen by orthopedics. These
In the elderly, unstable intertrochanteric fractures
fractures are becoming more common as life expectancy
are one of the leading causes of morbidity. Diabetic and
rises (1). By 2040, the prevalence of hip fractures is
cardiovascular conditions like diabetes are common in
predicted to have doubled because of a decrease in muscle
this age range. If these patients are confined to a hospital
mass surrounding the hip and osteoporosis, which is
bed, their health rapidly deteriorates as a result of these
growing more common as the elderly population grows.
conditions. Restoring pre-fracture activity levels,
IT fractures account for roughly 45 to 50 percent of all hip
allowing for early return to full weight bearing, and
fractures in the elderly, and of these, 50 to 60 percent are
avoiding the need for a second surgery are the most
considered unstable. For dynamic hip screw (DHS); the
important considerations when treating these fractures in
cut-out rate can be as high as 8%, and the likelihood of
the elderly. In some cases, as many as 10% of patients are
failure with unstable IT fractures can be as high as 50
described as having a failure of fixation. In older patients
percent (2).
with unstable intertrochanteric fractures of the femur,
When treating older patients with unstable
hemiarthroplasty employing bipolar prostheses results in
intertrochanteric fractures, it might be difficult to achieve
good clinical outcomes, including early postoperative
anatomical reduction because of the high rates of
ambulation. This will have a significant impact on the
morbidity and death that are associated with these
patient's overall health and ability to recover after surgery
fractures. There have been numerous studies showing
(6).
mechanical and technological failures in the treatment of
For treatment of intertrochanteric fractures, the
choice for many decades for older individuals with
gamma nail is a traditional intramedullary fixation device
unstable intertrochanteric fractures. Intertrochanteric hip
created using the sliding hip screw and intramedullary
fractures, both stable and unstable, are commonly treated
nail systems (7). A surgeon can easily and quickly use the
with a dynamic hip screw (DHS), which has a number of
standardized surgical approach for inserting gamma nails,
drawbacks, particularly in unstable fractures (3).
resulting in tiny incisions after surgery. If the medullary
Extramedullary implants were previously blamed for
cavities are thin or obstructed or the femur shafts have
these failures; however a recent study found no difference
wide anterior arches and the patient has apparent
in unstable intertrochanteric fracture fixation between
osteoporosis, this procedure is not recommended.
intra- and extramedullary types of implants (4).
Complications of the Gamma Nail include stress fractures
Restoring mobility safely and quickly, while
of the distal femoral shaft, worsened intertrochanteric
limiting the risk of medical consequences and
fractures, and the rupture of the major nails, in addition to
technological failure, is the primary goal of treatment. A
malunion of fractures. The lag screw lengths and
patient's ability to walk again depends on the quality of
positions are also a problem (8).
bone and the type of implant that was used. These patients
In the case of unstable or osteoporotic
may be able to return to their pre-injury level of activity
intertrochanteric fractures, conventional DHS may be
more soon with primary bipolar arthroplasty treatment,
able to provide useful stability, although this is not the
1561
Received: 26/10/2021
Accepted: 24/12/2021

Full Paper (vol.871 paper# 96)


c:\work\Jor\vol871_97 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1569-1574

Endoscopic Ultrasound-Guided Gastroenterostomy vs
Duodenal Stenting vs surgical Gastrojejunostomy for the
Treatment of Malignant Gastric Outlet Obstruction; Review Article
AlAmri Turki Abdullah
Division of Gastroenterology, Department of Internal Medicine, King Fahad University Hospital,
Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia
Corresponding author: AlAmri Turki Abdullah, Mobile: +966557521347, E-mail: taalamri@iau.edu.sa

ABSTRACT
Background:
Gastric outlet obstruction (GOO) is a clinical condition caused by a mechanical blockage of the upper
digestive tract at the level of the distal stomach, pylorus or duodenum. Often encountered in the context of advanced
malignancy, it is associated with debilitating symptoms including intractable nausea and vomiting, inability to tolerate
oral nutrition, abdominal pain and decreased quality of life.
Objective: The aim of the review is to evaluate endoscopic ultrasound-guided gastroenterostomy vs duodenal stenting
vs surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction.
Methods: PubMed, Google scholar and Science direct were searched using keywords. The author also screened
references from the relevant literature, including all the identified studies and reviews, only the most recent or complete
studies were included, which were published between 1992 and 2022. Documents in a language apart from English have
been excluded as sources for interpretation was not found. Papers apart from main scientific studies had been excluded:
documents unavailable as total written text, conversation, conference abstract papers and dissertations.
Conclusion:
Ultrasound-guided gastroenterostomy (EUS-GE) is emerging as a potential treatment option for GOO.
When compared to duodenal stenting and surgical gastrojejunostomy (SGJ), EUS-GE may provide a longer lasting
treatment for GOO. In the hands of experts, EUS-GE appears to be similar in efficacy and safety when compared to
surgery; yet it may be less costly.
Keywords: Duodenal Stenting, Endoscopic Ultrasound-Guided Gastroenterostomy, Malignant Gastric Outlet
Obstruction, Surgical gastrojejunostomy.

INTRODUCTION
Gastric outlet obstruction (GOO) among patients
concern for DS migration, as well as the invasiveness of
with malignant neoplasms within or adjacent to the
SGJ, alternative endoscopic strategies to improve the
gastric antrum, duodenum, or pancreatobiliary tract has
quality of life for these patients have been employed [5,6].
become increasingly encountered in clinical practice
Within the last 6 years, endoscopic ultrasound-
and is associated with significant morbidity and
guided gastroenterostomy (EUS-GE) with the
decreased quality of life [1]. Obstructive symptoms may
placement of a lumen-apposing metal stent (LAMS) has
present as intractable nausea or vomiting, abdominal
become an increasingly adopted approach for the
discomfort, fullness, early satiety, or dehydration along
management of malignant GOO. This strategy, similar
with multiple electrolyte derangements. Given these
to SGJ, aims to bypass the site of gastrointestinal
associated symptoms and a significant decrease in
obstruction and reduce the associated morbidity and
quality of life, effective treatments aimed at palliation
complication rates associated with a traditional surgical
remain critically important [2].
strategy [7]. The EUS-GE procedure involves the
Traditionally, the palliative treatment of
creation of an anastomosis between the stomach and an
malignant GOO was relegated to the operating room--
adjacent duodenal or jejunal loop via the placement of
only
able
to
be
achieved
with
surgical
an anastomotic LAMS. The goal, unlike DS placement,
gastrojejunostomy (SGJ), which aimed to provide a
is to bypass the gastric drainage course from the
long-term luminal bypass of the area of obstruction [3].
obstructive lesion to the small intestine distal to the site
However, since the 1990s [4], endoscopic placement of
of obstruction--potentially decreasing the risk of tumor
a self-expanding metal stent (SEMS) has been shown to
ingrowth. Furthermore, as the LAMS bypasses the site
be an effective treatment strategy and an increasingly
of obstruction, there is no risk of stent-related biliary
utilized alternative to SGJ. This endoscopic strategy
obstruction. Hence, a presumed increase in clinical
involving duodenal stent (DS) placement possesses
success and a decreased need for reintervention may be
some advantages compared to a surgical approach,
expected [8].
including less invasiveness, decreased procedure-
The aim of the review to evaluate endoscopic
associated morbidity, and shorter hospital stay. Yet,
ultrasound-guided gastroenterostomy vs duodenal
despite these advantages, DS placement has been
stenting vs surgical gastrojejunostomy for the treatment
associated with higher rates of reintervention due to
of malignant gastric outlet obstruction.
stent obstruction and migration--especially among
Surgical gastrojejunostomy, duodenal stenting,
patients with life expectancies greater than 6­12
and
endoscopic
ultrasound
(EUS)-guided
months. Given this increased rate of reintervention and
gastroenterostomy are the 3 methods currently available
1569
Received: 27/10/2021
Accepted: 25/12/2021

Full Paper (vol.871 paper# 97)


c:\work\Jor\vol871_98 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1575-1580

Diagnosis of Placenta Accreta Spectrum: Review Article
Mohamed Ahmed Abdellah*1, Yasser Ahmed Helmy1,
Hazem Mohamed Mohamed1, Doaa S. M. Bardis2, Mohamed Hasan Alameldin3
Departments of 1Obstetrics and Gynecology, 2Clinical and Chemical Pathology and 3Radiology,
Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Mohamed Ahmed Abdellah, Mobile: (+20) 01098437456,
E-Mail: mohamedabdelaah@med.sohag.edu.eg

ABSTRACT
Background:
Placenta accreta is defined as abnormal trophoblast invasion of part or all of the placenta into the
myometrium of the uterine wall. Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to
the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta.
Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often
requires blood transfusion. Rates of maternal death are increased for women with placenta accreta spectrum.
Objective: The purpose of this review was to highlight diagnosis by magnetic resonance imaging (MRI) and
ultrasonographic of the presence of placenta accreta spectrum (PAS).
Methods: These databases were searched for articles published in English in 3 data bases [PubMed ­ Google scholar-
science direct] and Boolean operators (AND, OR, NOT) had been used such as [Diagnosis of Placenta Accreta and
Placenta Accreta Spectrum OR PAS] and in peer-reviewed articles between June 2005 and February 2021. Documents
in a language apart from English have been excluded as sources for interpretation was not found. Papers apart from
main scientific studies had been excluded: documents unavailable as total written text, conversation, conference abstract
papers and dissertations.
Conclusion: The timely diagnosis of abnormal placentation is of great importance since, the earliest diagnosis implies
less risky, less costly and successful management. Ultrasonography may successfully achieve this goal. Furthermore,
MRI imaging, in cases of diagnostic dilemmas may be particularly useful and lead to safer and more precise diagnosis.
Keywords: Diagnosis of Placenta Accreta, MRI, Ultrasonography.


INTRODUCTION


The recent rapid increase in caesarean delivery
placenta (placenta accreta) and abnormally invasive
(CD) rates has changed the epidemiology of placenta
placenta (AIP ­ including placenta increta and placenta
accreta spectrum (PAS) worldwide from a rare, serious,
percreta); the term PAS encompasses the whole
pathological condition to an increasingly common
spectrum of the disorder (Figure 1).
major obstetric complication. The risk of placenta
In abnormally adherent placenta the implantation
previa increases following CD, and women presenting
of the villi is in direct contact with the myometrium in
with a low lying/placenta previa and history of CD are
the absence of an obvious plane of cleavage. In
at the highest risk of PAS (previa PAS) (1).
abnormally invasive placentation, the villi invade

deeply the myometrium, and cannot be easily removed
Historical background:
either manually or by curettage.
Placenta accreta was first described nearly 80 years ago
The result of different, sometimes incorrect,
as a clinicopathological condition in which the placenta
diagnostic criteria is a wide variability in the reported
fails to separate partially or totally from the uterine wall.
predictive value of antenatal imaging strategies, and the
It was first described in 1937 by obstetrician Frederick
outcomes associated with different management
C, Irving and pathologist Arthur T. Hertig at the Boston
strategies. Maternal morbidity and mortality can occur
Lying-In Hospital (2).
because of severe and sometimes life-threatening

hemorrhage, which often requires blood transfusion and
Definition:
the rates of maternal death are increased for women with
Placenta accreta is defined as abnormal trophoblast
placenta accreta spectrum. Additionally, patients with
invasion of part or all of the placenta into the
placenta accreta spectrum are more likely to require
myometrium of the uterine wall (3). Abnormal
hysterectomy at the time of delivery or during the
placentation includes both abnormally adherent
postpartum period and have longer hospital stays (4).
1575
Received: 28/10/2021
Accepted: 26/12/2021

Full Paper (vol.871 paper# 98)


c:\work\Jor\vol871_99 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1581-1585

Combination of Intradialytic Leg Cycling & Upper Limb Range of
Motion Exercises on Improving Dialysis Adequacy and Solutes Removal
Hoda Gaber El Said1, Azza Abd El-Aziz Abd El-Hady1,
Mustafa Mahmoud Noskhi2, Mona Ahmed Mohamed Abdel Wahab1
1Department of Physical therapy for Cardiovascular/ Respiratory Disorders and Geriatrics,
Faculty of Physical Therapy, Cairo University, Egypt
2Department of Nephrology at the Military Medical Academy Manager of Nephrology Hospital at
El-Galaa Military Hospital, Egypt
*Corresponding author: Hoda Gaber El Said, Mobile: (+20) 01100272020, E-Mail: huda.eaid68@gmail.com

ABSTRACT
Background:
Dialysis adequacy is an important survival indicator in patients with chronic hemodialysis (HD).
Intradialytic exercise in end-stage renal disease (ESRD) patients improve dialysis adequacy.
Objective: This study aimed to evaluate the effect of 2 months combining of intradialytic leg cycling and upper limb
range of motion exercises (ROM) on dialysis efficiency for patients with ESRD.
Patients and Methods:
Forty six hemodialysis patients of both sexes with ESRD participated in the study. They were
randomly assigned into two groups (A & B). Group (A) included 11 males and 12 females where they received 3 sessions
per week for 2 months of intradialytic leg cycling and upper limb range of motion exercise. Group (B) included 12 males
and 11 females who received only upper limb range of motion exercise. Their mean age were 60.76 ± 3.37 and 60.82 ±
3.41 years old for group A & B respectively.
Results: There was a significant decrease in urea level, K+ and phosphorus in group A post-treatment compared to their
pre-treatment (p < 0.01), while there was a significant increase in K t/V, URR and creatinine clearance post-treatment
compared to pretreatment (p < 0.001). There was no significant change in urea level, URR, creatinine clearance and K+
in group B (p > 0.05), while there was a significant increase in K t/V and a significant decrease in phosphorus post-
treatment compared to pre-treatment (p < 0.01).
Conclusion: Combination of Intradialytic leg cycling and upper limb range of motion exercises had a significant role
in increasing dialysis adequacy (URR & K t/V), creatinine reduction ratio and decreasing phosphorus and potassium for
ESRD patients on maintenance hemodialysis.
Keywords: Intradialytic exercise, Cycling exercise, Range of motion, Hemodialysis, ESRD, Chronic kidney disease.


INTRODUCTION

Chronic kidney disease (CKD) is a clinical
PATIENTS AND METHODS
syndrome secondary to the definitive change in function
Forty six hemodialysis patients of both sexes with
and/or structure of the kidney. It affects more than 10%
ESRD participated in the study. Their ages ranged from
of the world population. ESRD is final stage of CKD
55 to 65 years old. They were randomly assigned into
that is characterized by its irreversibility and slow and
two groups (A & B). Group (A) included 11 males and
progressive evolution and it exits in 8-16% of the
12 females who received 3 sessions per week for 2
population worldwide Huang et al. [1]. Hemodialysis
months of intradialytic lower extremities cycling and
(HD) represents the main mode for the treatment of
upper limb range of motion exercise, while group (B)
chronic kidney disease stage 5 [2]. As replaced part of
that included 12 males and 11 females received only
kidney's function in order to prolong the ESRD
upper limb range of motion exercise. All patients in
patients' survival time to remove waste and extra water
both groups were assessed through blood urea,
from blood [3]. Intradialytic aerobic exercise for lower
creatinine, phosphorus, potassium lab tests, urea
limb in HD patient by cycle-ergometer & ROM for
reduction ratio (URR) and Kt/V dialysis efficiency.

upper limb increase the rate of toxins removal due to
Sample size:
vasodilation with increase muscle blood flow and
Calculation is performed using G*Power statistical
opening of the capillary surface area associated with
software (version 3.1.9.2; Universitat Kiel, Germany)
increased flux of urea and other toxic agents [4, 5].
based on data of Sp Kt/V derived from Huang et al. [1]
Intradialytic exercise (IDE) performed during HD has
and revealed that the required size of each group is 23.
been accepted as a beneficial exercise intervention due
The calculations were made using = 0.05, = 0.2 and
to its feasibility and improvements in physical
effect size = 0.85 and allocation ratio N2/N1=1.
performance and dialysis efficacy [6].

Inclusion criteria:

This study was conducted to determine the effect of
Patient's age ranged from 55 to 65 years old from
combining intradialytic leg cycling and upper limb
both genders. Patient's body mass index (BMI) ranged
range of motion exercises on dialysis adequacy and
from 25 to 34.9. Patients diagnosed with ESRD on
solutes removal (creatinine, phosphorus, potassium and
hemodialysis more than 3 month. All patients have a
urea). According to our knowledge there are limited
vascular access through arteriovenous fistula. They are
studies such that.
medically and psychologically stable.


1581
Received: 30/10/2021
Accepted: 28/12/2021

Full Paper (vol.871 paper# 99)


c:\work\Jor\vol871_100 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1586-1590

Assessment of Retro Infundibular Laparoscopic
Cholecystectomy in Difficult Cases
Mahmoud Abdou Yassin, Wesam Mohamid Ali,
Mohamed Ebrahim Abd Elhamid*, Ahmed Mohamed Yehia
Department of General Surgery, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Mohamed Ebrahim Abd Elhamid, Mobile: (+2): 01279524645, Email: m7mdibrhm2@gmail.com

ABSTRACT
Background:
Laparoscopic cholecystectomy becomes the gold standard surgical procedure for treating gallstones.
Standard laparoscopic cholecystectomy (SLC) requires proper dissection of Calot's triangle to achieve the critical view
of safety.
Objective: To evaluate the role of application of Retroinfundibular laparoscopic cholecystectomy technique during
laparoscopic cholecystectomy regarding its impact on biliary and vascular injuries.
Patients and methods: A clinical trial study included 30 patients with gallstone diseases which were carried out at
Zagazig University Hospitals. All patients who had asymptomatic gallstone who admitted for laparoscopic
cholecystectomy and were fit for laparoscopic surgery. We selected the patients that had the preoperative predictors for
difficult cholecystectomy. Patients were operated on within 6 months duration.
Results: There is a statistically significant difference in the distribution of patients regarding the history of previous
hospitalization. Four patients (13.3%) had palpable gall bladder on preoperative abdominal examination with a
statistically significant difference in the distribution of patients. Five patients (16.7%) had thick gall bladder walls on
preoperative ultrasonographic examination with a statistically significant difference in the distribution of patients. Only
one patient needs conversion to open a statistically significant difference in the distribution of patients. One patient had
bile injury, one with bleeding, and one had infection with a statistically significant difference between those who
developed complications and those who passed uncomplicated.
Conclusion: Dissection to retroinfundibular area with mass ligation of cystic duct and artery is a safe and feasible
alternative method to conversion to open in difficult cholecystectomy.
Keywords: Laparoscopic Cholecystectomy, Difficult Cases, Gallstones.

INTRODUCTION

Laparoscopic cholecystectomy becomes the
This study aimed to evaluate the role of
standard surgical procedure for treating symptomatic
application of the Retroinfundibular laparoscopic
gallstones. Standard laparoscopic cholecystectomy
cholecystectomy technique during laparoscopic
(SLC) requires safe dissection of the contents of Calot's
cholecystectomy regarding its impact on biliary and
triangle, to achieve the critical view of safety (CVS) (1).
vascular injuries.
This step becomes difficult in cases of acute

inflammation, Mirizzi syndrome, longstanding chronic
PATIENTS AND METHODS
inflammation, and difficult access to the gallbladder due
This is a clinical trial study that included 30
to dense omental adhesions for any reason. These
patients with gallstone diseases which was carried out
results in a higher risk of bile duct injury (BDI), this risk
in Zagazig University Hospitals. Patients were operated
may reach up to 3.5 times as for easy cholecystectomy
on within 6 months duration.
(2). The traditional response in these cases was the
Inclusion criteria: All patients presented with chronic
conversion to open, which may reach up to 25% in some
calcular cholecystitis and have the preoperative
literature, with an average of 5-10%. But conversion
predictors for difficult cholecystectomy such as age >40
does not guarantee the avoidance of biliary or vascular
years, BMI >25, history of hospitalization for acute
injury. At the same time, conversion to open is
cholecystitis, previous upper abdominal surgery.
associated with sequelae of open surgery (3).
Sonographic picture of thick wall GB, pericholecystic
Difficult cholecystectomy is not clearly defined
collection, or impacted stone (Figure 1). Long-standing
because it is subjective. So many studies tried to use
cases of chronic calcular cholecystitis and cases of
objective
parameters
to
define
a
difficult
Mirrizi
syndrome
proved
by
pre-operative
cholecystectomy. These include male gender, age > 60,
investigations.
recurrent attacks, elevated amylase, history of previous

upper abdominal surgery post-ERCP, adhesion masking
Exclusion criteria: Patients unfit for laparoscopic
the gallbladder, acute inflammation, and Mirizzi
surgery as cardiac diseases and patient refusal.
syndrome (4).

Intraoperative cholangiography, antegrade or
Methods:
subtotal cholecystectomy are alternatives to conversion
All the patients had been submitted to thorough
to open in difficult cases, but these techniques are time-
history taking with special stress on symptoms of
consuming and need skills and experiences (5).
jaundice, cholangitis (fever, rigors, and jaundice.
1586
Received: 29/10/2021
Accepted: 27/12/2021

Full Paper (vol.871 paper# 100)


c:\work\Jor\vol871_101 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1591-1598

LncRNA MEG3 in Promoting Antiphospholipid Syndrome Nephropathy in
Patients with Systemic Lupus Erythematosus
Nearmeen M. Rashad*1, Usama A. Khalil1, Amira M. El-Helaly2, Manar H. Soliman 3, Magda M. Sherif 1
Departments of 1Internal Medicine, 2Clinical Pathology and 3Medical Microbiology & Immunology,
Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Nearmeen M. Rashad, Mobile: (+20) 1224248642,
E-mail: nrashad78@yahoo.com - n.rashad@zu.edu.eg

Abstract: Antiphospholipid syndrome (APS) is an autoimmune disease characterized by recurrent thrombotic events
and/or pregnancy morbidity associated with the presence of antiphospholipid antibodies (aPL). The role of long non-
coding RNAs (lncRNAs) has been of particular interest in the pathophysiology of APS.
Objective: We aimed to investigate lncRNA Maternally Expressed Gene 3 (MEG3) in patients with SLE and to assess
its association with susceptibility and clinicopathologic features of antiphospholipid syndrome nephropathy.
Patients and methods: A Controlled cross-sectional study was conducted at Faculty of Medicine, Zagazig University
Hospitals, with 211 females. After the exclusion of 16 patients according to exclusion criteria, 95 patients had SLE and
100 healthy controls. Results: There were significantly higher values of LncRNA MEG3 relative expression level in
the SLE group (5.29±2.8) compared to the control group (2.34±0.74), p< 0.001, Among patients with SLE, there were
significantly higher values in APS groups (6.65±3.58) compared to non-APS group (4.5±1.97) p< 0.001. There were
significant positive correlations between lncRNA MEG3 relative expression level and ESR, serum creatinine, LA, ACL
-IgG, ACL -IgM, leukocyturia, and erythrocyturia. However, there were significant negative correlations between
lncRNA MEG3 relative expression level and e GFR, C3, and hemoglobin. Interestingly, we further evaluated our results
by linear regression test our results showed that serum creatinine, LA, ACL -IgM, C3, hemoglobin, and ACL -IgG were
independently correlated with lncRNA MEG3 relative expression level among APL patients.
Conclusions: LncRNA MEG3 relative expression level was significantly higher in SLE in particular APS group
compared to control group and significantly positively correlated with ESR, serum creatinine, LA, ACL -IgG, ACL -
IgM, leukocyturia, and erythrocyturia.
Keywords: systemic lupus erythematosus, SLEDAI, lncRNA MEG3, APS nephropathy.

INTRODUCTION:
promote the release of inflammatory to aggravate or
Antiphospholipid Syndrome (APS) is an
alleviate diseases [5]. It has been assumed that lncRNAs
autoimmune disorder, clinically characterized by
are widely found in many bodily fluids and are highly
pregnancy morbidity and/or a hypercoagulable state
stable in the plasma, potentially serving as biomarkers
involving the venous or arterial vasculature. It may be
for multiple diseases [6].
assumed that APS is linked to antiphospholipid
Maternally Expressed Gene 3 (MEG3), an
antibodies (APIs), including anti-cardiolipin antibodies
embossed lncRNA within DLK1-MEG3 locus located
(ACL), anti-beta2-glycoprotein I (anti-ß2GPI), and
at human chromosome 14q32 and on mouse
Lupus anticoagulant (LA). A growing body of evidence
chromosome 12 [7]. There is growing evidence that
has documented that APS arises either as primary APS
MEG3 expression levels are associated with many
(PAPS) or secondary APS to other diseases for example
diseases; cancer [8-18], autoimmune disease [11], as well
systemic lupus erythematosus (SLE/APS) [1].
as metabolic diseases for example diabetic nephropathy
There is a lot of evidence that raised the fact that
[12]. The present study was designed to analyze the
renal pathology could be due to thrombosis of the renal
potential clinical usefulness of investigating lncRNA
artery or the intra parenchymatous arteries, glomerular
MEG3 relative expression level in patients with SLE
capillaries, or renal veins [2]. Diagnosis of APS
and to assess its association with susceptibility and
nephropathy requires the presence of one or more acute
clinicopathologic
features
of
antiphospholipid
or chronic typical intrarenal lesions on histology after
syndrome nephropathy.
ruling out other causes of renal microangiopathy[3].

PATIENTS AND METHODS
Substantial evidence implicates molecular,
A Controlled cross-sectional study was
genetic, and epigenetic mechanisms are considered as a
conducted with 211 females. After the exclusion of 16
critical mediator in the pathophysiology of APS as it has
patients according to exclusion criteria, 95 patients had
been suggested that APS induce genomic and epigenetic
SLE and 100 healthy controls. All participants
alterations that support a pro-thrombotic state. A
underwent complete history taking, thorough clinical
preponderance of evidence suggests that 98% of the
examination. The flowchart of the study is shown in
products are non-coding RNAs and those with a size
figure 1. Among 95 patients with SLE (the diagnosis of
length greater than 200 nucleotides (NT) are defined as
SLE were according to Petri[13]), 15 patients had APS
long non-coding RNAs (lncRNAs) [4]. There are
(the diagnosis of APS, were according to Miyakis et al.
intriguing reports investigating the role of lncRNAs in
[1]) the diagnosis of renal involvement was confirmed by
the pathogenesis of autoimmune diseases and they
renal biopsy. A history of proteinuria was defined as
observed that ncRNAs could participate in
500 mg or more per 24 hr. Disease activity was
inflammatory pathways in autoimmune diseases and
1591
Received: 29/10/2021
Accepted: 27/12/2021

Full Paper (vol.871 paper# 101)


c:\work\Jor\vol871_102 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1599-1601

Role of Verapamil in Keloids Management: Review Article
Marwa Mahmoud Abdel Rahman*, Sahar Al Mokadem, Mai Ahmed Samir
Department of Dermatology, Venereology & Andrology, Zagazig University Hospital, Egypt.
*Corresponding author: Marwa Mahmoud Abdel Rahman, E-Mail: merooody55@gmail.com

ABSTRACT
Background:
A keloid arises due to excessive production of collagen and fibroblasts in the dermis as an abnormal
healing response to skin injury. Unlike hypertrophic scars, it grows beyond the original margins of the scar. The exact
pathogenesis is still unclear. It is due to either excessive production or decreased degradation of collagen fibers. Some
molecular abnormalities are incorporated such as the excess production of growth factors and inactivation of pro-
apoptotic genes. Keloids are difficult to treat and the ideal treatment modality isn't yet identified. A wide range of
treatment modalities have been used as intralesional injections, radiotherapy, cryotherapy, surgical excision, occlusive
dressing, and compression therapy. Intralesional verapamil has been successfully used in the management of keloid and
hypertrophic scars. It acts through inhibition of the synthesis of extracellular matrix, reduction of fibrous tissue
production, inhibition of IL6, VEGF, TGF1 and induction of fibroblast procollagenase synthesis and apoptosis.
Methods:
PubMed, Google scholar and Science direct were searched using the following keywords: Verapamil and
keloids management. The authors also screened references from the relevant literature, including all the identified
studies and reviews, only the most recent or complete study was included.
Objective: Evaluate of the potential role of verapamil in keloids management.
Conclusion: Intralesional verapamil has a lower risk of side effects than standard corticosteroid injections for treating
keloid and hypertrophic scars.
Keywords: Verapamil, Keloids management.

INTRODUCTION

English in 3 data bases: PubMed, Google scholar and
Prevalent keloid is a dermal fibroproliferative
science direct. Also, Boolean operators (AND, OR,
condition due to improper wound healing and excessive
NOT) had been used such as verapamil and keloids
collagen deposition. It looks like a raised scar, which
management and in peer-reviewed articles between
might be mistaken for hypertrophic scars, a more
1996 and 2021. Documents in a language apart from
frequent type of scar (1). Distressing issues, such as
English have been excluded as sources for
keloids, can develop to cosmetic disfigurements that have
interpretation. Papers apart from main scientific studies
a significant psychological impact. In addition, keloids
had been excluded (documents unavailable as total
can cause sensations like as itching, burning, and
written text, conversation, conference abstract papers
soreness, which have a negative impact on a person's
and dissertations).
ability to perform daily tasks and activities. Earlobes and

cheekbones as well as anterior chest and shoulders are the
Clinical picture:
most vulnerable places for keloid development (2).
Depending on the severity of the damage, keloids
In contrast to hypertrophic scars, keloids spread
may begin to form between a few months to a year.
outward from the initial wound, resulting in a scar that is
Lesions have been recorded that were not caused by a
more noticeable than the surrounding skin. Pain,
disease. However, it is more possible that the injury was
hyperaesthesia, and pruritus are frequently linked with
forgotten or that the keloid formation was delayed for
keloids, and this can have a significant impact on the
months or even years because of its insignificance.
patient's quality of life (3). Keloids are more common
Keloids can form in any part of the body, although the
among people of African, Asian, and Hispanic heritage
deltoid, pre-sternal chest, upper back, and ear are the
who are between the ages of 10 and 30. Due to more
most prevalent places. Palms and soles, eyes and
aesthetic operations like ear piercing. Females are more
genitalia are all unusual places to find these parasites.
prone to have keloids than males (4).
Keloids are nodules that protrude from the skin's surface
The aim of the review was to evaluate the potential role
and are composed of a firm, rubbery material (5).
of verapamil in keloids management.
Keloids are difficult to treat and the ideal treatment

modality isn't yet identified. A wide range of treatment
Methods:
modalities have been used as intralesional injections,
A search strategy has been performed to determine
radiotherapy, cryotherapy, surgical excision, occlusive
the related literature. Initially, the objective of review
dressing, and compression therapy. Clinical trials to
was identified: Evaluation of the potential role of
compare the safety and efficacy of these variable
verapamil in keloids management. Relevant keywords
modalities are always needed to establish the best
included: Verapamil and keloids management. These
treatment protocol (6).
databases were searched for articles published in

1599
Received: 28/10/2021
Accepted: 26/12/2021

Full Paper (vol.871 paper# 102)


c:\work\Jor\vol871_103 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1602-1607

Evaluation of Laboratory Parameters and Their Correlation with Covid-19 Severity
Ahmed Atya Abdelmoty, Walid Ahmady Abdeldayem,
Reham Hosny Metwally*, Abdelmonem Mohamed Elshamy
Department of Tropical Medicine, Faculty of Medicine, Zagazig University Hospital, Egypt
*Corresponding author: Reham Hosny Metwally, E-mail: reham.7osny@gmail.com
ABSTRACT
Background:
Role of laboratory parameters in prediction of COVID-19 severity and the need for ICU admission is not
well established and needs further investigations.
Objective: This study aimed to evaluate the role of different laboratory parameters, as a minimally invasive method, in
prediction of COVID-19 severity and the need for ICU admission.
Patients and methods: Two hundred COVID-19 confirmed patients were admitted to Zagazig University Isolation
Hospitals. They were divided into 2 groups according to disease severity. Group I included 100 patients admitted to
ICU with severe COVID-19 infection and group II that included 100 patients with mild to moderate COVID-19
infection.
Results: There was a statistical significance increase in WBCs, PNL and neutrophil/lymphocyte ratio and decrease in
lymphocyte among sever cases compared to mild cases. WBCs, lymphocyte, PNL, neutrophil/lymphocyte ratio, urea,
d-dimer, LDH, ferritin and CRP had significant validity in prediction of severe cases with accuracy of 63%, 65%, 66%,
70%, 68%, 66%, 65%, 66.5% and 64.5% respectively. WBCs, lymphocyte, PNL, neutrophil/lymphocyte ratio, urea, d-
dimer, LDH, ferritin and CRP had significant validity in prediction of mortality among the studied cases with accuracy
of 55.5%, 55.5%, 63%, 64.5%, 63.5%, 57.5%, 56.5%, 65% and 62% respectively.
Conclusion: The studied biomarkers can be used as an important assistant in clinical practice at ICU admission to
improve prognosis, guide treatment and minimize the mortality rates.
Keywords: Covid-19 severity, Laboratory parameters.

Introduction:
confirmed COVID-19. They were divided into 2 groups
COVID-19 spreads mostly through the airways,
according to disease severity using Egyptian Ministry of
primarily via the lungs. Respiratory droplets or aerosols,
Health and Population (MOHP) protocol for diagnosis
which include virus-containing particles breathed by a
and treatment of COVID -19 as following: Group I
person who is infected, can infect others who are in
included 100 patients admitted to ICU with severe
close touch with the person (1). A mixture of cell-
COVID-19 infection, and group II that included 100
mediated and antibody-mediated immunity is involved
patients with mild to moderate COVID-19 infection.
in the human response to COV-19 (2). COVID-19's

severity can range from mild to severe. The illness may
Inclusion criteria: COVID-19 confirmed patients
progress slowly with few or no symptoms, much like
(diagnosed by PCR) and admitted to Zagazig University
the common cold or other upper respiratory illnesses.
Isolation Hospitals.
Some studies estimate that 10% to 20% of COVID-19
Exclusion criteria: Patients < 18 years, patients who
patients would develop symptoms lasting longer than a
were chronically immunosuppressed, pregnant women,
month (3). Septic shock and mortality may result from
patients with malignant disease, patients who were
complications such as pneumonia and acute respiratory
receiving long-term oral corticosteroids or antivirals,
distress syndrome (ARDS)(4). Several studies attempted
and patients had active gastrointestinal nematode
to use clinical evaluation and laboratory tests to predict
infections or allergies
severity and ICU admission in COVID-19 patients at

the time of initial presentation. According to a study
Methods:
conducted in Wuhan, neutrophilia and an elevated d-
Patients' demographics, presenting symptoms and
dimer level are both risk factors for ARDS and death (5).
laboratory findings reported at the time of admission, in
Liang et al. (6) hypothesized that LDH, direct bilirubin,
addition to radiological data and outcome of all enrolled
and the neutrophil to lymphocyte ratio are all indicators
patients positive for COVID-19 infection were obtained
of serious disease in COVID-19. As a result, more
as following:
research is needed on how laboratory measures might
Full history taking focusing on age, sex, and clinical
help predict COVID-19 severity and the requirement for
symptoms with special regard to co-morbidity and
ICU admission.
drug history.
We aimed for evaluation of role of different
Complete medical examination (general, chest, and
laboratory parameters, as a minimally invasive method,
abdominal examinations).
in prediction of COVID-19 severity and the need for

ICU admission.
Severity Assessment:

COVID-19 severity was accessed in the studied patients
PATIENTS AND METHODS
according to MOHP as follows:
At Zagazig University Isolation Hospitals, we
Group (I) involved mild cases when clinical symptoms
conducted this case-control on 200 cases with
were minimal without dyspnea or shortness of breath
1602
Received: 27/10/2021
Accepted: 25/12/2021

Full Paper (vol.871 paper# 103)


c:\work\Jor\vol871_104 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1608-1612

Incidence and Risk Factors of Funguria in Nosocomial
Septic Patients in Surgical Intensive Care Unit
Mohammad Elzanaty Ahmed*1, Sahar Mohammad Saad Aldeen1,
Ghada Elsayed Amr2, Abdel Monem Abdel Aziz Salem1
Departments of 1Anesthesia and Surgical Intensive Care and
2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohammad Elzanaty Ahmed, Mobile: (+20) 0212987646, Email: drmohamedzanaty81@gmail.com

ABSTRACT
Background:
Nosocomial candida infections had emerged as an increasing problem in the last years. Candidemia is
late-onset ICU-acquired infection associated with high mortality.
Objective: The aim of the present study was to prevent and control of funguria in nosocomial septic patients in surgical
ICU.
Patients and methods: The study was conducted in surgical Intensive Care Units (ICU) Zagazig University on 31
nosocomial patients with septic criteria after 7 days of admission in surgical ICU. Demographic features, underlying
disease and concomitant infections were recorded for each patient during a period of 6 months.
Results: Among the studied 31 patients 23 (74.2%) of them were admitted for damage control laparotomy (DCL), due
to road traffic accident (29.03%), (12.9%) were operated upon due to chronic subdural hematoma (SDH) or
subarachnoid hemorrhage (SAH), (9.6%) of the studied patients were admitted with SAH due to gunshot and (22.5) of
the studied patients due to metabolic acidosis. The most concomitant diseases was diabetes mellitus in (35.5%) of studied
patients, followed by hypertension and ischemic heart disease in (32.3% and 19.4%) respectively, other concomitant
diseases as chronic obstructive pulmonary disease (COPD) and hepatic disease were found in 9.7% and 3.2% of the
studied patients respectively. Funguria was positive in (41.9) of studied patients, negative in (58.1) of them and no
fungemia among the patients with positive funguria.
Conclusion:
The incidence of funguria among surgical ICU patients was high in our study. Pseudomonas aeruginosa
was the most frequent causative organism followed by acinetobacter baumannii and Klebsiella pneumonia.
Keywords: Funguria, ICU, Nosocomial Septic Patients.

Introduction:

Nosocomial infection is an infection acquired by
peroxide based and healthcare facilities, resulting in
patient during hospital stay(1). Studies conducted during
highest reduction of Candida colony-forming unit
the past two decades have documented changes in
(CFU) (6).
pathogens causing sepsis and nosocomial infections and
Fisher et al.(7) recommend that not administer
emphasized the increase of fungal infections,
antifungal agents unless the patient is symptomatic or at
particularly those due to Candida species (2). These
high risk for dissemination, such as post renal transplant
patients are associated with prolonged length of stay in
patients and patients who are undergoing urinary tract
intensive care unit (ICU) and high mortality, despite
instrumentation. Therefore, this study aimed to prevent
advances in management and the availability of more
and control of funguria in nosocomial septic patients in
active antifungal agents (3).
surgical ICU.
The presence of Candida species such as candida

albicans in the urine is known as candiduria. Candiduria
PATIENTS AND METHODS
is categorized into asymptomatic (in healthy people or
The study was conducted in surgical ICU
patients) and symptomatic forms. Symptomatic
University included 31 nosocomial patients with septic
candiduria is seen in patients with cystitis, prostatis,
criteria after 7 days of admission in surgical ICU.
pyelonephritis and renal candidiasis. However,

asymptomatic candiduria is mostly benign and is not
Inclusion criteria: Nosocomial septic patients in
counted as a definite disease. Candida albicans is one of
surgical ICU after 7 days of admission in surgical ICU
the most important fungal agents which may lead to
in age between 18 to 60, previous treatment with 5 days
candiduria (20% of nosocomial infections). A wide range
of antibiotic as well as previous treatment with
of reported data shows that, Candida albicans ranks first
immunosuppressive agents.
for causing candiduria among more than 200 Candida

species (4).
Exclusion criteria: Previous treatment with
The progressive increase of sporadic cases of
antifungals for 2 weeks and positive sepsis screen at
candida species infection emphasizes the need for
admission.
adequate prevention measures. Candida species found

on different objects and facilities, such as bedrails, a bed
Operational Design:
hand-controller, a mobile phone and floors (5).
All cases admitted to surgical ICU of during a
Disinfectants with sporicidal activity and hydrogen
period of 6 months were included. For each patient, the
1608
Received: 29/10/2021
Accepted: 27/12 /2021

Full Paper (vol.871 paper# 104)


c:\work\Jor\vol871_105 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1613-1618

Effect of Nebulized Dexamethasone versus Nebulized Ketamine on
Postoperative Sore Throat after Thyroid Surgeries
Osama Eiad Mohamed Ben Sasi, Zainab Mostafa Attia,
Ali Mohmd Ali Hassn, Reham Mohamed Mohamed Aamer
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine Zagazig University, Egypt
*Corresponding author: Osama Eiad Mohamed Ben Sasi, Mobile: (+20)01096181438, E-mail: osamabensasi1981@gmail.com

ABSTRACT
Background:
Endotracheal intubation is the prominent cause of airway mucosal injury which results in postoperative
sore throat (POST), with an incidence of 21%­65% if left unresolved, it produces significant agony and annoyance to
the patient. Objective: The aim of the present study was to compare the hemodynamic effect of nebulized dexamethasone
and nebulized ketamine on postoperative sore throat after thyroid surgeries. Patients and methods: This prospective
controlled randomized double-blind study was carried out in Zagazig University Hospitals during the period from
January to July 2021, included 72 patients of both gender in the age group 21-50 years, undergoing thyroidectomy under
general anesthesia. Results: There was statistically significant increase of the severity and incidence of sore throat in the
control groups immediately postoperatively, 2, 6, 12 and 24 hours postoperatively among the studied groups. While,
there was significant difference between dexamethasone groups and ketamine group regarding the severity and incidence
of sore throat immediatley, 2, and 6 hours (hr) postoperatively. Conclusions: We concluded that nebulized dexamethsone
may be considered as a safe alternative to nebulized ketamine for decreasing POST.
Keywords: Dexamethasone, General anesthesia, Ketamine, Nebulization, Sore throat.

INTRODUCTION
Ketamine, an N-methyl-d-aspartate (NMDA)
Endotracheal intubation is the prominent cause of
receptor antagonist, has been used for decreasing
airway mucosal injury, which results in postoperative
postoperative sore throat because of its anti-nociceptive
sore throat (POST), with an incidence of 21%­65% if
and anti-inflammatory action, as gargle as well as in
left unresolved, it produces significant agony and
nebulized form. However, nebulized ketamine is better
annoyance to the patient(1).
tolerated in patients due to many reasons such as: It saves
Postoperative sore throat is common after thyroid
the patient from the bitter taste of ketamine, also much
surgery due to manipulation of the trachea during
lesser volume is needed(7).
positioning, dissection of the gland and the neck being
The aim of the present study was to compare the
hyperextended leading to injury of the tracheal mucosa
effectiveness of nebulized dexamethasone and nebulized
and vocal folds(2). It is considered an important
ketamine on the incidence and severity of postoperative
complication as it may increase incidence of
sore throat after thyroid surgeries.
postoperative morbidity as hoarseness of voice and

dysphagia that cause patient dissatisfaction and
PATIENTS AND METHODS
discomfort. It may be unresolved for few days
72 adult patients belonging to American Society of
postoperatively and prolong hospital stay (3).
Anesthesiologists physical status I-II (ASA I-II) in the
There are non-pharmacological methods to reduce
age group 21-50 years of both gender, undergoing
postoperative sore throat as smaller sizes of tracheal
thyroid surgery, were randomly divided into three equal
tubes, careful airway manipulation, intubation after
groups using computer generated randomization table;
complete muscle relaxation, minimizing the number of
Group C: Patients received normal saline (total volume
laryngoscopy trials for intubation, fixation of
of 5 ml) for nebulization. Group D: Patients received
endotracheal tube intra cuff pressure at or below 20 cm
dexamethasone 8 mg (2 ml) with 3 ml of normal saline
H2O, gentle pharyngeal suctioning under vision and
(total volume of 5 ml) for nebulization. Group K:
extubation when the tracheal tube cuff is fully deflated
Patients received ketamine (preservative-free) 50 mg (1
to avoid coughing during extubation(4). The
ml) with 4 ml of normal saline (total volume of 5 ml) for
pharmacological methods used to reduce postoperative
nebulization.
sore throat include use of beclomethasone gel, lidocaine
Exclusion criteria were uncooperative patients,
spray, dexamethasone nebulizer and ketamine nebulizer
history of allergic reaction to the study drugs, patients
and intravenous magnesium sulfate (5).
with chronic obstructive pulmonary disease, heavy
Steroids have anti-inflammatory functions and are
smokers (20 packs/week), anticepated difficult
widely used in common practice. The inhaled
intubation or Mallampati grade >2, History of
corticosteroids deliver the drug to the site of action
preoperative upper respiratory tract infection, asthma,
where it is used in patients with airway diseases without
sore throat, recent use of nonsteroidal anti-inflammatory
systemic effects. Dexamethasone is a potent synthetic
drugs, pregnant or breast feeding patient, operation
glucocorticoid with anti-inflammatory effects. It has
lasting >2 hours in duration, patients of thyrotoxicosis
been reported that dexamethasone is effective in the
or retrosternal extension.
treatment of sore throat(6).
Sample size:
1613
Received: 30/10/2021
Accepted: 28/12/2021

Full Paper (vol.871 paper# 105)


c:\work\Jor\vol871_106 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1619-1625

Vaccine Hesitancy among Parents and its Determinants in
PHC in Al Madinah City 2020
Zamil Jamil Al Yamani1 and Mohammad Mater AlJohani2
1Family Medicine Resident, 2Family Medicine Consultant,
Joint Program of Family Medicine, Al Madinah Al Munawara, Saudi Arabia
Corresponding author: Zamil Jamil Al Yamani,Email: Dr.zamil@yahoo.com,Mobile: +966561116862

ABSTRACT
Background:
Vaccine hesitancy is caused by a variety of factors, which are complex and multifaceted. The perceived risks
of vaccines, the relationship between parents and health-care providers, and the social norm of vaccination are all factors
that influence vaccine decision making.
Objective: This study aimed to conclude the prevalence of vaccine indecision amongst parents visiting PHC in Al-Madinah
city, to identify socio-demographic determinants of vaccine hesitancy and to recognize agents and host-related factors,
which leads to hesitancy. Methods: A cross-sectional research was implemented on parents who attended the PHC using a
valid questionnaire filled by interviewing the parents. All data was confirmed manually then was implied and entered into
SPSS software. Then the data were analyzed using the appropriate statistical test.
Results: Vaccines can protect children from dangerous diseases, according to 98.1% of the 375 people who took part in our
study. 88.5% of parents preferred to get their children vaccinated with all of the vaccines that are recommended. 69.9% of
participants had ever been hesitant or unwilling to have their child vaccinated. 9.6% of parents were unable to get their child
vaccinated due to distance, clinic timing, time needed to get the clinic or wait at the clinic, and/or the cost of getting to the
clinic.
Conclusion: Finally, our findings demonstrated that vaccine apprehension is a prominent issue among parents in Saudi
Arabia. We discovered that vaccine fear is widespread, and that it spiked during the COVID-19 pandemic.
Key words:
Vaccine hesitancy, Parents, Determinants, PHC, Al Madinah, Saudi Arabia.

INTRODUCTION

Prevention (CDC) to achieve the immunity among all the
Vaccine, unique of the most imperative encounters
children and the community. These include; Polio, Rota,
in the 20th century, helped to eliminate some infectious
measles, mumps, Hemophilus influenza, Hepatitis A and
diseases, as well as to reduce the severity of others.
B, Diphtheria, Tetanus, BCG, Pertussis, Pneumococcal
Vaccine programs aid in the abolition of smallpox and
Conjugate, Meningococcal Conjugate quadrivalent and
poliomyelitis in the Americas, as well as the switch of
Varicella [6].
measles, rubella, tetanus, diphtheria, hemophilus
Unvaccinated individuals will put the community at
influenza type b, and additional transmittable illnesses in
risk of disease, which made the refusal and hesitancy to
the United States and elsewhere [1]. The first vaccination
the vaccine as an emerging issue [7]. Hence the term
was discovered in 1796 by Edward Jenner using cowpox
"vaccine hesitancy" appeared to us and many studies had
to inoculate against smallpox, which led to worldwide
been conducted tried to study this phenomenon globally
eradication of smallpox in 1980 [2].
and find appropriate solutions to it. There is different
A vaccine is a substance that encourages a person's
definition with same concept describe this status. Vaccine
immune system to create immunity against a certain
hesitancy is a postponement in accepting or refusing
disease, thus, protecting them from it. The vaccination is
vaccinations notwithstanding the convenience of
normally administered via needle, however it can also be
immunization facilities. Vaccine procrastination is
administered orally or via nasal spray [3]. Vaccines mainly
multifaceted and context-specific, changing over time,
consist of an attenuated or attenuated version of a
place, and vaccine type. It is prejudiced by issues such as
particular pathogen [4]. A vaccine is a biological agent that
complacency, convenience and confidence [8].
induces an immune response to a specific antigen derived
Vaccination reluctance is defined as a set of beliefs,
from the pathogen causing an infectious disease [2].
attitudes, behaviors, or a blend of these, expressed by non-
Vaccine helps the immunity system to fight against
professionals about immunizing themselves or their
pathogens like viruses or bacteria. Protect against more
children, and sometimes by health care professionals [9].
than 25 diseases. The majority of children receive their
It acknowledges a continuum among the domain names
vaccine on a specific time, while 20 million worldwide
of vaccine attractiveness and vaccine refusal and de-
miss-out, making them at risk of that disease, life-
polarizes preceding characterization of people and
threating ill [5]. The Ministry of Health (MOH) started to
agencies as both anti-vaccine or pro-vaccine [10].
design their own schedule, which can help the community
Vaccine hesitancy was considered as one of the ten
of certain disease, these schedules include the vaccine
most important threats to public health, due to the lack of
recommended by the centers for Disease Control and
vaccination and exposure of children and adults who are
1619
Received: 28/10/2021
Accepted: 26/12/2021

Full Paper (vol.871 paper# 106)


c:\work\Jor\vol871_107 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1626-1634

Influence of Heme Oxygenase- 1 Polymorphism (Rs2071746) on
Esophageal Varices among Patients with Cirrhosis
Ahmed Ahmed El-Shaarawy1, Eman Ahmed Gawish1,
Ahmed Kamal Khamis2, Omnia Salah Nabih Ahmed*1, Mary Albert Naguib1
Departments of 1Clinical Pathology, 2Hepatology, National Liver Institute, Menoufia University, Menoufia, Egypt
*Corresponding author: Omnia Salah Nabih Ahmed, Mobile: (+20)01066113510, E-mail: dromniasalah@yahoo.com

ABSTRACT
Background:
Portal hypertension (PHT) is a frequent clinical syndrome arising as a sequela of mesenchymal
dysfunction in a cirrhotic liver. Esophageal varices (EV) are portosystemic collaterals in the submucosa of the lower
esophagus. Heme oxygenase -1 (HO-1) was suggested as having vascular effects. So, in our study, we aimed to evaluate
the role of HO-1 promotor polymorphism (rs2071746) on esophageal varices among patients with cirrhosis.
Objectives: The present study was designed to evaluate the role of HO-1 SNP 413A>T promoter (rs2071746)
polymorphism in the development of esophageal varices among cirrhotic patients.
Patients and methods: A total of 105 subjects, including 35 cirrhotic patients with esophageal varices, 35 cirrhotic
patients without esophageal varices, and 35 healthy controls were selected. HO-1 rs2071746 polymorphism was studied
using Real-Time polymerase chain reaction (Real-Time PCR).
Results: we found that AA, AT, AA+AT genotypes were significantly associated with an elevated risk of EV
development (OR =6.82, 95% CI =1.24- 37.54), (OR= 6.43, 95% CI =1.21- 34.19), (OR= 6.60, 95% CI=1.33- 32.84)
respectively. And, the A allele was correlated with an increased risk of EV (OR= 2.06, 95% CI=1.40- 4.10). Patients
with the AA genotype were significantly associated with lower platelet levels (P= 0.026), lower platelets count/ spleen
diameter ratio (p-value= 0.014). Also, they had large varices (p-value= 0.025).
Conclusion: Our results suggest rs2071746 polymorphism could be used as a potential predictor and early diagnostic
marker of EV development.
Keywords: Esophageal Varices, Heme Oxygenase -1, Polymorphism.

INTRODUCTION

>11.5 mm, and a platelet spleen diameter ratio cutoff of
Cirrhosis is a diffuse morphology that is
909 were found to be predictors of large EVs (5).
characterized by excess fibrous tissue circumscribing
The major cause of portal hypertension in cirrhosis
parenchymal nodules, which consist of regenerating
is increasing intrahepatic vascular resistance associated
hepatocytes and alterations in hepatic vascular
with fibrosis/cirrhosis. Nitric oxide (NO), the most
architecture. Liver cirrhosis (LC) is the twelfth leading
powerful vasodilator substance, is significantly reduced
cause of death worldwide (1).
in cirrhotic livers (6).
Hepatitis C more than hepatitis B has emerged as
Heme oxygenase -1 (HO1) is a stress-responsive
the leading cause of chronic hepatitis and cirrhosis.
enzyme that catabolizes the heme resulting in the
Many cases of the formally called cryptogenic cirrhosis
formation of equivalent amounts of ferrous iron (Fe2+),
appear to be related to nonalcoholic fatty liver disease
biliverdin (BV), and carbon monoxide (CO). These
(2).
substances have a cytoprotective mechanism against
Portal hypertension (PHT) is one of the most
oxidative stress occurring in the vascular system (7).
important sequelae of cirrhosis leading to clinically
The up-regulation of HO-1 could inhibit the
relevant outcomes in terms of varices, ascites,
activity of the NO synthase enzyme through multiple
splenomegaly hepatopulmonary syndrome, and
mechanisms, as CO product could serve as a potent
hepatorenal syndrome. PHT is defined as a hepatic
inhibitor of the enzyme reaction resulting in suppressing
venous pressure gradient greater than 5 mmHg, with
the potent NO-mediated biological actions such as
clinical consequences arising once this exceeds 10
vasorelaxation and lowering intrasinusoidal resistance
mmHg (3).
occurring in cirrhosis (8).
Esophageal varices (EV) are portosystemic
In addition, the HO-1 reaction requires electrons
collaterals that form because of PHT preferentially in
from reduced nicotinamide adenine dinucleotide
the submucosa of the lower esophagus. Variceal
phosphate (NADPH) which competes for them with NO
bleeding accounts for 10­30% of all cases of upper
synthase (9).
gastrointestinal bleeding. EV can be graded based on
Variation in genes might play a role in the
diameter size and are classified as small or large at a cut-
development of esophageal varices and their risk of
off of 5 mm (North Italian Endoscopy Club
bleeding. This fact could improve the selection of
classification) and accordingly, they can be managed
candidates for esophagogastroduodenoscopy and could
either medically and/or endoscopically (4).
help in a detailed understanding of the pathogenesis of
Multiple factors were encountered as predictors of
esophageal varices and thereafter, the prognosis of liver
EV development and bleeding. Low platelet count,
cirrhosis (10).
spleen size >13.8 mm, portal vein >13 mm, splenic vein
1626
Received: 30/10/2021
Accepted: 28/12/2021

Full Paper (vol.871 paper# 107)


c:\work\Jor\vol871_108 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1635-1643

Cross-Talk between Apelin, Insulin Resistance, Thyroid Hormones, and Cardio-
metabolic Risk Factors in Polycystic Ovary Syndrome
Ragaa Abdelshaheed Matta*1, Ahmed Abdelfadel Saedii2
Departments of 1Internal Medicine and 2Clinical Pathology, Faculty of Medicine, Minia University, Minia, Egypt
*Corresponding author: Ragaa Abdelshaheed Matta, Telephone: 01008792833, Email: ragaamatta2017@gmail.com,
Ragaa Matta ORCID iD /https://orcid.org/0000-0002-3516-2566

ABSTRACT
Background:
Apelin and its receptor are located in hypothalamo-pituitary axis and inhibit TSH secretion. Insulin
resistance (IR) is linked to apelin, thyroid function, and polycystic ovary syndrome (PCOS). Apelin levels in obese
and non-obese PCOS women display contradictory results.
Objective: To compare serum apelin in IR PCOS and non-IR PCOS groups, evaluate the cross-talk of apelin, IR,
thyroid function, and cardiovascular risk factors in both groups, and identify the diagnostic value of apelin for IR in
PCOS.
Patients and Methods: The study included 60 young non-obese euthyroid PCOS women: IR PCOS (n=28) and non-
IR PCOS (n=32), and age-matched healthy fertile groups. Serum apelin-36, calculated homeostatic model
assessment­IR (HOMA-IR), and thyroid hormones were evaluated.
Results:
IRPCOS had significantly higher apelin compared to non-IR PCOS and healthy control groups with
insignificant differences between the two latter groups. The bivariate analysis demonstrated a significant positive
correlation between apelin and glucose, insulin, HOMA-IR, atherogenic lipid profile, and TSH and a significant
negative correlation with free T4 in IR PCOS while inverse relations were observed in non-IR PCOS. After
controlling for HOMA-IR, only HDL in IR PCOS and TSH and cholesterol in non­IR PCOS preserved the significant
correlations. Cut-off value 39 pg/dl of apelin showed high specificity (88%) and sensitivity (86%) to identify IR in
PCOS
Conclusion: Serum apelin is higher in IR than in non-IR PCOS patients. The relations between apelin and thyroid
function, and cardio-metabolic risk factors are IR dependent. Apelin is a marker of IR in PCOS and had a direct talk
with TSH, HDL-c, and cholesterol.
Keywords
: Apelin, TSH, HOMA-IR, polycystic ovary syndrome. Cardiovascular risk factors.

INTRODUCTION

decreased at the late luteal phase, and declined sharply
Polycystic ovary syndrome (PCOS) as the most
during corpus luteum (CL) regression. Apelin­APJ
common endocrinopathy in women is the main
system is involved in CL formation, function, and
etiology of anovulatory infertility. Insulin resistance
regression during the menstrual cycle. Notably,
(IR) is common in women (50-80%) with PCOS, even
progesterone stimulates the APJ expression in
if they are not obese. IR is linked to reproductive and
granulosa cells. Furthermore, apelin may participate in
metabolic abnormalities, dysfunctional adipokine
PCOS pathogenesis (5). Reports regarding serum apelin
secretion, and high normal thyroid-stimulating level
levels in PCOS are controversial as elevated or
(TSH) in PCOS. IR and hyperinsulinemia are
decreased levels were reported in previous studies (6-9).
associated with low-grade chronic inflammation and
Up to date, most of these studies classified PCOS
increased risk of hypertension, dyslipidemia, and type
women into obese and non-obese groups and not upon
2 diabetes mellitus(T2DM). TSH level even in
IR and non- IR despite more accurately of later
euthyroid PCOS women is linked to insulin resistance
classification.
and traditional cardiovascular risk factors (1-3).
Apelin also plays an important role in the
Apelin is an endogenous peptide and acts through
hypothalamic regulation of water and food intake and
its G protein-coupled receptor (APJ). Apelin­APJ
the endocrine axis. Apelin decreases TSH secretion by
system is expressed in a range of body tissues
the pituitary gland (10). In euthyroid and hypothyroid
including adipose tissue predominantly, hypothalamus-
rats, apelin administration produces a mild and marked
pituitary axis, ovary, heart, blood vessels, liver,
reduction in TSH levels respectively probably through
skeletal muscle, and kidney. It is an adipokine and
the APJ receptor in the hypothalamo-pituitary axis.
linked to obesity and IR. Similar to adiponectin, it
Apelin administration enhances thyroxin catabolism
stimulates glucose utilization, decreases insulin
and subsequent reduction in its level in the
secretion, and negatively regulates catecholamine-
hypothyroid rat. In addition, the apelin level is
mediated lipolysis. Apelin synthesis in adipocytes is
elevated in propylthiouracil-induced hypothyroid rats
stimulated by insulin, and plasma apelin levels are
(10,11). So, the relation between thyroid and apelin may
markedly increased under IR states such as obesity and
be bidirectional. Expression of thyroid receptor and
T2DM, and metabolic syndrome (4).
TSH receptor in adipose tissue are linked to IR state
Local ovarian expression of apelin­APJ system is
(12). Also, high normal TSH is linked to IR even in
significantly increased with ovarian follicle size,
PCOS (3). Clinical human studies reported either
1635
Received: 01/11/2021
Accepted: 29/12/2021

Full Paper (vol.871 paper# 108)


c:\work\Jor\vol871_109 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1644-1652

Transvaginal Doppler Ultrasonography and MRI for Prediction and Diagnosis of
Adherent Placenta in High-Risk Group in the Second Half of Pregnancy
Mohamed Ahmed Abdellah1, Yasser Ahmed Helmy1,
Hazem Mohamed Mohamed, Doaa S. M. Bardis2, Mohamed Hasan Alameldin3
Departments of 1Obstetrics & Gynecology, 2Clinical and Chemical Pathology and
3Radiology, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Mohamed Ahmed Abdellah, Mobile: (+20) 01098437456,
E-Mail: mohamedabdelaah@med.sohag.edu.eg

ABSTRACT
Background:
Placenta accreta is defined as abnormal trophoblast invasion of part or all of the placenta into the
myometrium of the uterine wall. Abnormal placentation includes both abnormally adherent placenta (placenta accreta)
and abnormally invasive placenta (AIP ­ including placenta increta and placenta percreta); the term PAS encompasses
the whole spectrum of the disorder.
Objective: This study aimed to construct the basic criteria of both sonographic and MRI for the diagnosis of placenta
accreta spectrum and figuring out the accuracy of those criteria parallel with the definition of the most peculiar features
in clinical practice.
Patients and methods: This was a prospective cohort study conducted from September 2017 to May 2021 among
women attending Sohag University Hospital which is considered to be the largest tertiary care maternity center in Sohag
Governorate. The study included 300 pregnant females with mean age of 30.58 years old. They were suspected to have
placenta accreta in the routine sonographic assessment. Moreover, the mean gestational age at which diagnosis was done
was 33.46 ± 2.54 weeks.
Results: The sensitivities of US and MRI were 91.66% and 93.51% respectively and their Specificities were 95.83%
and 96.35% respectively with statistically non-significant difference. Therefore, both ultrasonography and non-contrast
MRI examinations had an equal diagnostic reliability for diagnosis of placenta accreta spectrum.
Conclusion: Both modalities have nearly the same diagnostic accuracy. Ultrasonography remains the most sensitive
and commonly used imaging modality for the diagnosis of placenta accreta, because it is accurate, inexpensive, non-
invasive and time-saving.
Keywords:
Placenta accreta spectrum, Doppler ultrasonography, MRI.

INTRODUCTION
the risk of PAS, including decreasing the risk with a
Placenta accreta spectrum (PAS), encompassing
"normal" ultrasound, reduces the possibility of
the terms placenta accreta, placenta increta, placenta
iatrogenic complications associated with planned
percreta, morbidly adherent placenta, and invasive
premature delivery, preoperative invasive procedures,
placentation, includes the full range of abnormal
and patient and provider anxiety (4).
placental attachment to the uterus or other structures.
The prenatal detection and risk stratification for
There has been a dramatic rise in the incidence of PAS
PAS are primarily made by ultrasound. However,
over recent years. This rise is most notably driven by
ultrasound is an operator-dependent imaging modality
increasing rates of cesarean delivery. The risk is highest
with substantial variability in image quality among
in the presence of placenta previa and previous cesarean
providers. Furthermore, placental location and
deliveries (1).
challenging imaging conditions, including elevated
The use of Cesarean Section (C.S) has increased
body mass index (BMI) or posterior placentation, may
dramatically worldwide in the last decades (1). In Egypt,
impede the sonographic detection of PAS markers.
according to the latest data, more than half of all women
There has been limited consensus on the optimal
give birth by CS without much difference between
approach to the ultrasound evaluation of patients at risk
urban and rural areas .The incidence of placenta accreta
of PAS, such as the appropriate timing of screening,
in Egypt is rising due to rising rate of primary cesarean
need for transvaginal ultrasound (TVUS) imaging, use
delivery. There are high rates of neonatal mortality and
of color and pulsed Doppler, angle of placental
intraoperative complications, which can be explained
insonation, and equipment settings (5).
by morbidly adherent placenta (2).
Magnetic Resonance Imaging (MRI) is being
PAS is associated with a marked increase in
increasingly used both as a diagnostic adjunct and for
maternal morbidity and mortality. The morbidity is
pre-procedural planning. MRI and US are both non-
primarily related to massive hemorrhage with
invasive and non-ionizing imaging modalities and have
associated organ damage, cesarean hysterectomy, and
unique technical and practical advantages with respect
need for critical care resources (3). Prenatal detection of
to imaging the placenta. Importantly, the advantages of
PAS allows for mobilization of multidisciplinary care
one modality befittingly complement the drawbacks of
teams and surgical planning, which reduces maternal
the other (6).
morbidity. Furthermore, the ability to correctly stratify
1644
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 109)


c:\work\Jor\vol871_110 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1653-1657

Replacement of Complicated VP Shunts with
Endoscopic Third Ventriculostomy, Local Experience and Outcome
Karam Kenawy, Khalid Naser, Abdin K. Kasim*
Department of Neurosurgery, Faculty of Medicine, Sohag University, Sohag, Egypt
*Corresponding author: Abdin K. Kasim, Mobile: (+20) 01020196831, E-Mail: abdin_mail@yahoo.com

ABSTRACT
Background:
Until recent breakthroughs in neuroendoscopy, the ventriculoperitonal (VP) shunt remained the
mainstay of hydrocephalus therapy. However, shunt complications, including obstruction, infection and overshunting
are frequent. Getting out of the siege of VP shunt is the dream of those patients.
Objective: This study aimed to present our experience in managing VP shunt complications by endoscopic third
ventriculostomy (ETV) and shunt removal.
Patients and Methods: We reviewed 18 consecutive patients during the period from January 2017 to December 2020
with different ventriculoperitonal shunt complications. The authors retrospectively evaluated the causes, preoperative
symptoms, and postoperative results for those patients who underwent ETV and shunt removal for management of
shunt complications. Results: There were 11 males and 7 females with mean age of 12.9 years old. The mean shunt
duration was 8 years. Shunts were unilateral (15 cases) or bilateral (3 cases). Shunt complications included: shunt
obstruction (9 cases), shunt infection (8 cases) and overshunting (1 case). ETV was done in all cases with septostomy
in 7 cases. The mean follow up period was 15 months during which, 15 patients were shunt independent while three
patients needed new shunts within the first postoperative month. While transient CSF leak occurred in 4 cases, there
was no mortality in this series.
Conclusion: Removing a VP shunt and replacing it with ETV with or without septostomy is a possible option in
managing shunt complication.
Keywords: Hydrocephalus, ETV, Neuroendoscopy, VP Shunt complications.

INTRODUCTION

The function of continued cerebrospinal fluid
Endoscopic third ventriculostomy (ETV) is a
(CSF) diversion is still debatable, since shunt-
common
therapeutic
method
for
obstructive
dependence is gradually replaced by shunt-
hydrocephalus. In 1923, an urologist named William
independence. Furthermore, there is a theoretical
Mixter used an ureteroscope to fenestrate the third
danger that CSF diversion will reduce flow via the
ventricle floor for the first time (1). The invention of
ventriculostomy, lowering the success rate. For the
valve-regulated shunting technology has shown to be a
maturity of the fistulous link, some feel that
successful therapy for a variety of hydrocephalus
continuous flow is required (2).
forms (2). There has been an increase in the use of
The goal of the current study was to present our
endoscopes for ETV and management of various
experience with endoscopic third ventriculostomy for
ventricular lesions as technology advances, such as
management of shunt malfunction and infection
modern endoscopes with fiber-optics and advanced
highlighting our methods, results and potential
light sources that allow for excellent resolution of
complications.
ventricular anatomy and control the safe fenestration

of the floor of the third ventricle (2).
PATIENTS AND METHODS
ETV has been used to treat shunt dysfunction in
From January 2017 to December 2020, at the
individuals with obstructive hydrocephalus based on
Neurosurgical Department of Sohag University
imaging findings. Because of the likelihood of shunt
Hospital, Sohag University, 18 patients with
independence following successful ETV, it is worth
complicated VP shunt were endoscopically managed
considering in patients with shunt problems. ETV has
for their shunt complications.
a success rate of 67 to 80% in treating shunt
Inclusion criteria: Age of 1 year or more, unilateral
malfunction or infection (1, 3, 4, 5).
or bilateral VP shunts, history of at least 1 time
If chosen correctly, ETV is a successful and safe
previous shunt revision, presentation with shunt
therapy for individuals with shunt dysfunction. There
complication, and not associated with active brain
is no consensus on what will happen to the shunts that
tumors.
were previously implanted in this patient population.
Preoperative Evaluation:
Many studies have addressed the shunt by removing it,
All patients underwent preoperative clinical and
ligating it, externalising it, or removing it and
routine laboratory evaluation. All patients were
replacing it with an external ventricular drain.
subjected to CT and / or MRI brain prior to surgery.
According to Nishiyama et al. (6), there is a gradual
Surgical approach:
shift from a shunt-dependent state to a shunt-
Endoscopic third ventriculostomy with or without
independent state over the course of 1 week following
septostomy was done with one of the following
ETV.
options:
1653
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 110)


c:\work\Jor\vol871_111 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1658-1665

Spinal Anesthesia Using Hyperbaric Prilocaine 2% versus
Hyperbaric Bupivacaine 0.5% for Day case Surgery
Rabei Gheth Salem Etriki*, Howaida Kamal Abd Ellatif,
Ekram Fawzy Sayouh, Ahmed Mosallam Mohammed
Department of Anesthesia, Intensive Care and Pain Management, F
aculty of Medicine Zagazig University, Sharkia, Egypt
*Corresponding Author: Rabei Gheth Salem Etriki, Mobile: (+20)01066141694, E-mail: altryrby228@gmail.com

ABSTRACT


Background: Day-case spinal anesthesia with short-acting local anesthetics such as hyperbaric prilocaine, has a short
duration of action and the transient neurological symptoms (TNS) incidence is low.
Objective: The present study aimed to compare spinal anesthesia using hyperbaric prilocaine 2% and hyperbaric
bupivacaine 0.5% for day case surgery.
Patients and Methods:
This Prospective randomized controlled double-blind clinical trial study was carried out on 66
patients of both sexes scheduled for day case surgery under spinal anesthesia, They were divided into two groups; group
P: received 60mg hyperbaric prilocaine 2%; group C: received 15mg hyperbaric bupivacaine 0.5%.
Results:
The prilocaine group showed a faster onset time of sensory (1.95 ± 0.36 min) and motor block (4.87 ± 0.7 min)
and shorter time to reach maximal sensory block level(p<0.001). Prilocaine group also provides a shorter duration time
of sensory (92.4 2.5min) and motor block (110.7 8.8min) than that of the bupivacaine group (207.6 10.9&253.9
19.8 min) respectively). Prilocaine group showed a statistically significant shorter time to sit (113.3 7.7min), stand
(121.810.5min), walk unassisted (130.77.8 min) and void spontaneously (256.421.5 min) compared to the
corresponding times in the bupivacaine group, where the time to sit, stand, walk unassisted and void spontaneously
were (279.114.0 min) (285.510.9min), (301.813.9min), (345.424.5min) respectively.
Conclusions
: Hyperbaric prilocaine provides faster onset time, shorter duration of action, and earlier patient recovery
in ambulatory surgery compared to hyperbaric bupivacaine in day-case surgery.
Keywords: Spinal Anesthesia, Hyperbaric, Prilocaine 2%, Bupivacaine 0.5%

INTRODUCTION
bupivacaine (6). We aimed to compare spinal anesthesia
Spinal anesthesia has become increasingly
using hyperbaric prilocaine 2% and hyperbaric
popular for inpatient surgery, but, until recently, its use
bupivacaine 0.5% for day case surgery in terms of
has been limited in ambulatory surgery due to the lack
sensory block, and motor block resolution times.
of a safe and licensed short-acting local anesthetic
The time for first spontaneous voiding and
agent. An ideal intrathecal agent for ambulatory surgery
duration of stay in the PACU and time to home
should have a rapid onset of motor and sensory
readiness.
blockade, predictable regression within an acceptable

time frame, and a low incidence of adverse effects(1).
PATIENTS AND METHODS
Hyperbaric Bupivacaine is a long-acting local
This Prospective randomized controlled double-
anesthetic from the amide group and has a low incidence
blind clinical trial study was carried out on 66 patients
of transient neurological symptoms (TNS). Because of
of both sexes scheduled for day case surgery under
its pharmacological profile, the recovery of motor and
spinal anesthesia to compare between intrathecal
sensory blocks is delayed compared to short-acting
hyperbaric prilocaine 2% and hyperbaric bupivacaine
local anesthetics. The incidence of postoperative
0.5% in the improvement of safety and efficacy of
urinary retention with long-acting local anesthetics like
anesthesia and readiness for discharge after ambulatory
bupivacaine is higher than with short-acting local
surgery, they were admitted to Zagazig University
anesthetics (2).
Hospitals.
Successful spinal anesthesia with low doses of
The following patient parameters were recorded:
bupivacaine between 5 and 10 mg without additives has
both sexes, ages from 21- 60 years, scheduled for day
been described for outpatients. The incidence of urinary
case surgery under spinal anesthesia. American Society
retention was still 3.7­16%. Furthermore, with these
of Anesthesiologists ASA class I&II. The time of
low doses, block height becomes unpredictable and the
surgery does not exceed 75 min.
risk of block failure is high (3). Prilocaine is an amide
Exclusion criteria were; Allergy to the studied
local anesthetic with an intermediate duration of action
drugs. Patients with contraindications to spinal
after spinal administration. Recently, the old local
anesthesia. Patients with advanced cardiac, renal,
anesthetics prilocaine was reintroduced in the market. It
hepatic disease.
is available in the hyperbaric form and provides
Patients were randomly allocated by computer
anesthesia for 75­90 min after spinal administration (4).
randomization table into two equal groups according to
Hyperbaric prilocaine 2% is increasingly used for spinal
the study drugs: Group C (hyperbaric bupivacaine
anesthesia in the ambulatory setting (5), as it has the
group)[control group]; Included 33 patients were
advantage of faster recovery times than hyperbaric
received intrathecal 3mL (15 mg) 0.5% hyperbaric
1658
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 111)


c:\work\Jor\vol871_112 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1666-1673

Predictors of Subclinical Atherosclerotic Cardiovascular Disease in
Inflammatory Bowel Disease Patients
Hussein El-Amin1, Khaled M. Ali Shehata2, Ammar A. Ammar3,
Wageeh A. Ali4, Amal M. Abdel Aal5, Marwa M. Abokresha*1, Soheir M. Kassem2
Departments of 1Internal Medicine, Gastroenterology Unit, 2Internal Medicine Critical Care Unit, 3Internal Medicine,
4Radiology and 5Clinical Pathology, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
*Corresponding author: Marwa M. Abokresha, Mobile: (+20) 01000580208, E-mail: marwaabokresha@aun.edu.eg

ABSTRACT
Background
: Inflammatory bowel disease (IBD) is a chronic intestinal disease that can be caused by a variety of
environmental and genetic factors. Several processes that are chronically stimulated in IBD patients have been involved
in the pathophysiology of atherosclerotic cardiovascular disease (ASCVD).
Objective: We aimed to estimate 10 years of risk ASCVD in patients with IBD, and to clarify the importance of
laboratory and non-invasive imaging modalities in early detection and estimation of ASCVD risk in those populations.
Patients and methods: This was a cross-sectional observational study that was conducted on 80 candidates between
October 2019 and October 2021, forty of them were IBD patients and forty were healthy volunteers. Patients were
diagnosed as IBD by clinical picture, multi-slice spiral computed tomography (MSCT) abdomen, and colonoscopy
followed by histopathological study of the biopsies according to ECCO consensus criteria. For the control group, 40
healthy volunteers were matched by gender and age without other known risk factors for atherosclerosis.
Results: 25 patients were diagnosed as ulcerative colitis, while 15 were diagnosed as Crohn's Disease. IBD patients
showed significant dyslipidemia. The median and range of estimated ASCVD risk % among the patients were 27.0 (0.3-
46.0), while for the control group, 7.0 (0.3-46.0), and P-value was 0.001. IBD patients had significantly higher pericardial
fat in comparison with healthy controls (2.15 (0.04-4.80) vs 1.43 (0.04-3.20), P-value was 0.027*). Multivariate regression
analysis showed that increased both pericardial fat; carotid intima-media thickness (CIMT); hyperlipidemia and disease
activity were predictors for subclinical ASCVD in patients with IBD.
Conclusions: The risk of ASCVD is risen in IBD patients, particularly during active disease, with increased carotid
intimal thickness and wall stiffness. Estimating the thickness of epicardial adipose tissue (EAT) and CIMT were
significant predictors.
Keywords: IBD, ASCVD, Carotid duplex, Pericardial fat.

INTRODUCTION
patients among an Egyptian cohort, as well as the
Heart disease remains the top cause of mortality
association between the types of ASCVD and the
globally, despite enormous breakthroughs in illness
clinical manifestations of Crohn's disease (CD) and
detection and treatment. Obesity and type 2 diabetes, as
ulcerative colitis (UC) patients followed at the IBD
well as genetic, environmental, nutritional, and lifestyle
clinic.
variables, can all contribute to cardiovascular disease

(CVD). Aside from that, there's a lot of evidence
PATIENTS AND METHODS
indicating inflammation plays a function in heart
This
was
a
cross-sectional
single-center
disease and atherosclerosis etiology (1, 2).
observational study that was conducted on 80
Inflammatory bowel disease (IBD), which includes
candidates between October 2019 and October 2021,
ulcerative colitis and Crohn's disease, is the most
forty of whom were patients and forty of whom were
prevalent systemic inflammatory illness. IBD is a
healthy volunteers. The inclusion criteria were 40
chronic intestinal illness that can be caused by several
patients who were diagnosed as IBD (Crohn's Disease
reasons, including hereditary predisposition and
and Ulcerative Colitis) by clinical picture, MSCT
environmental influences (3, 4).
abdomen with contrast, and colonoscopy followed by
Several processes that are chronically stimulated
histopathological study of the biopsies according to The
in IBD patients have been involved in the
European Crohn's and Colitis Organisation [ECCO]
pathophysiology of ASCVD. These include local and
consensus criteria(6), who were attending to
systemic inflammation; gut microbiome irregularities,
gastrointestinal unit however inpatients and/or
endothelial
dysfunction,
thrombosis,
lipid
outpatients of Assiut University Hospital either in
dysfunction, and the negative effects of IBD therapies,
activity or in remission. For the control group, 40
particularly corticosteroids. (5)
healthy volunteers were matched by gender and age.
Our research attempted to assess the 10-year risk of

ASCVD in IBD patients and specify the relevance of
To avoid the confounding effect of other known risk
laboratory and non-invasive imaging modalities in early
factors for atherosclerosis, the exclusion criteria
diagnosis and valuation of ASCVD risk in those IBD
were as follows:
populations compared to the healthy population. It also
Previous history of HTN, dyslipidemia with lipid-
elucidates the detailed ASCVD predictors of IBD
lowering medications, or diabetes mellitus.
1666
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 112)


ZagazigUniversity The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1674-1678

Fragmented QRS and Exercise Tolerance in Patients with
Heart Failure with Preserved Ejection Fraction
Ragab Abd El-Salam Mahfouz, Waleed Salem Elawady,
Ahmed Shawky Sherif, Mohamed Salem Mohamed Abdelwanis*
Department of Cardiology, Faculty of Medicine - Zagazig University, Sharkia, Egypt
*Corresponding author: Mohamed Salem Mohamed Abdelwanis, Mobile: (+20)01099596383,
E-Mail: abdelwanism18@gmail.com

ABSTRACT
Background:
Fragment QRS (fQRS) complex is a myocardial conduction abnormality that indicates myocardial scar.
The significance of fQRS lies in the fact that it just requires a surface ECG for its recording and the value of
information about the condition of the heart it dispenses based on the clinical setting.
Objective:
Our study aimed to investigate the relationship between FQRS exercise tolerant patients with heart failure
with preserved ejection fraction.
Patients and methods: The study was an observational cross-sectional study. It was conducted at the Cardiology
Department, Zagazig University Hospitals. The studied sample consisted of 95 patients with diastolic dysfunction. All
patients were stratified into two groups according to the presence or absence of fragmented QRS complex in resting
surface ECG. Electrocardiogram, conventional echocardiographic examination, tissue doppler imaging, and 6 minutes
walk test were done.
Results: There was a statistically significant difference between 6 minutes walk test of heart failure with preserved
ejection fraction patients with and without FQRS. In addition, we found that 6 minutes walk test is considered a good
parameter to discriminate congestive heart failure patients with and without FQRS with a sensitivity of 81.5%,
specificity of 69.6%, and accuracy of 72.9%.
Conclusion: The value of FQRS in cardiology is much higher than what is being understood currently. FQRS is
considered to be an indicator of myocardial fibrosis or scar tissue and has already been observed to be closely
associated with a greater probability of adverse cardiac consequences and reduced tolerance of exercise in patients
with HFpEF.
Keywords: Fragmented QRS, Exercise Tolerance, Heart failure, Preserved Ejection Fraction.


INTRODUCTION


It was shown in some studies that a subtle
PATIENTS AND METHODS
abnormality within the QRS complex can represent
The observational cross-sectional study was
conduction disturbance and myocardial scar. A notch
conducted at the Cardiology Department, Zagazig
in the QRS complex in patients with left ventricular
University Hospitals, on 95 patients with diastolic
hypertrophy has been suggested to be a result of an
dysfunction during the period from December 2019 to
intraventricular conduction defect (1).
July 2020.
However, the diagnostic and prognostic values

of these subtle abnormalities within the QRS complex
Ethical consent:
were not clarified in prior studies. Fragmented QRS
Written informed consent was obtained from
complex in patients with coronary artery disease
all children's parents or their relatives and the
(CAD) was associated with myocardial conduction
study was approved by the research ethics
block due to myocardial scar detected by myocardial
committee of the Faculty of Medicine, Zagazig
single-photon emission tomography (SPECT) (2).
University. The work has been carried out
It is defined as additional notches in the QRS
following The Code of Ethics of the World Medical
complex. Though initially fQRS was defined in the
Association (Declaration of Helsinki) for studies
setting of normal QRS duration (<120 ms), later it has
involving humans.
been expanded to include conditions with wide QRS

complexes as in bundle branch block, ventricular
Inclusion criteria:
ectopy, and paced rhythm, when more than 2 notches
Patients with HFpEF and the inclusion criteria
are present. It is an important, yet often overlooked
were based on the following: Typical symptoms of
marker of mortality and arrhythmic events in many
heart failure; representative signs of heart failure. The
cardiac diseases(3).
LVEF 50% (by echocardiography), and Evidence of
Our study aimed to investigate the relationship FQRS
diastolic dysfunction on echocardiography (mitral
exercise tolerant patients with heart failure with a
inflow E/A ratio, e measured at the mitral annulus,
preserved ejection fraction.
and E/e ratio).




1674
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 113)


c:\work\Jor\vol871_114 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1679-1683

Analgesia for Postoperative Pain in Laparoscopic Surgery: Review Article
Emad Eldin Fatthy Mohamed*, Khaled M. Hassan, Wessam A. Aboelwafa, Islam M. Ahmed
Anesthesia, Intensive Care & Pain Management, Faculty of Medicine, Sohag University, Sohag, Egypt
*Corresponding author: Emad Eldin Fatthy Mohamed, Mobile: (+20) 01020330340, E-Mail: emad.fatthy.ef@gmail.com

ABSTRACT
Background:
Similar to all surgical procedures, patients have compelling postoperative pain. The patients
experience severe abdominal and throat pain at the start of the postoperative period and seek for pain relief after
laparoscopic surgery. Laparoscopy is a procedure that is done on a rather frequent basis. Delivering anesthesia in
this type of procedures may be difficult, especially in day case surgeries. Inadequate analgesia along with nausea
and vomiting may be distressing for patients and raises the health care costs due to extended stay.
Objective: This review article aimed to address strategies for anesthesia and analgesia for day-case laparoscopic
procedures in this review. The concepts include multi-mode analgesia as well as oral administration wherever
feasible.
Methods: These databases were searched for articles published in English in 3 data bases: PubMed, Google
scholar and science direct. Boolean operators (AND, OR, NOT) had been used such as laparoscopy and
postoperative pain OR minimally invasive surgery and in peer-reviewed articles between December 2000 and Jun
2021. Documents in a language apart from English have been excluded as sources for interpretation. Papers apart
from main scientific studies had been excluded (documents unavailable as total written text, conversation,
conference abstract papers and dissertations).
Conclusion: It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and
to have a proactive strategy in place for these individuals to reduce the intensity and of postoperative pain in
patients undergoing laparoscopic surgery.
Keywords
: Laparoscopy, Postoperative pain, Analgesia.

INTRODUCTION
upper abdomen discomfort [7]. Early release and a
The advancement of minimally invasive
shorter hospital stay are common with patients having
surgical procedures for diagnostic and therapeutic
MIS; nevertheless, by contributing to the high
purposes has led to a drastic and substantial shift in
likelihood
of
doctors
and
patients
being
the way surgery is used to handle many types of
inexperienced with post-MIS pain, this leads in
disorders [1]. Minimally invasive surgery (MIS),
missed diagnoses, insufficient assessment, and
particularly laparoscopic surgery, has gained
incorrect therapy. Certain types of post-MIS pain are
widespread acceptance as a viable alternative to
excruciating, resulting in a considerable increase in
traditional exploratory laparotomy in the treatment of
needless analgesic usage, a delayed recovery, longer
a variety of benign disorders [2]. Among them, MIS
hospitalization, and, in rare cases, readmission [7].
has been considered to be the best option for some
A deeper comprehension of the cause and/or
types of disorders, like endometriosis [3]. MIS has
pathophysiology of postoperative MIS pain may be
been shown to be equally successful as traditional
assumed and established as a result of the increasing
laparotomy in the treatment of some forms of cancer.
number of clinical studies and a more refined
This is because it offers the same benefits as standard
strategic algorithm for regulating and orchestrating
laparotomy without compromising the oncologic
prevention and care [8].
results. Even if several new papers express grave

concerns regarding the safety of MIS in the treatment
Pain:
of cervical cancer [4]. MIS has an edge over
As previously stated, MIS often results in less
conventional exploratory laparotomy, including a
pain compared to exploratory laparotomy. Despite
substantial minimizing in the size of the incision
that, post laparoscopic pain continues to impair
wound, decreased pain caused by the wound,
quality of life and is a significant cause for postponed
decreased need for analgesia, trifling trauma and
dismiss or difficulty in returning to routine
injury, improved cosmetic outcome, fewer days of
activities. Post-MIS discomfort may be classified as
hospitalization, shorter time for recuperation, and
surgical incision pain, STP and/or upper abdominal
faster resuming of life activities and work [5].
pain [9].
Despite the benefits of MIS, up to 80% of
Pain is a sensation and a psychological
patients (range: 35%­80%) endure significant pain
experience linked to existing or probable tissue
and demand pain medication for their uncomfortable
injury. Acute pain is the physiological response
experience or distress [6]. Pain characteristics vary
expected in response to a harmful chemical, thermal,
between laparoscopic surgery, particularly gas
or mechanical stimulus, as a result of activation of
laparoscopy, and exploratory laparotomy. The most
pain receptors (nociceptors) at the injury site, which
prevalent examples are shoulder-tip pain (STP) and
performs a crucial and sensitive role in delivering
1679
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 114)


c:\work\Jor\vol871_115 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1684-1690

Evaluation of Internal Fixation of Base of Fifth Metatarsal
Fracture of the Foot by Screw
Abdelsalam Eid Abdelsalam, Abdlkader Fadhl Almahdi Mautog*,
Fahmy Samir Fahmy Gerges, Salah Mahmoud Abdelkader
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Abdlkader Fadhl Almahdi Mautog, E-Mail: adbegtelawe1988@gmail.com

ABSTRACT
Background:
Although successful treatment of 5th metatarsal Jones fractures with intramedullary screw fixation is
common, nonunion and refracture rates are not insignificant.
Objective: This study aimed to monitor the management results of internal fixation of the base of the fifth metatarsal
fracture of the foot by the intramedullary screw.
Patients and Methods: At Zagazig University Hospitals, we performed a prospective study on 18 patients who had
"jones fractures" in zone II at the base of their fifth metatarsal bone and who had all been treated with intramedullary
screw fixation.
Results: All the fractured patients had close isolated fractures 83.3% of them operated within the first 48 hours, only
three patients needed more than 48 hours to be operated. The operation time in most of patients (77.8%) was less than
one hour with mean 63.3 minutes. Most of patients (72.2%) achieved excellent, while the rest had good outcome
according to AOFAS score at final follow up.
Conclusion: It is safe and effective to use early screw fixation in the treatment of acute Jones fractures, which leads to
a faster clinical union and a return to normal daily activities.
Keywords: Fifth metatarsal fracture, Internal fixation.

INTRODUCTION
to rule out a Lisfranc fracture dislocation in cases of more
A crucial diagnostic problem arises when dealing
severe midfoot trauma [5].
with fractures of the fifth metatarsal. Prognosis and
The treatment of a 5th metatarsal fracture is
treatment can be drastically altered by only millimeters
determined by the fracture type, the extent of the patient's
of variation in site. Re-injury and chronic incapacity can
previous ailments, and their personal characteristics.
be caused by a treatment plan that isn't up to standard.
Treatment options include non-operative and surgical
The difficulty of making an accurate diagnosis and
approaches that take into account a variety of factors,
treating a fracture is exacerbated by the use of confusing
including the amount of activity of the patient. If the
fracture nomenclature [1]. Surgeons frequently use
displacement or ten-degree plantar angulation of a neck
surgical fixation for Jones fractures of the metaphyseal-
or shaft fracture is greater than 3 to 4 mm and a closed
diaphyseal watershed junction in athletes. It is still the
reduction is not enough, operational intervention is
most often used method of fixation, with intramedullary
recommended [6].
screws [2].
The surgical treatment of proximal fifth metatarsal
As many as 70% of metatarsal fractures occur in the
fractures includes a number of options, such as, internal
fifth metatarsal, and 80% of these fractures occur in the
fixation with minifragment plate and screws, closed
proximal portion of the bone. Women with poor bone
reduction and cross-pinning with Kirschner-wire (K-
mineral density are more likely to suffer from these
wire) fixation, corticocancellous bone graft, open
fractures than women in their third or seventh decade. An
reduction and percutaneous fixation with an
athlete's fifth metatarsal bone is frequently fractured by
intramedullary screw. Although successful treatment of
stress [3]. Traumatic or recurrent forefoot damage can
5th metatarsal Jones fractures with intramedullary screw
cause an injury to the fifth metatarsal. It is common for
fixation is common, nonunion and refracture rates are not
avulsion fractures to occur in Zone 1. These fractures are
insignificant [7].
caused by an abrupt episode of supination of the forefoot
The purpose of this study was to monitor the
with plantar flexion. The plantar fascia's lateral band and
outcomes of intramedullary screw repair of the foot's fifth
the peroneus brevis are pulled as a result [4].
metatarsal fracture base.
Three conventional radiographic views of the foot

are utilized when imaging for a suspected metatarsal
PATIENTS AND METHODS
fracture: lateral, anteroposterior, and a 45-degree oblique.
This study was conducted in the Orthopedic Surgery
Standard three-views of the foot do not detect acute stress
Department, Zagazig University Hospitals. 18 patients
fractures in the majority of cases. It is recommended that
complaining of fracture base of fifth metatarsal bone
10 to 14 days following the onset of symptoms,
"Jones fracture" were included in this study. All the
radiographs are taken. As soon as a radiolucent
included patients were treated surgically through
reabsorption gap appears surrounding the fracture, the
percutaneous screw fixation.
diagnosis is deemed certain. A CT scan is recommended

1684
Received: 02/11/2021
Accepted: 30/12/2021

Full Paper (vol.871 paper# 115)


c:\work\Jor\vol871_116 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1691-1694
Epidemiological Study of Atrial Fibrillation
Mohamed Ibrahim Mostafa Al Awady, Yasser Gaber Metwally,
Eman Hesham Seddik, Ahmad Mohamed Tarek Abd Elhamid*
Department of Cardiology, Faculty of Medicine ­ Zagazig University, Egypt
*Corresponding author: Ahmad Mohamed Tarek, Mobile: (+20) 01090655773, E-Mail: nanato1992@gmail.com

ABSTRACT
Background:
The pathophysiology of AF is complex and multifactorial, involving ageing and a structural remodeling
whereby apoptosis, inflammation and fibrosis are the hallmarks. Systemic inflammation is a strong predictor of atrial
fibrillation. A key role for electrical remodeling is increasingly recognized, and experimental data suggest that
inflammatory cytokines can directly affect connexins resulting in gap junction dysfunction.
Objective: This study aimed to study epidemiology findings of paroxysmal atrial fibrillation.
Patients and Methods: This case-control study was conducted on thirty-eight participants (19 males and 19 females).
The included patients were recruited from Cardiology Department, Zagazig University Hospitals and Nasser Institute
for Research and Treatment.
Results: Regarding baseline characteristics, it was reported that mean age of AF group was 61.2 ± 9.1 years and control
group was 58 ± 12 years with no statistical significant difference between the two studied groups. Most of AF patients
were smokers and had hypertension. There were no statistical significant differences between the studied groups
regarding hypertension, smoking status, sex and age. Regarding clinical presentation, it was observed that palpitation
was more in AF group than in control group (78.9% and 10.6% respectively). Chest pain was more presented in AF
group than in control group (36.8% vs 26.3% respectively), while dyspnea was more presented in AF group than in
control group (47.4% vs 26.3% respectively).
Conclusion: Mean age of AF group and control group was high. Most of AF patients were smokers and had
hypertension. Palpitation occurred in about three fourths of AF patients' group.
Keywords: Epidemiology, ECG findings, Paroxysmal atrial fibrillation.


INTRODUCTION


Atrial fibrillation (AF) is the most common
pathophysiological and biochemical changes aiming to
arrhythmia, at least 2.3 million individuals suffer from
limit the harmful effects (inflammatory stimuli) and to
AF in the US alone. The etiology of AF is not
quickly recover homeostasis. They follow both acute
completely understood. Many factors such as neuro-
and chronic inflammation (4).
endocrine function, acute or chronic hemodynamics and
The objective of the study was to study
metabolism may cause atrial remodeling and thus play
epidemiology of paroxysmal atrial fibrillation.
a role in the initiation and progression of AF (1).

Paroxysmal atrial fibrillation occurs when a rapid,
PATIENTS AND METHODS
erratic heart rate begins suddenly and then terminates
This case-control study was conducted on thirty
spontaneously or with intervention within 7 days. It is
eight participants (19 males and 19 females) who aged
also known as intermittent A-fib and often lasts for less
between 48 and 82 years. The included patients were
than 24 hours (2).
recruited from Cardiology Department, Zagazig
The American Heart Association (AHA) estimate
University Hospitals and Nasser Institute for Research
that 2.7 million American people live with some form
and Treatment.
of A-fib. The likelihood of experiencing paroxysmal A-
Patients with AF were assigned into two groups
fib increases with age (2).
(AF and control who were individuals with sinus
Inflammation of atrial tissue leads to the
rhythm and no history of AF, as confirmed in a routine
denaturation, necrosis, apoptosis, fibrosis and scarring
physical examination and investigation, each group
of myocardial cells. Such changes alter their
enrolled age- and sex- matched nineteen patients.
electrophysiological function, increase their non-

uniform and anisotropic properties, and decrease the
Inclusion Criteria:
conduction of atrial muscles, facilitating reentry of the
The study population included 38 cases divided into
electrical signal and causing AF to persist. Interstitial
2 groups: AF group (19 cases) and Control group (19
fibrosis of atrial cells may be involved in atrial
cases).
structural remodeling (3).

Atrial fibrillation may occur and persist due to
Exclusion Criteria:
atrial remodeling exacerbated by inflammation. The
Those with missing HRV data on 2-min
systemic response to inflammation, which occurr in
recordings. Hepatic and renal insufficiency. Thyroid
human organism, is in its essence a combination of
disorders. Rheumatic heart diseases, and electrolyte

abnormalities e.g., hypomagnesemia.
1691
Received: 03/11/2021
Accepted: 01/01/2022

Full Paper (vol.871 paper# 116)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1695-1700

Prediction Of No Reflow Using Syntax II Score in
Patients of Acute ST Segment Elevation Myocardial Infarction
Undergoing Primary Percutaneous Coronary Intervention
Mahmoud Hamed Ibrahim*, Mahmoud Diaa Elmenshawy,
Mohammad Mustafa Al-Daydamony, Mohamed Abd Elhady Mohamed
Department of Cardiology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mahmoud Hamed Ibrahim, Email: m7amid89@gmail.com
ABSTRACT
Background:
Clinical characteristics are combined with an angiographic grading method to create the SYNTAX Score
II, which then compares the results to the SYNTAX II score.
Objective: This study aimed to make an early prediction of no reflow in patients receiving primary percutaneous
coronary intervention (PPCI) because of an acute ST-segment elevation myocardial infarction (STEMI), the SYNTAX
score II was used. Patients and Methods: Our cross-sectional trial was conducted on one hundred patients with acute
STEMI who underwent primary percutaneous coronary intervention at National Heart Institute, Zagazig University
Hospital. Standard coronary angiogram was done to all patients.
Results:
A statistically significant positive correlation was found between syntax score and age, also with LVESD post
treatment, while there was significant negative correlation with both EF pre- and post-treatment and TIMI flow grade.
According to the results of the multivariate logistic regression analysis, the most significant risk variables for no reflow
were revealed to be the door to balloon time > 2 hours, smoking, syntactic score > 27, EF below 44, and finally, chronic
kidney disease.
Conclusion: An independent predictor of no-reflow in STEMI patients who are treated with PPCI is the syntax score.
Keywords: Syntax II score, Acute ST segment elevation, Myocardial infarction.

INTRODUCTION
increased risk of cardiovascular events, initial PCI failure
When cardiac biomarkers (preferable troponin) rise
to achieve sufficient cardiac reperfusion may be a
or fall over the 99th percentile of the upper reference and
contributing factor (7).
one or more indications of ischemia are present,
Syntax score II was used as a predictor of no flow in
myocardial infarction is considered probable. Novel ST-T
individuals with ST segment elevation myocardial
modifications include things like aberrant Q waves, new
infarction who underwent primary percutaneous coronary
segmental wall motion abnormalities, and the
intervention.
identification of an intra-coronary thrombus through

angiography or autopsy (1).
PATIENTS AND METHODS
As a strategy to minimize myocardial damage and
The study was conducted retrospectively on 100 patients
restore normal blood flow in those affected by an acute ST
admitted to National Heart Institute with acute STEMI
segment elevation myocardial infarction, treatment is
subjected to PPCI. They consisted of 78 male and 22
focused on both of these goals. Both fibrinolytic treatment
female patients with a mean age of 53.4 years old.
and primary percutaneous coronary intervention can be
TIMI flow score was used to split patients into two
used to accomplish this goal (2). If high-quality PCI is
groups: Group I (Normal flow group): TIMI flow III: 55
accessible without significant delay, primary PCI is
patients with TIMI flow 3 post PCI, and group II: (No
preferable than fibrinolysis. Door-to-balloon time should
reflow group): TIMI flow < III: 45 patients with TIMI
be less than 90 minutes. The survival benefit of primary
flow 2 post intervention
PCI over fibrinolysis appears to be eliminated if the PCI-
Inclusion criteria: All patients with acute STEMI who
related delay is more than 60 to 90 minutes (3).
had: chest pain (lasting more than 30 minutes). ST
Without evidence of a mechanical obstruction, the
segment elevation (>1 mm) in two or more contiguous
"no-reflow phenomenon" is described as a lack of
leads or new start LBBB, or ECG abnormalities that imply
myocardial reperfusion in the coronary circulation (4).
posterior infarction, and exaggerated chest pain or
Patients with acute ST-segment elevation myocardial
presentation within 12 hours of the commencement of the
infarction who have myocardial no-reflow after the first
symptoms.
percutaneous coronary intervention had poorer clinical
Exclusion criteria: Patients with acute STEMI more than
outcomes and a lower survival rate after the procedure (5).
12 hours referred for PCI. Patients with previous stenting
Clinical characteristics are combined with an
in the culprit artery. Any contraindication to primary
angiographic grading method to create the SYNTAX
angioplasty. Patients of previous CABG, and
Score II, which then compares the results to the SYNTAX
retrospective patients with missed or incomplete data
I score (6). When calculating the SYNTAX II score during
records.
a primary PCI, we can use clinical data and information
on patency and area of myocardium at risk supplied by the
All patients underwent the following:
culprit vascular, as well as lesion complexity and severity.
A complete medical history and demographic data.
When a high SYNTAX II score is associated with an
Medical evaluation in-depth at time of admission.
1695
Received: 04/11/2021
Accepted: 02/01/2022

Full Paper (vol.871 paper# 117)


c:\work\Jor\vol871_118 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1701-1703

Outcome Evaluation of Laparoscopic Drainage of
Pelvi-Abdominal Abscess at Zagazig University Hospitals
Ahmed Mohamed Abd elhadi*, Emad Mohamed Salah**, Gamal Mohamed Osman**,
Abd Elrahman Moustafa Metwally**
*General surgery Department, Al Ahrar Zagazig Teaching Hospital, Zagazig, Egypt.
** General surgery Department, Zagazig Faculty of Medicine, Egypt.
Corresponding Author: Ahmed Mohamed Abd Elhadi, Phone: +201111697962,
E-mail: ahmedmsaleem85@gmail.com
ABSTRACT
Background:
Intra-abdominal abscesses remain a major cause of morbidity and mortality. Intra-abdominal abscesses
that are localized usually arise in connection to the damaged viscus. For timely treatment, a correct diagnosis and abscess
localization are required. Laparoscopic draining of a large intra-abdominal abscess is a minimally invasive procedure
that allows exploration of the abdominal cavity without a large incision.
Aim: This study aimed to to evaluate the outcome of laparoscopic management of abdominal abscesses not amenable
to percutaneous or transrectal CT guided or ultrasound US-guided drainage.
Patients and Methods: This prospective study included 24 patients presenting with clinical and radiological
manifestations of lower abdominal intraperitoneal abscesses at General Surgery Department, Zagazig University, Egypt.
This study was conducted through the period from Feb 2021 to Aug 2021.
Results:
Our analysis showed that mean operative time was 97.2 ± 12.3 min, mean intraoperative blood loss volume
was 176.5 ± 62.7 ml and 19 cases needed blood transfusion. The VAS score of preoperative pain decreased from 6.9
pre-operative to 5 immediate post-operative and 0.3 at 24 hr post-operative.
Conclusion: For pelvic-abdominal abscesses, laparoscopic drainage proved a realistic, safe, and effective treatment
option. Laparoscopic drainage is a minimally invasive treatment with few postoperative complications.
Keywords: Laparoscopic, Intra-abdominal abscesses, Drainage, Pelvi-abdominal abscess.


INTRODUCTION

percutaneous or transrectal CT guided or ultrasound US-
In today's surgical practice, intra-abdominal
guided drainage.
abscesses remain a major cause of morbidity and

mortality. The enigmatic nature of the underlying
PATIENTS AND METHODS
disorders, as well as the disease's varied clinical course,
This prospective study included 24 patients
can cause delays in diagnosis and treatment, which can
presented with clinical and radiological manifestations
have negative consequences for the patient's outcome,
of lower abdominal intraperitoneal abscesses. At
length of stay in the hospital, and healthcare expenses (1).
General Surgery Department, Zagazig University, Egypt
Localized intra-abdominal abscesses commonly
through the period from Feb 2021 to Aug 2021.
arise in relation to the injured viscus, such as an

appendicular abscess in the right iliac fossa in the case of
Ethical approval:
a perforated appendix or a tubo-ovarian abscess in the
This study was approved by the Faculty of
pelvis in the case of female adnexa. The omentum,
Medicine, Zagazig University Ethical Committee.
neighboring viscera, and inflammatory adhesions move
Every patient signed an informed written consent.
to the infection site and produce phlegmon, which acts
This work has been carried out in accordance with
as a barrier to the infection spreading to other peritoneal
The Code of Ethics of the World Medical Association
regions. (2).For timely treatment, a correct diagnosis and
(Declaration of Helsinki) for studies involving
abscess localization are required. Most intra-abdominal
humans.
abscesses are now treated using percutaneous computed

tomography (CT) guided catheter drainage (3). A surgical
Pre-Operative preparation:
drainage is an option in circumstances where
Preoperative resuscitation included intravenous
percutaneous drainage is not accessible or practicable
fluid correction of acid-base and electrolyte imbalances,
due to the presence of numerous abscesses. The surgery
hemodynamic parameter optimization, nutritional status,
can be performed laparoscopically or openly (4).
and coagulation profile adjustment for all patients.
Laparoscopic drainage of a large intra-
Diabetic patients received intensive insulin therapy
abdominal abscess is less invasive, allowing exploration
using regular insulin to adjust random blood glucose to a
of the abdominal cavity without a large incision and
range of 100­110mg/dl. Thromboprophylaxis was
aspiration of purulent exudates under direct vision. If the
performed whenever indicated.
general condition is good, laparoscopy can also be used
Surgical Technique:
to remove the source of sepsis, such as a perforated
All of the procedures were carried out under
appendix or a ruptured colonic diverticulum (5). In this
general anesthesia. Intravenous antibiotic therapy in the
study, we tended to evaluate the outcome of laparoscopic
form of a third-generation cephalosporin and
management of abdominal abscesses not amenable to
1701
Received: 11/10/2021
Accepted: 09/12/2021

Full Paper (vol.871 paper# 118)


c:\work\Jor\vol871_119 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1704-1706

Role of Platelet Rich Fibrin (PRF) in Treatment of Post Acne Scars: Review Article
Nagwa Ali Fahmy Diab, Aya Mohamed Abdallah, AlShimaa Mohamed Ibrahim
Department of Dermatology, Venereology and Andrology, Zagazig University Hospital, Egypt.
*Corresponding author: Aya Mohamed Abdallah, E-Mail: ayaabdallah781991@gmail.com

ABSTRACT
Background
: There are many forms of scars that can result from inflammatory acne. It has a negative impact on the
patient's personal and professional relationships. Acne scars are caused by the aberrant creation or breakdown of
collagen that happens during healing processes. Atrophic scarring is the consequence in the majority of instances (80­
90%) of collagen degradation at the dermal level. Hypertrophic or keloid scars are rarer manifestations of an enhanced
collagen synthesis. Platelet rich fibrin (PRF) was introduced into the acne scar care picture after platelet-derived growth
factor (PDGF) was proven to stimulate wound healing, angiogenesis, and tissue remodelling. Minimally invasive
platelet-rich plasma methods provide the advantage of a fast recovery time and low cost.
Objective: To examine the potential role of platelet rich fibrin in the treatment of post-acne scars.
Methods: The databases were searched for articles published in English in 3 data bases [PubMed ­ Google scholar-
Science direct] and Boolean operators (and, or, not) had been used such as [Platelet Rich Fibrin and Post Acne Sars OR
PRF] and in peer-reviewed articles between 2009 and 2021. Documents in a language apart from English were excluded
as sources for interpretation was not found. Papers apart from main scientific studies were excluded: documents
unavailable as total written text, conversation, conference abstract papers and dissertations.
Conclusion: Cell migration and proliferation are more efficient when fibrin is rich in platelets. When compared to
platelet rich plasma, the fibrin matrix favours a slow and steady release of growth factors over time.
Keywords: Platelet Rich Fibrin, Post Acne Sars.

INTRODUCTION
(5). Scars like hypertrophic scars and keloids can be
A delayed or poor medical treatment can cause acne
categorised as variants of wound healing. 6 to 8 weeks
scarring, although this can also happen despite receiving
after the initial injury, anabolic and catabolic processes
appropriate
medical
treatment.
Acne-related
reach balance in a normal wound. Wounds at this point
inflammation damages collagen and other tissues,
are around 30-40 percent as strong as healthy skin. In
causing persistent changes in skin texture and fibrosis.
time, the scar becomes stronger due to the cross-linking
Inflammation, granulation, and remodelling are all
of collagen fibres, which occurs as the scar matures. A
common wound healing stages for scars (1).
hyperemic and perhaps thicker scar forms at this stage,
There are several therapies for acne scars, however
but it gradually thins out over months to form a flat,
they may only be partially effective, leaving patients
white, malleable and possibly stretched mature scar.
frustrated and disappointed (1). Acne scarring has far-
When the healing process is out of balance, more
reaching consequences that go beyond a person's ability
collagen is created than destroyed, resulting in an out-of-
to enjoy life because of their appearance. It has been
control scar. A raised, hyperemic scar is still visible on
linked to depression and other mental health conditions,
the skin. A hypertrophic or keloid scar is one with an
suicidal thoughts, emotional debilitation, shame, low
overabundance of fibrous tissue (6).
self-esteem and overall social impairment (2).

Most acne scars are connected with a loss of
Platelet Rich Fibirin (PRF):
collagen (atrophic scars), whereas the rest are associated
To get rid of anticoagulants known as leukocyte
with a growth of collagen (fibrotic scars) (keloidal or
and platelet-rich fibrin (L-PRF), a new type of platelet
hypertrophic scars). Following fibre contraction, atrophic
concentrate was created. Due to the absence of anti-
scars appear in the form of depressions. Some acne scars
coagulants, the blood must be centrifuged quickly to
can be characterised as boxcar, icepick or rolling atrophic
separate the different layers of blood before it clots. In the
acne scars (3). Even though medical treatment for acne can
"platelet-rich" layer after centrifugation, a fibrin clot is
help prevent scarring, it can also exacerbate existing
discovered. Platelets and leukocytes are typically found
scarring if treatment is delayed or inadequate. Acne-
within this fibrin matrix, which is enriched with blood-
related inflammation damages collagen and other tissues,
derived growth factors and cytokines. When compared to
causing persistent changes in skin texture and fibrosis.
platelet rich plasma (PRP), the fibrin matrix favours the
Inflammation, granulation, and remodelling are all
progressive release of growth factors over time (6).
common wound healing stages for scars (4).
External anticoagulants are required with PRP,
Extracellular matrix components and parenchymal
and this has been highlighted as a disadvantage. Finally,
cells (keratinocytes and fibroblasts) are all involved in
anticoagulants inhibit the release of growth factors,
wound healing. Endothelial and nerve cells are also
which are associated to the clotting mechanism (7).
involved. lymphocytes, monocytes, and neutrophils, as
It is also a drawback that upon activation, growth
well as other immune-inflammatory blood cells,
factors from the liquid PRP are suddenly released.
penetrate the wound and contribute to its healing process
Calcium chloride or bovine thrombin activated nearly all
1704
Received: 04/11/2021
Accepted: 02/01/2022

Full Paper (vol.871 paper# 119)


c:\work\Jor\vol871_120 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1707-1712

Study of relation between Serum C1Q / TNF-Related Protein 9 (CTRP9) and
Diabetic Retinopathy in a Sample of Egyptian Patients With Type 2 Diabetes Mellitus
Mohamed Reda Halawa1, Hanan Mahmoud Ali2, Noureldin Hussein Abozeid2,
Fouad Abd Elfattah Ismail1, Salah Hussein Elhalawany1
Departments of 1Internal Medicine & Endocrinology and 2Ophthalmology,
Faculty of Medicine, Ain Shams University, Cairo, Egypt
*Corresponding author: Salah Hussein Elhalawany, Mobile: (+20) 01098127872,
E-Mail: salah.hussein@med.asu.edu.eg

ABSTRACT
Background:
C1q/TNF-Related Protein (CTRP) family members are novel adipokines that have immunomodulatory,
anti-inflammatory, glucose regulating, and vascular effects. However, their microvascular effects in diabetic patients
remain unclear.
Objective:
To evaluate the relation between serum CTRP9 and diabetic retinopathy (DR) in patients with type 2 diabetes
mellitus (T2DM).
Patients and Methods:
This cross-sectional study was conducted on 90 subjects with their ages ranging from 35-70
years, selected from diabetes and ophthalmology outpatient clinics of Ain shams University Hospitals for 6 months in
a period from May 2019 to November 2019. They were divided into 3 groups: Group (I): 35 Patients with T2DM with
diabetic retinopathy. Group (II): 35 Patients with T2DM without diabetic retinopathy. Group (III): 20 Apparently
healthy individuals.
Results: there is a highly statistically significant difference between the studied groups as regards S. CTRP9 being
highest in Group II Patients with T2DM without diabetic retinopathy followed by Group III Apparently healthy
individuals then Group I Patients with T2DM with diabetic retinopathy (P-value <0.001). Also, there is a negative
correlation between serum CTRP9 level and Duration of DM, HbA1C FBS, and 2hpp. On performing multiple linear
stepwise regression analysis to the statistically significant factors using CTRP9 as a dependent variable with other
independent variables, only HbA1C and Duration of DM remained significantly associated with CTRP9.
Conclusion:
T2DM patients with diabetic retinopathy have decreased CTRP9 levels regardless of the grade of
retinopathy. Loss of protective role of CTRP9 may attribute to DR in patients with long-standing Diabetes.
Keywords: Serum CTRP9, Diabetic retinopathy, T2DM.

INTRODUCTION
The CTRP superfamily has been found as a new
Diabetes mellitus is a group of metabolic
anti-inflammatory adipokine with major metabolic
illnesses marked by chronic hyperglycemia caused by a
effects (5). The CTRP family contains 16 members, all
lack of insulin action, secretion, or both, all of which
of which are hypothesized to play a role in energy
result in long-term damage and malfunction of several
balance via affecting insulin sensitivity in the muscles
organs, including the eyes, kidneys, nerves, heart, and
and liver (6).
blood vessels (1).
CTRP 9 is A member of the CTRP family which
Diabetic retinopathy is the most common and
shows the highest degree of amino acid identity to
dangerous microvascular consequence of diabetes, with
adiponectin (approximately 54%) in its globular C1q
an alarmingly high global prevalence (2). It is the leading
domain with a potent anti-diabetic, cardioprotective and
cause of vision loss and blindness (3).
anti-inflammatory adipokine (7,8,9).
Diabetic macular edema and proliferative
CTRP9 has been proven to improve insulin
retinopathy sequelae such as vitreous hemorrhage,
sensitivity and lipid metabolism, both of which help to
neovascular
glaucoma,
and
tractional
retinal
reduce blood sugar levels (8). Furthermore, because
detachment are the most common causes of visual loss
CTRP9's vasoactive potency is nearly three times that
in diabetic individuals. Appropriate blood sugar and
of adiponectin, it has a significant vaso-relaxing action
blood pressure control can considerably prevent the
and may have substantial therapeutic relevance in the
development or progression of these potentially
therapy of endothelial dysfunction (10).
blinding consequences, emphasizing the need for early
In addition, the anti-inflammatory effect of
DR recognition and treatment beginning (4).
CTRP9 was explained by inhibition of TNF-induced
In the past decade, the CTRP super-family has
monocytes adhesion to human aortic endothelial cell
been discovered as novel anti-inflammatory adipokines
and inhibits TNF-induced NF-B (nuclear factor-B)
with important metabolic effects (5). The CTRP family
activation (9). However, the role of CTRP9 in the
is composed of 16 members all of which were thought
development of microvascular complications in diabetic
to contribute to energy homeostasis, through altering
patients remains unclear. To the best of our knowledge,
insulin sensitivity specifically in the muscles and liver
this is the first study evaluating the relationship between
(6).
CTRP 9 and Diabetic Retinopathy in Patients with
T2DM.
1707
Received: 05/11/2021
Accepted: 03/01/2022

Full Paper (vol.871 paper# 120)


c:\work\Jor\vol871_121 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1713-1719

Evaluation of Proximal Humerus Internal Locking System in
Management of Proximal Humeral Fractures
Abdelsalam Eid Abdelsalam, Mohamed Hegazy Abdelhamid Ahmed,
Hany Mohamed Abdelfatah Bakr, Salah Mahmoud Abdelkader
Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Mohamed Hegazy Abdelhamid Ahmed, E-Mail: mohamed_hegazy2017@hotmail.com

ABSTRACT
Background:
Because they provide tight anatomical fixation and better angular stability, the proximal humerus
PHILOS plate is now the implant of choice for treating displaced proximal humerus fractures.
Objective: This study aimed to improve radiological & clinical outcome of proximal humeral fractures using PHILOS
Plate.
Patients and Methods: A prospective study involving 30 cases of proximal humeral fractures was done from January
to December 2021. All patients were operated at Zagazig University Hospitals. All patients were treated surgically, with
open reduction of the fractures and internal fixation with proximal humeral locking plates. The cases were followed for
6 months to a year.
Results: All fractures healed satisfactorily, except in five patients. In two patients, there was stiffness, one with avascular
necrosis (type 4 Neer classification) scheduled for plate removal and hemiarthoplasty and one with infection, which
subsided after treatment. Fracture healing happened with varus displacement in one patient, and the patient was pleased
with the outcome.
Conclusion: Locking plates offer more advantages than conventional plates specially when dealing with osteoporotic
bone. It is recommended to use locking plate whenever an elderly patient is indicated for internal fixation.
Keywords: Proximal humeral fractures, Internal locking system.

INTRODUCTION

PATIENTS AND METHODS
Approximately 5% of all adult fractures result in
This study was conducted in the period from
dislocation of the proximal humerus. Low-energy
January 2021 to December 2021 in the Orthopedic
trauma is the most common cause of injury in elderly
Surgery Department, Zagazig University Hospitals. We
osteoporotic patients. Even in cases of minor
retrieved 30 cases with proximal humeral fractures
displacement, sling therapy and functional rehabilitation
where open fracture reduction and internal fixation with
under medical supervision are effective. Displaced
proximal humeral locking plates were used in all of the
proximal
humerus
fractures
with
significant
cases.
displacement or comminution require surgical treatment

in 15% to 20% of cases (1, 2).
Ethical consent:
The number of fracture sections and the
Zagazig University's Research Ethics Council
displacement are the two key components of the Neer
approved the study as long as all participants signed
classification, which is one of the classifications for
informed consent forms and submitted them to ZU-
proximal humerus fractures (3).
IRB#6095.
The best treatment options for displaced proximal
We adhered to the Helsinki Declaration, which
humerus fractures are still up for dispute. For proximal
is the ethical norm for human testing established by
humerus fractures, various fixation techniques have
the World Medical Association.
evolved, including platting, arthroplasty, transosseous

suturing, tension band wiring nailing percutaneous, and
Inclusion criteria:
pinning. Nonunion, malunion, and osteonecrosis are
Patients with a displaced proximal humeral
major postoperative risks with any humeral-head-
fracture as defined by the Neer classification system,
preserving procedure. Humerus proximal PHILOS
skeletally mature patients aged above 18 years, fracture
plates are the preferred implant for treating displaced
dislocation proximal humerus, floating shoulder, and
proximal humerus fractures because they provide tight
elderly porotic patients.
anatomical fixation and increased angular stability,

allowing for early mobilization and a satisfactory
Exclusion criteria:
functional outcome (4, 5, and 6).
Infection, skeletally immature patients, and
It was the goal of this work to improve radiological
undisplaced proximal humeral fractures.
& clinical outcome of proximal humeral fractures using

PHILOS Plate.









1713
Received: 05/11/2021
Accepted: 03/01/2022

Full Paper (vol.871 paper# 121)


c:\work\Jor\vol871_122 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1720-1725

Added Value of Dual Energy CT Angiography in
Assessment of Pulmonary Embolism
Mona Hamed Ali, Mohamed Ahmed Denewar, Enas Mohamed Elfeky, Ahmed Fekry Salem
Department of Radiology, Faculty of Medicine ­ Zagazig University, Egypt
*Corresponding author: Mona Hamed Ali, Mobile: (+20)01091762456, E-Mail: monaamre76@gmail.com

ABSTRACT
Background:
Pulmonary embolism (PE) is a common clinical condition being third on the list of cardiovascular causes
of death. Computed tomography angiography (CTA) is considered the first-line imaging modality for suspected acute
PE. Dual-energy computed tomography (DECT) has made it possible to simultaneously obtain angiographic CT
imaging and pulmonary perfusion maps. The aim was to identify role of DECT angiography in diagnosing pulmonary
embolism. Objective: This study aimed to evaluate accuracy of iodine perfusion maps in diagnosing pulmonary
embolism using DECT scanner. To detect location of the small pulmonary emboli using iodine maps (segmental, sub
segmental).
Methods: This cross-sectional study was conducted at Radiology Department, Zagazig University Hospitals. This study
included 18 cases with pulmonary embolism. The duration of the study ranged from 6-12 months.
Results: Regarding per CT angiography findings, the current study showed that nine (50%) patients had pulmonary
embolism at right lung, 7 (38.9%) patients had pulmonary embolism at left lung and found in both lungs in two (11.1%)
patients. Pulmonary embolism was found in upper lobe in 44.4% patients, at lower lobe in 27.8% patients, at main
pulmonary artery in 16.7% patients and at middle lobe in 11.1% patients. Regarding level of pulmonary embolism,
Subsegmental level was the most common found (44.4%) followed by segmental level in 38.9% patients. 10 (55.6%)
were occlusive, and 8 (44.4%) were non-occlusive. Regarding distribution of the studied patients concerning matched
defect on iodine map, 8 (44.4%) patients had matched defect on iodine map.
Conclusion: The iodine maps have an important effective role in detection of pulmonary embolism.
Key words: Dual energy CT angiography, Conventional CT angiography, Pulmonary embolism.

INTRODUCTION
characteristics and has been proposed as a method to aid
Pulmonary embolism (PE) is blood clot that
in the detection of PE in the lungs, the pattern of iodine
occurs in lung, it is common and potentially fatal
enhancement at DE CT angiography has been shown to
disorder as it can damage part of lung due to restricted
correspond to lung blood volume at planar scintigraphy
blood flow and decreased oxygen level in the blood. So
and single photon-emission CT (1).
early diagnosis is effective and improves the chance of
The objectives of the study were to identify role
survival. PE is the third most common acute
of DECT angiography in diagnosing pulmonary
cardiovascular disease after myocardial infarction and
embolism. To evaluate accuracy of iodine perfusion
stroke and it leads to thousands of deaths each year
maps in diagnosing pulmonary embolism using DECT
because it often goes undetected. Early diagnosis and
scanner. To detect location of the small pulmonary
treatment of PE are essential for optimizing clinical
emboli using iodine maps (segmental, sub segmental).
outcomes (1).

In some cases, a pulmonary embolism can be
PATIENTS AND METHODS
difficult to diagnose, this is especially true if you have
This cross-sectional study was performed in the
an underlying lung or heart condition, such as
period from July 2020 to May 2021 in Zagazig
emphysema or high blood pressure (2). To detect the
University Hospitals and was conducted on thirty
cause, patient should do one or more investigation such
patients having renal masses previously diagnosed with
as: chest X-ray, pulmonary angiography, CT, MRI,
ultrasound and/or computed tomography, referred to the
duplex venous ultrasound, venography, ECG and D-
Radiology, Urology and Oncology Departments. These
dimer test but all cannot detect size and site of small
patients included (13) females and (17) males, their ages
blood clot exactly in some cases (3).
ranged from 3 years to 72 years old.
As the treatment of pulmonary embolism

depends on the size and location of the blood clot, we
Inclusion criteria: Age: all age groups (3-72 years old),
tend to try to use dual energy CT angiography using
sex: both sexes (males & females), and patient consent
iodine maps in diagnosing PE (2). Dual energy CT
to enter the study.

angiography is the current reference standard for the

detection of PE, allowing visualization of contrast
Exclusion criteria: Renal insufficiency, and
material within the pulmonary vasculature using iodine
hemodynamic instability.
maps and has been shown to be comparable to

conventional angiography for diagnosis of PE. Dual-
Collection of the recorded patient's data:
energy (DE) CT angiography allows differentiation of
(1) Full history taking.
materials based on their energy absorption
(2) Full clinical examination.
1720
Received: 05/11/2021
Accepted: 03/01/2022

Full Paper (vol.871 paper# 122)


c:\work\Jor\vol871_123 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1726-1731

Usefulness of Yolk Sac Diameter and Embryonic Heart Rate as Prognostic
Factors of Gestational Outcome in Early Singleton Pregnancies
Youssef Abo Elwan Elsyed, Fathy Mohamed El-Mansour,
Hala El-sayed Mohamed, Safaa Abdel-Salam Ibrahim
Department of Obstetrics and Gynecology, Zagazig University Hospital, Egypt.
*Corresponding author: Fathy Mohamed El-Mansour, E-Mail: mesa3ed.fathy@gmail.com

ABSTRACT
Background:
Within the gestational sac, the yolk sac is the first embryonic structure to be seen. The size, shape, and
function of the yolk sacs, as well as the heart rates of the developing embryos, all play a role in the evaluation and
prognosis of first-trimester pregnancy losses.
Objective: The purpose of this study was to determine if yolk sac diameter (YSD) and embryonic heart rate (HER)
could be used to predict pregnancy outcomes.
Patients and Methods: 52 pregnant women at gestational age ranged between 6-12 weeks who were included in the
study. Our prospective cohort study was carried out in Obstetrics and Gynecology Department at Fetomaternal Unit,
Zagazig University Hospital and Fetomaternal & Ultrasound Units, Matrouh Maternity Hospital. Measurements of the
embryo's crown-rump length as well as their heartbeat rate and the size and shape of the yolk sac were done.
Results: Normal sac diameter was seen in the great majority of YSD patients in the study groups (80.8 percent). Only
one case of normal diameter YSD ended in miscarriage after the first trimester in all patients with normal YSD. A 98.1%
success rate in predicting miscarriage was achieved by YSD, which had 97.6% sensitivity and 100% specificity. First-
trimester pregnancy outcomes were accurately predicted by EHR with a sensitivity of 97.5% and a specificity of 100%.
Conclusion: Maternal risk variables including age, weight, or parity have no effect on the poor pregnancy outcome
related with abnormal yolk sac diameter and embryonic bradycardia.
Keywords: Yolk sac diameter, Embryonic heart rate, Gestational outcome.

INTRODUCTION
First-trimester pregnancy losses are evaluated and
Approximately 30% to 40% of human pregnancies
prognosed by looking at yolk sac size, structure, and
terminate spontaneously in the first trimester following
function, as well as heart rate during embryonic
implantation. Abortion rates fall if a baby's heartbeat is
development. If a woman has bradycardia, a transvaginal
discovered (1). The yolk sac plays a significant role
ultrasonography can accurately show her EHR
throughout organogenesis,
supplying
metabolic,
(Embryonic Heart Rate) and determine her pregnancy's
immunological, endocrine, nutritional, and hemopoietic
fate (7).
functions, and its peak functional activity occurs during
An abnormally slow embryonic heart rate during
the fourth and seventh weeks of development (2). The
the first six to nine weeks of pregnancy has been linked
properties of the gestational sac, the yolk sac, and the
to 83.3% miscarriage rate, a heart rate of less than 100
heartbeats of the embryo all appear to be linked to the
beats per minute is considered abnormal (8).
health of the developing embryo (1).
The goal of this work was to determine if YSD and EHR
Research on the yolk sac's structure and function
could be used to predict pregnancy outcomes.
has been conducted in a variety of ways. A higher

percentage of pregnancies ended in miscarriage when the
PATIENTS AND METHODS
yolk sac was larger than 5 millimeters. Miscarriages
This study was conducted in the period between
occurred in 37.5% of pregnancies with larger yolk sacs
June 2021 to December 2021 in the Obstetrics and
and in 3.8% of pregnancies with irregular yolk sacs (3).
Gynecology Department at Fetomaternal Unit, Zagazig
The incidence of problems decreases as the pregnancy
University Hospital and Fetomaternal Unit & Ultrasound
progresses in the first trimester with a normal yolk sac.
Unit, Matrouh Maternity Hospital. 52 pregnant women
94.2% of the time, a typical yolk sac can anticipate a
aged from 20 to 40 years old at gestational age ranged
normal outcome (4).
from six to twelve weeks were involved in the study.
Within the gestational sac, the yolk sac is the first

embryonic structure to be seen. A round anechoic region
Inclusion criteria:
is usually visible from the fifth to the twelfth week of
Pregnancy of a singleton, an early ultrasound check
pregnancy; after that, it fades away (5). In most cases, it is
with CRL was used if the LMP was unsure about the
possible to detect the heartbeat of an embryo as early as
accuracy of the gestational age (GA), and action of the
five weeks of pregnancy. In this context, both Doppler
heart in the embryo is positive.
investigations and motion mode (M-mode) can be

helpful. Between 6 and 10 weeks of pregnancy, the fetal
Exclusion criteria:
heart rate increased considerably, rising from 118 to 167
Past abortions or miscarriages, blighted ovum,
beats per minute (6).
patient having a well-documented history of uterine
abnormalities, absent embryonic cardiac activity, and
1726
Received: 06/11/2021
Accepted: 04/01/2022

Full Paper (vol.871 paper# 123)


c:\work\Jor\vol871_124 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1732-1735

Effect of Local Application of N. Acetylcysteine Post-Functional
Endoscopic Sinus Surgery
Samer Badie Kamel 1
1 Otorhinolaryngology Department, Faculty of Medicine, Benha University, Egypt.
Corresponding author: Samer Badie Kamel

ABSTRACT
Background:


Objective: This study aimed to assess the role of local application of NAC post FESS in versus saline irrigation only.
Patients and Methods: This study was a prospective, randomized controlled study that included 150 patients suffering
from chronic allergic rhinosinusitis with nasal polyposis not responding to medical treatment. They underwent
Functional Endoscopic Sinus Surgery, then they were enrolled in the study. They were divided into 2 groups, 75 patients
per each group: The first group received N. acetylcysteine (NAC) nasal douches with saline irrigation for 3 weeks in
the post-operative follow up period in contrast to the second group that received saline nasal irrigation only for a similar
period.
Results: After 6 weeks of follow up period the formation of nasal crusts, nasal adhesions and blood clots were observed
in 5, 3 and 4 patients of the first group in contrast to 13, 10 and 12 patients from the second group consequently.
Conclusion:
Both NAC and saline irrigation promoted post-operative healing and prevented crusts formation, but
combination between both of them resulting in better healing of nasal mucosa and prevented crusts formation and nasal
adhesions.
Keywords: Sino nasal, polyposis, FESS & NAC.

INTRODUCTION


Chronic allergic rhinosinusitis with nasal
improved with medical treatment. They were prepared
polyposis represents one of the most common
for surgical treatment (FESS).
worldwide problems nowadays due to many factors

especially environmental irritants and allergens (1).
Inclusion criteria:
The most common symptoms of nasal polyposis
Age ranged between 18-45 years. Patients suffering
are nasal obstruction, facial pain, sneezing, runny nose,
from chronic allergic rhinosinusitis with nasal
post-nasal discharge and altered smell function (2).
polyposis.
Medical treatment represents the first line of

treatment in the form of antibiotics (3), local and
Exclusion criteria:
systemic steroids (4), antihistamines (5), antileukotriens (6)
Patients suffering from chronic debilitated
and mucolytics (7).
diseases as liver diseases, pulmonary diseases, renal
With failure of medical treatment, FESS
failure, cardiac diseases and malignancies, patients
represents the second line of treatment as safe and
suffering from allergic fungal sinusitis and patients with
effective treatment (8) for excision of polyps and
previous nasal surgery.
restoration of the physiological function of the affected
The patients were blindly divided into two groups,
sinuses (9) Post FESS follow up period is so important to
75 patients per each one.
maintain the nasal cavity clean from crusts and so
Functional Endoscopic Sinus Surgery was
prevent formation of adhesions (10).
performed to all patients with the standard.
The aim of the present study was to assess the
Messerklinger's technique (11) and nasal packings were
local effect of NAC post-FESS in prevention of
removed after 24 hours post operatively (12). The follow
crustations and nasal adhesions.
up regimen was designed as follows: Two visits per

week for the first 2 weeks, then one visit per week for
PATIENTS AND METHODS
the next month. Every patient received medical
This
study
was
conducted
in
the
treatment in the form of antibiotic (Amoxicillin/
otorhinolaryngology department of Benha University
Clavulinic acid) twice daily, analgesic (paracetamol)
Hospitals through the period from June 2019 to May
three times daily for 10 days, first group received N-
2020.
acetyl cysteine 300 mg/3 ml in the form of nasal spray

twice daily for three weeks post operatively followed by
Ethical approval:
saline irrigation, and the second group irrigated the nose
The Ethical Committee of Benha Faculty of
with saline only for a similar period.
Medicine approved this study. Informed written consent
During the follow up visits, each patient
was obtained from each patient after explanation of the
underwent endoscopic examination with rigid Hopkin's
plan of treatment and the follow-up regimen.
endoscope 0 degree blindly by the same investigator.
150 patients were enrolled in the study suffering
During examination, each patient was asked about
from allergic rhinosinustis with nasal polyposis not
anosmia, nasal pain, nasal obstruction, postnasal
1732
Received: 1/11/2021
Accepted: 29/12/2022

Full Paper (vol.871 paper# 124)


c:\work\Jor\vol871_125 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1736-1742

Study of Prevalence of Autoimmune Manifestations of
Chronic Hepatitis C Infection in Beni-Suef Governorate
Ahmed Amin Ibrahim*1, Hanan Ali Taha1, Rabab Afifi Mohammed2,
Shahenaz Hamdi El Genedi Khalil1, Nilly Abd-Allah1
Departments of 1Internal Medicine and 2Clinical Pathology,
Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
*Corresponding author: Ahmed Amin Ibrahim, Mobile: (+20) 01142741126, E-Mail: mahmoud.znaty@yahoo.com

ABSTRACT
Background
: Although most patients with chronic hepatitis C are asymptomatic, an appreciable number will experience
symptoms that are due to liver disease and /or extrahepatic manifestations of HCV infection. Recognition of these
symptoms will lead to early diagnosis and treatment of hepatitis C. Objective: This study aimed to assess the prevalence
of extrahepatic manifestations in patients with chronic hepatitis c infection in Beni-Suef Governorate. Patients and
methods:
200 patients with CHC are studied, their ages ranged between 20-60 years. They are collected randomly from
Beni-Suef University and general hospitals and outpatient clinics. Results: There is a wide range of prevalence of EHMS
of HCV infection, 8% were asymptomatic and accidentally discovered to have HCV. 92% of the total number of patients
have at least one EHM. The commonest extrahepatic manifestations are rheumatological 51%, hematological 26%,
fatigue 20%, dermatological 19%, neurological 16%, DM11%, cryoglobulinemia 9% and less common chest, renal,
lymphoproliferative disorders, cardiac, thyroid dysfunction. Conclusion: Extrahepatic manifestations appear earlier
than hepatic manifestations of HCV patients. Age and liver fibrosis are considered major risk factors of EHMs. Health
professionals should be aware of these HCV-associated complications and presentations.
Keywords: HCV, Autoimmune manifestations, Drugs, Hepatic manifestations.

INTRODUCTION

Sjögren syndrome, and ischemic retinopathy (11).
Egypt had one of the highest prevalence rates of
Hematological
manifestations
such
as
HCV in the world with about 10% chronic HCV
thrombocytopenia: may be due to a variety of non-
infection among people aged 15 to 59 years (1, 2). The
immune
and
immune
mechanisms
such
as
Ministry of Health revealed that the prevalence of HCV
hypersplenism and coombs-positive autoimmune
in 2021 reached 2%, marking a drop compared to7% in
hemolytic anemia (12).
2018 after the conduction of multiple national programs
Endocrinal manifestations; thyroid disorder
to control HCV infection (3). Although hepatitis C virus
including chronic thyroiditis, hypothyroidism, and
(HCV) infection primarily affects the liver, other organ
hyperthyroidism and increased levels of serum anti-
systems can become involved, which may result in a
thyroperoxidase and anti-thyroglobulin autoantibody
variety
of
clinical
complications,
including
and diabetes Mellitus up to one-third of patients with
cryoglobulinemia which may be asymptomatic or
chronic hepatitis C virus (HCV) develop type 2 diabetes
presented with a triad of purpura, myalgia, and arthralgia
mellitus (DM). Further, HCV seropositivity in patients
(Meltzer's triad) is the most common presentation with
with DM appears to be higher than in the general
HCV-related mixed cryoglobulinemia (4). Cutaneous
population (13, 14). Cardiac involvement HCV infection is
disorders are known to be linked to HCV infection
a proven independent risk factor for the development of
including mixed cryoglobulinemia, lichen planus,
cardiovascular disorders and Idiopathic pulmonary
porphyria cutanea tarda, and necrolytic acral
fibrosis is a serious condition with HCV infection
erythema. Besides these dermatoses, HCV can also be
histologically by interstitial inflammation with dense
associated with autoimmune cutaneous diseases such as
collagen fibrosis (15).
vitiligo and psoriasis (5). Arthralgia and arthritis are
These many HCV-associated extrahepatic
frequently observed EMS with no erosive joint changes
manifestations can have a major impact on morbidity,
with rheumatoid factor activity may be found, but
mortality, and medical costs (6).
antibodies to cyclic citrullinated peptides are absent (6),
Need for Recognition: Clinicians must consider the
renal manifestations of CHC mostly include type I
potential for HCV to cause extrahepatic manifestations
membranoproliferative glomerulonephritis (MPGN)
in persons with chronic HCV infection. An awareness of
with sub-endothelial deposits (7).
the range of potential extrahepatic manifestations could
Lymphoproliferative
disorders,
including
facilitate earlier diagnosis, more appropriate and timely
monoclonal gammopathies in addition to mixed
treatment of these disorders, and makes the need for
cryoglobulinemia and B-cell NHL. Patients positive for
DAA treatment of HCV considered urgent (16). Although
anti-HCV antigen had a 2.5-fold increased risk of NHL
both public plans and commercial policies regarding
versus controls (8). Neuropsychiatric manifestations
approval for HCV treatment are constantly changing,
include peripheral polyneuropathy, central nervous
these payers typically cover DAA therapies when any
system
manifestations
and
neuropsychological/
extrahepatic manifestation exists, despite the level of
psychiatric manifestations (9), and a higher prevalence of
hepatic fibrosis.
mental illness and substance abuse (10). Ocular
manifestations include a dry eye syndrome similar to
1736
Received: 06/11/2021
Accepted: 04/01/2022

Full Paper (vol.871 paper# 125)


c:\work\Jor\vol871_126 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1743-1747

Evaluation of Interleukin-6 and Interleukin-1 Levels in Febrile Status Seizures
Samar Elhady Mosa Fadl*1, Ahmad Galal Siam1, Ahmad Hosny Mohamad1, Ahmad Abdelsabour Mohamad2
Departments of 1Pediatrics and 2Clinical Pathology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
*Corresponding author: Samar Elhady Mosa Fadl, E-Mail: elhadysamar82@gmail.com

ABSTRACT
Background:
Seizures triggered by fever are known as febrile seizures, and they are the most common form in children.
The cause of febrile seizures is still a mystery, even though numerous studies have been carried out. Researchers have
found cytokines may play an important role in the development of febrile seizures.
Objective:
to evaluate the role of Interleukin-6 and interleukin-1 levels in febrile status epilepticus.
Patients and methods;
This was a prospective case-control study, conducted at the Neurological Unit of the Pediatric
Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt on 52 children (26 in each group), plasma
cytokine (IL-6 and IL-1) levels were detected as a main part of the initial study design.
Results:
A significant difference was found between both groups as regard IL-6 and IL-1. Conclusion: A genetic risk
factor for fever-related seizures in children may be associated with promotor variations in IL-1 genes rather than IL-
6 or HMGB1 genes.
Keyword:
Cytokines, Seizures, IL-6, IL-1.

INTRODUCTION

children's peripheral mononuclear cells were treated with
Children with a fever of 38°C or above with no
the gram-negative molecule lipopolysaccharide., That
history of an afebrile seizure, hypoglycemia, medication
their IL-1 was substantially higher than other children
withdrawal or drug use, or an electrolyte imbalance are
who had bacterial infections but had no seizures.
generally considered to have febrile seizures (FS) (1).
A study by Matsuo and his colleagues (9)
Pediatricians face a huge issue due to the prevalence of
indicated that FSD children's leukocytes were more
febrile seizures in young children. There has been a
sensitive to double-stranded RNA stimulation than those
considerable increase in knowledge about how to prevent
of healthy youngsters (a viral infection model). Several
and treat febrile seizures in recent years (2).
more studies have since investigated the role of cytokines
Febrile seizures are still a mystery as to their cause
in human FS in the time that has elapsed between the two
and pathogenesis. Patients with febrile seizures have
of these (10).
higher levels of IL-6 and IL-4 cytokines, which may be
Furthermore, it was shown that children with
important in the disease's etiology (3). Tumor necrosis
certain genetic abnormalities in the interleukin system
factor-alpha, interleukin-1, and tumor necrosis factor are
were also more prone to FS, which was confirmed by
among the immune system's most potent weapons against
cytokine measures. When LPS is administered to cultured
infection. Due to the immune system's overproduction of
monocytes with an IL-1 gene polymorphism, the
proinflammatory cytokines, children are more susceptible
monocytes produce more IL-1. This polymorphism has
to inflammation, which may be defined by the cytokine
been linked to a higher risk of developing FS (11).
response in response to infections (4).
It was the goal of this work to evaluate the role of
Both pro-inflammatory and anti-inflammatory
Interleukin-6 and interleukin-1 levels in febrile status
cytokines have been associated with elevated levels of
epilepticus.
cytokines such as TNF-alpha and IL-10 in the peripheral

blood of children with FS as well as children with epilepsy
PATIENTS AND METHODS
who had previously had seizures. There were significant
This study was undertaken as a case-control study in
variations in the levels of IL-1 and other proinflammatory
the Neurological Unit of the Pediatric Department,
cytokines between children who experienced a seizure
Faculty of Medicine, Zagazig University, Sharkia, Egypt.
attack and those who were feverish but not experiencing
Fifty -two patients were retrieved, 26 febrile status
seizures, in both groups of children (3). Child epilepsy
seizures children were considered as the case group and
sufferers have higher levels of IL-1, which suggests that
another 26 cases were controls.
this cytokine has a role in the development and

progression of the disease (5).
Ethical considerations:
IL-6 has been implicated in febrile seizures in the
Zagazig University's research ethics council
past, however, the results are mixed. The epileptogenic
approved the study and informed consent forms
effect of IL-6 in febrile seizures has been demonstrated by
signed by all participants' parents were collected
certain research (3), Serum IL-6 has been found to have an
following the Helsinki Declaration, which is the ethical
antiepileptic effect via adenosine receptors in rat research
norm for human testing established by the World
(6). Fever-induced seizures have also been linked to iron-
Medical Association.
deficient anemia (7).Children's higher IL-1 responses
Inclusion criteria: All subjects met the following
may play a role in FS patients' seizures, as demonstrated
inclusion criteria: Both sexes included. Age equal or
by Helminen and Vesikari's 1990 study (8). FS-affected
lower to 6. Convulsions lasting 30 minutes or more
1743
Received: 06/11/2021
Accepted: 04/01/2022

Full Paper (vol.871 paper# 126)


c:\work\Jor\vol871_127 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1748-1751

Evaluation of the Role of Serum Interleukin-1 Beta in Patients with Atopic Dermatitis
Mahmoud Yousry M. Abdel Mawla1, Naglaa Ali Khalifa2,
El-Sayed Mohamed Galal Khater1, Amira Maged Mohamed Mohamed*1
Departments of 1Dermatology, Venereology and Andrology, and
2Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Amira Maged Mohamed, Mobile: (+20) 01159310738, E-Mail: dr.moony93@yahoo.com

ABSTRACT
Background:
Atopic dermatitis (AD) is a common eczematous skin disease that is chronically relapsing. Interleukin -
1-beta (IL-1) is a pivotal agonist member of the IL-1 family that plays a master role in the induction of an adequate
immune response to regulate the sweeping of the diseased cells physiologically. Objective: The aim was to clarify the
possible participation of a certain IL (IL-1 beta) in the pathogenesis of atopic dermatitis. Patients and Methods: This
case-control study has been conducted in the Dermatology, Venereology and Andrology Department at Zagazig
University Hospitals. Our present study included 30 atopic patients and 30 apparently healthy control subjects of
matched age and sex. Serum IL-1 level was measured. Results: Gender had no significant effect on serum Il-1 in all
groups. Duration of the disease showed a non-significant positive one in atopic patients. The severity of the disease
showed a significant positive correlation in atopic patients and similarly, the disease score did. There was a significant
difference in serum IL-1 among the three degrees of severity in a topic patients. Conclusion: IL-1 serum level was
found in patients with moderate to severe cases of atopic dermatitis, marking the systemic inflammatory nature of these
diseases. On the other hand, IL-1 serum level was around normal values in the control group. These mentioned findings
were supported by the statistical evaluations on the relationship between serum IL-1 level, severity scores of AD
(SCORAD score) and clinical observations.
Keywords: Assessment, Atopic Dermatitis, Serum Interleukin-1 beta

INTRODUCTION

person as following: on cheeks, arms, legs and groin in
Atopic dermatitis is an inflammatory, chronically
infants, on feet and antecubital and popliteal fossae in
relapsing, non-contagious and pruritic skin disorder that
children/adolescents, and on hands, feet, ankles and
is very common in children but may occur at any age; it
groin in adults. There is a great interest to the disease
may start as early as age 2-6 months, and may persist
not only due to its special clinical manifestation but also
into adulthood. It is the most common form
due to its pathogenetic mechanism (4).
of dermatitis. Atopic dermatitis usually occurs in people
IL-1 is mainly produced in blood monocytes;
with
'atopic
tendency'.
This
means
they
macrophages and dendritic cells. IL-1 transmits its
may develop any or all of three closely linked
signal through binding to its cell surface receptor IL-
conditions;
atopic
dermatitis,
asthma
and
1R-1. IL-1 promotes T-cell activation, up regulates the
allergic rhinitis. Often these conditions run within
IL-2 receptor on lymphocyte surface, stimulates B-
families so, the family history is useful in diagnosing
lymphocytes for proliferation and antibody production
atopic dermatitis in infants (1).
and enhances Th17, Th1 and Th2 lymphocyte
Atopic dermatitis arises because of a complex
differentiation (5).
interaction of genetic and environmental factors. These
IL-1 requires the intracellular cysteine protease
include defects in skin barrier function making the skin
caspase-1 for biological activity. Activation of caspase-
more susceptible to irritation by contact irritants. This
1 is mediated by a cytosolic multiprotein oligomer
malfunctioning skin barrier also provides a golden key
called the inflammasome. The activity of the
to pathogens especially staphylococcus aureus to
inflammasome is triggered not only by microbial
colonize the skin and then aggravating the inflammatory
infection, but also by a noninfectious both exogenous
process. Atopic dermatitis manifests itself, not only as
and endogenous stimuli. The dysregulation of
an acute but also as a chronic disease (2).
inflammasome activity is associated with numerous
The disease is distinguished in acute, relapsing
proinflammatory and nonmicrobial diseases in human
form (episodes of acute eczema with intervals between
including atopic dermatitis (6).
them) and chronic form (episodes of acute eczema
The aim of the study is to clarify the possible
without intervals). The main first symptom of AD is
participation of a certain IL (IL-1 beta) in the
persistent severe pruritus. AD is defined in most people
pathogenesis of atopic dermatitis.
by acute flares with inflamed, red, sometimes blistered

and weepy patches. In-between flares, the skin may
PATIENTS AND METHODS
appear normal or suffer from chronic eczema with dry,
This case-control study has been conducted in the
thickened and itchy areas (3).
Dermatology, Venereology and Andrology Department
Many factors can alter the way eczema looks and
at Zagazig University Hospitals. The present study had
feels. There are some general patterns where the eczema
been carried out on 60 individuals. Participants were
is found on the body according to the age of the affected
divided into 2 groups, a diseased group, and a control
1748
Received: 04/11/2021
Accepted: 02/01/2022

Full Paper (vol.871 paper# 127)


c:\work\Jor\vol871_128 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1752-1756

Inferior Vena Cava Collapsibility Index versus Central Venous Pressure for
Assessment of Intravascular Volume Status in Injured Traumatized Patients
Mahmoud Adel Omar Al Arnous, Lobna Taha El Dorgham, Nermeen Mohamed Ali, Alaa ElSadat Ibrahim
Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Alaa Elsadat Ibrahim, Mobile: (+20) 01159310738, E-Mail: alla_ibrahim9090@yahoo.com

ABSTRACT

Background: Intravascular volume status assessment is one of the most challenging tasks for clinicians in intensive
care unit so fluid therapy is considered as cornerstone in improving the outcome of the injured traumatic patients.
Assessment of intravascular volume state is achieved by multiple methods; non-invasively (such as arterial blood
pressure (ABP), heart rate (HR), and urine output (UOP)) and invasively as using central venous catheter (CVC).
Objective: The aim was to assess inferior vena cava (IVC) collapsibility index by using ultrasound and to assess central
venous pressure through central venous catheter inserted in internal jugular vein to predict intravascular volume status
in injured traumatic patients.
Patients and Methods: This cohort prospective study was conducted at Zagazig University Hospitals. It included 36
polytraumatic patients who were admitted in Surgical and Emergent Intensive Care Unit. Male patients represented
55.6% and female patients represented 44.4% of them. Age ranged from 21 to 60 years with mean 35.33 years old,
mean BMI was 29.03 kg/m2 and the severity of trauma varies from moderate to severe (AIS grade 2-4).
Results: The results showed that the mean of IVC collapsibility index gradually decreased in the second day of
assessment to 30-38% and decreased more in the third day to 25-35 %. The mean CVP gradually increased in the second
day to 4-9 mmH2O and it increased more in the third day to 6-12 mmH2O. This study showed that there was statistically
significant inverse correlation between IVC collapsibility index and CVP.
Conclusion:
IVC collapsibility index has a strong statistically significant inverse correlation with central venous
pressure, which is more accurate at low central venous pressure values.
Keywords: Central venous pressure, Inferior vena cava collapsibility index, Injured traumatized patients, Intravascular
volume status.

INTRODUCTION
The aim of this study was to assess inferior vena
Trauma is considered as a common cause of
cava collapsibility index by using ultrasound and to
death worldwide as it may be associated with blood loss
assess central venous pressure through central venous
due to traumatic vascular or traumatic organ injury,
catheter inserted in internal jugular vein to predict
which may lead to hypovolemic shock (hemorrhage
intravascular volume status in injured traumatic
after trauma is responsible for more than 35% of pre-
patients. The aim was also to compare in between the
hospital deaths and more than 40% of deaths within the
inferior vena cava collapsibility index and central
first 24 h) (1). In case of severe blood loss, compensatory
venous pressure measurement in predicting the
mechanisms fail to maintain adequate peripheral
intravascular volume status and to monitoring the effect
circulation and lead to severe hypotension,
of optimization of intravascular volume status on the
hypoperfusion, multi-organ system failure and death (2).
outcome of injured traumatized patients.
Assessment of hemodynamics can be achieved

through invasive and non-invasive methods; invasive
PATIENTS AND METHODS
methods such as invasive arterial blood pressure and
This Cohort prospective study was conducted at
invasive central venous pressure through central venous
Zagazig University Hospitals. In the present study, 36
catheter inserted in jugular vein but their reliability are
polytraumatic patients were included. They were
reduced due to the invasive nature of the procedure and
admitted in Surgical and Emergent Intensive Care Unit.
linked complication risks (3).

Non-invasive methods include non-invasive
Inclusion criteria:
arterial blood pressure (ABP), heart rate (HR), and urine
Patient or relative acceptance. Age: 21-65 years old.
output (UOP) monitoring which are more applicable
Both sexes. Patient: traumatized patients in Surgical
and sensitive without risk of complications (4). IVC
Intensive Care Unit. Body mass index <35 kg\m2.
collapsibility index is considered as an indirect method
Severity of trauma: moderate to severe according to AIS
to assess central venous pressure by using ultrasound
(abbreviated injury score) AIS code (2-4), and type of
for assessment intravascular fluid status (5).
trauma: polytrauma.
Ultrasonography has an important role in injured

traumatic patients, it used to detect volume status,
Exclusion criteria:
which
can
affect
the
patient's
condition.
Pregnant women. Patient with severe tricuspid
Ultrasonography has a lot of advantages such as it is
regurge and pulmonary hypertension. Patient with
accurate, non-invasive and can be performed by non-
increase of intra-abdominal pressure (For fallacies due
radiologist (6).
to IVC compression). Patient with chronic obstructive
1752
Received: 04/11/2021
Accepted: 02/01/2022

Full Paper (vol.871 paper# 128)


c:\work\Jor\vol871_129 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1757-1763

Health Education Program on Prevention of
Needle Stick Injuries among Health Care Workers
Amina Ibrahim Eldosoky Mostafa*1, Hosnia Mohammed Ragab2, Amany Mohammed Abdallah1
Departments of 1Family Medicine and 2Public Health, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Amina Ibrahim Eldosoky Mostafa, Mobile: (+20)1028234520, Email: aminaeldodoky@gmail.com

ABSTRACT

Background: Needle stick injuries (NSIs) increasing day by day and globally a lot of health care workers suffer from
infection per year through this route.
Objective: This study was aimed to assess knowledge, attitude, and practice of primary health care workers toward
needle stick injury at Fakous district, Sharqia governorate.
Patients and Methods: This interventional study included a total of 104 personnel who were working in the of primary
health care centers (PHCs), at Fakous district, Sharqia Governorate. This study was conducted between January 2020
to January 2021.
Results: There was highly statistically significant association between history of needle stick injury and history of HBV
vaccination as positive history of HBV vaccination (Three doses) was associated with positive history of needle stick
injury. There was high statistically significant improvement in knowledge of the study participants about standard
precautions of infection control after intervention except for waste disposal. Before intervention, the highest proportion
of adequate knowledge was about waste disposal (93.3%) while the lowest proportion of adequate knowledge was about
sterile instruments and devices (15.4%).
Conclusion: It could be concluded that the effect of health education is remarkable in improving the development of
knowledge and increasing awareness of health care providers about infection control guidelines.
Keywords: Needle stick injuries, Health Education, PHCs

INTRODUCTION

stick injury--NSI, by a contaminated needle) is
The World Health Organization (WHO) defines
estimated to range between 10­30% for HBV, 1.8­10%
`a safe injection' as one that does not harm the recipient,
for HCV, and 0.3% for HIV infection (5).
does not expose the provider to any avoidable risk, and
According to WHO, approximately 66000
does not result in any waste that is dangerous to the
HBV, 16000 HCV and 200-5000 HIV accidental
community. Irrational and unsafe injection practices are
infections occurs to HCWs each year (3).
rife in developing countries. More than 80% of the
The rate of occupationally acquired infections
needle stick injuries can be prevented through the use of
is significantly higher than those currently projected or
safety devices and effective safety programs. Needle
reported. The non-reporting or low injury rate should
stick injuries can be prevented by applying "Universal
not be termed as a nonexistent crisis. The studies related
precautions" as a safety measure (1).
with the occupational injuries and associated infections
Needle stick injuries (NSI) are wounds caused
are therefore warranted to strengthen the healthcare
by needles that accidentally puncture the skin, are truly
management system (6).
an occupational hazard for medical personnel (2). These
This study was aimed to assess knowledge,
injuries are usually caused by hypodermic needles,
attitude & practice of PHC workers toward needle stick
blood collection needles, intravenous cannulas, etc.
injury at fakous district and to evaluate health education
during use, recapping, transferring samples, post
program about how to prevent & manage of NSI, so as
procedure cleaning, or disposal in non-puncture proof
to improve HCWs safety and, hence improving their
containers (3).
performance.
NSI increasing day by day and globally a lot of

health care workers suffer from infection per year
PATIENTS AND METHODS
through this route (2).
This interventional study included a total of 104
Hence, health care workers (HCWs) are prone
personnel who were working in the of primary health
to acquisition of multiple pathogens, such as
care centers (PHCs), at Fakous district, Sharqia
HIV/AIDS, hepatitis B and C, malaria, herpes,
Governorate. This study was conducted between
tuberculosis, brucellosis, spotted fever, and syphilis etc.
January 2020 to January 2021.
Although, the occupational injuries can transfer any

pathogen (Bacteria, Protozoa, Viruses etc.) but the
Inclusion criteria:
transmission of the hepatitis B, hepatitis C and the HIV
Health care workers (physicians, nurses,
is most important and critical(3).
technicians) of both sexes, who are working in the PHC
They also cause social consequences, such as
centers at Fakous district, Sharqia Governorate. Using
stigma and discrimination, and economic consequences
OPEN-EPI, the sample size was calculated to be 104.
associated with diagnostics and treatment (4). The risk of
Assuming that the total knowledge score before and
infection of the exposed person (from a single needle
1757
Received: 07/11/2021
Accepted: 05/01/2022

Full Paper (vol.871 paper# 129)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1764-1769

Evaluation of Serum Cholinesterase as an Early Diagnostic Marker of
Liver Cirrhosis
Hesham Attia Abd El-Ghany, Hany Abd EL-Malik Labib,
Aml Hamed Sadek Ibrahim*, Said Abdel Baky Gad Shamseldeen
Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Aml Hamed Sadek Ibrahim, E-mail: Amlhamed231@gmail.com

ABSTRACT
Background
: Hepatocytes are the primary source of acetyl cholinesterase, which is released into the bloodstream and
has a lower activity in liver dysfunction.
Objective: The aim of this study was to assess the value of serum cholinesterase in early diagnosis of cases with liver
cirrhosis.
Patients and Methods: This study included a total of 111 patients with liver cirrhosis, attending at Internal Medicine
Department, Zagazig University Hospitals and at Al-Ahrar Teaching Hospital. This study was conducted between April
2021 to October 2021. Patients were classified into 4 groups:1st group: 24 Child A score liver cirrhosis cases, 2nd
group:25 Child B score liver cirrhosis case,3rd group: 25 Child C score liver cirrhosis cases. And 4th group: Matching
control persons of a healthy 37 years old. Fibroscan and measurement of serum cholinesterase were done for all
subjects.
Results:
The serum cholinesterase levels drop rapidly in each of the three cirrhosis grades, Child A, Child B, and Child
C. In compensated cirrhosis, serum cholinesterase is higher than in decompensated cirrhosis. Blood albumin and
cholinesterase levels were found to be strongly linked. Serum bilirubin and serum cholinesterase levels have a strong
negative correlation. Patients with higher MELD scores have lower cholinesterase levels.
Conclusion: It could be concluded that serum cholinesterase levels can help in liver cirrhosis diagnosis and prognosis.
Serum cholinesterase concentration is strongly linked to the severity of cirrhosis.
Keywords: Cholinesterase, Liver Cirrhosis.

INTRODUCTION

complicated, the INR varies from one laboratory to the
One of the leading causes of death in the globe is
other (6).
liver cirrhosis (1). Excessive extracellular matrix
To hydrolyze acetylcholine, an enzyme known as
components (ECM), histological remodeling, and
Cholinesterase is required (7). Two forms of
structural microenvironment shifts are among these
cholinesterase are present: acetyl cholinesterase, or
modifications. A wound in the parenchyma of the hepatic
erythrocyte cholinesterase, and pseudocholinesterase, or
stellate cells is required for the production of collagen,
plasma cholinesterase, which is produced in the liver and
matrix proteins and a wide spectrum of proliferative, anti-
released into the blood; its activity is lowered in liver
inflammatory and growth factors (2). Patients with
failure due to diminished synthesis in these cells(8).
cirrhosis face a lowered life expectancy and an increased
The aim of this study was to assess the value of serum
risk of various complications (3).
cholinesterase in early diagnosis of cases with liver
The fact that many patients with liver cirrhosis are
cirrhosis.
asymptomatic in the early stages and that the vast

majority of patients with liver cirrhosis are admitted to
PATIENTS AND METHODS
the hospital owing to complications from the disease may
This study included a total of 111 patients with
lead to an underreporting of cases. Liver cirrhosis has a
liver cirrhosis, attending at Internal Medicine
mortality rate between 1% and 57% in a year, depending
Department, Zagazig University Hospitals and at Al-
on the severity of complications that emerge (4).
Ahrar Teaching Hospital. This study was conducted
Gastroenterologists use the Child-Pugh score to
between April 2021 to October 2021.
evaluate patients with chronic liver disease, including

cirrhosis. Besides predicting surgical mortality, this score
The included subjects were divided into four groups
is used to determine prognosis and the intensity of
according to the following inclusion criteria;
treatment required (5).
criteria: Group 1: 24 Child A score liver cirrhosis cases,
The prognosis of cirrhotic patients has long been
Group 2: 25 Child B score liver cirrhosis cases, Group
predicted using the Child­Pugh and MELD scores. This
3: 25 Child C score liver cirrhosis cases, and Group 4
does have certain disadvantages. Whether or not to alter
(control): Matching control persons of a healthy 37
the Child­Pugh scores for ascites and HE, two criteria
years old.
that can change, is the doctor's decision. In individuals

with cirrhosis, the INR components of the Child-Pugh
Exclusion criteria: patients aged under eighteen, a four-
and MELD scores do not effectively represent
week history of blood or albumin transfusion, patients
coagulopathy and liver function. To make matters more
with history or indication of variceal hemorrhage on
1764
Received: 07/11/2021
Accepted: 05/01/2022

Full Paper (vol.871 paper# 130)


c:\work\Jor\vol871_131 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1770-1775

Comparative Analysis of Caesarean Delivery Rates in a Tertiary and a
Secondary Hospitals Using Robson Ten Group Classification
Mamdouh Mohammed Hussein Shaaban, Mansour Ahmed Mohammed Khalifa,
Sarah Abdelrahman Ahmed Abdelrahman*
Department of Obstetrics and Gynaecology, Faculty of Medicine, Assit University, Egypt
*Corresponding author: Sarah Abdelrahman Ahmed, Mobile: (+20)1144997694, E-Mail: sarahabdelrahman1989@gmail.com

ABSTRACT
Background:
There is no justification for any reason to have a caesarean delivery (CD) rate higher than 10­15%. CD
rates higher than 10% are not associated with substantial decrease in maternal and neonatal mortality rates. Robson
Group Classification System has the advantage of analyzing the caesarean delivery rate in well-defined sub-groups of
women that are totally inclusive and mutally exclusive.
Objective: The aim of the current work was to make comparative analysis of increasing trends of caesarean delivery in
two hospitals at Assiut Governorate in Egypt.
Patients and methods: This retrospective cross-sectional study included a total of 2702 cases, attending for delivery
at Assiut University Hospital; a tertiary hospital and Assiut Police Hospital; a secondary hospital, both present in
Assiut Governorate. This study was conducted over 3-month between Jan 2016 to Mar 2016.
Results: Robson Group 5 constituted the most in both hospitals regarding the relative size of the group with higher and
significant percentage at the secondary hospital (53%) compared to (32.3%) at the tertiary one. Robson Group 5
contributed the most in both hospitals regarding the overall CD rate with higher and significant percentage at the
secondary hospital (74.8%) compared to (49.4%) at the tertiary one. Robson Group 5 also contributed the most in both
hospitals regarding the absolute contribution rate of all deliveries with higher and significant percentage at the secondary
hospital (50%) compared to (28.7) at the tertiary one.
Conclusion: On the basis of the study, TGCS is only a starting point, but it is important to have a common starting
point. Having implemented TGCS, we have concluded that Group 5 (previous caesarean delivery) is the largest of the
overall CD rate in both secondary and tertiary hospitals.
Keywords: Caesarean delivery, Assiut Governorate, Robson Ten Group Classification

INTRODUCTION

In the light of these issues, WHO, in 2011,
Caesarean delivery (CD) has become the most
conducted a systematic review of systems used to
common obstetric operation worldwide. When
classify CD and concluded that Robson Ten Group
medically indicated, it can effectively reduce maternal
Classification System (TGCS) is the most appropriate
and neonatal morbidity and mortality (1). But, the rate of
system to fulfill current international and local needs (6).
CD is increasing dramatically both locally and
In 2014, WHO conducted another systematic
internationally exceeding World Health Organization
review of the experience of Robson classification and
(WHO) recommendation of a rate not more than 10-
proposed TGCS as a global standard for assessing,
15% without a clear understanding of the main drivers
monitoring and comparing CD rates within health care
(2). An ecological study showed that out of 137
facilities over time and between facilities (7).
countries, approximately 50% have CD rates of more
The aim of the current work was to make
than 15%.Of these, 46 countries have a rate of more than
comparative analysis of increasing trends of caesarean
20% (3). Another ecological study was performed
delivery in two hospitals at Assiut Governorate in
(according to nationally representative CD rates from
Egypt, one is a tertiary hospital, and the other is a
2000 to 2012) and concluded that CD rates higher than
secondary one, to understand the ongoing rise of
10% are NOT associated with substantial decrease in
caesarean delivery rate.
maternal and neonatal mortality rates after controlling

of socio-economic conditions (4).
PATIENTS AND METHODS
Women who experience CD are at risk of
This retrospective cross-sectional study included a
classical complications such as surgical injury, post-
total of 2702 cases, attending for delivery at Assiut
partum haemorrhage and uterine rupture as well as
University Hospital; a tertiary hospital and Assiut
increasing risk of complications of placentation in
Police Hospital; a secondary hospital, both present in
subsequent pregnancies such as placenta accreta and
Assiut Governorate. This study was conducted over 3-
caesarean scar ectopic pregnancy (5).
month between Jan 2016 to Mar 2016.
Furthermore, CD represents substantial cost to

countries. According to WHO, the cost of global excess
Inclusion criteria:
CD (caesarean deliveries beyond the recommended rate
All women delivered in the two mentioned
of 15%) was estimated to approximately US$ 2.32
hospitals including both vaginal and caesarean
billion (all costs were denominated in 2005 constant $)
deliveries irrespective of obstetric indication, medical
(3).
history, or other maternal factors as BMI.
1770
Received: 07/11/2021
Accepted: 05/01/2022

Full Paper (vol.871 paper# 131)


c:\work\Jor\vol871_132 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1776-1780

High Risk NAFLD among Patients with Irritable Bowel Syndrome:
Frequency and Effect on Disease Severity
Ahmed Samir Allam, Kadry Mohamed El Saeed, Hazem Mahmoud Abozeid, Khaled Mohamed Raafat*
Department of Internal Medicine, Gastroenterology and Hepatology,
Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Khaled Mohamed Raafat, Email: khaled.raafat@med.asu.edu.eg

ABSTRACT
Background:
Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disease that can change a patient's
quality of life and impair his daily activities. Non-alcoholic fatty liver disease (NAFLD), on the other hand, has become
a widespread condition as the global obesity rates rises. The prevalence of NAFLD has reached up to 25% of the
adolescent population. The etiology of both diseases is still not clearly understood. The mechanism linking the two
seemingly similar diseases could be immune system activation and tissue inflammation.
Objective: The goal of our study was to see if there was a common link between them and to examine NAFLD
prevalence and severity in IBS patients.
Patients and methods:
Our study included 150 patients who had symptoms of IBS with different degrees of severity.
IBS was diagnosed according to modified ROME IV criteria. Patients were examined to see if they had NAFLD based
on abdominal ultrasonography and NAFLD fibrosis score calculation.
Results:
Our current study showed that regarding evaluating the association of IBS with NAFLD, there was a highly
statistically significant association between both diseases. Furthermore, there was a high statistically significant
association between higher grades of NAFLD and lipid profile parameters.
Conclusion
: Patients with IBS had a higher frequency of NAFLD. In addition, a significant association was noted
between IBS severity and increased NAFLD grades.
Keywords: NAFLD, Irritable bowel syndrome, NAFLD fibrosis score, Lipid profile.

INTRODUCTION
resistance, in the absence of secondary causes of hepatic
Irritable bowel syndrome (IBS) is a GI
steatosis such as alcohol consumption, chronic use of
functional disorder that can affect people of any age,
medications that can cause hepatic steatosis, or
gender, race, or socioeconomic status. This condition
hereditary disorders (6). NAFLD is diagnosed through
has an important economic impact on patients because
imaging, blood tests including liver function test,
it usually lasts for life and impairs their quality of life.
different scoring systems; nonetheless, liver biopsy
Furthermore, patients are more likely to seek medical
remains the most accurate test (7).
attention and take time off from work (1). IBS molecular
In the diagnosis of NAFLD patients, a variety of
markers and drug targets are difficult to identify due to
scoring systems based on different clinical and/or
its variability and unidentified underlying causes (2).
laboratory characteristics have been developed. One of
Irritable bowel syndrome (IBS) is defined by
the commonly used is the NAFLD fibrosis score. This
abdominal pain or discomfort, which is commonly
score depends on six different variables, which are age,
linked with changes in bowel movements. IBS affects a
hyperglycemia, body mass index (BMI), platelet count,
large percentage of the general population (between
albumin level, and AST/ALT ratio (8).
10% and 15%). Women are more likely than men to
Obesity, gut microbiota dysfunction, a
suffer from IBS (3). Four IBS subtypes have been
compromised intestinal barrier, and brain-gut axis
described based on stool features: diarrhoea (IBS-D),
dysfunction, all of which are crucial to their
constipation
(IBS-C),
mixed
(IBS-M),
and
pathogenesis and are linked to immune activation and
undetermined
(IBS-U)
(IBS-U).
Low-grade
inflammation, may play a role in the development of
inflammation, altered motility, alterations in intestinal
IBS and NAFLD, but there aren't enough studies to back
barriers, changes in gut­brain axis, and psychosocial
up this theory (9). As a result, the purpose of our research
variables appear to play a role in IBS pathophysiology
was to determine if there is a link between them and to
(4).
investigate the prevalence and severity of NAFLD in
Nonalcoholic fatty liver disease (NAFLD) is a
IBS patients.
wide term that refers to a variety of disorders marked by

fat deposition in hepatocytes in the presence or absence
PATIENTS AND METHODS
of liver inflammation. NAFLD refers to a group of fatty
This study was a cross-sectional study conducted
liver diseases that range from simple hepatosteatosis
at the Gastroenterology and Hepatology Department of
(HS), also known as nonalcoholic fatty liver (NAFL), to
Ain Shams University Hospitals. It was conducted on
nonalcoholic steatohepatitis (SH), also known as
150 patients who had symptoms suggestive of IBS after
NASH, and finally to liver cirrhosis (5).
excluding patients with infectious gastroenteritis or
The main cause of NAFLD is obesity and
IBD, patients with cancer colon and patients with other
increased body mass index (BMI), together with insulin
viral (B and C) or alcoholic, genetic, or liver affections.
1776
Received: 09/11/2021
Accepted: 07/01/2022

Full Paper (vol.871 paper# 132)


c:\work\Jor\vol871_133 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1781-1787
Banded versus Non-Banded Sleeve Gastrectomy:
A Non-Randomized Clinical Trial
Mohamed G. Fouly*, Ahmed M. Farrag, Ahmed Y. Elrifai
Department of Surgery, Faculty of Medicine, Ain Shams University, Egypt
*Corresponding author: Mohamed G. Fouly, Mobile: (+20) 01004654619, E-Mail: gamal6bs@gmail.com

ABSTRACT
Background:
Laparoscopic Sleeve Gastrectomy (LSG) may not have the best weight loss profile at long-term follow-
up. Many authors extrapolated the idea of applying bands from Roux-en Y gastric bypass (RYGB) literature to LSG to
enhance weight loss. Although the earlier reports seem encouraging, most of these studies were retrospective and
underpowered.
Objectives: To compare between body mass indexes (BMI) differences over 3 years between banded LSG (BLSG) and
non-Banded LSG (NLSG). We also aimed to compare the emergence/worsening of reflux symptoms.
Patients and methods: This was a prospective, single-center non-randomized clinical trial of 100 patients (N=100)
undergoing either BLSG or NLSG. Average age was 36.84 ± 8.91 years, 59 patients (59%) were females. Patients were
followed at 3, 6, 12, 24, 36 months to evaluate changes in BMI. Study outcomes included change in BMI between 3rd
and 36th months, emergence/worsening of reflux symptoms and remission of comorbidities.
Results: Mean difference in BMI between the first follow-up interval (3 months) and the last interval (36 months) was
13.56±1.93 in BLSG and 10.82±0.39 in NLSG (p < 0.001). Weight regain occurred at 36 months in NLSG but not in
BLSG. Mean operative time was 45.64±3.41 mins in BLSG and 40.64±4.6 in NLSG (p < 0.0001). Remission of
morbidities and worsening/emergence of de novo reflux symptoms was similar in both groups (p > 0.05).
Conclusions: BLSG may have favorable outcomes than NLSG, this effect persisted without weight regain.
Keywords: Banding, Comorbidities, Metabolic surgery, Reflux, Sleeve gastrectomy.

INTRODUCTION
address this problem, many authors suggested placing
Laparoscopic sleeve gastrectomy and roux-en-
adjustable gastric band below the gastroesophageal
Y gastric bypass (RYGB) are the two most performed
junction to restrict pouch expansion and to increase
bariatric operations, one study based on worldwide
satiety(10).
pooled data showed that LSG occupied 46% of the total
The usage of bands started in RYGB, bands in
bariatric operations till 2016(1). LSG was first
RYGB proved to maintain long-term weight loss
introduced as a part of the two-stage biliopancreatic
beyond 5-years, which was better than non-banded
diversion duodenal switch (BPD-DS) (2), then it proved
group(11). Banding LSG uses the same concepts to
its abilities as a stand-alone procedure, which started a
correct for the long-term weight regain, banded
new era in bariatric surgery. It provides a favorable
laparoscopic sleeve gastrectomy (BLSG) was first
profile with its technical simplicity, shorter operating
implemented in 2009 by applying silicone bands(12).
times and better perioperative morbidity, it is also more
Many studies have examined the effects of banding on
liable for revision and to be used as staged operation(3).
weight loss and regurgitation profiles in LSG, earlier
Although the scope of bariatric surgery has changed
studies showed better weight control over years at the
from focusing on weight loss to the broader concept of
expense of increased gastroesophageal reflux
metabolic surgery and treating co-morbidities, weight
symptoms(13). However, these studies relied mainly on
loss remains a key objective for patients undergoing
retrospective cohort patients and many of them were
surgery and should be addressed in the modern bariatric
underpowered.
literature(4, 5).
This prospective non-randomized clinical trial
With longer follow-up of the patients with
aims to compare between BLSG and NLSG regarding
LSG it seemed that failure rates are increasing, one
BMI changes over 3 years, we also aim to examine their
study showed that weight regain and de novo
effects on different obesity subcategories. Traditional
gastroesophageal reflux symptoms started to appear
operative metrics as mean operative time and post-
dreadfully(6). This, in some studies, necessitated
operative complication as well as the emergence of de
conversion to gastric bypass or duodenal switch to
novo gastroesophageal reflux w examined.
maintain significant weight loss and low ghrelin

levels(7). The cause of insufficient weight loss may be
PATIENTS AND METHODS
multifactorial and attributed to multiple factors,
This is a prospective non-randomized single-
however, increase reservoir size associated with long
center clinical trial to assess the differences between
term gastric pouch dilatation is hypothesized to be one
banded sleeve gastrectomy and non-banded sleeve
of the main causes(8). It was theorized that gastric pouch
gastrectomy regarding BMI changes over 3 years of
dilatation results from patients' non-compliance with
follow-up, traditional operative metrics as mean
dietary regimens that precipitates pouch dilatation by
operative time, mortality risk, remission of
the mechanical stretching effect of large meals(9). To
comorbidities and the development of reflux
Received:8/11/2021
Accepted:6/1/2022

1781


Full Paper (vol.871 paper# 133)


c:\work\Jor\vol871_134 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1788-1795

Different Treatment Options for Tubal Ectopic Pregnancy: A Systematic Review
Yasser Ahmed Helmy, Ahmed Tag Aldin Abdel Hafeez, Mohamed Abdel Hameid Mahammad*
Department of Obstetrics and Gynecology, Faculty of Medicine - Sohag University, Egypt
*Corresponding author: Mohamed Abdel Hameid Mahammad, Mobile: (+20) 01060386207,
E-Mail: mahammadhameid2@gmail.com

ABSTRACT
Background:
Treatment options for tubal ectopic pregnancy are: (1) surgery, such as salpingectomy or salpingostomy,
either performed laparoscopically or by open surgery, (2) medical treatment, with a variety of drugs, that can be
administered systemically and/or locally by various routes and (3) expectant management.
Objective: To be aware of the recent modalities in management of tubal pregnancy.
Methods: A systematic literature search of studies describing clinical trials published at the last twenty years was
conducted. Literature searches of the PubMed and Cochrane Library databases were conducted. Using the following
keywords: pregnancy, ectopic, tubal, interstitial, abdominal, angular, cornual, heterotopic, ovarian, gravidity, obstetric,
cervical ripening, labor onset, labor presentation, trial of labor, treatment, therapeutics, therapy, medical, medication &
surgical. The initial literature search identified articles were assessed for possible inclusion.
Results: Among the 62,588 women identified with ectopic pregnancy, 49,090 (78.4%) underwent surgery with
salpingectomy or salpingostomy, while 13,498 (21.6%) received medical management with methotrexate. As can be
seen in next figure, use of methotrexate increased significantly from 14.5% in 2011 to 27.3% by 2020 while surgical
management declined from 85.5% to 72.7% over the same time period (P < 0.001).
Conclusion:
Ectopic pregnancies account for the majority of first trimester maternal death. Tubal pregnancies account
for the majority of ectopic pregnancies.
Keywords:
Tubal ectopic pregnancy, Salpingostomy, Methotrexate.

INTRODUCTION


Ectopic pregnancy is an early pregnancy
introduced for women with a positive pregnancy test
complication in which a fertilized ovum implant outside
and an inconclusive transvaginal ultrasound (7).
the uterine cavity. Implantation may occur anywhere
During the 1970s and 1980s laparotomy was
along the reproductive tract with the most common
gradually replaced by operative laparoscopic options.
implantation site being the fallopian tube. The incidence
Shapiro and Adler (8) reported laparoscopic
of ectopic pregnancy is 1% of pregnant women, and
salpingectomy using electrocoagulation followed by
may seriously compromise women's health and future
excision for an ectopic pregnancy in 1973.
fertility. Currently, ectopic pregnancy can be often
When
methotrexate
is
administered
diagnosed before the woman's condition has
systemically, it can either be given in a fixed multiple
deteriorated, which has altered the former clinical
dose intramuscular regimen or in a variable dose
picture of a life-threatening disease into a more benign
intramuscular regimen. The fixed multiple dose
condition in frequently asymptomatic women (1, 2).
regimen is derived from the treatment of gestational
To improve the objective comparison of
trophoblastic disease and is combined with folinic acid
research outcomes in the diagnosis of ectopic pregnancy
(citrovorum/
leucovorin
rescue)
to
reduce
and to reduce clinical heterogeneity, a recent
chemotherapy toxicity (9, 10).
international consensus statement proposes uniformity
Only a few studies have been published
in definitions of population, target disease and final
describing expectant management in selected patients
outcome of women with a Pregnancy of unknown
with small ectopic pregnancies without fetal cardiac
location (PUL) (3).
activity, an upper limit for serum hCG concentration
Adopting this consensus statement will
that continues to decline and/or a low serum
hopefully lead to improved clinical care. A subgroup of
progesterone concentration (11, 12).
ectopic pregnancies was identified being self-limiting
Recent findings of no difference in fertility
and with spontaneous resolution without the need for an
during the 2 years after an ectopic pregnancy when
intervention. This new diagnostic category of women
comparing medical treatment versus conservative
was defined as having trophoblast in regression (TIR)
surgery and conservative surgery versus radical surgery
(4), a laparotomy to ligate the broad ligament and remove
have answered some longstanding questions and raised
a ruptured tube. By 1885, Tait (5) had accumulated a
new ones for determining the optimal management of
relatively large number of successful cases of
ectopic pregnancies. These findings in particular have
laparotomic salpingectomies. In 1985, Chotiner (6) was
allowed consideration and weighing of a wider range of
the first in English literature to describe a patient with
factors, including women's preferences, efficacy, and
tubal pregnancy treated successfully with systemic
the period of monitoring until recovery (13).
methotrexate. In 1999, the currently used term PUL was



1788
Received: 09/11/2021
Accepted: 07/01/2022

Full Paper (vol.871 paper# 134)


c:\work\Jor\vol871_135 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1896-1800
Tie Over with Pressing Interrupted Sutures versus Usual Karydakis in
Management of Sacrococcygeal Pilonidal Sinus Disease
Abdelhafez Seleem*, Mohammed Abbas
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Egypt
*Corresponding author: Abdelhafez Seleem, Mobile: (+20) 01118522021, E-Mail: abdelhafzsalim83@gmail.com

ABSTRACT
Background:
Sacrococcygeal pilonidal sinus disease is one of the most common annoying conditions that affecting
commonly sacrococcygeal area. The best management of that disease is surgical treatment. Although many surgical
methods used for treatment, recurrence rate is still the main challenge for all techniques. Karydakis procedure is one of
the most commonly used methods for management of pilonidal sinus.
Objective: In this study we tried to compare usual Karydakis procedure and tie over with pressing interrupted sutures
as management for pilonidal sinus as regard rate of recurrence, wound complication and hospital stay and off-work time.
Patients and methods: This is a prospective study done over 75 patients of sacrococcygeal pilonidal sinus who were
divided in two groups (group A) included 35 patients managed by Karydakis procedure and (group B) included 40
patients managed by tie over with pressing interrupted sutures, between June 2017 till May 2019 .
Results: In group B all patients were discharged on the same day of surgery but in group A the mean hospital stay was
of 3.9 ± 2.4 days. Three patients in group A developed seroma compared with one patient in group B. In group A, 11.4%
of patients developed wound infection compared with 2.5% in group B. Three patients in group A had recurrence but
No recurrences were noted in group B, although our study was limited as the duration of follow-up was short to
accurately weigh recurrence rate.
Conclusion: Tie over with pressing interrupted sutures is safe than usual Karydakis procedure with less hospital stay
and less recurrence rates.
Keywords: Karydakis flap, Pilonidal sinus, Tie over.

INTRODUCTION

Pilonidal sinus disease (PsD) is defined as chronic
recurrence rates and midline closure techniques with
inflammatory disease, which usually affecting the natal
high recurrence rates(4).
cleft. Herbert was the first one who described the
One of most commonly used asymmetrical flap
disease at Mayo in 1883(1). The exact cause of (PsD) is
techniques is Karydakis flap which is preferred by many
not known but many theories tried to explain the
surgeons rather than other asymmetrical methods
etiology. The most accepted one of them is the jeep seat
because it is easy and does not need more technical
theory, which proposes that the disease is caused by hair
experience(5).
accumulation at natal cleft and perforation of skin
This study compared tie over with pressing
making foreign body reaction at subcutaneous layer,
interrupted sutures versus usual Karydakis in
which open in multiple or single tracts to the skin
management of sacrococcygeal pilonidal sinus disease
surface. Suggested predisposing factors include family
regarding rate of recurrence, wound complication and
history, hair falling, prolonged settings, deep natal cleft
hospital stay and off-work time.
and obesity (2). The most common age affected is

adolescents and usually in male variants(3).
PATIENTS AND METHODS
The main complaint of the patients with (PsD) is
This was randomized prospective study conducted
low back pain and discharge. Sometimes the sinus
from June 2017 till May 2019 at General Surgery
opening is closed and this leads to pus accumulation and
Department, Bab Alsheria Hospital, Al-Azhar
abscess formation. If that happened the patient will feel
University. The study was done on 75 patients of
severe throbbing pain at abscess site with hectic fever
sacrococcygeal pilonidal sinus randomly divided in two
and hence urgent abscess incision and drainage is
groups; (group A) included 35 patients managed by
advised (3).
Karydakis procedure and (group B) included 40
Many conservative and surgical techniques are
patients managed by tie over with pressing interrupted
used for management of pilonidal sinus but surgical
sutures. Patients excluded in that study were patients
treatment still the ideal way for management.
with recurrent sinus, pilonidal abscess, cellulitis,
Conservative measures includes meticulous hair control
patients with chronic illness such as diabetes or
by natal cleft shaving or by laser ablation, improved
immunocompromized patients and patients refused to
perineal hygiene and phenol injection(1).
participate in the study.
Many studies used to compare different surgical

techniques as regard postoperative complications,
Ethical approval:
length of hospital stay and rates of recurrences. Surgical
An approval of the study was obtained from Al-
procedures for (PNS) in general could be divided in two
Azhar University Academic and Ethical Committee.
categories (asymmetric) flap techniques with less
Every patient signed an informed written consent
1796
Received: 09/11/2021
Accepted: 07/01/2022

Full Paper (vol.871 paper# 135)


Evaluation Of QT Interval In Diabetic Ketoacidosis In Medical Intensive Care Unit The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1801-1805

Early Results after Repair of Cut Wrist Structures at
Zone Five Volar Aspect of the Hand
Mostafa Mohamad El-Saadi, Yehia Zakaria Awwad,
Mohamed Reda Ahmad, Nader Tharwat Mohamed Abd El Atty*
Department of Plastic and Reconstructive Surgery, Zagazig University hospitals, Zagazig, Egypt
*Corresponding author: Nader Tharwat Mohamed Abd El Atty, Mobile: (+20) 01011838322,
E-Mail: dr.nader2030plastic.surgeon@gmail.com

ABSTRACT
Background:
Hand is one of the most active parts of the body, and its normal function is essential for daily activities.
Function of the hand and fingers is related to normal integrity of the bones, tendons and neurovascular structures, and
injuries in any parts of these organs can deteriorate the hand function.
Objective:
This study aimed to evaluate the early results after repair of cut volar structures at zone five within 24
hours after injury in comparison with the cases which repaired after 24 hours of injury.
Patients and Methods:
This was a cohort study that was performed in the period from 1/8/2017 to 1/8/2019 in
Plastic & Reconstructive Surgery Department, Zagazig University Hospitals and Al-Ahrar Teaching Hospital Al-
Sharqia Egypt. This study included sixty-four cases with sharp cut wounds in zone five of flexor tendons. They
fulfilled the inclusion criteria during the study period.
Results: This study revealed that the early repair of cut wrist structures in the 1st 24 hours have more better results
and good outcome than delayed repair after 24 hours. So we encourage the early repair of cut wrist structures as
early as possible to avoid complications of delayed repair. Conclusion: Care of patients with acute hand injury
begins with a focused history and physical examination. In most clinical scenarios, a diagnosis is achieve d
clinically. While most patients require straight forward treatment, the emergency clinician must rapidly identify
limb-threatening injuries and obtain critical clinical information.
Keywords: Repair, Cut wrist, Structures, Zone five, Volar aspect.

INTRODUCTION

Cut wrist is one of the most common hand injuries,
Hand is one of the most active parts of the body,
surgical repair of the injured structures requires an
and its normal function is essential for daily activities.
exact knowledge of anatomy, careful adherence to
Function of the hand and fingers is related to normal
some basic surgical principles, sound clinical
integrity of the bones, tendons and neurovascular
judgment, strict traumatic surgical technique and a
structures. Injuries in any part of these organs can
well-planned post-operative program (6). Injury of the
deteriorate the hand function (1). The hand can give
wrist produces nonfunctioning or deforming hand.
information about the position, size, and shape of an
Deformity is more when tendon injury occurs in zone-
object by its highly developed sensory mechanism and
v (especially when injury occurs in FDS and Flexor
described as third eye (2).
Digitorum Profundus (FDP) (7).
Flexor tendons of the hand are considered in five
Deformed or nonfunctioning hand of a man
anatomic zones due to peculiarities of each area; Zone
produces burden not only to the family but also to the
V extends from the proximal border of the transverse
society, with the development of human civilization or
carpal ligament to the musculotendinous junction in
the development of medical science day by day injured
the proximal part of the forearm. Flexor tendon
hand can be repaired. After repair of cut wrist
lacerations in the forearm are frequently associated
structures by proper technique hand function can be
with laceration of the nerve and artery which further
normal or near to normal and patient becomes able to
compromise the function of the hand (3).
re-back his/her normal job (8).
Despite many surgical techniques and appropriate
The aim of the current study was to evaluate the
rehabilitation programs, cut wrist injuries may be
early results after repair of cut volar structures at zone
associated with adhesion formation and loss of hand
five within 24 hours after injury in comparison with the
function (4). Primary surgical repair with restoration of
cases which repaired after 24 hours of injury.
length, strength and gliding excursion of tendon cut is

essential and primary repair would have the best
PATIENTS AND METHODS
outcome(5). Results of flexor tendon cut after repair
This study included 64 cases that were divided into
depends on many factors such as concomitant nerve
two groups: Group I included 32 cases presented in the
injury, technique and type of repair, surgeon's
1st 24 hours & repaired in the 1st 24 hours (primary
experience, nature of the lesion, and post operative
repair) in comparison with group II that included 32
rehabilitation. Though this injury is frequently seen at
cases which were repaired after 24 hours of injury
our emergency department, there is little in the
(delayed primary repair & secondary repair).
literature to indicate the best protocol of post operative
Comparison includes motor, sensory & power of small
rehabilitation after flexor tendon repair in zone five (6).
muscles of the hand for 12 months after operation.
1801
Received: 12/11/2021
Accepted: 10/01/2022

Full Paper (vol.871 paper# 136)


c:\work\Jor\vol871_137 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1806-1812

Implementation of the Policy of Enhanced Recovery after Surgery in
Gynecologic Oncology
Amr Ahmed AbdElrhman, Ashraf Mohamed Nasr Refaie,
Ibrahim Mohamed Ibrahim Abdou*, and Mustafa Salah Omara
Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Ibrahim Mohamed Ibrahim Abdou, Mobile: (+20)01019828389, E-mail: ibrahimhema958@gmail.com

ABSTRACT
Background:
Enhanced Recovery after Surgery (ERAS) is now firmly established as a global surgical quality
improvement initiative that results in both clinical improvements and cost benefits to the healthcare system.
Objective: The aim of this work was to evaluate the impact of the ERAS on outcome of gynecologic oncology surgery.
Patients and Methods: A case study was carried out in Zagazig University Hospital during the period from August
2021 and February 2022. The study included 30 patients presenting for gynecological oncologic surgeries. They were
classified into two groups: Group I (the ERAS group) included 15 patient who were exposed to the mean of enhanced
recovery protocols. Group II (the conventional group) included 15 patients who were treated with the standard care
known in the literature. All patients were subjected to general clinical examination, laboratory investigations and
radiological studies.
Results:
The catheterization period, movement time, audible intestinal sound, oral intake, time until discharge, and need
for opiates were all significantly shorter in the ERAS group. While the mean of the universal pain score was significantly
higher in the conventional group, 3.5 compared to 1.9 in the ERAS group.
Conclusions:
Implementation of the policy of enhanced recovery after surgery (ERAS) in gynecologic oncology was
associated with an overall improvement in postoperative outcomes.
Keywords: ERAS, Gynecologic oncology, Surgery, Enhanced recovery after surgery.

INTRODUCTION

Enhanced Recovery after Surgery (ERAS) is a
sparing analgesia, removal of the urinary catheter
perioperative quality-improvement program that uses
within 24 hours and early active mobilization (4).
evidence-based interventions within the preoperative,
ERAS pathways improve the length of hospital
intraoperative, and postoperative phases of surgical
stay, pain control, and hospital cost in patients
care. ERAS pathways have been implemented in
undergoing high-risk gynecologic oncology open
several surgical specialties and have proven beneficial
surgeries. The benefits of these pathways have been
for both the patient and health care systems (1).
demonstrated in several recent studies from a small
Surgical stress forces the body into a highly
number of specialized centers in both gynecologic and
catabolic state with increased cardiac demands,
gynecologic oncology patients (5).
relative tissue hypoxia, increased insulin resistance,
The aim of this study was to evaluate the impact
impaired coagulation profile, and altered pulmonary
of the ERAS on outcome of gynecologic oncology
and gastrointestinal functions. The body's response to
surgery.
surgical stress results in organ dysfunction, increased

morbidity, and, ultimately, delayed convalescence.
PATIENTS AND METHODS
The ERAS programs aim to maintain normal
The number of patients included in the study was
physiology perioperatively and optimize patient
30 patients presenting for gynecological oncologic
outcomes by introducing interventions that have been
surgeries. They were classified into 2 groups: Group I
proven to either decrease surgical stress or help the
(the ERAS group) included 15 patient who were
body mitigate the negative consequences associated
exposed to the mean of enhanced recovery protocols,
with it (2).
and group II (the conventional group) included 15
Patients with cancer undergoing open surgical
patients who were treated with the standard care known
procedures are at greatest risk for postoperative
in the literature.
complications with morbidity rates for laparotomy in

the range of 20-30% (3). ERAS Pre-operative
Inclusion criteria: Patients who were referred for
recommendations include permission of oral intake of
elective gynecological oncologic surgeries. Patients
clear fluids up to 2 hours before surgery, use of
who have complete mental clarity. Age >18 years.
carbohydrate loading and avoidance of mechanical

bowel preparation. Intra-operative recommendations
Exclusion criteria:
include deep vein thrombosis and antimicrobial
Patients with bowel resection. Patients with
prophylaxis, maintenance of euvolemia and
intestinal injuries. Patients with advanced gynecological
recommend the use of regional anesthesia. Post-
cancer. Patients receiving treatment for chronic pain.
operative recommendations include initiation of
Patients with coagulation disorders or organ failure or
regular diet within 24 hours, avoidance of peritoneal
severe dysfunction (heart, renal, pulmonary, hepatic).
drainage and nasogastric tubes, multimodal opioid-
Patients with previous abdominal oncology surgery.
1806
Received: 10/11/2021
Accepted: 08/01/2022

Full Paper (vol.871 paper# 137)


c:\work\Jor\vol871_138 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1813-1817

Comparative Study Between Closed Versus Open Internal
Sphincterotomy for Management of Chronic Anal Fissure
Abdelhafez Seleem*, Mohammed Abbas
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
*Corresponding author: Abdelhafez Seleem, Mobile: (+20) 01118522021, E-Mail: abdelhafzsalim83@gmail.com

ABSTRACT
Background:
Chronic anal fissure is one of the most common annoying anal disorders. Many medical treatments are
used to help the healing of the fissure but the recurrence rate is so high after the stoppage of medicine, so the surgical
treatment by lateral internal sphincterotomy is still the best way of management.
Objective: In our study, we compared two different techniques of lateral sphincterotomy either open or closed
techniques.
Patients and methods: This is a prospective study done on 150 patients with chronic anal fissures managed by lateral
sphincterotomy between June 2017 till May 2019. The patients were divided into two groups (group A) 70 patients
managed by open internal sphincterotomy and (group B) 80 patients managed by closed lateral sphincterotomy.
Results: In the present study, the main complaint of most patients was anal pain during defecation. The most common
site of the fissure was posterior at midline with Sentinel pile. Delayed postoperative healing was found in 4.28% of
group A. The mean pain score and duration of hospital stay were lower in group B. The risk of post-operative
complications such as anal fistula and bleeding was high in group A than in group B.
Conclusion: Closed lateral internal sphincterotomy is a better choice for the management of chronic anal fissure as it
was less in postoperative complications and early recovery.
Keywords: Lateral sphincterotomy, Anal pain, Anal bleeding.

INTRODUCTION

Anal fissure is a common benign disease that
management of chronic anal fissures after the failure of
usually causes irritability and variable degrees of anal
medical treatment. Surgery for a CAF aims to decrease
pain during defecation. It could be defined as a
the tone of the internal sphincter and hence increase the
longitudinal tear of the anal canal usually at the
blood flow with subsequent tissue healing. Surgical
mucocutaneous junction extending from the anal verge
options include manual anal dilatation and lateral or
towards the dentate line proximally. Most anal fissures
posterior internal sphincterotomy. Manual anal
are superficial involving the superficial layer of the
dilatation obsolete method by many surgeons as it has
mucosa of the anal canal however some fissures are
been associated with anal incontinence (5).
deep involving the whole mucosa. Fissures occur most
Sphincterolysis is a new method of treatment that
often in the posterior midline and are less common
is done by blunt division of the internal sphincter fibers
anteriorly seems to be a result of poor blood supply to
also been described (6). The golden standard for the
the posterior commissural region (1).
treatment of CAFs is lateral sphincterotomy. Various
Some anal fissures occur laterally (not in the
studies have shown the superiority of lateral
midline) and this is usually considered an indicator of
sphincterotomy over posterior sphincterotomy (7).
underlying diseases such as Crohn's disease, viral
Lateral sphincterotomy could be done by open or
illness, or malignancy (2). The main cause that prevents
closed methods. So this study aimed to compare both
anal fissures from healing is irritation of the anal
methods as regards safety, efficacy in fissure healing,
sphincter which leads to a decrease in the blood supply
and postoperative complications.
and displaced fissure edges, also sphincteric spasm

leads to more constipation, and constipation leads to
PATIENTS AND METHODS
more injury. Anal fissure for more than 6 weeks usually
This was a prospective study done over 150
turns into a chronic fissure. A chronic anal fissure
patients with chronic anal fissures managed by lateral
(CAF) is accompanied by a sentinel skin tag and
sphincterotomy between June 2017 till May 2019 at
hypertrophied anal papilla on examination (3).
General Surgery Department, Bab Al-Sharia Hospital,
In most cases of acute anal fissures and some
Al-Azhar University. The patients were divided into
cases of chronic fissures, medical treatment is effective
two groups, group A contained seventy patients
and leads to fissure healing in about two weeks of
managed by open lateral sphincterotomy, and group B
medication. Conservative medical treatment uses
consisted of eighty patients which were managed by
muscle relaxants, topical drugs, and sometimes drugs
closed lateral sphincterotomy.
given by mouth. These drugs include calcium channel
All the included patients had midline chronic anal
blockers,
nitrates
(glyceryl-trinitrate),
alpha-
fissures with recurrent anal pain and bleeding during
adrenoreceptor antagonists, and beta-adrenoreceptor
defecation.
agonists (4).

Surgical treatment is the best choice for the

1813
Received: 10/11/2021
Accepted: 08/01/2022

Full Paper (vol.871 paper# 138)


c:\work\Jor\vol871_139 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1818-1824

The Impact of Thyroid Dysfunction in ICU Patients upon the Weaning Difficulty from
Mechanical Ventilation. A Case-Control Observational Study
Salah Abd Alazeem Argoon1, Abd Elraheem Ahmad Abd Elraheem1,
Alaa Omar Ahmed2, Emad Zarief Kamel3, Soheir M. kassem*2
Departments of 1Internal Medicine-Endocrine Unit, 2Internal Medicine-Critical Care Unit and 3Anesthesia and
Intensive Care, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
*Corresponding author: Soheir M. Kassem, Mobile (020)1069347314; E- mail: Soheir@aun.edu.eg

ABSTRACT
Background
: Non-thyroidal illness syndrome has been associated with diverse manifestations of critical illness in the
ICU; it correlates significantly with severity of illness in clinically unstable patients.
Objectives: The aim of the current work was to clarify the impact of thyroid dysfunction on weaning difficulty from
mechanical ventilator in critically ill patients.
Patients and Methods: This case ­control observational study included a total of 50 patients received invasive
mechanical ventilation (MV) with age > 18 years, attending at Internal Medicine & Critical Care and Anesthesia ICU
departments, Faculty of Medicine, Assiut University Hospitals. This study was conducted between October 2020 to
September 2021. Full history taking and all routine laboratory investigations including complete thyroid panel were
done at the time of mechanical ventilation.
Results:
Out of the studied patients; 33 (66%) patients were males. The most common causes of ICU admission were
cardiogenic shock (30%) and toxicity (30%); the mean simplified acute physiology score (SAPS-II) among enrolled
patients was 65.18 ± 17.92. Based on thyroid function, it was found that majority (70%) of patients have normal thyroid
status while 15 (30%) has euthyroid sick syndrome (ESS) and all of them have low T3. Patients with ESS had
significantly higher body mass index and SAPS-II. (p=0.001;0.06 respectively) Also, diaphragmatic dysfunction was
significantly higher among patients with ESS (P=0.02) who showed longer duration of mechanical ventilation (p=0.03)
and hospital stay(p=0.02).
Conclusion: It could be concluded that critically ill patients who are admitted to intensive care units are vulnerable to
develop euthyroid sick syndrome. ESS can increase the difficulty of weaning from mechanical ventilation and affect the
outcome.
Keywords: Thyroid function test, Euthyroid Sick Syndrome, Critical Care.

INTRODUCTION

PATIENTS AND METHODS
Critically ill patients in the intensive care unit
This case ­control observational study included a
(ICU) exhibit profound inflammation, overwhelming
total of 50 patients received invasive mechanical
fluid overload with renal failure, and ultimately,
ventilation (MV) with age > 18 years, attending at
significant malnutrition with sarcopenia (1).
Internal Medicine & Critical Care and Anesthesia ICU
The initial response to acute stress is to
departments, Faculty of Medicine, Assiut University
decrease serum triiodothyronine levels (T3) to
Hospitals. This study was conducted between October
counteract biochemical catabolism. However, in those
2020 to September 2021.
with prolonged critical illness, the normal physiologic

response of the hypothalamus-pituitary-thyroid (HPT)
Ethical Consideration:
axis is altered, leading to low levels of both T3 and
This study was ethically approved by the
thyrotropin (TSH) (2).
Hospital's Ethics Committee (ID-1000450) and
Non-thyroidal illness syndrome has been
according to the principles of the Declaration of
associated with various manifestations of critical illness
Helsinki. The purpose of the study was explained to
in the ICU. Hypothyroidism can adversely affect
all participants and written informed consent was
respiratory function by blunting the body's response to
obtained.
The
study
was
registered
on
hypercapnia and hypoxia, impairing
skeletal
clinicaltrials.gov with identification number of
muscle/diaphragm function, and contributing to the
NCT0343145.
development of pleural effusions and obstructive sleep

apnea (OSA) (3). It was previously reported that thyroid
Exclusion criteria included patient with known
dysfunction particularly hypothyroidism in critically ill
previous intrinsic thyroid hypothalamic pituitary axis
patients is a considerable cause of failure to wean in
disease, usage of iodine contrast agents in the past 8
patients receiving mechanical ventilation (4).
weeks, pregnancy, or history of pregnancy within the
This study was aimed to clarify impact of
previous 6 months, any hormonal therapy except insulin
thyroid dysfunction on difficulty of weaning from
use or taking drugs causing hypothyroidism like oral
mechanical ventilator in critically ill patients.
amiodarone, palpable thyroid nodule and or goiter, and

patient's refusal.


1818
Received: 11/11/2021
Accepted: 09/01/2022

Full Paper (vol.871 paper# 139)


INTRODUCTION The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1825-1834

The Expression Level of Long Non-Coding RNA PVT1 as a Diagnostic Marker for
Advanced Stages in Patients with Nonalcoholic Fatty Liver Disease
Nearmeen M. Rashad1, Usama A. Khalil1, Sherweet M. Ahmed2,
Marwa H. Hussien3, May M. Sami4, Fady M. Wadea*1
Departments of 1Internal Medicine, 2Tropical Medicine, 3Medical Biochemistry and
4Clinical Pathology, Faculty of Medicine, Zagazig University Zagazig, Egypt
*Corresponding author: Fady M. Wadea, Mobile: (+20)1224562351, E-mail: fadymaher41@yahoo.com & f.maher@zu.edu.eg

ABSTRACT
Background
Non-alcoholic fatty liver disease (NAFLD) incorporates a wide spectrum of stages ranging from simple
steatosis to non-alcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma (HCC). The connection of
Long noncoding RNAs with NAFLD, as well as other metabolic syndromes remains relatively unexplored.
Objective: We aimed to investigate the circulatory level of lncRNA-PVT1 in patients with Non-alcoholic fatty liver
disease complicated with steatohepatitis, cirrhosis, and HCC. Also, to explore their association with different clinical
and laboratory variables.
Patients and methods A case-control study enrolled 100 patients with NAFLD and 100 healthy volunteers. NAFLD
patients included 53 patients with simple steatosis, 22 steatohepatitis patients, 17 cirrhotic patients, and 8 HCC patients
confirmed with histopathological examination. The expression of lncRNA PVT1 was evaluated by RT PCR.
Results The relative expression levels of lncRNA-PVT1 were significantly higher in the NAFLD group (2.29±0.37)
compared to control (0.84±0.52), P0.001 with a significant difference between the subgroups; (4.2 ± 0.1, 2.9 ± 0.16,
1.93 ± 0.14, 1.25 ± 0.18 in HCC, cirrhosis, NASH, and in simple steatosis respectively; P0.001). There were significant
direct correlations with liver function tests, lipid profile, and alpha-fetoprotein in the HCC subgroup. Alpha-fetoprotein
and AST were the main predictors of lncRNA-PVT1. Cut-off values 0.94, 1.2, 1.8, 2.98 were able to discriminate simple
steatosis, steatohepatitis, cirrhosis, and HCC with AUC 0.78, 0.64, 0.77, 0.81 respectively.
Conclusions Circulating lncRNA-PVT1 could be a useful diagnostic biomarker for discriminating patients with
advanced NAFLD stages.
Keywords: Carcinoma, Liver Cirrhosis, NASH, NAFLD, PVT1.

INTRODUCTION

death; however, the molecular pathways driving fibrosis
NAFLD incorporates various stages ranging from
and cirrhosis in NAFLD patients are unknown. Long
simple steatosis to NASH, cirrhosis, and HCC (1). The
non-coding RNAs (lncRNAs) are emerging as
clinical history of NAFLD is usually benign and
important contributors to biological processes that drive
nonprogressive. On the other hand, NASH is a
NAFLD fibrosis onset and progression (7).
potentially fatal illness; up to 25% of patients may
While many studies have been done on the
develop cirrhosis and develop consequences such as
pathophysiology of HCC development from hepatic
portal hypertension, liver failure, and hepatocellular
fibrosis, their regulating molecular mechanisms are
carcinoma (HCC) (2). LncRNAs are non-coding
only poorly known. The underlying pathogenic
ribonucleic acids (RNAs) with a length of more than
processes involving lncRNAs that lead to HCC from
200 base pairs. Previously, lncRNAs were thought to be
chronic liver disorders and cirrhosis are yet unknown (8).
worthless sections of the genome (3).
PVT1 is a LncRNA located in the 8q24.21 region
The significance of abnormal lncRNA expression
of the human chromosome. Recently, PVT1 was found
levels in many disorders has steadily caught people's
to be upregulated in diabetic cataracts and inhibits
attention. While the significance of lncRNAs in cancer
podocyte injury and apoptosis in diabetic nephropathy
has been studied extensively in recent years, their
through FOXA1 (9). In addition, PVT1 promotes the
relevance in the development of obesity, type 2 diabetes
synthesis and inhibits the oxidation of fatty acids in
(T2D), and its comorbidities, such as nonalcoholic fatty
obesity (10).
liver disease (NAFLD), has only just been discovered
PVT1's possible role in cancer development has
(4).
been widely investigated and reported in endometrial
lncRNA has been linked to elevated levels of
cancer (11), bladder cancer (12), and ovarian cancer (13).
steatosis, oxidative stress, inflammation, insulin
Like other cancers, HCC is distinguished by genetic and
resistance, and other pathogenic processes. For
epigenetic dysregulations. Among these alterations,
instance, 381 lncRNAs have been verified to be highly
lncRNAs may play crucial roles in the initiation and
elevated in NAFLD(5), while lncRNA MEG3 has been
progression of HCC
identified as being overexpressed and involved in
Therefore, we aimed to investigate the circulatory
insulin resistance in NAFLD and hepatocyte endothelial
level of lncRNAs PVT1 in patients with NAFLD-
cell aging (6).
related complications including patients with
The development of fibrosis in NASH patients is
steatohepatitis, cirrhosis, and HCC, and to explore their
linked to an increased risk of liver-related morbidity and
1825
Received: 10/11/2021
Accepted: 08/01/2022

Full Paper (vol.871 paper# 140)


c:\work\Jor\vol871_141 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1835-1842

Posterior Inferior Cerebellar Artery Infarction, Surgical Intervention and Outcome
Abdin K. Kasim*1, Bahaa Ghareeb Hassanin1, Mohamed Abdala Abbas2, Karam Kenawy1
1Department of Neurosurgery, Faculty of Medicine, Sohag University, Egypt
2Department of Neurology, Faculty of Medicine, Luxor University, Egypt
*Corresponding author: Abdin K. Kasim, Mobile: (+20)102019 6831, E-Mail: abdin_mail@yahoo.com

ABSTRACT
Background:
Posterior inferior cerebellar artery (PICA) infarcts are the most common of the cerebellar strokes and
generally produce the largest infarcts with major complications including obstructive hydrocephalus and downward
herniation of the cerebellar tonsils. Surgical intervention is widely accepted treatment choice but little data is available
about the procedure and outcome.
Objective: The aim of the current work was to evaluate the role of suboccipital decompression craniectomy, atlas
laminectomy, cerebellar tonsillectomy and duraplasty, in the management of isolated PICA territory infarction.
Patients and Methods: 12 patients, 7 males and 5 females, with PICA infarcts, were subjected to surgical intervention
with pre-operative and 1-month post-operative clinical and radiological assessment using the Glasgow Coma Scale
(GCS), the National Institutes of Health Stroke Scale (NIHSS), Barthel ADL index and Rankin scale in conjunction
with CT and / or MRI brain.
Results: There are significant improvements in post-operative as compared to pre-operative assessment in different
scales used in the study including the GCS, NIHSS, Barthel ADL index and Rankin Scale. Radiological evaluation
showed obvious decompression of the brainstem and fourth ventricle.
Conclusions: It could be concluded that suboccipital craniectomy, atlas laminectomy and duraplasty are very effective
treatment for patients with large PICA infarctions and can reverse effects of brainstem compression and hydrocephalus
in most cases.
Keywords: PICA infarction, Suboccipital craniectomy, Tonsillar herniation

INTRODUCTION

hydrocephalus. As conservative treatment is not
Posterior inferior cerebellar artery (PICA)
effective with extensive mass effect, and often fails;
territory infarcts are the most common of the cerebellar
surgery is usually an accepted choice. Meanwhile, the
strokes. The etiology of PICA infarcts includes
best time and the factors indicating surgery remain
intracranial vertebral atherosclerosis and embolism
unclear. Furthermore, it has not been sufficiently proved
from a cardiac or proximal arterial source. Clinical
in prospective, multicenter, randomized controlled
features commonly include sudden vertigo, gait ataxia,
trials, which of the surgical procedures are more
and suboccipital headache. Nausea and vomiting are
effective (2).
common. In large PICA territory infarcts, brainstem and
Conservative treatment includes airway
fourth ventricle compression causing obstructive
protection, adequate ventilation, monitoring of
hydrocephalus and tonsillar herniation may threaten
circulation and prevention of vascular thrombosis and
life. These patients may have decreased level of
embolism. The conscious level must be closely
consciousness, reduced corneal reflex, ipsilateral
monitored. Immediate brain imaging should be done if
facial palsy, and Babinski sign, denoting progression of
clinical deterioration or brainstem signs occurred (11-13).
mass effect. If conservative measures fail to control
Surgery includes ventricular drainage and
these manifestations, urgent surgery can be life-saving
decompressive suboccipital craniectomy. In contrast to
(1).
the debate regarding surgical treatment of massive
The general treatment of ischemic strokes is
cerebral infarction, surgical intervention is a globally
similar in cerebral and cerebellar infarctions. Treatment
accepted choice in cerebellar infarcts causing mass
of associated edema includes anti-edema medications,
effect and is advised strongly in current stroke
control of intracranial pressure, external ventricular
guidelines (12, 13). Ventricular Drainage is most
drains, and decompressive surgery, including resection
commonly done through an extraventricular drain
of dead tissue in some cases. Patients developing
(EVD) in one lateral ventricle (14, 15). Suboccipital
hydrocephalus or brainstem compression are candidates
Decompressive Craniectomy (SDC) is done to widen
for more extensive surgical treatment, if the conditions
the posterior fossa to accommodate the swollen tissue
are considered reversible (2).
and avoid fatal brainstem and fourth ventricle
The incidence of cases of cerebellar infarction
compression. Various surgical strategies include
complicated with massive edema range from 20% to
unilateral or bilateral craniectomy, opening of the
50% (3-10). Large infarctions of the cerebellum
foramen magnum, resection of the atlas lamina, and
developing space-occupying edema are often missed
duraplasty. Removal of necrotic cerebellum may be
until complications of mass effect cause clinical
used to create more space in the posterior fossa and
deterioration. The most dangerous complications are
lessen the developing cytotoxic edema (16-18).
compression
of
brainstem
and
secondary
1835
Received: 10/11/2021
Accepted: 08/01/2022

Full Paper (vol.871 paper# 141)


c:\work\Jor\vol871_142 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1843-1847

Should Computed Tomography be Performed in All Chest Trauma Patients
Ahmad AbdelAleem ElDerie*, Hatem Abdelmoneim Elsorogy, Mohammed AbdelFattah Sanad,
Mohammed Elshabrawy Saleh, Gehad Ibrahim Awad
Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
*Corresponding author: Ahmad AbdelAleem ElDerie, Mobile: (+2)01026626923,
Email: ahmadelderie@mans.edu.eg, ORCID: 0000-0001-6111-0439


ABSTRACT
Background:
Occult hemothorax is detected by Computed Tomography (CT) chest but missed initially by chest X-ray.
Supine position, presence of less than 300 ml of blood, and intrapleural adhesions are all causes of missed hemothorax
on initial chest x-ray.
Patients and methods: In this retrospective study, we revised 864 patients who had blunt chest trauma at Mansoura
Emergency Center from January 2016 to January 2020 and for them chest X-ray and CT chest were done. Patients having
hemothorax (320) were divided into occult and non-occult. The outcomes included patients' demographic data, number
of patients in each group, associated injuries, and lines of management.
Results: Chest X-ray helped diagnosis of 143 cases (44.68%) (Non-occult hemothorax). There were significant
statistical differences between the two groups as regard chest tube drainage (686+456 ml Vs 871+603 ml), hospital stays
(3-5 Vs 5-6 days), conservatively managed cases (33 (18.64%) Vs 3 (2,1%)), and surgical exploration for significant
bleeding (2 (1.13%) Vs 18 (12.58%)). On the other hand, there was no significant statistical deference as regard age
group, patient's gender, mortality, chest tube insertion, and exploration for associated injuries.
Conclusion: CT chest is the gold standard imaging tool for victims of chest trauma as it helps patient's evaluation and
diagnose occult cases of hemothorax who were missed in initial chest X-ray.
Keywords: Chest trauma, Computed tomography, Occult hemothorax.

INTRODUCTION

patients, the distribution of blood will be along the whole
Hemothorax is a collection of blood in the pleural
posterior surface of the pleural space in the affected side
cavity, which is usually the result of blunt trauma. Chest
rather than the costodiaphragmatic recess, this results in
X-ray has historically been the imaging tool once patient
less apparent hemothorax and occasionally missed
arrives to the hospital (1).
completely (4). Chest X-ray has its own limitations.
It has been reported that chest traumas are

considered one of the most significant reasons of
Additionally, it is important to recognize that
mortality among the persons in the 4th decade of life. The
blunting the costophrenic angle requires 300­500 ml of
use of different modalities of imaging such as plain chest
blood. Up to 1000 ml can be missed in the supine position.
X-ray (CXR) computed tomography (CT) scan, and
intrapleural adhesions can alter the collection of fluid that
ultrasonography (US) is essential. In addition, it is
will cause any fluid or blood to occupy spaces other than
essential to declare that CT scan is the best modality with
the costophrenic angle (5).
highly significant diagnostic value for soft tissue and
In the evaluation of blunt trauma in adult, the CT
occult injuries. On the other hand, limited CT scan
utilization has increased significantly in the last twenty
availability in the medical centers, limitations in the
years, and several centers of trauma perform pan-scan
transfer of patients to radiology department and exposure
(head-to-pelvis CT) routinely for victims of major trauma,
to radiation are the chief drawbacks (2).
however this protocol is associated with clear and
Chest CT can diagnose more injuries than CXR,
significant risk of cancer. American College of Surgeons
the so-called occult injuries. Of these occult injuries is
in 2014 mentioned avoiding routine whole body trauma
occult hemothorax, which is defined as that one detected
CT as one of its five choosing Wisely recommendations
by CT chest but missed initially by chest X-ray (3).
(6).

In this study we will discuss our experience with
Upright CXR helps diagnosis by finding blunting
occult hemothorax, its percentage, management and our
of the costodiaphragmatic recess, which is the commonest
future view for the wider use of CT chest for all chest
sign of pleural effusions and hemothorax. In the supine
trauma patients and updating lines of management.
position, which is the case in most severely injured

1843
Received: 11/11/2021
Accepted: 9/01/2022

Full Paper (vol.871 paper# 142)


ABSTRACT The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1848-1855

Incremental versus Conventional Hemodialysis: Which is Better for
Prevalent Hemodialysis Patients?
Ahmed Mohamed Tawfik Ahmed*1, Samah Ahmed Elsayed Ahmed2,
Haitham Ezzat Abd-Elaziz1, Gamal El-Sayed Mady1
1Department of Internal Medicine and Nephrology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2Department of Nephrology, Dar Alshefa Hospital, Ministry of Health, Cairo, Egypt
*Corresponding author: Ahmed Mohamed Tawfik Ahmed, Mobile: (+20)01003669416,
Email: ahmedtawfik84@yahoo.com

ABSTRACT
Background:
Incremental hemodialysis is based on the simple idea of adjusting its dose according to the metrics of
residual kidney function. Indeed, most patients initiating dialysis have some degree of residual kidney function.
Incremental dialysis may preserve residual renal function and improve survival in comparison with full-dose dialysis.
Objective: To compare the intervention arm (incremental hemodialysis) with the control arm (standard 3 hemodialysis
sessions/week).
Patients and Methods: A prospective cohort study was conducted, recruiting 50 patients from multiple hemodialysis
units, over six months. The prevalent patients were divided randomly into equal two treated groups. The outcomes
compared adequacy of hemodialysis and detection of hazards as well as complications, including vascular access failure
and associated interventions, cardiovascular events and hospital admissions, and mortality in both groups.
Results: Regarding the occurrence of cardiovascular events, chest pain, there were no significant differences between
both groups. Arrhythmia was not recorded in the incremental group, while in the conventional group it was recorded in
2 patients, and there was no significant difference between both groups. Regarding the need for hospital admission,
there was no significant difference between both groups. As regards the occurrence of vascular access failure, it was
recorded in 2 patients in the incremental group, compared to 4 patients in the conventional group, with no significant
difference between both groups. Adequacy of hemodialysis (in the form of urea reduction ratio and KT/V) was better
in the incremental group.
Conclusion: Incremental hemodialysis was superior to the conventional one regarding the adequacy of dialysis, with
monthly follow-up till 6 months. There were no significant differences between both groups regarding cardiovascular
events, vascular access failure, and hospitalization.
Keywords:
Incremental hemodialysis, Conventional hemodialysis, Cairo.

INTRODUCTION

episodes of hypotension appear to have deleterious
The majority of hemodialysis (HD) patients
effects on both cardiac and cerebral function (6).
initiate dialysis with a relatively intense thrice-weekly
The other organ susceptible to hypotension and
HD sessions /week regimen of 3­4 hours per session,
often overlooked is the kidney; repeated episodes of
with little individualization of prescription based on
intradialytic hypotension are implicated in the loss of
residual kidney function (RKF) or other patient factors
RKF, which in turn has a negative impact on UOP and
(1). Incredibly, the 3 HD sessions/week schedule has
greater ultrafiltration requirements, leading to a vicious
been widely accepted worldwide without ever
cycle with progressive renal injury (7). Aside from end-
undergoing any randomized controlled trial (RCT) to
organ effects, the Dialysis Outcomes and Practice
examine whether less frequent HD treatments would be
Patterns Study (DOPPS) has highlighted the wide
inadequate or harmful (2). It is plausible that the routine
variation in time to recovery. Ten percent of all patients
practice of fixed-dose 3 HD sessions/ week in patients
took longer than 12 hours to recover from an HD
with substantial RKF may be harmful, contributing to
session, with an increased recovery time associated with
an accelerated loss of RKF (3). The Kidney Diseases
age and comorbidity (8).
Outcomes Quality Initiative (KDOQI) suggests that
Incremental HD has a lower burden of treatment.
minimum targets of the adequacy of the dialysis dose
There appear to be no adverse clinical effects during the
(Kt/V) may be reduced in those with residual renal urea
first years of incremental HD and when there is significant
clearance (Kru) <2mL/min/1.73 m2 (2).
RKF (9). The advantages of incremental HD might be
The European Best Practice Guidelines (EBPG)
particularly important for elderly patients with short life
recommend measuring RKF in HD patients using the
expectancy, where transplantation is not an option (10).
mean of urea and creatinine clearances. The
RKF may confer many benefits to patients with
commencement of HD is associated with increased
end-stage renal disease (ESRD) on maintenance HD
levels of mortality, particularly in the elderly (4). This
including associations with better patient survival and
early period is associated with frequent episodes of
health-related quality of life (1). RKF in dialysis patients
hypotension even in units undertaking longer hours and
plays an important role in fluid and salt removal,
using slower ultrafiltration rates (5). Intradialytic
effective phosphorus excretion, middle molecule
clearance, and endogenous vitamin D and
1848
Received: 12/11/2021
Accepted: 10/1/2022

Full Paper (vol.871 paper# 143)


c:\work\Jor\vol871_144 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1856-1863

Genu Varum in Children; Various Treatment Modalities for
Bowleg's Correction: Review article
Abdul-Hameed A. El-Hak*, Ehab M. Shehata, Amr I. Zanfaly, El-Sayed E. Soudy
Orthopedic Surgery Department, Faculty of Medicine, Zagazig University, Egypt
* Corresponding author: Abdul-Hameed A. El-Hak, E-mail: drmido450@gmail.com

ABSTRACT
Backgound:
Genu varum (Bowlegs) is among the most prevalent lower-limb misalignments correlated with pain and
impairment, and it continues to be a source of concern for parents. Corrective osteotomy is generally performed on
children with pathologic genu varum (GV) deformities to rectify the deformity. The treatment's purpose is to get the
knee back to its normal mechanical axis. Non-surgical therapy is recommended in children under the age of three since
it is difficult to distinguish between physiological bowing and early tibia vara. Various osteotomy techniques have been
used, including closing wedge lateral tibial osteotomy, dome osteotomy, and opening wedge medial osteotomy.
Objective: The current review aimed to figure out a better, less expensive, and more pleasant way to keep the open
wedge of valgus tibial osteotomy for GV malformation without adding expense, an unsightly scar or requiring a re-
operation for implant removal.
Methods: PubMed, Google scholar and Science direct were searched using the following keywords: Genu varum,
osteotomy, open and closed wedge osteotomy and autologous fibular strut. The authors also screened references from
the relevant literature, including all the identified studies and reviews, only the most recent or complete study was
included.
Conclusion: Despite technological advances and new surgical operation. The treatment of GV deformity in kids is still
a serious concern for parents. Various osteotomy techniques have been used, including closing wedge lateral tibial
osteotomy, dome osteotomy, and opening wedge medial osteotomy. Autologous fibular strut graft is an excellent, if not
superior, graft for open wedge medial tibial osteotomy because of its strength, durability in preserving correction, cost-
effectiveness, ease of graft harvest, and restricted incision and pain sites.
Keywords: Genu varum, Osteotomy, Open and closed wedge osteotomy, Autologous fibular strut.

INTRODUCTION

Genu varum (GV) is a Latin term referr to
primary objective of therapy is to reestablish the
Bowlegs. It's one of the most prevalent lower-limb
mechanical axis of the limb [5].
misalignments linked to pain and dysfunction.
The most popular GV correction procedures are
However, minimal attention has been paid to limb
open and closed high tibial osteotomies. Numerous
position and muscle actions while doing tasks in
approaches have been utilized in children to preserve
patients with GV [1]. This condition can appear at any
the open wedge of the medial tibial osteotomy. Iliac
age, from infancy to maturity, and it can be caused by a
crest grafts, orthopaedic plates and screws, and artificial
variety of factors. As the condition worsens, the patient
bone replacements are a few examples [6].
may develop lateral knee thrust and a waddling gait.
The downsides of an iliac crest transplant include
There may be in-toeing as well as subsequent
the need for surgery at a remote location, pain, an
consequences on the hip and ankle [2].
unsightly scar, and infection. On the other side, bone
Its pathogenesis is both physiologic and
replacements are costly and add to the expense of what
pathologic. In physiologic GV, the condition is self-
appears to be a straightforward treatment, as well as an
limiting and normally requires just clinical follow-up.
additional burden in a poor country. Utilizing plates and
However, in pathological situations, the disease often
screws will necessitate a second operation to remove the
progresses over time, predisposing to mechanical lower
implant [7].
limb difficulties as well as joint disorders [3]. The
The current review aimed to figure out a better,
physiologic form is still the most frequent globally, with
less expensive, and more pleasant way to keep the open
nutritional rickets coming in second and other causes
wedge of valgus tibial osteotomy for GV malformation
being uncommon or even exceedingly rare. Systemic
without adding expense, an unsightly scar or requiring
disorders like achondroplasia, vitamin D-resistant
a re-operation for implant removal.
rickets, renal osteodystrophy, and osteogenesis

imperfecta may also be associated with GV [4].
Genu varum (GV):
Intervention indications are not usually properly
GV (tibia vara) is a varus malformation identified
defined. Focal fibrocartilaginous dysplasia is an
by outward knee bending that implies the lower leg is
uncommon condition that typically does not require
bent inside with relation to the thigh's axis, giving the
treatment. Several surgical techniques for pathologic
limb the image of an archer's bow (Figure 1). The femur
GV have been documented, including proximal tibial
and tibia are typically angled medially [8].
osteotomy, hemi epiphysiodesis, asymmetric physeal
distraction, and medial tibial plateau elevation. The
1856
Received: 14/11/2021
Accepted: 12/01/2022

Full Paper (vol.871 paper# 144)


c:\work\Jor\vol871_145 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1864-1871

Knowledge, Attitude and Practice about Foot Care among Adult Diabetic
Patients at Prince Abdul-Aziz bin Majid Diabetes Center in Al Madinah
City, Saudi Arabia
Mohammed Alean Albalawi*, Wafa Allauddin Sheikh
Family Medicine Academy, Al Madinah City, Saudi Arabia
Corresponding author: Mohammed Alean Albalawi,,Email: mohammedalean@hotmail.com, Mobile: 0552475825


ABSTRACT
Background:
Diabetic foot refers to various degrees of neurological and vascular abnormalities affecting the foot and
the tendency towards deep foot tissue destruction, ulceration and infection.
Objective: This study is conducted to assess the level of knowledge and practice about foot care among adult diabetic
patients attending Prince Abdul-Aziz ben Majid diabetic center in Al Madinah City, Saudi Arabia 2020.
Patients and Methods:
A descriptive cross-sectional study. A valid structured questionnaire was used to collect the
data of diabetic adult patients attending Diabetics Center Prince Abdul-Aziz bin Majid in Al Madinah city. The statistical
analysis was done by using the statistical package for the social sciences (SPSS).
Results: 363 participants completed the questionnaire, 57% of them were males and 43% were females. 90.6% of
participants scored good knowledge level while 9.4% scored poor knowledge score. 77.1% of participants scored good
attitude level while 22.9% scored poor attitude score. 93.7% of participants scored good practice level while 6.3% scored
poor practice score. Overall, good knowledge score was significantly associated with occupation of participant (P=
0.002), duration of diabetes (P= 0.024), and number of visits to the clinic (P= 0.020). There was a significant association
between good attitude score with educational level of participants (P= 0.001) but not with other sociodemographic
characteristics. A significant association was also found between good practice score with educational level of
participants (P= 0.005).
Conclusion: In conclusion, diabetic patients participated in our study showed good scores for knowledge, attitude and
practice when compared to previous literature in Saudi Arabia and worldwide.
Key words: Attitude, Diabetic patients, Foot Care, Knowledge, Practice.

INTRODUCTION

of DM in Saudi Arabia is 23.7%, where male to female
World Health Organization described diabetes
prevalence were 26.2% and 21.5% respectively [3].
mellitus (DM) as metabolic disorder of multiple
Previous studies show that, the lifetime risk of
etiology [1]. The world prevalence of diabetes among
developing a diabetic foot ulcer among diabetic patients
adults is 6.4%, in 2010, and will increase to 7.7%
is approximately 15% compared to those who are not
between 2010 and 2030. [2].
diabetic [5]
Diabetic foot refers to various degrees of
A descriptive cross-sectional study by
neurological and vascular abnormalities affecting the
Alshammari et al. determining the knowledge, attitude,
foot and the tendency towards deep foot tissue
and practice showed that only 76.6% had good
destruction, ulceration and infection. Diabetic foot are
knowledge, 11.1% attended an educational classes,
common throughout the world, which effect the
22.0%, were educated by doctor and 10.3% by a nurse
economic consequences of the patients, their families,
where only 47.6% inspect there foot daily [7].
and society. It is assessed that roughly 15% of the more
Another cross-sectional hospital-based study
than 150 million persons having DM globally at
conducted between 2011 and 2012 by Al Odhayani et
particular phase will grow diabetic foot ulcer [3,4].
al., in Riyadh hospitals, Saudi Arabia was done to judge
Improper foot care among diabetic lead to a
the side by side foot care practices among diabetics
major basis of indisposition and premature death and
showed that 64% percent are at high risk for diabetic
diabetic foot complications contribute substantially to
foot and 7.10% are at low risk only, 42% of total
health care costs. The prevalence of diabetic foot
participants have regular foot care the study showed that
complications among the diabetic patients overall 3.3%
over 60% of non-traumatic lower limb amputations are
in which foot ulcer 2.05%, gangrene 0.19%, and
due to foot ulcer [5].
amputations 1.06% [5,6].
One of the advanced centers in Al Madinah City
While in other view educating the patient about
for the treatment and follow-up of diabetics that
the complication and the need for proper foot care
includes many specialized clinics is Prince Abdul-Aziz
among diabetic will reduce the risk of complication and
bin Majid Diabetes Center. It has an educational clinic
lead to improve the quality of life and, consequently, an
unit that aims to change the wrong lifestyle into a
increased economic burden on the individual and
healthy lifestyle that helps reduce the complications of
society as a whole [6].
the disease.
In Saudi Arabia an epidemiological health
During our research working time at primary health
survey was conducted and showed that the prevalence
care center and clinical rotation at diabetic center, we
1864
Received: 14/11/2021
Accepted: 12/01/2022

Full Paper (vol.871 paper# 145)


Assessment of Triangular Fibro-cartilaginous Complex Injuries of The Wrist Using High Resolution Ultrasound versus Magnetic Resonance Imaging The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1872-1875

Use of Antiepileptics in Different Causes of
Acute Asymptomatic Seizures: Review Article
Ahmed El Sayed Badawy, Aya Abd El Hakeem Younis*, Mona Mohamad Amer
Neurology Department, Faculty of Medicine, Zagazig University, Egypt.
*Corresponding Author: Aya Abd El Hakeem Younis, Email: ayahbishr@gmail.com

ABSTRACT
Background
: Acute symptomatic seizures (ASS), also known as reactive, triggered, or situation-related seizures, used
to be described as a seizure that occurred at the time of or in close proximity to the occurrence of a recorded brain
damage, seizures that occur within a short period of time after neurological or systemic assaults, and are therefore
regarded to be a symptom of an acute disease affecting the brain in some way, shape, or form. After the active phase
of central nervous system (CNS) infection or inflammatory disease has ended, based on persistent clinical, laboratory,
or imaging finesse, a time window exists during which those acute seizures can be considered symptoms of an acute
disease, and the International League Against Epilepsy (ILAE) suggested that it is one week following stroke, head
trauma, or anoxic encephalopathy. The therapy of ASS is different from that of unprovoked seizures, therefore
antiepileptic treatment may be required in the acute phase, but it is rarely necessary long term because acute
symptomatic seizures are unlikely to return unless the underlying acute causative disease develops once again.
Objective: To make an overview of new guidelines for treatment of most common causes of acute symptomatic
seizures.
Conclusion: Acute symptomatic seizures are those caused by an acute general medical/surgical or neurological insult
and generally tending not to recur with no need for long-term antiepileptic drugs (AEDs) treatment.
Keywords: Acute symptomatic seizures, Antiepileptics, Central nervous system.

INTRODUCTION
OR, NOT) had been used such as [Antiepileptics AND
Beghi et al. (1) defined if you have an acute CNS
acute symptomatic seizures OR central nervous system]
insult caused by a metabolic or toxic or structural or
and in peer-reviewed articles between April 2008 and
viral process or inflammation, you are more likely to
June 2021; a 13-year date range was selected, however,
experience acute symptomatic seizures, and the time
the range of time interval for researches was wide as
between the injury and onset of the seizure may vary
there's scarcity of data on the particular reviewed,
based on your underlying clinical condition. Instead of
accurate and depth in the retrieved literature.
terms such as triggered seizure, reactive seizure, or
Documents in a language apart from English have been
situation-related seizure, they suggested using the
excluded as sources for interpretation was not found.
phrase acute symptomatic seizure instead.
Papers apart from main scientific studies had been
Seizures that occur within a short period of time
excluded: documents unavailable as total written text,
after neurological or systemic assaults, are therefore
conversation, conference abstract papers and
regarded to be a symptom of an acute disease affecting
dissertations.
the brain in some way, shape, or form. After the active

phase of CNS infection or inflammatory disease has
Epidemiology of ASS:
ended, based on persistent clinical, laboratory, or
Nearly 40% of all seizures, 40% of all afebrile
imaging finesse, a time window exists during which
seizures, and 50%­70% of all episodes of status
those acute seizures can be considered symptoms of an
epilepticus are caused by acute symptomatic seizures.
acute disease, and the International League Against
Acute symptomatic seizures had an overall life-time
Epilepsy (ILAE) suggested that it is one week
risk of 3.6 percent, which is close to the likelihood of
following
stroke,
head
trauma,
or
anoxic
developing epilepsy. Medical admissions in
encephalopathy(2).
underdeveloped nations have an acute symptomatic
The aim of this review article is to make an
seizure rate of 2% to 5%, while 3.5 percent of intensive
overview of new guidelines for treatment of most
care unit patients had acute symptomatic seizures (3).
common causes of acute symptomatic seizures.
As many as 29­39 seizures per 100,000 people

occur each year, according to the National Institutes of
Methods:
Health (NIH). Acute symptomatic seizures are more
A search strategy has been performed to
common in the younger and older populations. There
determine the related literature. Initially, the objective
are several typical triggers, including fever, traumatic
of review was identified. Relevant keywords and
brain injury (TBI), cerebrovascular illness, drug
synonymous key words had been used.
withdrawal and infection (4).
These databases were searched for articles

published in English in 3 data bases [PubMed ­ Google
Treatment of ASS:
scholar- science direct] and Boolean operators (AND,
According to Halawa(5) epilepsy does not have to

be diagnosed in all situations where seizures are
1872
Received: 14/11/2021
Accepted: 12/1/2022

Full Paper (vol.871 paper# 146)


c:\work\Jor\vol871_147 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1876-1882

Interventricular Septal Thickness and Doppler Indices as Multiparametric
Assessment of High-Risk Pregnancy and Their Relation to Fetal Outcome
Hend Galal Eldeen Mohamed Ali Hssan1,2, Mona Aly Abd El Wahed1, Mohamed M. Abdel Aziz*1
1Department of Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2Department of Technology of Radiology and Medical Imaging,
Faculty of Applied Health Science Technology, Galala University
*Corresponding author: Mohamed M. Abdel Aziz, Mobile: (+20) 01006265054,
E-mail addresses: m.mamdouh83@gmail.com, ORCID ID: 0000-0002-0699-9180

ABSTRACT
Background:
Basic ultrasound measurement is not enough for proper assessment for the high-risk pregnancy like
gestational diabetes mellitus and preeclampsia.
Objective: This study aimed to add more parameters for evaluation of high-risk pregnancy including Doppler parameter
and interventricular septal thickness, and their reflection on fetal outcome
Patients and methods: 75 pregnant women were presented between 28-38 weeks gestation. They were divided into
three groups: Group I included 25 pregnant diabetic women, group II included 25 pregnant women with gestational
diabetes mellitus (GDM) and preeclampsia, and group III included 25 normal pregnant women as a control group (NC).
Fetal hemodynamic indices were measured to all included groups and represented as the resistance index (RI), pulsatility
index (PI) of umbilical artery (UA), middle cerebral artery (MCA), and interventricular septal (IVS) thickness.
Results: The independent samples t-test showed that fetal weight, as well as the abdominal circumference (AC), was
larger in GDM than in NC (P < 0.05) while were smaller in GDM with preeclampsia than in NC. Also, IVS thickness
was larger in GDM than in NC (P < 0.05), while t-test showed that umbilical PI was higher in preeclampsia than in NC
(P < 0.05) vice versa the MCA PI was lower in the preeclampsia than in NC (P < 0.05).
Conclusion: Doppler indices especially MCA and umbilical PI as well as the interventricular septal thickness in late
pregnancy were helpful in the diagnosis and assessment of high-risk pregnancy as well as their follow-up and in turn
they could be considered as an indicator of poor fetal outcome.
Keywords: Fetus, Gestational diabetes mellitus, Infant, Middle cerebral artery, Ultrasound, Umbilical artery.

INTRODUCTION
the structure but also at the level of the cardiac function
Several factors can make pregnancy high risk,
(7).
including for example diabetes mellitus (DM), pre-
Asymmetrical increase of interventricular septal
eclampsia (PE), rupture of membrane (ROM) as well as
thickness is seen in the fetus with diabetic mother with
maternal age (1). Clinical assessment of high-risk
an increase in the incidence in the fetus of mothers with
pregnancy including the biophysical profile and daily
insulin- dependent diabetes mellitus (IDDM) rather
fetal movement does not offer a high stander level for
than insulin-independent DM (IIDM) (8).
assessment of fetal well-being with high sensitivity and
The diagnosis of the increased interventricular
specificity (2).
thickness
is
documented
by
using
Fetal
Antenatal screening of the uteroplacental flow by
echocardiography (9).
using Doppler indices of the umbilical, uterine arteries

like pulsatile index, resistant index, or the presence of
PATIETNS AND METHODS
an early diastolic notch are used as a predictor of the
This observational prospective study was
antenatal complication like intrauterine growth
conducted from September 2020 until August 2021.
restriction (IUGR) (3).
The study included 75 pregnant women presented
Decrease of the blood flow to fetal circulation leads
between 28-38 weeks gestation. They were divided into
to fetal brain hypoxia, which can be detected by an
three groups: Group I (GDM group) included 25
increase in the resistive index in the umbilical artery
pregnant women, group II (combined GDM with pre-
with a decrease in the middle cerebral artery resistive
eclampsia) included 25 pregnant women and group III
index, which is called "brain sparing" (4, 5).
(NC group) included 25 pregnant.
Assessment of feto-placental vascular bed by using

color Doppler gives information about feto-maternal
Inclusion criteria:
circulation and its state, colour Doppler can assess the
Pregnant women with age ranging between 25­38
early abnormal pattern in the blood flow to the fetus,
years, 3rd-trimester pregnant women of a single fetus
thus helping in the decision of the onset of the delivery,
between 28 weeks and 39-weeks gestation with GDM,
that leads to decrease of the maternal morbidity and
and combined GDM with preeclampsia. Control group
mortality (6). The fetal high insulin level due to changes
are 3rd-trimester pregnant women of a single fetus
in the diabetic mother metabolism leads to changes in
between 28 weeks and 39-weeks gestation with no risk
the cardiomyocyte gene expression that in turn leads to
factor, checked by measuring fasting plasma glucose
malformation of the fetal heart not only at the level of
(FPG) concentration that was less than 140 mg/dl and
1876
Received: 13/11/2021
Accepted: 11/01/2022

Full Paper (vol.871 paper# 147)


c:\work\Jor\vol871_148 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1883-1887

Tissue Doppler-Derived Left Ventricular Myocardial Performance Index in
Children with Type 1 Diabetes Mellitus
Sahar Abd El Raouf Elsharawy, Shaimaa Naser Abd Ellatif*, Heba Abouzeid
Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt
*Corresponding author: Shaimaa Naser Abd Ellatif, Mobile: (+20) 01024408896,
E-Mail: shiamaanaser71@gmail.com

ABSTRACT
Background:
Diabetes Mellitus (DM) is a serious global health problem currently reaching epidemic proportions. It
may be complicated with cardiomyopathy. Pulsed wave tissue Doppler can provide quantitative diagnostic information
for the assessment of myocardial systolic and diastolic velocity.
Objective: Our study aimed to assess ventricular myocardial performance in type I diabetes mellitus using tissue
Doppler echocardiography.
Patients and Methods:
This study was carried out at Pediatric Cardiology Unit, Zagazig University Hospitals. 64 age-
and sex-matched children were classified into case group included 32 type 1 DM and control group included 32 healthy
children. They underwent complete history and conventional and tissue Doppler echocardiographic examination.
Results: E` wave velocity was lower in cases compared to control children (p <0.001). A positive correlation was found
between mitral annular Ą wave velocity and left ventricular myocardial performance index (LV MPI) measured by
tissue Doppler imaging.
Conclusion: Early diastolic dysfunction was found in our patients evidenced by reduced E` wave velocity measured by
tissue Doppler imaging. The absolute value of LV MPI was higher in patients compared to control children. A finding
designating that statistical significance may be found at a longer term follow up study of our diabetic children. LV tissue
Doppler-derived MPI was found to have significant positive correlation with mitral annular Ą wave velocity although
systolic LV function was normal in patients when measured by traditional echocardiography in terms of EF and FS.
Keywords:
Diabetes mellitus, Tissue Doppler echocardiography, Myocardial performance index.

INTRODUCTION

Health, Zagazig, Egypt, were retrospectively recruited.
Type 1 diabetes mellitus (DM) is a metabolic
The control group included 32 asymptomatic healthy
disease characterized by sustained hyperglycemia that
children selected at outpatient clinic of Pediatric
leads to diabetic cardiomyopathy. While the diagnosis
Cardiology from children who were being investigated
rests on a simple measurement of blood glucose,
for cardiac
murmur and
accurate classification is often more involved (1). Type 1
whose echocardiography showed no structural heart
diabetes diagnosed in childhood often has an abrupt
disease.
onset with significant acute symptoms and is thus easily

identified but the progression of autoimmune diabetes
Patients: Thirty-two children with type I diabetes
is often more insidious in adults (2).
mellitus that was diagnosed according to the World
It remains hard to prove that uncomplicated
Health Organization criteria (5) together with a
diabetes mellitus already affects myocardial function in
permanent need for insulin therapy
asymptomatic children at an early stage of the disease.

Hence, children with uncomplicated diabetes may serve
Control subjects: Thirty-two healthy children of
as an ideal model to study the cardiac effect of diabetic
comparable age and gender to cases. Children in the
metabolic conditions in the absence of potentially
control group had to have no congenital heart disease,
confounding ischemic events (3).
hypertension, hypercholesterolemia, or diabetes.
Tissue Doppler Echocardiography can provide

quantitative diagnostic information for the assessment
Inclusion criteria: Patients had type I diabetes mellitus
of myocardial deformation (4). Therefore, our study
below 18 years of age.
aimed to assess ventricular myocardial performance in

type I diabetes mellitus using tissue Doppler
Exclusion criteria:
echocardiography.
-
Patients with congenital or rheumatic heart disease.

-
Patients with type 2 diabetes mellitus.
PATIENTS AND METHODS
-
Patients with acute heart failure, dilated
This study was performed at Pediatric Cardiology
cardiomyopathy, chronic renal failure, hypertension
Unit, Zagazig University Hospitals on 64 participants
and/or previous cardiac surgery.
divided equally into patients and control groups through
-
Family history of hypercholesterolemia
the period from January 2019 to July 2021.


All patients were subjected to the following:
Study population: 32 patients with type I diabetes, who
1- Full history taking.
were followed up at Outpatient Clinic of Ministry of
2- Full general examination.
1883
Received: 13/11/2021
Accepted: 11/01/2022

Full Paper (vol.871 paper# 148)


c:\work\Jor\vol871_149 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1888- 1892

Botulinum Toxin Type A injection versus placebo Treatment of
Primary Palmar Hyperhidrosis
Manal Mohamed Elsayed, Soheir Mohammed Ghonemy Mohammed, Najat Hussain Ali Sheneeb*
Department of Dermatology, Venereology & Andrology, Faculty of Medicine- Zagazig University, Egypt
*Corresponding author: Najat Hussain Ali Sheneeb, E-mail: nagat75200@gmail.com

ABSTRACT
Background:
When the hands, axillae and soles of the feet are excessively perspirated, it can be debilitating. Type A
botulinum toxin-A (BTX-A) prevents sweating by preventing sweat glands from releasing acetylcholine.
Objective: This study aimed to assess role of Botulinum toxin type A injection versus placebo treatment of primary
palmar hyperhidrosis.
Patients and Methods: twenty four patients presented with primary palmar hyperhidrosis (PPH) were collected from
Dermatology Outpatient Clinics, Zagazig University Hospital. Their left hands were treated by placebo and their right
hands were treated using BTX-A injection.
Results: Improvement of HDSS (score 4) regarding treatment modalities. HDSS (score 4) before treatment improved
after to be 6.7%, 66.7%,8.3%,8.3% score 1, score 2, score 3, score 4 in right side treated with Botulinum toxin type A
injection ,versus 16.7%, 33.3%,20.8%, in left side treated with placebo treatment. There was significant high percent of
excellent response for Botulinum toxin type A injection among females and patients with delay onset of disease
(p<0.05).
Conclusion: BTX injections appear to be more effective than placebo. It's still one of the most popular noninvasive
cosmetic procedures, and neurotoxin. BTX is still an effective and predictable agent.
Keywords: Botulinum toxin, Primary palmar hyperhidrosis.

INTRODUCTION

The acetylcholine release in sweat glands is blocked
When the hands, axillae and soles of the feet are
by botulinum toxin type A (BTX-A). Excessive
excessively perspirated, it can be debilitating. Those
sweating in primary axillary and palmoplantar
with palmar hyperhidrosis may find it difficult to write
hyperhidrosis was reduced by intradermal BTX-A
because the page becomes wet. They may have
injections. Topical anesthesia makes it simple to
difficulty writing with a pen or pencil. Sports that
administer intradermal BTX-A to the axillary skin. The
require a strong grip, as well as playing musical
majority of patients who undergo intradermal BTX-A
instruments, may be out of the question. It is possible
for palmoplantar sweating necessitate regional nerve
for the patient to become isolated and socially awkward.
block anesthesia (5, 6).
People who suffer from hyperhidrosis often seek

treatment for their palms and axillae, which are the most
PATIENTS AND METHODS
affected areas (1).
In this comparative study, twenty four patients
Palmar hyperhidrosis is a condition in which the
presented with primary palmar hyperhidrosis (PPH).
palms sweat excessively, above and beyond the amount
They were collected from Dermatology Outpatient
necessary to keep the body cool. Adults are more likely
Clinics, Zagazig University Hospital. These volunteers
to suffer from it than children. Disruptive to the patient's
were randomly divided into two groups, split hand that
social or work life, it can be emotionally challenging,
received four treatments at 2-week intervals.
socially embarrassing and professionally disruptive. In
extreme cases, sweat drips from the hands and gives the
Group A included left hands of the 24 patients
impression of nervousness. The most common
with excessive palmar perspiration and excessive
explanation is that it stems from stress or other
sweating treated with placebo treatment, and group B
emotional factors, but this is not always the case (2).
that included right hands of the 24 patients with
Most commonly, aluminium chloride hexahydrate
excessive palmar perspiration and excessive sweating
(ACH) is applied to the skin to alleviate symptoms of
treated with BTX-A injection.
mild to moderate severity. It is a first-line treatment

because of its wide availability, cost-effectiveness, and
Inclusion criteria:
ease of use. Water, alcohol, ether, and glycerol all
1. Aged up to 50.
contain ACH in concentrations ranging from 6.25% to
2. Male and females.
40%. ACH concentrations in over-the-counter (OTC)
3. Diagnosed with moderate and severe primary
antiperspirants are limited to 12.5%. Aluminum
palmar hyperhidrosis (PPH) and meeting
chloride in ethyl alcohol, 6.25% aluminum
diagnostic criteria. The symptoms of severe
tetrachloride, and 12% aluminum chloride in sodium
palmar hyperhidrosis include base score of 3 or
carbonate-water are all commonly prescribed
4 on the Hyperhidrosis Disease Severity Scale
formulations (3, 4).
and a minimum sweat production gravimetric
1888
Received: 15/11/2021
Accepted: 13/1/2022

Full Paper (vol.871 paper# 149)


c:\work\Jor\vol871_150 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1893-1898

The Impact of Social Support on The Mental and Physical State of Patients with
Epilepsy During the Covid-19 Pandemic
Mohammad Gamal Sehlo1, Wafaa Samir Mohamed2, Usama Mahmoud Youssef1,
Shrouk Esam Lotfi*3, Ghada Mohamed Salah El-deen1
Departments of 1Psychiatry, 2Neurology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
Department of 3Neuropsychiatry, Abbaseya Hospital for Mental Illness, Cairo, Egypt
*Corresponding author: Shrouk Esam Lotfi, E-Mail: drshrouk2aqsa@gmail.com

ABSTRACT
Background:
Social support has a significant role for patients with chronic conditions like epilepsy. The Covid-19
pandemic has had a negative impact on people around the world and is expected to have a greater impact on people with
disabilities. As a part of our Covid-19 pandemic study, we're looking at the impact of social support on patients with
epilepsy (PWE).
Objective: This study aims to assess social support and its effects on PWE during the Covid-19 pandemic.
Patients and Methods: A total of 290 PWE were included in this study. Personal interviews with each patient were
conducted using the Oslo Social Support Scale (OSSS 3) for measuring social support, the Patient Health Questionnaire
9 (PHO 9) scale for diagnosing and assessing the severity of depression, and the Generalized Anxiety Disorder scale for
diagnosing and assessing the severity of anxiety (GAD 7). Results: During the pandemic, we observed a decrease in
family support for PWE, which was associated with an increase in depression and anxiety. As the pandemic spreads,
we found that a lack of social support is linked to an increase in depressive symptoms and seizures.
Conclusion:
Social support plays an important role in psychological well-being and for a better course of disease in
PWE.
Keywords: Social support, Epilepsy, Covid-19.

INTRODUCTION

PATIENTS AND METHODS
Individuals in one's immediate social circle
To conduct this cross-sectional study, we enrolled
provide social support in the form of assistance (1).
two hundred and ninety patients who had been
Social support is a critical mechanism in the
previously diagnosed with epilepsy using the most
management of chronic conditions, and it is especially
recent ILAE classification. From August 2020 to
important in the treatment of epilepsy (2). Emotional and
September 2021, at Zagazig University Hospital,
physical stress can lead to seizures, which necessitate
Sharkia, Egypt, patients were gathered from the
the assistance of family members and friends (3). Social
Neurology Department's outpatient clinic and inpatient
support is thought to alleviate stressful events, ongoing
ward.
life stressors, and long-term health issues (1).
In the study, both sexes between the ages of 19 and 60
It has been noticed that patients with epilepsy who
were
included.
Non-epilepsy-related
medical
lack social experience a worse course of the disease (1).
conditions such as psychiatric illness and substance
The COVID-19 pandemic has instilled fear,
abuse were excluded from the study. Patients with
uncertainty, and a sense of helplessness within people
Covid-19 infections were also excluded.
all over the world (4).

Distress during the pandemic is caused not only by
Measures:
medical issues, but also by related phenomena such as
1-Form for collecting demographic and clinical
business closures, cultural discrimination, isolation
data on patients, including questions about their health
brought on by home quarantine, and financial problems
history and personal characteristics, as well as
(5). When a pandemic lasts for weeks or months, people
information about the COVID 19 pandemic. Inquire
experience a great deal of stress and anxiety due to the
about the patient's current and past health and well-
stress of being cooped up for long periods and not
being as well as their family's history of mental illness
knowing whether or not they will succumb to the
and epilepsy, as well as their marital and employment
disease (6).Evidence showed that many PWE
status, and the number and ages of their children.
experienced major disruptions in the quality and
Specific seizures, response to antiepileptic drugs
availability of care and that some people's seizure
(AEDs), the age of onset and time of the seizure as well
frequency had increased since the pandemic began.
as how many AEDs have been taken., Prevalence of
Furthermore, many PWE may experience higher levels
seizure visits to emergency rooms before and during the
of stress and social isolation than others (7).
pandemic, as well as the number of such visits during
The lack of social support during the pandemic is
the pandemic itself, the epidemic, fear of having an
expected to have a negative impact on PWE. During the
uncontrollable seizure, and regular follow-up during the
Covid-19 pandemic, our study aims to assess social
epidemic. People who are close to someone who is
support for PWE and investigate the possible effects of
infected or dies as a result of the pandemic and sleep
social isolation on PWE's mental and physical health.
disturbances, Data on family support, job changes, and

1893
Received: 16/11/2021
Accepted: 14/01/2022

Full Paper (vol.871 paper# 150)


Comparative study between Racz technique alone and Racz with radiofrequency in the management of failed back surgery syndrome The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1899-1906

Outcome of Neonatal Sepsis in Neonatal Intensive Care Unit in
Zagazig University Hospitals
Ali A. Abdou, Amal M. Abd El-Latef, Mahmoud M.M.A. Elnaggar*
Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
*Corresponding author: Mahmoud M.M.A. Elnaggar, Email: dr.mahmoud.elnagga1985r@gmail.com

ABSTRACT
Background:
Early and late onset sepsis is defined as presenting before and after the first 72 hours of birth. The general
fatality rate of early-onset sepsis varies between 15-40%.
Objective: The aim of study is to detect outcome of neonatal sepsis in Neonatal Intensive Care Unit.
Patients and methods: This study consisted of 190 neonates at Neonatal Intensive Care Unit in Zagazig University
Hospitals with (69.5%) of them were admitted to NICU in the 1st day, (27.9%) with gestational age more than 37 weeks,
(40.0%) had weight from 1500- 2000 gram, males represented (52.2%) and (55.3%) were born by cesarean section.
They were divided into 2 groups; positive and negative blood culture groups.
Results: Pregnancy age and birth weight were statistically significantly different between the groups, the septic and
non-septic groups differed statistically in all manipulations except IV cannula. There was statistically significant
difference between the septic and non-septic groups as premature labor, obstructed labor, mother RH -ve or +ve,
premature rupture of membranes (PROM), chorioamnionitis, antepartum hemorrhage, respiratory distress, prematurity,
CNS insult and perinatal asphyxia and congenital anomalies, ventilation modes, ventilation duration, hospital stay and
causes of death. Conclusion: Prematurity, low body weight (BW), obstructed labor, PROM, chorioamnionitis, umbilical
catheterization and mechanical ventilation are the most important risk factors. The commonest cause of admission to
NICU was respiratory distress followed by prematurity and lastly hypoglycemia. Klebsiella pneumonia, Staphylococcus
aureus and E-coli are the most common isolated organisms of blood cultures.
Keywords: Neonatal intensive care unit, Neonatal sepsis, Nosocomial infection.

INTRODUCTION
the costs and length of hospitalization associated with
Neonatal sepsis it is still the leading cause of
neonatal sepsis remain high in both developed and
newborn mortality and morbidity despite recent
developing countries (7).
improvements in health care facilities. A neonatal
Aim of this study is to detect outcome of neonatal
mortality rate of more than 40% results in the deaths of
sepsis in Neonatal Intensive Care Unit in Zagazig
more than 3.1 million newborns every year (1). In low-
University Hospitals.
and middle-income countries, more than a million of

these deaths are linked to infectious diseases like
PATIENTS AND METHODS
neonatal sepsis, meningitis, and pneumonia (2). Neonatal
From January 2018 to December 2018, Zagazig
sepsis/pneumonia alone is responsible for a quarter of
University Hospitals conducted a cross-sectional study
the estimated four million neonatal deaths worldwide
in the Neonatal Intensive Care Unit.
each year, representing a third of all severe infections (3).
Subjects:
When an infant is less than 28 days old and has
The medical records of patients admitted to Zagazig
systemic symptoms of infection and a bacterial
University Hospital's Neonatal Intensive Care Unit
pathogen in their bloodstream, they are considered to
(NICU) between January 2018 and December 2018
have neonatal sepsis, which is defined by this. (4). A
were screened for neonatal sepsis cases (190 cases).
fully developed immune system, as well as structural
Inclusion criteria:
components, are all missing in newborns, especially
All cases diagnosed with neonatal sepsis either acquired
those who were born prematurely or were underweight
it before admission (early sepsis: acquired before or
(5). Furthermore NICU admitted neonates are exposed to
during delivery) or after admission (late and nosocomial
interventional therapeutics that may allow entry of
sepsis) to Zagazig University Hospital NICU.
pathogens as intubation, ventilation, central venous
catheter, peripheral intravenous line, total parenteral
Exclusion criteria: Cases have multiple congenital
nutrition (TPN), venipuncture and urinary catheter that
anomalies incompatible with life, cases died before
may cause neonatal sepsis including blood stream
confirming the final diagnosis, and cases with deficient
infection, pneumonia, urinary tract infection, meningitis
data about the outcome.
and skin infection. Conversely, neonatal sepsis
METHODS
survivors are still at risk for long-term and short-term
Medical records of cases admitted to Zagazig
neurodevelopmental morbidity (6).
university hospital NICU in the period from January
Sepsis is still a significant contributor to mortality
2018 to December 2018 were searched for cases of
and morbidity among very-low-birthweight (VLBW,
neonatal sepsis according to the inclusion and exclusion
1500 g) infants in Neonatal Intensive Care Units
criteria (Figure 1).
(NICUs) despite advances in neonatal care. As a result,
1899
Received: 15/11/2021
Accepted: 13/01/2022

Full Paper (vol.871 paper# 151)


c:\work\Jor\vol871_152 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1907-1912

Immunohistochemical Expression of Ki67 in
Gastrointestinal Stromal Tumors
Zeinab Ibrahim Abdelhalim Elakabawy*1, Moshira Mohammed Abd-Elwahed1, Asmaa Gaber Abdou1, Hala
Said Bassyony El-rebey1, Iman Loay Hussein Abu Alkhair2, Mona Abd-Elhalim Kandil1
1Department of Pathology, Faculty of Medicine, Menoufia University, Egypt
2Department of Pathology, National Cancer Institute, Cairo University, Egypt
*Corresponding Author: Zeinab Ibrahim Abdelhalim Elakabawy, Mobile: (+20)01029090830,
E-mail: zainabalakabawy@gmail.com, ORCID: 0000-0002-7973-3252


ABSTRACT

Background: One of the most common types of gastrointestinal neoplasms is a GIST (gastrointestinal stromal
tumourKi67 is a proliferation marker that can detect all but G0 proliferating cells.
Objective: To evaluate Ki67 expression in GIST and its correlation with the clinicopathologic parameters including
survival using immunohistochemical method.
Patients and Methods: In this study, Ki67 immunohistochemistry was performed on sections cut from 56 formalin-
fixed, paraffin-embedded GIST. Diagnosis of GIST was confirmed by positive expression of C-kit in all cases except 5
negative cases that were positive for PDGFRA. Clinical data included age, gender, tumour location (gastrointestinal and
extra gastrointestinal), tumour size, lymph node status, presence of distant metastasis, and patient status. The assessed
pathological parameters included mitotic count, cell type (spindle, mixed spindle and epithelioid, epithelioid) and
necrosis. Cases are divided into very low, low, moderate and high-risk groups according to National institute of health
and 2006 risk stratification.
Results: Ki67 expression ranged between 0.5-6.6 % with a median of 3 % and a mean±SD of 3.08±1.77 %. 60.7% had
low Ki67 labelling index (LI) (below the median, 3%), 39.3% had high Ki67 LI (above the median 3%). Ki67 LI was
significantly correlated to mitosis (P=0.010), 2006 risk stratification (P value=0.027) and with young patients (P=0.019).
However, it has no correlation with the overall survival and rest of clinicopathological parameters.
Conclusion: Ki67 could be included in risk stratification of GIST since its expression is correlated with GIST risk
stratification.
Keywords: Immunostaining, GIST, Ki67, Mitosis, Risk stratification.

INTRODUCTION

including GIST, can use Ki67 as an appropriate
Mesenchymal tumors in the digestive tract, such as
proliferation marker (5).
gastrointestinal stromal tumors (GIST), are the most
The aim of the present study was to evaluate
common, accounting for 0.1­3% of all cases of
Ki67 expression in GIST and its correlation with the
gastrointestinal cancer. GIST are clinically relevant,
clinicopathologic parameters including survival using
despite their rarity, because at least 10­30% of them are
immunohistochemical method.
malignant (1).

More than 60% of tumors are found in the stomach,
PATIENTS AND METHODS
which is followed by the duodenum (4-5%), colon (4%),
There were 56 patients with gastrointestinal stromal
oesophagus (1-2%), and rectal (1-2%) regions (1-2%)
tumors included in the research (GIST). The National
(2). Appendix and gallbladder GIST are extremely rare.
Cancer Institute, Cairo University's archive of formalin-
Extra-visceral GIST, such as in the mesentery, pelvis,
fixed, paraffin-embedded tissue blocks was searched
omentum, or retroperitoneum, is extremely rare. Extra
from 2006 to 2013. Data from the medical files of
gastrointestinal GIST is the name given to tumors found
patients at Cairo University's National Cancer Institute
in the preceding locations (3).
were retrieved for this study. The patients' medical
An indicator of cell division and proliferation, the
records and/or personal contact provided the source of
nuclear antigen Ki67 is closely linked to cell mitosis.
the follow-up data.
Ki67 is only found in cells that are actively
Clinical data included age, gender, tumour location
proliferating, and it is present throughout the cell cycle
(gastrointestinal and extra gastrointestinal), tumour
at stages G1, S, and G2 (4). Except for G0, the mitotic
size, lymph node status, presence of distant metastasis,
index only reflects the M stage of mitosis, which Ki67
and patient status. Necrosis, mitotic count, cell type
can recognise. As a result, any malignant tumour,
(epithelioid, epithelioid mixed), and cell type were all
examined as pathological parameters. It was determined
1907
Received: 16/11/2021
Accepted: 14/1/2022

Full Paper (vol.871 paper# 152)


c:\work\Jor\vol871_153 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1913-1919

Complications of Laparoscopic Restorative Rectal Carcinoma Resection
Mohamed W. Arafa*, Ayman M.A. Ali, Hosam F. Abdelhameed, Abd-El Hafiz Hosny Mohamed
Department of General Surgery, Faculty of Medicine, Sohag University, Egypt
*Corresponding author: Mohamed W. Arafa, Mobile: (+20) 01020036846, E-Mail: mohamadwagehsurg@yahoo.com

ABSTRACT
Background:
Laparoscopic restorative proctectomy (LRP) for rectal carcinoma (RC) is considered to be a technically
demanding procedure with many risk factors known to be associated with occurrence of complications.
Objective: We aimed with this study to evaluate the various risk factors affecting perioperative and postoperative
morbidity in LRP for RC.
Patients and Methods: This is a prospective observational study included patients suffering from middle and distal
third RC admitted electively to Sohag University Hospital and Colorectal Unit in Ain Shams University between January
2017 and December 2019 with a mean follow-up of 20 months. Patients were evaluated and analysed regarding
demographics, clinical picture, different investigations, efficacy of LRP, and different risk factors for perioperative and
postoperative complications.
Results: A total of 35 patients underwent LRP for RC, perioperative complications happened in 8.5% and postoperative
complications happened in 22.9%. Analysis of the variables affecting the occurrence of complications by univariate
logistic regression showed that patients with co-morbidity were more likely to have complications than others (P=0.002),
also patients with higher American Society of Anaesthesiologists' risk scoring grade were more likely to develop
complications (P= 0.004), and in the same time the more advanced pathological stage had the same effect (P= 0.004).
Conclusion: We found that the significant influencing factors for the occurrence of surgical complications were co-
morbidity, more advanced pathological staging and higher ASA grade.
Keywords: Laparoscopic restorative proctectomy, Laparoscopy, Rectal cancer.

INTRODUCTION
tertiary centers in the hands of professional
Colorectal cancer is recorded as the third
surgeons (6).
most deadly and fourth most common cancer all
Avoiding injury to adjacent structures,
over the world constituting a major burden over
besides
autonomic
nerve
identification
and
the health care system authorities(1). Despite the
preservation,
are
fundamental
to
avoid
great advantages of laparoscopic surgery, yet it is
complications and achieve a good sexual and
associated with higher complication rates when
urinary functional outcome (7). In the same time
performed for RC than when performed for colon
data suggest that postoperative complications
cancer because of technical difficulties and
may promote tumor recurrence and decrease
anatomical limitations in the pelvic cavity (2).
long-term survival. So, efforts should be paid to
Despite important progress with the introduction
avoid the occurrence of complications as far as
of surgical staplers, techniques and perioperative
possible (8).
management, patients who receive LRP for rectal
The aim of this study was to evaluate
cancer may still inevitably experience surgical
factors affecting perioperative and postoperative
complications (3). Morbidity rates occur within 30
complications after LRC for RC.
days of the LRP at a rate ranges from 25%-32%

while surgical deaths during the same period
PATIENTS AND METHODS
reaches 6% to 8% (4).
This was a prospective single arm study,
Laparoscopic restorative proctectomy is
which included 35 patients which was conducted
technically demanding procedures, especially in
from January 2017 till December 2019 at General
male pelvis, due to the narrow space in the pelvic
Surgery Department, Sohag University Hospital
cavity, add to this familiarity with deep pelvic
and Colorectal Unit in Ain Shams University.
anatomy is a prerequisite, and mastery of
Only patients presented with symptoms
laparoscopic techniques is needed to accomplish
suggestive of RC, confirmed histologically to be
a safe and thorough dissection of the rectum out
adenocarcinoma (T2-T4, N0 or N1 tumors),
of the pelvis, which is often deep and limited.
without evidence of distant metastases, located in
Although
laparoscopy
is
a
well-established
the distal or middle third and with a functioning,
technique yet cumulating results suggest that the
disease-free sphincter mechanism were included
learning
curve
is
indispensable
to
avoid
in the study.
postoperative complications(5). It is estimated that
Patients were excluded if they had distant
a learning curve of 60-80 resections are required
metastases,
locally
advanced
tumors
(not
to obtain expertise and mastery of the technique,
responding
to
neo-adjuvant
therapy),
tumor
which is only attainable in highly specialized
invasion
to
adjacent
organs,
acute
bowel
obstruction or perforation from cancer, patients
1913
Received: 15/11/2021
Accepted: 13/01/2022

Full Paper (vol.871 paper# 153)


c:\work\Jor\vol871_154 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1920-1927

Scoring Systems Used to Predict Mortality in Patients with Acute Upper
Gastrointestinal Bleeding in Emergency Room
Tarek Amin El-Shazly1, Mohamed El Saeed Ahmed2,
Ahmed Mohamed Abd-Almodaber3, Ahmed Farouk Ahmed Hussain4
Departments of 1Internal Medicine, Gastroenterology and Hepatology, 2Critical Care Medicine,
3General Surgery, 4Emergency Medicine, Faculty of Medicine- Mansoura University
*Corresponding author: Ahmed Farouk Ahmed Hussain, Mobile: (+20) 01066345224, E-Mail: ahmedfarouk1989@yahoo.com

ABSTRACT
Background:
Upper gastrointestinal bleeding (UGIB) is defined as hemorrhage that involves the mouth to the
duodenum proximal to the ligament of Treitz. Upper gastrointestinal bleeding (UGIB) is a major public health problem,
its prevalence being around 150 per 100,000 adults per year.
Objective: The aim of this study was to predict mortality in patients with acute upper gastrointestinal bleeding in the
emergency room using AIMS65 and Glasgow-Blatchford scoring systems and to assess which scoring system
(Blatchford or AIMS65) is more accurate in predicting mortality in AUGIB.
Patients and methods: This was a retrospective cohort study that was conducted at Emergency Department, Faculty of
Medicine, Mansoura University. The study was carried out on records of acute upper GIT bleeding patients. We enrolled
in this study a total of 362 patients who matched with our inclusion criteria. The mean age was 55.21 years, 61.6% were
males and the mean BMI was 25.47 kg/m2.
Results: Blatchford score at cut off 13 and AIMS65 at 3 are valid in the prediction of mortality in patients with
acute upper gastrointestinal bleeding in emergency room. AIMS65 3 was more accurate (sensitivity of 77.78% and
specificity of 84.88%) than Blatchford score (sensitivity of 55.56% and specificity of 71.51%) in the prediction of
mortality in patients with acute upper gastrointestinal bleeding in emergency room.
Conclusion: AIMS65 score was superior to Blatchford score in prediction of mortality in patients with acute upper
gastrointestinal bleeding in emergency room. GIT cancer, re-bleeding and increase INR value are independent predictors
of mortality in patients with acute upper gastrointestinal bleeding in emergency room.
Keywords: Upper gastrointestinal bleeding, AIMS65 score, Blatchford score, Emergency room.

INTRODUCTION

variables, requiring no prior upper GI endoscopy
Acute upper gastrointestinal bleeding (AUGIB) is
procedure (5).
common, costly, potentially life-threatening medical
AIMS65 (Albumin, INR, mental status, systolic bl.
emergency, requires prompt assessment and aggressive
Pressure and age above 65) was found to be a simple,
medical management. Significant AUGIB is often
accurate risk score to predict in-hospital mortality,
caused by hemorrhage from varices, ulcers, Mallory-
length of hospital stay, and health care costs in patients
Weiss tears and neoplasms. Elderly patients and those
with acute UGIB. This score is better than commonly
with chronic medical diseases as liver cell failure,
used pre-endoscopy scores and as well as the post-
chronic renal failure and ischemic heart disease
endoscopy Rockall score in predicting in-hospital
withstand AUGIB less well than younger, fitter
mortality (6).
patients, and have a higher risk of death (1).
Aim of the study was prediction of mortality in
Upper gastrointestinal bleeding is one of the most
patients with acute upper gastrointestinal bleeding in
common gastrointestinal emergencies, with an average
the emergency room using AIMS56 and Glasgow­
mortality rate of 10%. Despite advances in the
Blatchford scoring systems and to assess which scoring
diagnosis and management of UGIB, the mortality rate
system (AIMS65 or Blatchford) is more accurate in
has not changed significantly in the last 50 years (2).
predicting mortality in AUGIB.
Multiple scoring systems have been developed to

predict the outcomes of these patients. The most
PATIENTS AND METHODS
common one, designed to predict in-hospital death, is
This was a retrospective cohort study that was
the Rockall score (RS), application of which in clinical
conducted at Emergency Department, Faculty of
practice is complex because it includes many variables.
Medicine, Mansoura University. The study was carried
The search for a pre-endoscopic clinically applicable
out on records of acute upper GIT bleeding patients. We
score to predict high and low risk patients has led to the
enrolled in this study a total of 362 cases who matched
development of other scores, such as the Glasgow­
with our inclusion criteria. The mean age was 55.21
Blatchford score (GBS) (3), and the AIMS65 score (4).
years ranging from 42-66 years, 61.6% were males and
The Glasgow-Blatchford score is used for
the mean BMI was 25.47 ranging from 19.8-32.7
predicting patient mortality, and in identifying patients
kg/m2.
with low-risk AUGIB requiring no intervention. This
The definition of acute AUGIB was based on the
scale allows a risk assessment of patients with AUGIB
presence of at least one of the following three features:
according to a number of clinical and laboratory
hematemesis, melena, and firm clinical evidence and
1920
Received: 18/11/2021
Accepted: 16/01/2022

Full Paper (vol.871 paper# 154)


Anterior urethra is divided anatomically into 2 parts, namely penile and bulbar urethra The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1928-1931

Outcome of Pyeloplasty in Children with Split Renal Function
Less Than 10%: A Retrospective Study
Ahmed Mohamed Nabil Ahmed Sakr, Salem Ahmed Salem Khalil,
Mohamed Mahmoud Hassan Abd Alla, Walid Moftah Ahmed Elawami*
Departments of Urology, Faculty of Medicine ­ Zagazig University, Egypt
*Corresponding author: Walid Moftah Ahmed Elawami, Mobile: (+20) 01147207062, E-mail: walid.awamii.78@gmail.com

ABSTRACT
Background:
Ureteropelvic junction obstruction (UPJO) is one of the most common causes of upper urinary tract
obstruction in the pediatric age group. Surgical repair is indicated in cases with significantly impaired renal drainage
or progressive deterioration of renal function.
Objective: The aim of the current study was to identify the outcome of pyeloplasty in children with split renal
function (SRF) less than 10%.
Patients and methods: This observational retrospective analytical study carried out on 28 children 16 years with
split renal function of ipsilateral kidney 10% in the Urology Department, Faculty of Medicine, Zagazig University.
The study was conducted during the period from 2013 to 2019. All patients were subjected at the time of pyeloplasty
to clinical assessment, laboratory investigation & imaging study.
Results: GFR, SRF were highly significantly increased in post-operative follow up renogram at 6 months and 12
months. Antero-posterior diameter (APD) and parenchymal thickness were highly significantly reduced at 6 month
post-operative follow up ultrasound. There were a highly significant improvement in degree of hydronephrosis from
grades III & IV to I & II.
Conclusion: Our data confirm emerging evidence that the outcome and prognosis of Anderson-Hynes pyeloplasty
(AHP) in children with severely impaired renal function is good that show highly significant improvement of renal
function postoperative.
Keywords: Ureteropelvic junction obstruction, Renal function, Pyeloplasty.


INTRODUCTION

of < 10%, a significant improvement of SRF may be
Ureteropelvic junction obstruction (UPJO) is
seen when pyeloplasty is performed (5).
the commonest cause of pediatric hydronephrosis
The aim of the present study was to identify
occurring in 1/1000-1500 live births. UPJO is defined
the outcome of pyeloplasty in children with split renal
as obstruction to the flow of urine from the kidney to
function less than 10%.
proximal ureter that results in renal damage and

symptoms (1).
PATIENTS AND METHODS
The Gold standard surgical treatment for UPJO is
This observational retrospective analytical study
Anderson Hynes (AH) dismembered pyeloplasty with
was carried out on 28 children 16 years with split
or without surgical reduction of the renal pelvis. There
renal function of ipsilateral kidney 10% in the
are certain parameters to assess the post-operative
Pediatric Unit, Urology Department, Faculty of
outcomes of pyeloplasty. The ultrasound parameters
Medicine, Zagazig University, after review of our data
are the reduction in the AP diameter of the pelvis and
base system to identify the outcome of pyeloplasty in
increase in parenchymal thickness in a growing kidney
children with split renal function less than 10%, during
(2).
the period from 2013 to 2019.
There are certain parameters to assess the post-

operative outcomes of pyeloplasty. The ultrasound
Inclusion criteria: Children who were 16 years at
parameters are the reduction in the AP diameter of
the time of pyeloplasty for 1ry pelviureteric junction
the pelvis and increase in parenchymal thickness in a
obstruction (UPJO), split renal function of ipsilateral
growing kidney. The definitive evidence of improved
kidney 10%. All patients underwent stented
function is by doing an isotope renogram in the
Anderson-Hynes dismembered pyeloplasty.
follow-up period, objectively to look for the

improvement in GFR (glomerular filtration rate) and
Exclusion criteria: Bilateral UPJO, redo pyeloplasty,
also the radiotracer clearance from the PCS (pelvi-
children with ureteral anomalies associated with UPJO
calyceal system). (3)
(VUR or ureteric stricture) and secondary cause of
The indication for pyeloplasty versus nephrectomy
UPJO.
is mainly based on the results of repeated renal

ultrasonography (US) and diuretic renogram with SRF
Intraoperative: All patients in our study underwent
(4). Nephrectomy is usually recommended if SRF is
stented Anderson­Hynes dismembered pyeloplasty
less than 10 %. However, recent studies with long-
(with reduction of dilated renal pelvis).
term follow-up indicate that even with an initial SRF

1928
Received: 18/11/2021
Accepted: 16/01/2022

Full Paper (vol.871 paper# 155)


c:\work\Jor\vol871_156 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1932-1938

Common Breastfeeding Myths in Derna City in the North-Eastern Part of Libya
Abdullatif Mohammed Amneenah* and Mohamed A. Alshalwi
Pediatrics Department, Faculty of Medicine University of Derna
* Corresponding author: Abdullatif Mohammed Amneenah,
Mobile Phone: 00218913851536, E-mail: aemnaina@gmail.com

ABSTRACT
Background:
Breastfeeding's advantages are well-known, yet the percentage of women who choose to breastfeed
has been stagnant for decades. Providing neonates with the nutrition they need to grow and develop normally
requires breastfeeding.
Aim and objectives; to know how common breastfeeding myths among women in the child-bearing age in Derna
City are.
Subjects and methods: This cross-sectional study was conducted in Derna City in the north-eastern part of Libya,
the objective was to know how common breastfeeding myths among women are in the child-bearing age in this
city. The participants in this study comprised 1000 women in childbearing age.
Result: 72.8% of the participants had information about breastfeeding and the most frequent source of information
was family (64.7%). Meanwhile, 87% of the participants had children.
Conclusion: Women in Derna City in the north-eastern part of Libya have many breastfeeding myths, which
can lead to discontinuation of breastfeeding. Our study emphasizes the importance of supporting and educating
family members and society as a whole, rather than simply mothers, because everyone, whether directly or
indirectly, influences a mother's decision to breastfeed.
Keywords:
breastfeeding, myths, Libya.

INTRODUCTION

Questionnaire about breastfeeding
Despite the widespread acceptance of
1. How old are you?
breastfeeding's advantages, the prevalence of the
o below 20 years
practice has remained stagnant for decades. In order
o 20-30 years
to provide a good start in life for a child, breast milk
o 30-40 years
is the most common method of nutrition delivery.
o 40-50 years
Infants and early children are fed milk from a
o Over 50 years
woman's breast through breastfeeding, also known as
2. What is your educational level?
nursing (1).
o Not educated.
UNICEF and WHO recommend exclusive
o Primary school.
breastfeeding for the 1st six months of life, beginning
o Middle school.
in the 1st hour of a baby's life and continue for at least
o Secondary school.
the next two years, even after the introduction of
o University or higher institute.
nutritionally appropriate and safe supplementary
o Postgraduate degree.
meals (solids). WHO recommends breastfeeding on
3. Do you think you have enough information
demands that is as often as the child wants, day and
about breastfeeding?
night(2,3).
o Yes
There are many breastfeeding myths
o No
(misconceptions) in Libya and worldwide and they
4. If you have information about breastfeeding,
are responsible for discontinuation of breast-feeding.
what is its source?
These myths are deeply rooted and have an origin
o The family
related to people habits, social environment and
o Doctor
traditional cultural practices and beliefs (1).
o The school
Aim of the Work was to know how common
o Leaflets & Books
breastfeeding myths among women in child-bearing
o Internet & social media & Radio & TV
age in Derna City.
5. Do you Have Children?

o Yes
MATERIAL AND METHODOLOGY
o No
A cross sectional study was carried in Derna
6. Have you ever breastfed your baby?
City in the north-eastern part of Libya. Predesigned,
o Yes
closed-ended questions questionnaire (26 questions)
o No
was prepared and a thousand women in childbearing
7. How long did you breastfeed him or her?
age contributed in the study who were selected
o Less than 6 months
randomly. With inclusion criteria as childbearing age
o Between 6-12 months
women
o More than 12 months
1932
Received: 18/11/2021
Accepted: 16/01/2022

Full Paper (vol.871 paper# 156)


c:\work\Jor\vol871_157 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1939-1943

Association between Changes of Blood Indices, Ultrasound Parameters and the
Severity of Preeclampsia
Heba Farag Mohamed Salama*, Mohamed El-Sebaaey Antar, Mohamed Zakaria Sayer Dayer
Department of Obstetrics and Gynecology, Menoufia University, Menoufia, Egypt
*Corresponding author: Heba Farag Mohamed Salama, Mobile: (+20)01003570673, Email: hoba.salama22@gmail.com

ABSTRACT
Background:
Preeclampsia (PE) affects 2 to 8% of pregnancies with its enormous effect on maternal and newborn
morbidity. Placental dysfunction and placental hypoxia are thought to have systemic inflammation, and endothelial
dysfunction leading to increased neutrophil numbers and thrombocyte activation through different immunological
mechanisms.
Objective: Appraisal the changes occur in both platelet, white blood cell indices and ultrasound with preeclampsia.
Patients and methods: case control observational study conducted in Menoufia University Hospital started on May
2020, ended by May 2021. The study included 120 patients divided to group (A) 70 pregnant participants with PE and
group (B) 50 healthy pregnant participants. Venous blood sample was obtained and ultrasound examination for each
women was done.
Results: this study resulted in significant difference between both groups regarding the WBC indices (TLC, ANC,
ALC), platelets indices (PLT, MPV and PDW) and US parameters including the placental site and umbilical artery
Doppler (S/D and RI) (p-value < 0.05). Lateral placenta was presented in 25 cases of PE. There was statistical difference
in TLC, ALC, ANC and PLT in women with PE had lateral placenta than same group with other sites of placenta.
Conclusions: Blood indices (PLT, WBC) have been recognized as possible markers for predicting preeclampsia.
Especially if they are associated with lateral placenta.
Keywords:
Platelet indices, Preeclampsia and lateral placenta.

INTRODUCTION
Lateral placenta and its association with women
Pregnancy-induced hypertension represented the
developed PE was estimated in different studies
second cause of maternal death (9%­26%), coming
depending on the theories that in lateral placenta, the
after hemorrhagic disease(1). Preeclampsia defined as
uterine artery close to the placenta has lower resistance
new onset of hypertension and proteinuria after 20
than the opposite one, so the uteroplacental blood flow
weeks of pregnancy which affect 5­8% of pregnancies
have unequal contribution from both uterine arteries.
leading to more than 500 000 fetal deaths and 70 000
This is not found in case of central placenta by
maternal deaths each year(2).
ultrasound(8).
The pathological cause of preeclampsia is unclear
The aim of the present study was to appraisal the
but many theories about the endothelial dysfunction and
changes occur in both platelet, white blood cell indices
hemostatic changes due to underlying genetics and the
and ultrasound with preeclampsia.
epigenetics factors(3). There is a request for a low-cost

test and markers for early diagnosis and prognosis of
PATIENTS AND METHODS
PE, essentially in underdeveloped nations particularly
An observational study applied at Menoufia
in community health clinics where wide range of
University Hospital, Egypt started on May 2020 and
clinical presentations and early identification remains a
completed on May 2021.
challenge(4).
Each participant included in the study was
The leukocyte activation due to interactions of
pregnant woman attended the hospital at third trimester.
platelets with different cell types (endothelial, dendritic,
70 pregnant women (group A) were diagnosed with
T-lymphocytes,
neutrophils
and
mononuclear
preeclampsia by hypertension (systolic blood pressure
phagocytes) makes and exaggerates the inflammation in
>140 mmHg or diastolic blood pressure > 90 mmHg)
the arterial wall(5).
after 20 weeks of gestation in addition to proteinuria
Platelet
indices
represent
unpretentious
(presence of 300 mg or more of protein in 24 h urine
performed procedure in the clinical laboratory mainly in
sample or ++ on dipstick). Preeclampsia cases were
resource-limited hospitals. Different parameters are
considered mild or severe according to the diastolic
used to evaluate platelet activity like, platelet count
blood pressure of <110 or >110 mmHg(9). About 50
(PLT), mean platelet volume (MPV), and platelet
Healthy pregnant women (group B) attended the
distribution width (PDW) (6).
hospital at same time were added as control.
Impaired placental perfusion in PE and its adverse
Pregnant patients with obstetric history of
outcome can be predicted by ultrasound Doppler
habitual miscarriage, pre-term labor, intrauterine
analysis. Umbilical artery Doppler is the simple one
growth restriction, gestational diabetes or pre-
included in the evaluation but no complete data about
gestational DM, chronic hypertension, renal or liver
the most frequently altered Doppler parameters(7).
disorders, disseminated intravascular coagulation,
1939
Received: 18/11/2021
Accepted: 16/01/2022

Full Paper (vol.871 paper# 157)


c:\work\Jor\vol871_158 The Egyptian Journal of Hospital Medicine (April 2022) Vol. 87, Page 1944-1952

Role of Ophthalmic Artery Doppler in Prediction of Preeclampsia
Eman Ragab Selima, Ahmed Magdy Abar, Basma Abd Elmoneim Dessouky
Department of Radiology, Faculty of Medicine, Menoufia University, Egypt
*Corresponding author: Ahmed Magdy Abar, Mobile: (+20) 01005878552, E-Mail: abar.ahmed152@gmail.com

ABSTRACT
Background:
Preeclampsia (PE) is a crucial health issue that complicates roughly 10% of gestations and causes more
than 50,000 deaths yearly worldwide. Many studies have appeared in the recent decade attempting to utilize Doppler
study of the ophthalmic artery to anticipate the occurrence of preeclampsia and comparing its effectiveness to uterine
artery Doppler, which is now considered the most accurate method employed, with promising results of equal sensitivity
and specificity.
Objective: This study was designed to demonstrate the ability of changes in ophthalmic artery Doppler indices to predict
the progression of preeclampsia.
Patients and methods: This prospective study comprised 120 pregnant women in total. The control group who
remained normotensive throughout pregnancy included 96 women and those who developed preeclampsia
(preeclampsia group) comprised of 24 women (16 with mild preeclampsia and 8 with severe preeclampsia).Those with
severe preeclampsia had considerably higher ophthalmic artery PSV (P1), 2nd systolic peak (P2), peak ratio (p2/p1),
and EDV than patients who remained normotensive.
Results: Ophthalmic artery PI had sensitivity of 89.7% and specificity of 75.12% at cutoff value < 1.76 in predicting
pre-eclampsia. Also, ophthalmic artery RI had sensitivity of 80.2% and specificity of 74.9% at cutoff value < 0.77 in
predicting pre-eclampsia. Peak Ratio (PR) of the ophthalmic artery had sensitivity of 77.3% and specificity of 65.8% at
cutoff value > 0.59 in predicting pre-eclampsia. In addition, 2nd systolic peak (P2) ophthalmic artery had sensitivity of
91.7% and specificity of 61.7% at cutoff value > 20.1 in prophesying pre-eclampsia.
Conclusion: Doppler of the ophthalmic artery is an easy, reliable and unbiased technique with a standalone predictive
diagnostic value for the development of PE and a promising excellent imaging procedure as the area under the curve for