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   Table of Contents - Current issue
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April-June 2020
Volume 33 | Issue 2
Page Nos. 333-722

Online since Saturday, June 27, 2020

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OTORHINOLARYNGOLOGY - REVIEW ARTICLE  

Role of steroids injection in treatment of minimal associated pathological lesions Highly accessed article p. 333
Mohamed Baraka, Hossam El-Dessouky, Essam A Behiry, Eman Ezzat, Reham M El-Ashry
DOI:10.4103/mmj.mmj_167_18  
Objectives This review aims to determine the effectiveness of glucocorticoids local intralesional injection in the treatment of minimal associated pathological lesions and counter its adverse effects and possible complications Data sources Medline databases (PubMed, laryngoscope, Arch Otoloaryngol Head Neck Surg, Journal of Voice) using the terms 'Steroid' or 'Dexamethasone' with the word 'Vocal fold' as a search criteria. Resulting materials are available in the internet from 1983 to 2017. Study selection This search presented 40 articles. The researches that met the inclusion criteria were six articles. The articles studied the Steroids Injection in Treatment of Vocal Folds Lesions. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls used, adequate information collected, and assessment measures defined. Data synthesis Significant data were collected. It was heterogeneous. Thus, a structured review was performed with the results tabulated. Conclusion Treatment for minimal associated pathological lesions generally initiates with the behavioral modification of phonation habits. When conservative managements fail, laryngeal microsurgery might represent the only available treatment option. However, potential adverse effects following the laryngeal suspension include injury to the teeth or cervical spine or tongue paresthesia. Besides, violation of the layered structure of the vocal fold during surgery can also result in fibrosis of the lamina propria. Vocal fold steroid injection might provide an alternative treatment option for benign lesions of the vocal folds.
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ANESTHESIOLOGY - REVIEW ARTICLES Top

Analgesia and sedation for patients in the intensive care unit: a systematic review p. 339
Nagwa M Doha, Tarek A El-Henawy, Moaaz M Mohammed
DOI:10.4103/mmj.mmj_417_18  
Objective To review the importance of sedation and analgesia in the ICU. Data sources A systematic search of MEDLINE (PubMed, Medscape, ScienceDirect, EMF-Portal) and internet was conducted on all articles published from 1974 to 2016. Study selection English language reports on the importance of sedation and analgesia in the ICU. The initial search presented 157 articles, where 23 had inclusion criteria. Data extraction Articles not reporting on the importance of sedation and analgesia in the ICU in the title or abstract were not included. Five independent investigators extracted data on the methods. Data synthesis Comparisons were made by a structured review with the results tabulated. Seven studies about the importance of the role of sedation and analgesia in the ICU, eight about assessing the adequacy of sedation, and eight about the strategies for administering sedatives in the ICU. Findings Pain perception varies according to the various factors including personality, cultural background, surroundings, and fear. It has been associated with the detrimental effects on sleep, agitation, and stress response. Anxiety is also brought about by continuous noise within the ICU. Patients in the ICU may also suffer from insomnia caused by a loss of normal melatonin secretion. Newer sedation scales are reported to show improvements in validity and reliability. Propofol may be associated with a more rapid wake-up than benzodiazepines. Conclusion Sedation is an important component of the treatment of mechanically ventilated, critically ill patients. Directing treatment to specific and individualized goals will assure that the patient needs are met. The use of a spontaneous waking trial, followed, when possible, by a spontaneous breathing trial, should be implemented widely in the care of critically ill patients requiring mechanical ventilation.
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The effect of general anesthesia on geriatric patients' cognitive function p. 346
Ezz Eldeen S. Mohamed, Elham E Elfeky, Amal I Abd-Elrahman, Ahmed S Gendy
DOI:10.4103/mmj.mmj_288_19  
Objective The objective of this study was to review how these effects of general anesthesia affect geriatric patients' cognitive function and the precautions taken by anesthesiologists to reduce these effects. Data analysis A systematic search of MEDLINE (PubMed, Medscape, Science Direct, Journal of Clinical Anesthesia, ASA Publications, The Open Anesthesia Journal) and also of the materials available on the internet was carried out. The search was performed in the electronic databases in the English language only from 2003 to 2019. Study selection The initial search presented 150 articles of which 40 met the inclusion criteria. The articles studied the effect of general anesthesia on geriatric patients' cognitive function. Data extraction Articles not reporting on the effect of general anesthesia on geriatric patients' cognitive function in the title or abstract were not included. Four independent investigators extracted data on methods, health outcomes and traditional protocol. Data synthesis Data were synthesized qualitatively, and we did not perform a quantitative data analysis. Findings Multiple studies have found that postoperative cognitive disorders including delirium and postoperative cognitive dysfunction are common postanesthesia complications in elderly patients. Conclusion As the population ages, the number of geriatric patients undergoing surgery is increasing and, with it, the prevalence of postoperative cognitive disorders. Postoperative cognitive disorders including delirium and postoperative cognitive dysfunction are common postanesthesia complications in elderly patients. Several risk factors for postoperative disorders have been identified, and anesthesiologists usually adapt their practice habits when taking care of elderly patients to try to reduce the effects of the anesthetics on postoperative cognitive functions.
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OTORHINOLARYNGOLOGY - ORIGINAL ARTICLES Top

Development of the Arabic version of the Vertigo Symptom Scale-Short Form: Validity and reliability p. 351
Hossam Sanyelbahaa Talaat, Ahmed Mahmoud Zein El Abedein, Mariam Elsayed Gad
DOI:10.4103/mmj.mmj_31_19  
Objectives To translate the vertigo Symptom Scale-Short Form (VSS-SF) into Arabic and cross-cultural adaptation along with examining its validity and reliability. Background The VSS-SF is a common self-assessment dizziness questionnaire that assesses aspects of vertigo and vertigo-related anxiety which has two subscales: vestibular/balance subscale and autonomic/anxiety subscale. The VSS-SF can differentiate between a pure vestibular disorder and vertigo associated with anxiety. Patients and methods The VSS-SF was translated into Arabic and then cross-cultural adaptation was carried out. The questionnaire was completed by: study group (n = 60) patients diagnosed with vestibular disorders and healthy participants with no history of vertigo (n = 120). Internal consistency and test–retest reliability of the scale were examined by Cronbach's α and Spearman's correlation coefficients subsequently. Discriminant validity of the scale was examined by the Mann–Whitney U test and the receiver-operating characteristic curve. Results The Arabic VSS-SF showed good reliability for the total scale and its subscales with Cronbach's α coefficients (range, 0.716–0.880). Test–retest correlation showed high repeatability of the Arabic VSS-SF total score and its subscales such as Spearman's coefficient (range, 0.985–0.988). The Arabic VSS-SF discriminative ability was excellent to discriminate between the study group and healthy individuals using the Mann–Whitney test (P < 0.001). Conclusion The Arabic version of VSS-SF is a valid and reliable tool that is able to differentiate between dizzy patients and healthy people and patients with pure vestibular symptoms and patients with comorbid anxiety, in the Arabic populations.
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Arabization and validation of the complete intelligibility spatiality quality questionnaire p. 357
Hossam S Talaat, Marian M Mina, Ahmed M Zein El-Abedein
DOI:10.4103/mmj.mmj_397_19  
Objectives To translate complete intelligibility spatiality quality (CISQ) questionnaire into Arabic language. Background CISQ is a new questionnaire used to evaluate hearing aid benefit in patients with hearing loss. Patients and method The original Italian version was converted into English version and then translated to Arabic. The finished translation of the Arabic CISQ process was applied to 170 patients (100 normal not complaining of hearing loss as control and 70 patients with history of hearing loss before using hearing aids and after 2–3 months of using hearing aids). The questionnaire's reliability and validity were assessed. Receiver operating characteristic curve and independent t test were also applied. Results The Arabic CISQ showed high internal consistency reliability coefficients with Cronbach's alpha. Test–retest correspondence was done following the first visit by 1 week for all items of the questionnaire for study and control groups. The questionnaire repeatability was high for Arabic CISQ using paired t test correlation for both groups correspondingly. The use of independent t test showed to a significant difference between both groups regarding the mean of each question and the total score of the Arabic CISQ, which was higher in cases with hearing aid than cases without hearing aid (P < 0.001). Conclusion The Arabic version of the CISQ questionnaire is a dependable convincing tool to estimate the benefit of hearing aid on the quality of life of people with hearing loss in Egyptian and Arab populations.
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Standardization of the Arabic version of Beck anxiety inventory in Egyptian population p. 361
Hossam S Talaat, Enas I Abdelfatah, Ahmed M. Z. El Abedein
DOI:10.4103/mmj.mmj_6_20  
Objective The aim was to diagnose anxiety in patients with tinnitus using Beck anxiety inventory (BAI) after modification and standardization on the Egyptian population. Background Tinnitus is a common complaint that can affect life aspects, such as emotions, increasing anxiety. Early diagnosis of anxiety helps treatment of tinnitus. The aim of this study was to standardize the Arabic version of BAI in the Egyptians and apply the standardized form on patients with tinnitus. Patients and methods BAI was modified to suite Egyptians. It was backtranslated and judged by an expert committee. It was then applied on 100 healthy adult participants, and then on 30 patients with anxiety for standardization. It was then applied on 30 patients with tinnitus for diagnosis. Examination of reliability and the validity was done. The authors used the receiver operating characteristic curve for getting the possible cutoff value. Results It showed a good reliability by Cronbach's α of 0.73 among controls and patients with anxiety and 0.84 among patients with tinnitus. Test-retest reliability was done after 1 week. Repeatability was significant for the total score using Spearman's correlation. The mean value of the items of Arabic BAI was higher among patients than controls. The discriminant validity found that patients with tinnitus and patients with anxiety scored higher than controls. The authors found that 73.3% of patients with tinnitus experienced anxiety. Conclusion This study confirms that anxiety is a commonly associated complaint with patients with tinnitus. The modified-Arabic version of BAI was found to be a reliable and effective scale for diagnosis of anxiety among Egyptians.
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Nasal headache Highly accessed article p. 367
Abdel-Latif I El-Rashidy, Ayman E Abo El-Enin, Heba A Abo El-Naga, Reiham B Abo Hiba
DOI:10.4103/mmj.mmj_155_16  
Objective Identification of diagnosis and treatment of headache due to nasal pathology using subjective and objective criteria. Background Headache is a very common manifestation that is nearly universal in the course of everyone's life, due to nasal pathology (nasal headache), or due to other causes (nonrhinogenic headache). Patients and methods This prospective study was conducted among 225 patients with a symptomatic headache. All studied patients underwent otorhinolaryngologic examination and computed tomography scan for nasal/paranasal sinuses. After consultation with a neurologist, ophthalmologist, dentist, internist, and other related specialist, the patients were divided into two groups, A and B, as regards the origin of headache. Group A included nonrhinogenic headache cases, while group B included nasal headache cases (represent the core of this study). The mean, SD, and χ2-test was performed by the Statistical Package for the Social Sciences program for Windows, version 20.P values of less than 0.05 were considered statistically significant. Results Group A included 125 nonrhinogenic headache cases, while group B included 100 nasal headache cases which were classified according to the cause of nasal headache regarding age and sex distribution, associated symptoms, response to medical and surgical treatment, whereasP values were 0.014, 0.155, less than 0.0001, less than 0.0001, and 0.195, respectively. Conclusion Nasal pathology is the most common cause of headaches. Rhinosinusitis, allergic rhinitis, and deviated nasal septum, respectively, are the most common causes of nasal headaches.
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Effect of cochlear implantation on the cervical vestibular evoked myogenic potentials p. 375
Abdel-Latif El-Rasheedy, Ahmed Khashaba, Waled Ezzat, Yasser Nafie, Ahmed Elshafai
DOI:10.4103/mmj.mmj_538_15  
Objective The aim was to evaluate the effect of cochlear implantation (CI) on the cervical vestibular-evoked myogenic potentials (cVEMP), and to examine the correlation between the different approaches of CI and vestibular insult. Background The function of the CI is to bypass the damaged or missing cochlear structures by exciting neurons in the auditory nerve directly with electrical stimuli. Although studies have shown that CI is effective and safe, the potential effects on vestibular function are of clinical concern. Patients and methods Twenty patients with bilateral sensorineural hearing loss subjected to CI surgery by two different surgical techniques (11 with posterior tympanotomy approach, nine with transcanal approach) were enrolled in the study. The patients were subjected to preoperative evaluation of the vestibular function with cVEMP. Revaluation of the vestibular function with the same test was done 2–3 months postoperatively. Results cVEMP results revealed that 7/20 (35%) had abnormal responses preoperatively. There was significant difference between cVEMP results preoperatively and postoperatively where nine patients out of 13 patients (69%) lost cVEMP response postoperatively (P = 0.004). There was no significant difference between the two different surgical approaches used during the study. cVEMP was normal postoperatively when the round window insertion technique was used (80%), while there was loss of cVEMP response postoperatively in all patients (100%) with bony cochleostomy insertion. Conclusion Vestibular system function deficit was found in 69% of CI children as measured by cVEMP postoperatively. There was no significant difference between the classic posterior tympanotomy approach and the transcanal approach regarding the vestibular deficit. Insertion of electrodes through the round window carries less harmful effects to the vestibular system (20%), than insertion through cochleostomy (100%).
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Foreign body aspiration in children: what is variant in management? p. 381
Adel T Atallah, Essam A Beheiry, Ibrahim A Abdel-Shafy, Khaled M Zamzam, Mennat-Allah G El-Dahshan
DOI:10.4103/mmj.mmj_203_19  
Objective To evaluate children with foreign body aspiration (FBA) according to its incidence in pediatric, diagnostic tools, and the effectiveness of rigid bronchoscope. Background FBA is an important cause of morbidity and mortality in pediatrics. Management depends on the acuity of the presentation. Patients with evidence of complete upper airway obstruction should have age-appropriate basic life support maneuvers performed. Patients with partial obstruction who are able to maintain their airway but with potential for deterioration should be taken immediately to the operating room for removal whenever possible. Patients and methods In this prospective case series study, patients with suspected FBA up to 12 years old; presented to the Department of Otorhinolaryngology in Menoufia University Hospital in a period between April 2017 and September 2018 were enrolled to our work. Results Our study included 45 patients with different age groups prepared for bronchoscopic extraction. 43.9% of patients had right-sided foreign body (FB). Overall complications rate was 21.875%. These complications include hemoptysis, hoarseness of voice, laryngeal spasm, pulmonary edema, and temporary bronchospasm. Only one case failed to extract its FB. Conclusion It is concluded that the FB extraction in children occurred more for whom with low socioeconomic standard and higher number of siblings in one family. Rigid bronchoscope is used as diagnostic and therapeutic tool for patients with FBA to that could not be detected in radiological study.
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OBSTETRICS AND GYNECOLOGY - ORIGINAL ARTICLES Top

Ovulation triggers in infertility p. 387
Saeed A Saleh, Haitham A Aboali, Heba T M El-Rakhawy
DOI:10.4103/mmj.mmj_158_19  
Objective To compare the effect of oxytocin (OXT) versus human chorionic gonadotropin (HCG) versus combination of both on ovulation triggering. Background HCG has been used as an alternative to luteinizing hormone for triggering ovulation. HCG has high cost and needs close monitoring. In this study, we try to clarify the possible role of OXT as an alternative to HCG for triggering ovulation. Patients and methods A randomized controlled clinical trial was carried out on 108 infertile women with anovulation or oligo-ovulation; each of them received 100-mg clomiphene citrate from the second to the sixth day of the cycle and were monitored by transvaginal sonography. They were randomly divided into four groups: group 1 received 10 000 IU HCG, group 2 received 10 IU OXT, group 3 received both of them, and group 4 did not receive any triggering medication. Results There was significant difference regarding ovulation between studied groups and control (33.3%). There was no significant difference in ovulation between HCG group versus OXT group (χ2 = 0.83,P= 0.362), HCG group versus combination group (χ2 = 0.11,P= 0.735) and OXT group versus combination group (χ2 = 1.54,P= 0.214). There were statistically significant high plasma progesterone levels between studied groups and control (P = 0.001). There was significant difference in pain sensation between HCG group versus OXT and combination groups (P = 0.001). Conclusion OXT is suggested to be used alone or in combination with HCG for triggering ovulation.
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Continuous versus interrupted sutures for repair of episiotomy using monofilament versus synthetic absorbable multifilament suture materials: a randomized controlled trial p. 392
Ayman Abd El-Kader Shabana, Tarek M Sayyed, Ehab M El-Mallah, Mohamed Abd El-Monem Mobarak
DOI:10.4103/mmj.mmj_394_15  
Objective To compare different repair techniques and different suture materials for episiotomy. Background Care of the perineum during and after childbirth has been a topic of considerable interest to all involved for many years. A considerable amount of research has been carried out in the area of perineal care, particularly in relation to the practice of performing episiotomy and to the methods of suturing. Patients and methods A total of 90 primigravidae were admitted for labor and underwent a mediolateral episiotomy after vaginal delivery. They were randomly allocated into four groups in which continuous and interrupted episiotomy repair techniques were performed under two different types of suture materials, that is, monofilament type in the form of poliglecaprone 25 and multifilament type in the form of polyglactin 910. Perineal pain during different activities on the first and seventh day postpartum was questioned by visual analog scale, and the presence of perineal pain after 3 months of delivery, repair time, amount of suture material, and episiotomy complications were investigated in each group. Results The results of the present study showed that the assessments of pain in the first day and after 1 week in movement, repose, sitting, urination, and defecation were insignificant regarding suture techniques and suture materials. The repair time and the length of suture material were statistically less in the continuous technique groups. The type of suture material did not show significant effect on either the length of suture material used or the episiotomy repair time. Conclusion The use of continuous technique of episiotomy repair is better than interrupted technique, because the former is quicker and cheaper as less suture material is used with no differences on either short-term or long-term morbidity.
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Hysteroscopy versus transvaginal ultrasound in infertile women prior to intracytoplasmic sperm injection p. 400
Mohammed A Kandeel, Tarek M Sayyed, Ahmed M Tharwat, Amal S Hamed
DOI:10.4103/mmj.mmj_284_19  
Objective The aim of this study was to compare the efficacy of transvaginal sonography (TVS) and hysteroscopy regarding the diagnosis of uterine cavity pathologies in a population of infertile women. Background The presence of uterine pathology may negatively affect the chance of implantation. Patients and methods A cross-sectional study at the Department of Obstetrics and Gynaecology at Menoufia University Hospital between March 2018 and March 2019 on 60 women who underwent TVS in the early follicular phase for detection of any uterine cavity abnormalities, followed by diagnostic hysteroscopy for all cases. Results The study included 60 women in the age range of 20–39 years. All cases were divided into two groups, women who were scheduled for first-time in-vitro fertilization (number 52) and women for recurrent in-vitro fertilization (number 8). The cases of primary infertility constituted 46.6% of all participants and 53.3% of cases were of secondary infertility. The abnormal uterine cavity was detected in about 25% of cases evaluated by TVS versus 45% of cases evaluated by hysteroscopy. Using hysteroscopy the most common uterine pathology was endometrial polyp which constituted 18.3% of all cases. TVS missed the diagnosis of 12 cases, three cases of polyps, two case of submucous fibroids, five cases of intrauterine septum, and two cases of intrauterine adhesions in comparison with diagnostic hysteroscopy. Conclusion Diagnostic hysteroscopy is superior to TVS in the diagnosis of intrauterine pathology. Office hysteroscopy takes little time comparable to TVS with little or no complications in experienced skilled hands. TVS has many screening parameters in the detection of polyps and submucous fibroids.
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Effect of clomiphene citrate, tamoxifen, and letrozole on endometrial thickness in cycles of ovulation induction: a randomized controlled trial p. 405
Mehany Mahmoud Abdel Sattar, Alaa ElDin F. El-Halaby, El-Sayed Ahmed El-Shamy, Sally Nagah Taha
DOI:10.4103/mmj.mmj_427_18  
Objectives To compare the effect of clomiphene citrate, tamoxifen, and letrozole on endometrial thickness in anovulatory cycles. Background Infertility is frequently caused by anovulation. The affected women were presented with irregular menstrual cycles and the most common diagnosis was polycystic ovary syndrome. Ovulation induction is commonly used to treat these women. We compare between the three drugs to conclude their efficacy on endometrial thickness, number of follicles, and clinical pregnancy rate. Patients and methods This prospective study was done in Talkha Hospital. One hundred infertile cases meeting the selection criteria especially patients with polycystic ovarian syndrome were included. They were randomized into three groups. Group A (n = 34) took 100 mg clomiphene citrate, group B (n = 33) took 5 mg letrozole, and group C (n = 33) took 40 mg tamoxifen from day 2 to day 6 of the cycle, once after breakfast for three cycles. The outcome measure was endometrial thickness, number of follicles, and clinical pregnancy rate. Results Endometrial thickness was higher in groups B and C than group A, higher number of follicles in group A with no difference regarding the clinical pregnancy rate between the three groups. Conclusion Groups B and C had better effect on endometrial thickness than group A although it had higher number of follicles, clinical pregnancy rate increased with group B than groups A and C.
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The necessity of urethral catheterization in repeated versus primary cesarean section p. 410
Fatheia S Mohamed, Mohamed M Fahmy, Alaa El Deen F. El Halaby, Nabih I El Khouly
DOI:10.4103/mmj.mmj_12_19  
Objectives To determine the necessity and safety of urethral catheterization in repeated versus primary cesarean section as it is not addressed clearly in the previous literature. Background Urethral catheterization is done as a routine procedure in a cesarean section. It is associated with high incidence of urinary tract infections, discomfort, delayed ambulation, and longer hospital stay. Patients and methods This randomized, controlled trial was carried out from April 2016 to October 2018; the study was conducted at Menoufia University Hospital, Obstetrics and Gynecology Department, the patients were recruited from the inward section. The study included 200 patients who were subjected to a cesarean section. After the selection of all patients, informed consent was obtained from all the participants. Ethics committee approval was obtained prior to the start of the study. The patients were randomly allocated by using a computer-generated random number table to either catheterized or noncatheterized. Results There were highly significant differences between primary and repeated cesarean sections with and without catheter as regards urine culture and sensitivity, signs and symptoms of urinary tract infection, first ambulation, and first voiding discomfort (P < 0.001), while there was no significant difference between them as regards the time of surgery and Postpartum hemorrhage (PPH) and there was no significant difference between them as regards age, gestational age, urine retention, bladder injury, and blood loss (P = 0.005). Conclusion Routine placement of indwelling urinary catheters for cesarean delivery in hemodynamically stable patients is not necessary and can be harmful. Moreover, the women needing catheterization should be selectively chosen. Thus, it should be selective catheterization rather than catheterization for all.
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Ectopic pregnancy at a teaching hospital, Nigeria: an analysis of presentation and risk factors p. 415
Collins E. M. Okoror, Benjamin O Uhunmwangho, Osayomore Idemudia
DOI:10.4103/mmj.mmj_21_19  
Objective The aim of this study was to determine and evaluate the incidence, clinical presentation and risk factors of ectopic pregnancies. Background Ectopic pregnancy is a life-threatening gynaecological emergency, and a significant cause of maternal morbidity and mortality in Nigeria. Patients and methods This was a retrospective, descriptive study of ectopic pregnancies managed during the study period (1 January 2009 to 31 December 2013). The medical records of the patients managed for ectopic pregnancy as well as the total birth record and gynaecological admission records during the period under review were retrieved, and data were collected. There were 3719 gynaecological admissions and 14 150 deliveries, with 121 cases of ectopic pregnancies. A total of 115 cases were suitable for analysis after excluding cases with incomplete and missing records. The relevant data collected were analysed with simple descriptive statistics and presented in frequency charts and tables. Results Ectopic pregnancy constituted 3.25% of all gynaecological admissions, and its incidence was 0.86%. The mean age of the patients was 28.6 ± 6.6 years. The common (99 of 115, 86.09%) clinical presentation was abdominal pain, and the commonly (79 of 115, 68.70%) identified risk factor was a previous history of miscarriage. Conclusion Ectopic pregnancy is a recognised cause of maternal morbidity and mortality and has remained a reproductive health challenge to Nigerian women, as well as a threat to efforts in achieving the United Nations Sustainable Development Goal 3 in sub-Saharan Africa.
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Comparison between transvaginal and transabdominal ultrasound-guided embryo transfer: a randomized, prospective trial p. 419
Ahmed A Samy, Yasser S El-Kassar, Shreef S Gaafar, Haitham A Hamza, Shreef S Menshawi
DOI:10.4103/mmj.mmj_24_19  
Objective The aim of this study was to compare between transvaginal ultrasound (TVS) and transabdominal ultrasound (TAS)-guided embryo transfer (ET) as regards clinical pregnancy rate, patient discomfort, time required for ET, and endometrial visualization during ET. Background ET is an operator, and equipment-dependent procedure. Ultrasound-guided ET allows placing embryos at the desired level within the endometrial cavity. Patients and methods This randomized, prospective trial included 178 infertile couples from Al Shatbi Reproductive Gynecology Unit in Alexandria University Hospital, during the period between June 2016 and May 2018. The patients were divided randomly prior to ET into two equal groups: the first group used TAS guidance for ET and the second group used the TVS guidance for ET. Results The clinical pregnancy rate showed no statistical differences in both groups: 39/89 (43.8%) versus 42/89 (47.2%) (P = 0.652). The mean discomfort intensity during ET was significantly higher in TAS-guided ET group (1.81 ± 1.03 vs. 1.50 ± 0.92) (P = 0.040). The ET took longer time in the transvaginal group. Median 66.0 versus 60.0 s in the transabdominal group (P = 0.125). The optimal endometrial visualization during ET was statistically higher in the transvaginal group: 25 (28.1%) and 45 (50.6%) (P = 0.002). Conclusion There was no significant difference between TVS-guided ET and TAS-guided ET as regards the clinical pregnancy rate. Although the TVS-guided ET took longer time, it allowed less patient discomfort and better endometrial visualization during ET.
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Regain of gastrointestinal motility after general anesthesia versus spinal anesthesia in a cesarean section p. 427
Mehanny M Abd El-Sattar, Mohammed A Rezk, Ahmed M Nofal, Ahmed H Hashish
DOI:10.4103/mmj.mmj_44_19  
Objective The objective of the study was to compare the effect of spinal and general anesthesia in return of gastrointestinal motility in an elective cesarean section (CS). Background CS is a common major hospital surgical procedure performed nowadays. One of the most common postoperative complications is postoperative gastrointestinal paralysis (ileus) that must be minimized due to its possible serious consequences. Patients and methods One hunderd and forty pregnant women who were admitted for CS and fulfilled the criteria of the study population were enlisted in this prospective, controlled study and were then assigned to either group A or B. Group A included 70 patients for general anesthesia, while group B included 70 patients for spinal anesthesia. Results This study results were shown to have a statistically significant effect of spinal anesthesia versus general anesthesia in terms of shorter mean time interval to normal intestinal sound, passage of flatus, first motion, and discharge from hospital. Also, the study showed beneficial effect of spinal anesthesia versus general anesthesia in terms of less use of opioids, less use of NSAIDs, less incidence of distension, and less incidence of ileus. Conclusion Spinal anesthesia results in a quicker return of bowel activity after a CS, decreased hospital stay, and less use of postoperative opioids than general anesthesia.
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Effects of metformin alone and in combination with spironolactone on hyperandrogenism in polycystic ovarian syndrome Highly accessed article p. 433
Nasser K Abd Elaal, Hamed E Ellakwa, Alaa Eldeen F. El Halaby, Shaza S Maklad
DOI:10.4103/mmj.mmj_61_19  
Objective To evaluate the efficacy of combined therapy with metformin and low-dose spironolactone as compared with metformin alone on the clinical and endocrine-metabolic alterations of patients with polycystic ovarian syndrome (PCOS). Background PCOS is the most common endocrinological disorder in reproductive-age women. Thus, at least theoretically, metformin plus spironolactone therapy may be an effective and safe combination for PCOS. Patients and methods A prospective randomized comparative study was carried out on 48 patients with the PCOS in Obstetrics and Gynecology Department, Menoufia University Hospital, and Al-Shohadaa Hospital, Egypt, from the period of May 2016 till January 2018. Detailed history, laboratory investigations, obstetric examination, and follow-up were done. Results Mean hirsutism score and BMI (kg/m2) were 10.8 ± 3.9 and 26.8 ± 2.2, respectively, before treatment, which decreased significantly to 7.6 ± 2.4 and 22.10 ± 1.92, respectively, after 6 months of treatment. Luteinizing hormone, follicle-stimulating hormone, free testosterone, dehydroepiandrosterone sulfate, fasting glucose, fasting insulin, and homeostasis model assessment of insulin resistance were decreased significantly after 6 months of treatment as compared with before treatment among women who received metformin + hypocaloric diet and received metformin + spironolactone + hypocaloric diet before treatment. Free testosterone was decreased in group B (58.2 ± 9.1) more than group A (73.6 ± 12. 9). Conclusion The results confirm the beneficial effects of metformin in patients with PCOS. It also proves that the addition of low-dose spironolactone induces a more marked reduction of clinical and biochemical hyperandrogenism in patients with PCOS present with hyperandrogenic conditions.
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Predicting successful use of post-placental intrauterine contraceptive device by ultrasound p. 440
Mohamed A Emarah, Emad E. A. Soliman, Haitham A Aboali, Sara E Hasan
DOI:10.4103/mmj.mmj_76_19  
Objective To assess the role of ultrasound in predicting the successful insertion of intrauterine contraceptive device (IUD) immediately after delivery. Background Waiting until the 6-week postpartum visit to initiate a method of birth control puts women at risk for unintended pregnancy. Patients and methods A single experienced doctor measured the distance from each wall of the uterus to the body of the IUD and from the lower edge of the IUD to the internal cervical OS following delivery and again at 6 weeks following delivery in women who received a postpartum IUD and then compared in unsuccessful and successful cases of postvaginal delivery (PVD) and postcesarean section (PCS) IUD insertion. The difference in success between the two modes of delivery and the optimal cutoff distance for successful retention were assessed using logistic regression and receiver-operating characteristics curve analysis, respectively. Results One hundred women, comprising 63 PVD and 37 PCS IUD insertions, were recruited. Eleven PVD and eight PCS IUDs were either expelled or extracted due to improper placement at the 6-week visit. The mean difference between the distance from the internal OS to the lower end of the IUD in successful versus unsuccessful cases was 8.91 ± 5.64 and 11.77 ± 5.25 mm (P < 0.001) in PVD and PCS insertions, respectively. This distance at the discharge scan was moderately accurate in predicting retention of the IUD, with an area under the curve of 0.72 (sensitivity, 73%; specificity, 83%). Conclusion Ultrasound could be considered for predicting the success of IUD retention after delivery.
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Association between first-trimester maternal level of pregnancy-associated plasma protein-A and adverse pregnancy outcomes p. 445
Mohamed M Fahmy, Abeer M Mohie-Aldeen, Tarek M Sayyed, Samar M Shehata
DOI:10.4103/mmj.mmj_128_19  
Objectives To study the association between low first-trimester pregnancy-associated plasma protein-A (PAPP-A) and adverse pregnancy outcomes. Background PAPP-A is produced by the placenta during pregnancy. Low plasma level of this protein has been suggested as a biochemical marker for pregnancies with aneuploidy fetuses. Other studies found associations between low PAPP-A and adverse pregnancy outcomes during the first-trimester screening. Patients and methods The present study was conducted at Al-Amrya General Hospital, Gynecology and Obstetrics Department, after informed consent from participants was taken. The research ethics committee at Faculty of Medicine, Menoufia University, approved it. The study included 90 pregnant women booked for routine antenatal care while they were in their first-trimester after fulfilling the inclusion criteria. A blood sample (3–4 ml of venous blood) was withdrawn from all study participants. Then, samples were collected in plain tubes, followed by centrifugation of the samples, where the sera were collected for PAPP-A assay and stored at −20°C. Actual assay of PAPP-A would not be done except after development of any of adverse pregnancy outcome, including preeclampsia, gestational hypertension, intrauterine growth restriction, intrauterine fetal death, or spontaneous preterm. Results There is an association between low PAPP-A less than or equal to 0.41 in the first-trimester and development of adverse pregnancy outcomes. Conclusion Maternal serum PAPP-A level was significantly lower during the first-trimester in women who developed adverse pregnancy outcomes than women who did not develop.
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Cystatin C and β2 microglobulin in preeclampsia: a prospective study p. 452
Mohamed A Elsayed, Hamed E Ellakwa, Haitham A Hamza, Ahmed A Sonbol, Mohamed S. A. Soliman
DOI:10.4103/mmj.mmj_135_19  
Objective To study the plasma levels of β-2-microglobulin (β2M) and cystatin C in patients with preeclampsia. Background The plasma level of cystatin C has been reported to have a better diagnostic performance for diagnosing preeclampsia. Patients and methods A prospective case–control study was carried out on 20 women diagnosed as having preeclampsia as well as 20 pregnant healthy. All patients attended the Obstetrics and Gynecology Department and outpatient clinic of Menoufia University Hospital, Menoufia Governorate, and Suez Insurance Hospital, Suez Governorate, during the study period from December 2016 to November 2017. Full history, routine, physical examination, and other investigations were taken. Results Mean antepartum and postpartum serum cystatin C, mean antepartum and postpartum serum β2M, albuminuria, and creatinine were increased significantly in preeclamptic patient group than the normal pregnancy group. The mean serum level of cystatin C before delivery was 1.78 ± 0.58 and 1.19 ± 0.32, which reduced significantly to 1.31 ± 0.49 and 0.91 ± 0.18 after delivery among preeclamptic patient and normotensive pregnancy groups, respectively. The mean serum level of β2M before delivery was 2.49 ± 0.56 and 1.92 ± 0.64, which reduced significantly to 1.98 ± 0.43 and 1.58 ± 0.49 after delivery among preeclamptic patients and normotensive pregnancy group, respectively. Conclusion Maternal serum cystatin C and β2M concentrations were significantly higher in preeclampsia compared with the normotensives. Cystatin C and β2M can be used as significant and independent predictive factors affecting the occurrence of preeclampsia.
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Comparative study of cesarean section in secondary and tertiary healthcare levels p. 458
Mohamed M Fahmy, Alaa F Al Halaby, Hala M Gabr, Heba F Salama, Abdullah G Arafat
DOI:10.4103/mmj.mmj_144_19  
Objective To clarify the prevalence of cesarean section (CS) in Menoufia University Hospital and Menouf General Hospital regarding the rate, indications, and complications of CS. Background CS rate is rising worldwide with increasing concern especially in developed countries. It is associated with higher maternal and neonatal morbidity. Patients and methods This was a retrospective analytical study. The rates of CS in both Menoufia University Hospital and Menouf General Hospital were reviewed from 2013 to 2017, and detailed patient records in both hospitals were reviewed from January 2017 to December 2017. Robson Ten Group Classification System was applied to categorize the different indications of CS. Results There was a significant rise in CS rate in both hospitals every year. In Menoufia University Hospital, it increased from 48.50% in 2013 to 59.43% in 2017, and in Menouf General Hospital, it increased from 45.95% in 2013 to 53.50% in 2017. The most common indication in both hospitals was a previous CS. According to Robson Ten Group Classification System, the most common group in both hospitals was group five. The most common maternal complication in both hospitals was postpartum hemorrhage, but the rate of cesarean hysterectomy was more common in Menoufia University Hospital. Wound sepsis was more common in Menouf General Hospital than Menoufia University Hospital. Conclusion Rate of CS in Menoufia University Hospital is higher than Menouf General Hospital owing to its nature as a tertiary care and referral hospital for difficult and complicated cases.
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Early versus delayed amniotomy after vaginal misoprostol for labor induction in nulliparous women p. 464
Ayman Shabbana, Alaa Alhalabi, Nabih Elkhouly, Mohamed El-Sibai, Hager A. A. Youssif
DOI:10.4103/mmj.mmj_151_19  
Objectives To compare between the effectiveness and safety of early versus delayed amniotomy after vaginal misoprostol for the induction of labor. Background The aim of successful induction of labor is to achieve vaginal delivery when continuation of pregnancy presents a threat to the life or well-being of the mother or fetus. The process of induction of labor should only be considered when vaginal delivery is felt to be the appropriate route of delivery. Patients and methods A randomized, clinical trial that included 80 nulliparous women with medical or obstetric indication for labor induction. They were randomly assigned into two equal groups, the first group for early amniotomy and the second group for late amniotomy after use of vaginal misoprostol. Data were collected and tabulated. Results There was significant difference in the duration of labor between the two groups of early and late amniotomy with aP value of 0.000.There was also no significant difference in the mode of delivery with aP value equal to 0.197. Conclusion In well-selected cases, vaginal misoprostol followed by early intervention with amniotomy for labor induction appears to be associated with higher successful vaginal delivery rate, shorter induction-delivery interval, and better neonatal outcome over standard care.
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Accuracy of two-dimensional ultrasound versus three-dimensional power Doppler for diagnosis of placenta accrete p. 469
Ahmed N Abdelhamid, Ahmed Z Elsheikhah, Alaa E. F. Al Halaby, Mohamed A Rezk, Rehab A Zahran
DOI:10.4103/mmj.mmj_161_19  
Objective The aim of this study was to assess the value of adding three-dimensional (3D) ultrasound (US) power Doppler vascular indices (as a diagnostic technique) to gray-scale technique for antenatal diagnosis of placenta accreta. Background Abnormal invasive placentation represents obstetric challenge that is associated with catastrophic hemorrhage. Varied terminologies have been applied to this condition; however, the recent guidelines suggested placenta accreta spectrum, which includes accreta, increta, and percreta. Patients and methods Evaluation of 100 pregnant patients with placenta previa was done. They had a mean age of 33.3 years. All patients were subjected to two-dimensional US and 3D power Doppler vascular indices US at gestational age between 28 and 34 weeks, before elective cesarean delivery. Results Of the 100 patients, 62 (62%) patients were proved to have abnormal placental invasion based on pathological outcome and 38 (38%) patients had conservative surgical management. The sensitivity of 3D power Doppler parameters was 96.6% for intraplacental hypervascularity, 88.7% for torturous vascularity and 88.7% for basal vessels involving bladder. Regarding the vascular indices, for vascularization index, sensitivity was 67.7%; for flow index, sensitivity was 48%; for vascular flow index, sensitivity was 87%; and for Virtual Organ Computer-aided Analysis (placental volume), sensitivity was 87%. In comparison, regarding the two-dimensional US parameters for diagnosis of placental invasion, for absence of sonolucent areas, sensitivity was 67.7%, for myometrial thickness less than 1 mm, sensitivity was 79%, for number of lacunae more than 4, sensitivity was 67.7%, and for presence of vascularity between placenta and cervix, sensitivity was 74%. Conclusion Combining 3D power Doppler to gray-scale and color Doppler US was more predictive of abnormal placental invasion.
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Role of intrapartum transperineal ultrasound in predicting mode of delivery in primigravida women p. 474
Mohamed M Fahmy, Alaa Eldin F. Elhalaby, Haitham A Hamza, Ibrahim S Elnasr, Noha M. T. Elshaikh
DOI:10.4103/mmj.mmj_218_19  
Objectives To evaluate if the different intrapartum transperineal ultrasound (ITU) parameters [angel of progression (AOP), head direction (HD), and head progression distance (HPD)] are significant indicators to predict mode of delivery and discuss the role of ITU parameters in the prediction of mode of delivery in primigravida women. Background Spontaneous vaginal delivery without obstetric intervention is the suitable outcome for most pregnancies. However, some women fail to progress in the second stage of labor and so require operative delivery. Patients and methods In this cross-sectional study, a transperineal ultrasound examination was performed in 70 nulliparous women aged from 18 to 40 years old with single live fetus in cephalic presentation, at term (≥37 weeks), in the active phase of labor. Data were collected and tabulated. Results There were good correlations between ITU parameters and delivery mode using a cutoff of more than or equal to 120° for the AOP and a cutoff of less than or equal to 45 mm for the HPD. The HD was divided into three categories of more than 30°, 0–30°, and less than 0°. Conclusion The sonographic parameters AOP, HPD, and HD can be used to predict the mode of delivery in primigravida women.
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Menoufia University Hospital experience in management of the patients with morbidly adherent placenta p. 480
Medhat E Abdel Khalek, Alaa E Elhalaby, Nabih I Elkhouly, Mohamed E Anter, Hoda I Assaf
DOI:10.4103/mmj.mmj_249_19  
Objective To determine the outcome of management of placenta accreta when the policy of hysterectomy was adopted without attempt of manual separation of placenta. Background Placenta accreta occurs when the chorionic villi invade the myometrium abnormally. The incidence of placenta accreta has been steadily increasing, attributed to the increasing prevalence of cesarean delivery in recent years. Patients and methods A retrospective randomized study was conducted on 70 cases of morbidly adherent placenta accreta attending the Obstetrics and Gynecology Outpatient Clinic at Menoufia Teaching Hospital over a 4-year interval, during the period between January 2015 and December 2018. Results The incidence of placenta accreta was 1.67% of cesarean deliveries. The ultrasonography was suggestive of morbid adherent in only 32 (45.7%) cases. ICU admission occurred in eight (11.4%) cases. Two (2.8%) patients had wound infection. One (1.4%) case needed reoperation. Postpartum pyrexia occurred in one (1.4%) case. Median duration of hospital stay was 5 days (range, 3–35 days). The mean gestational age at delivery was 36.87 weeks (range, 32–39 weeks), and 11 (15.7%) infants were admitted to neonatal ICU. Conclusion Placenta accreta is highly associated with placenta previa, especially in cases with previous cesarean section. When placenta accreta is diagnosed or suspected antenatally, the patient must be referred to tertiary center. Generally, the recommended management is cesarean hysterectomy with placenta left in situ after bilateral clamping of uterine artery below insertion of placenta with blunt dissection of urinary bladder from lateral to medial.
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Intrapartum ultrasound to predict vaginal labor in primigravida p. 487
Mohamed A. S. Kandil, Alaa Eldeen F. Elhalaby, Hesham A Ammar, Mohamed E Anter, Shady M. S. Amin
DOI:10.4103/mmj.mmj_250_19  
Objectives To evaluate head–perineum distance (HPD) and angle of progression (AOP) as predictors of successful vaginal delivery in the active phase of first stage of labor in primigravida. Background Intrapartum ultrasonography has enabled further understanding of the complex physiology of childbirth. It has been shown to provide objective information on the dynamics of different stages of labor and may also be used to assess the mode of delivery. Patients and methods This prospective cohort study was conducted at obstetrics departments of Om El-Masryeen General Hospital, Giza, Egypt, from November 2018 to March 2019. This study included 80 pregnant women in the active phase of first stage of labor who fulfilled inclusion and exclusion criteria. Full history taking, physical and local examination, and obstetric ultrasound were done, and transperineal ultrasound was done to measure HPD and AOP. Results Women who delivered vaginally showed a statistically significant higher mean of the AOP (120.3 ± 11.9°) versus who delivered by cesarean section (89.1 ± 10.7°), with aP value of 0.001. At a cutoff of more than 104°, AOP predicted successful vaginal labor, with a sensitivity of ~90% and a specificity of 86%. At cutoff less than 4.5 cm, HPD predicted successful vaginal labor with a sensitivity of ~88% and a specificity of 91%. Conclusion Transperineal ultrasound measurement of HPD and AOP in the first stage of labor accurately predicts the mode of delivery.
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Effects of cabergoline administration on uterine perfusion in women with polycystic ovarian syndrome p. 492
Osama A El Kelany, Nabih I El Khouly, HithamAbo Ali Hamza, Hanaa H. AbdelMagied Gafar
DOI:10.4103/mmj.mmj_299_19  
Objective The objective of this study was to assess the effects of cabergoline administration on uterine blood flow in women suffering from polycystic ovarian syndrome (PCOS). Background Many women with PCOs experience infrequent ovulation or lack of ovulation altogether and may face many challenges in becoming pregnant. Patients and methods A randomized controlled study was conducted on 108 patients with PCOS who attended the Shebin El-Kom Teaching Hospital outpatient clinic during the period spanning from May 2016 to March 2018. Doppler ultrasound was performed for both groups. Then weekly dose of cabergoline 0.5 mg was administrated for the case group for 12 weeks, while the control group did not receive any treatment. At the end of 12th week, another Doppler ultrasound was performed for all participants, and the results were recorded. Results There was no significant difference between the two groups with regard to age, BMI, luteinizing hormone and follicle-stimulating hormone levels. Before the intervention, the uterine pulsatility index and resistance index, and the ovarian stromal pulsatility index and resistance index, showed no significant difference between the case and control groups. Before treatment, 45 patients from the case group had oligomenorrhea, and, after treatment with cabergoline, 40 patients showed regular menstrual cycle. Side effects (vomiting and blurred vision) occurred in four patients from the case group; hence, they were excluded, and four patients (two got pregnant and two were on treatment) were also excluded during booking of the patients. Conclusion PCOS patients were shown to have more resistance in uterine blood flow and lower ovarian resistance than healthy people. Cabergoline administration proved to increase uterine blood perfusion, increase ovarian stromal resistance, and regulate the menstruation cycle.
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Role of uterine artery Doppler in the diagnosis of placenta accrete in patients with placenta previa p. 497
Mohammed Fahmy, Alaa Alhalabi, Haitham Hamza, Essam Abd El Zaher, Yara Abd El Fattah Khourshid, Mohammed El Sibai
DOI:10.4103/mmj.mmj_369_19  
Objectives To show the role of pulsatility index (PI) of uterine artery Doppler in the diagnosis of placenta accreta in patients with placenta previa. Background Placenta accrete occurs in the complete or partial absence of the decidua basalis. In clinical practice, nonseparation of the placenta at the time of delivery leads to massive blood transfusion, disseminated intravascular coagulability, injury to the bladder and intestine, and urgent need for hysterectomy. Patients and methods A diagnostic accuracy test study was done on 54 patients with placenta previa. Ultrasound examination (two-dimensional grayscale and color Doppler) via transabdominal and transvaginal approach and the PI of uterine artery Doppler was done to these patients. Data were collected and tabulated. Results Significant changes in PI of uterine artery Doppler were detected. The accreta group had significantly lowered PI (0.62 ± 0.20) than the term group (0.89 ± 0.23) (P < 0.001). Conclusion From our study, we concluded that the accuracy of loss of normally presented retroplacental clear zone was the most important ultrasound criteria in the diagnosis of placenta accreta among patients who had a previous cesarean section with a placenta previa overlying previous uterine scar.
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Accuracy of ultrasonographic visceral slide test in predicting the presence of intra-abdominal adhesions p. 501
Zakaria F Sanad, Hamed E Ellakwa, Tarek M Sayyed, Ayman E Solyman, Rehab M Haggag
DOI:10.4103/mmj.mmj_371_19  
Objective The aim was to evaluate whether the visceral slide test was an effective screening test for the prediction of intra-abdominal adhesions. Background Intra-abdominal adhesions result in intraoperative and postoperative morbidities; adhesions to the abdominal wall bring bowel and blood vessels close to the sites of laparoscopic entry. Serious injury to the bowel or blood vessels occurs during the insertion of the trocar, and unrecognized injuries can have catastrophic morbidity and mortality. So, the prediction of the presence of adhesions can prevent these complications. Patients and methods In this cross-sectional study, a visceral slide test was performed on 151 women who underwent gynecologic surgery and the results of this screening test were correlated with the intraoperative presence of adhesions. Results Of the patients67% had risk factors for pelvic infections. Approximately half of them had previous abdominal surgeries (50.3%). The visceral slid test showed a sensitivity of 78.8%, specificity of 95.9%, and a diagnostic accuracy of 90% in predicting the presence of intra-abdominal adhesions. Conclusion The visceral slide test is a good, simple, nonexpensive, and noninvasive test for predicting intra-abdominal adhesions.
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Acquired uterine enhanced myometrial vascularity after dilation and curettage diagnosed by color flow Doppler ultrasonography p. 505
Mohamed A Emara, Abdelhaseib S Saad, Sara M Fadl, Abdel Hameid E. Shahin
DOI:10.4103/mmj.mmj_378_19  
Objectives To assess the role of color flow Doppler ultrasonography (US) in the diagnosis of acquired uterine enhanced myometrial vascularities (EMV). Background EMV represents arteriovenous malformations that may be acquired after dilatation and curettage (D&C). Patients and methods This was a prospective study that included 107 patients presented with abnormal uterine bleeding, and after D&C, they were followed up to detect acquired EMV by using two-dimensional US and color flow Doppler. Results This study included 107 patients with age ranged between 18 and 59 years. The patients presented with intermittent or progressive vaginal bleeding owing to abortion (n = 95) (88.8%), dysfunctional uterine bleeding (n = 6) not controlled by medications, and secondary postpartum hemorrhage after caesarian section (n = 6). Two-dimensional ultrasonic picture of myometrial texture after D&C was done, and it showed heterogeneous lesion in 34 (31.8%) and homogeneous texture in 73 (68.2%) patients. The use of color power Doppler on suspected lesion showed high-velocity blood flow within the vascular 'web' with peak systolic velocity ranging from 16 to 48 cm/s in 24 (22.4%) patients and the resistance index recorded ranging from 0.28 to 0.79, with a mean of 0.56. The incidence of highly suggested EMV among 107 patients who had undergone dilation and curettage in the Department of Obstetrics and Gynecology in Menoufia University Hospital was 22.4%. Conclusion Routine gray-scale and color Doppler US evaluation of patients with early pregnancy failure or cesarean scar pregnancy is indicated to detect EMV as early as possible.
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Predictive value of C-reactive protein level and pregnancy rate in intracytoplasmic sperm injection cycle p. 511
Alaa E. F. A. Elhalaby, Abd E. E. Shaheen, Doha G. M. Hashish, Nabih I El-Khouly
DOI:10.4103/mmj.mmj_379_19  
Objective The aim was to determine the possible relation between the maternal serum C-reactive protein (CRP) level and outcome of controlled ovarian stimulation and pregnancy rate in patients undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection. Background Controlled ovarian hyperstimulation is apparently a key factor in the success of IVF embryo transfer. CRP is a sensitive marker in the inflammatory process rises following hormonal stimulation and does not have diurnal alterations but administration of exogenous estrogen increases its level. Materials and methods This prospective cohort study was conducted at the outpatient clinic in a Private Infertility Unit, Menoufia, Egypt, from November 2018 to August 2019. This study included 100 infertile patients who were candidates for IVF/intracytoplasmic sperm injection and fulfilled the inclusion and exclusion criteria. Full history was taken. Participants underwent CRP measuring at three times, at the day of beginning of ovarian stimulation, ovum pickup, and the day of transfer. Two groups were identified for those who get pregnant and those who did not get pregnant. Results Patients whose CRP level decreased on transfer day (19 cases) 14 got pregnant (73.7%), whereas only five failed to get pregnant (26.3%). Patients whose CRP level increased on transfer day (81 cases) 52 got pregnant (64%), whereas 29 failed to get pregnant (36%). Conclusion Ovulation induction is an inflammatory process leading to increased levels of CRP but with different patterns. These patterns of changes failed to be used as markers of successful outcome of IVF treatment.
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Maternal thyroid function with placental hemodynamics and their effect on fetal and maternal outcomes p. 516
Abdelhamed E Shahin, Nasser K Abd El Aal, Osama A El-Kelany, Alaa Eldeen F. El Halaby, Amira M Elsayed
DOI:10.4103/mmj.mmj_392_19  
Objectives To evaluate the relationship between maternal mild fluctuation in thyroid hormones not amounting to hypothyroidism or hyperthyroidism and altered fetoplacental hemodynamic changes allowing early detection of adverse maternal and perinatal outcomes. Background Suboptimal placental function is associated with preeclampsia and intrauterine growth restriction. Studies suggested that thyroid hormones play a role in placental development through the effects on trophoblastic invasion. Patients and methods A prospective cohort study, included 123 healthy pregnant women recruited from the antenatal care in Obstetrics and Gynecology Department, at Menoufia University Hospital and Damas Central Hospital, from October 2018 till August 2019. Free thyroxine (FT4) concentrations and thyroid-stimulating hormone were measured in early pregnancy (at 9 and 18 weeks). Placental function was measured by Doppler ultrasound measuring umbilical artery pulsatility index and uterine artery resistance index (between 18–23 and 28–32 gestational weeks). Results The data of 123 patients were analyzed. Increased FT4 concentration in early pregnancy was associated with higher vascular resistance in the second and third trimesters in both umbilical artery pulsatility index and uterine artery resistance index. These effects on placental function may demonstrate the association of FT4 with pregnancy outcomes, such as preeclampsia and birth weight. Conclusion The data shows that increased) FT4 concentration in early pregnancy is associated with placental vascular function during the second and third trimesters. Other pregnancy-associated complications are preeclampsia and low birth weight.
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UROLOGY - ORIGINAL ARTICLES Top

Role of bipolar plasma enucleation of the prostate in the treatment of benign prostatic hyperplasia p. 523
Ahmed G El Din, Tarek M Abd-Al Baky, Eid A. R. El-Sherif, Ahmed S Ghonaimy
DOI:10.4103/mmj.mmj_249_16  
Objective The aim was to evaluate the role of bipolar plasma enucleation of the prostate as regards surgical efficacy and perioperative morbidity in the treatment of benign prostatic hyperplasia (BPH) in comparison with bipolar transurethral resection of the prostate (TURP). Background Bipolar plasma enucleation has been reported to be a new method for the management of BPH. Patients and methods A total of 30 patients with lower urinary tract symptoms associated with BPH were included in this study. Of these, 20 patients underwent bipolar TURP and 10 underwent bipolar plasma enucleation. All patients were preoperatively assessed and were evaluated at 3 months after surgery. The International Prostate Symptom Score, postvoid residual urine volume, and maximum flow rate were obtained at the follow-up. Immediate and late complications were recorded. Results The authors found that the differences were statistically significant regarding calculated blood loss during operation with less blood loss in the enucleation group. The resected tissue volume was more in the enucleation group but without statistically significant difference. Postoperative hemoglobin and sodium drop were less in the enucleation group. The mean postoperative bladder irrigation time, catheter time, and hospital stay were similar in both groups. Transurethral resection syndrome did not occur in any patient in this study. All patients in both groups showed marked improvement in clinical evaluation after 3 months postoperatively. Conclusion The authors observed that bipolar plasma enucleation of the prostate can be a promising endoscopic treatment alternative for patients with BPH, showing comparable efficacy, hospital stay, and faster recovery compared with bipolar TURP, with less incidence of intraoperative and postoperative complications.
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A simplified model of Clinical Research Office of Endourological Society nomogram to predict percutaneous nephrolithotomy outcomes p. 528
Abd E. M. Elderay, Mohamed M Abdallah, Mohamed A Selim, Ahmed Hamady Mostafa
DOI:10.4103/mmj.mmj_254_19  
Objective The aim was to predict stone-free status calculated by the Clinical Research Office of Endourological Society (CROES) nomogram and to test the accuracy of our regression model to predict outcomes of percutaneous nephrolithotomy (PCNL). Patients and methods From July 2018 to May 2019, data of 100 patients who underwent PCNL procedure at Urology Department of the Menoufia University were collected, and postoperative results were compared with the preoperative predicted stone-free status. The CROES nomogram was applied to the data of all cases using its scale to calculate the total score and percent of stone-free status. The authors used binary logistic regression to test whether the six factors in the study can predict the PCNL outcome. We compared the calculated probabilities of stone free by the regression model with the traditional method using the six parameters on the scale of nomogram. Results A total of 100 patients were included in the study. Mean patients' age was 41 ± 9.6 years, and mean stone burden was 564.59 ± 533.869 mm2. Postoperative treatment success rate was 62%. CROES score was found to be an independent predictor of treatment success. The estimated area under the curve was 0.96, and the model provided good calibration. The accuracy of the fitted logistic model was 78% when using it as a single method when compared with the probabilities of CROES nomogram. Conclusion CROES nomogram is an efficient tool to predict outcomes of PCNL. The model has noticeable accuracy in predicting PCNL outcomes using the most influent variables in the CROES nomogram.
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OPHTHALMOLOGY - ORIGINAL ARTICLES Top

Determining the correlation between axial length/spherical equivalent and macular thickness in myopia p. 534
Abdel R. E. Sarhan, Marwa A Zaky, Basma A. E. Hassan
DOI:10.4103/mmj.mmj_172_16  
Objective The aim was to assess the relationship between macular thickness in each of the nine regions and the axial length (AL) and spherical equivalent (SE) in myopes. Background Myopia is the most common error of refraction and, in many countries; complications related to high myopia are a major cause of blindness. The relation between macular thickness and AL in myopia has been one of much interest over the past few years. Many researchers believe that since in axial myopia, the globe elongates and the sclera stretches, so the macula must thin. Patients and methods One hundred eyes of 50 myopes, free of any other ocular abnormalities were assessed. All were above 18 years of age. Each patient was subjected to a full clinical examination, refraction, AL assessment by A scan ultrasonography and macular thickness was determined by spectral domain optical coherence tomography. The patients were subdivided into three diagnostic groups into high myopia (>–6.00 D), moderate myopia between (–3.00 and –6.00 D), and low myopia (< –3.00 D). Results The study revealed a highly significant negative correlation between increasing AL and macular thickness in all quadrants except in the fovea (positive correlation found) and outer temporal quadrant, and a highly significant positive correlation between SE and macular thickness in all quadrants except in the fovea (negative correlation found) and outer temporal quadrant. Macular thickness was significantly less in high myopes than low and moderate myopes except in the fovea (more thickness in high myopes). The SE was significantly correlated with increasing AL. Conclusion In myopes, increasing AL and degree of myopia can be correlated with a decrease in macular thickness except in the foveal region.
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Changes in macular thickness after trabeculectomy with or without adjunctive mitomycin C p. 540
Hoda M. K El Sobky, Ahmed A AL Masry, Moataz F El Sawey, Basma A. Moustafa
DOI:10.4103/mmj.mmj_419_18  
Objective To assess macular thickness changes posttrabeculectomy with and without mitomycin C (MMC) and to find the association between these postoperative changes and intraocular pressure (IOP). Patients and methods This study included 40 eyes of 31 patients who underwent trabeculectomy. It was done at a private eye center in Alexandria from December 2017 to September 2018. Study patients were stratified into two groups (20 each): trabeculectomy with MMC and trabeculectomy without MMC. Results The mean (±SD) (IOP) reduced from 29.48 (±3.57) mmHg before trabeculectomy to 19.05 (±2.86) mmHg 1 week (P < 0.001) and to 15.38 (±3.05) mmHg 6 months (P < 0.001) after the operation. One week postoperatively, the mean macular thickness increased from 289.98 (±18.11) μm to 296.81 (±17.15) μm (P < 0.001); macular thickening was significant in all macular subfields. Mean macular thickness correlated positively with postoperative IOP reduction (P < 0.005). Significant correlation was found at central (P < 0.001), superior inner (P = 0.014), inferior outer (P = 0.001), and nasal outer (P = 0.023) macular subfields. Six months later, macular thickening remained significant only at the central and inner nasal macular subfields (P2=0.007, P2 <0.001), respectively, and there was no significant correlation between IOP reduction and macular thickness at the same time. MMC had no effect on these changes. Conclusion Trabeculectomy may increase macular thickness in the early postoperative period. However, MMC has no effect despite its possible toxic effects on the retina.
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The role of preoperative Pentacam in optimizing visual outcome after cataract surgery p. 546
Abd El-Rahman E. Sarhan, Ahmed A Elhagaa, Fatma A. A. Shakal
DOI:10.4103/mmj.mmj_421_18  
Objective To evaluate the role of preoperative Pentacam in optimizing visual outcome after cataract surgery. Background It has been suggested that Pentacam gives comprehensive data about preoperative astigmatism, lens density, and refractive power helping in optimizing the visual outcome after cataract surgery. Patients and methods Preoperatively, the patients were subjected to careful history taking, thorough ocular examination including assessment of manifest refraction, measurement of logMAR uncorrected distance visual acuity, and corrected distance visual acuity, biometry and keratometry with the Intraocular lens (IOL) Master partial coherence interferometry device, corneal topography (Pentacam) and to exclude irregular astigmatism, mean lens density, and cataract grading score were evaluated. Slit lamp examination, dilated funduscopy under pharmacological, intraocular pressure, and Hoffer Q formula was used in eyes with an axial length shorter than 22 mm, and SRK/T formula was used for all other cases. Cataract surgery were performed according to the standard protocols. Postoperative manifest refraction (sphere and cylinder) and visual acuity (uncorrected and corrected) were obtained. Results There was significant improvement of astigmatism postoperatively. Also, there were significant improvements of UCVA and BCVA in postoperative assessment as compared with preoperative evaluation. Conclusion Preoperative Pentacam can help in the improvement of preoperative astigmatism. It also resulted in the improvement of Uncorrected visual acuity (UCVA) and Best corrected visual acuity (BCVA).
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Results of probing guided with soft cannula in children with nasolacrimal duct obstruction p. 551
Abd El Khalek I. El Saadani, Hatem M Marey, Sameh S Mandour, Ghada M El-Halaby
DOI:10.4103/mmj.mmj_17_19  
Objectives To compare between the successes of probing using soft cannula (a 22 G) versus conventional probing in children with congenital nasolacrimal duct obstruction. Background Congenital obstruction of the nasolacrimal duct is a common problem in the early years of life. Obstruction can occur in 6–20% of neonates. The usual cause is failure of canalization of the epithelial cells that form the nasolacrimal duct as it enters the valve of Hasner. Patients and methods This prospective, randomized study was conducted on 36 children (48 eyes) having congenital nasolacrimal duct obstruction presented to the outpatient clinic of Menoufia University Hospital and Kafer El-Sheikh Ophthalmology Center from November 2016 to July 2018. The children were divided into two groups: group A, 18 children (24 eyes) operated by conventional probing and group B, 18 children (24 eyes) operated by probing using soft cannula. The patients were monitored for 6 months postoperatively. Results Clinically successful results were achieved in 20 eyes (83.4%) for conventional probing group and 19 eyes (79.2%) for soft cannula group. No significant complication occurred intraoperatively or postoperatively. Conclusion Soft cannula probing is an effective and simple method with no significant complication for the treatment of congenital nasolacrimal duct obstruction. This method allows probing in a more controlled way. However, there was no statistical difference between it and conventional probing.
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Comparison of the ocular response analyzer and the Goldmann applanation tonometer for measuring intraocular pressure after penetrating keratoplasty p. 556
Hoda M Elsobky, Mohammed S Abdel Aziz, Eslam A. M. Hassan
DOI:10.4103/mmj.mmj_28_19  
Objectives To compare intraocular pressure (IOP) readings measured by the ocular response analyzer (ORA) with those measured by the Goldmann applanation tonometer (GAT) following penetrating keratoplasty (PKP) and evaluate the influence of biomechanical properties of the grafts on IOP measurements. Background The ORA (Reichert Technologies) is a device that shows the biomechanical properties of the cornea. It reflects certain biomechanical properties of the cornea such as corneal hysteresis (CH) and corneal resistance factor (CRF). Patients and methods IOP using the GAT [IOP (GAT)], CH, CRF, Goldmann-correlated IOP (IOPg), cornea-compensated IOP (IOPcc) using the ORA, and central graft thickness (CGT) were measured in 30 eyes undergoing PKP. Bland–Altman plots were used to evaluate agreement between the tonometers. The correlation between refraction, graft curvature, astigmatism, CH, CRF, and CGT with IOP readings was investigated using multivariate regression analysis. Results The mean CGT, CH, and CRF were 532.43 ± 30 μm, 8.52 ± 1.81 mmHg, and 8.56 ± 1.59 mmHg, respectively. Mean IOP (GAT), IOPg, and IOPcc were 11.88 ± 3.66, 14.64 ± 4.08, and 17.27 ± 4.60 mmHg, respectively. The 95% limit of agreement between IOP (GAT) and IOPg ranged from 2.39 to 3.29 mmHg, and for IOPcc and IOP (GAT) it ranged from 4.7 to 6.2 mmHg. No significant association was found between CGT and IOP readings. According to IOP (GAT), there was significant negative association with CH. According to IOPcc, there was significant negative association with CH and mean keratometry. According to IOPg, there was significant positive association with CRF. Conclusion Following PKP, graft biomechanics had more influence on IOP values than anatomical features. In comparison to the GAT, the ORA yielded higher IOP values.
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Comparison between axial and tangential corneal topography maps in localization of cone in keratoconus p. 563
Abdel Rahman EL-Sebaey, Asmaa M Ibrahim, Rofaida M Serag EL-Deen
DOI:10.4103/mmj.mmj_36_19  
Objectives The objectives of this study were to compare axial maps versus tangential maps in the localization of a keratoconus cone using pentacam and to describe the cone characteristics for the different stages of keratoconus. Background Cone location is an essential factor in the selection of intrastromal corneal ring segments' specification used in the treatment of keratoconus. Patients and methods This was a retrospective case series' study conducted between October 2017 and October 2018 on a sample of 100 eyes with keratoconus. Corneal topography with a rotating Scheimpflug device was carried out. Cone location, cone decentration, and morphological patterns were analyzed. Cone location was determined for each eye with both axial and tangential maps and compared for matching. A correlation between kmaxlocation and cone location according to axial and tangential maps was also carried out. Results The matching rate between axial and tangential maps in the total sample was 100, 5, and 9.6% for central, paracentral, and peripheral groups, respectively, which was statistically significant (P < 0.001). For stages I, II, and III, the results were statistically significant (P < 0.001). Correlations between kmaxand tangential map were greater than correlations between kmaxlocation and axial map (P < 0.001). For cone apex decentration, the most frequent value of decentration was between 0.5 and 1 mm in the different stages. For morphological pattern, the most frequent cone morphology in different stages was a nipple-shaped cone. Conclusion Analysis of axial and tangential corneal topography maps showed a significant discrepancy in cone location in the form of 'centralization tendency' on the tangential map. No correlations between stage, morphology, or decentration were revealed.
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Corneal surface changes after cross-linking in patients of keratoconus p. 569
Abd El Khalek I. El Saadany, Hatem M Marey, Asmaa M Ibrahim, Ahmed M Abd-Elhamid Akel
DOI:10.4103/mmj.mmj_192_19  
Objectives To evaluate the outcome of the corneal cross-linking procedure regarding their effect on morphological and optical properties of the cornea. Background Cross-linking using ultraviolet A light and riboflavin is a method to stop the progression of keratoconus. The orbscan system has the ability to yield corneal thickness, curvature, and elevation data. Patients and methods The study was carried out on 40 eyes of 30 patients, with a mean age 22.55 ± 3.15 years. All underwent corneal cross-linking.Uncorrected visual acuity and best-corrected visual acuity were assessed. Orbscan's Kmax, thickness at thinnest corneal point and at the center of the cornea, irregularity at 3 and at 5 mm optical zone and topographic astigmatism, were all determined before cross-linking and 6 months after. Results There was improvement of uncorrected visual acuity from 0.21 ± 0.09 to 0.23 ± 0.08 and best-corrected visual acuity from 0.62 ± 0.13 to 0.72 ± 0.10 after 6 months (P < 0.001). Significant decreases after 6 months were found in Kmaxvalue from 48.81 ± 2.05 to 47.83 ± 1.94 D (P < 0.001). There was decrease in thickness at thinnest corneal point and at the corneal center (P < 0.001). Irregularity at 3 mm optical zone and irregularity at 5 mm optical zone showed stability without significant change (P = 1.000 and 0.888, respectively). Corneal astigmatism also showed stability without significant change (P = 0.88). Conclusion Patients with progressive keratoconus appear to have improvements in most of the anterior surface topographic measures.
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Topical bromfenac vs focal laser photocoagulation in treatment of focal diabetic macular edema p. 574
Abd El Khalek Ebrahim Al Saadany, Sameh M Elgouhary, Marwa A Zaky, Eman A Hossam Eldin
DOI:10.4103/mmj.mmj_223_19  
Objective The aim was to evaluate the safety and efficacy of topical bromfenac in comparison with focal laser photocoagulation in treatment of focal diabetic macular edema (DME). Background DME, a serious eye condition caused primarily by hyperglycemia, is the major cause of visual loss in the working population of developed countries. Patients and methods A total of 30 eyes from 30 diabetic patients with previously untreated focal DME were enrolled in this prospective randomized controlled study from October 2017 to October 2018. Patients with central macular thickness (CMT) less than 350 μm were included. Patients were divided into two equal groups, each of 15 eyes. Group 1 patients received focal laser as needed and group 2 patients received topical bromfenac eye drops twice daily for 6 months. Best-corrected visual acuity and CMT were measured initially and at 1, 3, and 6 months of follow-up. Results After 6 months, best-corrected visual acuity was stabilized as baseline in 60 and 53.3% of group 1 and group 2 patients, respectively. After 6 months, the mean baseline CMT was significantly reduced from 290.5 ± 10.1 to 266.4 ± 8.6 μm in group 1 (P < 0.001) and from 286.9 ± 10.59 to 265 ± 14.14 μm in group 2 (P < 0.001). Conclusion Topical bromfenac showed good results close to that of focal laser on stabilization of vision and reduction of CMT in patients of focal DME with favorable safety and tolerability. Topical bromfenac twice daily for 6 months may play an effective role in treatment of early focal DME.
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Hyperopic peripapillary retinal nerve fiber layer thickness and foveal thickness using optical coherence tomography p. 581
Eman N El Gohary, Hoda M El Sobky, Asmaa M. A. Ibrahim
DOI:10.4103/mmj.mmj_285_19  
Purpose Studying the peripapillary retinal nerve fiber layer (RNFL) thickness and foveal thickness in hyperopia using optical coherence tomography. Background Significant hyperopia is defined to be any degree of hyperopia sufficient to cause symptoms requiring remediation. Peripapillary RNFL thickness was approved to be conversely correlated with axial length (AL) and the spherical equivalent in hyperopic populations. Optical coherence tomography is a modern noncontact and noninvasive imaging technique designed to produce high-resolution images and accurate measurements of the different retinal components. Patients and methods The presented study included ninety eyes: 45 of them were simple hyperopic eyes, and the other 45 eyes were emmetropic. The emmetropic eyes were age and sex matched to the case group. The participants were included in the study after obtaining informed consent and a detailed history. Ophthalmological examination including visual acuity assessment, cycloplegic refraction, best-corrected visual acuity, cover–uncover test and extraocular muscle movement examination, anterior segment examination, intraocular pressure measurement, fundus examination, AL measurement, and peripapillary RNFL thickness and foveal thickness measurements (all methods of assessment are mentioned in detail in the patients and methods section) was carried out. Results There was no statistically significant difference between the hyperopic and the emmetropic groups with regard to age and sex. There was a statistically significant increase in the thickness of the RNFL in the hyperopic group that was more than that of the emmetropic group, and there was a statistically significant increase in the thickness of the superior, inferior, and nasal quadrants in the hyperopic group more than that of the emmetropic group. There was no statistically significant difference in the temporal quadrant between both groups. Conclusion The AL is statistically significantly short, and the mean foveal thickness is statistically significantly high in the hyperopic eyes. The RNFL thickness is statistically significantly thick, and the superior, inferior, and nasal quadrants were thicker in the hyperopic eyes than in the emmetropic ones.
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Intraocular pressure, ganglion cell complex, and retinal nerve fiber layer changes by optical coherence tomography in pseudotumor cerebri p. 588
Hassan G. E. Farahat, Hatem M Marey, Marwa A Zaky, Ismail A Ismail
DOI:10.4103/mmj.mmj_287_19  
Objectives The purpose of this study was to evaluate the changes in retinal nerve fiber layer (RNFL) thickness measured by optical coherence tomography (OCT) in idiopathic intracranial hypertension or pseudotumor cerebri (PTC). Patients and methods This cross-sectional comparative study involved 50 patients with PTC (group I) and 50 age-matched and sex-matched normal persons as controls (group II). Retinal nerve fiber thickness is measured using OCT for all studied population and then recorded and collected to be statistically analyzed. Results Visual acuity and best-corrected visual acuity were measured in both groups. Comparison between both groups shows a statistically highly significant difference (P < 0.01). Both groups showed a statistically highly significant difference between both groups (P < 0.01) regarding intraocular pressure. Thickness of the RNFL in the studied groups according to OCT measures showed a statistically very highly significant difference between both groups (P < 0.001). Conclusion RNFL thickness measurements can provide important information regarding retinal axonal loss in patients with papilledema from PTC. Although axonal loss was documented in the chronic phase of papilledema, our findings, to be confirmed in future prospective studies, suggest a possible use of OCT during the treatment of PTC syndrome.
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Changes of the choroid in preeclampsia and healthy pregnant women by using optical coherence tomography p. 593
Hatem M Marey, Mai A Mokhtar, Asmaa M Ibrahim
DOI:10.4103/mmj.mmj_297_19  
Objective The aim of the study is to evaluate choroidal thickness alteration in women with preeclampsia and compare with healthy pregnant and nonpregnant controls by using optical coherence tomography (OCT). Background Pregnancy is a predisposing factor for central serous chorioretinopathy. Choroidal thickness (CT) increases in central serous chorioretinopathy and this study evaluates changes in computed tomography (CT) during pregnancy and preeclampsia. Patients and methods This was a cross-sectional study conducted at Menoufia University Hospital Ophthalmology Department during the period from April 2018 to March 2019 on 66 eyes of 33 patients divided into groups. Each group had 22 eyes. Group 1 is the pregnant group and group 2 is the preeclampsia. Group 3 included healthy nonpregnant controls. Each of the patients underwent full ophthalmologic examination followed by OCT assessment and the procedure was achieved without pupillary dilatation. Macular thickness was determined automatically and was analyzed by OCT. Results The choroid thickness increases in both healthy pregnant women and preeclampsia women. Choroidal thickness in healthy pregnant women was significantly thicker than preeclampsia. The most likely mechanism for this increase is pregnancy-related fluid retention in the choroid layer. The choroidal thickness in preeclampsia was lower than healthy pregnant women. This lower rise in choroidal thickness can be generally attributed to the markedly increased systemic vascular vasospasm secondary to preeclampsia. Conclusion This study has shown that CT measured using OCT increased in women with preeclampsia and healthy pregnant women but the increase of CT in preeclampsia was lower than healthy pregnant controls.
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Aflibercept vs ranibizumab in management of diabetic macular edema p. 599
Khaled E Ahmed, Ahmed I Basiony, Eman S Hamad
DOI:10.4103/mmj.mmj_302_19  
Objective The aim was to compare the efficacy of intravitreal injection of aflibercept and ranibizumab in the treatment of diabetic macular edema (DME). Background Diabetic retinopathy is a microangiopathy of the retina from which nearly all persons with diabetes eventually suffer. DME is one of its complications that threaten the patient's vision. Patients and methods This is a randomized prospective study. Fifty eyes with DME were divided into two groups (each containing 25 eyes). Eyes in group I were treated with intravitreal injection of aflibercept, and eyes in group II were treated with intravitreal injection of ranibizumab. All eyes had three successive injections. The outcomes were visual acuity and central subfield macular thickness. Results The mean baseline best-corrected visual acuity (BCVA) in group I was 0.65 ± 0.12 μm and in group II was 0.63 ± 0.19 μm (P = 0.72). After 3 months, the mean BCVA in group I improved to 0.34 ± 0.16 and in group II improved to 0.44 ± 0.21 (P = 0.10). At the end of sixth month, the BCVA was 0.42 ± 0.18 in group I and0.47 ± 0.18 in group II (P = 0.23). The mean baseline central subfield thickness (CST) of eyes in group I was 523.8 ± 105.3 μm and in group II was 477.4 ± 143.6 μm (P = 0.11). After 3 months, the mean CST in eyes of group I decreased to 348.04 ± 98.4 μm, whereas in eyes of group II, the mean CST decreased to 377.5 ± 115.7 μm (P = 0.031). After 6 months, the mean CST in the eyes of the group I became 373.6 ± 139.8 μm, whereas in eyes of group II became 371.7 ± 102.3 μm (P = 0.96). Conclusion Aflibercept and ranibizumab have the same efficacy in the treatment of DME.
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Evaluation of nepafenac eye drops in prevention of macular edema following cataract surgery p. 604
Amin F Ellakwa, Nermeen M Badawy, Marwa A Al Said
DOI:10.4103/mmj.mmj_333_19  
Objective The aim was to evaluate the prophylactic use of topical NSAIDs instead of topical steroids preoperatively and postoperatively to reduce the incidence of macular edema. Background Macular thickening is a postoperative complication following cataract surgery, even with uncomplicated small-incision phacoemulsification surgery. Subclinical cystoid macular edema (CME) is diagnosed with fluorescein angiography as leakage from perifoveal dilated capillaries without visual acuity affection. After uncomplicated phacoemulsification in healthy individuals, the incidence of subclinical CME has been reported to be less than 20%. Patients and methods The study included 75 patients who visited the Outpatient Clinics, previously diagnosed as having cataract between January 2018 and December 2018. The eligible 75 patients were randomly allocated into three equal groups (25 patients each) by using a computer-generated list of random permutations according to the drugs that were used. Results There was no statistically significant difference between the study groups. The preoperative mean of Best-corrected visual acuity (BCVA) was 1.56, 1.39, and 1.48 in the control, nepafenac, and dexamethasone groups, and there was no significant difference among them (P = 0.433). Regarding central macular thickness, there was no statistically significant difference between the study groups (P = 0.126). Despite being not statistically different from each other in the preoperative period regarding central macular thickness, there was improvement in the nepafenac and dexamethasone groups when compared with the placebo group at 1-week, 1-month, and 3-month follow-up visits. Conclusion This study revealed the prophylactic effect of topical NSAIDs and steroids in reducing the frequency and severity of CME in patients undergoing cataract surgery.
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Difluprednate 0.05% vs prednisolone acetate 1% for treatment of endogenous anterior uveitis p. 611
Amin F Ellakwa, Ahmed I Basiony, Dalia M Yousef
DOI:10.4103/mmj.mmj_335_19  
Objective The aim was to compare topical difluprednate 0.05% vs prednisolone acetate 1% in the management of acute anterior uveitis (AAU) regarding their efficacy and safety. Patients and methods A prospective clinical trial was conducted on two parallel groups comprising 48 patients who attended the Shebin El-Kom Ophthalmology Outpatient Clinic. All were diagnosed with AAU. Patients in the first group received difluprednate 0.05% eye drops four times daily, whereas patients of the second group received prednisolone acetate 1% eight times per day for 2 weeks. The 14-day treatment period was followed by 14-day tapering dose period. The observation was continued until day 35. Results At day 14, there was no significant difference between the two studied groups regarding anterior chamber cell grading, as all cases were detected to have grade 0 in both groups. Complete clearing of anterior chamber cells at day 3 were seen in eight eyes (8/24; 33.3%) in both groups (P = 0.2). Intraocular pressure change was higher among the prednisolone group at seventh day (P = 0.2) and 14th day (P = 0.03) compared with the difluprednate group, except at day 3, where intraocular pressure change was the same in both groups. The mean IOP values in both groups remained less than 21 mmHg throughout the study. Conclusion Difluprednate 0.05% four times daily is well tolerated and safe compared with prednisolone acetate 1% eight times daily for the treatment of endogenous AU. Difluprednate exhibits better bioavailability, strong efficacy, and low incidence of adverse effects.
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Axial length variation with the use of silicone oil tamponade p. 617
Abd El Rahman El Sebaey, Amin F Ellakwa, Ahmed M Youssef
DOI:10.4103/mmj.mmj_343_19  
Background Silicone oil (SO) tamponade is the method of choice as a long-term stable retinal tamponade. Axial length (AL) and ocular biometry are reported to change with the use of SO. However, these changes are not well studied in eyes. Objectives To measure the change in AL before SO injection, as a tamponade, and then following its removal for accurate choice of intraocular lens (IOL) power. Patients and methods This prospective case series study was conducted in the Ophthalmology Department, Menoufia University Hospital, Egypt. The study included 100 eyes of 100 patients who gave consent, with age ranging from 9 to 83 years, undergoing retinal detachment (RD) repair via three-port vasectomy with SO injection and combined SO removal with phacoemulsification after 3–6 months. Eyes with rhegmatogenous RD less than 3 months old with no other significant eye disease were included. Ophthalmic examination included best-corrected visual acuity, intraocular pressure Goldmann tonometry, and AL measurement by A-scan ultrasound and IOL Master500. Results Using IOL Master500 and A-scan, there were no significant differences between the two devices in the mean values of AL at different times of assessment (P = 0.137 and 0.075); otherwise, there was a significant higher mean values of the AL in SO-filled eyes than before operation (P 1 = 0.053 and 0.025). On the contrary, there were no significant differences in the AL either after SO removal than before operation (P 2 = 0.577 and 0.151, respectively), or after SO removal than in SO-filled eyes (P 3 = 0.167 and 0.415, respectively). Conclusion From our study, we conclude that the AL after injection of SO increased by 0.70 mm, whereas following removal of SO would increase by 0.2 mm compared with before SO injection in cases with RD status.
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Conventional photorefractive keratectomy vs laser in-situ keratomileusis regarding regression in low myopia at 6-month follow-up p. 623
Amin F Amin Ellakwa, Mohamed S Abd Alaziz, Eman M. Abd-Allah El-Asser
DOI:10.4103/mmj.mmj_345_19  
Objective The aim was to compare between laser-assisted in-situ keratomileusis (LASIK) and conventional photorefractive keratectomy (PRK) regarding postoperative myopic regression after 6 months. Background Myopia is a condition in which the refractive power of the eye is greater than required. The most frequent complaint of people with myopia is blurred distance vision, which can be eliminated by refractive surgery procedures such as PRK and LASIK. Materials and methods A prospective comparative case series study was conducted on 50 patients with mild to moderate myopia with or without astigmatism, who were divided into two groups: group A included 25 patients operated with PRK and group B included 25 patients operated with LASIK. Follow-up was done by slit lamp and assessment of uncorrected distance visual acuity, manifest refraction, and best spectacle corrected distance visual acuity at 1 week, 1 month, 3 months, and 6 months. Results Mean uncorrected visual acuity after 1 week was 0.60 ± 0.11 for the PRK group and 0.84 ± 0.12 for the LASIK group (P < 0.001). Mean uncorrected visual acuity after 1 month was 0.98 ± 0.13 for the PRK group and 0.89 ± 0.13 for the LASIK group (P < 0.002). Mean uncorrected visual acuity after 6 months was 1.07 ± 0.12 for the PRK group and 0.90 ± 0.12 for the LASIK group (P < 0.001). Mean spherical equivalent after 6 months was −0.32 ± 0.22 D for the PRK group and −0.05 ± 0.52 D for the LASIK group (P < 0.024). Conclusion Uncorrected visual acuity 1 week after surgery is significantly better in eyes undergoing LASIK than in eyes undergoing PRK. Both procedures provide functional vision by 1 week after surgery. No refractive regression was noted after 6 months of follow-up.
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Higher order aberration after wavefront-guided laser in-situ keratomileusis vs wavefront-guided photorefractive keratectomy p. 630
Hany A Khairy, Mohammed S Abd-Alaziz, Marwa M Ahmed Meliha
DOI:10.4103/mmj.mmj_360_19  
Objective The aim was to assess visual outcome and higher order aberrations between wavefront-guided laser in-situ keratomileusis (LASIK) and wavefront-guided photorefractive keratectomy (PRK). Background LASIK is the most popular and commonly performed procedure in the field of corneal refractive surgery. Laser refractive surgery works on the principle of modification of corneal refractive power by means of photoablation of the stromal tissue. Patients and methods A total of 30 patients (60 eyes) with errors of refraction and higher order aberration underwent wavefront-guided LASIK and wavefront-guided PRK. Follow-up was performed on the first day, fifth day, first week, first month, third month, and 6 months postoperatively, and wavefront ocular analysis was performed at the first month, third months, and 6 months postoperatively. Results This study included 60 eyes of 30 patients. The patients were divided into two groups: A and B. Wavefront-customized LASIK was performed on patients in group A, whereas patients in group B received wavefront-customized PRK. The age of the participants in group A ranged from 18 to 35 years. On the contrary, group B patients' age ranged from 19 to 36 years. Total higher order aberration root mean square in LASIK showed nonsignificant increase from 0.37 ± 0.15 (P = 0.922) preoperatively to 0.57 ± 0.17 (P = 0.764) postoperatively. It also showed nonsignificant increase in PRK from 0.38 ± 0.15 preoperatively to 0.59 ± 0.18 postoperatively. Conclusion The study showed significant improvement in visual acuity and refractive result, with increase of total higher order aberration root mean square.
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Maximal levator resection in congenital blepharoptosis p. 636
Sameh S Mandour, Ghada Z Rajab, Ola E Abdou
DOI:10.4103/mmj.mmj_383_19  
Objective The aim was to evaluate the surgical effect of maximal levator muscle resection technique for moderate to severe simple congenital blepharoptosis with poor levator function. Background Surgical treatments for the correction of congenital ptosis with poor levator function including frontalis suspension or maximal levator resection remain controversial. However, the levator resection approach seems to be the most physiological. Maximal levator resection, assuming that it is employed appropriately, is highly effective in cases of moderate to severe congenital ptosis with poor levator function. This surgery advances and plicates the levator muscle, thus increasing its effect. Patients and methods This prospective study included 29 eyelids of 20 patients who underwent maximal levator resection procedure, and their ages ranged from 3 to 8 years. Patients who presented with ptosis were examined and enrolled from January 2018 to January 2019, from the Outpatient Ophthalmic Clinic of Menoufia University Hospital. Follow-up was done at first week, first month, and sixth month postoperatively to evaluate the functional, cosmetic results, and complications. Results There is a statistically significant increase of mean postoperative marginal reflex distance-1 (MRD-1) at first week, first month, and sixth month in comparison with preoperative MRD-1 (P < 0.05). Successful outcome of the maximal levator resection procedure that was evaluated by postoperative MRD-1 was met by 79.31% (23/29) in the first week, 82.76% (24/29) in the first month, and 86.21% (25/29) in the sixth month. Satisfactory eyelid contour was met by 28 of 29 eyelids. The most common complications at 6 months were undercorrection in 10.3% (3/29) and overcorrection in 3.4% (1/29). Conclusion Maximal levator resection procedure is very effective in the treatment of simple congenital blepharoptosis with poor levator function.
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Role of central corneal thickness in intraocular pressure changes after corneal refractive surgery p. 641
Melad N Sadek, Abd El-Khalik E. El-Saadany, Moataz F Elsawy
DOI:10.4103/mmj.mmj_385_19  
Objective The aim of the study was to assess importance of central corneal thickness (CCT) in the intraocular pressure (IOP) variation after corneal refractive surgery. Patients and methods This prospective, interventional study contains 75 patients who were divided into three equal groups. Group I had undergone femtosecond laser-assisted in-situ keratomileusis (femto-LASIK); Group II had undergone laser in-situ keratomileusis (LASIK); and group III had undergone photorefractive keratectomy (PRK). The evaluated parameters included age, sex, spherical equivalent refraction (preoperative and postoperative), CCT preoperatively and postoperatively and IOP preoperatively and postoperatively at 1, 3, and 6 months by Goldmann applanation tonometry (GAT) and ocular response analyzer. Result The mean CCT reductions were 56.6 ± 34.1, 52.8 ± 25.5, and 40.5 ± 25.9 μm after femto-LASIK, LASIK, and PRK surgery. The mean IOP reductions by GAT were 2.42 ± 1.9, 2.46 ± 2.56, and 1.14 ± 1.31 mmHg after 1 month in femto-LASIK, LASIK, and PRK; however, after 3 months 3.14 ± 1.87, 3.22 ± 2.99, and 2.7 ± 2.23 mmHg after femto-LASIK, LASIK, and PRK. After 6 months the mean IOP reduction was 3.22 ± 1.83, 3.44 ± 2.91, and 2.84 ± 2.32 mmHg after femto-LASIK, LASIK, and PRK. The mean IOPg reduction was 2.53 ± 1.81, 3.19 ± 1.76, and 3.29 ± 1.87 mmHg at 1, 3, and 6 months after femto-LASIK. However, the mean decrease in IOPg was 2.67 ± 2.08, 3.28 ± 1.95, and3.52 ± 1.89 mmHg at 1, 3, and 6 months after LASIK. The mean decrease in IOPg was 1.26 ± 1.98, 2.85 ± 1.98, and 2.98 ± 1.79 mmHg at 1, 3, and 6 months after PRK. IOPcc is not correlated with CCT. Conclusion The IOP by GAT and IOPg reduction after corneal refractive surgery significantly depends on CCT changes, but IOPcc measurements are not associated with CCT.
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Topographic corneal changes in children with vernal keratoconjunctivitis p. 646
Adel G Zaky, Hoda M. K. El-Sobky, Nagwan A Gad
DOI:10.4103/mmj.mmj_390_19  
Objectives To determine corneal topographic characteristics of children with vernal keratoconjunctivitis (VKC) and compare the corneal topographic indices between patients with VKC and normal participants. Background Keratoconus is the most common corneal ectatic disorder, the cause of which is largely unknown. Many factors have been implicated, and ocular allergy is one of them. Patients and methods A cross-sectional prospective study was conducted on children with VKC who attended outpatient clinic of Menoufia University Hospital, Faculty of Medicine, Menoufia University, in the period from February 2018 to February 2019. All study patients were divided in two groups: group I included 50 eyes of children with VKC aged between 7 and 18 years and group II included 30 eyes of normal age-matched and sex-matched participants. Full history, routine and physical examination, general topography, and Pentacam imaging were done. Results Children with VKC had significantly increased keratoconus index, index of surface variance, and index of vertical asymmetry than normal group. However, children with VKC had significantly decreased thinnest location (529.43 ± 34.72) than normal groups (569.30 ± 16.43) (P < 0.001). In addition, there were non statistical significant differences between the studied children regarding anterior chamber depth (P = 0.913) and corneal volume (P = 0.286). Moreover, max elevation front was significantly increased among children with VKC (9.03 ± 5.59) than normal groups (3.57 ± 1.28) (P < 0.001). Conclusions There was a higher prevalence of keratoconus-like topography in patients with VKC. However, owing to small sample size, being hospital-based study, lack of population-based randomized study, and lack of correlation between clinical findings and topographic findings, the data have limited role in extrapolation to the general population. So, patients with VKC should be advised to have corneal topography, especially when presentation of VKC is of long duration, a significant proportion of high refractive error is present, and Best Spectacle-Corrected Visual Acuity (BSCVA) is decreased.
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Comparison between Ahmed glaucoma valve and diode laser cyclophotocoagulation in the management of refractory glaucoma p. 653
Hany A Khairy, Moataz F El-Sawy, Asmaa A El-Enany
DOI:10.4103/mmj.mmj_393_19  
Objective The aim of the study is to compare between Ahmed glaucoma valve (AGV) and cyclodiode laser photocoagulation in the management of refractory glaucoma. Background To compare the intraocular pressure (IOP) reduction and safety of diode laser contact cyclophotocoagulation (DCPC) and AGV in cases of refractory glaucoma. Patients and methods This study was a prospective, consecutive trial. Patients were recruited from the Eye Outpatient Department at Menoufia University Hospital, Egypt. The study was conducted on 20 eyes of 20 patients. Patients were divided into two groups, with 10 patients each. All patients underwent a baseline complete ophthalmologic examination and IOP measurement before and after 1, 3, and 6 months of follow-up. Complications were recorded. Group I underwent AGV surgery and group II underwent DCPC. Results There was no significant difference among group I and group II regarding age, sex, and preoperative IOP. The mean postoperative IOP after 1 month for group I was 14.80 ± 4.10 and was 25.0 ± 6.68 for group II, with a significant difference (P = 0.004). The mean postoperative IOP after 6 months for group I was 19.10 ± 5.74 and was 20.0 ± 7.44 for group II, with no significant difference (P = 0.436). In patients with AGV, the most frequent complication was hyphema. In patients with DCPC, eye pain was the most frequently observed complaint. Conclusion Greater IOP reduction was achieved by AGV, but the difference between it and cyclodiode laser was not significant. AGV had more serious complications.
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GENERAL SURGERY - ORIGINAL ARTICLES Top

Role of early endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis p. 659
Hatem M Sultan, Ahmed G El Tatawy, Mohamed A Mohamed
DOI:10.4103/mmj.mmj_400_19  
Objective The aim was to evaluate the role of early endoscopic retrograde cholangiopancreatography (ERCP) in reducing mortality and morbidity of acute biliary pancreatitis with the consideration of the economic burden of this maneuver. Background A stone that obstructs the ampulla of Vater can cause biliary pancreatitis. ERCP is used to remove the stones that obstruct the ampulla. The risk-to-benefit ratio of this in the setting of acute pancreatitis is a matter of debate. In this research, we intend to overweight one of the both schools (conservative vs early ERCP). Patients and methods This prospective randomized comparative study was done at the Menoufia University Hospital between April 2015 and January 2018 which included 40 patients who were divided into two groups: groups A included 20 patients managed by early ERCP. Group B included 20 patients managed initially conservatively and they will be divided into three subgroups according to the course of jaundice. B1 subgroup: Those who will continue the conservative course due to continuous daily serial declination of their direct serum bilirubin. Group B2: those with continuous daily serial rising of the serum bilirubin (for 2 consecutive days) and they will be subjected to urgent ERCP. Group B3: those with fluctuating levels of serum bilirubin and they will be subjected to elective ERCP. Both group A and B patients will be subjected to laparoscopic cholecystectomy and were compared as regards the complications, mortality, economic burden, and hospital admission time. Results There was only one complication in group A with a percentage of 5% while there were three complications in group B and there were three with a percentage of 15%; thus, there was a significant reduction in complications in group A (P 0=0.05–0.001). Conclusion Early ERCP by a well-trained endoscopist in acute biliary pancreatitis is effective in reducing the complications and hospital admission time though it has more cost.
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Redo surgery in hypospadias p. 665
Magdi A Lolah, Tarek F Kishk, Tamer A Sultan, Tamer Fakhry, Shiamaa M Kalama
DOI:10.4103/mmj.mmj_19_19  
Objective The aim of this study was to determine and evaluate the types of complications and the best type of redo repair. Background Hypospadias surgery is characterized by a constant evolution. The surgeon should use the technique that is suitable for the patient and with which he is most conversant. The best operation for hypospadias correction is the operation that brings the best results. Patients and methods A prospective, randomized, controlled study was conducted during the period from July 2015 to October 2017 on 30 patients presented with crippled hypospadias to the outpatient clinic of Menoufia University Hospitals. All patients in the study presented with complication due to previously repaired hypospadias. The patients were divided into four groups: group A was operated upon with tubularized incised plate urethroplasty; group B was operated upon with Thiersch–Duplay; group C patients were operated upon with buccal mucosal graft; and group D patients were operated upon with one-stage or two-stage repair. Results Successful repair was done for 19 (63.3%) patients, complications occurred in 11 (36.6%) patients. The most common complications were urethrocutaneous fistula affecting six (20%) patients, meatal stenosis affecting four (13.3%) patients, urethral stricture affecting two (6.6%) patients, complete disruption affecting one (3.3%) patient, and donor site complication affecting one (3.3%) patient. Conclusion From this study, it seems that the repair depends on the type of hypospadias, presence or absence of chordee, condition of the nearby skin, and the experience of the surgeon.
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Raja Isteri Pengiran Anak Saleha appendicitis and Alvarado scores in diagnosis of patients with acute appendicitis p. 671
Mohamed S Amar, Mahmoud S Abd Hallem, Mohamed M Elsayad
DOI:10.4103/mmj.mmj_219_19  
Objective The aim was to compare between Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) and Alvarado scoring systems in the diagnosis of acute appendicitis. Background Acute appendicitis is one of the most common surgical emergencies. The RIPASA and Alvarado scores are new diagnostic scoring systems developed for the diagnosis of acute appendicitis. Patients and methods A cross-sectional study was carried out on 186 patients complaining of acute abdominal pain during the 8-month period in the Department of Surgery, Menoufia University and Tala Control Hospital. Histopathological reports of the cases were collected and compared with the scores. Full history was taken, and routine investigation was done. Results There was poor agreement between Alvarado and RIPASA scoring systems in the diagnosis of appendicitis. The agreement in appendicitis was 43%. Moreover, RIPSA score diagnosis and histopathological diagnosis were not significantly different among the studied patients. However, there was a significant difference between RIPSA score and histopathological diagnosis in the diagnosis of appendicitis among patients. Regarding accuracy of diagnosis, RIPSA score had a sensitive level (94%) higher than Alvarado score (54%) in diagnosis of appendicitis, whereas Alvarado score had specificity level (62%) higher than RIPSA score (10%). Conclusion The difference in the diagnostic accuracy between Alvarado and RIPASA scoring system is significant, indicating that the RIPASA score is a much better diagnostic tool for the diagnosis of acute appendicitis.
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Invasive and noninvasive tip rhinoplasty in a group of Egyptian thick-skinned patients p. 675
Tarek F Keshk, Ahmed A Taalab, Ahmed Fergany, Mohamed M Ghoneim, Hanan A Dawoud
DOI:10.4103/mmj.mmj_301_19  
Objective The aim was to evaluate the indications, contraindications, and complications of surgical and filler nasal tip rhinoplasty among Egyptians. Background Egyptian nasal tip is predominantly characterized by the bulbous tip, thick skin, and weak cartilage with broad lateral crus. Preoperative analysis guides the selection of the suitable operative technique. Patients and methods This is a prospective cohort study that was done on 32 patients with nasal tip deformities in the period from December 2017 to September 2019 in Menoufia University Hospital, Egypt. Patients were divided into two groups: invasive (surgery) and noninvasive (filler). Patient data (age, sex, and comorbidities), nasal tip analysis (definition, skin thickness, projection, and rotation), operative techniques, postoperative complications, and follow-up data were recorded. Results Surgery group included 21 (65.6%) patients. All cases were operated under general anesthesia in the operating room. Most patients were females (71.4%), with a mean age of 28.05 years. Filler group included 11 (34.4%) patients. All cases were operated under local anesthesia in the outpatient clinic. All patients were females, with a mean age of 30.4 years. Doctor satisfaction was significant among the surgery group (P < 0.05). Conclusion The predominant anatomic nature of Egyptian nose (thick skin and weak saucer-shaped cartilage) made surgical techniques more suitable to correct nasal tip deformity and achieve satisfying permanent results.
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Comparative study between early mobilizations vs late mobilization after flexor tendon repair in the hand p. 683
Magdi A Lolah, Dalia M Elsakka, Medhat A Samy, Mostafa G Hanot
DOI:10.4103/mmj.mmj_351_19  
Objective The aim was to study the different types of mobilization after flexor tendon repair and their effect on the prognosis of healing and rehabilitation. Background Tendon injuries are the second most common hand injury type. Most tendon injuries require surgical repair and rehabilitation to restore hand function. Postsurgical rehabilitation improves the functions and outcomes and is an essential step in managing repaired tendons. Patients and methods The study included 60 patients after repair of flexor tendons in the hand, who were divided into early, intermediate, and late groups as A, B, and C, respectively (randomized controlled clinical trial). To clarify the timing distribution of rehabilitation after tendon repair, the authors subdivided the patients into three groups: early rehabilitation (<1 week), intermediate rehabilitation (1–6 weeks), and late rehabilitation (>6 weeks) after tendon repair. The period selection (<1 week, 1–6 week, and > 6 week) was based on the physiology of tendon healing. The resurgery rate and the use of rehabilitation resources after tendon repair were calculated. Complications were studied and compared (reduced range of finger movement, rupture of the repair, and flexor tendon adhesion). Results The resurgery rate was highest (12.08%) in those commencing rehabilitation more than 6 weeks after tendon repair, and lowest (3.81%) in those commencing it within 1 week. Patients in the early rehabilitation group required fewer rehabilitation sessions (median: 11.5 sessions) than did those in the intermediate (29 sessions) and late (33 sessions) rehabilitation groups. Conclusion The early rehabilitation group exhibited the lowest resurgery rate and used the fewest rehabilitation resources. Compared with late rehabilitation, early or intermediate rehabilitation conferred protective effects against resurgery and fewer complications.
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PLASTIC SURGERY - ORIGINAL ARTICLES Top

Biochemical and immunological changes as prognostic factors after homografts application for the management of major burn patients p. 688
Mohamed A Megahed, Sherief M El Kashty, Ahmed T Nassar, Mohamed I Ghazal
DOI:10.4103/mmj.mmj_32_19  
Objectives To study the immunological and biochemical changes occurring after the application of homografts in the management of major burns and their implication as prognostic indices. Background Early excision of deep burn has been one of the critical advances in burn care. The advantages of early burn excision and closure is well established and it is generally accepted that it is a life-saving procedure. Patients and methods This study was done at the Plastic and Reconstructive Surgery Department, Menoufia University Hospitals as well as Al-Babtain Plastic Surgery and Burn Center in Kuwait. It was done from April 2016 to October 2018 on 15 patients with a follow- up period of more than 1 year in some cases. All patients were subjected to early excision of the burn eschar and then immediate coverage with either homografts, cadaveric grafts, or debridement only when grafts were not available. The changes in the laboratory parameters after 72 h postsurgery were compared with those 24 h before surgery to detect the effect of each technique on the clinical outcome. Results Three groups were investigated with the most significant fluctuation in the parameters measured in the first group of living donor homografts as compared with the second group cadaveric homograft and sole burn debridement as the third group. Conclusion The immunological parameters and inflammatory cytokines were improved by the use of homografts; detecting these changes in burned patients can anticipate whether the course of treatment is favorable or not.
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Potential of stem cells for skin regeneration following burn p. 694
Tarek F. A. Keshk, Dalia M El-Sakka, Ahmed T Nassar, Thoria A Omar, Ahmed I. F. Ibrahim
DOI:10.4103/mmj.mmj_48_19  
Objective To evaluate the possible additive effects of the use of stem cells for skin regeneration following superficial burn. Background Stem cell therapy has offered a great method in the management of burns. There are different sources of stem cell, such as adipose tissue-derived stem cells (ADSCS), bone marrow-derived stem cells, umbilical cord-derived stem cells, or amniotic fluid stem cells. We tried to prove the potential of ADSCS in the management of superficial burn. Patients and methods This clinical trial was performed at the Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, from January 2014 to January 2016. It was done on 30 patients with superficial burn. The ages of the patients ranged from 20 to 60 years. Patients were of both sexes, who were divided into two groups: group A was scheduled for application of ADSCS in burnt area after its isolation by liposuction, and group B was scheduled for application of silver sulfadiazine. Results Postoperative follow-up assessment took place on the third, fifth, seventh, 14th, and 21st day. The supervisors and researchers assessed results based on clinical observation and analysis of the preoperative and postoperative photographs, with significant superiority of using ADSCSs with respect to rapid healing, pain tolerance, and patient's satisfaction. Conclusion Adipose tissue-derived mesenchymal stem cell dressing application can be an option and may become an ideal therapy in the treatment of superficial burn. Its use would shorten the period of healing and provide a cheap alternative to other techniques.
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ONCOLOGY - ORIGINAL ARTICLE Top

The prognostic value of Glasgow prognostic score in epithelial ovarian cancer p. 699
Tarek A Hashem, Mohammad A Shehata, Suzan A Alhassanin, Salma M El-Menshawy, Suzy F Gohar
DOI:10.4103/mmj.mmj_264_19  
Objective In this study, the authors assessed the prognostic value of Glasgow prognostic score (GPS) in overall survival (OS) and progression-free survival. Background Inflammation plays an important role in the pathogenesis of ovarian cancer. The GPS is an inflammation-based prognostic score composed of C-reactive protein and albumin. Patients and methods A prospective study was conducted in the Department of Clinical Oncology, Menoufia University, between June 2016 and December 2018. The authors analyzed the clinicopathological characteristics and pretreatment C-reactive protein and serum albumin levels of 57 patients with epithelial ovarian cancer. Time to treatment failure and OS were determined using Kaplan–Meier method. Results High GPS was significantly associated with age, performance status, elevated Ca125 level, advanced stage, ascites, size of residual tumor after the debulking surgery, and platinum sensitivity (P < 0.001). In addition, patients with higher GPS had shorter progression-free survival (P < 0.001) and OS (P = 0.107). However, multivariate analysis revealed that GPS is not an independent prognostic factor in those group of patients. Conclusion High GPS is a poor prognostic factor in patients with epithelial ovarian cancer.
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VASCULAR SURGERY - ORIGINAL ARTICLE Top

Factors affecting the outcome of superficial femoral artery stenting p. 706
Mohammed S. Ahmed Abd Allah, Hesham S Abu Grida, Abd El-monem F. Mohammed, Yahia M Al Khateep
DOI:10.4103/mmj.mmj_376_19  
Objectives The aim of this study was to assess the durability of superficial femoral artery stents and factors that affect stent patency. Patients and methods This prospective study was carried out on 30 patients who were complaining of critical limb ischemia (CLI). CLI was recorded in 22 right lower limbs and in 11 left lower limbs. Results There was a significant correlation between the occurrenace of CLI and diabetes mellitus (P = 0.001), hypertension (P = 0.011), ischemic heart disease (P = 0.028), chronic renal failure (P = 0.001), and cerebrovascular disease (P = 0.001). In all, 59% of lesions treated were chronic total occlusions and the remaining 41% were for stenotic lesions. Trans-Atlantic Inter-Society Consensus (TASC) II A group lesions were found in 11 (33.3%) limbs; TASC II B group lesions were found in 13 (39.4%) limbs; TASC II C group lesions were found in five (15.2%) limbs; and TASC II C or D group lesions were found in four (12.1%) limbs. There was a significant (P = 0.001) decrease of primary and secondary patency in smokers and in diabetic patients. Conclusion Diabetes mellitus, hypertension, ischemic heart disease, chronic renal failure, and cerebrovascular diseases are risk factors for the occurrence of CLI.
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PEDIATRICS SURGERY - ORIGINAL ARTICLE Top

Laparoscopic inguinal hernia repair in girls using the percutaneous internal ring suturing technique – our own experience p. 713
Ramesh Tanger, Aditya P Singh, Arun K Gupta, Vinay Mathur
DOI:10.4103/mmj.mmj_306_18  
Objective We evaluate d the usefulness of the percutaneous internal ring suturing (PIRS) technique in girls only. Background PIRS is a percutaneous closure of the internal inguinal ring under the control of a telescope/laparoscope placed through the umbilicus. Material and methods Thirty girls underwent surgery using this method in our institution between 2016 and 2017. We used telescope (3 mm, 0°), spinal needle (20 G), and nonabsorbable polypropylene 3-0 suture. The insufflation pressure in the peritoneal cavity was maintained at 8–10 mmHg. Results We selected the isolated cases of the inguinal hernia in only girls. There was no need of conversion to open surgery in our study. The recurrence was seen in two (6.6%) cases. These were treated by open herniotomy. We did follow-up with local clinical examination only. Conclusion PIRS technique is an alternative for the open inguinal surgery. It is effective and minimally invasive surgery and without visible scar. It is also useful to detect the other abnormalities and can perform other procedure in same session such as contralateral inguinal hernia and umbilical hernia.
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PEDIATRICS SURGERY - CASE REPORTS Top

Type 3 sacrococcygeal teratoma presenting as a huge abdominal lump in a neonate p. 717
Aditya P Singh, Arun K Gupta, Maryem Ansari, Ramesh Tanger
DOI:10.4103/mmj.mmj_173_18  
Sacrococcygeal teratoma (SCT) is the commonest solid tumor in neonates, occurring in one in 40 000 births. Early removal of the tumor is advised in neonates as there is increased chance of malignant transformation with age. There are four types of the SCT. Type 3 is a relatively rare and usually present in older children. We are presenting here a case of type 3 SCT in a neonate with huge abdominal lump.
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Patent vitellointestinal duct with foreign body: a rare case p. 720
Dileep Garg, Aditya P Singh, Vinay Mathur, Dinesh K Barolia
DOI:10.4103/mmj.mmj_225_18  
Patent vitellointestinal duct (PVID) is one of the congenital malformation of incomplete obliteration of the vitelline duct. The foreign body impaction in PVID is a rare cause of gastrointestinal obstruction in the children. Here we are presenting a case of a 1-year-old child who presented with abdominal pain and bilious vomiting. Patient had history of serous umbilical discharge since birth. On exploration, we found a watermelon seed in the lumen of PVID. It was obstructing the lumen of small intestine. Foreign body was removed, and resection of patent duct was done. Moreover, an end-to-end ileoileal anastomosis was performed. Patient was discharged uneventfully.
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ERRATUM Top

Erratum: Use of azacytidine in differentiation of mesenchymal stem cells p. 722

DOI:10.4103/1110-2098.288209  
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