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   Table of Contents - Current issue
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October-December 2017
Volume 30 | Issue 4
Page Nos. 971-1262

Online since Wednesday, April 4, 2018

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REVIEW ARTICLES  

Efficacy of early goal-directed therapy in severe sepsis and septic shock Highly accessed article p. 971
Khaled M Abu El-Einein, Enas Abd El-Mohsen Shaaheen, Neveen I Samy, Naglaa S Abd El-Hady Hammad
DOI:10.4103/mmj.mmj_263_17  
Objective The aim of this review was to present the current trends and methodologies of the use of early goal-directed therapy (EGDT) and its efficacy in patients in severe sepsis and septic shock. Data sources Data were obtained from Medline databases (PubMed, Medscape, and Science Direct) and from materials available on the Internet from the start date of each database to February 2017. Data selection The selected articles are systematic reviews and experimental studies that address EGDT in severe sepsis and septic shock. Data extraction Extraction was performed according to the validity, quality, and originality of the selected reviews and studies that fulfilled the previous criteria; in addition, the focus was on studies that present the latest or the most updated findings on application of EGDT. Data synthesis Each review and study was reviewed. The layout was selected to present a wide range of data including the most recent findings on this subject. Significant data were collected; thus, a structured review was performed. Results Most of studies conclude that EGDT is very important and its use markedly decreases mortality and morbidity in patients with severe sepsis and septic shock. Conclusion The main conclusion of the reviews and studies that were presented in the current research paper is that the use of EGDT in severe sepsis and septic shock reduces the length of hospital stay and reduces the hospital mortality rate in selected patients.
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Effect of quercetin treatment on hyperuricemic renal dysfunctions and hemodynamic parameters Highly accessed article p. 978
Sohair A El-Hamid Saleh, Gergess S Youssef, Hayam A El-Samea Aiad, Safaa M Al-Kotb, Sally S Donia, Heba F El-Domiaty
DOI:10.4103/mmj.mmj_220_17  
Objective The aim of this study was to assess the potential effect of quercetin treatment on hyperuricemic renal dysfunctions and hemodynamic changes in in vivo and in vitro published studies. Materials and methods Data were obtained from Medline databases (PubMed, Medscape, ScienceDirect.) and all materials available in the internet from 2001 to 2016. The initial search presented 170 articles, of which 47 met the inclusion criteria. The articles studied the effect of quercetin treatment on hyperuricemic renal dysfunctions and hemodynamic changes. 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, adequate information, and defined assessment measures. Comparisons were made using structured review with the results tabulated. Findings In total 47 potentially relevant publications were included. There was an association between hyperuricemia and renal function impairment together with deterioration of hemodynamic parameters. This association was due to hyperuricemic vascular endothelial dysfunction and oxidative stress. Studies concerned with quercetin treatment found that quercetin was able to improve hyperuricemic renal functions and hemodynamic parameter mainly due to its antioxidant effect. Conclusion Quercetin treatment improved hyperuricemic renal dysfunctions and hemodynamic parameters.
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ORIGINAL ARTICLES Top

Serum level of mannose-binding lectin in cirrhotic patients with spontaneous bacterial peritonitis Highly accessed article p. 984
Ahmed B Mahmoud, Azza M Abd El Aziz, Tawfik M Abd El Motelb, Nashwa A El Fetoh Shebl, Radwa H Abdel Sattar Salem
DOI:10.4103/1110-2098.229231  
Objectives To evaluate the role of mannose-binding lectin (MBL) in cirrhotic patients with and without spontaneous bacterial peritonitis (SBP) and to determine its role in the diagnosis of peritonitis. Background MBL deficiency increases the risk of various infections mostly in immunodeficient conditions. SBP is one of the bacterial infections causing morbidity and mortality under liver cirrhotic patients. Materials and methods A total of 90 individuals (66 male and 24 female with the mean age 52.55 ± 9.90 years) were included: 35 cirrhotic patients with ascites and SBP, 35 cirrhotic patients with ascites and no SBP and 20 apparently healthy persons as a control. The studied groups were subjected to full medical history, clinical examination and measurement of serum level of mannose-binding lectin (sr MBL) by enzyme-linked immunosorbent assay. Cirrhotic patients were subjected to liver function tests, and biochemical and bacteriological examination of ascitic fluid including culture and sensitivity testing was performed for all cirrhotic patients with ascetic fluid total leucocytic count (TLC) greater than 500 cells/mm3. Results sr MBL was significantly lower in group 1 than in group 2 (P < 0.001); sr MBL can predicts SBP with a sensitivity of 71.4% at a cutoff point of 1202.5 ng/ml; also, the sr MBL level was significantly lower in culture-positive ascitic fluid samples than in culture-negative samples (P < 0.05). Patients with positive cultures for Gram-negative isolates had a significantly lower sr MBL than those with Gram-positive isolates (P < 0.05). A negative correlation was found between sr mannose-binding lectin (MBL) and sr albumin, ascitic fluid TLC, and glucose, but a positive correlation was found between sr MBL and aspartate aminotransferase, ascitic fluid albumin, and total protein. Conclusion sr MBL could be considered as a predictive marker for SBP in cirrhotic patients.
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The value of lipocalin-2 as a predictive biomarker of bacterial infection in hepatic patients p. 991
Enas M Ghoniem, Azza M Abd El Aziz, Tawfik M Abd El-Motelb, Ahmed A Aly Salama, Hanaa M I. El Gazzar
DOI:10.4103/1110-2098.229210  
Objective The aim of this study was to assess serum levels of lipocalin-2 in hepatic patients with bacterial infection and evaluate the role of lipocalin-2 as a diagnostic marker for bacterial infection. Background Lipocalin-2 is a 25-kDa protein present in peroxidase-negative granules of neutrophils, colocalized with lactoferrin, and is released following neutrophil activation. Lipocalin-2 exerts bacteriostatic effects, which are explained by its ability to capture and deplete siderophores, small iron-binding molecules that are synthesized by certain bacteria as a means of iron acquisition. Patients and methods Eighty patients divided into three groups were included in the study: group 1 included 40 hepatic patients with bacterial infection; group 2 included 20 hepatic patients without bacterial infection; and group 3 included 20 healthy patients as the control group. Liver function tests, complete blood count, evaluation of serum level of C reactive protein, and serum measurement of lipocalin-2 were carried out in all groups. Microbiological examination (blood, urine, sputum, and ascetic fluid cultures) was performed for patients. Results Serum level of lipocalin-2 was significantly increased in hepatic patients with bacterial infection than in other groups (P ≤ 0.0001). Lipocalin-2 at cutoff less than 60 ng/ml could predict bacterial infection with 90% sensitivity and 72% specificity. Conclusion Lipocalin-2 is an excellent predictive biomarker of bacterial infection. It can be used as a diagnostic marker with better sensitivity and specificity than C reactive protein for the diagnosis of bacterial infection, especially in chronic liver disease.
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Study of interferon-γ-inducible protein-10 levels during antiviral therapy of hepatitis C patients with sofosbuvir plus ribavirin and interferon in Menoufia hospitals p. 997
Ghada R El-Hendawy, Ahmed A Salama, Elsayed I Elshayb, Nancy R Ahmed Elhosseny
DOI:10.4103/mmj.mmj_555_16  
Objective The aim of this work was to study the effect of treatment with sofosbuvir, ribavirin, and interferon on the level of interferon-γ-inducible protein-10 (IP-10) and to determine its role in hepatitis C virus (HCV) patients with liver cirrhosis. Background IP-10 is a small cytokine belonging to the CXC chemokine secreted by several cell types in response to interferons (interferon-γ). IP-10 has been attributed to several roles, such as chemoattraction for monocytes, macrophages, T cells, natural killer cells, and dendritic cells, promotion of T cell adhesion to endothelial cells, antitumor activity, and inhibition of bone marrow colony formation and angiogenesis. Patients and methods The study was conducted on 27 hepatitis C patients with cirrhosis and 15 age-matched and sex-matched healthy individuals. Serum levels of IP-10 were measured in patients using enzyme-linked immunosorbent assay technique three times: before beginning the treatment, after 1 week of treatment, and finally after 3 months of treatment. IP-10 levels were statistically analyzed in relation to liver cirrhosis and treatment outcome. Results IP-10 serum levels were highly elevated in patients when compared with healthy people. Serum IP-10 was significantly higher before beginning HCV treatment and then decreased after 1 week of treatment, and it was markedly decreased after 3 months of treatment. Conclusion IP-10 had a fundamental role in the pathogenesis of liver fibrosis and cirrhosis as it was significantly elevated in cirrhotic patients. Furthermore, there was a significant reduction in serum IP-10 concentration following a successful course of HCV treatment.
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Surgical site infections: Problem of multidrug-resistant bacteria p. 1005
Wafaa A Zahran, Ashraf A Zein-Eldeen, Sanaa S Hamam, Mona S Elsayed Sabal
DOI:10.4103/mmj.mmj_119_17  
Objectives The present study aimed (a) to determine the prevalence and risk factors of surgical site infections (SSIs) at Menoufia University Hospitals; (b) to determine bacterial pathogens and their antimicrobial susceptibility patterns frequently causing SSIs; (c) to determine the prevalence of multidrug-resistant (MDR) bacteria; and (d) to assess infection control practices related to surgeries. Background SSI is the most surveyed and frequent type of healthcare-associated infection. A high prevalence of MDR strains has been observed in patients with SSIs. Patients and methods This study involved 148 patients who were admitted and chosen randomly from the General Surgery and Orthopedics Departments of Menoufia University Hospitals. Isolated organisms and antimicrobial susceptibility were identified. Detection of and phenotypic confirmation of MDR strains were carried out according to Clinical and Laboratory Standards Institute guidelines. Correlation between compliance rate of the surgical team to infection control measures in operating theater and SSI rate was determined. Results Prevalence of SSI was found to be 67.6%. The most common type of operative wounds were contaminated wounds and the most common wound infections were superficial wounds. The most frequently isolated species was Staphylococcus aureus (27.4%). Methicillin resistance was detected in S. aureus and coagulase-negative staphylococci by 88.3 and 62.5%, respectively. Extended spectrum β-lactamases were detected in 65.1% of Enterobacteriaceae isolates and metallo-β-lactamases in 73% of Gram-negative isolates. MDR isolates were detected in 37.2%. Furthermore, a reverse correlation between compliance rate and infection rate was detected. Conclusion In our study, there was a high prevalence of SSI and great problem of MDR bacteria with reflected difficulty in managing SSIs. Focused efforts should be directed to support infection control strategies.
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Interleukin-18 and vascular endothelial growth factor as predictors for end-stage renal disease p. 1014
Aml F A. Makled, Eman H M. Salem, Amira H A. El-Khayat, Mahmoud M A. Emara, Sara I M. El Shohady
DOI:10.4103/mmj.mmj_352_17  
Objective The objective of this study was to evaluate the role of interleukin-18 (IL-18) and vascular endothelial growth factor (VEGF) in end-stage renal disease (ESRD), and the influence of comorbidities like diabetes and viral hepatitis on their levels. Background IL-18 and VEGF are inflammatory cytokines playing important roles in the pathogenesis of ESRD and related comorbidities like diabetic nephropathy and viral hepatitis. Patients and methods This study was conducted on 96 patients undergoing hemodialysis (25 diabetic patients with hepatic viral infections, 25 diabetic patients without hepatic viral infections, 25 nondiabetic patients with hepatic viral infections, and 21 age-matched and sex-matched healthy individuals as a control group). All patients were subjected to full history taking, clinical examination, and laboratory investigations. Serum IL-18 and VEGF levels were measured for all the study individuals by using enzyme-linked immunosorbent assay technique. Results The prevalence of IL-18 and VEGF was higher in diabetic patients and patients with hepatitis comparing with the controls (P = 0.001). A detectable level of IL-18 was found in 100% of diabetic patients with and without viral hepatitis, and in 44% of the ones with only hepatitis (P = 0.001). A detectable level of VEFG was found in 100% of the patients with only diabetes and only hepatitis, and in 80% of the ones with combined diabetes and hepatitis (P = 0.001). Conclusion There is high elevation of both IL-18 and VEGF serum levels in ESRD associated with diabetic nephropathy and viral hepatitis. Serum IL-18 is higher in diabetic than hepatic nephropathy, whereas the opposite is seen with VEGF.
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Paediatric health significance of prevalent stratified indigenous Lactobacillus spp. species in diet-dependent infantile faecal specimens p. 1022
Adenike A O. Ogunshe
DOI:10.4103/mmj.mmj_182_16  
Background Composition of early gut microbiome changes in breast-fed and formula-fed infants as solids foods are introduced into their diet. Objective This study aims to investigate the stratified of easily culturable indigenous Lactobacillus spp. with probiotic potentials in infant faecal specimens. Participants and methods Questionnaires were administered on 41 healthy and well-nourished neonates and infants between 1.5 and 11 months of age through their mothers. Isolated bacterial florae were identified using standard phenotypic cultural and taxonomic procedures and tools. Results Most of the infants were fed on breast milk and industrial baby cereal foods; however, more male babies (seven) were exclusively breast-fed than female babies (two). The pH range of the infantile faecal specimens was 4.8–5.9, but the enumerated viable counts as colony-forming units were between 1.1 × 103 and 7.2 × 103 cfu g-1. No lactobacilli were isolated from 39% faecal specimens of 4–16 days old infants, but there were higher recovery rates of Lactobacillus strains from faecal specimens of older (5–11 months) infants. Diversity of isolated 151 Lactobacillus strains included one or more different phenotypes characterized as Lactobacillus acidophilus, Lactobacillus bifidus, Lactobacillus brevis, Lactobacillus casei, Lactobacillus plantarum and Lactobacillus reuteri. The overall most-prevalent Lactobacillus strains were L. reuteri (46.4%), L. casei (23.2%) and L. acidophilus (19.9%), whereas L. bifidus (7.28%), L. brevis (1.99%) although L. plantarum (1.32%) were isolated from faecal specimens of healthy infants above 5 months of age. L. acidophilus (32.5%), L. casei (26.0%), L. reuteri (31.2%) vs. L. casei (20.0%) and L. reuteri (62.7%) were the most-prevalent phenotypes from female and male babies, respectively. Conclusion Diet-dependent Lactobacillus spp., which reflected rich indigenous infantile bacterial consortium, were recoverable from faeces of less than 12-month-old breast milk-fed and industrial cereal-fed, healthy Nigerian infants without antibiotherapy.
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Phenotypic and molecular characterization of clinical Acinetobacter isolates from Menoufia University Hospitals p. 1030
Ahmed M Baker, Amal F Makled, Eman H Salem, Ahmed A Salama, Soma E Ajlan
DOI:10.4103/mmj.mmj_452_17  
Objectives The aims of this study were to investigate the prevalence of Acinetobacter spp. in Menoufia University Hospitals, to investigate their antimicrobial susceptibility patterns, and to assess carbapenemases production in these isolates. Background Acinetobacter spp. are important opportunistic pathogens responsible for nosocomial infections. Materials and methods This study was conducted on 603 clinical samples from patients admitted to Menoufia University Hospitals. Acinetobacter spp. were identified by standard microbiological methods and API20NE test kits. Antimicrobial susceptibility was tested using disk diffusion and agar dilution methods. Imipenem-resistant Acinetobacter isolates were further tested for metallo-β-lactamase (MβL) production. Results This study was conducted at Medical Microbiology and Immunology Laboratory, Faculty of Medicine, Menoufia University. Acinetobacter spp. represented 10.6% of all collected nosocomial isolates. With regards to API20NE results, A. baumanii was the predominant Acinetobacter spp. (80.8%) followed by A. baumanniiA. calcoaceticus complex (7.7%), A. lwoffii (5.8%), A. haemolyticus (3.8%), and A. pitti (2.6%). Acinetobacter isolates were highly resistant to cefepime (92.3%), ampicillin–sulbactam, piperacillin, piperacillin–tazobactam, ceftazidime, tobramycin (91% for each), amikacin (84.6%), and imipenem (67.9%). Overall, 56.4% of Acinetobacter isolates were susceptible to tigecycline. On agar dilution method, 96.2% of Acinetobacter isolates were found to be susceptible to colistin and 66.7% were imipenem resistant. Imipenem/ethylenediaminetetraacetic acid combined disk test showed that 81.1% of imipenem-resistant Acinetobacter were MβL producers, and multiplex PCR showed that 15.1% of imipenem-resistant Acinetobacter were positive for blaVIM2, but none of them were positive for blaIMP1 gene. Conclusion Acinetobacter spp. are serious nosocomial pathogens with high prevalence of carbapenems resistance. Production of carbapenemases, especially MβLs, is considered the main carbapenem-resistance mechanism. Tigecycline and colistin can be valuable therapeutic options for the treatment of Acinetobacter infections.
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Evaluation of Midkine and Golgi protein 73 as diagnostic biomarkers in hepatocellular carcinoma patients p. 1037
Amal F Makled, Shymaa A ElAskary, Amira H ElKhyat, Asmaa I Gomaa, Ebtehal M Galbat
DOI:10.4103/mmj.mmj_427_17  
Objective The aim of this work was to assess the clinical utility of Midkine (MDK) and Golgi protein 73 (GP73) among Egyptian hepatocellular carcinoma (HCC) patients in comparison with α-fetoprotein (AFP). Background Serum MDK and serum Golgi protein 73 (sGP73) are promising biomarkers for the detection of HCC. Patients and methods This study included 96 patients; 40 of them had proved HCC, 36 patients had chronic liver diseases and 20 apparently healthy individuals were considered as controls. Clinical examination, abdominal ultrasonography, and triphasic computerized tomography for focal lesion were performed. Liver function tests, hepatitis markers and serum AFP were measured. Serum MDK and GP73 levels were determined by enzyme-linked immunosorbent assay. Results There was a high statistically significant difference in MDK and GP73 between HCC and the control group. For the diagnosis of HCC, the receiver operating characteristic (ROC) curve showed that serum MDK and GP73 levels had an area under the receiver operating characteristic (AUROC) curve of (1.00, 0.952), sensitivity of (100%, 90%) and specificity of 88.9% and 83.3% at a cutoff point of 1585.0 pg/l, 42.5 ng/l, respectively. For early diagnosis of HCC, the ROC curve showed that the serum MDK and GP73 levels had the AUROC curve of 0.869 and 0.941, sensitivity of 88.9 and 94.4% and specificity of 79.5 and 83.3% at a cutoff point of 3825 pg/l and 84.5 ng/l, respectively. Conclusion MDK and GP73 serum levels are highly increased in HCC patients. Their diagnostic performance is superior to that of AFP.
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Association of janus kinase 2 with primary Budd–Chiari syndrome in Egyptian patients p. 1044
Hatem M El Sebay, Manal A Safan, Ashraf A Daoud, Safaa I Tayel, Alaa Nouh, Shymaa El Shafie
DOI:10.4103/1110-2098.229198  
Objective The aim of this study was to evaluate the association of janus kinase 2 (JAK2) V617F mutation with primary Budd–Chiari syndrome (BCS) in Egyptian patients. Background BCS is a rare disorder caused by thrombosis of the hepatic veins or the terminal portion of the inferior vena cava. JAK2 V617F mutation is an objective tool for diagnosing BCS patients. Patients and methods This study was conducted on 50 patients: 35 patients with primary BCS, and 15 age-matched and sex-matched healthy individuals who were taken as the control group. Patient and control groups were subjected to full history taking, general clinical examination, and laboratory investigations including measurement of complete blood count; liver function tests – serum aspartate aminotransferase and serum alanine aminotransferase (ALT), total and direct bilirubin, serum albumin, prothrombin time, partial thromboplastin time, and international normalized ratio; and renal function tests – serum blood urea and serum creatinine. Genotyping of JAK2 mutation was performed by PCR-RFLP method to diagnose the underlying etiology of BCS. Results There was a statistically significant difference between patients and controls regarding hemoglobin, platelets, ALT, aspartate aminotransferase, direct and total bilirubin, albumin, prothrombin time, partial thromboplastin time, international normalized ratio, urea, and creatinine. There was no statistically significant difference between studied patients and control groups regarding JAK2 mutations. Mutant form of JAK2 had significantly increased platelets count and ALT serum levels than wild form, whereas there was no significant difference regarding other laboratory parameters. Conclusion JAK2 V617F mutation was not significantly different between patients and controls.
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Circulatingcell-free DNA as a biomarker in the serum of patients with colorectal cancer p. 1051
Maathir K El Shafie, Manal A Safan, Elsayed S Abou Elnour, Mona S Habib, Tarek M Rageh, Alshimaa M Alhanafy, Amany M Wahb
DOI:10.4103/mmj.mmj_349_17  
Objective The aim was to study whether the concentration of circulating cell-free DNA (ccf-DNA) in serum could be used as a diagnostic biomarker for patients with colorectal cancer (CRC). Background Early diagnosis of CRC represents the best chance for cure. The present screening programs have limited sensitivity and specificity. Increased levels of ccf-DNA provide promising biomarker for several diseases including cancer. It has been postulated that tumor necrosis causes release of DNA of varying sizes which is in contrast to apoptosis of normal cells where smaller amount of DNA fragments are released. Patients and methods This study was carried out on 80 participants classified into the following groups: group I included 40 patients with CRC, group II included 20 patients with benign diseases in colon and rectum, and group III included 20 healthy controls. Laboratory investigations including carbohydrate antigen 19-9 serum level by enzyme-linked immunosorbent assay technique and quantitative analysis of ccf-DNA through detection of short (115 bp) DNA fragments in serum by real-time quantitative PCR by amplifying the Associative Location Unit (ALU) repeats (ALU-qPCR) were performed for all participants. Results The median absolute serum ALU115 levels in CRC group was significantly higher than those in intestinal polyp and normal control groups (P = 0.001) Conclusion It was concluded that serum DNA concentrations may be valuable in early diagnosis, monitoring of progression, and prognosis of CRC.
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C677T single-nucleotide polymorphism of methylenetetrahydrofolate reductase gene and colorectal cancer p. 1057
Maathir K El Shafie, Esam El Din I S. Radwan, Rania M A. El Shazly, Tarek M Rageh, Alshimaa M Alhanafy, Sara A Abd El-Rahman El Derbaly
DOI:10.4103/mmj.mmj_713_16  
Objective The aim of the study was to investigate the association between methylenetetrahydrofolate reductase gene (MTHFR) C677T single-nucleotide polymorphism (SNP) and colorectal cancer (CRC) in the Egyptian population. Background MTHFR is the most critical enzyme in the folate-metabolizing pathway. Its C677T SNP (rs1801133) is the most important one regulating the function of this enzyme, and it has been linked to many types of cancers, cardiovascular diseases, and neurological diseases. Patients and methods This study was carried out as a collaborative effort between Departments of Medical Biochemistry, General Surgery, and Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Menoufia University, from May 2015 to December 2015. It was conducted on 70 individuals who were classified into the following groups: group I, subdivided into group Ia and group Ib, and group II. Group I included 50 CRC patients (26 men and 24 women); subgroup Ia included 29 CRC patients under 5-fluorouracil chemotherapy, and subgroup Ib included 21 CRC patients without chemotherapeutic treatment (under follow-up). Group II included 20 healthy controls (11 men and nine women). Laboratory investigations included detection of MTHFR gene C677T SNP (rs1801133) by real-time PCR using the TaqMan allelic discrimination assay. Results Results showed that the T/T genotype and the T allele of MTHFR C677T were significantly higher in CRC patients compared with healthy controls (P = 0.01 and 0.009, respectively). Conclusion It was concluded that the T allele of MTHFR C677T increases the risk for developing CRC in the Egyptian population, whereas the C allele appeared to have a protective effect.
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The value of osteopontin and matrix metalloproteinase-3 in the assessment of bone mineral density in postmenopausal women p. 1065
Azza M Abdu Allah, Shereen A El Tarhouny, Seham A Khodeer, Walid A Shehab-Eldin
DOI:10.4103/mmj.mmj_41_17  
Objective The aim of this study was to assess the value of osteopontin (OPN) and matrix metalloproteinase-3 (MMP-3) in the assessment of bone mineral density (BMD) in postmenopausal women. Background Osteoporosis is a widespread age-related skeletal disorder characterized by bone loss that increases skeletal fragility. Patients and methods This study was conducted on 172 postmenopausal female individuals. OPN and MMP-3 were assayed by enzyme-linked immunosorbent assay. BMD assessment was carried out by dual-energy X-ray absorptiometry. The patients were divided into three groups according to BMD: osteopenic, osteoporotic and control groups. Results OPN and MMP-3 levels were significantly greater in the osteoporotic and osteopenic groups than in the control group (P < 0.001). In the osteoporotic group, negative correlations between OPN, calcium, and BMD were found as well as positive correlations between OPN and MMP-3. By using the receiver operating characteristic curve, the sensitivities of both OPN and MMP-3 were found to be equal (93%), and the specificities were 100 and 84%, respectively. Conclusion OPN and MMP-3 were significantly increased in postmenopausal women with osteoporosis, suggesting their role in bone turnover. The preserving of normal bone mass density is a challenge for postmenopausal women to prevent bone disabilities. Hence, further studies are recommended to use the presence of OPN and MMP-3 as a regular monitoring system – being sensitive and easy to measure – for the early detection of osteoporosis in postmenopausal women.
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Urinary 8-hydroxy-2′-deoxyguanosine as an oxidative DNA damage biomarker in chronic heart failure p. 1072
Naglaa M Ghanayem, Eman A E. Badr, Ibrahim Elmadbouh, Mahmoud A Soliman, Sara K Rizk
DOI:10.4103/mmj.mmj_700_16  
Objective The aim of this study was to evaluate the role of urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG) as a biomarker of oxidative DNA damage in patients with chronic heart failure (CHF). Background CHF is the leading cause of morbidity, mortality, and increasing healthcare costs around the world. Oxidative stress is known to play a crucial role in the pathogenesis of heart failure. In nuclear and mitochondrial DNA, 8-OHdG is one of the predominant forms of free radical-induced oxidative lesions. Patients and methods This study was conducted on 80 individuals: 50 CHF patients (22 men and 28 women) and 30 healthy controls (16 men and 14 women). The patients were selected from the Cardiology Department of Menoufia University Hospital during the period June 2015 to December 2015. All individuals included in this study were subjected to full history taking, clinical examination, echocardiography, and laboratory investigations that included tests for evaluation of serum lipid profiles, fasting blood sugar, 2 h postprandial glucose, serum creatinine, malondialdehyde, catalase, and urinary 8-OHdG, which was carried out by enzyme-linked immunosorbent assay technique. Results Urinary 8-OHdG was significantly higher in patients than in controls. There was a significant statistical increase in malondialdehyde in patients compared with controls. There was a significant statistical decrease in catalase in patients compared with controls. There was a significant negative correlation between urinary 8-OHdG and systolic ejection fraction in the patients' group. Urinary 8-OHdG can be used as a biomarker in CHF at a cutoff of 5.5 ng/mg creatinine with an accuracy of 87.5%. Conclusion In CHF, urinary 8-OHdG can be a reliable marker of DNA damage as it reflects the level of oxidative stress and degree of CHF severity.
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A comparative study on the effect of aging on the hippocampal CA1 area of male albino rat p. 1079
Fatma El-Nabawia A El-Safti, Wael B El-Kholoy, Abeer E El-Mehi, Rasha R Selima
DOI:10.4103/1110-2098.229200  
Objectives This work aimed to study the effect of aging on the structure of the hippocampus in the adult and aged male albino rats. Background Dementia is one of the most important problems nowadays. Aging is associated with learning and memory impairments. Aging is the progressive accumulation of changes with time that are associated with or responsible for the ever-increasing susceptibility to disease and death, which accompanies advancing age. The hippocampal formation is one of the most common brain areas affected by aging in both humans and other mammalian species. Materials and methods Eighteen male albino rats were divided into three groups of six rats each: Group I included adult animals aged 6 months; group II included rats aged 20 months; and group III included rats aged 24 months. All animals were killed after 8 weeks. Hippocampus sections were prepared for light microscopic examination. Morphometric and statistical analysis were carried out. Results In comparison with the control group aged 8 months, both groups aged 22 and 26 months showed a significant decrease in the number of pyramidal cells of the hippocampus (P<0.001), and a significant increase in the astrocyte surface area in glial fibrillary acidic protein immunostaining (P<0.001). Conclusion Aging process involves degenerative changes in the hippocampus. Aging is more serious as it can produce Alzheimer's disease-like pathological changes. Alzheimer's is the most common form of dementia, a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Alzheimer's disease accounts for 60–80% of dementia cases.
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Depression and anxiety burden among families of patients with malignant disease p. 1085
Hala M Shaheen, Naser Abd El Bary, Nagwa Nashat Hegazy, Mohamed A Dawood
DOI:10.4103/mmj.mmj_147_17  
Objective The aim of this work is to estimate the frequency of different malignant diseases among the families in Manshaat Sultan village, Menoufia Government, and also estimate the depression and anxiety burden among the families of the studied patients with malignant disease. Background The prevalence of anxiety and depression was 47 and 18%, respectively, among family caregivers of patients with cancer. The psychological stress of caregiving has a negative effect not only on the health of the family caregivers but also on the health and well-being of the patients with cancer. Patients and methods The study was approved by the Ethical Committee of Faculty of Medicine, Menoufia University. In total, 356 families were identified as having one patient with cancer. There were 356 (1.424%) patients with cancer from 25 000 individuals registered in Manshaat Sultan village. Overall, 10 families were excluded for the pilot study. A total of 312 families accepted to complete the interview, with a response rate of 87.6%. Predesigned questionnaire included socioeconomic history and hospital anxiety depression scale to assess depression and anxiety burden among families of the studied patients with malignant disease. Results The result found that 312 families accepted to complete the interview in Manshaat Sultan village. The results also showed that anxiety and depression were prevalent among the selected family caregivers in the study area at 47 and 18%, respectively. Depression and anxiety significantly increased among family caregivers with low socioeconomic level in Manshaat Sultan. Conclusion Anxiety and depression among family caregivers has been associated with sex, the patient's medical problem, and financial and social level of family caregivers.
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Prevalence of stunted growth in children less than 5-year old in Qualyoubia governorate p. 1089
Taghreed M Farahat, Seham Ragab, Aml A Salama, Hend N Abdel El Halim
DOI:10.4103/mmj.mmj_158_17  
Objectives The objective of this study was to study the prevalence of stunted growth in children under 5 years of age (in primary healthcare) in a rural area, in Qualyoubia governorate. Background Stunting remains an important problem in Egypt, where ∼ one-third of children under 5 years of age are affected. Patients and methods This is a cross-sectional study that was conducted on 1255 cases. All studied children were subjected to history taking, complete physical examination [height (cm), length (cm), weight (kg)], and laboratory investigations (measurement of hemoglobin level). Then, the stunting group was compared with the control group regarding their different characteristics according to national Egyptian growth chart. Results The prevalence of stunted growth in children under 5 years of age was 13.32%; stunted growth was significantly associated with age of children (stunting was more in children aged <24 months) (P = 0.005), socioeconomic level (P = 0.004), family history of short stature (P < 0.05), family size more than five (P = 0.004), and low hemoglobin level (P < 0.001). Conclusion The prevalence of stunted growth in children under 5 years of age attending primary healthcare in a rural area in Qualyoubia governorate was 13.32%.
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Risky pregnancy among women attending a rural, family healthcare unit p. 1093
Omima A Muhammed, Nora A Khalil, Mohammed A Omara, Mona A Khattab
DOI:10.4103/mmj.mmj_3_17  
Objective The aim of this study was to determine the prevalence of high-risk pregnancy among women attending a rural, family healthcare unit to evaluate different risk factors for high-risk pregnancy. Background High-risk pregnancy is considered to be a major worldwide health problem with an increased risk of perinatal and maternal mortality. Although only 10–30% of the mothers seen in the antenatal period can be classified as high risk, they account for 70–80% of perinatal mortality and morbidity. Patients and methods The present study was cross-sectional study carried out in a rural village in El-Mehalla city in Gharbia governorate. It included all pregnant women attending a family healthcare unit for antenatal care (Bolkina Family Health Care Unit) during the period of data collection. A predesigned questionnaire was used for interviewing the study participants for data collection – the first part included socioeconomic data, and the second part included obstetric history, present pregnancy history, and associated disease history. The Dutta and Das Scoring System was used for classification of risk factors and identification of high-risk pregnancies. Results The results revealed that 51.3% of the sample had risky pregnancies and 48.7% had no-risk pregnancies. High-risk pregnancy was found in 9.6% and mild risk was found in 41.8% of the sample according to the Dutta and Das Scoring System. The most significant risk factors in the risky group were abortion, anemia, hypertension, edema, albuminuria, cardiac disease, diabetes, and multiple pregnancies. Conclusion Early identification and prompt treatment of high-risk pregnancy can prevent the development of both maternal and fetal morbidity and mortality.
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Psychosocial impact of acne vulgaris on adolescents in preparatory and secondary schools p. 1098
Omaima A Mahrous, Mohamed Abd Elwahed, Aml A Salama, Heba-Alla M Eshak Omar
DOI:10.4103/mmj.mmj_179_17  
Objective The aim of this work was to assess the psychosocial impact of acne on adolescents to improve their quality of life. Background Acne vulgaris is a common skin condition with substantial cutaneous and psychological burden. Studies suggest that the emotional impact of acne is comparable to that experienced by patients with systemic diseases. Patients and methods This cross-sectional study included 425 students with acne aged between 11 and 19 years. The psychosocial effect of acne was assessed using the acne quality of life questionnaires. Results Overall, 55.5% of our patients were female and 45.5% were male. The mean age was 15.91 years. In all, 90.1% had facial acne, 32.9% had acne in the back, 74.8% had closed comedo, 55.3% had open comedo, 18.4% had pustules, and only 8.2% had cysts and nodules. Of the total, 76, 17.9, and 6.1% of patients had mild, moderate, and severe acne, respectively. Acne severely affected the patients' perception, emotional state, and social activities. The most affected sector in patients' perception was dissatisfaction with their appearance, feeling unattractive, and disturbed self-confidence (P < 0.001). Being bothered by the need to have medication and cover-up available and not looking their best was the worst emotional impact (P < 0.001). The most affected social activity was interacting with the opposite sex (P < 0.001). Conclusion Acne vulgaris is incriminated in affecting the patients' perception, psychological state, and social activities with increasing affection with increasing the degree of acne.
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Neurobehavioral and hematological health disorders among fuel supply station workers p. 1103
Gaafar M Abdel Rasoul, Eman A Salem, Heba K Allam, Yasser A Shehata, Mahmoud E Abu-Salem, Asmaa F El-Sayed Zagloul
DOI:10.4103/mmj.mmj_252_17  
Objectives This study aimed to study neurobehavioral and hematological health disorders among fuel supply station workers and its relation to the workplace environment. Background Gasoline and its constituents are one of the most hazardous chemicals to the nervous and hematological systems. Patients and methods A case–control nested cross-sectional study was carried out on 92 workers in all licensed fuel supply stations in Shebin El-Kom district, Menoufia governorate, and 92 nonoccupationally exposed matched participants matched for age and sex were selected as a nonexposed group. Environmental studies for light-chain aromatic hydrocarbons [benzene, toluene, ethyl benzene, and xylene (BTEX components)] were carried out. Neurobehavioral test battery and complete blood picture were applied. Results The mean values of BTEX levels (3.69 ± 1.88, 120.59 ± 1.17, 133.70 ± 7.20, and 114.35 ± 6.86 ppm, respectively) were higher than the threshold limit value of the American Conference of Governmental and Industrial Hygienists (0.5, 100, 100, and 100 ppm for BTEX, respectively). Fuel supply station workers had significantly lower performance on the neurobehavioral test battery than nonexposed participants (P < 0.001). Hematological findings including hemoglobin% and platelet count were significantly lower among the exposed workers (13.73 ± 1.13 and 247.36 ± 57.69, respectively) than the nonexposed participants (14.18 ± 0.94 and 268.46 ± 46.83, respectively) (P = 0.004 and 0.007, respectively). Conclusion Exposure to BTEX concentrations higher than permissible levels resulted in deteriorated performance on the neurobehavioral test battery and abnormal hematological findings in exposed workers. Regular use of good-quality personal protective equipment especially masks and gloves and periodic medical examination is highly recommended.
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Potential protective effects of trimetazidine and quercetin on isoprenaline-induced myocardial infarction in rats p. 1110
Abd El-Rahman A. Yaseen, Mohammad I Shaban, Mahmoud H El-Odemi, Safa R El-Fiky, Doaa Z Mohammad Shebl
DOI:10.4103/mmj.mmj_183_17  
Objective The aim of this study was to investigate the protective effects of trimetazidine (TMZ), quercetin, and their combination on isoprenaline (ISO)-induced myocardial infarction (MI) in rats. Background ISO has been found to produce MI in large doses; it generates highly cytotoxic free radicals that produce severe damage to the myocardial membrane. Pretreatment with TMZ and quercetin reduce oxidative stress induced by ISO. Materials and methods Fifty adult rats were divided into five groups (n = 10). Group 1 (control) and group 2 (ISO-treated) received normal saline orally through a orogastric tube for 14 days and subcutaneously for the last 2 days. Group 3 (quercetin–ISO treated) received quercetin (50 mg/kg; orally), group 4 (TMZ–ISO treated) received TMZ (10 mg/kg; orally), and group 5 (quercetin-treated and TMZ–ISO treated) received combined drugs for 14 days. All groups except the control group received ISO (100 mg/kg; subcutaneously) in the last 2 days. Serum separation and estimation of highly sensitive cardiac troponin-I, C-reactive protein, serum malondialdehyde, and total serum antioxidant were performed. In addition, histopathological changes of the rat heart were assessed. Results The ISO-treated group showed increased serum levels of highly sensitive cardiac troponin-I, C-reactive protein, and malondialdehyde and decreased serum levels of total serum antioxidant, pathological picture of MI by hematoxylin and eosin staining, and negative myoglobin expression. These parameters improved better in the group receiving combined drugs compared with rats receiving TMZ or quercetin alone. Conclusion The combined treatment showed better synergistic antioxidant and anti-inflammatory effects compared with either treatment alone.
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Histological study on the effect of rosuvastatin (Crestor) on the skeletal muscle of adult male albino rats and the possible protective effect of coenzyme Q10 p. 1117
Maha E Soliman, Samy E Atteia, Maisa A Kefafy, Amira F Ali, Eman M Radwan
DOI:10.4103/1110-2098.229223  
Objective The aim of this study was to evaluate the effect of rosuvastatin drug on the histological structure of the skeletal muscle fiber of adult male albino rats and the possible protective role of coenzyme Q10. Background Rosuvastatin has been proven to be effective in improving serum lipid profiles. It decreases the risk for mortality in patients with coronary heart disease. It was reported that some patients treated with various statins have developed symptoms of myopathy. Coenzyme Q10 has a powerful antioxidant activity and affects membrane stability in many tissues, including skeletal muscle. Materials and methods A total of 54 adult male albino rats were used in this study and divided into four groups: group I rats served as negative controls, group II rats served as positive controls, group III rats were treated with rosuvastatin orally for 4 and 12 weeks, and group IV rats were treated with rosuvastatin and Coenzyme Q10 orally for 4 and 12 weeks. The gastrocnemius muscle was dissected and prepared for light and electron microscopic study. Results The light microscopic study of the gastrocnemius muscle of rats treated with a high therapeutic dose of rosuvastatin for 4 and 12 weeks (group III) showed variation in size, mononuclear cellular infiltration, splitting, and focal degeneration of myofibers with increased collagen fiber deposition between muscle fibers. Electron microscopic study showed mitochondrial accumulation between myofibrils and in the subsarcolemmal space, mitochondrial degeneration, and dilatation of sarcoplasmic reticulum cisterna. Coadministration of coenzyme Q10 with rosuvastatin for 4 and 12 weeks ameliorated most of the above-mentioned histological alterations in the rat skeletal muscles. Conclusion Rosuvastatin drug caused skeletal muscle fiber damage. Coenzyme Q10 leads to the protection of the skeletal muscle fibers when given concomitantly with rosuvastatin.
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The effect of tramadol on seminiferous epithelium of albino rats and the protective effect of vitamin C p. 1125
Maha E Soliman, Samy E Atteya, Hosam A. E. Ghobashy, Dalia A. E. Noya, Reham A Mahmoud
DOI:10.4103/mmj.mmj_716_16  
Objective The aim of the study was to assess the effect of tramadol on the testes of adult male albino rats and to elucidate the possible protective effect of vitamin C. Background Tramadol is an opioid pain medication used to treat mild to severe pain, both acute and chronic, and premature ejaculation and as an antidepressant. Materials and methods Sixty adult male albino rats were used in the present study. Animals were divided into four groups: group I, the control group; group II, which received 500 mg/kg/day vitamin C orally for 4 weeks; group III, which was divided into two subgroups, subgroup IIIa and subgroup IIIb (receiving 50 mg/kg/day tramadol orally for 4 weeks) and subgroup IIIb, which was left without treatment for another 4 weeks; and group IV, which received tramadol and vitamin C in the doses same as the previous ones. At the end of the experiment, the testes were excised and specimens were processed for light, electron microscopic, morphometric studies and statistical analyses. Results Tramadol-treated rats showed degeneration, irregularity of seminiferous tubules with disorganization and exfoliation of spermatogenic cells in the lumen, which showed absence of sperms. Vascular dilatation and congestion was present. In addition, there was collagen fiber deposition in the interstitium and around the blood vessels with thickening of tunica albuginea. Cessation of tramadol administration showed reversibility of the previous changes but not complete recovery. However, coadministration of vitamin C with tramadol showed improvement. Conclusion Tramadol has harmful effect on the testes of rats. This effect is reversible when tramadol administration is stopped but complete recovery is not achieved. Vitamin C and tramadol in combination revealed improvement.
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Effect of antidepressant drug (fluoxetine) on the testes of adult male albino rats and the possible protective role of omega-3 p. 1135
Maha E Soliman, Bothina L Mahmoud, Maisa A Kefafy, Rania I Yassien, Eman S. A. El-Roghy
DOI:10.4103/mmj.mmj_521_17  
Objective The aim of this study was to evaluate the possible protective effect of omega-3 on testicular tissue damage induced by antidepressant drug (fluoxetine), in adult male albino rats. Background Fluoxetine is a selective serotonin reuptake inhibitor drug commonly used in the treatment of depression, but it causes structural changes of testicular tissue. Omega-3 has a range of anti-inflammation and antioxidation. Materials and methods This animal study was carried out during the period from December 2016 to June 2017 on 50 adult male albino rats that were kept in the animal house of the Faculty of Medicine, Menoufiya University, and divided into four groups: group I (control); Group II (omega-3); group III, subdivided into two subgroups – IIIa (fluoxetine) and IIIb (recovery); and group IV (fluoxetine and omega-3). All groups received drugs orally for 4 weeks, and the recovery subgroup was left untreated for another 4 weeks. Then, animals were sacrified and weighted. Testis samples were obtained for histological and immunohistochemical study. Results Fluoxetine-treated rats showed a highly significant decrease of body and testis weight (P < 0.001). Fluoxetine led to distortion of seminiferous tubules, germ cell degeneration with sloughing, and vacuolation. The interstitium appeared wide containing degenerated Leydig cells, congested blood vessels, and acidophilic material. Fluoxetine induced intense expression of caspase-3, decrease in the mean number of positive proliferating cell nuclear antigen immunostaining, and negative expression of androgen receptor. The recovery group still showed persistence of some changes. Fluoxetine and omega-3 groups showed marked improvement. Conclusion Omega-3 alleviates testicular damage induced by fluoxetine more than arresting fluoxetine.
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A study on the effect of estrogen on the insulin signaling pathway in diabetic rats p. 1143
Gergiss Y Hana, Amal I Ali, Sally S Donia, Anwaar M Shaban
DOI:10.4103/mmj.mmj_57_17  
Background Diabetes mellitus (DM) is a worldwide metabolic disorder that is associated with many complications. Recently, it has been noted that estrogen has a beneficial effect on type II DM. Objective The aim of this study was to prove that the use estrogen could improve the metabolic state in type II DM. Materials and methods Eighty adult female albino rats weighing 200–250 g were used. Diabetes was induced by means of a single intraperitoneal injection of streptozotocin 40 mg/kg. Rats were divided into the following groups: the control group (group C); the ovariectomized control group (group OVX C); the diabetic group (group D); the diabetic ovariectomized group (group OVX D); the diabetic insulin-treated group (group DI), in which insulin was administered at a dose of 10–20 IU/kg for 6 days/week by means of subcutaneous injection; the diabetic ovariectomized insulin-treated group (group OVX DI); the diabetic nonovariectomized estrogen and insulin treated group (group DEI), in which estradiol was administered at a dose of 50 μg/kg; and the diabetic ovariectomized estrogen and insulin treated group (group OVX DEI). After 12 weeks, fasting blood glucose level, glycosylated hemoglobin level, and fasting serum lipids were measured. Retroperitoneal adipose tissue was taken for measurement of insulin receptor substrate 1 (IRS1) gene expression using reverse transcriptase-PCR. Results Combined estrogen and insulin treatment induced a significant decrease in fasting blood glucose, HbA1C Glycated hemoglobin, and fasting serum lipid profile with an increase in IRS1 protein gene expression level. Conclusion Results should be considered in prediabetic and or diabetic postmenopausal women.
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The diagnostic role of vimentin in differentiation between muscularis propria and muscularis mucosa in urinary bladder carcinoma p. 1149
Mona A Kandil, Asmaa G Abdou, Noha M El-Kady, Noha H Ghanem
DOI:10.4103/1110-2098.229226  
Objective The aim of this study was to evaluate the diagnostic value of vimentin expression for differentiation between muscularis mucosa (MM) and muscularis propria (MP) in urinary bladder carcinoma cases. Background The single most important prognostic factor in urothelial carcinoma is the pathological stage, which includes the anatomic depth of invasion on which major therapeutic decisions are made. Correct assessment of invasion necessitates discrimination between MM and MP. Vimentin is the most widely distributed intermediate filament and is expressed in virtually all mesenchymal tissues. Materials and methods This study was carried out on 70 urinary bladder specimens, including 59 cases of primary urinary bladder carcinoma and 11 cystitis specimens. The specimens were submitted to vimentin immunostaining under the streptavidin–biotin amplified system. Results MM was identified histologically in 40 cases, whereas MP was morphologically designated in all cases (70 cases). Vimentin was negative in MP and showed positive expression in 32/40 (80%) cases of MM with a statistically significant difference (P = 0.000), 80% of sensitivity, and 100% of specificity. Conclusion Negative vimentin expression in MP could be a useful tool for identification of MP with 80% of sensitivity and 100% of specificity in urinary bladder carcinoma cases.
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Expression of nuclear factor-κB1/P105 in Helicobacter pylori-induced gastric lesions p. 1155
Afkar A Badawy, Mona M Moussa, Zeinab S Omran, Noha S Helal, Ali A El-Hindawi, Maha M Mosaad, Olfat A Hammam, Mona M Mohammed
DOI:10.4103/mmj.mmj_53_17  
Background and aim The current study aimed to assess the proliferative activity of gastric epithelium in Helicobacter pylori (H. pylori) associated lesions through immunohistochemical tissue localization of NF-κB1/p105. Patients and methods Forty seven gastric specimens were included in this study as follows: 33 chronic gastritis specimens (24 H. pylori associated and nine H. pylori negative); seven gastric cancer (GC) specimens; and seven specimens from areas adjacent to GC. H. pylori intensity, gastric activity, chronicity, intestinal metaplasia, and glandular atrophy were assessed and graded by the Sydney system and correlated with NF-κB1/p105 expression. Results Gastric epithelial cells in H. pylori negative specimens expressed NFκB1/p105 as weak heterogeneous cytoplasmic staining without nuclear positivity and served as a control for immunostaining. Nuclear positivity was found in 83.3% of H. pylori gastritis, 71.4% of areas adjacent to cancer lesions and in 100% of GC lesions. The mean values of the NFκB1/p105 nuclear labeling index were significantly increased in H. pylori gastritis (46.83 ± 30.43) (P < 0.01), premalignant gastric lesions (82.0 ± 5.44) (P < 0.01), and GC (95.0 ± 3.55) (P < 0.01) compared with H. pylori-negative controls (0 ± 0). Conclusion It is concluded that aberrant activation of NF-κB1 plays an important role in H. pylori associated gastritis, precancerous, and cancerous lesions. Hence, methods of inhibiting NF-κB signaling may have potential therapeutic application in cancer and inflammatory diseases. A better understanding of the molecular mechanisms would contribute toward both prevention and treatment of gastric carcinoma.
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Different methods of remote ischemic preconditioning and its effect on outcome of elective percutaneous coronary intervention p. 1162
Ahmed A Reda, Hany I Ragy, Awny G Salem, Mohamed R Mahmoud
DOI:10.4103/mmj.mmj_348_15  
Objective The purpose of this study was to assess and compare different methods of remote ischemic preconditioning (RIPC) to reduce cardiac myonecrosis as measured by evaluating cardiac troponin I (cTnI) after elective percutaneous coronary intervention (PCI) and to reduce major adverse cardiac event rate at 6 months of follow-up. Background RIPC is a way to reduce cardiac myonecrosis. Patients and methods This study was conducted on 120 symptomatic patients with coronary heart disease who were scheduled for elective PCI. Patients were randomized into three groups: group A included 40 patients who underwent RIPC immediately before PCI through the upper arm; group B included 40 patients who underwent RIPC immediately before PCI through the upper thigh; and group C (the control group) included 40 patients with no RIPC. Results Results of the current study showed that ST-segment deviation during intervention was statistically significantly lower (P < 0.05) in the leg and arm groups versus the control group. Results of the current study showed that rise in cTnI was statistically significantly lower (P < 0.05) in the leg and arm groups versus the control group. However, no significant difference was found between the arm and leg groups as regards rise in cTnI. There was no significant difference between groups as regards the incidence of major adverse cardiac event at 6 months. Conclusion RIPC is a simple, cheap, well-tolerated procedure that has a significant effect on the reduction in postprocedural elevations of cTnI. RIPC increases the tolerance of the myocardium to ischemia, reduces ischemic chest discomfort during coronary balloon occlusion, reduces ST-segment deviation during intervention, reduces the rise in cTnI release after elective PCI, and appears to reduce subsequent cardiovascular events. RIPC using the upper thigh or upper arm has same protective effects on the myocardium.
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Predictive significance of stromal-associated lymphocytes in response to neoadjuvant chemotherapy in breast cancer p. 1168
Afaf T Ibrahiem, Hala A Mouhamed, Abeer H Anter
DOI:10.4103/mmj.mmj_522_17  
Objective In this work, we aimed to assess whether the high stromal-associated lymphocytes and their subtypes in pretreatment core biopsies from patients with invasive breast carcinoma have a predictive role in pathologic response to neoadjuvant chemotherapy (NACT). Background Tumor-infiltrating lymphocytes including stromal-associated lymphocytes in breast cancer are considered a form of the host immune response to malignancy. Several studies suggested that tumor-infiltrating lymphocytes could predict better response to NACT, but their roles in predicting complete pathologic response (pCR) rate after NACT still needs further evaluation. Patients and methods Stromal-associated lymphocytes were evaluated in 100 pretreatment core biopsies from primary breast cancer patients eligible for NACT. Cases were defined as lymphocyte-rich if the percentage of lymphocytes was more than 50% and also the lymphocytes were evaluated for CD20, CD3, CD8, and CD4. Type of pathological response to NACT was determined in post-therapy surgical specimens of the same patients, and we correlated between type of response to stromal-associated lymphocytes and their subtypes. Results pCR was detected in 22 (22%) breast cancer patients, partial pathologic response in 54 (54%), and no pathologic response in 24 (24%) patients. There was a significant association between percentage of stromal-associated lymphocytes and achievement of pCR rate (P = 0.006). In addition, high stromal-associated lymphocytes are significantly associated with advanced histological grade (P = 0.004), Ki-67 (P = 0.028), and negative estrogen receptor state (P = 0.015). Conclusion High stromal-associated lymphocytes and high percentage of CD8-positive T cells in stromal-associated lymphocytes could be reliable predictors for pCR rate after NACT.
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Patterns of antiepileptic drugs–poisoned cases arrived at Menoufia University Poison and Dependence Control Center p. 1178
Safaa A Amin, Azza W Zanaty, Fatma S Kandeel, Maha S El-Nady
DOI:10.4103/mmj.mmj_45_17  
Objectives The present work aims to study antiepileptic drugs (AEDs)–poisoned cases arrived at Menoufia University Poison and Dependence Control Center regarding sociodemographic pattern, clinical presentation, investigations, poison severity score, and outcome. Background AEDs are groups of pharmacological agents used to treat several neurological and psychiatric disorders such as epilepsy, prophylaxis of migraine, neuropathic pain, and bipolar disorders. In poisoning with AEDs, central nervous system is the most affected region; therefore, loss of consciousness, hyper-reflexia, hyporeflexia, ataxia, tremor, hallucinations, pupillary changes, dizziness, headache, insomnia, convulsions, and even death are the most expected symptoms. AEDs could be classified into first, second, and third generations. Among AED intoxication cases, most are caused by first-generation antiepileptic drugs, whereas intoxications with new-generation antiepileptics are rarely seen. Patient and methods The study was conducted on all cases with AEDs poisoning that arrived at Menoufia University Poison and Dependence Control Center throughout the 1-year period from the first of February 2014 to the last of January 2015. For every case, clinical toxicological sheet was fulfilled after taking his/her consent. Cases were classified according to clinical manifestation and investigations by using poison severity score. Outcome of cases was determined. Results Of 98 poisoned cases, the most affected age group was more than 20–40 years (38.8%). Females outnumbered males (74.5 and 25.5%, respectively). Carbamazepine represented the highest percent of cases at 49% followed by benzodiazepines (38.8%). Suicidal cases represented 74.5%. Conclusion Intentional drug exposures are at a high prevalence in AEDs ingestions. It is mostly seen in the adult group and females. The most frequently ingested drugs are carbamazepine and benzodiazepines.
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Patterns of facial trauma in menoufia university hospital p. 1186
Naira F Girgis, Azza W Zanaty, Situhom S El Agmy, Soha H Abd El Magid Abd El Khalek
DOI:10.4103/mmj.mmj_620_16  
Objective The aim of this study was to analyze patterns of face injuries, the relationship between face trauma cases and instruments used, type of injuries, and outcome at Menoufia University Hospital. Background Among the innumerous injuries seen at trauma centers, facial trauma is one of the most prevalent, as the face is the most exposed and least protected part of the body. Patients and methods The present study was conducted on patients presenting with facial trauma to Menoufia University Hospital from the period between 1 January 2014 and 31 December 2014, regarding demographic data, types, instruments used, causes, and radiological pattern. Retrospective data were collected from files (January 2014–June 2014), and the prospective study was carried out between July 2014 and December 2014. All cases were included in the study after obtaining valid written consent for examination and photography. Results The total number of patients with facial injuries during the study period was 1038 patients. The most common age group among injured cases was 30– less than 50 years; 61.1% of facial injuries were due to assault, followed by 35.3% accidental injuries. The clinical outcome revealed that 68% of injured cases improved, whereas 17.5% of cases suffered from complications [e.g., scar (7.9%), facial deformity (7.7%), and infection (1.9%)]. 6.2% of the injured cases suffered from impaired function, and 4.4% of cases suffered from loss of function, whereas 3.9% of injured cases died. Conclusion and recommendation Pan facial traumas led to complications, loss of function, and had a high mortality rate. Strict legislation against violence and stricter implementation of traffic rules must be followed.
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Parasitological and histopathological effects of some antischistosome drugs in Schistosoma mansoni- infected mice p. 1193
Mohamed M Abdel-Ghaffar, Abdel-Gawad E Saad, Ismail M Moharm, Osama F Sharaf, Mohamed T Badr, Asmaa F Ibrahim
DOI:10.4103/mmj.mmj_672_16  
Objective To assess the in-vivo effects of artemisinin (ART), arachidonic acid (ARA), and nifedipine (NIF) compared with praziquantel (PZQ) on experimental Schistosoma mansoni infection in terms of worm burden, liver histopathological, immunohistochemical alterations, cytokines changes, and scanning electron microscopy (SEM) on both juvenile and adult stages of S. mansoni in experimentally infected mice. Background Reliance on a single drug for schistosomiasis control may promote the spread of drug-resistant parasites. Materials and methods The study was carried out in Theodor Bilharz Research Institute (Giza, Egypt) in April 2015 and included 120 laboratory-bred female albino mice. These mice were divided into nine groups: group 1) uninfected and untreated), group 2 (infected untreated), group 3 (infected and ART treated), group 4 (infected and ARA treated), group 5 (infected and NIF treated), group 6 (infected and PZQ treated), group 7 (infected and ART plus PZQ treated), group 8 (infected and ARA plus PZQ treated), and group 9 (infected and NIF plus PZQ treated). Mice were subjected to worm burden, liver histopathology, and SEM. Results ART plus PZQ-treated mice showed the lowest total worm burden (6.10 ± 5.30), the lowest schistosomula stage worm burden (11.0 ± 1.58), the lowest adult stage worm burden (1.20 ± 0.83), the lowest granuloma number (1.60 ± 0.54), and the smallest granuloma diameter (100.20 ± 8.25 μm). NIF plus PZQ were the most effective on the schistosomula and the adult stages of S. mansoni; however, PZQ was the least effective on the schistosomula and ART was the least effective on the adult of S. mansoni by SEM. Conclusion A combination of ART plus PZQ was the most effective in reducing total, schistosomula stage, and adult stage worm burdens, and also the number and diameter of granuloma. NIF plus PZQ were the most effective against the schistosomula and the adult stages of S. mansoni by SEM, but PZQ was the least effective against schistosomula stage worm burden reduction and was the least effective against it by SEM.
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Relationship between mannose-binding lectin-2 gene polymorphism and CD25 with hepatocellular carcinoma-induced hepatitis-C development p. 1203
Waleed M Abd El Azeem, Ann A Faried, Eman A Mahmoud, Karema A Diab
DOI:10.4103/mmj.mmj_17_17  
Objectives The aim of the study was to evaluate the role of mannose-binding lectin-2 ( MBL-2) gene polymorphism and soluble CD25 (sCD25) in the development of hepatitis C-inducing hepatocellular carcinoma (HCC) in Egyptian patients. Background Hepatitis C virus (HCV) plays a major role as a cause of chronic liver injury, with potential for neoplastic degeneration. HCC represents an important public health problem in Egypt. MBL is an important constituent of the human innate immune system that acts as an acute-phase reactant and is secreted by the liver. It affects the inflammation severity or disease progression. Patients and methods Blood samples from 118 individuals – 88 patients (58 HCC patients and 30 HCV positive patients) and 30 apparently healthy individuals as a control group – were tested for MBL-2 gene polymorphism by real-time PCR and soluble CD25 by using ELISA. Results MBL-2 genotype GC was significantly higher among HCC cases than among HCV cases [odds ratio: 8.25 and 95% confidence interval (CI): 2.81–24.24]. Moreover, genotype was significantly more frequent in HCC cases than in HCV cases (odds ratio: 7.22 and 95% CI: 2.67–19.49). On comparing alleles, G allele was of higher rate among HCC cases than among HCV cases (odds ratio: 3.53 and 95% CI: 1.63–7.65). There was a significant increase in (sCD25) level in HCC cases compared with control and HCV groups. CD25 was significantly higher among GG/GC than among CC genotype patients in the HCC group only. In addition, there was significant positive correlation between CD25 and aspartate aminotransferase, total protein, albumin, direct bilirubin, total bilirubin, and α-fetoprotein. Conclusion Functionally relevant MBL-2 promoter polymorphism may play a role in the development of HCV-related HCC, and sCD25 can be used to distinguish HCC from appropriate controls with early tumors.
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Hospitalization of systemic lupus patients: Causes and outcomes p. 1210
Sabry A Shoeib, Alaa E Elhamid, Emad M Elshebiny, Yasser A Shehata, Amr A Elshormilisy, Mohammed R Mazen
DOI:10.4103/mmj.mmj_666_16  
Objective The aim of this study was to describe the most common causes of admission of Egyptian patients with systemic lupus erythematosus (SLE) and the outcomes of these hospitalizations. Background SLE is a prototypic multisystem autoimmune disorder with a broad spectrum of clinical presentations. Studying the causes and outcomes of SLE patients will guide rheumatologists in better management of cases to improve outcomes. Patients and methods The charts of patients with SLE who were hospitalized at our Department of Internal Medicine during a 10-month period from August 2015 to June 2016 were reviewed in a retrospective manner, and their demographic, clinical, and laboratory data were collected. Results There were 85 admissions of 40 patients with SLE. Seventeen (42.5%) patients were admitted twice or more. The mean length of stay for all admissions was 8 days (2–30). The most common cause of admission was active SLE (62 events, 72.9%). SLE was initially diagnosed in 11 (27.5%) patients in our department of internal medicine. Other causes of hospitalization were infections (9.4%), drug complications (2.4%), thromboembolic events (3.5%), and assessment of the disease (10.6%). Three (3.5%) hospitalizations resulted in death. Conclusion Our study of this Egyptian SLE population confirms the findings of previous studies suggesting that active SLE and infection remain the most common causes of hospitalization of patients with SLE.
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The relationship between electrocardiographic fish-hook sign and early diastolic left ventricular velocity in athletes p. 1214
Mohamed Yahia
DOI:10.4103/mmj.mmj_93_17  
Objectives The aim of the present study was to find a relationship between ECG fish-hook sign and echocardiographic variables in football athletes. Background Early repolarization is a common finding among athletes. The notched or irregular J point is known as the fish-hook sign, and it is a pattern of early repolarization. Patients and methods The present cross-sectional study was conducted using 61, male football players who were recruited during precompetition medical assessments in June 2016. The study was carried out at the medical clinics of two sports clubs in the Kingdom of Saudi Arabia. Standard 12-lead resting ECG and two-dimensional echocardiography were performed for all participants. Results The mean age was 25.7 ± 4.47, the mean body surface area was 1.86 ± 0.11 cm2, the mean corrected QT interval was 408.7 ± 22.12 ms, the main left ventricular (LV) mass index was 104.9 ± 18.5 g/m2, and the main LV ejection fraction was 59.9 ± 4.53%. The fish-hook sign was present in 32 (52.4%) athletes. The presence of a fish-hook sign was not statistically different with respect to age, body surface area, QRS duration, corrected QT interval, and LV hypertrophy. Athletes with a fish-hook sign had higher early diastolic mitral annulus velocity (E') and lower E/E' compared with athletes who had no fish-hook sign (P < 0.05). Conclusion Athletes with a fish-hook sign had higher peak early diastolic mitral annular (E') velocity and lower E/E' compared with athletes who had no fish-hook sign.
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Study of γ-glutamyltranspeptidase as a prognostic marker in radiofrequency: Ablation treatment of hepatocellular carcinoma p. 1220
Mohamed Alaa Nouh, Eman Masoud Abd Elgayed, Basma Mohiy Eissa
DOI:10.4103/mmj.mmj_515_15  
Objective This study was conducted to investigate the prognostic significance of γ-glutamyltranspeptidase (GGT) serum levels in patients undergoing radiofrequency ablation (RFA) therapy for the treatment of hepatocellular carcinoma (HCC). Background HCC is one of the prominent types of malignancies and ranks third in mortality worldwide. RFA is regarded as an alternative to surgical resection for curative treatment of a small HCC. GGT is a key enzyme that catalyzes the transpeptidation and hydrolysis of the C-terminal glutamyl group of glutathione and related molecules, and it correlates with biotransformation, nucleic acid metabolism, and tumorigenesis. Patients and methods This study was conducted on 20 patients with a small HCC who had been treated with RFA. Baseline serum GGT was estimated before therapy and then after 1–2 months to see its possible prognostic tool as a marker in HCC. In addition, 20 apparently healthy individuals matched for age and sex were selected as a control group. Results Our study revealed that level of GGT was significantly reduced compared with pretreated level in patients with HCC treated with RFA. Moreover, high GGT level and big tumor size were risk factors for recurrence. Conclusion We can use GGT as a marker for prognosis of HCC patients treated with RFA.
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Role of homocysteine in patients with hepatorenal syndrome p. 1226
Gamal S El-Deeb, Moamena S El-Hamouly, Amira M. F. Shehata, Mohamed H Elsbaey Elseady
DOI:10.4103/mmj.mmj_326_17  
Objective The aim of this study was to investigate the role of homocysteine (Hcy) in patients with hepatorenal syndrome (HRS). Background Hcy increases in cirrhosis than in noncirrhotic liver diseases. Hyperhomocysteinemia is correlated with the clinical course of liver disease and is characteristically detected at late stages of cirrhosis. Patients and methods A total of 78 patients and 20 controls were divided into four groups. Group 1 included 28 cirrhotic patients without ascites. Group 2 included 25 cirrhotic patients with ascites. Group 3 included 25 patients with HRS. Group 4 included 20 healthy participants as a control group. Liver and kidney function tests, complete blood count, viral marker analysis, evaluation of serum Hcy using enzyme-linked immunosorbent assay, and renal duplex ultrasonography were carried out. Results Patients with liver cirrhosis showed significantly higher serum Hcy levels in comparison with controls. Positive correlations were found between Hcy and age, child classification, model for end-stage liver disease score, creatinine level, and renal resistive index (RRI), whereas serum Hcy was negatively correlated with creatinine clearance. Hcy at a cutoff value of more than 17 micromol/l could predict patients with HRS with 89% sensitivity and 80% specificity.RRI at cutoff value of more than 0.75 could predict patients with HRS with 85% sensitivity and 80% specificity. The sensitivity was 94%, and accuracy was 87%, when Hcy and RRI were estimated together in patients with HRS. Conclusion Hcy can be considered as a predictive marker for patients with HRS.
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Effects of transdermal nitroglycerin and intravenous pancuronium added to lidocaine for intravenous regional anesthesia p. 1232
Ahmed S Elgebaly, Mona B Elmorad, Salama Elhawary, Mohammed Elhalafawy
DOI:10.4103/mmj.mmj_163_17  
Objective The aim of this study was to evaluate the effects of transdermal nitroglycerin patch, pancuronium, or a combination of both when added to low-dose lidocaine compared with standard-dose lidocaine alone in the intravenous regional anesthesia (IVRA) technique in adult healthy participants. Background Administration of neuromuscular blocking agents or nitroglycerin with local anesthetics in the upper limb during IVRA improves surgical conditions in adults. Patients and methods A total of 100 patients of both sexes aged 18 years or older undergoing elective forearm and hand surgeries were divided into four groups: group A received only lidocaine, group B received lidocaine + pancuronium, group C received lidocaine + nitroglycerin patch, and group D received lidocaine + pancuronium + nitroglycerin patch. Sensory and motor block onset and recovery times, Visual Analog Scale for Pain (VAS scores) for tourniquet pain, postoperative VAS score, and analgesic requirements were recorded. Results Sensory block onset times were shorter in groups D and C. Motor block onset times were shorter in groups D and B. Sensory block recovery time prolonged in group D. Motor block recovery time was prolonged in group D. There was a significant difference between the four groups in intraoperative pethidine requirements. The lowest dose of pethidine needed was in group D. Postoperative VAS scores showed significant differences between groups. Postoperative analgesic effect was the longest in group D. Conclusion A combination of 0.5 mg of pancuronium and 5 mg of transdermal nitroglycerin patch as adjuvant to 1.5 mg/kg lidocaine 0.25% improves the quality of IVRA without any side effects.
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Hypotensive epidural anesthesia in patients with preoperative renal dysfunction presenting for hip arthroplasty p. 1238
Ahmed S El-Gebaly, Ahmed Abd El-Aziz Shama, Mohamad Gamal El-Maw
DOI:10.4103/mmj.mmj_137_17  
Objective To investigate the benefits and safety of hypotensive epidural anesthesia (HEA) in comparison with normotensive epidural anesthesia in patients with preoperative renal dysfunction presenting for hip arthroplasty. Background HEA is one of the anesthetic techniques used to reduce perioperative blood loss for total hip replacement. The technique includes a combination of an extensive epidural block and an intravenous infusion of low-dose epinephrine (1–5 μg/min) to adjust and control the mean arterial blood pressure together with preserving central venous pressure and cardiac output. Patients and methods Forty adult patients of both sexes undergoing primary unilateral hip arthroplasty, ranging in age from 60 to 74 years, ASA II–III with mild renal dysfunction were divided into two groups: group I received epidural anesthesia with strict preservation of the mean arterial blood pressure (65–90 mmHg) during surgery using vasopressors, fluids, and/or blood transfusions and group II received epidural anesthesia and hypotension was induced by maintaining the mean arterial blood pressure at 55–60 mmHg during the entire surgery. Results The heart rate and the mean arterial blood pressure showed a significant difference between the two groups at 15, 30, 45, 60, and 90 min intraoperatively (P < 0.05). Serum creatinine was significantly increased in group II at 6 h (P < 0.05) and postoperatively, with a significant decrease in creatinine clearance in group II at 24 h postoperatively (P < 0.05). The mean values of blood urea showed a significant increase in group II than group I after 6, 12, 24, and 48 h postoperatively. The duration of surgery was significantly different between the groups; it was longer in group I than group II (P < 0.05). Blood loss and blood transfusion were significantly decreased (P < 0.05) in group II than group I. The mean epinephrine infusion rate was significantly increased in group I (P < 0.05). Hematocrit was significantly decreased in both groups postoperatively (P < 0.05). Conclusion HEA is superior to normotensive epidural anesthesia in patients with renal impairment undergoing hip arthroplasty in the form of decreased blood loss and the need for blood infusion, provides a clear surgical field, and leads to an improvement in cement fixation and decreased incidence of postoperative deep vein thrombosis and blood loss, with no evidence of acute kidney injury postoperatively.
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The clinical significance of serum anti-heat-shock protein 27 antibody levels in β-thalassemia patients p. 1244
Seham M Ragab, Mahmoud A El-Hawy, Amira M. F. Shehata, Shereen M El-Shazly
DOI:10.4103/mmj.mmj_244_17  
Objective The aim of this study was to measure serum anti-heat-shock protein 27 (HSP27) antibody levels in β-thalassemia patients and to assess the potential associations with the clinical and laboratory characteristics in these patients. Background β-Thalassemia syndromes are one of the most common quantitative hemoglobinopathies. HSP27 is a protein that is produced by the cells as a result of exposure to oxidative stress. Anti-HSP27 antibodies are formed as a result of autoimmune response against HSP27 and they are responsible for the pathogenesis of various disorders. Patients and methods In this study, we analyzed serum anti-HSP27 antibody levels in 60 β-thalassemia patients (30 β-thalassemia major and 30 β-thalassemia intermedia patients) who were recruited from the Pediatric Department, Menoufia University Hospitals, in the period between January 2016 and May 2016. In addition, 30 healthy children matched for age and sex were included as controls. Results Significantly higher serum levels of anti-HSP27 antibodies were found in β-thalassemia patients compared with the controls (P < 0.001). The levels of anti-HSP27 antibodies showed a significantly positive correlation with serum ferritin (r = 0.568; P < 0.001) and serum bilirubin (r = 0.321; P = 0.01) and a significantly negative correlation with age at first diagnosis of thalassemia (r=−0.763; P < 0.001) and the interval of blood transfusions (r=−0.775; P < 0.001). Conclusion Serum anti-HSP27 antibody may be a useful biomarker of oxidative stress in patients with β-thalassemia.
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CASE REPORTS Top

Unusual association of testicular yolk sac tumor with pectus excavatum in an 18-month-old child: A case report p. 1250
Aditya P Singh, Arvind K Shukla, Pramila Sharma, Dinesh K Barolia
DOI:10.4103/mmj.mmj_159_17  
Testicular tumors are rare in children, but highly treatable and usually curable. In children, testicular tumor accounts for ~ 1–2% of all tumors. Among testicular tumors, germ cell tumors have a bimodal age distribution. One peak occurs in the first 2 years of life and the second peak occurs in young adults 15–35 years of age. Germ cell tumors in children are distinct from that in adults in term of their behavior, histological nature, metastasis, and the treatment needed. Here, we present a case of testicular tumor with a chest wall deformity in an 18-month-old male child. This is the first case of testicular yolk sac tumor in an 18-month-old male child with chest wall deformity (pectus excavatum).
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Acinar cell carcinoma of pancreas mimicking as pseudocyst – Report of an interesting case p. 1254
Mandal P Kumar, Adhikari Anindya, Pal R Datta, Khan Kalyan
DOI:10.4103/mmj.mmj_295_17  
Acinar cell carcinoma of the pancreas is a rare and aggressive malignancy, comprising less than 5% of all pancreatic neoplasms. Middle-aged men are commonly affected. In our case, a 35-year-old man presented with epigastric fullness, anorexia, and weight loss for 3 months. Computed tomogram scan of the abdomen revealed a cystic lesion (93 × 83 × 62 mm) over the head of pancreas, suggestive of pancreatic pseudocyst. Serum amylase and lipase levels were 25 710 and 292.50 U/l, respectively. Excision followed by histopathological examination revealed acinar cell carcinoma of pancreas. The patient developed pancreatic fistula postoperatively. Chemotherapy with 5-fluorouracil was initiated. There was no residual tumor. The patient remained disease free for 8 months postoperatively.
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Late presentation of the Currarino triad in a 7-year-old female child p. 1257
Aditya P Singh, Vinay M Mathur, Dinesh K Barolia, Arun K Gupta
DOI:10.4103/mmj.mmj_315_17  
Currarino triad is a rare clinical condition. The Currarino triad refers to a specific malformation complex characterized by three main features – congenital anorectal stenosis (or any type of low anorectal malformation), anterior sacral defect, and a presacral mass that may be a meningocoele/a teratoma/an enteric cyst or a combination thereof. We are presenting here a case of late presentation of the Currarino triad in a 7-year-old female child.
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Hair tourniquet syndrome: A rare case report p. 1260
Aditya P Singh, Ramesh Tanger, Vinay Mathur, Arun K Gupta
DOI:10.4103/mmj.mmj_111_17  
Hair tourniquet (HT) syndrome is a rare disorder. Although most cases are considered to be accidental, child abuse must be considered in selected cases. HT syndrome involving the toes occurs during the time period when post-partum mothers are experiencing increased hair loss. In this article, we report a rare case of HT in a 1.5-month-old male child.
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ERRATUM Top

Erratum: Collagen I and collagen III expression in fibrotic bone marrow p. 1262

DOI:10.4103/1110-2098.229241  
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