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   Table of Contents - Current issue
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April-June 2019
Volume 32 | Issue 2
Page Nos. 389-749

Online since Tuesday, June 25, 2019

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REVIEW ARTICLES  

Predictors of effective fluid therapy in the intensive care unit Highly accessed article p. 389
Essam A Ghoniem, Wesam El-Din Sultan, Heba M Naguib
DOI:10.4103/mmj.mmj_721_17  
Objective Static and dynamic indices predicting fluid responsiveness (FR) in critically ill patients, physiological basis, advantages, disadvantages, and cut-off values for each method. Materials and methods Medical textbooks, Medscape, PubMed, and the ScienceDirect. The databases were searched from the start date of the database and a search was performed on May 2016 with no language restriction. The initial search found 25 articles of which 15 met the inclusion criteria that address preload responsiveness, FR, and cardiac output monitoring devices. Extraction was carried out depending on the validity, quality, and originality of the selected reviews and studies; and the focus was on studies that presented the latest updated findings on FR in the ICU. Each review and study was reviewed independently without intercomparisons. The layout was selected to present a big data including the most updated findings on the subject. Result Dynamic indices predicting FR in the ICU provide the best prognosis and outcome. Early detection of fluid nonresponsive patients in the ICU will help avoid fluid overload, which is an independent predictor of mortality. Conclusion Dynamic FR monitoring methods are preferable to static methods. Each dynamic method has its benefits and limitations. Inferior vena cava (IVC) sonography such as IVC collapsibility, IVC distensibillity, and delta IVC might provide a valuable tool and alternate approach for guidance of fluid therapy in spontaneously breathing and mechanically ventilated patients, respectively.
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Fluid responsiveness in hemodynamically unstable patients: a systematic review Highly accessed article p. 397
Hatem A Atallah, Khaled M Gaballah, Abdallah NA Khattab
DOI:10.4103/mmj.mmj_8_18  
Objective To evaluate the usefulness of different hemodynamic measurements in the detection of fluid responsiveness (FR) among patients with hemodynamic instability. Backgrounds Close hemodynamic monitoring of unstable patients' response to volume expansion is a central component of intensive care. Previous reports demonstrated that only 50% of patients respond to fluid administration with an increase in stroke volume or cardiac output. Data sources A computer literature search of PubMed, Scopus, and Cochrane Central was conducted. Study selection Records were screened for eligible studies according to the predetermined inclusion criteria. Data extraction Data were extracted and synthesized using standardized tables. Data synthesis Data were synthesized qualitatively, and we did not perform a quantitative data analysis. Findings The present review included 21 studies of moderate to high quality. All included studies found that CVP does neither correlate with intravascular volume nor accurately predict the FR. The included studies showed significant heterogeneity regarding the predictive value of pulse pressure variation and stroke volume variation. Passive leg raising-induced changes in cardiac output or related parameters were highly predictive for FR. Conclusion The current literature suggests that the static measures are not reliable indicators of FR. Dynamic indices are of good predictive value regarding FR. In addition, passive leg raising appears to be the most useful test for predicting FR in hemodynamically unstable adults.
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Immune checkpoint blockade in malignant lymphomas p. 405
Eman A Razek, Suzan El-Hassanin, Amira El-Desouky, Amira Fouad, Dina El-Habashy
DOI:10.4103/mmj.mmj_90_18  
Objective The objective of this study was to identify the emerging role of immune checkpoint inhibitors in lymphomas. Materials and methods Medline databases (Google Scholar, PubMed, http://www.ekb.eg) and all materials available on the Internet from 2008 till 2015. The initial search presented 10 articles of which seven have met the inclusion criteria. These articles studied the emerging role of immune checkpoint inhibitors in lymphoma. Studies that did not fulfill were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures have been undertaken. Comparisons were made by a structured review with the results tabulated. Results Antibodies blocking immune checkpoints (programmed death 1 ligand, programmed death 1, and cytotoxic T-lymphocyte-associated protein 4) have shown promising results in relapsed/refractory lymphoma. Formal approval of these drugs is being awaited, and the results of combination therapy of checkpoint inhibitors with other treatment modalities, including chemotherapy, small-molecule inhibitors, and other immune therapies. Conclusion Immune therapy with checkpoint inhibitors shows promising results against relapsed/refractory Hodgkin's lymphoma (HL) and non-HL. The efficacy of checkpoint inhibitors against HL is questionable compared with that against non-HL and other solid tumors. Despite these treatment modalities are effective in relapsed/refractory lymphoma, caution is needed due to serious immune-related adverse effects. Results from currently ongoing studies are awaited and will hopefully provide us with better understanding of treatment efficacy as well as increased information about biomarkers of response that will guide in patient selection.
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ORIGINAL ARTICLES Top

Magnesium sulfate versus dexmedetomidine as adjuvants to bupivacaine in postoperative epidural analgesia after total knee replacement p. 411
Magda F Yehia, Abd-Elrahman A Ahmad, Esam AE Esmaeil, Ashraf M Eskandar, Amany A Sultan
DOI:10.4103/mmj.mmj_56_16  
Objective The purpose of this study was to evaluate magnesium sulfate (MgSO4) or dexmedetomidine combined with bupivacaine versus bupivacaine for postoperative epidural analgesia in patients undergoing total knee replacement (TKR). Background Epidural analgesia after TKR is an effective widely used technique. Plain bupivacaine is one of the commonly used drugs. Several adjuvants are emerging to enhance its analgesic properties and decrease possible side effects. MgSO4 and dexmedetomidine are promising. Patients and methods This prospective randomized controlled study included 60 patients undergoing TKR who were randomized into three groups for postoperative epidural analgesia: group B bupivacaine, group BM bupivacaine plus MgSO4, and group BD bupivacaine plus dexmedetomidine. Patients received first dose in the postanesthetic care unit and top-up doses were administered if patients had visual analog score greater than 4. The three groups were compared as regards analgesic efficacy, hemodynamic stability, and possible complications. Results No statistically significant difference was found between the three groups as regards patient demographics (age, sex, and the American Society of Anesthesiologists score). Group BD showed superior analgesic criteria with onset at 8.25 ± 1.1 min versus 9.8 ± 1.5 min in group BM and 10.1 ± 1.3 min in group B (P = 0.0002). Earliest peak analgesic effect was noticed in group BD at 14.5 ± 1.2 min versus 16.5 ± 1.6 min in group BM and 16.3 ± 1.5 min in group B (P = 0.0003). Time to top-up dose was longest in group BD (230.4 ± 26.7 min) versus 283.6 ± 32.5 min in group BM and 362 ± 50.1 min in group B (P = 0.0001). Patients in the three groups were hemodynamically stable, apart from four patients in group BM who developed hypotension requiring support (P = 0.01). Conclusion Dexmedetomidine and MgSO4 are safe adjuvants to bupivacaine in post-TKR epidural analgesia. Dexmedetomidine has superior analgesic characters and hemodynamic stability.
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Traumatic brain injury: serum S-100B protein measurement related to neuroradiological findings p. 417
Nagwa M Doha, Amany S Ammar, Mohammed M El-Mashad, Ahmed A Metwally
DOI:10.4103/mmj.mmj_564_17  
Objective The aim of this study was to estimate the level of S-100B protein as a biological marker and to assess its sensitivity in the detection and prediction of outcome of traumatic brain injury (TBI) patients compared with radiological and clinical scores. Background TBI has a tremendous impact on public health. S-100B protein increases in cases of TBI and does not increase in nonbrain injuries. S-100B has been found to correlate with the severity of head injury. Patients and methods The study was a prospective, randomized, controlled study. Forty critical patients were divided into two groups; group I had 20 patients with TBI and group II had 20 patients with head-free trauma. Group I had a sampling of serum S-100B at day 1, 3, 5, and at discharge, and the results were correlated with computed tomography brain findings, Glasgow Coma Scale, and outcome. Group II had a sampling of serum S-100B at day 1, and the result was correlated with the results of group I. Results Significant difference between the results of S-100B in group I and group II was detected (P < 0.001), with higher results of S-100B in TBI patients. Significant difference between the results of S-100B in survival and nonsurvival for patients in group I was detected (P = 0.002), with higher results of S-100B in nonsurvival patients. Significant correlation between the results of S-100B and Glasgow Coma Scale in group I was detected (P = 0.002). Conclusion S-100B is a prognostic marker in TBI, specific to TBI, and not correlated to the findings in computed tomography brain.
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Noninvasive versus invasive ventilation in weaning of patients with type 2 respiratory failure p. 423
Mohamed HI Afifi, Yasser I Fathy, Sami SA El_Dahdouh, Mahmoud NZ Ghoneum
DOI:10.4103/mmj.mmj_749_17  
Objective The aim of this study was to investigate noninvasive ventilation (NIV) effectiveness as an early weaning technique in difficult-weaning patients with chronic hypercapnic respiratory failure. Background Although invasive ventilation is effective, it is associated with complications like ventilator-associated pneumonia. Ventilator-associated pneumonia has been associated with increased morbidity and mortality. So, minimizing the duration of invasive mechanical support without increasing the risk of adverse events is an important goal. NIV may provide a means of reducing the duration of invasive mechanical support for patients with respiratory failure. Patients and methods A prospective, randomized controlled study was conducted on 40 mechanically ventilated patients having chronic obstructive pulmonary disease with acute exacerbation and type 2 respiratory failures. As the patients were considered for weaning, those who failed the spontaneous breathing trial were randomly allocated into two groups each of 20 patients as follows: (1) Group 1: patients were extubated and received NIV. (2) Group 2: patients received invasive ventilation and were gradually weaned. Results There was no statistically significant difference between the two groups in invasive ventilation-free days at day 28 (P = 0.885), mechanical ventilation period (P = 0.688), weaning duration in hours (P = 0.578), ICU stay (P = 0.427), and 28-day survival rate (P = 0.518). Although there were a higher number of complications in group 1 compared with group 2, the difference was statistically insignificant. Conclusion NIV has no upper hand in weaning of difficult-weaning patients with chronic hypercapnic respiratory failure over invasive ventilation.
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Combined second trimester maternal serum α-fetoprotein and uterine artery Doppler in the prediction of pre-eclampsia p. 430
Nasser K Abd El-Aal, Alaa El-Deen F El-Halaby, Ahmed H Taie
DOI:10.4103/mmj.mmj_534_17  
Objective The objective was to evaluate the combination of second trimester maternal serum α-fetoprotein (MSAFP) and uterine artery Doppler (UAD) as a tool for the prediction of pre-eclampsia (PE). Background PE is a complex multisystem disease and the main cause of fetomaternal morbidity and mortality. The ultimate aim of antenatal care is to identify women at high risk and provide them with prophylactic treatment. No single test has emerged as a front runner and screening based on risk factors has low sensitivity. This has highlighted the need for an alternative. Patients and methods A prospective study on a total of 297 pregnant women had MSAFP measured between 15 and 19 weeks gestation and UAD measured between 19 and 21 weeks of gestation. Resistance index, pulsatility index (PI), and the presence of notches were measured. Receiver operator characteristic curves were created for MSAFP and UAD alone and in combination and then the outcomes were compared. The study was carried out at the Department of Obstetrics and Gynecology of the Faculty of Medicine, Menoufia University and Nasr City Police Hospital during a period from June 2016 to June 2017. Result A total of 17 women developed PE. The sensitivity of using UAD (resistance index) was 70.59% and for MSAFP was 52.94%. The combined sensitivity of UAD and MSAFP was 64.7% Conclusion The combination of MSAFP with UAD did not improve the screening efficacy for the prediction of PE and UAD performed significantly better as a stand-alone test.
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Transvaginal needle versus laparoscopic ovarian drilling in drug-resistant polycystic ovary syndrome: a randomized, controlled study p. 436
Medhat E Helmy, Saied A Saleh, Nabih I El-Khouly, Ayman E Soliman, Heba M Abou-Shady
DOI:10.4103/mmj.mmj_651_17  
Objective The aim of this study was to evaluate the outcome of ovarian needle drilling using transvaginal ultrasound guidance as an alternative to the traditional laparoscopic electrosurgical drilling for patients with polycystic ovary syndrome (PCOS). Background Ovarian drilling has been established as a treatment for drug-resistant PCOS. Patients and methods The study comprised 84 patients with PCOS who are resistant to ovulation induction using clomiphene citrate. The patients were randomly divided into two groups; in the first group of 42 patients ovarian needle drilling was done using transvaginal ultrasound guidance, whereas in the other group of 42 patients laparoscopic electrosurgery ovarian drilling was done. Results No significant differences were found between the two groups with regard to age, parity, BMI, and ultrasound finding of PCOS. The duration of ultrasound-guided transvaginal ovarian drilling was 15.59 ± 2.83 min, whereas it was 38.45 ± 5.46 min for laparoscopic drilling, with a statistically significant difference between the two groups. There were significant improvements after intervention in both groups without differences regarding resumption of regular menstruation, improvement of hyperandrogenic symptoms such as acne and hirsutism, occurrence of ovulation, and pregnancy. As regards hormonal profiles; serum luteinizing hormone, and luteinizing hormone/follicle stimulating hormone levels, were found to be markedly decreased after intervention in both groups. Conclusion The results of this study have shown that the outcome of a simple rapid technique such as ultrasound-guided transvaginal ovarian drilling was comparable to the standard laparoscopic monopolar drilling in resumption of regular menstruation, improvement of hyperandrogenic symptoms, occurrence of ovulation and pregnancy in patients with PCOS resistant to ovulation induction using clomiphene citrate without all the risks expected from the later.
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The outcome of induced labor after oxytocin infusion discontinuation in the active phase p. 441
Ahmed N Eissa, Tarek M Sayyed, Alaa El-Din El-Halaby, Rania A Tahoon
DOI:10.4103/mmj.mmj_652_17  
Objective The objective was to determine whether discontinuation of oxytocin infusion after established active phase of induced labor gives good obstetric outcome without any adverse maternal and neonatal effect. Background Oxytocin is one of the most widely drugs used in induction of labor. Continuous infusion of oxytocin after establishment of the active phase of labor may lead to uterine atony and postpartum hemorrhage. Therefore, we should stop oxytocin infusion once the active phase has started. Patients and methods A total of 90 pregnant women who required labor induction and fulfilled the criteria of the study population were enlisted in this prospective controlled randomized clinical trial and then were assigned to either group A or B. In group A cases, infusion of oxytocin was started in incremental doses until 5 cm of cervical dilatation and to be maintained at that level throughout the labor, whereas in group B cases, infusion of oxytocin was started incrementally but discontinued when cervical dilatation reached 5 cm. Results This study showed that there was a statistically significant difference between group A and group B regarding the first stage of labor, uterine hyperstimulation, maximal and total doses of oxytocin, neonatal outcome, and incidence of postpartum hemorrhage. There was statistically insignificant difference between group A and group B regarding age, BMI, mean gestational age, parity, indications for induction of labor, detection of meconium upon rupture of membranes, and mode of delivery. Conclusion There is no need to continue oxytocin infusion after the establishment of active phase of labor.
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Effect of umbilical cord entanglement on pregnancy outcomes Menoufia Medical Journal p. 448
Zakaria F Sanad, Tarek M Sayyed, Hesham A Ammar, Mohamed F El-Kherbawy
DOI:10.4103/mmj.mmj_672_17  
Objective This work aimed to study the effect of umbilical cord entanglement on the mode of delivery. In addition, this study aimed to evaluate the sensitivity of ultrasound with Doppler for the detection of nuchal entanglement of the umbilical cord. Background The umbilical cord is a narrow tube-like structure that connects the developing baby to the placenta. Most of the nuchal cords diagnosed in early pregnancy become spontaneously uncoiled. Materials and methods This cohort study included 300 pregnant laboring women with singleton pregnancies more than 37 weeks. This study was carried out from January 2016 to February 2017 in the Obstetrics and Gynecology Department of El Moniera General Hospital, Cairo. A transabdominal ultrasound scan was performed using gray-scale and color Doppler imaging immediately to screen for any cord loops around the fetal neck or around the trunk. Cases were classified into either no cord entanglement or cord entanglement groups. Pregnancy outcomes were compared among these groups. Results No cord and cord entanglement groups included 226 and 74 pregnancies, respectively. The mode of delivery was not significantly different among the study groups (P = 0.231). However, the mean of 1 min Apgar scores was significantly lower in the umbilical cord entanglement group than in the 'no cord' group (P = 0.001). Both the sensitivity and the specificity of ultrasound with color Doppler were 95 and 99%, respectively. Conclusion There was no effect of umbilical cord entanglement on the mode of delivery. Ultrasound with Doppler is sensitive for the detection of nuchal entanglement of the umbilical cord.
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Scalpel versus diathermy skin incisions in cesarean sections p. 453
Nasser K AbdElaal, Hamed E Ellakwa, AllaaEldin F Elhalaby, AbdElhameed E Shaheen, Ahmed H Aish
DOI:10.4103/mmj.mmj_828_17  
Objective The aim was to compare the use of diathermy versus scalpel in making skin incision during cesarean section to judge the variations in postoperative pain, incision time, incisional blood loss, operative time, wound healing, and wound complications. Background Surgical scalpels are traditionally used for making skin incisions during cesarean delivery. The evolutions in electrosurgical devices bring an alternative method for making skin incision by the usage of cutting diathermy. Patients and methods This was a prospective, randomized comparative study conducted during the period from March 2016 to February 2017 on 200 patients; 100 patients had skin incisions using the surgical scalpel, while 100 patients had skin incisions with diathermy. The comparison between the two groups was done regarding postoperative pain, incision time, incisional blood loss, operative time, wound healing, and wound complications. Results We observed a significant difference between the two groups regarding incision time (P < 0.001), incisional blood loss (P < 0.001), operative time (P < 0.001), and postoperative pain (P < 0.001), where these parameters were less in the diathermy group. No significant difference was observed between the two groups regarding wound healing (P = 0.387) and wound infection rates (P = 0.468). Conclusion The use of diathermy for skin incisions to perform cesarean section in this study was associated with reduced incisional blood loss, incisional time, operative time, and postoperative pain. It had no effect on wound complications, and was not associated with any delay in wound healing. We can conclude that the usage of diathermy in making skin incision during cesarean section in this study achieved better results than scalpel incision.
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Comparison study between nifedipine and progesterone as maintenance tocolysis after arrested preterm labor p. 458
Alaa M Abdelgaied, Ragab M Dawood, Ahmed M Nofal, Elham F El-Sisi
DOI:10.4103/mmj.mmj_915_17  
Objective The aim was to compare the efficacy and safety of nifedipine and progesterone for maintenance tocolysis after arrested preterm labor and their perinatal outcomes. Background Preterm birth (before 37 completed weeks of gestation) is a 'major cause of death' and a significant cause of long-term loss of human potential. Maintenance tocolysis is continued tocolysis after arrested preterm labor to prevent the recurrence of preterm labor pains. Patients and methods A prospective randomized comparative clinical study was carried out on 66 pregnant women who had preterm labor (six cases lost to follow-up) and attended the Obstetrics and Gynecology Outpatient Clinic at Menoufia Teaching Hospital during the period from March to August 2017. Detailed history, laboratory investigations, obstetric, and ultrasound follow-up study were performed. Results There was no significant difference (P > 0.5) between nifedipine and progesterone groups regarding maternal age and gestational age on admission (weeks), mode of delivery, and neonatal birth weight. However, there was a statistically significant difference (P ≤ 0.05) regarding mean blood pressure before and after treatment in nifedipine group. Moreover, there were less occurrences of neonatal respiratory distress and neonatal ICU admission in the nifedipine group. Additionally, onset of labor between 24 and 34 and between 34 and 37 weeks was significantly less frequent in progesterone group than in nifedipine group. Conclusion We found a superiority of progesterone over nifedipine for maintenance tocolysis. We would only comment that progesterone looks like a promising drug in this regard, and further large studies are required to establish this fact.
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Misoprostol and tranexamic acid role in reducing blood loss during the elective cesarean section p. 465
Mehany MA El-Sttar, Alaa MA El-Gayed, Ragab M Dawood, Yehia Z El-Sayd Ghnnam
DOI:10.4103/mmj.mmj_916_17  
Objective To compare the efficacy of using misoprostol alone or in combination with tranexamic acid (TA) in reducing blood loss during elective cesarean section (CS). Background Normal blood loss during labor is ∼300–400 ml. Blood loss more than 500 ml following vaginal birth or greater than 1000 ml following CS means postpartum hemorrhage. Patients and methods A prospective randomized comparative clinical study was conducted on 150 patients who were divided into two groups: group A (75 patients) received misoprostal 600 mcg rectally before the incision, and group B (75 patients) received misoprostal 600 mcg rectally and 1-g TA slowly intravenously 10 min before the incision. Full medical history, physical examination (general condition and vital signs), prothrombin time, liver and kidney functions, and blood loss volume were recorded. Results Mean age of the studied patients was 28.32 ± 4.65 years in group A and 27.81 ± 5.07 years in group B. Moreover, there was a statistically significant difference between groups regarding hemoglobin postoperatively (P = 0.038), hematocrit postoperatively (P = 0.033), systolic (P = 0.043) and diastolic (P = 0.037) blood pressures 2 h postoperatively, heart rate 2 h postoperatively (P = 0.045), blood loss in the first (P < 0.001) and second periods (P = 0.019), and total blood loss (P < 0.001), with a difference of 146.15 ml (22.6%) less blood loss observed in group B than group A. Conclusion The use of TA before CS is significantly effective in reducing blood loss during cesarean birth, with no observed maternal or neonatal adverse effects (in addition to its low cost). Misoprostol in combination with TA is the most effective treatment in decreasing the amount of blood loss during CS.
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Role of serum leptin as a marker of severity of pre-eclampsia p. 470
Ahmed N Eissa, Tarek M Sayyed, Amr S El-Bagoury
DOI:10.4103/mmj.mmj_97_18  
Objective The objective of this study was to evaluate the role of serum leptin level as a marker of severity of pre-eclampsia (PE). Background PE is a hypertensive disorder in pregnancy that is associated with high blood pressure and proteinuria and develops after 20 weeks of gestation. PE is a major contributor to maternal mortality, complicating 2–8% of pregnancies. Patients and methods This study was conducted at the outpatient clinic and obstetric departments of Shebin El-Kom Teaching Hospital from February 2016 to January 2017. This study included 95 pregnant women, among which 20 were diagnosed as having mild PE (group A) and 45 had severe PE (group B), according to American College of Obstetricians and Gynecologists criteria, and 30 participants with normal pregnancy were taken as a control group (group C). Full history was taken; physical examination and obstetric ultrasound were done; and single blood sample was taken from all groups. The serum leptin level was measured using enzyme-linked immunosorbent assay kits. Results There were no statistical significant differences between the studied groups with respect to the maternal age, parity, and the gestational age. Maternal serum leptin levels were statistically significantly higher (P < 0.001) in the PE groups (43.51±15.49 ng/ml) than in the control group (13.87±4.24 ng/ml). The serum leptin levels were found to be statistically significant higher (P < 0.001) in the severe group (49.37±14.4 ng/ml) than in the mild group (30.32±7.8 ng/ml). Conclusion Maternal serum leptin level is increased in PE. It can be taken independently or along with other parameters as a marker for severity of PE.
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Predictive value of fetal renal artery Doppler indices in idiopathic oligohydramnios and polyhydramnios p. 476
Zakaria F Sanad, Alaa M Abdel Gaied, Ragab M Dawod, Hesham S Mahmoud, Kyrillos NF Fahmy
DOI:10.4103/mmj.mmj_220_18  
Objective The aim of this work was to study the relation of renal artery (RA) and umbilical artery (UA) flow velocity waveforms and amniotic fluid volume in normal pregnancies and those complicated by either polyhydramnios or oligohydramnios. Background There is a relation between RA and UA flow velocity waveforms and amniotic fluid volume in normal pregnancies and those complicated by either polyhydramnios or oligohydramnios. Patients and methods All patients were enrolled from patients attending the outpatient clinic of El-Galaa Maternity Teaching Hospital. All patients were matched for maternal age, gestational age, and parity at the time of sonography, comparing RA Doppler indices pulsatility index (PI) and resistance index at 22, 28, and 34 weeks in three groups. Group I consisted of 20 patients of normal amniotic fluid index, group II consisted of 20 patients with oligohydramnios, and group III consisted of 20 patients with polyhydramnios. Results RA PI values were higher in group II than group I at 22 weeks, 28 weeks, and 34 weeks. The PI value at 28 weeks of gestation was statistically significant (P = 0.016). At 28 weeks of gestation, group II also had higher UA PI and resistance index values than group I. Conclusion An increase in RA PI develops in early pregnancy before the development of oligohydramnios. In pregnancies developing polyhydramnios, RA PI was lower.
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The diagnostic value of cervicovaginal and serum ferritin levels in relation to spontaneous preterm delivery p. 483
Zeinab G Baraka, Mehany MA Satar, Mohammed AG Emara, Ibrahim AS El-Nasr
DOI:10.4103/mmj.mmj_120_18  
Objective The objective of the study was to detect the diagnostic value of cervicovaginal and serum ferritin levels in 20–24 weeks of gestation in the prediction of spontaneous preterm delivery in singleton pregnancies with no well-known risk factors of preterm delivery. Background Preterm delivery is one of the most important health problems in the world that may lead to severe short-term and long-term medical and developmental problems in infants. Patients and methods Venous blood and cervicovaginal fluid samples are drawn from 100 women with singleton pregnancies within 20–24 weeks of gestation at the Department of Obstetric and Gynecologies, El Mehalla Hospital and then they were followed up and the term of delivery were noted. Results Spontaneous preterm delivery in singleton pregnancies with no well-known risk factors is associated with increased levels of cervicovaginal and serum ferritin when measured within 20–24 weeks of gestation and there is a strong positive correlation between both serum and cervicovaginal ferritin levels measuring 0.83. However, the only significant predictor is serum ferritin as an increase by one unit of its value increases the preterm risk by 1.277. About 85% of preterm deliveries can be predicted by serum ferritin. Conclusion It has been observed that 20–24 weeks of gestation serum ferritin level is a significant predictor of preterm delivery in singleton normal pregnancies.
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A comparative study between Snodgrass versus Mathieu with dartos flap urethroplasty for distal hypospadias repair p. 489
Mohammed LA Badr, Magdy A Loulah, Ahmed G Eltatawy, Allam SS Gamea
DOI:10.4103/mmj.mmj_578_17  
Objective The aim of this study was to compare between Snodgrass and modified Mathieu procedures regarding the complications rates and the operative time. Background Hypospadias is the presence of abnormal meatal opening along the ventral aspect of the penile shaft or into the perineum. Surgical management of hypospadias abnormality has challenged and perplexed surgeons. Patients and methods From April 2015 to December 2016, eligible boys were randomly assigned with equal probability to undergo one of the two techniques of hypospadias repair. The study included 40 children experiencing anterior distal shaft hypospadias. Surgeries were performed by a single surgeon. Patients were followed up after discharge. Results Mean age for the patients was 23 months, and the mean operative time varied from 70 min for Snodgrass to 100 min for Mathieu (P = 0.170). Success rate was 17 (85%) of 20 for the Snodgrass and 18 (90%) of 20 for modified Mathieu (P = 0.072). Complication rates in the form of urethrocutaneous fistula and meatal stenosis were the commonest, being 15% in Snodgrass and 10% in modified Mathieu repair. No statistically significant difference was found between tubularized incised plate and modified Mathieu procedure regarding complications (P = 0.721). Conclusion Snodgrass and modified Mathieu repair were safe, and the choice of one of the techniques will depend on the surgeon's decision.
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Endovascular management of central venous stenosis in hemodialysis patients p. 494
Hesham S Abugruidah, Mahmoud S Abdelhalim, Emad M El-Areef
DOI:10.4103/mmj.mmj_656_17  
Objectives The aim of this study was to assess the effectiveness of percutaneous transluminal angioplasty (PTA) with or without stent deployment for treatment of venous hypertension resulting from central venous stenosis (CVS) in hemodialysis (HD) patients and to determine the relationship between the temporary dialysis catheters and the type of the fistula from one side and development of CVS on the other side. Background The quality of life of HD patients depends mainly on the patency and proper function of their arteriovenous shunts. Vascular surgeons should have many surgical and endovascular plans to keep the hemodialysis access working properly, endovascular management of CVS is one of these plans. Patients and methods A prospective study in which 30 recruited patients with end-stage kidney disease on regular hemodialysis (HD) complaining of venous hypertension owing to CVS with functioning arteriovenous fistulas or arteriovenous grafts was carried out during the period from October 2015 to February 2017. Results Endovascular management through percutaneous transluminal angioplasty and/or stent deployment resulted in a significant higher fistula flow rate at 3 months (593.18 vs. 1964.54 ml/min; P = 0.05), and there was a significant improvement of patient symptoms and angiographic findings. Additionally, there was a higher incidence of CVS with past history of central veins cannulation and proximal arteriovenous fistulas. Conclusion Endovascular treatment of the CVS and venous hypertension whether by balloons and/or stents has a significant positive effect on the fistula flow and relief of venous hypertension symptoms in HD patients.
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The role of laparoscopic adhesiolysis in the treatment of patients with recurrent, adhesive intestinal obstruction Menoufia Medical Journal p. 499
Ayman A Albatanony, Mohammed H El Meligy, Mohamed A Dorbok
DOI:10.4103/mmj.mmj_688_17  
Objective The aim of this study was to assess the role of laparoscopic adhesiolysis in the treatment of patients with recurrent attacks of adhesive intestinal obstruction. Background Adhesive intestinal obstruction represents a common clinical problem following abdominal surgery with a high recurrence rate. Once adhesion has formed, its only means of elimination is operative adhesiolysis. Theoretically, adhesiolysis performed through a laparoscope is expected to provide better outcomes than the conventional open procedure. Patients and methods This is a prospective study that was done on a consecutive sample of 20 patients who were admitted to Menoufia University Hospital and Damanhour Medical National Institute during the period between April 2016 and February 2017 with recurrent postoperative adhesive intestinal obstruction that improved with conservative management. Exclusion criteria were peritonitis, severe abdominal distension, pregnancy, liver diseases, and previously confirmed or strongly suspected abdominal malignancy. All patients had undergone elective laparoscopic adhesiolysis after obtaining informed consent. Patients were followed up for 6 months. The complications and the outcome of the operation were recorded. Results Postoperative adhesions were identified laparoscopically in all patients. In the majority of cases (80%), the location of adhesions was distal to the lower abdomen. Successful complete laparoscopic adhesiolysis was feasible in 18 (90%) patients. Conversion to laparotomy was required for two (10%) patients because of intestinal perforation (n = 1) or a convoluted mass of adherent bowel (n = 1). One recurrence of intestinal obstruction was noted over a follow-up period of 6 months and improved with conservative management. Conclusion Laparoscopic adhesiolysis for recurrent postoperative adhesive bowel obstruction is feasible and safe, with a high success rate in experienced hands and results in minimal perioperative morbidity.
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Evaluation of the role of sucralfate cream in decreasing pain intensity and improving healing following open hemorrhoidectomy: a randomized controlled study p. 506
Yahia M Al Khateeb, Ahmed M Abdel Sattar, Ayman A Al Batanony
DOI:10.4103/mmj.mmj_766_17  
Objective The aim was to evaluate the role of sucralfate cream in decreasing postoperative pain intensity and in improving the rate of healing. Background Hemorrhoids are one of the common anorectal complaints. Pain after hemorrhoidectomy is usual and multifactorial. Various topical applications were used to reduce pain from the open wound of hemorrhoidectomy. The aim of this study was to evaluate the role of sucralfate cream in decreasing postoperative pain intensity and in improving the rate of healing. Patients and methods In this prospective cohort study, all enrolled patients (n = 50) were presented to Menoufia University Hospital from May 2016 to December 2016 with third or fourth degree hemorrhoids and indicated for open hemorrhoidectomy. All surgeries were carried out by two consultant surgeons using the same technique. After the end of surgery, the patients were randomly assigned into two groups. Sucralfate group (n = 25) received topical 8% sucralfate cream. The placebo group (n = 25) received topical placebo. Results Postoperative pain at day 1, the mean visual analog scale in the sucralfate group was significantly lower than the placebo group (5.72 vs. 8.20, P < 0.001). After 4 weeks, the degree of wound healing was significantly higher in the sucralfate group (P = 0.0001). Conclusion Sucralfate cream may be effective in reducing postoperative pain associated with open hemorrhoidectomy and it can improve the rate of wound healing.
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Trauma-injury severity score versus acute physiology and chronic health evaluation IV score in predicting mortality p. 511
Ayman A Albatanony, Moharam A Abd Elshaheed, Mohammed N Nassar, Mona KM Mesrega
DOI:10.4103/mmj.mmj_783_17  
Objective The objective of this study was to compare the performances of Trauma-Injury Severity Score (TRISS) and Acute Physiology and Chronic Health Evaluation (APACHE) IV in predicting mortality of seriously injured patients with polytrauma. Background Several scoring systems have been developed to evaluate trauma outcomes. The TRISS and APACHE IV are commonly used to predict injury severity and the risk of mortality. Patients and methods The study was conducted on 100 of seriously injured patients with polytrauma attending the Emergency Department of the Menoufia University Hospital from 2016 to 2017. The required variables for calculating the two scores were recorded. The accuracy of the two models in predicting mortality was compared using area under the receiver operating characteristic curve. Results The mean TRISS-estimated mortality rate was 17.41 ± 25.03, whereas the mean APACHE IV Score was 18.87 ± 19.89. There was a statistically significant difference between survived and dead patients regarding the two scores (P = 0.001). The best cutoff value of TRISS and APACHE IV for prediction of mortality among studied patients was 32.5 and 32, respectively, with sensitivity of 96 and 84%, respectively; specificity of 98 and 96%, respectively; and accuracy of 97 and 93%, respectively. Conclusion Both scores can be used in predicting mortality of seriously injured patients with polytrauma but TRISS model is better and more applicable than APACHE IV.
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Comparative study of laparoscopic versus open repair of incisional hernia p. 517
Mohammed Leithy, Ashraf A Elhady, Asem Fayed, Ahmed Elghazaly
DOI:10.4103/mmj.mmj_825_17  
Objective The aim was to compare between laparoscopic and open repair of incisional hernia regarding the technique and outcome. Background One of the most common complications of laparotomy is incisional hernia, with an estimated incidence of 3–20% after laparotomy. Materials and methods This clinical trial was conducted on 100 patients presented with ventral incisional hernia to Menoufia University Hospital, General Surgery Department, during the period from June 2015 to August 2017. They were randomly distributed into two groups: 50 cases had open repair and 50 cases had laparoscopic repair. Operative and postoperative details were recorded and compared. Follow-up was conducted for 1 year after surgery. Results The mean postoperative hospital stay was longer in the open group than laparoscopic group (2.72 ± 0.68 vs. 1.92 ± 0.69 days, P < 0.001). The total postoperative complications were more in the open group than laparoscopic group (23 vs. 13, P = 0.03). The mean operative time of laparoscopic repair was significant statistically longer than the open repair (151.9 ± 20.07 vs. 106.6 ± 13.77 min, P < 0.001). Short-term postoperative pain was more intense in the open repair group than the laparoscopic group (4.72 ± 1.10 vs. 3.78 ± 1.30, P < 0.001). Conclusion Laparoscopic incisional hernia repair is a safe alternative to open incisional hernia repair. We recommend increased application of laparoscopic repair of incisional hernia and a large multicenter randomized trial with long follow-up to measure the long-term results.
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Feasibility of local anesthesia for treatment of uncomplicated umbilical hernia in patients with ascitic cirrhosis p. 522
Ayman A Albatanony, Mohammed A El Balshy, Mohamed M Zeater
DOI:10.4103/mmj.mmj_834_17  
Objective The aim of this study was to evaluate the effectiveness of local anesthesia in umbilical herniorrhaphy in patients having cirrhosis with controlled ascites. Background Umbilical hernia is a common abdominal wall complication of liver cirrhosis. The prevalence of umbilical hernia in patients having cirrhosis with ascites is up to 20%. Local anesthesia often provides maximum comfort for patients when it is accurately performed in open repairs. However, convincing evidence is lacking. Patients and methods This prospective study was carried out on 40 patients at Menoufia University Hospital and Damanhour Medical National Institute during the period from June 2016 till October 2017. All patients with cirrhosis with controlled ascites and uncomplicated umbilical hernia were included in this study. Exclusion criteria were complicated hernia, huge hernia, and local anesthesia hypersensitivity. All patients underwent elective umbilical herniorrhaphy under local anesthesia. Patients were followed up for 1 year. The complications and the outcome of the operation were recorded. Results Overall, 87.5% of patients passed without any complications, and 2.5% of them converted from local anesthesia to general anesthesia owing to omental injury (one patient). We inserted a surgical drain in 10% of patients. Most of patients (92.5%) were satisfied by this technique with different degrees of satisfaction, with 2.5% recurrence rate. Conclusion Umbilical herniorrhaphy under local anesthesia in patients with cirrhosis is feasible and safe, with a high success rate in experienced hands and results in minimal perioperative morbidity.
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Staged breast reconstruction after mastectomy using tissue expander followed by permanent prosthesis p. 528
Alaa A El Sisi, Sherif M El Kashty, Ahmed G El Tatawy, Alaa M. El Shamly El Sayed Shoeib
DOI:10.4103/mmj.mmj_855_17  
Objective The aim of this study was to evaluate immediate breast reconstruction after mastectomy, by using tissue expander, followed by insertion of permanent prosthesis, as regards advantages, its complications and patient satisfaction. Background Social and psychological effects of mastectomy on women make breast reconstruction a great challenge for oncoplastic surgeons; hence, staged breast reconstruction depends on tissue expander, and a prosthetic device may provide a good solution for that challenge. Patients and methods This study included 20 patients admitted in Menoufia University Hospitals and El-Obour Insurance Hospital with a diagnosis of breast carcinoma in the 2-year period spanning from January 2015 to February 2017. The studied patients refused autogenous reconstruction, and all of them were classified as early staged breast cancer. The first stage of reconstruction included mastectomy with axillary clearance, submuscular expander insertion, and their regular expansion, whereas in the second stage, the expander was removed and replaced by permanent prosthesis. Results Seroma formation occurred in two patients, wound infection in two patients, one patient had a ruptured implant and another had expander leakage, whereas one patient failed by capsular contracture. All postoperative complications were managed conservatively or by surgical intervention. Conclusion Staged breast reconstruction, by using tissue expander, followed by permanent prosthesis, is an excellent solution in some patients, provided they are carefully selected.
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Evaluation of the proximal radio cephalic arteriovenous fistula for hemodialysis p. 534
Hesham S Abu-Gruidah, Mahmoud S Abd El-Haleim, Mohamed A Haridy
DOI:10.4103/mmj.mmj_881_17  
Objective To evaluate the proximal radiocephalic arteriovenous fistula (pRCF) as a hemodialysis access. Background The gold standard arteriovenous fistula is the distal radiocephalic fistula at wrist. If distal vessels are not suitable, a brachiocephalic fistula is a good vascular access, but many cases were reported to have dialysis access steal syndrome, so doing pRCF is a good alternative option. Patients and methods A prospective study was conducted on 30 patients who were in need for hemodialysis access between May 2016 to November 2016 and follow-up of patients was carried out until May 2017 at Menoufia University Hospital. The data for primary success rate, primary patency, secondary patency rates, and complications were collected and analyzed. Results Thirty patients underwent pRCF. Primary fistula failure was seen in 0%, whereas six (20%) fistulas failed later, four of them owing to thrombosis, one owing to anastomotic aneurysm, and one owing to extensive edema. Two (6.7%) patients were lost (censored) to follow-up. No patients developed steal syndrome, and the incidence of it was 0%. One (3.3%) fistula showed weak flow. Primary patency rate was 63.3%, whereas secondary patency rate was 73.3%. Conclusion For patients with prior forearm arterio-venous (AV) fistula dysfunction, or inadequate wrist vessels, we believe that a proximal radiocephalic approach should precede creation of brachiocephalic fistula to avoid the risk of dialysis-associated steal syndrome.
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Evaluation of different techniques in the management of crippled hypospadias p. 539
Tamer A Sultan, Mohammed H Abdel-Satar, Kareem M Ouda
DOI:10.4103/mmj.mmj_882_17  
Objective To evaluate and compare different modalities that used in the management of different complications that we face in cases of crippled hypospadias. Background Hypospadias is one of the most common congenital deformities in humans. It has many causes and its repair is a challenging topic of urogenital reconstructive surgery. Many different techniques are currently being used. Patients and methods This was a randomized prospective study which included 30 patients with crippled hypospadias who presented to Menoufia University Hospital and who were classified into three groups: group A patients underwent tubularized incised plate (TIP) urethroplasty; group B patients underwent Thiersch–Duplay urethroplasty and group C patients underwent buccal mucosal graft. Results The age of the cases at the time of repair ranged between 2 and 14 (8.55 ± 2.3) years. The most common postoperative complications in the whole groups were urethrocutaneous fistula (13.3%), followed by meatal stenosis (6.7%), while urethral stricture and donor site complications were the rarest encountered in only one (3.3%) case. Conclusion There is no single applicable technique for hypospadias repair, if the urethral plate is healthy we can repair with TIP, if we have available nearby penile or preputial skin we use Duplay graft. Moreover buccal mucosa could be used in rest crinkled hypospadias.
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Reliability of the adult appendicitis score in diagnosing acute appendicitis p. 544
Soliman Elshakhs, Moharram Abdelsamie, Abdelmonem Fareed, Mohannad H Abuomar
DOI:10.4103/mmj.mmj_914_17  
Context Appendicitis is a common cause of abdominal pain. Nevertheless, diagnosis of acute appendicitis is still a challenge, with the hazards of either negative appendectomy or complicated appendicitis. Using an optimum scoring system, such as adult appendicitis score (AAS), can increase the diagnostic accuracy eliminating the need for potentially harmful and costly imaging studies. Aims The aim was to test the reliability of AAS in diagnosis of acute appendicitis. Settings and design This was a prospective, noninterventional study in the emergency department of Menoufia University hospitals. Patients and methods Eligible patients who presented with right lower quadrant pain in the period from January 2016 to April 2017 were enrolled in the study. History taking, clinical examination, and laboratory testing (white cell count, neutrophil count, and C-reactive protein) were carried out to test the reliability of the AAS, and it was compared with the Alvarado score and appendicitis inflammatory response score. Sensitivity and specificity, as well as negative and positive predictive values were calculated for each score. Correlation analysis was conducted between each score results and final pathological results. Receiver operating characteristic curves were plotted to estimate the reliability. Results AAS was the most specific one at score 16, with specificity 97.9% and positive and predictive value 97.4%, whereas the appendicitis inflammatory response score was the most sensitive at score 5, with sensitivity and negative predictive values of 100%. Using the receiver operating characteristic curves showed the AAS was the most reliable, with area under the curve of 0.936 (P = 0.00). Conclusion AAS is a reliable score to risk stratify patients with suspected acute appendicitis, guiding only intermediate-risk cases to further imaging. At score greater than or equal to 18, cases can be directed confidently to surgery without delay.
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Laparoscopic for acute cholecystitis: an analysis for expanding the golden time p. 549
Ayman A Al-Batanony, Tamer F Abdel-Aziz, Ahmed AA El-Abd
DOI:10.4103/mmj.mmj_51_18  
Objective Our objective is to evaluate safety and efficacy of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in the first 7 days of acute attack. Background Gallstone disease constitutes up to 23% of AC, which is a common emergency. LC is the treatment of AC. There is confusion in the optimal timing for LC from the onset of symptoms. Patients and methods A total of 30 patients of AC at Menoufia University Hospital and Kafr El-Dawar General Hospital were selected based on clinical diagnosis, ultrasonographic finding, and laboratory finding for AC. They were divided into two groups: group A included 15 patients with AC who were managed conservatively and then surgically after 72 h and group B included 15 patients with AC assigned to LC within 72 h. Results There was no statistical significant difference between patients of both groups regarding age or sex. Operative time was significantly increased in group A than in group B, whereas there was no statistical significant difference between both groups regarding blood loss, intraoperative complications, conversion to open cholecystectomy, postoperative hospital stay, or follow-up period complications. Conclusion Extending the golden time for LC associated with the same hospital stay, cost-effectiveness, conversion rate, and complications, and therefore can be considered as a preferred approach in the treatment of AC.
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Laparoscopic versus open appendectomy in complicated acute appendicitis p. 554
Hatem M Soltan, Ahmed G El-Tatawy, Aiman HM Alsegaey
DOI:10.4103/mmj.mmj_78_18  
Objective To compare between laparoscopic appendectomy (LA) and open appendectomy (OA) in complicated acute appendicitis to determine which procedure is better. Background OA is the standard operation for patients with complicated acute appendicitis. Recently, LA was introduced. LA could become a great method to treat complicated acute appendicitis. Patients and methods A prospective equivalence randomized study was conducted in 40 patients who were divided into two groups. One of the group was operated using ordinary open technique, and the other group was operated using laparoscopic technique. They were admitted to the emergency room in the Menoufia University and Shebein El Kom Teaching Hospitals during the period from September 2014 to November 2015. Results OA and LA was performed in 40 patients (20 patients for each procedure). The laparoscopic technique was better in operative time (P = 0.014), less intraoperative complication, less postoperative complications (7.5% of all patients had complications postoperatively all in open group), less length of hospital stay (P = 0.025), and less oral intake time (P = 0.365). Conclusion LA is a safe and feasible option in the management of complicated acute appendicitis.
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Comparative study between intrahemorrhoidal diode laser treatment and Milligan–Morgan hemorrhoidectomy p. 560
Alla A Alsisy, Yahia M Alkhateep, Ibrahim EI Salem
DOI:10.4103/mmj.mmj_101_18  
Objective The aim of this study was to compare between intrahemorrhoidal diode laser coagulation with Milligan–Morgan (MM) hemorrhoidectomy. Background Because of the increased number of patients suffering from hemorrhoids and increased complications of MM hemorrhoidectomy, using intrahemorrhoidal diode laser therapy in this study was proved to be beneficial in terms of being easily used, noninvasive, nontoxic, painless, and highly effective. Patients and methods This study included 60 patients with symptomatic hemorrhoids of grades II and III. Thirty patients were treated with intrahemorrhoidal diode laser coagulation and the remaining were treated with MM hemorrhoidectomy. We measured operative time, postoperative pain, complications, and resolution of symptoms. We followed up patients for 3 months for evaluating healing, resolution of symptoms, and complications. Results Postoperative pain scores at the first 24 h were significantly lower in the laser group compared with the MM group (P < 0.001). The operative time and intraoperative bleeding were much more in the MM group (P < 0.001). The consumption of analgesics was significantly reduced in the laser group (P = 0.018). Three patients in the laser group were presented with thrombosis of hemorrhoids 3–4 days after the laser procedure, which was resolved with medical treatment, but no patients in the MM group developed thrombosis of hemorrhoids (P = 0.076). Three months of follow-up showed comparable results in terms of resolution of symptoms and curability rate. Conclusion Intrahemorrhoidal therapy with a 980-nm diode laser is associated with reduction of postoperative pain, intraoperative bleeding, and administered with analgesics. Our results suggest that intrahemorrhoidal diode laser treatment if available is preferred to open hemorrhoidectomy.
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Different surgical modalities in the management of lumbar canal stenosis p. 566
Mohamed K Eissa, Adel M Hanafy, Hesham Y Aborahma, Ahmed S El Gammal, Hazem M Negm
DOI:10.4103/mmj.mmj_897_17  
Objective The aim of this study was to evaluate the results of different methods of decompression in lumbar canal stenosis (LCS) with regard to the effectiveness of different techniques in relieving symptoms, duration of surgery, intraoperative blood loss, and decreasing of postoperative complications. Background LCS is defined as a narrowing of any part of the lumbar spinal canal. Several surgical techniques for lumbar spine decompression have been described over the last few decades. The aim of surgery for symptomatic LCS is to relieve the symptoms by adequate neural decompression while preserving the anatomy and the biomechanical function of the lumbar spine as much as possible. Patients and methods This prospective study was conducted from September 2015 to August 2017 including three groups: group A treated with conventional laminectomy (CL), group B treated with CL with posterolateral fusion, and group C treated with unilateral laminectomy with bilateral decompression. We used Oswestry disability index to assess preoperative and postoperative disabilities and pain. Results In this study, statistical results revealed that there was statistical significance in the improvement of claudicating sciatica between the three groups as regards the Oswestry disability index (P < 0.001). There was statistical significance between three groups with regard to blood loss (P < 0.001), length of surgical procedure (P = 0.009), postoperative hospital stays (P < 0.001), and postoperative complication. Conclusion On the basis of short-term follow-up, a minimally invasive technique like unilateral laminectomy with bilateral decompression allowed decompression, preserving spine stability with a natural range of motion, with less blood loss, less hospital stay, and decreased intraoperative and postoperative complication rather than CL with or without posterolateral fusion.
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Risk factors for leak in emergent small bowel anastomosis p. 574
Awatef E Farghaly, Mohamed S Ammar, Ahmed S Algammal, Ahmed SA Arafa
DOI:10.4103/mmj.mmj_111_18  
Objective The objective of this study was to identify risk factors associated with intestinal anastomotic leakage (AL) to generate hypothesis for further investigation to practically assist in surgical decision making and reduction of postoperative morbidity and mortality. Background AL is a frequent complication of intestinal surgery and has been associated with postoperative morbidity and mortality. Patients and methods The study included 51 patients who presented to the Emergency Department at Menoufia University Hospital in the period between March and September 2017 requiring small bowel resection and reconstruction as an emergency procedure after illustrating the study to them and taking their consent to participate. Overall complication and leak rates were compared using Fisher's exact test. Individual case review by a group of peers was performed for patients with a leak who died to determine the relationship with mortality. Results A total of 51 emergency patients meeting the inclusion criteria underwent resection with anastomosis during the study period. There were 13/51 (25.4%) patients with leaks, four of whom died. In bivariate analysis, factors that were associated with AL were advancing age, hypoalbuminemia 12/13 (92.3%), intraoperative hypovolemia 8/13 (61.5%), intraoperative hypotension, diffuse peritonitis, and low hemoglobin concentration. Mortality was significantly increased in patients with AL, as four (4/51, 7.843%) cases died; three (3/13, 23.07%) of them had AL. Conclusion Multiple factors should be taken into consideration before and during emergency small bowel resection anastomosis surgery to comprehensively assess the risk for AL and reduce postoperative morbidity and mortality.
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Left atrial maze efficacy for treatment of concomitant atrial fibrillation with mitral valve disease p. 581
Ahmed L Dokhan, Ali H Taher, Amr M Allama, Ahmed H Ayanah, Walid KA Simry
DOI:10.4103/mmj.mmj_586_17  
Objective This study aims to compare the efficacy of mitral valve surgery with left atrial maze versus isolated mitral valve surgery. Background Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, especially with mitral valve disease. It represents a significant health burden especially with the associated thromboembolic complications. Several surgical approaches have been developed. The most effective one is Cox-Maze III procedure using cut-and-sew technique. Recently, surgical ablation has been transformed into an easier and faster procedure using radiofrequency, microwave, and cryothermal energy. Patients and methods This is a prospective cohort study conducted after the approval of the Human Ethics Committee of Faculty of Medicine, Menoufia University. A total of 100 patients with permanent AF and concomitant mitral valve disease have been recruited. The patients were allocated into two equal groups. Group A included mitral valve surgery and left atrial maze procedure, whereas group B included mitral valve surgery without left atrial maze. Results Group A had significant longer bypass and clamp times than group B (P < 0.001). Group A had significant less postoperative AF as assessed at '1 week, 1 months, 3 months, and 6 months'. At 6 months, 74% of patients in group A were in sinus rhythm as compared with 20% of patients in group B (P < 0.0001). Moreover, it was noticed that 74% of patients in group A had atrial kick postoperatively as opposed to only 20% of patients in group B (P < 0.0001). Conclusion Left atrial maze with mitral valve surgery results in a better outcome in terms of myocardial function and dimensions. In addition, sinus rhythm restoration has the potential benefit of reducing the incidence of thromboembolic complications.
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Impact of tricuspid ring annuloplasty on functional tricuspid regurgitation after mitral valve surgery p. 587
Ahmed L Dokhan, Mohammed E Abdelraof, Amr M Allama, Shahzad G Raja, Hesham H Ahmed
DOI:10.4103/mmj.mmj_621_17  
Objective The objective of this study was to evaluate tricuspid valve (TV) ring annuloplasty for moderate functional tricuspid regurgitation (FTR) in patients undergoing mitral valve (MV) surgery. Background TV ring annuloplasty during MV surgery for severe FTR is recommended but for moderate FTR is controversial. Patients and methods Eighty patients with moderate FTR who were listed for MV surgery were classified into group A, the TV annuloplasty group which included 34 patients who underwent MV surgery and TV annuloplasty and group B, the TV nonrepair group, 46 patients who underwent MV surgery alone. Results At 1-month follow-up, in group A: no, mild, and severe FTR were detected in 70.6, 26.5, and 2.9% of patients, respectively, whereas in group B, no, mild, moderate, and severe FTR were detected in 26.1, 58.7, 13, and 2.9% of patients, respectively (P = 0.001). Pulmonary artery pressure (PAP) in groups A and B was 27.2 ± 5.1 and 31.7 ± 6.8 mmHg, respectively (P = 0.001). At 6-month follow-up, in group A no, mild, and severe FTR were detected in 64.7, 32.4, and 2.9% of patients, respectively, whereas in group B, no, mild, moderate, and severe FTR were detected in 32.6, 50, 15.2, and 2.2% of patients, respectively (P = 0.01). PAP in groups A and B was 27.6 ± 5.1 and 32.2 ± 7.1 mmHg, respectively (P = 0.003). Conclusion Intervention for moderate FTR is recommended during MV surgery to avoid persistence or progression of the TR especially in patients with high PAP.
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Clinical implications of moderate ischemic mitral regurgitation in patients undergoing coronary artery bypass grafting p. 592
Ahmed L Dokhan, Ali H Taher, Mohammed A El-Hag-Aly, Yasser F Asswaf
DOI:10.4103/mmj.mmj_690_17  
Objective The aim of this study was to explore the fate of moderate ischemic mitral regurgitation (IMR) following isolated coronary artery bypass grafting (CABG). Background IMR is a frequently encountered problem seen in patients with coronary artery disease. A much-debated question is whether surgical revascularization alone will correct moderate (2+) IMR in such patients. Patients and methods The study group included 20 patients with moderate IMR associated with coronary artery disease undergoing isolated CABG. All patients had an ejection fraction of more than 30%. The patients were clinically and echocardiographically evaluated preoperatively, 1 week postoperatively and at 3- and 6-month intervals. Results CABG alone reduced the degree of IMR in 12 (60%) patients, did not improve it in five (25%) patients, and increased its degree to 3–4 + in three (15%) patients at 6-month follow-up echocardiography. Our study showed improved functional capacity of the patients. A significant reduction in the New York Heart Association functional class was observed. The mean preoperative value for New York Heart Association was 2.45 ± 0.51 versus 2.05 ± 0.88 postoperatively (P = 0.042). Some important variables showed a role in the progression of IMR. These were: left ventricular end-systolic dimension, left ventricular end-diastolic dimension, preoperative ejection fraction%, and failure to graft the diseased right coronary system. Conclusion The presence of moderate IMR in patients undergoing revascularization alone does not add additional burden to the operative risk nor does it affect the short-term outcome of these patients.
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Comparison of perioperative morbidity and mortality in minimally invasive versus conventional mitral valve surgery p. 599
Ahmed L Dokhan, Mahmoud H Mazen, Islam M Ibrahim, Samer WG Girgis
DOI:10.4103/mmj.mmj_767_17  
Objective The aim of this study was to evaluate a new approach for mitral valve surgery (MVS) in National Heart Institute, Egypt, comparing operative data, total hospital stay, and hospital morbidity and mortality between conventional and minimally invasive mitral valve surgery (MIMVS). Background MVS using full sternotomy is the conventional approach. Despite this procedure showing excellent postoperative outcomes, in the past two decades, MIMVS has gained consensus among surgeons as it provided greater patients satisfaction, better cosmoses, less hospital stay, and faster recovery maintaining same quality and safety. Patients and methods This prospective study was conducted on fifty patients requiring mitral valve replacement with or without tricuspid valve repair, and the patients were classified into two groups: group I (conventional) was operated on using conventional median sternotomy, and group II (minimally invasive) was operated on using video-assisted right anterolateral mini-thoracotomy and peripheral femoral cannulation. Results There was no significant difference in the preoperative data for patients of both groups. Moreover, there was no mortality in both groups but significant differences in incision length, ventilation time, blood loss (P = 0.001), blood transfusion (P = 0.01), and ICU stay (P = 0.001) were found. In addition, total hospital stay was significantly less in group II (9.6 ± 2.18 vs. 5.64 ± 0.7 days, P = 0.001). Conclusion In patients with mitral valve diseases, MIMVS is feasible for MVS without affecting the core of surgery or compromising the surgical target, with some advantages such as shorter ICU stay and faster recovery.
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Transcatheter aortic valve implantation versus surgical replacement in high-risk patients with aortic stenosis p. 604
Ahmed L Dokhan, Ali H Taher, Amr M Allama, Medhat R Nashy, Ahmed M Fekry
DOI:10.4103/mmj.mmj_879_17  
Objectives The aim of this study was to demonstrate whether transcatheter aortic valve implantation (TAVI) improves mortality and morbidity compared with surgical aortic valve replacement in high-risk patients who require intervention for aortic valve stenosis (AS). Many patients with severe AS and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, TAVI has been suggested as a less invasive treatment for high-risk patients with AS. Patients and methods Fifty patients with severe AS for aortic valve intervention were classified as follows: group A, as TAVI group, included 25 patients who underwent aortic valve replacement by transcatheter femoral approach, and group B, as surgical aortic valve replacement group, included 25 patients who underwent aortic valve replacement by median sternotomy. Results Intraoperatively, procedure duration was 101.8 ± 10.6 and 191.2 ± 7.5 min in group A and B, respectively (P < 0.001). Major vascular complications occurred in 20% of patients in group A and 0% of patients in group B (P = 0.018). Postoperative follow-up mean ICU stay was 3 ± 2.4 and 4.8 ± 3.5 days in groups A and B, respectively (P = 0.035). In group A, 32% of patients needed permanent pacemaker. In group A, 12% of patients developed stroke or transient ischemic attacks. Paravalvular aortic regurgitation occurred in 36.3 and 4.5% of patients in groups A and B, respectively (P = 0.009). Conclusion In high-risk patients with severe AS, transcatheter and surgical procedures for aortic valve replacement were comparable for survival at 3 months, although there were important differences in periprocedural outcomes.
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Surgical management of infective endocarditis: risk factors affecting early outcome p. 610
Mohamed O Mahmoud, Ahmed L Dokhan, Amr M Allama, Mohamed OM Mostafa
DOI:10.4103/mmj.mmj_121_18  
Objective To evaluate the risk factors affecting the early outcome of surgical treatment of infective endocarditis (IE). Background IE represents a series of clinical conditions with high in-hospital mortality, so early diagnosis and treatment can improve outcomes. Diagnosis depends on constant history and classic manifestations like sustained bacteremia or fungemia or active valvulitis. IE is a medical-surgical disease in which surgical treatment is a part of the therapeutic process rather than a result of the failure of medical treatment. Patients and methods A prospective cohort study was conducted on 50 consecutive patients diagnosed with definite IE and underwent cardiac surgery after being admitted to the Cardiothoracic Surgical Department, National Heart Institute, Giza, Egypt, during the period from December 2015 till March 2017. Preoperative, intraoperative, and postoperative data as potential predictors of mortality were tested. Results Our results showed that rheumatic heart disease was the most common underlying cardiac disease. Native valve endocarditis was present in 31 (62%) and prosthetic valve endocarditis in 19 (38%) patients. Mean Euro SCORE II was 5.71%. The hospital mortality was 22%, whereas the 6-month mortality was 10%. Congestive heart failure, embolization, and periannular extension of infection are the most powerful predictors of hospital mortality and also 6-month mortality. Conclusion Surgery for IE continues to be challenging. Euro SCORE II has a good discrimination ability to predict in-hospital mortality in IE surgery. Satisfactory results can be obtained with valve repair in IE.
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The use of twin-ring Ilizarov in the treatment of periarticular or intra-articular fractures of the tibia p. 618
Hesham F Ghoneem, Amr SE Omar, Mohammed MM Mohammed
DOI:10.4103/mmj.mmj_588_17  
Objective The aim of the present study was to report the results of using the twin-ring (TR) module in treatments of juxta-articular fractures of the tibia and the merits of this technique in Menoufia University Hospitals and El-Obour Insurance Hospital over 3 years. Background In juxta-articular fractures of the tibia, the presence of short metaphyseal bone fragments may make the application of an Ilizarov external fixator (IEF) challenging. It may be necessary to bridge the adjacent joint to ensure stable fixation. The TR module is proposed as an alternative method that avoids joint bridging, without compromising the stability of fixation. Patients and methods This is a descriptive retrospective study with data collected from the analysis of medical records of 20 patients admitted in Menoufia University Hospitals and El-Obour Insurance Hospital with a diagnosis of juxta-articular fractures of the tibia over a 3-year period from May 2013 to July 2016. The patients studied were retrospectively analyzed for sociodemographic data, clinical parameters, duration of hospitalization, the application of TR IEF, and clinical outcome according to the knee society scoring system and the clinical rating system for the ankle and hind foot. Results The TR IEF shows more stability, less joint stiffness, and less time needed for both fracture union and physiotherapy. Conclusion When treating selected trauma patients, the application of the TR IEF is suggested as a promising surgical alternative, offering satisfactory outcomes and reduced patient morbidity.
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Evaluation of results of cemented modular hemiarthroplasty in comminuted fractures of the proximal humerus p. 624
Hassan A Neanaa, Taher A Eid, Ayman M Ebied, Adel I El-Seedy, Bahaa Z Hassan, Ahmed N El Barbarey
DOI:10.4103/mmj.mmj_625_17  
Objective The aim of this work was to evaluate the results of use of cemented modular hemiarthroplasty prosthesis in cases of comminuted fractures of the proximal humerus. Background Proximal humeral fractures account for ∼5% of all joint fractures. More than 70% of patients with these fractures are older than 60 years of age, 75% are women and most of these fractures are related to osteoporosis. Shoulder hemiarthroplasty is a method of treatment of comminuted proximal humeral fractures in which complication of fracture fixation is avoided with a restoration of the anatomy of the shoulder joint. Materials and methods In the period between February 2012 and February 2016, a prospective study of 20 patients with post-traumatic comminuted fracture of the proximal humerus with or without dislocation of the humeral head had been admitted to El-Menoufia University Hospital. All cases that fulfilled the inclusion criteria had been treated with cemented modular hemiarthroplasty. Results The age of the patients in this study range from 30 to 75 years, 14 (70%) women and six (30%) men. The shoulder range of motion in two (10%) cases had an excellent result, eight (40%) cases had good results, seven (35%) cases had fair results, and three (15%) cases had poor results. Seventeen (85%) cases were satisfied with the results and three (15%) cases were not satisfied with the procedure. Conclusion Shoulder hemiarthroplasty is a method of treatment of comminuted proximal humeral fractures particularly in osteoporotic bone.
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Results of flexor tendon grafting with early active mobilization p. 630
Hesham M El-Mowafy, Hassan A Neanaa, Mohamed A Ahmed
DOI:10.4103/mmj.mmj_662_17  
Objective The aim was to evaluate the results of early active motion regimen after hand flexor tendon grafting. Background The application of proper postoperative rehabilitation program is an integral part to achieve good results after hand flexor tendon grafting. The aim of application of early, active mobilization rehabilitation program is to limit adhesion formation which limits active motion. Patients and methods Twenty-three fingers were managed by flexor tendon grafting and assessed from February 2015 till August 2016 at Menoufia University Hospital. In all, 17 fingers had two stages tendon grafting and six fingers had single-stage tendon grafting. Early active mobilization rehabilitation regimen was applied for all patients. Postoperative assessment was done by the American Society for Surgery of the Hand system, Strickland system, Buck-Gramcko method, and LaSalle formula. Results Final assessment was done at 6 months postoperatively and the results were as follows: good (52.17%), fair (39.13%), and poor (8.7%) according to the American Society for Surgery of the Hand system. According to the Strickland system, the results were excellent (13.04%), good (34.78%), fair (39.13%) and poor (13.04%). According to the Buck-Gramcko score, the results were excellent (21.7%), very good (17.4%), good (39.1%) good, fair (8.7%), and poor. (13.1%) According to LaSalle formula, the results were excellent (34.78%), good (52.17%), fair (8.7%), and poor (4.4%). Complications were adhesion formation (8.7%), infection (8.7%), flexor pulley rupture (4.3%), graft rupture (4.3%), and tourniquet palsy (4.3%). Conclusion The results were found to be affected by sex, dominance of affected hand, affected tendon(s), flexor pulley integrity, type of procedure, and by the type of tendon graft.
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Open versus percutaneous fixation of unstable posterior pelvic ring injuries p. 640
El-Sayed M Zaki, Mahmoud M Hadhood, Mostafa A Ayoub, Mohamed A El Sawy, Emad E El Agroudy
DOI:10.4103/mmj.mmj_699_17  
Objective This is a prospective clinical study on 40 patients with unstable posterior pelvic ring injuries to compare percutaneous fixation technique with open fixation technique. Background Unstable pelvic ring fractures are usually secondary to high-energy trauma and usually associated with high mortality and morbidity. There are several surgical approaches to the treatment of unstable posterior pelvic ring injury: open or percutaneous screw fixation and plate fixation of posterior pelvic ring injury, each having respective advantages and disadvantages. Patients and methods Two techniques have been used for the fixation of the posterior pelvis, each with advantages and disadvantages specific to the technique. A total of 40 cases of completely unstable pelvic ring injuries type C were managed by either percutaneous techniques (group I included 20 patients) or open reduction and internal fixation (group II included 20 patients). Anatomical reduction and restoration of the length of limb were the main aim during the surgery. Results The data were analyzed as follows. Tile classification, radiological evaluation according to maximal residual displacement at final follow-up, and functional evaluation according to Lindhal scoring system. Forty patients were included, with 31 male and nine female patients. Overall, 11 patients had excellent results, 20 patients had good, eight patients had fair, and one patient had poor. Conclusion Percutaneous fixation of unstable posterior pelvic ring injuries shows better results and fewer complications in comparison with open technique of fixation.
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Fixation of acute posterior cruciate ligament avulsion fracture from tibial insertion by cannulated screws p. 646
Ayman Ebied, Mohammed A Alsawy, Ahmed I Zayda, Islam M Hamdan
DOI:10.4103/mmj.mmj_789_17  
Objective The aim of the study was to evaluate the efficacy of fixation of the acute posterior cruciate ligament (PCL) avulsion fracture from tibial insertion by cannulated screws in Menoufia University Hospitals. Background PCL is the main posterior stabilizer of the knee. Open reduction and internal fixation of the avulsed ligament fragment by screws is recommended. Patients and methods A prospective study of 20 patients with acute PCL avulsion fracture was conducted. All patients were treated by open reduction and internal fixation using cannulated screws. We used a posteromedial approach using an inverted L-shaped approach (Burks Schaffer's approach) at Minoufia University Hospitals. Results All the avulsion fractures achieved union at an average of 10 weeks. Patients were followed up for an average of 8.2 months (range: 6–12 months). Of the 20 patients included in the study, Lysholm score improved from poor in all patients to excellent in 14 (70%) patients and good in six (30%) patients. Conclusion Open reduction and internal fixation of acute PCL avulsion fracture from tibial insertion with cannulated screws is an excellent technique and gives excellent Lysholm score.
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Closed reduction and percutaneous pinning for the treatment of lateral humeral condyle fracture p. 650
Hassan A Neena, Mohammed E Habib, Ahmed M Mabrouk
DOI:10.4103/mmj.mmj_793_17  
Objective The aim of the present study was to evaluate the result of treatment of recent fracture of the lateral humeral condyle in children using closed reduction and percutaneous pinning. Background Few reports have focused on closed reduction and internal fixation of fractures of the lateral humeral condyle in children. We prospectively studied closed reduction and internal fixation to determine its usefulness as the treatment for fractures of the lateral condyle of the humerus in children. Patients and methods The lateral condylar humeral fractures were classified into three groups according to the degree of displacement and the fracture pattern as determined on four radiographic views (Jacob classification). On the basis of this classification system, we prospectively treated 60 fractures and assessed the quality of closed reduction according to the criteria of Hardacre and colleagues Results All six patients of stage 1 fractures were reduced to 1 mm of residual displacement with excellent results. A total of 42, stage 2 fractures were reduced to less than 2 mm of displacement with excellent results and four patients had good results. In six patients of stage 3 had excellent results and two patients had good result. There were no major complications such as early physeal arrest, osteonecrosis of the trochlea or capitellum, nonunion, malunion or osteomyelitis. Conclusion Closed reduction and internal fixation is an effective treatment for lateral humeral condylar fractures of the humerus in children. If fracture displacement, after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended.
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Choroidal change assessment with enhanced depth imaging optical coherence tomography in myopic choroidal neovascularization p. 655
Hany A Khairy, Marwa A Zaky, Hend AM Elabshihy
DOI:10.4103/mmj.mmj_604_17  
Objectives The aim was to evaluate the importance of choroidal changes as measured by enhanced depth imaging optical coherence tomography (OCT) in patient with myopic choroidal neovascularization (mCNV) and to assess the correlation between choroidal thickness (CT) and other parameters such as age, sex, refraction, and staphyloma. Background High myopia is associated with profound changes in the choroid, which are important in the pathogenesis of many important visually significant abnormalities such as choroidal atrophy, CNV, and lattice degeneration. Therefore, it is called pathologic myopia. Patients and methods This prospective study was conducted from June 2016 to January 2017. Two groups of eyes were included: mCNV eyes (31 eyes) and eyes without CNV (19 eyes). CT was measured using the spectralis spectral domain OCT (specralis software version 4.0) in the Ophthalmology Department of the Menoufia University Hospital. Results It was found that CT was significantly decreased in the mCNV eyes compared with normal eyes, as the mean subfoveal CT in eyes with CNV was 103.10 ± 41.09. The mean subfoveal CT in eyes without CNV was 193.28 ± 17.38 (P < 0.001). Conclusion The ability of enhanced depth imaging OCT to visualize the ocular structure provides a more in-depth understanding of the various ocular pathologies. We found that in patients, CT decreased with the presence of mCNV, as compared with controls.
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Role of phaco time and microscopic light exposure time in causing dryness after phacoemulsification p. 660
Adel G Zaky, Hatem M Maray, Khaled El-Gonemy Said, Ramy N Ahmed
DOI:10.4103/mmj.mmj_758_17  
Objective To investigate the effects of phaco time and microscopic light exposure time in patients undergoing phacoemulsification on the development of dry eye. Background Phacoemulsification is a widespread surgery; it may produce some sort of dryness. We aimed to study whether phaco time and microscopic light exposure time can cause eye dryness or not. Patients and methods A prospective consecutive observational nonrandomized study was carried out on 40 eyes without preoperative dry eye. Lissamine green staining of cornea and conjunctiva, tear break-up time, tear meniscus height, Schirmer's test I, and Schirmer's test II were performed immediately before the surgery and at 1 day, 7 days, 1 month, and 2 months after phacoemulsification surgery, followed by assessment of subjective symptoms. The correlation between these values with the phaco time and the microscopic light exposure time was determined. Results There was an increase in subjective symptoms and a marked decrease in the dry eye test values after phacoemulsification surgery. Non significant correlations were found between phaco time and microscopic light exposure time at one hand and dry eye test values at the other hand. Postoperative dry eye test values started to improve 1 month after surgery reaching preoperative values 2 months after surgery. For example the average preoperative Schirmer test I was 17.4 ± 6.11 m; after 1 month, it decreased to 9.23 ± 6.26 m and started to increase at 2 months to 12.30 ± 5.49 m. The preoperative Schirmer test II was 13.5 ± 5.1 m; after 1 month, it decreased to 6.2 ± 3 m and then started to increase at 2 months to 9.3 ± 4 m. Conclusion The surgeon should know that more phaco time can produce dry eye. Exposure to the light of the microscope should be decreased.
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Comparing the corneal biomechanical stability after small incision lenticule extraction and laser-assisted in situ keratomileusis for myopic correction using an ultra-high-speed camera (Corvis ST) p. 665
Khaled ES Ahmed, Sameh M El-Gohary, Hossam F El-Barbry
DOI:10.4103/mmj.mmj_761_17  
Objectives The aim of this study was to invest igate the differences in corneal deformation parameters after femtosecond laser small incision lenticule extraction (SMILE) and laser-assisted in situ keratomileusis (LASIK). Background Applanation time and deformation amplitude [as measured with the CorVis ST (CST)] may be useful in assessing corneal biomechanical changes after corneal refractive surgery. The aim of this study was to evaluate the corneal biomechanical changes using the CST in eyes with LASIK and SMILE. Participants and methods This is a small prospective clinical interventional series study carried out from March 2016 to April 2017 on 50 eyes divided equally into two groups. The first group included eyes that were subjected to the LASIK procedure using the EX500 Allegretto excimer laser platform and the second group included eyes that were subjected to the SMILE procedure using the VisuMax 500 kHz laser system; the CST measured the corneal biomechanical changes before and after the procedures. Results Using CST, the deformation amplitude increased significantly in both groups. It was also noted that the mean percentage of change of the deformation amplitude was nearly two times higher in group I (0.13 ± 0.03) than group II (0.07 ± 0.01) (P < 0.001). First applanation time showed a significant decrease from preoperative to postoperative values in both groups (P < 0.001). Also, the highest concavity time, radius, and peak distance showed a significant decrease from preoperative to postoperative values in both groups. Conclusion Both LASIK and SMILE considerably decreased the corneal biomechanical properties, with greater reduction in the LASIK group.
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Evaluation of macular changes during pregnancy by optical coherence tomography p. 672
Hassan Gamal El Din Farahat, Motaz Fayez Elsawy, Ahmed Abd Elhakiem Darrag
DOI:10.4103/mmj.mmj_886_17  
Objective The aim of the study was to evaluate macular changes during pregnancy by optical coherence tomography (OCT). Background The study included pregnant female individuals during the three trimesters. Patients and methods This prospective cohort study was carried out from October 2015 to August 2017 on a total number of 52 eyes (26 right eyes and 26 left eyes) of pregnant women of noncomplicated pregnancy recruited from the outpatient ophthalmology clinic at Menoufia University Hospital and Mansoura Ophthalmology Hospital. The certificate approval number is 886. The study was subdivided into three groups: group 1 includes pregnant women during the third month of the first trimester, group 2 includes the same pregnant women during the second month of the second trimester, and group 3 includes the same pregnant women during the second month of the third trimester. All patients were subjected to full ophthalmological examination including OCT, fundus examination, intraocular pressure measurement, visual acuity, and best corrected visual acuity measurement. Results Among the 52 eyes of those normal pregnant women, three eyes showed central serous retinopathy; two of them started in the second trimester and one in the third trimester. Conclusion This study showed that the central macular thickness increased in the second trimester than in the first and increased in the third trimester than in the second. There were three cases of central serous retinopathy among the 52 (5.7%) eyes.
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The effect of hypertension on choroidal thickness measured by optical coherence tomography p. 678
Amin F Ellakwa, Asmaa M Ibraheem, Asela N Yousef
DOI:10.4103/mmj.mmj_887_17  
Objective The aim of the study was to investigate the effect of hypertension on choroidal thickness using the enhanced-depth imaging mode of spectralis Heidelberg optical coherence tomography. Background Hypertension is an important risk factor in developing systemic vascular disease and ocular vascular disease. The effect of hypertension on the retina and deeper retinal tissues is now a topic of great interest besides being a risk factor for ocular vascular disease. Recently, optical coherence tomography has been shown to be effective in evaluating choroidal thickness. Patients and methods We include in this study 100 participants (50 healthy normotensive and 50 hypertensive patients). Patients recruited from the internal medicine department and diagnosed with hypertension according to the guidelines of clinical hypertension criteria and controlled with treatment with no cardiac problems. We measured the choroidal thicknesses of the normotensive patients as a control group and the choroidal thicknesses of the hypertensive patients. Choroidal thickness measurements were taken at the fovea and at four more points which are located at, respectively, 500 μm nasal to the fovea, 1000 μm nasal to the fovea, 500 μm temporal to the fovea, and 1000 μm temporal to the fovea. Results A significant difference was found for the choroidal thickness as the choroidal thickness decreases in hypertensive patients in comparison to normotensive participants. Conclusion The results of this study demonstrated that choroidal thickness decreases in patients with systemic arterial hypertension. This may be caused by arteriolar sclerosis and vascular contraction caused by high intravascular pressure in the choroid.
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Corneal wavefront-guided versus aberration-free transepithelial photorefractive keratectomy in patients with myopia with high pre-existing corneal higher order aberrations p. 683
Rana M Ashour Gebril, Amin F El-lakwa, Marwa A Zaky
DOI:10.4103/mmj.mmj_49_18  
Objective The aim was to compare the efficacy, safety, and predictability of corneal wavefront-guided (WFG) and aberration-free ablation in single-step transepithelial photorefractive keratectomy (TransPRK) in patients with myopia with high pre-existing corneal higher order aberrations (HOAs). Background Corneal WFG and aberration-free treatments have been proposed as methods to achieve better visual, refractive, and optical outcomes. Patients and methods A prospective case series was conducted in El-Hekma Eye-LASIK Center, Menoufia Governorate, Egypt, during the period from January 2017 to December 2017. TransPRK was performed for eligible patients with myopia with or without astigmatism with corneal HOAs greater than or equal to 0.35 μm using either aberration-free or corneal WFG patterns provided by ORK-CAM software. Uncorrected distance visual acuity, manifest and cycloplegic refractions, best spectacle corrected distance visual acuity, thorough slit lamp examination, and corneal topography were assessed and repeated 6 months postoperatively. Results Six months postoperatively, 97.6 and 100% of patients achieved manifest refraction spherical equivalent within ±1 D and 76.2 and 66.67% of patients achieved uncorrected distance visual acuity of greater than or equal to 20/20 in aberration-free and corneal WFG groups, respectively. Both groups showed increase in spherical and total corneal HOAs, with no significant difference in corneal WFG (P = 0.08 and 0.28, respectively), though significantly higher postoperatively in aberration-free group (P < 0.001 and 0.001, respectively). Coma and trefoil aberrations decreased after corneal WFG technique, yet increased after aberration-free one. Conclusion Both aberration-free and corneal WFG TransPRK were safe, effective, and predictable in treatment of myopia in patients with high pre-existing corneal HOAs with better aberrometric outcomes in corneal WFG group.
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Evaluation of aphakic iris-claw intraocular lens implantation p. 690
Abdel-Khalik I El-Saadany, Hany A Khairy, Ghada Z Rajab, Ahmed M Shebl Fayed
DOI:10.4103/mmj.mmj_363_18  
Objectives To evaluate the technique of aphakic iris-claw (IC) intraocular lens (IOL) implantation, the visual outcome, and the incidence of postoperative complications. Background Several techniques are available for visual rehabilitation of eyes with inadequate capsular support following complicated cataract surgery or owing to lens subluxation or dislocation. IC-IOL is an effective option with several advantages over other techniques. Patients and methods Patients with inadequate capsular support underwent aphakic IC-IOL implantation. We used two techniques: anterior chamber (AC) and retropupillary fixation of IC lens. Eyes were evaluated for uncorrected and corrected distance visual acuity, intraocular pressure (IOP), and the incidence of postoperative complications. Results The study comprised 12 eyes of 11 patients. Indications for surgery included aphakia following complicated cataract surgery (n = 8), lens dislocation (n = 1), and lens subluxation (n = 3). Eight eyes had AC IC lens implantation and four eyes underwent retropupillary implantation. The final postoperative uncorrected and corrected distance visual acuity improved significantly compared with preoperative values. There was no statistically significant difference between preoperative and postoperative IOP. Postoperative complications included corneal edema, IOP elevation, inflammatory reaction, pupil ovalization, vitreous hemorrhage, and lens disenclavation. There was no statistically significant difference between the two techniques of implantation regarding any of the studied variables. Conclusion Aphakic IC-IOL is an effective option for visual rehabilitation in eyes with inadequate capsular support, providing a good visual outcome and high safety profile. Both AC and retropupillary fixation can achieve a satisfactory outcome.
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Topography-guided photorefractive keratectomy combined with accelerated corneal collagen cross-linking (The Athens Protocol) for keratoconus p. 698
Wagih K Makar, Hatem M Marey, Hani A Khairy
DOI:10.4103/mmj.mmj_316_18  
Objective The aim was to evaluate corneal changes after topography-guided partial photorefractive keratectomy (PRK) combined with accelerated corneal collagen cross-linking (CXL) (the Athens protocol) in progressive keratoconus with Pentacam Scheimpflug imaging. Background Keratoconus is a bilateral noninflammatory progressive corneal thinning that results in irregular astigmatism and progressive myopia. Topography-guided partial PRK combined with CXL (The Athens Protocol) has been developed not only to arrest progression of keratoconus but also to offer the patients functional vision. Patients and methods This prospective study included 20 eyes that underwent topography-guided partial PRK combined with accelerated CXL (The Athens Protocol). Preoperative and postoperative assessments included visual acuity, slit lamp evaluation, and Pentacam. All investigation and examination were done during the period from June 2017 to June 2018. Results All study parameters demonstrated a statistically significant improvement with uncorrected distance visual acuity of 0.55 ± 0.29 Snellen line postoperatively vs. 0.33 ± 0.24 Snellen line preoperatively and best-corrected visual acuity of 0.73 ± 0.25 Snellen line postoperatively vs. 0.61 ± 0.27 Snellen line preoperatively, with a P value of 0.005; flat keratometry of 44.76 ± 1.64 D postoperatively vs. 45.29 ± 2.01 D preoperatively and steep keratometry of 46.55 ± 2.09 D vs. 47.68 ± 2.42 D, preoperatively, with a P value of less than 0.001; mean postoperative index of surface variance of 50.70 ± 18.34 postoperatively vs. 65.25 ± 29.29 preoperatively, with P value less than 0.001; and mean postoperative index of height decentration of 0.053 ± 0.033 postoperatively vs. 0.091 ± 0.052 preoperatively, with P value less than 0.001. Conclusion Topography-guided partial PRK combined with accelerated CXL (The Athens Protocol) is a relatively new and revolutionary procedure aimed at stabilization of corneal ectatic disorders and achieving a good visual quality. Longer duration of follow-up and a larger sample may further provide more reliable results.
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Assessment of prognostic factors in patients diagnosed with acute invasive fungal rhinosinusitis in Egypt p. 703
Abd Ellatif I El-Rashidy, Omar A El-Banhawy, Ibrahim A Abd El-Shafy, Ahmed M Basha
DOI:10.4103/mmj.mmj_804_17  
Objective To evaluate the prognostic factors in patients with invasive fungal rhinosinusitis and their effects on disease outcome. Background Invasive fungal sinusitis is a fatal disease and its relative rarity has made precise identification of treatment protocols and prognostic factors difficult. Patients and methods Twenty patients diagnosed with invasive fungal sinusitis were recruited for a descriptive study. All patients were treated with antifungal drugs with proper control of their underlying diseases. Surgical debridement of necrotic and gangrenous tissue was performed in 15 patients. We divided the patients into two groups (surviving and nonsurviving). Both the groups were compared regarding the suggested prognostic factors such as the timing of presentation, the extent of gangrene at the time of presentation, state of the underlying disease, surgical treatment, and the involvement of other nearby structures. Results The overall survival rate was 45%. There was a significant difference between both groups regarding the control of original disease (P = 0.0001). There was a significant difference between both groups regarding neurological deficit (P = 0.0001) as the intracranial involvement lowered survival outcome. There was a significant difference between both groups regarding the timing of presentation (P = 0.010) with early presentation improving the survival outcome. There was a significant difference between both groups regarding the extent of gangrene (P = 0.028) with extensive gangrene at the time of presentation lowering the survival outcome. Conclusion Patients with early presentation and good control of underlying diseases had better survival outcomes. Extensive surgical debridement offered better results, but the improvement was not to the level of statistical significance. However, patients with extensive gangrene and intracranial involvement generally had worse survival outcomes; therefore, these conditions were considered negative prognostic factors.
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Assessment of the role of Cerebrolysin in treatment of idiopathic facial nerve paralysis p. 712
Tamer M Attia
DOI:10.4103/mmj.mmj_849_17  
Objective The aim was to evaluate the role of Cerebrolysin in the treatment of Bell's palsy as a form of peripheral nerve disorder. Background Bell's palsy is a common facial nerve disorder with no available studies assessing the role of Cerebrolysin in its treatment. Patients and methods This is a single-blinded randomized clinical trial conducted on 52 patients with Bell's palsy who were distributed between two groups to receive the classical treatment for Bell's palsy. Group I received a placebo in the form of normal saline, whereas group II received Cerebrolysin. Both groups were compared regarding the overall rates of recovery and the time intervals between the onset of the disease and the onset of first clinical improvement at one hand and the onset of maximally achieved recovery at the other hand. Moreover, the rate of recovery was correlated with initial electroneurographic value. Results Cerebrolysin had no effect on the overall rate of recovery compared with placebo (P = 0.27). However, it shortened the time intervals between the onset of the disease and the onset of first clinical improvement at one hand and the onset of maximally achieved recovery at the other hand, with a highly statistically significant difference when compared with placebo (P < 0.001 for both). Its effect was more prominent in more severe degrees of nerve degeneration, with no statistical significance (P = 0.07). Conclusions Cerebrolysin has a therapeutic effect as an adjunctive treatment in the management of idiopathic facial paralysis with a significant effect on the speed of recovery rather than the overall rate of recovery.
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Deantigenicity of skin homografts in management of major burn cases p. 717
Mohamed Ahmed Megahed, Sherief M ElKashty, Ahmed TT Nassar, Ezzat AM Allam
DOI:10.4103/mmj.mmj_851_17  
Objective The aim was to assess the ability of deantigenicity of skin homograft to decrease its rejection and improve its survival in management of patients with major burns. Background Skin homograft is considered as a good skin substitute in major burn cases. The major problem of the skin homograft is rejection. So, many methods are used to decrease antigenicity of the skin homograft and prolong its survival. Patients and methods This clinical trial included 32 patients with burn who were managed in Plastic Surgery Department, Menoufia University Hospital, from October 2015 to October 2017. Four groups were formed: control group had nine patients without deantigenicity of the homograft; group A had seven patients with freezing of the skin homograft at 4°C; group B had eight patients with skin homograft applied for irradiation; and group C had eight patients, with the recipient patient receiving dexamethasone injection. After escharotomy and coverage with skin homograft, follow-up was done for rejection of the homograft clinically. Results In the control group, the mean percentage of rejection of homograft was 62.22 ± 12.01%. In group A, the mean percentage of rejection was 61.4 ± 10.6%, with P value of 0.9. In group B, the mean percentage of rejection was 21.8 ± 10.69%, with P value of less than 0.001. In group C, the mean percentage of rejection was 48.7 ± 15.07%, with P value of 0.036. Conclusion Local irradiation dose to the skin homograft can minimize its rejection. Systemic corticosteroids produce less effect regarding the rejection of skin homograft when used with the usual dose, but with increasing dose, the rejection decreased. Freezing of the skin homograft in 4°C has no significant effect on the rejection of the skin homograft.
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The role of autologous platelet-rich plasma in healing of gaping and chronic wounds p. 723
Mohamed A Megahed, Tarek M Rageh, Ahmed T Nassar, Mohamed El-Sayed Abdel Razek
DOI:10.4103/mmj.mmj_57_18  
Objective The aim was to evaluate the efficacy of platelet-rich plasma (PRP) in the treatment of gaping and chronic wounds. Background Nonhealing ulcers are a major health problem with high cost in terms of human and material resources. Application of autologous PRP has been a major breakthrough for the treatment of nonhealing ulcers, as it is an easy and cost-effective method and provides the necessary growth factors that enhance wound healing. Patients and methods A study was performed on 28 patients with nonhealing ulcers of various etiologies. Overall, 19 patients were treated with PRP at weekly intervals for a maximum of seven treatments and nine patients were treated with saline gauze dressings on alternative days. At the end of the 7, 14, 21, and 28-day periods, reduction in size of the ulcers (area and volume) was assessed and followed up till the healing completed, and the patients were followed up for a period of 12 weeks after treatment. Results The mean age ± SD of the patients was 39.68 ± 12.11 years. Of 19 ulcers in study group, there were two venous ulcers, nine traumatic ulcers, five pressure ulcers, and three diabetic ulcers. The mean ± SD duration of healing of the ulcers was 49.84 ± 22.23 days in study group and 108.67 ± 5.64 days in control group (P < 0.001). Conclusion Conventional therapies do not provide satisfactory healing for chronic nonhealing ulcers as they are not able to provide the necessary growth factors essential for the healing process. PRP is a safe, affordable, biocompatible, and simple office-based procedure for the treatment of nonhealing ulcers.
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A comparative study between tubularized incised plate urethroplasty with and without fibrin glue p. 729
Tarek F Kishk, Alaa Abd El-Azeem El-Sisy, Shreif M El-Kashty, Ahmed AM Fawzy
DOI:10.4103/mmj.mmj_118_18  
Objective To compare the results of two single-stage hypospadias repairs, namely, tubularized incised plate (TIP) repair with and without fibrin glue as regards fistula formation, penile edema, wound infection, and cosmetic outcome. Background One of the most important factors in reducing the incidence of fistula and other complications is incorporation of an intermediate layer between the neourethra and the skin layer. It may be dartos fascia, tunica vaginalis, and others. The key step is using fibrin sealants as a protective covering layer. Patients and methods Between December 2014 and December 2016, we enrolled 32 male patients into our study at Menoufia University Hospital. The patients will be divided into two groups. The first group included about 18 patients where fibrin glue was applied after construction of a neourethra before closure of the skin. The second group consisted of about 14 patients who were treated by a construction of a neourethra but without the use of fibrin glue. Results The results of group I which underwent TIP urethroplasty with fibrin glue showed an 11% incidence of fistulation. Group II which underwent TIP urethroplasty without fibrin glue showed a 43% incidence of fistulation. Conclusion Applying a clot of fibrin glue between the layers of hypospadias repair will decrease the incidence of the complications after the repair. The fibrin glue results are poorer because of the increase in the rate of infection which will be the cause of fistula and wound dehiscence.
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Role of vitamin E supplementation in neonates with hyperbiirubinemia p. 734
Ghada M El Mashad, Hanan M El Sayed, Nashwa A Abd El Samie El Refaey
DOI:10.4103/mmj.mmj_27_19  
Objective The objective of this study was to evaluate the effect of vitamin E supplementation in the treatment of indirect hyperbilirubinemia in neonates receiving phototherapy. Background Hyperbilirubinemia is a common neonatal problem. Phototherapy is the primary treatment in neonates with indirect hyperbilirubinemia. Patients and methods This randomized controlled clinical trial was conducted on 150 full-term neonates with indirect hyperbilirubinemia, received phototherapy in the neonatal ICU of Menoufia University Hospital. They were randomly divided into three groups: (a) case group (n = 50) who received 25 mg/kg/day oral vitamin E with phototherapy, (b) case group (n = 50) who received 50 mg/kg/day oral vitamin E with phototherapy, and (c) control group (n = 50) who received only phototherapy. Total serum bilirubin (TSB) levels were measured every day until cessation of phototherapy. Results There was a highly significant difference in the duration of hospital stay of the studied groups. There was no significant difference in TSB on admission, but there was a highly significant difference in TSB at discharge of the studied groups. There was a highly significant difference in bilirubin decline of the studied groups, groups II and I and groups I and III, but no significant difference between groups II and III. There was no correlation between age and body weight in bilirubin decline in all groups. There was no significant difference in bilirubin decline with regard to sex in all groups. Conclusion The addition of oral vitamin E 25 mg/kg/day to phototherapy in the treatment of indirect hyperbilirubinemia is better than oral vitamin E 50 mg/kg/day or phototherapy alone.
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Mean platelet volume as a diagnostic marker in children with acute hepatitis A p. 740
Soheir S Abou El-Ella, Maha A Tawfik, Amany F Ismael
DOI:10.4103/mmj.mmj_312_18  
Objective The aim of this study was to assess the level of mean platelet volume (MPV) in children with acute hepatitis A as compared with the control group. Background MPV is a marker that indicates platelet size, function, and the rate of platelet production and activation. Patients and methods Our study was conducted on 100 Egyptian children, aged from 2 to 14 years (58 male and 42 female) previously diagnosed as having hepatitis A as a patient group and 100 apparently healthy age-matched and sex-matched children as a control group. All of them were subjected to full history, physical examination, C-reactive protein, erythrocyte sedimentation rate, complete blood count, MPV levels, liver function tests (alanine aminotransferase and aspartate aminotransferase), serum bilirubin level (total and direct), prothrombin time, and platelet count. The diagnosis of hepatitis A virus infection was based on antihepatitis A virus immunoglobulin M positivity. Results MPV in the study group was significantly lower than the control group (P < 0.001). The MPV levels revealed no correlation with the alanine aminotransferase and aspartate aminotransferase (P > 0.05), but the MPV level was directly proportionate to the platelet counts (P < 0.05). Our study showed that there was 9% of cases with complications, mainly dehydration. Conclusion This study demonstrated that MPV is a negative acute-phase reactant for children with acute hepatitis A.
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CASE REPORT Top

Early onset necrotizing enterocolitis in a full-term neonate p. 745
Aditya P Singh, Arun K Gupta, Rajlaxmi Pardeshi, Vinay Mathur
DOI:10.4103/mmj.mmj_695_17  
Objective We are presenting a case of necrotizing enterocolitis (NEC) in a full term neonate. Backround NEC usually affect the preterm baby while in our case baby was full term neonate. Method A 2 days old male neonate who had diagnosis of NEC, was managed by us. Result Baby had the involvement of large bowel with sever faecal peritonitis and baby was expired due to septicemia. Conclusion NEC may occurs in full term baby with large bowel involvement. Resection of the gangrenous colon and rectoascending anastomosis with protective ileostomy was done. Baby was expired after 3 days due to septicemiasepticemia.
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LETTER TO THE EDITOR Top

Screening of Helicobacter pylori in patients with alopecia areata p. 748
Mahmood D Al-Mendalawi
DOI:10.4103/mmj.mmj_826_17  
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ERRATUM Top

Erratum: Circulating cell-free DNA as a sensitive biomarker in patients with acute myocardial infarction p. 749

DOI:10.4103/1110-2098.260945  
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