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October-December 2018
Volume 31 | Issue 4
Page Nos. 1105-1484

Online since Thursday, February 14, 2019

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REVIEW ARTICLES  

Changes in choroidal thickness in diabetic retinopathy Highly accessed article p. 1105
Khaled El-Ghonemy, Ghada Z Al Abeden Rajab, Asmaa M Ibrahim, Ibrahim M Ibrahim Gohar
DOI:10.4103/mmj.mmj_224_17  
Objective The aim of this study was to evaluate choroidal thickness (CT) in patients with diabetic retinopathy (DR) and normal individuals. Data sources Data were collected from Medline databases (PubMed, Medscape, Science Direct, and EMF-Portal) and all materials available in the Internet from 2004 to 2015. Study selection The initial search presented 27 articles, of which five met the inclusion criteria. The articles studied the changes in the mean subfoveal choroidal thickness (SFCT) in different stages of DR. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Data synthesis Comparisons were made using structured review with the results tabulated. Findings In total, five potentially relevant publications were included; three studies detected a significant decrease in SFCT with progression of DR. Some authors found a correlation between the presence of diabetic macular edema (DME) and changes in choroidal thickness. Three studies detected a significant decrease in SFCT in DME. Conclusion CT is altered in diabetes and may be related to the severity of retinopathy. The presence of DME is associated with a significant decrease in the CT.
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Biomarkers in sepsis Highly accessed article p. 1110
Hatem A Atalla, Ahmed A Abdelaziz, Mohammed A. M. Ragab
DOI:10.4103/mmj.mmj_145_18  
Objectives To perform a systematic review of the different categories of sepsis biomarkers including the new promising biomarkers and their role in diagnosis and prognosis of sepsis. Data sources Data were obtained from Medline databases (PubMed, Medscape, and Science Direct) and from materials available on the network from 2003 to April 2017. Study selection The initial search presented 30 articles. The research studies that met the inclusion criteria were 10 articles. All articles studied the role of biomarkers in diagnosis and prognosis of sepsis. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls mentioned, adequate information provided, and assessment measures defined. Data synthesis Comparisons were made by structured review with the results tabulated. Results The use of combined biomarkers can be more efficient than using a single biomarker in diagnosis and prognosis of sepsis. Conclusion Biomarkers play a vital role for early diagnosis of sepsis, to predict outcome, and to guide choice of antibiotic therapy. In these modern times, clinicians encounter the laboratory results on a daily basis. Therefore, proper interpretation and wise use of biomarkers are necessary. Combination approaches of biomarkers with new techniques have shown promising results and need to be further evaluated.
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Noninvasive ventilation as a method of weaning from mechanical ventilation p. 1116
Amany S Ammar, Elham M El-Feky, Mohammed A Rahman
DOI:10.4103/mmj.mmj_334_17  
Objective The aim of this study was to evaluate the adequacy of noninvasive ventilation (NIV) as a technique of weaning from mechanical ventilation. Materials and methods Medline databases (PubMed, Medscape, and ScienceDirect), all materials accessible on the Internet from the beginning date of every database to 2016. The initial investigation exhibited 43 articles, of which, nine met the incorporation criteria. The articles concentrated on the viability of NIV as a technique of liberation from mechanical ventilation. In light of heterogeneity in the gathered information, it had been impractical to perform meta-investigation. Noteworthy information had been gathered; accordingly an organized audit had been performed. Results NIV observed to be successful in encouraging weaning in cases fit to be freed from mechanical ventilation, but failed an unrestrained breathing trial. Likewise, when utilized as a measure to avoid respiratory failure after removal of the endotracheal tube in high-hazard cases, it had benefits as far as mortality and reintubation rates that had not accomplished if NIV had been utilized as a treatment for postextubation respiratory failure. Conclusion We talk about the adequacy of NIV as a liberation strategy from mechanical ventilation, its utilization to encourage weaning, prohibit, or treat postextubation respiratory failure.
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Update management of thromboembolism Highly accessed article p. 1121
Ashraf M Mostafa, Enas A. E. Shahin, Mostafa F El-Said
DOI:10.4103/mmj.mmj_89_18  
Objective The aim of this review was to perform a systematic review to highlight thromboembolic diseases and current strategies to manage and prevent it. Data sources Data were obtained from Medline databases (PubMed, Medscape, and Science Direct) and all materials available on the internet from the start data of each database to 2017. Study selection The selected articles are systematic reviews and experimental studies that address the management of thromboembolic diseases. Data extraction Extraction was performed according to the validity, quality, and originality of the selected reviews and studies that fulfilled the previous criteria; in addition, the focus was on studies that present the latest or the most updated findings on application of management of thromboembolism. Data synthesis Each review and study was examined. The layout was selected to present wide range of data including the most recent findings on this participants. Significant data were collected, thus a structured review was performed. Conclusion We found that thromboprophylaxis is recommended. Low-molecular-weight heparin could be more effective than unfractionated heparin for thromboprophylaxis. Vitamin K antagonists need regular monitoring to avoid both thrombotic and bleeding complications, whereas NOACs do not require laboratory monitoring. Results In total 12 potentially relevant publications were included: six discussed management of thromboembolism and six discussed new oral anticoagulants (NOACs). NOACs can be viewed as an alternative to standard treatment.
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Surgical site infection in abdominal surgery: A prospective study p. 1126
Mohammed L Alam El-Din, Mohamed S Amar, Ahmed I Swelam
DOI:10.4103/mmj.mmj_292_17  
Objective The objective of this review was to characterize risk factors for surgical site infection (SSI) within observational studies describing incidence of SSI in a real-world setting. Data sources Medline databases (PubMed, Medscape, ScienceDirect and EMF-Portal) and all materials available on the Internet from 1991 to 2016 were used. Study selection An initial search identified 328 titles published in 2000–2016; 57 were identified as relevant for data extraction. The articles studied the incidence and risk factors of SSI in general or in specific types of surgeries on variable number of patients. Data extraction If the studies did not fulfill inclusion criteria, they were excluded. Study quality assessment included whether ethics approval was gained, eligibility criteria were specified, appropriate controls were used, and adequate information and defined assessment measures were described. Data synthesis Comparisons were made by structured review with the results tabulated. Findings The median SSI incidence was 3.7%, ranging from 0.1 to 50.4%. Incidence of overall SSI and Staphylococcus aureus SSI were both highest in tumor-related and transplant surgeries. The median time until SSI onset was 17.0 days. Risk factors consistently identified as associated with SSI included comorbidities, advanced age, risk indexes, patient comorbidity, and surgery complexity. Thirteen studies considered diabetes as a risk factor in multivariable analyses; 85% found a significant association with SSI. Longer surgeries were associated with increased SSI risk, with a median odds ratio of 2.3 across 11 studies reporting significant results. Conclusion In a broad review of the published literature, the median SSI incidence was 3.7%. Risk factors for SSI were characterized as describing reduced fitness, patient comorbidity, surgery duration, and complexity. Recognition of risk factors frequently associated with SSI allows for optimal preventive measures before surgery.
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ORIGINAL ARTICLES Top

Predictive factors for conservative treatment of liver trauma p. 1133
Hatem A Saleh, Hesham S Abu-Gruida, Walid R. A. Youssef
DOI:10.4103/mmj.mmj_625_16  
Objectives The aim of this study was to evaluate the management of patients with liver injury and the possible predictive factors for conservative treatment. Background Injuries are a major public health problem. The liver is the most commonly injured intra-abdominal organ. Conservative treatment thereby not only decreases the number of nontherapeutic laparotomies, but also achieves a reduction in morbidity and mortality. Patients and methods The present study was conducted on all patients with traumatic liver injury (20 patients) admitted to Menoufia University Hospital and El-Senbellawein General Hospital in the period between April 2015 and April 2016. Liver trauma was classified according to the Hepatic Injury Scale of the American Association for the Surgery of Trauma. To analyze the results, patients were divided into two groups – group A included patients with blunt trauma and group B included patients with penetrating trauma. According to the management plan, patients were further divided into group I (conservative treatment) and group II (operative treatment). Results Patients who were successfully managed conservatively had significantly higher mean systolic blood pressure (P = 0.004), lower mean pulse rate on admission (P = 0.003), and significantly lower American Association for the Surgery of Trauma grade of liver injury than patients who underwent operative management (P = 0.001). There was a significant difference in the number of blood unit transfusions between the types of management plan groups (P = 0.006). Conclusion Conservative management of traumatic liver injuries is safe when the decision is based on careful initial evaluation. During management, we identified possible predictive factors that may influence the management plan and outcome of patients with liver injury: pulse rate, systolic blood pressure at arrival to the hospital, the amount of blood transfused, and the grade of injury.
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Predictive value of angiographic characteristics for endovascular revascularization of ischemic diabetic foot p. 1138
Said I El-Mallah, Abdelmonem F Abdallah, Ahmed S Atta
DOI:10.4103/mmj.mmj_100_17  
Background Endovascular techniques have undergone major advances with regard to the treatment of infrapopliteal arterial occlusive disease. Objective The objective of this study was to determine angiographic characteristics of infrapopliteal arterial lesions that are dependent predictors of endoluminal revascularization in diabetic patients with ischemic foot ulcers. Patients and methods The present study included 64 patients with ischemic diabetic foot ulcers who were admitted to the vascular surgery unit at Gamal Abdel Naser Hospital (Alexandria) during October 2014–December 2015. Informed consent was obtained from all patients. Patients underwent angioplasty and were followed-up for an average of 12 months. The clinical and procedural data of all included patients were collected. Preprocedural and postprocedural angiographic images were reviewed to classify lower-limb arterial involvement according to the Joint Vascular Society Council classification of calf and foot scores. Foot lesions were graded according to The University of Texas wound classification system. Clinical results (healing, nonhealing, or major amputation) were compared with baseline clinical data and angiographic results using Student's t test. All statistical analyses were performed using SAS software. Results During the study period, 64 percutaneous procedures were performed, with an immediate technical success rate of 89.8%. Before the procedure, the mean ± SD calf and foot scores were 7.8 ± 1.6 and 7.3 ± 2.3, respectively. After the procedure, the mean calf and foot scores were 4.8 ± 2.3 and 5.9 ± 2.6, respectively. The limb salvage rate was 87%, and the major amputation rate was 9.4%. Among all the clinical and angiographic variables included in the analysis, only preprocedural and postprocedural foot scores were significantly associated with the clinical outcome (P < 0.05). Conclusion Preprocedural and postprocedural foot scores represent the most significant angiographic parameters to evaluate chances for ulcer healing, and consequently to determine the success of the revascularization procedure.
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Operative versus conservative management of splenic trauma in pediatric patients p. 1145
Shawky S Mohamed Gad, Tamer Ali Sultan, Medhat A Dewedar
DOI:10.4103/mmj.mmj_161_17  
Objective The aim of this study was to compare between operative and conservative management of splenic trauma in pediatric patients. Background In the past the management of blunt splenic injuries was carried out using splenectomy. However, the high rate of operative complications caused a paradigm shift from operative to nonoperative management in hemodynamically stable blunt abdominal trauma patients. Patients and methods This prospective study included a total of 40 patients. The patients were managed conservatively or operatively. Nonoperative management criteria included hemodynamic stability and absence of other injuries requiring laparotomy. Unstable patients were operated using splenectomy. Results Road traffic accident was the most common mechanism of trauma in this study (55%) in the patients who were managed conservatively and (60%) in the patients who were managed operatively (χ2 = 1.507; P = 1.000). Computed tomography was performed for stable patients only; grade I and grade II splenic injury comprised 70% of cases. The incidence of complications was 5% in the patients who were managed conservatively and 10% in the patients who were managed operatively (χ2 = 0.360; P = 1.000). The incidence of blood transfusion was less in the patients who were managed conservatively (25%) than in the patients who were managed operatively (100%) (χ2 = 24.000; P < 0.001). There was no mortality in the patients who were managed conservatively, whereas in the patients who were managed operatively the incidence of mortality was 5% (χ2 = 1.026; P = 1.000). All these tests were used as tests of significance at P less than 0.05. Conclusion The nonoperative management is considered the ideal management for blunt splenic injuries in pediatric patients because of fewer complications, lower blood transfusion rate, shorter hospital stay, and less mortality compared with operative management.
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The role of fibrinolytics in prevention of adhesive intestinal obstruction p. 1151
Alaa A Elsesi, Asem F Moustafa, Mohammed M Ahmed
DOI:10.4103/mmj.mmj_248_17  
Objective The objective of this study was to evaluate the efficacy and safety of fibrinolytic drugs in the prevention of adhesive intestinal obstruction in high-risk patients. Background Postoperative peritoneal adhesions represent an important clinical challenge in gastrointestinal surgery. Fibrin plays an important role in postoperative adhesion formation. Resolution of the intraperitoneal fibrin deposits is essential for proper restoration of preoperative, noninflamed conditions. Patients and methods This randomized controlled trial study included 60 patients randomized into two groups (A and B). Each group included 30 patients presented with bacterial peritonitis of different causes. All patients were treated surgically. Patients in group A were managed intraoperatively by peritoneal toilet with abundant warm isotonic saline until obtaining a clear fluid after excision or repair of the cause of peritonitis with subsequent intraperitoneal instillation of one vial of streptolase (1 500 000 IU of streptokinase) diluted in 500 ml; of isotonic saline, but patients in group B were managed by good peritoneal toilet with abundant warm isotonic saline only. Patients in both groups were followed up for a period of 2 years for the incidence of postoperative adhesive intestinal obstruction and for any complication related to intraperitoneal instillation of streptokinase in group A. Results The incidence of postoperative adhesive intestinal obstruction was one patient from the 30 (3.3%) patients of group A versus six (20%) patients from the 30 patients of group B, with a statistically significant difference between both groups in the incidence of postoperative adhesive intestinal obstruction (P = 0.041) with no documented complications related to intraperitoneal instillation of streptokinase. Conclusion Local intraperitoneal instillation of streptokinase can be used safely in decreasing the incidence of adhesive intestinal obstruction in high-risk patients.
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Mesh repair in complicated inguinal hernia p. 1159
Ashraf A Zeineldin, Ahmed G El Tatawy, Amr N Frig
DOI:10.4103/mmj.mmj_322_17  
Objective The aim of this study was to evaluate the role of mesh repair short-term outcome in adult incarcerated inguinal hernia from the point of view of availability, advantages and disadvantages. Background Hernia is the most frequent abdominal surgery. The standard treatment of inguinal hernia is hernioplasty with mesh repair; we aimed to evaluate the short-term complications after mesh repair in incarcerated inguinal hernia in emergency. Patients and methods This study was carried out on 20 consecutive adult men in Menoufia University Faculty of Medicine and Dessouq General Hospital; all of them presented with symptoms of irreducible inguinal hernia from April 2015 to September 2016. This study included 20 patients because of the limited number of patients presented to our hospital in this period of time and those who fulfill the inclusion criteria, to assess postoperative short-term complications. Results A total of 20 cases did mesh repair in incarcerated inguinal hernia in the same admission in hospital, operative time and the difficulty was average; all of them (100%) had no recurrence in the postoperative follow-up. Conclusion Mesh repair in adult incarcerated inguinal hernia is safe and should be done during the same hospital admission to prevent further attacks of recurrence.
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Factors affecting success rate of endoscopic retrograde cholangiopancreatography in malignant obstructive jaundice p. 1165
Hatem M Sultan, Tarek M Rageh, Hamed A Khodeer
DOI:10.4103/mmj.mmj_331_17  
Objective The aim of the study was to assess the success of endoscopic retrograde cholangiopancreatography (ERCP) for malignant obstructive jaundice using laboratory and radiological investigation. Background ERCP is a diagnostic and palliative treatment, which is used as the standard of investigation for patients with malignant obstructive jaundice; however, it failed in some patients. The prediction for success will be useful in the decision of management plan for patients with malignant obstructive jaundice and time and costs for patients and even countries. Patients and methods Collected laboratory investigation and radiological data for 20 patients presenting with malignant obstructive jaundice are included in this study, and malignant appearance of the tumor is confirmed using radiological finding or elevated tumor marker level. All patients presenting with benign stricture and duct stone are excluded from this study. Results ERCP was performed on 20 patients with malignant obstructive jaundice; the procedure was completed in 75% of patient and failed in 25% of them. P (0.0436) was significant for irresectable large-sized tumors or metastatic carcinoma. Common factors were found with failure such as advancement of the disease and comorbidities in those patients. Conclusion ERCP in patients with malignant obstructive jaundice is feasible and easy to perform in early stage. In advanced cases, other plans for biliary drainage such as surgical bypass and percutaneous transhepatic biliary drainage may be useful.
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One-stage versus multiple-stage surgery in the management of left colorectal emergencies p. 1169
Ashraf A. E. Z. El-Din, Hossam A. E. El Fol, Tamer A Sultan, Waleed M Allam
DOI:10.4103/mmj.mmj_449_17  
Objective The aim of this study was to compare between the surgical outcomes of one-stage and multiple-stage surgery in patients with left colorectal emergencies. Background Classically a primary colonic anastomosis is not performed in the emergency conditions, but recently there is a trend toward primary anastomosis aiming to avoid second hospital admission and second operation required to re-establish intestinal continuity. Patients and methods This is a prospective randomized study that included 40 patients. A total of 20 patients agreed to undergo one-stage primary anastomosis subtotal colectomy (group A). The other 20 patients underwent Hartmann's procedure (group B). Exclusion criteria were inoperable colorectal cancer and profound septic shock. Results Males predominated females in both groups. The most common causes in both groups were colorectal cancer, in 16 cases. There was one case of leak in group A, whereas two cases of leak after the Hartman's reversal in group B. Operative time was significantly lower in group A compared with group B (154.25 ± 13.28 vs. 246.50 ± 45.77 min; P < 0.001). Hospital stay was significantly lower in group A compared with group B patients (10.0 ± 1.69 vs. 18.85 ± 5.55 days; P < 0.001). There is no mortality in group A, whereas in group B, there was one case. Conclusion One-stage surgical procedure subtotal colectomy for left colonic emergencies avoids the inconvenience of a staged operation Hartmann's procedure, without increasing morbidity and mortality and providing overall shorter operative time and duration of hospital stay.
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Conventional method versus no-touch technique in radiocephalic arteriovenous fistula p. 1175
Said I ElMallah, Hesham S Abu-Gruidah, Walid M Omran, Abdalaziz R Sakr
DOI:10.4103/mmj.mmj_187_18  
Objectives The aim was to evaluate the feasibility of no-touch technique (NTT) in radiocephalic fistula and to compare conventional method with NTT in the creation of radiocephalic fistula regarding the rate of complication, failure of maturity, and patency rate. Background Radiocephalic fistula is consider the first fistula to be created; however, it has a higher failure rate. NTT represents an attractive option for performing radiocephalic fistula. Patients and methods This is a prospective comparative study done on 80 patients with end-stage renal disease who were prepared for dialysis. Half of the patients were operated by NTT and the other half by conventional technique at vascular surgery unit in department of general surgery, Menoufia University Hospital, between November 2016 and April 2018. Results A total of 80 patients who had end-stage renal disease underwent radiocephalic arteriovenous fistula: half of them with conventional (Brescia and Cimino) technique and the other half with no-touch method. The primary failure rate in NTT (7.5%) was not statistically significantly different from the conventional method (17.5%). The primary patency also had no statistically significant difference during the follow-up period at 1 and 3 months between the two methods, but NTT at 6 months had better primary and secondary patency rates than conventional method. There was no difference in infection and pseudoaneurysm rates between the two methods. Conclusions The results of this study indicate that NTT can be used for primary radiocephalic fistula surgery and showed better results than conventional method in the long-term follow-up.
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Laparoscopic sleeve gastrectomy versus laparoscopic mini-gastric bypass in management of morbid obesity and its comorbidities Highly accessed article p. 1181
Elsayed A Mostafa, Elsayed M Abdel Wahab, Yehia G Abo Sayed, Mohamed H Gafar
DOI:10.4103/mmj.mmj_236_18  
Background Laparoscopic mini-gastric bypass (MGBP) is gaining popularity among the bariatric procedures today, and laparoscopic sleeve gastrectomy (SG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Patients and methods Between October 2016 and July 2018, 50 obese patients were randomized, operated upon, and followed up for 12 months in Al Zahraa Hospital and Shebin El-Kom teaching Hospital. A total of 25 patients underwent SG, and 25 patients underwent MGBP. The mean BMI of all patients was 47.8 ± 5.5 kg/m2, their mean age was 30 ± 8.3 years, and 80% of them were female. Patients were followed up at 1, 3, 6, 9, and 12 months. Operative time, length of hospital stays, weight loss, comorbidity improvement or resolution, postoperative complications, reinterventions, and mortality were evaluated. Results Age, sex, BMI, and comorbidities were equal. The mean operative time for SG was 86.9 ± 51.6 min and that for MGBP was 108.4 ± 41.8 min; the percentage of 1-year excess weight loss was similar (76.2 ± 4.49% for SG and 80.3 ± 8.3% for MGBP). The comorbidities were significantly improved after both procedures, except for type 2 diabetes mellitus, which showed a higher resolution rate after MGBP. Conclusion Laparoscopic SG regarding excess weight loss is comparable to laparoscopic MGBP in short-term follow-up (1 year) with less metabolic effect. Further long-term studies are needed.
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Anesthetic considerations during intraoperative neurophysiological monitoring in spine surgery p. 1187
Safaa M Helal, Ahmed A Abd Elaziz, Adel G. E. Dawoud
DOI:10.4103/mmj.mmj_123_17  
Objective We conducted an overview of the intraoperative neurophysiological monitoring (IONM) modalities in spine surgeries and effects of anesthesia and physiological factors on these modalities. Background The development of IONM minimizes iatrogenic neurological complications. All anesthetic agents impact on the modalities of IONM. Materials and methods Medline, articles in Medscape, ScienceDirect, and PubMed were searched. The search was performed in January 2016 and included all articles with no language restriction. The initial search presented 50 articles. The articles studied the types of IONM modalities and effects of anesthesia on these modalities. Data from each study were independently abstracted to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest. Significant data were collected and thus a structured review was performed. Results A close working relationship of the monitoring team, the anesthesiologist, and the surgeon is a key to the successful conduct and interpretation of IONM, prevention of complications of spinal surgeries, and early detection of these complications. On the basis of the monitoring modalities involved, the basic anesthetic constraints can be identified. Conclusion Using IONM such as somatosensory and motor-evoked potentials has become common to minimize neural risk and to improve intraoperative decision making for any spine surgery. IONM is affected by the choice of the different anesthetic agents and skeletal muscle relaxants, because anesthetic agents have effects on neural synaptic and skeletal muscle relaxants have effects on neuromuscular junctions.
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Effect of methylprednisolone on inflammatory markers and patients' outcomes in acute respiratory distress syndrome p. 1193
Ahmad A Metwally, Waleed M Fathy, Elham M El-Feky, Mohammad E. S. Saleh
DOI:10.4103/mmj.mmj_152_17  
Objective The aim of this study wa s to evaluate the effect of methylprednisolone on inflammatory markers including C-reactive protein and interleukin-6 (IL-6) in acute respiratory distress syndrome (ARDS) at an early stage and on patients' outcomes. Background ARDS is started by an inflammatory injury to the lung that results in severe gas exchange impairment and lung compliance abnormalities. Increased levels of bronchoalveolar lavage and blood level of inflammatory biomarkers at ARDS onset are associated with worst prognosis that persists for no less than 7 days. Believing the way that inflammation is the main pathophysiology of ARDS, steroids would be an ideal treatment for the ARDS management. Patients and methods We conducted a randomized prospective observational study included 40 patients with ARDS in the ICU of Menoufia University Hospital who were divided equally into two groups: group I received standard treatment and group II received methylprednisolone beside standard treatment. C-reactive protein and IL-6 levels were measured in serum, and their changes were compared between both the groups. Results The groups were matched by demographic, sequential organ failure assessment, and lung injury score. Methylprednisolone and standard treatment group showed significant decrease in IL-6 level compared with only standard treatment group at day 7 (P < 0.05). Methylprednisolone improved significantly sequential organ failure assessment and lung injury score by seventh day and shortened the mechanical ventilation duration, but it did not improve significantly ICU stay duration and 60-day mortality. Conclusion In the early period of ARDS, administration of methylprednisolone improved significantly biomarkers of inflammation and clinical outcomes.
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Comparison between intrathecal bupivacaine, intrathecal bupivacaine plus dexmedetomidine, and caudal anesthesia with bupivacaine in pediatric patients p. 1200
Khaled Mousa Abo El-Enein, Neveen M Soliman, Zeinab A Kasemy, Marwa A Mahmoud
DOI:10.4103/mmj.mmj_278_17  
Objective The aim of this study was to compare between anesthesia with intrathecal bupivacaine only, intrathecal bupivacaine plus dexmedetomidine, and caudal bupivacaine in children between 1 and 5 years of age. Background Regional anesthesia is mainly used to provide analgesia after surgery. Dexmedetomidine has been used to increase the duration of postoperative analgesia. Our study aimed to compare between intrathecal bupivacaine only, intrathecal bupivacaine plus dexmedetomidine, and caudal bupivacaine in children between 1 and 5 years of age. Patients and methods Sixty-three patients were included in a clinical trial from April 2015 to September 2016 and were divided into three groups of 21 each: patients in group I were given intrathecal bupivacaine only at a dose of 0.4 mg/kg bupivacaine 0.5%; patients in group II were given intrathecal bupivacaine plus dexmedetomidine at a dose of 0.4 mg/kg bupivacaine 0.5% with 0.25 μg dexmedetomidine for every 1 mg bupivacaine; and patients in group III were given caudal bupivacaine 0.5% at a dose of 3 mg/kg. Our primary outcome measures were duration of analgesia (time from the block to first dose of analgesia or observed pain score ≥12) and frequency of analgesic consumption, whereas the secondary outcome measures were onset of block (time from performing block until recording sensory loss using the pin prick method and motor loss, which was recorded using the modified Bromage scale), level of block, effects on hemodynamics, and occurrence of complications. Results Group III had a significantly longer duration of analgesia compared with the other groups and it was longer in group II than in group I (P = 0.000). Frequency of analgesic need was significantly lower in group II compared with the other groups and in group III than in group I (I vs. II and I vs. III, P = 0.000; and II vs. III, P = 0.003). Conclusion Caudal anesthesia has a longer duration of analgesia compared with spinal anesthesia. Adding dexmedetomidine to intrathecal bupivacaine prolongs the duration of analgesia and decreases the total analgesic consumption.
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Intravenous infusion of ketamine versus fentanyl for postoperative analgesia in spine surgeries p. 1206
Hatem A Attalla, Rabab M Habeeb, Asmaa I Elzwedy
DOI:10.4103/mmj.mmj_308_17  
Objective The aim of this study was to compare the intraoperative hemodynamics and postoperative recovery profile and analgesia while using ketamine versus fentanyl infusion in patients undergoing spine surgery. Background Acute pain management is an important aspect of perioperative anesthetic care. Inadequate postoperative analgesia contributes to adverse outcomes including immunosuppression, hyperglycemia, poor rehabilitation, and progression to chronic pain. Patients and methods This prospective trial included 60 adult patients with American Society of Anesthesia status I or II (undergoing elective spine surgery under general anesthesia in neurosurgery operation room of Menoufia University Hospital. They were divided into two groups of 30 patients each. In group A, analgesia is maintained intraoperative and postoperatively till 24 h with ketamine infusion (0.02–0.2 mg/kg/h). In group B, analgesia is maintained intraoperatively with fentanyl infusion (1–2 mcg/kg/h) and continued 24 h after operation. We assessed heart rate, mean arterial pressure, and duration of operation. Recovery score (Modified Aldrete Scoring System), visual analogue scale, total analgesic consumption, sedation score (Ramsey score), and occurrence of any complication in the form of nausea and vomiting, hallucination, skin rashes, or any other complications were recorded. Results There is a highly significant statistical difference between ketamine group and fentanyl group regarding hemodynamics, sedation score, visual analogue scale, first call of analgesia, and occurrence of complications. P > 0.05 was considered not statistically significant. P ≤ 0.05 was considered statistically significant. P ≤ 0.001 was considered statistically highly significant. Conclusion Low-dose ketamine infusion is more effective in postoperative pain management after spine surgery when compared with fentanyl as it maintains intraoperative hemodynamic stability and provides good postoperative analgesia. It decreases incidence of complications associated with the use of opioid infusion.
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Comparison between fiberoptic bronchoscopy under general anesthesia using laryngeal mask and local anesthesia with conscious sedation p. 1213
Essam Abd El-Hameed, Noran Yahia Azab, Hala Koptan, Hend M Nassar
DOI:10.4103/mmj.mmj_362_17  
Objective The aim of the study was to compare fiberoptic bronchoscopy under general anesthesia (GA) using laryngeal mask versus local anesthesia (LA) with conscious sedation regarding hemodynamics, duration of the procedure, patient satisfaction, cough, desaturation events, and occurrence of complications, intraoperatively and, postoperatively. Background Symptomatic bronchoscopy has turned into a well-known technique for diagnosing different midsection diseases, and the point is that it should be perform without complications with the least occurrence of hemodynamic changes. Patients and methods Between mid-2015 and December 2016, this prospective randomized study incorporated 40 patients. Patients were randomized into two groups: group I included patients in whom symptomatic bronchoscope was performed under LA for aware sedation, and group II included patients in whom symptomatic bronchoscope was performed under GA with laryngeal mask. Results A total of 40 patients were included in the study and divided into two groups, with 20 patients in each group. Overall, 17 patients in group I had tachycardia and, hypertension during performance of the symptomatic bronchoscopy under LA, whereas four patients, in the group II had tachycardia and, hypertension. On the contrary, 10 patients in group II had postoperative difficulties such as claiming of laryngospasm and, oversedation, whereas only five patients in group I had postoperative difficulties of laryngospasm and, oversedation. Conclusion Symptomatic bronchoscope under GA with laryngeal mask is associated with greater amount hemodynamic stability and, more tolerant fulfillment over symptomatic bronchoscope under LA for aware sedation. Primary goal The aim is to analyze which method of sedation leads to more hemodynamic stability and carries less complications among patients undergoing diagnostic bronchoscope. Secondary goal The secondary aim is to increase satisfaction of patients undergoing bronchoscopy and analyze, their acceptance level for repeating the procedure in the future.
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Pentraxin3 as an early marker in the diagnosis of ventilator-associated pneumonia p. 1218
Amany S Ammar, Ibrahim I El-Mahalawy, Waleed M Fathy, Asmaa E Salama, Walaa S Mokhtar
DOI:10.4103/mmj.mmj_459_17  
Objective The aim of this study was to assess the role of pentraxin3 (PTX3) in the early diagnosis of ventilator-associated pneumonia (VAP). Background The early diagnosis of VAP remains a challenge because the clinical signs and symptoms lack sensitivity and specificity and because microbiological analysis and identification of organisms may take 48–72 h. Patients and methods This prospective randomized study was carried out on 40 patients diagnosed with VAP using clinical pulmonary infection score in Menoufia University Hospital's ICU. We measured the level of PTX3 in serum and bronchoalveolar lavage and the level of C-reactive protein within 24 h from intubation and mechanical ventilation and after the onset of VAP diagnosed using clinical pulmonary infection score more than 6. Results The study showed that VAP was diagnosed in 31 patients; 30 had bronchoalveolar lavage PTX3 level of at least 6 ng/ml with 96.7% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 90% negative predictive value (NPV) for pneumonia confirmed using area under the receiver operating characteristic curve (AUCROC) analysis [AUCROC= 0.966, SE = 0.006, 95% confidence interval (CI)=0.985–1, P < 0.0001]; 27 had serum PTX3 level of at least 6 ng/ml with 87% sensitivity, 88.8% specificity, 96.4% PPV, and 66.6% NPV for pneumonia confirmed using AUCROCanalysis (AUCROC= 0.842, SE = 0.104, 95% CI = 0.639–1, P = 0.002); and 24 had C-reactive protein level of at least 12 mg/l with 77.4% sensitivity, 33.3% specificity, 80% PPV, and 30% NPV for pneumonia confirmed using AUCROCanalysis (AUCROC= 0.590, SE = 0.1, 95% CI = 0.39–0.79, P = 0.418). Conclusion Alveolar PTX3 level of at least 6 ng/ml is discriminative for microbiologically confirmed VAP; serum PTX3 is also sensitive but to a lower extent than alveolar PTX3.
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Ventilator-waveforms analysis improves gas exchange and patient-ventilator synchrony during noninvasive ventilation p. 1225
Khaled M Mahmoud, Elham M El-Fekky, Abdelrhman A Aboshady
DOI:10.4103/mmj.mmj_478_17  
Objective The aim of this study was to assess the role of waveforms analysis in optimizing patient–ventilator interactions. Background Ventilator-waveforms analysis may help in optimizing patient–ventilator interactions, especially during noninvasive ventilation (NIV). However, published data on this tool are very limited. Patients and methods A randomized controlled trial was conducted in which 50 patients with acute exacerbation of chronic obstructive pulmonary disease who underwent NIV were randomly allocated to receive either optimized ventilation guided by waveform analysis or standard ventilation. Our primary outcome was pH normalization rate during first 24 h of treatment. Secondary outcomes included physiological response [tidal volume, respiratory rate, and partial pressure of arterial carbon dioxide (PaCO2)], ventilator settings changes (external positive end-expiratory pressure, pressure support, rise time, and inspiratory trigger), patient–ventilator interaction [tolerance and Asynchrony Index (AI)], and major endpoints (NIV success rate, on-ventilator days, length of stay, and mortality rate). Results 'Optimized ventilation' resulted in significantly higher pH normalization rate at 6 h (36% instead of 12%; P = 0.047). PaCO2was decreased significantly at 2 and 6 h (P = 0.032 and 0.008, respectively). This group was characterized by greater external positive end-expiratory pressure, greater inspiratory triggering sensitivity, and lower rise time. In addition, there was a significant improvement in AI after 2 h (P = 0.002), with no significant difference in patient tolerance. Conclusion The usage of waveform analysis during NIV for acute chronic obstructive pulmonary disease exacerbations showed a significantly positive effect in pH normalization rate, PaCO2reduction, and AI improvement.
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Predictive value of uric acid and carotid intima-media thickness in hypertensive postmenopausal women p. 1231
Nasser K Abd Elaal, Said A Saleh, Alaa M Abd Elgayed, Eman S. O. Badr
DOI:10.4103/mmj.mmj_528_15  
Objectives To study the correlation between serum uric acid (SUA) and carotid artery intima-media thickness (CAIMT) in healthy postmenopausal women as prognostic factors of late development of hypertensive disorders in this age group. Background Uric acid is recently identified as a crucial parameter in the pathogenesis of hypertension. Hyperuricemia affects CAIMT; more so, a combination of measuring SUA and CAIMT could be predictors of hypertensive disorders. Patients and methods The study was conducted on 100 healthy postmenopausal women. All participants were subjected to thorough history taking, complete medical examination, and laboratory and radiological investigations including SUA and CAIMT measurement. Results Our participant mean age was 54.24 ± 6.30 years with range 45.0–66.10 years. Menopausal years had a mean of 7.82 ± 5.94 and range 1.0–20.0. All participants had normal blood pressure at baseline, after 1 year 28 participants from the whole population developed hypertension. They had high significance (P < 0.001) in relation to uric acid, CAIMT, and BMI. Waist circumference only is of no significant value (P = 0.188). To show the validity of SUA and CAIMT regarding the development of hypertension, cutoff point was, respectively, 0.77 and 7.55 for both. Sensitivity for both was 82 and 100% and when combined it become 100%. Specificity was 78 and 72%, respectively, and 78% when combined. Accuracy was 79 and 80%, respectively, and 70% when combined. Conclusion SUA and CAIMT are good predictors for the development of hypertension in healthy postmenopausal women.
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The use of sildenafil citrate versus nifedipine in women with recurrent miscarriages: a pilot study p. 1238
Said A Saleh, Tarek M Sayed, Nabih I Elkhouly, May E Elaidy
DOI:10.4103/mmj.mmj_122_17  
Objective The aim of this study was to assess the effect of sildenafil citrate versus nifedipine in improving uterine and endometrial arterial blood flow in patients suffering from recurrent unexplained pregnancy loss. Background Recurrent pregnancy loss is unexplained in 50% of cases. Therefore, the use of sildenafil citrate and other new drugs such as nifedipine may prevent miscarriages. Patients and methods The present study included a control group of 20 normal fertile women with at least one live birth, and two groups of 20 patients each with recurrent unexplained miscarriages. Participants were subjected to full history taking, clinical examination, ultrasonography, and transvaginal color Doppler test. Blood flow assessments were performed two times, before and after intervention by the same operator, to measure maximum endometrial thickness and uterine arterial blood flow parameters including systolic/diastolic blood pressure ratio, pulsatility index, and resistance index. Results Sildenafil citrate improves endometrial thickness and uterine artery blood flow indexes significantly compared with nifedipine. Conclusion Sildenafil citrate improves endometrial thickness and uterine arterial blood flow parameters including systolic/diastolic ratio, pulsatility index, and resistance index significantly compared with nifedipine.
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The effect of the duration of the third stage of labor on the amount of maternal blood loss p. 1244
Medhat E Helmy, Tarek M Sayyed, Abdo A Abdo
DOI:10.4103/mmj.mmj_135_17  
Objective The aim of this study was to estimate the specific duration of the third stage of labor (TSL) above which the risk of increased maternal blood loss occurs. The primary outcome included the correlation between duration of the TSL and vaginal blood loss during the third stage and postpartum hemorrhage (PPH). Secondary outcomes included required blood transfusion, amount of ecbolics used during the third stage, analgesics used during labor, and neonatal outcome parameters. Background The practice of removing placentas that have not been spontaneously expelled within 30 min of delivery has been poorly evaluated; therefore, the purpose of this study was to estimate the most specific cutoff time of the TSL at which the palcenta should be removed to prevent further blood loss and in turn PPH. Materials and methods This cross-sectional study was carried out at the Department of Obstetrics and Gynecology at Dekernis General Hospital after obtaining approval from the Medical Ethics Committee for Human Research, from March 2014 to December 2015. The study included 600 women during their TSL. Informed consent was obtained from all participants. We calculated the duration of the TSL using a stopwatch from the time of delivery of the neonate until the delivery of the placenta. The amount of blood lost during the TSL was calculated using graduated collection containers and leather sheets designed for vaginal deliveries. Results The receiver operating characteristic curve of the duration of the TSL and the amount of third-stage blood loss detected a cutoff duration of 18 min, at which the risk of PPH increased with a sensitivity of 36.8% and a specificity of 93.6%; at this point, the false-positive result was 6.4% only. Conclusion The duration of the TSL is shorter in a modern obstetric cohort relative to historically reported norms. In term, vaginal deliveries, duration of the TSL of greater than 18 min was associated with increased risk of PPH.
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Effect of different episiotomy techniques on perineal pain and sexual activity 3 months after delivery p. 1253
Mohamed M Fahmy, Hamed E Al-Lakwa, Alaa El-Deen F Al-Halaby, Eman A Al-Sharkawy
DOI:10.4103/mmj.mmj_346_17  
Objective The aim of this study was to examine the relationship between different episiotomy techniques and sexual activity and perineal pain 3 months after delivery with episiotomy. Background Despite the controversy regarding the routine use of episiotomy-assisted delivery, it is still one of the commonly performed procedures worldwide. Patients and methods This study comprised a purposive sample of 150 uncircumcised, primigravida with episiotomy during normal delivery. These women were divided into three equal groups according to the type of episiotomy. The first group was patients with lateral episiotomy (N = 50), the second group was patients with mediolateral episiotomy (N = 50), and the last group was patients with median episiotomy (N = 50). The study was conducted at Obstetrics and Gynecology Department, at a Governmental Central Hospital. Two tools were used: a questionnaire containing sociodemographic data, episiotomy type, type of wound healing, vaginal dryness assessment, type of baby feeding, and sexual activity assessment, and pain assessment by visual analog scale. Results There was no difference in pain score distribution by visual analog scale when comparing midline, mediolateral, and lateral technique (P = 0.4). The study showed that 76.0% of the studied sample had a decreased coitus frequency. The main reason of coitus decrease was pain (49.0%). There was no statistically significant difference between type of episiotomy of the studied sample and postpartum sexual satisfaction (P = 0.2). Conclusion No difference was detected in perineal pain perception 3 months after delivery between different episiotomy techniques.
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Role of glycosylated hemoglobin in prediction of birth weight and amniotic volume in gestational diabetes p. 1258
Mehany M Abdelsttar, Mohamed A Omarah, Alaa M Abdelgaied, Mohamed A El-Sharkawy
DOI:10.4103/mmj.mmj_417_17  
Objective The aim of this st udy is to investigate the relation between glycemic control in first half of pregnancy by measuring mid-pregnancy glycated hemoglobin (HbA1c), neonatal birth weight, and amniotic fluid volume. Background Glycosylated hemoglobin is an important method for assessing glycemic control showing both fasting and postpradial plasma glucose levels. Patients and methods A prospective observational study was conducted on 150 pregnant women attending the Obstetrics and Gynecology Outpatient Clinic at Tala General Hospital from January 2015 to December 2016. Detailed history and general, abdominal, and sonographic examination were analyzed for all patients. Results A statistical difference between normal birth weight (NBW) and macrosomia regarding obstructed and preterm labor up to 36 weeks was recorded, which was higher in macrosomic group, whereas a highly significant difference regarding perineal tear, Neonatal Intensive Care Unit admission, hypoglycemia, and hyperbilirubinemia occurred in 11, 17, eight, and 21 cases of NBW group, and occurred in three, five, and four cases of macrosomic group, respectively. Moreover, HbA1c was positively correlated with BMI, amniotic fluid index (AFI), expected fetal weight (EFW) at 36 weeks of gestation, gestational age at delivery (GA), and diabetic history family, whereas, AFI was positively correlated with body weight. Conclusion HbA1c was positively correlated with BMI, AFI, EFW, GA, and family history of diabetes, and birth weight with AFI and EFW. In addition, highly statistical significantly difference between macrosomic and NBW groups was seen regarding GA, AFI, EFW, and cesarean birth, which were high in macrosomic group.
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Effect of vaginal progesterone and cervical cerclage in twin pregnancy and their perinatal outcome p. 1265
Nasser K Abd Elaal, Zakaria F Sanad, Abdel H Essam Shaheen, Haitham A Hamza, Amira A Ebrahim Gabr
DOI:10.4103/mmj.mmj_498_17  
Objective The aim of this study was to eva lu ate the effectiveness of vaginal progesterone, cervical cerclage, and combination in preventing preterm labor (PTL) in twin pregnancy and impact on perinatal outcome. Background Several studies showed the efficacy of vaginal progesterone and cervical cerclage or both in prevention of PTL in twin pregnancy. Patients and methods A sample size of 75 patients has been taken from outpatient clinic at Menoufia University Hospital. All fulfilled eligibility criteria of having a twin pregnancy with a history of spontaneous PTL, a sonographic short cervical length of less than 25 mm in mid-trimester. The participants were randomly assigned to three groups: group 1 (N = 25) received vaginal progesterone; group 2 (N = 25) were remedied with cervical cerclage; and group 3 (N = 25) received both vaginal progesterone and cervical cerclage. The primary outcome measure was spontaneous delivery between 34 and 37 weeks of gestation. Secondary outcomes were delivery before 34 weeks of gestation. Results There were no significant differences between the three studied groups concerning their demographic data. There were no statistical significant differences between the three studied groups regarding the transvaginal sonographic cervical length (P > 0.05). There was a statistically significant higher gestational age in the combination group than the progesterone group or cerclage group (P < 0.001). Comparison between progesterone and cerclage groups did not reach statistical significance (P=−0.85). Both demonstrated significantly lower birth weights, lower APGAR scores, and a higher NICU admission rate than in the combination group (P < 0.001). Conclusion Combination of vaginal progesterone and cervical cerclage can prevent PTL in twin pregnancy and improve perinatal morbidity and mortality.
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Tympanometric changes before and after treatment with functional endoscopic sinus surgery in cases of chronic sinusitis p. 1270
Amr F El-Badry, Abd El-Aziz K. Saad, Mohammed A Shams El-Din, Ayman A El-Shehally, Ahmed M. A. Mahmoud, Osama F. A. Besar
DOI:10.4103/mmj.mmj_350_16  
Objective The aim was to detect the effect of chronic rhinosinusitis (CRS) on eustachian tube function and evaluate the tympanometric changes in these cases after functional endoscopic sinus surgery. Background CRS can alter the function of eustachian tube and the middle ear pressure. Materials and methods This prospective study was carried out on 60 patients from the otorhinolaryngology departments of El-Hussien University Hospital and Bab El Shaeria University Hospital and at the audiology unit of Al Azhar University. The patients included in this study were classified into two groups: group I included 40 patients diagnosed as having CRS with or without nasal polyposis, and group II (control group) included 20 patients who were ENT free at the time of examination. Tympanometry and eustachian tube patency function test (EFT) before and 3 and 6 months after functional endoscopic sinus surgery were done in group 1 and at the time of first presentation in the control group. Results A significant effect of nasal obstruction on middle ear pressure and EFT was noticed (P > 0.005). There was no significant relation between laterality of nasal obstruction and the result of tympanometry and EFT preoperatively. Not all the cases with type A tympanogram had good EFT, and this indicted that cases with type A tympanogram may have good or poor EFT, that is, not always good EFT. The changes of the type of tympanometry between before and after operation from type C to type A were statistically highly significant. Conclusion CRS causes eustachian tube dysfunction, and surgery of nasal obstruction had a significant effect in improving the middle ear pressure and the EFT.
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Analysis of tonsillectomy malpractice claims in Egypt: 2010–2015 p. 1277
Ahmed Ragab, Safaa A Amin, Ayman A Abdel Fatah, Tarek A Rahman, Mohammed F Abdelhakim
DOI:10.4103/mmj.mmj_317_17  
Objective The aim of this study was to analyze malpractice claims following tonsillectomy in Egypt in the period 2010–2015, including the risk of liabilities (surgical complications), adverse events, and plaintiff (patient) and definitive (doctor) characteristics. Background Analyzing malpractice litigation trends following tonsillectomy will help in improving physician awareness and preventing future litigation. Patients and method The data were collected from archived reports in Egypt's Forensic Medical Authority and from Egyptian doctor's syndicate. Data analysis of malpractice cases after tonsillectomy operations in Egypt (2010–2015) was performed. The authors analyzed the different criteria of the alleged physicians, practicing places, patients' criteria, and the type of complications. Results Post-tonsillectomy malpractice claims were 26/90 (29%) from the total otorhinolaryngology claims: surgical complications (24 patients) and noncomplication causes (two patients). Specialists with experience of less than 10 years (P = 0.001) and working in private sectors (P = 0.001) were mostly responsible for more litigation. The mortality liabilities, 13 (62.5%) claims, were much higher than morbidity liabilities (37.5%). Post-tonsillectomy hemorrhage represented a considerable section of mortality and morbidity malpractice claims (45%). The other causes of mortality liabilities were the airway-related anesthetic problems in three (12.5%) patients and intraoperative medication reactions in two (8.3%) patients. Conclusion Tonsillectomy is a common procedure that carries a relatively large risk from a medicolegal standpoint. Post-tonsillectomy hemorrhage had the highest mortality and morbidity fates and malpractice claims. The junior otolaryngologist specialists with low experience should be cautious in all aspects of tonsillectomy patient care to avoid litigations.
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Synedra, a free digital imaging viewer, is relevant in assessment of frontal sinus drainage pathway Highly accessed article p. 1282
Ahmed Ragab, Ayman A Abdel Fatah, Mohammed S Abdullah, Hosam A Hussin, Shaimaa A Hassanein, Mohammed Abdulrahman
DOI:10.4103/mmj.mmj_76_18  
Objective The aim was to evaluate the most relevant free radiological digital imaging and communications in medicine (DICOM) software in analysis of air cells related to the frontal sinus drainage pathway (FSDP). Background DICOM is the leading standard for computed tomography (CT) scan image data management in different paranasal sinuses and rhinology practice. Patients and methods In the present prospective randomized case-series study of 51 patients scheduled for CT scan for nose and paranasal sinuses, six DICOM image viewers (Onis, Synerdra, 3D-Slicer, InVesalius, RadiAnt, and Philips) were compared by two expert head and neck radiologists for analysis of CT FSDP anatomy using modified Bent–Kuhn classification, which presents a total score for 10 commonly used radiological parameters. Each was scored from 0 to 10, and a total score and mean were calculated. Results Synedra software had the highest total mean scores (64.5/100) followed by RadiAnt (45/100), 3D-slicer (29.5/100), Onis (16/100), and Invesalius (15/100), with the least being Philips (14.5/100). Conclusion Synedra could be a relevant free DICOM viewer for analysis of air cells related to the FSDP.
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Results of management of tibial plateau fractures Schatzker types V and VI using Ilizarov fixator p. 1287
Ahmed I Zayda, Hesham F Ghoneem, Ahmed E Shahein, Mohamed M. M El-Deeb
DOI:10.4103/mmj.mmj_645_16  
Background Management of comminuted bicondylar tibial plateau fractures remains a challenge to orthopedic surgeons. Studies on long-term outcomes of treatment of the tibial plateau have included a mixture of fracture types, including low-energy split and split-depressed fractures. Thus, the middle-to-long-term results of management of high-energy fractures are still lacking. Objective The aim of this study was to evaluate the knee function and development of arthrosis after a minimum of 3 years in high-energy tibial plateau fractures treated with the Ilizarov external fixator. Patients and methods There were 30 patients in this study and they were followed up for a minimum of 3 years. Completion of the Iowa knee score and the Short Form-36 General Health Survey was a must. This retrospective study was performed at an academically supervised level III, trauma center, in which percutaneous and/or limited open internal fixation and an Ilizarov frame were applied for displaced bicondylar high-energy tibial plateau fractures (Schatzker types V and VI, and Orthopedic Trauma Association types C1, C2, and C3). Results After healing, none of the studied patients needed a secondary reconstructive procedure. The knee motion ranged between 15° of extension and 155° of flexion, with an average of 88% of the total arc of the contralateral knee. Conclusion Patients suffering from high-energy bicondylar tibial plateau fractures could be safely treated with minimal internal fixation and Ilizarov external fixation. This procedure has good prognosis for satisfactory knee function for up to 16 years of follow-up.
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Treatment of intertrochanteric fracture femur by Ilizarov fixator in elderly patients p. 1293
Hesham F Ghoneem, Ahmed I Zayda, Ali F Ali El Sayed
DOI:10.4103/mmj.mmj_64_16  
Objective To assess the effectiveness of fixation of intertrochanteric fracture femur in elderly high-risk patients using Ilizarov fixator. Background Internal fixation of intertrochanteric fractures is a routine procedure, but in patients with anesthetic risks, external fixation can be considered a semiconservative method to reduce operative time and complications. In this study, the functional and radiological results of management of intertrochanteric fracture femur in elderly patients using Ilizarov fixator is evaluated. Patients and methods A total of 20 elderly high-risk patients with intertrochanteric fracture were treated by Ilizarov fixator. All patients had uncontrolled concomitant medical disorders such as hypertension, diabetes mellitus, and chronic hepatic or renal failure. The age range was 50–85 years. Results The patients were followed up for a mean of 7.5 months with a range from 6 to 9 months. Excellent and good (satisfactory) results were found in 16 patients and fair and poor (unsatisfactory) results were found in four patients. The time of radiological union and fixator removal ranged from 10 to 16 weeks. Pin-tract infection occurred in all patients. Varus malalignment occurred in 20% of patients. Shortening ranged from 0 to 3°. There were two cases of penetration of the femoral head. Conclusion It was found that external fixation of intertrochanteric fractures in elderly high-risk patients is a reliable, effective, and safe treatment option. It offers minimal operative risk, no blood loss, early mobilization, short hospital stay, and low morbidity and mortality.
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Arthroscopic management of work-related overhead shoulder injuries: A retrospective case series p. 1299
Amr A Kandeel, Ahmed I Zayda, Ahmed A El-Herraoui, Bahaa-Eldin M El-Serwi, Mohamed H Dawoud
DOI:10.4103/mmj.mmj_313_17  
Objective This study was conducted to review the results of arthroscopic management of different work-related overhead shoulder injuries. Background Acute and overuse shoulder injuries are common among overhead workers, usually with secondary compromised glenohumeral stability due to mechanical damage, muscular fatigue, and neuromuscular control deficits. Patients and methods This study was conducted retrospectively on 30 patients who underwent shoulder arthroscopy for the diagnosis and management of different work-related overhead shoulder injuries with minimum postoperative follow-up of 6 months. Patients had been reviewed for history, examination, arthroscopic findings, and lines of management. Patients had been evaluated using University of California Los Anglos score. Results The mean age of patients was 47.7 years. There were 14 male and 16 female patients. The mean duration of postoperative follow-up was 27 months. Subacromial impingement was evident in all 30 (100%) patients. Rotator cuff tear was found in 26 (86.7%) patients. Pathology of the long head of the biceps tendon was found in 19 (63.3%) patients. Superior labrum anterior posterior lesions were found in all 30 (100%) patients. The active range of motions showed highly significant postoperative improvement (P = 0.000). The mean overall University of California Los Anglos score showed highly significant improvement from 11.9 ± 4.088 preoperatively to 32.37 ± 2.141 postoperatively (P = 0.000). Conclusion Overhead work can cause different shoulder injuries; the most common lesions are superior labrum anterior posterior lesions, rotator cuff tears 'partial-thickness more than full-thickness', and less commonly biceps tendon lesions. Arthroscopic management even of concurrent procedures can achieve satisfactory outcomes.
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Percutaneous vertebroplasty in the treatment of thoracolumbar fractures p. 1305
Mahmoud M Hadhoud, Ahmed I Zayda, Mohammed N Ali El Agreed
DOI:10.4103/mmj.mmj_391_17  
Objective The objective was to determine the effect of percutaneous vertebroplasty (PV) through cement injection in relief of pain in case of painful osteoporotic and pathological thoracolumbar fractures. Background Vertebroplasty is a percutaneous polymethylmethacrylate cement injection inside the vertebral body through the pedicle and used mainly in the treatment of painful osteoporotic and pathological spinal fractures. Patients and methods A total of 20 patients in this study had thoracolumbar fractures (15 of them had osteoporotic fractures and five of them had pathological fractures). Patients were submitted into one of the three age groups. Group 1: less than 60 years, group 2: between 60 and 70 years, and group 3: above 70 years. Results The analgesic effect of PV was evaluated using visual analogue scale and activities of daily living immediately after operation and the patients were followed for 6 months radiologically and clinically using these scales. All of them were improved and four of them had cement leakage with no neurological insult. One of them had leakage with neurological insult which is improved by overnight injection of methylprednisolone. Conclusion PV has become common in many practices worldwide. It has been used by surgeons as a good therapy for the treatment of painful osteoporotic and pathological compression fractures of the spine which do not respond to medical treatment of osteoporosis. Nowadays, it has been the best option of treatment for these compression fractures in the world. PV is a simple operation and can be done in an outpatient clinic. Pain relief has been high and risks low, when done by experienced surgeons who exercise good judgment.
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Bouquet technique in the treatment of metacarpal fractures p. 1312
Hisham M Elmowafy, Adel I Elsaedy, Abdelatai M Hassan
DOI:10.4103/mmj.mmj_445_17  
Objectives The aim of this study was to evaluate the results of bouquet technique in fixation of metacarpal subcapital, neck, or shaft fractures regarding fixation stability and functional and radiological outcomes. Background Metacarpal subcapital, neck, or shaft fractures can be managed conservatively or operatively depending on fracture pattern and stability. Patients and methods A follow-up study in Boulak Eldakror Allgemein Hospital from July 2014 to February 2016 was conducted. Thirty cases of unstable metacarpal fractures were managed by antegrade intramedullary K-wires fixation and were documented and evaluated radiographically and functionally with follow-up for 6 months. Result Thirty cases were enrolled in this study. Fracture union was achieved in all cases at the mean of 5 weeks. At the last visit (6 months postoperatively), the total active motion score for 30 patients ranged from 170° to 260°, with mean of 222°. Normal score of 260°, with good functional and completely powerful hand, was recorded in three patients. The range of grip strength was 60–100%, with the mean of 86% compared with the healthy side. The range for Quick-DASH scores for 30 patients was from 15.9 to 0.0. Score 0 with sound union was recorded in 12 patients. Conclusion Antegrade intramedullary K-wires fixation in this study showed good functional and radiographic results with fewer complications.
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Corneal endothelial and central corneal thickness changes in patients with type II diabetes mellitus p. 1317
Hoda M. K. Elsobky, Farid M. W. Farid, Engy E. M. El-Sayed
DOI:10.4103/mmj.mmj_128_17  
Objective The aim of this study was to evaluate the changes in corneal endothelium (endothelial cell morphology and density) and central corneal thickness (CCT) in type II diabetes mellitus. Background Worldwide, the incidence of type II diabetes mellitus is increasing, reaching epidemic proportions in developing countries. Diabetes mellitus can affect almost all structures of the eye; it can cause anterior ischemic optic neuropathy, glaucoma, cataract, retinal vascular occlusions, and retinopathy. Corneal damage such as endothelial defects, punctate epithelial keratopathy, recurrent corneal erosions, and persistent epithelial defects may occur. The disease affects the corneal endothelial cells and corneal thickness. Patients and methods This analytical and descriptive study included 200 eyes of 100 diabetic patients and 100 healthy controls, 98 left and 102 right eyes; there were 125 were female and 80 male patients. Patients' ages ranged between 41 and 65 years. The following parameters were evaluated in the current study in both the healthy control group and age-matched patients with type II diabetes mellitus: central corneal thickness, endothelial cell count, coefficient of variation, and percentage of hexagonal cells. Results Endothelial cell density in the diabetic group (2262.1 ± 344.5 cells/mm2) was significantly lower than that in the control group (2623.07 ± 187.1 cells/mm2, <0.05). The coefficient of variation of cell area was significantly higher in diabetic patients. Hexagonality was significantly lower in diabetic patients, and CCT was significantly higher in diabetic patients. The diabetic group was subdivided according to severity of diabetic retinopathy (DR) into no DR, nonproliferative DR and proliferative DR. Duration of diabetes and severity of DR were significantly correlated with corneal endothelial changes. Conclusion Type II diabetes causes a significant alteration in corneal structure and function in the long term. Our study seems to confirm the effect of diabetes duration and poor glycemic control on CCT and endothelial cell structure and morphology.
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Ocular coherence tomography study of the retinal nerve fiber layer following retinal vein occlusion p. 1324
Ahmed Y Abd-Elmonem, Hany Khairy, Hassan Farahat
DOI:10.4103/mmj.mmj_142_17  
Objectives The objective of this article is to analyze the changes in the retinal nerve fiber layer (RNFL) thickness in retinal vein occlusion using optical coherence tomography. Background Optical coherence tomography is a noninvasive test that gives high-resolution sectional images of the RNFL that are used to measure RNFL thickness in studies of glaucoma and other optic neuropathies. Patients and methods The study included 50 eyes (25 right and 25 left eyes) of 25 adult patients having unilateral branch retinal vein occlusion, for which optical coherence tomography was obtained. Results There was a statistical significant difference between normal and diseased eyes regarding retinal nerve fiber thickness (P < 0.001). The RNFL thickness is significantly lower in patient with history of diabetes mellitus than those with no history (P = 0.0321). The mean RNFL thickness was 50.10 ± 25.23 μm for diabetic patients. The nerve fiber layer thickness is significantly lower in patients with hypertension than in those with no history (P = 0.002). The mean nerve fiber layer thickness was 44.38 ± 23.2 μm for patients with hypertension. The thickness is significantly lower in patient with history of glaucoma than those with no history (P = 0.002). The mean nerve fiber layer thickness was 40.42 ± 23.15 μm for patients with glaucoma. Conclusion Optical coherence tomography might reflect the thinning of the RNFL after branch vein occlusion and showed that RNFL damage had a relationship with other ocular and systemic diseases.
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Arthritis in type 2 diabetes mellitus p. 1329
Reda M Badr, Ahmed A Shoaib, Khaled M El-Zorkany, Eman E Hassan
DOI:10.4103/1110-2098.252035  
Objectives The objective of this study was to estimate the correlation between diabetes mellitus (DM) and arthritis through some laboratory changes in patients with type 2 DM complaining of arthropathy. Patients were recruited from outpatient clinics of Internal Medicine Department at Menoufia University Hospital. Background DM has become one of the main threats to human health in recent decades. Uncontrolled diabetes is strongly correlated to causing long-term microvascular and macrovascular complications. Rheumatological diseases are now common, which have an increased prevalence in the diabetic population. Patients and methods The study included 90 patients. Patients were divided into three groups: group 1 comprised 30 patients with type 2 DM without arthropathy, group 2 comprised 30 patients with type 2 DM with arthropathy, and group 3 comprised 30 nondiabetic patients with arthropathy. Results BMI was significantly higher among patients with arthropathy (33.64 ± 2.26), random blood sugar was significantly higher among patients with arthropathy (288.10 ± 83.64), Alc was significantly higher among patients with arthropathy (8.72 ± 1.09), erythrocyte sedimentation rate was significantly higher among nondiabetic patients (58.60 ± 27.29), serum uric acid was significantly higher among nondiabetic patients (5.11 ± 1.18), C-reactive protein was higher among diabetic patients with arthropathy (60%), rheumatoid factor was significantly higher among patients with arthropathy (75.0%), and antinuclear antibody was significantly higher among patients with arthropathy (98.0%). Conclusion Musculoskeletal complications were most commonly seen in patients with a long-standing history of type 2 DM. The incidence of DM and the life expectancy of the diabetic patient have both increased, resulting in increased prevalence and clinical importance of musculoskeletal alterations in diabetic patients. The development of musculoskeletal disorders is dependent on age and the duration of DM.
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Femtosecond laser versus mechanical microkeratome regarding predictability of laser in-situ keratomileusis flap thickness p. 1335
Abdel R. E. Sarhan, Marwa A Zaky, Nehal G Youssef
DOI:10.4103/mmj.mmj_433_17  
Objective The aim of this study is to compare the predictability and accuracy of laser in-situ keratomileusis (LASIK) corneal flap thickness when created using either a VisuMax femtosecond laser or a classic Moria M2 microkeratome, because of the direct impact of the residual stromal bed on post-LASIK ectasia. Background LASIK is now considered the most popular procedure of correcting refractive errors. A great advancement had been accomplished in this field since it was first practiced. The technology of femtosecond laser has been used to achieve more safe and accurate results. Patients and methods This study was carried on a total number of 80 patients (i.e., 160 eyes). Each patient underwent a bilateral LASIK surgery. Patients were divided into two equal groups; thus, each group included 40 patients (i.e., 80 eyes). In the first group (Femto), the corneal flaps were made using the VisuMax femtosecond laser, whereas in the second group (Moria), the corneal flaps were made using a Moria M2 microkeratome. The flap evaluation and thickness measurement was performed 3 months postoperatively with a noncontact anterior-segment optical coherence tomography system, Cirrus HD-OCT 5000. Results At 3 months postoperatively, the mean central flap thickness achieved in the Femto group was 102.06 ± 5.37 μm (with a deviation from the target thickness of 100 μm by 2.06 ± 5.37 mm). Although the mean central flap thickness achieved in the Moria group was 130.25 ± 12.61 μm (with a deviation from the target thickness of 90 μm by 40.25 ± 12.61 mm). By comparing the deviation in both groups, the P value was found to be less than 0.001 indicating a high significant difference between them. Conclusion This study shows the superiority of the VisuMax femtosecond laser system over the popular Moria M2 mechanical microkeratome in terms of flap uniformity, predictability, and accuracy.
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Evaluation of peripapillary retinal nerve fiber thickness and macular changes before and after phacoemulsification p. 1342
Moustafa K Nasar, Marwa A Zaky, Heba A Radwan Saleh
DOI:10.4103/mmj.mmj_464_17  
Objective The objectives of the study were assessment of the effect of phacoemulsification on the retinal nerve fiber layer (RNFL) and macular thickness compared with preoperative thickness, and assessment of the correlation between phaco time and the macular thickness changes after surgery. Backgrounds Phacoemulsification is the most common technique used for cataract surgery. Ultrasonic energy and fluidics produce inflammatory reactions that lead to cystoid macular edema. Patients and methods The present study included 50 eyes of 50 patients who underwent phacoemulsification. RNFL thickness and macular thickness were measured 1 day before phacoemulsification and 1 week and 1 month after the operation using the spectral domain optical coherence tomography at the ophthalmology clinic at the Menoufia University Hospital, and the phaco time was estimated during the operation. Results The average retinal nerve fiber thickness was 96.52 ± 12.00, 101.28 ± 11.87, and 111.96 ± 11.43 μm, 1 day before cataract surgery, after first week of surgery, and after 1 month, respectively. We found that the central retinal nerve fiber thickness measurements after 1 week and 1 month of the operation were significantly higher than those measured preoperatively (P < 0.001). The average central macular thickness was 230.58 ± 25.46, 259.22 ± 25.44, and 271.12 ± 24.61 μm 1 day before phacoemulsion, after 1 week of surgery, and 1 month later, respectively. We found a statistically significant increase in the central macular thickness in the first week and the first month after surgery than before the procedure (P < 0.001). This increase in macular thickness was significant in all nine areas of macula (P < 0.001). The increase of macular thickness is positively correlated with the phaco time after first week (P < 0.001) and first month of phacoemulsification (P = 0.001). Conclusion Phacoemulsification leads to a significant increase in the central retinal nerve fiber thickness and in nine macular area thicknesses after 1 week and 1 month of phacoemulsification than before the procedure. These results support the concept that ultrasonification in phacoemulsification leads to an inflammatory reaction causing macular edema, and the removal of opacified media improves the transmittance and reflectivity of the RNFL boundary, so the RNFL thickness increases after phacoemulsification.
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Limbal conjunctival autograft versus simple excision with intraoperative mitomycin C in pterygium surgery p. 1350
Moustafa K Nassar, Hany A Khairy, Asmaa M Shalaby
DOI:10.4103/mmj.mmj_523_17  
Objective The aim of this study was to evaluate the recurrence and complications of limbal conjunctival autograft (LCAG) compared to simple excision with intraoperative mitomycin C (MMC). Background Pterygium recurrence is the most common postoperative complication. Many adjunctive methods have been used to reduce the recurrence such as chemical agents as MMC. In addition, the traditional bare sclera technique largely has been replaced by procedures that cover the sclera with conjunctival graft. Patients and methods This is a follow-up study of a randomized uncontrolled trial conducted on 100 eyes of 100 patients presented for pterygium excision. They were randomly allocated into two equally sized groups (50 patients in each): group 1 received intraoperative 0.02% MMC and group 2 received LCAG. After a follow-up time of 1 year, recurrences and complications were assessed. Results At 1 year of follow-up time, LCAG group had only one (2%) recurrence compared to eight (16%) recurrences in the MMC group that revealed a statistically significant difference (P = 0.031). Complications such as corneal epithelial defects, lacrimation, and photophobia were more commonly encountered in the MMC group but other complications such as graft retraction, dellen, fibrosis and symblepharon, conjunctival cyst, conjunctival hyperemia, irritation, and subconjunctival haemorrhage were similar in both groups. Conclusion Both LCAG and MMC are effective in the treatment of pterygium however, LCAG decreases recurrence rate and complications.
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Intraocular pressure changes after laser-assisted in-situ keratomileusis versus photorefractive keratectomy in myopic eyes p. 1356
Moustafa K Nassar, Faried M. W. Faried, Hatem A Anwer
DOI:10.4103/mmj.mmj_133_18  
Objective The aim was to compare intraocular pressure (IOP) changes after laser-assisted in-situ keratomileusis (LASIK) versus photorefractive keratectomy (PRK) in myopic eyes. Background IOP measurement is necessary for diagnosing glaucoma. LASIK and PRK are used for correction of myopia. IOP is underestimated after LASIK and PRK. It is very important to evaluate IOP changes after LASIK and PRK especially in myopic patients, as myopia is a risk factor for primary open-angle glaucoma. Patients and methods A total of 50 patients diagnosed clinically to have myopia were selected. Their ages ranged from 18 to 48 years. A total of 50 eyes were operated using LASIK 1 and 50 eyes were operated using PRK 2. Patients were subjected to corneal topography by pentacam and IOP measurement by Goldmann applanation tonometer (GAT), preoperatively and postoperatively at the end of the first week, the first month, and the third month. Results The mean IOP in LASIK and PRK groups, which was preoperatively 15.86 ± 1.99 and 15.62 ± 2.12 mmHg, respectively, decreased postoperatively to 12.98 ± 1.83 and 12.98 ± 2.03 mmHg, respectively. There is a statistically nonsignificant difference between LASIK and PRK, postoperatively (P = 0.164), whereas there was a statistically highly significant difference between preoperative and postoperative IOP in both LASIK and PRK groups (P = 0.000). Conclusion IOP is underestimated after laser correction. IOP decrease can be dramatic in highly myopic corrections. Preoperative IOP is the single strongest predictor of postoperative IOP change, with eyes with higher preoperative IOP having greater IOP decrease. LASIK correction will lower IOP by ∼1 mmHg because of the effect of the lamellar flap.
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Evaluation of septum-based reduction mammaplasty p. 1362
Tarek F Kishk, Dalia M Elsakka, Gehan F Elakabawy, Ahmed T Nassar, Ahmed F Elborgy
DOI:10.4103/mmj.mmj_143_17  
Objectives The aim of this study was to evaluate the technique of septum-based reduction mammaplasty regarding safety, esthetic results, and patient satisfaction. Background Improved understanding of anatomy and continuous evolution in surgical techniques helped to shift the focus from simple reduction surgery to keeping long-lasting esthetic results. The present study evaluated the reduction mammaplasty based on the fixed anatomical structure called Würinger's septum which carries the main nerve and blood supply to the nipple. Patients and methods This study included 30 patients experiencing macromastia who visited the outpatient clinic of Department of Plastic Surgery, Menoufia University Hospital, from April 2015 to December 2016, and they underwent septum-based reduction mammaplasty based on Würinger's septum. Overall, 16 medial and 14 lateral septum-based pedicles were designed according to each patient characteristics. The patient characteristics, operative data, and results of the work were recorded. Results Septum-based reduction mammaplasty was done for 30 patients, with an age range of 29–56 years. The mean nipple to sternal notch distance (suprasternal notch to nipple) was 31 cm, with range of 27–40 cm. The mean distance of nipple–areola complex elevation was 12 ± 2 cm, with range of 6–18 cm. The mean weight of tissue resection was 638 ± 22 g. The mean operative time was 101 min (range: 85–119 min) in reduction-only procedures and 146 min (range: 125–185 min) with those requiring additional procedures. No major complications were recorded. Conclusion Septum-based mammaplasty is a safe and reliable breast reduction technique. It preserves the nipple sensation more than other mammaplasty techniques, and also major complications can be avoided.
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Reconstruction of the middle third of the leg by distally based hemigastrocnemius muscle flap p. 1369
Shawky S Gad, Tarek F Kishk, Sherif M Elkashty, Mohammad K Bassam
DOI:10.4103/mmj.mmj_249_17  
Objective The aim of this study was to evaluate coverage of middle third leg soft tissue defects using distally based hemigastrocnemius muscle flap regarding advantages, disadvantages, and rate of complications. Background Skin defects of the leg still present a reconstructive problem particularly if associated with complicated orthopedic lesions, which is why coverage of the soft tissue defects of the middle third leg is a challenge to plastic surgeons Patients and methods This study was done at the Department of Plastic and Reconstructive Surgery, Menoufia University Hospitals, from January 2015 to January 2017, with a follow-up period of 12 months. The study included 20 patients – 15 males and five females – and their ages ranged between 22 and 65 years. Patients presented with posttraumatic pretibial defects, and the main cause was motorcycle accidents. Some patients were associated with fracture of the tibia or both bones of the leg. All defects were covered by the distally based hemigastrocnemius muscle flap. Results Early complication included graft rejection in two (10%) patients, partial flap necrosis in two (10%) patients, wound infection in one (5%) patient, postoperative hematoma in one (5%) patient, and delayed graft take in one (5%) patient. Late results during follow-up showed one (5%) patient with hypertrophic scar of the donor area and one (5%) patient with hyperkeratosis. All postoperative complications were managed conservatively, and flap provided stable reconstructive option. Conclusion The distally based hemigastrocnemius muscle flap can be used for reconstruction of the middle third leg soft tissue defects.
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Functional and cosmetic outcomes of posterior interosseous artery flap in reconstructing hand defects p. 1375
Fouad M Ghareeb, Mohamed A Megahed, Sherif M El Kashty, Alaa A Labeb, Hesham K. H Abd El Kader
DOI:10.4103/mmj.mmj_274_17  
Objective The objective of this study was to evaluate the fu ncti onal and cosmetic results of reversed-flow posterior interosseous artery (PIA) flap for reconstruction of hand defects and to assess them by follow-up and physiotherapy. Background Reconstruction of soft-tissue defects in the hand needs a single-stage procedure that can provide well-vascularized graft coverage at the earliest to give the best functional result. Patients and methods This follow-up study that included 20 patients (16 male and four female) was carried out in Menoufia University, Plastic and Reconstructive Surgery Department, from March 2015 to January 2017, with assessment by a follow-up period of 12 months and physiotherapy. All our patients had PIA flap for coverage of the defects. The defects were due to post-traumatic raw areas in 15 cases, postburn deformities in two cases, postcongenital hand deformity surgeries in one case, and post-tumor ablation in two cases. The first webspace defect occurred most often and the largest flap was 10 × 12 cm2. The donor site was covered by split skin graft in 14 cases, and in six cases the donor site was directly closed. Results Regarding flap course and survival, 15 (75%) flaps passed uneventfully, four (20%) flaps suffered from venous congestion, and one (5%) flap showed ischemia. Three flaps (the ischemic flap and two congested flaps) suffered total loss. Two congested flaps survived without loss, and thus we had 17 (85%) survived flaps. All cases were satisfied with cosmetic outcome. Conclusion The reverse-flow flap based on PIA is a reliable and versatile source for coverage of complex soft-tissue defects in the hand.
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Surgical aspects of common acute abdominal problems in infants and children p. 1380
Tamer A Sultan, Tamer F Abd El-Aziz, Eslam M Abd El-Hafez
DOI:10.4103/mmj.mmj_291_17  
Objective The aim of this study was to discuss and evaluate the best diagnostic tool (clinical, radiological, laboratory, or endoscopy) used to reach a final diagnosis and best intervention for most common presentation of surgical causes of common acute abdominal problems in infants and children. Background Acute abdominal pain is a group of acute life-threatening condition that requires emergency hospital admission and often emergency surgical intervention within 24 h of duration. Patients and methods Hundred children of both sexes aged between 1 day and 12 years who presented with surgical causes of common acute abdominal problems were divided into two groups. Group A included 83 patients who required surgical intervention. Group B included 12 patients who were managed conservatively. Results A total of 100 children attended with complaints of abdominal pain during the study. Thirty-six children had confirmed final diagnosis as appendicitis and eight had complicated appendix, and 20 were diagnosed radiologically (either on ultrasonography or computed tomography scan) as intussusception. The remaining 24 cases were diagnosed clinically. The majority of cases of intestinal obstruction were diagnosed radiologically. All diagnoses of Mickel's diverticulum, necrotizing enterocolitis, incarcerated inguinal hernia, and ovarian and testicular torsion were confirmed by means of radiological investigation. The remaining 12 patients who did not need surgical intervention were managed conservatively. Conclusion Radiological and minimally invasive techniques are becoming important in the diagnosis of surgical abdomen in children. Urgent surgical intervention remains the gold standard for most cases. Appendicitis is mainly clinical diagnosis.
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Reconstruction of complex soft tissue defects in the lower extremities with free anterolateral thigh perforator flap p. 1386
Tarek F Keshk, Sherif M El Kashty, Ahmed Abdelaziz Taalab, Mohamed A M. El-Nahas
DOI:10.4103/mmj.mmj_177_18  
Objectives To study and evaluate the indications, advantages, disadvantages, and complications of reconstruction of complex soft tissue defects in the lower extremities using free anterolateral thigh (ALT) perforator flap. Background Selection of the best suitable free flap for reconstruction of extensive lower limb soft tissue defects continues to pose a formidable challenge for plastic surgeons. The free ALT perforator flap provides a perfect solution for reconstruction of complex lower limb defects. The present study evaluates the usage of free ALT flap in lower limb reconstruction. Patients and methods Twenty-one patients who had extensive soft tissue defect in the lower extremities and were reconstructed by free ALT flap have been reported in this prospective study from December 2016 to March 2018. All of the patients' data (age, sex, and comorbidities), defects data (etiology, site, and size), microvascular and flap data, postoperative complications, and follow-up data including esthetic and functional outcome were recorded. Results The mean age was 27.7 years. The main cause of soft tissue defects was trauma in 13 patients, and the most common site was dorsum of the foot in seven patients. Overall, 15 fasciocutaneous and 4 myofaciocutaneous free ALT had been done on posterior tibial vessels, mainly in 12 cases. The success rate was 89.6%, with total flap necrosis in 5.4% and partial necrosis in 5.4%. Conclusion The free ALT perforator flap offers a variety of tissues available from a single donor site as an excellent option for reconstruction of large and extensive soft tissue defects in the lower extremities.
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Preoperative intra-aortic balloon pumping in poor left ventricular function patients undergoing coronary bypass graft surgery p. 1392
Ahmed L Dokhan, Mohamed A Helmy, Amr M Allama, Mohamed A. A . Salama
DOI:10.4103/mmj.mmj_347_17  
Objective Assessment of the effectiveness associated with preoperative intra-aortic balloon pump (IABP) treatment on postoperative cardiac performance, morbidity, and mortality. Background Preoperative IABP enhances the end result in poor left ventricular function patients undergoing coronary artery bypass grafting (CABG). Patients and methods A prospective analytical cohort study was conducted on 40 patients with preoperative left ventricular ejection fraction (<40%) who experienced myocardial revascularization (CABG) at Nasser Institute Hospital between February 2014 and July 2016. There was a random allocation of patients before surgery, where group I (N = 20) had been inserted with the IABP 1–2 h before aortic cross-clamp and group II (N = 20) was the control group, which did not have IABP inserted preoperatively. Results The mean cardiac index in group I (IAB) before cardiopulmonary bypass time was 2.49 ± 0.21 and in group II (control) it was 1.99 ± 0.34, with a statistically considerable enhancement among two groups (P = 0.003). The mean ischemic time in group I was 54.20 ± 17.63 and in group II it was 57 ± 10.64, with no statistically significant difference among two groups (P = 0.2). The mean cardiopulmonary bypass time in group I was 75.60 ± 22.73, with a statistically substantial enhancement among two organizations (P = 0.015). The mean mechanical ventilation time (h) was 24.7 ± 1.80 in group I compared with 81.9 ± 31.09 in group II, with a highly statistically significant difference among two groups (P = 0.001). The mean ICU stay (hours) in group II was 138.10 ± 50.27, with a highly statistically significant difference (P = 0.001). The mean NYHA class and the mean left ventricular ejection fraction in group I postoperatively was 1.20 ± 0.40 and 54.78 ± 3.75, respectively, with a highly statistically significant difference in group I (P = 0.001) regarding preoperative and postoperative periods. Conclusion Poor left ventricular function patients undergoing CABG possibly require perioperative IABP assistance to decrease morbidity and mortality.
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Early outcome of thoracoscopic minimally invasive versus conventional mitral valve surgery for mitral valve diseases p. 1397
Ahmed L Dokhan, Ali H Taher, Medhat R Nashy, Mohamed B. A. Elbaki
DOI:10.4103/mmj.mmj_429_17  
Objective The aim of the study was to evaluate this new technique introduced in Egyptian National Heart Institute comparing the postoperative pain, hospital stay, recovery speed, cosmosis, pulmonary function, and hospital mortality and morbidity between minimally invasive mitral valve surgery (MIMVS) and conventional mitral surgery. Background Over the past few years, MIMVS has become the preferred option for the treatment of mitral valve (MV) diseases worldwide. That is mainly due to minimizing surgical trauma and its direct impact on reduced postoperative pain, improved cosmosis, quicker recovery, and earlier return to work. Patients and methods This prospective study was conducted on 50 patients requiring MV surgery classified into two equal groups. Group A (minimally invasive group), who were operated on using a video-assisted right anterolateral minithoracotomy technique. Group B (sternotomy group), who were operated on using a conventional median sternotomy technique. Results There was no operative mortality in both groups but significant difference in incision length, ventilation time, blood drainage, blood transfusion, and ICU stay (P = 0.003, 0.002, 0.004, 0.03, 0.004, respectively). Moreover, the total hospital stay was significantly less in group A (6.04 ± 1.1 vs. 11.2 ± 2.45 days, P = 0.005). Conclusion In patients with MV diseases, MIMVS can be an alternative to conventional MV surgery with comparable short-term mortality, morbidity, and superior results regarding the hospital stay.
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Aneurysm geometrics impact on microsurgical modality of ruptured and unruptured middle cerebral artery aneurysms p. 1402
Ahmed Mansour, Saeed Alemam, Haitham Albeltagy, Tamer Hassan, Esam Gaber
DOI:10.4103/mmj.mmj_371_17  
Objective The aim of this study was to evaluate the influence of study of parent vessel and aneurysm geometry in modifying surgical therapeutic modalities of cerebral aneurysms. Background Saccular aneurysms are localized bulging of intracranial blood vessels. Imaging technologies have improved our understanding of the three-dimensional orientation of cerebral aneurysms. The localization, size, and morphology of middle cerebral artery (MCA) aneurysms are recognized as essential for the rupture risk prediction. Patients and methods Forty-one patients who underwent surgical treatment of at least one MCA aneurysm (nine patients in the ruptured group and 32 patients in the unruptured group) were analyzed for information on aneurysm morphology: shape, diameters, neck width, parent vessel diameter, location of the aneurysm [ first part of the MCA (M1) or the bifurcation segment], and the presence of branching vessels. Aneurysm occlusion and parent artery patency were assessed by intraoperative indocyanine green angiography. Postprocedural assessment included assessment of the patient's clinical condition and radiological follow-up. Results Forty-one aneurysms were clipped (100%) and nine aneurysms were wrapped and clipped (21%). The frequency of multilobulated aneurysms and aneurysms with bleb were significantly different in the subrachnoidal hemorrhage (SAH) group versus the non-SAH group. Branching vessels out of the aneurismal neck were registered and the frequency of aneurysms with the branch vessel was significantly different in the SAH versus the non-SAH group. Conclusion In MCA aneurysms, independent predictors for the risk of rupture and for the postsurgical outcome are the presence of SAH, location on the bifurcation segment, multilobulation, blebs, size, and finger-shaped aneurysm.
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Hemostatic effect of monopolar and bipolar resection of the prostate p. 1410
Ahmed A Gamal El-Deen, Tarek M Abd-Elbaky, Mohammed F Sultan, Sheren F Younes, Mohammed H Abd El-Raheem Salama
DOI:10.4103/mmj.mmj_799_17  
Objective The aim of this study was to measure the hemostatic efficacy of bipolar versus monopolar transurethral resection of the prostate (TURP). Background TURP is the most effective surgical modality for treatment of a symptomatic benign prostatic hyperplasia. Bipolar TURP is a new technique developed in the last decade, with a difference in electrical energy delivered in comparison to the monopolar technique. Patients and methods The study was conducted after local approval was obtained from the ethics committee of our hospital. A prospective case–control study, including 60 patients with prostatic enlargement was successfully consented. Of these, 20 patients were treated by bipolar TURP, 20 patients by monopolar TURP, and 20 patients by open transvesical prostatectomy, done at the Urology Department, Menoufia University Hospitals, Shibin El-Kom, Menoufia, during the period between April 2015 and April 2016. Histopathologic evaluation was done to measure the microvascular diameter of open prostatectomy specimens, in which 10 random sites of each case were randomly photographed at ×100 magnification, depth of coagulation in monopolar, and bipolar TURP specimens were randomly photographed at regular intervals at ×100 magnification and stained with routine hematoxylin and Eosin (H & E) stains. Result Out of the 60 patients recruited into the study, the mean depth of coagulation in bipolar TURP (257.39 μm) which was more than the mean depth of coagulation in monopolar TURP (241.87 μm) patients (measured by using Digimizer image analysis software). Conclusion We found that the bipolar TURP provides more depth of coagulation resulting in better sealing of the prostatic vessel diameter and a better hemostatic effect.
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Assessment of health-related quality of life of hemodialysis patients in Benha City, Qalyubia Governorate p. 1414
Ossama M Wassef, Mahmoud F El-Gendy, Rabaa M El-Anwar, Sherif M El-Taher, Basma M Hani
DOI:10.4103/mmj.mmj_488_15  
Objective The first was to assess health-related quality of life (HRQOL) of hemodialysis patients attending dialysis unit in Benha University and Teaching Hospitals, and the second was to determine the factors and predictors affecting HROOL of hemodialysis patients. Background Hemodialysis results in a significant change in daily living, physical and psychological impairments, and disruption of marital, family, and social life. HRQOL assessment helps to plan individual management strategies and determine the efficacy and quality of medical and social care provided. Patients and methods This was a cross-sectional study that included 228 hemodialysis patients, with 144 males and 84 females, and their mean age was 46.62 ± 14.59 years. Data were collected by a questionnaire that included demographic, social, and medical questions. Kidney Disease Quality of Life short form questionnaire 36 was used as a tool for assessment of HRQOL. The collected data were presented and analyzed by using statistical package for the social sciences, version 20, software. The significance was tested by independent t test, analysis of variance, and multiple linear regression analysis. Result HRQOL in the studied hemodialysis patients was relatively low. The mean score for physical component summary was 39.3 ± 10.98, and the mean score for mental component summary was 47.59 ± 12.21. Better HRQOL was revealed in less than 60 years old, males, single patients, those with higher educational level, and in patients on maintenance hemodialysis of less than 6 years. Hepatitis C virus (HCV) positive, diabetic, and anemic patients had the lowest HRQOL scores for comorbidities. Age, duration of dialysis, anemia, and HCV positivity were statistically significant predictors of physical component summary; diabetes was a statistically significant predictor of mental component summary. Conclusion The most important sociodemographic factors affecting HRQOL were age, sex, education, occupation, and marital status. The most important comorbidities affecting quality of life were anemia, HCV infection, and diabetes.
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Glutathione S-transferase enzyme in type 1 diabetes mellitus p. 1422
Soheir S Abou-El-Ella, Maha A Tawfik, Naglaa F Barseem, Ahella H Gad
DOI:10.4103/mmj.mmj_678_16  
Objectives The aim of the present work is to study glutathione S-transferase (GST) genetic variants in patients with type 1 diabetes and its relation to its complications. Background Persistent oxidative stress is one of the several factors that participate in the pathogenesis of type 1 diabetes mellitus. GSTs are a family of antioxidant enzymes that exert important antioxidant roles in the elimination of reactive oxygen species. Patients and methods Forty type 1diabetes mellitus patients were compared with 20 healthy volunteers. GSTM1 and GSTT1 genotypes were screened using PCR and gel electrophoresis. Results The percentage of GSTT1-1 present genotype was 77.5% and GSTT1-0 null genotype was 22.5 versus 100% of the GSTT1-1 present genotype and 0% of the GSTT1-0 null genotype in control. This difference was found to be statistically significant with a P value = 0.023. There was significant positive association between GSTT1-0 null genotype and mean glycosylated hemoglobin in diabetic groups. Among the complicated cases which presented by peripheral numbness and nephropathy, GSTT1-0 null genotype showed a statistically significant association with P value = 0.007. Conclusion The GSTT1genotype may involve in the pathogenesis of type 1 diabetes mellitus and susceptibility to complication.
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Blood eosinophil levels in newborns with severe indirect hyperbilirubinemia treated with phototherapy p. 1428
Ghada M El Mashad, Hanan M El Sayed, Asmaa M Tolba
DOI:10.4103/1110-2098.252070  
Objective The aim of this study was to investigate the effect of phototherapy on peripheral eosinophil counts in newborns with severe indirect hyperbilirubinemia needing phototherapy. Methods We conducted a search of Medline databases (PubMed, Medscape, ScienceDirect) and all materials available on the Internet. The initial search presented one articles that met the inclusion criteria. The articles studied the relation between peripheral eosinophil count and exposure to phototherapy. If the studies did not fulfill the inclusion criteria, they were excluded. Studies were assessed for whether ethical approval had been obtained, eligibility criteria has been specified, appropriate controls had been considered, adequate information had been provided, and assessment measures had been defined. Comparisons were made by means of structured review with the results tabulated. Results The study was conducted on 30 neonates suffering from severe indirect hyperbilirubinemia who served as the patient group and another 30 neonates who were normal and served as the control group. It was found that there was an increase in peripheral eosinophil count in neonates who were treated with phototherapy for 48–72 h. Conclusion Peripheral eosinophil count may be affected by phototherapy. The exact mechanism of neonatal jaundice/phototherapy and later risk of developing asthma is not clear yet, and further prospective studies in larger groups are needed. Neonatologists should concentrate on underlying problems, as eosinophilia is sometimes clinically insignificant with regard to morbidity and requires no specific treatment. In fact, it may be indirect evidence of clinical recovery. Unless eosinophilia is associated with clinical symptomatology, medical evaluation should be limited to routine follow-up examinations and repeat monitoring of absolute eosinophil counts.
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Assessment of circulating endothelial cells in preeclamptic and normotensive pregnancies p. 1435
Waleed M Fathy, Ahmed A Sonbol, Wael G Al-Damaty, Shymaa A El Askary, Bahaa El-Deen W. El-Aswad
DOI:10.4103/mmj.mmj_467_17  
Objective The aim of this study was to assess the level of circulating endothelial cells (CECs) in women with preeclampsia (PE) in comparison with normotensive healthy pregnant controls. Background PE is a medical disorder that may affect pregnant women after 20th week of gestation, and in this condition, the patients experience new-onset hypertension and new-onset proteinuria or organ dysfunctional. There is placental ischemia with systemic maternal endothelium dysfunction. CECs are mature cells that shed from the endothelium in various diseases associated with vessel damage, and they are characterized as being CD146+ and CD45 cells. Patients and methods The current study included 30 patients with preeclampsia and 30 normotensive pregnant women as the control group. All the participants attended Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University Hospitals. They were subjected to collection of demographic data (age and length of gestation), general clinical examination, in addition to undergoing some routine laboratory investigations. Flow cytometry was applied for quantification of CECs using both mouse antihuman fluorescein isothiocyanate-conjugated CD146 antibody and mouse antihuman phycoerythrin conjugated CD45 antibody. Results The CEC counts were significantly (P < 0.001) lower in women with PE (4026.67 ± 1464.5/5 × 106 peripheral mononuclear cells) in comparison with the healthy pregnant ones (9281.33 ± 1764.06/5 × 106 peripheral mononuclear cells). Additionally, CD146 expression strength (mean) was significantly (P < 0.001) higher in healthy pregnant women (93.81 ± 27.57) compared with that of those with PE (43.51 ± 14.47). Conclusion The number of CECs decreased significantly in patients with PE in comparison with normotensive healthy pregnant women.
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Sleep pattern changes in patients with rheumatoid arthritis p. 1442
Mohamed A Zamzam, Ibrahim I El-Mahallawy, Rana H El-Helbawy, Dina R Alsharaki, Emad E Abd El-Hamid
DOI:10.4103/mmj.mmj_23_16  
Objective The aim of this study was to assess sleep pattern changes in patients with rheumatoid arthritis (RA). Background There is evidence that patients with RA may be at increased risk for sleep disorders, particularly obstructive sleep apnea (OSA). Sleep abnormalities have also been linked to increased pain and fatigue perception, which are common concerns in rheumatology patients. Untreated OSA with intermittent hypoxia is associated with elevated levels of systemic inflammatory markers: C-reactive protein (CRP) and proinflammatory cytokines. Patients and methods Thirty patients diagnosed as having RA, and 30 apparent healthy control participants were invited to participate in the study. All the patients were subjected to full medical history, Epworth sleepiness score, thorough clinical examination with evaluation of the disease activity, laboratory assessment of CRP, and complete overnight polysomnography. Results In the current work, the prevalence of sleep apnea in RA patients was 18/30 (60%). Sleep apnea was obstructive. Mean apnea–hypopnea index was 23.42 ± 26.27/h. Among these OSA patients, 36.7% had severe, 10% had moderate, and 36.7% had mild OSA. The study showed a significant correlation between apnea–hypopnea index and BMI, neck circumference, Epworth sleepiness score, erythrocyte sedimentation rate, CRP, and hematocrit. Conclusion OSA is commonly associated with RA patients. Coexistence of OSA in RA patients may influence the disease activity and the level of circulating inflammatory markers.
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Evaluation of the effect of some plant molluscicides on the infectivity of Schistosoma mansoni cercariae p. 1448
Mohamed M Abd El-Ghaffar, Gehan S Sadek, Nancy M Harba, Mona F. Abd El-Samee Faheem
DOI:10.4103/mmj.mmj_500_15  
Objectives To study the effect of sublethal concentrations (LC50) of methanol extracts from Solanum nigrum and Callistemon citrinus leaves on the infectivity of Schistosoma mansoni cercariae by an in-vivo study. Background The high cost of synthetic molluscicides and their negative impacts on the environment necessitated search for an alternative approach by using plant extracts for the control of schistosomiasis. Using molluscicides could be more effective if these agents also possess cercaricidal activity. Materials and methods Methanol extracts of S. nigrum and C. citrinus leaves were prepared and their LC50on S. mansoni cercariae were determined. The experimental mice used in this study were divided into three groups. Group I including mice infected with S. mansoni cercariae preexposed to S. nigrum. Group II included mice infected with S. mansoni cercariae preexposed to C. citirnus. Group III included mice infected with nonexposed S. mansoni cercariae (control group). The attenuating effect of the plants on cercariae was evaluated through different parameters including parasitological, histopathological, and scanning electron microscopic examinations. Results LC50of S. nigrum and C. citrinus methanol extracts were 25 and 40 mg/l, respectively. Parasitological results showed a significant reduction in worm burden, mean number of ova per gram tissue in mice of group I and group II in comparison with those of group III (control group). These results were associated with decrease in the size and number of hepatic granulomas. All these obtained results were more significant with S. nigrum than C. citrinus. Obvious tegmental damages were also detected by scanning electron microscopic in both groups (I and II). Conclusion Methanol extracts of both S. nigrum and C. citrinus leaves exhibited cercariicidal activity but S. nigrum was found to be more potent. This study provides a considerable scope in exploiting local indigenous resources for schistosomiasis control.
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Role of multidetector computed tomography in the diagnosis of intestinal obstruction p. 1456
Elsayed E. M. Elsayed, Rehab M Habib, Belal S. H. Soltan
DOI:10.4103/mmj.mmj_194_16  
Objective The objectives of the study are to discuss the usefulness of multidetector computed tomography (CT) in the evaluation of intestinal obstruction and the underlying causes. Background CT has become a mainstay in diagnosing bowel obstruction. Since the management of obstruction has dramatically changed with a decrease in the proportion of patients who need surgery, a precise CT evaluation is now both the gold standard and the common approach in patients with suspected bowel obstruction. Materials and methods Twenty patients were included in this study. They were referred to the Radiology Department, Menoufia University, in the period from July 2014 to November 2015. These patients were referred for multidetector CT assessment complaining of one or more of the following symptoms: inability to pass stools, constipation, acute abdomen, vomiting, and nausea. Results Mechanical causes were the dominant (95%) in the referred patients with bowel obstruction. The dilated bowel loops in the referred patients were: 11/20 patients with small bowel dilatation (55%), 8/20 patients with large bowel dilatation (40%), and 1/20 patient with small and large bowel dilatation (5%). Adhesive intestinal obstruction and obstructed hernias are the main causes of small bowel obstruction in our study. Cancer sigmoid is the main cause of large bowel obstruction in our study. Conclusion Our results showed a very high sensitivity and specificity which had been at 100% mark. This study has confidently ascertained the role of MSCT in diagnosing and altering the treatment plans of a wide range of bowel obstruction causes.
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Electrocardiographic prediction of culprit artery in acute ST-segment elevation myocardial infarction p. 1463
Abdulla M Kamal, Ghada M Soltan, Momen A. A. Ali
DOI:10.4103/mmj.mmj_51_16  
Background Early prediction of the site and proximity of the occlusion in the culprit artery is essential from a clinical point of view. Objective This study aimed to assess the accuracy of previously defined ECG criteria determined from ECG angiographic correlative studies in predicting not only the infarct-related artery but also the site of the culprit lesion within that artery. Patients and methods ECG and angiographic findings were correlated in 187 patients with an ST-segment elevation myocardial infarction (STEMI). Results In the first group (Anterior ST elevation Myocardial infarction; STEMI), ECG criteria that predict the angiographic findings showed sensitivity and specificity of 55.6% and 100% respectively with 100 % PPV and 80% NPV in subgroup 1 (occlusion proximal to the first diagonal branch; D1). While in subgroup II (occlusion distal to D1), the sensitivity and specificity of the ECG criteria scored 84.4% and 100 % respectively with 100% PPV and 78.3% NPV Whereas in the second group (Inferior STEMI), The sensitivity of the ECG criteria to predict Right Coronary artery (RCA) as the culprit artery was 76.92% and its specificity was 100% with 100% PPV and 92.5 NPV. While to predict Left circumference Artery (LCX) as the culprit artery, the sensitivity and specificity were 100% and 76.92 % respectively with 92.5% PPV and 100% NPV. Conclusion This sequential ECG algorithm based on ST-segment deviations in different leads allowed us to predict the location of occlusion with good accuracy. We recommend the use of the algorithm in everyday clinical practice.
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Patients with breast cancer: screening of the disease among their families in Menoufia University Hospital, Egypt p. 1470
Taghreed M Farahat, Naser M Abd El-Bary, Hala M Shaheen, Nora A Khalil, Yasmin H Hassan Hussein
DOI:10.4103/mmj.mmj_689_17  
Objective To assess the frequency of breast cancer (BC) among families of diagnosed cases and to determine BC risk factors among the screened relatives. Background BC is the most common malignancy among women. The family history of BC increases the risk of the disease. Screening with mammography reduces BC mortality. Patients and methods The study included 150 women from first-degree and second-degree relatives of diagnosed BC cases attending Oncology Outpatient Clinics, Menoufia University Hospital, during the period from January 2016 to February 2017. The participated relatives were subjected to history taking and clinical breast examination. Sonomammography was done for those aged at least 40 years and those who had clinical findings suspicious for malignancy. Breast biopsy was indicated for mammography results suspicious for malignancy. Results The study revealed that the frequency of BC among screened women was 4.7%. Family history of more than or equal to three diagnosed BC cases, presence of two first-degree relatives diagnosed with BC before the age of 50 years old, age, occupation, residence, obesity, early menarche, menstrual history, and hormonal contraception use for more than or equal to 5 years were identified as the most important BC risk factors. Breastfeeding had protective effect. Conclusion The frequency of familial BC was 4.7%. BC family history among two first-degree relatives diagnosed before the age of 50 years, early menarche, and using hormonal contraception for at least 5 years are strong factors affecting BC risk.
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CASE REPORTS Top

Boerhaave syndrome: A dilemma for the private practitioner (a case report) p. 1476
Ezekiel O Ogunleye, Oyebola O Adekola, Augustine J Olugbemi, Olugbenga O Ojo, Saheed B Sanni
DOI:10.4103/mmj.mmj_365_17  
Spontaneous esophageal rupture (Boerhaave syndrome) is a rare condition, and many physicians may be unfamiliar with its presentation. A delay in diagnosis and intervention leads to increased morbidity and mortality. We report on a 43-year-old man referred to our facility with a 9-day history of worsening chest pain, respiratory distress, and fever after bouts of retching and vomiting following binge drinking at a party. He presented 8 days earlier at a private hospital, where he underwent a left-sided thoracostomy for empyema thoracis. A computerized tomography of the chest and abdomen was ordered. It indicated a left-sided hydropneumothorax with a collapsed ipsilateral lower lobe, and contrast extravasation into the left pleural space at the distal one-third of the esophagus anterior to the descending thoracic aorta. The diagnosis of Boerhaave syndrome with mediastinitis was confirmed. He was transferred to the ICU and subsequently underwent a left posterior lateral thoracotomy, with esophageal resection performed. Seven days postoperatively, he developed an esophageal leakage, which required an esophageal stent.
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Hepatoblastoma misdiagnosed as infantile hemangioendothelioma in a child – a case report p. 1479
Aditya P Singh, Arun Gupta, Vinay Mathur, Dinesh K Barolia
DOI:10.4103/mmj.mmj_430_17  
Infantile hemangioendothelioma (IHH) is the most common benign tumor of the liver in children, which accounts for 12% of all pediatric liver tumors, and hepatoblastoma (HBL) is the most common malignant liver tumor in children. Although they share some clinical manifestations, the treatment strategies and prognoses are quite different. The most important alternative diagnosis to IHH in children is HBL. Histopathologic confirmation of a radiologically suspected hemangioendothelioma is often obtained before medical treatment is initiated. We are presenting here a case of HBL in a 2-year-male child misdiagnosed as having IHH on imaging studies.
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LETTER TO THE EDITOR Top

Quality of life in patients with irritable bowel syndrome in Qaliobeya Governorate, Egypt p. 1482
Mahmood D Al-Mendalawi
DOI:10.4103/mmj.mmj_288_18  
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ERRATA Top

Erratum: Prolactin contributes to the pathogenesis of thrombocytopenia in patients with hepatitis C virus p. 1483

DOI:10.4103/1110-2098.252079  
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Erratum: Effects of transdermal nitroglycerin and intravenous pancuronium added to lidocaine for intravenous regional anesthesia p. 1484

DOI:10.4103/1110-2098.252080  
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