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   Table of Contents - Current issue
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January-March 2020
Volume 33 | Issue 1
Page Nos. 1-332

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FAMILY MEDICINE - REVIEW ARTICLE  

Evidence base for cervical cancer screening and prevention among average-risk women in family practice p. 1
Hala M Shaheen, Samah M. A El Galil Ebied
DOI:10.4103/mmj.mmj_418_15  
Objective The aim was to perform a systematic review to identify and summarize evidence base for cervical cancer screening in asymptomatic women who were aged 21 years or older attending family practice. Materials and methods Medline, articles in Medscape, American Academy of Family Physicians, and PubMed were searched. Data were collected from April 1, 2015 till August 1, 2015. The initial search presented 150 articles. The researches which met the inclusion criteria were 24 articles. The articles included screening modalities for cervical cancer in asymptomatic women who were aged 21 years or older attending family practice. 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 assessment measures defined. Comparisons were made by a structured review with the results tabulated. Recent findings Total 24 potentially relevant publications were included. All relevant studies stated that screening should start at 21 years, mean age (±3) till 65 years (grade A recommendation). Regarding the screening test, all studies recommended cervical cytology (pap test) with a 3-year screening interval (grade A recommendation). All studies recommended screening with a combination of cytology and human papillomavirus (HPV)(co-testing) every 5 years for women in the age group of 30–65 years who want to lengthen the screening interval (grade A recommendation). All studies recommended against using HPV testing as a primary screening method or under 30 years. Regarding vaccination two studies suggest HPV vaccine for cervical cancer prevention. Conclusion Screening for cervical cancer is recommended from 21 to 65 years old with cytology (Pap) test with a 3-year screening interval. Women 30 years and older who want to lengthen the screening interval are screened by cytology plus HPV (co-testing) every 5 years.
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FAMILY MEDICINE - ORIGINAL ARTICLES Top

Diarrheal management approach among caregivers of under-5-year-old children in an Egyptian rural area p. 5
Taghreed M Farahat, Hala M Shaheen, Ayah M.A. Barakat, Safa H Alkalash
DOI:10.4103/mmj.mmj_39_19  
Objective The objective of this study was to assess the quality of diarrheal management practice and its relation to the sociodemographic characteristics of under-5-year-old children's caregivers. Background Diarrhea among under-5-year-oldchildren is a serious public health problem in many developing countries, including Egypt. Adequate diarrhea management approaches including the increased use of oral rehydration solution (ORS), extra fluid intake, and continued feeding are cost-effective in reducing the child mortality associated with diarrhea and the overall burden of the disease. Patients and methods A cross-sectional study was conducted on 100 under-5-year-oldchildren's caregivers in Munshaat Sultan village. All the studied children were evaluated through a questionnaire that involved questions about the history of diarrhea within two weeks before the interview, sociodemographic characteristics, and questions to classify the quality of diarrheal management practices into good, fair, or poor on the basis of mothers' reports for children with diarrhea, using WHO/United Nations International Children's Emergency Fund recommendations for appropriate treatment. Results Good diarrhea management practice was present among 36% of caregivers. About 24, 3, and 1% of children were given ORS and continued feeding, continued feeding and extra fluids, and ORS and extra fluids, respectively. There was a statistically significant difference between the quality of diarrheal management practice and mother's education, number of children in the family, socioeconomic standard, and child age. Children were given ORS, antibiotic, antidiarrheal medicine, and zinc in 43, 67, 52, and 21%, respectively. Conclusion Too many children are not receiving adequate management for diarrhea. Hence, the efforts should be increased to improve the quality of care for childhood diarrhea in both health facilities and at the community level.
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Mothers' knowledge, attitude, and practice regarding their primary school children's oral hygiene p. 11
Aml A Salama, Eslam M Konsowa, Safa H Alkalash
DOI:10.4103/mmj.mmj_300_19  
Background Evaluation of parental knowledge, attitude, and practice regarding dental hygiene is an important tool which projects parent's outlook toward oral health of their children. Proper dental hygiene prevents dental caries and allows early detection for any abnormality in earlier stages. Objective The aim was to assess knowledge, attitude, and practice of mothers regarding oral health and its effect on their children's dental health status. Patients and methods This is a cross-sectional study of a random sample of 392 primary school children and their mothers. The children were selected randomly from two primary schools randomly selected from Shebeen El-Kom district's primary schools and proportionally allocated according to the total number of children in each school. A predesigned questionnaire was used to assess mother's knowledge, attitude, and practice regarding their child's oral hygiene. Results Good knowledge of proper oral hygiene was represented by 88.5% of the studied group. Approximately 70% of the studied group had positive attitude toward proper oral hygiene, and 52.3% had satisfactory level of oral hygiene practice. The study shows a statistical significant difference of mothers' good knowledge level and their education, occupation, and socioeconomic status. Proper knowledge and practice regarding oral hygiene statistically significantly increase the absence of decayed or filled teeth. Conclusion Good knowledge, positive attitude, and satisfactory practice of mothers regarding child's oral hygiene affect dental health status of the studied children.
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Factors affecting body mass index of female individuals at 1 year after delivery p. 18
Nagwa N Hegazy, Safaa Abd El-Fatah Badr, Nehad Abd El Moneam Mohamed
DOI:10.4103/mmj.mmj_411_18  
Objective This study was conducted to assess factors affecting the BMI of women at 1 year after delivery. Background The postpartum period is a very special phase during a woman's life. A woman's ability to manage her weight through the postpartum transition has life-long implications for her weight status. Patients and methods A case–control study was conducted on female individuals who attended the Kafrekla Family Health Unit at 1 year after delivery; 278 cases with a BMI more than or equal to 25 and 278 controls with a BMI less than 25 were included in the study during the period spanning from August 2017 to October 2017. The data were collected by a predesigned questionnaire, which consisted of the following (and they are): sociodemographic data, obestetric history, breastfeeding data, contraceptive use data, and dietary behavior data. Results The most significant factors increasing the BMI of female individuals at 1 year after delivery were type of infant feeding [odds ratio (OR), 84.11], type of delivery (OR, 1.96), and hormonal contraception use (OR, 0.858), with exact P value (P = 0.0001, 0.003, 0.001, respectively). Conclusion Predictive factors for BMI of female individuals at 1 year after delivery were type of delivery, duration and type of breastfeeding, hormonal contraception use, breakfast consumption, multigravidity, last gestational period, and last birth interval, respectively.
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Menstrual hygiene among secondary school students p. 24
Hala M El Meselhy, Aml A Salama, Sanaa R El Mawardy
DOI:10.4103/mmj.mmj_883_17  
Objectives The aim of this study was to assess menstrual hygiene of secondary school girls in El Mahallah Elkobra, El Gharbia Governorate. Background As every level of a woman's health influences the next stage, menstrual hygiene is an important component of adolescent health in women, as poor menstrual hygiene can potentially be a cause of urinary tract contagion, reproductive tract infections, and sexually transmitted diseases like cervical cancer, HIV/AIDS, etc. Patients and methods The study was conducted on 704 secondary school female students. They were chosen randomly from four public secondary schools during the scholastic year 2015/2016. A predesigned questionnaire was used to test their menstrual hygiene. Results The study showed that 90% of students had acceptable menstrual hygiene. The majority of the selected girls (98.6%) used disposable sanitary pads. Conclusion Most of the participants in this study have an acceptable menstrual hygiene. Menstrual hygiene is an issue that needs to be addressed at all levels.
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Frequency of unmet needs among women in childbearing period attending Quweisna district, Menoufia Governorate, Egypt p. 29
Taghreed M Farahat, Hala M Shaheen, Fatma A El-Esrigy, Bassma I. M. Morsy
DOI:10.4103/mmj.mmj_211_19  
Objective To assess the possible causes of failure of contraceptive methods and women behavior after failure of different methods. Background Contraceptive failure contributes to a substantial proportion of unintended pregnancy, particularly in the developed world. Patients and methods This descriptive cross-sectional study was conducted on 100 participants in childbearing period aged from 19 to 45 years old with history of failure of contraception or pregnant on top of contraceptive method in the past 3 years. The studied participants were selected from Quweisna Family Health Center (urban area) and Meet Abou-Shikha Family Health Unit (rural area) during the period from the June 1 till the end of September 2017. Participants were assessed through detailed medical, obstetric, and contraceptive history. Results Of 100 studied women with history of failure of contraception, intrauterine contraceptive device (IUCD) and the progesterone-only pills had the highest failure rate among the studied groups (28 and 22%, respectively). Most of the participants with progesterone-only pills and combined oral contraceptives (84 and 70.6%, respectively) had a history of missing pills. Besides approximately half of the participants with missing pills referred it to fear of their adverse effects. Moreover, approximately half of the participants with contraceptive failure (57%) suspected that IUCD displacement was the cause of its failure and 53.3% referred the failure of condom to the irregular use owing to husband refusal. Conclusion The failure of contraceptive method may be related to misuse either missing of pills owing to fear of adverse effects, displacement of IUCD, or partner refusal of condom.
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PUBLIC HEALTH - ORIGINAL ARTICLES Top

Effect of internet use on health-related behaviors and patient–physician relationship p. 33
Mahmoud E Abu Salem, Nagwa N Hegazy, Marwa A Akram Ali
DOI:10.4103/mmj.mmj_218_18  
Objectives This work aimed to understand the relationship between internet use and health-related behaviors. Furthermore, the relationship between internet use and the quality of patient–physician relationship was assessed. Background The rise of the internet has been one of the most striking developments. First, it was quite different from all other media. Second, its presence also influenced communication systems, including interpersonal relationships. Most internet users use the internet to find information about health. They take knowledge gained from the internet to their physicians' consulting rooms. Patients and methods The study was a cross-sectional study. It was conducted on 600 patients. All participants were interviewed using a predesigned questionnaire included socioeconomic status, health behavior, and doctor–patient relationship. Results Overall, 31.8% of internet users were in the age group 31–40 years. Regarding socioeconomic standard, most cases were from high social background (57.3%). Regarding internet use, more than half of the studied group used the internet (87.8%). Regarding health behavior, there was a significant difference in internet use (P ≤ 0.001) and access to the internet at home and work (P ≤ 0.001). Regarding doctor–patient relationship, there was significant difference in age of patient (P = 0.004) and internet use (P ≤ 0.001). Conclusion This study explained that the internet use was an important factor in changing in the communication system, and its effect on physician and patient relationship. With the increasing years of internet use, the doctor–patient relationship became better.
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Evaluation of hospital waste management among tertiary-care hospitals, Menoufia Governorate, Egypt p. 39
Shaimaa Y. Abd El Raouf, Omiyma A El Fateh Mahrous, Yasser H Ibrahim, Hala M Gabr, Aziza S El Badry, Faten E Younis
DOI:10.4103/mmj.mmj_274_19  
Objective To assess the current status of hospital waste management (HWM) and assess environmental lead and cadmium levels at tertiary-care hospitals in Menoufia Governorate. Background HWM has become a critical issue as it poses risks to health and the environment. Materials and methods This is a cross-sectional study that included tertiary-care hospitals in Menoufia Governorate (Menoufia University, National Liver Institute, and Shebin El-Kom Teaching Hospitals) to evaluate HWM through an observational checklist. Air samples had been taken from the studied hospitals for environmental measurements of lead and cadmium levels. Results The administrative tools for HWM were sufficient in the studied hospitals. Waste sorting items were somewhat sufficient, but characteristics of bags and practices during collection and transport of health-care waste were sufficient in the studied hospitals. Waste storage items and special records for hospital waste were somewhat sufficient. Lead and cadmium environmental measurements were within the recommended exposure limit reported by NIOSH. Conclusion HWM was still in its early stage in Menoufia Governorate Hospitals. So, more supervision and implementation of strict rules for HWM were recommended.
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Knowledge, attitude, and practice of breast self-examination among women attending primary health care facility, Menoufia Governorate, Egypt p. 44
Mahmoud A Abo Salem, Howida A Al Shazly, Reda A Ibrahem, Zeinab A Kasemy, Shaimaa Yaihya Abd El-Roaf
DOI:10.4103/mmj.mmj_557_15  
Objectives To evaluate the level of knowledge, attitude, and practice of breast self-examination (BSE) among female in childbearing period (18–49 years old) in Menoufia Governorate. Background BSE is a process whereby women examine their breasts regularly to detect any abnormal swelling or lumps to seek prompt medical attention. Breast cancer is the most common form of cancer among females in developed and developing countries. The early detection of breast cancer is the most important and beneficial area of protective techniques and has been positively linked with decrease of mortality and morbidity owing to the illness. Patients and methods A cross-sectional study was conducted on women attending primary health care facilities in Menoufia Governorate, Egypt. A total of 271 women were included and subjected to predesigned questionnaire to assess their knowledge, attitude, and practice for BSE. Results It was found that 79.7% respondents were aware of BSE. The mass media were the major sources of information (68.4%), whereas the health workers accounted for only 14%. The attitude of participants to health information on BSE was positive. Despite the positive attitude to BSE, its knowledge and practice were low (33.6 and 39.2% had unsatisfactory knowledge and bad practice, respectively). Women with higher level of education (P = 0.009) and those employed in professional jobs (P = 0.001) were significantly more knowledgeable about BSE. Conclusion and recommendations There was low level of knowledge about BSE. The attitude of participant was generally positive, but the rate of practicing BSE was low. We recommend the establishment of institutional framework and policy guidelines that will enhance adequate and urgent dissemination of information about breast cancer and BSE to all women in Menoufia.
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Epidemiology of nocturnal enuresis among primary school children (6–12 years) in Gharbia Governorate p. 50
Mahmoud E Abu Salem, Hewaida M El Shazly, Safa'a Badr, Faten Younis, Sherin M. Derbala
DOI:10.4103/mmj.mmj_200_18  
Objective The aim of this study was to determine the prevalence of nocturnal enuresis (NE) and identify its risk factors among primary school children (6–12 years) in Gharbia Governorate. Background NE is a challenging issue, mostly seen during childhood. However, the exact prevalence is often under-reported. Large epidemiological studies suggested the prevalence rates of 15–20% among children 5 years and older. Participants and methods A case–control cross-sectional study was conducted during the academic year 2017–2018 in Gharbia Governorate primary schools on 510 school students aged 6–12 years. The students were chosen from two schools using multistage random sample. Student's families were asked to complete a predesigned questionnaire. Urine and stool analyses were done. Results The prevalence of NE was 14.3%. The prevalence was slightly higher among boys than girls, with 14.8 and 13.9%, respectively, and it was more common among rural children than urban ones, with 19.1 and 7.5%, respectively. NE prevalence markedly decreases by increase in age. Primary enuresis more than secondary, low socioeconomic standard, low educational level of parents, and family history of NE were the contributing factors of NE among studied children. Deep sleep, constipation, and urinary tract infection were associated with NE. Conclusion Enuresis is a pediatric public health problem that is often associated with young age. It may lead to low self-esteem, some secondary psychological problems, and low school success. Consequently, it is necessary to recommended health promotion and prevention programs that are directed toward the screening, diagnosis, and management of NE among primary school students.
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TROPICAL MEDICINE - ORIGINAL ARTICLE Top

Insulin resistance as a noninvasive predictor of esophageal varices in hepatitis C virus cirrhotic patients p. 55
Atef A Ali, Belal A Montaser, Heba G Abdel-Fattah, Ahmed R El-Gazzarah
DOI:10.4103/mmj.mmj_62_19  
Objectives The aim was to evaluate sensitivity and specificity of insulin resistance (IR) as a noninvasive predictor of esophageal varices (EV) in hepatitis C virus (HCV) cirrhotic patients. Background Variceal bleeding due to portal hypertension is associated with a high probability of circulatory dysfunction and even death. However, routine endoscopy is an invasive maneuver which consumes effort, time, and money. IR was studied as an early noninvasive predictor of EV. Patients and methods Eighty cirrhotic patients were included in this prospective case–control study and 20 nondiabetic nonhepatic patients served as the control group. Patients were recruited from the Gastrointestinal Endoscopy Unit of Tropical Medicine Department, Menoufia University Hospitals from January 2017 to March 2018. IR was calculated by the homeostasis model assessment (HOMA-IR)=fasting insulin (μU/ml)×fasting glucose (mmol/l)/22.5. Results HOMA-IR showed a high statistically significant correlation with the presence and grade of EV in HCV cirrhotic patients (P < 0.001). In comparison with others noninvasive predictors, HOMA-IR gave the highest sensitivity at a cutoff value of 4.41. Next, the midclavicular liver span/albumin ratio at a cutoff value of 3.51 was followed by the portal vein diameter at a cutoff value of 13 mm. The least sensitive predictor was the platelet count/splenic bipolar diameter ratio at a cutoff value of 1414. Conclusion IR estimated by HOMA-IR can provide sensitive information for determination of the presence and grade of EV in HCV cirrhotic patients regardless of their Child–Turcotte–Pugh classification.
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Study the efficacy of sofosbuvir/daclatasvir in treatment of hepatitis C virus in Egypt p. 62
Mohammed A Nouh, Ayman A. E Ahmed Ali, Ahmed R El-Gazzarah
DOI:10.4103/mmj.mmj_95_19  
Objectives To evaluate the efficacy of combination therapy of sofosbuvir and daclatasvir with or without ribavirin as a treatment of chronic hepatitis C virus (HCV), estimated by the rate of achievement of sustained viral response 12 weeks. Background Direct-acting antiviral agents opened the gate to a new era for the management of HCV. These agents have shown high sustained viral response rates of ~90% in clinical trials, shorter therapies, less toxicity, and interferon-free regimens. Patients and methods This prospective, population-based study included 401 HCV-infected patients, 18–75 years of age, attending the Viral Hepatitis Unit of the National Committee for Control of Viral Hepatitis at Center of Cardiac and Digestive System, Sohag, who were divided into two groups: group I (easy to treat) was treated by sofosbuvir + daclatasvir for 3 months, and group II (difficult to treat) was treated by sofosbuvir + daclatasvir + ribavirin for 3 months. Results There was a high statistically significant difference between the studied groups regarding liver echo pattern, splenic size, fibrosis index based on the 4 factors, blood glucose, international normalized ratio, total bilirubin, serum albumin, aspartate transaminase, and platelet count (P < 0.001). Moreover there was a statistically significant difference regarding diabetes prevalence, alanine transaminase, and hemoglobin (P < 0.05). There was a statistically insignificant difference regarding total leukocytic count and serum creatinine levels (P > 0.05). Conclusion The treatment regimen of sofosbuvir + daclatasvir with/without ribavirin for chronic HCV patients was of high efficacy.
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Role of serotonin in development of esophageal and gastric fundal varices p. 69
Mohamed Alaa El-Din Nouh, Hossam El-Din Mostafa Seleem, Sally Mohammed Elhefnawy, Sabrin Mohammed Samy Asila
DOI:10.4103/mmj.mmj_274_18  
Objective The aim was to determine the role of plasma free serotonin concentrations on the development of esophageal and gastric fundal varices. Background Esophageal and gastric varices are a serious consequence of portal hypertension in patients with the chronic liver disease. Several studies have evaluated possible noninvasive predictors for the presence of varices including plasma serotonin level. Materials and methods This study was conducted on 100 patients: 60 hepatic patients with esophageal and/or gastric varices, 20 hepatic patients without varices, and 20 nonhepatic patients who were admitted to Tropical Medicine Department in Menoufia University Hospitals. Patients and control were subjected to laboratory investigations, abdominal ultrasound, upper endoscopy, and quantitative measurement of plasma free serotonin using enzyme-linked immunosorbent assay technique. Results The plasma free serotonin levels were much higher in patients with liver cirrhosis with varices than in nonhepatic patients (mean: 92.240 ± 18.534 vs. 20.015 ± 3.042 ng/ml; P < 0.0001). Moreover, plasma serotonin level was much higher in patients with varices than patients without varices (mean: 92.240 ± 18.534 vs. 42.220 ± 9.891 ng/ml; P < 0.0001). The best cutoff value of free serotonin in the prediction of esophageal and gastric varices was greater than or equal to 25.3 ng/ml, with sensitivity of 98.75%, specificity of 100%, positive predictive value of 100.0%, and negative predictive value of 95.2%. Conclusion Free serotonin is significant in the development of esophageal and fundal varices, indicating the clinical value of serotonergic receptor blockers in these patients.
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INTERNAL MEDICINE - ORIGINAL ARTICLES Top

Effect of direct-acting antiviral agents on hepatitis C virus-associated thrombocytopenia p. 76
Aly M El-Kholy, Sabry A Shoeib, Hasan A Zagla, Mohamed A Abdelhafez, Alaa E Abdelhamid, Zeinab A. A. Kasemy, Essam A Abdelmohsen
DOI:10.4103/mmj.mmj_55_19  
Objectives To evaluate the effect of direct-acting antiviral agents (DAAs) on hepatitis C virus (HCV)-associated thrombocytopenia. Background The prevalence of thrombocytopenia in HCV infection ranged from 0.16 to 45.4%. The pathophysiology of HCV-associated thrombocytopenia is poorly understood and multifactorial. Cellular immunity has an important role. Antiplatelet antibodies are common. Production of thrombopoietin may be reduced. Infection of megakaryocytes with HCV may impair platelet production. Clearance of HCV with DAA is expected to restore innate functions of the hepatocytes and immune system reconstitution. Patients and methods This was a prospective study on 104 patients with HCV-associated thrombocytopenia receiving DAA (sofosbuvir and daclatasvir); the selected patients were followed up every 4 weeks during antiviral therapy, and at 24 weeks, clinically, and by complete blood count. Results The results show that the platelet counts initially decreased on starting the antiviral treatment, then increased gradually and steady during and after the treatment. Thirty-four patients obtained a normal platelet count of more than 150 000 × 103/mm3 at 24 weeks of starting the treatment, and 72 patients obtained a platelet count of more than 100 000 × 103/mm3 at 24 weeks of starting the treatment. There was a significant correlation with the Child–Pugh class, and FibroScan score, and no significant correlation with splenomegaly. Conclusion DAA therapy is an effective and safe treatment, and is recommended as a first-line treatment for HCV-associated thrombocytopenia. The main postulated mechanism of HCV-associated thrombocytopenia is the immune-mediated effects of HCV, and DAA therapy has the ability of immune system reconstitution.
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Paraoxonase-1 enzyme activity in rheumatoid arthritis patients: association with carotid intima-media thickness? p. 82
Sabry A Shoeib, Ahmed R Tawfeek, Waleed M Fathy, Mohamed Z Nouh, Aly M El-Kholy
DOI:10.4103/mmj.mmj_5_16  
Objectives The aim was to find the relationship of biochemical determinants of paraoxonase-1 (PON1) enzyme activity with carotid intima-media thickness (IMT) as a surrogate marker of atherosclerotic cardiovascular (CV) disease risk in patients with rheumatoid arthritis (RA). Background There is strong correlation between patients with RA and CV morbidity and mortality that cannot be explained by traditional risk factors alone. And this could be due to abnormal function of high-density lipoproteins (HDL). HDL promotes cholesterol efflux, as well as protects low-density lipoprotein (LDL) against oxidation, and this ability has been referred to as an 'anti-inflammatory' function because the lipid oxidation products derived from LDL are highly proinflammatory. PON1 is an HDL-associated enzyme that promotes antioxidant and anti-inflammatory properties of HDL by preventing the formation of oxidized LDL and inactivating oxidized phospholipids. Patients and methods The authors conducted a case–control study, including 30 RA patients and 20 controls, enrolled in Menoufia, Egypt. B-mode Doppler ultrasound imaging to measure carotid IMT, C-reactive protein (CRP), erythrocyte sedimentation rate, lipid profile, and PON1 activity were measured. Results RA patients tended to be more dyslipidemic as evidenced by decreased HDL and increased total cholesterol, tryglycerides (TGD), and LDL, which showed increased carotid IMT and decreased PON1 activity than the control group. Patients with carotid plaque tended to be more dyslipidemic and plasma PON1 activity tended to be lower than in patients without carotid plaque. A significant correlation between plasma PON1 activity and systemic inflammation as measured by the erythrocyte sedimentation rate and hsCRP level was noted. Conclusion Our data suggest that the lower the activity of PON1, the higher the atherosclerotic CV disease risk in RA patients, as assessed by the presence of carotid plaque. There is a significant correlation between plasma PON1 activity and systemic inflammation in RA patients. Higher hsCRP levels were associated with lower PON1 activity.
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Effect of obesity on YKL-40 serum level to evaluate its role as an independent marker in type 2 diabetic nephropathy Highly accessed article p. 89
Mohamed A. E. Korany, Mohamed Z Nouh, Thoria A Omar, Fady W. T. Morkos
DOI:10.4103/mmj.mmj_331_18  
Objective The objective of this study was to evaluate the serum YKL-40 level as an independent marker in patients with type 2 diabetic nephropathy (DN). Background DN is a microvascular complication of type 2 diabetes mellitus. The association of YKL 40 serum level with obesity and type 2 DN has not been adequately studied. Patients and methods This study was conducted on 75patients with type 2 DN(25 obese with type 2 DN,25 nonobese patients with type 2 DN,and25 obese without diabetes) fromJuly 2017 to February 2018. Full history, physical examination, serum urea, serum creatinine, estimated glomerular filtration rate (eGFR), glycated hemoglobin 1c (HbA1c), serum YKL-40, urinary albumin/creatinine ratio (ACR) and abdominal ultrasonography were done. Results There was no significant difference among the three groups regarding sex (P = 0.527), drug taking (P = 1.0), age (P = 0.149), and serum urea (P = 0.496), whereas there was a highly significant difference among all groups regarding BMI, YKL 40 serum level, ACR, HbA1c, eGFR, and serum creatinine level (P = 0.001 for all). YKL-40 level was significantly positively correlated with BMI, creatinine level, ACR, and HbA1c and in a negative correlation with eGFR in all groups. Conclusion YKL-40 significantly correlates with biochemical renal parameters like ACR, creatinine, and eGFR; glycemic parameter, HbA1c; and obesity measure, BMI. Our study suggests that YKL-40 can be a marker of microvascular complications such as DN but not an independent marker owing to positive affection of obesity on its serum level.
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Study of pepsin level in saliva as a noninvasive marker for diagnosis of gastroesophageal reflux disease p. 94
Hosam I Mohamed, Siham A Khodeer, Walaa A Shaheen
DOI:10.4103/mmj.mmj_371_16  
Objective This study aimed to evaluate the role of salivary pepsin level as a noninvasive marker for diagnosis of gastroesophageal reflux disease (GERD) and its endoscopic severity. Background GERD is one of the most commonly encountered gastrointestinal diseases. Confirmation of the diagnosis mostly entails the use of invasive procedures. Salivary pepsin level has been discussed previously in studies of extraesophageal symptoms of GERD. Patients and methods This study was conducted on 50 patients with clinical and endoscopic evidences of erosive reflux disease (GERD group) versus 25 patients with upper gastrointestinal symptoms not consistent with GERD and in whom endoscopic findings proved absence of GERD (non-GERD group). In addition, 20 healthy participants were selected as a control group. Patients and control were subjected to GERD Q questionnaire, upper gastrointestinal endoscopy, and quantitative measurement of salivary pepsin using ELISA kits. Results There was a highly significant increase in the mean value of salivary pepsin in GERD group (88.64 ± 46.37 ng/ml) when compared with non-GERD (38.08 ± 35.57) and control group (18.65 ± 14.71) (P = 0.0008 and 0.001, respectively), whereas there was no significant difference (P = 0.226) between non-GERD and control group. There was a highly significant increase (P = 0.0008) in mean value of salivary pepsin in patients with GERD complicated with Barrett's esophagus (152.50 ± 27.12) when compared with patients with GERD without this complication (76.48 ± 38.70). Conclusion Salivary pepsin is a simple noninvasive marker for diagnosis of GERD and its severity.
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Evaluation of klotho protein level in chronic kidney disease patients p. 101
Ahmed R El-Arbagy, Hany S El-Barbary, Mahmoud M Emara, Heba A.M. Anwar Dawoud
DOI:10.4103/mmj.mmj_11_19  
Objective The aim of this study is to assay the level of serum klotho protein in chronic kidney disease (CKDs) patients and the relation between its level and cardiovascular complications and mineral bone diseases. Background Klotho protein is a new diagnostic and prognostic biomarker in kidney diseases. Klotho protein deficiency plays an important role in the calcification of vascular and soft tissues. Cardiovascular diseases are the most important causes of morbidity and mortality in CKD patients. Patients and methods The study included 60 CKD patients on hemodialysis, 15 CKD patients without hemodialysis, and 14 apparent healthy persons; all are of different age and sex. All groups underwent the same examination and investigation: serum klotho levels assessment and other routine laboratory investigation, for example, blood urea, serum creatinine, serum phosphorous, serum calcium, complete blood count, and serum parathormone. Echocardiography and abdominal radiography are done to all the studied groups and the results are tabulated and analyzed. Results The serum klotho levels are markedly decreased in CKD patients. Serum klotho level is decreased with the increase in age; there was an inverse relationship between serum klotho, blood urea and serum creatinine (P = 0.001) and between serum klotho and phosphorous (P = 0.004); the relation between serum klotho and echo findings was significant (P = 0.025). Conclusion CKD is a statement of klotho deficiency, there is a marked decrease in serum klotho level in the CKD patients Cardiovascular complications especially aortic calcification were found with low-serum klotho level.
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Predictors of erythropoietin hyporesponsiveness in chronic hemodialysis patients p. 105
Ahmed Rabea, Ahmed Ragheb, Mahmoud Emara, Ahmed M Kamal
DOI:10.4103/mmj.mmj_52_19  
Objective The aim of this work was to assess different clinical and laboratory parameters to predict erythropoietin hyporesponsiveness in chronic hemodialysis patients with anemia. Background Anemia resistant to erythropoietin-stimulating agents (ESAs) is a risk factor for all-cause mortality. Determining the etiologies of hyporesponsiveness may help to overcome the resistance. Patients and methods This cross-sectional study was carried out on 97 chronic hemodialysis patients attending Menoufia University Hospital and Manshiet Sultan hemodialysis units. Patients were classified according to the presence of anemia (hemoglobin < 10 g/dl) and ESA hyporesponsiveness index more than or equal to 10 into four groups: group I comprised nonanemic and ESA-responsive patients, group II comprised nonanemic and ESA-hyporesponsive patients, group III comprised anemic and ESA-responsive patients, and group IV comprised anemic and ESA-hyporesponsive patients. We compared groups I and IV with respect to influential factors. Results The proportion of patients treated with renin-angiotensin-aldosterone system blockers (RAAS blockers) was significantly higher in group IV compared with group I (P = 0.000). Group IV patients had significantly lower dialysis adequacy (Kt/V) (P = 0.029) and significantly higher platelet to lymphocyte ratio (PLR), C-reactive protein (CRP), and intact parathormone hormone (P = 0.002, 0.000, and 0.006, respectively). There were significant positive correlations between mean ESA hyporesponsiveness index and CRP, PLR, and intact parathormone hormone and negative correlation with Kt/V. In multivariate analysis, treatment with RAAS blockers, inflammatory markers (PLR and CRP), and secondary hyperparathyroidism were independent predictors of ESA resistance. Conclusion RAAS blockers' treatment, inflammation, and secondary hyperparathyroidism could be considered as predictors of ESA hyporesponsiveness.
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The relationship between hypoalbuminemia and intradialytic hypotention in hemodialysis patients p. 110
Mahmoud Kora, Ahmed Tawfeek, Khaled El-zorkany, Asmaa H Abd El-Mohsen
DOI:10.4103/mmj.mmj_108_18  
Objective The aim of this study was to evaluate the relationship between serum albumin and intradialytic hypotension (IDH). Background Hypoalbuminemia and IDH are common complications during hemodialysis (HD) session. Hypotension is a risk factor for mortality and morbidity in HD patients. Patients and methods We conducted a cross-sectional study on 50 patients with end-stage renal disease who received regular HD session three times weekly for more than 3 months (from April to July 2017) at Ashmoun General Hospital. They were divided into two groups: group 1 included patients who developed recurrent attacks of IDH (24 patients) and group 2 included patients who did not develop IDH (26 patients). Data collected from each patient included the following: (i) demographic features and clinical features (blood pressure (BP) changes during session, ultrafiltration rate, intradialytic weight gain, duration of dialysis, cause of end-stage renal disease, surface area of dialyzer, and blood flow of the machine); (ii) blood chemistry (creatinine level, urea, hemoglobin, hematocrit value, albumin, triglycerides, cholesterol, aspartate aminotransferase, alanine aminotransferase, Na*, K*, and KT/V); (iii) echocardiographic assessment of left ventricular geometry; and (iv) inferior vena cava-guided ultrasonography. Results Serum albumin level among group I ranged between 2.4 and 4.7 mg/dl, with mean ± SD of 3.1 + 0.53 mg/dl, whereas in group II, serum albumin level ranged between 2.6 and 4.6 mg/dl with mean ± SD of 3.6 ± 0.48 mg/dl, with P value of 0.002, indicating there was a high significant difference between both groups. There was a highly significant positive correlation between delta systolic BP and IVC collapsibility index (IVCC). There was a highly significant negative correlation between serum albumin and IVCC, and there was a highly significant negative correlation between delta systolic BP and IVC diameter. Conclusion We concluded that serum albumin is a parameter that is associated with IDH and found that bedside measurements of IVCC and IVC diameter are easy and good markers for prediction of IDH.
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MicroRNA and liver diseases p. 116
Ehab A Abdel-Atti, Alsayed I Alshayeeb, Ahmed A Abdalwahab
DOI:10.4103/mmj.mmj_227_18  
Objective The aim was to review and update the relationship between microRNA and various liver diseases such as viral hepatitis, liver cirrhosis, alcoholic liver disease, liver fibrosis, and hepatocellular carcinoma. Background MicroRNAs play an important role in miscellaneous cellular process including development, immunity, cell-cycle control metabolism, viral or bacterial disease, stem cell differentiation, and oncogenesis. Materials and methods Medline databases, including PubMed, Medscape, Science Direct, and EMF-Portal, and all materials available on the internet from 2004 to 2018 were searched. The initial search presented many articles that studied the microRNA and its relation to various liver diseases. 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. Comparisons were made by structured review with the results tabulated. Findings MicroRNAs are recognized to play an important role in diagnosis, prognosis, and treatment in various liver diseases. Conclusion The significance of miRNA regulation in different physiological and pathological conditions is becoming increasingly visible and undeniable. A number of studies have reported the crucial roles that miRNAs exert along the onset and development of various pathologies including acute and chronic liver diseases such as nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, liver fibrosis, liver cirrhosis, and also hepatocellular carcinoma.
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Assessment of vitamin D in hemodialysis patients p. 122
Ahmed R El-Arbagy, Khaled M. A El-Zorkany, Mohamed A Helwa, Eslam A.M El-Khalifa
DOI:10.4103/mmj.mmj_317_18  
Objective To evaluate vitamin D status among our prevalent dialysis population to help rapid treatment and prevent complications. Background Hemodialysis patients have markedly higher rates of severe vitamin D deficiency and reduced ability to convert 25(OH) vitamin D into the active form 1, 25-dihydroxyvitamin D. Patients and methods This cross-sectional study includes 70 patients randomly selected from prevalent dialysis population in Elshohda Hospital in Menoufia, and 20 healthy participants with no chronic illness enrolled as a control group. Their 25(OH) vitamin D level was estimated, and individuals who had 25(OH) vitamin D level less than or equal to 30 ng/ml were considered 25(OH) vitamin D deficient and individuals who had 25(OH) vitamin D level more than 30 ng/ml were considered 25(OH) vitamin D sufficient. Patients were subjected to complete history taking and full clinical examinations, and peripheral blood samples were analyzed for complete blood picture, serum albumin, serum calcium, serum phosphorus, intact parathyroid hormone, and serum 25-hydroxyvitamin D. Results This study showed that 74.3% of patients had 25(OH) vitamin D level less than or equal to 30 ng/ml and 25.7% had 25 (OH) vitamin D level more than 30 ng/ml. The control group showed that 70% had 25(OH) vitamin D level less than 30 ng/ml and 30% had 25(OH) vitamin D more than 30 ng/ml. No significant association was found between 25-hydroxyvitamin D and age, sex, parathyroid hormone, BMI, duration of dialysis, calcium, and phosphorus. Conclusion Our study showed that most of our hemodialysis patients (74.3%) had vitamin D deficiency. This percentage is more than the deficiency in control group. No significant association was found between 25-hydroxyvitamin D and age, sex, intact parathyroid hormone (iPTH), calcium, phosphorus, BMI, and duration of dialysis.
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PEDIATRICS - ORIGINAL ARTICLES Top

Prevalence of glucose level abnormalities in neonatal sepsis and its association with mortality p. 127
Dalia M Ellahony, Muhammad S El-Mekkawy, Abd El Hameed R A. Issa
DOI:10.4103/mmj.mmj_216_18  
Objective To determine the prevalence of plasma glucose abnormalities among infants with neonatal sepsis and their association with mortality and morbidity. Background Plasma glucose abnormalities were previously noted in neonatal sepsis, but data in full-term neonates is limited and the association with mortality and morbidity is not established. Patients and methods This was a prospective observational study including 114 full-term neonates with culture-proven and probable sepsis. Plasma glucose level was measured within 2 h of neonatal intensive care unit admission and the patients were monitored till discharge or mortality. The patients were divided into three groups according to their plasma glucose level into hyperglycemic, hypoglycemic, and normoglycemic subgroups. Results Of the patients, 8.7% were hyperglycaemic; 8.7% were hypoglycemic, and 82.6% were normoglycemic. Mortality in the hypoglycemic, hyperglycemic, and normoglycemic subgroups were 20, 20, and 17%, respectively (P = 0.8). There was no significant difference in the length of hospital stay according to the glycemic status (P = 0.3). In addition, the glycemic status was not associated with the need for mechanical ventilation (P = 0.99). Conclusion Plasma glucose abnormalities are not uncommon among full-term neonates with sepsis. However, these abnormalities are not associated with morbidity or mortality. Larger studies are needed to confirm these findings.
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The role of measurement of serum mannose-binding lectin in diagnosis of sepsis and prediction of prognosis among children admitted into the pediatric intensive care unit p. 132
Fady M El Gendy, Muhammad S El-Mekkawy, Ahmed A Sonbol, Osama A.R. Diab
DOI:10.4103/mmj.mmj_260_19  
Objective To evaluate validity of serum mannose-binding lectin (MBL) measurement in diagnosis and prognosis of sepsis among critically ill children. Background MBL is a part of the innate immune system with a potential role in sepsis susceptibility. Patients and methods A prospective observational study was conducted that included 50 critically ill children admitted into the pediatric intensive care unit. Another group of 38 healthy children served as a control group. Serum MBL level was measured for all patients (within 24 h) and controls. Patients were monitored till hospital discharge to determine the diagnosis of sepsis and occurrence of morbidity and mortality. Results No significant difference in MBL level was noted between septic patients and controls [median and range = 2.1 (1.2–298) vs. 2.25 (1.4–134); P = 0.45] or between survivors and nonsurvivors [median and range = 2.4 (1.1–298) vs. 10.95 (1.3–244); P = 0.75]. MBL had a significant negative correlation with C-reactive protein (rs=−0.33; P = 0.021) but not with pediatric risk of mortality, pediatric index of mortality 2, or sequential organ failure assessment score. MBL had a poor area under receiver operating characteristic (area under the curve) curve for prediction of mortality compared with pediatric risk of mortality, sequential organ failure assessment, and pediatric index of mortality 2 (area under the curve = 0.54, 0.91, 0.90, and 0.75, respectively). No significant correlation was found between MBL and length of pediatric intensive care unit stay or mechanical ventilation duration. Conclusion MBL is neither useful for sepsis diagnosis nor prediction of mortality or morbidity. The routinely available markers and prognostic scores are much more powerful compared with an expensive marker like MBL.
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Left ventricular functions in patients with beta-thalassemia major: a speckle tracking imaging study p. 138
Ahmed A Khattab, Mohamed F Elnoamany, Naglaa F Ahmed, Doaa M Elian, Amir I Lashin
DOI:10.4103/mmj.mmj_639_16  
Objectives To assess left ventricular (LV) functions in patients with beta-thalassemia major (β-TM) on regular blood transfusion (without cardiac manifestations) by speckle tracking echocardiography and correlate the findings with serum ferritin levels of these patients. Background Patients with β-TM have extravasal hemolysis and ineffective erythropoiesis, resulting in severe anemia. Thus, they require regular blood transfusions, which results in iron overload. Patients with thalassemia absorb more iron than normal individuals. Iron overload results in iron deposition in a variety of parenchymal tissues including the heart leading to ventricular systolic and diastolic dysfunctions. Iron-mediated cardiomyopathy is the main cause of death in patients with thalassemia. Early detection of cardiac abnormalities is important as aggressive chelation therapy may improve prognosis in these patients. Patients and methods A total of 50 patients with β-TM on regular blood transfusion for more than or equal to 4 years and 25 sex-matched and age-matched controls were included. The laboratory parameters measured were blood hemoglobin and ferritin, which were measured 2 h before doing echocardiography with Doppler imaging and speckle tracking analysis. Results There were no significant differences in LV ejection fraction and fractional shortening between the groups by conventional echocardiography. However, by using speckle tracking echocardiography, systolic strain and strain rate of the LV walls were significantly lower in patients with thalassemia. Conclusion Patients with thalassemia have regional systolic dysfunction in the LV walls, even if they do not have overt heart failure. Strain imaging is more helpful than conventional echocardiography in early detection of LV systolic dysfunction in patients with thalassemia.
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Study of serum leptin level in children with cyanotic and acyanotic congenital heart disease p. 152
Fahima M Hassan, Ahmed A Khatab, Rania S El-Zayat, Mona S Habib, Rania S.H. Ali
DOI:10.4103/mmj.mmj_21_17  
Objective The aim of this study was to measure serum leptin levels in children with cyanotic and acyanotic congenital heart disease and to examine its possible role in growth in these children. Background Leptin has been shown to be an integral component of energy homeostasis and regulation of body weight. Leptin regulates adipose tissue mass and correlates with the fat mass. Research on the physiological function of leptin has primarily focused on its role in the pathogenesis of obesity. Children with congenital heart disease are at increased risk for poor growth. Several factors may play a role in poor growth, including feeding difficulties, increased caloric requirements, and the effects of cardiac lesions on growth regulation. Patients and methods This study was carried out over 1 year on 35 patients with congenital heart disease [20 patients were acyanotic (12 boys, 8 girls) and 15 patients were cyanotic (9 boys, 6 girls)] in the Pediatric Cardiology Department in Menoufia University Hospital and 35 apparently healthy children of the same age (range: 3 months–12 years), sex, and socioeconomic status. All patients and controls were subjected to a complete assessment of history, a thorough clinical examination, chest radiograph, ECG, echocardiography, and measurement of serum leptin level. Results Children with cyanotic congenital heart disease had statistically significant lower weight, length, mid-arm circumference, and BMI. There was no statistically significant difference in serum leptin levels in the cyanotic, acyanotic, and control groups. Serum leptin level was correlated positively with BMI and mid-arm circumference in all groups. Conclusion Serum leptin level did not change in children with acyanotic and cyanotic congenital heart disease, suggesting that other factors may regulate nutrient intake, growth, weight, and energy input and output in these children.
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Probable relationship between Toxoplasma gondii and children with cryptogenic epilepsy p. 157
Ahmed A Khatab, Mohamed A Soliman, Sameh A Abd El-Naby, Sally S. M El-Dabaa
DOI:10.4103/mmj.mmj_263_18  
Objective The aim was to determine the association between Toxoplasma gondii infection and cryptogenic epilepsy. Background Cryptogenic epilepsy is defined as a group of epilepsy syndromes for which etiology is unknown, but an underlying brain disease is suspected. We selected patients in this subgroup of epilepsy and investigated the seropositivity rate for antitoxoplasma immunoglobin (Ig)G antibodies by enzyme-linked immunosorbent assay. T. gondii is found in up to 20% of the US population, forming dormant brain cysts in the latent bradyzoite form. We investigated the probable relationship between T. gondii infection and cryptogenic epilepsy. Materials and methods This was a case–control prospective study conducted on 70 children in the time period between 1/2017 and 4/2018 from those attending the outpatient clinic of pediatric neurology at Menoufia University Hospital and Shebein El-Kom teaching hospital. We selected 30 patients with cryptogenic epilepsy, 20 patients with known-cause epilepsy, and 20 healthy children sex-matched and age-matched with epileptic children who served as a control group. We investigated the seropositivity rate for antitoxoplasma IgG antibodies by enzyme-linked immunosorbent assay. Results The seropositivity rate for antitoxoplasma IgG antibodies among patients with cryptogenic epilepsy (40%) was found to be higher than healthy volunteers (10%) and patients with known-cause epilepsy (10%), with statistical significance (χ2 = 8.006, P = 0.014). This significance persists after adjustment for subjects' sex and age in a multiple logistic regression model. Conclusion Our results suggest that chronic T. gondii infection may be a cause of cryptogenic epilepsy.
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Prevalence of rheumatic heart disease in school children aged 6–15 years p. 162
Salem E Deraz, Rania S El-Zayat, Ahmed M Badawy
DOI:10.4103/mmj.mmj_264_18  
Objective The aim of the study was to detect the prevalence of rheumatic heart disease among school children aged 6–15 years old. Background Acute rheumatic fever is a disease that affects skin, subcutaneous tissue, joints, brain and heart. Before the availability of echocardiography, the diagnosis of rheumatic carditis depended upon clinical evidence of valvulitis. Nowadays, patients with definite rheumatic fever or suspected cases should undergo echocardiography to identify carditis. Patients and methods A permission was obtained from the ethical committee on the research. This study was done on 5000 student aged 6–15 years. The children had comprehensive history taking and clinical examination for signs of rheumatic heart disease. Those with any abnormality in history or clinical examination were investigated by echocardiography. Results A total of 5000 school children aged 6–15 years were included in this study. An abnormal cardiac examination and abnormal history were reported in 48 students. Overall, 13 students refused to undergo echocardiography. The result of echocardiography done was as follows: five cases had definite rheumatic heart disease, 10 cases had mitral regurge not meeting the criteria of rheumatic heart disease, one case had aortic regurge not meeting the criteria, one case had a ventricular septal defect, and the others were normal. Conclusion The use of echocardiography as diagnostic criteria of rheumatic heart disease can prevent both overdiagnosis and underdiagnosis of that disease. The prevalence rate of rheumatic heart disease in our study was found to be one per thousand (0.1%), which is less than other studies done in Egypt.
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Study of some factors associated with prolonged neonatal jaundice p. 167
Maha A Tawfeek, Dalia M Ellahony, Ismail A.A. Abdulhadi
DOI:10.4103/mmj.mmj_279_18  
Objective The aim was to study some factors associated with prolonged neonatal jaundice and to find out the important investigations that should be performed to such cases. Background Prolonged neonatal jaundice represents a dilemma for many doctors. Many factors are responsible for its occurrence. Patients and methods This is a cross-sectional study on 55 cases of prolonged neonatal jaundice, conducted from Menoufia and Benha university hospitals from November 2017 to July 2018. All cases were subjected to history taking, clinical assessment, and investigations including complete blood count, c-reactive protein, total and direct serum bilirubin, blood group and RH factor for the cases and their mothers and urine analysis. We investigated cases with prolonged direct hyperbilirubinemia for alanine aminotransferase, aspartate aminotransferase and abdominal ultrasonography. Results Cases aged ranged from 14 to 49 days of life, with mean age '19.3 ± 5.3' that included nine preterm and 46 full term. Prolonged indirect neonatal hyperbilirubinemia was found in 85% of cases, while 15% had direct hyperbilirubinemia. All cases showed normal complete blood count. C-reactive protein is negative in all cases. Breast-milk jaundice was found in 32.7%, ABO incompatibility in 22%, while RH incompatibility in only 3.6% of cases. Pyuria greater than or equal to 6 pus cells/ High power field (HPF) was found in 20% of cases and they had higher serum bilirubin than the other cases without pyuria. Conclusion The most common associated factor was breast-milk jaundice, then ABO incompatibility and then pyuria. Blood group identification to the mother and their neonates and urine analysis have a great diagnostic value in these cases. Larger studies are needed to confirm these findings.
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Evaluation of serum resistin in children with chronic renal failure p. 173
Maha A Tawfik, Mohamed A Soliman, Zein A Omar, Sekina Z. M Elsawy Derbala
DOI:10.4103/mmj.mmj_310_18  
Objective To evaluate the serum level of resistin in kids with persistent renal failure and correlation with other medical and laboratory parameters. Background Serum resistin is elevated in chronic renal failure due to a reduced renal clearance and there may be an inverse correlation between resistin and renal characteristic. Patients and methods This study was carried out as a case–control study and included 96 children aged from 6 to 18 years (34 undergoing hemodialysis and 30 on conservative remedy) and 32 apparently healthy kids who constituted the control group, who were recruited from the pediatric hemodialysis unit of Menoufia University Health Facility, Egypt, from May 2017 to April 2018. Complete blood count and electrolytes have been measured before hemodialysis; however, serum resistin was measured before and after hemodialysis in kids with persistent renal failure. Results A highly significant increase in resistin level in the case groups and the control group. This highly significant difference found in the resistin level differed according to the chronic kidney disease stage of progression as the hemodialysis patients have higher resistin levels than patients on conservative treatment. There was a highly significant decrease in resistin level after hemodialysis session than before. Conclusion Patients with chronic renal failure had higher serum resistin levels than the control group and it was found that resistin levels were more elevated in hemodialysis patients than patients on conservative treatment. So, it could be considered as a new diagnostic marker in chronic renal failure and serum resistin levels are reduced by hemodialysis treatment.
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Assessment of blood level of vitamin C in children with bronchial asthma p. 179
Fahima M Hassan, Ahmed A Khatab, Rania S El-Zayat, Sally M El-Hefnawy, Heba G. A El-Hameed
DOI:10.4103/mmj.mmj_287_18  
Objective The aim was to assess the serum level of vitamin C in children with bronchial asthma. Background Vitamin C is abundant in the extracellular and intracellular lining fluid of the lungs, so it can participate in the primary lung defense against the reduction of oxidative mechanisms and therefore it has protective effects against bronchial asthma. Patients and methods This study was a case–control study that involved 60 pediatric patients with bronchial asthma as the cases group and 25 apparently normal children as the control group. All patients and controls were subjected to the same history taking, clinical examination, and investigations which involved: (a) laboratory investigations such as (i) complete blood count (red blood cells–white blood cells–platelets) by coulter, (ii) Differential leukocytic count especially (eosinophils), (iii) estimation of plasma level of vit C; (b) plain radiography for chest and heart (posteroanterior view): to exclude other chest diseases such as atelectasis or pneumonia and heart failure or cardiomegaly; and (c) pulmonary function tests such as spirometry: the apparatus used was ZAN 100 Spirometry. This was a portable spirometer capable of measuring both expiratory and inspiratory parameters. It was done to children above 6 years of age only. The pulmonary function tests used were forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC%). Results Bronchial asthma was predominant in men (about 31 men, 51.66%) than women (about 29 women 48.33%) in the cases group. Thirty-two asthmatic children (about 53.3%) had a positive history of consanguinity and 32 asthmatic children (about 53.33%) had a positive history of atopy. There were highly statistically significant differences between cases and control groups as regards FVC% and FEV1(P < 0.001) as mean + SD of FVC% of the cases group were 80.25 ± 7.0123 while in the control group it were 92.36 ± 3.463 and mean + SD of FEV1of cases group were 69.68 ± 8.977 while in the control group it were 84.36 ± 6.987. There were highly statistically significant differences between cases and control groups as regards serum vitamin C level (P < 0.001) as mean + SD of vitamin C level in the cases group was 175.85 ± 101.607 and in the control group was 884.40 ± 439.878. Conclusion We found that children with bronchial asthma had significant lower levels of serum vitamin C than the control children. There were statistically significant differences between cases and control groups as regards severity of asthma and serum vitamin C levels. We concluded that a low level of vitamin C may influence the development of bronchial asthma and serum vitamin C deficiency may be caused or aggravated in asthmatic children.
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PHYSICAL MEDICINE, RHEUMATOLOGY AND REHABILITATION - ORIGINAL ARTICLE Top

Platelet rich plasma injection versus extracorporeal shock-wave therapy in treatment of plantar fasciitis p. 186
Samar G Soliman, Alaa A Labeeb, Eman A Abd Allah, Tarek F Abd-Ella, El Zahraa A. Abd-El Hady Hammad
DOI:10.4103/mmj.mmj_297_18  
Objective The aim of this study was to determine the efficacy of local platelet-rich plasma (PRP) injection compared with extracorporeal shock-wave therapy (ESWT) for treatment of plantar fasciitis. Background Plantar fasciitis is an important cause of heel pain. ESWT and PRP have emerged as new management options, alternative for surgery. Patients and methods This comparative study included 60 patients, comprising 48 female and 12 male patients with plantar fasciitis diagnosed clinically and by ultrasound. The patients were divided into two groups: 30 patients received single local PRP injection and 30 patients received three sessions of ESWT weekly. All patients were assessed using pain visual analog scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale, and plantar fascia thickness by ultrasound before treatment and at 1 and 3 months after treatment. Results VAS, AOFAS ankle-hind foot score, and plantar fascia thickness improved significantly in both groups. The AOFAS ankle-hind foot scale shows more improvement in the ESWT group at 1 month after treatment (P = 0.009). Significant improvement in plantar fascia thickness was seen clearly in PRP group at 1 and 3 months after treatment (P < 0.001). VAS and AOFAS ankle-hind foot scale score in patients with calcaneal spur show more improvement in ESWT group at 1 month after treatment (P = 0.019 and P = 0.009, respectively). Conclusion Local PRP injection and ESWT improve pain and function in patients with plantar fasciitis. ESWT showed early improvement if plantar fasciitis is associated with calcaneal spur.
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PARASITOLOGY - ORIGINAL ARTICLE Top

Anti-Toxocara effects of Cassia nodosa plant extract in experimentally infected mice p. 191
Nadia S El-Nahas, Amira F Abd-Elatty, Amany A Rady, Bahaa El-Deen W. El-Aswad, Amira M Attallah, Aiat S Hemida
DOI:10.4103/mmj.mmj_465_17  
Objective The current study aimed to evaluate the parasitological and pathological effects of the ethanolic extract of Cassia nodosa in the treatment of murine toxocariasis. Background Toxocariasis is mainly treated by albendazole (ALZ) and thiabendazole. C. nodosa is a plant which has been used in the traditional medicine. Materials and methods BALB/c mice (n = 50) were divided into five groups (10 mice each): group I (normal control), group II (infected untreated control), group III (infected and received ALZ), group IV (infected and received C. nodosa), and group V (infected and received both ALZ and C. nodosa). All the infected mice were orally given 1000 embryonated eggs of Toxocara canis. Results All treatments revealed significant reduction of total T. canis larvae. C. nodosa achieved 69.45% reduction, which was better than ALZ (44%). The plant extract showed better control of pathology than ALZ. ALZ +C. nodosa revealed the highest reduction percentage with 93.2% (P < 0.001), in addition to decreasing the pathological lesions caused by T. canis in different organs. Conclusion C. nodosa reduced Toxocara larvae number and improved the pathological lesions, initiated by T. canis larvae, so C. nodosa extract can be a potential natural drug against this parasitic infection.
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PHARMACOLOGY - ORIGINAL ARTICLE Top

Protective effect of caffeine and curcumin versus silymarin on nonalcoholic steatohepatitis in rats p. 196
Fatma El-Desoky, Abd El-Hamid Gaber, Nanis Shawky Holah, Esam EL-Din Ibrahim S. Radwan, Mohamad–Hesham Y Daba, Abd Elrahman A. Yassin, Ghada A Hegazy
DOI:10.4103/mmj.mmj_253_18  
Objective To compare between the effect of curcumin, caffeine with silymarin on an animal model of nonalcoholic steatohepatitis induced by a high-fat and high-sucrose (HFHS) diet. Background Nonalcoholic fatty liver disease is recognized as the most common cause of chronic liver disease. Pro-inflammatory and anti-inflammatory cytokines play a part in the pathogenesis of nonalcoholic fatty liver disease, oxidative stress, and insulin resistance. Materials and methods Fifty male albino rats were divided into five groups: control group; group B receives a HFHS diet for 16 weeks; group C receives a HFHS diet for 16 weeks and was treated by silymarin in the last 8 weeks; group D receives a HFHS diet for 16 weeks and was treated with curcumin in the last 8 weeks; and group E receives a HFHS diet for 16 weeks and was treated with caffeine in the last 8 weeks. Results The HFHS group shows a significant increase in body weight, insulin, tumor necrosis factor α, malonaldehyde, total cholesterol, and triglycerides; compared with the control group, silymarin-treated, curcumin-treated, and caffeine-treated groups show a significant decrease in these parameters. Conclusion Silymarin-treated, curcumin-treated, and caffeine-treated groups show a significant protection against HFHS (western) diet-induced nonalcoholic steatohepatitis.
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CLINICAL PATHOLOGY - ORIGINAL ARTICLES Top

Role of AdeB gene in multidrug-resistance Acinetobacter p. 205
Rawheia H Aladel, Soheir A Abdalsameea, Hanem M Badwy, Shimaa A Refat, Reem M ElKholy
DOI:10.4103/mmj.mmj_434_18  
Objective The aim was to determine the role of the Ade B gene in multidrug-resistant Acinetobacter isolated from ICUs of Menoufia University Hospitals. Background Acinetobacter is a gram-negative bacteria that may cause serious infections. Numerous mechanisms are involved in its resistance to drug therapy. The active efflux mechanism is an important factor for development of multidrug resistance. The Ade ABC system is important efflux system in mediating such resistance. Therefore, the present study was designed to analyze the association between the expression level of Ade B gene and drug resistance in Acinetobacter. Materials and methods This case–control study was carried out in the period between October 2016 and October 2018. It was done at Clinical Pathology Department, Faculty of Medicine, Menoufia University Hospitals. The patients were selected from ICUs of Menoufia University Hospitals. The study included clinical samples collected from 614 patients admitted to ICUs. All clinical Acinetobacter isolates were further studied for determination of antibiotic susceptibility patterns and detection of Ade B gene by real-time PCR. Results Of the 614 samples, 70 (11.4%) Acinetobacter were isolated. Regarding antimicrobial resistance pattern, 61.4% of the Acinetobacter isolates were found multidrug and extensive drug resistant. There was significant increase in Ade B gene expression (P < 0.001) in multidrug-resistant isolates in relation to susceptible isolates. Conclusion AdeB gene plays a vital role in multidrug resistance in clinical Acinetobacter isolates. These results may benefit to design active efflux pump inhibitors. Moreover, implementation of strict microbial policies and infection control programs may prevent the rapid dissemination of this organism.
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Herpes virus incidence after liver transplantation p. 210
Yasser M Ismail, Ann A Farid, Amira A Alhendy, Abeer H Elshalakany, Wesam E Hamed
DOI:10.4103/mmj.mmj_185_19  
Objective To study the incidence of herpes virus infection after liver transplantation (LT). Background Viral infections are common after LT patients; human cytomegalovirus (HCMV) infection is considered as the most frequent one. Human herpes virus 6 (HHV-6) can cause primary infection or reactivation from latency in LT recipients. Many techniques are used for viral load identification. Multiplex real-time PCR reduces test costs, improves turnaround times, and increases test throughput. Patients and methods This study was conducted on 70 patients, comprising 40 LT patients who presented to Surgical Department, National Liver Institute, Menoufia University. and 30 age-matched and sex-matched healthy donors a control group, in the period from 2014 to 2018. HCMV and HHV-6 were determined by multiplex PCR analysis once before and twice (1 and 3 months, correspondingly) after LT. Results Our study detected HCMV in six cases 3 months after LT, whereas HHV-6 was detected in only two cases. Conclusion LT could be associated with increased incidence of HCMV and HHV-6.
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Do all chronic hepatitis C virus bleeders develop iron deficiency? p. 217
Khalid A Khalifa, Omaima M Abbas, Nahla O Shokri, Asmaa S Atta
DOI:10.4103/mmj.mmj_168_18  
Objectives To investigate the changes in hepcidin regulation in anemic chronic hepatitis C virus (HCV) patients with and without bleeding and the role of hepcidin in ameliorating the development of iron deficiency in anemic HCV bleeders. Background Chronic liver disease is frequently associated with anemia in about 75% of patients which is usually multifactorial. One of the causes of anemia in chronic liver disease is acute or chronic blood loss into the gastrointestinal tract, resulting in iron deficiency anemia. Hepcidin, the key regulator of iron homeostasis, has a relatively low expression level in the liver in chronic HCV patients; however, the changes in hepcidin regulation have not been examined previously in anemic chronic HCV bleeders compared with nonbleeders. Patients and methods This case–control study was carried out at the Faculty of Medicine and National Liver Institute, Menoufia University, in the duration between February 2016 and February 2017. The study included 70 individuals: 50 treatment-naive compensated chronic hepatitis C patients (25 anemic nonbleeders and 25 anemic bleeders) and 20 age-matched and sex-matched healthy individuals. Complete blood counts, iron profile, prothrombin, and serum hepcidin using enzyme-linked immunosorbent assay were done. Results Serum hepcidin levels were significantly lower in anemic nonbleeder patients (70.08 ± 13.40) and anemic bleeders (68.91 ± 10.66) than in controls (78.52 ± 7.46). P value is 0.017. There was no significant difference between the patient groups compared with each other. No statistically significant differences between the studied groups were found regarding serum iron, total iron binding capacity, transferrin saturation, and serum ferritin. Conclusion Chronic HCV bleeders do not develop iron deficiency.
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Nitrate assessment in patients with thalassemia and sickle cell anemia p. 222
Mohamed A Soliman, Rasha I Noreldin, Doaa M Elian, Hamdia S Mohamed
DOI:10.4103/mmj.mmj_183_18  
Objective To evaluate the plasma levels of nitrate in patients with thalassemia and sickle cell anemia. Background The bioavailability of nitric oxide (NO) in patients with thalassemia and sickle cell anemia is decreased due to chronic hemolysis and consequently endothelial dysfunction that can result in the development of certain complications in both the diseases. Plasma concentration of nitrate is considered as an important reservoir for NO whose level can be a landmark for the bioavailability of NO. Patients and methods Our case–control study involved 93 patients aged 10–18 years divided into two groups, a case group composed of 73 patients; 44 patients with thalassemia and 29 patients with sickle cell anemia and 20 age-matched apparently healthy persons as a control group. Plasma levels of nitrate were evaluated by enzyme-linked immunosorbent assay. Results The results of our study have revealed that the plasma levels of nitrate are significantly lower in the case group than the control group. Conclusion An evidence of decreased NO bioavailability proved by a decreased plasma nitrate is present in patients with thalassemia and sickle cell anemia that can be implicated for multiple complications in both the diseases.
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Differentiation of mesenchymal stem cells into chondrocytes as a future therapy for skeletal diseases p. 226
Rawhia H Eledel, Maha M Elbatsh, Rasha I Noreldin, Thoria A Omar, Zahraa A.M. Abu-Alata
DOI:10.4103/mmj.mmj_255_18  
Objective The aim of this study was to assess the ability of mesenchymal stem cells (MSCs) to differentiate into chondrocytes in vitro. Background MSCs with their ability of self-renewal and multilineage differentiation can differentiate into several types of cells including chondrocytes. It is reported that adult cartilage lacks the ability to repair itself, making articular cartilage a very attractive target for regenerative medicine therapy. Materials and methods This study was conducted at Clinical Pathology, Gynecology and Obstetrics Departments, Menoufia University Hospital, from December 2016 to May 2018, and included a collection of 30 umbilical cord samples under complete aseptic conditions, after obtaining Menoufia ethical committee approval. Samples were processed with the explant method. MSCs were separated using plastic adherence. MSCs were subcultured in a petri dish 35 mm2 then treated with chondrocytes' differentiation media. Results Identification of isolated MSCs was carried out by morphology and flow cytometry. MSCs were positive to flow cytometric markers CD44 and CD73 and negative for CD34 with a highly statistically significant difference P value of less than 0.001 in comparison with differentiated chondrogenic cells. MSCs were able to differentiate into chondrocytes after adding of chondrogenic differentiation media. Chondrocytes could be identified by morphology and immunocytochemistry method. Chondrogenic cells showed negative flow cytometric markers CD44 and CD73. Conclusion This study showed the ability of MSCs to differentiate into chondrocytes after the adding of chondrogenic differentiation media in vitro as a future therapy for skeletal diseases.
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Isolation and osteogenic differentiation of umbilical cord mesenchymal stem cells p. 231
Rawhia H El-Edel, Mona M Hassouna, Alaa M. Abd El-Gayed, Rasha I Noreldin, Asmaa Z.A. Turky
DOI:10.4103/mmj.mmj_265_18  
Objective To investigate the isolation and in-vitro differentiation of umbilical cord mesenchymal stem cells (MSC) into osteocytes. Background Umbilical cord is an important source of multiple cell types such as MSCs that possess the ability of self-renewal and differentiation into several cell types including osteocytes. Bone healing is a complex process that can eventually lead to the formation of malunions, delayed unions, and osteomyelitis. Cellular therapy and bone tissue engineering are becoming a useful addition to medical therapies for bone repairing and restoring function which is a potential tool for the treatment of multiple bone diseases. Patients and methods The present experimental study was conducted at Clinical Pathology, Obstetrics and Gynecology Departments, Menoufia University Hospital from May 2017 to April 2018 after obtaining Menoufia Ethical Committee approval. The study was carried out on 35 umbilical cord samples. Wharton's jelly separated from the umbilical cord was divided into small pieces and cultured in tissue culture plastic flasks. MSCs were separated by plastic adherence, then subcultured in Petri dish 35 mm, treated with osteogenic differentiation media and identified by morphology and immunocytochemistry. Results MSCs were isolated from Wharton's jelly of the umbilical cord. Isolated MSCs were positive for the markers cluster of differentiation (CD) 44 and CD73 and negative for CD34. They were able to differentiate into osteocytes. Conclusion The present study showed that MSCs can be isolated from Wharton's jelly of the human umbilical cord and can be differentiated into osteocytes.
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Mesenchymal stem cell applications on the chronic liver disease p. 236
Laila M Montaser, Dina S El-Azab, Eman A.Z. Kotb
DOI:10.4103/mmj.mmj_301_18  
Objective The aim was to evaluate the effect of application of bone marrow mesenchymal stem cells (BMMSCs) after transplantation into mice with carbon tetrachloride-induced chronic liver. Background Chronic disease causes hepatocyte fibrosis, with subsequent morbidity and mortality. Stem cells have emerged an alternative therapy for liver fibrosis, which can be harvested from different sources, such as mesenchymal stem cells (MSCs). Materials and methods This study was conducted on 55 mice and 18 human bone marrow samples. Primarily, liver fibrosis was induced in five mice, and after the fourth week of CCl4induction, they were killed, and liver biopsy was done to estimate fibrosis occurrence. The remaining 50 mice were classified as 25 mice injected with 0.9% saline to be used as control (group I) and 25 mice were infused intravenously with 1 × 106 human BMMSC (group II) after continuous CCl4administration in both groups. After 4 weeks of MSCs infusion, serum alanine transaminase, aspartate transaminase, albumin, and total bilirubin were determined for all 50 mice. Moreover, liver histology was performed to determine the fibrosis degree as well as α-fetoprotein immunohistochemistry, and RT-PCR was done for α-smooth muscle actin expression. Human BMMSCs were collected and isolated by bone marrow culture and evaluated by flow cytometric characterization of MSCs using CD45-negative and CD90-positive cell markers. Results MSCs-treated group revealed significant lower alanine transaminase, aspartate transaminase, and albumin; higher total bilirubin levels; decreased histopathological fibrosis; diffuse α-fetoprotein immunostaining; and lower α-smooth muscle actin gene expression when compared with the control group. Conclusion MSCs could be used as a therapeutic tool in end-stage liver disease.
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DERMATOLOGY - ORIGINAL ARTICLES Top

Thymocyte selection-associated HMG-box 'thymocyte selection-associated HMG-box' in mycosis fungoides: should it be mandatory in diagnosis? p. 243
Mohamed A Gaber, Asmaa G Abdou, Hesham N Khaled, Mona E Kamel
DOI:10.4103/mmj.mmj_195_19  
Objective To study the immunohistochemical expression of thymocyte selection-associated HMG-box (TOX) as a diagnostic marker in mycosis fungoides (MF). Background MF is the most common type of cutaneous T-cell lymphoma. Differentiation of MF from benign inflammatory dermatoses is important to ensure proper management. TOX is a critical regulator of early T-cell development that is considered as a useful marker for MF diagnosis and prognosis. Patients and methods This study was carried out on 32 skin biopsies, 20 MF cases, and 12 benign inflammatory dermatosis. The diagnosis was established after clinicopathologic correlation immunohistochemical (IHC) was done in MF cases and benign inflammatory dermatosis for TOX. This was a cross-sectional analytical study. Results TOX expression showed significant positive expression in MF cases compared with benign inflammatory dermatoses, with 80% sensitivity and 83% specificity. Also, TOX positivity increased with the progression of the disease in MF cases. There was a significant difference between MF and inflammatory groups as regards TOX expression which was in favor of the malignant group (P = 0.001). Conclusion TOX may have a potential role as a molecular diagnostic marker for MF and overexpression of it correlates with increased risk of disease progression and poor prognosis.
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Pediculosis among school children in a primary school in Millij Village, Menoufia Governorate p. 248
Mohamed A Basha, Hala M El Moselhy, Walaa S. A El Mowafy
DOI:10.4103/mmj.mmj_162_15  
Objectives To determine the prevalence of pediculosis among school children and possible risk factors. Background Pediculosis capitis is an obligate ectoparasite that only affects the human scalp. Pediculosis (i.e., louse infestation) dates back to prehistory. The oldest known fossils of louse eggs (i.e., nits) are ~10 000 years old. Patients and methods This was an analytic cross-section study. The calculated sample size was 355 participants from the children attending the health unit with their families during the period from December 2013 to June 2014 in Millij Village. All students were evaluated through history taking and completing medical examination followed by laboratory investigations, including hemoglobin %, urine, and stool analyses. A full head examination was conducted by using a hand lens. A child was considered infested if alive or dead lice or eggs were found. Children were classified into two groups: group I Shad pediculosis and group II did not have pediculosis. Statistical presentation and analysis of the present study was conducted by using the mean, SD, and Student test for weight and height, as well as number, percentage, and χ2 test by SPSS, version 8. Results The prevalence rate of pediculosis among the studied children was 35.8%. There were significant differences (P < 0.05) between group I and group II regarding sociodemographic data, except for age, which exhibited a nonsignificant difference (P > 0.05). There were statistically significant differences (P < 0.05) between group I and group II regarding risk factors such as long hair, poor hygiene, and use of shared combs/brushes. There were nonsignificant differences (P > 0.05) between group I and group II regarding clinical examination, except for pallor or anemia, which exhibited a significant difference (P < 0.05). Conclusion Pediculosis affected more than one-third of the studied school children. Prevalence of pediculosis was very high in grade 4, which was 54.7%. Moreover, the percent of anemia was 57.9%.
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Role of insulin-like growth factor-1 receptor in female androgenetic alopecia p. 253
Mostafa A Hamam, Hossam A Yasien, Shereen F Mahmoud, Sabreen A.A. Elsherif
DOI:10.4103/mmj.mmj_185_18  
Objectives To find if there is a role of insulin-like growth factor-1 receptor (IGF-1R) in female androgenetic alopecia (FAGA). Background Patterned hair loss continues to be one of the most important hair problems affecting both men and women. It is the most common form of alopecia, affecting up to 50% of women in the course of their lives. Insulin-like growth factor-1 (IGF-1) is one of the most potent natural activators of the protein kinase B signaling pathway, a stimulator of cell growth and proliferation, and a potent inhibitor of programed cell death. IGF-1 is a physiological regulator of hair growth cycle. It helps maintain the anagen stage. Patients and methods This case–control study was conducted on 20 FAGA patients and 10 age-matched healthy female patients with no androgenetic alopecia as control. They were chosen from Dermatology Clinic at Menoufia University Hospital between April 2017 to April 2018.They were subjected to history taking and complete medical examination. Punch biopsies were taken, and by immunohistochemical staining, the degree of intensity and the percentage of IGF-1R were determined. Results The degree of intensity and percentage of IGF-1R in the diseased patients showed statistically significant difference from the normal patients (P = 0.001). There was no significant correlation between IGF-1R expression and age (P = 0.120) and menstrual history (P = 0.189), respectively. Conclusion On the basis of the results, it could be concluded that IGF-1R markedly diminished in FAGA.
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Study of serum level of interleukin-31 in patients with uremic pruritus p. 257
Magda M Haggag, Mahmoud A Kora, Manal A Safan, Hossam A Yasien, Amany M Yousef
DOI:10.4103/mmj.mmj_186_18  
Objective The aim was to assess the role of interleukin-31 (IL-31) in the pathogenesis of uremic pruritus (UP) in patients with chronic kidney disease (CKD) with and without hemodialysis and its relation to severity of pruritus. Background UP is a very distressing symptom in patients with CKD, with unclear etiopathogenesis. Patients and methods This study was conducted on 88 patients with CKD. These patients were divided into four groups: group 1 included 22 patients with CKD having pruritus of different degrees, group 2 included 22 patients with CKD not having pruritus (control group), group 3 included 22 patients with end-stage renal disease on maintenance hemodialysis having pruritus of different degrees, and group 4 included 22 patients with end-stage renal disease on maintenance hemodialysis not having pruritus (control group). Itch intensity was scored as mild, moderate, and severe using numerical rating itch scale, and serum levels of IL-31 was evaluated. Results The results showed that IL-31 serum level was higher in patients with UP in group 1 compared with the controls in group 2; however, it was not statistically significant. Moreover, IL-31 serum level was higher in patients with UP in group 3 compared with controls in group 4; however, it was not statistically significant. The result also showed no significant difference in IL-31 levels according to severity of UP. Conclusion Future studies are need with larger sample sizes to understand the contribution of IL-31 in the pathogenesis of UP.
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Determination of oxidative stress in vitiligo by measuring superoxide dismutase levels in vitiliginous skin p. 262
Ola Bakry, Sally Elhefnawy, Eman Seliet, Mai A Omar
DOI:10.4103/mmj.mmj_246_18  
Objective This study was conducted to determine the association between oxidative stress and vitiligo by measuring antioxidant enzyme superoxide dismutase (SOD) in vitiliginous skin. Background Vitiligo is an acquired depigmenting disease characterized by milky white patches of skin due to local destruction and loss of the epidermal melanocytes. Complex genetic, immunological, neural and self-destructive mechanisms interplay in its pathogenesis. According to autocytotoxic hypothesis, oxidative stress has been suggested to be the initial pathogenic event in melanocyte degeneration. Oxidative stress is defined as a disruption of the delicate balance between the formation of reactive oxygen species and the antioxidant defense system, The dismutation of superoxide (O2-) by SOD to hydrogen peroxide (H2O2) is generally considered to be the primary antioxidant defense of the body, because this enzyme prevents the further generation of free radicals. SOD exists in virtually every oxygen-respiring organism, and its major function is to catalyze dismutative reaction. Patients and methods We determined the activity of SOD in lesional skin only of 20 female patients with vitiligo. The ages of the patients ranged from 18 to 53 years. A total of 17 patients had nonsegmental vitiligo and three had segmental vitiligo, and 10 age-matched and gender-matched apparently healthy volunteers with no past, present or family history of vitiligo, served as a control group. Every case and control was subjected to skin biopsy, and SOD assay of the obtained biopsy was carried out by spectrophotometry. Results A significant difference was found between cases and controls with regard to tissue SOD (P = 0.01, <0.05). Conclusion There was a significant association between oxidative stress and vitiligo.
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Cutaneous manifestation of β-thalassemic patients p. 267
Mohamed A Gaber, Marwa Galal
DOI:10.4103/mmj.mmj_247_18  
Objective The aim was to study the prevalence of common dermatological problems in patients with β-thalassemia major to help rapid treatment and prevent complications. Background β-Thalassemia major affects multiple organs and is associated with considerable morbidity and mortality. In β-thalassemia, a wide spectrum of skin diseases was identified, which were caused by both the hemoglobin disorder and the complications of treatment. Patients and methods This cross-sectional study included 105 Egyptian patients (50 female individuals and 55 male individuals) with transfusion-dependent β-thalassemia major in the period spanning from June 2017 to February 2018. The study was performed on child and adult patients of β-thalassemia who presented to the hematology clinic, Menoufia University hospital. Skin examination of each patient was carried out, and any skin disease present was recorded. Results The main skin disorders that were noticed in decreasing order of frequency were pruritus (34.4%), xerosis (24.8%), urticaria (21.1%), freckles (17.1%), tinea infections (11.6%), pitriasis alba reported in 10.5%, scars (10.5%), hypersensitivity to deferoxamine pump (9.5%), herpes simplex (9.5%), acne vulgaris (8.6%), miliaria (6.7%), contact dermatitis (4.8%). Conclusion Skin diseases were frequent among patients with β-thalassemia major. The most common skin lesions in our patients were pruritus, xerosis, and hyperpigmentation. Careful skin examination of thalassemia patients is required to provide early diagnosis of dermatological diseases and a better quality of life.
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Skin diseases in elderly p. 272
Mohamed A Gaber, Al Zahraa A Hasanin
DOI:10.4103/mmj.mmj_278_18  
Objective The present study aimed to determine the prevalence of the most common dermatological conditions in elderly patients and to investigate their associations with systemic diseases. Background Skin problems in the elderly population have rarely been the subject of scientific research. Patients and methods The study involved a group of 260 consecutive patients aged more than or equal to 60 years who were admitted to the Departments of Dermatology at the study institution. All participants were thoroughly evaluated in a clinical interview and physical examination in which special emphasis was placed on dermatological issues. Results All patients presented at least one dermatological condition. A significant correlation was found between the number of systemic diseases and the number of different skin lesions observed. The most common skin diseases presented in our study are dermatitis (24.2%), fungal infections (17.6%), papulosquamous lesions (11.5%), and immunobullous diseases (7.3%).Female cases showed significantly higher rate of fungal infections, hair and nail diseases, connective tissue diseases, and dermatitis but also lower rate of immunobullous diseases and bacterial diseases when compared with males. Conclusion Skin disorders are common in elderly people. Systemic diseases promote the development of dermatological conditions. A comprehensive approach to health problems in elderly patients requires knowledge of dermatology.
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The effect of aging on the sexual function among Menoufia women p. 277
Mohamed A Gaber, Asmaa A Barseem
DOI:10.4103/mmj.mmj_282_18  
Objective The aim of this work was to evaluate the effect of aging on the sexual function among Menoufia women. Background Female sexual function does not appear to decline appreciably with age. However, a range of methodological issues limit the conclusions that can be drawn from many published studies in this area. Patients and methods A cross-sectional study was conducted on 240 married women between 18 and 60 years old. The calculated sample was collected from gynecology clinic at Shebin EL Kom teaching hospital. Women were interviewed by predesigned questionnaire. Results The evidence indicates that a woman's sexual function declines with age. Specifically, desire, frequency of orgasm, arousal, and frequency of sexual intercourse decrease with age. The prevalence of most sexual difficulties or dysfunctions changes little with age, with the exception of sexual pain, which may decrease with age. Conclusion Regarding our study on Menoufia women, we found there was a strong evidence that sexual activities and sexual function decline with age; however, the importance of sex does not appear to decline with age. Data in this area are limited, and more research needs to be carried out before we have a clearer idea of the processes involved.
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Role of melatonin in constitutional delayed puberty in boys p. 283
Abdallah M Attia, Belal A Montaser, Nehal K Abdallah
DOI:10.4103/mmj.mmj_300_18  
Objective The aim of this work to assess melatonin level in boys with constitutional delayed puberty (CDP) and study its correlation to follicle-stimulating hormone (FSH), total testosterone, and prolactin hormones. Background CDP is a common cause of pubertal delay. These boys have no underlying pathology and will progress normally. Melatonin hormone has an important role in pubertal onset. Before puberty, it is too high for hypothalamic activation. However, at puberty, it drop below threshold value, after which pubertal changes start occurring. Patients and methods This study was carried out on 50 boys aged 14–18 years who were divided into two groups: 25 boys with CDP as a patient group and another 25 age-matched boys with full pubertal development as a control group. All boys were subjected to full history taking, clinical examination, bone age determination, and laboratory investigations (testosterone, FSH, prolactin, and melatonin). Results Our results showed that in CDP, bone age is significantly delayed compared with their chronological age as well as the bone age of control group. Weight and height are significantly less in CDP than control. Both serum total testosterone and FSH are significantly lower in CDP compared with controls, whereas there were insignificant differences in serum prolactin. Melatonin is significantly higher in CDP compared with control. Melatonin is inversely correlated with both testosterone and FSH and has no correlation with prolactin. Conclusion Melatonin is significantly elevated in CDP boys, and it is negatively correlated with hormones of sexual maturation (testosterone) and reproduction (FSH).
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CARDIOLOGY - ORIGINAL ARTICLES Top

Chemerin levels in patients with coronary artery disease p. 288
Mohammed F Elnoamany, Ashraf A Dawood, Mahmoud A Aboelezz
DOI:10.4103/mmj.mmj_127_19  
Objectives To evaluate chemerin levels in patients with coronary artery disease and detect the correlation between these levels (if any) with the severity of coronary artery disease. Background Recent evidence demonstrated that the circulating adipokines were associated with the onset of coronary artery disease (CAD). As a novel adipokine; chemerin has been related to atherosclerosis and the presence of coronary artery disease. However, the plasma levels of chemerin in patients with acute coronary syndrome (ACS) have yet to be investigated. Methods This study a prospective case-control study included 96 participates undergoing coronary angiography at cath lab, cardiology department-Menoufia University from January 2018 to September 2018. Serumchemerin levels weremeasured by an enzyme-linked immunosorbent assay (ELISA). Echocardiography, electrocardiography and routine laboratory investigations were done. The severity of coronary stenosis was estimated usingGensini, vessel and severity coronary scores. Results Among the 96 patients, 4groups were described: group I included 24 Acute myocardial infarction (AMI) patients, 30 unstable angina (UA) patients in group II, 27 stable angina (SA) patients inGroup III, 15 patients with normal coronary artery findings (control group) in Group IV. Serumchemerin levels were significantly higher in AMI and UA groups than SAand control groups P < 0.001. Also there was a high significant positive correlation between serum chemerin levels and severity of CAD as regard to Gensiniscore P < 0.001, severity score P < 0.001 and vessel score P = 0.005. Conclusion Chemerin is a novel biomarker for CAD and it was significantly correlated with various metabolic risk factors and atherosclerotic cardiovascular disease.
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Assessment of left atrial function in patients with ischemic and nonischemic dilated cardiomyopathy using speckle-tracking echocardiography p. 295
Abdalla M Kamal, Naglaa F Ahmed, Ahmed A Kamal, Mohamed H Mostafa
DOI:10.4103/mmj.mmj_179_18  
Objective The aim was to assess left atrial (LA) function in patients with ischemic and nonischemic dilated cardiomyopathy using speckle tracking echocardiography. Background LA changes occur in patients with dilated cardiomyopathy and LA enlargement is commonly found by echocardiography. Two-dimensional speckle tracking echocardiography is a tool for the evaluation of LA function. Patients and methods This casecontrol study was conducted on 67 randomly selected individuals who presented to the Cardiology Department of Faculty of Medicine, Menoufia University, Egypt, during the period from January 2017 to December 2017. They included 52 patients with systolic heart failure (HF) and 15 normal individuals. In this study, the LA maximum, minimum volumes, and volume before the atrial systole, and calculated total emptying, active emptying volumes, expansion index, and fraction were measured. Strains and strain rates during left ventricular (LV) systole and late LV diastole using speckle-tracking imaging were measured. Results The study showed no significant differences between the nonischemic dilated cardiomyopathy (NIDCM) and ischemic dilated cardiomyopathy (IDCM) groups in the A peak, DT, septal e′, E/A, E/e′ and LAD, LVEDD. LA maximum volume (LAVmax) and the active emptying volume of LA (LAEV) showed no significant difference between the studied groups, but the total emptying capacity of the LA (LATV), the left atrial expansion index, and the left atrial active ejection fraction (LAAEF) were significantly lower in the NIDCM group. The LA strain and strain rate during LV systole (Ss, SRs) and during late LV diastole (Sa, SRa) representing the reservoir and booster pump function of the LA, respectively, were significantly lower in the NIDCM group. Conclusion LA systolic and late diastolic strains and strain rates were significantly lower in NIDCM patients. The LA dynamic reservoir and booster pump function were more severely impaired in NIDCM.
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Epicardial fat measured by multidetector computed tomography and coronary artery disease p. 303
Neveen I Samy, Walaa F Abdalzez, Mohammad F Alnaggar
DOI:10.4103/mmj.mmj_262_18  
Objective To assess the relationship between epicardial fat (EF) as well as pericoronary fat measured by multidetector computed tomography (CT) and coronary calcium score, and coronary artery disease (CAD). Background EF is associated with increased risk of cardiovascular events. CT is an accurate and highly reproducible method to measure EF and can be used as a noninvasive tool to assess the cardiovascular risk. Patients and methods The current study included 70 patients with suspected CAD (low-intermediate probability). All patients were subjected to 256-row multidetector CT coronary angiography scans and were divided into three groups: group 1: no atherosclerosis (20 patients), group 2: nonobstructive atherosclerosis (luminal narrowing <50% in diameter) (25 patients), and group 3: obstructive atherosclerosis (luminal narrowing ≥50%) (25 patients). EF thickness and the mean thickness of the pericoronary fat surrounding the three coronary arteries were measured by CT. Results Calcium score, the average EF thickness, and the average pericoronary fat thickness (PCFT) were significantly higher in group 3 compared with other groups (P < 0.001, 0.013, and <0.001, respectively). Receiver operating characteristic curve was used to define the best cutoff value of the thickness of both epicardial and pericoronary fat in predicting obstructive CAD (group 3), and it was more than or equal to 7.2 and 12.6 mm for epicardial and pericoronary fat, respectively. Conclusion There was a positive correlation between both epicardial and PCFT and the severity of coronary stenosis. Epicardial and PCFT can be used in predicting the severity of CAD.
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RADIOLOGY - ORIGINAL ARTICLES Top

Role of ultrasonography in assessment of postoperative vascular complications in recipients of living donor liver transplantation p. 309
El Sayed El Mekkawy El Sayed, Mohamed S El Warraky, Dalia I Aggour
DOI:10.4103/mmj.mmj_276_18  
Objective The aim was to evaluate the role of color Doppler ultrasonography (CDUS) in the evaluation of vascular complications detected in recipients of living donor liver transplantation (LDLT). Background Post-transplant-related vascular complications remain threat to the recipients' survival. A higher risk for vascular complications was found in LDLT recipients because of complex vascular reconstruction and slender vessels. CDUS acted as a first-modality imaging technique to detect vascular complications in the early and late follow-up period. Patients and methods A total of 60 liver transplant recipients who underwent LDLT in National Liver Institute Menoufia University were included. The study was done over a period of 25 months from January 2016 to January 2018. These recipients underwent serial color Doppler sonographic evaluation of hepatic arteries, portal vein, and hepatic veins after surgery. Patients with abnormal sonographic finding underwent subsequent angiography. Results The study was done by gray-scale, CDUS and included 47 patients of 60 recipients who showed suspicious vascular complications as follows: 26, 13, and eight patients had suspected arterial, portal, and hepatic venous complications, respectively. All these patients underwent conventional angiography. The sensitivity and specificity of CDUS in the evaluation of arterial, portal, and hepatic venous complications were 95, 87.5, and 87%, respectively, and 86, 91, and 96%, respectively, and for the latest complications was 87 and 96%, respectively. Conclusion CDUS was the preferred postoperative screening method; it was an initial recipient workup for post-LDLT. Providing a perfect evaluation of hepatic vasculature and assessment of early and lately presented vascular complications.
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Role of multidetector computed tomography in detection of extrahepatic metastases of hepatocellular carcinoma p. 315
Adel M Elwakeel, Mohamed M Houseni, Shaimaa A Hassanein, Hanan A Meky
DOI:10.4103/mmj.mmj_241_18  
Objective To evaluate the role of multidetector computed tomography (CT) in the detection of hepatocellular carcinoma (HCC) and its metastases regarding its radiological characteristics and sites of metastases. Background To discuss radiological criteria of HCC in contrast-enhanced CT. These criteria will help us to detect the tumor in the liver and sites of its extrahepatic metastases. Patients and methods We included in this study 218 patients already diagnosed as having HCC. Of them, 139 did not have any extrahepatic metastases and 79 patients had extrahepatic metastases by contrast-enhanced CT assessment. The patients underwent ultrasound examination, clinical examination, and contrast-enhanced CT. Extrahepatic metastases were evaluated by their radiological criteria (enhanced in arterial phase and washout in portal phase and delayed phase) and by their specific sites. Results There is a significant relationship between age of the patients and extrahepatic metastases, sites of extrahepatic metastases, grading of extrahepatic metastases according to TNM classification, sensitivity and specificity of CT in detection of metastases of HCC in comparison with the sizes of the detected lesions. Conclusion Multidetector CT has the main role in detection of HCC and its extrahepatic metastases.
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The role of diffusion magnetic resonance imaging in evaluation of suspicious breast lesions p. 320
Mohamed A Maaly, Safaa A.E. Mohamed, Mahmoud A Abdella
DOI:10.4103/mmj.mmj_224_18  
Objective The aim was to evaluate the role of diffusion-weighted (DW) MRI with apparent diffusion coefficient (ADC) value measurement in differentiating benign from malignant breast lesions. Background DW imaging is a potential resource as a coadjutant of MRI in the differentiation between benign and malignant lesions. Patients and methods This prospective study included 30 patients with suspicious breast lesions in mammography and/or ultrasound study from April 2017 to April 2018. Patients had undergone dynamic contrast-enhanced MRI and DW imaging before their biopsy. ADC value was calculated by placing region-of-interest over required area in DW-MRI at b value 1000 s/mm2. The sensitivity and specificity of DW-MRI were determined for comparison with histological results. Results The study included 30 cases, where 21 were malignant and nine were benign. Significant results were obtained between ADC values of benign and malignant lesions (P < 0.001). The mean ADC for benign lesions was 1.10 × 10-3 mm2/s, whereas mean ADC for malignant lesions was 1.63 × 10-3 mm2/s. Cut-off level of ADC was 1.03 × 10-3 mm2/s. DW-MRI achieved a sensitivity of 62% and a specificity of 88% for differentiating benign and malignant lesions. Conclusion DW imaging is a potential resource as a coadjutant of MRI in the differentiation between benign and malignant breast lesions.
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Role of magnetic resonance imaging in diagnosis of pediatric posterior fossa tumors p. 326
Zeinab A.E. Ali, Rehab M Habib, Shaimaa A.E. Fotoh
DOI:10.4103/mmj.mmj_248_18  
Objective The aim was to study the role of MRI in diagnosis of pediatric posterior fossa tumors. Background Brain tumors represent the most common solid neoplasms in children and the second most common pediatric malignancy following leukemia. Patients and methods A retrospective study was conducted on 25 pediatric patients with known brain posterior fossa masses, who ranged in age from 1 to 15 years and had suspected posterior fossa tumor by computed tomography. All participants attended the MR unit of Radiology Department, Menoufia University, Menoufia Governorate, during the period from October 2016 to November 2017. Complete history taking, clinical examination, and MR data were compared with histopathology obtained from all patients. Results The mean age of the cases was 7.2 ± 3.9 years. The most common tumors were medulloblastoma (MB) and pilocytic astrocytoma. MB showed restricted diffusion with low apparent diffusion coefficient value, and pilocytic astrocytoma showed free diffusion with higher apparent diffusion coefficient value. High-grade tumors such as MB and brain stem glioma showed elevated choline and reduced N-acetyl aspartate in magnetic resonance spectroscopy curve. Low-grade tumors such as low-grade glioma showed mild rise of choline and mild reduction of creatine in magnetic resonance spectroscopy curve. Conclusion Conventional MRI provided limited information regarding tumor type and grade, falling short as a definitive diagnostic examination. Advanced brain MRI techniques provided incremental diagnostic value over conventional MRI. However, no single advanced technique was perfect, but different techniques typically complement one another.
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PEDIATRICS - LETTER TO THE EDITOR Top

Epidemiology of metabolic syndrome in Menoufia University students p. 332
Mahmood D Al-Mendalawi
DOI:10.4103/mmj.mmj_1_19  
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