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July-September 2020
Volume 33 | Issue 3
Page Nos. 723-1113

Online since Wednesday, September 30, 2020

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INTERNAL MEDICINE - REVIEW ARTICLES  

Studies on inherited platelet disorder: a systematic review Highly accessed article p. 723
Sabry A Shoieb, Mohammed A Abdelhafez, Alaa E. A. El-Hameed, Bassam H Ramadan Alemam
DOI:10.4103/mmj.mmj_381_18  
Objective The aim was to review the studies on clinical presentation, diagnosis, and management of inherited platelet disorder (IPD). Materials and methods A systematic search of MEDLINE (PubMed, Medscape, Science Direct, EMF-Portal) and internet was conducted on all articles published from 1997 to 2016. English language reports of perianal fistula were assessed. The initial search presented 150 articles where 26 satisfied the inclusion criteria. Articles not reporting on IPD in the title or abstract were not included. A total of 11 independent investigators extracted data on methods. Comparisons were made by structured review, with the results tabulated. Eight authors emphasized clinical presentation of IPD, nine about diagnosis of IPD, and nine about management of IPD. Findings Common symptoms include ecchymosis, epistaxis, menorrhagia, and excessive bleeding with childbirth, surgery, dental procedures, and trauma. IPD diagnosis is straightforward in the major platelet function disorders such as Bernard-Soulier Syndrome (BSS) and Glanzmann thrombasthenia (GT). Establishing a conclusive molecular diagnosis is the bedrock of good hematological practice, because it informs optimal treatment and can provide clarity about disease progression. The management of patients with IPDs usually consists of general measures aimed at avoiding bleeding and the use of supportive therapy to control hemorrhagic episodes. Conclusion IPDs are important causes of bleeding that can quantitatively and qualitatively alter platelets, impairing their function. The management of patients with IPDs usually consists of general measures aimed at avoiding bleeding and the use of supportive therapy to control hemorrhagic episodes. Moreover, patients and their parents must be instructed about drugs that impair platelet functions.
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Neutrophil extracellular traps in systemic lupus erythematosus p. 729
Emad M El-Shebini, Sabry A Shoeib, Alaa H Elghotmy
DOI:10.4103/mmj.mmj_431_18  
Objectives To study the role of neutrophil extracellular traps (NETs) in the pathogenesis, clinical manifestations, and treatment of systemic lupus erythematosus (SLE). Materials and methods All medical databases including PubMed, Google Scholar, ScienceDirect, and Springer were searched for relevant data and the studies were published according to specific criteria and all materials available on the internet from 2011 to 2018. Search methodology All medical databases including PubMed, Google Scholar, ScienceDirect, and Springer were searched for relevant data. Data sources All medical databases including PubMed, Google Scholar, ScienceDirect, and Springer were searched for relevant data and all materials available on the internet from 2011 to 2018. Language covered English. Study selection (a) Published in English language. (b) Focused on NETs and lupus. (c) We used the latest publication giving the most relevant data. (d) All materials available on the internet from 2011 to 2018. Data extraction If the studies not fulfill the above criteria, then they were excluded. Data synthesis Short reviews were made on NETs and its role in SLE. Recent findings NETs are involved in the pathogenesis of SLE. They are associated with increased disease activity and considered as a potential therapeutic target. The ineffective clearance of NETs in patients with SLE exposes self-molecules to the immune system and contributes to the development of autoantibodies and proinflammatory cytokines, driving the pathogenesis of SLE. Conclusion Being in its early phase, studies related to the role of NETs in autoimmune diseases including SLE should be directed toward a better understanding of SLE pathogenesis and focusing on the association between the formation of NETs and various clinical aspects in SLE. Moreover, the relation between NET formation and other pathological and genetic determinants of SLE development is a rich area of future research.
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Pathobiology and management of essential thrombocythemia: a systematic review p. 733
Sabry A Shoeib, Mohamed A Abdel-Hafez, Alaa E Abd El Hamid, Ahmed A Fathallah
DOI:10.4103/mmj.mmj_54_19  
Objective The objective of this study was to review the pathobiology and management of essential thrombocythemia (ET). Materials and methods A systematic search of MEDLINE (PubMed, Medscape, Science Direct, EMF-Portal) and Internet was conducted on all articles published from 1996 to 2017. English language reports of the pathobiology and management of ET were included. The initial search presented 155 articles; of which, 27 satisfied the inclusion criteria. Articles not reporting on the pathobiology and management of ET in the title or abstract were not included. Eleven independent investigators extracted data on methods. Comparisons were made by structured review with the results tabulated. The included articles were eight studies about the pathogenesis of the thrombosis, eight about prognostic factors and risk stratification, and 11 about management of ET. Results The pathogenesis of the thrombosis seen in ET is not fully understood. Advanced age and previous history of thrombosis are the more important determinants of thrombosis. The possible importance in myeloproliferative neoplasm thrombosis of leukocytes and JAK 2 mutational status and allele burden has been a field of intense investigation. Antiplatelet therapy reduced the risk of venous thrombosis in JAK2-positive patients and the risk of arterial thrombosis in those with cardiovascular risk factors, whereas it was associated with an excess of bleeding episodes in patients with platelet counts above 1000 × 109/l. Conclusion ET is a chronic disease that has no cure. It may not need treatment in a mild condition, whereas in severe condition, it may need medicine that lowers platelet count, blood thinners, or both. Treatment is controversial but may include aspirin.
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CARDIOLOGY - REVIEW ARTICLE Top

Stem cell therapy for dilated cardiomyopathy: systematic review of the existing data and ongoing trials p. 739
Abdalla M Kamal, Waleed A Ibrahim, Ehsan S Sarhan
DOI:10.4103/mmj.mmj_397_18  
Objectives The aim of this review is to preview recent advances in clinical applications of stem cell therapy in nonischemic dilated cardiomyopathy (DCM). Data sources PubMed and OVID Library were searched. There was no restriction on the publication year. Articles in English language only were reviewed. Clinicaltrials.gov was searched also to find ongoing and unpublished trials. Study selection Studies that included adult DCM patients injected with any type of stem cells were selected. Data extraction: in this review, data from published studies were manually extracted and summarized. Data synthesis In this review, the data revealed that stem cell therapy can change the course of the disease through improving Left Ventricular Ejection Fraction (LVEF), New York Heart Association (NYHA) functional class, exercise tolerance, and quality of life of the patients. Findings The results of clinical trials in this field are encouraging, so DCM may be a more attractive target for stem cell therapy than chronic ischemic heart failure, where studies up till now failed to demonstrate a standardized result of treatment with stem cells on myocardial performance. Conclusion Stem cells have been considered in the treatment of DCM to improve myocardial performance, functional capacity, and neurohumoral activation; this may pave the way for more prevalent clinical use in DCM treatment. Future stem cell methods ought to aim for additional individual therapeutic approach by establishing the optimum stem cell type or their combination, dose, and delivery technique for each patient adjusted for the patient's age and stage of the disease.
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PEDIATRICS - REVIEW ARTICLE Top

Updated management protocols of common situations in neonatal intensive care units p. 744
Ghada M El-Mashad, Hanan M El Said, Mohammad H. A. Shahin
DOI:10.4103/mmj.mmj_10_19  
Objective To review the updated management protocols of common situations in the neonatal intensive care unit (NICU). Data sources A systematic search of MEDLINE (PubMed, Medscape, ScienceDirect, EMF-Portal) and Internet was conducted on all articles published from 2000 to 2018. Study selection English-language reports of the updated management protocols of common situations in the NICU. The initial search presented 160 articles where 23 had inclusion criteria. Data extraction Articles not reporting on updated management protocols of common situations in the NICU in the title or abstract were not included. Fifteen independent investigators extracted data on the methods. Data synthesis Comparisons were made by a structured review with the results tabulated. Seven authors emphasized on the new approaches for managing neonatal hypoglycemia, 16 about the management of neonatal hyperthermia, seizures, and transport. Findings Dextrose gel is safe and has the potential to decrease health-care costs and other risks related to the treatment of hypoglycemia. Antiepileptic drugs are then administered according to clinical preference, independent of the seizure cause. It should only be initiated once seizure activity is confirmed, due to a lack of evidence for any positive outcomes if they are administered in the absence of seizures. As a mobile ICU, transport vehicles, equipment, and supplies must reflect the needs of the patient population. Conclusion Further phrasing of guidelines to cover all aspects of neonatal care in the NICU, following the application of the set protocols in the practical field. Detecting improvement or deterioration of the outcome after applying these protocols to have an 'evidence-based' judgment over these selected guidelines.
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INTERNAL MEDICINE - ORIGINAL ARTICLES Top

The use of human stem cells in the treatment of experimentally induced acute kidney injury p. 750
Mahmoud A Kora, Ahmed M Zahran, Mahmoud M Emara, Yahya M. N. Abdelsalam, Mahmoud A Sobhy
DOI:10.4103/mmj.mmj_346_18  
Objective The aim of this study was to evaluate the effect of stem cell therapy in sepsis-induced acute kidney injury (AKI) in rats. Background AKI is defined as an abrupt or rapid decline in renal filtration function; thus, sepsis-induced AKI remains an important challenge in critical care medicine. The science of stem cells is a field with great potential for treating injury and disease. Materials and methods A total of 30 male Swiss albino rats were used in the present study. Animals were randomly divided into three groups. Group I was the control group (10 rats). Group II was the AKI group (10 rats), where sepsis-induced AKI rat model was used. Group III was the stem cell-treated AKI group (10 rats). Rats with established AKI were injected with CD34-positive stem cells. The three studied groups were assessed for serum urea, blood urea nitrogen, serum creatinine, and cystatin C. At the end, all rats were killed, and the kidneys were excised for histopathology and immunohistochemical studies. Results Cystatin C level shows high significant difference between AKI group in comparison with both control group and stem cell-treated group (P = 0.001) whereas there is no significant difference between control group and stem cell-treated group (P = 0.944). Conclusion This study showed that AKI markers improved after treatment by stem cells in AKI-induced group.
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The association between osteoporosis and diabetic neuropathy in patients with type 2 diabetes p. 755
Nabil A El-Kafrawy, Mostafa M El-Najjar, Walid A Shehab Eldin, Mohammad G Alhelbawy, Hytham R Badr
DOI:10.4103/mmj.mmj_380_18  
Objective The objective of this study was to evaluate the association between osteoporosis and diabetic peripheral neuropathy in patients with type 2 diabetes mellitus (T2DM). Background Diabetic complications and osteoporotic fractures are two of the most important causes of morbidity and mortality in older patients. There is increased fracture rate associated with T2DM, despite these patients having greater bone mineral density. Osteocalcin, one of the bone turnover markers, is a peptide secreted by bone cells and reflects bone formation and consequently indicates bone remodeling status; which is the major mechanism underlying osteoporosis. Patients and methods This case–control study was done on 78 patients with T2DM. They were classified into two groups. Group I (neuropathy group) included 39 patients with diabetic neuropathy. Group II (control group) included 39 patients without diabetic neuropathy. Dual-energy X-ray absorptiometry (DEXA) and serum osteocalcin measurement were done for both the studied groups. Results There was no significant difference between the two studied groups in the DEXA scan results; the mean least T-score of the neuropathy group was −1.4 and that of the control group was −1.2 (P = 0.27). The mean osteocalcin level of the neuropathy group was 35.8, whereas that of the control group was 13.8, showing significant difference between the two groups (P = 0.03). Conclusion Osteoporosis is more prevalent in T2DM with microvascular complications, and serum osteocalcin level is better in its diagnosis than DEXA scan.
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Liver-type fatty acid-binding protein as an early biomarker of nephropathy in type-2 diabetes p. 760
Ahmed A Rabie, Ahmed T Ragheb, Waleed F Mohammed, Sameh A Serag
DOI:10.4103/mmj.mmj_392_18  
Objective The aim of this study was to evaluate serum liver-type fatty acid-binding protein (L-FABP) level as an early biomarker of diabetic nephropathy (DN) in type-2 diabetic patients. Background Tubular hypoxia upregulates the expression of the L-FABP gene in the kidney and increases the urinary excretion of L-FABP from the proximal tubules. Thus, in early stage DN, it is possible that chronic hypoxia could have induced an increase in urinary excretion of L-FABP. Patients and methods This was a case–control study that included ninety patients with type-2 diabetes mellitus selected from Military Hospital and Menoufia University Hospital who were divided into three groups: the first group comprised diabetic patients with microalbuminuria, second group comprised diabetic patients with macroalbuminuria, and the third group comprised nondiabetic patients with chronic kidney disease. A fourth group of healthy participants served as the control group. Results We found a significant increase of urinary L-FABP level in microalbuminuric diabetic patients and a significant positive correlation between urinary L-FABP level and the duration of diabetes. By using receiver operating characteristics curve analysis, calcium level at a cutoff point (≤8.3) discriminated patients with microalbuminuria from patients with macroalbuminuria, with excellent accuracy, sensitivity of 95% and specificity of 96%. Conclusion We conclude that the L-FABP level could be a suitable biomarker for early detection with good value to detect DN in patients with type-2 diabetes.
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Prevalence and etiology of end-stage renal disease patients on maintenance hemodialysis p. 766
Hassan A Ahmed, Ahmed M Zahran, Rasha A. A. H. Issawi
DOI:10.4103/mmj.mmj_395_18  
Objectives The objective of this work is to study the prevalence and etiology of end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD) in a central governmental Hospital of El-Sharkia governorate, Egypt. Background ESRD has become a public health concern worldwide as the total number of ESRD patients requiring renal replacement therapy has been growing dramatically. The main problem in developing countries is the lack and inaccuracy of data registry. Patients and methods This descriptive study had been done in the El-Sharkia governorate central governmental hospitals on adult patients' resident in the El-Sharkia governorate with ESRD on maintenance HD for more than or equal to 3 months. The study was done during the period from February 2017 to November 2017. Results The prevalence of ESRD patients on maintenance HD in the Sharkia governorate is 442 per million populations (pmp). The etiology of the studied ESRD patients: hypertension (30.1%), undetermined etiology (19.5%), diabetes mellitus (17.6%), recurrent urinary stone (10.3%), recurrent urinary tract infection (8.5%), analgesic nephropathy (4.3%), chronic glomerulonephritis (4.1%), autosomal dominant polycystic kidney disease (2.9%), systemic lupus erythematosus (1.5%), and gout (1.1%). Of the studied ESRD patients, 44.7% had positive antibodies for hepatitis C virus (+ve) and patients with hepatitis B virus surface antigen (+ve) were 2.2%. Conclusion The total prevalence of ESRD patients on maintenance HD in 2017 in Sharkia governorate, Egypt is 442 per million populations (0.0442%). The highest proportion of patients with ESRD was between 50 and 59 years (30.8%). Most of the ESRD patients were from the rural area (60.4%).
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Serum magnesium, parathormone levels, and cardiovascular calcification in chronic hemodialysis patients p. 772
Hassan A. M. Attia, Said S. A. Khamis, Ahmed M Zahran, Khaled M El-Zorkany, Waleed A Ebrahim, Mohammad S Amer
DOI:10.4103/mmj.mmj_429_18  
Objectives To elucidate the correlation between serum magnesium (Mg) and intact parathormone hormone (iPTH) levels and between serum Mg and cardiac calcification in chronic hemodialysis patients. Background Patients with chronic kidney disease (CKD) have various complications, one of which is mineral and bone disorder. iPTH is a major player in CKD-mineral and bone disorder and it may have a relation with Mg. Also, lower serum Mg levels may BE associated with cardiac calcification in CKD. Patients and methods Medical charts of 50 hemodialysis patients were reviewed retrospectively. Demographic and laboratory analyses were recorded. Echocardiographic findings were collected, with stressing on valve calcification (VC). We investigated their serum Mg levels and the correlation between iPTH and serum Mg levels, and other clinical parameters. Results Regarding dividing patients into two groups according to Mg level: iPTH, abdominal aortic radiography calcification, carotid intima thickness, BMI, age, and VC were lower in patients with high Mg than other patients (306.36 ± 69.53 vs. 365.36 ± 116.72 pg/ml; P = 0.042) in multiple regression analysis according to the serum Mg level. the iPTH level was an independent variable after adjustment for other factors. VC was found in 31 (62.2%) patients and significantly increased with older age (P = 0.018). Also, aortic calcification, lower serum Mg, and high low-density lipoprotein levels were found in patients with VC. Conclusion The results of this study indicate a significant negative correlation between serum Mg and iPTH in regular hemodialysis patients, and it was an independent factor among other significant parameters according to serum Mg levels. Also, low Mg level is frequent in regular hemodialysis patients with VC.
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Hematological and biochemical changes due to anti-hepatitis C virus therapy p. 778
Ashraf G Dala, Mohamed H Badr, Mohamed A Helwa, Baher E Maadawi Radi
DOI:10.4103/mmj.mmj_398_18  
Objective The aim of the study was to assess the hematological and biochemical changes in patients who have received anti-hepatitis C virus (HCV) therapy before treatment and follow-up after 3 months of treatment as regards the advantages and disadvantages through a follow up of the studied patients. Background There is a dramatic improvement in HCV therapy following the introduction of oral medicines that directly inhibit the replication cycle of HCV, so the follow up of patients who are receiving therapy before and 6 months after treatment is mandatory to choose the best drug for each patient with the least side effects. Patients and methods This study was done on 200 patients admitted to the Kafr El-Sheikh Hepatology Center diagnosed as HCV-infected patients. Those patients were classified according to the Child classification as Child A score 6. Of them, 100 patients received sofosbuvir + ledipasvir and another 100 patients received sofosbuvir + daclatasvir, respectively. All patients were subjected to the following investigations before and 6 months after treatment: complete blood count, biochemical investigations including serum albumin, alanine transaminase, aspartate transaminase, random blood sugar, blood urea, serum creatinine, total and direct bilirubin, and alkaline phosphatase, thyroid-stimulating hormone level, alpha-fetoprotein, and antinuclear antibody. Results All the previous laboratory investigations were done to all 200 patients, recorded and compared before treatment and 6 months after treatment. Conclusion Ledipasvir and sofosbuvir for 8 weeks or 12 weeks is a highly effective treatment option for the treatment of hepatitis C-infected patients and give best results more than sofosbuvir and daclatasvir.
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Dialysis sodium gradient: a modifiable risk factor for fluid overload in hemodialysis patients p. 783
Mahmoud A Kora, Ahmed R Tawfeek, Heba A Kasem, Ahmed A. B. Z. Omar
DOI:10.4103/mmj.mmj_441_18  
Objective The aim was to study the value of dialysis sodium gradient as a modifiable risk factor for fluid overload in hemodialysis patients. Background It is important to minimize sodium gradient in hemodialysis patients, as it positively correlates with changes in blood pressure during hemodialysis and intradialytic weight gain (IDWG). Patients and methods A cross-sectional analytical study was done on a group of 102 hemodialysis patients divided into three groups: group I included 56 patients with no blood pressure variability, group II included 24 patients who had intradialytic hypotension, and group III included 22 patients who had intradialytic hypertension. All patients attended the Hemodialysis Unit, Zefta General Hospital, Al-Gharbia Governorate, Egypt, during the period from May 2018 to November 2018. Complete history, hemoglobin level, predialysis and postdialysis urea and creatinine, and predialysis sodium were tested. Results There were no statistically significant differences between the studied groups regarding sex (P = 0.1939), age (P = 0.192), primary renal diseases (P = 0.189), vascular access type (P = 0.978), dialysis duration (0.976), hemoglobin (P = 0.131), predialytic and postdialytic urea (P = 0.839, P = 0.120), predialytic and postdialytic creatinine (P = 0.584, P = 0.190), ultrafiltration (UF) rate (P = 0.729), UF volume (P = 0.698), IDWG% (P = 0.777), and sodium gradient (P = 0.468). There was a positive correlation between sodium gradient and the mean IDWG%, mean UF volume, and mean UF rate among the studied hemodialysis patients. Conclusion There was a positive correlation between sodium gradient and IDWG and consequently UF volume and UF rate.
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Is diabetic micro angiopathy a risk factor for variceal bleeding in diabetic cirrhotic patients? p. 789
Ashraf G Dala, Mohammed H Badr, El-Sayed S Abou Elnour, Mohammed K Saad
DOI:10.4103/mmj.mmj_34_19  
Objective To study the impact of diabetic microangiopathy on the outcome of cirrhotic patients with variceal bleeding. Background There are various risk factors for variceal bleeding in cirrhotic patients such as diabetes mellitus, and so follow up of these patients to determine the effects of diabetic microangiopathy on presentation, course, and mortality is mandatory to improve the plane of care. Patients and methods This study is an observational–analytic case–control hospital-based study, which was conducted on 60 patients admitted with acute variceal bleeding. Based on the WHO criteria of diabetes mellitus, the patients were divided into three groups. Group I: 20 diabetic cirrhotic patients with microvascular complications, group II: 20 diabetic cirrhotic patients without microvascular complications, and group III: 20 cirrhotic patients only. All patients were subjected to: full history, clinical examination, complete blood count, liver functions, kidney functions, fasting and 2 h postprandial blood glucose, glycated hemoglobin, vascular endothelial growth factor assay, abdominal ultrasound, fundus examination, monofilament test, and upper gastrointestinal endoscopy. Results The results showed that the mean frequency of rebleeding attacks was significantly higher in group I than other groups and the mean length of hospital stay was significantly higher in group I than other groups. The mortality rate during the period of follow-up was higher in group I than other groups. Conclusion The study showed that cirrhotic patients with diabetic microangiopathy are associated with increased risk of rebleeding esophageal varices, multiple admissions to hospital, long hospital stay, and mortality rate higher than other patients.
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Study of effect of glycemic gap on adverse outcomes in critically ill patients with diabetes p. 794
Sanaa S Gazareen, Adel A. S. EL Eslam, Shimaa K Zewain
DOI:10.4103/mmj.mmj_16_20  
Objective To study if higher levels of glycemic gap can be used as a tool to predict adverse outcomes in patients with diabetes mellitus admitted with critical illness. Background The glycemic gap is calculated as a difference between the A1C-derived average glucose and the admission glucose and may be a better reflector of outcomes. Patients and methods This study was conducted on 150 patients with type 2 diabetes mellitus who were admitted to the ICUs of Menoufia University Hospitals and Benha Teaching Hospital. Full detailed history, Simplified Acute Physiologic Score II, Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II score, glycated hemoglobin, and glycemic gap were assessed. Results The best cutoff value for prediction of adverse outcomes in critically ill patients with diabetes for random blood sugar on admission was 329, with sensitivity of 98.8% and specificity of 89.5%; glycated hemoglobin was 11.88, with sensitivity of 99% and specificity of 98.3%; A1C-derived average glucose was 295.12, with sensitivity of 98.8% and specificity of 98.3%; glycemic gap was 64.25, with sensitivity of 62.5% and specificity of 60%; Acute Physiology and Chronic Health Evaluation II score was 37.0, with sensitivity of 92.2% and specificity of 90.5%; Simplified Acute Physiologic Score II score was 30, with sensitivity of 90% and specificity of 88.8%; and Sequential Organ Failure Assessment score was 6.0, with sensitivity of 83.3% and specificity of 78.6%. Conclusion Higher glycemic gap levels were significantly associated with an increased risk of multiorgan dysfunction syndrome, acute respiratory distress syndrome, shock, upper gastrointestinal bleed, acute kidney injury, acute respiratory failure, as well as ICU mortality. The glycemic gap is a tool that may be used to assess the severity and prognosis of patients with type 2 diabetes admitted with critical illness.
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Serum adiponectin level in osteoporotic postmenopausal women with type 2 diabetes mellitus p. 801
Mohammed A Shaaban, Mohammed G Habsh, Rasha G Mostafa, Shimaa K Zewain
DOI:10.4103/mmj.mmj_85_20  
Objective The aim was to evaluate the relationships between serum adiponectin level and lumbar bone mineral density (BMD) in osteoporotic postmenopausal women with or without type 2 diabetes mellitus. Background Adiponectin is a novel adipocytokine that could influence bone metabolism. Patients and methods This case–control study was conducted on 55 postmenopausal women selected from diabetic endocrinology inpatient and outpatient clinics. Patients were divided into three groups: osteoporotic group (group A), which included 20 nondiabetic osteoporotic postmenopausal women; diabetic osteoporotic group (group B), which included 20 type 2 diabetic osteoporotic postmenopausal women; and control group (group C), which included 15 nonosteoporotic, nondiabetic women postmenopausal. All patients were subjected to complete history, clinical examination, we measured and recorded the anthropometric measures, fasting blood sugar, hemoglobin A1c, serum calcium, serum phosphorus, parathyroid hormone, thyroid-stimulating hormone, erythrocyte sedimentation rate, C-reactive protein, serum adiponectin levels measured by ELISA, and lumbar spine BMD by dual-energy x-ray absorptiometry scan. Results In osteoporotic group (group A), serum adiponectin had a negative significant correlation with BMD (r=−0.45 and P = 0.04). The diabetic osteoporotic postmenopausal group (group B) showed the lowest concentration of serum adiponectin (μg/ml) compared with group A and the control. Lumbar BMD of group B was significantly higher than that of group A. Conclusion Serum adiponectin is associated with lumber BMD in osteoporotic postmenopausal women, which suggests that serum adiponectin was involved in bone metabolism.
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Does nonalcoholic fatty liver disease predict kidney injury in type 2 diabetic patients? p. 806
Hassan Abdelhady, Yassin S Yassin, Khaled M Elzorkany, Yasser M. A. Shahein
DOI:10.4103/mmj.mmj_265_19  
Objective To explore the association between the presence of nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease in type 2 diabetic patients. Background NAFLD is the most common cause of chronic liver disease worldwide. The histologic spectrum of NAFLD ranges from simple steatosis to nonalcoholic steatohepatitis, liver fibrosis, and cirrhosis. Patients and methods A prospective randomized comparative study was conducted during March 2018 to February 2019 on 40 type 2 diabetic patients, who were classified into two groups: group I included 20 patients with type 2 diabetes with fatty liver, and they were classified by ultrasound into patients with mild, moderate, and severe fatty liver, and group II consisted of 20 patients with type 2 diabetes without fatty liver. Full history was taken, and routine examination, physical examination, and special investigations were done. Results The mean albumin/creatinine ratio in group I was higher than in group II (77.24 ± 89.98 and 10.94 ± 2.76, respectively), and the difference was statistically significant (t = 3.294, P = 0.004). Estimated glomerular filtration rate was lower in group I than in group II, and the difference was statistically insignificant. Estimated glomerular filtration rate mean value was higher in patients with mild degree of fatty liver, and the differences were statistically insignificant. Albumin/creatinine ratio, serum creatinine, and serum uric acid were higher in patients with severe fatty liver, and the differences were statistically significant (t = 3.542, P = 0.024; t = 3.132, P = 0.037; and t = 7.647, P = 0.000, respectively). Conclusion Kidney injury in diabetic patients with NAFLD was higher than in diabetic patients without fatty liver and was obvious in those with severe degree of fatty liver. NAFLD is associated with an increased frequency of chronic kidney disease in type 2 diabetic patients.
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Study of glycated albumin to glycated hemoglobin ratio as a predictor of esophageal varices bleeding risk p. 813
Ehab A Elatty, Elsayed I Elshayeb, Mohammed H Badr, Belal A. E Mohsen Montaser, Mokhtar S Hewezy
DOI:10.4103/mmj.mmj_306_19  
Objectives To evaluate glycated albumin (GA) to glycated hemoglobin (HbA1c) ratio as a predictor of variceal bleeding in patients with liver cirrhosis. Background Variceal hemorrhage is a severe complication of liver cirrhosis and can be a direct cause of bleeding-related death. Therefore, upper endoscopy is considered necessary for all cirrhotic patients to evaluate the risk of variceal bleeding. Patients and methods A prospective clinical study was conducted on 100 patients with chronic hepatitis C-related cirrhosis who attended the Gastrointestinal Endoscopy Unit of the Department of Internal Medicine, Menoufia University hospitals, during the period between January 2017 and March 2018. Liver cirrhosis was diagnosed depending upon clinical examination in addition to laboratory and imaging studies. Various indicators for hepatic functions, HbA1c, and GA were measured. GA/HbA1c ratio was measured, and its relationship with the presence and bleeding risk of esophageal varices was analyzed. Results The GA/HbA1c ratio in hepatitis C virus (HCV)-positive cirrhotic patients increases with the severity of the esophageal varices. GA/HbA1c ratio may help in discrimination of low-risk from high-risk varices because GA/HbA1c ratio was the most significantly different among all of the other parameters tested; however, this is still doubtful. Conclusion Thrombocytopenia and prolonged prothrombin time parameters are associated with an increased risk of variceal bleeding. GA/HbA1c ratio in HCV-positive cirrhotic patients increases with the severity of the esophageal varices. GA/HbA1c ratio may help in discrimination of low-risk from high-risk varices. It is of interest and is not redundant to use the GA/HbA1c ratio to predict esophageal variceal bleeding risk in chronic HCV disease.
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TROPICAL MEDICINE - ORIGINAL ARTICLES Top

Comparative study of radiofrequency ablation combined with either percutaneous ethanol injection or percutaneous acetic acid injection in the management of hepatocellular carcinoma p. 819
Mohamed A Nouh, Mohamed K El Sharkawy, Gamal S El Deeb, Amira M Badawy, Haytham M Azab
DOI:10.4103/mmj.mmj_408_18  
Objective The objective of this study was to compare radiofrequency ablation (RFA) plus percutaneous ethanol injection with RFA plus percutaneous acetic acid injection in hepatocellular carcinoma (HCC) treatment in patients having single focal lesions more than 5 cm and up to 7 cm in diameter. Background RFA has proved its effectiveness and safety between various local ablative therapies. Acetic acid, which has the ability to penetrate cells with the property of extracting collagen and dissolving lipids, has a stronger killing effect on hepatocytes than ethanol. Patients and methods This prospective study was carried out from April 2014 to January 2017; it included 60 patients with compensated HCC who had a single lesion more than 5 cm and up to 7 cm in diameter; they were Child A. The patients were selected according to the triphasic computed tomography scanning characteristics of HCC. They were randomly allocated into two groups: group I was ablated for one setting of RFA, followed by percutaneous ethanol injection in the same setting. Group II was ablated by one setting of RFA with two overlaps to decrease the size of the unablated areas, followed by percutaneous acetic acid injection in the same setting. Results Evaluation of the response to ablation 1 month later using triphasic computed tomography showed significant better responses in group II compared with group I (83.3 vs. 60%). The response 3 months later was not changed significantly compared with the response after 1 month. Conclusion Combined techniques give the best results for management of HCCs in comparison with individual techniques. Acetic acid-enhanced RFA is a very effective method of HCC ablation.
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Study of the role of serum methylated septin9 in early detection of colorectal cancers in comparison with colonoscopy p. 824
Gamal S Eldeeb, Ahmed N Fawzy, Sally M El-Hefnawy, Sherif Z Awad, Ayman A Sakr
DOI:10.4103/mmj.mmj_3_20  
Objective To assess role of serum methylated septin9 (mSEPT9) in early detection of colorectal cancers (CRCs) in comparison with colonoscopy. Background mSEPT9 has been suggested as a reliable biomarker in CRC detection. We aimed to determine the diagnostic role of mSEPT9 for CRCs detection in Egyptian patients. Moreover, we compared the diagnostic efficacy of adding mSEPT9 to carcinoembryonic antigen (CEA). Patients and methods A single-center prospective study was done on 90 patients presented with signs or symptoms of CRCs. They were divided into three groups: group I (n = 45) patients with CRCs, group II patients with colorectal polyps (benign lesions) (n = 25), and group III the control group (n = 20). All patients and controls were subjected to history taking, proper examination, and investigations. Serum samples were collected for mSEPT9 and CEA. Sensitivity and specificity were calculated to evaluate the diagnostic efficacy. Results mSEPT9 achieved overall sensitivity of 84% and specificity of 78%, with an area under the curve value of 0.911. This was superior to CEA, which achieved overall sensitivity of 78% and specificity of 76%, with an area under the curve value of 0.911. The combination of mSEPT9 and CEA further improved sensitivity 100%, whereas specificity was declined to 56%. Conclusion mSEPT9 demonstrated better diagnostic ability in CRC detection compared with colonoscopy. The combination of mSEPT9 and CEA further improved diagnostic sensitivity, especially for early-stage disease, which may provide a new approach for future CRC screening.
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CARDIOLOGY - ORIGINAL ARTICLES Top

Pattern of lipid profile in pregnancy and its impact on the gestational course p. 830
Ashraf Reda, Awni Gamal, Mohamed Rezk, Gehad Gamal, Ommaima Idris, Marwa Sharaf
DOI:10.4103/mmj.mmj_327_18  
Objective The aim was to screen lipid profile in pregnancy and assess the association between second trimester maternal lipid profile and gestational outcome. Background Major changes in lipid profile occur during normal pregnancy and significant association with gestational complications could be confirmed. Materials and methods This cohort study included 94 women with maternal lipid profile assessed during the second trimester (16–18 weeks). Serial antenatal visits were conducted to record the development of maternal gestational hypertension (GH), preeclampsia (PE), gestational diabetes mellitus (GDM), and low birth weight. Results Lipid profile components in pregnancy are higher than normal references. Meanwhile, GH was the most common complication in the study affecting 13 (13.8%) patients followed by PE in eight (8.5%) patients, GDM in seven (7.4%) patients, and lastly low birth weight in four (4.3%) neonates. A positive association between second trimester lipid profile components and GH, PE, and GDM was found. Conclusion Lipid profile during the second trimester should be done routinely especially in patients with hypertensive disorders and GDM.
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Assessment of left atrial function in patients with heart failure: correlation with brain natriuretic peptide levels p. 835
Mohamed F Al-Noamany, Ghada M Sultan, Ashraf A. E. Dawood, Naglaa F Sebaeia, Mohamed L. H. Moustafa
DOI:10.4103/mmj.mmj_348_18  
Objectives To assess left atrial function by speckle tracking in patients with heart failure (HF) with reduced ejection fraction and HF with preserved ejection fraction and correlate it with brain natriuretic peptide (BNP). Background HF is a clinical syndrome characterized by impaired structure and/or function of the heart, leading to dyspnea and fatigue at rest or with exertion. The pathophysiology of HF is complex, and there is no single etiological lesion. Patients and methods The study comprised 80 randomly selected persons presented to Cardiology Department of Menoufia University Hospitals, Egypt, from January to October 2016 to April 2018. They included 35 patients with Ejection fraction (EF) less than 50% Heart failure with reduced ejection fraction (HFrEF) (group I), 35 patients with Ejection fraction (EF) more than 50% Heart failure with preserved ejection fraction (HFpEF) (group II), and 10 normal individuals (control group), with typical signs and symptoms of HF and normal sinus rhythm. Results Patients with HF with reduced EF had significant increase in left ventricular volumes and left atrium (LA)volumes when compared with controls. All HF patients with reduced EF had a significant decrease in LA active emptying (volume, fraction)and LA passive emptying fraction, volume) when compared with controls. BNP had significantly higher values in HF patients with reduced EF compared with controls. Conclusion LA increased (volumes) and decreased (function), measured by strain and volumetric parameters in HF patients with reduced ejection fraction regarding controls. There was a significant increase in BNP in patients with HF with reduced ejection fraction and those with preserved ejection fraction compared with controls. The current study showed that BNP level was higher among HF groups (groups I and II) than among the controls (group III).
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PEDIATRICS - ORIGINAL ARTICLES Top

Detection of beta-thalassemia carriers among relatives of patients with thalassemia in Menoufia Governorate p. 843
Seham M Ragab, Sameh A Abdelnaby, Mohamed A Soliman, Zein Abd El Latife Omar, Eman Y. S Mohamed Amer
DOI:10.4103/mmj.mmj_292_18  
Objectives To detect thalassemia carriers among relatives of patients with thalassemia major. Background Thalassemia syndromes are a group of blood disorders inherited in autosomal recessive manner that cause hemolytic anemia because of the decreased or absent synthesis of a globin chain. Imbalances of globin chains cause hemolysis and impair erythropoiesis. Thalassemia is the most common type of genetic abnormalities in the world. It is one of the most common genetic disorders in Egypt. Thalassemia major is variably referred to as 'Cooley's anemia' and 'Mediterranean anemia.' Thalassemia minor is also called 'beta-thalassemia carrier,' 'beta-thalassemia trait,' or 'heterozygous beta-thalassemia.' Patients and methods This study includes 100 children. All of them are relatives of patients with beta-thalassemia major who attended the Pediatric Hematology Clinic, Menoufia University Hospitals, in the period from May 2015 to November 2017. The age of our group ranged from 6 months to 18 years. Complete blood count, blood film, iron profile (serum iron, serum ferritin, and total iron-binding capacity), and hemoglobin electrophoresis were done for all. Results A total of 30 (30%) children were found to be carriers of beta-thalassemia, 20 (20%) children were found to have iron-deficiency anemia, 20 (20%) children were found to be both carriers of beta-thalassemia and have iron-deficiency anemia, two (2%) children had thalassemia intermediate, two (2%) children had sickle cell trait, and 26 (26%) children were normal. Conclusion Beta-thalassemia carrier status is the most common cause of microcytic anemia among relatives of patients with beta-thalassemia major.
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The effects of inhaled β-adrenergic agonists in transient tachypnea of the newborn p. 847
Dalia M Al Lahony, Hanan M Elsayed, Ismail S Mohammed
DOI:10.4103/mmj.mmj_320_18  
Objective The objective of this study was to evaluate the efficacy of inhaled salbutamol for the treatment of transient tachypnea of the newborn (TTN). Background The most commonly reported cause of neonatal respiratory distress is TTN, with estimated incidence of 0.5–2.8% of all newborn. Patient and methods This is a randomized controlled trial study considering patient with even registration number as cases. Inhaled salbutamol or normal saline solution was administered to 60 infants diagnosed as having TTN. The response was evaluated by determining respiratory rate, heart rate, TTN clinical score, and level of respiratory support, before and at 30 min and 1 and 4 h after drugs therapy. The standard dose of salbutamol was 0.15 mg/kg added to 2 ml normal saline. The second group received dose of 2 ml nebulized (0.9%) normal saline only. Results The studied neonates were between 36 and 39 weeks of gestation. There were 30 (50%) males and 30 (50%) females. Comparing the two groups after 4 h of inhaled therapy, highly significant lower respiratory rate, oxygen, TTN score, respiratory support, and duration of hospitalization were detected in salbutamol group rather than saline group. Regarding arterial blood gas findings after 4 h of inhaled therapy, pH and partial pressure of arterial oxygen were significantly higher in salbutamol group than saline group. No significant difference was detected between the two groups regarding heart rate and serum potassium. Conclusion A single dose of inhaled salbutamol resulted in better clinical aspect and better laboratory outcome measures in cases of TTN.
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Nonsyndromic X-linked mental retardation p. 852
Maha A Tawfik, Wafaa M Abo El-Fotoh, Shiamaa E El-Nashar
DOI:10.4103/mmj.mmj_360_18  
Objective To evaluate the role of the Aristaless-related homeobox (ARX2) gene to detect cases of nonsyndromic X-linked mental retardation (MR) and genetic counseling of patients and their families to detect possible cases and high risk group. Background MR is a genetic disorder manifested in significantly below average overall intellectual functioning and deficits in adaptive behavior. Patients and methods This study included 50 boys who had an intelligence quotient of less than 70. They were recruited from the pediatrics genetic clinic at El Menoufia University Hospital in the period from October 2015 to April 2017. Their ages ranged between 3 and 16 years. After presenting a written informed consent from parents, all patients have been clinically evaluated and had routine assessment. Results The ages of the included patients ranged between 3 and 16 years, most of them were in the late childhood period (6–12 years), followed by the pubertal period (12–15 years). Regarding the genotypes of ARX2: 16% had full mutation, 12% had premutation and 72% had unexpanded alleles. Distribution of the degree of mentality between genotypes of the studied patients has shown that 63% of patients of full mutation had moderate MR; of the premutation patients 50% had moderate MR; and 69% of the unexpanded allele had moderate MR with highly significant P value = 0.001. Conclusion Diagnosis of ARX gene prevalence should depend on proper selection of cases and sensitive molecular techniques in detecting gene mutations in mentally retarded patients and their relatives to detect full mutation and premutation cases for early diagnosis, intervention, and give proper genetic counseling for patients and their families.
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Identification of risk factors of attention-deficit hyperactivity disorder in Egyptian children p. 856
Fahima M Hassaan, Sameh A. A Abd Elnaby, Wafaa M. M Abo El-Fotoh, Rasha I. M. Noreldin, Mohammed E. A Abd Elhady
DOI:10.4103/mmj.mmj_373_18  
Objective The aim was to identify the risk factors of attention-deficit hyperactivity disorder (ADHD) in Egyptian children. Background ADHD is the most commonly diagnosed neurodevelopmental disorder that begins during early childhood. Various psychological, social, genetic, and biochemical factors are thought to be involved in the etiopathogenesis of ADHD. Participants and methods A prospective, randomized comparative study was conducted on 50 children with the diagnosis of ADHD and 35 healthy children as the control group. All patients were selected from those attending the outpatient neurology clinic and those admitted in the Pediatric Department Menoufia University Hospital in the period from October 2017 to March 2018. Full history taking and clinical examination as well as assessment of possible risk factors were done. Results There was a high frequency of ADHD among male children, school aged children living in urban areas, children of low socioeconomic status living with a single parent, large families and in families who have past history of ADHD. ADHD-C is the most predominant type (38%), followed by ADHD-I (34%) and ADHD-HI (28%). ADHD-C and ADHD-HI were found in the men more than women. Also, epilepsy was found in 10% of ADHD. Conclusion There are many factors that are associated with increased possibility of developing ADHD such as male gender, school age, living in urban areas, low socioeconomic status, large families, and families who have a past history of ADHD and children living with a single parent. So, parent training programs should focus on encouraging parents'' positive interaction with their children.
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Incidence of hyponatremia in acute bronchiolitis p. 862
Ahmed A Khatab, Salem El Sayed Deraz, Wael A Bahbah, Haitham Y Hassbou
DOI:10.4103/mmj.mmj_377_18  
Objective To assess the incidence and early detection of hyponatremia (below 135 mmol/l) associated with acute bronchoilitis in infants. Background Acute bronchiolitis is the most common disease of lower respiratory tract during the first year of life. It occurs as an annual epidemic in winter, and it often affects the child's ability to feed. Hyponatremia is a prognostic factor that might predict the disease course of children with severe bronchiolitis. Patients and methods This study was conducted on 300 patients having acute bronchiolitis from February 2015 to February 2016. They were divided into two groups: group I included 240 patients with normal serum sodium level (135–145 mmol/l), and group II consisted of 60 patients with low serum sodium level (<135 mmol/l). Detailed history; routine, physical examination; length of hospital stay; and clinical severity scores were done. Results There was a highly significant statistical difference regarding length of stay in hospital (P = 0.001) and clinical scores on days 3 and 5 (P = 0.001 for both). There was a highly significant positive correlation between chest radiography and length of stay in hospital (r = 0.441, P = 0.001). There was a significant negative correlation between family history of allergy and length of stay in hospital in normonatremic patients (r = −0.238, P = 0.008), as well as a negative correlation between age and length of stay in hospital (r = −0.241, P = 0.007). Conclusion Hyponatremia on the day of hospitalization was associated with a higher severity of disease. It is a prognostic factor that might improve our ability to predict the disease course of children with severe bronchiolitis. Serum sodium should be measured in all patients with bronchiolitis within 48 h from admission. Further studies are needed to assess the incidence of hyponatremia in bronchiolitis on a broad scale and to follow-up the course of the disease.
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Assessment of growth and blood pressure measurements in Gharbia urban and rural primary school children p. 868
Aml Y Mahmoud, Wafaa M Abo Elfotoh, Soheir S Abou El.Ella
DOI:10.4103/mmj.mmj_379_18  
Objective To assess the growth using anthropometric measurements and determine the prevalence of obesity, short stature, and hypertension among primary school children. Background Healthy growth for children is of great importance in the development of their physical and mental growth. Growth is influenced by many factors that act to modify a child's genetic growth. Patients and methods A cross-sectional study was conducted on 1050 children aged 6 to less than 12 years, including 515 (49%) boys and 535 (51%) girls, who were recruited from primary schools in Zefta city, Gharbeya Governorate. All children were assessed for anthropometric measurements such as weight (kg), height (cm), BMI (kg/m2), and arm span (cm). Moreover, blood pressure (BP) was measurement. Results The mean age was 8.50 + 1.70 years. The overall anthropometric values for boys were as follows: mean height was 134.55 ± 11.75 cm, mean weight was 32.38 ± 9.24 kg, and mean BMI was 17.47 ± 2.68 kg/m2. The corresponding measurements for girls were 133.55 ± 12.38 cm for height, 32.68 ± 10.73 kg for weight, and 17.84 ± 3.096 kg/m2 for BMI. Prevalence of overweight and obesity in boys were 4.9 and 6.8% and in girls were 11.2 and 7.5%, respectively. Mean BP for male children was 102.53 and 61.59 mmHg for systolic BP and diastolic BP, respectively, and for girls was 102.42 and 61.48 mmHg for systolic BP and diastolic BP, respectively. Prevalence of prehypertension in boys was 7.7% and in girls was 11.2%. No cases of short stature were seen. Conclusion Most children have normal growth patterns. Obesity was positively associated with higher BP.
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The effect of head covering in the prevention of phototherapy-induced hypocalcemia in icterus newborns p. 873
Maha A Tawfik, Fady M Elgendy, Rania El-Sayed Z. Aman
DOI:10.4103/mmj.mmj_383_18  
Objective The aim of the study was to determine the prevalence of phototherapy-induced hypocalcemia in icterus newborns and to evaluate the role of head covering in preventing the occurrence of hypocalcemia in the neonatal ICU of Menoufia University hospitals. Background Neonatal jaundice is defined as the yellowish discoloration of the sclera and skin caused by hyperbilirubinemia, which is one of the most common conditions confronting neonatologists daily. About 60% of term and 80% of preterm infants develop jaundice in the first week of life. Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia Patients and methods Our study was conducted on 200 neonates recruited from the neonatal ICU in Menoufia University hospitals, and they were divided into two groups: group A comprised 100 term babies with head covering (hat) during phototherapy. Group B comprised 100 term babies without head covering during phototherapy. Total serum calcium was checked on arrival and 48 h after starting phototherapy. Results There was a highly significant increase in total calcium 48 h after phototherapy (mg/dl) and ionized calcium 48 h after phototherapy (mg/dl) in neonates with head covering compared with neonates without head covering. In contrast, there was no significant difference (P > 0.05) between both groups with regard to total and ionized calcium on admission (mg/dl). Conclusion Covering the head of infants under phototherapy using a hat was an effective, safe, noninvasive, and cheap method for the prevention of phototherapy-induced hypocalcaemia.
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Free thyroxine and thyroid-stimulating hormone in preterm neonates with respiratory distress syndrome p. 878
Maha A Tawfik, Fady M El Gendy, Asmaa A. M. M. Zidan
DOI:10.4103/mmj.mmj_440_18  
Objective To study the level of serum free tetraiodothyronine (FT4) and thyroid-stimulating hormone (TSH) in cases of respiratory distress syndrome (RDS) in preterm neonates and its correlation with other clinical findings. Background RDS is one of the most common respiratory complications of prematurity. The relationship between RDS and thyroid hormones levels was the target of this study. Patients and methods This was a case-control study that included 90 preterm neonates (60 preterm neonates with RDS and 30 healthy preterm neonates with matched gestational age and sex as controls), conducted in the neonatal ICU, Menoufia University Hospital, Egypt, from October 2017 to September 2018. Results Mean value of serum FT4 was statistically significant lower among cases than controls, whereas serum TSH was statistically significant higher among cases than controls. There were statistically significant positive correlations between serum FT4 and gestational age, New Ballard score, weight, Apgar score at 1 min, and Apgar score at 5 min, whereas statistically significant negative correlation between FT4 and Downes score. There were statistically significant positive correlations between serum TSH and Downes score, whereas there were statistically significant negative correlations between serum TSH and gestational age, New Ballard score, weight, Apgar score at 1 min, and Apgar score at 5 min. Conclusion The present study showed that there was a negative significant correlation between serum FT4 level and the occurrence and severity of RDS, and there was a positive significant correlation between serum TSH level and the occurrence and severity of RDS.
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Association of iron deficiency anemia with simple febrile seizures: a hospital-based observational case–control study p. 882
Jehangir A Bhat, Sajad A Sheikh, Sami U Bhat, Roshan Ara
DOI:10.4103/mmj.mmj_37_19  
Objectives To reveal the association of iron deficiency anemia with simple febrile seizures. Background Iron deficiency anemia has aa defined role in a variety of neurological and psychological problems in children such as stroke, behavioral, and cognitive problems. Therefore, it is hypothesized that iron deficiency anemia may have a role in febrile seizures. Patients and methods It was a hospital-based observational case–control study conducted on 320 children of age group 6–59 months. Children were divided into groups. Cases (160) who presented with simple febrile seizures and controls (160) who had fever of short duration without any type of seizure or abnormal body movement. At the time of presentation to hospital, venous blood sample for routine investigations along with complete blood count of all children included in study were sent to laboratory. All data were tabulated and analyzed with relevant statistical tests. Results Iron deficiency anemia is prevalent more (nearly > 5 times) in children who has simple febrile seizures than in normal children. Thus, evaluation for iron deficiency should be done in every child who present with simple febrile seizure. Conclusion Iron deficiency was recorded in 42 and 12.5% of cases and controls, respectively. Statistically significant association was seen between iron deficiency anemia and simple febrile seizures (P = 0.001) with odds ratio of 5.139. All hematological parameters which define iron deficiency anemia were low and statistically significant in cases as compared to controls.
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Hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma p. 886
Soheir S. A. Elella, Maha A Tawfiq, Mohamed Mekawy, Manal A Elsayed Yousef
DOI:10.4103/mmj.mmj_46_19  
Objective The main objective is to study the frequency of hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma and its relation to severity of the disease. Background Hyponatremia is the most common electrolyte abnormality seen in hospitalized patients with lower respiratory tract infections such as bronchiolitis and bronchial asthma. Patients and methods This is a case–control study, involving 69 cases of bronchiolitis and 31 cases of severe bronchial asthma, conducted in Menoufia University Hospitals from November 2017 to April 2018. All cases were subjected to history taking, clinical assessment, and investigations, including complete blood count, C-reactive protein, serum urea, serum creatinine, serum glutamic oxaloacetic transaminase, serum glutamate pyruvate transaminase, serum sodium, and serum potassium. Results The age of bronchiolitis cases ranged from 1 to 24 months of life, with mean age of 7.39 ± 7.63 months, whereas the age of severe bronchial asthma cases ranged from 36–138 months of life, with mean age of 56.71 ± 25.0 months. Clinical presentation of bronchiolitis was cough (100%), fever (40.8%), and poor feeding (55%), whereas that of patients with severe asthma was cough (100%), wheezy chest (67.7%), dyspnea (38.7%), and tight chest (25.8%). Incidence of hyponatremia in patients with bronchiolitis was 5.8% whereas in patients with severe bronchial asthma was 25.8%. Conclusion Hyponatremia is a common electrolyte abnormality in hospitalized children with lower respiratory tract infections such as bronchiolitis and bronchial asthma. The incidence of hyponatremia increased with the severity of the disease.
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Causal relationship between cord blood leptin level and different patterns of birth weight p. 891
Ahmed A Khattab, Dalia M El-Lahony, Wafaa M Abo El-Fotoh, Osama T Abd El-Fattah
DOI:10.4103/mmj.mmj_49_19  
Objective To estimate the cord blood leptin level in different patterns of birth weight. Background Birth weight is a strong predictor of both neonatal mortality and morbidity. Umbilical cord blood leptin has been consistently shown to be positively associated with birth weight. It has been widely accepted as a marker of neonatal adiposity. Patients and methods A case–control study was conducted on 60 neonates who were divided into 20 small for gestational age (SGA), 20 appropriate for gestational age (AGA), and 20 large for gestational age (LGA). All neonates were recruited from the gynecology and obstetrics department at Menoufia University Hospital and Shebin El-Kom Teaching Hospital, Egypt, during 1 June till 25 November 2018. Full history, physical examination, and cord leptin level were examined in all neonates. Results Most patients of SGA group were males (60%), whereas females were the most frequent in AGA (60%) and LGA (80%) groups. LGA had significantly higher cord leptin (53.58 ± 19.75 ng/ml) than AGA (20.99 ± 12.8 ng/ml) and SGA (5.77 ± 8.27 ng/ml) groups (P < 0.005). It was significantly higher in AGA group than SGA group (P = 0.014). Cord leptin was significantly positive correlated with birth weight in SGA (P < 0.01) and AGA groups (P = 0.013) and BMI in SGA group only (P = 0.026). Conclusion Umbilical cord leptin level was significantly higher in LGA and AGA groups than SGA group. Umbilical cord leptin level was positively correlated with birth weight in SGA, AGA, and LGA groups. However, it was not correlated with sex of neonates in all studied groups.
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Thyroid dysgenesis as a risk factor for patients with poorly controlled congenital hypothyroidism p. 898
Sohier S Abu EL-Liaa, Essam S Khattab, Naglaa F Barseem, Rehab K. A. beddah
DOI:10.4103/mmj.mmj_66_19  
Objective Our aim was to search for the risk factors of cases with poor controlled congenital hypothyroidism (CH) in correspondence to their clinical aspect. Background CH is largely caused by thyroid gland dysgenesis, and there is lack of a standardized approach for diagnosis, follow-up, education, and genetic counseling of patients with CH. Patients and methods Genetic counseling and thyroid ultrasonography (US) were done. Blood samples were collected from 56 children (30 girls and 26 boys) with CH, diagnosed on the basis of neonatal screening program done by Egyptian Ministry of Health and Population, Central Health Laboratories, Hormones and Tumour Marker Department. All patients confirmed biochemically with low free thyroxine and high thyroid-stimulating hormone levels were enrolled as cases (group I), along with 56 apparently healthy individuals as controls (group II), who attended the Genetic laboratory of Genetic and Endocrinology Unit, Paediatric Department, Faculty of Medicine, Menoufia University, Egypt. Results A total of 16 (28.6%) patients had poor response to treatment. They were on a high dose of L-thyroxin (100 μg/day or more), with their US findings ranging from normal thyroid sonar in six patients, hypoplastic gland in four patients, and thyroid agenesis in six patients. All healthy control children showed normal US findings. Conclusion US is the first-choice imaging method in revealing the etiology of CH. Family counseling is a key component for enhancing the care of patients with CH.
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CLINICAL PATHOLOGY - ORIGINAL ARTICLES Top

Association of type 1 collagen (COLIA1) gene polymorphism with osteoporosis in thalassemia major p. 904
Rawhia H Eledel, Amal H Abdelhamid, Seham M Ragab, Thoria A Omar, Samya S. M. Mashal
DOI:10.4103/mmj.mmj_318_18  
Objectives The objective of this article is to study the association of COLIA1 gene polymorphism with osteoporosis in thalassemia major. Background Beta-thalassemia is a group of autosomal recessive hereditary hemoglobinopathy characterized by a deficiency or absence of B globin chain of adult hemoglobin. Osteoporosis is common sequelae in these patients. Several genes are involved in the development of osteoporosis such as collagen type I alpha 1, vitamin D receptors, estrogen receptors, and interleukin-6 which monitor bone mineral density and bone shape and structure. COLIA1 encodes the alpha 1 chain of collagen type I which is the most abundant structural protein in the bone matrix. Patients and methods Sixty patients with beta-thalassemia (29 women, 31 men) aged 4–15 years and 20 healthy participants were cross-matched with age and sex. Serum calcium, serum phosphorus, serum alkaline phosphatase, and dual-energy radiograph absorptiometry scan were examined in the studied groups. The COLIA1 gene polymorphism was measured by restriction fragment length polymorphism-PCR. Results The study indicated that the SS genotype in thalassemia is 48.3%, but higher in the control group (80%). The Ss genotype in thalassemia is 43.3% but lower in the control group (20%) and the ss genotype in thalassemia is 8.3 but in the control group is 0% (P = 0.042). The frequency of S alleles in thalassemia is 70% but in the control group is 90% and the frequency of s alleles in thalassemia is 30% but in the control group is 10% (P = 0.011). Conclusion Early detection of the SP1 binding site on the COLIA1 gene polymorphism among thalassemic patients could help in the management of these patients.
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Value of mtDNA and ctDNA in patients with hepatocellular carcinoma p. 909
Laila M Montaser, Ahmed A El-Shaarawy, Naser M. A. El-Bary, Waleed M Fathy, Suzan El-Morshedy
DOI:10.4103/mmj.mmj_349_18  
Objective The aim was to evaluate the diagnostic value of mitochondrial DNA and circulating tumor DNA in patients with hepatocellular carcinoma (HCC). Background HCC is one of the most common malignant tumors worldwide. Not all patients with HCC are diagnosed using α-fetoprotein alone. Mitochondrial DNA and circulating tumor DNA have been extensively studied over the past few decades and have a high sensitivity and specificity in the detection of HCC. Patients and methods Blood samples were obtained from 150 individuals, comprising 50 patients with HCC and 100 apparently healthy participants as a control group. The blood samples were collected in the time period from August 2013 to September 2016. All patients were subjected to routine laboratory investigations and quantification of mitochondrial DNA and circulating tumor DNA by real-time PCR. Results There was a significant increase in the levels of mitochondrial DNA and circulating tumor DNA in patients with HCC in comparison with the healthy control group. By using receiver operator characteristic curve, sensitivity and specificity of mtDNA for HCC group were 70% and 75%, respectively with a cutoff of 480 GE/ml, whereas sensitivity and specificity of ctDNA for HCC group was 81% and 88%, respectively, with a cutoff of 348 GE/ml. Conclusion Increase sensitivity and specificity of circulating tumor DNA and mitochondrial DNA in HCC make us consider them as potential tumor markers, and analysis of circulating tumor DNA and mitochondrial DNA with other tumor markers could improve the diagnostic sensitivity for HCC.
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Total antioxidant capacity as an aging marker in Egyptian patients with Alzheimer disease p. 914
Rawhia H El-Edel, Dalia H Abou-Elela, Ahmed A Sonbol, Amr S Shalaby, Mariam A Fouaad
DOI:10.4103/mmj.mmj_409_18  
Objective This study aimed to evaluate the total antioxidant capacity (TAC) as an aging marker in patients with Alzheimer disease (AD). Background AD is a neurodegenerative disorder that affects elderly and is the most common type of dementia. Reactive oxygen species is a major risk factor of Alzheimer. Oxidative stress, the most important factor in the pathogenesis of Alzheimer, occurs when reactive oxygen species and reactive nitrogen species increase and/or antioxidant defense system decreases. TAC is a marker of DNA oxidation. These data will explain pathogenesis and prevention and help in the treatment of AD. Patients and methods This study was carried on 90 individuals categorized into three groups: group 1 (patients group) included 30 patients with AD, group II (control matched group) included 30 age-matched and sex-matched apparently healthy participants, and group III (pregeriatric group) included 30 apparently healthy participants. Their age was between 30 and 60 years old. The determination of the TAC is performed calorimetrically by the reaction of antioxidants in the sample with a defined amount of exogenously provide hydrogen peroxide. Results There was a highly significant decrease in TAC in all studied group. Receiver operating characteristic curve for antioxidant to predict Alzheimer's cases versus control matched group showed that at a cutoff point of less than or equal to 1.16, it had a sensitivity of 73.33%, specificity of 83.33%, positive predictive value of 81.5% and negative predictive value of 75.8%. Conclusion Our results indicate a relation between oxidative stress and AD, indicating a possible role of these markers in diagnosis of AD.
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Role of tumor necrosis factor alpha in type 2 diabetic nephropathy p. 920
Rawhia H El-Edel, Waleed M Fathy, Dalia H Abou-Elela, Mahmoud M Emara, Noran T Abo El-Khair
DOI:10.4103/mmj.mmj_430_18  
Objectives To study the role of tumor necrosis factor alpha (TNF-α) in type 2 diabetic nephropathy (DN). Background DN, a long-term major microvascular complication of uncontrolled hyperglycemia, affects a large population worldwide. It is considered the driving cause of end-stage kidney disease. TNF-α is a proinflammatory cytokine and plays an important role in the pathogenesis and clinical outcome of DN. Patients and methods The present case–control study was conducted on three groups: group I included 20 healthy controls, group II [diabetes mellitus (DM)] included 38 patients with type 2 DM without nephropathy, and group III comprised diabetes with chronic kidney disease (DM-CKD) and included 40 patients with type 2 DM with nephropathy. TNF-α level was determined using enzyme-linked immunosorbent assay. Routine chemical tests were done using chemistry autoanalyzer, and glycated hemoglobin was measured using ion-exchange resin chromatography. Correlations were tested by Pearson's correlation analysis. Logistic regression was used to detect the most independent/affecting factor for development of the DN. Results Serum level of TNF-α in DM group was significantly higher than controls (P < 0.001); in addition, the level in DM-CKD was significantly higher than controls and DM (P < 0.001). Moreover, there was a significant positive correlation between serum levels of TNF-α and fasting blood glucose, creatinine, total cholesterol, low-density lipoprotein-cholesterol, glycated hemoglobin, and microalbumin/creatinine ratio among DM-CKD group (r = 0.042, <0.001, <0.001, <0.001, 0.027, and 0.043, respectively). Conclusion Serum TNF-α was significantly increased in patients with DM and DM-CKD but was higher in patients with DM-CKD, which designates that TNF-α can participate in progression of DM to DN and might play an important role in mediating DN.
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Evaluation of CYP2B6 G15631T polymorphism as a risk factor for development of chronic myeloid leukemia p. 926
Enas S Essa, Suzan A AlHassanin, Wafaa M Radwan, Mayada G Hagag
DOI:10.4103/mmj.mmj_8_19  
Objectives The objective of this study was to investigate the possible relationship between CYP2B6 G15631T gene polymorphism and chronic myeloid leukemia (CML) risk. Background The cytochrome P450 (CYP) enzymes constitute one of the biggest gene families and play a vital role in the metabolism of endogenous biomolecules, drugs, and xenobiotics. One of the members of this family, CYP2B6, plays a very important role in metabolizing carcinogens and medications. CYP2B6 G15631T gene polymorphism reduces CYP2B6 enzyme activity. Patients and methods Fifty CML patients and 32 matched healthy controls were enrolled in this study. CYP2B6 G15631T polymorphic variant was detected by PCR-restriction fragment length polymorphism. Results The frequencies of GG genotype (wild type) were 60% and 43% in CML and control groups, respectively. The frequencies of polymorphic GT genotype (heterozygous variant) were found to be 32% in CML patients and 37.5% in controls (P = 0.608). The TT genotype (homozygous variant) was 8% in CML cases and 18.8% in the control group (P = 0.147). The frequency of the T allele was 24% in CML patients and 37.5% in healthy individuals (P = 0.064). We did not find any association between CYP2B6 G15631T polymorphic variant and CML risk. Conclusion CYP2B6 G15631T is not a risk factor for CML. Further studies on this polymorphism using large number of cases may provide valuable information.
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p53 as an apoptotic marker before and after phototherapy in hyperbilirubinemic neonates p. 930
Gehan K Sead, Belal A Montaser, Thoria A Omar, Zain A Omar, Amr A Alkorashy
DOI:10.4103/mmj.mmj_9_19  
Objective The objective of this study was to study the serum level of p53 before, during, and after phototherapy in full-term neonates with hyperbilirubinemia and to confirm that p53 is an apoptotic marker related to phototherapy. Background Jaundice is a serious condition that can lead to death or lifelong neurological sequela in newborns, so it requires medical attention. Phototherapy is the standard treatment for neonatal hyperbilirubinemia; however, it led to potential side effects such as retinal degeneration, diarrhea, dehydration, and skin rash. Experimental studies demonstrated that phototherapy increased apoptosis in lymphoma cell line and neonatal small intestine cells. p53 is a tumor-suppressor protein that regulates the cell cycle preserving stability by preventing genome mutation. Patients and methods This study was conducted at the Clinical Pathology and Pediatric Departments of Menoufia University Hospitals from June 2017 to December 2018 on 22 neonates with hyperbilirubinemia necessitating phototherapy, 11 neonates with hyperbilirubinemia not necessitating phototherapy, and 11 apparently healthy normal neonates They have undergone full history, clinical examination, hemoglobin, reticulocyte count, Coombs test, and blood and Rh grouping. Quantification of p53 was done by enzyme-linked immunosorbent assay. Results Serum p53 level was highly significant (P < 0.001) in patients with hyperbilirubinemia necessitating phototherapy at the peak of phototherapy compared with other groups. Conclusion Serum p53 level was raised in neonates who become exposed to phototherapy and it may be used as a marker of apoptosis.
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Relationship of methylenetetrahydrofolate reductase C677T genetic polymorphism and oxidative changes in Egyptian patients with β-thalassemia major p. 936
Rawhia H El Edel, Emad F Abdalhalim, Mohammad G Alhelbawy, Alshimaa R. S. Elkholy
DOI:10.4103/mmj.mmj_87_19  
Objectives To evaluate the genetic polymorphism of methylenetetrahydrofolate reductase (MTHFR) C677T among patients with beta-thalassemia major and its related oxidative changes. Background Accelerated oxidative damage is one of the hallmarks in beta-thalassemia major. Genetic polymorphism of MTHFR C677T has been shown to cause hyperhomocysteinemia, which acts as a prooxidant. Material and methods Genotyping for MTHFR C677T was evaluated by PCR-restriction fragment length polymorphism technique. Complete blood picture, hemoglobin electrophoresis, serum ferritin, and total antioxidant capacity (TAC) were determined in 60 patients with beta-thalassemia major and 20 controls of matched age and sex. Results MTHFR 677TT genotype was significantly higher among patients with beta-thalassemia major (23.3%) compared with controls (5%). There was significant decrease in TAC in thalassemic patients as compared with controls. TAC was significantly lower in TT group than both of CC and CT groups. Ferritin level was significantly higher in thalassemic group than controls. Conclusion Detection of MTHFR (C6777T) genetic polymorphism among thalassemic patients could be helpful in assessment of oxidative stress among these patients.
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Vascular endothelial growth factor gene polymorphism in Egyptian patients with B-cell chronic lymphocytic leukemia p. 942
Iman A Ahmedy, Mohamed A Soliman, Enas A Elkhouly, Soha A. K. Zanaty, Rasha I. N. El-Din
DOI:10.4103/mmj.mmj_132_19  
Objective The objective of this study was to add to the scope of the role of vascular endothelial growth factor (VEGF) +936C/T gene polymorphism in the prognosis of B-cell chronic lymphocytic leukemia (CLL) in Egyptian patients. Background CLL is a common lymphoid malignancy that has a highly variable clinical course. Several studies have targeted to determine the high risk of disease progression; VEGF-mediated angiogenesis is one of the most vital regulators of angiogenesis and vascular permeability, which can contribute to the pathogenesis of B-CLL. Patients and methods This prospective case–control study was conducted on 30 patients of CLL and 20 age-matched and sex-matched healthy individuals as a control group from January 2016 to January 2018. All patients were subjected to full history taking, clinical examination, and laboratory investigations. Genotyping of VEGF + 936C/T (rs3025039) single nucleotide polymorphism was done using PCR-restriction fragment length polymorphism method. Results VEGF + 936C/T gene polymorphism showed no statistically significant differences in the distribution of the genotypes and allele frequencies between patients and controls. No significant relation was found between genotype distribution and sex, age, somatic hypermutation, hemoglobin, total leukocytic count, and absolute lymphocytes; however, TT genotype and recessive genetic model (CT + CC) revealed a significant relationship with the platelet count in patients with CLL (P = 0.014). A statistically significant relationship was depicted between TT genotype and recessive genetic model (CT + CC) and poor prognostic markers such as lactate dehydrogenase, β2 microglobulin, and modified Rai staging system (IV). Conclusion VEGF + 936C/T gene polymorphism can predict poor prognosis in patients with CLL.
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Clinical significance of nucleated red blood cell count in pediatric patients with transfusion-dependent beta thalassemia p. 949
Amira M.F. Shehata, Sohier A Wanas, Mahmoud A El-Hawy, Khalid A Khalifa
DOI:10.4103/mmj.mmj_14_20  
Objectives The aim of this study was to assess the count of nucleated red blood cells (NRBCs) as a potential marker of erythropoietic stress and transfusion therapy adequacy. To achieve this goal, we evaluated the performance of the Sysmex XN-1000 hematology analyzer and flow cytometry (FC) in counting NRBCs in comparison with manual microscopic counting (MC). Background NRBCs recognition by manual and automatic technologies has been widely evaluated. As transfusion of packed red blood cells is a principal supportive intervention for patients with thalassemia major, monitoring markers of an adequate transfusion therapy is essential in their management. Patients and methods NRBC percentages from 61 thalassemia major patients were analyzed by automated technologies, Sysmex XN-1000 analyzer and FC, and the results were compared with traditional MC as a reference method. Markers of ineffective erythropoiesis were estimated for all patients. Results Pretransfusion hemoglobin levels showed significant negative correlation with NRBC% obtained by Sysmex XN-1000 (r=−0.302, P = 0.018). Furthermore, NRBC% was positively correlated with reticulocyte% (r = 0.852, P < 0.001) and serum soluble transferrin receptor (r = 0.303, P = 0.017). The comparison of NRBCs% given by both automated methods versus MC showed strong and significant correlation (r2 = 0.999, P < 0.001). The degree of the agreement between methods was analyzed by the Bland–Altman plot; the mean bias between MC versus XN-1000 analyzer and MC versus FC were1.1 and − 0.4, respectively. Conclusion Monitoring of NRBC% by Sysmex XN-1000 analyzer has many advantages over manual counting and can help to optimize transfusion therapy for patients with beta thalassemia major.
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Magnetic resonance imaging of temporomandibular joint disorders p. 956
Adel M Al Wakeel, Mohamed S Abdullah, Maged F. A. El Monem
DOI:10.4103/mmj.mmj_325_18  
Objective The aim was to highlight the role of MRI in the evaluation of temporomandibular joint (TMJ) disorders. Background MRI has become a mainstay in the evaluation of TMJ disorders given its ability of noninvasively depicting major regional anatomic structures and demonstrating the presence of joint effusion and bone marrow signal-intensity abnormalities. Consequently, MRI has become the gold standard in diagnosing articular disc displacement. Patients and methods In this study, we included 30 patients (60 joints) who were referred from dentist's and rheumatologist clinics. They had clinical manifestations of TMJ affection. They were subjected to clinical history and examination. The main tool for diagnostic assessment was the conventional MR study of the TMJ in both opened and closed mouth positions. Results This study suggests the use of MRI as a proper diagnostic modality for TMJ disorders owing to the excellent soft tissue contrast and multiplanar capabilities that enable enhanced demonstration of complex anatomy and superior assessment of the pathological conditions of the TMJ, especially internal derangement of the TMJ. Conclusion There were 28 normally positioned discs out of the examined 60 joints. There were 13 joints showing partial anterior disc displacement (ADD) with reduction. We found five joints showing partial ADD without reduction. We found 13 joints showing complete ADD without reduction. We found one joint showing osteoarthritis.
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Role of multi-detector computed tomography in diagnosis of non cardiac causes of acute chest pain p. 962
Maha M. A. Mousa, Hala H Mohammed, Yasmin H Hemeda
DOI:10.4103/mmj.mmj_364_18  
Objective The objective of this study was to evaluate the role of multidetector computed tomography (CT) in the diagnosis of noncardiac causes of chest pain. Background Noncardiac chest pain is common in the general population and impacts significantly the quality of life, yet only a minority seeks medical attention. Patients and methods This study was carried out as a cross-sectional study and included 55 patients who presented with acute or chronic chest pain and some of them had with chest pain one or more of the following symptoms and signs: cough, fever, dyspnea, hemoptysis, and bulging mass. They were recruited from the Radiology Department of Menoufia University Hospital and Al-Azhar University Hospital within the period from February 2016 to December 2017; their ages ranged between 1 and 75 years. An informed consent was obtained from all participants in this research after full explanation of the benefits and risks of the CT examination. All patients were clinically evaluated and had routine assessment and underwent multidetector CT chest examination. Results According to chest CT diagnosis of the studied population, infection (30.9%) and pulmonary embolism (12.7%) were the most common diagnosis. Regarding the ability of CT to diagnose bronchogenic carcinoma, the sensitivity and specificity were found to be 83 and 50%, respectively, and for pulmonary embolism the sensitivity and specificity were found to be 100 and 100%, respectively. Conclusion Chest pain is one of the most common presenting symptoms for patients coming to the emergency department. Contrast-enhanced multidetector CT has replaced previous invasive diagnostic procedures when there is the clinical suspicion of pulmonary embolism or acute aortic syndrome.
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First-trimester uterine artery Doppler in the prediction of later pregnancy complication Highly accessed article p. 966
Adel M Elwakel, Sameh M Azab, Amira M Elbakry
DOI:10.4103/mmj.mmj_399_18  
Objective The objective of this study was to highlight the role of first-trimester uterine artery Doppler in the prediction of later pregnancy complication. Background Hypertensive disorders represent the second most common cause of maternal death, affecting 5–10% of pregnancies worldwide. Pre-eclampsia is believed to develop from inadequate trophoblast invasion of the maternal spiral arteries. Doppler imaging permits noninvasive evaluation of the uteroplacental circulation and is invaluable in the management of high-risk pregnancies. Patients and methods Convenience sampling allowed for the recruitment of 120 patients (11–14 weeks gestation) who attended the obstetric outpatient clinic and department at Menoufia University Hospital between March 2017 and April 2018. A complete record of 103 participants was available for the final analysis. Seventeen women were later excluded for the following reasons: four pregnancies miscarried, one pregnancy was complicated by intrauterine fetal death and, finally, 12 (10%) women did not give birth in our departments and were thus lost at follow-up. Results The results of this study revealed that six (6%) participants developed pre-eclampsia [four (66.6%) cases of the six patients had a pulsatility index value above the 95th centile, whereas two (33.4%) cases had pulsatility index values above the 50th centile]. Conclusion Uterine artery Doppler is promising. An ultrasound screening program in high-risk pregnant women would offer clinicians the opportunity to prevent the disease before it manifests clinically.
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Role of magnetic resonance sialography in diagnosis of salivary gland diseases: a meta-analysis p. 972
El-Sayed El-Mekkawy El-Sayed, Rehab M Habib, Mohamed I. M. Elhalal
DOI:10.4103/mmj.mmj_420_18  
Objectives To establish the diagnostic accuracy of magnetic resonance sialography (MRS) when compared with the gold standard conventional sialography (CS) in patients with suspected salivary gland disease. Background This is a systematic review and meta-analysis to compare both studies. CS is still considered the standard modality for assessing ductal abnormalities. MRS has been applied as an alternative. Methods We searched PubMed, Cochrane CENTRAL, Scopus, Science Direct, and Web of Science for all studies that compared MRS versus CS regarding radiological outcomes and diagnostic performance as primary outcomes. Combined outcomes were pooled as risk ratios in a fixed model or diagnostic odds ratio (DOR) in a random model, using Reviewer Manager 5.3 and Meta-DiSc 1.4 for Windows. Results Eight studies (n = 285 patients) were included in the final analysis. Our results showed that MRS was effective in the detection of main duct according to patients more than CS [risk ratio = 0.84, 95% confidence interval (CI), 0.71–1, P = 0.05). However, it showed no significant difference between the two groups in detection of main duct according to glands. Moreover, there are no significant differences between MRS and CS regarding detection of sialolithiasis, sialectasis, stenosis with stones, or strictures. The diagnostic performance in the detection of sialolithiasis according to glands was as follow: the pooled sensitivity was 0.88 (95% CI, 0.75–0.95), the pooled specificity was 0.98 (95% CI, 0.93–1.00), and the pooled DOR under random effect was 181.64 (95% CI, 39.420–837). Moreover, the diagnostic performance in the detection of the stenosis with stones according to patients was as follows: the pooled sensitivity was 0.727 (95% CI, 0.498–0.893), the pooled specificity was 0.979 (95% CI, 0.889–0.99), and the diagnostic odds ratio under random effect was 78.73 (95% CI, 2.18–508.81). Conclusion There is no difference between MRS and CS in radiological findings except in case of detection of main duct according to patients, which indicates that MRS is more effective in revealing the proper information about main salivary ducts. Moreover, MRS provides a noninvasive alternative to CS especially if acute sialadenitis is present or cannulation is not successful.
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Role of diffusion-weighted imaging as a new technique in diagnosis of cholangiocarcinoma p. 981
Mohamed R Elkholy, Tarek F abdellah, Mohamed S Abdelgawad, Heba S Ellaban
DOI:10.4103/mmj.mmj_437_18  
Objective To study the role of diffusion-weighted (DW) imaging in the evaluation of cholangiocarcinoma (CC). Background In analyzing the presentation of different types of CC, DW-MRI as a noninvasive, safe technique had great importance. Patients and methods The patients were referred from Hepatobiliary Surgery and Hepatology Departments of the National Liver Institute, Menoufia University, during the period from October 2016 to November 2018. The study included 50 cases, comprising 34 males and 16 females, with age ranging from 34 to 77 years. Patients who were diagnosed with CC by pathology underwent dynamic MRI. Results The study included 50 cases, comprising 34 (68%) men and 16 (32%) women. The sensitivity of dynamic study and DW imaging is 100% in detection of mass-forming and intraductal CCs. We found that apparent diffusion coefficient value of CC is lower than that of the liver and higher than that of the spleen. Relation between the apparent diffusion coefficient and CC pathological grading is evident. Conclusion DW imaging is a new effective technique in the detection and improvement of the diagnosis of CC.
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In-phase and out-of-phase MRI: a quantitative method for assessment of nonalcoholic fatty liver disease p. 987
Shaimaa A Hassanein, Hala H Mohamed, Aya Y Mostafa, Manal I Gomaa
DOI:10.4103/mmj.mmj_79_19  
Objective The objective of this study was to assess the efficacy of MRI in-phase and out-of-phase (IPOP) technique in the diagnosis of nonalcoholic fatty liver disease (NAFLD). Background NAFLD is raising great concern nowadays due to its prevalence. It was routinely diagnosed by liver biopsy, which is a highly invasive procedure; hence, the need for a noninvasive method for diagnosis was required. MRI IPOP technique was introduced to fulfill this role. Patients and methods This prospective study was carried out during the period spanning from July 2016 to December 2017; 50 asymptomatic patients with clinical diagnosis of NAFLD and diffuse hyperechogenicity of the liver by ultrasound underwent MRI of the liver with IPOP technique. Manually placed region of interest and two equations, namely F1 and F2, for determination of the grades of steatosis were used. Results The first equation (F1) revealed one patient (male individual) to have minimal steatosis, 24 patients (17 female individuals, seven male individuals) to have mild steatosis, 22 patients (15 female individuals, seven male individuals) to have moderate steatosis and three patients (two female individuals, one male individual) to have marked steatosis, whereas the second equation (F2) revealed one patient (male individual) to have minimal steatosis, 20 patients (13 female individuals, seven male individuals) to have mild steatosis, 26 patients (19 female individuals, seven male individuals) to have moderate steatosis and three patients (two female individuals, one male individual) to have marked steatosis. Conclusion Liver MRI with IPOP technique can be used rapidly and quantitatively to estimate the liver fat content in patients with NAFLD.
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The value of elevated serum resistin levels as a diagnostic marker in psoriasis p. 993
Shawky M El-Farargy, Naglaa M Ghanayem, Sara E. S. Matar
DOI:10.4103/mmj.mmj_337_18  
Objective The objective of this study was to assess the value of elevated serum resistin levels as a diagnostic marker in psoriasis. Background Psoriasis is a chronic, recurrent, immune-mediated, inflammatory skin disease. Hormonal as well as metabolic factors may play a role in the pathogenesis of psoriasis. Resistin is an adipose tissue-derived adipokine and is linked to inflammation, immunity, obesity, and insulin resistance. Resistin is considered to be important modulator of chronic inflammation contributing to the development of many disorders, including psoriasis. Several studies have showed that resistin and psoriasis are positively correlated. Patients and methods This case–control study was conducted on 34 patients: 17 patients with psoriasis and 17 age-matched and sex-matched healthy controls during the period from November 2017 to March 2018. All patients were subjected to full history taking, clinical examination, and laboratory investigations. Serum resistin levels were measured by using enzyme-linked immunosorbent assay technique. Results Serum resistin levels were significantly elevated in patients with psoriasis (22.96 ± 14.90) compared with healthy controls (10.66 ± 2.57). There was a significant positive correlation between serum resistin level and each of Psoriasis Area and Severity Index score (r = 0.821, P < 0.001) and duration of disease (r = 0.872, P < 0.001). Conclusion Serum resistin levels were higher in patients with psoriasis compared with healthy controls. The levels were correlated with clinical severity in patients with psoriasis. Therefore, serum resistin level can be used as a diagnostic biomarker for evaluating the clinical status of patients with psoriasis and may predict the occurrence of co-morbidities in patients with psoriasis.
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Study of the role of kisspeptin in constitutional delayed puberty in boys p. 998
Abdallah M Attia, Belal A Montaser, Mohamed R. M. Ellotf
DOI:10.4103/mmj.mmj_384_18  
Objectives To assess the level of kisspeptin in the serum of boys with constitutional delayed puberty (CDP) and to study its correlation with the main hormones of reproduction [follicle-stimulating hormone (FSH), testosterone, and prolactin). Background CDP is a common problem with a prevalence of 2–2.5% of population, with unclear etiopathogenesis. Patients and methods This study was done on 25 boys; aged 14–18 years and having CDP (Tanner's stages I, II, and III) as the patient group and another 25 boys age-matched with full pubertal manifestations (Tanner's stage V) as a control group with exclusion of delayed puberty due to other causes, for example; hypogonadotropic or hypergonadotropic hypogonadism and exclusion of any diseases, operations, or drugs that may affect the onset of puberty. Results The result showed that serum kisspeptin is much significantly lower in the CDP group compared with the control. Serum kisspeptin is positively correlated to both testosterone and FSH and have no relation with prolactin. There was no significant differences between chronological and bone age of the control group, while in the CDP group, bone age is significantly delayed compared with their chronological age as well as the bone age of the control group. Weight and height are significantly less in the CDP group than that of the control. Serum testosterone and FSH is significantly lower in CDP compared with the control group, while serum prolactin showed no significant differences between both groups. Conclusion Further studies on CDP on a larger number of patients with trial of kisspeptin drug as a line of treatment for such cases.
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The role of CXCL12 chemokine in patients with alopecia areata p. 1003
Shawky M El-Farargy, Naglaa M Ghanayem, Noha A. A. Shaheen
DOI:10.4103/mmj.mmj_393_18  
Objective The aim was to study the role of CXCL12 in patients with alopecia areata. Background Alopecia areata is an organ-specific autoimmune disease targeting the hair follicles. It causes nonscarring hair loss. It is a lymphocyte cell-mediated inflammatory type of hair loss. Chemokines are the main components of the immune system and play fundamental roles in pathogenesis of inflammatory disorders. CXCL12 is an ELR-CXC chemokine with angiogenic effects. CXCL12 (as ELR-) is strongly chemotactic for lymphocytes and neutrophils. It is plausible that failed angiogenesis in the alopecia areata patients are involved in hair loss. As CXCL12 is an angiogenic chemokine, decreased CXCL12 levels may possibly in turn lead to decreased angiogenesis and cause hair loss in the patients. Patients and methods This case–control study was conducted on 50 participants: 25 patients with alopecia areata and 25 age-matched and sex-matched healthy controls during the period from February 2018 to August 2018. All patients were subjected to full history taking, clinical examination, and laboratory investigations. Serum CXCL12 chemokine levels were measured by using the enzyme-linked immunosorbent assay technique. Results Serum CXCL12 levels were significantly decreased in alopecia areata patients (mean: 15.55 ± 6.35) compared with healthy controls (mean: 46.94 ± 41.42) (P = 0.005). There is negative significant correlation between CXCL12 and duration of disease (r = −0.491, P = 0.013). Conclusion CXCL12 chemokine is decreased in patients with alopecia areata. There is a dependent relationship between CXCL12 serum level and AA. It can be used as a diagnostic biomarker of AA activity.
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Mucocutaneous findings in down syndrome p. 1007
Mohamed A Gaber, Menan S. A.. Alghobashy
DOI:10.4103/mmj.mmj_405_18  
Objective To study and evaluate the dermatological signs found in patients with Down syndrome (DS). Background The dermatological signs found in patients with DS have been less clear and infrequently studied and must be completely elucidated. Patients and methods This cross-sectional study included 50 patients with DS confirmed clinically. The sample comprised 28 boys and 22 girls. Their ages ranged between 1 and 40 years. We separated the sample into five age groups: 0–5 years, 14 patients; 6–10 years, 22 patients; 11–15 years, eight patients; and older than 16 years, 6 patients. Results Seborrheic dermatitis was the most frequent sign in our study with frequency of 65% followed correspondingly by xerosis, 42%; fissured tongue, 30%; palmoplantar hyperkeratosis, 24%; macroglossia, 20%; and syringomas, 12%. Cheilitis, keratosis pilaris, and premature hair graying had the same overall frequency in the present study, which was 8%. Atopic dermatitis, vitiligo, and geographic tongue had the same overall frequency, which was 6%. Acanthosis nigricans and scabies had the same overall frequency, which was 4%. Skin tags, freckles, trichotillomania, alopecia areata, and acne keloidalis nuchae had 2% overall frequency. Conclusion In conclusion, the lower prevalence of atopic dermatitis in our series was in concordance with its low prevalence reported in recent articles. Improved hygiene owing to patient care at home may underlie the absence of infections among our children. Mucocutaneous findings are commonly seen in DS, although they are usually not serious.
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Clinical significance of serum prolactin levels in patients with alopecia areata p. 1011
Shawky M El-Farargy, Naglaa M Ghanayem, Hanem N AbdEl-Fattah Habib
DOI:10.4103/mmj.mmj_5_19  
Objectives To assess the value of elevated serum prolactin levels as a diagnostic marker in alopecia areata (AA). Background AA is characterized by areas of nonscarring hair loss that ranges from a single oval patch to multiple patches. Immunological, environmental, psychological, and genetic factors may play a role in the pathogenesis of AA. Prolactin is a polypeptide hormone secreted from the anterior pituitary gland that has a variety of physiological actions including growth promoting activity and exerts a proliferative effect on human keratinocytes. Prolactin may therefore play an important role in the pathogenesis of AA, through its immunomodulatory function. Several studies have shown that prolactin and AA are positively correlated. Patients and methods This case–control study was conducted on 50 patients: 25 AA patients and 25 age-matched and sex-matched healthy controls during the period from November 2017 to March 2018. All patients were subjected to full history taking, clinical examination, and laboratory investigations. Serum prolactin levels were measured by chemiluminescence through an immunoassay-automated access 2 Beckman coulter. Results Serum prolactin levels were significantly elevated in AA patients (mean ± SD, 16.8 ± 2.3) compared with healthy controls (mean ± SD, 9.7 ± 3.00). There was significant positive correlation between serum prolactin level and size of the AA lesion (r = 0.661, P < 0.005). Conclusion Serum prolactin levels were higher in AA patients compared with healthy controls. The levels were correlated with clinical severity in patients with AA. Therefore, serum prolactin level can be used as a diagnostic biomarker for evaluating the clinical status of AA.
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Correlation between vitamin D serum level and severity of psoriasis p. 1016
Shawky M El-Farargy, Naglaa M Ghanayem, Aya M Elrashidy
DOI:10.4103/mmj.mmj_6_19  
Objectives To investigate serum levels of vitamin D in patients with psoriasis compared with healthy controls, and to consider their relation to disease severity. Background Psoriasis is a chronic, recurrent, immune-mediated, inflammatory skin disease. Vitamin D is a fat-soluble vitamin that is obtained from food supplements and sun exposure. Vitamin D deficiency has been incriminated in a long panel of diseases including cancers, autoimmune diseases, and cardiovascular and neurological disorders. In psoriasis, vitamin D is involved in the maintenance of cutaneous barrier homeostasis. Several studies have identified an association between polymorphisms of vitamin D receptor and psoriasis susceptibility. Patients and methods This case–control study was conducted on 30 patients with chronic plaque psoriasis and 10 age-matched and sex-matched healthy controls during the period from March 2017 to March 2018. All patients were subjected to full history taking, clinical examination, and laboratory investigations. Serum vitamin D levels were measured by using enzyme-linked immunosorbent assay technique. Results There is significant decrease in the level of serum vitamin D in moderate (mean ± SD, 27.57 ± 6.96) and severe (mean ± SD, 19.28 ± 6.35) patient groups compared with the control group (mean ± SD, 40.04 ± 11.12) whereas nonsignificant difference existed with the mild group (mean ± SD, 33.28 ± 5.34). There is significant negative correlation between serum vitamin D and each of age (r = −0.418, P = 0.022), disease duration (r = −0.572, P = 0.001), and psoriasis area and severity index score (r = −0.680, P < 0.001). Conclusion Decreased 25 OH vitamin D serum level was found in psoriatic patients. The 25 OH vitamin D serum level may be used as a marker of psoriasis severity and response to treatment.
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Role of β-catenin in vitiligo: a clinical and immunohistochemical study p. 1021
Mohamed A Shoeib, Azza G. A. Farag, Dalia R Al-Sharaky, Reem A Hassan, Eman N El-Shafey, Heba N. N. Shehata
DOI:10.4103/mmj.mmj_13_19  
Objective This study aimed at evaluating the immunohistochemical expression of β-catenin in the involved skin in vitiligo patients and to correlate its evaluated expression with the available clinicopathological parameters in those patients. Background Vitiligo is an autoimmune skin disorder in which the loss of melanocytes is mainly attributed to defective autoimmune mechanisms, cytotoxic mechanisms, an intrinsic defect of melanocytes, oxidant–antioxidant mechanisms, and neural mechanisms. The assessment of maintenance of vitiligo could be related to β-catenin expression. The treatment of vitiligo remains a challenge. Patients and methods Thirty-five patients with different degrees of vitiligo severity versus 20 patients of age-matched and sex-matched healthy controls were enrolled in this study. Biopsies were taken from vitiliginous lesion of patients and from healthy skin of controls. Results The relative expression of β-catenin protein in vitiligo patients showed nonsignificant differences between vitiligo cases and their matched controls regarding all studied parameters (P > 0.05) except for cellular localization, which was mainly cytoplasmic in vitiligo cases (25, 80.6%) versus 50% in the control group (P = 0.001). Conclusion β-Catenin may have an active role in the pathogenesis of vitiligo.
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Correlation between serum vitamin D levels and severity of vitiligo p. 1026
Shawky M El-Farargy, Naglaa M Ghanayem, Hossam A Yasien, Mai M Gamal
DOI:10.4103/mmj.mmj_29_19  
Objective To correlate between serum vitamin D levels and severity of vitiligo. Background Vitiligo is an acquired depigmentary disorder that affects more than 0.5–1% of the worldwide population. Vitamin D has been implicated in the pathogenesis of various autoimmune diseases. The correlation between vitiligo and vitamin D is discussed in this study. Patients and methods This case–control study was conducted on 60 patients with vitiligo and 60 age-matched and sex-matched healthy individuals. All patients were recruited from the Outpatient Clinic of Dermatology and Andrology Department of Shebeen El-Kom University Hospital between 1 May 2018 and 31 August 2018. Blood samples were taken, and serum levels of vitamin D were measured by enzyme-linked immunosorbent assay technique. Serum levels of vitamin D were statistically analyzed in relation to Vitiligo Area Severity Index (VASI) score using Spearman coefficient test. Results The patients had higher serum vitamin D levels than the controls with highly significant difference (P < 0.001). There was no significant correlation between vitamin D and VASI score in patients (P = 0.966). Conclusion There was no significant correlation between vitamin D levels and VASI score. Future larger controlled studies are required to obtain a wider assessment of the relationship between vitamin D level and vitiligo disease severity.
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The role of chemokine CXC-motif receptor 3 in vitiligo: a clinical and immunohistochemical study p. 1031
Azza G Farag, Dalia R Al-Sharaky, Reem A Hassan, Eman N Elshafey, Noura N. N. Shehata
DOI:10.4103/mmj.mmj_38_19  
Objectives The present study aimed at evaluating the immunohistochemical expression of CXCR3 in the involved skin in vitiligo patients and to correlate its evaluated expression with the available clinicopathological parameters in those patients. Background Vitiligo is an autoimmune skin disorder in which the loss of melanocytes is mainly attributed to defective autoimmune mechanisms, cytotoxic mechanisms, an intrinsic defect of melanocytes, oxidant–antioxidant mechanisms, and neural mechanisms. The assessment of maintenance of vitiligo could be related to CXCR3 expression. The treatment of vitiligo remains a challenge. Patients and methods This case–control study was carried out on 35 patients with variable degrees of vitiligo severity. They were recruited from the Dermatology Outpatient Clinic, Faculty of Medicine, Menoufia University Hospital from May 2016 to March 2017. Normal skin biopsies were obtained from the control group which included 20 persons of age, sex, Fitzpatrick skin phototype, and occupation-matched healthy participants attending the Plastic Surgery Department. Results The results were collected, tabulated, and statistically analyzed by an IBM-compatible personal computer with SPSS statistical package, version 20 (SPSS Inc. Released 2011, IBM SPSS statistics for Windows, version 20.0). The relative expression of CXCR3 chemokine in vitiligo patients showed that the percent of CXCR3 expression in the epidermis was significantly higher in vitiligo cases (median, 80) than controls (median, 20) (P = 0.001). H score was significantly higher in vitiligo cases (median, 100) than controls (median, 30) (P = 0.003). Conclusion CXCR3 may have an active role in the pathogenesis of vitiligo.
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Serum granulysin as a possible key marker of activity of alopecia areata p. 1036
Alaa H Maraee, Sally M El-Hefnawy, Enas A. M. Mahrous, Doaa M. A. El-Wareth Tolba
DOI:10.4103/mmj.mmj_45_19  
Objective To study whether granulysin (GNLY) level, which is known to reflect the activity of cytotoxic immune response, is related to the disease activity of alopecia areata (AA). Background AA is a common type of hair loss or alopecia in humans. GNLY is an important mediator of damage in a variety of skin diseases. Patients and methods A case–control study was carried out on 72 individuals. A total of 36 patients experiencing AA circumscripta, selected from the Dermatology Outpatient Clinic, Menoufia University Hospital, and 36 healthy individuals as a control group were recruited during the period from October 2017 to March 2018. Detailed history, laboratory investigations, and dermatological examination were done. Results There was a statistically highly significant difference (P < 0.001) between both groups regarding serum GNLY level. Moreover, most patients (30 case, 83.3%) were complaining of alopecia without association with any other allergic diseases. Serum GNLY level (ng/ml) was highly significantly positively correlated (P < 0.001) with recurrence of AA and course of AA. Moreover, it showed a significant positive correlation (P < 0.05) with the extent of alopecia in the body and the association with other allergic diseases. Conclusion Serum GNLY level was significantly positively correlated with recurrence, course, extent of alopecia, and association with other allergic diseases. Serum GNLY levels in the acute phase can be a useful and novel marker for the disease activity and prognosis of AA.
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Tissue expression of endothelial selectin in patients with atopic dermatitis p. 1041
Azza G. A. Farag, Dalia R. A. Sharaky, Eman N El-Shafey, Sawsan S Allam
DOI:10.4103/mmj.mmj_72_19  
Objective To investigate the role of endothelial selectin (E-selectin) in atopic dermatitis (AD) through evaluation of the immunohistochemical expressions in lesional skin biopsies. Background AD is a chronic, pruritic inflammatory skin disease that occurs most frequently in children. In AD, the inflammatory cascade is initiated by the release of proinflammatory cytokines from atopic keratinocytes. Patients and methods A total of 50 patients with AD and 10 healthy control participants were included in this case–control study. From all participants, skin biopsies were taken, and immunohistochemical staining by E-selectin monoclonal antibodies was done. Results There were significant elevations in E-selectin cellular localization (P = 0.01) as well as dermal inflammatory infiltrates in AD cases than controls. Conclusion E-selectin participates in AD pathogenesis.
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Evaluate the efficacy of carboxytherapy for localized lipolysis in a sample of Egyptian patients p. 1045
Alaa H Maraee, Azza G. A. Farag, Ashraf A Zytoon, Shahlaa A. E. R. Essa
DOI:10.4103/mmj.mmj_82_19  
Objective To evaluate the efficacy of injection of carbon dioxide (CO2) in the treatment of localized fat deposits. Background Obesity is a serious medical problem resulting in significant morbidity and mortality. CO2 therapy or carboxytherapy is the transcutaneous administration of CO2 for therapeutic purposes. Patients and methods A prospective, cross-sectional study was carried out on 15 men having localized fat deposits in the abdomen, who attended the Dermatology Outpatient Clinic, Faculty of Medicine, Menoufia University Hospitals, during the period from July 2017 to January 2018. Detailed history, clinical examination, digital photographic registration, and ultrasound measurements of the thickness of subcutaneous fat and therapeutic regimen were done. Results Abdominal measurements by tape and ultrasound showed a statically significant reduction in abdominal circumference (P < 0.0001) and in fat thickness (P < 0.0001). Conclusion Carboxytherapy appeared to be effective in the treatment of localized obesity, without remarkable adverse effects, and can be used as a safe, complementary treatment option.
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Lipid profile in cases of lichen planus p. 1050
Mustafa A Hammam, Ola A Bakry, Shaimaa El Shafey Soliman, Eman M. H Abd El Hamid El Khateeb
DOI:10.4103/mmj.mmj_92_19  
Objective The aim of this work is to measure serum lipid profile in lichen planus) LP (cases for assessment of possible myocardial ischemia in these cases. Background LP is a chronic inflammatory disease that affects the skin and mucous membranes. It occurs mostly in individuals older than 45 years, and it is more common among women. Lipids are a broad group of naturally occurring molecules. High levels of triglycerides in the blood stream have been linked to atherosclerosis and, by extension, the risk of heart disease and stroke. Atherogenic lipid profile leads to atherosclerosis, which may be complicated by cerebral stroke, myocardial infarction, and/or peripheral vascular disease. Patients and methods This case–control study was carried out on 20 nonobese cases with LP as patient group and 20 age-matched, sex-matched, and BMI-matched healthy participants as a control group. All participants were subjected to full history taking, clinical examination, and laboratory investigations (blood lipid profile). Results Our results showed no significant difference between cases and controls regarding age and sex. There was no significant difference between cases and controls regarding blood pressure and BMI. There was a highly significant difference between case and control groups regarding serum cholesterol, high-density lipoprotein, and low-density lipoprotein. Conclusion Serum cholesterol, high-density lipoprotein, and low-density lipoprotein may be better predictors of cardiovascular risk in patients with LP.
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Matrix metalloproteinase-9 in the blood of acne patients: The possible use of matrix metalloproteinase-9 as a biomarker of acne severity p. 1055
Mostafa A Hammam, Nesreen G Alhelbawy, Sarah N Hanafy Mahmoud
DOI:10.4103/mmj.mmj_98_19  
Objectives The aim of this study was to study the blood level of matrix metalloproteinase-9 (MMP-9) in acne patients and its relation to disease severity. Background The possible use of MMP-9 as a biomarker of acne severity. Patients and methods This case–control study was conducted on 45 patients with acne vulgaris collected from the Dermatology Outpatient Clinic in Menoufia University Hospital with age ranging from 18 to 25 years. The study was done during the period from June 2018 to January 2019. Acne grading was performed according to the Global Acne Grading System. Twenty normal controls matched for age and sex were included. Detailed history and clinical exa mination were carried out to exclude patients with hyperproliferative skin disorders such as psoriasis and lichen planus, patients with bullous diseases, therapy. MMP-9 was measured by the enzyme-linked immunosorbent assay method for patients and controls and the results were statistically analyzed and tabulated. Results The level of MMP-9 recorded significant elevation when compared with normal control level. In addition, a significant difference was obtained when comparing its level among mild, moderate, and severe cases. There was also an association between its level and the number of regions with inflammatory pustules and nodules but not with scars. Conclusion MMP-9 can be used in the future as a biomarker of acne severity to choose the best treatment modalities.
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8-hydroxy-2-deoxyguanosine as a new biomarker of oxidative stress in patients with acne vulgaris p. 1059
Magda M Hagag, Nesreen G Elhelbawy, Eman F. Abd Elfadil Albarqi
DOI:10.4103/mmj.mmj_217_19  
Objectives To evaluate the serum level of 8-hydroxy-2-deoxyguanosine (8-OHdG) in patients with acne vulgaris and also to detect relation between serum level of 8-OHdG and acne vulgaris severity. Background Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, characterized mainly by comedones. The precise mechanisms of acne are not known. Oxidative stress within the pilosebaceous unit are considered an important initiating step in the pathogenesis of acne. 8-OHdG is considered to be one of the main biomarkers of oxidative stress. Patients and methods This cross-sectional study was carried out on 75 patients with mild, moderate, and severe acne vulgaris, along with 15 age-matched and sex-matched healthy individuals. Acne severity was assessed by using the global acne score. Blood samples were taken for measuring serum 8-OHdG levels in patients and controls by using commercial enzyme-linked immunosorbent assay kit. Results The serum levels of 8-OHdG were significantly higher in patients with acne vulgaris when compared with healthy individuals (P = 0.005). A strong positive correlation between serum levels of 8-OHdG and acne severity was found (P < 0.001, r = 0.53). Conclusion Oxidative stress has an important role in acne pathogenesis represented by elevated 8-OHdG levels.
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Effect of vaginal pH in preconceptional fetal sex determination p. 1063
Mohamed A Gaber, Saeed A Saleh, Nashwa H Allam
DOI:10.4103/mmj.mmj_338_18  
Objective To assess the effect of vaginal pH on fetal sex determination. Background Sex determination is a very important topic. Changing of the normal vaginal pH (3.8–4.5) can affect the activity of different types of spermatozoa and therefore affect the fetal sex. Patients and methods This prospective study was carried on 20 patients coming to clinic of gynecology and obstetrics, with variable ages ranging from 21 to 37 years and free of any gynecological or obstetric disorders; vaginal swab from each case was taken on a litmus paper on preovulatory time to assess the acidity and alkalinity of vagina and define its effect on fetal sex. Results Overall, 20 patients were from different gravidity and parity. Regarding the comparison between acidic and alkaline vaginal pH and fetal sex, there were significant associations between fetal male sex and alkaline vaginal pH, and significant association between fetal female sex and acidic vaginal pH. Conclusion Vaginal pH could be used as a natural method to determine the fetal sex.
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NEUROPSYCHIATRY - ORIGINAL ARTICLES Top

Neutrophils-to-lymphocyte ratio in acute ischemic stroke patients p. 1067
Wafeek M Elsheik, Ibrahim E Alahmar, Gelan M M. Ali, Eman S Matar
DOI:10.4103/mmj.mmj_371_18  
Objective The aim of this study was to evaluate the neutrophils-to-lymphocyte ratio (NLR) among patients with ischemic stroke and to determine the relationship between NLR and poststroke prognosis Background Inflammations play a role in the pathogenesis of cerebral infarction. Cytokines and adhesion molecules regulate the increased migration of leukocytes to the brain. Neutrophils are the first type of leukocytes to infiltrate ischemic brain (30 min of cerebral ischemia), peak earlier (days 1–3), and then decrease rapidly with time. Lymphocyte recruitment into the brain is involved in the later stages of ischemic brain injury. Patients and methods A retrospective study was done on 60 patients with ischemic stroke and 35 age-matched and sex-matched healthy controls. NLR was assessed from the patients' blood samples. Results The results were collected, tabulated, and statistically analyzed by IBM personal computer and statistical package SPSS, version 2, a P value of less than 0.05 was considered statistically significant. NLR among ischemic stroke patients was significantly higher than that of the control group. The optimal cutoff value of NLR for the prediction of primary unfavorable outcome was 2.05 with a sensitivity of 90% and a specificity of 96%. Conclusion NLR is a nonexpensive and easy marker for predicting stroke severity on admission, which is a primary unfavorable functional outcome.
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Ischemia-modified albumin for evaluating severity and predicting prognosis in patients with acute cerebrovascular disease p. 1072
Mohammed A Okda, Rasha A El-Kabany, Hosna S Soliman, Mona S El-Kholy
DOI:10.4103/mmj.mmj_65_19  
Objective To evaluate the role of serum ischemia-modified albumin (IMA) level in cerebrovascular stroke and its relation to the severity or prognosis in patients with acute cerebrovascular disease. Background It was recently demonstrated that IMA levels increase in the acute phase of cerebrovascular diseases. Yet the data regarding IMA levels in various types of cerebrovascular events are still insufficient. Patients and methods A case–control study on 100 consecutive patients and 75 normal individuals as controls was conducted. National Institute of Health Stroke Scale and Glasgow Coma Scale were assessed at admission time. Lesion volume was calculated using computed tomography scan. IMA levels were measured at the same time using the available chemical method. Patients were followed up after 3 months, and the modified Rankin scale (MRS) was evaluated. Results IMA was significantly higher in the patient group than in the control group (96.83 ± 12.01 vs. 44.47 ± 5.28, P < 0.001). There were significantly higher mean values of IMA in patients with ischemic stroke than those with hemorrhagic stroke (P = 0.036). Regarding severity, serum IMA concentrations were positively correlated with National Institute of Health Stroke Scale (r = 0.252, P = 0.01) and lesion volume calculated by computed tomography scan (r = 0.21, P = 0.04) but inversely correlated with Glasgow Coma Scale score (r = −0.227, P = 0.02). Regarding prognosis, on applying MRS 3 months after stroke, this study showed that MRS had no statistically significant correlation with IMA (r = 0.01, P = 0.938). Conclusion IMA levels are higher in patients with acute cerebrovascular disease compared with healthy individuals. The level of IMA is higher in patients with ischemic stroke than those with hemorrhagic stroke. IMA can be used as an indicator of stroke severity.
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Predictors of response to plasmapheresis in patients with myasthenia gravis p. 1077
Wafik M El-Sheikh, Mohammed A Okda, Rasha A El-Kabany, Aktham I Al-Emam, Ibraheim Al-Ahmer, Hany Taher
DOI:10.4103/mmj.mmj_78_19  
Objective To measure the clinical responses, after plasmapheresis, in patients with moderate to severe degree of myasthenia gravis (MG), then correlate these responses with the initial clinical picture, acetylcholine receptor antibodies (AChR-Ab) level, and thymus gland changes. Background Plasmapheresis is used for acute management of MG exacerbations and when rapid clinical responses are needed. It is effective in reducing the quantitative myasthenia gravis (QMG) score for disease severity in patients with moderate to severe MG. However, little is known about factors that predict response to plasmapheresis, and knowing these clinical factors may help in giving information to clinicians about patient outcome after plasmapheresis. Patients and methods A total of 81 patients participated in this study. They had full clinical examination primarily on the first date of plasmapheresis and after 1 month (14 days after finishing plasmapheresis). Disease severity was determined according to QMG scale. Results The scores of QMG scales had significantly improved two weeks after plasmapheresis. The improvement in QMG scores had a good correlation with initial severity, presence of AChR-Ab and their levels, thymectomy, and thymus gland pathology. Conclusion Initial severity, presence of AChR-Ab, and thymectomy are good predictors of improvement after plasmapheresis in patients with MG.
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Predictive value of fractional anisotropy changes of the corticospinal tract in the acute phase of ischemic stroke p. 1082
Rasha A Elkabany, Ibrahim E Al-Ahmer, Khaled H Afifi, Mohamed E Abdelsamea, Aya M Elkordy
DOI:10.4103/mmj.mmj_55_20  
Objective To evaluate the role of reduction in fractional anisotropy (FA) of the ipsilesional corticospinal tract detected by diffusion tensor imaging (DTI) as a prognostic tool to predict the outcome following an acute ischemic stroke. Background There are high costs and concerns about postischemic stroke disability worldwide. DTI is an emerging neuroimaging technique that allows us to measure the integrity of white matter tracts. The reduction of FA value detected by DTI can predict residual neurological deficit in the acute phase of ischemic stroke after 3 months. Patients and methods A nonrandomized, retrospective cohort study was conducted on 40 patients with acute ischemic stroke for the first time and 40 controls of healthy individuals. We assessed our patients according to the size of the infarction, stroke severity using the National Institute of Health and Stroke Scale (NIHSS), and degree of reduction of FA detected by DTI. Patients were followed up clinically using NIHSS after 3 months for residual neurological deficits. Results We observed a good association between reduction of FA value measured by DTI and clinical findings of acute ischemic stroke assessed by NIHSS at the time of onset and after 3 months (P = 0.004, 0.007), respectively. The reduction of FA value was measured by DTI, which is also correlated with the size of the infarction of ischemic stroke (P < 0.001). Conclusion Reduction of FA of the corticospinal tract was measured by DTI. The image could be used as a useful tool for predicting long-term poststroke disability after 3 months.
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A comparative study of ketamine vs electroconvulsive therapy in the management of major depressive disorder p. 1088
Lamyaa G El-Hamrawy, Ashraf M Eskander, Mohamed A. E. Hamad
DOI:10.4103/mmj.mmj_49_20  
Objective The aim was to investigate the efficacy of ketamine vs electroconvulsive therapy (ECT) in hospitalized patients suffering from treatment-resistant major depressive disorder (MDD). Background Both propofol and ketamine are the commonly used anesthetic agents, but recent clinical studies have suggested that ketamine has rapid-acting antidepressant properties, itself, at subanesthetic doses. Patients and methods A clinical comparative randomized cross-sectional study was conducted on 20 patients suffering from treatment-resistant MDD, and receiving ketamine only (group 1) and 20 patients suffering from treatment-resistant MDD receiving ECT only (group 2), who were recruited from inpatients wards of Neuropsychiatry Department, Menoufia University and Met-Khalaf Hospital for Psychiatric Health from December 1, 2018 until March 14, 2019. All participates were subjected to full detailed general medical, neurological, and psychiatric history and examination. Results There was a statistically insignificant differences between the studied patients regarding the types of depression (P = 0.61). Bipolar depression and MDDs were represented in 57 and 54% in the ECT group and 43 and 46% in the Ketamine group, respectively. Also, catatonic depression, melancholic subtype, and seasonal affective disorder were represented by 80, 66.7, and 100% in the Ketamine group vs 20, 33.3, and 0.00% in ECT group, respectively. Conclusion There was statistically significant difference between the ketamine group and ECT, regarding the efficacy of both ketamine and ECT in favor of the ketamine group as ketamine has a more rapid effect in improving depressive symptoms in MDD patients and have more rapid antidepressant effects compared with ECT.
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FAMILY MEDICINE - ORIGINAL ARTICLE Top

Nomophobia among medical residents p. 1094
Hala M Shaheen, Salwa A Alkorma, Safa H Alkalash
DOI:10.4103/mmj.mmj_17_20  
Objective To assess the prevalence and severity of nomophobia among medical residents in Menoufia University Hospitals and to assess its relation with anxiety, doctor–patient relationship, and residents' specialty/subspecialty. Background Nomophobia is an abbreviation for 'no-mobile-phone phobia,' which describes anxiety experienced by mobile phone users in its absence; it is the fear of becoming technologically incommunicable. This fear is characterized by physical, psychological, and cognitive symptoms in the context of stress or danger. Patients and methods A descriptive cross-sectional study was conducted on 221 medical residents in Menoufia University Hospitals in the frame of 13 months. They were assessed through predesigned questionnaires to determine the prevalence and severity of nomophobia and anxiety. Doctor–patient relationship was observed through Kalamazoo checklist. Results Prevalence of both nomophobia and anxiety was 100% among the studied group. More than half of the participants had moderate nomophobia and ~ 73% of the participants had mild anxiety. There was a positive moderate correlation between anxiety and nomophobia (r = 0.51), as increasing the severity of anxiety was associated with increasing in severity of nomophobia. Relation between nomophobia and anxiety was significant positive regarding doctor–patient relationship (P < 0.001), whereas a strong negative correlation regarding good doctor–patient relationship (r=−0.37) was detected. There was a highly statistically significant relationship between nomophobia severity and the residents' specialty, as 40% severely nomophobic residents were surgeons and 58.3% of them were gynecologists and obstetricians. Conclusion Prevalence of nomophobia was 100% among medical residents in Menoufia University Hospitals. Approximately half of the studied residents who had a poor doctor–patient relationships had severe nomophobia. Specialty of medical residents had effect on nomophobia severity.
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BIOCHEMISTRY - ORIGINAL ARTICLE Top

Assessment of N-terminal pro-brain natriuretic peptide level in chronic hepatitis C patients p. 1101
Ahmed A Raouf, Maathir K El-Shafie, Ayman K Abd El-Hamed, Ayman A Azzam, Shimaa M Hamad, Samer E Ghanem
DOI:10.4103/mmj.mmj_616_17  
Objective The aim of the study was to evaluate N terminal pro brain natriuretic peptide (NT-pro-BNP) level as a predictor of myocardial dysfunction in chronic hepatitis C (CHC) patients. Background Hepatitis C virus (HCV) infection represents a major health issue worldwide because of its burden of chronic liver disease and extrahepatic manifestations including cardiovascular diseases. Elevated NT-pro-BNP levels were observed in CHC, free of heart failure. Patients and methods This study was carried out on CHC patients (n = 45) (mean age: 45.6 ± 7.3 years) and sex-matched and age-matched healthy controls (n = 35). All participants were subjected to a full assessment of history, clinical examination, ECG and abdominal ultrasound, and FibroScan for cases. Blood samples were obtained for the HCV antibody, hepatitis B surface antigen, liver and renal function tests, fasting blood sugar, lipid profile, NT-pro-BNP, and HCV RNA quantification for cases. Results The NT-pro-BNP concentration of the CHC patients (mean: 120.6 ± 72.6 pg/ml) was significantly higher than that of the controls (mean: 36.1 ± 28.1 pg/ml) (P = 0.001). Eighty percent of the CHC patients had high NT-pro-BNP (>65 pg/ml; the cut-off value of NT-pro-BNP) and 28.9% of the CHC patients had high NT-pro-BNP (>125 pg/ml; the proposed cut-off value for heart failure <75 years of age). Multivariate analysis showed that chronic HCV infection was correlated independently with high NT-pro-BNP. Conclusion Our study suggests that chronic HCV infection is associated with increased NT-pro-BNP, indicating that it might induce myocardial dysfunction.
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PEDIATRICS - LETTER TO THE EDITOR Top

Seroprevalence of Helicobacter pylori infection among school children in Al Qulubia governorate p. 1108
Mahmood D Al-Mendalawi
DOI:10.4103/mmj.mmj_103_19  
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COMMUNITY MEDICINE - LETTERS TO THE EDITOR Top

The proposed bridging management protocol for COVID-19 p. 1109
Sudhir Bhandari, Ajit Singh, Raman Sharma, Sudhir Mehta, Amitabh Dube, Jitendra Gupta, Kapil Gupta, Amit Tak, Shivankan Kakkar
DOI:10.4103/mmj.mmj_177_2  
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COVID-19 readiness, emergency response, and recovery in slums and informal settings p. 1111
Saurabh R Shrivastava, Prateek S Shrivastava
DOI:10.4103/mmj.mmj_158_20  
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ERRATUM Top

Erratum: Accuracy of ultrasonographic visceral slide test in predicting the presence of intra-abdominal adhesions p. 1113

DOI:10.4103/1110-2098.296719  
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